 Good morning everyone my name is Kevin Mullen chair of the board I'm going to convene this meeting of the Green Mountain Care Board for the purposes of two hospital budget hearings this morning one is Grace Cottage and one is Springfield and at this point I want members of the public to know that after each hospital budget presentation there is an opportunity for public comment and also we have an open public comment period that is on our website and anyone can offer a public comment on any budget or hospital budgets in general by logging into the Green Mountain Care Board website and going to that public comment portal at this time Kim if you could swear and Doug and Steve do you please raise your right hands do you swear the testimony you're about to give shall be the truth the whole truth and nothing but the truth will help you God I do thank you great so Doug whenever you're ready you can just proceed great happy to so as the as the smallest hospital in the state of Vermont I anticipate that we should be able to get through this probably pretty efficiently and perhaps quite a bit more quickly than some of the other presentations you've heard this couple of past week or more and we're really happy to be able to do this we're happy to be able to do it via zoom given what's going on with the virus and keeping us distant and safe we are very much ensconced in managing the pandemic here in our local communities and are very much looking forward to starting the process of giving third vaccines to people who are who qualify for the first wave of those vaccines starting in September and we're going to continue our fight and keep on the good work going so that we can beat this thing and hopefully get our get back to normal and you know someday have our meetings face-to-face again which I think would be nice you know Stephen and I we've been here before we've been introduced this morning and just as a quick overview I know I know you you already are quite familiar with Grace Cottage I know our organization quite well we're a 19-bed critical access acute and swing bed facility we have a full-time emergency department we have diagnostic imaging including x-ray CT ultrasound loan dense automotry we have a laboratory on on campus and we provide rather extensive inpatient and outpatient rehabilitation we have six hospitals that cover our inpatient facility and manage the bedside care of our patients who are here when they're admitted we I like to tell people that we're unlike a lot of small hospitals that have the rural health clinics associated affiliated with that have attached to them we're kind of like the the opposite of that in that we're really probably more so a rural health clinic with a small hospital attached our rural health clinic is extremely busy does a lot of direct patient care within a facility we have an extensive team of providers we have nine family practitioners we have two pediatricians a behavioral health provider and two licensed clinical social workers that take care of patients in our rural health clinic and we're currently recruiting for a second psychiatric provider probably a nurse practitioner or PA we we were also currently recruiting for primary care providers as well we are going through some transition we we're losing two of our primary care providers a pediatrician and a family practitioner who are moving out to the Midwest and so we are we're actively in the recruitment phase to replace them we also have an on campus retail pharmacy messenger Valley pharmacy which is extremely busy here locally and is extremely convenient for the people who live in this region the nearest retail pharmacy from Townsend Vermont is in Brattleboro which is about a half an hour south of us my team loves to remind me that to remind listeners that we're an extremely well received organization we're extremely popular and for the second year in a row we've won seven best of Brattleboro awards these are awards that are voted on by the people who who are readers of the of the newspaper and this year as as we did last year we won best hospital best doctor best pediatrician best pharmacy best physical therapy best emergency department and best place to work which is probably the most the most impressive of all those awards best place to work our turnover I was just talking with my HR director yesterday our turnover rate Grace Cottage continues to be quite low and actually quite a bit lower than that national average which tells you that people who work here like working here and they tend to stay at Grace Cottage we we have a mission of serving the health care needs of our community obviously our focus is on wellness relieving suffering and restoring health but most important to to us and to those who count on Grace Cottage for their care is we develop a very close relationship with our patients that relationship is is is one that is respected and cultivated from the first visit of a patient when they're a new patient until the time that they stop coming to Grace Cottage they see their provider on a regular basis we manage their wellness through a number of programs through data through communication channels and vehicles we provide them with feedback we have a patient portal they can talk to and communicate with their providers regularly and continuously we give them frequent reminders when it's time for them to come in for blood pressure checks for wellness visits for physicals if they're being managed for a chronic issue we communicate with them regularly about testing and about follow-up care about follow-up visits we make sure that that their care is being managed rather than relying on our patients to have to remember what to do and when to do it and I think that really separates us quite a bit from the competition in that you know we are we're a smaller organization and we we can really have a close and cultivated relationship with every single one of our patients our vision obviously is to to have that personalized relationship to provide that accessible primary care to be available when patients need us whether they're an established patient or whether they're just somebody visiting the area who happens to have an acute issue and calls to sit to see if they can see somebody we provide them with a quick and convenient appointment slot we have accessibility at Grace Cottage to provide quick and give convenient appointments and we stay ahead of the curve because we don't wait until our appointment times are drifting out further and further it's our goal to make sure that we can provide quick and convenient access and so it's one of the reasons why we're aggressively recruiting right now to stay ahead of the curve and to make sure we have enough providers with enough access to get people in quickly and conveniently we provide very competent inpatient care predominantly swing patient care for patients who are post-acute and need rehabilitation and focus in order to prepare themselves to return home after their episode of care so we coordinate and collaborate with other acute care organizations proceduralists in the region and we are very well respected for our follow-up swing and rehabilitation services our emergency department is open 24-7 we pride ourselves and that we have a very tiny waiting room because we don't believe that patient should have to wait for an emergency provider so our goal is to get them into a room as soon as they walk through the door and to make sure that we're providing quick and timely triage evaluation and care planning for those with emergency issues and serve any emergency services we also have an extremely close relationship with tertiary care facilities and trauma centers and we have an incredible transportation mechanism for people who might need a higher level of care that they can't get a grace cottage and we regularly receive positive feedback from providers at tertiary and trauma center locations that receive our patients thanking us for doing such an incredibly comprehensive and competent job of evaluating triaging and documenting before transferring patients to their care so we really pride ourselves in having that close affiliation and relationship our focuses on preventive care as I mentioned earlier we're our goal is to keep people out of the hospital we don't have any beds for for for you know patients that are that are waiting for people to to show up because they haven't been managed and haven't had a comprehensive wellness and preventive care we we prefer to keep our patients at home in the community and well cared for and and it's one of the things that I think again separates us from a lot of full service community hospitals that rely on procedures and interventions to drive revenue and volume we really don't we don't do procedures here we don't have an operating room we don't do anything internally in terms of a procedural base services so for us it's really all about seeing the acute patients showing up in our ED hopefully treating them and sending them home if they need to be admitted as an acute we admit them take care of them on a short basis and get them home as quickly as we possibly can or to a higher level of care if they need it so our our focus is really on wellness and to treat the entire person as our vision says next slide Catherine so you have our our requested budget for fiscal 22 the net patient service revenue number in that budget is based on current volume run rates with with two slight areas of a decrease that we're trying we're preparing for and those two are first and foremost a return to somewhat normal outpatient laboratory volume as you know for the last year and a half with COVID testing being as as brisk and busy as it's been our outpatient laboratory volumes have been quite a bit higher than normal and we anticipate that as the pandemic begins to wane hopefully