 So good morning everybody. It's a pleasure to be here today. You know I've been in my role as CBO of Northeastern Vermont Regional Hospital for nine months now and It's been it's been a great adventure and I'm really grateful to be here today with the team I can have. I'd like to start by introducing everybody. So to my right, I have Bob Hersey, RCFO, Laurel Ruggles, Laura Newell, her patient practices, Julie Schneckenberger, our newly appointed chief nursing officer and Mike Roos, our chief medical officer. We also will be joined a little bit later today by Michael Costa, our the leader, the CEO of Northeastern Vermont Northern counties health care where I came from. Many of you already know Michael, but they're a great community partner and he'll be telling part of our story. Today, but unfortunately, he's time to come traffic. So when I walked across the parking lot from Northern counties last winter to NPRH and started my role at the hospital, I communicated to many of our stakeholders, our corporators, our board, our staff, our community. What I saw some of the big strategic challenges we've had facing Northeastern Vermont Regional Hospital and our health care system in general. And they are navigating health care and payment reform. Dealing with this demographic tsunami we have hitting us as our population ages and closely tied to that, our workforce challenges and ensuring that we have the workforce we need to care for that aging population. I think the story you're going to hear today is the story about NPRH. Our budget, our solid budget, which will help us ensure that we are ready to meet those challenges. The story of how we're rising to the occasion. With that, I'm going to pass it over to Bob to start the dialogue on our budget. Good morning. So we're going to follow the format that was given to us for presentation. So we'll go right through the letter 1 through 10 and I assume you'll ask questions at the end or Yes, pull them to the end. Pull them to the end. Great, thank you. So starting on item number two, talking about a net patient revenue change from fiscal 2019 budget to fiscal 2020 budget. This contains, this table contains a lot of information. So I'm going to spend a few minutes going through it because again there's a lot of good data here that explains our revenue growth from fiscal 2019 budget to fiscal 2020 budget. Starting with first the total rate request, we've asked for a three and a half percent rate increase. We determined that after going through all the budgets, reviewing expenses, reviewing all the revenue services, reviewing utilization, and then determining what we would need to make our operating margin which is budgeted at $1.20 million. And it was determined that the three and a half percent was what was required to meet that need until that gap. It represents about $376,000 for every one percent, a rate increase. And we're going to implement the rate increase by increasing hospital charges by 3.8 percent and we will not be increasing the physician charges or provided charges at all. So the weighted average of that formula comes out to two, three and a half percent and we're requesting for a rate increase. Bob, did you want to put your slide? I'm sorry? We're just going by this. Would it be helpful if we saw? It would be helpful. Especially the audience. Yeah, the light's not as good as it used to be. Or my eyes are as good as it used to be. Hold on. Yes, thanks, Sean. We improvise. I'm from a farm family. So I think I covered all the points about the three and a half percent and how we got there and how we're going to implement it. Next is the 3.7 percent utilization increase. That is spread mostly in patients. We have seen tremendous growth of in patients this year. So our fiscal 2019 projected shows about 20 percent increase in patient days. We have been full many times during this year. It's a critical access hospital. We are limited to 25 beds. We really can't staff on more than 25 beds with available resources. And a number of times throughout the year we've been at that maximum. We're not projecting to be quite that full next year. But it has put a tremendous amount of pressure on hospital resources, especially our staff and the inpatient units. So they have waited again. Average utilization increase we're projecting is 3.7 percent. The reimbursement and payment mix, a couple of things I want to highlight here. One is a critical access hospital. Medicare payment is tied to our costs. Charge increases do nothing to affect Medicare reimbursement. Again, it's a critical access hospital. It's affected by cost increases. So roughly 38 percent of the cost increases become additional Medicaid and revenue. We're also seeing an increase in Medicare as a percent of our total business. So putting those two together, you can see Medicare is going out by about $2.3 million. The combination began with the cost increase and the utilization increase. The other reimbursement changes are really changes in payment mix. We've seen a little bit of shifting, as I said, to Medicare from some of the other payers. No surprise given on demographics. No surprise given on demographics, exactly. This is a very much thought. Bad debts and free care. What have we seen significant change in bad debts and free care that went down a little bit from budget to budget? But as a percentage of gross revenue, it's pretty flat. We've been pretty flat for quite a while. We haven't seen any significant increases or decreases in our bad debts and free care. We, during fiscal 2019, acquired physical therapy practice. The next item here just is a full-year effect. We acquired the practice in December. A full-year effect of adding that practice adds about $200,000 to our net revenue. The dish payments going up a little bit next year. The other change is the risk associated with the many key next generation while we're participating in this one care. When we put the budget together, we estimated based on information from one care that our maximum risk would be about $579,000. Actually, since then, we've gotten revised projections to 2019 that shows that it's actually $679,000. And we just recently received an estimate for fiscal 2020. It's raised it to $739,000. So our projection to 2020 and net-page of revenue has already off by $160,000 unanticipated increase. And so the net, again, net change percentage-wise in our net-page and revenue budget to budget is about 7.2%. With that, we're going to turn to risks and opportunities. We combined this hospital issues, risks and opportunities into one right category. And I'm going to turn it over to Laura. Good morning. So the first thing we want to talk about is our total cost of care numbers that I think you've all received and we received the same numbers. One point on a couple things. Most of that's from 2017 data. And we've looked at that data and also some more recent data that was we have in our own internal systems and also from one care and from recruitment for health. And we're going to have to say that the trend is heading down. And some of that is due to some of the things that we're going to discuss this morning. So there's really three main reasons for our high total cost of care. The first one is the high cost of what they call advanced imaging. And one of the things that we're just introducing now is in our hospital system is the point of care ultrasound, which will provide our clinicians with another diagnostic tool at a lower cost. The second high cost was due to a high prescription medication cost. And in digging into that data, particularly with the one care data, we found that most of that high per-member per month was coming from one patient who was getting treated very appropriately with medications. This person lives in our region, but is actually treated outside of our region. And if you take that one patient out, our high prescription medication costs come in right at the average for the rest of the state. And then the third area is avoidable emergency department visits, which did you know that is really all about access to care, particularly primary care, and going to turn it over to Lauren and just talk about some of that interesting and innovative things we've already been working on. Good morning. So as we looked at our avoidable ED visits, we came to realize that just below 20% of those visits occurred between the hours of 5 p.m. and 8 p.m. So we've committed as a health service area to open a convenient care model. What this will be is almost like an urgent type care that will be embedded into our primary care offices. So our patients will be able to walk in at any time to receive care up until the hours of 8 p.m. and hopefully reduce those avoidable ED visits. I'm also happy to announce that all of our primary care offices at this point are fully staffed. We improved our access by reporting last year that our well visits were at one week. They're now down to three days. And our acute visits still hold steady at two days. And that's the third next available appointment method. We still continue to work on quality improvement initiatives to form a solid relationship with all of our patients so that they feel comfortable coming to primary care versus realizing the emergency department. We've now worked on a project embedding a psychiatric provider into our PCP offices so our patients can be seen again at their medical home versus having to go to another office. I'm happy to report that we are fully staffed in both the general surgery areas in OD and YN. We've been looking for surgeons for quite a while. And I'd also like to report that both of the physicians that we've brought on in those two specialties were welcome providers. So they found in the area as such a great place where they decided to stay. Last year some of you might remember that I reported that cardiology, we had a very long wait time. We were out about four months for patients which is not acceptable. Unfortunately due to physician recruitment issues, CDC, who we had the contract with was unable to provide us with any more cardiac coverage. So we decided to shift our contract services to Dartmouth-Hitchcock and they will provide us a dedicated physician four days a week. And so we're super excited about offering that to our community. I'll just mention that we continue to do a lot of quality improvement work as a health service area on our quality measures. We work really closely with northern counties on the care to make sure we are addressing those issues as a health service area. Thank you. So I want to take just a minute to kind of give a shout out to all of our care coordination efforts that we're doing in our community because I'm really proud of the work that we've been doing for the last 10 years. And I brought this morning a couple of extra handouts like the green and the blue sheets. I think many of you are familiar with the one care care model, the four quadrants, the one, two, three, four risk replication provisions. So what we did in our community with our community partners and our integrated care teams, we spent some time this winter really trying to make those quadrants real because people are just on numbers and on the chart. And so we were trying to describe who are the people that are in these categories, what do they look like, who are they and what services do they need. And so if you look at the green sheet and it's two-sided, well, this is what we came up with, a description of people here. We've got adults on one side and kids on the other side. And then also on the blue sheet what we have is we identified what kinds of services that they would require and also what kind of resources we have in our area that we can provide for them. And so the beginning of this hearing last week I reached out to some of our integrated care team members and I said, you know, I need some stories around what you've been doing with care coordination working with team-based care by intelligent care board. And all the stories that they were giving me were people who I would say would fall into this category for description. People with very, very complex medical needs layered with complex social needs on top of mental health issues. And they talked about the care coming together as a team of care they were giving to people and really making incremental changes in their health and well-being. Maybe finding more stable housing for someone. Someone who had been to the ED literally 70 times in six months not visiting the ED anymore because this person is in a crisis care mental health bed. So it's a kind of a rare institution and we're still working on a longer term solution. But my point with this is these are real people they've got very complicated lives very complex histories. They're going to require a lot of resources for a very long time probably for the rest of their lives and those are the people who are caring for their community. I'm going to turn it over to my colleagues. This is the risk section. We have Dr. Bruce and Julie Shekinberg joining us. We need a longer table, Frank Barry. Thank you presenters. So I'm Mike Bruce, Chief Medical Officer. And we have had, as Bob said, a very busy year. We've been full a lot of the time. It's been a major stress on the staff including the hospitalists and the hospitalist program. So a couple things I was going to address is tertiary care availability and skilled nursing care. So starting with tertiary care you may have heard already our meeting referral center in Dartmouth which is an hour down the road and UBM both have been full a lot of the time which is, as you might imagine somewhat distressing if you're in a critical access hospital in North East Kingdom you have a very sick patient that you need to try to access a higher level of care and the answer that you get is we have no beds. You'll have to find another facility. So we've had to hold on to some of these patients maybe a little longer than we like keeping safety