 It is 1103 that the meeting will be reconvened. And Joe, if you could just quickly introduce anyone who will be speaking and then we'll ask the court reporter to swear everyone in. Good morning. You're muted, Joe. I can't hear anything. We good now? Yes. Okay. Jeff Haber, it's going to be speaking. The controller, sorry, Chief Financial Officer and Dr. Dupuis, the Chief Medical Officer and myself. So three of us. Okay, great, Kim. Could you please raise your right hands? You swear the testimony you're about to give shall be the truth, the whole truth and nothing but the truth, so I'll help you, God. Yes, yes, we do. Thank you. And Joe, whenever you're ready to proceed, go ahead. Okay. I think Jeff's going to try to put up the slides. I'm going to cross our fingers. We have success. Nice. Thank you very much. Okay. Thanks very much, everybody. Just going through these, here's sort of our agenda, the items that we're going to talk about. It's a long list of things. We generally follow the instructions, going to spend some time with COVID in the beginning and then talk about operating margin rate requests in comparison to ourselves, comparison over time, comparison to other hospitals, which I think gives good perspective and with some discussion on risks, opportunities and capital. As I said, it's myself here, Jeff Hebert, on my right, Chief Financial Officer, Dr. Dupuis. Jeff's new, I'm new to the organization coming up on two years, haven't completed that yet. Most of it's been with COVID, Jeff is less so. Thankfully, he's had experience in the past working for Fletcher Allen, Central Montt Medical Center, Gifford and Littleton, New Hampshire. So he had some taste of New Hampshire dynamics. And Dr. Dupuis, who we're very happy, I think he's been here about five or six years, I think closer to six. Background is working at the clinic, Dartmouth-Hitchcock down in King and also a UVM grad. So he covers a lot of great territory. So I appreciate their involvement. Kathy DeMars, she's our board chair. She's not gonna be able to make that. She's a nurse and she's also the Executive Director of the Home Health and Hospice Agency here at Lemoile. So she's just got a lot going on. We appreciate our board members, their involvement, but sometimes they get busy too. And that's a whole discussion about how to get board members who are young enough to be working. So I appreciate Kathy's, but she's not gonna make it. I wanna talk about our mission, which is to help people live healthier lives by providing exceptional care and superior service. I'm not a big fan of mission statements or vision statements. Sometimes they can be really lofty, but the two things in our mission I like is exceptional care, which speaks to the clinical measurement of quality of care. And the superior service speaks to the experience and our empathy and nurturing of patients. So I really like that mission because it talks about the clinical as well as the patient experience and all of our experiences. The items below, I'm actually sitting in a room, a pretty large conference room, but these are all to the right-hand side of our wall. Community is really important. Always has been for our patients, family members, board members, donors, all of them honors. So we couldn't exist without the community support and help and feedback for us. Service excellence do enjoy those words because it speaks to the pride that we try to achieve and the work that we do. Nothing more meaningful than being proud of the work that you do. And I think that shows in a lot of our satisfaction surveys. And I think people do enjoy working here. Respect and compassion. Of course, very important that we respect the staff, the patients, again, folks opinion. There are thoughts about care delivery and working here. So I think we're pretty good about that. And the lifelong learning piece, that's probably not just clinical learning, which is important. We have new standards. We've learned a lot this past year because of COVID. We learned a lot about vaccines, about management of the epidemiology. But we also learned a lot about ourselves. So that life learning is learning about ourselves and how we act as a team and how we manage, lead or become a really good follower. Followership is just as important as leadership. And then the lifelong nonprofit status, we are very thankful, humble and really appreciate that we are granted a nonprofit services to the community. So those are just some pictures of our staff having a lot of fun and love those pictures. And the next one, just to highlight, we're an independent nonprofit critical access hospital, one of eight in the state, service area population. This is a subject matter we should continue to talk about because it's listed around 30,000, but service areas, the old fashioned was hospital service area. Now we talk about covered lives. Now we talk about the ACO model. When you look at Copley, maybe our orthopedic service area because we draw so many people from other areas is probably closer to 100,000. When you look at our OBGYN service area, it's probably closer to 20,000. When you look at our ear, nose and throat, ENT service area, it's zero because we don't provide those services. So service area population and how you manage the inflow and outflow of folks that come to you, much like the discussion with Mount Scutney about people coming over the board. And we still have that porousness in Vermont amongst counties. So it's hard to come up with just one number. I wish we would come up with like health service line area because that would be actually more, I think helpful in the process. We're a 25 bed CAH with 1,900 admissions, 11,000 emergency apartment visits. How many employees? I always love that question. And I just broke it down for fun. Employees, you can either count FTEs which is full-time equivalents or paychecks, which includes everybody that get paid for a particular period or a month. How many active staff do you have? Not counting travelers. So we generally land on about 470. We have 165 members of the medical staff representing 28 specialties. A lot of those are telehealth. So it's interesting in healthcare when you talk about efficiency and how to save money and make things easier, it would be great if we didn't have to credential every tele-radiologist and many other tele-services because we're relying on very competent either tertiary care centers or for-profit organizations that have done that work. But that's why our number is so high. We have about 50 active staff, although it's listed at sort of 165. We have 69 million in net revenue, which is about 2.8% of the states oversight of the 14 hospitals. This next chart just puts us in perspective with all that. This is where from our perspective size does matter. We are 2.8% out of the $2.5 billion budget. Understandably, UVM is 50%. When you look at their network, it's 61%, probably growing a bit, which is fine. We offer our humble opinion. We work as hard as we can, but we know we're not sort of setting the agenda in the state where one of about 1,350 critical access hospitals in the country. So that's important. If you look at the next slide, one has to just go over the payment methodology that we have in the state. We have one tertiary care center and we have eight critical access hospitals in the bottom. And the rest used to be described as tweeners. And I don't know what that was because they're between. It's kind of a funny name for years. They would call them tweeners, but those are PPS hospitals. So for us, the CH designation is really important when it comes to payment methodologies. It does drive us to understand better ACO models and total cost of care. So it's important. When you look at comparisons for us, it's hard to say, well, listen, your comparison for Copley Hospital should be in line with what Central Mott's doing or UVM Medical Center, probably not. So I think many in the state and others are sort of looking at critical access hospitals as their own sort of comparison group. Dr. Dupuis is gonna go over some of the COVID-19 accomplishments, I'm just gonna start with that first bullet. So when this hit, we didn't understand how this was gonna unfold, but fairly quickly, we said, why don't we use this as the incident command exercise? So why don't we look at the hospital incident command system? I'm looking at a chart in the wall that we have regularly up in terms of all the positions and people setting up an operations section chief, a logistics section chief, a planning section chief. And so we just sort of did that right off. And we realized we gotta get organized and then we gotta help others get organized in our sort of neck of the woods. So the first thing we did was CRT, Coronavirus Response Team, CRT-CH. And that was all the internal providers, doctor, staff. And we didn't keep the group really large, but we met basically daily, set out bulletins, interpreted policy and changes. We then set up a larger one for the Morrisville area, CRT-MV, which included us, the FQHC, Lemoyle County Mental Health Services, Lemoyle Home Health and Hospice, Tamrac Family Medicine, a large PCP practice, and then the manner which is a nursing home and assisted living. So we still meet. When you talk about this whole epidemic, I think we really got some teamwork here, both in the hospital and also with these six members of the CRT-MV and we have shared a lot and have done a lot. And then we immediately also started up CRT-LV, which is Lemoyle Valley, not just technically the Lemoyle County because they should know rivers and folks and shopping sometimes gets not as clear. But that group was 39 organizations and they sort of spun off, but it was very helpful to be organized as the hospital and the community. And so Don's gonna go over some other, many other things that we did that might give interest. Yeah, thanks, Joe. So the main challenge when the pandemic hit about a year and a half ago was how to continue our mission as a hospital caring for our community while still making our patients, staff and community safe. And as you can all remember at the beginning, it was quite confusing. So organization, education and communication was extremely important right off. And that was a early and continued part of our effort was just to keep everyone up to date with what we saw the state being up to, what we were up to and translating the literature on COVID and making it as operational as possible sort of up and down our organizational structures and our community partners. We directly helped our community partners with policy procedures and protocol as we had a little bit more in terms of people who could devote some time to really learning about this and being current than say the manner. We shared the expertise, time and energy of our infection prevention nurse. We directly shared PPE and shared PPE resourcing. And of course, COVID testing and later, vaccinating an early effort when it became clear that basically fear of healthcare was becoming as big a problem or worse than the pandemic itself was to get together with our CRT Morrisville community partners and started don't put your healthcare on the whole policy. And it's been fun to go around to the various businesses around the county still and seeing the stickers and sort of remembering that time as we sort of approach a little bit more normal. The next thing was resource management. I'm gonna sound a little bit like a management consultant but sort of our guiding principles around resource management that should be prudent, science driven and innovative. And when we started thinking about it, the first part was to behaviors or I guess you can think of it as the software of hospital operations. Universal masking and distancing are two of the most important and early on were some of the only things that we could actually do. So we certainly started universal masking very early. The distancing is tough when it's your job to actually care for people. So a thoughtful and adaptive visitor policy basically kept people who didn't need to be here out of the hospital, reducing the number of people in the hospital and allowing for as much distancing as possible. We started testing patients, staff and the community early as knowledge of who was infected and who wasn't was vital. We started screening our staff, patients and visitors. We developed a homegrown no touch employee temperature and screening station. The later involved into just an attestation of good health status as you enter the building. We started the vaccination sticker implementation that most of us proudly wear. We changed the way we're cleaning the hospital. We switched the product that we