 Okay, so I will call our meeting back into order for August 14th and we are going to hear from Rutland next. And what we'll do is Mr. McCracken will swear in the Rutland witnesses and then Miss Fox. I'll turn it to you for you and your team to introduce yourselves and provide an opening statement to the board. And before you get started, thank you all for being here and Miss Fox. Congratulations on your new position. So happy to hear from you. Thank you. Good afternoon, Miss Fox and the Rutland team. If you could let me let us know who is going to be presenting and answering questions. And if you wouldn't mind also spelling your name when you introduce yourself, that would be very helpful. My name is Elizabeth Cahill Elizabeth traditional spelling and then Cahill K Y H I L L. Good afternoon, Jonathan Reynolds, Vice President clinical operations here J O N A T H A N R E Y N O L DS and Judy Fox president and CEO and it's Judy with an I J U D I F O X. Mark Foley chair of the board of directors. It's M A R K F O L E Y Kelly Watson chief nursing officer and it's K E L L Y W A T S O N. Thank you all very much. I feel raise your right hand I'll swear you in. Do you solemnly swear that the evidence you shall give relative to the cause no under consideration shall be the whole truth and nothing but the truth so help you God. I do. Great. Thanks very much and I will turn it over to you. So thank you. I'd like to start by thanking chair foster and all the members of the Green Mountain care board for the opportunity for us to support the Rutland community by allowing us to highlight information that we feel is informative and relevant and important to the decision that you the board has before them. I'd also like to thank director Lindbergh who has been a consistent and transparent partner to Rutland regional as we've moved through all aspects of this budget. We have found director Lindbergh's questions to be both inquisitive and helpful and we'd like to acknowledge her in her work in providing a benchmarking tool that is consistent among hospitals. I won't introduce the team again. We have introduced ourselves. You'll hear from each one of us. In addition to the team that will provide testimony. We are also joined by hospital leaders by physicians and board members who are all here in sport in support of our community and our budget. But I first want to ask our board chair Mark fully junior to provide a few opening comments. Thank you Judy. Good afternoon chair foster and members of the Green Mountain care board. So much has happened since you visited Rutland regional last December. Most significantly as Judy noted the board named her as permanent CEO in June. Judy's exceptional leadership and organizational credibility has made an immediate impact on Rutland regional. I want to thank you for the opportunity to provide comments on behalf of Rutland regional. I've had the privilege and honor to serve on the hospital's board of directors for nearly eight years spending the last 18 months as board chair. As a native of Rutland and a fourth generation business owner. This community in this state are especially important to me and my family. Rutland is where I grew up. It's where I raised my family developed my business and where I focus much of my volunteer service. Rutland is a special place with much to be proud of and like many rural communities. It faces ongoing challenges. Rutland is an aging community. We are impacted by increased substance misuse and addiction. We struggle with increased mental health issues and like communities across the state we struggle with housing and workforce shortages. More and more our community relies on Rutland regional medical center. Our local health care providers and human service agencies for support in a variety of central services. As a longtime resident of this community. I want to ensure that Rutland is a vibrant and strong one with a thriving economy and healthy population who can experience all that the region has to offer. This requires a strong community hospital. As one of the region's largest employers the hospital plays a significant role in the strength of our local economy. It is a relied upon leader and partner in the community collaborating for the greater good. Supporting economic development and revitalization efforts and helping to further the mission of local nonprofit organizations aimed at improving the health and wellness of our Rutland County region. For more than 25 years the hospital has led a community health needs assessment identifying health improvement priorities and supporting projects that address the health needs of residents in the Rutland region. The hospital has worked closely with community partners, coalitions and organizations to address the identified health priority areas outlined in the 2021 health assessment including housing, mental health, childcare and parenting and supporting an aging community. In support of those health needs of our community, Rutland Regionals James T. Bowes Health Trust has been awarding and managing grants in the Rutland region since 1997. Since its inception the Bowes Trust has awarded more than 4 million to programs aimed at improving the health status of residents throughout our region. Because of these efforts and more, Rutland region is a trusted and relied upon partner in our community. 2022 was a difficult year and while we needed to raise rates we have also taken a diligent approach to lowering costs. The hospital has done considerable and effective work over the past number of months to reduce costs, address culture, workforce and safety issues. We are focused on keeping high quality care in our community by investing in physicians, nurses, staff and equipment as support community needs with timely access to care right here in our region. As a board, we realize that our workforce is our most important resource. Our community relies on our dedicated healthcare leaders, providers and staff in so many ways. Attracting and retaining experienced providers and staff to live and work in our region is critical to our ability to provide high quality healthcare to our community. It's also important to understand that Rutland Regionals is just one of the many health core organizations in our community. We value our strong collaboration with our partners and we are committed to our continued work with primary care, mental health, home health and other Vermont hospitals to provide care in the right place by the right provider and at the right time. Thank you for the opportunity to be here this afternoon. At this