in mind or transferring these patients further in the field including as far away as Springfield, Massachusetts Portland, Maine Manchester, and Hampshire. So we have a capacity issue in the healthcare system in general and in the Northeast Kingdom we are managing some capacity issues that can be difficult. These are dialysis patients that need inpatient dialysis cardiac patients that need urgent cardiac care, surgical care or intensive care. So that needs to be addressed and we're really doing the best we can with it but that is what we're trying to account for with this budget. The other big issue that we're facing we have two skilled nursing facilities in our region St. John'sbury Health and Rehab and the Pines and Duneville both are struggling with workforce issues RN, LNAs and medical leadership we are trying to help with those issues we need those facilities to remain open we're talking about 140 people that need that extra level of care and it would be devastating to our community if we can't keep that up and running. The pines, I just want to add to that you don't have to move like that I'll just talk really loud but the pines especially have a lot of older patients with mental health issues and they're well cared for today but the institution is in a very fragile state and we're really concerned about it. Last thing I was going to talk about is our workforce well-being we as you may have heard last year were saddened by three major losses of providers who have took their lives by suicide we have undertaken a large effort to work on our workplace well-being Sean has been doing individual workplace well-being visits with each of the departments and we've got a large committee together a multidisciplinary committee to work on workplace well-being at the provider level we're employing a group called Luminos to do facilitated workshops with providers to make sure that we're aware of what's going on with provider burnout and provider mental health and trying to be on top of that so those are the areas of risk that we're working on for my work. So I just want to touch again on the two related items that are strategic challenges for us and the first is kind of demographic realities for our region and our patients we all know that Vermont is the second oldest state in the union if you look at median age we're right behind Maine and the Northeast Kingdom is the oldest and poorest region of Vermont so if you look at our median household income we're at the bottom of the scale and our median age is at the highest end of the scale these are the demographic realities that we face when we serve the needs of our community and it is impacting everything we do that aging population is the pressure that we're feeling which is driving demand for services within our community and is putting the tremendous strain that might pop up on our staff and our whole system you know traditionally we've had a staffing model that was geared around an average patient census of what about 14 so we traditionally averaged about 14 patients in-house on any day or night and in the last year we've been up around 18 without dramatically changing the staffing model although you do see in our proposed budget an FTE increase to address that because when you're dealing with that number of patients through your system it contributes to the extreme burnout that our staff and patients are feeling which is why we're putting so much effort and energy into supporting our staff that also ties into the workforce challenges we are committed to being the best employer we can be the best employer in the Northeast Kingdom we want to be the go-to place within any professional IT professional, healthcare professional to work and we're committed to doing that and that means helping people navigate and deal with the incredible stress of these very challenging jobs we also need to speak to some of the challenges when you have a small community hospital and you have a specialty with one provider for example urology or ophthalmology when something happens to that provider it can really upend your system and we experienced that first time this summer when our local ophthalmologist who was not employed by the hospital that served our community and did surgeries at the hospital lost his license we now have in Caledonia County no ophthalmologists there are a couple of ophthalmologists who operate out of the Newport area but they're at capacity and we have no ophthalmology services any more in our community we're scrambling to support that ophthalmologist getting his license back and we're really trying to be creative in how we meet that community's needs our concern is that patients have no place to go or they're traveling extreme distances for those services and again, I come back to the demographic challenges when we have an older population that I care really important oh right they lost their license this is for ophthalmology too and we're trying to communicate and send them across the river that had a direct impact on our budget but more importantly has a direct impact on the quality of care and the care that our patients are able to receive within our community some of the other risks that we're dealing with is the high cost of ophthalms and temporary staffing we put our budget together for 2018 we estimated about $300,000 of temporary staffing from nurses to healthcare professionals and physicians we're projecting that we'll actually spend about $3.2 million in fiscal 19 on temporary staffing costs we're working hard to put new resources into our recruitment effort to find somebody dedicated to recruiting and we're putting together a competitive wage and salary package that should help us as well but we're still budgeting in 2020 about $1.2 million of temporary staffing costs we're hoping if that's enough again we're putting all our efforts into making sure we can recruit people and retain them but it's a pretty competitive market out there for a number of healthcare professional positions one of the other risks we're facing is the need to add FDEs there's a CFO an agency that costs increasing but I also have to recognize that our employees have been working at capacity or above for a good part of the year we need to support them for their safety the safety of the patients to just provide good quality care so we are putting efforts into there's about a 17 FDEs increase between our budget to 2019 and our budget to 2020 believe me I've looked at all those justifications and those positions are definitely needed the other risks that are always out there for hospitals that rely on the 340B program there's something happening to that that would reduce the benefit to us in total the 340B benefit is about $3 million a year to us what we save and costs and what we receive through the retail 340B program our bottom line is $1.8 million if we didn't have that $3 million we'd be in the hole by $1.2 million the other thing the 340B program allows us to do is to provide some medications to patients that can't afford them that's for our community connections program and it also helps us we provide about $14.7 million a year community benefit that's calculated right on the $1.990 a year that $3 million benefit of the 340B helps us to be able to continue to provide that level of community benefits that we have but I meant to tell you that we will talk we have to increase that I mentioned we'll walk through a table and we'll fit it through those new positions the other risk and opportunity as I mentioned before is the one care the next generation Medicaid program we have downside risk but there is a potential for upside risk and the same amounts that I mentioned earlier the last one that Julie is going to talk about is the needs of dealing with a mentally ill and substance abuse disorder patients the mentally ill and substance abuse patients that we see at the hospital are quite complex at times and we are unable to keep patients in the ED we don't have a space for segregated beds for them to stay as other hospitals do so we have built a unit at the end of the one end of the MedSurg unit it's not unit it's really beds it's just transition beds for beds that we can house these patients and care for them they're away from the goals on the rest of the MedSurg unit where we're having patients recover from total joint surgeries, medical illnesses and we've just moved them away so they're in a safer place for themselves the rest of the patients on the unit and it's a quieter place for them to be cared for by our nurses we've had one particular patient recently that actually taught us a lot about some of our risks involved with care for these patients excessively violent very vocal unpleasant language coming from that particular patient it took a lot of staff to care for that patient it also made some of the patients that were being cared for of MedSurg patients very uncomfortable feeling that they may not be safe on our unit and that's very disturbing to everyone because we do keep them safe and so we're just trying to mitigate some of that discomfort for everyone to have them in a separate unit we have not had a lot of mental health nurses available to us nursing typically does not get the same education and psychiatry that I had 35 years ago they just don't have that exposure so it's led to some turnover on the unit of nurses not wanting to be in that environment they wanted they came to a small community hospital to take care of their community members so we've been dealing with some of that but we are fortunate to have a couple of nurses on staff that are very interested in caring for the mental health patients and we're working on some education for their education to make everybody feel safer and I'm going to interject again it's okay I'll just talk about it again I think we've been very innovative in how we support these patients and we've had to be because the challenge we face is although there may be mental health beds available throughout the state the response we get when we try to find placement for these patients in appropriate care facilities is that to go to a facility that indicated their support so they end up staying with us so moving on from the hospital issues and opportunities to the financial health of the hospital there we go so I'm going to highlight a couple of things on this table first is that our property margin has been really consistent as a percent of region revenue for several years now back in 2014 we're always trying to maintain an operating margin of 1.5 to 2 percent and we have to do that and we are planning to increase our operating margin gradually gradually between now and fiscal 22 to fund a much needed emergency department expansion I'll talk more details about that soon but we need to start now preparing financially building up the balance sheet to support that project in a few years by day's cash on hand we went up a bit during this year I'm sorry by day's cash on hand it's lower than the previous we're building it up next year so it came down to this year in part because of our acquisition of the nose and physical therapy practice we're building it back up during this year and next year again looking forward to the PD project in a few years by capital structure it is solid and improving that's important because we're going to need to borrow money for that PD project some of it will be united between 11 million dollars around fiscal 22 so we need to be able to have the debt capacity to make that happen I think to maintain a financial health so we're in a position where that is possible the cost metrics I will say if you look at the some of the productivity measures salaries or FDs projected on that they're projected to go up a little bit but still get well within industry standards last thing I want to touch on is that by day's cash receivable those will have the hit during this year we went through a review of conversion I think anybody at this sort of conversion will tell you especially from the CFO position it's not a pleasant experience cash does go down the cash receivable does go up but we're past that and depending on the direction the hour is going down and the cash is bouncing back up so I'm happy to report we've made it through that a lot of crisis but we'll bump into it the next one is more financials the problem losses balance sheets we've talked about the medication revenue growth 7.2% I went through some of those details previously the next one we'll talk about a little bit is the growth in operating expenses coming up on a couple of pages just looking at the balance sheet again putting the bill to cash out to keep the accounts receivable down keep maintaining our ability to borrow money that's what I'll highlight there's one number of data accounts receivable that was like 5 million dollars a lot of that is our employees' earned time back about almost 3 million dollars our employees are able to approve and maintain a balance of their earned time to a large portion of that liability the accounts receivable liability should be related to our salary to keep on time looking to the next page this is the expense drivers the growth in our expenses that we touch upon new positions $875,000 seems like a large number certainly gave me the possibility to put it together in the total but definitely look at the fact of what we're spending on what we're spending on staffing we need to provide adequate staffing so that we can prune the police and retain them and have them come and want to leave over the works that we can do with too many patients we try to maintain appropriate staffing levels and inpatient units and all of our departments and to do that we're going to need to add FDEs most of our FDEs save a one on clinical areas every hour each if you look at the story we have the lowest overhead percentages of percentages of our total expenses all of our increases I should want so maybe we're second lowest depending on the area you look at