 So I'm going to just start by convening the meeting and welcoming you all to the North Country hospital budget hearing. What we will do to start is we're going to turn it over to you North Country to for your opening remarks. If you want to just quickly. Introduce your team as well. That's terrific. So, but before we do that, Russ needs to swear you in. So, Russ, you want to take it away? Thank you acting chair lunch and good afternoon for the North Country team. I have a list here, I believe, but could you just confirm who will be presenting and answering questions today? So, it'll be myself, Tom Frank, Tracy Paul, Denise Carter, Dr. Greg Walker and Steve Wright. Great, thank you. If you could all raise your right hands, I'll swear you in. Do you solemnly swear that the evidence you shall give relative to the cause and under consideration shall be the whole truth and nothing but the truth. So help you God. Great, thank you very much. And I will turn it over to you for opening remarks. Thank you. My name is Tom Frank and I'm the president and CEO here at North Country hospital. I've been back in North Country in this role since mid April. Prior to that the last 3 and a half years I've spent at a Rutland regional medical center is their vice president of medical group operations. So, I'd like to introduce our team immediately to my left as our interim CFO and the CEO Tracy Paul. Next to Tracy is our interim CFO, Denise Carter. Immediately to my right is Dr. Greg Walker, chief of anesthesia, Med Staff president, and also a member of our board of directors. And next to Dr. Walker is Steve Wright. Steve is our vice chair of our board of directors and the president and CEO of JP Resort. So with that, I will kick it off. First of all, thank you very much. Remount Care Board and our health care advocates for allowing us to present you our North Country budget. As an introduction, I just want to remind folks where we're located. We are in the Northeast Kingdom, the ruralist of the rural. We are in Newport, Vermont. We are 45 miles from the nearest hospital in two hours on a good day from UVM in Dartmouth. Travel is obviously a challenge for us here in the Northeast Kingdom. To get anywhere, it's never easy. There is obviously no public transportation, no buses, etc. We take care of our own here in North Country. Based on the statistics that you provided us, it just reinforces what we already knew that 91% of our discharges from the hospital are folks from our community. That's the highest percentage of any hospital in the state of Vermont. We have a very challenging payor mix. 70% of our payor mix is government, either Medicare or Medicaid. We have a very small portion of that that is made of commercial. We have an elderly population in an aging state. As you heard from NVRH, we are the oldest area in the state of Vermont and not getting any younger. Our community health needs assessment highlighted four issues that we are trying to deal with and we're dealing with in this budget. Housing, which is always an issue and it is throughout the state of Vermont. Jobs. Not only is North Country the healthcare hub for this community, we're also an economic engine. Without North Country Hospital, I can't imagine what the unemployment rate would look like considering it's already the highest in the state. Urgent care facility was one of the items also highlighted. Partnering with our FQAC, Northern counties, we have established that urgent care in downtown Newport. It's doing exactly what we hope it would do. It's pulling folks that don't belong in our emergency. Yes, it's pulling folks out of the ED that don't belong there and they're going to the urgent care. Although it is definitely doing its job, it still requires subsidy. We're averaging a subsidy to the tune of about $30,000 a month. Substance abuse. Substance abuse is not, it's not just the Northeast Kingdoms. It's all of Vermont. In fact, it's the whole country. We're doing what we can, working with our providers to assist any way we possibly can. Current challenges. A year and a half ago, we implemented a new EMR from CERNA now Oracle. It's not something that we wanted to do. It was something the organization had to do. Our former vendor pulled out of the hospital market and is only focused on outpatient or clinics. So it was necessary for us to invest in a new EMR. Unfortunately, that implementation was a disaster. It's created huge financial burden on this organization that's not necessarily in our control. Last year, year-end, we wrote off $6 million of uncollectable bills for a critical access hospital, as you can imagine, that's a lot of money. We're still not where we need to be with our EMR. Our days in AR, a year and a half later, are still in the low 60s. With our former vendor, we were in the low 30s. It's getting better, slowly, but it's taking time. We're having to use external resources to assist our internal team for both coding and collections. Finances, year-to-date, we've lost $2.8 million. That's the bad news. The good news is that we've stabilized and that's the theme of our budget stabilization and improvement. For the last five months, we've either broken even or showed a slight profit from operations. That's huge considering where we are without our billing and collecting. On top of that, for the first time in almost two years, we've shown a positive even a year-to-date. It's small, but it gives us some light at the end of the tunnel. Administrative rebuild. We've been through a lot here at North Country over the last year and a half, not just our EMR. When I arrived here, we did not have a CFO. We did not have a compliance officer. We did not have a VP of human resources. Our chief nursing officer two months into my tenure, her family received an amazing opportunity in North Carolina and they moved. We're doing our best to rebuild our team while we put our budget together and turn the organization back to profitability if possible. Denise is serving as our interim CNO. Tracy is moving back to her CO role as we were able to find and hire a qualified quality CFO who begins after Labor Day. Our CFO will also handle the role of compliance officer. We've made a difficult decision in this budget process to eliminate the VP of HR role. And we're looking at a second VP position that we are more than likely going to eliminate as well. It just means a little more work for the rest of us. Primary care, physician recruitment, it's one of the most difficult things we do. The services we provide in this budget and what we provide to our community is just meat potatoes. Primary care and primary care related services. We're not an orthopedic hub, we don't have boutique services. We just try to supply what we can to this community. Primary care positions are one of the most difficult recruits, not only in this area but in the entire country. A typical primary care physician has a panel of 2,000 patients. We've recently lost one of our primary care physicians to a direct patient care model or cashier practice. A practice that doesn't accept government payers and caps their panel at 650. That individual will be now working out of the St. Johnsbury area. We have in our budget a low-come physician with a cost of approximately two and a half times of what it would cost us to employ our own physician. Based on what I have seen and what we've worked on since I've come back in full cooperation with our med staff and our board, we've developed a set of pillars that this budget hopefully addresses. Over the last several years, the organization, as I've just described, has had some struggles. We've had a change in administration, we've had an EMR disaster, we've had coming out of COVID. The number one pillar that we need to really work on and continue to move forward with is our morale and our culture and our reputation. It's suffered recently, we're doing some great things to turn that around. If you walk into our hospital today, there's a very positive vibe because everyone's on the same page. Denise is going to talk a little bit about that and one of the things we're doing when it's our turn to present. Quality. Quality is job one. You've heard it everywhere. I'm not going to say that our quality hasn't been good, but it has an opportunity for improvement. But when your reputation is taken ahead and your culture is not where it needs to be, it's connected to quality. So we've made a major effort there that we're improving our quality situation. Staffing. At one time, we're the employer of choice. We need to become that again and we're working hard to do it. We can't compete salary-wise with Chittin County or some other areas in the state. But what we do is we really focus on benefits and we have folks look at total income. So we've held a line on our health care cost passed on to our staff. Our brokers tell us that we have a platinum health care plan that we offer our employees. And I'm told it's the best of any hospital in the state of Vermont. We have approximately 600 FTEs in this organization and a total of 7 to 800 employees. Almost 500 employees take our health care plan and it does not include their families. Access to care is an absolute priority in this organization. We have to get our folks in the door. We struggled with access and primary care again due to our new EMR and the difficulty in our folks being able to utilize it. We've had to bring inscribes. We're using artificial intelligence as a help. But it's driven down the ability for us to see patients. Two things that we have done though in our new Port Clinic and Barton Clinic is we have a mid-level nurse practitioner who's seeing acutes. So if you were to call primary care and want to see your provider, we may not be able to get you to see your provider. But our goal is to get you in to see a provider. Again, keeping folks out of the ED and doing our best to meet the needs, the health care needs of our community. Financial discipline. We have moved away from some of the financial discipline that existed here historically. Our goal is to get back to what we need to be. We're beginning that process now. In order for you to bring forward a new position into our organization, if you want to add a position, it has to be the increased access, pay for itself, or you need to find a way into your budget to remove an equal amount of expense in order to even be considered to add a position. We've asked our staff, when it's non-clinical, to lag positions. So if we have a position in our IT department that moves on, how can we for a period of time not post and add that position and just do ourselves? We monitor over time on a regular basis. Every organization needs some over time. It's when you get that situation where it's too much over time. That's when we know we need to add that position back. Business plans, return on investments, all of that is coming back to this organization. We have some work to do. Our positions aren't immune to being held accountable for financial discipline. We have a physician compensation plan that was created several years ago that hasn't been followed in the way it should be. Our positions are now back on that comp plan and are being held to access and productivity standards. Infrastructure, our hospital was built in 1974 and it's a 1974 facility. If you've never been here, I certainly would welcome you to visit. It's a beautiful hospital. It's clean. But like many other facilities in the state, it's aging. If we can't in the future generate a positive margin, we can't invest back in our organization. That's what we do. Every penny that's earned goes right back into our facility. Right now we're adding a $3 million addition to our emergency