 work with us for many years. We are a 19 bedroom glass hospital with acute and swing patients. The majority of our patients are our swing patients. Our average daily census for acute patients is less than two. We have a full service emergency department 24-7 diagnostic imaging services including X-ray, ultrasound, CT, and bone density. We have a laboratory on site that does the majority of our laboratory work. We do send more complicated tests to reference laboratories outside of Grace College. We also have a very busy and very well utilized rehabilitation programs at Grace College that provides PT and OT services for the patient and outpatient. We are a licensed rural health clinic that's pretty well staffed with primary care providers. We have six primary care MDs. We have one full-time nutrition. We have four advanced practice providers with APPs that work in our health clinic. We have a psychiatric and nurse practitioner and we have a full-time licensed closure order in our health clinic. We also have a very well staffed and very talented community health team that consists of an art and care coordinator, a nurse outreach coordinator, an IVs educator, a behavioral health specialist, a health coach, and also a nutrition resource advocate. In addition to the hospital we also have an on-campus, not attached to the hospital, but on-campus, retail pharmacy called Messenger Valley Pharmacy which is an extremely well utilized service that's of tremendous benefit to the local community relative to their pharmaceutical needs. Grace College is very proud of its reputation and its culture of being a highly patient focused customer service organization. Two years in a row we received the award from the National Rural Health Association as a top 20 critical access hospital for patient satisfaction in the country. We're very proud of that two years in a row. Most recently in the local William County Best of Poll we won these five awards. Best hospital in William County, Best Emergency Department. Second year we were awarded the best place to work in William County. We have a very, very highly satisfied staff at Grace College. We also won second year in a row Best Physical Therapy in William County and this year Best Pediatrician in William County. So very pleased with the results of the local community survey about Grace College and the services we provide. This slide is just a reminder when Steve presents the financials for Grace College he talks about our increase in that initial service revenue that's being forecasted for next year. I think he's been a burden to recognize that of the terrible net patient service revenue in the entire state of Vermont's health system, Grace College constitutes less than one percent of that total net patient service revenue. So you know we we have a very very miniscule impact on overall revenue as a percentage of total in the state of Vermont. So I just wanted to point that out as a reminder because you will see forecasted increase in net patient service revenue for next year that's based on volume projections. So what are some of the issues that Grace College is contending with going into next year? Well clearly we want to continue to increase access to primary care. The primary care is what Grace College does really well. It's the foundation of what we do as a health care organization and we truly believe that by providing access to everyone who needs a relationship with a primary care provider we are doing everything we possibly can to improve the health of our communities, the health of our patients which subsequently we believe reduces the cost of health care because if you take care of people and you keep them managing their care well they tend to stay out of emergency departments and hopefully they don't end up in in high cost acute care settings like operating rooms and cancer centers and other types of high cost services. So we really believe in managing the health of well-being of our patients in our community and by doing that for a primary care services and having access for additional patients with any primary care we're really contributing to health and wellness. We're also looking to expand our access to rehab services. You know we have a very highly skilled team of rehabilitation providers who do an excellent job of getting patients back home and out of the facility where they belong or they need to be and you know we see that as a center of excellence for us and so we want to make sure we're available and we're getting many patients to be benefited from the skill and expertise of those providers that work in our rehabilitation program. So it's really about about expanding access to services and reducing the cost of care that's really germane to our positive opportunities going forward. Some of the challenges and issues we deal with you know I mean CHT for example community health team is a very very valuable service to our community but it's also not well funded and so it is a an expense anger for Grace College but we truly believe that it's a program and it's a group of provider clinicians who really complement the work we're doing in primary care and also complement our efforts to improve the health of our communities and so by having CHT available to our patients we really offer a complimentary cadre of services that help our primary care providers and caregivers to maximize the impact they can have on our patients. Primary care recruitment and retention I'm sure you've heard that from other hospitals during the last week or so primary care recruitment is always a challenge particularly given the fact that there aren't enough providers nationwide to meet all the demand for primary care and so when we have a vacancy Grace College you know recruiting to fill that position is always something of a challenge. However we've been quite successful in bringing primary care providers to Grace College and we truly believe that the reason for our success is because of the model of care that we deliver it and also the culture of support and respect for our employees and the work