but the resources that we're putting in clinical areas again to provide patient care and making sure our staff is supported properly inflation increases it's about less than one percent to look at what we're actually planning for non salary related inflation we're struggling and working hard to keep those costs down on eventual supply and other control over costs we're looking at a point nine percent increase related to inflation a salary and wage program high landing begins is important we need to be able to provide salaries that are competitive to recruit and retain employees in the competitive market so we put money in the budget to help us do that our friends and friends are going out we're going to help our employees so that these health care coverage and we're putting in a new benefit as well to help us again recruiting and retain employees we have a number of employees came out of college with student loans and we're implementing a new program to help them take some of that student loan back that is a new new year supplies, volume all of this is volume related we're working hard to increase the cost of our supplies with budget of $90,000 in savings so we're maximizing the purposes throughout the major GPO supplier and to work with our providers to make sure that there's just much standardization to hospital on the supplies that they're using in the O-Learn in different parts of the hospital this number, by the way that you see here the $265,000 is gross it does not include the savings shown in a different line item that drug cost I'm sure you've heard of the increase in budgets increasing drug costs in spring there's critical access hospital for the 340D program our cost savings have grown since 2017 about $500,000 in 2020 we're projecting a million dollars a year in cost savings in the 340D program drug diplomacy does a great job making sure that we're maximizing the savings again, that number is gross the savings that show up elsewhere IT related, you know with the people living in Hube O-Learn in health projects comes to us a warranty for a year but those warranties are going to be out September 1st so we need some budget money for increased maintenance contracts in the system Appreciation is just out of that, but that will come online next year and this year, last year we completely renovated our first project edited to pre-built it so the cost of that appreciation on that project is coming online as well we had some interest savings from that borrowing we anticipated perhaps borrowing in 2018 that's been pushed off to 2020 the provider tax is going up as a percentage of our medication revenue as that goes up by about 6% the physical therapy practice transfer again that costs the full year impact the building budget budgets and the last item is our ACO infrastructure fees under 500 last year when we put the budget together we didn't have a good estimate what those fees would be working year to year is close to $125,000 that's going to save into $290,000 I mentioned that's mostly the incremental 3.2B savings year to year and some life-changing savings so with the prosecution that I haven't mentioned we as a leadership team require justification for any new service any new FDE a process to evaluate this and we do a lot of purchasing and equipment that you can imagine a new service called ECRI which we get through our affiliations and women alliance to help and every purchase that we make is run by ECRI to make sure we get the best possible price and it's great tool to help us make sure we get the maximum savings and all of our equipment purchases the next the next is the FDE increase that I said I recovered putting again increasing efforts as Laura mentioned in the position practices providers looking to expand convenience here services in the community supporting those providers is going to add to 6.2B FDEs expanding coverage and respiratory because we get so many patients because of putting a lot of pressure on nursing staff we need to have respiratory coverage 24-7 we're not adding so many resources into that our FDE volume we are staffing this emergency nurse association that guidelines to use appropriate staffing in the emergency room without volume increases with the QV increases that are seeing in the emergency room we need to make sure we're staffing appropriately in the safety of the staff and the patients we're going to have a new physician providers that come on and providers that are in the hospital even non-providers finding a lot of support as the electronic health market to make sure that they're getting as efficient as possible in use of that so they have a dedicated person that's going out on board with new providers but also help with existing providers to make sure that standardization that everybody's aware of all the ways to maximize we probably the next action is environmental services volume increase and QV increase in the ED and then surgery we need to make sure that housekeeping environmental services staff is adequately staff adequately that handles the constant turnover we have patients for example in the emergency room we should have our slide we had nine emergency room beds and then we could have place markers for sex beds and all of them on the nursing station patients waiting to go upstairs or waiting to get into the world exam room so we need the support staff from environmental services to help clean the rooms and turn the rooms over quickly so that we can move the patients through to the appropriate let me interject there because one thing that I've discovered my nine months at NBRA can you hear me okay? I think you should use the mic okay one thing that I've discovered in my nine months at NBRA is who knew that hospitals run on laundry right? it's unbelievable but every time a bed turns over or you have a new patient come in the emergency department those are linen changeovers that have to happen so as our volume of patients has increased number of patients we've seen this going up so has the volume of laundry we do and that is what you're ministering on that workforce and it's really fascinating to see to think about just seeing patients or providers need for providers but it impacts everything we do at the hospital that's at the other position the list up there we may not be able to see them actually we have a chief medical officer we've met half an FTE increase for that position we're increasing hospital services again more patients up there a lot of pressure on our hospital services and we're increasing our behavioral health and putting a clear coordination in our position practices there's one practice that does not have a behavioral specialist to get it and we don't want to get a behavioral specialist in that practice and we have eliminated some positions you know as physicians become they can we do go through a process of evaluating them and have eliminated some positions next we're asked to do an updated reconciliation between 2019 approved budget in 2020 full year 2019 full year budgets to projection reconciliation some of the key things that are on here the first is the fixed payment that's just we didn't break that out in the budget initially again we put the budget together and then we went with through the year to determine that this year we're projecting the 340B revenue to be out a little bit to set the delay in capturing some of that revenue on some of our providers our reference lab we last year took reference lab out of operation to put it into other revenue and we just missed it we just grossly overstated both revenue and expenses associated with that recognize that during the year and rectify that as we went through the year so we've got a number of positions again we've got the Philips with temporary staffing at a much higher cost the health insurance increases so through the year and the pharmacy benefit constant increases so we've put them up on fringe benefits to provide a tax again just tightened revenue that we projected depreciation in additional fulfillment purchases during the year and the bond issue as I mentioned and then talked about interest expenses to be doubted so those are the key what we saw in the management fiscal 19 budget and you can stop those in three for a while what are you doing also does Michael need to be yes that's where him at I should who is the CEO and probably do you want to swear him in yes so clarifying information telling the hospitals financial story our story really all about our community and I'd like to hold in this section by recognizing some people that we have in the room here that really represent our community I'm going to ask we have a number of our board members here today and I'm going to ask our board members who are in the audience if you guys can just stand up and be recognized for a moment please I don't want to put down the slide okay thank you I'm not sure if members of our boards or classes hospitals get enough recognition for the amount of work and effort and energy they put in to ensuring that our hospitals are meeting the needs of our community but these folks I have watched and work countless volunteer hours supporting our staff looking at our members Tom our board chair probably tell you that it's a hard time job and it really is the work these people put in and they are the voices of our community then along with our corporators to help guide and steer the strategic direction of the hospital now there's a reason why this board and the folks at NDRH asking to be the organization coming from within our own community in the community health center it's because of our relationships with the community that we're all in this together meeting the needs of our community the partnerships go beyond just our health service area but we're also building on our relationships and our partnerships with other health care institutions for example north country hospital we just expanded our state disorder center with them and we're exploring other opportunities to do that same thing because we recognize that those partnerships will be critical to meet our community's needs moving forward especially when we are resource constrained and workforce challenged another area that we're starting to have early conversations with is around occupational health we have an occupational health program at NDRH it's a strong program and right now there isn't one in the new board area for financial reasons they had to cut it a couple of years ago but there are a lot of employers who have access to those occupational health services you know manufacturers that have injuries on the job big ski areas like J etc. who are looking for those services so we're exploring how we partner with north country hospital to serve that need within our community I think part of my job here today is to kind of to talk a little bit about our community collaborations N.E.K. Prosper our accountable health community and why that is so incredibly important to the future of the health and well-being for the people we serve Michael are you ready for that talk? Good morning and my apologies for being a bit of a distraction there is diversity in modern American healthcare every day and today we're through 89 and so I'm really grateful to be here with our partners from NDRH to tell a little bit about the community story of our partnership and where it is today and how important it is and perhaps where it's going tomorrow the board and many people who know me through my work with Governor Sheldon's office and as deputy commissioner of the state Medicaid program and as one of the people working to draft and implement the all pair model and to set up the Medicaid next generation ECO program I was bothered by a couple questions about my work does any of this stuff in healthcare reform really matter for Vermont and Vermonters and what I came to realize about my position in Medicaid which really was the best job I ever had in my life and allowed me a great opportunity to do good work on behalf of the state was that it was a little bit like an obstructive view seated Fenway Park I knew I was at a baseball game I generally knew what the score was I generally knew if people were happy or sad whether any of this work was to be out in the provider community and at that point it's no accident that I landed in the northeast kingdom because I think consistently in the years that I've been working on healthcare in the state the northeast kingdom generally and the NBRH specifically for all banks in Bob and Laurel and now Sean have been really committed to wearing their community hat first and trying to think about how do we really make sure that we're in the right way and so for me part of what drew me was the work that we do in NAK Prosper which really asked five really straightforward questions about our organizations and about our communities which is are we physically healthy are we mentally healthy are we well housed are we well nourished are we financially secure and so for me going to serving the northeast kingdom with strategic partnerships with NBRH in north country and public hospitals was an opportunity to work on that every single day 100% believe it's the right choice because I get to work on how things to work in the community and how things ought to be different in the future I think a lot of us worry about a healthcare innovation bubble where there are lots of really smart people spending all their time trying to change the system at the same time there's a much larger group of people that actually care for people every single day who sometimes think what are those people doing and so I think NBRH is one of those hospitals that not only talks about how we innovate and care but it actually does that on a daily basis and so my piece of it is to work in partnership on NAK Prosper and when I talk to my board of directors about NAK Prosper I say look it allows us to do three really interesting things it allows us to come together with many community partners