 Good morning, everyone. I'm going to read out your work. Our executive director is currently testifying it over in the legislature, so I will give the executive director's report on her behalf. And the first thing that Susan had asked me to acknowledge and give a shout out to the hard work of a lot of people in the state government. And that is that the final evaluation for the level one state innovation grants came back. And there were nine grants that were analyzed from six different states. And really the only one that showed really positive results was Vermont. So there are a lot of people in Vermont who did an awful lot of hard work that are on our gratitude. And they were able to build off early successes and things like blueprint for health. I know that Pat Jones is in the room today. She did a lot of work. Craig Jones, Georgia Mejerez, Robin Munch, Justin Disable, Kate O'Neill. It just goes on and on and on. And I just want to say that I think that this evaluation, which was brought up at our recent meeting in Washington DC, is going to add rocket fuel to the support that we're going to have from people as we move forward with the all-parent model. I don't know, maybe Robin might want to say a few words. Yes, I just want to echo your thanks. And particularly, I want to thank Georgia Mejerez, who is the staff lead on this project and really did heroic work in terms of managing the federal relationship and all the nitty-gritty nuts and bolts of the contracting, which was a lot. And as a former member of the SIFC court team, I think we couldn't have had such a good result without the deep engagement by all sectors, by the provider community, by the payer community, as well as, as you said, many, many, many state employees, including Amy Kunrath, who's in the audience. I'll give her a shout-out, too. So I'm so pleased at the result. And I'm thankful that we were able to get the grant and that we were able to use it wisely. I guess I would just add to it, having come into the board probably midway through this, I can only see it from the folks at the board level that were heavily engaged. But I know Alivay and Nina Backus and Richard Slotsky really were very engaged in stakeholder meetings. And I just look back and say all the work, the hard work that went into this. And I think about the quality measures aligned with Pat Jones, and there's a big shout-out at the report about getting that right. And I know you took a lot more than that. So anyway, I'm grateful to Alivay that came before us. And this is exciting, exciting news, and a validation of all that hard work. And I think it's a validation of the all-care model that you raised, and I'm excited to be a part of it. So just a couple of updates, of course. In addition to this morning's meeting, we have two enforcement hearings this afternoon with Mono Stutney in North Country. We are back here again on Friday. The last enforcement hearing will be next Wednesday morning with Springfield. And we'll also have a hearing next Wednesday morning with Springfield on their request to have an increase to their charge. And we do have public comment is open. So anyone can go to our website and express their public comment at this time. So with that, I am going to move to the minutes of Monday, April 8th. Is there a motion? So moved. Second. Seconded to approve the minutes of Monday, April 8th. Without any corrections, variations, or additions. Is there any discussion? Seeing none, all those in favor signify by saying aye. Aye. Any opposed? So with that, we're going to move to the all-care model implementation in the ACL regulation update. So come on down, people. And all-care model implementation teams Marissa Malma, Michelle DeGree, and Sarah Lindberg to provide an update on the first quarter of 2019 and to give you a preview of several activities to come in 2019. Thank you. So this is the agenda that we plan to cover today. Marissa will provide an update on our 2019 ACO budget commentary and timeline, review the reports that are in the budget order from 2019. And she'll also give you a preview into planning for 2020 ACO budget review and certification. Then Michelle, myself, and Sarah will all speak on different components of the ACO model agreement, the all-care model, ACO model agreement, including an upcoming evaluation, reporting, and some updates on where we are in terms of our goals with quality and health, scale, and financial performance. And then finally, at the end, we will have an interactive demonstration of our total cost of care tool. So this is the logic model that we've been using as a reminder and a touchstone for the questions that we're testing through the all-care model. So the questions are, if we increase the share of value-based payments in Vermont and put providers at risk for quality and cost, will we be able to accelerate care delivery transformation? We're looking to improve outcomes on the 20 population-based schools that are in the agreement that were identified by the state, and while slowing or maintaining the growth of health care in Vermont. So we have found, as we start to go into the second year of the model, that we're starting to see results where payment changes are providing flexibility for providers to develop local transformations in care delivery. Couple examples would include you heard last month or in February from a provider who said he was able to hire a mental health practitioner to be embedded in his practice. We know that there's increased care coordination being embedded in the community. We also know that the state and one care identified that they wanted to put more investments into the parent child centers. So they expanded a project that was running in 2018 to from one site to four new sites in 2019. So we're hoping that all of these process changes will get us to the improved outcomes that we would like to see, including access to primary care, fewer deaths due to suicide and drug overdose, and a reduced prevalence and morbidity of chronic disease. With that, I will turn it over to Marissa. So my name is Marissa Millimet, and I've been working with the team to bring the ACO monitoring and reporting into more a regular and standard cycle. So the ACO reports to us on a quarterly, semi-annual and annual deadlines, as well as some additional reporting that's required according to occurrence of certain activities of the ACO. The budget order reporting timeline was written according to calendar year quarters with reporting for the quarter due 30 days after the end of the quarter. So we have those time frames up on the slide there. So for quarterly reporting that we received on a regular basis, that includes financial statements and financial statements, balance sheet, income statement, cash flow. These include specific ratios that you've asked us to monitor. The administrative expense ratio, population health management payment for program investment ratios, as well as reserve requirements. In addition, we've asked the ACO to provide to us updated policies and procedures. These are generally a certification requirement. There's a long list of policies and procedures. They have certain ones that we review regularly for certification requirements. And so we want to get those on a regular basis as they're approved by their board. Some of these items have to be reported more frequently if they're required. On a semi-annual reporting basis, we've asked for complaints and reasons information by payer, as well as performance monitoring, performance to targets. That includes attribution by payer risk to hospitals, financial performance by payer contracts. And I also wanted to make note that in preparation for the first receipt of reports, a quarterly reporting on April 30th, the staff has been working to develop the reporting timeline and standard manual and templates for the ACO. So this quarter, we've been working with the hospital budget and financial team at the board to develop reporting templates and to upload these into our adaptive software, which is used for hospital budget reporting. Using the adaptive software will help us to streamline the reporting by creating a shared platform between the board and the ACO to review these reports. We're gonna start specifically with financial templates for planning to move toward more reporting towards adaptive ads. It makes sense, and that's what they need to. So this slide lists annual reporting and reporting on new programs and one-time reports that are financial and other programs. The ones, and I apologize, the ones with the asterisks are specifically required for all payer model reporting, and they're also included in the budget. So that includes data that we need for the payer differential reports and all payer model requirement. Both the budget and certification require interim financial reporting on the 2019 comprehensive payment reform pilot and final reporting on the 2018 comprehensive payment reform pilot. We will also be getting the value-based incentive on distribution methodology for 2020 quarter three under population health and other programs. We will be receiving, most of these in quarter one includes the scale target ACO initiative report for the 2020 network development strategy and timeline quality improvement and management work plan and the timeline for 2019 plan to address childhood adversity. As these are required for certification, there's also reporting for the specialist payment pilot and the community innovation fund. So I want to make a note that one care is scheduled to come and present before the board on May 22nd for a program update and update on their contracts and budget numbers. Finally, I want to review with you today the timeline for budget guidance, development and ACO certification guidance. So currently April through May we're in internal development of ACO budget guidance and the 2020 certification eligibility verification form. In June, we were planning to present the guidance to the board for your review as well as accept and open up to public comment. We expect to post the guidance in July after a board vote. The ACO submit their budget in October. This will be open to public comments. We're again working to concurrently do certification review. In October early November, the ACO will present their budget to the board. We will present analysis in December, close the public comment period and vote by the end of December. Okay, now we're going to switch into the Vermont-Alpair ACO model agreement update. I wanted to give you an update on the Alpair model evaluation that is required for section 17 of the agreement. CMMI shall conduct an evaluation to test the impact of the Alpair model across the five years. They have contracted with NORC and ORC at the University of Chicago who has background and experience in evaluating next generation programs. They are taking Vermont's history of health care reform into their design and we've been speaking with them since January. So they've shared with us that they're going to be, they're considering Vermont's first Medicaid global commitment waiver which happened in 2006. And then the start of the blueprint in 2008, the creation of the board in 2011, the pursuit of single-pair, the short savings programs in the STEM grant, all of which they are supposing lay the groundwork for the current Alpair model. So our first visit from NORC will be in June of 2019. The documents on the background of their evaluation and the course evaluation report are both on this page. So I wanted to review what their initial evaluation questions will be. They're looking at the, how and why the model is successful including implementation challenges and successes. They're looking for replicability at a state community or nation level. They will be looking at the impact on population health and claims-based outcomes. And they have a variety of methods by which to do this. So the model will be evaluated using both state and ACO level comparison groups when identifying states in the comparison groups. They did share with us that several important characteristics will be prior history of payment reform and SIM and also participation in the MAPCP. And you know, finally of note, they keep naming three unique characteristics of our model when they're taking this into consideration for the evaluation. And those are the state level flexibility that we have to design the Medicare program, the investments in care management that our state is making, and the regulatory oversight activity and authority that the board has. So turning to the flexibility that we have in designing the Vermont next generation program, we do call it the Vermont ACO Medicare Initiative where we in year two had the flexibility to design the ACO Medicare Initiative of which you would approve several items of that participation agreement over the summer, including the quality measures. So when we're designing the program, we and CMS look for alignment and attribution in different payment mechanisms in the risk arrangements that the ACO has with both Medicare and the other payers and the ACO quality measures. And it was quite a bit of work done over the summer to align all of the ACO quality measures as much as possible with the Medicare program and all of the payers are also working on that task. So in the agreement each year, CMS and Vermont need to agree to the benchmark growth rate, which we did last winter, and how it ties to quality performance, the ACO quality measures, and then any additional operational changes of which we're beginning to speak with CMS right now to identify if there are any things that we'd like to add in for performance year three. This slide should look sort of familiar. What's this called, Amy? So this slide outlines the reports that were responsible for submitting to CMMI through the duration of the agreement. So on here, we've sort of just started with the reports that are due, starting with just their initial due date, and then just noting that a lot of these are quarterly or annual, but I just wanted to note, so I did a quick count this morning. So from now moving forward, there are roughly 37 additional reports that we will be submitting to CMMI between now and 2023, which we'll be reporting on the final year of the agreement. So it's a lot, that would be too much on one slide. So for example, total cost of care reporting, as we got, you're getting it from Sarah, you're gonna see a super cool data visualization from the analytics team, and that will continue quarterly through the duration of the agreement. We've got our first pair differential report will be coming out this month. Our first scale target report is due in June, and our first health outcomes and quality of care report will be coming out in September. So you'll probably be seeing a lot of us this summer. And I do have, all of these reports are outlined quite well in the agreement, but if you have questions on what any of them mean, I'm happy to walk you through that. This slide should look really familiar and draw your memories. Pat Jones archives right here, and shout out to Pat in the audience. So this is just a quick reminder of the quality framework. The three domains listed in the infographic here have associated targets that will be measuring through that annual reporting. I wanted to just kind of regroup and remind everyone that this is a cumulative improvement approach. And so we're going to sort of recognize that quality improvement interventions take time. So each measure has a target, there are 20 of them. Sometimes you'll hear us saying there are 21. There is an additional measure in the agreement to be specified. We're working on that with our analytics vendor, but it will be reporting only through the duration of the agreement. There's no performance tied to that. So just reminding folks that looking at these domains here, we have to achieve five of seven of the process milestones, four of seven of the healthcare delivery system quality targets and four of six of the health outcomes quality targets to be considered by the end of the agreement. And, this is pretty boring, but just to say that we're still collecting data for 2018 and we won't have it all and that's why the report is due in September. So we're starting to get some of it in, starting to analyze that and looking forward to being able to present a report to you in the fall of this year for the 2018 performance year. So I'm going to talk to you about some of the reporting that we're going to do each day. So there's quite a lag on the results. So it's about nine month lag. So we just recently submitted our quarter two report for the 2018 performance year for our financial targets. Our scale targets actually won't be reported on until June of this year for last year. So none of the information I have for you today is exactly final. There are some challenges in any measurement. The main challenge with our scale target is that we know, we don't have an exact picture of the number of self-funded lives that are out there that aren't submitting to our claims database. I always think of it as a known unknown. So estimates may change between now and the final reporting but at a high level, we believe that on the top you can see the scale target and our performance. There's one for Medicare. So last year it was 60% and we came in around 35%. And in performance year 19, the target for Medicare is 75% and we think we came in about 51%. Again, subject to change, that's a similar magnitude of growth between the first two years but we're about a year behind in terms of the target. So we're working hard on trying to figure out the best strategy for trying to address that. So the all payer target, again this is gonna be include self-funded groups not reporting the V-Cures. It includes commercial plans, including Medicare Advantage which is considered commercial for the purposes of this market, for this reporting framework. And that target last year was 36%. We think we came in about 20. And the performance target for this year is half the population, that's ambitious. And we think we're gonna be