that they do and making sure that all of our employees whether they're providers clinical providers or not have the resources and the the tools they need to do their job successfully and do their job well. Not to mention that Southern Vermont is a beautiful place to work and live and so we believe in that that helps us recruit well. We are an employer of choice with very very low turnover relative to other organizations that we benchmark against and I think that reputation you know is something that benefits us when it comes to recruitment. Nursing standard recruitment is also a challenge because nursing is one of the largest employee programs at Grace College but I'm actually quite pleased when I look at again the turnover rate within nursing at Grace College is exceptionally low and I'm also pleased when I look at the money we spend to staff our nursing program and how much money we have to spend on on agency or local tenants nurses it's extremely low compared to other hospitals and compared to benchmarks and so I think that's a testament again to employee satisfaction and the desire for nurses to want to work at Grace College. Oftentimes when we have a vacant position we get in there be multiple candidates and can make the best one and we also have the the ability to to pass on on nursing candidates that we don't feel are a good fit for Grace College so something that a lot of hospitals don't have the benefit of being able to do so. I will miss the mic over to Stephen to help pick up with this next slide. Just want to do we've brought this a couple of different years in the past I don't think we actually brought this slide last year but just to remind or reiterate or point out what truly is the biggest risk in my opinion for Grace Cottage's survival and the basically the barrier to us having a positive bottom line is the continued increase in the amount of money that essentially Grace Cottage is supporting the state of Vermont covering shortfalls from the Vermont Medicaid program. This slide which is information you have it's directly off from the schedule H that was submitted in 2018 994. Our gross Medicaid charges in 2018 were just under four million dollars. The actual cost to Grace Cottage to provide those services was about 2.7 million dollars. Medicaid actually paid us only just under 1.4 million dollars for those so they're only paying us 50 percent of what actually even costs us to take care of those patients much less the ability to even make a dollar. We're actually losing that money we're losing 1.3 million dollars taking care of Medicaid patients. In addition to that we write them a check for six hundred and twenty thousand dollars for Medicaid tax which we have no benefit from being that we are not eligible for disproportionate share payments so you know on a facility with a budget hour size to basically be writing a check for two million dollars through the state of Vermont is a very large hit to our bottom line. I mean you know it's a good 10 percent of our total operating costs is taking care of Medicaid patients. Thanks for the question should we bother taking care of Medicaid patients unfortunately as they are not unfortunately but as a hospital that's one of our duties is to take care of anybody that needs it but you know it's a very difficult decision to make to continue to be part of a Medicaid program in the state of Vermont. Then just pointing out some of the main indicators for Grace Cottage's financial help these numbers are all directly off reports that were provided giving the last few years of actual history the current year budget current year projection and the coming year budget. No dramatic changes up or down in any of the numbers. You'll see pretty consistent year to year over the last couple or three years with the exception of the top one which is almost flat or the budgeted number will be almost flat to our 2018 actual most of the rest of them are slightly improved over 2018 actual days payable although high at the end of 2019 and that was one of the written responses we provided it's essentially timing of cost-report settlements but what we're budgeting is improved days payable improved days receivable although still negative and improved operating margin over where we ended up in 2018 and where we're projecting end up in 2019 and an overall total margin percentage though down from 2018 considerably improved over 2019 projection you all have in front of you the income statement and the balance sheet which are the next two slides so I won't spend a whole lot of time looking at them just wanted to point out a couple of high level items this particular slide doesn't show the breakdown of gross patient revenues so I'll wait and talk about that later when we talk about how our current projections are versus what we had originally submitted and where some of the increase in net patient service revenue is coming from in the volume growth this slide though does however show that we are making progress in reducing bad debt right off you'll see from on what we're projecting as significantly more business for both 2019 and 2020 versus the 2018 actual year our bed debt right off is significantly down due to probably several things better collections is one but as Mount Eskudney pointed out we also have a full-time patient resource advocate they're doing signing people up for health insurance that was on the community health team we had the one we had was actually a 0.8 FTE and when she left earlier this spring we actually replaced her with a full-time person it's very beneficial to getting people covered whether it be for health exchange coverage or Medicaid coverage also helpful in for those that don't qualify getting those people that are willing to fill out a reduced fee application to fill them out which is part of the reason why you'll see that our free care has been creeping up over the past two or three years that are on here and we've always I've said this before here part of the issue is getting people to fill out reduce the applications there are a lot of our employee our