really driven and led by NBRH and a few other key organizations to say what does our community really want how do we actually determine community intention right how do we invest in prevention one of the amazing stories in Vermont healthcare reform is that NBRH takes its capitated payment from the ACO and takes 1% off the top of that to invest in prevention and that is really putting your money where your mouth is when it comes to healthcare reform and then three how do we work on prosperity in a community and so thinking about what type of investments do we need to make downstream to make people healthy and to make our communities more prosperous I think when we were setting up the all-pair model in 2015 and 2016 if you had told me by 2019 there would be a hospital that was taking part of its payments and putting into prevention and convening its community several times a month to do actual work and to work on bigger picture prosperity issues I would say hey I don't know whether it's ultimately going to be successful but we are definitely on the right track this is exactly the type of stuff that we wanted to see when we set up that system and so I'm really grateful for the leadership of NBRH Northern County's healthcare has its part of it because a lot of what we do now is centered on primary care and we're grateful to be there and I sort of knew that healthcare reform part of it was going to work well and it hasn't worked really part of that what I didn't know when I took my job was how much the operations of Northern County's healthcare and NBRH are a collaborative thing Chris Town who's in the audience is our director of primary care operations and is outstanding works with Laura Newell who spoke earlier and Laura and others all the time to try to make sure that our operations are integrated so that it works for our patients instead of being a burden for our patients and one very specific example is that like a lot of our monitors our patients struggle with the financial aspects of healthcare one specific example is laboratory fees and so we came to an agreement with NBRH over the past year to redo lab fees for our patients in a way that I think serves the community really well and tries to get out of affordability when it comes to recruitment which is much like NBRH view it as a win if someone is interested in the Northeast Kingdom and takes a position with us or NBRH or North Country or NKHS it is not a fight between us it's more about how can we get people to understand that this is an amazing place to live, work and raise a family and it's a win for us if anybody wants to come into the community I've been with Sean and Brian Knoll at North Country Hospital and Gail O'Clair, Little Rivers and we do support moms and kids and I really credit NBRH for as usual being a real leader about how we work on collaboration that sounds so simple but I can't overstate it's important it's really only two theories of the case in healthcare reform, competition or collaboration Vermont is clearly all in on collaboration which means it's a big resource allocation problem and I think NBRH is really excellent about saying how do we first work through the problem in a community oriented way and then all figure out what this means for our respective organizations and how do we best leverage the strengths of our organizations instead of duplicating what might already be out there that's probably a 100,000 foot view of our collaboration on what NKH Prosper looks like the thing I truly love about NKH Prosper is it doesn't stop at 100,000 feet it gets down to the immediate gradient okay we're all in, we're on task we're on message but what are we really going to do and to give an example of where that conversation is moving forward we have an ECO 18 meeting that meets every month to talk about the ECO program and I think Sean and I are very well aligned on the following thing which is okay at some point in the future we entirely delink healthcare payments and when people visit our organizations what would we do differently what would we buy that's different how would we serve people that are different and I think we're trying to get to that same conversation on all of those five major questions are we physically healthy, mentally healthy well nourished, well housed and financially secure and so to the extent that we can all agree that strong hospitals meet strong communities we're really passionate about supporting NVH budget process and look forward to being great partners with them in the future then we'll pass it over to Laura Laura I'm really incredibly grateful to have partners like Michael and his team at Harding County to drive this work forward you know thought for a long time what's the single most important thing we could do to improve the health and health outcomes for the community we serve it's raising median household income think about that for a second raising median household income that people can better afford caring they can better afford housing they can buy nutritious food and they can build a future for their kids that will be better than the life they have and any gate prosper and our collaborative partnerships to get at addressing the social drivers of health is the vehicle that enables us to work on that initiative and it's incredibly important for all of us here to do that one more person I know Michael you touched on it one of the things that we've committed to as part of our partnership with OneCare and our participation in the ACO there's always been a lot of talk about care organizations, the model that if you can achieve some savings that you can then invest those savings into social drives for health or the social driver to work I long held that that's a chimera there is no such thing as shared savings it doesn't exist because this year's shared savings is next year's bottom line budget and it's impossible to get to so we flipped that on its head and we said okay we're in on the ACO we're participating in the Medicaid risk track and we're going to take one percent of our revenue from that program and dedicate it to this work and our hope is that in the coming years we can grow the percentage that we're committed but we are building it into the budget that's what we're doing and this I think is a paradigm shift and it's incredibly important to how delivering care can be in our communities so just two quick things with the prevention fund that Sean just described I can tell you for our organization it's a different way in a data driven way and so just to give you one example of how it made our folks think differently though it's about a project we're working on right now we talk about food insecurity and for example we have a site of an island pond it's pretty far out there it's a tight knit community as Sean said it's an older community income is low but QD healthcare wise is pretty high we do one food distribution a month through community folks up there and by the end of the month people are really struggling is there any way that we could pay for a second food distribution and then they say well we know Michael since we've now known you for five months you're going to ask about the data is there any way to use that as an opportunity to create a data set of food insecure people and then try to link that to their healthcare utilization to figure out whether their utilization during that time of the month than for example other folks on our patient panel and so it just gives us the opportunity to think in a totally different way instead of waiting for that person to show up in the emergency room or to be in mental health crisis because they can't feed their family and so it just gives us a real NVRH's commitment on the prevention fund just really opens a lot of doors for our whole organization to think in different ways I feel like it's actually the right work but you have to be careful is it just us or is it really moving the needle and I will tell you about the FQHC federal oversight agency HRSA came to visit a bunch of Vermont New Hampshire sites over the past couple months and they came to visit Northern County's health care to talk specifically about NET and Prosper because everybody's talking about collaboration and they wanted to talk about this example of people doing collaboration and what they said to us at the end of that meeting was hey if there's not a promise but if we could make a one-time investment in NEDK prospering this type of work what would you ask for? What would you buy? And so we're putting our heads together to try to figure that out I've written up just an example of other people seeing this and thinking hey you're on the right track and we're curious about this being a replicable model either in other spots in Vermont or broader geographically and so you know we're only able to do this in partnership with our financial commitment and you know I would really urge you to allow them to continue to be able to make these types of investments So now I get to talk about some of the benefit to our community from our hospital and we have I want to thank everyone from our community this is what you made your fans These are our fans of NBRA Thank you all for making this trip over this morning So NBRA we are by far the largest employer in our region Last year we were actually voted the best employer in the Northeast Kingdom by a poll done by the California record and using some kind of standard multipliers that are out there we estimate that we had about $15 million to the local economy by both So we also have our community benefit reporting that we report on through Schedule H of our 990 to the IRS every year We just completed that Thank you Terry As Bob mentioned we had $14.6 million in community benefit which includes chair and care That's 17.6% of our total expenses which is really on the high side of hospitals across the country Anything that we use whenever we make decisions around allocating money towards community benefits we use our community health news assessment as a guide to decide how we're going to spend that money I also want to point out there's a slide that's up there right now we have several different ways of funding interventions in the community two of which we just heard about from Sean about the newly created healthy sense fund that comes off the top from our ACO payments for Medicaid that comes out of hospital operations comes out of the bottom line and then also any of our community benefit funding initiatives that we talk about that also comes directly out of our hospital operating budget so we need a healthy bottom line in order to be able to provide those funds So last year you may remember I talked about a program that we were going to launch in this fiscal year we call it rights to work this came directly out of our community health news assessment process it was first brought to my attention by Mary Grant who is the executive director of our regional transportation public transportation agency RCT which she said no or although real gap in transportation in our area is around people trying to find transportation to work through the community health news assessment that was also verified when I went to speak to some reach up participants about barriers for them to find a job they said the same thing that's where the gap in transportation is so I went to a couple of the counselors I spoke with to just confirm what they were seeing and also to do some problem solving around that issue and that's where the rights to work program was launched so I want to tell you a story about one of the people that we've been able to help with the rights to work program in the last year and I chose this story because I actually got to meet this young man because he came to my office to drop off the repeater for his car so I'm going to call him Ted that's not his real name although he didn't give us permission to tell his story today so he's a young man and he's worked with Vogue Rehab for about eight years he had a history of some anxiety and some anger issues so over those years working with Vogue Rehab they were able to capitalize on his strengths which one included he was very artistic very skilled artist and one of the things that he wanted to do was to be able to give back to the community by helping people with their art so over time he was able to find a job get an apartment buy a car he's teaching and he's working in a local school and he also teaches art to kids on the side so he's very self-sufficient he came off disability benefits very self-sufficient and then all of a sudden he has this these looming car repairs he has car needed brakes and wheel bearings so I'm not a mechanic but I listened to car talking over the years so that I know that you should not be driving your car if you need some brakes or wheel bearings so for just a little under let's see it was about $600 we were able to pay for his car repairs and literally get him back on the road so I have in the last year almost a year I have five other people with similar stories where we repair their car bought snow tires we spend about just $3100 to do this and about another $400 in gas that both rehab gave out and so this just shows that if you have the right partners coming together with just a little bit of money you can make a huge difference in people's lives and that's why I'm proud to work at NBRH can I just build on that story as well there's another story I think we just got off the ground we're getting it off the ground around Rice Wellness there was an employer in the Newport area that's been struggling to find work force and they reached out to a vocation tab and said hey, we're willing we're multi-shift operation but if we can find four or five people from St. John's Bay Area who are willing to come up and make a drive up to Newport for this job we'll make sure that they all work the same shift and we'll provide a van that the employee will definitely pay for but if you can cover the cost