used to something called eradicate. It's an acetic acid based cleaner, whereas most hospital cleaners are ammonia based or bleach based. The eradicate is actually better at killing coronaviruses and MRSA. And it's much easier on the people doing it and as much fewer concerning health side effects. We rapidly recovered and rebooted our elective surgeries after they were suspended and then restarted. We were one of the first hospitals in Vermont to have our nursing students, volunteers and even Mitzi, the therapy dog which was just walked down the hall, back in the hospital. As a personal note, although it was very confusing early on closing the medical schools and the nursing schools during the pandemic always seemed like an odd thing to me as a little bit like closing a munition plant during a war. Because we definitely needed all those people to fight this thing. And now that it's becoming endemic I think the truth of that is clearer. Then we did changes to the hospital physically or to the hardware itself. We engineered new COVID isolation rooms. We transformed our five ICU capable beds into what is now a COVID isolation unit. We did this really rather minimally but quite effectively we changed the conduit in the bathroom fans. All these rooms have bathrooms. We just changed the conduit size and the strength of the blower. Turns out the filters had plenty of capacity. And just by those changes we could change all of these rooms could either be isolation rooms individually or as a unit that became fantastically helpful. We transformed an ED room into a new COVID isolation room. So altogether our 25 bed hospital had nine COVID isolation rooms. So we felt really quite prepared. Somewhat serendipitously we found out that we could also engineer two of our ORs to be negative pressures. It turns out admittedly somewhat by luck that both the fans and the impellers were bi-directional. All you had to do was change the polarity and running backwards work just as well as running forwards. We transformed many of our high tech services into no tech services. So basically all the doors and the stairwells and the halls that generally remain closed usually for fire concerns are now held magnetically open. So if there is a problem they'll shut but throughout the day not hundreds and hundreds and hundreds of people have to touch all the door knobs like we used to. So that felt really helpful. We marshaled our resources effectively in PPE. We acquired PPE creatively and industriously and we certainly had a lot of help from the community very early on concept two somehow got 500,000 masks out of the people they work with in China which helped us tremendously and allowed us to help our other community partners as well. We initiated what I think was very helpful and seemed like a very clever burn rate approach. We have an example of that to show here in a second that allowed us to track our PPE, to know where to put our efforts and to coming up with more PPE. And of course we actually shared the PPE and all our resourcing knowledge with our community partners through the strategic national supply. We acquired three Hamilton T1 ventilators. These are just marvels of modern medical technology. They're small, they're portable. They also work on neonates. So it's the first time we had a ventilator that we could use on a neonate. We're thrilled to have them and they're all up and working. We manage expenses by asking senior leadership and physicians to take a pay reduction which we happily did with no expectation or remuneration or payback. And when I say we are mostly talking about the gentleman on the other side of the table that secured PPE and PRF funding. The telehealth things that we usually have pulmonology and nephrology were expanded really to all practitioners during COVID. But that was really just an expansion of things that we kind of already did. We basically just changed what we did in the clinic to what we could do over the phone or if someone did have a Zoom, we could do it that way. We're fairly heavy surgically here. So that had some limitation to it because in surgery you do have to see things and touch things pretty frequently. But we also added entirely new telehealth technologies to us. One thing was forced therapeutics which allowed us basically to replace all our in-person presurgical joint classes and prehab which is getting people to understand what they needed to do to rehab post-operatively well. We got this all online through forced therapeutics and it can also serve as a communication device between the nurses and the doctors and the PAs and the patients. Additionally, it was very anxiety producing, I think for the families when their loved ones were in surgery to really not know what was going on when they couldn't be here in the waiting room. There's something comforting about it actually just being in the waiting room I think during a surgery. We introduced a new program called Ease that allowed the operating room nurse to talk to the families via their cell phones and keep them updated as to what was going on all the time. So when they just couldn't be in the hospital they still felt like they knew what was going on. That's been a very popular thing to do and we're quite happy about that. For PCR testing, if you weren't actually basically where the rubber meet the road on this about last April or March you might not have recognized this but at the start of the pandemic the ability to do real-time COVID testing was really limited throughout the state. There were really just a few hospitals who could do that but rapidly knowing the COVID status of someone coming in who might have COVID was key to how you treat them. And if you didn't know you had to treat them like they had COVID which has a whole bunch of unpleasant knock on effects. First of all, the patient doesn't know which is terrible. The patient's family doesn't know which is terrible. You have to treat the patient like they have COVID so you're burning through your very most hard to get PPE like crazy and it's very hard on the staff because they all think they're taking care of COVID patients but they don't really know. And so what it led to was just two standards of care in Vermont, one for hospitals that could do this and one for hospitals that couldn't. And although at Cotley, we actually did have the ability to do this real-time COVID testing. We thought that it was really not the right thing for Vermonters to be living in a situation where there are two standards of care. So we worked with our own Ethics Committee collaborated with Vaas, VMS, the COVID response team Morrisville and the Vermont Ethics Network and we strongly advocated to ensure that all the hospitals in Vermont be given the capacity to do on-site real-time COVID testing and change the way the test kits were distributed. So not only had the analyzer could actually run the test and fortunately this actually came to pass and that was the normal state of affairs in Vermont. We're quite pleased about that. We developed one of the first few covered all-weather Vermont winter compliance drive-through COVID PCR testing sites in the state. Although we had the step in one hour COVID analyzers which are the real-time ones. We thought that really to serve our community we needed an analyzer with a much higher throughput and fortunately we heard about the Rionics analyzer made over in Ithaca, New York, the state of New York gave them a grant because they saw that small and mid-sized hospitals were going to have a need for this early in the pandemic and a bunch of folks from Cornell and places like that got together and came up with this and we were the first people in the state to get one of these. So this combined with our Cepheid analyzer made Copley the first Vermont critical access hospital really to be self-sufficient in terms of COVID PCR testing. So primarily using the Rionics and the Cepheid along with some use of UVM, VDH and Broad mostly early on in the pandemic we performed over 20,000 COVID PCR tests to date. Another interesting thing, at least we think it's interesting, that we did early on was sort of born out of us not only really feeling responsible for the situation in our house and in our locale but recognizing that part of our community was also Vermont and the rest of the country. And so novel approaches to dealing with this we thought were worth the effort if we could be engaged in such a thing. And as it turned out, one of the many companies trying to develop a useful antibody testing for COVID ray biotech out of Georgia obtained an FDA emergency use observation for their test kit and we acquired some of these and we were the first people that we certainly heard of to actually test this in a real life clinical conditions. And unfortunately we found out that it wasn't quite ready for prime time but I think it's pretty indicative of the approach we took to the whole thing. And finally in vaccinations we took the lead role in creating and managing vaccine clinics responsible for most of the COVID vaccinations in this area. All together we gave over 14,000 vaccines during phase one actually here at the hospital for healthcare workers and first responders. We gave almost 3000 doses and then we moved over to the local BFW where we gave over 11,000 doses. This was particularly satisfying for two reasons. One is that the whole medical community in LaMoyle coalesced around this process and they volunteered their time. We always had a physician NPRPA at these clinics and they were from all the different groups in LaMoyle and we had a real chance to meet and work with the veterans at the BFW. They really continued their lifelong dedication to service by really adopting and making this clinic possible and successful. And LaMoyle last time I looked was the number one county in the state with a vaccination rate of 86 and a half which even beat Chinden at 85 and eight tenths. Great. Thanks Don. Lot to talk about but it's what has consumed us for the past 18 months and still there's a lot of residual co-tail about this that we still talk about of course. Couple of things. Interestingly we did this first off what is critical PPE? What is our performance in black? What is required attention and yellow? And then if we go below the critically low red line and these are set for different time periods but this sort of helped us quite a bit. We've evolved that to only needing four indicators. So this is what we currently do. This is our latest printout of this. We look at this all the time. It's just a great monitoring technique over time to make sure that we're not getting too excited about natural variation or when do we start to get excited about the community to improve things. Going into finances. I wanted to mention these things before I turn it over to Jeff. Really if you say what's most important to us it's really this particular chart which looks at our operating margin as opposed to our total margin. We've had a pretty challenging number of years. We've got projected 21 but we've got five years of losses there. And those have been pretty staggering. I got here towards the end of FY19. I thought FY20 we're actually gonna work double time which we did and really apply ourselves to do everything possible to manage expenses and look at improving systems. But because of COVID and because of all those disruptions we sort of ended another year negative. So I just wanted to share that because it does become a real driver. And Jeff wants to talk about some of the numbers that got us there. So I'm gonna turn it over to him go to the income statement balance sheet and cash flow. So again up on the screen right now is the three statements the income statement balance sheet and cash flow. A lot of numbers. I'm gonna jump into the next slide which is our volumes. And when we take a look at this go over some of the major volume assumptions that we had going into this year. The first thing I'd like to communicate is when we look at our budget process we give our managers the experts in regards to where we've been with volume where we currently are with volume and where we're gonna be over four years of data. We really felt that it was needed to give them as much data as possible because of unfortunately the last 18 months of COVID has really been kind of an interesting issue with budgeting. So when we take a look at these numbers up on the screen we have how we compare to annualized 21 our budget 22 and how we compare to budget 2021. Overall when we came to you last year with our 2021 budget our managers went into that process not knowing what the new year was gonna look like so they were very conservative with their volume