department. That addition isn't to generate revenue. That addition is for our patients. We have mental health holds here on a regular basis, just like everyone else in the state. We've been putting patients in hallways, et cetera, because we don't have the space because we can't transfer certain types of patients. We struggle with transferring patients to both UVM and Dartmouth as well as they're facing the same struggles we have. So it's necessary to build this ED addition, but not to generate more revenue. This budget was created with full transparency to the entire organization. As I had said, Med Staff, Administration, and our board have been intimately involved in building this budget that meets the community needs short term and address some of the pillars and our health care assessment that I described to you earlier. We continue to invest in primary care and we'll continue to do so because that's ultimately what we need here in the Northeast Kingdom. We've recently had a higher cardiologist and we've added them to our Med Staff. Historically, for 20 plus years, we're able to contract with Dartmouth for two or three day a week cardiologist. Dartmouth can no longer provide us that service. We have to take it on ourselves. With our aging population, the need for a cardiologist in this community is immense. Unfortunately, hiring a cardiologist is not a cheap process. It's a very expensive hire. It doesn't only require the cost of the physician, but it also does the infrastructure in order to meet the needs of that cardiologist. On average, it takes about three years for outpatient physician to build a successful practice. That means for the first two to three years, we have to supplement the cost of that practice with other resources. Urology, another service that we have in place here because of the population and because of what we need to provide. Again, historically, we're able to lease or contract with the University of Vermont Medicine Center for a two or three day a week urologist. They can no longer supply that urologist to us because they're facing the same exact challenges that we have. That hospital, UVM, is critical to the state of Vermont and it's critical to critical access hospitals like us who can only do what we do and only take care of who we can take care of. That's a practice that we call a lost leader. We do not make money on that practice, quote unquote. We have to find other ways to support those services. Collaboration, even though we're the ruralist of the rural, we work with as many organizations as possible to take care of our patients. We can't do it all ourselves. No hospital can. A few examples with the University of Vermont, we contract for a pathology services. We have dialysis here in the Northeast Kingdom and we just developed the program with UVM around Tallinn, NICU. Dartmouth, one of the main things that we work with Dartmouth that in collaboration is through NIA, our purchasing agent. That saves us tremendous amounts of money that we don't have to pass on to our customers, our patients. NBRH, we have an LLC with NBRH. We built a sleep clinic and down in St. John'sbury about five years ago. That clinic in St. Jay is staffed by North Country personnel. Contestering myself, continued to have conversations around what services we can work together to offer to the Northeast Kingdom. Northeast Kingdom human services, we've co-recruited a psychiatric nurse practitioner who spends four days in our clinic and one day in theirs. There's not enough mental health services anywhere in the state, let alone the Northeast Kingdom of Vermont. Northern counties, our FQAC partner, we talked about our urgent care facility. We've also had discussions around how we could work together around primary care and how we can improve that service for the area. We even work with Upper Connecticut Valley Hospital, a small hospital in Colbrook, New Hampshire. When we have access, capacity and our general surgery, they contract with us to provide some general surgeon services to them. So in closing, I just really want to make clear that this budget is really about us being able to stabilize where we are. We know that it's incumbent on ourselves to help with our financial situation, not just about asking for a large fee increase. Our fee increase asked this year was 4.5% with a break-even budget. That gives us the leeway to be able to do the things internally that we need to do to help us generate, hopefully, a margin in the future that we can reinvest in our organization. Thank you. I'd like to turn it over to Tracy to talk a little bit more about finance. Thank you, Tom. Good afternoon, everyone. As Tom has mentioned, North Country Hospital is the main source of healthcare here for our community. Over the past year, we've treated and discharged 1,400 patients from our inpatient floor. We've had 53,000 visits to lab radiology and other healthcare services. We've had 14,000 visits to our emergency room. As Tom mentioned earlier, Northern County's Express Care started in July 22, and we thought that it would decrease our ER visits. It hasn't, but it has shifted. As he mentioned, the lower acuity are going to the right place of care, and we are actually seeing higher acuity patients in our ED. We've had about 50,000 visits to our hospital and practices, which are made up of primary care and specialty practices. Our friends and family here count on us being here to provide those services for them. As Tom said also, Fiscal Year 2023 has not been easy financially for North Country Hospital. We have been trying to stabilize this year, and as he mentioned, we're at $3.4 million loss in January. At the end of July, we're at 2.8, so we have made up some ground in those six months. It was a huge undertaking. It involved everyone understanding what the gravity of our financial situation was. It was a collaborative effort with administration again, and the board and the medical staff talking about what we could do to help our financial situation, and we're making progress. The rate increase again will continue the story of our stabilization and help us to move forward to sustainability. The budget does reflect a break-even, but the amount of financials seen, it shows, will generate cash to be able to invest back into our facility. For Fiscal 24, the ask is 4.5%. Five out of the last six years, we've presented budgets. Our rate increase has been 4.9% or below. When we were putting together this budget, obviously, we looked at what our community could afford, but we also had to be able to continue to provide the care we need to provide. Our prayer, our parents does greatly affect the rate increase ask. As you know, Medicaid and Medicare very minimally share in that net revenue increase and our percentage is 70%. Medicare advantage plans are also growing in this area, and the costs associated with those are not part of our cost report. So the rate increase of 4.5% equates to approximately $2.8 million for the hospital. So the breakdown of how that translates into the budget. Basically, 34% of that is for salary and benefit increases. We put a minimal 2% increase for our staff, effective April 1, and a 2% increase in for our physicians to align with the MGMA benchmarks. 26% of that amount is for supply cost increase. 14% of it is for expenses we have no control over, an increase of provider tax and ACO fees. And the last 26% is made primarily of costs that as Tom mentioned earlier also about our implementation issues we had with our new EMR. We have using an outside billing service and we had to draw on a line of credit that we're paying interest on that had to be built into this next year's budget. As we're on the road to sustainability, we know we have to work on our cost containment. Salary and benefits are 61% of our total expenses in the budget 24. But it comes to the benefits. We chose not to increase premiums for this year. As Tom said, we have a first rate health insurance plan. We had to make a choice of passing on the added costs to our employees or not. We decided against it. We incorporated a small wage increase this year and did not want to offset it with health insurance premium increases. In regards to the salary, we're working on lots of ways for cost containment. We have position control as Tom mentioned. We have business plans that are being done before providers are hired or services are changed. We're delaying asking our managers and directors to do more with less. You know, sometimes great efficiencies are realized out of necessity or by someone else doing the job and we have seen that. Staff salaries are benchmark to ensure we're competitive in the labor market. Administrative and director salaries are benchmark to the Northern New England Healthcare Compensation Survey. Our administrative salaries are at the 35% of the benchmark, well below the median. Physicians and APP salaries are benchmark to MGMA. As I spoke to earlier, we are giving minimal raises this year. We have done a lot of work in the last two fiscal years to on salary adjustments for recruitment and retention. This year, we put a small wage increase in in order to keep our rate requests low. Every time we have a vacant position, we look for cost saving opportunities. We have conversations on a daily basis with our directors about if the position actually has to be replaced or can we do a half of an FT instead of a one? So those conversations are ongoing. We have realized some savings by changing some structures of departments like Tom had said earlier. As far as other benchmarking, historically we used a product called Premiere for our benchmarking for our staffing. Post COVID the decision was made to discontinue this, but we will be reestablishing this premiere in this organization. There's been some great work done to reduce travelers across the organization that you can see in our numbers. My colleague Denise Carter will talk about that in a moment when it's her turn. So in regards to the rest of the expenses we can impact, we're part of NIA that saves us about $300,000 a year in med supplies. It also provides education and support to our material management department that we don't have to pay for. We are aligned with Vizient as our primary GPO. We have a defined process for approvals for our capital purchases. We have been on a capital freeze for almost a year now. We really need to be able to start purchasing items. As Tom had mentioned, we're in old plants and we need to be able to do some capital purchases. We've frozen external education and travel. One thing we are aware of multiple grants that exist out there, but we haven't had the resources for people to pursue them. We've placed a vacant position in our HR department and this individual had experience in both human resources and grant writing. So we're going to allocate this person one day a week to work on grant writing and help our directors capitalize on opportunities we haven't been able to before. Contract services, including service agreements, is about 11% of our total expenses. We have a robust contract management system to monitor these contracts for the services, the cost, and the quality. So those are things that we are doing on that side. Now I'd like to switch my gears from a financial standpoint to a community standpoint and let you know about a couple of great things that's happened in our community that the hospital helps us support. I personally grew up in this community. I have worked at this hospital for 26 years. I'm very proud of the work we do here at North Country and what we do to help our neighbors in need. One of the things we support is a program, Veggie Van Gogh, that I'm sure you guys have heard of. It's