 April 16th, the 30th, the Thursday, excuse me, April 16th. And we are continuing our work to understand today some of the relationships between the federal COVID-3 law and the money that will be coming to the state. And we've invited folks to speak to that. Sarah Green is with us this morning. And Sarah, I'm sorry, Sarah Clark. Do you know what? Sarah Green and Devin Clark. I know. So Sarah Clark is here with us. This is great. Sarah, why don't you introduce yourself for the record? We're not going to go through the committee introductions that always would take much too long, but we will have folks introduce themselves when they ask questions. You don't have anything online at this point, any information that you've shared yet, do you? I do not, but I do have talking points that I've prepared that I can share with the committee after my testimony today. That would be helpful. Thank you. Okay. So good morning for the record. My name is Sarah Clark and I'm the Chief Financial Officer for the Agency of Human Services. Would you like me to just kind of get started? Yes, ma'am. Okay, great. So first I'll tell you, I don't have a printer at home, so you're going to see my head shifting back and forth to my other monitor as I speak with you because that's where my talking points are. That's fine. And we are all doing the same thing, looking back and forth at agendas and notes. So that's part of the system. The new world order here. So great. So as you are aware, there are multiple different federal funding sources that are going to be coming to Vermont to help us in the dealing with both the COVID-19 crisis itself and then the recovery. To date, there have been three relief bills. I understand that there is a fourth bill that's being contemplated by the US Congress and we've been working to kind of get our input to what would potentially be useful in that bill on top of what we've already received. But for the funds that we've received, it's kind of it goes the gamut between having specific guidance from the federal government about the parameters of the funding to we're still waiting for some additional details to really be able to fully understand how we can best utilize those funds. In addition, at a high level, we don't have the actual awards for some of the AHS specific grants yet. We do in some areas, but not in all. And so we just are kind of continuously evaluating the available funding streams to AHS. But until we have more specific guidance, we are making some assumptions on how to best proceed. We've been working closely with commission aggression and finance and management in terms of understanding all of the federal funding that could be available to both AHS and all of state government. Towards that end, we've established, at least for now preliminarily, what would be a funding hierarchy of how we would and when we would access the federal funds because there are multiple different sources. And so I'm gonna kind of run through with you as of today what we believe the hierarchy of funding would be. And then from there, I'm gonna talk a little bit more specifically about grants specific to AHS, Medicaid and the FMAP Bump, as well as some funds that go direct to providers and what we know about that, that don't pass through the state. And then the last thing I'll let you know about some grants that we're applying for. And so that we don't know yet, but that we are kind of pursuing any and all avenues of funding to support us. And that's great. Sarah, when you talk about funding hierarchy and what you'll be looking at accessing first, is that a prioritization of the needs within the state or is that related to the type of funding? It's related to the type of funding. Okay. And kind of based on what we know now, the order in which we would access those different federal fund sources. I will say that this is something that will likely evolve as we learn more. Okay. I won't interrupt you again. I just wanted to clarify what you meant by that. Thank you. So let me kind of talk through that hierarchy that we is under development. So the first line would be AHS specific grants that are a hundred percent federal dollars. And so, and we would be looking at those to cover known expenditures. So for example, this would include childcare development block grant funding. As you know, and we'll talk a little bit more about it later. As you know, we have put forth a childcare center stabilization program as well as making sure that we're providing essential employees with childcare. And so we would be looking at this kind of block grant, childcare block grant dollars to help pay for that known expenditure. And so that's our kind of first line. We look at what are a hundred percent federal dollars coming to AHS and how do we best utilize those? The second fund source in that hierarchy is the Coronavirus Relief Fund. As you know, that is the $1.25 billion that will be coming to the state of Vermont from the U.S. Treasury. We know that those dollars cannot be used to replace lost state revenues, nor can it be used to supplant other dollars that we've already appropriated. Beyond that, I don't think there is a lot more specific guidance from the federal government in that area. But it is still the kind of, and that waterfall of funding at AHS, it is the second one on our list because it is a hundred percent federal dollars. A quick question. When you say that it can't supplant previous state expenditures, does that mean previously allocated through our budget? Yeah, so if we have... It doesn't include some of the sort of emergency funds that we've sent out there and we'd like to look for reconciliation. Correct. My understanding it would be it can't supplant previous appropriations that we would have made together to support our recovery efforts. Then third on the hierarchy would be FEMA dollars, where applicable and appropriate. We are working closely at the Agency of Human Services with the State Emergency Operations Center, the SEOC. The Department of Public Safety is essentially the single state agency for FEMA dollars. As part of this emergency response, the SEOC has stood up a human services branch as part of the response to this crisis. And so we have fiscal representation on that human services branch. And so as we move forward in our response, where FEMA dollars make sense to be used to help address some of the significant needs, we would be looking at that. As of right now, that is a 75, 25, 75% from the federal government, 25% from the state. So that's third in our hierarchy. For now, the fourth in our hierarchy is Medicaid. As you know, we'll talk a little bit more about it. There is a 6.2% FMAP bump, which brings us to roughly 60% federal share for Medicaid program. That's fourth in our hierarchy, similar to FEMA, because we're going to need a state match to access those dollars. And as you are aware, state revenue is not in a good place. And so at a high level, when we look at the hierarchy of spending and fund sources, we are targeting the 100% federal dollars first. I'm sorry to interrupt you, but if I let this question go, I might forget it. So for the state match piece for Medicaid going forward, is there going to be any allowance for expenditures that the state has had relative to COVID to add that into our match? I mean, are there any points of forgiveness right now to be more inclusive of expenditures in the state? For example, putting in temporary facilities and so on. We'll be able to use that within our match. Is that makes sense? Yeah, I think I understand your question. We're working closely with CMS to ensure that we have the kind of maximum flexibility that we need to be able to leverage Medicaid dollars as appropriate as we move through this crisis. I would say that the reason why having that kind of hierarchy of funding in our minds is important is because even if something could potentially be Medicaid allowable, we may not have the state match to actually leverage those Medicaid dollars and so we may want to look to the other federal fund sources as a way to pay for those activities. We'll say to you, this hierarchy, as I said earlier, this hierarchy is subject to change as we learn more about the allowable uses of these federal dollars. But in my mind, we're doing all that we can to track expenses as they come up and then identify what we think is the most appropriate fund source. Okay, so then if there aren't any other questions on the hierarchy for now, I will proceed with my testimony. For the next area I wanna talk to you a little bit more about are the AHS specific grants. These could be our formula block grants where we now know the specific allocations that Vermont will be receiving. I know Nolan from the Joint Fiscal Office did give you an excellent overview on some of these sources last week and so I'm just gonna build upon that with a little bit more detail and talk to you about some of those sources. So from the CDC, the Centers for Disease Control, we have the Public Health Emergency Response Grant. To date, we've essentially, we've received one award where we have the actual award and we've drawn down those funds, that's $4.9 million. That was in the COVID-1 bill. These funds are what the health department is using to help support the kind of monitoring and response activities surrounding COVID-19. We've drawn down through March, $2.6 million of that first $4.9 million. We draw down based on estimates. We are anticipating that we're going to fully expend this initial $4.9 million by roughly mid-April. So kind of where we are now, but due to the timing of the accounting systems, it typically, it takes time between when we spend the dollars and when we draw the dollars down, but essentially the note for you to take away is that we will spend $4.9 million essentially through mid-April where we are today. We are anticipating another $5.4 million from the CDC for this public health emergency response grant. We don't know yet when we'll receive that award, but anticipate that it will be shortly. Those funds were appropriated in the COVID-3 legislation at the federal level. So all together between those two tranches of funding, we have roughly $10 million associated with the emergency response grant. We do expect that we will fully expend, draw down that $10 million by the end of this state fiscal year by June 30th based on our current tracking of rate of expenditure at the health department. We actually think in total by June 30th, we will spend $15 million, okay? So that's going to leave about roughly based on our projections, a $5 million shortfall. So this is where that funding hierarchy that we talked about earlier becomes important because in my mind, unless we receive an additional installment of emergency response grants, we would look to the coronavirus relief fund to make up that difference. So that's kind of the public health emergency response grant. The next, and Nolan spoke with you a bit about these last week, we received some funding, two different tranches for congregate and home delivered meals. These are funds that go to the Department of Disabilities, Aging, Independent Living. Two awards, one for $1.2 million that we have received. And we are actually in the process of spending. We've done an excess receipts request, which is a mechanism that the Departments of State Government have to access spending authority for specific grants kind of outside of the legislative cycle with the report that comes to the legislature that is required. And then we are anticipating and another $2.4 million will be coming to support congregate and home delivered meals. There's also funds going, also going to Dale, family caregivers and supportive services we've received between, for those two programs, roughly $1.5 million in awards to Dale. And the expenditure of those funds is also in progress. I spoke a little bit about this earlier. There's the childcare and development block grant. Vermont has received $4.3 million from this block grant who aid in our response. We are using those funds to support, to stabilize the childcare system and ensure that we're able to provide childcare for essential workers as we move through this process. Again, this is another area where the hierarchy of funding is important because we've received 4.3 million. We know that our costs are likely going to be higher. And so we would be looking to the Coronavirus Relief Fund unless we receive additional childcare development block grant dollars. LIHEAP, the Low Income Heating Energy Assistance Program has also received funding from the federal government through the block grant process. We've received $4.1 million. We don't actually have the award letter on these LIHEAP funds yet, but that we would anticipate using these funds to extend the crisis fuel system, purchase wood and pay for unpaid utility bills for individuals impacted by the COVID crisis. In addition, we've received emergency solutions grants, ESG funding. These are funds that go to support essentially the homeless population and providing them shelter. There was an initial award released of $4.6 