between 30 and 40. The range there has to do with some potential programs that may or may not come to fruition within the current performance year. So looking ahead through the course of the model. So the magnitude of increase from 19 to 18 is a little less ambitious. So we're looking at for 279% of Medicare population and 58% of the all payer. So again, we just submitted our second quarterly report for our financial targets. These targets are designed to be a per person growth and there's two different buckets that they come in. One is just for Medicare, the Medicare total cost of care and the second one is the all payer total cost of care. Now in the final two years of the agreement the Medicare total cost of care will be a subset of the all payer target. But in these first few years the Medicare total cost of care is exactly aligned to the ACO population. So that they're not one to one. And we can get into some more details about that but it can be really confusing pretty fast. So yeah, hey man. Just wanna remind people of how it's calculated. So we are on the hook for basically most of the folks with claims and v-cures for this. So we're not on the hook for those self-funded people for whom we don't have claims. We're not on the hook for the federal employees at this point or military groups. It's people who have claims and v-cures. And the way we calculate it is we for each person in v-cures for the month we try and figure out what we think their primary payer is. So for instance, if I have both Medicare and Medicaid I'm gonna consider you to be a Medicare person for the all payer model purposes because that's who's generally paying first. Always exceptions to these rules. But there are some services that maybe Medicare doesn't cover where Medicaid would pay first but we're just calling them a Medicare person. And then we look for any spending in our claims database for that month in that payer type. So that means that if the spending has an in-state, out-of-state it doesn't matter or have a hook for all that spending. In addition to the clean stuff that we're seeing we are also adding a component that doesn't run through claims. So the primary care medical home and community health team and SASH payments they're not flowing through v-cures. Shared savings is another example of something that we're including a spending that doesn't flow through claims. So what we do is we try to find a per person per month add-on to the claims-based spending to try and get a comprehensive picture of the spending. We are not including retail pharmacy spending and there's a good portion of Medicaid spending that's not a covered service in the agreement between ACO and Medicaid. And per the agreement those services are not included. The upshot is it's about half of Medicaid spending that is in the total cost of care. The sum of some care, that's what it is. So in these first years of the agreement the Medicare total cost of care is just that ACO population. And to try and be fair to the ACO what we're gonna do is compare the actual spending in 2018 to a hypothetical population in 2017. So what happens is our federal partners run a pretend performance year. So who would have been attributed to one care in 2017 based on the 2018 provider list and how did all that spending shake out? And we're gonna compare the actuals in 2018 to that hypothetical 17 population. So I think that's probably the best way to do it because when you're prospectively aligned you're inevitably gonna lose people along the way. And one particularly material way that you lose people is due to death, they're very expensive. And so we wanna make sure that those costs are in the base so that it says one to one is possible. However, that means that the numerator, the spending in 2018 is not going to be our denominator for 19. We're gonna have a different hypothetical population run in 2018 based on the 2019 provider list. So there'll be a lot of overlap but these nuances can be pretty material which is why I'll probably repeat it a million times. But for performance year 18, and here's another confusing thing, the Medicare target is 3.5%, not anything to do with the all-payer model per se but because the board chose to use the floor. So the target was 3.7% and we need to be 0.2 below that which is the 3.5%. So all-payer and Medicare happen to be the same for performance year 2018 but that's not going to be true for the most part. And so here it is. So our Medicare data are not final. We're still mapping some fields into V-Cures that we're gonna need to be able to run this in the all-payer claims database and we also are lacking some baseline information from our federal partners. So in its stead, we are using some standard reports associated with the next generation program with Medicare. We feel good about the data here, the ACOs reported that they're able to tie out to this pretty well. So I think they have comfort with this data source. However, the final numbers are likely to change but I believe that the magnitude and direction of the growth are gonna be substantially similar within a few percentage points, 10 to 15 percentage points. But as so far through Q2, so this would be claims incurred, so a service date from January to June of 2018 with paid run out through the end of the year. So we have time for those claims to accumulate. So in 2017 that estimate was about $818 per person per month, unilaterally through the first two quarters and it's about $834 so far in 2018. So that shows a 1.9% growth rate today. Keep in mind that because you set the target for the ACO, spoiler alert, this is gonna come in at 3.5 at the end of the year. So it looks great and it shows that the ACO is being pretty efficient in their peer delivery but you can't already know the answers of this particular measure. And here's showing the trend. So you can see that sometimes it's gone up by as much as 4.4%, sometimes it's gone up by as little as 1.1%. The important thing to keep in mind is that this is a trend based on the 2018 provider list. So this is basically a series of hypothetical populations based on that performance list. So these aren't the same people that this wouldn't be the same trend line as we would draw today based on the 2019 provider list. So just the important thing is a lot harder to think about trends when your base is changing all the time. Yeah, and so for the all payer target, it's a little bit simpler in terms of wrapping your mind around in my opinion. So basically this is more of a straight compounding annual growth rate. 2017 is gonna be our base through the course of the entire agreement. And for this, we'll also have the same target the entire time and that's a performance to date of 3.5% or less. And so far, we are coming in and I think we're on track. We see a growth rate estimated to be 2.5%. This is going to change for a couple of reasons. One is that with more run out, you'll see the growth just in Q2 year over years, 0.7% of the additional run out. We expect that will increase. Not as high as Q1 came in. We don't expect it to go as high as 4.3, but it will go up. Also we're using a placeholder for provision in the agreement. So it allows us to treat certain Medicaid price increases in a special way. So if Medicaid is increasing its reimbursement to either narrow the gap with Medicare or increase access to services, then we're not on the hook for those increases. So we're using 6.6% as a placeholder and we're actually working with our partners right now to actually reprice those claims that were incurred in 2018 back to the 2017 prices and the Medicaid portion of the all pair will be replaced by those values. And just to try and keep your eye on the ball, our Medicare growth target is always going to be performance to date being 0.2% below national projections. So there are no annual targets for our Medicare total cost of care. It's always the performance period to date. We recently got the estimate for 2020, so we'll be able to update you very soon on what that means for our performance goals. And because 2017 is the base, we now know what our goal is for 2022 for the all pair target. So we came in at 496 as our estimated base for the entire year. 3.5% growth would put us at 591 per person per month in 2022. However, we wouldn't expect corrective action to be triggered based on this until it hit $614 per member per month. These numbers might change a little bit. Again, just with additional runout, they might go change a little bit, but they're gonna be pretty final at this point. The only other reason we might see something material change is that in future years of the agreement, there are additional services that we are likely to fold in on the Medicaid side of things. And so we would obviously want our base to reflect that change. So those are the only kind of main things, but I think for the most part, you could hang your hat on these numbers. Questions from the board? So I have a couple of questions. One, from Marissa, when you look at slide five, you talk about the population health management reform program and also quarterly tracking. One suggestion would be since this was an area that the ACLL short came last year, is asking them also for a projection when they come in. So if in Q1, you know, obviously we're hoping they'll be spending, you know, at the 3.5%, was it a 3.1%? But if they're coming in lower, like what's the projection for the rest of the year? So that we can get ahead of, if in fact, you know, they're tracking behind, which at the beginning of the year they may be and they're supposed to catch up by year end, but last year we really didn't know about that until the end of the year. So I'll kind of leave it up to you guys as how do we do that so we can make sure we'll get a quarter one number and then understand where they're gonna track for the year to make sure they're gonna stay on track with that. Just gonna say, I would maybe phone a friend for this moment, I'm getting a nod from our financial analyst in the back there that that seems to be something that we could do. Okay. And then my next question is for Sarah on slide 20. And it's more of a comment too from a format. One thing that might be helpful is at the bottom to put, you know, prior quarters. So meaning, you know, at the end of Q1, what was that line looking like? So it was just we would have just had Q1 performance and then so when we get into Q3, we'd actually have three rows, right? You'd have kind of Q1 and where were we? Q2, we know we're at 2.5% at this point, but it will show what you're saying, which is, you know, we don't expect 0.7% to be in Q2, but it'll help for me to be able to see how does the trend build. So that when we get to the end of the year, we'll have, you know, Q1, we'll have four data points and we'll see how much did it change. Q2 would have three, Q3, Q2. And then, you know, we can at least start to say, oh, well we can see, you know, if we projected that forward. And the reason why is because we don't want people to pick up the wrong number and say, oh, we're running at 2.5%, even though you caveat it that it doesn't have a full run out, you know, yet we won't see. So, great idea. Okay. Tom. Just sticking to slide 20 here. The all pair model has that pair differential paragraph 10 in it. And a reasonable person looking at it, I think it would interpret it in a number of different ways, but ultimately that final interpretation is between the state and CMS, which I understand is going on. The issue is whether or not to differentiate between any Medicaid increase or is there a way to calculate Medicaid increases that close the pair differential or increase access? And obviously every rate increase, one could interpret increases access. So my understanding is that as we go forward, there will be two sets of these tables presented so that we can see clearly how much is being excluded from the total cost of care calculation. Understanding that the 6% number includes that settlement with Dartmouth and therefore it's probably an anomaly, but going forward that those numbers should change and may or may not be significant. Is that your understanding as well? Yeah, absolutely. I didn't include both sets of tables which are in the hopes of reducing confusion, but yeah, we're tracking it both ways and without that adjustment. Okay, other questions? I just have a quick one on the NORG evaluation. Are there going to be interim reports from them? Is it just an evaluation in the end? And I'm going to the time on when we're going to see the interim reports. Looking at the timeline yesterday, I think the first report that we'll receive is 18 months from, so in a year and a half from China 19, as long as we'll receive our pressure report. So we'll receive several through the life of you. Thank you. Yeah. Okay, anything else from the board? If not, I'll open it up to the public for any questions or comments. Susan. Yes, can you tell us what the current attribution is by the payers? If you don't have the numbers now on that spoke, can we do any of those numbers? Okay, thank you, Dean. Why would I say our adult standard? Yep, I would also say that when one here comes in May, they will be providing their final attribution numbers. They were still finalizing their commercial number at the time that we were putting this presentation together. And that is why the scale targets and that slide are still estimates. My understanding, I think it was with the staff in New York. So my understanding is that the attribution has to be final as of January one. Like they can't, they prospectively attribute, they can't add in ACO, can't add new lives after January one. So it's able to have now. So are the numbers final for 2019 or not? So the numbers for Medicaid and Medicare are final. And the commercial number is final as well. With commercial, the reason why it takes several months for them to run their final attribution for the year is because they need to wait to know who the population is that is enrolled in the QHP program. And they will not know that until the end of January, beginning of February. And then they start to run their attribution. Other questions or comments from the public? Seeing none, thank you very much. And then Jess, come on down. Yeah, well, let me turn it up here. I just wanna give people a little bit of a background. So our 18 is working hard on trying to produce more responsive information. So if you have a question at a summary level or wanna do a deeper dive, we're trying to produce products that offer both those options. So anything we produce, we're gonna make sure that there is data available for that. We're also trying to release things at a maybe more immature stage, just to give people a chance to react to them and give us suggestions for improvement. So we do encourage you to send us any feedback about how we could make this information more useful. And with that, I'll turn it off to the people who actually did the work. Thank you. Jessica, I'm indisible. This is. David Gladden. And so what we're gonna show you today is the dashboard that represents the total cost of care over time, starting with 2012 through 2017, which is our most recent data. And we have a couple of things to note about the data. It's a resident look, and I know Sarah actually went through a lot of this, but just for a reminder, this is based on where people live and not necessarily when they're receiving care. It's limited to those that are in the cures. And the data is tied to a primary care type. So I know Sarah explained that, but this is to ensure that we are only counting a person one time. So one more. Yes, some of some care. So this is excluding all of those things that Sarah had mentioned. And I'll just note that if you click here, you'll link to our website where there's a document that describes the background and methodology, and all of those caveats are noted there. While we're on the cover sheet, the data is also available for download. So what we're showing you today doesn't include everything that's in the data set. So folks are welcome to come and take a look at what else is included. And let us know your questions and what else you might wanna see out of this data. So the dashboard has two different looks. If you click the tabs up at the top, we are going to take a minute and then look at the per member per month cost over time. So there's a lot of different ways to filter here. On the left hand side, it's small, but it's showing by year and it's gonna default in 2017. If you use the slider bar, and you can kind of take that all the way back to 2012, we can click through the years and just see how the heat map is changing over time. So if we click, the lighter shades are representative of the lower cost per member per month and the darker shades are representing a higher cost there. We can also filter by payer. So right now I'm just showing the all payer, but if you wanted to drill down by payer, you can see how it's changing by year and payer. You can take a look at the different years over time for payer. And the map itself is also a filter. So if you wanted to drill down into a specific hospital service area, you could click on a hospital service area and then the graphs on the right hand side and the tables will adjust to the amounts that are representative of that service area. There's some neat interactive ways to view the data. The table at the bottom is showing you the percent difference from each previous year. So 2012 is like because we don't have something to compare that to, that's our base year. Any questions on this look? One question. So in this particular look for the Medicare total cost of care, this is a subset of the all payer total cost of care, not what you explained earlier about what we're doing in the first three years of the agreement. That's accurate, right? Yeah, and ultimately in the obvious, we'll be one of the same quotes. Round to it, yeah. So the second look looks at members and it functions similar to that first look, but we're showing members over time. And again, if you're clicking on a different