of that van service for the first one was at month until they start getting paychecks rolling in then we could pull the whole thing together and we said sure, let's make that happen that is a really good example of a public-private partnership where we're helping the local business get employees into their run job helping people step up I just got an update on that yesterday it's probably going to be 12 people so they'll be able to ride from the St. John's Bay Area to their good-paying job at Newport every day awesome capital plans I think we'll see I'm just here to read I'm going to touch on all of them but I just want to point out a couple of key things the first of our ride project very excited to report that that's still on time and on budget what I didn't put in the note here is that we're actually able to upgrade to newer technology equipment than what was in the original CON application at no additional cost it's about $10,000 of additional cost so minimal that won't add to the project cost we'll get that covered in our contingency but very excited that we're able to upgrade the technology at no additional cost in that project the other things here that you can read highlight that we capital budget is re-prioritized every month, things change put the budget together in July and it doesn't end until the 18 months when we start the process so we do re-prioritize every month at a community meeting in our ED project I touched on it a couple of times I think we talked about it last year Ryan was not able to attend to help us as you can see in the footnote we were going to ask him he's not here so I do want to highlight just by today's standards if we were to build the same ED with the nine rooms until 1972 we would have to add 2,200 square feet just to comply with today's standards so right out of the gate before we start the project we need to add that number of square feet just to comply with today's standards and then we need to expand that for a number of reasons that you heard we talked about the hallway benefits we talked about dealing with patients with mental illness in a place to put down right now we put them upstairs we're planning to add capacity right in the emergency room so that we can sleep and care for them without putting them upstairs and I talked a little bit about how we're going to fund it and competing we're planning to build up our balance sheet and that capacity so that we can pay some cash do some borrowing we're going to do philanthropic support for the project as well and we're actually looking to do market tax credits and they could provide up to 3 million dollars for this project so we're certainly exploring that opportunity that our fingers crossed next page aware of our time so I'm hoping not going to be too fast but we want to keep to our lives long range financial outlook we're participating in the next year next year in the next gym we want to be able to participate in the others but at this point we just can't take on the risk but to add Medicare one care next gym project would add almost 3 million dollars of additional risk as you've heard and as I'll repeat we need to book that 3 million dollars on our income statement as a revenue deduction until we know how the actual program results which are 18 months after the year begins until that time we have to work and carry that liability and hit to our income statement and we also want to do geographic attribution right now we're in the pilot program with Diva we have added almost 6,000 attributed lives through the geographic attribution so our base attribution was about 6,000 adding the geographic attribution two beneficiaries two that doubled it almost from 6,000 to 12,000 around members you've heard about us shrinking the balance sheet expanding our knowledge of total cost of care we're really starting to understand it get a handle on it know what resources to go to better to drive down dig deeper into the data I want to mention the one patient who's just the patient's medication costs $1,000 per member per month to the total cost of care so we're really starting to understand that understanding that the drivers will help us put preventative services and finally do better ways to care and be more efficient to care for the people they need collaborative efforts with both countries we've talked about and so I'll move on to compliance with historical budget orders we're trying to comply but we're busy we're meeting the community needs and we're driving revenue and we're doing the best we can to keep us in a lot of budgets but we're not the same hospital we were in 2014 we added services we made access to care improved added providers doing what the community is asking us to do and doing that it's not been possible that people the growth caps that we've been able to achieve were successful and we think that's a good thing but we understand the pressure we're trying to contain costs 3.5% without that cap as I've said in 40 and another states we're doing great but we're struggling to the budget caps so the other thing I would point out is that the non-financial compliance issues with compliance with budget orders we've done we've continued to do the financial challenges that are facing 3.5% so with that I think we're just about done Steve has done our final on that but John I think does want to make a couple of calls and comments so I think what you heard today is that NBRH is a stable and healthy hospital that is poised to continue to meet our community's needs we enjoy tremendous community support and despite the fact that our population continues to be older, sicker and poorer than the rest of the state you know I think it's important to recognize that both of our community members have had the same experience in a relationship with NBRH that I have had it's the hospital where my kids were born it's the hospital where my family receives both acute and preventative care it's the hospital where my wife is a frequent flier in the emergency department but we don't have to get into that it's where my grandmother received her palliative care and it's the hospital where I recently lost a loved one due to a heart attack this hospital is very much a part of the fabric of our community and it is the economic driver for our region it's important to recognize that we really appreciate all of your support we see the green matter care board as both stakeholders and partners ensuring our success and the ability to meet our mission of serving our community I want to thank again our community partners like NCHC and the other agencies that helped work with us to keep our patients healthy thank you for the time and we would appreciate your support of our budget thank you Sean we're going to take a 5 minute bio break and resume with questioning at that point I was just going to say that you could speak in a little more depth to your emergency department utilization which seems like it's up significantly from what you had budgeted it sounds like you're doing some work around that with the urgent care so I was also interested if you had a cost impact from shifting that utilization from the ED to urgent care so I started by saying we're just at the very infant stages of putting that plan together so we haven't really done any we've made some estimates but not any in-depth cost analysis or in fact a study at this point the ED is busy, the volume is up despite our efforts we've been working through the chronic care coordinators to make sure that those patients avoid going to the ED and see that primary care provider for visits do so just put recovery coach in the ED to help patients with substance abuse disorders to help prevent those repeat visits we've had care managers in the ED working for maybe two years maybe a little bit longer now for patients to present without the primary care provider to get them into a primary care setting just as quickly as possible so we're doing the steps of doing the right things that we think to bring the volume down but we're still seeing that increase and Laurel wants to add something so not all ED utilization is due to those avoidable ED visits I just ran I looked at the report of the top ED users last week and the top ED users are the people that I would say fit the characteristics in that category 4 very complex medical mental health, substance use social issues so those are the types of people and patients that are probably going to continue to need a lot of resources hopefully we can find something that doesn't helps to avoid heat so they don't have to go to our ED but that's going to take a while so I just want to make that point and see avoidable visits Thank you I would say that the reason I particularly wanted to ask is because what we're seeing with many of the other hospitals is a drop in ED visits so you're a little bit of an outlier in terms of going in the other direction Michael, did you have something you wanted to add? If I may have just say this is an example where Sean and the team have challenged us at the FQAC to think about what we can do in primary care clinic and do that with our existing space so we're not investing money in sticks and bricks unnecessarily we've thought about expanded hours we're also thinking about ways to bring the solution to the problem so in primary care could we embed primary care into NKHS, our designated agency could we partner with local housing agencies to get space downtown in their buildings and so we're looking at lots of different ways where we can utilize existing assets in a potential order over utilization of the ED I would add that patients have redeemed confidence in our emergency room we have upgraded the providers we have improved turnaround times in the ED patients who used to go to EDs elsewhere are coming back to our facility and that has certainly been a factor Sean just mentioned there's this bike trail called Kingdom Trails just a little bit north of us incredibly busy people doing incredible things that I would never try and some of them do get hurt and that is also a factor we're seeing in our ED especially at this time of the year in terms of the Medicaid pilot I wanted to hear what you're thinking about in terms of current or future operational changes to address the movement to more of a fixed payment methodology and I think Michael alluded to it a little bit but I wanted to hear more about your operational planning to really shift the way you've been doing business with the new Cayman model you want to touch on that more so Robert, are you particularly talking about the pilot to test the geographic attribution? yes I guess I wouldn't describe it as that we're changing things in fact, we most often when we're talking to our care coordinators or our different community partners it's really the same workflow that we've been putting into place and laying foundation for the past 10 years now around the team-based care there's just some additional steps with the Care Navigator which is the Care Coordination Tool supplied by OneCare but there are workflow issues but there's not dramatic changes it's just trying to incorporate the additional steps for the attributed and the non-attributed population one of the things that we keep stressing is you're not just providing this care Care Coordination for people who are attributed to the ACL it's everyone it was Medicaid patients, it's Medicare private payers, it's everyone one of the things that the ACL said to me last year as we were gearing up to joining the ACL is they said, you know, we are going to have to have a plan to take people off the care model if they come off of Medicaid and I said, no I'm not and I said, we're going to continue they're still our patients, we're going to continue to care for them we just want to get paid for them that's the only thing that's different does that answer your question? yes, thank you last question I think this is my last question according to the blueprint practice profiles the St. John'sbury area is one of two hospital service areas with the highest relative value use index meaning that on a risk adjusted basis your utilization is higher than other hospitals in the state this is a pattern which we've seen repeatedly I think in your net patient revenue targets being higher than the guidance and in this case this year asking for twice the guidance over twice the guidance in revenue growth and that's after we've already rebased your budget in fiscal year 18 we rebased fiscal year 17 so I'm wondering if you've looked at doing something like a variation analysis with your physicians to see if there's practice patterns that may be contributing to this and we know from Dr. Bent Wenberg's work from many many years ago that practice variation can often drive cost without higher quality as a result just given the repeated pattern of your utilization and NPR increases where they've been I'm wondering if that's something that you would consider doing to see if there are areas where you could be educating physicians in your community that they may be higher prescribers or pushing higher utilization that perhaps is average so I think the short answer is yes that data is not always that easy to get but we just looked at some data yesterday Norm Ward came over and showed us some SEO data and in some of these areas there are clearly better performers than us in some areas not just within our region but also across the state and that is one of the things we're going to do is look and see who's got these best practices and what can we learn from them That's welcome because definitely you have the community like I think one of the superstars is not seeing it in terms of the total cost of care and so you're not really getting that return on your investment in a way So we're definitely looking at total cost of care from many different angles the blueprint information is one the v-cures data is another and the data we're now getting from one kid and Laurel alluded to is a third