patients I know that would be eligible if they would fill them out or willing to share their information but they're not and then they choose to not pay their bills so eventually it gets written off as a bad debt so it kind of goes hand in hand the middle line here since we were talking about pbms earlier or you were talking about pbms earlier would not shut me the other operating revenue line you'll see a relatively large decrease in that from the past two or three years that's almost entirely a result of our retail pharmacy the net proceeds of the retail pharmacy end up in that line and the current horrendous trend in pbm reimbursements for prescriptions for commercial payers is going down so dramatically that our retail pharmacy with really no other change in operations or volumes over the past three years has gone from being just slightly over break even to probably heading this year at about a $300,000 operating loss simply due to decreased reimbursements for drugs that we really have no control over to the point where we have we fill a lot of prescriptions for our community where the money coming from the pbm isn't even enough to cover what we're paying for that drug much less something for dispensing it the other point on here was other operating expenses neck down the other bottom you know we're really working hard to control those operating expenses that we have some control over salary and benefits are clearly our biggest expense no control over healthcare provider tax but other operating expenses we've been doing a really good job of keeping flat or decreasing you'll see that what we budgeted for 2020 on that line is actually less than where we ended in 2018 and negligibly different from where we're expecting to end in 2019 nothing real significant to point out on the balance sheet the benchmarks were already on the previous page you know you'll see that the balance sheet despite having operating losses is continuing in the a relatively positive projection 2020 budget is still is an increase in fund balance over 2018 actuals so we're working anywhere we can to increase our overall financial health this this slide talks about expense drivers and cost containment so i think steven alluded to the fact that a largest expense driver approximately 57 percent of our total expense is in salaries and benefits um and we work i'm sorry salary is fine salary alone i'm sorry we uh we work really hard to to make sure that we have the high quality employee team to take care of our patients and whenever possible ever position becomes vacant a gray Scottish we we take a really critical look at that position to determine whether or not it's position that needs to be replaced and if so doesn't need to be replaced the way it was previously staffed i.e. kind of full-time position be changed to a per diem position or pretend potentially two part-time positions to give us more flexibility and ability to adjust our cost per per unit around volumes and and security benefits of the second largest expense driver at approximately 19 percent percent of our total expense and we review our benefits routinely and regularly to make sure that we're competitive in the market and that we can have a really recruit retain staff at the most cost-effective means possible agency staff is a large expense as a percentage of total expense for grace cottage and definitely varies from year to year and uh and based on experience in terms of what types of positions um turnover at grace cottage as i mentioned earlier nursing has been extremely well staffed this past year based on our calculation less than a full-time FT over the course of the entire year in agency or local expense for for nursing so very very small turnover there we had a full-time contract employee in diagnostic imaging for the year and we had about three months of a contracted employee in the lab for for the year so if you look at this and you compare you know the cost of standing at grace cottage compared to other organizations in the state i think we're we're in a very very positive position and hope to to keep ourselves in that in that position going forward and managing our labor costs and benefit costs as taking in as efficiently as we possibly can can manage those expenses and to address address the question of how our projection current rejection is compared with the projection we submitted with the budget are the three blue columns here over toward the right that 2019 budget is the first one that's what we actually approved for the current year the middle blue column is what was submitted for a 2019 budget back on july 1st when we submitted the budget and the right hand column is the most current projection that was submitted in june with the nine month submission and as you can see actually our projection improved just slightly over what was submitted with the budget from a net operating a net overall loss of 219 to a positive number of 148 with this about a 265 thousand dollar or 200 thousand dollar decrease in net operating come loss so we are making some strides in this while i'm here we'll talk a little bit to answer the question of our overall net patient revenue increase and it is not at all related really to charge increases it is strictly related to volume and on this slide you can see a little better because this one breaks it down what areas are increasing as i pointed out in the written responses we did not are not including any new services for the coming year over what we're currently doing the biggest increase is in volume for primary care providers based on the needs in our community and the number of patients that we have coming through our doors of late we have two new advanced practice professionals starting next month to replace some decrease in md hours so the biggest increase you'll see on there from the 2019 both budget and projection is a large increase in physician revenue is just strictly increased primary care volume directly correlated to that is the fact that the majority of our outpatient revenue is directly proportional to the primary care visits