HSA, you can see how it's changing over time. And one thing to note here in the line graph, we're looking at commercial. The drop here in members is due to the GOBA decision where we don't have those self-funded reporting to be here any longer. And again, you can drill down and look by payer and the map will change. If you're curious, you can take a look at each HSA over time. Just when we continue to see a drop to the GOBA decision and anything that we can do proactively to try to encourage people to report. That's a great question. I don't have the answer for that, Sarah. Likewise. Yeah, so it's a great question. We are seeing more and more fully insured groups choosing to self-insure and many of those have access to the exemption. So in that way we might see slight drops. I don't think it will be anywhere near as dramatic as this. And I think the best thing that we can do is that this is the decision that's ultimately up to the employer. So reaching out to employers and encouraging them to submit their data is the best thing that we can do. And on our team, one of our missions is to kind of provide some data products that might be more useful to an employer group. So kind of providing benchmarks and stuff in that population. Benchmarks is a strong word, but information about variability and whatnot. So this interaction or visualization is available from the Green Mountain Corp. website under analytics and analytic reports. And there is, as I said, the data set is available and future looks might include a breakout by age category per payer as well as utilization by type of camera. And just so people know that the age group breakouts are already in the download and it also has it on a quarterly basis. So there's a much more nuanced data set. Any questions? I have a question back on the other chart, the all payer total cluster care chart that you showed. What do you think about looking at the all payer bottom, you know, the numbers at the bottom. For 2018, it was 5.2 and 2017, it's 6.8. So how does that correlate to the 3.5? And if there are differences, how can we bridge back to those when we're gonna be looking at each year? That's also Sarah's question. Yeah, and so 17 surveys, so we're not seeing that yet. So yeah, so basically, these are the terms that would be the components of the compounding growth rate. So if you wanted to calculate it from 12 to 17 and you could do it back in the napkin, I don't know what that is, but they should tick and tie, I think somebody once said. So history is, so in 18, when we see a number, that number should tie to what we're gonna be as in the total cluster care. Yeah, and we didn't include 18 because it's only a partial year. We just thought that for this, we should try and keep it as apples to apples as possible. But that said, there's obviously a population shift that makes it not so great for trending with the go-bay thing. Yeah, but it's obviously an 18 that the numbers are. Yeah, 17 and 17, the numbers are high. Exactly. But you're changed, so to be able to get to a 3.5. Sarah, I know you and the team, the 18 over there, this is the start of many wonderful products to come. But data analytics, do you want to share with folks some of the things that you think, thinking about how you're gonna use this data and other things that you can look forward to? Sure, well David's working on completing one related to the hospital budget process that I'm super excited about. They'll be kind of two different looks. One is like a, really kind of like, what we've been missing in my opinion is like that 30,000 kind of simple, stupid look of the comparison over time. But he's also gonna, been working really closely with some people to try and think of some more granular information to provide at the hospital level. So that should be at, what do you think? What do we have? April. End of April. End of the month. So we'll be releasing that one. The next one I think is that we want to turn our attention to you is like a market composition kind of look, and that will be broader than the resources that we have. So how has that changed over time? How are people covered? Kind of that crosswalk of multiple coverage is. So how many people went to Marshall? Also I've got to care and that kind of stuff. And then also we would really like to view some more with the hospital discharge data. And that would be more about patient origin and how that's changing over time and how it varies by the type of service. And then, yeah, we've got a lot of exciting projects. Those are the ones in the nearest term I think. Thank you. But David just wanted to point out one more thing. I just, I know, I'm sorry to be back. So the visualizations can be accessed through links that we have through our data analytics website from the GMCB site. But I just want to point out that the visual is those, the hyperlinks take you to what's called Tableau Public. So anybody can just log into Tableau Public or not the only one you have to log in, you just search for Tableau Public and within this search menu here you can just put in GMCB. I put a bunch of tags in so GMCB usually works pretty well as you can get into our visualization page. If you go to the state of Vermont, you'll see that we've got a couple of, we have the expenditure analysis up. So this is where we'll be our repository for future visualizations. In fact, we're gonna post one that was produced by Morrison Element that's also a sort of different look in total cost of care. I think it's very interesting. So this is the area that if you do not want to go searching through our website to try to find a link to it, you can just go to Tableau Public and do a search at the top for GMCB or create that variable order. I forget the other tags, but it's pretty easy to find. And if you want to create an account, you can do that as well. I'm always trying to get followers. Well, I'm doing this pain, so I know that the more likes, the better, right? You can get notified then when there's a new prop. Not yet, I think you have to get to 100 in there. You're in at that point. We don't want to inundate you if you have the system crash. So as we go forward, is it the intent to develop a kind of a parallel set of Tableau screens having to do with population health targets in the unfair model? Yeah, that's a great question. And we've been talking about how we can better kind of demonstrate key performance indicators, if you will. And I think that there will be probably a dashboard dedicated to those, including quality measures. Those are a little bit, the cadence of those is a little bit slower. So it's always like hard when you just show one year, but that doesn't mean we won't do that. It's just harder to interpret a single. I'm just wondering about the statistical reliability of you kind of want to compare the two intuitively, but it might not be statistically an appropriate approach in trying to say, oh gee, population health is going down in this HSA and the money's going down, so the unfair model is working and that's an association that may or may not be true. So when you get down to a more granular level of the kind of total population down to the HSA level, is there a limit or is there a part of some HSAs where the data just has a white margin of margin bearer around it? So when I think about the question you're asking is, so there's like two different kind of things that are going through my head. One is like a lot of what we're tracking is like what actually happened, so it's not really estimated. It's like we know how many suicides occurred. So in that way, there's not really error around that. However, there is noise, meaning that a smaller population is going to bounce around a lot more than a larger population. So in that way, it's harder to interpret changes, which is why it's nice to have kind of a longitudinal look just to see like how amazing the curve has been. And there are some techniques we can use to try and smooth it out. So if you wanted to go to a ruling five-year average for something like suicide, that's a way that you can kind of help control for some of that. And in that case, you could put a confidence interval around it and figure out what's statistically significant. But I would look, in a lot of these matters, I think kind of the effect size, like if it makes your jaw drop, statistics don't matter. You got to kind of, there's a gut check with a lot of these numbers. Great, and again, we welcome feedback on what we could do and keep producing so these kind of things are designed. And when I think of analysis, there's like kind of this exploratory look where we're not really doing much to interpret anything. We're just kind of giving people self-serve access to try and answer their own questions. I think another kind of way we'll likely go is more like a data brief where we offer more like interpretation where appropriate and kind of put things into context. So these intentionally don't involve any interpretation. All right. So we'll open it up to public comments and questions. Yes, Sarah? You know, I was, we're all kind of moving towards the direction of surfing up more information and you know, presumably like, and this is a criticism of our own work. My office's work too is, you know, I think as one group that's accessing this information is consumers. And I think we all need to begin to think about how consumers get to these things and whether going through the board's pretty current model of the website makes sense. So I think that's something we've struggled with with our website and consumer information is like, is this really the best way to get it to consumers? Or are we all living in this world where we're locked into web systems that were designed in the past and aren't really aligned with what we're trying to develop the products for. And I think, you know, at some point, obviously not now, but as these tools keep developing, I think it is a project our office is looking at. And I think the board should probably consider is does the current way this information is served to the public actually makes sense? Or should we all be looking at a different way of surfing it up that isn't buried in the analytics tab of the Green Mountain Care Board? Well, we'd love to work with you. I'm trying to get it as user-friendly as possible. It's discouraging when you get a public comment. We've had some public comments that they believe that most of the things that are on our website are written for either insurance industries or medical administrators. And that's not the purpose. The purpose of the website is for volunteers. So as you're having that conversation, you're having great ideas that we'll be hearing about. Please share with us. No, and it's something else. We'll talk with Sarah about and work with her. But I think it's a really high-level thing that's kind of above our pay grade, right? Like, my pay grade is in works, you know, the web stuff happens at a much higher level than me. And I think that your guys' web stuff happens at a much higher level. So I'm just throwing this at you. I could tell you how it happens there. Yeah, exactly. What I would just chime in is there are some state limitations that we are subject to, as you probably know, that having, in the past, tried to make better websites that we can run into challenges at a state level with other agencies. Other questions or comments from the public? Yeah. Let's share a couple of questions, Mr. Chairman, about the URISA companies and the GOBAE issue. I'm curious, the, one question is, I think that the URISA company could agree to buy, in other words, you go through one care to get a fixed-price contract for their care with a medical thing, okay? There's no question that we hope that over time, as more people are using the accountable care organization that we're gonna get better data, but what we were talking about earlier was trying to figure out if we could try to coerce them into, Encourage. Encourage. Encourage. Encourage. Encourage them. Coers is absolutely right. And I'm not gonna call anyone myself, but I'm inquiring if we have any URISA companies that will report voluntarily? We have some in there today, and we actually shout out to our partners at Blue Cross Blue Shield. They did a lot of outreach, so 80% of the people that wouldn't have to submit are submitting voluntarily in their book of business. So it's only a 20% lag in there? For Blue Cross Blue Shield. Yep. Other, just a comment, Mr. Chairman, and that is that, that issue, the question of, Tom wrote it up too. I mean, how do you move that? Basically a, it's basically a political question. My guess is, for example, if Rich Tarrant doesn't run IDX anymore, but if he did, okay, and he had the full protection of the Govay decision by the Supreme Court, but if the governor went to him and said, listen, we really need you to do this for the state, Rich would have done it the next day. And so I think that is a, my opinion, just a comment. Maybe it's, I don't need much to get you coffee, but I think that it's a political problem and that it's not anywhere five percent possible to make a lot of progress here and to push. You might be pretty easily able to push into the last, into Sarah's last 20% and end up with a residual that was insignificant. That's it. Thank you. I just want to point out that you can get coffee now for 50 cents at Burger King. That was good, it was the coffee. I actually think the coffee's very, very good at McDonald's and they put it in a cup that keeps it nice and warm and you can reuse that cup over and over again. It's a pretty good deal. And they'll give you a card every fifth one and you get a free one. Any other public comment? Yes, John. John, I'm from the Department of Health. Hi Sarah. Using the heat maps and the Tableau, I love that idea and being able to see the data over time and also how it changes. One of the questions I'm not clear about because probably I can't see the screen, I haven't looked in that data set is over each year that map is gonna get darker and darker and darker. How much of that is because of either inflation or something like that and how do you suggest that casual users of that data set understand how the cost keep going up? And is there a median for the state that's listed in each year? So people can say, oh, my HSA is above or below the state median, any thoughts on that? Yeah, sure. So the way that, I believe, and I believe that the color coding resets within each year so it wouldn't all get darker over time. Is that right, guys? Okay. But like a high group and a mid group and a low group each year. Correct, yeah. And when you download it, you can certainly adjust for inflation if you chose to, but that all payer value is what I would consider as kind of the average or the benchmark for the state. Yeah, no problem. Any other questions or comments, Sam, just one more question for Sarah. Sarah, if the 80% of the erases are in, okay, if it was a statistical test, that would be a hell of a sample. And could it, would it be valid to simply project the results of the 80 over the other 20 and then take that as a piece of a data that would have value? So the tricky thing is that basically the half of the market covered by SIGNA doesn't have that grade of compliance or didn't choose to voluntarily submit at that rate. So we're missing about half of the self-funded population. So Blue Cross has been a great partner in trying to get us. So the overall number is 50, not 80. Yeah, yeah. And there's a lot more than SIGNA, you got to add on and on. Yeah, I mean, I think the most, SIGNA's got about half that business and that's about what we're missing. And yeah, and I would say so the other kind of confounder that makes it a tricky statistical exercise is that certain self-funded groups don't have a choice. They still have to do it. And those are municipal groups, the state of Vermont, UVM. So no matter what the teachers union. So the groups that still have to submit and are the great proportion of business left have much richer plans and aren't a great representation of the population at large, unfortunately. Other questions or comments? We're seeing none. Thank you very much. We're going to recess the board meeting so one o'clock this afternoon at which time we'll take up the enforcement hearings for Lone Scutney and for North Carolina. So if everybody could get back properly up on that, that'd be great. So welcome back, everyone. We're going to turn it over to the staff to tee us up for the first hearing. Oh, Lori. Good afternoon, Lauren, Harry and Patrick Kessler. We are giving a brief rundown of Lone Scutney's enforcement discussion for today. And we missed our second day of enforcement hearings for review. And we will be showing the actions for fiscal year 18. We will be also the fiscal year 19 and the date as of February 28th, 2019. The fiscal year 19 forecast, the larger results into the discussion with Lone Scutney will be after this. So this is what we, Lone Scutney submitted their quite 18 budget and the board approved the 48682309, which we also adjusted their budget for Dish. And we approved their fiscal year 19 budget at 51195770. We are having discussions, minor housekeeping with Lone Scutney because of our data in our software. So that's what that note of rate there means, $756,000. For fiscal year 18, the submitted and approved charge or rate, we used to call it was 4.9%. For fiscal year 19, the submitted and approved charge was 2.9%. For fiscal year 18 actions from Lone Scutney, we're seeing a 4.4% variance from the budget for NPR and MPP and a 1% variance from the operating expenses. They have a 1.9% margin, a 5.3% total margin and days cash on hand is 187.8 as of September 30th. For the actual comparison, 17 to 18, the NPR MPP change was 5.3%. The operating expenses changed 6.1%. And we talk about points for these percentages of operating margin. So they had a drop of 0.8% for operating margin, 5.2% for total margin. And they had almost 11 days change in the days cash on hand. In fiscal year 19, what we are currently receiving from the hospital, this