time I'd like to invite Judy Fox to share some of the details of our 2024 budget. Judy. So like other hospitals in Vermont, all of whom we've heard from Rutland Regional has faced significant challenges in trying to strike the right balance and providing high quality access to care while addressing our cost structure and acknowledging concerns of affordability. As Mark had said, 2022 was a very difficult year. We lost $12 million from operations and when you layer on our investment losses that amasses $41 million of loss. As a result, we were in breach of debt covenants risking a bank call of $43 million of debt. We were able to agree on a covenant suspension that but unfortunately the process was costly and it also required that we increase our liquidity position to be increased until we could demonstrate ongoing compliance. And so that was difficult. The breach also weakened our ability and capacity to consider additional debt while we are also at the same time trying to come out of COVID and support our mission and vision. While our loss was significant in many ways, we need you to know it was also deliberate. We have faced and continue to face staffing shortages both within nursing and direct care providers and also with our own physicians. To date, we have 176 open positions and we're also recruiting for 12 full time positions. Regardless, we made the decision not to limit access to care. Instead, our RMC remained committed to reinforcing our workforce through use of temporary staff and our locum physicians. This was costly. In 2022, it drove additional costs of nearly $24 million. In 2023, we expect about $21 million of additional cost. And in 2024, while we've made some impact, it's still $18 million. Elizabeth Cuyhill will share how our RMC maintains our strategy to deliver value based care in our own community, despite these staffing shortages. Thanks, Judy. Good afternoon. Again, I'm Elizabeth Cuyhill and I'm the vice president of medical group operations at Rutland Regional Medical Center. So at Rutland, we take the strategy to ensure access to value based care seriously as it requires that we care for 60,000 residents in our service area. It's an honor to take care of our community and to provide the right care at the right time. Last year, we cared for just over 6,500 inpatients in our facility, more than 100,000 patients in our clinics, and we provided nearly 300,000 outpatient testing, imaging and ancillary services. We treated 31,000 patients in our emergency department. This strategy involves a carefully crafted multi-pronged approach that enables us to assess the immediate and long-term needs of our patients and to put a system in place that allows us to have our practitioners be the best that they can be. It's not easy because we continue to struggle with increased complex care needs of our patients, changes in payment systems and a workforce that seems to be shrinking and harder to hire. The metric of lag time provides a high-level comparison for patient appointments, and then we have patient satisfaction surveys that ask questions like, did you get the appointment as soon as you thought you needed it? And that gives us some insight into kind of a high-level comparison for patient appointments as well as our patient's perception. However, even combined, they don't give the full picture of is this the right care at the right time? Prior to and in between those visits, there's a significant amount of care that's occurring. The goal is to create touch points for the patient so that when their scheduled visits occur, the patient has gotten the right care at the right time. The practitioner is performing to the top of their license and the costs are controlled. However, even with all those touch points happening and that we're putting in place, we still need to have available provider appointments. That just has to happen. So with our greatest workforce challenge being provider at recruitment and retention, we struggle to provide enough of those appointments. Physician vacancies have a direct correlation with our access. It's true and with our patient satisfaction. Recruitment has been a challenge due to the decline in available physicians wanting to come in coming out of their training, willing to work in rural areas that have that don't have that plethora of sub-specialties as well as minimal call requirements in rural communities that they're on call more. Cardiology, OBGYN, infectious disease, ICU and ENT are areas that we have struggled with recruitment due to those reasons. We have incorporated advanced practice providers. We've increased call stipends contracted with third party telehealth services. We've utilized locum agencies. Those have all been the things we've been doing to make sure our patients still have the right care at the right time. Daily, our physicians, advanced practice providers, nurses and staff work with our patients to help them navigate through the system. We get the care in a timely manner, but it does take a lot of work and touch points. This continues to be a challenge at the system level and we're going to continue to work hard to find solutions and take care of our community. Thank you for your time and I'll turn it back to Judy. So acknowledging the challenging position that our RMC faced, we appreciate the Green Mountain Care Board's support of our 2023 budget request. And we acknowledge that this request is far more significant than any other year. While our 2023 rates bolstered our financial position by providing necessary funding for inflationary costs, we knew as a leadership team that our financial stability would require actions greater than rates. And so this spring, the senior leadership team in alignment with our board initiated a cost reduction program that resulted in savings of $5.6 million and we eliminated 45 positions. Again, our goal was not to impact access to care, but rather to focus on administrative overhead and efficiencies in patient care. Our reduction plan was an appropriate balance between clinical services and administrative overhead. The impact of the reduction drove our cost per adjusted discharge down by more than $275 a discharge. And we'll support improvement in our RMC's cost as we compare ourselves to other benchmarks as those benchmarks are updated. Together, the rate increase and our disciplined approach to cost containment provided a foundation to develop our 24 budget. To stabilize our financial position, our RMC used realistic assumptions that support utilization trends, inflationary factors and cash flow needs. And it