in partnership with the Vermont Food Bank. Once per month it comes to Newport and we serve 650 families every month on average. We also do a program called Health Care Shares that we support. This is in partnership with the Vermont Youth Conservation Corp. They grow this produce in a farm in Richmond. It's veggies and fruits that we can supply. It's an eight-week program that runs through July and August and it serves 64 families. These families are people from our primary care practice that either have health-related, diet-related health issues. Or have expressed food insecurity in the past. Both of these programs greatly help our families in our area. We all know that the price of fresh produce is high and it's really difficult to purchase on a limited budget. This supplements them for a lot of people in our area. I want to thank you for your time today and I'm now going to turn it over to Denise Carter, our Interim Chief Nursing Officer. Thank you Tracy. Thanks everyone for the opportunity to share our story today. Anytime there's a change in a key leadership role in health care such as the CNO, there's always a challenge of making sure that doesn't have a negative impact on employee engagement and morale. The nurse leaders met once our CNO resigned and we talked about the need for one of us to step into the interim role with Tom and Tracy's support. That's me and we did that because we wanted to maintain the changes and the momentum that we have started within the nursing and the patient care services. In last March, we created our first nursing strategic plan and it supports the hospital's overall strategic plan. One of those pillars is the employee pillar. That's an important pillar for us because we want to improve employee engagement and morale because that helps to improve the quality of care that we provide. One of the things we're doing to improve morale and engagement is we created a group that meets monthly and it's called the CAPE Crusaders. CAPE stands for caring about patient and peer experiences. We meet monthly, as I said, it's all departments are represented and we talk about ways that we can improve not only the patient experience but the employee experience. We do that through managing up and that is creating, talking about departments and each other positively. By managing up, that creates confidence in that patient when we take them to the department or hand them off to the next shift and we introduce that person and we assure them they're going to receive great care. That improves their confidence in the care they're receiving and it also decreases their anxiety because they're anxious to come to the hospital for a test or procedure or an inpatient admission. By creating a positive work environment, we also improve retention. Because with a positive work environment, people want to work here. They want to be here. They want to be part of something meaningful. It also helps with recruitment because as our employees and our team members are out in the community and talking about what a great place North Country Hospital is to work, then people want to work here. For the past 15 years through our partnership with Vermont State University, their school nursing program to grow our own. We have been their site for their daily didactic sessions for their clinical rotations and their post clinical sessions. Every year there are nine RN and nine LPN spots available. This week began their new school year and we have eight RNs and eight LPNs in orientation here. After graduation, if they choose to work at North Country Hospital, they would begin our nurse grad residency program. It's a program that we started seven years ago. It's a year long program where the new grads meet on a regular basis on a monthly basis. They learn new skills. It's also kind of a support group where they talk about challenges and things that they're encountering in their work. And through that year long process, they develop good relationships and that helps with their foundation and being a nurse because healthcare is difficult and being a nurse is tough. And so it's good to be able to support each other. We also partner with VSU with our respiratory therapist with their respiratory therapy program and we provide clinicals for respiratory therapy students. Through this partnership, we successfully filled vacant positions and we've been able to decrease our travelers. Another pillar of our strategic plan is quality care. And everyone is focused on providing quality care. We look at best practices, review the literature, we look at what we can implement here to improve patient outcomes. We also encourage our staff to report safety and quality concerns. If something's missing, if an outcome, if we had an unexpected outcome, whatever it is, but to report that through our incident reporting system. And then daily on our leader huddle call, we look at trends and we report those. Any patterns or any trends that we see. And then monthly in our patient care leader meeting, we deep dive into those trends and we look at where do we need to make changes? Where is the gap? Is it in knowledge? Is it in skill set? And what can we do to improve the quality of patient care that we provide? Another pillar in our strategic plan is stewardship. Financial discipline, as Tom mentioned, is all of our responsibility. Within our patient care leader group, we found that there was a gap in knowledge about finance and budget processes. So we started monthly meetings with our patient financial services to look at our department variances. We're also looking at costs and things that we can do. And that's in our control changes that we can make. Every pay period senior team, we look at overtime during senior team meetings and premium pay. Our leaders are held accountable to decrease those costs. And then we're working with materials management or materials management department and looking at how we can streamline costs and supplies and supply cost. We started in surgery in the emergency department and just one example, nasal packing in the ED. We had two different boxes. One box and one brand cost $234 a box and the other brand cost $89 a box. So guess what? We're stocking the $89 a box nasal packing, same quality, just different brand and less cost. And then access, as Tom mentioned, urgent care was built and we thought that would impact our volumes in the ED, but it hasn't. Thankfully, it's impacted in the right way that we're seeing the higher acuity patients. So we have space for them to feed them timely whenever they present to the ED. And the lower acuity patients are going to express care or primary care to be seen and treated timely. But daily, we continue to have challenges of capacity in the ED, even with the help of the express care. For example, we had an inmate from the prison that was brought here to be seen. They had a full workup, the physician determined they could be discharged and then when the nurse called the infirmary, they refused to take the prisoner back. So a few hours later, the ER physician called the medical director and he refused to take the prisoner back. So for 36 hours, we held someone who did not have a medical need and took up a bed that we could use for someone that was acutely ill. We partnered with Northeast Kingdom Human Services for our mental health patients. We medically cleared them and then they looked for an inpatient bed for them. It's not uncommon to hold one or more patients waiting for an inpatient placement. And then that decreases our capacity to be able to see other patients, acutely ill patients or trauma patients. We also partner with Journey to Recovery. They have a care bed in our community for people who need to detox safely. So the patient presents to our ED, they're medically cleared. We call Journey to Recovery for them to assess. And if the bed's available, then they are discharged to Journey to Recovery. And if not, then we hold the patient until they are, until they do have a bed and they can be safely sent to Journey to Recovery to Detox. On our inpatient progressive care unit, we've been challenged with patients who need long-term care facility placement. The nursing home in our community closed last year and that's really diminished our resources and our ability to find placement for our skilled patients. It isn't unusual for half of the patients on our progressive care unit to be skilled and in need of a long-term care bed. Last January, last January 12th, a patient was brought to us in the ED after her son had passed away, who was also her primary care provider. She had no place to go. She had dementia and could not live along safely. So she was brought here. We admitted her to our primary, to our progressive care unit. And on August 10th, surrounded by the progressive care unit team who had become her family, she passed away. We were not able to place her. She didn't have a payer source. And so she lived her last months with us. So that's what we do. We take care of our community. That's who we are. But the holds and the skilled patients on the inpatient unit really limit our capacity for patient throughput and to see patients in the ED. Finally, I just wanted to say that last December, I moved here from Kentucky. I relocated and it wasn't because of the fall leaves, although that was a plus. It really was because of this community, this hospital, and I just wanted to be part of this team because day after day, our team members show up for our community to provide the best care possible. So now I'm turning it over to Dr. Walker. Oh, it's all you. Good afternoon. Yeah. I was on call last night. I don't know what time. Anyways, thank you for all your time that you guys put into this. I take my hat off and throw it up that you put into this. I'm going to sort of springboard off what Denise said. I, you know, as Tom mentioned, I'm a medical director. He all are and he's in department. I'm president of medical staff and I'm on the board. But in addition to that, you know, this is my home. It's been my home since I've been nine years old. I grew up here. I went to grade school here. I went to junior high here. I went to high school with Tracy. I'm older than her. And so this is, this is my home. And I went to UVM for undergrad. I went to UVM medical school. I did go off to Pittsburgh, Pennsylvania for all my residency and internship. But I came back in 95 because my mom was on the board here and they needed an anesthesiologist in the worst way. So I said, all right, mom, I'll come back for a little while. And 28 years later, I'm still here. So this is, this is my home. And because it's my home and I grew up here and I've worked here for 100 years, it's safe to say that I know this community. I know the people here. I understand the people here. I am one of the people here, you know, as is Tracy and then actually our CEO has been coming to this area since 1970s. So even though he was born down south, he is a local as well. So, and the majority of the people that work here at this hospital grew up in this area. They, it's their hospital, you know, this hospital is supported by loans. And, you know, through the years, especially since I've been working here, I've really come to understand how important this institution is for this community. I cannot imagine this community that has its challenges in many other ways. If we didn't have this small of a community hospital, I mean, I just cannot imagine it. And when I, I've worked at some other places as doing some temporary money and three kids in college need mixed money, money, et cetera, type of thing. So I've seen other places around it. And, you know, we are, we are a true community hospital. We