is year to date February 28th. The NPR that we're seeing is 1.7% negative to their budget. Their operating expenses is 1.7% positive. The operating margin is a negative 1.5%. The total margin is a negative 0.9% and they're at 177.5 days cash on hand. And then some of these figures are based on our calculations and some of it is based on their days cash on hand. 18 to 19, the NPR MPP changes 2.3%. They have changed the operating expenses of 6.1% and the operating margin is 1.8%. Total margin is 1.4%. And days cash on hand, we don't have that information next time. With a lot of scutney has projected for fiscal year 19, their NPR MPP for year end is 519.5177. The operating expenses are 54,837.975. There was no change in the operating margin. Total margin change of 1.6%. And then the days cash on hand is 176.4%. We were given, asked to give a five year results for their NPR MPP in a five year figure. And for our records, we have a 2.6% five year figure. And the number for their fiscal year 19 is what we will be asking to have monoskutney either change and adapt it or we'll be talking again with them to find out what the correct number is for their budget. Their operating expenses five year figure is 2.1%. The operating margin five year results for monoskutney are here. As of 2014, they were a negative 163,804, for fiscal year 18, there are 1,052,225. And they're expecting 17,584 for their fiscal year 19. Total margin in 2014 was 216,182. In 2018, it's 2,986,749, just a good kind of an idea of change to all these years. Any questions on the data that we're showing you? Any questions? So then we can have monoskutney to that. Great. Dr. Harris, if you could just order the Swarovski through the mail. Do you sell them in Swarovski or a firm that says the more you're about to give, it'll be the truth, the whole truth and nothing but the truth. Great for us. These are, how was your story? Yes, so good morning, thanks for having us. After we closed the books on February of 19, I wanted to add another slide to our presentation and title, The Tale of Two Cities. And for folks that remember reading that Dickens Nightmare High School of College starts out with it was the best of times, it was the worst of times. And our swing in the last couple of months have kind of raised the issue of how tenuous even good performance can be in Vermont. So I'll be providing a fair amount of color commentary while Dave Sandvil, my chief financial officer, will be providing a lot of the detail work as we move to our presentation. I think in general, we probably have too much information for this enforcement hearing. So I'll rely on Dave to editorialize as we go through and leave time for the questions. We will be talking about the drivers of our PRFPP variants, the drivers of our operating margin variants. We don't have to deal with bullet three this time around. We'll also discuss in depth our year-to-date results through February of 19 and our forecast for the rest of this year. So with that, I'm going to transition over to Dave. So to be honest with you, we weren't really sure how much detail or how little detail we haven't been here for this type of hearing before. So feel free to say less or more as we go along and I'll be willing to adjust the amount of information coming from my mouth. So gross patient revenue for FY18, we actually had every line of business exceeding gross revenue targets for the year. So that was very positive. Acute inpatient revenue was up 23%. Discharges were up 10%. The days were up 12%. But really the big gain in the 23% revenue variance came from a disproportionate number of inpatient surgeries. Typically we might have one, maybe two a month. We had some months last year, we were having six. So that was really the driver on the inpatient side of that favorable variance. And we had a very high case mix because of the disproportionate number of inpatient surgeries. Our acute inpatient rehab unit, the revenue was up 6% from budget. And although discharges were down a little bit, the days were up 2%. And again, we had a higher case mix. And usually if you look at days, discharges aren't so relevant, but a number of days are. And if you say days are up 2%, the new revenue should have been up 2%. But it's up 6%. Usually that's an indicator of a higher case mix. Our swing bed or sub-Q unit was up 6% in gross revenue as well. The discharges were up 12.5%. And the days were only up 1.8%, which mean we had a lot more turnover or a shorter length of stay on the average patient, which is usually an indicator of lower Q&A and lower case mix index. And then we have a typo in here that we have, we talked about this last year and a couple of our presentations up here. And that was, we had seven to nine borders residing in Mount Estatney for several months each. In fact, some broke the one year mark and one approach two years, as I recall. And we have 2,000 patient days of ICF level care when you're in the med-surge unit and really that number is more like 10,000. So we've been aggressively working on that for almost a year now and we're down to just a couple. So I don't know if Joe wants to comment on that. Yeah, I think actually numbers closer to 1,000, about 10,000. Yeah, sorry. We had four patients who were in the hospital for a calendar year. It was a remarkable stress on the institution. So while it looks like we report on our stats, our patient days are much higher than usual. These are folks that lost their skilled needs many months previously. And we're just getting ICF level care, basically nursing home level care, custodial care in the hospital. And that goes to the issues around what's the next step for these patients as nursing homes close as there's not enough capacity in adult group homes and all of the post-acute care issues. We really felt it. Now, the promising bit is that we actually brought in a new director of care management who's been thinking differently about some of these things that we've been able to find the next appropriate step for a big chunk of those folks but it's still a significant stressor for the organization. It's not just the financial stress, our nurses, our healthcare nurses who were spending a lot of their time with custodial care. It's our hospitalists that are functioning with their working in a nursing home. It's not why they got into the business. So a little bit of a typo there. It's the number is about having just done the math again last night about 1,500 patient days with those seven to nine patients that have been in the month. I have just a follow-up question on that. Dr. Perez, you talked about it due to a reduction in the number of nursing home beds available. I'm curious if it's actually a problem with nursing home beds available or if the patients just weren't accepted by the nursing home facility. Yeah, maybe we did some mix. We have overall in the state a number of nursing home beds has decreased. And I know it's a lot of those counties specific. We probably had about 150 beds come offline in Windsor County in the last five to 10 years. So that hurts, but it's also the willingness or ability of these nursing homes to take Medicaid patients. And all, every one of those board of patients had long-term care through Medicaid. I mean, every single one. There wasn't a private pay amongst them. So you can kind of do the math there. Yeah, yeah. I would add to that one of the issues we run into as a border hospital is the nursing home beds are open across the river in New Hampshire and the patient is covered by Vermont Medicaid. And trying to figure out how to make that jump for the patient happen and for the families is very difficult because and you've got people staying 200 days, guess what? They're a resident of Vermont. So even if they had New Hampshire Medicaid now it's kind of a question. So these are some of the complexities that we have to deal with being across the river. Going on with the discussion of gross patient revenue well, patient was up four and a half percent from budget and most of what we call our core outpatient stats were very favorable. The only one that was unfavorable was the OR chemotherapy infusion, therapy, all the radiology modalities, laboratory, emergency were all up for the year and that resulted in that four and a half percent favorable variance. Physician provider revenue was actually slightly above budget, the hospital based and specialty provider surgeons and the like all did fairly well in volume as well but our primary care department in the two locations did struggle but they did finish favorable to budget relative to revenue. So total gross patient service revenue was up five percent. We had no new programs. We didn't really expand any programs or enhance programs. Joe was gonna talk a little bit about primary care transition because that's been having an ongoing discussion with you folks for a number of years and talk a little bit about the services. I've spoken at a couple of presentations around our desire as an institution to get off the boom bust cycle of hospital finance in the sense that we just talked about this this morning at our VOS board meeting, the departure of one orthopedic surgeon can be the difference between life and death of a balance sheet. So we have made a contraceptive move away from that and in the absence of adding more of the pod neurology service would have you know we live and die on our core mission which is around primary care and our rehabilitation services. We have been suffering with a lack of access in primary care for the last few years. We had a major exodus four and a half years ago docs due to retirement, relocation just getting out of business altogether. And so we struggle them in the outpatient space. And I think that the question arises is does that drive some of the emergency room volume? Are there things that could be happening in the primary care clinic that couldn't happen in recent to the ER today? So happy to update that we've hired three primary care docs in the last six weeks and we'll be in a much better place with much better access. As you'll see when we talk about 19 some of the other improvements that we've done around access in our work with better outpatient care management is actually driving some of the inpatient business down because we're better managing folks in the outpatient setting. So as I, Dave and I will constantly talk about what makes me happy from an ACO standpoint makes him unhappy from the CFO standpoint and that's the balance that we have to follow. Relative to deductions from revenue. Generally speaking, if your gross revenue is up 5% you would expect your deductions to be also up 5% but changes in lines within lines of business or with the payer mix change that number. And so our deductions were up 5.8% utilizing your reporting methodology. And when we throw in bad dentury care on our end it was up 7.3% in our purview. And 5% of that was really related to utilization and the remainder was up due to changes in payer mix. We had less government, less commercial in Blue Cross and more government. We did get some of that back because Medicare was the government payer they grew the most. So when we filed our cost report we were able to mitigate that at year end. We always run an interim cost report at, well, at budget season and then at year end to make sure our hopes are that those got correctly. This resulted in net patient revenue that was again favorable as your staff already reported and 2.9% if we don't include FPP and 4.4% if we do. So hence we're sitting here today. Other operating revenue, again going from my books to your books, we move that FPP up so it's reflected in the net patient revenue. But the remaining other operating room revenue was extremely favorable. We received $290,000 in meaningful use funds which will probably be the last amount that we'll be receiving of any significance. We had $100,000 of repurchasing rebates come through the Dartmouth-Hitchcock repurchasing system and really the other notable one is really the 222,000 and 340B revenues which we're always trying to stay on top of and trying to make sure we're getting what we can out of that system. Our big concern we've mentioned is the last few times we've been here is that our reliance on something other than our core business which is taking care of patients is a growing concern, floating on a margin with services that really are our core services. So overall our total net revenues went up 5.5% positively. Expenses, we did a really good job of managing expenses that tends to be what we do and any expense that we have control or managed enough I feel like we do a pretty good job of that year in, year out. We had a 5% volume increase loosely speaking and our expense increase was only 1% and that really speaks to two issues in my mind. One is that we are doing good job managing expenses but secondarily, and this has come up also in other hearings, is that we have a large percentage of fixed costs in a critical access hospital and so oftentimes when we have more volume than expected we're able to absorb that in the overhead that we already have and so I think those two things are what you need to take away from that particular discussion. Salaries and Purchase Labor put a great deal of pressure on our expenses, they were up 1.75 million and that was with a favorable FTE count. So we were under budget for a number of FTEs but because of locums and traveler costs that really, we really ballooned up in the total salary and labor costs. Market salary competition, so we're we're in a little bit different situation. You're a North country, we'll probably speak to the same thing. We're competing with New Hampshire, not only the other Vermont hospitals but New Hampshire which is essentially the wild west with healthcare finance so we're constantly trying to stay in the game with that and in order to get the, to replace some of these travelers we need to address that and at least stay in the game. We'll never be a market industry leader but we need to be staying in the game. We also, Purchase Labor went up because we have been renting a few managers from Dartmouth-Hinchcock to manage areas of our facility in the B-Quike Frank. If I were to pick one thing that has been extremely beneficial from our relationship with Dartmouth it is some of those folks that we have brought in the field positions within our organization in another level of expertise, knowledge and skill. They have to kind of retrain their mind to think like a critical access hospital but the ones that are in my mind as I speak right now have been fabulous, fabulous improvements for our organization. And then travelers, welcome to you guys I'm sure are aware of that and nauseating so I welcome to speak to that. We did have favorable benefits to offset that by almost $100,000. Supplies were only up 1% despite 5% volume increase. Purchase services were down 7.4%. We're really careful about the consulting and service contracts we signed. We're able to leverage some of Dartmouth's terms and pricing for some of our service contracts. We are very aggressive in our negotiations with vendors and have done fairly well in knocking that number down. That was about 335,000 for last year. Utilities, we've talked about our ongoing energy saving efforts and we do consider ourselves a leader within the state of Vermont relative to that and we are seeing those savings in our utility costs. Rent equipment and basically all other expenses. Again, we just scrutinized some of our IT subscriptions and more of the things we could do within the facility and not contract out. Specialized patient equipment, bariatric beds for instance, some of those types of things. The frequency of you renting those items for specific patients had grown to a level where it made more sense for us to buy and no longer rent so that accounts for about 120,000 in savings. I believe this time last year we spoke to you about our workers' cost carry we're looking at 150% premium increase and we were actually able to save money on that. It was Mr. Tone's wild ride but we got through it and that contributed heavily towards saving a fair amount of money the last several months of last year. And provider tax, we actually paid $40,000 last of the year and we anticipated so we're happy. Interest and depreciation, we didn't buy everything that we had on our schedule to buy and we have some favorable borrow and raise that we were able to get through Dartmouth-Hitchcock. So as a result we also saved about 270,000 in those areas. Just a quick point, I mentioned this at prior budget presentations. Our historical strength and expense management and reduction is what's kept us in the game when volumes weren't what we expected they would be so I think what a team showed was ongoing focus on our expense reduction but in the setting of we actually had higher than expected volume so the stars aligned for a year and as we talk about that team we'll discuss a little bit of a misalignment of the date run of it in there. So we did make our operating budget so we're skipping the next little point. And going to results as of February 28th, 2019. The short story is we're about $700,000 behind budget on operating margin through five months and it's kind of as I lose internally at the hospital and a lot of death by a million paper cuts. I know if any one thing that is running away from us or creating chaos that we cannot get in front of but we can start right at the top of the P&L and we can talk about some of our inpatient volumes. So last year we were up for acute days and discharges. We are significant down this year and Joe will talk a little bit about some of our referral patterns and folks we get from Dartmouth. And then we have acute rehab discharges were up but the patient days were down and really when we're looking about revenue I only really care about the days. The clinical people care about the admissions and the discharges. I only look at the days as the staff because I'm always trying to think what's the revenue per day. And so our days were down despite the number of discharges