is important to note that most, if not all of these assumptions were supported by Green Mountain Care Board guidelines. The inflationary impacts facing healthcare have been profound. Jonathan Reynolds will provide information as to the inflationary impacts in our 24 budget, as well as to discuss the impact of diminished revenue capture opportunities within our 340B program. Great JR. Thanks Judy. I'm Jonathan Reynolds again. Supply chain disruption coupled with high demand for supplies have driven cost up. Increased pharmaceutical costs, especially with many new drugs coming to market, demand inflationary funding that is excessive. The inflationary impact of pharmacy alone in our budget is driving more than $1.3 million. RMC mitigates inflationary costs for both supplies and pharmacy medications by participating with Vizient in the Northeast Purchasing Coalition to secure discounts related to group purchasing programs. Through NPC alone, RMC leverages cost savings and excess of $1.1 million each year. In addition to significant inflationary pressures, RMC has been confronted with sharp declines in our 340B revenue. Our 2024 340B revenue budget has been reduced by $3.5 million, a result of many drug manufacturers imposing contract pharmacy restrictions. 26 drug manufacturers have imposed restrictions thus far. As of June, we estimated our annual loss to be $6 million while our budget only projected a loss of $3.5 million, proving to be an assumption that is already negatively impacting our performance. It's vital for our state legislators, state health departments, and hospital leaders to recognize that declines in 340B program will significantly impact all Vermont hospitals. Based on our 2023 projected operating performance, Vermont hospitals across the state would have an aggregate loss from operations of more than $5.6 million if not for the 340B program. This is in stark contrast to an operating gain with the 340B program intact of $59 million. 340B serves to subsidize underfunding in state and federal health care programs, and without 340B, Vermont hospitals will be at risk for financial sustainability. To continue our cost efficiency efforts and to offset these negative impacts to financial performance, RMC has put in place a controlled hiring process that requires the review of every position, whether budgeted or not, to determine the need for funding. The process is not only a tool to manage costs, but also to stabilize our workforce. Regardless, RMC continues to be challenged with staffing shortages, most notably in our nursing and direct patient care services like diagnostic imaging. I'll now transfer it over to Kelly Watson, our chief nursing officer, who will provide an overview of these workforce challenges. Thank you, Jonathan. And thank you members of the Green Mountain Care Board for your time this afternoon. As Mark Foley mentioned in his opening remarks, our workforce is our most important resource. Judy shared that we have over 170 positions open or org-wide, with over 100 being nursing-related positions. Efforts on recruitment and retention to address critical staffing shortages are top priorities, as is lowering costs associated with managing those critical shortages. As Jonathan mentioned, ongoing assessments of resources, resource needs are reviewed weekly, where we utilize benchmarking and productivity data to validate any staffing request. After we validate the need, we move quickly to fill vacancies to ensure access to care remains intact. Recruitment efforts have included grow our own programs, tuition reimbursement, sign-on bonuses, flexible working schedules, and developing meaningful partnerships with local academic institutions. Several of our employees, myself included, serve as faculty and clinical facilitators with Vermont State University's Vermont Tech and Castleton Nursing Programs. This allows opportunities to engage with students while also providing exposure to our organization. In collaboration with the Vermont AHEC, we engage with high school students interested in healthcare careers, which is another workforce pipeline we believe is worthy of our investment. While workforce recruitment is a top priority, equally as important is retention. Retention efforts include enhancing our recognition programs to ensure employees feel valued and appreciated for their dedication and hard work. Creating a safe work environment is another key element of retaining employees. We have heavily invested in creating a safer work environment by implementing new violence prevention tools, a new training program, increased security surveillance, and enhanced access controlled practices. We recently hired 30 new graduate nurses to join our team, and their success is critical to our success. We are in the process of reassessing our new grad residency program to ensure its value. This includes adding a mentorship component and utilizing new grad feedback to make program adjustments as needed. Another retention tactics, other retention tactics include listening to our employees, working collaboratively with our nursing union, utilizing exit interview data to improve our performance, and developing leadership training programs for our current and future leaders. Investing in our workforce, implementing innovative staffing models to maximize resources, and partnering with academic institutions are key components of both recruitment and retention. Critical staffing shortages have pushed us to be more innovative than ever before to ensure effective utilization of resources while we have continued to provide high quality care to the communities we serve. At this time, I will return the presentation to Judy Fox. So to conclude our introductory comments, I'd like to talk about our rate increase. So, as you know, our RMC is seeking an increase of 5.6%. We understand that the impact of increases in our community and we strive to limit the increase as much as we can. We have been responsible in both our request and have complied with the 8.6% trend factor that was established by the board's guidelines. It is important to note, however, that while our increase is 5.6%, commercial payers are only paying about half of that. The difference relates to contractual agreements or changes and payment rules that impact our reimbursement structure. We'd be happy to discuss this further, but ask that this would be considered privileged information and we would be looking to talk with you about this outside of the public setting. We'd also like to convey our approach in supporting individuals who do not have