really are. We're not just a little Band-Aid station. We're not a specialty hospital. We are a true critical access community hospital with the primary goal of providing care for our people here. And everybody here recognizes the challenge we face in doing that. I mean, as you guys know, we're the most economically challenged, depressed area in the state. And with that, a lot of our folks, if they didn't have this hospital, they wouldn't be able, they wouldn't get care. It's, yes, we have the tertiary cares and things like that, but a lot of folks have been on that car. We don't have a car. We don't have public transportation. We're very limited. We have RCT, which thankfully we have, because it does help get folks to our hospital. But if they didn't have this little place here, it's not going to go somewhere else. They just wouldn't get care. And that's just a reality. And a lot of our folks to travel, it's just too overwhelming and they don't have the resources, which is just a reality we face here. Now, despite, you know, let me get in the area with minimal economics, we do have some economic engines here, but not like a lot of the other parts of the state. Despite that, we still have this great little hospital. And, you know, and through COVID, we had a lot of locums come through here. And there wasn't every single locum that came and worked here just would compliment us on what great care we give at this, at our hospital. A lot of them said, Jesus, you weren't so rural. I'd actually, you know, consider moving there. I'm for, you know, that's just a reality recruiting. This is our rural physician. But, you know, it was nice to see that, hear that, and it made me feel proud to be a part of this. But, you know, so how are we able to keep this great little hospital with provided great care? I haven't been able to keep this going with minimal resources. And one of the biggest factors here are the people that work here and how hard they work. And I know you probably hear that from every hospital that you talk to that the people are the main resources, but I can't help but emphasize the fact that here, we really from from the nursing staff to the med staff to the administration to the support staff. We have people that do the work of three people. We do more with less here and we've always done that. And that allows us to, you know, I had an old man that used to say no patients, no money, no money, no patients, you know. And then by us working harder, taking people basically just accepting the responsibility of needing to do more, we've been able to keep this place moving forward in a very positive way. Another reason why we're able to move forward and provide great care and provide excellent care to our community is actually the collaboration that goes on here. We don't live in little silos here since it's not the med staff over here and the nursing staff over here, administration board here. We have an amazing collaboration that happens here. We solve problems together. We don't ever say much their problem, but then do we figure things out together, which is just another reflection of how our whole hospital works together from from the maintenance guys to, you know, I know along or all friends and if I know like there's something in the and I'm probably right up, you know, and we figure it out and we work with the nurses and, and then we say, I don't know, I better give Tracy a call too. So she come, you know, and that's how we work here. We are a true, true team here, but that that itself lends us to be able to, despite, like I said, our limited resources sometimes to still provide great care here. The one of the things that happens here is because of the type of the folks up here with their limited resources and stuff and in their inability to travel and sometimes just life for them we see a lot of sick people here at our hospital. An awful lot of sick people. One of our surgeons who just recently started part time retire and keeps threatening to retire full time, but he comments that it's amazing the pathology that we see up here. It's just amazing advanced pathology. And we know so these patients present to us and because of the tertiary care centers being overwhelmed with their own situation stuff. A lot of times we're forced to take care of these very sick people. I mean, we, you know, going through COVID we accepted that reality that, you know, we need to do this and transferring patients a lot of times is not an option. So we have to have the resources and the skill to take care of these people and and people have stepped up and we do the best we can and sometimes it means just stabilizing these folks for something. It's really out of our way. You know, we shouldn't be doing these here, but we're doing our best until the bed opens up. Sometimes we can actually see that care completely through. And we're contained. Denise and I and the whole medical staff are working on getting our nurses more skilled to be able to take care of some of these problems. So we don't have to rely on the tertiary care centers as much because we learned it. So now you just can't we need it. Somebody needs to take care of these, you know, you know, we had to, you know, it's crazy when we have to be calling down in Hartford, Connecticut and stuff to try to get people transferred down there. It's really a challenge. And so it's we're grabbing the bull by the horns here. My apologies, Dr Walker. I just wanted to note that we'll need the team to wrap up soon because we do need to move on to questions and make sure we have time for public comment and and such. So I don't don't didn't mean to cut you off. No, no worries. So, yes, so the but so basically the budget we're presenting here is it's a reflection of a true collaboration between clinical staff, hospital staff, hospital board. It reflects the hard work for staff. It really doesn't reflect the inherent Yankee frugality. We bring to everything that we do here. And it reflects the final cost, financial cost of being actually a true, a true critical access community hospital. I mean, that's what we are. And I really, I just hope that, you know, you can help us support with this budget and help us help us support the people of our area. Thanks, Greg. Steve will have a couple of ending comments for us following the question that's occurring. Thank you for indulging us. No problem. We're we welcome learning about your hospital. So I'm going to turn it over to Sarah Lindberg now to walk through the tool and the metrics. All right. So thank you so much. You know, one thing that's always struck me about our interactions is you're clear about the work ahead and don't shy away from how difficult it is. So I appreciate your being forthright about the improvement you're tackling. So North country does come in at a relatively higher growth in the NPR from fiscal year twenty to twenty four. However, I noticed that the expense growth is under that benchmark. So just just under that not we know there wasn't an official benchmark for operating expense, but we see that that is relatively less common among this peer group. And we also see the third lowest I think the third lowest charge change in charge increase. So that indicates to me that this budget isn't being driven by a commercial rate increase. And when I, you know, you spoke to it, finances have been extremely challenging for North country over the last few years. And we see, you know, a moderate plan for recovery. And I would say that, you know, you notice that North country was fortunate to have a substantial reserve of cash to help absorb some of that challenge. And I think that that's one of those tricky things when we think about trying to stabilize rates and reduce the impacts of some of these situations that that's one place where having reserves can be helpful. So do you are your kind of longer term plans going to include being back to that level of cash, do you suppose? Or is that too soon to tell? Well, you know, that's, Sarah, that's sort of the plan. Obviously, we want the more cash, the better, but we want to begin to take some of that invested back into the organization, but we have to be stabilized on a, you know, an annual bottom line perspective before we want to necessarily lead that cash for improvements into the organization. Yeah, that makes sense. And when I look at your labor costs, so again, this was just looking at what the per FTE compensation was in 2017, just trending it ahead by that employment cost index. And we see that in 22 North country was right there. A little bit of a depletion in your salaried FTEs. I'm sure that's some of the pandemic and other great resignation pressures. And I had, I really appreciated the details about how some of the position management controls and wanted to ask specifically about the premier being back in the mix. Is that going to be in fiscal year 24 that comes back online? I missed that part. Well, that's the whole, you know, that's our plan. It's a great program. You know, I know that we helped bring it down to Rutland, but they're utilizing it now. It saved this organization a lot of money in the past and there is opportunity to engage with premier. Right. Okay. Thank you. And as far as utilization goes, you know, the bounciness here largely is due to small numbers. So anytime you're dealing with small numbers, you're less surprised to see super bumpy graphs like this. But one thing that I think I had kind of missed is you have a pretty stable range of your operating expense growth. So despite, you know, saying that you've got a lot of work to do in ahead, I just think that's a testament to some longer term operating expense management. I'm not seeing a ton of like super dramatic bounces there. So I think, again, given the small numbers that stood out to me, you got it kind of the rebound of ED utilization and spoke to the question I had about the urgent care. So you got ahead of me there. And when I look at your kind of in and out migration, first I do notice that unlike some of the other facilities, you didn't seem to have quite as a larger rebound in utilization in fiscal year 21. And I just wasn't aware if there might be anything specific to that fiscal year that kind of hampered the return for you folks up there. I guess, Sarah, what I would say, I think things hit us a little later up here because that seems to be the case. So I think maybe a rebound was a little bit beyond, you know, behind the curve. And also, you know, we never really got too low. So the rebound, you know, proportionally what it was less, right? Because we were very fortunate and we were not hit as hard by COVID is why a lot of a lot of our other hospitals were. Yeah. Yeah, that makes sense. Yeah. And, you know, as I read this chart again, so this would be all folks who live in the Newport service area and the bottom part being the dollars that kind of stay within the service area, whether or not they're going to North country hospital. But when I see this dip in traditional Medicare from 21 to 22, the first thing I start to think of is Medicare Advantage. So I didn't know if you wanted to speak about some of the challenges you're facing with that transition in your community. Yeah. I mean, Medicare Advantage is definitely, you know, on the upswing up here. And I, you know, I hear at our utilization review meetings, I hear a lot of challenges regarding the Medicare Advantage plans and what, you know, the case managers and the physicians have to do in order to try to get claims paid under the Medicare Advantage plan. So I think that's, you know, that's the biggest challenge that we have. It's the resources we have to invest to even try to get the piece of the