up. Swing discharges were down 20% but swing days were up 7% this year to date through February. And generally what we're seeing is a lower acuity for lack of a better word for those types of patients and as Joe's reference, languishing in that unit and not being able to get them out. We do not yet paid well. We talked with a little primer on CAH finances a year or so, go here. We're getting a couple under bucks a day on those patients and we're probably giving them $800 worth of services and true costs. So on direct costs. So that's very concerning. So basically, if you look at the inpatient as a total, total discharges were down days were up slightly but the real technical way from here is the area that did the best for the worst payer mix and the worst reimbursement. Outpatient volumes, ERs right on and actually one visit of what we had budgeted. Ancillaries are still doing good and that's radiology and laboratory predominantly. Our therapies, which were very busy last year are slightly ahead of budget and the OR is operating 5% below which is what we do last year. Provider visits, again, the hospital based docs the hospitalists and the anesthesiologists those types and the specialists, mostly surgeons. They're all performing fairly well. They are ahead of budget through February but you can see all three areas of our primary care as we work through that transitioning process are still labbing budget volumes. Yeah, just to add that we set a pretty low bar for productivity in our primary care clinics. We made a conscious decision as we got a sense of fixed prospective payments coming down the track and the ACO coming down the track that we would move our primary care docs away from any productivity or RVU incentive whatsoever. So we have a flat salary for folks but still have limited access. So I would say that our primary care workforce has been a significant driver here. I think folks would love to see more patients but we have structurally changed how we built out our clinics over time but again, trying to see what it's gonna look like two or three years down the road as opposed to what it looks like now. So that has been a challenging an ongoing challenging primary care. I think we're getting close to getting to the promised land. On the inpatient referral side, I've said this at prior hearings, we get around 500 post-acute patients from Dartmouth-Fishhock every year. These are what we call swing patients, not necessarily the patients that go to our 10-bed acute rehab unit but the folks that are just not quite ready for prime time after they're discharged from the hospital. Dartmouth-Fishhock has struggled at times internally with its care management and with the referrals process. The way we move patients around in a larger health system can sometimes be rather clumsy. I was away on a vacation in February and I was getting emails, one from our referrals office saying, nearly a three people would email you that are on the list to come to Dartmouth today. Moments later, I get an email from Dartmouth-Fishhock saying, you tried to transfer two people to our ICU less and I thought we couldn't take them because we had no beds and then in two minutes after that, another email from DH saying, why aren't you taking any of our patients? I said, well, you're not pushing anything to us. We're trying to pull, you're not pushing. So our referrals for some reason in February which was kind of the big smoke and crater here for 19, dropped 30% in one month while DH was verging with patients, literally versing at the same patients much like the struggles in VMs going through now. So this is an ongoing process. I was the medical director of care management at Dartmouth-Fishhock before I went down to Manuskutney and spent something we've been working on for 15 years and something we still have to keep the focus on because again, as I mentioned earlier without that orthopedic surgeon making hay, I have got nothing to fill in the gaps if we're not full of all those DH patients getting our rehab services and I think February bore that out. So as you see on this slide, we've got referrals from the DHA significantly down and February was the deciding month in our first five months, clearly. What we experienced last year in 18 was more inpatient surgeries than we had anticipated or that we'd ever had historically in a year and we did not budget at FY 18 levels. We budgeted at more historical levels and this year we're actually having fewer inpatient surgeries and it just speaks to the small N we have. We're talking about two inpatient surgeries and that two becomes six, that's where you fork or the CFOs you fork over that but to go from two to one is a 50% reduction. So that's really one of the things we're up against here. Again, the operating room was not performing well. It's not that there's anything wrong with it. We had providers on vacation and throughout the system in February and we've got the swing referrals were coming in but they were really leftovers from January and February. So at the end of the day, the gross patient revenue was up 1.65% which on paper sounds good but that being said, we get into some of the deductions from revenue and the payer myth was close to budget levels is off a little bit. A little bit favorable for the government payers not so favorable for us but one of the things we're bumping into this year is the ACO reserves and when we file our budget when you folks last July, we had not received adequate modeling information for us to consider the other two programs and in fact, we've just recently got our attribution numbers so we really don't even have our head around where we should be on that yet. Now we're working on that currently and so we are reserving for all three programs somewhat blindly at this point. So if I were to err on any side of anything as a CFO would be on the conservative side so that it's easier to loosen the belt during the course of the year than to try to cinch it up three notches in September. So we're taking a little bit of liberty for lack of a better word with our reserves in that regard. We also receive some duplicate payments in our ACO activity so we had the reserve against those and then we also have built a reserve for Springfield Hospital and some of our receivables that are patients and non-patients and so we've had a reserve for those as well and so that has really skewed our deductions. Can you expand on that a little bit more in my question so I don't understand that? So Springfield is a self-funded health insurance plan and if they are not sending money to be a third party administrator the third party administrator is not paying the facilities who are rendered care to their employees and dependents to their children next door. We were told back in January that they had indeed caught themselves up-to-date with Blue Cross which was the TPA and are we still seeing the lagging payments? We have a reserve of about $90,000 for those patients that were and that's over 30 days old and then we had another $10,000 reserve for medical services we provided to their patients like their CTE was down so they brought somebody up for a CTE at our shop. We billed Springfield, Springfield bills they insured so we had about $10,000 in receivables for that. Just a quick question on this to clarify. Reserving for all three programs because how much was in the budget and if it was zero that's fine but how much are you booking? So when we look at if you're off 5.7% year-to-date I mean how significant is that? It's really not that significant because we really only had two months of the other two payers that we hadn't contracted or didn't have bottling information. So our reserves for Medicaid are essentially the same because our risk went up 100,000 a year on that so the Medicaid last year looks a lot like the Medicaid this year but for the commercial and the Medicare we have some small placeholders within our reserves and the exact amount is Medicaid they're both less than Medicaid and probably by themselves are somewhat immaterial. They're probably 100,000, the two of them somewhere's around there. And then a duplicate payment reserve since you weren't supposed to get it I guess if you booked it that should be it basically in less than some crossing years. So if you got paid 100,000 you were supposed to get it and you're reserving for the 100,000 and making up a number of minutes not enough impact. Yeah, in theory, absolutely. But I'm just saying that you've got cash and the offset is the contractual allowance. So we have both and so we booked the reserve to cancel them out to your point but that's when we look down our reserve our third party reserves they run through contractual allowances that's a bucket in there so. The big concern, my big concern actually is that we are kind of woefully under reserve for what our potential downside risk is. And you know what, put on my one care hat and vice chair of the one care board of managers a believer in the program but it's been a challenge mostly because of CMS not releasing good modeling data. For us you get a real firm number on what our downside risk is for Medicare especially and that's the biggest pot there. Initial modeling had total downside risk for Medicare, Medicaid and commercials of around 600,000. That was the number we used to, I used to cajole and convince my board that we needed to go into all three programs for 19. The latest modeling shows a downside risk of $1.6 million. So that's a number I wouldn't even take into my board because we, unless I had a wing wing nod from Dartmouth saying that they would backstop our risk because that's just too much for a hospital like us to bear. That's two years of margin that we could be sending off. So we've done a lot to mitigate that downside risk. There's extra population health payments that we get and to probably cut that in half but it's still a big number for a small hospital. So moving through the rest of this year we're going to have to be a little more aggressive with our reserve. So there are, you know, any one of these issues by themselves is not super critical to our February results but they are all contributors. Trying to move this along here. Other operating revenues on budget only would be FPP money. The expenses, again, FTEs are down just like they were last year. The difference is that this year the salaries are up and we've listed a couple of reasons why that is occurring. Number one, we spread our budget by historical utilization by month and so we spread it a little bit light on the front end and a little bit heavier on the back end than we intended to. So we're having an unfavorable variance for salaries but even from March we've looked at March and it started, it's kind of coming back into line again. So I'm not overly concerned about that but it is a contributor through February. We have a poll up here called companion age sitter and we have some folks who stay on the floor who need some oversight that the nurses can't just sit there and be with them. It's a safety issue. And so we have these two types of folks that sit in with the patients and keep an eye on them and alert the nursing if there's any problems. And we've had difficulty hiring for those jobs so now we have more expensive employees filling those roles. And then we also had a bonus that came out through the Dartmouth-Hitchcock system. That was about 100,000 to us. They paid our books, it is a budgeted B a one-time hit so it'll soften up as the year goes on. And relative to purchase labor, that's up 11% and really again it's predominantly driven by travelers and locums and some contracted staff that were recently hired. So benefits this year, we've had a really good run for a number of years on our benefits costs and we have come in under budget for benefits year-in-year out for at least three years. We did not change our plan but we are having a lot more folks tapping into their benefits early in the year. And so that was a key contributor, a few hundred thousand dollars unfavorable for your to date. Supplies are up mostly in the area of infusion and chemo. Depreciation is running over budget. We're actually on pace. We're actually a little bit early on some of our capital purchasing this year. Usually start off really slow to build steam as the year goes on. This year we actually get the ground running and we're actually in front of this so we're running a little ahead in depreciation. All other expenses are running and those are all things that we generally control. We're all running under budget expectation. So our operating margin as we mentioned earlier is near to a $340,000 or $700,000 budget. And relative to total margin which we have very little control over. We have a, we're at 138 versus the budget of 283. And so we're down 144K from a budget year to date. For your enjoyment, I have an L for you. And so kind of looking at the prior year which I thought was an interesting question. I haven't really processed through whether I like it or not. So FY19 versus 18, so all these bullet points refer to how 19 is compared to 18. So inpatient is clearly performing worse, $425,000 in gross revenue short. Outpatient is actually performing really well and ahead of last year. Acute rehab is behind by $40,000. Swing is a little bit better but again, worst payer mix ever. Provider revenues are actually slightly up. And now out of all those revenue discussions you have to remember there's a price increase in there. And we're not talking about net revenue, we're talking about a price increase that two folks approved that we have put in. So you have to mitigate all of those numbers. And then deductions are up 7.4% from last year and net patient revenues up 1%. So total net revenues up 2.7%. So we are ahead of last year on the top half of the P&L. But some of that is vapor because it's a gross price increase in there. Looking at expenses, the most concerning on this list is salaries and we've pulled that apart for the last two finance committee meetings internally. And we think we can mitigate it and we think part of it's associated with the spread of expenses over the course of the year. So we probably will not stay at that number for the remainder of the year. Purchase labor is up, as we mentioned. Benefits is running hot compared to last year. Purchase services are up. Supplies are up mostly because of volume. And all of the other expenses are actually running two to three and a half percent below where they were last year. Depreciation is up because we're on our capital programs earlier. We're about 700,000 behind last year's performance just like we are against budget. And total margin is running about $1.2 million behind last year and that was really because last year it has excellent investment market returns. So we asked for projection. So early in the year, I tend not to try to trend everything, especially where February was just by itself just such a bad month. The first four months were not great, but they weren't horrible. But February really just cratered the year to date. And so I really didn't want to trend that and feel comfortable with that. So we took actual results for five months and budgets for the remaining seven. And really, when we look at that, we've gone over some senior leadership discussions about expenses and revenues and how likely is this to continue for the remainder of the year. We feel like we can definitely mitigate, if not change the results the next seven months. Our gross patient revenue trend will not make up for the early shortcoming. So we don't have a secret service that we've been waiting to unleash on the planet to generate a lot of revenue. So it really is going to happen at the expense side and really spending some time analyzing our deductions. NPR will stay the same or get slightly worse as a percentage based on our ACO activity and our reserves. And those are really kind of the big drivers to how we look forward on the top half of the BNL. Other operating revenue will be on the same track. Again, no, we have no tricks up our sleeve on that. So it's probably just going to continue the way it's gone and it's gone fairly well. We're going to keep managing FTEs relative to expenses. We have a market salary increase scheduled and budgeted for July. And that is clearly at risk at this point. We've made a lot of ground on the market. I don't think we're a market commensurate yet, but we're in the hunt and we may not be able to do that. And then we're going to look at addressing these companion aids and patient centers. The percentage of patients that we have coming in the door that require this 24 hour oversight is actually a very large percentage of who we have on that surge specifically in the swim bed area. So these are just people who are just around the clock essentially for a handful of patients. And it adds up, even though they're not super highly paid, it does add up. Purchased labor, we've made a couple of moves with recruiting to reduce some travelers. We've seen a big drop off in February and March, especially on travel, our locations costs. So we're just going to continue with those plans that we put in place earlier in the year. And hopefully that will continue. Benefits, we don't have a lot of control over that. And we've had a really good run for three years. I'm hoping this is just kind of an anomaly for the first couple of calendar years and months of the year, and that they will slow back down again. And the rest of the expenses will probably not change markedly better or worse for the remainder of this fiscal year. So we're actually, earlier this week, we worked on it and revised our projection. This is I think conservative. I hate putting negative numbers up anywhere, but we have a projecting a negative margin of 670,000 on operations. And I'm fairly confident we're going to do better than that. But that relies on the 300-some-odd people that we have in the organizational agenda. What are we going to do? We're going to manage FTEs. We've talked about in our prior presentations here that every FTE goes before a committee to be determined