insurance or who face high deductible plans. Our RMC's financial assistance program allows full funding up to 300% of the federal poverty level and partial funding up to 500% of the federal poverty level. The result is that we budgeted included in our 2024 budget $7.3 million, which is equivalent to 40% of our entire self-pay reserve, which would include bad debt. Our RMC agrees that the current system is not sustainable and that it is our shared responsibility to find collaborative, creative, and innovative ways to change the way health care is delivered and paid for. That said, we caution any decisions that attempt to impact the cost of care without a full understanding of the factors that drive our current challenges, merely taking funding out of the system without changing care delivery, investing in supportive community programs that address mental health and substance misuse, or acknowledging the inequity in the current payment systems will not serve anyone well. Particularly Vermonters, who need a strong health system to be in place to care for them. Thank you. All right, thank you. Those were substantive opening remarks. I think I took good notes. You presupposed some of the questions I was going to be asking today. So, you know, thank you. It's almost like you've been through this before. All right. So we're bringing up the two here and the board, I think it's important to note that this is one of two submissions that did fulfill the benchmark, which again is net patient revenue growth from fiscal year 22 actuals to the 24 budget of 8.6% or less, which was established in the fiscal year 23 guidance. And then that they met that very ambitious target. I think that's just something really important to keep in mind as we walk through this. So, they are the only PPS hospital that was able to fulfill that target. We heard from two others that were quite close. And they also have note the negative find in the operating expense field so that is largely what is helping make this budget comply with those requirements. We spoke at length about how you're approaching labor and how you were thoughtful about the reduction in workforce. I'm curious, it sounds like, you know, best laid plans and all that. How confident are you that operations will be smooth at this level of staffing or do you have any concerns about having to replace some of these positions. Well, from the nursing perspective, we're, we're being very mindful of staffing to our census to make sure that we're not just assuming that we, we need every single resource at every single moment. So this is working really closely with our leaders throughout various levels of nursing to ensure that we are monitoring that. But we do have, as Jonathan and I both mentioned, we are looking at our staffing needs every single week and really trying to be mindful to see, you know, we absolutely have to replace this person to keep this service intact. And so that's, that's an ongoing, I don't even want to say weekly, it's a daily assessment to ensure that we're utilizing our resources. It's the best we can. Yeah, and it sounds like part of your assessment in addressing those resources has to do with productivity. How does that fit into the equation about hiring versus addressing it through productivity measures. So we have a new benchmarking process that we subscribe to, we submit data on a pay period basis, and we then are allowed to get information back that tracks our productivity against like peers and cohorts. We use that information. That's part of our controlled hiring. And that helps to inform those decisions. As Kelly and Jonathan both said, controlled hiring is a process that, you know, we meet every week discussions honestly happen every day. Sounds like a lot of information that you keep up to date, but that makes a lot of sense. Any other questions from the board related to labor expenses specifically. Just one quick follow up. I'm just wondering what percentile you benchmark against when you're thinking about that productivity, the new data that you have. Sure. So our goal is to get to 50, the 50th percentile. There are some departments that are already there. There are some departments that are a ways away. So this goal is really needs to be addressed and managed at the department level with the long term goal of getting everybody close to that 50th percentile. Thank you. Miss Fox, what's the name of that tool? It's called premier. And how long has Rutland been using it? We have been using the productivity component of this system for about, I'm going to say three or four months. We use that in earnest when we began our cost reduction program in the spring of the year. It has two modules, a productivity module and a benchmarking module. Honestly, we're just beginning the benchmarking module. I can't sit here and tell you that we are proficient and mature in that. But certainly that is our goal as we move forward. Thank you. All right. Advocate, any labor related questions? Yeah, thanks, Sam push healthcare advocate. I just want to commend Rutland and you, Judy and your team for the coming in below the guidance and implementing the cost reduction plan. I think that obviously takes courage, commitment and a lot of careful planning. So I was wondering if you could just at a high level speak to how you arrived at that decision rather than asking for an increase in commercial charge and or NPR. And if what kind of obstacles you had to overcome and doing that. Sure. So I will speak on behalf of Rutland Regional Medical Center. Every hospital in the state has a different set of challenges and you'll hear from them. But we were really coming off from COVID. We had provided a number of services during COVID that we had to make decisions on as to whether those were important to move forward. And so was really looking at how we were redefining our hospital and our services post COVID. It starts with at the top. Our board is fully engaged and is working with us on strategic strategic plans. And then it moves throughout our senior leadership team and our leadership on the ground. And so it takes it takes everyone the courage. We came off from a year where we had to ask for excessive rate increases. We knew that that was very difficult for our community. Having said that there is high demand for our services. And so we were trying to strike that balance between access and cost. Thank you. Thank you very much. As far as utilization. Seeing that it was up quite high in fiscal year 22. I know that that's not a terribly representative year for utilization most places. So