as the pandemic begins to wane we could potentially see a drop in some of our outpatient laboratory volume so we factor that into our our NPR for 22 again I also mentioned that we are in the process of recruiting at the provider level so we're anticipating at least for a period of time in 22 a drop in total visits to our provider practice as quickly as we can recruit providers to fill that void the quicker we can return to to continuous growth in our rural health clinic our NPR growth request is somewhat modest but it's really and I'm sure you've heard this from other hospitals that have presented to you we need to have some growth in NPR at Grace Cottage in order to cover the increasing operating expenses that we're seeing due to both supply and demand there's a tremendous inflation right now in health care supply costs the pandemic has created problems for the supplier vendors and they're passing those increased costs fuel cost shipping costs manufacturing costs on to us the consumers and we're having to pay higher prices for goods and services and supplies so we really need to have some growth in order to cover that increase in operating expenses and as you've heard from us before and you'll probably continue to hear from us we can't we're continuing to see a somewhat continuous shift in payer mix from commercial to Medicaid and self pay payer classifications and that's consistent with what we saw in 21 and we factored that into our budget for fiscal 22 and with that I want to pass the slide deck over to Steven and he'll get he'll cover some of the more granular aspects of our budget request for next year Steve help if I unmute Catherine the income statement slide so you have in your packet that was submitted the this slide which is shows our current year budget adjusted for COVID related expenses and our submitted budget for next year overall net patient revenue increase from projection to budget is a 6.1% increase which includes the rate increase as well as change not while overall volumes are drastically different some of the areas that they are and it makes a big difference in our net patient revenue such as we get reimbursed much higher on inpatient versus outpatient stays so the slight mix of where services lie makes a big difference in that our as Doug said our request is essentially a flat volume budget going forward we truly expect in a lot of areas especially if we find the providers were currently looking for and the physical therapist based on our result for the last few months I would expect a an increase in our volume in those areas but I didn't want to overestimate my presumption is this is a best guess not pessimistic but reasonable expectation of what our volumes will be for the coming year the expense side however I think I am hopeful I should say that it's an pessimistic outlook and that we can keep our expenses lower than that that being said I'm not sure you know sitting here today even what's changed in the last month or so if that's reasonable knowing that costs continue to increase above and beyond what Doug was talking about particularly in travelers and things like that and I'll talk about that a little more and we get the operating expense page but overall I think our 22 budget is completely achievable it's not particularly far above from a net patient revenue standpoint what we budgeted for the current year and considering most of the current year or much the current year early on particularly was still highly affected by COVID it is a truly reasonable expectation balance sheet Catherine the balance sheet continues to look stronger at Grace Cottage than it has in years I'm not sure how to say this but in some ways COVID has actually been a positive thing for us particularly in some of the revenues that we received as a result of that it has helped our cash position significantly the payroll protection loan especially which as I should have mentioned that on the income statement but you saw in the narrative that we did indeed get almost a three million dollar payroll protection loan early on in the process which was forgiven a couple of months ago and thus showed up in as revenue recognized as revenue in fiscal year 21 and that is revenue cash essentially sitting on our balance sheet that is ours to keep versus the Medicare advance monies which are slowly being repaid those are all so all still in our account and ready to be repaid we fortunately we're not required to use any of those and that liability will continue to decrease as Medicare recoups that money over the next couple of years next slide cash flow statement gives you a quick look at where our cash balance went you can see at the end of 2019 to the end of 2020 was a significant change all entirely a result of the COVID related funds that we had in the bank combination of the payroll protection money the HRSA cares act fund and the Medicare advance monies and that will continue going forward through the end of the 21 as well as into 22 keeping us a large positive balance until all of that Medicare advance money is paid back next slide our overall chain rate increase request was five percent I felt and calculated that that was the minimum amount necessary to get us a large enough net patient revenue to cover all of the increased operating expenses we've outlined that is the highest rate increase we've had in the last several years it's been 3.2 for the last few years it gives us an overall per gross patient revenue projection when once you adjust for the covert things of 3.6 percent from 21 projection to 22 budget and a 2.8 percent increase from 21 budget to 22 budget next slide grace college does not have any adjustments or provider transfers or accounting adjustments to report so that keeps it simple next slide included in our other operating and non-operating revenue lines as I just discussed in other operating revenue for the 21 projection we include the grant revenue of 2.97 million dollars in payroll protection money there's also a small amount of additional cares act funding recognized in fiscal year 21 of the money that we had had left over as of September 30th last year we will be returning our unused funds later when we do the reporting in September for that the other items included in our other operating revenue are our 340b retail pharmacy program of roughly one million dollars in fiscal year 21 and one point one million dollars in fiscal year 22 and our retail pharmacy that Doug mentioned operates at a loss of approximately 130 thousand and 21 and 178 thousand and 22 non-operating revenue continues to be the large community support we get which has in all of my years at grace cottage going on 35 or so now have what have been always allowed grace cottage to continue to exist in most years next slide operating expenses are drastically up in a lot of areas not as a result of any new programs as a result of anything out of the ordinary from a daily operating standpoint aside from simply increased costs to maintain the normal operations the cost of supplies is significant as Doug outlined other areas as you well know salary and benefits and staffing are by far our biggest percentage of operating expenses we've had to do market adjustments in a lot of areas to maintain competitiveness with surrounding areas as to in order to recruit and retain qualified staff for the positions that we have not yet filled we currently have more travelers in the building than we have ever had in all my years here it's rare that we have more than a couple and usually just nurses sometimes we have one in some other ancillary area as of today we have four traveling nurses on our floor we have one traveling nurse in our rural health clinic which is a first we have two physical therapy travelers we've never had more than one there and we just posted yesterday for a traveling radiology tech which is as a result of someone leaving due to our mandatory COVID vaccine policy going into effect October 1st and I as I've outlined in the narrative the cost of travelers has skyrocketed at this time last year we were paying about $65 an hour for a nurse traveler RN on the nursing floor right now we're paying 120 or 130 and may need to increase that we just one of the travelers that's currently in the building is leaving mid contract to go to it she's not only leaving here she's leaving the traveling company she's working with to go to a different traveling company at a higher rate and that's according to the traveling company happening a lot across the board it's just you know there's such a shortage of nursing staff that they can demand anything they want essentially and that's a drastic cost increase you know when you're paying to and going on three times what it costs for a regular staff person but the alternative is not being able to treat the patients and that's not an alternative we have patients we need to take care of those patients but essentially operating expenses are up across the board in a lot of areas and it's we do our best to maintain and decrease those and hold them tight wherever we can but some things we simply do not have control over next slide Catherine so as I said our budget is extremely conservative as it relates to expected net patient revenue it's not any drastic volume expectations that I feel we cannot achieve it's essentially exactly what we're doing right now it's been very consistent the entire year as far as pretty much everything across the board the expense budget as I said is high due to inflated costs particularly mostly as a result of COVID-19 we do have a positive total margin budgeted for 22 but that is based on the generosity of our community and allowing us to continue to exist and our community being willing to cover the lack of particularly Medicaid reimbursement you know Medicare reimbursement for our facility due to our high