and we're learning as we go we've identified, we do have some avoidable ED visits in 2017 I know in 2017 one of our primary care practices lost both physicians through retirement to have been in the community for 25 years it took us a while to get those replaced so there was definitely some capacity and access issues that we were dealing with in 2017 so we continued to look at ways even though we filled those positions now looking at ways to reduce avoidable ED visits even today which is the first quarter of 2019 has us right in line with all of the one care metrics in terms of total cost of care so I think we've taken steps but we're going to do the point of service I'll preside and Laurel alluded to before the urgent care models of convenient care we're planning to do all I think improve where we are now which is right in line with other one care system with one care system the short answer to Robin I would say is I don't think right now that's driving a lot of our revenue growth over the 3.5% cap a little bit of a factor but it's not a material factor I don't believe at this point then what is driving that patients coming back well patients coming back to us for years we talked about orthopedic patients coming back we've now fully staffed with general surgery fully staffed with all of our specialty practices all of our primary care practices are full so we're providing the services that the community needs and making it busier and that's driving the cost and I have to also add demographics and then we have as alluded to earlier the oldest population in Vermont Vermont is the oldest and the Northeast Kingdom is the oldest in Vermont and there are a lot of graphic issues as well maybe now is a good time for me to show one of my exhibits I brought I hope you guys maybe now is a good time for me to show one of the exhibits I brought I hope you'll indulge me for a minute but I know that Northeast New Vermont Regional Hospital is not the only word hospital in the state of Vermont and there are several of us but I think it is good to illustrate just what our community experiences and what we deal with on a daily basis so we have a local paper we're blessed to still have a daily it's the Caledonia record and I brought actually I got two separate ads but this is an example of what Littleton Regional Hospital puts in the Caledonia record on a relatively regular basis this is a full page ad for their services and I know that friends who've traditionally bypassed NDRH and gone to Littleton for their ortho care for their regular care because of perception or whatever and the positive is in the last four or five years that perception is changing and those people who have been spending Vermont dollars in New Hampshire are now spending Vermont dollars in our own community and that's incredibly important and I think that is part of that sport despite the fact that Littleton Regional Hospital does a heck of a lot more advertising in our own markets than we do if you have data around in St. James we would love to see that we're trying to get it it's difficult and not timely and if you would know of any way to get it please let us know some hospitals seem to be able to get it out of their EMR but that doesn't vary based on EMR well that doesn't help with the leakage what went out of them is not coming back so Robin you asked such good questions that both Jess and I wanted to follow up so Jess I'll go to you so Robin's concerns were similar to mine not surprisingly probably so I'm encouraged about the total cost of care actually let me back up for a second because I didn't think I was going to go second so I just want to say thank you to you because I think it's incredibly helpful to learn about your community and a lot of the hospital initiatives that you're taking to improve population health and economic growth in your area I mean these are helpful budget hearings to learn that what's happening and I just want to echo and not really too much emphasize other than to say I agree wholeheartedly with some of Robin's observations about the total cost of care and I'm encouraged that you're looking at your total costs of care you know in the measures that we provided in our budget guidance you know your St. John's Bear area was slightly above the state median but it was growing at a faster rate it was growing at 4.2 according to that that's not risk adjusted and it's not limited to care you know at your hospital it's a resident analysis but the blueprint is another interesting way to take a slice at it and again I recognize it's 2017 and so I'm encouraged to see the new updated data that I think the blueprint will be coming out with this fall so hopefully we'll see some progress there but St. John's Bear is the fourth highest per capita spend in the state in 2017 and that's risk adjusted so that helps us understand even apples to apples after we risk adjusted spend there is high and where it was high was an inpatient surgery ED as you mentioned outpatient surgery radiology pharmacy at the hospital and I think the worrisome piece to me is the resource use so that's the second highest in the state and again that was risk adjusted so I echo the initiative to do some variation analysis and to try and look at provider patterns I think that's really important to see if some of that is driving some of that cost the ED visits is a worrisome thing for me too and I was going to bring this up but for two reasons one is you were high on risk adjusted just regular ED visits also high on avoidable ED visits but just avoidable and on avoidable ED visits St. John's Bear was high and I'm worried because you're up 12% budget to budget on ED visits as Robin was saying most hospitals are seeing a decline so even if we look at that's 2017 data you're still growing in your ED visits that's not changing despite some of the initiatives that you're taking on so I'm wondering a couple things one of the things you're budgeting for additional 1000 visits over 2019 projected for 2020 that seems high you also were budgeting 1000 visits for your urgent care I think there was some narrative there and I'm wondering is that the same 1000 visits if it is what is the cost reduction assumed on those 1000 visits assuming it's not going to cost as much and is that also budgeting it did you load up the ED visits did you also reduce the revenue assumption that would be those are now not going to be taking place in the ER that can be an urgent care center at a lower cost so how is that all baked in there it's all baked in there the best estimate of what the cost is going to be so what is the cost of avoidance per visit than estimated to be I don't have that with me I guess I'd start by saying in the first year probably not a lot because it's going to take a while for people in the community to understand what the program is and how to access it and even those that it's there to help make them aware but it's going to take time for the community to adjust and to change patient habits they used to go into the ED changing that habit is going to take some time so the initial cost per visit is probably going to be higher than it will be down the road after the community starts getting used to going there and the cost per visit will go down because they're using that service more than the ED okay and you're thinking about expanding your ED so there's an expansion proposed for your ED so I'm wondering as you are making the changes that it sounds like you're making at the FQHC and also in the convenient are you factoring in the presumed hopeful reduction in ED visits in your proposed expansion of your ED yes well the visits that are not going to be coming to the ED are those level 5 as they call them the earwaxes that need to get blown out and the scratchy throat that needs to be seen those aren't our resource intensive visits that are going to and they're not going to take a lot of time in the ED the turnaround time for those patients is very low you know we're building the ED again I'll start by saying 2200 square feet short just by today's standards and we're building it for those higher acuity patients including those patients with mental illness that are going to take a lot more resources require a lot more space in staffing so yes we may be losing some of the level 5s but that's not what we're doing in the project and I want to talk a little bit about some of the NPR growth and there's two, seems to me two rationales for it one is increased demand and to the extent that you're clawing back from Littleton or New Hampshire and there's more renewed confidence in the hospital do you have a sense from other hospitals that are seeing increased demand or seeing data on unique patient visits do you have similar data on actually unique patients that are coming into your hospital over time unique patients yeah unique patients so you're really looking at individuals oh yeah not duplicated visits unique individuals that are showing up at your hospital over time right yes can you do that assessment for us analysis we can I believe we're still learning how to use our EMR rate efficiently and get all the data out of it that's in there but yes we'll make that be really helpful and related to that you talked about your acuity increasing to the extent that you've got an aging population do you have similar data on your case mix index over time so as a matter of fact we just got something that I think it's okay for me to say that the hospital association put together they think you're going to receive today that showed our case mix index increasing from 2015 I believe from an index of 1.18 to 2019 that's 1.3 so we're talking roughly 10-11% increase in acuity we're going to get that today you said well if you could share it with us what you've seen that's what the data showed for us it may not be ready for prime time so I hope I'm not speaking out of the term but I know the hospital association is working on providing you with ideas okay that's very helpful I'm trying to get a sense of relative pricing so if on average Medicare reimburses $100 for a service what would your commercial payers on average reimburse there's a percent of charges if it's $100 for a Medicare service what on average oh gotcha so commercials probably can you just finish the whole question yes if it's $100 for a Medicare service that same service reimbursed by a commercial payer would cost on average what would be reimbursed so for $100 the Medicare pays a commercial probably pay $175 maybe in that fallback I could do a better calculation but off the top of my head that's a problem perfect thank you and after the budgets were submitted we're hearing from some hospitals that Medicaid gave notice that there may be some small rate adjustments increases did you factor that in or estimated what that might be for NBRH or did you even receive it I was going to say some hospitals may not have I have not seen anything from divas saying that we're going to get a Medicaid increase we would welcome one so none has been factored into the budget okay and you haven't received any notice that suggests otherwise where do you start perfect and I think my last question is my last question is around I see a lot of wonderful collaboration within your community that's really inspiring one of the things that we've noticed that the hospitals that tend to be doing the best financially and also I think providing high quality care those that are collaborating with other hospitals to share services to save economy to scale, increase access to their patient population to share services and I hear from you this collaboration with Dartmouth Hitchcock around the cardiac and with North Country around the sleep center I'm wondering if you could talk a little bit more about other proposed collaborations that might potentially reduce costs, increase access and maybe even perhaps talk about telemedicine if that's an opportunity for you to bring more services into your community sure about that would be great yeah so I'll build on some things we've already shared I'll come back to we've started a conversation with North Country Hospital and we partner on occupational health and explaining those services throughout the Northeast Kingdom the cardiology service it's not only a partnership with Dartmouth but Dartmouth is placing cardiologists or PANS at North Country Hospital as well as the Littleton Regional so for creating a pool of professionals within our region we'll be working together under the same network and then affiliate with Dartmouth at the same time so that's a real strength we have been exploring a lot of telehealth solutions within the hospital and how we leverage those solutions Dartmouth has some really compelling options that we're considering one is around access to telepsych and teleneuro that would help especially our emergency services team provide care on an emergency basis some of the services are very expensive and it's hard to find an ROI to justify them but those services in particular the Dartmouth structure seem attractive because they're as a pay-as-you-use-them or pay-as-you-use-them type of feature we're continuing to explore all the options I'm going to touch base I want to pull it back a little bit and talk about some of the opportunities that the ACL also gives us because once you de-link how we're being paid from the act of showing up at the office we're early days in this but it gives us a lot of opportunity to consider how we provide care to people on an ongoing basis you know you do a lot over the telephone you know an awful lot over the telephone and you don't think of that as telehealth but kindness and so we're trying to figure that out I think maybe next year will people tell a better story around that we're also talking to North Venture Hospital about how we cross-train nursing staff especially in our Bergen Center you know it's no surprise you guys have heard of Bergen Center but we've got a great Bergen Center we need