million that has essentially now been cut in half. So these are funds that come from HUD. Though the initial award of 4.6 is probably what Nolan updated you on last week. We have since learned that HUD is only distributing 50% of those funds to states at this point. So Vermont now has $2.3 million at our disposal. We understand that HUD will be issuing guidance and perhaps either releasing the balance of that award or telling states what they wanna do with it instead of issuing it to us. So the kind of bottom line is we have $2.3 million and hope to have more, but that is still unknown. One of the things that Vermont is doing, as you are aware, we are trying to establish isolation housing for individuals that are homeless, that may become COVID positive. And so there have been a lot of response efforts to that end. We know that those efforts are gonna cost us more than this $2.3 million that we've received. One of the things that we are working with the federal government on is asking for a waiver to allow us to use these funds to cover expenses within the general assistance emergency housing program, which is where a lot of the isolation housing is being made available to individuals in this situation. And so we're hoping to be able to use those funds to help offset costs that we've already incurred. And then the last grant that I will make you aware of, it's one that actually the agency of commerce and community development manages and that is the community development block grant. I just raised that. I know that Nolan discussed it with you, but I just wanna put it out there because I think those funds can also go to support, for example, food shelves, do play a critical role in their response to COVID like that. So those are, that's kind of my update on the AHS specific grants. Again, that's number one in the hierarchy of funding. I'll pause to see if there are any questions. Oh, I see questions. Okay. Question from Senator Ingram. Go ahead. Thank you. Thank you. Yeah, actually I have two questions. So it sounds kind of like the COVID relief money, the 1.25 billion is sort of the backstop for funds if we're overspending some of the other grants. Is that right? Is it sort of unrestricted in that sense? Yes, to our knowledge from what we've learned that that is outside of the two big exclusions that is supposed to give us flexibility. I am always cautious though because we don't have a lot of the specific guidance yet. And so this situation may change, but that is how we're thinking of it for now. Okay, okay. And then my other question is about the ASG for the homeless. Did you get any comments from the federal government about why they've, why had kept that in half? What's the deal there? Yeah, to my knowledge, we're still waiting to understand why they did that and when or if they will release the second half of that funding. Thank you. Any other questions? Okay, so that was, those were the AHS specific unencumbered, well, call them unencumbered. Yes. Okay, so why don't you go ahead with the next part of the hierarchy? The next thing, so I'm not gonna talk much more about the Coronavirus Relief Fund. I think that really will be something that will fall to the agency of administration working with the legislature in terms of how those funds will be accessed and prioritized. So just to let you know, Joint Fiscal Committee, and we have two members, three members sitting here today who are on Joint Fiscal is working very closely, I think with the administration on this one. I also think it's very important to hear what you have to say and any of the recommendations that are two committees sitting here today can help make so that those funds are used as effectively as possible. We've heard a lot of testimony currently from people out in the real world away from some of us, and we wanna make sure that that money gets deployed to help the most, the best way. So we'll stay connected on that one. Yeah, that makes a lot of sense. Okay, good, thanks. I'm also just, I wanna kind of acknowledge the hierarchy. The third one was FEMA. I'm not really, to talk in any more detail than the high level that we have today, just so you know that we're plugging in on all the right places so that we're gonna maximize those FEMA dollars to the extent it makes sense. So I will talk a little bit more about the Medicaid Enhanced F-MAP. As you know, we received a 6.2% bump, which brings us to a roughly 60% federal participation on Medicaid. The estimate for what that means from a dollar perspective for the last six months of this state fiscal year is roughly $38 million. That is just an estimate based on budgeted numbers. But as we kind of move through the coming weeks and months, that estimate gets more solid, we'll know more. So for example, we file our federal report with the CMS April 30th. And so after that, we'll know more in terms of what those actual dollars were for the first quarter. And so you can expect an update from me if that's something that you would be interested in. If you include the F-MAP bump on the Children's Health Insurance Program, CHIP, that's another $378,000 of savings for the last six months of this state fiscal year. And that's, you know, I think as was also discussed at the joint fiscal committee meeting, the agency of administration is preparing a FY20 Budget Adjustment Act supplement. And so I think that as we, as an administration work on that information to bring to the legislature, you're going to see the kind of impact of this Medicaid F-MAP bump and that information. Oops, I think you're muted. Senator Lyons. Thank you. Thank you. I'm getting a question. And Sarah, do you mind if we interrupt you? No, of course not. At this point. Representative Donahue, you have a question. Thank you. Yes, I just wanted to clarify then the F-MAP bump is not tied to the restriction on replacing existing revenues. Is that right? That difference can help backfill existing budgeted Medicaid. That's exactly correct, Representative Donahue. Yep. Do you want to clarify that for everyone briefly, Sarah? Sure, yeah, I can do that. So basically what that, for every dollar of Medicaid that we spend, we are essentially getting another six cents from the federal government. And so that additional federal revenue frees up state revenue. And so it will, I think, be part of how, as a state, we address the kind of rapid decline in state revenues that we've seen from the economists. I see Senator Cummings has a question. You're muted, Senator. Okay, I'm muted. We're still learning. We're still learning. I'm starting to become concerned and wondering if anybody is thinking we've required that insurance companies cover the cost of COVID testing and treatment. My sense that one person on a ventilator for a couple of weeks is probably pretty expensive is anybody starting to pay attention to the potential impact on health insurance rates next year? Senator, that's a good question. I will let Sarah answer, but I do know that I had a conversation yesterday with Senator Westman about this. And I think that either individually or collectively our two committees should speak with the Green Mountain Care Board regarding that issue, because I think it steps outside of the work that perhaps AHS can do, but Sarah, I'll let you respond to that. Yeah, no, I agree with that assessment. I think it's an excellent question. And I believe there have been conversations, but they're not things that I have participated in. So I think directing that to the Green Mountain Care Board is an excellent step. So, and just as an FYI and a heads up, I'm looking to try to fit that in sometime next week, at least the beginning conversation. And I did talk with House members, Bill Lippert and his team yesterday about trying to fit this in. So we'll look for a spot. Yeah, just to say, I also spoke briefly with Susan Barrett this morning. And they are also, I think, as we speak or releasing a memorandum to us about a broad number of issues, but they are prepared to come before us next week or the following week, as when we can speak. All right, that's great, yeah. So, and I wanted to say thank you to Senator Westman for stirring this up again. I know it's been on the minds, some of us have had it on our minds for a while, but thanks, thank you all. All right, Sara, any other questions? Sara, do you wanna, you can weigh in on that one again or not? And Nolan, did you have a question? No, okay. And then keep going. Okay, sounds great. So, the next part of my testimony, I'm gonna talk a little bit about federal funds that are direct to providers. So, they do not pass through the state. So, the first is from the Health Resources and Services Administration, HRSA. They have released two different pools of money that go direct to health centers. There was an initial $683,000 awarded in the COVID-1 bill and then another $8.7 million that was awarded in the COVID-3 bill. So, those funds provide significant support to our health centers. In addition- Ken, I'm sorry, can you define health centers for us? Because as soon as you say that, some of us think of FQHCs and others think of hospitals. So, just that would be helpful. So, I believe it is the FQHCs and actually as part of Nolan's testimony last week, he distributed to you the list of where those funds will go by provider. And so, I can include that when I send you my talking points as well. So, you have it all in one place, but that it is very helpful and the timing was very useful to Vermont to have those funds come through. Okay, the next in the CARES Act is the Provider Relief Fund. So, this is at a national level, $100 billion in relief funds to hospitals and other healthcare providers that the Federal Health and Human Services Agency will be administering. Those funds can be used to support healthcare-related expenses or lost revenue attributable to COVID-19 and also to ensure that the uninsured Americans get testing and treatment for COVID-19. So, again, these are funds that the Federal Health and Human Services Agency are going to be administering. We learned on Friday, we were kind of waiting for additional guidance on how those funds will flow. On Friday, HHS released $30 billion of that $100 billion in payments direct to healthcare providers across the country. Those payments were distributed based on Medicare fee for service reimbursements in 2019. Vermont received roughly $54.5 million from that initial $30 billion release. Those funds were distributed to 1,011 providers. It's important to understand that these funds do not need to be repaid to the federal government. They were direct payments. So, one issue that we understand about this one is that because it was determined on Medicare fee for service and not our all-payer program, that payment actually is lower than we would have expected, had it been calculated differently. That is correct. And we are working with the federal government to try to resolve that issue. Okay, so directly with CMS on that, I- Health and Human Services. Oh, HHS. Yes. Okay, thank you. Yeah. And so, that still leaves $70 billion in that $100 billion. The administration, the federal administration is working on how those funds will be distributed. I think because the first tranche of funding went out based on Medicare fee for service payments, it left out like children's hospitals or if you're primarily a Medicaid organization. And so, I think in this, when they distribute the $70 billion, they're working to address some of those, let's say inequities in terms of how that initial tranche was distributed. And so, no additional guidance right now on that $70 billion, but hope to have that in the next couple of weeks. So, that's kind of it for the section related to federal funds direct to providers. The next, and I don't know if there's any more questions on that area. I do have a question. Sure. When we talk about direct payments to providers and know that this one is really more for our hospitals, what will we be seeing as you're going forward or within the CARES III or possibly CARES IV to your knowledge? We'll be looking at any independent provider support. So, I believe though it's one of the things, there was a call with HHS on Friday and one of the questions that States were asking is how do we know who received those funds? And so, as of Friday anyway, they were still trying to figure out if they were gonna be communicating more publicly about who received the funds. And so, it could be, since it was based on the Medicare fee for service payments in 2019, it went to 1,100 providers. So, it's obviously more broad than hospitals. But from where I sit to my knowledge, I can't tell who received those funds, which is definitely something I'm interested in because as you know, we in the state are doing what we need to do to stabilize the system. So, as we move forward, it's important for us to understand what providers are receiving in direct support from the federal government because we wanna make sure that we shore up the system, but we don't wanna duplicate either, right? And as you guys know, resources are precious. Yeah, and so, and as