percentage of Medicare patients in both the hospital and the rural health clinic is close to at least covering their costs doesn't completely commercial in most cases pays a little better than cost and as we've discussed year after year and you are well aware Medicaid pays less than half the cost of taking care of their patients and unfortunately as Doug pointed out and as you'll see can see in our net patient revenue columns this current year and what I projected going forward the medic percentage of Medicaid patients has gone up as commercial has gone down as again as a result of COVID-19 people losing their jobs losing their health insurance and that is not something truthfully that we have any control over we just have to try and adjust and cover that in ever-increasing decrease in reimbursement next slide so I'm this point I'm going to turn it back over to Doug so he can talk about our risks and opportunities he's got to unmute it first though thanks Stephen I appreciate Stephen's comments this is really been a incredibly unique year for Grace Cottage with everything going on with with with the way we're running the organization with the demands on our hospital with the pandemic with the change in demographics change of payer mix but you know it's interesting when you look at this year as a whole and you and you can you look at at just your volume and performance relative to prior years this is probably been one of our best if not our best year ever at Grace Cottage if you if you would you adjust out you know some of the cash from from the the COVID related assistance we received from the feds and you look at what we brought in through our philanthropy program this year which is a record year for us so we're we're we're going to finish this this fiscal year just shy of two million dollars in in gifts to Grace Cottage which is a record highest of all time for for our organization and you look at our our non-operating revenue and the performance of our endowment is that a record high as high as it's ever been at Grace Cottage our our non-operating revenue from investments is at a record high which when you factor all that together we we actually all probably if not for the pandemic we could possibly have finished this year with with a positive margin on operations which is something we almost never do at Grace Cottage so we're really really happy with with our performance all of our strategic initiatives for this past year have paid off in terms of a growing access recruiting providers marketing new services changing the way we we allow patients to enter our organization and our system the way we manage productivity at the provider level the performance of our emergency department and the reputation that those providers have developed in our community which has allowed us to grow our ED business you know everything is kind of firing on all all cylinders right now and so we're really happy about that and it's one of the reasons why as Stephen said you know this is this is not has not been a bad year if anything it's actually been a good year for Grace Cottage there are however still risks that we have to be prepared for you know this this Delta variant that we're seeing popping up we're seeing you know obviously numbers in the state of Vermont slowly climbing for a number of patients hospitalized on any given day across the state which is not a good trend to see but it's because of the variant and it's because of the fact that there are still Vermonters that aren't vaccinated yet and the initial vaccine that we all received is starting to it's effective it's starting to wane over time which is one of the reasons why we're all going to be looking at the option of getting a booster shot to keep those those immunities strong but we have to to be prepared in the event that we see things get worse before they get better and we're going to do that we're going to be prepared for it and hopefully it doesn't happen as Stephen mentioned you know staffing continues to be a problem you we we like most hospitals in the state of Vermont are seeing today more difficult to recruit than in the past and I don't profess to be able to explain why that is some suggest that you know people are are being paid very generously unemployment and and so some folks are staying staying on employment rather than working I suspect that's that's part of it I also believe that when organizations reduced staffing levels implemented furloughs and cut services and programs during the height of the pandemic something that Grace Cottage did not do a lot of people found other things to do to earn a living and now that we are seeing volumes returning and demand returning those folks are not are not sitting by their phones waiting for a call to come back to work and I knew that was going to be a problem it's one of the reasons why I didn't want to put people on the street at Grace Cottage during the height of the pandemic and so hospitals that are now trying to grow and recruit and increase staffing levels are having a hard time of it which is creating you know an escalation and a bidding war and pricing escalation for interim staffing solutions and we're even feeling that at Grace Cottage so even though our turnover is not been very high as I mentioned earlier it's not we have not had the the quick and an easy success of filling positions when people do decide to leave the organization and that's why we have more more travelers more locums now than we've generally have had in the past so that's definitely a risk we continue to believe that increasing access to primary care not only is good for Grace Cottage but it's good for the community it's good for for lowering costs of health care in the state across the state of Vermont we we have a bit busier than normal pediatric practice we had two providers we're losing one of them and so we we really feel that there's an opportunity to get another pediatrician or family practitioner who can take care of kids and grow our pediatric program in the coming year and in years to come and we did make the decision this year to hire a second behavioral health provider we have one currently right now working with a couple of social workers but he his practice is currently you know bursting at the seams and it's getting harder and harder to get patients in to see him and so we're looking for a second behavioral health provider which I think will obviously will double our access and help us to move patients through our primary care practices because right now when a family practitioner or an internal medicine provider can't get somebody in to see our behavioral health provider then they have to manage the patient's behavioral health issues themselves it's not something it's not their sweet spot it's not something they like to do and it just bogs down their ability to efficiently take care of their non behavioral health patients so we do need another provider we're going to recruit somebody this year if everything goes according to plan so those are our risks and opportunities currently on the value-based care participation question we continue to have open dialogue with one care of Vermont we are optimistic that they're going to be able to assist us in joining the ACO potentially as early as 2023 you know our participation has to be different than a standard than a traditional community hospital in the state of Vermont we're more like a practice than we are like a hospital and we're currently talking with them about risk mitigation we're talking about revenue flow and reimbursement flow and how that would work for a hospital like Grace Cottage and I think we we're getting to the point where it's starting to make sense for us to participate I know we're the only hospital in the state right now who are not card-carrying members of one care of Vermont and I look forward to our continued discussions with Vicki Loner and her team in 2022 and hopefully by mid-year initiating some some agreements to to present to their board and to our board and hopefully having us join and being participants in 2023 any questions there on the capital budget side you know because of this this year we've had we've had a bottom line which is something we don't often say Grace Cottage we've been able to spend some money on capital and you know I'd be lying to you if I told you we've had money for the past couple of years to keep up with our capital needs we have not but it's it's reassuring to see that that we're able to spend a little bit of money on capital and our plans going forward in 2022 are to upgrade our ultrasound services we're going to have to do some paving our parking lots are really starting to suffer we're going to be upgrading some of our HVAC services with with really high efficiency mini-split systems which provide localized thermostatic control to allow our employees to keep temperatures at a at an efficient level and and lower our costs for for heating and cooling we've got some IT upgrades that we're planning to do this year however we have no no plans to submit any COA projects in 2022 just spending some money on some day-to-day operating needs capital operating needs for the hospital COVID-19 well I think we've dabbled on the impact of COVID throughout our presentation this slide just kind of summarizes the fact that we've had to limit access to our providers because of the the infectious nature of the the virus and having to extend appointment slots that we could terminally clean and disinfect exam rooms we've had to provide care to patients via telephone and telehealth technology so a lot of our patients actually were able to work with their providers without having to physically come into the hospital to see them face-to-face that's a really good thing and I think it's a it was an opportunity for us to test some of those those care solutions