assumptions. Since then we've had an opportunity we'll dig into this a little bit deeper into the presentation but we added a neurologist to our staff as well as a podiatrist to our staff which have increased our volumes as well. And if you take a look where you look at the budget 2021 to the budget 22 you see that there is a shifting between the inpatient and outpatient. And what is causing that is something that happened with Medicare. Medicare has a list of what they call inpatient only procedures meaning that if we were to do them in the outpatient setting Medicare wouldn't actually reimburse them. They in 2021 actually changed and started to move a lot of the inpatient procedures and considered them to be able to be done in an outpatient setting. This is something that Copley embraced quite quickly and one of those procedures was actually the inpatient ortho cases. And so because of that you're seeing that budget to budget we have a decrease of 8.6 and an increase of the outpatient and that's what's causing that. Overall, I know a lot of the questions is always the projections that you came in with in regards to 2021 are those still valid and on track and I'm happy to communicate that they are. And on the other thing that I have been hearing that I've been watching some of the presentations is what about the numbers if you went back to pre-COVID volumes? And we did run that study, I ran that study. And overall when I got to the 2022 budget I saw that those numbers only produced and a 0.8 of a percent of a variance. So that made me even feel more confident with what we're submitting to you guys today. The other volume assumption is in the Morrisville area we do continue to see that our populations are getting older and we do still are seeing that we are moving away from a commercial type pair of addicts more into a Medicare pair of addicts. Next slide is our reimbursement methodologies. First and foremost is our Medicare. And again, when we take a look at the rate increase it's important to know that we are a critical access hospital. We are a cost-based hospital. And for Medicare if our rate increase is commensurate with our cost increase then for Medicare we will actually capitalize on that rate increase in its entirety. The Medicaid in regards to our 2022 budget we did not actually assume that we were going to get anything through the rate increase from them. And then moving into the commercial payers we did realize in the 2022 budget the complete increase in rates. So overall our rate increase we requested a 5% rate increase that equates to 3.8 million. And 1% of that is equates for us to be 734,000. Even though that we are going with the 5% we still are forecasting a very modest margin of 1.2. Feel that a critical access hospital should be closer to a 2 to a 2.5% margin. But when we take a look Joe showed you that slide prior which had our history we are in a rebuild year. We need to address the poor years of performance and we need to be able to invest in the capital for this organization. We need to invest in the staff of this organization and we need to just cover all the inflationary concerns that we're currently undergoing. Great, thanks. Just wanted to go over this chart. This is rate request, past performance and comparisons. So coblies in blue, you've got columns there of average submitted and then what was approved five year, 10 year, 15 year comparison those three columns. Green means it was the lowest increase out of everybody in the state. Red means it was the highest increase. So that first five years of late we've actually had 2.5% less than we requested. So we requested 5.14 and the average that we got is 2.64. If you look at the past 10 years our request dropped by only 1.4%. We requested 377 granted 242 in the past 15 years, much closer. We were only sort of clipped for lack of a better word by 0.9%. So it's interesting. I think Cotley in the past five years has really suffered a lot of changes in terms of trying to figure out what to ask for how does that work and what does that look like over time? And how does that compare to others which seems fair and reasonable? We're looking at a 5% system average and the bottom right there is 4.91. System weighted average is 6%. I think 5% is probably reasonable in retrospect. And I'll go back to some previous conversation with Mount Scudney. I'm hopeful that you might even tell us that we should be requesting more than 5% because when you listen to the rest of the story maybe we're still not getting it right. If you go to this next one this is the past comparison and outcome. So again, we've been the lowest for a number of years with a second lowest in the past five years. I think relatively the lowest in the past five years. But if you look at the all-payer cost of care chart to the right for this timeframe and then some we have always been the lowest in the state only tying with Burlington in 2013. But we have been by far the lowest and we are waiting for the updated data. This is claims data and it's always very frustrating because it takes so long. I'm just hopeful that we'll get 2018, if not 20 data so that people can sort of look at this and the total cost of care definitions are we have those, we have any questions about that. When you look at our rate requests how well we're doing on outcome and overall cost I wanna bring up another subject which is just actual prices and what we charge. I think prices, I think prices still matter. People have health savings accounts. People really do look at prices. I think we've had a lot of disclosure of prices on the internet and so this will continue. So we were asked to do this for some local folks here in our service area to do a price comparison for laboratory services. So they gave us these 10, particularly CPT codes that were most commonly used by these primary care folks. There's the coply price. There's the quest price. Quest is a for-profit out-of-state lab organization that is housed in New Jersey. So I'll just say this. Unfortunately, all the profits and capital and investment goes there. And then to the right, there is the Vermont average with all the hospitals in state and then the four to the right of that are ones more proximate to us than we thought people had a choice to drive to. So when you look at these charts and prices we are the lowest on all tests by far. And if you look at a few of them like Lipton panel which is the second one down, our price is $60. Quest is charging 148, the average is 107. And we are significantly lower and sedimentation rate down below third from the bottom we're $11 and the highest at least in the study that we saw for the few is up $50. So our prices on lab testing is quite low. If you go to this next chart this is just price comparison inpatient rooms. This stuff used to be easier collected through Act 53. And since we've been through some of these changes it does take more effort, but price does matter. So inpatient room and bed count we're at 1,300 emergency room levels of care. The next section is the five levels of care. Again, we're less than the Vermont average and sometimes significantly less and then there's some on diagnostic imaging. And I think on three of those that have been starred with the lowest in the state but we're actually second lowest on a lot of those too. So I think our prices are extremely reasonable and fair and we probably need to work on those as it relates to our operating margin and trying to get healthy. If you look at fourth from the bottom for diagnostic imaging it's kind of interesting CT of the abdomen and pelvic with contrast we're charging 1423, the average is 3,600. The highest is 6,000 on the very far right, 5,921. That's $4,500 more. Some people do ask about this stuff and some people are shopping and I think that's healthy. It's part of the pressure on all of us to say keep your costs down and there's a variety of ways of measuring costs. One of them is actually how much did it cost me? What is the price? And in the very bottom one MRI joint of lower extremity without dye, we're at 1665. We are the second lowest, the lowest one to the very far right, second to the right is 1525. So you could save $140 if you went to that hospital but there's one sort of towards the middle at 4,321. So again, we're $2,600 less. That's actually a really big deal. So we've had some price issues that Jeff and I and others continue to look at. If you go back to operating margin not really proud of this chart we end up becoming possibly the biggest loser. If you remember that old TV sitcom show I guess it was reality TV, not sure but we've lost money for those five years in a row. We haven't finished FY 21. So that's not on here. We expect to have a positive operating margin with some of the relief coming from COVID funds. And there's a note in the box in the middle about the sustainability efforts and the board ordering six of the 14 hospitals to look at sustainability planning and dress concerns about consistent operating losses. This all came out of the Springfield eventual bankruptcy. I think everybody sort of knows that and politically that became a very sensitive and difficult issue. So we were one of the six. I think we've done, you know we're working really hard. So if you look at the chart on the right five year average Springfield certainly takes the cake with the amount of losses but sadly copy is right behind. So we're in a turnaround. It's a financial turnaround. It's going to take a lot of time and effort. We have a lot of passion behind it and teamwork but I do wonder if you're an outside person just looking at the tea leaves you would think Copley probably needs some more help and assistance. Otherwise I don't want us to be labeled as a Springfield. If you go to the next chart this is looking at our losses and also looking at the approved rate increase in blue and what we requested. So for 2016 we requested negative three. We got negative four. The next two years we just asked for a zero rate request increase but we got hit pretty hard with negative 3.7, 3.4%. And so we did get decreases up until 2020. So I think there is a correlation between those in terms of your ability to generate an operating margin and just your basic rates regardless of whether you're a CAH or a PPS because there's other mechanisms that come into play. If you look at our 2020 margin request we're at 1.2% Grace Cottage is less. We probably many of us know Grace Cottage enjoys some significant support through donors in the community which we are very happy for them. Ours looks modest. We do all hope Springfield can pull out 3.4% because everybody's been caring for them on the side. And this is all based upon rate increase of only 5%. You look at the next chart this is long-term debt to capitalization. You know, one of the most important things that I can think about we should all look at as a hospital. I mean, there are so many indicators but what are the most important? I think your operating margin is really important. I think cash is important. Jeff's gonna talk about that. You know, your rate, your long-term debt to capitalization. So in this particular chart on the far right summary of the table where down there with Springfield at 16% you might think that's a good thing. I actually spent a year and a half down at Martha's Vineyard as the CEO down there that they had so many donors that their debt to capitalization was 0.6. It didn't even cross the 1% but they raised $50 million in the blink of an eye to build a new hospital. So it's nice to have that lower. The problem with some of us, Springfield might be in that case, Copley is definitely in that case we have underfunded a lot of capital around here. And although the average age of plant doesn't look that bad I would love for us to talk more about that because Jeff discovered a significant write-off that occurred a year or so ago that really drove our average age of plant probably inappropriate in the wrong direction but we've been working on broken sidewalks. We've got sewer drains in parking lots that have collapsed, you know, fearful that a truck or a person would fall down in them. We've got IT infrastructure issues pretty much 100% of our laptops and PCs that needed to be replaced because they're running such old software. And we've been in fear of that and we're putting as much money as we can because of the experience at UVM with that cyber terrorism. We've got parking lots that are so rippled some people's cars scrape the bottom of them when they park. So we're trying to work on a lot of those. And we have rooms here that are so antiquated. There's a few that have bifolding doors that you can't actually use the toilet