just curious how you in a nutshell tackled the puzzle of utilization in your budget. Yeah, sure. So speaking of 22, which serves as the base for this trend, our patients came back quick. And we were very busy as soon as restrictions were lifted. I think we were in the OR the next day. So we were ready to move forward and have really worked with our community and building kind of a safe environment for them to come back in. Having said that there's an enormous amount of delayed care. And as our patients were coming back online, that has certainly been very evident, whether it's in our ED or in our inpatient units or in our clinics. If you look at our ED utilization, which is your bottom graph there, 17% of our patients are admitted from our ED that's a little higher than the state average. The state average is around 13%. We are seeing patients who are our sicker come through our emergency emergency room. On average, we see about 85 patients a day, but that varies that can go anywhere from 60 to 130. And so the transition in those in those patients really are challenging for our care teams. And as far as 23 and 24, we're staying the course. What you see for utilization is really what we're treating in patients today for patients with the exception of a couple of areas. We use our wait times and our lag information to make decisions. And in that case, we saw that high end imaging, particularly CT and MR had very long lag times, not good for the patient, not good for our providers caring for that patient. So we've opened up hours, lengthened the hours in the day. The equipment is the equipment, but then also opened up weekend hours. We also have an expansion project underway for infusion where we have seen a great demand in our community for infusion services, which is a good segue to pharmaceutical expenses. I know oncology is a huge structure for a lot of organizations. Just curious how you're kind of grappling with that coupled with the 340 be challenges. Yeah, of course. So we're able to benchmark the medications that we use, especially in our cancer center in our non cancer infusion settings. Visiting our GPO provides a drug pricing forecast that comes out twice a year that we can run our drug mix through. And you'll see that as a result of that, that's where the projected inflation of 4% came to be. I know that the benchmark nationwide was 2.3%, but the 4% is a highly specific number to Rutland Regional and hence the rationale for that being in there. So it is based on true data and true utilization numbers. You know, in terms of the volume, we, as Judy mentioned, we're just seeing increased requirements for medications that need to be infused. And for Vermonters, it's all about access in rural areas. We support these patients that come to us and receive this care as it's a bit different than other metro areas where there are more in home services. So that is really a difference in this setting here. Great. So I think, again, given that these just, I'm sorry, these factors and their sources were very well documented and the submission came in within the benchmark. I don't have a ton of questions and the rest of the content areas. So I wonder if we want to cover anymore from the board or the advocate before we go through the other cost exhibits. I have one question. Sorry, Sarah. And I could hold this for later. I'm not sure when is best to ask it, but also I'll ask it now in the narrative on page seven. Judy, you talked about the Medicaid fixed payment change. And I'm wondering if you have any information about what's driving that. Are you talking about the $600,000 budgeted loss? Sure. Yes. Yes. So that number is quite volatile. And so that is the difference between what we get and fixed payments from one care and what we call shadow payments. What we would have received had we not been in a one care fixed payment program. And at the time we were putting our budget together for the months of March, April and May, we were behind by about $250,000. And so this kind of eeks and flows in terms of patient demand. But as we see the increase in costs, we don't expect that this is going to get much better. And so that is really a result of looking at our fixed payment against both our adjudicated claims and those claims that we consider lag and waiting to be processed. Thank you. One question I'd like to pose. First of all, I just want to say thank you so much for the very well written concise but detailed budget submission. It was incredibly helpful. And one thing I really wanted to highlight in this, which has been I think a really great addition to the discussion on custodial care patients is your analysis on on page 16, which is really very helpful to understand the problems, the challenges and the financial impact that you're experiencing from these various challenges with discharges. And so I thought this was a really helpful and clear description of that problem. So thank you. My question relates to this, which is actually to have you, what are other challenges that you have found with throughput of in patients challenges length of stay other than custodial patients. And what are the other challenges that you've been able to identify and understand the impact of them and any mitigation strategies. Sure. So before I answer that question, I do want to give a shout out to Springfield hospital. So with our custodial patients. Our care team has gotten together with Springfield hospitals care team looking at ways in which we can provide care for these patients. A better location and with a better reimbursement structure. We're very early in on this process of only transferred one patient, but it's really important as we think about how Vermont hospitals work together. And in this particular case, these custodial patients are really important. And that happens to be our Medicare patients actually awaiting a waiting placement. So there's that piece. I would tell you that when we look at our utilization, our utilization is less other than the custodial. It's less about who's getting in and more about how long they're staying. And so if you look at our utilization statistics over the last four years, in total, we had less than the 150 days denied for in patients because of a utilization denial. Where we are seeing what we call avoidable days is where a patient has come to us for acute need, but we can't get them out of the system. And that's not just custodial. It's altogether different. So we could be holding a psychiatric patient in our ED and the state has provided some reimbursement for some of those patients, but