people needing lab x-ray patient rehab services so there's a corresponding increase in outpatient revenue as well there's also a minor increase in swing bed revenue based on the volume of patients we have seen coming into our swing bed program in the past few months of the fiscal year it's none of it is acute you'll in fact see that the acute budget is actually flat other than the minor 3.2 rate increase no huge capital budget plans for the coming year there are no approved or planned c o n projects a few of the larger items included in our fiscal year 2020 capital plans are a new ct unit ours is that essentially approaching end of life even though it's not very old nurse call system upgrades some new patient beds a lab analyzer continued hospital security surveillance equipment installations primarily not so much upgrades but installation and of course there's always idea from goodbye just a couple of additional points we are currently in active discussions with the aco regarding our decision to join or not join we've been evaluating that position and you're monitoring the information that is available to us from one care of mine and like other hospitals i'm sure have testified during these proceedings we are extremely worried about your downside risk of being an hco given the size of our organization our ability to weather a significant risk is relatively low and so that's something that we're talking with aco leadership about we are very unique in that we're the only facility in the state that doesn't do elective procedures at our organization you don't do surgery we don't do anything procedurally that's elected so we don't have the same levers relative to other hospitals abilities to to manage and control cost of services and number of services that are provided we take care of every patient who calls and says we need an appointment i need an appointment to see a provider primary care provider and we don't turn anyone away and so you know our objective and our mission is to be available to respond to demand as demand changes and as far as race cottage is concerned demand for primary care is increasing so part of the discussion we're having with the aco is is whether or not race cottage should be treated like a full service community hospital if we were joined as a formal member of the aco and that's something we were exploring with them and they're very interested in talking with us about we continue to work on controlling our costs and reducing our costs and doing what we do best which is providing high quality primary care in patient care skilled care and outpatient rehabilitation we believe that the budget we submitted is conservative as Stephen said it's based on on forecasted change in volume and demand for services we believe the operating costs in the budget are are prudent they're they're low and they're only necessary to take care of the patients that we're forecasting to see next year and so we're hoping that that you'll agree with us and that you'll approve the budget as we've submitted and as we've requested and we'd be happy to dig any questions respond to any concerns Robin really a couple of comments I think the biggest issue in your budget is the forecast around the volume and I think other people's questions will be more appropriate on that topic so my first comment is really just that I find your comments about Medicaid to be a little bit disturbing to be frank two over two decades ago Congress made the quick pro quo between Dish and provider tax illegal so that's really not an appropriate way to look at it I'm not going to say anything else but you know I certainly understand that Medicaid is not the best payer it's very tough when you have mostly Medicaid and Medicare patients but I just wanted to make that comment um a clarification on the ACO um I think you're looking at Medicaid only risk am I remembering and you Medicaid only program is that am I remembering that right most likely it would only be the Medicaid program at this point yeah and have you been talking to some other hospitals about their experience there I know you are very different so we talk a lot um particularly on our regular CFO calls and talk to them individually and you know I mean it's our biggest concern as you can see from our limited ability to absorb any further losses in our bottom line is the potential of downside risk well I think it's great that you're talking with the ACO and exploring perhaps some creative options for treating you a little bit differently we're open to the idea of participating we certainly don't disagree with it it's just the ability to be able to absorb that potential loss yeah thank you that's that's all I have Tom well it's good to see you again um I have a couple of of uh questions just in terms of you answered the one I had about bad debt as to why that was uh trending favorably um and it sounds like you uh you know assigned more of your resources uh to that um in fringe benefits just to question um a fairly big increase in uh the fringe benefits for non non-nds 2020 over 2019 at 19 percent which is a big number for you folks $676,000 I'm just wondering if most of that has to do with the 20 hour per week that was a significant portion of it the fact that when we submitted the current year budget um that was a decision made long after that and trying to fill some of those vacant positions yeah I'm just trying to connect the dots yeah that's what I thought it was but um looking at your other other operating revenue dropping significantly from 368,000 down to 54,000 projected in 2020 um is there what is going on there you said other operating yes I think I've got it right um other operating revenue oh you were you were looking at the decrease in the amount other operating revenue total budgeted of 935 going forward down from 1.2 million in 2018 yes yes that was what I was actually just talking about the retail pharmacy loss okay that's one of the biggest numbers that's in there and it's okay and so the the biggest thing I want to talk about is when I visited with you folks down there