reimbursement that they're going to give us in the future, you know, some of the frustration that goes along with that for the care of the patient. And I will say also patients, I think oftentimes get confused and they think they have Medicare. And in reality, they don't. They have a commercial product. And that's exactly what Medicare Advantage is. Right, right. And my understanding is that once successfully implemented that EMRs can help along the way and tracking down some of that revenue. Is that still the hope on the ground there? That would be the hope. That's not strategy. And again, you have a fantastic case manager team that are really, you know, on top of all this. And so, yes, it's just a lot of work. Yeah, yeah, yeah, I, we've heard that more than once. And then when we look at the cost report. So among the small rural hospitals, you, oops, that is not your comparator group. I was like, wait a minute, there's not enough dots here. Okay, there we are. So there is North country between the 50th and 75th percentile. So kind of midsize among the critical access hospitals in terms of volume. And I was seeing that your CMI very similar to your neighbor there in the Northeast Kingdom. And I think to me that validates kind of what we've heard in both of those hearings about the greater acuity of need. So are you finding that this number has crept up over time as we see at other facilities with some of the deferred care during the pandemic? Yes, I think we've seen that. Yeah. Yeah. Yeah. And I know that's probably a number as a critical access hospital, you're less cognizant of tracking. Yeah. So this admin ratio, we've heard of a variety of testimony about its relative merits and opportunities for it to improve. I just want to give you an opportunity to comment about your reaction to that indicator. Yes, my comment, Sarah, would just be that in the admin salaries and I'm sure my peers in the elder hospitals have said the same thing that we see admin salaries and people think, you know, the C-suite, but that's not the case. Right? It's all admin, you know, IT, human resource, you know, everything that basically supports everything we do here at the hospital. So I guess that's the only comment I would have on that. But it reflects a lot of different departments and that helps support our organization and what we do. And the other thing is every hospital is different and what they have for administration. So you're almost comparing apples to oranges in this particular case, from my perspective. Yeah, we, yeah, I think there's certainly opportunity for improvement in the measure and appreciate people's feedback so that we can, you know, measure something that's actionable and valid in the statistical sense. Sorry to be clear in statistical measurement, but validity has to do with the same thing or reliability is you get the same answer every time validity is that you're measuring what you thought you are. So just to be clear for the record. And then, yeah, so this is the number that almost, you know, sometimes you can kind of feel these numbers and that's that's a really rough one to see and I think it's just really important to put your financial struggles into context. So among peer groups, you know, that's the bottom whisker with only one other result that is is worse than that. So again, I don't think you're you're kidding yourselves about the struggles you're facing. But we do see that you have among this peer group that also the for Vermont hospitals, the lowest cost per adjusted discharge, which is right at that 25th percentile mark, which given the higher acuity, you know, that's going to help adjust for that. But just think that that shows that you're likely providing community based care and taking the tertiary care to the appropriate setting. Anything you want to say about that? Before I move on, I apologize. Don't want to move too fast. I think that tells the story and reinforces what we've been saying. And so for cost coverage, so this is an area where, you know, North country does have, you know, a similar reimbursement compared to its peers and the cost is a little bit lower than its peers. So we see the cost coverage at 211% of that Medicare allowable cost, obviously see a great delta between the inpatient and the outpatient cost coverage there. So I was just curious. I was trying to remember, because I think that is the outpatient setting, the one that has been even trickier in the implementation for the Surner. Okay. It's a hospital based system that you try to make in the outpatient world. So, yeah, so I was just, you know, this is just me thinking out loud. I kind of expect that's probably going to look pretty go down a little bit again due to some of those struggles, but we'll see as time goes on. But yeah, I think the other thing that like I think of, and I've meant to say this out loud with NVRH, but you know, like 211% of this amount is less than, you know, a taller bars percentage because it's, you know, less amount, but also your payer mix is obviously much lower. So that's for very few patients that you're receiving that. So I think it's trying to think of ways to help put that into perspective. But again, I was a little, the only other thing I just curious if you had any insight about it, I was surprised to see all the bumpiness for the inpatient reimbursement from Vermont Medicaid. We usually kind of see a more standard slope and I didn't know if you knew off the top of your head. No pressure if you didn't, but I didn't know if that was just mostly small numbers or what you might have to say about that. I guess probably small numbers. I mean, we can obviously dig into it if there's a follow up question or answer. Yeah, Sarah. I don't, yeah, I don't know what that would be besides the small numbers. Yeah. Okay. Yeah. Okay. Just just checking. Sometimes there's something funky, mostly for my own edification. And then yeah, so again, if we take all the commercial payments divide them by a standard unit of service from 2018 to 2019, we do see in our North country at a relatively higher commercial reimbursement at 25 per discharge, 25,000 per discharge in the inpatient setting and 477 in the outpatient. So, you know, relatively more robust cost coverage than others in this peer group. But when we compare critical access hospitals to PPS hospitals, you know, you can see kind of that it's even more relatively up there compare for the outpatient services, but within the range and inpatient. So no need to respond, but just want to give you a chance to if you want to. Okay. All right. That was all I had acting director or acting chair of lunch. So if the board would like to do their questions, I can stand by. Great. I'll go ahead and jump in first. And I do have a few questions. So you did mention that you were intending to participate in the ACO. Could you remind me which programs you participate in? Yeah, we participate in everything besides Medicare. So Medicaid MVP and the blue, you know, the Blue Cross Self-assured team. Okay, great. And could you talk a little bit about what you're seeing in terms of Medicaid redetermination says and how that is hitting the Northeast Kingdom in your area as well as whether you included any budget assumptions related to that. Yeah, I'd be glad to speak to that. We're, you know, we're expecting it. We did not include any assumptions on the budget in regards to it. And I'll tell you why we have an extremely robust navigator program here at the hospital. We have five full-time navigators. One that's placed in our, our largest primary care practice. And I'll tell you those, those five ladies do everything they can in order to help our patients. We have a system where practices or people will call and say, I have, you know, Tracy here. She's asking about insurance and they'll hook them up with an appointment. They're very active and very proactive. They have, you know, lists of people that need to contact. And one of the other great things that they're just beginning to do is they've sent out letters to the area employers who don't offer their own health insurance plans. So they know that they have a large amount of people that would be on Medicaid and they're off. They're actually offering to go on site and do like group sessions or individual sessions or whatever accommodates the people in order to get these people, you know, research provider, you know, re-enrolled in Medicaid. So, and they've been doing this for quite a few years. So I have a lot of faith in the fact that they're going to help that be a minimal impact on North Country. Great. That's great to hear. On your profit and loss statement, I had a couple questions. It looks like your fiscal year 23 projected compared to budget for your total net patient revenue and fixed payments is coming right right in on target. So that's pretty impressive. And that what is driving some of the operating loss, at least as far as I can tell, looks like it's something in the other operating expense line. I wonder if you could just speak to that a little bit. I think I'm going to have to look into that a little bit. I'm not exactly sure, you know, what's going in that bucket. So if it would be okay for me to get back to you on that. So we're looking for what's the difference in the other operating expenses. Great. And you may not have the same look that we do since ours comes out of adaptive, but it looks like there's about a $4 million budget to projected shift in those expenses. So just having a better understanding of what's driving that would be very helpful. Absolutely. Thank you. Let's see. The other question that I had was, you did mention in your opening discussion, a focus on quality and I wondered if you could give us a couple of examples of what areas you've been focusing on in terms of the quality opportunities and in your hospital. We have a falls program that was primarily in our inpatient units and we have moved that to the ED because we realized that that was a gap and that we needed to be doing fall assessments on our patients because of the aging population on a regular basis and then implementing the falls protocol. The other thing is we realized we didn't have a good sepsis protocol that where care begins in the emergency department, you know, that first hour that patient is here with sepsis. It's important to get antibiotics and and fluid started and source of infection identified. And so we have created a sepsis team. We have a protocol and order set for adult patients in the emergency department. And we're going to include working with Dr. Stewart to include our maternal child health population and then Dr. Stewart to talk our pediatrician to look at our smallest patients, our littlest patients and then primary care. World sepsis days September 13th and we're going to educate our campus on the acronym time so that we're all on the same page and we can get patients to our ED for appropriate treatment and care. Those are two of the things that we've been focusing on for our 24 quality plan. We're looking at patient throughput because of our challenges with holds and with the skilled patients and our inpatient unit to include all departments so that we can be more efficient to get patients through the ED and admitted or home. What's more examples or is that good? Why don't we, why don't we pause there? Because I want to make sure others have time to ask questions and you may come back to it if other people are interested. So that's terrific. Thank you. And then my last question has to do with sort of the expected increase in utilization as Sarah mentioned. And as you mentioned, the commercial. And charge increase is a relatively low amount of the NPR