we look at who we are and how our system works, the extension to some of our DAs and our SSAs and it does get more complicated. And then knowing that we have, especially in rural parts of the state, we've got some independent providers who are so critical right now to care. So, anything you can do to help us understand what's available and what's going on would be really welcome. So... Sure, let me, and I don't apologize. I don't know if you've had any testimony on some of the efforts that the state has put in place. I can maybe give you a high level on that. If you're interested. Yes. We've had a little bit. So, we'll circle back to that. Okay. See where we get to. Okay. Let me just see, is there another, Bill, you go ahead. Well, just to say, I would be interested in having us hear that if we can do that. But also, when you talked about some of the money from HHS being available for covering uninsured, is that the language that you use for uninsured? Yes. Is that strictly uninsured? And also, did you say COVID testing and treatment or just testing? Testing and treatment. Okay. Thank you. So, these are talking points that I pulled from the HHS's website. And so, one of the, with this hundred billion, they're also wanting to ensure that hospitals and other providers use these funds to help them treat uninsured individuals and test uninsured individuals for the COVID-19. One of the phrase you used was uninsured Americans. And so that might... That was a quote from the website. I copied the language exactly. We understand. Right. Without going into discussion. Okay. And then also, when we're talking about hospitals, are we, how broadly is the definition, what is the definition or do you understand? Maybe this is too much detail at this point, but hospitals often are in some communities. It's not just an inpatient program. It's programming for substance abuse or in some cases, primary care practices that are playing a critical role, et cetera. Do you have any sense of that? I'm probably not the best one to respond to that. I mean, I think I'll go back to like, it was really formula-based in terms of how they released that first $30 billion on their Medicare fee-for-service. So I would assume any provider that received Medicare fee-for-service reimbursements in 2019 was on their list. Okay. Because that is that broad list of providers, right? Which puts us at a disadvantage because so much of our payment reform is our all-payer program. So truing that up, I think becomes really important. Correct. Back to you, Sarah. Okay, great. So then the last area that I wanted to talk about was there are a few grant opportunities that AHS has either submitted applications for or is in the process of submitting. And so I'll talk to you about those two right now. And I expect that this will be an ongoing process as these opportunities become available. So one is from the Substance Abuse and Mental Health Services Administration, SAMHSA. They issued an opportunity for emergency grants to address mental and substance abuse, substance use disorders during COVID-19. States are allowed to apply for a maximum of $2 million. So on Friday, the Departments of Mental Health and BDH through ADAP submitted an application to SAMHSA for $2 million. So I anticipate that we'll hear back in the coming weeks whether we were successful in that application, but essentially it would be funds to expand the current mental health emergency services program to include access, SUD specialists and tools to assist with this crisis. Do we know how that our allocation is determined? No, the guidance that they issued, they're gonna distribute the funds and if they're through this kind of initial application process and if there's funds left over, I think they'll continue to receive applications. I'm thinking about how they made the determination that we get $2 million. They just said a maximum that states could apply for was $2 million. I got it. Okay, sorry. Yeah. Thank you. And then the other opportunity is with the Department of Justice, Office of Justice Programs. This is an application that the Department of Corrections is working on with the Department of Public Safety and it would provide funding to help in the response to the coronavirus crisis. It could cover things like overtime, equipment, training and funding used to help address the medical needs of inmates. And so we're working in collaboration with Public Safety on submitting an application. How much money is in that one? That's part of the same though, it's different. It's different. I can tell you because the funds would be split between public safety and corrections, I know that what corrections, what we put together was about a $700,000 package. But I don't know yet what will be awarded. That'll be interesting to see how that sugars off. Yeah, it will. And so those are just kind of two of the opportunities that I know of now. I believe there's another SAMHSA one that will be coming down the pipeline shortly that we were pursuing. So that's kind of it for my formal talking points. I will share this document with you so you can have it to go back to. And then I'll always follow up with questions if you have. Well, Sarah, thank you very much. This is really extremely helpful. And the more we learn, the more we understand we don't know. The guidelines, the criteria, all the formulation that's coming to us from the federal government. We understand that this has been a very quick turnaround relative to federal government. And as we go forward, it'll be really important for us to learn more and more about some of the details that are there. I'm looking at the committee members for questions. Nolan, did you want to weigh in anything or have a question for Sarah? What be left? There you go. No, I'm right here, sorry. No, I think Sarah's covered it up. I'll raise my hand if I have more comments. Okay, we're good. Anybody else? Representative Donahue has a question. I got Ann, good. Anyone else? I'll just try and see if there's a, okay. Representative Donahue, go for it. Thank you. I just wanted to check in terms of the mental health and the corrections grant opportunities. Does that include potentially reimbursement for supplemental salary enhancements for working with people with potential COVID-19 or ACT? So those specific grant applications did not include supplemental pay. I can tell you that we are working on proposals to provide supplemental pay. I mean, that's a really good question. And it sort of goes through all of the money that's coming to us and how if any of the grants or monies that we're receiving can be used for supplemental pay. Yeah, I will say so. I think you're familiar that the state negotiated with the union for some supplemental pay for 24-7 facilities, $1.50 an hour additional, as well as for employees that will be working with COVID-positive individuals face-to-face, 20%. And so I understand that kind of the intention for how we would fund those increases from the state perspective is the coronavirus relief fund at 1.25 billion. And so in my mind, as we kind of move forward and figure out where else we need to provide potentially supplemental pay that we would likely be looking to the coronavirus relief fund. So then that would include, we've heard so much information from our designated agencies and others about the extraordinary work that's going on and thinking that there's some hero pay, we call it hero pay, we can call it hazard pay or hero pay. But so that those folks are also going to be looking for some, at least reconciliation. And so keeping tabs on all of this becomes important. I know, for example, Washington County Mental Health Howard Center and others have been reporting in to you, I guess to you and to others on what they're using. Do you have a sense of that right now and how that's going? I don't have a sense in terms of the dollars that they've spent. I know that commissioners Squirrel and Hut are in very frequent conversations with the leadership for the DAs and the SSAs. And so as I said, we have also been working very closely with them on a package to help support them and their very important efforts. And I would expect that there will be an update available to you very shortly. Good, well, we'll look for that. We'll actually ask them to provide that. What comes to mind while you're talking about this and especially the 1.25 billion is what priorities or hierarchy have you set for that 1.25? It sounds like there's a lot that's coming out of it right now, which is a good thing. We need it, but what has the administration collectively looked at priorities for that fund? I think kind of similar to Commissioner Greshman's testimony at the Joint Fiscal Committee this week, the administration is really still working hard to kind of understand the allowable uses of that fund and wants to work closely with the legislature on how we will prioritize them from the AHS perspective. I'm trying to track the dollars that I know we're spending and identify the Coronavirus Relief Fund as the potential mechanism to pay for them. And so I'm in close conversations with Adam about what we're spending, what I think we're going to need to spend, but I expect that over the coming week, there'll be more kind of mobilization between the administration and the legislature on that. That's great. That's good to hear and I know it's difficult, but I know that both the House and Senate committees have been hearing testimony and trying to sort out our priorities as well. So, and I know that Representative Lippert and Senator Cummings and Senator Westman are very much engaged in the process. Any other questions? Senator Cummings, did you have a question? No? Okay. Anyone else? Senator McCormick, did you have a question? Okay. I see hands go up, but I don't know whether it's for a question or not. I was turning the video back on. All right. Well, you're good. Thank you. I'm going to turn the audio. All right. So Senator Lyons, I have a question. So. Go for it. Sarah, you said at this point, you do not have the list of, what was it, 1,100 providers? Yeah. And what they've received is that, could we request that as soon as that is made available to you that you make it available to us as well? Yeah. So that we're, we have some sense of that. Yes. Yeah. You can, you can just link it in through our committee assistance or through Nolan. And keep in mind there is a chance that it may not be something that eventually is publicly available. When we spoke with HHS officials on Friday, they, I don't think it was clear yet on the path forward. Of course, that was almost a week ago. So I'm sure there's been additional thinking. Well, look at, then why don't we do this? Why don't you send it through Jen Carby and Nolan and Bill and myself? Yeah. That'd be good. And Senator Westman, your hand is up. Sarah, if we can't, if we can't do specific to that, can you by categories create an overall picture? I've heard that it was 60, it was 40% hospitals and 60% everybody else, but there has to be a way if they don't do specific facilities to paint a picture by category. Yes. Let me, I will revisit the issue with leadership at HHS and perhaps at the Green Mountain Care Board too, to see what sort of information we do have and if there's an update that I can provide to you. Excellent. Can I just ask, and maybe I'm missing something here, but what precedent would there be for the federal government to give money directly to a provider in Vermont and have that not be public information? So I think, and I'm not an expert. And maybe I think you said that Devin was coming by later. I think because of the, it's calculated based off of their Medicare book of business, I think that there are some concerns from providers about that being public. So I, again, it's not an area that I'm an expert in, but that is kind of what I heard on the call on Friday. But that's a good point. It strikes me as completely outside the realm of public disclosure that the federal government would be. So good as to give money, but to not tell us who they're giving it to. Well, I'd like to get some of that. Okay, Devin Green, you just showed up. Do you want to add in a comment here? Sure, I mean, I think part of it may be because everything happened very quickly again, which is why we think that there was an issue with the all payer model calculation. We heard Thursday night that they were still trying to figure out the formula. And then Friday morning, people were getting checks in their bank accounts and they didn't know where money was from. I just had a tagline that said HHS. And so everything was happening very quickly. Well, I missed my check. Sorry, Bill, go ahead. I just thought I missed my check. I didn't check, get one. Okay, so it's all very clear. And it's lack of clarity. Any other questions? So, Sarah, you can see that we're very appreciative, extremely appreciative of what you're bringing to us and your continuing work. And we'll be calling on you again. Just keep us posted. If you think there's information that we should have, as I said, get it to us, that would be helpful. We'll