um you talked about your other uh non-operating revenue and most of that comes from contributions and that you had kind of two board structures one operating the hospital and the other kind of trying to raise money for the community yeah and that that has been struggling a bit just because the economy will say in the Townsend area is is not as strong as it once was and that um you know but but people who buy property there that are second homeless just want to know that there's a a good medical facility hospital near to them but then the connection you make in your presentation is as discussed earlier Medicaid is our primary source of cost shift 1.7 million in fiscal 2018 per the remount care where it's cost shift analysis unfortunately the very generous support of our community the bulk of our non-operating revenue goes toward covering Medicaid's failure to pay adequately rather than toward bettering our facility and the ability to provide patient care and I was kind of looking at your growth in charges and your growth in contract allowances and for commercial that's actually a favorable relationship but for Medicaid it's a highly negative relationship right as charges go up the contract allowances go down and I'm you know looking at your bottom line just just wondering whether the cost shift is an existential threat to Grace Cottage over time it's a concern certainly um over time and and I'm our ultimate goal at Grace Cottage is to try and shift business primarily I mean honestly from Medicaid to get more commercial I kind of believe that that's going to be helped a little in the year going forward we take pretty much care we probably currently take care of all the Medicaid people that live in our area we can see that a lot of the additional primary care people that are now traveling more so to come to our area for services fortunately are commercial so hopefully that is dish some of that additional business we're getting is going to be a larger percentage of commercial payers versus Medicaid payers going following up on the earlier discussion with Matt Scotton we all know that the population is aging as well and although Medicare is not a top-notch payer it is certainly considerably better than Medicaid so every Medicaid patient that becomes a Medicare patient is also helpful to our bottom line I think that's it it's a it's a pretty simple buzz to look at in the moving parts I think you've explained and I would hope that you're not as hopeless about addressing the cost shift which is something I I think needs to be addressed and London is accepting it as a fated complaint that maybe we can all kind of raise our voices a little bit so those that are vulnerable to it most vulnerable to it aren't you know that that stresses less and right Maureen thank you I appreciate your comment saying that your NPR overall is small relative to all the other hospitals um and that maybe that's why you're trying to have us look at you know a 12 percent increase year-over-year from where your projection was in NPR is small dollars but you've missed your budget the past several years including this year even with your revised projection you're missing your 2019 budget and one of the areas that's been a great concern is the smaller hospitals that miss their top line budget their expenses stay relatively fixed and you continue to lose money and you've lost money year over year so just trying to really get a handle on your 2020 increase and a couple questions one in 2019 commentary one of the things you talked about was the pretty large decline in emergency room visits and that was one of the main reasons why you're missing your numbers this year and can you talk a little bit about that what's going on there and if you think that's going to continue for next year the that was one of the questions that was asked by the board I mean I I don't remember talking about the significant I mean I answered the question that was asked in that yes it's a 10 decline I don't recall bringing up that one of our reasons for not meeting 2019 projections was based on emergency room revenue our biggest reason for not meeting 29 projections was the fact 2019 projections originally was that we didn't have the primary care providers and staff in the early part of the fiscal year that we had planned on having I mean I did answer the question that was asked about ED a significant decrease in ED volume of almost 10 percent right but I don't remember using that as justification why we weren't meeting our projections okay it seemed like that was one of the comments just looking at trying to dissect the 2020 forecast and I'm looking at kind of your quarterly year over year change and in your commentary you did say that in January I think you were fully staffed up for the primary care correct correct so in the first quarter of your year which would have been obviously October through December year over year you were down 8.2 percent in the second quarter you were up 1.4 percent in the third quarter you were down 0.6 percent in the fourth quarter prior to this change you were up 2.6 percent and so to then take that forward I get the first quarter as an outlier you were down like 8 percent but every other quarter you've only been up between 1 to 3 percent over a prior year and so your new forecast is up 12.3 percent over your 19 projection so I'm just having a hard time getting there because you would think some of that trend if you're fully staffed up now for your primary care that that would be we'd be seeing that quarter to quarter the increase this current year with that provider started it was the second week of January as Joe said earlier it takes a while for a primary care provider to build up a full practice so you know it's taking through this year to get him fully up and running you know knock on wood you can't control providers coming and going we've had a lot of flux over the past year when you look when we were here last year at this time we had just had three providers leave all for varying reasons one located out of the area to be close to the family