increase that you're looking at. And could you just speak a little more directly for how you think that increase in volume will be. Attainable. Yeah, so the, so we're talking about what we're seeing for just the pure volume increases without the, without the rate. Yes. Okay. Yes. So basically, when we, when we figure out our revenues for the budget, obviously we go through what we're what we're working on at that point. So what's happening in our projected. And then into next year, you'll see what the things that we've seen changed or we've increased is cardiology is one service. As Tom mentioned, we had a cardiologist full time cardiologist that started in January and there's an expectation that he will build his practice as time goes on. So by the time we get into this fiscal year, he would have been here, you know, nine, 10 months. So there's some volume built in there. We also, and along with that, with the professional fees and the practice piece of that, we have echoes cardiac rehab stress tests, nuclear stress tests. So that ancillary revenue is projected to go out and go up in a percentage to what, you know, his revenue is going to go up. We also have another full time general surgeon, not another, I'm going to say replacement general surgeon who's starting September 5th that we're super excited about. We've been using low comes for a while now. And as you can imagine, their revenue output is not what a full time general surgeon would be. So there's revenue added into our budget for the addition of our, you know, to fill out our general surgery free compliment. And again, there's ancillaries that go along with that. So those are probably the two, two biggest drivers that you're going to see for volume in the next year. So I think those are the two biggest ones. Terrific. Thank you. You're welcome. I think that's it for me. Any other board member have some questions and wants to jump in. I can jump in with a few, if that's all right, Tom. Hi Dave Merman. So I work as an emergency physician and your story about the woman who came to the hospital in January after the death of her son with dementia who lived at the last six months for life in your care kind of speaks to a lot of everyday occurrence, but a not infrequent occurrence in clinical medicine and speaks to the role, the traditional role of a hospital in its, in its caring for people that has that there's this big gap in our system, our broad system where patients like this can live out their days because they're not sick enough for a subcute rehab that dementia creates too much behavioral concerns for other places and, and, but yet from a hospital standpoint they're financially just terrible because they take a lot of unreimbursed resources. So I think it's a larger conversation as to what to do about it and to think about it, and it's way beyond just the Vermont context, probably. But I really appreciate the story and the context of that and, and, and what it means to, to care for your community. I'm sorry, but the other thing I want to comment on is your comments to about being a local hospital and and how you grew up there and you grew up there and a lot of your staff grew up there and at that at this at this juncture in the labor markets of so much portability of staff and traveling nurses I think that's a real asset that you should lean into I think that's come out to me as obvious in these budget hearings where a hospitals can really invest in their community. You mentioned unemployment in your region. Lift up your region while supporting your hospital and in keeping people working there and getting people working there you don't have to recruit, because there's no housing I'm sure they're either. If you do have housing, the interest rates are way too high to buy a house and the rents are way too high to rent a place so anyways, I just want to sort of. That was a reflection and some of the and I just want to share that with you a few a few questions though. Mr. Franks you mentioned that your, your budgets looking a lot better over the last six or eight months or time frame you're creating you're getting a margin after having been at a loss. And I was wondering if you could identify any specific parts of the budget that either where you're having cost reduction or cost avoidance or you're having revenue growth that you've been experiencing the last few months. I think it's a combination of both expense, holding the line on expenses, especially around FTEs. And really about getting the EMR to do its job, which is billing and collecting. I mean if you're seeing the patients and you're unable to bill. You know, obviously that's going to have a negative impact on the bottom line, but we are seeing improvement in our ability to bill and collect utilizing external resources to help with that. It's not a perfect system. It's still going to take some time to get where we need to be. But, you know, through financial discipline and improved performance from EMR. Our goal is to continue to see that, you know, profit increase, you know, from my perspective, the key is EBITDA. I'm sure you've heard a million times brother hospitals, it's about generating cash. And that's what we need to be able to do when we're finally to a point. When we've generated some positive cash here to date, which is the first time in almost two years. Thank you for that. You also mentioned urgent care being a money loss and not and also not diverting patients from the emergency department as you expected or in a sense your emergency department volumes are going up and I'm just trying to fill this out in my head. So it looked like somewhere around 2019, 2021, I guess probably COVID mixed with your EHR challenges, your ED volumes dropped. Is it that your ED volumes are coming back up to where they were plus the urgent care? Or do you think the urgent care is actually your ED volumes are climbing but you're, but they would be climbing higher without the urgent care? Absolutely. And Denise can talk a little more about this, but the acuity rate in our ED as well. And I think we're seeing an average of about 1200 to 1300 visits a month. So, I don't know if that's a good thing or a bad thing, but we certainly stabilized the volume, but we have seen an increase overall between urgent care and the ED. The idea of the success with the urgent care is that the lower acuity folks aren't clogging up the emergency department. Yeah, so we're seeing a decrease in our level for patients, the ones that should go to urgent care and our level three volume has really increased over the last few months. Okay. One thing that I'm trying to understand and is that and with critical access hospitals being cost based and the high increase in costs that occurred through the last year or two with high labor costs. When do you see that adjustment from Medicare payments to your bottom line from the, as I assume Medicare payments are going to increase to reflect that cost at some point. Yep, you're absolutely correct. So basically the mechanism for that increase is a finished cost report to Medicare. You know, so our fiscal year ends at the end of September, cost reports to Medicare are due by the following end of February. And then the cost report goes to Medicare. They do all their work with that cost report. And then a year or so later is when you get a letter saying this is what you're new interim rate would be. Whether it's your outpatient percentage or your inpatient rate, you know, a lot of times it's a year later before you find out what your new rates are going to be. Sometimes it's, you know, six to nine months, it varies based on what, you know, the staffing at Medicare and that's kind of your unaudited rate, but that's kind of how that system works. So in our budget for next year, we did have a rate adjustment in January. I don't think we got the information until like April, but it went back to January. And those increase in reimbursements have been figured into next year's budget. And so would that be a retrospective increase too. They go back to January one year. So it doesn't go into the next fiscal year just goes Medicare runs on it. And so within the last two year to three years we've had substantial cost increases compared to typical baseline prior to that. So are you realizing now the 2021 and 2022 increases, but not the 2020 the 2023 will be realized. That's exactly right. Yeah, it's like it's like a year or a year and a half or, you know, depending on how fast they turn them around lag. Yeah. So anything that's happened in 23 we won't see until 24, but we did see an increase for our 22 costs in the spring of 23. Okay. I'm sorry I'm going to give you another comment instead of a question but I just wanted to sort of bring up another common theme that you raised that I thought was brings up sort of it a complex relationship and clinical medicine right now, which is the balance between moral hazard of the balance that people who are providing care on the front lines feel between the moral hazard and the new generation in the sense that, you know, that there's been a lot of in like, at least in the emergency kind of we call like the throw away journal literature that you know the trade journals the sort of impact to frontline providers of feeling like they're harming their patients financially while trying to help them medically because of the cost of care and then balancing that with the organizational goals of trying to instill a culture which I think you mentioned of responsible financial responsibility and sustainability and I applaud your efforts and trying to they're both very important and they both are very impactful and so I just want to say applaud your efforts and trying to like figure out how to message those balance because I trained at a safety net hospital where that that's part of it right the only way you can deliver care to people who need it is to generate the revenue to keep the hospital open to deliver care to the people who need it and so it's the cycle but there is this there's been a this complex moral hazard I think that's really come in and healthcare over the last couple years it's really been been hurting people on the frontline so I anyways you mentioned that I just want to say I applaud your efforts working on that. The other question I have is do you expect the center implementation to affect your CMI on those Medicare cost reports and how so. I don't think that I don't know if the center implementation will affect the case make index it can affect if we haven't captured all the you know so Medicare cost report is you know based on the cost of charge ratios and such so if we don't if we haven't captured the charges that we've expected it could have you know it could affect it affected that way. You know right off the top of my head that's the only thing I could think of that House Turner would could possibly affect it from one year to the next. And I guess my last question is is some hospitals are coming in with budget requests that give them a much more robust margin than you're asking for and you clearly have a lot of vintage facilities that you've mentioned although sounds like you try to keep them up that you know your physical plant needs needs work. Why not request more if we were to request more at this point it would be through an increased ask on fee increase and we understand where we live and we understand right now that folks too are suffering with inflation and can't can't necessarily handle a large increase on health care. I talked about what we do for our staff with health care. We also have to be sensitive to the community we live in. We believe we have some work to do on our own again with our M.R. with some