whether we're actually going to hire that or not. And that has never stopped and will continue. We're working aggressively on the referral processes with Dartmouth. We're coming up with some creative solutions from recruiting and retention. Talk about one now just to give you an idea of kind of how we're looking at things. So we had a lot of retention issues of respiratory therapy. Call is a huge dissatisfier. A lot of hospitals are, we're going to talk about smaller hospitals, larger hospitals who are running ICUs and special care units have respiratory therapy three shifts. Smaller hospitals historically don't. Most of us. So we, when that department started reporting to me, we looked at it and said, what are we doing wrong with recruiting? What are we doing wrong with retention? And as we went through all of that, I ended up deciding, you know what? We actually don't need to throw money at this on a per person level. What people are telling us is it's not the pay, it's the call responsibility and the changing schedules. So we just need to lock in a schedule. And so we went three shifts for respiratory therapy. And when we looked at the revenue and expense pluses and minuses by giving employees greater satisfaction, not touching the pay rates, we were very easily able to recruit the third shift staff, allow our manager to actually manage the department more of the time because most hospitals, small hospitals are working managers. And oh, by the way, we were able to take separate patients from our community that Dartmouth couldn't get out because we didn't have the ability to provide respiratory therapy three shifts seven weeks a week. And so we're looking at it and we're about $250,000 on the bottom line. We went live with that coincidentally in February and we estimated we needed to take in about 12 patients a year to make that happen in worthwhile. And so still really, really yet a month into it, essentially we had three patients that came in the first month. So we're confident that that is going to, a, get rid of all of our travelers and respiratory therapy and be put little money on the bottom line and do a better job for our community. We got a small gain on meaningful use not like last year. Again, we're gonna, we're working currently on completing the analysis of modeling for ACO potential risks for Mount of Scotty specifically. And then one of the things that I was here for the Gifford presentation and saw your list of four and a half million things if they're going to do to save money and having generated those lists in the past immediately cringed because it's a lot of reporting back to people more so than the work itself. And so we've got a list of our own going and we'll be managing through that over the coming months and we would be happy to provide updates as requested or needed. My last thing here is a reminder of our operating income over the last 18 years. So the blue line is the budget and the orange line is the actual performance. And so I started here. So kind of, you know, we've kind of gone flat. We've had a big multi-year succession of losses and this is a cumulative margin calculator. And so we've kind of flattened out and for the last three years we've been in the black but we haven't made up for the losses in the prior years. If you like our graphs, a slightly different look at this as our performance actually is orange and our budget is blue. And so we're definitely the bars are on the right side of the zero line for the last few years and we hope to keep that going. So there's a couple of things. It seems to be a swing and the employee benefits last year being down here on employee benefits but this current year that you're in going through that. Is any of that related to reporting or? I'm sorry, related to reporting? Well, you had, in your 18, it looked like your employee benefits came under budget and in the 19 year way above budget and I'm just curious to see that came in that can be a kind of pouring in the reporting cycle so that, or is it just totally different things that were making those variances in each year? No, it's just actual experience. So we don't, there's not much of an accrual associated with the benefit line item so pretty much whatever happened in January is what happened in January and it's the books accordingly. We reserve for our lag or run out which is basically 17 days currently through the process but if our fiscal year ended in September so if you think about your benefits your deductible out of pockets have probably met as you get closer to the end of the calendar year so our first three months of this year were actually last calendar year's program policy and so October, November, December are usually a higher utilization because folks, they're out of pockets have been met and this year, January, February we just had a lot of claims. You came to us a couple of months ago with some pretty good optimism about the comparative effective research program that you were putting in place. Do you have any early results? So, boy, we're under oath, right? So I am underwhelmed by the speed of implementation of that program in a very large system. So we're, as I like to say, a herd of turtles and I'm not talking about the little turtles scampering down to the ocean, we're talking about the giant ones that seemingly don't vote for you. So I'm pushing on that and I'm being completely inappropriate right now for my personal career but I am pushing very hard at the system level for faster adoption and I think all the good intentions but when they started rolling it out it's the complexity of 12 facilities converting on to this. So we've seen something and it's in line with what I had hoped for but it is really slow. Okay, and then you had to slay up in other revenue from the sale of services. What was that? We contract some of our own staff out here and there. That's a large portion of that. So we have, we rent out our speech therapists, for example, we don't have really full-time work for her so when we have an opportunity to rent out for a vacation, we make her a traveler and that's generally what's in there. Some catering stuff of that, but generally staff rental. And what you consider one of the risks is the reserves for Springfield. I'm just curious, not anybody should find any positive if somebody else is paying but have you seen any uptick in either patients or job applicants in case of what's happening in the White Hospital? So yes on both, not an exodus but I think a steady drip whether it be nursing, administrative, help. We, knowing that their inpatient capacity is limited right now because of some of their nursing losses, I've reached out to their emergency medicine folks and said we have some inpatient capacity if you can't take these folks, don't call DH their burgeoning, they can't handle them either. So we are now, our other local partnering with hospitals are under some stress too. We all are in the same community. So we have pretty robust physician staff in the inpatient side of the hospital so we take patients from the Springfield ED and from the Valley Regional ED regularly. The other new wrinkle in our regional healthcare issue is a new staffing model that is starting in Springfield this week in their emergency room. So they're very busy, PD 16, 17,000 visits a year and they've got a new staffing model and I think it's unclear what that'll mean for the rest of us. My guess is I have concerns of that staffing model might not be able to handle that far new visits so it's gonna be more folks in our emergency room and probably more folks heading into the DH which they'd like UVM really to have the capacity for. Right now. What has happened to the docs that chose not to consider going to a different employer? So it was really just one doc, it was all the PA's, the physician's assistants. We worked hard to try to find a home for them in the DH system but as Dave talked about hurting turtles all the members of that system can sometimes be difficult to wrangle as well and they weren't ready to go to a PA staff to model in their small emergency rooms. So unfortunately, I think we're gonna lose some of that workforce out of the market which we simply, I agree, cannot afford. A lot of effort went into trying to salvage it and frankly we could be in that position later in the summer if, cause we are still contracted with that PA group through this fiscal year if they were to come apart and have assurances that they won't but we could be looking at plan B and what we're gonna do to staff RAD by the end of the summer if we can't turn things around. Questions from the board? Wanted to talk a little bit about the relationship with Dartmouth-Hitchcock and I think it's obviously a beneficial thing for the hospital but how should we think about it when you originally were supposed to get a contribution for them for 18, so I'm looking really more 18 in 18 performance and it came in higher right top line. You had some swing beds, stuff that went on and a lot of that you don't make as much money on and I think comes from Dartmouth-Hitchcock. Just really what do we think and I guess the other part of that would be are you getting influx from New Hampshire residents into the state and maybe that was driving some of the top line that you had? But with all that it's really, I think the relationship with Dartmouth is great but when we're looking just at Vermont and the Vermont performance and whether or not we're subsidizing Dartmouth through that process or not, do you know what I mean? So it's just because they were gonna give us money and they didn't because you made more in total but if we kind of isolated it out, should there be a contribution from Dartmouth in there and how does that play out? So I think there are a lot of layers in that question and I've said this before too when DH sneezes we get a cold, right? So little loose services or gang services depending on how DH is doing. But generally you're right, it has been beneficial for us. We, I've always been a believer that full hospital beds, even in an ACL world, full hospital beds allow you to regularize your staffing to have predictable revenue and our relationship with DH generally allows us except in February to keep our hospital full and keep our staffing where it should be. But they, you know, they set a, on the system level, they set a margin target for every member in the hospital and it's our job to reach that. We, and we work very hard in a challenging environment to get to what they're, what they'd like the margin target to be so we have to balance that with, you know, our growth targets through the Rewind Care Board as well. So it's a real balancing act. I don't know another way to put it more eloquently but, you know, my concern every budget season as it is with Dave is the margin target that we get from the system. Are we able to get there with, you know, without hay-making, surgical specialists? We can't primary care our way out of these issues. So I don't think, I don't think Vermont is subsidizing DH. I think, I don't think we would be in one care if I wasn't part of a larger system. In fact, I'm quite certain that 19 would be my last year because we just can't, you know, if one month throws us behind the budget that much, you know, six tough months in the setting of potential downside risk, when all of our most expensive care does not happen for our HSA, it doesn't happen in winter. All our expensive care happens at DH or the state by the center when DH is full or UVM and patients go that way. It's just too much for a little place to manage, but because I'm part of a larger system and DH would be our founders and again, we think it's the right thing to do. If I didn't have DH's backstopping, then it would be really tough to engage in an alternative payment model. Did I answer the question? I mean, it's a tough one to answer. It catches me on a different day, I'll say. Something different, depending on what the stressors are for that given day. No, I think you did that. I wanted to get your perspective on it if you think, right, the models are subsidizing, you know, in this situation because, you know, we're taking these swing beds and things. So I think that's a very good point. And when we, some of the earlier, a few years back when we did have a, we always struggled with what to call it, is it a subsidy, is it a system allocation payment? There was no good name for it and really terrible accounting for it. So, you know, we determined that our swing bed volume is probably gonna be, it's probably really about a million dollars worth of value. And I think we kind of settled on that over a couple of years. We never codified it into a contract or anything else, but 500 swing patients a year for 1500 patient days of borders, it's probably worth around a million bucks. And that was about what the system allocation payment or subsidy was at that time. Now, we've, again, because of our expense reduction and expense management over the years, we were, I think, able to keep that at around a million dollars. And then after a few things broke our way from volume, like last in 2018, then we actually turned the corner from an operating margin. But part of my fear is that we are returning to more historical norms on volume. And, you know, we may be bringing that bell at DH again saying, okay, we're still taking all of these swing patients and a good chunk of those borders were folks that started their journey at DH and ended up with us after complex care up there. So, you know, at the end of the day, the DH to the system is, wants us to succeed. They would like us to float on, you know, our own bottom line, but, you know, today it can be a challenge. Today is, that's the thing is just as a consideration because if you, on average, were getting about a million dollars and now we're doing a lot better because of expense management and things like that, that we do it here, you're sitting as a standalone, you need to make certain margins that you support, you know, partially by raising things like that. And if you were to get that million dollars from Dartmouth, you wouldn't need to press that button as hard. So it's, I don't know what the right answer is, but, you know. We don't either. I mean, we just, you know, we just, the fire of our approval process last year was documenting the increase of New Hampshire business within our four walls. That has continued through, at least through January, it was the last time we looked at it. And when we look at things like the respiratory therapy program, we just, you know, enhanced for lack of a better word. You know, we are going to see some New Hampshire business for that. They're not only New Hampshire patients, but they're patients, they were generating bills in New Hampshire. They will now be generating bills in Vermont. And so, you know, it is kind of hard to track all of that because we do get jammed with New Hampshire people in the swing bed unit that are not very lucrative and hard to discharge. So we have to pay that price. But I think if Dartmouth were sitting here today and I would never speak for them, the finance, the CFO, Dan Jansen would remind the group, you know, that, hey, we're working with you on terminating, you know, this pension. And you would never be able to get the funding for that any other way. And that is going to save the system $1.3 million, which would be entirely accurate and true. So we have a pro and con that's going all the time and try to weigh it. Other questions? So I went back and kind of looked at the budget that was presented for the 2019 budget. And I was looking at the payer mix and there's quite a, and I noticed in the presentation here, I think it's on page 17, it says payer mix close to budgeted levels. And I so went back to submit the 2019 budget documents and looked at the 2018 projected versus the 2019 proposed. And it had Medicaid dropping significantly as a proportion from almost by 55% a year over a year. And Medicare going up in terms of the dollar value by 12% because it's a much bigger base. It basically balanced out of the Medicaid reduction. And if maybe you told me at one point or told the board one point and done, you'll buy that dramatic change in projections for Medicaid and Medicare. And assuming that's where you said that the payer mix seems to be as projected is it unfolding in those kind of proportions? So our budget for FY19 was kind of a hybrid relative to payer mix between what we were experiencing in FY18 and what historically we had seen. So Medicaid, for example, we had seen a steady increase as a percentage for many years, 10 to 12 to 14 to 15 to 16, bumping around that 14 to 16 range. And then we saw an improvement last year and those folks actually, those people not so much but that money ended up in the Medicare bucket as a percentage and Medicare base more than Medicaid. And so we budgeted this year somewhere between the high and the low of our expectations last year and what we actually lived with. So we kind of budgeted in the middle of that and that's kind of where we're running right now. I think Medicaid's within a half a percentage point. It's up a half a percentage point and Medicare's up a bit and commercial will cross her down a little bit but it's five months of the year and it's pretty close. So Medicaid is up by half a percentage point relative to 2018? No, relative to our budget for FY19, which was somewhere between actual budget of 18, does that make sense? Other questions? Jess? First of all, thank you. It's always important for us to hear the story of what's happening in hospitals and it was always interesting and your humor is always welcome. Yes, well the fact that you still had a job after several days is some amazing. But I clarify a question. I know how important primary care is to you and your community and how you've always been a supporter of building more primary care in your community, Dr. Harrison. I was a little bit confused about what's happening with primary care. My understanding is the volumes are down but you still have access issues. So is that a