and we like most organizations will probably probably be continuing to avail ourselves of some of that technology in the future but it's not the optimum way of taking care of patients by any means we still believe that face-to-face with the provider is really the best way of taking care of our patients and the sooner we can we can get back to the normal efficiencies of bringing patients through the organization putting them in an exam room in front of a physician or EPP the sooner we can get back to the efficiencies of taking care of our patients the way we have in the past so you know I'm happy to answer any any other questions you might have about COVID and the impact that it's had on our organization but suffice to say I think we've really done a great job of managing care during a very turbulent and challenging time for us and for all hospitals in the state of Vermont and that's the end of our slide deck. Thank you so much Doug and also thank you Steve. We're going to start the board questions with board member Pelham. Tom. Thank you all. It's small as beautiful in my mind and I'm happy to see that you know you're looking down the road and seeing a future for yourself. That's just it's just always nice to have those small outliers out there kind of proving that just you know that they they can can be a little bit more nimble and quick on their feet and and serve their communities. I don't have a lot of questions I mean small is beautiful in that regard too that it's not sometimes the smaller the budget the less complicated it is. I did spend some time on the the Medicare advance and I'm just kind of wanting to kind of go over that a little bit with you to check my math. As I I could tie your Appendix 7 out to your balance sheet and that all made sense to me but I have so I'm looking at your Medicare advance repayment and you have a recorded liability at the end of 2021 or September 30 2021 at 3.99 million and that drops on Appendix 7 to 1.856 million at the end as of September 30 of 2022 and so it looks like kind of the the repayment rate for that year annual period was a little over 2 million bucks 2.14 million dollars which averages out to 178 thousand dollars a month and so I'm just asking or trying to understand that given the remaining liability of 1.856 million at the end of September as of September 30 2022 whether that that is what you expect to be facing going into 2023 with about 10 months left of kind of recapture in Medicare payments is that a kind of a rough view of that of that repayment plan? Yes Tom it will continue into 2023 before it's finally all paid off and that unless they change it again I believe actually because at the end of 23 we had gotten part of our money in April of 2020 about half of it give or take it was like 2.9 million of it we got in April the remainder of it another 2.9 roughly came in September and the repayment starts from a year after you get it so we actually started paying back in April of 21 on the first 2.9 million and just starting now will be starting in September on the second 2.9 million and it there's a graduated payment that gets higher toward the end after I think it's after another year I would have to go back and look they changed it so many times and they may very well change it again but um yes so uh so uh a bunch of this will carry forward into 2023 correct right and you and you have a staggered staggered start uh based on on the the two allocations correct okay basically because they recalculated it wrong the first time so my next question is on value-based participation and this is just an observation um I kind of uh get a sense that um your big brother a big sister which is uh Scott me in my book is has the same kind of uh kind of less aggressive approach to value-based care or participation than some of the other hospitals um you know some of the hospitals are up in terms of their FPPs in the in the mid 20% now um but uh so I was during our hearing with Mount of Scott me I asked about um what their you know what their feeling was about Medicaid and whether or not that was some jeopardy of Mount of Scott me and uh the energy that came back to the screen was a surprise um it was like absolutely not we love our Medicaid uh pro uh value-based program um it simplifies life and reduces a lot of administrative cost and so I'm just wondering if you spent some time with the folks at Mount of Scott me they are bigger than you but they're the next rung on the ladder have you spent any time with the folks I'm out of Scott me kind of getting their insight as to how helpful and valuable the Medicaid uh the ACO's Medicaid program might be no Tommy we haven't done that but that's a great recommendation I really appreciate you bringing you know pointing that out to us and I will I will definitely reach out to them um that's great that's a great idea because the more we're going to need that information when we when we present you know this to our local board here at Grace Cottage and to the extent that we can get you know some some positive feedback on the impact that it's had on another hospital in the state um uh the easier will be for us to to reach a decision hopefully a positive one yeah well I think Mount of Scott the folks at Mount of Scott me folks that are your counterparts will um be a soulmate in that regard I was just surprised the level of energy and the pushback on my question you know so um the my next question is I'm looking at just your salaries I'm listening to your your you know your narrative and your uh you know kind of voice over on the travelers and what an extensive increase that is and so looking at salaries from 2020 actual at 16.6 million 2021 projected at 17.5 million and 20 22 budget at 18.4 million so those are a little over 5 increases each year um so how how have you rolled into the 2020 uh the 2022 budget the increases in travel costs that you're experiencing in 2021 projected the actual traveler costs budgeted in 22 um I believe the only departments are actually or any traveler cost budgeted in our nursing we you know when at the time we did the budget um we had into building one physical therapy traveler that we were expecting would be gone by the beginning of the fiscal year and we would have replaced that person with a staff member which may still happen or shortly thereafter um the radiology one again we had no intention of having a radiology traveler that just happened a couple of days ago when we published the mandatory COVID vaccine policy and he chose to not work here anymore because he doesn't want to get vaccinated the way I budget travelers in general so in the nursing department is I budget all of the FTEs presuming they're filled under salaries I then budget a premium above that under agency staffing so for instance if a full-time nurse costs me $50,000 a year to be here they'd be $50,000 in the salary line if if that same position as a traveler was going to cost me 75,000 I would put the extra 25,000 on the agency line still in the nursing department because you never really know I mean we could you know a lot of years when I do the budget we might have three nurses in the building and by October 1st they're gone I mean we have gotten down to zero more than once as far as travelers go sitting here today I truly don't see that happening this year but you know we are aggressively recruiting hopefully we'll be able that hopefully the rad tech position will only be here for one stint a 12 week period the rehab travelers again we're very desperately trying to hire permanent physicians for those the nurse travelers you know at this point I think we're probably going forward at least for the whole next year we'll have three to four in there because there's just not nurses around anywhere what I'm what I'm taking away from that is that there is some risk there that that you in terms of whether it's your agency or salary budget you you might not you haven't folded into 2022 be the amount of travelers you now have no a line of your hospital no only in the nursing department and I don't believe there was even I think when I did that nursing I believe I only budgeted to have two yep but you know and we we may get it back down to two shortly after the beginning of the year but it it goes up and down well good luck with that it's amazing the stories that we're hearing about yes travel travel costs it's incredible and I think my final question is in terms of when when you have to hand off an acute care patient to another provider partner somewhere out there who are your partners that you're aligned with and and have those relationships changed in the last year or so would covid I would say that you know our primary partners of course always have been you know the generally the closest hospital that the patient can safely go to you know brad bro certainly would be the first choice if whatever if they've got a bed and can take care of what this patient needs second is usually either Cheshire or Dartmouth occasionally and usually it's one of those three unless the beds aren't available I know the other day they had somebody in the ER and they called all of them I don't think they called but bmh saying the person needed more than that but they those were all full they called uvm they called base date they call they eventually took the patient to Albany after calling like five different hospitals because nobody had a bed so and that's you know not because of covid so much as everybody's been busy right now the last few months so would you see the new bed tower at Dartmouth as an as an asset relative to your operation almost certainly yeah I think I know when they said that the other day I think they I think it was Dartmouth they said they had like 60 this was one day over the weekend I think they had 60 patients in the ER waiting for their own beds they didn't