not all. We have same day surgeries where we have a surgery that is predicted to be outpatient. But for whatever reason, the needs of that patient, they have to stay. We call it same day surgery extent. They may spend the night with us unplanned. We have observation patients. On average, we have about three observation patients a day. Most of these observation patients are medical patients. Most of them relate to cardiac and rule outs. But those are all areas in which we have what I would consider patients in inpatient beds that may not be fully acute. I don't know if that's helpful or not. I think so. I guess I guess I was trying to get at is, are there patients that you have an inpatient bed? Do you have a process of trying to identify those that could be managed more expeditiously? And if you found from that process, anything that you could find benefit to intervening on? Yeah, great question. So last month, we had two patients undergo surgical procedures. Those patients, one was a general surgery patient. Another was an orthopedic patient. Both of those patients did very, very well. We discharged them the same day. We then received a denial from the insurance company. In this case, it was Medicare because those procedures are only paid on an inpatient basis. So although we did everything right, we didn't receive any reimbursement. So my point in sharing this with you is it's complicated. And we really have to really lean on our utilization department. We have to lean on our physician leaders to help us make some of those really skilled decisions. The other pieces with Medicare Advantage, we have patients who we hold in our facility longer than we need to because they're in a Medicare Advantage plan. And we have to wait for a prior authorization to get them to their next stage of care. That can hold up care two to three days depending on the situation. Thank you. That's an area we've been hearing about frequently this last two weeks. Judy mentioned a quick follow up question to this whole conversation around, you know, uncompensated care. We heard from another hospital that there's a new long term care facility opening up. There's going to be increased capacity. My understanding is 60 new beds. Will this help in your mind in the Rutland area and how might it impact your assumptions about length of stay and utilization. So I hope so. I hope it helps. The largest impediment of custodial patients and moving patients on our lack of bed for either a payment source or for a perceived behavioral issue. And so depending on what this long term care facility criteria is, we would really be looking to partner with them. Having said that, not sure when this facility is supposed to come online. I'm not sure that it will be too impactful in the near future. More of a long term planning tool. Okay, thank you. Any other board questions or advocate questions? Hi, so this is Charles Becker. I'm a staff attorney with the health care advocates office. I suppose I should have waited for the board to make sure that there were no more board questions before I jumped in. Were there no more? Okay. All right. So it was unclear to me to where my question might fit in. So I it relates to 340 B. So I thought I'd jump in now. So thank you. You noted earlier that there are 340 B revenue declines stemming from manufacturer restrictions on contract pharmacies and I read that in your narrative and that got me to thinking that, well, you also have an in house pharmacy. And and that led me to be to wonder even more. So what is RMC doing to help uninsured and underinsured patients with high pharmacy costs because you serve a community with a lot of lower income folks. And I imagine a lot of people get great care from one of your specialist physicians, but then they get prescribed the medication they can't afford and so they don't adhere to the treatment. You know, looking over your website, it doesn't look like our RMC offers any financial assistance to its in house pharmacy. And so my question is, has our RMC ever considered passing through some of its 340 B savings to uninsured or underinsured patients by implementing a prescription drug financial assistance program through its in house pharmacy. I will say indirectly, not directly. If you look at our financial assistance program, we provide full financial assistance up to 300% of our federal poverty level. We also provide a tiered financial assistance up to 500% of the federal poverty level, which I I believe is the highest in the state. And so we use our financial assistance program to work with those patients that are most vulnerable. If a patient is receiving pharmaceuticals as an outpatient, those those pharmaceuticals would be part of our financial assistance program and they would be eligible for reimbursement or assistance. Thank you for that. And maybe following these hearings, if you would be open to it. I mean, I was reviewing your websites just just today and it is not at all clear. In fact, it says that pharmacy costs are excluded from your financial assistance policy. So, so maybe we could work together to make that a little bit more clear to folks. Absolutely. Thank you. I'm going to jump off, Charlie, just a kind of more broad question. From reading your community health needs assessment and just being a little bit familiar with the work of the bow's health trust, it's pretty clear that Robland is committed to health equity. And I was wondering how your team evaluates making progress towards specific, you know, goals that you set or specific race equity metrics over time. So the first step is measuring and putting together a measurement system that allows us to understand where baseline is and where we're headed. We have a team in place that is working through that process. That team is in working in partnership with our diversity equity inclusion committee to support the work of the committee. The bow's health trust took a fairly inflexible stance, if you will, to begin our process that we would not entertain the funding of any community project if they could not validate and confirm for us their stance in DEI and how their funding, our funding would impact those vulnerable communities. Thank you. Sarah, I think the whole HCA team is keying in here. So I've got one more. Actually, I'm the last member of the HCA team to ask a question. Good afternoon, Mike Fisher, health care advocate. I wanted to spend a moment talking with you all about bad debt and free care and I'll start with a recognition of, you know, your hospital over time over the last number of years