more financial discipline to be able to help turn that break even budget next year into a positive. When we're having this conversation next year I anticipate you asking you know how did you guys do it. Why you know with such a low fee increase to get that positive margin to invest back into your organization. I really look forward to that conversation and you and me both. We all do. Yes. Thank you. Back to you. Acting chair lunch. Thank you. Member Welsh. Yes. Thank you. I want to thank you all for joining us on a Friday afternoon and actually this has been one of my favorite sessions. Having grown up in a small village of about 500 people in northern New York you're sitting in a very similar place where I to where I come from and your commitment to your community the way you described it earlier. It may sound sappy to say but it's inspiring and I really appreciate you sharing your stories with us. I also have had the opportunity and my consulting career to work with some people that I have considered to be mentors who they built their careers on turning around organizations that were struggling. I didn't I don't have that type of work the volume that they did. But Michael Leonard was a physician who did that specifically and he gave me some advice on time. He said when you go into an organization. Ask them their priorities. The organizations that tell you that quality. Culture safety and reliability are their top priorities. They're going to be fine. They're going to get where they want to go. Over 90% of the time you'll hear that finance is a priority. This is my second time through with this board. You're the first time I've heard quality and culture as a top priority in Vermont. So that's downright made my day. Your your discussion about how you're going about writing your ship. The financial discipline that you talked about the letting go of administrative layers as painful as that may be. The lagged position positions and the pay for additions are all the top notch things focusing on those and maintaining your commitment to clinical care. Voluntarily focusing on reducing the size of your administrative layers. Sometimes executive salaries. Those are those are the things that organizations that need to turn around. They're the ones that can when they start there. The admin to clinical ratio and the cost report. That's two years old. So I think when we look at that in the future, your efforts will show up more clearly. The reason that you're not a top performer right now is because the efforts you're making are too new. But already you've got five months going in the right direction. The other thing that I learned from some of those mentors is when you're starting to work on expense management and you're really getting a handle on it. The next thing to really try to get a handle on is what are the needs of the community that you serve and how do you measure those and really get your finger on the pulse of how it's doing so that you can be agile enough to make changes as you need to. Because if you can if you can manage your expenses and with a laser focus on the needs of your community, you can then make the type of operating margin you need to serve that community. Some other organizations in your situation try to grow out of that by bringing in all the the high revenue things right and the community can afford it. So they their premiums go up. They stop going to the doctor. Right. Their care becomes unaffordable. Right. They get very sick still or they have accidents still and they end up needing very expensive care and can't pay their bills. They go broke. The community goes broke and then the hospital goes under. So designing an affordable system is the key to sustainability. And you do that through expense management and measuring the outcomes that matter to the community you serve. And I know this was saying apologizing for comments and all I've done is comment but you really have made my day. Right. So I but I do have a question. I wonder if you could tell us a little bit more about the steps you're taking with your needs assessment that's often done with a survey. I'm wondering if you if you have any other ideas or thoughts about how to really get your finger on the pulse of what your community needs. So you know this spring we're going to be doing a new strategic plan for the organization. And hopefully we're going to be updating that health care assessment. And that's going to be one of the drivers of our new strategic plan. So they need to go hand in hand. As I said I've only been back here since April. We definitely have taken what we currently have and that help assessment into how we built this budget. But going forward as we look at our new strategic model it's got to be a priority of where we're going. I can't just be about we need to generate margin. It really has to look at that. I mean we have some unique situations here on the Northeast King. That you know aren't necessarily applicable to the rest of the state that might be in our plans a bit different than other hospitals. So it's really something we have to focus on more for the future right and then we are right now. That makes sense. One of the things that you might consider are convening focus groups and doing interviews. Individual interviews and then rolling that up into focus groups. We're going to be doing that type of stuff through Act 167. But that's also some stuff that I've seen previously that has worked really well for organizations to try to fine tune their understanding of what the community needs. So they can best meet that while maintaining their financial discipline. We don't want to tell the community what they need. They need to tell us what that's right sir. That's right sir. So yeah that was my question and again thanks for spending time with us and I'm very happy that you were the last of the week. I feel much better. So thank you. Back to you acting chair. Thank you for the chance to ask question. Of course. Thank you. So we'll turn now to the health care advocate. Eric or Sam. Take it away. Thank you. Thank you acting chair. Good afternoon. A couple of positives I just want to highlight kind of piggybacking on what member Walsh and number Merman have outlined. It was really encouraging and also inspiring to see the adoption of a social determinants of health approach and how you work with patients particularly around patient financial assistance. Particularly I you mentioned highlighting connecting individuals with the immigrant health insurance plan which is obviously we think an important equity initiative across the state. I don't think this is duplicative number Walsh's question but you said in your opening remarks that part of your process for developing a rate increase is assessing the level of affordability in your community. I'm wondering if you could talk about what that process looks like. So it's more of a general understanding of where we are as a community. As Tracy mentioned prior to the last year our average ask over the last five years was 4.9 percent. We don't garner as much revenue from a fee increase. And remember the fee increase isn't necessarily exactly what we're going to get right so that's our whole. So that fee increase we have to take into consideration who can afford what. If we price ourselves out of the game as has been discussed here people aren't going to come from service. And what's going to happen down the road is excuse this expression we're going to see trainwrecks. And what we're trying to do in our budget is encourage people to get care so they can be more proactive than react. And that has to be part of what we take into consideration when we look at a fee increase. If they can't afford they're not going to come. Yep I agree. Thank you. Thank you. In your narrative you talked a little bit about potential partnerships with Northeastern and VRH for sharing services specifically you highlighted specialty services in the Northeast Kingdom. I imagine this is still early days but I'm wondering to the extent you're able. Can you talk about that a bit. Well I know that there's been an analysis done of what we need or what we could support here in the kingdom. One of the things that we talked about actually most recently and I can I can say this is interventional radiology. Down at NBRH their folks don't do their radiologists don't do the interventional piece of that work or our radiologist does. So there's an opportunity for folks to come this way and keep the keep folks closer to home. Keep the business and I'll be honest the dollars in the community versus it going to Dartmouth. Because once that business leaves once those dollars leave the community it's not doing the Northeast Kingdom any good but it's certainly helping to have. Thank you. I appreciate that. You spoke about this a little bit I'm just wondering at a high level if you could talk about any lessons learned from the center EMR implementation and any potential loss recovery. Well I wasn't here to talk about implementation but I you know I from an outsider looking in I can I can tell you that it wasn't well prepared for. You know six years ago we had done an EMR implementation where we we took a line of credit of $2 million when in two months it was paying back and we were seeing more cash than we'd ever seen. So we are actually going back now doing a root cause analysis of exactly what went on and we're working with Cerner on that analysis and we have a meeting a face to face meeting to discuss this actually coming up September 12. Thank you. I appreciate it. A couple I think clarification questions if I may on your patient financial assistance. You noted that patients are not given a financial assistance application at the first attempt to collect a debt. I'm just wondering why that might be the case. Yeah it's just true at the moment and basically what happens I mean it's technically not at the first attempt but what happens is we have an outside service that makes those first phone calls. So when that outside service speaks to that person they're attempting to get a to collect a debt from they put that out as an option right there's an option to get a you know do free care. And what happens is once they have told that then they're they communicate back to our people in our collections and they get the free care application to that patient. That makes sense. They talk to them so it's like they don't give them one because it's an outside service that's doing this on the phone but the outside service on that first attempt tells us and then we contact that patient. Give them the free care application and our navigators ask them if they need any assistance and you know such to fill it out. Okay that's helpful. You can probably imagine why I'm asking this question but I guess how do you assess you know the relative value like cost benefit of hiring you know collections. You know having a contract for collections versus trying to do that in house because we've heard some hospitals trying to do that mostly internally. If you can talk about that process. Yeah we you know it's hard to speak to we've been doing it externally for a long time you know and the evaluations were done then you know we have a small staff right so we've you know focused our efforts on the navigators and trying to get people covered to try to you know not have to go the collection round and we you know we've you know chosen to put our energies into hiring the staff internally to do that work and then letting the you know having the outside agency do the other work. There's only so many people to go around I guess is what would be part of it but we're trying to get you know get the coverage on the front end. Thank