expect to have a bed for at least a day or more so they were just packed and then some they had more patients and they could take care of of their own well that's all my question I do I do make note of the fact that if you take your your change in charge over the last three years at I think it's like 3.2% or something like that and average that in with a 5% and we're still at 3.6% you know as a trend rate so um I I think that's that's just an important factoid to stick in the back of the mind as we go forward here so those are my questions thanks tom thank you next we're going to go to board member Yusuf or Maureen first thank you for the presentation and everything you've been doing um throughout the year and the pandemic um just a couple questions you talked about um the Medicare advance but you also talked about some unused CARES Act funding that you may have to pay back um do you have the specifics on how much that might be in the time yes I can tell you hold on just one moment I'll pull it up I think it's just over a million dollars I haven't done the final um calculation of it yet because we're working on the reporting as we speak um but at the moment it's roughly 1.4 million but I know that I have some capital costs and stuff that I can take out of there first so I think it's probably going to be at just over a million 1.1 maybe that we end up having to send back okay and that's projected in the 22 cash flow yes okay um and then you know as your net patient revenue um trend from 19 to 20 21 um is is a little bit of an outlier from most of the other hospitals most of the other hospitals in the state saw a decline in 20 um and you know certainly you're impacted by you know second home people who come up and we know a lot of people did relocate places throughout Vermont um during the pandemic so one concern or you know I would have might be that some of those people aren't going to be able to stay through this this year as they did last year and can you isolate I guess the impact of maybe the out of state people and it was that driving some of your increase in 20 21 um and then you know potentially um if they can't work remotely anymore and their kids have to go back to school and they didn't permanently relocate here um you know you might see some impact from that so I guess how how have you accounted for that in your company I think you know a lot of the increase in net patient revenue for our facility in both 20 and 21 and going forward is the fact of our Medicare reimbursement based on um primary the critical access hospital but also the real health clinic like for instance when we submitted our fiscal year 20 cost report we had 2.3 million dollar settlement due to us by Medicare which directly increases the net patient revenue because it reduces the Medicare contractual allowance and you know that the plus side of the increased expenses is Medicare is paying that much more of a bill for instance if before if a bill was a hundred dollars and they were paying 65 of it once you submit that cost report and they're taking into account expenses particularly if they're in highly reimbursable areas such as the inpatient unit so the traveler cost is a good example Medicare is paying me if we have 85 percent of our inpatients are Medicare Medicare is paying me 85 percent of those costs so having that additional hundred dollars an hour isn't as detrimental to me because Medicare is going to give me 85 of it versus say Rutland Regional that hundred dollars an hour is a hundred dollars that comes out of their bottom line truthfully all those out-of-staters commercial people that came here I don't believe is a large increase in our net patient revenue most you know you might have had a few of them coming into the emergency room chances are they would have come in to the emergency room whether they were living here or not because you would have other people traveling to the area our emergency room volumes aren't that much different maybe a different out-of-state person coming because they are staying in their second home here versus traveling through but not a huge difference you know the other and would they be coming to get primary care for the short time they've been here maybe maybe not we've had some increase in our primary care as a result of second homeowners but a lot of them if they were only here for you know the short time their expectations are staying in their second home for until the covid's over they probably haven't changed their primary care service you know what I'm saying so I don't think our volume currently is drastically affected a lot by those second homeowners okay and do you have any concerns about the Medicare settlements in the future I mean I know some hospitals have had some issues there in the past and so just making sure you know that that's not going to reverse it all or you know I mean truthfully like the current year you know when I first got that money back in the spring I said you know what I said immediately when we got it is we need to be prepared that if volumes are high in 21 and expenses aren't we need to be prepared for that fact that we might be getting overpaid throughout 21 but truthfully as we sit here today with the large increase in expenses particularly in the nursing unit and reimbursable areas and the fact that our inpatient volumes although they're good aren't actually even that aren't even at the level of last year I think we're fairly safe this year you can't tell until you actually do the cost report but it's I'm fairly confident we're not going to have a large settlement due to them this year and then on the retail pharmacy loss can you kind of go through the accounting of that like like is there more revenue like what's the rep like how does that net out to a loss on the revenue line the retail pharmacy has been operating at a loss for years it continues to get bigger the problem is which you can ask any retail pharmacy third party payers for health insurances they all use pharmacy benefit administrators in a lot of cases we get paid less than a drug costs us to fill the prescription you know we we might actually pay five dollars for it and the total reimbursement might be three dollars which not only doesn't cover the cost of the drugs it doesn't cover anything for the pharmacist time and all of that to fill it there's a retail pharmacy from an actual pharmacy standpoint the prescription filling is a losing operation now you know there is a reason Walgreens and CVS's and all those have those in the back of the store because they make their money on the stuff you buy when you walk to the back of the store we although have a small front store people don't buy a lot of that kind of stuff in a small local mom and pop organization which is another reason there's almost no mom and pop organizations anymore in a lot of small towns i mean i know that a lot of the ones in this state just a woodstock recently that one suddenly closed the one that's been there forever because you just can't make it support it you know if we were running a true business model here we would not have a retail pharmacy you know we choose to keep the retail pharmacy because it's a badly needed community service for our patients because as Doug said the next closest pharmacies are basically 30 minutes away Browdebro or Bellas Falls and it's a valuable asset to the community it's also helpful for us in the fact that we've got the ability to have a couple it allows us the ability to have a couple more pharmacists on staff than we would normally have if we were only running the hospital pharmacy within the building within our organization we have five full-time pharmacists which allows for a little cross coverage if something happens to one of the hospital pharmacists you know one's on vacation and somebody else gets sick you've got somebody available to help cover um so that's a benefit but it is it worth that loss probably not i think the other probably the most important benefit of having a a retail pharmacy across the street from the hospital is that our primary care providers have much more control over um their patients um access and use of prescription medications right so when when one of our providers orders a drug for a patient who really needs to be taking medication for their acute problem he or she knows whether that whether that patient is actually getting their medication or not and the fact that the the drug is across the street and they can they don't even they can walk right across and get it before they get in their car and go home the likelihood of them taking the medication that's being ordered for them is much greater which means better control of the care of the patient and and and healthier patients over the long run so it's a bit of a loss leader for us but i really believe that if if the nearest pharmacy for our patients was a half an hour away the health of our patients would would decline as a result of that for access reasons for cost reasons for a variety of reasons so i've got providers who will call a patient and say look you know i i i i sent the order for your for your prescription to the the pharmacy across the street but but you haven't picked it up is there a problem do you need help paying for it um and so it just makes it easier for them to manage the medication utilization of their patients the other important thing to remember is if you go remember back on the slide i said that we included the um 340b retail contract pharmacy revenue that million dollars of revenue is a result of us operating the retail pharmacy as a contract pharmacy and that's what allows us to generate that if messenger valley pharmacy didn't exist yes we could contract with all of those surrounding pharmacies because all of our patients would have to go somewhere so i would have to then contract with every