has, I think, been in the lead or close to it. And with regard to that relationship between bad debt and free care. And yes, Judy, I think you're right. You also lead in the generosity of the 500%. For partial payment. So I wanted to recognize that, you know, 2022 was a bit worse. But over time years, you know, you've been doing a great job. I wanted to spend a moment asking to understand a little bit of these numbers. I have to admit, board and public, I have a little concern that my focus on the relationship between what's counted as free care and what's counted as bad debt might have some some challenges with the math in how people in different hospitals calculate the value of free care and bad debt. So I wanted to ask when a claim becomes recognized as free care. I think that the math is, you know, amount generally billed or or an average commercial rate. Do I have that right. So if you are looking at our 990, that would be a correct statement. If you're looking at internal financial statements, it's a bit different. It's the full charge. It's the full charge for financial statements. Okay, that's interesting. A similar question. How is is bad debt valued? How's the claim become recognized in in bad debt? So there, there is a waiting process. There's 100 a day window where we will try to engage with our patients to not not ask for full payment, but to at least get to an agreement of a payment plan. After the 120 days we're unable to to make that reach to to the patient, then we will begin to move through a bad debt process, which then does provide additional notification. Right. I'm sorry. My question maybe wasn't clear. I'm saying, after you've moved through that whole process and the claim, you know, you delivered some care and the person isn't paying for whatever reason. And it's being counted as bad debt. How does it gets valued? You know, is it an amount generally billed or is it the charges or is it the amount that you're expecting? It's it's it's charges. It's charges. Okay. Are there any scenarios where an individual claim can get counted in multiple categories only give it, for instance, you know that you have a commercial payer who pays part of charges. And so there's an amount between what was contracted with the payer and charges. Would it be reasonable to count part of that claim as bad debt? So that's where I think you're referring to likely or possibly high deductible plans where there is an adjudication process of payment processing with the insurer. The residual value would then be transferred to self pay. At self pay balance, we would look to collect from the individual patient. At that point, the value is, is the deductible or the copay? Yeah, that makes perfect sense in that scenario. I'm sort of, I think I was asking in a different scenario where sort of the difference between the commercial, the agreed, the negotiated payment and charges could be counted. I've heard stories of hospitals counting that difference as bad debt. And I was asking whether you could envision that or whether that's a practice that Rutland would use. And so that's getting into pricing transparency. And our commitment to follow those rules and regulations with pricing transparency, where we do use the metric generally payments generally accepted. Do you know if I also have been hearing that there's some changes in the, you know, counting standards update that is going to require hospitals or maybe it already does require hospitals to count bad debt as more akin to what you would expect to collect. Yeah, so that's the revenue recognition standard that generally accepted accounting principles has adopted. That that took months to implement here. Probably not great for a dialogue here, but it would certainly entertain a conversation with you if that would be helpful. I think that's the right answer. That's the that's the right next step. I am interested in sort of what's next or how has things changed recently and what's next in terms of how these things are calculated and I would be thank you for this dialogue here. I wanted to have some of it here and I would welcome an opportunity to do follow up later. Thank you. And I'll tell you on that, you know, I think making sure we're as congruent as possible and clear about definitions in our own financial data collection that that's what the board's all about we want to get that cleaned up and predictable so well taken. So, I know we have a hard stop at three and I just want to make sure that the board feels like we're using our time to the best of what we want to do so I don't know if you want me to go through these cost exhibits or if you wanted to have any other conversation before we do that. Are you asking the board Sarah. Yep. Yep. Is there anything else you wanted to tackle before we go through these tools. I just want to make sure we have time. Okay. I'm okay with proceeding. Okay. Great. So, again, curious person data is an information can sometimes be harder to get to as we discussed earlier so from the relative standing of Rutland on the cost reports we see that you are pretty large for a midsize rural hospital. Between the 75th and over the 75th percentile, but, you know, not quite an outlier. And one thing that I think is always important to note is that, you know, this not the hugest hospital in the world, but in terms of the relationship between the hospital and the ED, your, your ED is pretty big compared to your hospital compared to what we might typically see. So I think that's something to also keep in mind. So, you and CVMC have very similar acuity ratings. It's hard to get you at 1.46 are just kind of wondering if you also are feeling that the coding intensity might be not as accurate as you like from your experience. No, I think I would say our coding teams do a really good job. We actually have audits and their work is reviewed on an annual basis. Okay, cool. All right, that's helpful. And again, you and CVMC are very close at around 20% of that ratio. Again, that would be line five salaries compared to the full gamut of clinical salaries. I have a feeling that your corporate structure might be distorting this indicator. I wonder if you have anything to say about that. This is 2022 data. It's already old. And the, the cost reduction that we put in play for this spring certainly will be impactful there. I would also just based on your previous comment, Sarah, that this is one look at administrative costs. If you look at our, our financial statements, you're going to get it all together. And so really understanding the source of data is really