and close the door. It's not even possible. You have to actually leave the door open when you stand or sit using the toilet. Hard to believe, not proud of that fact but I'll tell you it's pretty shocking. So with that, I'm gonna give this to Jeff to talk about day's cash on hand. So the next two slides, Joe was talking about our capital our need to invest in this organization both in the facility itself, as well as the equipment. We just had our interim audit and we were talking to our auditors and saying that we were looking at working with different organizations to see what the possibility of securing debt was. And I love that the auditors kind of came back and said if there was a time for new financing, now is that time for us as Copley. So the next indicator that we're currently on is day's cash on hand. Again, these two indicators, day's cash on hand and debt service coverage ratio are very popular indicators related to debt covenants. And in regards to day's cash on hand, the higher you are, the better you are. The higher you are, the more an organization is willing to take that risk on giving you financing for your upcoming projects. Overall, what we did with this graph is we've been talking a lot about COVID and a lot of our numbers right now are getting a little bit skewed. One of the areas that is getting skewed is the Medicare advanced payments. This was substantial money that when COVID started, Medicare basically gave all hospitals. Right now, that money does live on our balance sheet and that money is going to be, as Medicare makes their payments, we're actually utilizing that money to, they don't pay us and they're using the, they're telling us to take it from the Medicare advanced payments. So for this graph, I actually removed that. I do wanna communicate that the COVID monies in 2020 are still in there. That's our PPP and our PRF monies. But when you take a look at that, we're at 84. Again, the second lowest only to Springfield. When we asked BKD what that number means, they actually basically communicated and said, look, if you are running between 60 and 70 days, that represents a hospital in distress. So we're not that far off. We need to get that indicator better. The next day's cash on hand chart is just a chart. We're putting back in the advanced payments. It does get us up to 98, but by the end of next year, that money will be consumed and won't be actually on our balance sheet. The next indicator is the debt service coverage ratio. This ratio on specifically measures an organization's ability to produce enough cash to cover its debt. Again, this indicator basically looks at the higher numbers, the better number. And so over the last five years, Copley has had cash issues due to its poor performance. So we went out and we worked with Echo Financials to say, what is our ability to secure additional debt? And unfortunately, when they came back with the study, they pointed to this indicator and they said, look, right now, looking at your past year's performance, it was this indicator that would just be too risky for anybody to grant us or to give us that money to actually start investing into our capital needs. The next chart, again, is now just looking at the last four years. And when you take a look at that, that gets us down to even lower about 1.7. Grace and Springfield are the only two lower ones in regards to this indicator. So right now, overall, the next slide that we're looking at is our provider transfers. I did communicate earlier that we did have on two, we did, in 2021, work with the Green Mountain Care Board on getting the appropriate paperwork supplied. We were able to actually hold onto a neurologist who worked across the street at the local FQHC, who's going to leave the area, but has since changed direction and we were able to hire. So overall, we will be picking up in the 2022 budget additional clinic and lab revenue from that provider. Another provider actually came from Central Vermont, wanted to work with us as well. And this provider will represent additional overall revenue in clinic as well as all other hospital services. Jumping on to operating expenses. Due to our prior year performances, one of the easiest areas that everybody seems to go after is they look at cutting salaries and wages. And that was the case for Copley over these last five years. This is unfortunately resulted in a high burnout rate for us and it only was exacerbated due to the COVID situation. And so what has been happening is we're actually finding that, as you've been hearing from other organizations, that we needed to, as these employees moved on from Copley, we have been using a great deal of travelers as well as contracted services to offer the care here at Copley. Overall, we feel that we really need to pay special attention. I guess you could call it an opportunity to rebuild our FTE, to be able to put a redundancy into our department so that if we lose a key personnel, that we have another FTE to take that place, that personnel instead of relying on contracted services. Yeah, just as a specific example, when I got here six years ago, I was the only surgeon at Copley. Every two weeks, we brought a locombs in if we could find one to take some call for a while, but mine was the only clinic. I had a clinic every day and I had a nurse and an MA over the years of cost cutting that has led us to the situation now that we have two surgeons in general surgery here at Copley. I'm busier now than I was then. Dr. Olmsted is at least as busy as I am and we have one nurse that we share between us. The department we worked in, the multi-specialty clinic also used to have a office manager that was lost in the cost cutting as well. So we've seen our availability decrease, not really so much in that we couldn't see the people, but we just don't have enough hands to help us to operate the clinics efficiently and at appropriate volumes. So this is not really a theoretical thing at all. We see it in practice every day here and it's just the people analog to the problems we're having with the physical plan. We're all out of the next slide. It goes over other key areas, our benefits. Came in line with where we expected them working with our brokers at 4%. We did see utilities go up overall 13.2%. Our big driver on this one is when we went and asked for pricing on our oil and gas, that had an overall increase of 25.5%. One of the indicators that typically we talk about during these presentations is pharmaceuticals and how that raises urine and urine out. And for this year, it was actually in line. So that was a story. Our provider tax, again, is generated by Net Patient Revenue. It looks at the annualized six months 2021. So that one, we have no control over. And then all of our other expenses overall did come in line either plus or minus 3%. Non-operating for us, this is basically what we submitted last year. And that is our annual fund going up 240,000 and our income on gains and investments going up 57,000. Thanks, Jeff. Back to me, just talking before I get into risks and opportunities is the slide that keeps me up at night. Keeps us up at night. And that is, you know, where we're going to really aggressively turn things around. Without the projected 21, the curve is pretty steep with that regression line. We're hopeful to make a difference and settle things out. So that's just been our mandate. In terms of risks and opportunities, I think financial stability is right there. COVID is right there because of what it has done to us over the past 18 months, certainly the Delta variant or any additional waves. We sort of see waves that occur, the lingering operational expenses, you know, it does change some of the future volumes, it changes staffing. I mean, we've really worked double time to ask people to be extraordinarily flexible with their schedules and to address things with our patients as much as possible, here regardless of the cost and who pays for it. I think we've done well with that. We've also been looking at and have that curious thought about what about the demand destruction that is occurring because we've changed. We've significantly changed and some stuff's not gonna come back. In telehealth, we've had telehealth in place, that has changed dramatically and we don't know five years from now and five years is not very far period of time. You know, there might be a lot more interesting telehealth services offered by tertiary care centers, UBM, maybe Dartmouth nationally. I think this whole pandemic has changed a lot of how we deliver things and the legacy services, I think, might be changing quite a bit. Staffing is a huge risk, we're very small. So if we lose one or more key providers, even one, it makes a difference. If we pick up a couple of providers, I know Jeff talked about, you know, we gained a couple of providers. We took those because those folks would have actually left the area. They would have actually left Vermont and we said, well, I think that's probably something that we should look at addressing, but we're very fragile in that regard. So it's true for not just the providers, nurses, support staff, technologists, billers and even leadership. So leadership changes and I prostitute one of those, of course, but we've had a lot of changes in the past year or so, probably around 70% of our senior management teams has changed for a variety of reasons and we're very open and willing and try to encourage people to find their niche and to find their place and to make sure that this job feels rewarding and agreeable. We've had a couple of people and I think the pandemic's been a big part of it all across this country. They have decided to change careers. They have decided to, you know, elevate their relationship with their kids that might live in Ohio or somewhere else and they're just gonna say, it's time to move. I just wanna be with my kids or my grandparents or my parents. And so we've seen that. We've had senior manager actually change their job and become one of the chaplains. We had a vacancy in a chaplain position and we had a senior manager say, that's something I'd like to do. So we're just seeing a lot of that. So that's a lot of change. We had about 16 managers and mid-level managers sort of middle management also changed. So leadership's been a big deal. When it comes to staffing, we need to both rely on good people and not just good systems. We also do need travelers currently. We need lab techs. I mean, the lab tech traveling business went from zero to a hundred. You could get a lab tech as a traveler, easy. Diamond doesn't up until when COVID hit. When COVID hit, everybody was consuming lab, personnel and resources. So it was interesting, whether it's the department of health, other hospitals, everybody testing, for-profit, pharmaceutical companies. It just sort of went crazy. I couldn't believe it. We all couldn't believe how much it costs to get lab travelers. Although we've been filling the pipeline with all of these with both nursing students, LNAs, radiology techs, lab techs. So we're working on that. For us, we are gonna be looking at some more housing options because we've lost travelers who come here. They're really happy. And within a short period of time, they said, I can't even find housing. And they leave because of the pressure from sort of the stow area. This is everywhere. So I'm not saying it's hard here, but it's hard everywhere. We're looking at benefits like daycare. We'd love to have some on-site daycare to help folks, younger staff. So the six organizations that I mentioned earlier, CRTMV, we're all looking at participating and a daycare program, we're six of us support. And we've got benefit issues that we're working on and spending money on. And the sustainability issue, I think we've talked about that. We must improve operations, standardize more things, increase the accuracy in our data collection, indicators and the management feedback. And the, John, did you wanna make a comment? Yeah, it's really hard to overestimate how difficult it is when good people leave small organizations like Copley. That the curse of the competent operates in places like Copley to a tremendous degree. The more competent you are, the more hats you have. And when those people leave, it leaves a huge hole in your organization that's very hard, very, very hard to fix. So working people to the nub before COVID and basically everyone got worked to the nub during COVID is just, it's a tremendous risk and the threat to our ability to be sustainable. Thanks, John, curse of the competent. I haven't heard that before, but that's a really good point. So lastly, in terms of opportunities, probably the biggest opportunity