pharmacy in brother bro every pharmacy in bellis falls walmart all of those and i would be able to keep some of that contract pharmacy money but it would be a drastically smaller amount it would be faral you know i may be a conservative estimate is i might be able to contract with enough of them to keep half of that money so i'd be losing a half a million dollars there and only doing away with a 170 000 loss in the retail pharmacy so it you know it something we have to try and remember when we look at it you can't really net the two together but in theory one is responsible for the other right okay um and my last question is i first i do you know agree that in uh you know the covid has strengthened the balance sheets of many of the hospitals because you know the the cares act and some of the money did what what it was supposed to do right in a very unfortunate situation so looking at that looking at where your cash balance is and then looking at your p&l and you've talked about you know potentially being conservative on the top line and pessimistic on the expense line you know with those kind of going opposite directions just just really wondering you know how we should think about that i mean you know it seems like there's a potential that um you will do better in in 22 uh you certainly have a strong balance sheet and and cash flow and i appreciate what tom said about your average for your commercial rate but you are asking for a 5 rate this year which is above you know what we'd be looking at uh what we had you know put out there and you know i know it's small dollars we've gone through this before but it's it's small dollars to the hospital but not to the individual right a 5 percent is a 5 percent increase to an individual when you look at their commercial rate i mean total dollars to the system right it's it's not significant but um just wondering how i should think about it because i i think you've got a strong position and i think you're hedged hedged a bit from what you're telling us on you know well you need to remember that that five percent the only individual that's going to pay that five percent is a self-pay person who isn't getting any reduced fee the majority of our self-paid patients have some sort of reduced fee very few of them pay 100 of the charge based on income um a commercial patient isn't going to pay five percent because almost all of our commercial reimbursement is based on a fee schedule um the clinics particularly even within the hospital the majority of lab x-ray and all those you know so if i'm charging a hundred dollars for a lab test i'm going to now charge 105 but i'm only going to get whatever blue cross says is the reimbursement rate for that particular cpt code it doesn't matter that i'm charging an extra five dollars i'm going to write off another five dollars in contractual allowance on that particular test aside from whatever they're increasing so if they increase three percent say for inflation for one year to the next i'm going to write off two percent there are a few areas where we do get paid based on a percent of the charges um in some of the outpatient departments but very few of them i mean in in theory i mean what does happen on a lot of the charges and i understand what you're saying and those specific but ultimately if we have commercial rate increases um then you know the the commercial payer pays through the premium you know the premium okay i'm not saying they're not here but it you know if all the hospitals take a five percent increase then you know their premiums are going to go up by five percent there what they may pay to you may be the same because their deductible stayed the same things like that but but you know and i understand some things don't go up but and you know and remembering what tom said about looking at you know if you average it over two or three years it's been a we've had a lower than average increase the last couple of years no absolutely true but i also look at the balance sheet and strength of the balance sheet and the cash i mean you know looking just at this chart right the you know where you were pre-pandemic at two hundred fifty two thousand dollars to post-pandemic at or we're not post-pandemic i shouldn't say that sorry about that but you know we wish i know we wish we were post-pandemic but you know ending at three point two million you know this is very significant and as Doug said you know we've got we've been putting off a lot of capital projects that need to be done you know i mean things such the things that you keep putting off such as paving and all those things that really do have to be done to keep the facility safe for patients coming here so um yeah it's nice to have a few dollars in the bank um but we need to do some of that work too. I'm all set thank you thank you Maureen next we're going to go to Gordon member Holmes Jessica great well thank you both for the presentation and you know again for all that you've done for your community during this pandemic it's really appreciated um i guess i'm going to pick up a little bit maybe where Maureen left off on the rate request i just want to think through a little bit of this um with you so you're asking for five percent rate increase um in addition that you know this higher than your usual admittedly rate request is needed to cover escalating costs uh operating costs which i think you've made a strong case about um your inflation calculation and the appendix puts those operating escalating operating costs at three percent so when you're calculating your rate increase inflation is obviously one component three percent i understand the three percent of the five percent being simply just operating cost growth um some hospitals need additional rate to cover cost shift recognizing that not all payers are going to even you know accommodate that percent inflation but when i look at your payer mix um i don't see a lot of cost shift in there to the degree that medicare and commercial make up about 86 percent of your gross revenue payer mix and 92 percent of your you know net patient revenue payer mix and as you mentioned just before as a critical access hospital you're largely reimbursed at cost for medicare so really most of your cost shift is going to come through Medicaid which agreeably does not cover any inflationary costs but Medicaid's about you know eight percent i think of your you know NPR or so it's a very small component of your revenue anyway you have a small well it's i'm sorry you were just talking over each other i just need i'm sorry i didn't mean to do that no no worries so i'm just thinking about the five percent three percent certainly understandably operating cost growth help me think from the three to the five okay um so first medicare is the large you're right is the largest percentage payer for the entire facility and they pay one percent less than cost on all of their services at best they pay one percent less they're paying 99 percent of cost um so you've got to make up that percent number one just cover your costs on a large volume of business the Medicaid while you're right our actual net patient revenue i don't have in front of me but eight percent even seems low but you can't look at the net patient revenue you've got to look at the fact that medic you're right we're only getting a small percentage of our net patient revenue from Medicaid but the patients are a lot more than eight percent of our patients you've got to look at the gross about yeah your gross payment revenue at 14 percent Medicaid right so you've got you know that's a big percentage that you've got to take care of all those patients where you're getting less than half your costs back on um and truthfully not even the commercial payers don't even all pay in some cases they're full costs um but it's mostly the it is the cost shift to those Medicaid and the fact that medicare is paying less than the actual costs on the biggest percentage of our business and in the rural health clinic even is the reimbursement is even worse our cost per encounter in Medicaid because they subject it to a limit is paying about I think it's 40 percent of our actual cost on all our rural health clinic visits so we're actually I mean at some point it would be great to you know maybe a next year's budget trying to understand what component of your rate request is driven by cost shift so that we can start quantifying that impact across the state so just a you know future thought it would be helpful to think about how you would do that but yes I hear you yeah um we can talk about that maybe you know as the budget goes around um did somebody ask was I am I good okay uh so I guess my my next question is back in December actually Congress passed a new law that introduces a new rural emergency hospital medicare designation and some researchers are suggesting that small hospitals and rural areas that have net patient revenues less than 20 million dollars very low relatively low average daily census and and three years of losses might be the most likely to convert and I'm wondering if you've looked into this new designation whether it might make sense for grace especially given the capacity in the southeast corner of the state particularly as Dartmouth Hitchcock expands is this something that you've thought about moving forward at the moment we have not know um you know if Dartmouth expands and our average daily census is suddenly one or two rather than 10 or 11 which is what it normally is that might be worth looking at um I you know I'm also not sure that the reimbursement would be a whole lot different it's still a cost-based reimbursed system is it not as a way to keep small hospitals in business that don't qualify to be a critical access hospital is what I was under the impression it was so I don't really think it would from my understanding