important. We did put that in our narrative to try to highlight that as a concern as we move forward. Having said that our corporate structure that we have all services within the hospital. I think we have one FTE that we float out to our parent company. But other than that, all services and all FTEs are reported within the hospital structure. Yeah. Okay. Thank you. Very helpful. So fiscal year 22 is not very representative in terms of current position and any means. So I don't know if you want to say anything about the cash available for operations indicator. Yes. So talking about our corporate structure, I will tell you that early in the year from a cash perspective, it was, it was really difficult. We actually transferred cash from our parent into the hospital so that we didn't have to immediately realize any losses within our investments. And so that's a little different for us. And that that was probably important to share with you. Yeah. Thank you. And then really tough to see that operating result 22 is just really, really hard here and I think some hospitals hit harder than others. But that stands out. And then here. So again, this is per Medicare discharge adjusted by the Medicare CMI. So seeing you're at the kind of top end of that whisker. So about one and a half times above the Sunday. Anyway, what do you want to say? So that was a driving force behind our cost reduction plan this spring. We have numerous benchmarks that we look at and knew that we had an opportunity that we needed to begin to to move forward with. I just appreciate your, your directness and candor. I appreciate that. As far as cost coverage goes, I'm going to go to the right section this time and I'll see Rutland here. So, in terms of a cost standpoint, you know, pretty close to peer hospitals, a little bit higher. And seeing that cost coverage is very similar to Brattle boroughs among the commercial population, but a higher average payment those assumes that you're probably doing more intensive services. And then I see that the inpatient kind of commercial, you know, Medicare allowable cost coverage has been pretty flat and just barely covering costs. Whereas we again see kind of the deterioration for Medicare and kind of a slow downwards slope on both sectors for Medicaid. So just curious, especially with the Medicare Advantage penetration, how you're kind of tackling some of these case mix challenges. There are so Medicare Advantage just to speak a moment on that we've had about a 25% increase in that utilization Medicare Advantage is about 16% of our total revenue. However, our denials for the organization Medicare Advantage drives 40% of our denials. And so that's just an important piece to note. In this commentary, in terms of costs, again, I will see these change just a bit as we think about the cost reduction. And there's a there's an awful lot to say within cost coverage and with commercials and I have highlighted that in some of our testimony. But probably I consider that to be some privileged information that I like the opportunity to talk with the board if if you so desire to drill down on that any further. Understood. I was just validating you can see both the cost and reimbursement for commercial in 2017 and how far that's really come down. Not just for yourself, but I just think that's always important to keep in mind. And last but certainly not least is a random data, you show up in the exact same spot in both distributions so just probably whatever is halfway between 50% and 75% half of that is where you are on both distributions so kind of in the 50% of the data so not really stand out in that way. So I think that was all I had to cover on that those exhibits I don't know if there are any questions, comments from board members of the advocate sounds like there might be some other conversation that we might have in an executive session but leave that up to you all. This is Tom Walsh. I just wanted to take a moment to acknowledge the hard work that you did based upon the cost data and you've mentioned several times that in the face of data that showed higher administration expenses per discharge. You've taken aggressive action and managed to stay within guidance. I think that's to be commended. So I just wanted to be sure to say that. Thank you very much. Thank you. Anything else? I share Tom's feelings. Well done. Strong submission and thank you for making the hard decisions you needed to make for your community. Any other board or advocate questions for Rutland at this time? Are we going to go into executive session or are you trying to get all of the public in questions out first? I don't know if the board has interest in pursuing any of those questions. I think that's up to you all and I also think it would be fine to do a public comment before we entertain that. So if any members of the public have a comment, why don't you use the raise your hand function? Sometimes midwestern questions aren't translated so it looks like no public comment. So does the board have interest in any further inquiry in an executive session? We're going to let them off the hook, huh? Yeah, I think that's a testament to a straightforward complete submission within guidance. So we genuinely appreciate the hard work you're doing and thank you for your time. Hope you enjoy a little free time back everyone. Thank you. Thank you. We appreciate your time today. Oh, I'm sorry. Any closing comment before we send you on your way? I mean, I'll be the chance. Yeah, I guess I would just offer that it's really important we want you to know our operating margin has been really thoughtful. It is we're not trying to get 3% or it really was derived out of needs for this organization both within just liquidity and debt repayment as well as capital needs. We have some pent up demands for capital. If you look at our four year plan that is associated again data matters. It's really important and we have an aging plant. And so we're really positioning ourselves to address some of those needs for our community. Some of those needs are linked to safety issues. Some of them are linked to increasing access based on some of those wait times. So I just really want you to understand that we were really thoughtful in that approach and that honestly is what drove a lot of the work in the budget. Thank you. Yeah. Thank you. Right. We're good. All right. Well, thank you. Thank you. Thank you. Have a good day. Bye. It was well. So, sir, I think. Are you all set? We're all set. Yeah, we'll be back. But Wednesday is a state holiday, so we won't see y'all till Friday.