a Bergen Center to be there for a lot of really important reasons number one is an important it's important service to provide our community number two we have an aging population we're struggling to track young people one of the single worst things you can do if you're trying to track young people to the community is close your Bergen Center because where are people going to have their babies right so it's an important asset for the entire community North Country is an important asset for them too and so how do we knowing that our birth rate is declining and how do we ensure that our staff are highly trained and how do we ensure that those services are available in our communities so that's a great opportunity where we're trying to figure out how best to collaborate and maybe even volunteer resources between our organizations that's great to hear because I worry about as our population is declining we want to ensure access we want to ensure access with a certain level of quality and volume and quality can be correlated with some procedures and surgeries so when it comes to collaboration relationships matter and I've got to say I know we've lost our math and they're going through a leadership change but I've always had a strong relationship with our same thing Brian and I we probably communicate at least once a week I just got an email from him the other day they were recruiting a specialist but the specialist partner is a urologist and the email said hey where are you guys at with urology do you need one how can we work together to recruit true professionals to our region right and those are those relationships matter having that being able to work together on that that's very encouraging I realize I have one final question Bobby you were talking about you're fully staffed and some of the reasons now that you're getting this increased revenue is that you're fully staffed in some of the areas that you were not staffed before any of the increased net patient revenue qualify under our provider acquisition are these services that they were already receiving in the community but now they're coming in under employee positions are there any worlds in which this can qualify under any of our carve outs unfortunately other than the physical therapy practice there were all of the existing practices that we've had that just had been short staffed just not enough providers in the being fully staffed thank you Robin did you have further questions now okay Tom well thank you for your very broad presentation that certainly offers a very good feel for for your hospital I'd like to emphasize to Shawn when I'm down visiting Southwest the hospital which room you were born as you go through this these older age facilities my first question is having to do with the contractual allowances in Medicare that you project Medicare more than half of the NPR that you're looking for in 2020 over 2019 and I would just kind of did a calculation on the contractual allowances at the percentage of patient revenue in the recent past and for 2016 it was 59.7% 2017 at 59.6% 2018 at 56.6% 2019 so far projected at 57.9% but the percentage projection for 2020 is 55.7% which is lower than any of the observed rates and I'm wondering about that because if the contract allowance actually just rose back up to where it was now in 2019 that would be a 1.7 million differential which basically wipes out your operating margin so I'm just wondering do you feel that any risk about the relatively historically low contract allowance associated with Medicare in 2020? No. I'm confident that those are the right numbers as I mentioned during the presentation you know our Medicare reimbursement is tied to our cost and as our cost changes our Medicare reimbursement changes so we take the formula that we used to estimate it and the increase in cost in addition to this current year's projected Medicare is what we determined to be the net revenue and the difference between what we built and the revenue was the contractual so I didn't do the analysis that you did but I'm confident that we're projecting for net revenue for Medicare and therefore the contractuals are accurate. My next question has to do with the provider tax and we envision that relationship that as you know the provider tax is kind of going up over time and the dish is going down because of some ACA concerns I think mostly and what I see is a large trend statewide that Delta is growing since 2017 it's about a 30 million dollar hit to hospitals collectively their bottom line as their costs go up with the provider tax and their revenue goes down with the dish you folks it would be you're projecting provider tax moving from 4.3 million to 5.1 million and dish payments dropping even from 1.6 million in 2017 to 987 thousand which is a slight increase but it's not offsetting the change in the provider tax and I'm just wondering if given who your legislative delegation is that family kind of controls the state budget Jane and Kitty have you had conversations with them about this because it is during your presentation you were talking about savings and ACO and efficiencies and things of that sort and I worry that these other kinds of wins in your face like the relationship between the provider tax and the dish payment are kind of sapping that energy out of the efforts that you're putting in just the numbers are the difference between the provider tax and our dish reimbursement is 4 million dollars 4 million more in tax than we get in the dish revenue so we had extensive discussions with our legislators particularly back when they took the money the dish money from hospitals and moved it to shore up the mental health services in the community made them well aware of the challenges that they were going to present I think it's important to scale it because that number two kind of like the metric number I was referencing is pretty close to your operating market and so on the scale of things these are not small corners of the world they're significant this thing is a 4 million dollar car shift great just a question on your mountain biking and hiking injuries my simple mind says that those people might be younger than I mean you're not out there going into either of mine you're saying old how do you know Bob doesn't train every day on this bike how do you know Bob's not training every day on this bike so but I'm just wondering if and that these folks might be more out of state and I'm just wondering in terms of payment for services in the emergency room do they fit the average profile or are they folks that either young and don't have insurance or out of state and is there an issue there maybe there hasn't been no we've been successful the younger they bounce back quicker so they don't require a lot of the extensive resources and something like me for example if I get into but we do get there and I will tell you it doesn't come down from Canada it's a huge attraction from people from Canada and we are able to work with the Canadian system and get paid for because as well as other states in the United States as well can I just follow up on that one sure what percentage of reimbursement are you getting from the Canadian system yeah it's good I don't have it with me but a recollection is it's like 75% charges roughly the commercial payers super sorry Tom I'm just thinking about a quick follow up to one of Jesse's questions if Medicare is paying 100 bucks for a procedure or for service and the commercial is paying you 175 what is Medicaid paying you Medicaid would be paying us roughly 70 to 75 of Medicare of 100 Medicare payment you mentioned that there's some delay in capturing in 2019 some 340B revenue estimated about $450,000 and I'm looking at then rolling into 2020 is any of that recovery embedded in your 2020 estimate some of it footnote there simplified part of it was we didn't get as much as we anticipated and part of it was the transition was while green system took over some of the local 340B right-aid pharmacies and we had a little hiccup there that took a while to discover so it was a timing issue and so it was just an over budget the timing issue has been being resolved and has been built into our 2020 budget and two final questions relating to that the first is in 2017-2018 the total amount of that debt that you recognized was around $4 million and only 440B appendix that you submitted to us was put into collections and resulting from collections was $84,000 in recovery or an 18% rate and that's about the average rate that we saw on those appendixes and I fully admit that it's not an art and financial approach but it gives us some information and I'm just wondering why more of your bad debt doesn't go to collections well we send everything to collections that we think is going to be collectible and we go through a process for everybody I don't have the table in front of me but I would say we work all of our accounts and that's very hard so if we turn an account over to collection it's pretty much dead that's why our, I don't know what the other hospitals are that's why our collection return recovery rate is low because we work hard the recoveries I'll tell you mostly that the credit score has been impacted by going to collection and when it's needed to access credit they then pay the bill and we have to, accounts are pretty much dead by the time we send them and maybe Mike can offer some insight on this going back to your tax reform days the state has a program called the offset program the tax department where they intercept people's income tax refunds if they have a debt owed to the state and you know this is a program that's well established well organized very sensitive to people's rights of appeal and things of that sort and it's used by BSAC and the defendant general of the state collar system child support over at AHS and it's I'm just wondering if the state opened its doors to that program would you be interested in the option, not the mandate of the option to place some of your bad debt in that program to recover some revenue I think that's a very good question for the hospital association and the state legislature, not for the CEO of an FBHC I'm going to politely decline to offer any opinion on that that's my question okay Maureen first I really want to applaud the fact that you guys have been able to maintain the operating margin for the past five years and you're really about one of the only critical access hospitals that has been able to do that that's not an affiliated hospital so I think that's great news and we want to keep it one of the concerns that I have over the past couple years 2019-2018 you've been exceeding your top line in your NPR but your expenses have exceeded even the growth of your top line and typically we see the opposite of this, most of the struggling hospitals are using their top line they have fixed costs and so their costs are not able to come down by the amount that their revenue is also going down and so it creates kind of a spiral situation you guys are really on the opposite of that you keep exceeding your numbers so we've gone through some of the rationale of why that's happening but you absolutely maintain almost to the dollar your operating income that you were targeting and it seems to me this should be really an opportunity where you're leveraging those fixed costs because you're not always potentially going to be in this situation where you have that flexibility so just wanted to talk a little bit about why that continues to happen and why you aren't able to leverage some of those fixed costs and generate some additional bottom line income on the top line that you continue to beat Sure, I guess I'll start by saying we're constantly looking at expenses to make sure that we're saving and reducing and not adding wherever possible I'll also say that we have a lot of fixed expenses but when you have to pay $3.2 million for temporary staffing that's a huge increase a huge expense driver so our revenue is going up because our volume is going up we need to staff the departments appropriately again to maintain safety for the patients and the staff in order to do that we need to provide staffing if we can't do it on our own we have to add staff and that's what we're doing with the temporary agency expenses so with our own employee staff the fixed cost is there but we're adding staff to handle the additional volume in an additional premium when we're talking about the low cost and then we have just the general inflation going if a health care going up higher than overall inflation drug costs I mentioned the increase there we're doing whatever we can to maximize the 340B savings but the drug cost increases really that's just one example I hear your concern it's a certainly appropriate my concern every single day and we're doing the best we can to reduce costs and only spend what we actually have to because I would hope then we would get some of that leverage eventually in the future years because the other thing and I'm not going to try to minimize that you're not looking for cost savings but the hospitals that are having trouble we actually have kind of the tail of two cities today Northeastern and Northwestern the list of cost savings programs that they're working on aggressively are significant and a much larger percentage it's been one of the things I think you know I've been focusing on the past several years is how do we get some waste out of the system how do we optimize these cost savings without doing anything for quality of care and when you're in a situation where you keep top line each year there's less need maybe to have to really go after every single dollar that you can on a cost savings and you know I'd really like you to give some more documentation on all the cost savings and efficiencies that you're putting in and maybe how you can leverage what some of the other hospitals are doing as well so again I'm not saying you're not doing it it's just you know there's