do, and I will follow up with my written testimony. Excellent, and we'll make sure that our agenda keeps some room. This is going to become, at least for the Senate Health and Welfare, the funding piece is gonna be extraordinarily important to us and how we prioritize so that we can communicate with joint fiscal and then ultimately with our appropriations folks. So our role will become advisory, but we're seeing that role as extremely important. And I think that probably goes, Bill. I would say that goes without saying that the same is true for the House Healthcare Committee. And I think that we, in our conversation yesterday, anticipate having some additional fiscal briefing for our committee separate from your committee since you had some, you were ahead of us on one point. And so we're looking to do some more of that as we move forward. Yeah, well, we'll eventually we'll meet at the junction. Yeah, I think we're getting close to there. Actually, Sarah's testimony is very helpful today. And I think it's pretty, I appreciate you're going through in some level the detail that you did. I think it won't, we'll be able to follow it quite easily. Terrific. Okay, any other questions? We actually, in the spirit of the Senate Health and Welfare Committee, we have four minutes. And what I would like to recommend is that we take a four minute break and come back exactly at 1030 and renew our testimony. So thank you. So Senator Lyons, am I correct in understanding that when we're on break, we are still on live feed? Yes, we are. So people should mute themselves so that we're not live feedings things during the break. One of the things that we've gotten very concerned about that we have been concerned about the entire time, even pre COVID is the financial health and the ability of our hospitals. And I know that we've all taken testimony since COVID on what's going on with our hospitals to help out and catch up. But we're, and we also know that that is putting a significant strain on many of our community hospitals, not just all of our hospitals. So I'm gonna ask Devin if you could, Devin Green is here. I got the last name right this time, Devin. If we can, Bill, do you wanna say anything more at this point? Well, I just to say that both of our committees over the last several weeks had the opportunity to hear from Dr. Laughler at UVMMC, which was very helpful both in terms of the preparations around COVID-19. And I think there was a great deal of interest on our committee and I think both our committees here, not just from UVMMC and their extended network, perhaps, but from other more rural hospitals in the state. And so I'll just say before Devin starts, if I may, that we had reached out, several of our members had helped reach out to North Country Hospital, who we will be hearing from later this morning. And we reached out through Devin to several other hospitals, but because of the timing of reaching out, they didn't feel prepared to testify today, but hopefully we will be able to do more of that in the future both. So I think some of us are interested in both the financial situation, certainly, but also to understand the preparations that have been required and the responsiveness that we've had to COVID-19, so. Yeah, good, that's good. And just so you know that. In North Country, just to say that later in the morning, we will have both, I think the chair of the board as well as the CEO from North Country joining us. Yeah. Bill, it's just the CEO and president of North Country. Okay, fine, we, that's fine. Okay. So Senate Health and Welfare did have an opportunity here from. We'll take a little walk on, a little. If you're not speaking, you may wanna, Senator McCormick. Senator McCormick muted. You may wanna mute. Okay. Sorry. That's okay. This is all sequestered. So we did have a chance to talk with some of the folks from Gifford this year and we have met with them in the past and we're very, our interests as Representative Lippert has said, certainly go beyond the hospitals that we've heard from or very concerned about Springfield right now. We know that Southwest Vermont's doing a pilot program and we know that North Country is feeling some pressure. So Devin, it's all yours. Thank you for being here. Thank you for having me. Devin Green, Vermont Association of Hospitals and Health Systems and I do have some written testimony that's on your website if you want. It was actually kind of nice to feel normal again and do something that I normally do. So thank you for the opportunity to have me testify here. I do want to go through a little bit and describe the hospital landscape right now and the coordination efforts that are happening then address some key issues and finally finish with some real appreciation and thanks for all that's happening. So as you know, our hospital system was fragile prior going into COVID-19. They have stepped up in every way imaginable. Now that we are in COVID-19, as Dr. Lechler testified to all of you, we feel as ready as we could possibly be with this and what all of our hospitals have done has been establishing incident command, doing parking lot testing, creating new areas of emergency departments. We have one hospital that actually put up a wall so that there was a separate sort of area for people who had respiratory issues, creating negative pressure rooms, moving units, creating alternatives to ICU and ventilation for those hospitals that do not have ICU beds, bringing on other providers to their emergency departments, so cross-training providers, getting them into the EMR system and bringing them on in case the sort of first-line workforce gets sick, they can rapidly bring on other providers and have them ready to go. Housing providers who don't wanna expose their families, so working with the local hotels for housing for providers, they've been involved in the surge, planning efforts, PPE, procurement, and as you know, they've suspended non-essential procedures which has contributed to every hospital being financially precarious because those procedures tend to subsidize more costly procedures and what we're doing now is certainly very costly. Amongst all this though, there's been a lot of coordination which I think just speaks to the nature of Vermont and the accessibility that we all have to each other within the hospital community and through VAS, we've had calls three times per week with CEOs, we have weekly meeting with chief medical officers so that they can share what's working and what's not working in their hospitals. Same for the emergency department directors, we've had regular calls with chief nursing officers, chief financial officers, quality directors, inpatient psychiatric leadership and community outreach directors and we have a website forum so that hospitals can share policies and not try to reinvent the wheel. So due to our small nature, we are able to share information easily which I think is really helpful in this sort of situation. Beyond our own hospital community, we have been working in concert with all of the other provider associations. So we have a daily call at 830, headed up by Jill Olson of the VNAs which we really appreciate. We're able to share policies, sort of have a coordinated effort, have people who have already done some piece of work be able to share other pieces of work with their members and really maximize the work that we're doing for providers. And that's central society, VNAs, nursing homes, DAs, it's really the full spectrum and it's been hugely helpful. We also have weekly conversations with the Vermont care partners on dealing with mental health patients or patients who are in mental health crisis because we understand that similar to nursing homes and other places our inpatient areas can be hotspots for these sorts of things where it can spread very easily. So we wanna pay particular attention to that. We also don't want people spending weeks at a time in emergency departments during this time period and we have seen a significant decrease in number of people who are in emergency departments as well as length of time that they're staying. So patients in mental health crisis are still staying one or two days but that's a vast improvement from the weeks long or days long weights that we had previously. We've also been working closely with nursing homes and home health agencies, nursing homes because again, that's primarily where the hotspots may be and are right now and home health agencies because there's a lot of value there where we can have providers go into the home and we're able to discharge patients to homes. The state has been an incredible partner throughout all of this. We do daily submissions to their system called the EM resource of all of our available beds, our surge beds, our ICU beds, our PPE, ventilators, all of that information to the state is reported daily. We do weekly calls with Dr. Levine, the commissioner of the Department of Health. We do daily meetings on surge capacity planning. We've been working with Diva and the Green Mountain Care Board on our financial issues and having regular meetings with them to keep them updated on what's happening with hospital finances. We do a weekly meeting with DFR for input on all of the bulletins and rules that are coming out and they've done a great job at quickly getting those things out. We've been working with Diva and Dale on 1135 waivers. I thought I knew all the waivers that you could possibly get from CMS. Turns out there's an 1135 waiver for emergencies and they've been really helpful in that area and that's greatly reduced a lot of the administrative burden that would come with moving patients to different areas or providing oxygen in the home and those sorts of things. So that's been hugely helpful. The Board of Medical Practice and the Office of Professional Regulation have been invaluable partners in this. They have set up a really fast system for getting people licensed. They've provided a ton of information for our providers and we really appreciate their effort. We've also been meeting with DMH regularly and we've had a call with the Department of Labor and we've also had a meeting with DOC. So working really closely with the state, we really appreciate all the work that they're doing and they've been really great partners. In addition, we are working with the public as well. We've put out six PSAs at this point to try to give information to the public. We've done that in partnership with the Vermont Department of Health. Our latest PSA is encouraging Vermonters to get necessary care. We're seeing low numbers of things that you wouldn't necessarily think would go away during this crisis like heart attacks and other things and we've been seeing people come in later than they should be coming in when they have issues and we wanna send out the message that people, you do need to do all the efforts that are happening now but if you need necessary care, there are alternatives. Call your providers, you may get care through telehealth. Let the provider triage you through either a telehealth appointment or going to the emergency department and we wanna make sure that people still get the care that they need. So that is a little bit of what we've been up to. The next piece I was going to hit was the financial picture but I'm happy to take any questions at this point. Okay. So- That was quick. That was quick. No, but no questions. I don't see a hand up. Go for it. Representative Rogers has a question. Oh God, sorry, sorry. I was just wondering about childbirth. I've heard from, I know someone who does, she delivers babies at home and she said she's just been completely flooded with requests for home deliveries, which I understand the reasoning behind that. I'm wondering if that's based on a valid concern about delivery in hospital or if that might be more fear-based. I was just wondering if you could speak to childbirth and deliveries during this time. Yeah, so I think it's possible that that is, I don't necessarily wanna say it's fear-based. I think it's just hard to decipher all the information at this point and what the best thing to do is we are, I cannot emphasize enough how much we are in uncharted territory right now for our hospital systems and probably everywhere, but hospitals are continuing to deliver babies. They're doing it as safely as possible. The thing that we are trying to avoid is non-essential care and clearly delivery is very essential. So we have all the precautions around that, but I'm not surprised here that people are still understandably nervous, especially given stories coming out of New York and everywhere else. Good question and thank you for that. Any other questions? They represent down here? Yep. Sorry, Jenny, I just... No, no, it's fine. Go ahead. Thank you. I was just intrigued by one of the things you said, which was that mental health emergency department weights are still there but down to one or two days and it's sort of the two part. One is understanding why because that'd be a great thing to sustain. But the other thing is I'm surprised that there's still a one to two day wait