you appreciate it. Those are all my questions back to you. Sure. Great. I'll just pause. Are there any other follow-ups from my fellow board members before I move to public comment. Robert can do we have Steve right to our closing comments now or do we wait to laugh the public comment. We usually wait till after the public comment. So we'll do public comment real quick and then we'll turn it back to you. So if anyone has a public comment if you could please let us know by raising your hand which is a feature at the top of your team screen. And if you when you speak please indicate your name and spell it for our court reporter. I see Mike Del Treco. Mike you can go ahead. And I'm not hearing you so you might be on mute. Can you hear me now. I can hear you now. Excellent. Well to the board members that are here today thanks for your time and commitment to this process. I know I know it takes a lot of work and I know the dedication that you're committed to through that process. I can't see Sarah Lindberg on the screen but Sarah I just want to really acknowledge your work your collaboration with my organization to to set up some of these tools and discussions. You know I wish you really well in the future and I certainly will miss our connections. As an industry we work tirelessly to balance the demands of affordability with meeting the needs of our community in an ongoing effort to provide quality and accessible care. It's it's difficult work. I think in my opening remarks I call I called out that we're at a pivotal moment. I'll repeat that. I think we're at a pivotal moment in health care. Not I think but I believe considering the history and the current efforts to curtail cost growth that are being neutralized by greater cost pressures of workforce inflation. You heard from this group today managing some of the mental health and long term care systems that are very challenged. We're seeing increased demands unfortunately from older and sicker patients making this equation very difficult to work. As you heard from every hospital leadership team the 24 budgets presented are expertly crafted needs based. Maybe equal importance are creative which seeks to seek to study our hospitals from years of low or no margins. Vermont hospitals are still digging out from the aftermath of the pandemic. Not only is it showing up in the economics of what we're managing but sadly it's showing up on the faces of our staff and our patients. Dr. Merman you mentioned moral injury and the moral injury that you other physicians caregivers are facing is frankly unimaginable. Our organizations are stressed and we're stretching every dimension of our delivery system to meet the needs of our communities. You know as a place of last resort the results have been increased utilization in our emergency departments. Mental health and long term care patients in our in our facilities in patient outpatient units that are at capacity. And this does not even begin to account for the pressures that the many primary care specialty physicians and their teams are having trouble meeting the health needs of our monitors. This is this is pretty serious. One thing that I know that does help is the collaboration you heard it today. And you heard you've heard it throughout these presentations organizations sharing physicians organizations sharing resources the telemedicine program that the network. Copley and North Country Hospital has set up for the for Nick you and care is very impressive and we can do this I think largely because we're not for profit delivery system. We choose to collaborate rather than compete and I think for honors are much healthier and better cared for as a result. One thing that I have to say is we acknowledge that we must keep moving forward to improve access to services. Especially in our rural areas especially to ensure that we provide for monitors with the latest medical research and treatments without requiring long drives. My colleague Tom mentioned the challenge and the importance of keeping things in the state of Vermont as we've discussed keeping care local for monitors needs to be a priority. It's better for our patients. It's more cost effective for the system and it's better for our local economies. Approving these budgets as submitted is the start of meeting some of these goals and I know you have some challenging work ahead of you board members. But in closing you know I sat through all of these hearings and in the spirit of collaboration. I want to add a few observations and some of them are maybe a little more critical than others and some are you know some opportunities that I think we have internally. So to work together I would say so with the direction of using benchmarking and moving forward. I think this type of work provides a cleaner and a clearer line of sight on how performance could be measured. But within any process improvement endeavor variables of accuracy comparison cohorts reporting consistencies need to be understood to be implemented. Over the course of the hearings I witnessed both the board and staff as well as our hospitals trying to manage and and and make some determinations of what was being looked at and reviewed. And it's a little uncertain how the board's decision making process will will take into account some of those targets and measures. So if the board plans to use this tool in the future. I respectfully ask that you continue to work with our hospitals to understand the variability and allow for appropriate timing to get this process right so we can move forward. Again I think that I think having consistency and an implementation process there's some there could be some true benefit from this. I clearly understand the timing issue between rate rate and insurance review as it relates to hospital budgets. But when I saw the the remarks and the announcement that the board was going to reduce hospital amounts by 50% I was concerned. So where the magnitude of this adjustment is not trivial. We asked for a review to see if there's an opportunity to adjust this process to avoid the situation in the future. And the situation that I'm talking about is making the potential decisions or around hospital budgets ahead of hearing what is actually happening. And I know you do get a lot of information but that I think that's an important thing to mark. Is there somebody unmuted. I can definitely hear some background noise. Hold on just one moment. Let me see if I think I think I adjusted that. Thanks. Thank you. So thank you. I didn't know if my head was echoing or something else. So lastly I think there's been a lot of work by the board to understand our hospitals and the topic of price and market power presentations is unclear if the theory actually applies to Vermont. I question this because within the hospital budget review process the board regulates actual hospital increases and then also governs what can be passed along to commercial insurance. So it's unclear to me and that's why I ask for this for this opportunity to talk about this. So like with my other observations I asked the board to carefully consider this relationship. And you know Mr. Steslund Mr. Whaley and Mr. Cooper during their presentations offered words of caution and you know how we implement how we think about these things. So I asked the board to think about is this a Vermont specific theory that can be applied. If it is how do we move forward and what is the what's the what's the goal and what does this mean. So again Sarah and your team board members very grateful for your efforts and and attention to this detail. It's really important. As I said we're at a pivotal moment. So thanks for your time and attention to this process. And I am always available. My team is always available to meet to work together collaborate to make health care better for Vermont. So thank you. Thank you. Do we have any other public comments. OK seeing none I will turn it back to the North Country team for closing remarks. Thank you Steve. Yeah I appreciate that I have the the dead man's spot here as the last speaker of the last review of the process on a Friday afternoon at three o'clock show. I'll be as short as possible. I was also so I'm the president CEO of JP care about 2000 employees. The largest employer in the region probably the highest utilization of a business of this hospital of anyone in the region. And I am also the was the chair of the hiring committee that brought Tom back to the organization and part of the charge of anyone coming into this role was can you build a lean operational budget without and not at the expense of culture or community which is something that he and his senior team the people in this room and the people outside this room have put together so I want to say publicly how proud I am of what was put together but not only what was put together but how it was presented because I came away in this meeting with the same feeling that many of you did that community and collaboration is at the forefront of how we got to where we are today I am the least knowledgeable of hospital mechanics of anybody in this room by a factor of 10 although I will say I now understand the cost of nasal packing and then we're saving money on that I don't know what nasal packing is but I'm happy to hear that we're saving money on and I know when world sepsis day is I feel like I've taken my own spot up a notch and I just want to close by saying obviously it is important as as Dr. Walker mentioned the practice of care in our community the actual care being distributed but what what I do know something about is is workforce in the state of Vermont I chaired the governor's TRC council I've worked with with chairman palimid BDT M on a project to increase workforce I've worked with Lindsay at ACC D to improve to increase workforce and along with the the practice of care in the community which is so important to all of us that that live and work here is the theory of care in the community and by that I mean with 2000 employers or employees at the mountain I cannot tell you how many times that a during the interview process the very first question that comes up is tell me about the hospital. It comes up before the school system because not every employee engages with the school system. It comes before anything and for me to be able to say that that the hospital is not only stable and stability is certainly been a buzzword here but but really is trending and heading towards thriving. You know there's there's an awful lot of stable in thriving for us here getting to that point where we feel very good about what it is that we're doing and the care that we're giving and for me to be able to use that as a magnet as a selling point to either keep good employees here in the region or to use that to attract additional ones into the region so they can become part of the tax base here for for years to come is absolutely critical and it's why I am on this board here it certainly is not because of my my competency relating to the hospital it's to make sure that both my employees are covered with a strong hospital but but to also to help increase the vibrancy within this community through the vehicle of having a hospital that is firing on all cylinders and I think that that's what we have there. Thank you. Well thank you very very much to the oh did you have one more word you'd like to say. That's it. That's us. Well thank you very much. I appreciate your time today and this afternoon and that will conclude your budget hearing. Do we have any older new business to come before the board. Okay seeing none. Could I get a motion to adjourn please. So moved. Okay all those in favor. Aye. Okay the meeting will be adjourned.