one didn't want to do primary care anymore it wasn't that we had people leave to go down the street to work it makes when primary care is your biggest business much like if we were sitting here as a hospital that did surgeries when you have a surgeon leaves it takes a long time to recover from that primary care is the bulk of our business and when you have even two FTEs leave out of 10 that's a big hit from what we can see the the patients coming the patients that are calling looking for service we see that we have the volume needed to have all the providers that we have both in-house incoming in the month of September be full and take care of those patients in the coming year you're right i mean you can't predict that it could all change i also can't sit here and say that i can predict next month i'm going to have the same number of swing bed patients that i had this month i mean i can only use my best guess that i'm going to continue needing to take care of those patients no i understand i mean just you know our guidance obviously was you know three and a half percent and you've missed your budget year over year on the top line for various reasons and now you know to ask for such a large increase and you're going to have expenses tying to that you know the concern is more that we get here next year and you didn't hit that number that you were projecting you hit it hit the expenses and you're losing a lot of money right you know because your commercial rate is a hundred thousand dollars is all it contributes you know so you're you are a hospital that i think has the lowest commercial reimbursement as a percentage of your total and any of the others like if you're 28 percent we inverse commercial so right you know your commercial is not what's making it up that's not the big concern concern is what we've talked about for many of the hospitals on aspirate rational budgeting and you know we all know it's going out of Springfield but we challenge them year over year to say your numbers are too high you're not going to hit these numbers it doesn't make sense and i'm still not convinced on your numbers here based on your trend this year based on what you're up year over year that you're going to hit a 12 increase i mean you know with it's almost like if they it is what it is it's going to we're going to end up here next year you either came in with that number or not but the concern again is that you don't hit that you miss and you're you're losing a million to two million dollars and you do have a community that's stepped up and helped you support your business yes you're subsidizing with Medicaid but so is everybody else i mean commercial and medicare where where that gets made up so that's not different than the other hospitals so i just want you know i guess was one of the follow-ups will be to really have you guys go back and just bridge the difference between this forecast and 2020 where you're trending right now and how how we can feel convinced that that's where you're going to come in again with the concern being you don't hit the number and you lose lose a bit of money i think everybody else says that's all i have thanks thank you marine and steve i know that uh grace is very committed to the mission of meeting all the needs of the population so i didn't take what you were saying in the negative light i just want you to to know that i appreciated your documentation of where you are at the beginning to try to get back to that margin because if you have no margin you have no mission that's true you guys certainly have a history of you know starting with dr otis going right on through that in the 34 years i've worked there we've never had a margin yep one year i think we had 69 000 out of 34 years it's not a real good track record fortunately you have some good donors yes so steve can you walk me through um how you came up to your request for the the change in charge the change in charge or the change in charge the change in charge um we build the budget based on our best estimate starting with volumes um we put that together i based the revenue on where i think it will be at the end of next year again um it's truly a crap shoot i mean figuring out what patients are going to come in um we look at the excuse me expenses necessary to cover that and as has been pointed out before particularly in a critical access hospital the majority of our expenses are fixed expenses you know i've got to have certain number of x-ray text in the building every day a certain number have text in the building every day whether i'm seeing patients or not um and then look at some various charge increases to try and cover that bottom line and that what we requested was about as low or high as low an increase as i could go to get close to a positive bottom line even a 3.2 percent gross charge increase only adds at best depending on the service line a couple of percent to the bottom line can you talk about that across the service lines um as day pointed out earlier we have very few payers who actually pay as a percent integers um we essentially in in truth it really doesn't matter what we charge in the physician practice everything in the physician practices are paid either on a fee schedule or costs for the Medicare patients on the hospital side because we're a critical access hospital truthfully what we charge doesn't really matter for any of the Medicare patients it doesn't matter for any of the Medicaid patients because they're all paid on a fee schedule the we only have a few commercial payers who pay a percent of charges on whether it be inpatient or outpatient charges um and even those don't pay everything blue cross as an example they pay a percent of charges for most inpatient work and for some outpatient work but for instance our biggest area of outpatient businesses lab in x-ray and those are all paid on fee schedule as long as what we're charging is more than the fee schedule which is not hard to do since the fee schedule is so well it doesn't matter what we're charging so it's really a you know there's very very little area