when my understanding is that inpatient capacity is only running at 50 or 60%. Yeah, and I think it's entirely possible. We're still working on that too and I'm not saying that many people are waiting one to two days. I think in some cases there's still one to two day wait, which we'd like to try to get down. I agree with you 100% that we are going to come out of this with some things that we hope will stay in place and that's one of them. What has ramped up around that? I think there are a couple things coming into play from what I've heard and there's one general sense of people staying home again for the reasons that they're staying home because of having childbirths in their home. They're nervous about this and nervous about going to the hospital. So I think there's less actual physical patients because of that. I think we've done a good job working with the DA's and getting further systems in place to help keep people in their homes. And then I think we've also worked on the medical clearance piece a great deal so that we can try to make, before people go on to inpatient units, typically they need to be medically cleared because there's not the same sort of medical things available on an inpatient unit. And so a lot of times we wanna make sure that that person doesn't have an underlying medical condition that needs medical treatment before they go on to an inpatient unit that doesn't have your typical hospital bed and monitors and those sorts of things. So we've done a lot to try to streamline that process as well, which I think has helped. I guess I wanted to ask has telehealth remote consulting has that done had any effect on this as well? Yeah, I think that's entirely possible too. I think for the folks that it works for, I think mental health treatment is set up well for telehealth in that it doesn't require physical touch. So there are some people where it will not work out for them but for those who it does work for it, it would be very effective I think. Okay, any other questions? All right, back to you. Great, so the next piece that I wanted to talk about was the financial picture and healthcare reform. As I mentioned, hospitals are not doing, they are not doing non-essential procedures. And this has created a 50 to 70% loss in revenue for hospitals right now. Considering that about half of our hospitals were in the red going into this, it's really detrimental for our entire system. So because of that, we have a careful eye on the federal financial relief. Right now, there's still a lot of uncertainty, things are moving quickly and slowly and details are coming out and not coming out. As I mentioned with the $30 billion payment, but we do have a couple of options here. So the first one that you heard from Sarah Clark was the $100 billion provider relief fund. And as she mentioned, that does go to all providers. That includes census, really all providers. The first tranche that they delivered starting Friday was the $30 billion and that was based on Medicare. As soon as I heard fee for service, my ears went up, I contacted the American Hospital Association. They were on it, our federal delegation has been on it, the state has been on it, we are attacking this at all angles. I do want to warn that I'm not sure we will be, I wouldn't look to that as our windfall. I'm not sure we will receive much more than we have already received. And almost all of our hospitals have received funding at this point. We're still checking in with Springfield. We think that they will receive some funding soon, just due to, it looks like some of their bank account activity and what the feds were doing there. So we hope that they will receive some funding soon, but almost all of our hospitals have received that funding at this point. And again, we hope to receive a little bit more, some more funding once we figure out that snafu with the all payer model payments. But I don't yet want to say that we will be getting a windfall or that we should hang our hat on that. But we've certainly raised the issue going forward and HHS and CMS have been in contact with each other now. I think a big problem with this initial tranche was HHS actually did this without even talking to CMS, which is fascinating, but they are speaking now. And so we're hoping to recover some funding and we're hoping that this doesn't happen into the future. We've also raised the issue. It seems like for this next piece, which we've been told may come out sometime between Friday and Monday, this next piece looks like it's focusing on the people who lost out in the last round. So children's hospitals, we've raised the issue of mental health providers because those folks don't always get a lot of Medicare and hotspots. So people that are dealing with a lot of COVID-19 right now. We are also going to raise the issue of, we're not thinking that we will see that 70 billion in the next coming days. We think we will see more along the lines of 15 to 30 billion coming out in the next couple of days. So there will be a couple iterations of this and we'll be advocating for rural hospitals in particular in our rural system. I have a question and it might be best to answer this later on, but in conversations with some folks, I've heard that states or places where there are global budgets for hospitals, that they're making out, they're doing better. And do you know, and maybe it's not an answer you give right now, but something we talk about coming out of all of this. Yeah, no, it'd be interesting, especially given this bump that we've seen with the first tranche of federal funding. And we've heard from the Association of Academic Medical Centers that they have also, all of them have seen the Lons and Meldon sort of advanced payment models have all seen this bump. So I would certainly say that having a study funding stream and not relying on fee for service is more helpful for hospitals. And certainly one care's participation is helpful, but as you know, only a fraction of our monitors are in one care at this point. So it doesn't cover the gamut. So that therein lies perhaps a lesson going forward and we can improve the number of attributable lives. Okay, we'll leave that one for now. There is an accelerated advanced payment program under Medicare for hospitals where they can get advanced payments. This is a loan program. Many of our hospitals took advantage of this because it was the first program to come out. But there is a caveat to this, which is that hospitals do have to pay this money back and an interest rate of 10.25% kicks in. I know. Trust me, we are doing some advocating in that arena. So we are hoping to substantially lower that interest rate. Typically it's more along the lines of a 2% interest rate. We'd like to eliminate the interest rate altogether. Now granted, they don't have to pay that back. Most hospitals will not have to pay that back for a year. But given how long opening up is looking like it's going to be, that clock starts ticking as soon as you get the funding. And so we are nervous about that source of payment. We are looking at FEMA as well. There's opportunities directly for our hospitals and we're passing along the application process information to them and learning more about that. But as you probably understand, that's not our area expertise. And we're quickly ramping up on figuring out how FEMA works. And I think that is, and the state has been a great partner in this as well. So we have been having regular discussions with the Green Mountain Care Board and Diva and providing financial data to them. Diva has been helpful in providing some advanced payments to our hospitals, a couple of our hospitals that are most critically in need. So helping them to shore up that way. And we really appreciate the work that they've done and effort and we'll continue to work with Diva and the Green Mountain Care Board on that. And that's what I have for federal and state financing. I was going to move on to the one care model and what's happening with healthcare reform if you're interested in hearing about that. Yes, please. I think we have a couple of questions. I have one and I see that Woody has one. Woody wants to go ahead. Why don't we do that first? Yeah, go ahead. Woody, do you want to ask your question? Two questions and it looks like you're going to be talking about one care. But the first one is for the loans for many of the hospitals, have they been suspended regarding payments or is there an ability for them to suspend their payments during this crisis? And then regarding one care, I realize that not all hospitals are involved with that. Why is it that they weren't originally wanting to sign up for one care? Because now it looks like from the testimony that we've received, that we may be a, this may be a great program for a lot of states to follow us in. So I'll just let you talk about it. Yeah, so I think I'm just going to give a high, so to answer your first question about loans to hospitals, I may let Brian answer that one a little bit more but I assume the hospitals are working with their banks to deal with any particular loans that they may have. I think this is an unprecedented time and so a lot of people are willing to work in that area in terms of one care. So we only have one hospital that is not fully in one care that's Grace Cottage. It is a very, very small hospital and it primarily takes a lot of Medicare. And so Grace Cottage looked at one care and was cautious about joining because any swing in their finances or risk that they might take on would really impact them quite a lot. And I think when you look at one care, the issue for participating is a little bit on the Medicare side. So we have all our hospitals except for Grace Cottage. In the Medicaid piece of one care and that's been working well. I think we have a lot of opportunity to have back and forth with Siva on that to check in on how it's working to set what the terms will be. And so that has been fairly successful. On the Medicare piece, there's a lot more concern because the federal government has not always been as responsive, particularly to critical access hospitals and the accounting that goes into critical access hospitals. So I would say largely any hesitation has been due to the federal government and working with them. I'm hoping that the federal government, one of their lessons learned will be to place more priority in this area and figure out a way to administer this better because we have seen some issues from their side into this. And then I do wanna say that it's not a panacea for this type of situation. While it's helpful to have the cash flow, that we are asking for flexibility. We're asking to invoke the exogenous factors clause because this is not, well, it's beyond the scope of what we were agreeing to when we entered into the agreement. And so that is part of the letter that the agreement and care board and the director of healthcare reform and the state have all written is to essentially just say, we are, this is beyond anything that we imagine going into this and we will need flexibility around it. We will collect quality data but we are not going to base financial payout on it because it's gonna be blown off the map. So that's where we are essentially. One cares and the all pair model. We are not giving up on this healthcare reform effort but we do need some flexibility around it and we are going to have to, we're going to have to chart and create a new course when this is all over. We're really, I cannot emphasize enough how extreme and unprecedented this situation is. I usually say we can't do things because we can't close hospitals and now we've essentially closed most parts of a lot of hospitals. And so it is a totally different thing than we've ever seen. And so coming out of this will be, it will be a reevaluation of everything I think. Right, and we don't need to go into the details on that right now. I know that it's been extremely stressful. The question about quality metrics is one that we would all wanna hear about at some point but we did hear from Vicki Loner at OneCare who indicated that OneCare has put forth some protocols and metrics for COVID and the treatment of that disease. So at some point it might be helpful to hear about how if at all hospitals are collecting that type of quality data going forward. Cause this is the first surge where no doubt we're going to be seeing additional incidences that we're sitting in right now. So, but that's a broader conversation and I'm sure you're already having it. Instead of realizing, I do notice that Brian and Frank are here and I don't wanna take too much of their time. So I'm happy to step aside for now and come back later if that works. I think that is a very sensible thing to do. I wanna look around the screen. Does anyone have a question at this point for Devin? Well, I see the two or three people have questions but I'm wondering if we might, I was gonna suggest actually that perhaps in respect for the folks from North Country Hospital who made their time available to us, maybe we could hear from them and then return to talking with Devin