is it wouldn't really change the our actual reimbursement very much they're still only going to cover the cost of keeping the business open or the almost yeah I think it reduces some of the fixed costs because in patient largely goes away so some of the fixed costs of maintaining an inpatient suite is eliminated and it effectively becomes you know uh an emergency standing emergency room with some attached to it but maintaining an you know an inpatient um floor goes away and therefore the fixed costs associated with that go away but our intake we don't mean I'm sorry I'm sorry I didn't hear that Jessica I'm still getting overlapping voices there go ahead Jessica I was just saying I think that you lose some of the fixed costs associated with the inpatient floor and it may be you know given that you have rural populations where population is declining and it's difficult to cover those fixed costs it may be a designation that allows access to care and cost-based reimbursement so it's it's it's a new possibility for hospitals and as my question I guess largely is are you considering it and what would what would the factors be that would make you think that that's a good option well I would I would say this is this is obviously something we we are aware of but we have not done a lot of research into what that would mean for us so I'd have to say um we have not started our consideration of that as an option but that's not to say that we won't look at it okay great just as a question thank you my last question actually is around Mathematica's analysis so Mathematica did some in-depth analysis of potentially avoidable utilization at rural hospitals around the country and they shared some of their results with the board a few weeks ago now the results are only for Medicare fee-for-service but that actually is your largest you know payer group and their analysis actually show that Grace Cottage has the highest rate of admissions for ambulatory sensitive conditions in the state they estimated that 34 percent of your admissions are for ambulatory sensitive conditions the state's median was only 19.5 so these are admissions that could have been avoided with you know timely appropriate care so I'm wondering given your emphasis on primary care if this number surprises you do you track this yourself and if this number does you know make some sense to what you're seeing in your inpatient admissions what steps could you take to bring down this potentially avoidable utilization that does seem much higher than the state media I did I did see that data I was a little bit surprised by it you know it's something that we're going to talk about with our medical staff obviously you know we as administrators you know rely on our on our providers to make care decisions for the patients who who present to our organization and so I want to get some feedback from the medical staff in terms of you know whether they believe that there are some things we can can do to avoid some of those those interactions or to lower the cost of care for some of those patients so I think it's it's new data for us and we're definitely gonna gonna do some analysis great thank you very much well I'd love to hear any follow-up on that you bet thank you that's all my questions Kevin thanks Jessica next we're gonna turn to board member launch Robin thank you it's nice sometimes to be the last person to go because many of my questions have been answered but I I did have a couple of clarifications I wanted to ask about the first is it sounds like your utilization compared to 2019 which might be considered at least old normal who knows about new normal seems to still be down due to some of your COVID mitigation measures and you talked in your narrative about the cleaning and all and the reduced number of appointments I'm wondering if that sounds about right to you or if I missed something in reading that your materials Stephen you want to speak to that I admit I had trouble hearing the first part can you just repeat the first part oh sure sorry about that um yes I was just trying to get a sense of your current utilization compared to 2019 you talked in your narrative about some of the mitigation measures you are taking due to COVID which makes sense what we are seeing in some of the other hospitals is a bit of a surge from pent-up demand that kind of thing and I and it didn't seem like you were experiencing that so I just wanted to get a little color commentary about that yeah I think particularly in the in the rural health clinic um and I believe I talked about that but you know that's the area where we had the biggest limitation on the number of patients we could see by you know it's hard almost impossible say to put three patients through a provider in an hour they're mostly 40-minute appointments now occasionally they'll stick in a 20 but it's so I think that's another reason why even if we don't aren't able to hire the provide the additional providers I think our volume will probably increase some in the rural health clinic simply by being able to add even a couple more appointments a day to each provider being able to not have to have the as much social distancing thing like things like that um it also took a lot longer with patients you know when we were for instance say letting visitors come in with patients where normally quite often it's the husband or wife comes in with you to your appointment you know you can you get the patient who doesn't understand what's going on you can explain it to them well now they're got to go back out and explain it to the person waiting outside when they're done and it just makes the whole appointment longer um from an inpatient standpoint we really didn't have other than in the beginning when we were having to do COVID tests on all patients coming in that was limiting our ability to have the number of people in the building because all of those people had to be assumed that they had it for the first two or three days now that we can do instant tests that's much quicker um we didn't the outpatient during the actual initial parts of the pandemic yes rehab was very low and then rehab continued even after hospitals opened back up because it took a while for all those people that had missed their surgeries to have them and then need those services which is probably part of the reason right now that we have two rehab travelers and still have a long wait time honestly if you need to have an initial eval and follow up appointments to be able to get it done we just can't provide all the outpatient rehab services we need to provide right now thank you um and then my other question was could you and i'm sorry that i don't remember all of the details of your staffing but it is tough with 14 hospitals um but i wonder if you could put your vacancies in context so i know you said you were down uh in pediatrics to primary care docs family practitioners um but can you repeat the context of how many folks you have in in your rural health clinic the rural health clinic normally has about um rather than just rattle numbers off my head here hold on just a moment we normally have um we had a half to go back start with that with the ones that left the the two providers that were left were both half time a half time family practice and a half time pediatrics who had both been here for 30 some odd years and retired early to they're currently as we speak riding their bicycles from here to New Mexico very ambitious um but so we're trying to replace both of them um what we normally have in the rural health clinic hold on just a moment fte comparison we have a total in the rural health clinic practitioners fte total of we've had 10.96 in the current year and in those are all primary care with the exception of about two that are mental health and although pediatrics is primary care about 1.2 of that was pediatrics and then next year what we budgeted was only 10.4 um which at the moment um again is same amount of mental health and the rest is primary care great thank you that's very helpful um and that's it for me thank you robin i i don't really have any questions dugger steve but i do have a comment um you know when you take a look at the hospital infrastructure in vermont um much of what you see especially in your area of the state along the connecticut river and the i-91 corridor um reflects a time period with um that was appropriate for the geography and the infrastructure and the demographics of the time but you worry about it going forward and i would just strongly encourage you to be proactive in your planning rather than reactive steve had mentioned um you might make a different case depending on what happens after the bed tower opened at dartmouth and dug you had mentioned that you thought it would be a very positive thing and i think it is a positive thing as far as being able to make sure that patients are are getting um that hospital care but i i don't think that people have paid enough attention to the negative impacts of what that's going to be on the workforce and when you talk about um you don't see a way to get away from travelers this year i think that can be multiplied exponentially once that construction project is finished and open so i just strongly encourage you to you know to be reaching out to your feeders for your um new nurses and things like that because every possible thing that can be done to try to create that workforce is going to be necessary because you're going to get hammered yep i agreed okay appreciate the comment with that i'll turn it over to the health care advocates office for questions good morning can you hear me yes we can carly my name is kiley kiper and i'm here with sam pish representing the office of the health care advocates i just want to start by thanking you for your presentation and for all that you do for your community