productivity issue? Is it a, some providers left and now you're replacing them? I'm just trying to understand the volume to down but access issues are up. Yeah, so it is a little bit of a productivity issue and I sometimes have to remind our physician staff or provider staff in the clinic that even though I'm ringing the bell on our attributed lives all the time, attributed lives are attributions probably around 6,000 patients in total amongst the three programs and we've got somewhere between, probably around 14,000 primary care population split amongst our two primary care clinics. So there's a lot of patients that aren't in risk programs through either commercial programs in Vermont or the entire international population which again is 25 to 28% of our primary care base. So I still need the docs to be productive. And we've probably swung the pendulum toward non-productivity a little too much trying to step that back a little bit. But we were down probably four FTE and our physician staff in the clinics the last few years steadily would hire someone or they would either be a good hire or they didn't like it or whatever it was. And it's only recently that we've just gotten some momentum and we're our access, we have the wrong kind of access. If you have a sore throat or a hurt your back we can see you that day or the next day. If you wanna see more provider, if you wanna, what we lack is paneled primary care providers. We basically shut off the valve and have a hundred plus patient waiting list right now to get into, to have a physician of record and attending physician. That said, we're starting to use some of the wrong kind of access, that same day access to tee up these folks on the waiting list for our new providers which are coming first of June, middle of July, end of September, just to get them in the door. Frankly, we certainly do need the volume and we need the revenue. Our issue in clinic has been the wrong kind of access. When a bunch of folks retire who've been in practice a long time, that's what happens. You end up with a number of PAs and MPs who do the same day work, but they're not gonna manage your diabetes over the long term, they're there for urgency. So I think we're finally getting ahead of that. Yeah, and then get the struggle of all new providers. And I was myself, when I went up to DH almost 19 years ago, I took over the practice of a long time, doc at DH, and every patient's needed me for a year and a half. And that is rural, so it's hard when a bunch of people leave and you try to redo your practices. I know that other folks in the audience are looking at Steve Gordon and you've got a bunch of people leave the clinics. It takes a long time to recover. That makes a lot of sense. It sounds like you're on our track and it's a temporary. The other question I have, and this relates to the small end problem that you've referred to, I think as I start thinking, this is something I've been thinking about a lot more in the last year, but as we move towards, not only in a cost containment era, but we're in a quality accountability era. And I think a lot now about the choices of scope of services at hospitals as you may hear and hear me talk about. And so the red flag went off when I heard one to two surgeries a month. So those are inpatients or something that comes in, not scheduled surgeries, but folks that come in through the EDE, transfers from another hospital. Okay. Yeah, there's more. And I will see. Okay, because my question was, well, I guess I'm still going to have a question, but I'm glad to hear that that's not what I thought it was when I first heard it. In fact, those were almost all done by our general surgeons, our general surgery practice. And out of, you know, we were going, we kicked off budget this week and we went through all of the clinic volumes and said, ah, general surgery, I don't have to worry about them. They're doing their job. You know, they're seeing the patients, they're generating the revenue, they're managing their expenses, they're doing all the right things. So those were general surgeries that we either inherited from another organization or came in through the EDE. We just don't typically do that scope of service and a lot of the general surgeries are typically outpatient. Okay, but let me, so I'm still, I'm glad to hear that, that's clarifying and thank you. But I do want to know, how do you choose, you know, the scope of services that you're going to offer and how do you know, how do you decide that the volume is enough to achieve the efficiency and the economy's a scale that's going to reduce the cost of care and the volume is enough to ensure that the quality of care is going to be at a high level? How do you respond? Great questions. And I knew where you were angling, toward it makes sense. So another benefit of being part of the system is we were part of system credentialing as well. So in that work is growing in the sense that as we credential new providers at the system level, A, we want the credential that all of the system members so that we can move parts around the system if our general surgeon's on vacation, we need someone to do a gall rider and have a deck to meet, we have the ability to move that people over. But the more complex cases, and especially surgical cases and surgical oncology cases, the providers have to have a minimum number of cases or the system will not credential them for that work. So we fall right into that as well. Our general surgeries are what are called misinfunded placations, we're rapidly esophagus to help deal with reflux, appendectities, lumped activities for breast masses, gall ladders. These are all outpatient surgeries. Every once in a while we'll get a bowel obstruction that we have to do. Keep in mind that half of our general surgeon, actually 60% of our general surgery coverage is in Dartmouth-Hitchcock, community general surgeon who spends time at both places where volumes of teach total. Some visits are different, some visits are not. Exactly. Oh, I just said it's a volume in total. Exactly. And we track all of that. The other part of our general surgeon surgery coverage does cases with us and as well in that we want an hospital in New Hampshire. So we, again, just to go back, that's a real benefit of the system. If they said I want to start doing surgical oncology cases or a surgeon came to us and said, we want to do that at your place, we would say no. They would cry. They would cry when I would say no. Or if you wanted to do one to two surgeries a month, you would probably say no. Just to general, that number was correct. Thank you. Probably questions are important. Not at this time of all, if you'd help the public comment. Seeing none, we want to thank you for coming up and sharing the story and I'm just gonna. All right, let's hope that the worry was just a flip on the radar. I'm up next. Thank you. Thank you. We'll see you at North Country, who's the next hospital that you're hearing from. This is the information that, again, we've asked the hospitals to respond to and we'll provide it for you here. This slide shows the Patient Revenue FPP for FY18 and FY19 as submitted by the hospital and as approved. In FY18, the hospital asked for and was approved minus 2.6% increase over their FY17 budget. There was an adjustment made for addition there, so see the numbers, they're not exactly the same. In FY19, the hospital asked for and was approved for a 3.1% increase over their FY18 budget. In terms of charge, again, they asked for and were approved in FY18 and 5.0% increase in their charge and in FY19, they asked for and were approved a 3.6% increase in their charge over FY18. I just want to point out, and we've mentioned this when we're doing our FY18 year and result analysis that North Country's data is still considered preliminary and some of the data that we have is through email, is through the adaptive system and is through verbal conversations with the staff at the hospital, so just want to point that out to you. So for example, if you picked up the FY18 year and report right now, the information would not match what you're seeing today. Their FY18 year end results on NPR, if you're looking at budget to actual, they came in minus 3.4% on NPRPP, which is why they're here today. They were under 1.1% on operating expenses. Their operating margin, total margin, and base cash on hand are minus 2.3% on operating margin, 1.2% on total margin, and 196 days cash on hand. That same information, but looking at it from an actual to actual perspective, they're under on their NPR of minus 0.4%, under on operating expenses minus 1.0%. Operating margin, the change from FY17 to FY18 is zero points, no change there. They're changed on the total margin from FY18 compared to FY17 is minus 1.1 and they're up 11 days cash on hand. We asked the hospital to come and tap up their year-to-date performance as of February 28th. So they are down on their NPR at PPP minus 2.6 when looking at a budget, comparing their budget to actual. They're down minus 0.2 on operating expenses and their operating margin is minus 2.3 as of February 28th as a point in time, minus 2.3%. Their total margin is minus 2.2% and their base cash on hand is 183 days. If you're looking at same information but an actual to actual comparison of where they are February 28th, 2019 compared to February 28th, 2018, their NPR has increased 1.5%. Their operating expenses has increased 5.7% and their operating margin this time last year was 0.4%, total margin 4.5% and days cash on hand. We did not request that information this time last year and so we don't have that data. The hospital submitted a FY19 projection with their February 28th submission. They're projecting their NPR to come in at a little above 80 million which will be a minus 1.7% variance from their budget to projection. Their operating expenses is 86,441,332 which is slightly lower than their budget to projection minus 0.2%. Their operating margin, their projecting is gonna be minus 0.3% from their budget. Their total margin, their projecting will be minus 1.4 points lower than their projection and they were not able to provide it to the days cash on hand projection. These next two slides just showed a five year results for NPR, FPP operating expenses, operating margin and total margins. You can see the five year cater is 1.6% with the budget for FY 2019 coming in at 81,523,350 dollars on operating expenses. Their five year cater is 2.4% and their operating margin, you can see the five year results there in their FY 2019 budget similarly to total margin, their five year results. So the last two years on operating margin, they have dipped into the negative minus 2.3% the last two years in a row and total margin has stayed above in the positive. So are there any questions on the data? Any questions for staff? We'll be right in the moderator room. If you saw my swear word for the testimony you're about to give, will be the truth, the whole truth and nothing but the truth. I'm excited. Well, good afternoon. Good afternoon. It's a pleasure to visit with you this afternoon and we're going to go ahead and, this is the basis of our presentation and we'll start real quickly with our adaptation running up and for bad debt, we've seen an FY 2018 variance driver who were bad debt and our decreased utilization, July through September. So bad debt, what's contributed to the bad debt incline and it's been a steady incline over the last several years. We do attribute some of that to high deductibles and then also we had our integration into our convergence Athena Health for our information system. And so when you're going through those convergence you're also anticipating that delay in building and in collections. So right now we're treating our incline and bad debt to those two key drivers. And then I arrived at the hospital in October and this was my welcoming present to see a decrease in utilization for the first quarter or last quarter of our year. And so we did not hit our marks for budgets in emergency department, inpatient admissions, inpatient respiratory care and diagnostic imaging and laboratory. So all these through low utilization really deeply impacted the net patient revenue for your hospital. And this is a visual, I'm going to go through the visual detail of how that works. So these are the drivers to our margin performance at the end of 2018. Brian just said a big part of the net revenue is the impact hit in the last quarter of the year last year. As you walk through, we also had an issue with 340B revenues last year. That is when Rite Aid was purchased by Walgreens and that transaction occurred in January. We didn't start seeing any revenues until August. They did back date some of those but we feel that we did lose some of those. If we go a little bit further to the right under pharmacy drugs, we did have a favorable expense variance on pharmacy drugs, which is a relation to that 8-340B revenues. We also had a decrease in some of our other revenues across the board. We had a lot of miscellaneous other revenues and those I think were impacted by the slowdown. Some of our services over some of the implementation. So we did have some expense, favorable variances, the benefits and pharmacy drugs were the largest drivers of that. One other point to make on this is in our maintenance agreement. You'll see that we are starting operationalized on Athena Health and that previously has been a capitalized project but that structure has been new to the way we handle that in our income statement. And the hospital expects to save roughly one and a half million dollars in annual operating costs with this new shared agreement. So what's unique about Athena Health is they're tied into the hospital performance and success. So the hospital utilization is good and collections are good. That's good for Athena because they're a partner in that. Rather than a typical product is you just pay for, you pay for the software and those can be the millions of dollars since they're upgrades whether you need this or not. And there's no, and it's just whatever support you get on that. So this is a cloud-based product which is, I would say, a new line of work as far as you're seeing information systems starting to participate in the success of the hospital rather than just rolling out products in a cost environment. So when we look back to February or to date that patient revenue is compared to budget, you can see the blue represents our actual and the red represents our budget and these are aggregates of year-to-date numbers for each column. So when you look through November, December, January, February, you'll see those lines are very close to being on track. Contrast that to the start of FY19. This is what it's looked like through this, through the, oh sorry, there. So for FY19, you'll see that there's a little gap there. So starting in October, we were riding line with our net patient revenue budget and then November, December were our large gaps. This possibly could be the high-deductible environment where patients may access coming into the year-end, knowing they have some health care that they're going to anticipate. They could decide to start that in January, February. And so we did see a pickup in utilization in January and February and so when you look at year-to-date that gap has shrunk to roughly $350,000 and then we're just finished. We have our march, march has been above budget and we believe this gap will shrink or disappear. So here's what that looks like when we're looking at our operating margin for the hospital. So as the utilization played out, you can see our gap in our bottom line grew to the lowest point in December 31st, of roughly $1.8 million operating loss. And the black line represents what our budget operating margin was to be. So in January, we were part of the team to roll out our budget mitigation plans which represented about $2 million in conceptual revenue and operating expense improvements. We froze our capital budget which is a $3.5 million spent and that's an average spend every year, about $3.5 million. So our FY19 budget currently is frozen and then we also were tired on our position controls with replacement of positions. So as people turn retired, we froze some of those positions if it didn't impact the patient care. And here's a visual of what current state for FY19 is like. Again, compared to the year end 2018 there's a lot more black in the expense areas which means favorable variances on the expense lines. The net revenues year-to-date are off about 400,000. But the other large line that you see in there is locums. As you've also heard from Scott, our contract labor is much higher than we anticipated this year. Right now we don't see that changing drastically. We have another slide that shows the breakout of where those positions are. A good back majority of those are in our RN area but we do have some ally health that we're contracting with too which are also pretty expensive. The chargeable supplies is unfavorable as an expense variance but those are by definition of the expense. We do charge for those. And then we also have supplies that are favorable variance on our expense line. Part of that is our contracting through NIA to give better supply price. So you can see at the end there that shows that $350,000 gap that we have currently in our operating margin. And again, as we look at the projection through March we believe that thank you continue to improve. Historically, it appears in our market that summer months are stronger than the last or the start of the fiscal year. So we're on a good run right now. Here's a visual of the contract labor just for purposes of illustrating all across the organization what we work on. So this is an internal document that we use to track every person that's in an agency. And on this list, this is through the beginning of March. We have 13 positions that are, we can count three columns. Four positions are docs, six are RNs, and three are specialists. And that's one of these columns, third column from the right, represents what our anticipated