following that. That makes a lot of sense. Can we hold our questions till then I have a question myself. It's Lucy and... Ann Marie. Ann Marie. Okay, I'm gonna write them down so they're going first. Yeah, and I was on that list. Yeah, I know you are. I'm putting you first. Oh well, that's great. Devin, thank you. So if you are able to stay on, we might circle back. Okay, Bill, do you wanna welcome our next two guests, Frank Knoll and Brian Knoll from North Country? Yes, in fact, yeah, I'm on. I was going to welcome them but I thought perhaps represent Brian Smith who I think has also reached out to them. Brian, maybe you'd like to introduce them and then we'll, again, we appreciate making yourselves available to us today and we're particularly interested in hearing about both the preparations that you've been required to do and that you have done in preparation for COVID-19 response and any other concerns particularly as we've listened to financial pressures. So Brian, might you introduce the guest from North Country Hospital? I'd be happy to. I see that you are there, Brian. Do you have a mute button on your? Yeah, I think you can hear me now. You were by yourself saying Frank didn't make this meeting? I see Frank is on the screen. I don't. Frank is here. Oh, good. Well, Brian Knoll is the CEO of North Country Hospital. Frank Knoll is, oh, there you are. I see you, Frank. Is the chairman of the Board of Directors of North Country Hospital. Thank you both for joining us in this meeting this morning. And I think the committee will appreciate all the information that you may have. So I'll let you take the floor, Brian. Okay, thank you for having me and appreciate the time to visit with you. Good to see that everybody's doing their social distancing. If I had to take my pick of who I wanted to be with right now, it'd be, I think it's with Representative Donahue. Your names are partial, but seeing your background, I think I'd rather be at that location. So what I'd like to do is just give you the framework of my time with you and kind of share just briefly about perspective, you know, past perspective, real brief, talk about our current state, what we're actively doing, future state, and then just enclosing what we North Country Hospital need from you all as our leaders and legislators. So I'll start with perspective. Our hospitals, Devon reported, many hospitals are operating in the red. Our hospital for FY19, proud to share that we actually had a positive operating margin and we returned to positive after multi-year losses. One of the tough decisions we made this past year was to wind down our long-term care, 23-bed long-term care unit, which is an off-site building. And that was to be effective April 30th. And many thanks to Secretary Mike Smith and many others, Laura Pelosi and legislators who helped us through that process and happy to report that that actually wound down and closed effective April 1st and coincidentally now serves as a possible overflow surge site because we have the 23 beds there still in play. Fingers crossed that we won't have to use that, but it's nice to have that resource and everybody was transitioned to a new home safely. We've, again, past perspective, increased correspondence and requests for information with organizations, with Green Mountain Care Board and their sustainability. Many of us working on our hospital, working on workforce recruitment and retention strategies for our end and doctors and decreasing our dependence on use of locums, medication shortages, those are just a couple examples. So on current state, so here's what's actively happening now. As of March 11th, which seems like an eternity ago, we activated our incident command. In fact, that's where I'm sitting right now is our incident command that we set up, effective March 11th. This is where we, a small team has been leading and relocated to, we have breakout offices outside the perimeter here where we have other meetings. And we've been, since March 11th, we've been having daily calls with our medical staff and with our leaders every morning and then communications to all staff every day, seven days a week. Since that time, we switched our model from outpatient centered to inpatient centered. So the model for our hospital and across the country clearly switched from to an inpatient model, which has, of course, had us postponing all bread and butter business, deeply impacting operation performance. We moved in our hospital campus itself. We have some medical office buildings outside the main hospital building that we've had several clinics inside the building that we had to relocate and find alternative spots for them to see patients. So we relocated our sleep services, our cardiology and our infusion clinics to keep less people from circulating in the hospital. And then, of course, we increased our use of telehealth. So that's really on an operation standpoint from a communication standpoint. We've increased COVID awareness and decreasing mainly that the drive is to decrease anxiety through emails and ongoing communication with our staff, increasing campus security personnel on the front end. Since the community has adapted, we've been able to back off from campus security a little bit more. We've restricted, of course, access points into the campus, screening all employees and visitors and effective this week. We now are doing temperature checks when people come into the campus. We set up a COVID nursing line that's staffed by three nurses through the course of the week. And we monitor that activity throughout the course of the week. And we've seen that start to steady off, which is an indication our community's adapting. We have also set up COVID testing sites. We have one here, Monday, Wednesday, and Friday. It's a drive-through arrangement. And then on Tuesdays and Thursdays, we have a COVID testing site that we support at Island Pond. So we're covering two counties. Under supply management, you've heard much of, you know, nationally and locally about PPE management. Currently, I can tell you for our staff and for our front-line staff, we have what we need. It's a matter of, you know, assessing if we receive a surge. It's at the burn rate. How long can we, how long will we have ample supply? Secretary Smith has done a good job of working within his authority to try to redistribute as appropriate to those surge sites. So we've had guests from Ford Motor Company. That sent us 500 face shields to help. We have the high school and a local partner of one of our physicians that is printing face shields through the use of 3D printers. And we have a lot of tons of non-clinical masks that have been donated that we are distributing, not only to our staff so that they can use, but now we're starting to distribute those to patients. And we've also ordered 10,000 procedure masks through our joint supply chain with the new England area hospitals through Dartmouth. We don't have no delivery date on those. The price point, of course, is higher than we normally pay, but that's what we're trying to do for just procedure masks. And then on N95 masks, we have the supply we need now. We have a fitting station that we put in play and fit our masks. It's just a matter, again, about the burn rate and medications shortages. That's something that we've been dealing with pre and currently, so we have a framework that we always deal with medication shortages. Left and meeting. So on the staff side, we keep clinicians on hand for surge. We've furloughed today, not today, but up to today that the number is approaching north of 145 people. That's about 30% of our staff. We're working with one less vice president. We closed, we did close our neurology clinic and that service line. We also providing staff housing on an as needed basis because we have workers that come across the border from Canada. And then we also have staffing or housing available for those that would test positive and want to stay or need to stay in isolation. On the cash flow side of things, current state, again, is managing, of course, the cash flow. Our hospital received the advance loan that Devin was speaking to. For our hospital, that amounts to about $8 million. And last week, we received $1.3 million in stimulus. To give you perspective, we believe that would, that loan and then that stimulus check and our cash situation, we could operate at current state through June. We have a $5 million line as well. And this is, we would still have to dip into those resources but that's what we are with the cash situation right now. And then on the community, assisting organizations outside our walls, we redirect food donations to the food bank. We have a dietary department here that we use. In fact, the dietary department set up a small marketplace so that our staff can pick up and shop through the market here and get their groceries needs and keep them from going to the supermarkets. And then we have, we were distributing cloth masks to rural edge, V&A, EMS, patients and employees. And then we also have 50 cuts on our surge trailer. And those were moved to the Rutland area to support the stand up surge site there. So that's really a touch point of current state. And then I'm gonna move into future state. So and the current state, again, we're meeting every morning and adopting and dressing on the fly and as the situation evolves. We, for future state looking at possible effects of North Country Hospital, first of all, the FY20 budget we all know logically, that's not gonna be met. If we project off of what we know today and then make some assumptions about trying to return back to outpatient services, getting back to our bread and butter, I would project that we will lose $21 million this year. And again, remember, we were in the black before this. So I guess the way I would have you recall that is the flattening of the curve has been very effective. But that equals the flat, it'll equal and have us gravitate to a flattening of a financial recovery. So we were looking at how we would ramp back up and anticipating a second surge of medical care. So we have postponed surgeries. How we'll be able to proceed with those postponed surgeries and we have, of course, our personal protective equipment to be concerned of, getting the surgery packs that we need and what's the supply for that. So that will definitely impact our return to business norm. We will also, I'm projecting that we will also be managing a lot of staff burnout. So we have plenty of staff that have been working around the clock to anticipate, navigate, prepare for this crisis and that reward will be more hard work in the recovery phase. So that will lead to a staff burnout. Of course, the repaying of loans will be another burden. We'll continue to seek creative ways to get reimbursed for COVID related expenses, continue to use telehealth. In the current state, we're using telehealth and planning of use of telehealth even for intensivist through Dartmouth Hitchcock, where we can use telehealth for ICU patients. We've started that application for a business interruption filing with our insurer. We expect that they'll be denied, but if there is to be any federal or state assistance that would direct that as a means for recovery, we wanna make sure that we're anticipating that being a possible player. We'll still have workforce retention and retention issues to work through. And I project we have, we won't know that till we navigate through this, but a potential for an increase in nursing shortages at hospitals. So it could very well be that some employees will shift away from hospital work and try to get into other settings. And again, pre, current and post will still be dealing with medication shortages. So in closing, here's just my list of suggestions for what we need from our legislators. First, continue working with Jeff Thiemann and Devin Green and Vaz. They represent our hospitals exceptionally well and carrying our voice. They're great leaders and I'm always encouraged to hear how they're interacting with you. And it's just a good mechanism for 14 hospitals to voice and consolidate our request and interest through those individuals. I also wanna thank you for passing legislation for the reimbursement of telehealth and the flexibility of the recent flexibility of licensing workforce during COVID. So those are good things to continue to build upon. I would ask that legislators and others be mindful of requests for information. Using Vaz to coordinate those requests is extremely helpful. It allows our hospitals, my leaders like myself to manage the hospital, to do what we're paid to do and manage nosing and work through the day-to-day operations. So reaching out to them helps us to consolidate those requests. We, you know, for example, budget cycle is gonna need to be handled differently this next year. FY20 budget is out the window. And if we reflect for a moment, how many thousands of hours we're put together and projecting what our FY20 budgets would be and getting going through approval process that took months and then now we'll spend. So now that that's behind