particularly during the pandemic um as you know we submitted several pre-hearing questions that primarily focused on race equity efforts we just wanted to use this time to ask you to focus specifically on how much funding in your current and future budgets have been allocated to diversity equity and inclusion and our race equity focused projects trainings or collaborations jog you want to answer that um zero from a specific standpoint yes we don't have a specific line item that is identified for any of those things um Doug can speak to all of what we're currently doing here as far as the committees and working to make people realize though we are totally inclusive from whether it be staffing or a patient standpoint um to make sure people are understand they're free and welcome to come here i mean we don't turn anybody away for anything of any type um but we don't have specific light items for that or positions higher just to do that it's all done by people within the organization could you speak a little bit about um how you assess uh the needs of your community as far as language access and um those types of things it's really um you know it's really based on on um actual experience um we you know we uh are small organizations so we can be very adaptable and so we're able to uh to monitor uh the needs of our community as it relates to um diversity and diversity related access issues we have a community health needs assessment that we do routinely where we ask our community whether or not we're meeting their needs and we prioritize the feedback we get from our community most of the community healthcare needs that are identified with the community are really about about direct care needs like um like chronic disease management mental health uh things of that nature very very few needs identified as it relates to ethnicity or um you know other non-healthcare related diversity issues um we're always um quick to respond when we do have identified needs as uh as steven mentioned we are working pretty aggressively right now on developing our organizational uh response to uh to um the needs of the LGBTQ community we're working closely with the human rights campaign uh healthcare equity uh index to try and get our organizations listed with them uh and we're in the process now of going through all of our written materials and doing some diversity training with our employees to raise awareness uh on how we take care of those those individuals with those types of unique needs and I think we're you know this is something that's relatively new for Grace Cottage but it's not new you know in terms of of communities across the world across the nation and across the state of Vermont so like a lot of hospitals we're starting to recognize that making sure that our community our patients our customers understand that we are a welcoming organization uh is really important to us and we're going to continue that work going into the next year it's one of our our new goals for our operating plan for 2022 okay thank you understandably a number of the hospitals have expressed concerns about taking on financial risk particularly through the ACO and in your response to the board's questions you wrote that you were looking for ways to minimize your risk if you participate in one care payment programs and you discussed that a little bit today we understand that there are different possible payment structures through the ACO but we are interested uh you being the smallest hospital what your thoughts are on the risk you take on uh if you were to take on fixed prospective payments versus the risk you take on currently through the fee-for-service payment structure well we we've we've looked at both sides of that of that knife and you know the the reality is we're just not large enough diverse enough or financially in a position to to take you know risk that other organizations can take because of the the small size of our of our hospital and so what it really comes down to is you know we we we believe that we have a very important role to play in lowering the cost of care in the state of Vermont primary care and and wellness is where it all starts keeping people healthy and out of the hospital is where cost control and cost containment starts and that's what we do best and so we want to we believe we can contribute and can help the ACO in its efforts to lower the the cost of care but we we just can't be in a position to share in the downside risk if um if the ACO is not successful in lowering the cost of care and quite frankly we have not heard a tremendous amount of positive feedback on the result that the ACO has been able to deliver as it relates to lowering the cost of care in the state of Vermont uh in in fact we hear more about what it costs to operate the ACO and or or or not hear about the what the costs are to operate the ACO because apparently that information is is confidential but um I think uh like all Vermonters uh we're beginning to to uh to question whether the ACO is going to be able to really achieve its long-term mission and until we have some comfort in knowing that the ACO is going to survive and is going to deliver on its objectives of lowering the cost of care in the state of Vermont uh our participation really needs to be guarded and we need to make sure that we don't add risk and cost to our organization because every dollar that we have at our disposal goes into caring for our patients we can't afford to pay uh you know bills to keep the ACO afloat if uh if its objectives fail and so those are the discussions we're having with the ACO and and you know we want to participate we want to help uh we think we have a role to play and hopefully we'll get there but they have to treat us a little differently than organizations that have more direct impact on controlling costs like UVM and some of the larger hospitals that have very very expensive programs and take care of very very complex and expensive uh uh care for the Vermont you know the the residents of this state hopefully I answered answered the question oh well uh that wasn't I mean I appreciate your answer and it was interesting what I was actually specifically trying to get at was um was what are your thoughts on budgeting with with fixed perspective payments versus fee for service I can imagine that there is different pluses and minuses uh if you were going to have a like a per patient payment that so you kind of know ahead of time or more of a global budget that you know ahead of time that doesn't increase or decrease based on volume versus the current situation where you get fee for service that does increase and decrease based on volume but it's less predictable um how much you'll be taking in I'm I'm I'm just curious as a small hospital as a particularly small hospital um what you see is the pluses and minuses of those two payment structures does that make sense I think so I think you just answered it um uh if we if we can if we can reach an agreement with the ACO where where for example if we enter uh as as participants in the medic and most organizations go in with their their Medicare patients first um and and if we know on a month-to-month basis what our payment will be for caring for our Medicare beneficiaries uh yes it simplifies the the you know the the cost accounting and and the program um profitability analysis um you know by by knowing you know what that reimbursement is going to be uh going forward and having adjustments you know from year to year based on actual um it does simplify things um and so if we can get them to agree to do that for us um uh we're willing to do that but again we you know the the one thing that that causes us pause is the the fact that um um there is a downside risk uh to uh to being in the ACO and we don't have any any uh excess uh cash to uh to to to put at risk for for participating and so we're trying to negotiate an arrangement with the ACO that treats us differently than a full service community hospital because we're not a full service community hospital we're much more like a like a like a rural health clinic or primary care practice than we are like a hospital and so uh our hope is that we can uh participate and be treated that way uh that makes us more comfortable and and I think that we're going to get there uh the ACO has been very collaborative and very uh accommodating to our concerns they understand what they are and uh they're working diligently to come up with a structure that will work for them and work for us Kylie might I interject just for a second here absolutely so Doug I just want to uh make sure that the record is right because everything is being transcribed and in earlier in your hearings um I believe it was Steven that talked about um looking at Medicaid but in your your answer that you just made to Kylie you mentioned Medicare several times yeah I'm sorry yeah Medicaid was really that Kevin thank you that's like not and it's it's a common mistake but I just want to make sure the record is accurate and so yeah I wish we didn't both start with an M it would be a lot easier yes but you know Medicaid was really meant not Medicare thank you yes thank you for that clarification I have no further questions and did Sam have any questions Kylie nope I believe that's it for us no questions great so next I'm going to turn to public comment on the Grace Cottage budget presentation is there any member of the public who wishes to offer comment at this time if so either raise your hand in the team's function or just begin speaking and hearing none I want to thank you gentlemen for a good presentation this morning and your thoughtful answers and at this point I'm going to place the Green Mountain Care Board meeting in recess until 1022 for a 10 minute bio break at which time we will commence with Springfield Hospital hearing thank you everyone