truthfully to increase charges and expect to get any money from it so you know as part of the all-payer model there's been a real focus on trying to promote more um primary care and that really is central to what your mission is really on primary that's our primary mission yep so can you just talk to us um it might be Doug that might be better off on this one um Doug about how um your measuring whether or not the primary care that's being given is really the type of primary care that actually does promote prevention of wellness and does save costs to the system how are you measuring you know um for example um consultations on pre-diabetic care things like that that in the long run save the system money but only if they're done right that's a really great question and um we we confront that challenge every single day and I wish I could give you a really scientific and mathematical answer as to how to measure the impact but it's really all about social determinants of health it's it's it's more conjecture and really less science um you know we we talk with our with our medical staff and providers regularly the medical executive committee and the medical staff meets regularly and they and they talk about protocols they talk about the things they're seeing in their practices in their offices the types of of needs being presented by the community and how they're meeting those needs and it's really the the the art of of of taking care of patients as designed by the providers every single day in the exam in the exam rooms with you know face to face with their patients but we know that we're making a difference because the the types of services we we provide the types of of patients that and the the medical challenges that those patients present to our providers are things that are treatable they're uh they're able to to to to tell us whether or not patients who coming or coming into the into the practice pre-diabetic are are actually heeding their advice and and doing the things they need to do to improve their condition they can tell us whether or not patients who are coming into the practice with hypertension are changing the way they eat whether they're they're taking their medication whether they're filling their prescriptions coming back and being reassessed and showing improvement in their in their their medical well-being and so as I said you know there's not a whole lot of science that can help us truly larger the impact but we know from you know historical studies and we know from the the literature that having a relationship with a provider whether it's a physician or an advanced practice provider really does make an impact in improving the health of the patient and we really pride ourselves on the relationship it's really about building relationships and as long as we continue to see new patients coming to Grace Cottage new patients developing relationships with our providers and coming back routinely for well visits and for care in the office we truly believe and we know in our hearts that we're making a difference well I gotta tell you I'm really rooting for you to hopefully your negotiations with one care is successful because you know so much of everything that we do is rooted in that primary care and I would be really disappointed if there was one black hole in the state that was Grace Cottage so now we actually as Stephen said you know we we believe we believe in the ACO and we believe that the work they're trying to do is the right work for health care in the state of Vermont and we want to we want to participate and we also believe that we bring we can bring great value to the ACO and we can't we can't go out of business trying yeah we get that so thank you at this time I'm going to turn it over to the health care advocates I will be quick I always go last I'll be quick because I know the health care advocates together we all probably want lunch so we'll try to be fast I just want to echo some of Maureen's concerns and just suggest that I think some more backup to dispensate the growth from projected to 2020 in your physician services and I think something that might be helpful it's not clear to me so you mentioned that you've got these primary care providers that you've onboarded but you said MD hours were coming down so the net effect it would be helpful to understand a little bit more what the pent up demand was was there wait times for primary care providers that now you're you know meeting some unmet need what was the percentage of the population in your area that didn't have access to a primary care provider something like that to help us understand how you're going to get from where you are in 2019 to 2020 simply based on expansion of primary care so I'll just share that because I have some of these same concerns that Maureen does a lot of the hospitals that we've been hearing from this year more than in previous years have really initiated some cost savings initiatives and I think largely that's because of the financial situation of many of our hospitals with their operating margins Grace College with your history of negative operating margins I'm wondering if I didn't see much in the narrative to talk about specific cost savings initiatives that you're taking on generally you talked about and trying to look at staffing when there's turnover but you also said there's very little turnover and so I'm wondering if you can speak a little bit to what initiatives you might be seeing in 2020 how can you start to think about bending that cost for recognizing your small hospital and how you're going to fix costs right are you part of a group purchasing agreement that you can leverage even further what are other things that you can be doing in the event as some of us are concerned you don't hit that top line in terms of revenue from these new practices for practitioners your expenses can be yeah I'll let Stephen speak to the from the from the financial side of that question but I truly believe that that keeping our costs relatively flat year-over-year is is a demonstration of our ability to lower costs