Copley has is in building relationships and trying to help develop social capital. All of us, members of the medical staff, leadership people, supervisors, managers, just folks working in teams, that relationship building I think has taken a hit over a number of years. So we're trying to invest in those opportunities. We do like the efficiency of teams in Zoom and it's been very helpful for where we were through a pandemic, but we're very happy to be meeting again and to getting to know people because when you have that, you can operate and have much greater commitment in a variety of ways. So with that, hopefully we will also get donors, board members, volunteers and even staff. So we're working on all that. And hopefully our total margin starts to get better. I always say to folks here, we can only control our operating margin. That's what we do each and every day. Total margin is driven off of donations of the stock market or some other benevolence, but we're hopeful to work on that at some point too. To build on our outstanding reputation for clinical patient care, services, experiences. We are looking to build a little bit of the OB-GYN program. We have one provider, much like Don was describing himself, who works tirelessly and we have to bring in a lot of support for him to keep our birthing center and everything to work smoothly. So we're looking at maybe an OB-GYN. We're doing some joint recruiting with other organizations which is helpful and we do a lot of shared staffing. Master facility plan is a big issue. If we're going to spend any dollars on facility or equipment related things, we really need to make sure that we've got a long-term plan. So there hasn't been a very good one up until this point since the surgical build a few years ago, which came out excellent. That was actually a very well sound project, but we're working on the next one to five to 10 years. And then I think a lot of opportunities are with that group that I mentioned, the six members of the CRTMD. And so there's a lot to be said there. I want to pass this over to Jeff. He's going to finish up quite quickly with budget numbers and some of the value-based programs. Thanks. So overall for our value-based care participation, right now we did work with the GreenMap, I mean with OneCare. We as an organization will be joining the commercial product that OneCare offers. Obviously we will continue to be invested in the Medicaid product, but at this time we are not looking at dipping our toe into the Medicare program. Next slide is capital. On this slide, what I'd like to point out is our FY 18 to FY 20 capital. Overall, that was low and why that was low is that was another indicator or that was another trigger point that if we were having a poor performance year, we would look at our capital and we would pair it back. And so for 18, 19 and 20, we had low capital overall. When you take a look at what was projected for 2021 as well as what was budgeted as well as budget 2022, this is us taking that opportunity, reinvesting back into this organization, reinvesting in the equipment that this organization needs to actually offer the excellent care that we've been able to offer. Moving to the overall detailed capital, these are our capital expenditures that are over 100,000. The biggest one is going to be an MRI project that will be ending the first quarter of 2022. That's actually a $2.7 million project. The overall renovations are coming in at 1.2 and then the equipment itself is about 1.5. We have a great deal on this list of infrastructure projects, air handling units, negative pressure rooms, fire department connections, as well as major movable that we need to invest in. We have a $500,000 x-ray project for an x-ray room that's very inefficient, an ultrasound machine of 150,000 and upgrading our car to get monitors which is about 142,000. Sure. Great. Thanks everybody for listening. Appreciate your time. I know these are long discussions with a lot of data and hearing, so Jeff's going to try to bring this back, ask him. And guys, did we stop sharing or? All we see is the C. If you could get back to where we could see you, it would be good. There we go. There you go, perfect. So we're going to start the board questions with board member Pelham. Tom. Thank you and thank you folks from Copley. You know, I'm impressed with the fact that you have painted a, you know, a tough love picture, you know, and you could, but you, I think sometimes you have to do that and understand it in order to pull yourself from where you are to where you want to be. And so I appreciate the frankness in your presentation and recognition and also the hope that if two or three years from now you're in a different place you will feel rewarded for that. And that's always a good feeling. So my first question just is about bad debt and free care. I'm looking at your 2019 through 2022 budget and bad debt has grown at a 34.9% annual rate from 1.81 million to 4.44 million. And free care has grown at the rate of 23% a year from 841,000 to 1.56 million. And I'm, the year over year rates are respectively 54% for bad debt and 15% for free care. And I'm just wondering, and I know this is always a sensitive topic, but do you think there is potential there to better align these trends with the need for you to create more operating margin at the bottom line? Yeah, well, I mean, our bad debt, some of the reasons for the growth is we have seen that our revenue also has been increasing. I look at bad debt as a relationship of the expense to the overall gross charge. And when I take a look at 2021, 2000 and the budget as well as the 22 budget, I see that our free care overall to gross charges is very consistent year to year. I do see that our bad debt has crept up a little. And I feel that it is a relationship to the pandemic and the inability for people to be able to pay their bills. But overall, I mean, when it comes to bad debt, that is a federal program. And we do follow the federal Medicare guidelines on that program. Well, thank you. Just always looking into every nook and cranny to see what the small successes we might find. One very small one, I would think maybe the success is just looking at the provider tax is that hospitals in this last year have come in 5.8%, 6% right on 6% as a percentage of their 2021 projection for NPR and FPP. And it's small money, but everything counts that if you're in at 6.24% of your 2021 NPR FPP, and if you drop that down to 6%, which is the rate, the established rate, there's $194,000 that would float down to your bottom line, which is small potatoes, but relative to the size of your margin, it's something, just an observation. So I'm looking here at the COVID-19 liabilities and on your balance sheet, you're carrying for 2021, I think 16.9 million and in Appendix 7, you project them as of September 30th, 2021 at 19.8 million in liabilities, including CARES Act funding at 5.8 million, Medicare advanced repayments at 8.9 million and PPP funds at 5 million. And as of September 30th, 2022, the CARES Act and PPP liabilities have been recognized as revenues. So two questions. One, relative to those that have you moved out of the liability column to the revenue column, is that a firm awareness on your part or is there some risk to that? Yeah, I wish I could communicate that there's a firm understanding of that. The thing that we have definitely discovered with both our PPP loan as well as our PRF funds is nothing is known, everything constantly changes. And that's been the case overall with the federal regulations on how to best handle this. I can't communicate that our PPP loan, we did submit that information to be converted from a loan into a grant that is still pending. We're still waiting for the SBA to get back to us with what that is going to look like. In regards to our PRF, as you've been hearing, the period ended as of July 1st. We have been working closely with our auditors, making sure that we're filling out the application for forgiveness appropriately. And we're hoping to have that application submitted for review by HRSA in the middle of September. So there's some risk there. You just did still a bit unknown. Bit unknown. And we're hearing that from other hospitals as well. In terms of the repayment schedule for the Medicare advanced repayment, what is the rollout of that? How much are you, how much are they kind of hitting you for in terms of the repayment of that on a monthly basis? And when do you think it will be fully repaid? I won't, in my brain, I don't wanna do the calculation, but overall, when Medicare released those, they said that when the repayment starts, which was late spring, they predicted it would take about a year to have that repaid. And that's where we kind of came in. And that's why you see on that Appendix 7 that liability being totally consumed in 2022. Okay, and those loss of revenues are reflected in your payer mix, Medicare payer mix. There's lots of revenues. Well, the recapture, Medicare's recapture out of your... Okay. That's all reflected in your payer mix schedule. Absolutely. So basically, instead of when the remittance advice came in for Medicare, it used to be with cash. And now the remittance advices are coming in and they're just saying, okay, now, revert to your advanced payments for that cash payment. So yes, it is reflected. So I'm curious, I get the difficulties and it's happening everywhere with staffing. So on one of the budget documents, you were showing an increase in FTEs, 2022 budget over 2021 projected, I think was 35 or so FTEs. And I'm just wondering how you internally consider, given your financial situation, what positions that are new to the organization, these 35 FTEs, and what positions are ones that become vacant and whether or not to fill them? So is there a net there? I don't know whether there is, but is there a net there? Well, I'm just gonna jump in here, Tom, that we have actually had some pretty high expenses and lack of efficiency and even degradation of buildings and equipment because we don't have enough staff. And I think Don alluded to that because of burnout and other situations. So we have actually found that we need clinical staff and we need support staff because we are just missing opportunity and we are causing problems. I'll tell you one of the things that we now look at in detail is every contract that is signed, not just a labor contract, but any contract of any service, piece of equipment goes through, it ends up going through the CFO in my office and we have just found a lot of gaping problems and opportunity, which is great, but it's just because we haven't had controls in place. I think we're kind of on the edge of not having sufficient personnel to have controls and it's actually costing us a lot of money. Both with the providers, their efficiency, our charge capture management. And so I know that's part of it. And I could give you a lot of examples where it's been surprising how much they have cut back over the years, and it's been an expensive place to work because of that. Just a couple of more. I think in your payer mix for Medicaid 22 budget over 21 budget, you're profiling a 21.7% increase in NPR FPP. And I'm just wondering, in the world of the cost shift, that seems like a big number to me. Yeah, Tom, if I could, that one I'd love to be able to. I don't have that in front of me right now. If I could get an IT through an email, that would be great. That's fine. Just a couple of more here. If Copley does decide, as I read from your narrative that you're considering engaging in one CARES Blue Cross Blue Shield Vermont program, if you do decide to do that, what's the scale of that? What kind of revenues would be moved into the FPP column? We did decide to do that. And I'm sure Jeff can find those. So I think the one care offer was, if you don't participate in that, then you actually are removed from the Medicaid program. So that's sort of changed the dynamics of our thought process. I'm sure you're familiar with that. So there was sort of us either join that or jump out of all of it. So that was an interesting choice. Didn't have to remind them, and I'll remind folks everywhere that the critical access hospital designation is such that we're gonna find it really difficult and would have to do a lot of review and soul searching to figure out if we would wanna join the Medicare side and drop out of the current reimbursement methodology. So we did join the commercial, but Jeff, I don't know if you've got the numbers right. Yeah, the numbers in regards to the commercial. And again, we'll work with our orders. We're all new to this modeling. But what was communicated through one care is that