us, we need to look at what the FY21 budget process is and how can we focus more on real-time work and projections. So for example, managing our hospitals by day's cash on hand, debt service, operating margins, staff turnover, use of locums, really conception looking at a 13 month. So how did we perform last month? How do we expect to perform in the future month? How do we perform in the same month a year ago? So that's what I mean by actively manage. And that allows us to repurpose that effort to do an active management then and too much forecasting and then six months from now that work unravels. So we'll continue to focus on federal relief as Devin has mentioned before. I dropped on the call. Local consideration, the provider tax, maybe there's some opportunity there. Our hospital pays $4.7 million a year and through the dish revenue received back 900,000. So that's about a net of $3.7 million and expense. We also had a lot of good work that many of you were a part of with the material covered under Laura Pelosi's leadership with the Rural Health Task Force, Workforce Subcommittee. And there's good actionable material in there that with the pandemic it underscores our need to increase our focus on workforce. So things in there include interstate medical license compact, tax and loan incentives for attracting healthcare workers, expanded use or continued use of telehealth and reimbursement for those services. So those are some quick laundry list things that in my brief time that I had to think about this that I would just share with you from my perspective. And then I'd like to pass it off to Frank to give him a few moments to share a few remarks and then we'll take your questions. So thank you. I just want to say thank you. You're passing it to Frank, but this has been very clear and consolidated testimony. Thank you very much. Yes, thank you. Oh, thank you. My pleasure. I appreciate it. Hi. Thank you for this opportunity to come before you as the, as a board member for North country hospital. I think it's a curve from a lot of different sides in this case, but hearing from a board member might be something a little different. We faced a lot of challenges at the hospital as you've heard from everybody. I think it's we're not different than the other rural hospital. It's a hospital board. I think it's our main duty to provide guidance, oversight and strategic direction. So hospital boards are really being tested during these unprecedented times. So we've been able to provide guidance. Luckily we have a mixture of healthcare professionals. People from the expertise in business and finance and law. So with that background of expertise, we've been able to help Brian, I think in terms of providing some guidance. We're very fortunate to have a CEO that is highly organized and we work. We're very pleased to work with with Brian and his senior team. To try to get through this particular. Set of hurdles that we're face. We also want to thank vase has been a great organization. To support hospitals. Brian has already pointed out. Our board, of course, is working closely to look at and beyond the epidemic. We are at necessity rethinking the ways we probably have to deliver healthcare. Royal areas such as ours in the future. After the epidemic crest. Brian has mentioned again, some of these things. Rural hospitals have always had to balance the way it provides its services. Meaning that we are always having to provide a central inpatient outpatient services as a critical access hospital. Again, the hospital has to balance these services that lose money with those that generate some income. Example, we are there to provide emergency care, emergency rooms. We have to do that. We're certainly there to deliver babies. These things typically are lost leaders in our jargon. And we have to balance that with other services that generate some profitability. That's always been there. But operating margins, if you've heard or should know that have always been notoriously thin. So dealing with these uncertainties caused by COVID-19 is a real catch 22. For all hospitals. Hospitals want to do everything that is possible to be ready for a rise in COVID-19 patients. But this preparedness requires a lot of resources. In terms of labor materials. That means the readiness results in very large increases in unbudgeted expenses. On the revenue side, the hospital is sidelining most of the income producing service lines. Her Dev and others confirmed that to prepare for the safety and treatment of incoming patients while maintaining safe operating conditions for old staff. And the financial costs for this catch 22 for North country hospital. I think Brian has already mentioned. It's north of $20 million by through September of this year. So when you compare that loss to our 2019 operating income of just over a million dollars. The question becomes one of survival. And we are one of only 14 hospitals, Vermont. So yes, we do have credit lines and expect federal assistance beyond the present amounts. But that's probably nowhere near enough to cover the loss of this magnitude. So this probably takes on. A whole different meaning for not for profit hospitals. No, no pun intended. But if we could hope to return to normal and again, normal should be in quotes. Then generating one to $2 million a year of net operating income is in the recent past. We'll take 10 to 20 years. To fill that gap without allowing any room for new investments in health care, which we need to make. We have an aging facility, I should point out. This is why hospitals need your support for all of the financial assistance and relief possible to navigate our way back. We are also likely need your support to possibly change the way we provide health care in the future. And again, Brian has touched on some of these things. Health medicine, et cetera. And specifically, I think from my side, they probably emphasize some things that are maybe. Difficult for others to mention, but some of the suggestions in terms of relieving administrative burdens. Again, specifically removing the green mountain care boards cap on our net patient revenues. This has been a kind of a bone of contention, I guess, for boards. So we look at, you know, trying to make our way forward and just difficult balance of services we provide. To have a cap on our net patient revenues doesn't seem realistic, especially now as we try to recover, or we will try to recover from the current situation. So that's extremely important. Again, green mountain care board, we like to reduce the hospital dues that we contribute to that. Of course, this year, 2020, that formula for the green mountain care board reimbursement will be not met in terms of the budget not being met. But again, the burden going forward in the future should be reduced. From the board side, I think it is our duty to govern more and then we should have more responsibility and local governance. And I think that's, we're prepared to do that and step up to that. And I think that's something that should be considered overall. Again, to emphasize reducing the administrative burden, anything the legislators can do to oversee that and see that our legislative burden is reduced. And we will understand that we have to keep these good things in place. And I think that's one of the things that we should do. And I think that's one of the things that we should do. And I think that's one of the things that we should do. And I think that's a series of checks and balances in place, but emphasize that easing or eliminating some of the layers of administrative burden is essential. So with that, I want to thank you all for your service and for the committee for, for having us today. Thank you, Frank. Very much. Very helpful. And from the other side of the table. Very, very important. Representative Durfee has a question. Maybe for, for Brian, but I wanted to get it in before the two of you signed off. And it's also a broader question for, for Devin going back to. So, so. Moving just for a moment from the financial concerns, which are obviously critical, but. Going back to the point that Devin made earlier. I don't know whether two of you were on the call at that point about concerns about patients for going care. And the PSA that the associations put out. Are you seeing in North country. Any. Any. Negative outcomes in the community from people who might not be getting the care that they would otherwise be able to get. So my answer today. Thank you for your question. My answer for today would be. No. But we are seeing an increase. And I expected this would happen some more increase in mental health needs. And ironically, the flu season is almost all but done. Because of social isolating. So that's actually a positive thing. It doesn't help our inpatient volume. But so there's, there is some, some positive negative. But I think, you know, for the most part, we probably are doing maybe 60 to 70% of primary care business that we normally would do. And, and trying to manage to the telehealth. And so that's keeping us in tune with the, what the needs are and people are getting their meds refilled. I think it's just the more of how long. You know, this goes on. It would be more apparent to. Of that. Of that people for going healthcare. Does that answer your question? Okay. I got the thumbs up. I can't see your thumb. Thumbs are happy to answer. Yes. I'm happy to get a different minute. Thank you. Yeah. Yeah. I have a question. You indicated the concerns about. You know, running short on medications and our, the Senate committee has recently taken testimony about the availability of such things as hydrochloroquine, which has been touted as a therapeutic therapeutic for COVID. At the same time. We don't want to eliminate the availability of those types of medications for patients who are. You know, chronic conditions and need them. So our, have you seen any challenges with respect to. Some of the medications. I believe the office of professional regulation recently set out a list of some of the medications that are of concern that would be used therapeutically for COVID, but at the same time might need to be kept available. Is your pharmacy seeing any issues associated with those types of. Yeah. Thank you for your questions. So first, I would, am I remarks? What, what I want you to understand is that medication shortages is something we've dealt with pre COVID and we expect to deal with that post COVID. So it's something we're very familiar with. An example would be when the hurricane hit and took out the insulin manufacturing facility in. Yeah, I think it was in, I can't remember. Devin can maybe help me, but overseas in Puerto Rico. So, so it's just an example of we, we, we continue to deal with that today. We don't have, we on our call every morning. Pharmacy is part of that update and they would bring up any to our physicians and to our leaders, any particular shortages at the moment. So it's a real time. So for a COVID treatment, we don't have anything. We are projecting very much concerned about when we open back up for bread and butter business. The medications that we would need for surgeries would be in short supply. Okay. Thank you for that. And any suggestions that you or your pharmacy might have? Probably we would like to hear them, but I think they also go to the office of professional regulations or any help that we can offer. If you have any other questions, any other questions, if you have any other questions, get your information to Devin and she can send it off to us. Be helpful. All right. Thank you. Happy to. Any other questions? No further questions for Brian or Frank. Well, thank. Thank you. Woody has a question. We have a question from representative. Good morning. Good morning. Thank you. Thank you. And Lucy and Amory. Good morning. Can you mute your mic when you're not speaking? Thank you. That was good. Let's see who was first on that list. Bill, you were actually first on the list. Well, I was, I was wanting to ask a question of Devin afterwards, but I think Woody's Woody has a question at this time. Okay. It has to do with the treatment of prisoners. How are you handling the treatment of prisoners? At North country. Sure. So. We. First of all, we went with the transportation of president, prisoners to St. John's, Barry. Sean tester, the CEO at NVRH. And I've been close in communication of what their search capacity is. And over the weekend, we were going back and forth and just kind of game planning. If they had a surge from the prison, we have an understanding that we would be there to assist and they could send patients here. The plan A is that those patients would go to UVM. So we technically are plan B. But we're so, but as far as the treatment of prisoners, it depends on their state. So if, if they're, if they need to be accompanied. And they're awake and alert. Then we would work with the, with the guards to protect them, give them the protective equipment and have them on site. But if it's a situation where they're going to be unconscious and vented, then we won't need them to be on site because the patient