because expenses go up every year and if we can keep our expenses our increase or our change in expenses below inflation we are actually I believe making progress and we are we are a very small organization and as such there there's there are less opportunities for reducing costs as Stephen says you know a lot of our costs are are variable but yet they behave like fixed costs because of the lack of the economy of scale in in terms of the smaller volume we just don't we don't have the ability to to cut below a certain a certain level of of staffing within the organization or some departments that just will never go below where they are today in terms of work hours so but I think that the fact that are you know we're able to keep our expenses year-over-year relatively in check it is a demonstration that we are making some progress in tackling costs but there's not a lot going through lack of a great strategy and I agree when you look at take excuse me particularly operating expenses they have stayed flat or even gone down in the last couple of years however we look continually and to answer your first question we are part of group purchasing particularly the NEA group purchasing program I was just up there last Friday there are seven hospitals including us who are looking to do a group workers comp plan we'll be changing workers comp companies on October 1st which is a $17,000 savings for us we look every day our maintenance director is desperately trying to reduce utility expenses even further than they have been he was just talking the day about wanting to do LED lighting and two more of our buildings taking advantage of efficiency Vermont having a large rebate program right now we got a new HVAC system last year in our administrative and physician practices offices and he realized that it had the ability to limit when the heat could come on and off and even though the maintenance department reports to me they won't let me have heat at 6 a.m I have to wait for the heat to come on at 7 so be prepared when I get there at 6 that I'm going to eat the coal I'm not kidding but you know we look every day we look at every time we buy something it's a question of do we really need it is there a cheaper place to get it without compromising patient care we really try to reduce costs wherever we can keep at it how about it I guess my last question is relative I'm asking this question of all the hospitals to just get a sense of relative pricing so you've probably heard that I've asked this question to hopefully about the answer for it which is if on average you know Medicare reimbursed $100 for a particular service what on average would your commercial payers reimburse for that same service off the top of my head I would say somewhere around $130 probably thank you okay now Eric and again my apologies Jess no worries okay just two quick questions okay just two questions firstly just want to acknowledge that or congratulate you on onboarding three mental health providers such as the licensed clinical social workers advanced practice RN and the mental health counselor um so do you you stated that the collection agency follows patient friendly billing policies for practices um are there internal mechanisms to check on that so I asked just because there's a you guys have a relatively high or solid good collection rate on that debt and of course to me that's like either your collection agency is doing the right thing or it also makes me concerned maybe they're not I guess I'm worried about whether they're following the guidelines as they say they are how you know whether what the case is I am fairly certain in my response here that we have they do record their calls and we have the ability if we wanted to listen to patient calls that their representatives were making to our patients I'm not sure if we've done that recently I think we did when they first started they have predefined scripts they use when they call to and that's essentially the extent of our collections it's essentially phone calls to the patients they don't do anything outside of that threatening collect um you know legal services or anything like that and so the second question the last question is just that so if you look over um your FAP approvals over time so between 14 and 18 you're hitting an average of around 58 60 percent except um in 17 where it drops down to 38 percent and then at that same time between 14 and 18 the amount of applications denied for being incomplete is around 28 percent I would say except in 17 where it spikes to 60 percent denied for being incomplete and so it's wondering if you could say what happened in 17 and the fact it looks like you've corrected or how it looks like it's corrected in 18 but why or how that's a really good question I'm not sure the answer to that um the person who processed all of our applications actually just left two months ago it's actually now being done by our new resource advocate but I'm not truthfully sure of what specifically happened that year thank you that's all my question thank you Eric at this time we'll open up to the public for any comments on the grace cottage budget yes Dale the ones that had testified in the past that they have a specific population they serve in the summer only they're vacationers that they serve and therefore they're only they're part of the year and come to them for primary care while they're on vacation no I don't think we've ever made that our population changes a little bit we have probably have a lot of people that are only there in the summer alternative we have a lot of people that are only there in the winter but our overall population of who we serve doesn't is pretty consistent throughout the whole year we don't have large swings okay is there other public comment if not just a before we break for lunch I just want to clarify that on the agenda after we hear from boss there is an item for general discussion later today and that general discussion will include our staff and with that I think uh 115 some reasonable okay we'll uh we'll resume at 115 let's break it up