the commercial product is still going to be paid through the typical remittance advice. It's not going to look like a Medicaid fixed payment. So right now on the attribution, which was supplied for our Medicaid. Just wanna go to that slide. Yeah, is our Medicaid attribution right now is running about 5,100. And the attribution for the commercial product will jump to 3,400. So we'll be increasing by 3,400. And one final quick question. During our review of the certificate of need for silver pines, we were worried a bit that they would be a competitor with you for staff. And so I'm just curious now that they're up and running. Have you seen any impact of silver pines and to you and ProvoCon? We learned about them last year at this very same time when we did a hearing, did not know who they were. That's called Sana. So Dr. Dupri knows who that is. So they've come to us and asked for some help and assistance in managing some of their quality program, maybe perhaps looking at issues of infection control and some staffing. So we've been working with them. They've been actually reimbursing us some of the expenses, not making any money off of that. But we've had some great discussions with them. Don and I took a tour. So they're asking for help. So we're helping them. I think there is probably some staffing impact in this community, in this county, because they are hiring people. I think they're doing a slow startup. But I think a lot of us, it's a for-profit, separate organization. But the issue that they deal with is near and dear to all of our hearts. So whatever we can do to help people sort of transition away from behavior to more success is important. So we talk a lot about that, Don, probably. Yeah, Tom, to the best of my knowledge, we haven't had anyone leave here to go there, but we certainly compete with the same pool of nurses. Although people might have a somewhat different approach to their profession working there than they would hear, we don't really have an overlap of medical concerns. Actually, my father-in-law just became their internal medicine chief. There, he came out of retirement to do that. So yeah, we wouldn't get him. So I think it doesn't help us, but it's certainly a plus for the community. It's hard to feel bad about him, I think. And mostly, we just feel we're glad they're doing what they're doing. Yeah. So your father-in-law went to work for Silver Pines. That's such a small world. Indeed. Thank you very much. I'm through, Kevin. Thank you. I just want to add one comment, Tom, going back to the PPPPRF money. The government last administration and even this administration has given away trillions of dollars, a word that I never knew existed. We all have learned the T word, trillions, but they never put the accounting construct around that. And it's been frustrating for all of us. And I wonder if there are any lessons learned that get, lessons learned that move their way up to our politicians and leadership to say, if we ever did this again, let's kind of put some parameters around this so that people all know what you should recognize and book and manage because it's been very unclear, which is a bit disheartening when you're talking trillions of dollars of what are gonna be the rules, what is ours, what's gonna be a loan, what's gonna be a grant, what is some of each? So it's been kind of a national problem with trillions of dollars. Thanks for asking that. Well, I'm sure at the time in the beginning part of the crisis it was get the money out the door and we'll clean up the mess later. And so, so now it's time to clean up the mess. And I think that's where your congressional folks come into play because they wanted to get the money out the door first, which was probably the right decision. But it's also people shouldn't be punished because they were sloppy getting the money out the door. Yeah, that's true. Yeah, good point. Okay, thank you, Tom. Next we're gonna go to member Yusuf Mourine. Thank you. Thank you for your presentation. Actually, I'll start where you just left off on kind of the accounting for all of the COVID money and the PPP. Jeff, I'm still having a hard time figuring out what's in your, you know, at the bottom line because it still seems that there is. I'm sorry, Mourine. What's in your what for the bottom line? What's in the bottom line numbers because it still seems you're hanging some up on the balance sheet and not passing it through for 22. So if we talk about the CARES Act funding and the PPP and where that would sit on the income statement, knowing that you lost money in 2020 and many of the hospitals booked it in 2020. And then in 21, you're making a little bit of money and same in 22. But I just wanna make sure we understand how much Mourine is gonna hit the income statement. Yeah, so. Yeah, potentially could hit the income statement. So one thing that I wanna communicate is in the state of Vermont, Copley was, I thought one of three hospitals. I don't know if Springfield actually did get the PPP monies but I know that Grace and Copley actually got the PPP monies. At first due to the uncertainty of how to book those monies, our auditors were like, okay, you're gonna book like all the other Vermont hospitals, a percentage of that, probably the majority of that in the 2020 financial close. But then at the last minute told us that we had to bring it back to the balance sheet which we did. In regards to when we'll realize the bottom line effect, it's all gonna be contingent on us understanding what the final say is from the SBA and the final say from the HRSA. And so it's either going to be that we're able to book a good majority of it in 2021, which we hope to be able to do. Or we'll have to have that role into 2022. We're just working on our auditors to best understand how that needs to happen. But that's about 5.5 over $5 million, right? That's not reflected in these operating margins that could potentially flow through. It's not. Okay, that's what I thought. And then on the CARES Act funding, similarly, the amount of money on the CARES Act funding that you could get relief for, is that, where is that showing in the income statement? It's the same situation. At this point, our auditors have put us on hold until we have clarification. So it is not being represented. Right, and that's hugely significant when we look at all the data you guys were talking about where you stand for operating margin, what your historical trend has been. If we put in $10 million more, that obviously changes that picture dramatically. Of course, it's from that type of funding, but that was what some of that funding was supposed to do, was to try to get us back on track for volume that we lost and things like that. So I just wanna make sure when we, because some of the other hospitals have already rolled that in, particularly the CARES, PPP most didn't get, but the CARES funding, they've moved off their balance sheet for the most part. They have very little left. I'll just sort of jump in by saying, I've said this for years, if we've got a system called the Vermont hospitals, it would be really nice if we had a single auditor. Then we're all following the same rules and advice, and then you're not having the problem which we're having right now with the pandemic. We've had it in the past, we'll continue to have it. And that is you folks are trying to discern how people are interpreting big financial movements when in fact there's no consistency in the advice given to the hospital. So I'm a big proponent of a single auditor, not necessarily single payer, but single auditor. Just, yeah. No, no, and I know. But I'm trying to get every from myself to be able to look at this on the same playing field because other people have rolled it through on the cabinet. You made a lot of basis of your presentation on history and where you stand on the operating margins. And when this is all said and done in a year from now, we may reflect back and say, oh, well actually your operating margins, for whatever reason, COVID money actually will be in a very different position than what we're looking at here. I'm hopeful, I'm hopeful that's the case. I'm hopeful that all the efforts around every grant opportunity, all the federal issues that Jeff and his team went through. I mean, we spent a lot of time and effort to make sure that we could capture that opportunity. And hopefully if that draws down money for us or the state, people are pleased with that. I know that that was one of our goals. And I guess the other side would be then looking at the cash flow statement and what your assumptions are for the money that's being paid back in or not captured. If we're optimistic and you get to keep the PPP money, you get to keep the CARES Act money, how, if at all, will it change the cash flow position that you're showing in 22? It would, you know, I wouldn't be able to adapt to get back to you, you know, plug that through the modeling and stuff, you know, but when you take a look at day's cash on hand, that is actually with the PRF monies as well as the PPP monies. And so you do get an understanding of what it means to that indicator. Well, it is in 20, in 21, but we're, you know, that goes away. So it seems like your, is that only the Medicare advance money or are you assuming you're going to have to pay some of that back? In 20, we had both the PPP on the balance sheet as well as the PRF. So that is actually showing it fully in there. Yes, no, I agree with that. I agree with it. So to talk numbers, right, in 20, you had $34 million of cash on your balance sheet. Yeah. And in 21, right now, projection, you're saying 22.9. And then in 22, you're saying 8.5, but the COVID liabilities are wiped clean. And I'm just wondering, are you assuming in the 8.5 million cash balance in 22 that you've had to pay back any of the PPP or the CRF money? That would be the assumption at this point, yes. Is that we would have had to, because we didn't know, we don't have a clarification on that yet. Yeah, so if we just hung it up on the balance sheet, for now you'd have an additional, at least $10 million more in cash, assuming for 22. Yes. Okay, okay, no, that's what I thought. So. Yep. I think we ran some numbers with that Maureen to see the impact. And we go from being paltry to better, but still not in a great position. We just, you know, we've got sort of today's cash on hand problem that is pretty deep. So if that all works in our favor, I don't think we're gonna be certainly flushing any stretch of the imagination. Do you know what I mean? Yeah, pretty significantly. I mean, you know, some that there, when you look at a five year trend, is not really as relevant to look at for cash flow. At the end of the day, how much cash are you gonna have in 22? Yeah. I'm not gonna average that on a five year basis because that's a different animal. I think you'll be pretty good relative to the numbers you were talking about. I can run the numbers too. It's, you know, it's gonna double, it's gonna double your days cash on hand, potentially, or more than double where you thought you were gonna be, if you get to keep that $10 million. So it actually, you know, on the days cash on hand, you know, indicator, we go from days cash on hand, around 84, and it brings it up to days cash on hand with 98, and that is with the PPP and PRF included. So it's 14 days. Okay, so I'll have to look at that calculation because you're going up quite a bit, but I know it puts in your other asset, four designated assets too, which you don't have many. So in 21, in 20, you were at about 130, right? We can look at that. Okay. And then just, you know, on a comment on your, some of your trends and your rating increase trend, where you, you know, we're showing charts of how low you are, you know, that's also a matter of timeframe, right? If you look at a five years, you're low. If you look at a four year, including 20, your 22 requests, you're the highest of all the hospitals with that four year trend, including Northwestern getting 13%, including others. So when you look at the four year trend, you would be the highest hospital in rate request. And of course, there was a reason why the, some of the things were adjusted, you know, years back, you know, because of some of the issues with, you know, CON and things like that. There was a reason why there was adjustments, but, you know, I just wanna focus on, we can kind of slice and dice. And if you slice and dice on the five years, you're low, you slice and dice on four year, you're the highest. Just talking about the reinstallation of the IT, the CPSI in 2021. Can you talk about any implications on, you know, revenue? You know, we've had some issues with