will obviously is in a dire situation. And so they would not be, we would not have security with them. Cause they would be sedated. And that's my quick answer. Any other questions for. Ann Marie, represent Christian has a question. You're muted. Yeah. Okay. On now. The medications you were talking about. A shortage of those for surgery afterwards. And we hear national stories about not being enough sedation in some places for ventilator, people on ventilators. Can you say what the shortages do to, is it big demand around the country? Or is it a shortage of supply? I'm not that I'm not the industry expert on that. So I couldn't tell you the source. But what I can assure you is that our, our staff are sure. Physicians and clinicians are. And involved in dialogue of what to do in, in case of shortages of. Like propofol and other such anesthesia drugs. Thank you. Yep. And I'd just like to add that Devon green from us that we are working with. Our federal delegation and FEMA on this issue in concert with the New Hampshire hospital association and the main hospital association. Thank you. Representative how did I see your hand up? No, okay. Did anyone else have a hand up for Brian or Frank? All right. Before. Bill. I just wanted to say, I appreciate the amount of time that you've given us this morning. And it's been helpful. And informative. So I appreciate the demands on your time. And thank you so much for giving us your attention and time this morning. Absolutely. Thank you very much. Yeah, you're welcome. We have plenty of good people here stepping up and at the ready to serve. So thank you for your service and your support. Well, thank you and good luck. Thank you. We have, we had three people lined up to ask Devon a question. Bill, you were first. And then Lucy and then Ann Marie. I think that. That's the list I have. So I have two, two different questions. If I quickly. First, we, I think we heard about furloughs. And we've heard, I've seen in the media reports of furloughs, but I don't think that's really in terms of. Do you have a sense of statewide? The hospital systems. The number of employees being furloughed because I think. The number of employees being furloughed. I mean, I think we've heard a lot of people are closing and we've heard people applying for an employee, but frankly, I don't think as much attention has been given to what the impact has been on actually employment in hospital settings as well. So that's the first question. And the second has to do with also picking up on something which was alluded to. Again, here. That there are certain areas which are. Cost. Negative, which basically you lose money. You don't have to. You don't have to. That's a good point. I'm interested in the substance abuse. And. I'm interested in knowing what. You see as statewide again, or. Are there particular areas where there's an impact on hospitals being able to continue to sustain their substance abuse services. Or mental health services. Or making decisions to no longer provide them in the same way. So that's the first question on furloughs. I think hospitals. Are looking at ways to reduce costs. And. At this point, they. Are either asking. I would say that everyone is stepping up in a big way. And some hospitals have asked for ways to reduce costs. And some hospitals are. Doing some cuts at this point, but we are trying to do it in a thoughtful way because we certainly don't. This is the last. This is the wrong time for us to lose our workforce. So. This has impacted hospitals. This has impact the workforce. And we're nervous about it because we don't want to lose our workforce. And so we are. Just looking for every funding opportunity and. Wait. Employees being furloughed. I do not. Okay. Could you get that for us? I can. I can work for us to have a sense of really what's on the ground happening. Because I was in the media, I understand Rutland's furloughed 150 employees. And I think we just heard that number of other employees here. And so I think the cumulative impact across the state is something we should be aware. Yeah. And in terms of. Mental health procedures and. Delivering babies. Those are again. Substance abuse. Substance abuse. Those are things that typically cost hospitals money. As far as I can tell, they are not cutting. Necessary procedures. So like I said, we're still delivering babies. I think a lot of the. Substance abuse treatment and the. Mental health treatment is being done through telemedicine. We have our inpatient. Units still open. And we have received. Flexibility from the federal government for. Things in substance abuse treatment. Like. Not needing an in-person. Visit to begin. M. A T and other areas that give us some flexibility there. So I haven't. Heard of a. Reduction in necessary care in those arenas. But again, we don't know what we don't know. We don't know what people aren't getting help because they are worried about the situation and all of those things. And the children's hospital tends to be a lost leader as well. Which is, it's good to see the federal government acknowledging that one. Any other. Okay. Oh wait, I'm going through my list bill. Is that. Is that okay. Lucy Rogers. Thank you, Devin. The money you were speaking about appearing in the hospitals. Accounts. That was the federal HHS. That was the federal. That was the hundred. That was 30 billion. Of the hundred billion. For. Providers from the H8 from HHS. So during. Sarah Clark's testimony this morning, we heard that that was specifically for. Uninsured Americans getting testing and treatment. Did it. Arrive to the hospitals with a set of guidelines and stipulations or. Just. Trying to understand. So. It looks like representative. Donnie is going apoplectic. So we're going to. Make a comment. You may want to correct me, but my under. My understanding is that. Providers will be in reimbursed at Medicare rates. Through the hundred billion dollars in funding. For. That treatment of uninsured folks. But the money is. Already in. Their account. Part of the money is in the account. Just a portion of the money is in. Their account. And that. Money was. Predicated on the fee for service. From 2019. So. I'm not sure if. HHS is going to. Require. Hospitals to submit claims for uninsured folks or just say. This is the money that you need to use to treat. Uninsured folks. I don't have clarity around that yet, but I can try to track that down for you. Okay. I guess what would be helpful for me to know and. I think that would be helpful. Maybe this is what you're saying you don't know yet is. The money that's in the hospitals accounts now from HHS. Is that money carrying stipulations of. This. To be used for payment for care for uninsured or is that money. General money. That's already in their account to use however is needed. I don't know. I don't know what you're looking for clarification on. Yeah, I don't know. I don't know what the mechanism will be for the. Uninsured. I just know that we were hoping that the. Coverage of the uninsured would be on top of the hundred billion. And it is actually included in the hundred billion. Okay. Okay. I think some of the clarity on that is going to have to come into the bill itself. But it seems like HHS is not particularly involved in, right? No, no, they're not involved in this one at all. I apologize. You're right. It'll come from HHS. HHS. I said the wrong. I put the A in front so that HHS. Okay. Ann Marie. Hi, I have two questions with the furloughed workers. You know, there's a lot of furloughed workers. They're still using traveling nurses. I don't know the answer to that question, but I believe that we are still using traveling nurses. Yes. I see people shaking their heads. Yes. And now that I think about it now that I remember back, sorry, I didn't initially know, but yeah, we have been using traveling nurses and. It is not optimal. I don't know. It's too bad. My other question is, are there some, where everybody seems to be prepared for the surge? Are there some hospitals that have no COVID patients? And are there hospitals that are at capacity? So I don't believe that there are hospitals that are at capacity. And in the search phase at this point, I don't know the latest from today. If there are hospitals with no COVID patients, but I do know that there are hospitals with. One or a few COVID patients. So. It is entirely possible at this point that there. I would have to check on whether or not there are any hospitals without any COVID patients. Hey, Devin, I'm still on stuff out of chime in here. Thank you, Brian. I think for most patient, for most hospitals, there's, there's plenty of activity of what we call PUIs patients under investigation. And then you're waiting for the testing results and many of those end up coming back negative, which is good. So there's COVID activity, but there's not many COVID positive. I think it's only 30 right now 30 to 33 in the state. So that might help. Yeah. And I think there are very few inpatient to a lot are being managed as outpatient. And also if they're in the hospital. As under investigation. And that must mean they have symptoms. And, but some are still coming back negative. I don't, I don't quite understand that. Are they vulnerable? In general. So they, so they usually meet the criteria. For the symptoms. Through chess X Ray and. And so they, they present with what looks like COVID. But we're, you know, some of them, I would say, are strong candidates and some are weak rule outs. Thank you. Representative quarters. Thank you. So I'm putting my nurse hat on now. Working at UVM medical center. And I can say that. First, I think the vast majority of active COVID infections are being treated at the university of Vermont medical center. And I think that as far as the P. I think also the vast majority of patients who are under investigation are not hospitalized. Only when the acuity of their illness gets to a specific. Point. Are they hospitalized? So most of the P. Y. People are managed. And for that. So that leads to, I think. Probably the majority of hospitals. In the state have. Because we, all the hospitals have. Stopped nonessential procedures. The furloughs happen because. For a number of reasons. One is because the staff, they, they, they have to be paid for the. The staff. There's nothing for the staff to do. And so it doesn't. It makes sense to support the staff, but for not for the hospital to be paying them to do nothing, especially when there are, they're not taking care of COVID patients and they're not doing the work that they normally would do. The travelers. Or the locums. I think. Partly because we are staffing up. In the areas we have three units. That are actively taking care of. Extremely symptomatic P. Y. As well as people that have known infections. So my understanding, at least through UVM is that the locums. And for the most part. People are not being furloughed and then replaced with travelers. Right. If that makes sense. There are places in the hospital so that there's another consideration is a nurse is not a nurse is not a nurse. So there are nurses who. Whose work. Are not active right now because they're not doing those. Providing those services. So it's a, it's a huge. I don't want to say a jigsaw puzzle, but. I'm going to say juggle sounds like a juggle. A lot of juggling. Yes. A lot of juggling. And I think for the most part. I'll just reiterate the people that are being furloughed or not. I don't think are being replaced with travelers. The travelers are going where there's an actual need. Would you agree? I see you nodding, Devin. Would you agree? Yes. Thank you. Representative Cortez. I was really helpful. All right. Other questions. Wow. Thank you. Devin, thank you for your availability and information. And Brian and Frank. Thank you. I think Brian is still on. We greatly appreciate the time. I'm going to turn it over to Bill and the meeting. Well, again, I think. The meeting jointly today has proven to be valuable, both as we've heard from our witnesses in terms of efficient use of their precious time right now. And I'm going to use that as a segue to Jenny to just say that we've done some preliminary planning for next week, which includes joint meetings between the house healthcare committee and the Senate health and welfare committee. Again, I sent out a preliminary. Noticed to our house members just so you could begin to plan some of your time. But. Senator Lyons and myself. We'll. Work to get out a more specific. Plan. And time. So that we can again, use this. To address the ongoing needs as we meet remotely. In COVID-19. Emergency situation. I think that's, that's, I think I just want to again, express my appreciation for all the witnesses who made themselves available today. Yeah. Thank you. I forgot, I should, I should mention to a Senate health and welfare. We are meeting at nine o'clock. Tomorrow morning. I failed to mention that earlier, but we're all getting used to each other. This is really great. And it's fun to be together. Thank you. Thanks a lot. It's working well. Good. All right. We are leaving. The meeting. Take care. Yeah.