end date is. Some of these are six week or 12 week assignments. And so as those assignments are near in completion we're asking ourselves, do we have the position replaced or are we going to extend it? And so we always have eyes on the scene and look at this on a regular basis. We had some, you know, some of these are anticipated turnover of staff and uttered arms. So we had, for example, one ED position that went on unexpected medically. And so that all of a sudden, we have to fill the shift. And so that's an illustration of why we would have an ED doctor welcome. We're, I'm, since joining the team here, I am exploring some out of the box thinking about how we can work with other organizations, other hospitals to share staffing. So, since this goes up or down, is there an opportunity to share with neighboring hospitals so that we don't have to adjust staffing but we can depend on some sort of flow pool, if you will. And so with our proximity to St. John'sbury, Sean Tester and I are working together and our chief nursing officers are working together to explore a concept through a limited liability corporation of establishing a shared RN flow pool. And so out of that idea is generating other ideas such as shared flow pool for obstetric personnel and even considering it for onboarding new staff. So, for example, if a RN is onboarding on an OV with a low volumes and maternal child health, it's hard to train new staff and get the volumes. So we're exploring an opportunity where we could share the staff between the two facilities and flipping back and forth based on the volume of the organizations. So again, here is the financial forecast projection for actual, and the black is our budget that we're seeing that come back to Ryan. We have a $1.8 million line that we've had to draw on in the last year for cash flow purposes and that was related to our Athena transition. I'm happy to report that as of last week, we paid that down to $1.2 million. So we are seeing an increase in cash flow despite the small operating loss. And I think that's important to point out that it's going in the right direction and we anticipate continuing to pay that down. I have asked for a physician development plan working with an organization that will help us keep to work with our physicians and seek to understand what our population base can support across all specialties. So we'll have a survey with our physicians and then we're doing analytical work with a company called 3D and out of that we'll have a roadmap for the next three to five years of what specialties that we can support in our market. And I have asked St. John's Berry to also consider using that product because it could show that we could share resources between the two hospitals for the development of physicians. Our limited liability corporation already shares some staffing. We have a sleep lab and pulinary program at the hospital and North Country fronts and then lends the staff to the program that's down in St. John's Berry. So that's an example of things that we're trying to work and do at the end of the box. Also, keeping an eye on our campus development we have a facility master plan that will soon go underway where we seek to understand what infrastructure improvements will we need to make in the next three to five years and even 10 plus years because we have, we want to be mindful of the operating margin that we need to produce so that we can fund those through our capital programs and spending our capital wisely. And then the last thing we have also we're exploring federal grants for programs and maternal child help that would fund a program for four years that could result in as much as $3 million over four years to it's very competitive grant that would be a partnership with St. John's Berry and also Bradford, Vermont FQHC. So those are some things that we'll be working on as well. So with that, we kept our presentation very high level but we're here to answer your questions. We believe that we're on track that we would, we believe that we don't need to be rebased going into our next year. We see that we're coming back in line. So thank you. Thank you. And I hate to kick anybody when they're going through an IT changeover process but you update us on where you're really at on that and also let us know because as a regulatory body we can't make good decisions we don't have good data and we still don't even have your audit, we're 18. So maybe if you could just update us on your audit and your IT transition. Yeah. So you're talking about the FY18 actual final numbers being put into that for the COVID-19 team. We're hoping to get that completed next week. So 18 will be up to date. I believe February is, some through February correct is in there and we're about ready to close out on March's financials. So hopefully within a week or so we'll have that back on track and in line. As far as our conversions go no, we can convert it to EHR where we also convert it to our accounting system at the same time. And since that wasn't enough we actually just also implemented a new budget system two weeks ago. So we're jamming it all in and at the same time we've lost two senior accounting team members. I was going to puzzle that chain. Yeah. The one, no, the one may be a much. One of the team members actually she had a prior career in IT compliance and she kind of went back to the bank for that recently career. It's obviously you don't have a monthly closed schedule that you're tied to when you're in that kind of environment. So she kind of went more for an additional opportunity. The other one may have come back because of the additional pressures. It is what it is. That's where we are. So I'm hoping that next week or so we can have those numbers update. We want to get March closed or March financials closed out. And then the next priority right after that is to get Lori and her team the 18 members of today. So you had said that in your explanation on the bad debt, you talked about the change to Athena. Maybe you could just expand on that a little bit because I can see where if there's a delay in collections because of the change. But why would the change add to the bad debt? Well, part of what's happened, we have seen her add that climbing over the last couple of years. But one of the things that it's the last thing that we're looking at with our AR with Athena is the self paid piece of it. And because we switched systems, we actually had an outside vendor that helped us manage our self paid accounts. And we're doing call collections and putting people on payment plans, the access for them into Athena. There was a delay in getting that access so the AR is actually grown. We actually have Athena on site right now to do a revenue cycle evaluation with us to do a deeper dive and make sure, we're at a point now where we can actually look deeper into our revenue cycle and our AR management. And one of the big things is self paid. It's grown to roughly 20% of our current AR. So when that happens, self paid age is out and we're reserving those aged out amounts. So that number is growing, which hasn't even had it done our back in it. We re-engaged that outside vendor about a month ago. So we're starting to see those collections come in but since it is self paid, it's slow to work that down. Given some of the recent press about other institutions that have had security breaches, do you ever be concerned about the cloud based product? I always have concerns of security breaches because I'm also the compliance officer and IT security officer. But the cloud based product tends to be more secure because there's less avenues of access as opposed to an onsite network. So the cloud based is actually a little bit more secure as far as a breach from the outside into Athena. I think there's always going to be a concern of that. You see breaches all the time with everything all the way through what should be an extremely secure government entity that gets penetrated. So there's always a little bit of a in the back of my mind concern. Do they offer you any type of guarantees? I did not offer us guarantees but we do have in the contract dollars and cents for mitigation of breaches that were increased above and beyond in our financial contracts. Okay, I would add just a real quick question that anytime there's a breach in our state or anywhere else in the country of a hospital, IT is the first place that we're asking the questions of okay, what can we learn from that? It's an industry that continues to reinvent how they infiltrate. And so there was a breach I think that looked in the last month or two in our state and we were pleased to know that we had some mechanisms already in place that potentially guarded us from those but you just seek to learn across your fingers that your hospital isn't the first one to have that happen. My last question was on the travelers and locals. What percentage of the normal cost of an employee, how are you seeing your actual expenses for these travelers? I'd say it's about three times. Three times? Depending on the position. Yeah, yeah. Okay, other questions from the board? Marie? Just a couple questions. I like the breaches that you did and I think you could also do that for the net revenue because particularly where you're saying the bad debt was down a million seven fifteen but your total NPR was down a million seven so wondering whether free care was lower as well if I can look at the two of those together but if you had a bridge to show that that may show that as well. So did you see a change in free care? No, our free care has actually has been running really close to what our budget has been both last year and this year, fiscal year to date so that number's been pretty consistent. The bad debt's the one that's actually spiked. And then just your trend for operating margin with a loss of 1.9 and 17, 1.9 and 18 and then potentially trending negative with your new forecast, that's something that obviously we're worried about in the state and just when you talked about whether or not you'd be rebased, we're gonna make final decisions in a couple weeks but you probably don't necessarily hit the threshold because what we did for NPR was we said you'd get to be up 5% from where your actuals was trending but that said, the concern is that you are forecasting your top nine tied into your expenses and you guys do seem to be managing the expense control well but your NPR is dropping greater than what's going on so you end up losing money and so I just wanna talk about that trend because prior to that you were making money every year and I know at the total margin you are but you can't always rely on what's gonna happen. Yeah, so I'll start and you can tell me I'm wrong. So I think what we're seeing is the growth of the inflation rate overall and operating expense is more and more challenging so there's certain things like management contracts for equipment and supply expense from vendors where we have a little control of the inflations that have been passed on to us. I think one of the big things and it was on the chart that you saw that's impacting us is that low-come, those dollars and in fact, we've seen that I think in the last budget cycle when we were projecting our budget for FY19 we didn't anticipate this much low-income expense and so that's probably our deepest driver right now is that work for shortage. We do have some encouraging things that are developing. We have a cardiologist that we have just this week signed on that will give us back the coverage that we had before. We have one retired within this budget cycle and then we have a ED physician that we are in active agreements negotiating terms so those types of things are things that will help us to decrease that low-income expense but the work for shortage isn't going away and you've heard that topic from every, I know you've heard from every hospital. So my development now, LC looking at trying to do these things differently, that's what I look to see to elevate and control some of our operating expense at the same time. I want the North country to be in a position to invest in the health of the community step away from the hospital so we currently don't participate in Ry's remark and that's a program that I want us to invest dollars into that's going to take an investment that will I think rewards in the future but there's capital operating expense out late for that. We are one step in with one care meaning just Medicaid and Mountain Scouting is what their risk level is, what their risk count is so we have to, we're considering what that impact could be on us as well. So I'm going to give all of the other comments. Let's do it. I think listening to Mountain Scouting that almost seemed like a nearer image of what we're going through with the volumes where they had strong volumes in their last quarter, the first quarter now it's dip down or is where the reverse, very strange environment that we're in when we're really two and a half hours apart from each other, we have differences in our volumes. That's the only other comment that I have. I see our volumes coming back right now from where we were in the first quarter. Other questions from the board, Tom? My first question was the same as this Marine had sitting here trying to add up the pluses and minuses of the red and blue lines and organize them by expenses and revenues and I never got a right after three tries and tried to listen at the same time. And that bridge would be very helpful. I'm just, I'm not an expert at all by any means in additional payments but I was looking at your trend here in 2016 at 1.8 million, 2017 at 1.4 million, 2018 at 400,000 and then it looks like the projected for 2019 was up to like 880,000. What drives that from your perspective? The calculation over the years, there are three different buckets of dish funding it's all done through the equation now. One of the years, one of the buckets, one of the hospitals in one of the buckets fell out because they were in that bucket long had that money got distributed, changed when it became two buckets. Then in 2017, the legislature took $10 million out of our dish money hospital-wide and then in 2018 they took another almost $5 million out. So between those two things, changes in calculations and the reduction in actual dish dollars, you see that significant downward trend. And you still have buyer tax with the other side of that? Yeah, that's gone up. Yeah. And I was just looking at your projected payer mix for 2019 and you had Medicaid which was your smaller revenue line but you had that going up 13% does that look like it's on track? Right now it looks like the payer mix is pretty much on track. Our Medicare and Medicaid combined is about 65% of our payer mix with Blue Cross being 16 and then everything else falls under that. So those are the, our three major payers that make a good chunk of our revenue. The road trial one just in terms of bad debt, it seems just a common refrain hospitals are bad as far enough because of the high deductibles. And so when you mentioned high deductibles are you talking about the QHP population or other forms of private insurance? QHP? Oh, okay. Exchange, yeah. I think it's a combination of the two. We see the exchange has a high deductible but even the private insurers can only have some smaller, pretty significant businesses in our area that's small compared to statewide that are on a Blue Cross or a significant plan and they deductibles are in a $5,000 range. So that automatically falls to your self pay after an insurance base. Other questions to the board, Robin? Do you want to go ahead and stress? I just have a quick one. I'm just interested in the agreements that you're pursuing with St. John's very to share services and build a flow pool. And I was wondering if you had any estimate of the cost savings you might achieve in doing that or is it too early to tell? Yeah, it's too early. First of all, it's just to float the idea so both Sean and I met. And once I got his interest then this connecting our CNOs and making sure that they're on board with scoring that idea, we got that label combined. We, you know, one hospital's CNO is transitioning to Porter. So good that we're still gonna keep that up in the state. So Sean is still actually he started later than I did. So I'm not going to be anymore. But so we're both getting our feet on the ground and floating out ideas. So it's really high level right now. But out of that is surfacing others. Like, okay, well maybe float pool is too aggressive. Maybe there's something like the OB maternal child out that we can start. And then we have to check in with our malpractice carrier and then talk about those things. So as far as estimating the cost, we're not at that level yet. Okay, thank you. I might have a similar question. So I wanted to ask it first, but I wanted to say I applaud your creative thinking. I think that's exactly what we need right now in this area. So I appreciated hearing about some of the preliminary ideas that the two of you are working on together. I also am very interested in your physician development plan in terms of understanding the population needs and also what the population can support in terms of specialty in that area. We are working on the health resource allocation plan, which is kind of a statewide assessment of need resources and gaps. So we'll be very interested, I think, in hearing more about that in the future. So no questions. Just wanted to give you a heads up for the summer when we'll all at least come back to that question. I got a thousand questions. Okay, any other questions from the board? If not, comments or questions from the public? Seeing none, we wish to thank you. All right, thank you. Our fingers are crossed by the transition. IT is not an easy thing. Is there any old business to come before the board? Seeing none, is there any new business to come before the board? Seeing none, do I hear a motion to adjourn? So moved. It's been moved and seconded to adjourn. All those in favor, signify by saying aye. Aye, any opposed? Thank you, everyone.