some of the hospitals. When you're putting in new EMR, re-implementing, do you expect any issues there with anything? So overall, you know, like other organizations, the nice thing about doing a refresh is we're just basically going through setting up a new company, but for our employees, for our billers, for our registration staff, they're still using the same system. It will just be a more efficient system. However, you know, we are expecting that when this goes live, we will see our days in AR actually increase because of it. There will be inefficiencies because we'll have to make sure that those new tables are all working. So we are trying to go in with eyes wide open, understanding, you know, the financial implications as to whether we feel like we will see additional revenues. You know, we don't feel that that's the case. It's more of a balance sheet exercise looking at our days in AR. Okay. And then just looking at your revenue growth, and you know, I know there's been some bumps, maybe I could say in prior years, but 21, 20 to 21, so the 69 to 79 million NPR, and then 79 million to 87 million. I think those are the two largest increases we're seeing, you know, an NPR change year over year. And just wanted to talk a little bit about, you know, particularly the NPR change, you know, in 2022 against the guidance of three and a half percent. So, you know, overall, when we went into last year with our budget presentation, we communicated to our managers that, you know, the future is definitely unknown with how we need to budget for COVID and what it means to the organization. So there was roughly, you know, a calculation of a little bit over 5% reduction in volumes due to the unknown COVID experience. In addition, in 2021, we did have the ability to acquire or hire the neurologist and podiatrist which is also influencing the 2022 budgets with additional net revenues that were not in 2021 or not in the 2021 budget. And then the rest, the remaining increase is the actual rate increase. Okay, thanks. And then just on some of the price comparisons where I think that's good to be able to show, you know, where you stand and you guys are lower in a lot of the things that you're looking at. What are the areas though where you get most of your revenue and where do you stand there? So like orthopedics, the cancer treatment, things like that aren't really included here. So I just wonder what percentage of the things you're showing the pricing on, what percentage of your NPR do they represent? I don't think we know that. That's a good question, Maureen. We just did the lab one because it was a crested of us this past year. We figured we'd share that with you. And we just did, you know, what's the old fashioned inpatient room rates, the emergency room diagnostic imaging. But I think more discussion about how do we look at rates? I think it's warranted. I'd be happy to do that. I think that's, you know, it does get convoluted when you sort of ultimately figure out what you get paid, but with patients and people who are shopping around with an HSA that they're trying to use to potentially supplement their retirement income, Christ matters and they want to know that. And so in Vermont, in the small state of Vermont, we've got some significant variation. And we're on the low end of that, which is a little bit problematic. I'd love to advocate just, you know, Vermont average prices for everybody, so you don't have to necessarily shop around. You pursue what you think to be quality, not necessarily a price savings. I don't know the answer. Yeah, I mean, I don't have the answer to that, but we could do more studies to look at that. I think we're pretty cost effective because people come to us of a large part of orthopedics and surgery related for both price and because of quality of care. We get both, actually. It is helpful for us to be able to look at that and compare. So, I'm all set. Thank you. Thank you, Morgan. Next, we'll turn to Jessica, Jessica Holmes. Great. Thank you for the presentation. Really helpful. Jeff, I think this is probably a question for you. I'm trying to understand, you mentioned in the presentation, and I think in answer to the staff questions that your projections from 2021 haven't changed. And I'm trying to, so I was looking at year to date results through June. And again, I'm getting this data off of our Tableau Interactive, so hopefully what I'm downloading is correct. So correct me if I'm wrong on any of this, but from what I can see your NPR as of June is already about $5 million over budget. 62.5 versus 57.5 in the budget. Is that right? Yeah, I believe it is, yep. Okay. And so your submitted projections have you coming in about $4 million over budget. You still have three months to go. And from what we hear about hospitals at capacity, volume is stronger than ever. In June alone, from what I can tell, your NPR was about $1 million over budget, if that's also right. So as I'm thinking about this, your $5 million over budget already, if July, August, and September look like your June, that sounds to me like you could be upwards of $8 million over budget for NPR when you're projecting only to be about $4 million. Oh my, am I thinking about this correctly or is there another way to, I guess I'm just trying to figure out from what I'm seeing. And again, I could have these numbers off, but it sounds to me like your projections of $80 million for 2021 might be off given the volumes that we're seeing now and where you're already at. So overall for Copley, when we take a look at our revenue and we have to understand that COVID has been, is exacerbating this issue. We have a lot of staff that need to take time off more so than ever. We are experiencing that as well. And basically what we're seeing is our surgery revenue. There was a lot of COVID need that was getting pushed through the system. We are seeing that that is backing off. People are taking the appropriate time off and that is what's causing the major variance that you're looking at. Okay. And so your current operating gain through Q3 was 1.4 million. You're in the presentation, you projected 500K for the whole year. So is there something that's going to reduce that operating gain from 1.4 back down to 500? Yeah, and again, right now as we closed our financials, we're running about 1 million to 1.5. We're predicting for the last two months, which typically always run at operating losses, that that will get us close. Are we going to be at the 500,000? We'll be close to that due to the operating losses that we've always seen year in and year out. And that's what's built into that prediction. Okay. Okay, it was surprising to me because most other hospitals are seeing so much surge and so much volume returning in their EDs and elsewhere that they're now revising upward their projections for 2021. So it was surprising to see Copley not doing that. Also another surprise was actually the only 57K in investment returns, particularly given the market performance this year, that was just seemed surprising to me and a little bit lower than what we've seen elsewhere. Was that a surprise to you? I mean, that's... There's not many investments. If you take a look at our balance sheet for Copley, so we don't have great endowments and stuff. So that's the reason for the low return. Okay. That's what I mean. That's what I figured, but it was just surprising for some reason to me. Dr. Please, might be a question for you. So a couple of weeks ago, Mathematica, which is a consultant that we have provided us with some hospital-by-hospital analyses of potentially avoidable utilizations. And the analyses that they did, it's only for Medicare fee-for-service, but about a third of Copley's inpatient and ED Medicare fee-for-service. I'm sorry, Jessica, you're cutting out. About a third of, did you say a third? Yeah, a third, 33% of Copley's inpatient and ED Medicare fee-for-service revenue. It's potentially avoidable if patients had access to timely care and more appropriate setting and all of that. Your rate, Copley's rate is actually higher than the state median on that measure, as is the proportion of Medicare fee-for-service coming from 30-day readmissions. Now, I know that Copley doesn't own care practices, but I'm wondering, as we're thinking more about moving towards value-based payments and your participation in a lot of these one-cares programs, how do you think about partnering with the primary care practices and other community partners to bring down some of that potentially avoidable utilization at the hospital? It's particularly, it sounds like your community collaborations have expanded through COVID, so there's hope that some of these measures might come down. Yeah, I couldn't agree more with pretty much everything you said. One issue with the Mathematica study, which I did get to look at, was that it was kind of hard to tell just where the data came from, so it was kind of hard to know. And it's claims data, and with claims data, it devils always in the details, so we'll just assume that the story it tells is roughly right. The one thing on the readmission data that it had in the Mathematica study, it doesn't seem to jive with the VOS data, you know, I don't know if you can see that, but the readmission data is really different. So we're not quite sure, but yeah, so we're a hospital without primary care. So when people show up, we're obligated and it's our duty and it's what we do to take care of them. So what we can really do to address this problem is what we are in fact trying to do, which is make sure that when people leave the ED or leave the hospital, that they do have a primary care physician and they do have an appointment. And if they need home health, they have that. If they need elder care, meals on wheels, if they need those services, that's how we close the loop. You know, the issues of how soon people get in and how happy people are to go to their primary care providers, all we can really do is root for them. And we work really hard with our local primary care offices to be supportive and to any way that we can help you obviously want to do that. We have traditionally worked with the manner on readmissions from the manner to try to figure out how we can reduce that. We have a social worker that we used to share with the FQHC across the street to do exactly that, to get conduits, particularly high volume users, to get them into the primary care. And we have two case managers and the social worker on the floor that essentially do the same thing. But until we actually, or unless we actually had our own primary care, the number of levers we can pull on that are somewhat limited. And I feel like we're definitely pulling them, but we are not unaware of this issue, that the COPD, the CHF, diabetes issues, which we agree could definitely be not driven to zero, but could be approved now. Is it something that you track internally? I know we heard from Northeastern that they are starting to track the potentially avoidable utilization, particularly in their ED. And so maybe Mathematica isn't doing it the way that you would like to do it. Is it something that you're actually tracking internally? We sure were before COVID. Okay. And there's no question that that and almost any other thing like that you could think of just got brutalized the last year. But yeah, it was something we were quite mindful on and we had a dedicated person who worked just at that. So yeah, it's definitely, we see that as our job. We think it's important. And we'll give more energy to it as the energy gets sucked away less. And actually I think I'm probably gonna, after the debrief of all these hospitals budget presentations, one of the things I'm gonna suggest actually is that's part of the submission. So we can understand how hospitals are working their way at bringing down some of that. So if you're already tracking it or plan to start tracking it again, that's great because I would like to see all hospitals do that. And for us to learn how that number can be diminished. Wait times. I'm just wanted to bring that up. What is your target for third next available appointment? Actually, it's something I've meant to ask all the hospitals but what would be an ideal target for days for third next available appointment? I don't think that at this time we have a- Yeah, I mean, are there any specific specialty or for all? Well, in general, I'm just sort of wondering, we can sweep down the hospitals I've submitted them. I'm wondering where the hospitals shoot for. Some of them are looking high on yours, oncology, neurology, ortho, cardiology. They're all over two months. That seems high to me, but maybe that isn't high. So I'm trying to figure out what is, where do you say, this is high and we need to work on increasing access or reducing days to third next available appointment? Sure. Yeah, so the easy answer is, it's very hard to know what the number should be as it's particularly in our case because we're a resource limited facility where we have limited resources to adjust it. I can tell you with cardiology, at least once a year, Dr. Kuhnen sits down with everyone and we look at exactly how the referral patterns are going about what the return intervals are because we would like it to be less than 65 days. What the right answer is, that's hard to say. And in one sense, we'll do the best we can, but if the right answer is 12, it's probably not realistic for one general practitioner, cardiologists in the system. For general surgery, it's eight. My feeling is that it's probably too long. Most people that need us, need us pretty soon. And I think what I talked about before was that we've cut our office staff way past cutting away the fat, and it's made us definitely slower and responsive. So I know we can improve on that. Orthopedics was exactly the same issue. At one point we cut so much that it was just hard to answer the phones. And we're definitely working on that. Oncology is basically whatever I said about cardiology, you could just apply to oncology. Dr. Ospina comes over from CDH pretty frequently, but it's really almost never more than four times a month and the demand is definitely higher. So we understand where you're coming from, we feel the same way, and we'll get it as low as we can, but it's gonna be hard to get it where anyone would really like it. There's so many indicators that we're always looking at hundreds of indicators. I don't think any of us look at it and say, well, we're gonna spend a whole bunch of money and time on pulmonology or orthopedics. We're just too small, it doesn't work that way. And plus you can't even get locoms as much. I mean, travelers are even hard to find. So for us, it's not an easy thing to say, why don't we really address the top three or four areas that have the longest third next available appointment? We'd go bankrupt, our expenses would go through the roof and you'd be asking me next year, what did you do? And I said, well, I addressed the three, four highest areas, spent a ton of money, but it's still in a small organization, it still doesn't work to find another cardiologist. It takes relationships, it takes time, it's not like I can just hire a cardiologist. I mean, I'm saying that as a small hospital, I think the same is true for some of the larger hospitals, it's just hard to get these people to move with their families, to wanna be in Vermont. So I wish we could turn it up and down a little bit better. We can't really though, just to be honest with you, I wish we could, it just, it's really hard to. Yeah, we're painfully aware that there are people on the other side of the phone who wanna see us that we're not accommodating as promptly as they'd like. Yeah. And I guess my final question, it builds a little bit on some of Maureen's questions around the pricing and for us to try and actually to joke your point about trying to understand pricing comparisons across hospitals and all of that. When you submitted your budget, you responded to the HCA's questions about the reimbursement ratios relative to Medicare by saying that Copley doesn't track the info that way, but you'd be willing to work with the HCA to provide suitable information. So I'm wondering, what did you work out with the HCA in terms of an alternative way to provide that kind of baseline comparison across all services, not just the ones that you provided in the presentation which were extremely helpful, but a baseline alternative way to measure Copley's reimbursement rates relative to other, relative to Medicare or something else. So we actually, last week that we finally talked with the HCA, had a great conversation about reimbursement, all the different models. One of my first recommendations with them is to try to understand the differences in the reimbursement models throughout all the organizations, come up with a grid, understand what an APC means in regards to Medicare reimbursement versus a critical access reimbursement. I think it's really important. It kind of goes to one of the slides that we presented. You have your tweeners, you have your medical center, and then you have your critical access hospitals. But even within the critical access hospitals, you have an issue and that issue is what you were saying. We are an organization that doesn't have primary care. We have an organization that for the most part is specialists. So even within critical access, you have all these different methodologies that you need to really first and foremost and try to understand what that means to the organization because for Medicare, it changes our cost. It changes our cost of charge ratio and it changes our reimbursement. But if you were to take us and compare us maybe to a North country that does have primary care, you might not actually be able to utilize that in the most appropriate way and stuff. So that was step one. I love having conversations about trying to figure this out and encourage them to keep talking with us. But that was my first thing is really start to get the grids. Start to understand just with Medicare and I think it's gonna be an incredibly complicated grid to put together, but so that we all know what we're looking at. So that was my recommendation to start with the process. Okay, great. Thank you very much. That's all I have, Kevin. Thank you, Jess. Next we have board member, Lunge Robin. Thank you. Good to see you all. All of my questions have been answered, asked and answered. So I'm good. Great. Thank you, Robin. Don, I must admit that I'm tempted to interrogate you about why your father-in-law won't come to work for you. But since it's close to lunchtime, I'm gonna pass on that question. And Joe, in the historical look at the data that you prepared, did you include mid-year adjustments as well as just at the hearings? I have to ask Jeff, mid-year adjustments in the approved rates. We didn't have any mid-year adjustments in our approved rates. Okay, so for example, Springfield a couple of years ago got a 5% mid-year up. I'm going back in time, like five or six years ago, Rutland came in and asked for a 5% down. Yeah, so Kevin, in regards to all this data was acquired off of the Green Mountain Care Board website. So yes, those would be in there, as long as they were in the data that was... Not sure they are, because when I look at my own staff's calculations, I don't think mid-year adjustments are in there. That's why I was asking. I was hoping yours was more complete, but it doesn't appear to be. Yeah, we were relying on your data. So I hate to ask this question, given that Joe was talking about trillions of dollars, but Jeff, I'm struggling on the change of charge. You're saying that 1% equals 734,279, and then you're saying that equates to 3.8 million in additional revenues. When I do the multiplication, it comes up to 3.67 million. What am I missing? I'm probably nothing. Let me, if I could, Kevin, let me go back and verify that calculation. Okay, great. So with that... You're like... You can get it to me at a later time, as long as I get it. With that, I'm gonna move to the healthcare advocate and turn it over to them for questioning. Thanks so much, Chairman. Just in the interest of time, I'm just gonna ask one question. I wanted to start off by thanking the hospital for all your work during the pandemic, of course, particularly during the surge now. So thank you. I just wanna communicate our gratitude. Our question is, and we asked this of Mountain of Scotland as well. There was a high-profile piece in the Sunday edition of the New York Times over the weekend about the tremendous variation in hospital insurer prices for the same product or service around the country. If so, do you have any comment about that article, if you had a chance to read it? And if not, do you think it, or if you have, do you think it applies to Vermont? And if not, do you have any explanation for the variation in those different services? Thanks. I didn't read the article. I think we have rediscovered this problem in America dozens of times in states and across the country in terms of the variation of cost and prices and all that. I don't know the variation in Vermont, but I don't know if you've seen that article, have you seen that article? Yeah, I read the article and I was probably just as appalled at every other American that you could have a four, five times difference. But I mean, I don't know how much our prices vary from insurer to insurer on the individual contracts. That's not really what I do here. So Sam, again, I think it comes down to, we all have to understand our data. We all have to understand all the different payment methodologies that are out there. And I think that that without that understanding, that's why we're seeing these incredible swings from one payer to another payer. And it's just coming out. I think I feel that there was a lot on writing on the price transparency rules that Medicare released. Unfortunately, for people that worked in that kind of reimbursement area, it was like, holy Moses, this is just gonna be very confusing to the consumers because there is this incredible variation between these internal contracts that individuals have. There is, just with the price to charge ratio for a critical access hospital versus what a tertiary care center gets through APCs. Variations pretty incredible. But Sam, even though it's probably not apples to apples, but our price for an MRI of a joint is 1600, which would have put us way on the low side of the prices in that study. Got it. Thanks, appreciate it. Back to you, Chairman. Thank you so much, Sam. At this point, I'm gonna open it up for public comment on the Copley budget presentation. Does any member of the public wish to offer public comment? Dale. I do see a hand up. So Dale. Yes, could you clarify me for me a little more? I just quickly went and read an article from Moody because I read on this four or five months ago. Days cash on hand is, they classified it as, well, if you're gonna do capital investments, et cetera, you want 63 days cash on hand. You want six months days cash on hand. What do you consider a reasonable number for days cash on hand, considering all the factors that Copley mentioned. They've got staff that needs vacation. They haven't had vacation. This comes out of days cash on hand. It just hasn't been accounted that way yet. So any kind of clarification in there you can give so that those listening in can understand this number better. So I'll just make a couple of comments, Dale. I think going back to Sam's question about data. Oftentimes we don't look at data critically and we don't question the highs and lows. You have to look at data over time and the range. Sometimes we need to throw out high data points because they might not be accurate or low data points. For us, we're hopeful to move towards the average. That's what we're looking at. We've got two average points from critical access hospital data average and then Northeast CH average. We're significantly below average, so it's a concern for us. And I would at least be in the range of average or certainly less expensive. But moving towards the middle is not a bad thing. I think that is sometimes helpful. So I don't know if Jeff wants to add more about what our goal is. Yeah, the one thing that I will say, Dale, is the Moody's data and the Fitch data for small critical access hospitals, there's quite a difference. We're talking about the Moody's data is for very large hospital organizations. For us as critical access hospitals, I do like what has been presented by the Green Island Care Board. And that's looking at your Northeast critical access average or just looking at the, as Joe was saying, the Vermont average as kind of our guide to what we need to best strive for. Okay, thanks. That actually helps me to understand this issue a little better too as I look at the broader picture. Thank you. Thank you, Dale. Is there other public comment? Seeing and hearing none, I wish to thank you gentlemen for a thorough budget presentation. There were a couple of things you were gonna get back to us on. We appreciate that. And with that, do I have a motion from a board member to adjourn this hearing? So moved. Second. It's been moved and seconded to adjourn the meeting. All those in favor signify by saying aye. Aye. Those opposed signify by saying nay. Thank you and have a great rest of the day.