a different drive if your top line is going down you've got these fixed costs and you're able to do it and there's a lot more room in a hospital that's growing double the expectations that we've put forward and just want to talk a little bit about convince me that your cost savings are driving just want to talk a little bit about the ACO risk and the reserves and you know we see various positions from each of the hospitals as they come in for that and I understand you know auditors may be saying you need a hundred percent we're not going to change that but when you start to look at the compounding of that so you have a hundred percent booked for nineteen and then you'll have a hundred percent booked for twenty and we would hope that the likelihood that you'll actually you know hit a hundred percent max downside risk year over year so at some point and I know you'll end up getting a resolution you know of nineteen potentially sometime in twenty you know how should we think about that because particularly in your case you know that's about you know you want half of what your commercial rate increases year over year even though of course it's not saying it's contributing to commercial rate but the way you put your P&L together you look for a bottom line two percent you know there's things that get plugged in if you will and you know I just would say for you guys it might actually be you're being a little bit too conservative with that and if in fact you have to book that whole thing what's going to happen then when some comes back favorably as we hope it does right because the swing could be a hundred percent the other way right if you look at it some hospitals are saying the number we get is straight up the middle there should be as much risk upside as downside and so we're not booking anything and that's difficult for you know a hospital year size but booking a hundred percent when it could swing a hundred percent the other way just want to kind of set up that you know there will be expectations that you know how do you handle that in your P&L I think I can answer this somewhat simply you know this is a one time build up that we've got enough reserves so that in the future results are favorable and we don't have to add anything going forward so in the other case if we get money back then the reserve will come down and there will be a pickup to a net operating patient revenue I just want to go through a few questions on page six of your documentation what some of the changes have been from your budget to your projection you talk about the reference lab work and that's up about a million dollars in your revenue side and just wanted to get what's the net impact of that so how much of expenses were there on the expense side related to that so that is the net of the incremental expenses so it was about 350,000 I think additional expenses associated with the additional revenue but that is net already in that number right so to me that's another example of you went from a million to 2.1 million so you had a million dollars of net that just that one thing is dropping to the bottom line right so actually it's dropping from net patient revenue to other operating revenue so the total operating revenue can change it's just a shift from net patient revenue to the other operating revenue so that's what I'm trying to ask so you changed this from budget from a million forty nine to two one five seven so you went up a million dollars where did that million dollars come from from other net patient revenue so a net patient revenue would have been a million dollars higher if we didn't make that change would have been a million higher even so in your budget okay and then going down to because I think you answered this in questions but it seems to be different on here so your fringe benefits went up from eight point eight million to ten point nine million and your empty fringe benefits two six to three one but then you said there was a fiscal 2019 reporting error so I corrected that statement it was not a reporting error okay but that's still on your documents just submitted so I just wanted to thank you I will change that I was a staff note about it but I guess I did not change it okay so that was a reporting error so the increase so the big increase you had in your other expense categories was really you know the salaries in French I'm sorry there's two different things I know what you're talking about is the one point six when we put the budget together there was another non salary expenses and it should have been infringed that was a one point six million I was thinking something else that the fringe is changing year to year to change and then just one last on your non-operating revenue and I understand you don't budget for non-operating revenue because we don't obviously know what the market is going to do and a lot of those that but in your 2019 projection now what would you say you're going to pick up or lose in non-operating revenue because you still have it as a zero but we're you know six months through the year ten, eleven months through the year so again I would be hesitant to even predict what the stock market is going to do between now and September 30th so I still say zero today I think we still have a loss in our investments year to date so right now it would be a negative you'd have a loss just one final question when we look at where you've been historically for NPR so you've grown 5.9 and 15 9.2 and 16 7.3 and 17 2.1 and 18 7.7 and 19 and now from 19 to 20 against your projection is three and a half so you know we don't want to be back here again next year with you exceeding your budget you know how are you going to stick to three and a half when you're coming off the year of over seven we're going to do our best to stick to the three and a half I want to say we're not going to turn patients away if patients come and need services we need to take care of them I think part of what we've been asking to and maybe you can get back to us is you know some of this if it's the unique patients or you know people coming back to Vermont or from the state you know it helps understand their growth year over year each year so we will do that so just to follow up on that Bob is there any way that you could get information on what the revenues have looked like from year to year at Littleton well we've taken back from New Hampshire hospitals if you're gaining people back they should be losing so the question is can you provide the board with any historical information about what the revenues have been at the Littleton hospital we could re-estimate right I put together things last year the year before an estimate of what we thought it was but it could only be an estimate that we don't have access to revenues of Littleton hospitals saw from St. John's we can only make our best estimates of what that number is okay I mean clearly what you're hearing from this board is if you're bringing business back that's a very good thing but there's got to be some way to document it and so as I think one of the other board members mentioned earlier other hospitals have been able with their own software to document it so Bennington was able to show the dollars coming in from Massachusetts with the closure of North Adams hospital and the dollars coming in from New York with the closure of the Glens Falls hospital clinic there you're right what was that I wasn't sure you would answer the question I wasn't but go ahead it's hard for us those patients that were getting services from St. John's in New Hampshire were New Hampshire residents New Hampshire I mean were Vermont residents with Vermont zip codes so now they're in our system getting services in REHR with Vermont zip codes so we can't tell from that analysis who had been going to Littleton and it's not coming back to St. John's okay I'm not going to beat that dead horse any longer but my understanding is that the v-cures data can help with some of that analysis but it's a little dated and it does not include some revenue sources like any of the Orissa revenues I mean we can use that as sort of a rough estimate but it's not complete can I just say another way of putting it Kevin is we don't consider New Hampshire our service area we don't try to pull people from New Hampshire to our area Littleton has a they think exactly opposite they strongly market I live in Danville, Vermont I get through my mail postal advertisements for their stuff all the time so that's why it's hard to quantify we're just trying to keep people who live in our area at our hospital they're trying to pull people over we don't do that I also we do not pull a lot of New Hampshire business into our hospital people that were from Vermont come back to Vermont but we can do an analysis of what revenue we have from New Hampshire hospital New Hampshire residents that would be helpful but it's not going to change and that's we don't think there's been a significant change in that direction I mean it's just that every year you come forward and you always make a very compelling case and you do a really good job into presentation but you have grown faster than your peers and you're in an area of the state that has not seen population growth like other areas so it's just it's a tough thing to you know the board has to be fair as they treat all 14 hospitals and so I'll leave that one at that I think you did a great job Bob on explaining the change in charges but I just want to clarify and make sure that I understand completely because I believe that what you were saying that other than physician practices it was 3.8% across the other hospital service areas and I just wanted to know if that 3.8% was consistently applied across other service areas or whether ups and downs that will be consistent across all areas with one exception I will say MRI will not go up because that was the condition of our sealant approval right and then on the provider transfer adjustment that you're seeking for the PT practice that you acquired are you using as the base number what the revenues were from that practice previously or are you using as a base a number that you have projected we use the number we protected so as you know we are trying to contain overall cost from the system to really be a fair addition to your NPR to be more helpful if we knew what that number was previously it was not significantly different it was our projection but it was based on a lot of the data that they gave us and we didn't change too significantly okay that's helpful I have all the questions that I had so I'm going to staff any further questions for you no further questions I'm going to turn it over to the health care advocate thanks thanks I didn't want to mean that one maybe I'll just start by admitting that I'm one of those people who, those crazy people I come here here I didn't mean to offend you I didn't mean to offend you but it's a phenomenal thing people, yes a lot of Canadians a lot of people come to them to join the outdoors it's a great thing I'm kind of jealous I'm old so as you know we've been focusing some on bad debt and free care and from our perspective for the most part your story about bad debt and free care you in the sort of strict comparison of bad debt and free care you're about one-to-one which puts you in the top tier hospitals that have a higher amount of free care in comparison to your bad debt but I think it's just a little bit deeper on your numbers because it tells a bit of an interesting story and that is that as a percent of medication revenue your bad debt is pretty much in the middle of the pack of hospitals 3.8% but your free care as a percent of that patient revenue is really high you're doing a better job of helping people get free care than all of one and so I say that just to lead up to the question I don't know what it is that makes your experience with making sure people in your community have access to your free care program but I would welcome any thoughts about what is it you're doing on the ground that whether it's making it make sure people know about it or helping people complete their applications both we do try and make everybody aware of the program in all of our position practices our VD access department is posted everywhere in those areas that they have access to free care all of the billing statements that go out it's referenced through the patient assistance please call we have a dedicated person who's great at their job making sure that patients fill out the application completely and accurately they can get qualified if they meet the criteria and I think our program is pretty good you can be a family of four making $103,000 and still get a 47% discount so I think our program is a good program as well I also think we've done a really good job of educating our staff so if there's any sense when they're interacting with patients that there's any concern about the bill they are very well versed in our patient assistance program and know where to help navigate them to the right people so and then I think my last question is well maybe I have two more but if you report that your free care is about $3 million it's about 1200 feet you see free care free care and I guess I don't expect you to have an answer on this but something I'm curious about whether you'd be able to get an answer again a little bit over $3 million for your bad debt would you have a way of backing into knowing how many patients that is they get free care they get the bad debt I would say yes we could get it I don't have it handy but I'm pretty certain I can get a very good estimate of that more exactly so all of the hospitals are very quick to remind me that the doors are open and that people get care even when they have bad debt but I did want to ask if you could you've done a very good job on the experience of people coming to you and the human face on their way that you've been able to help populations I would welcome any thoughts you have about that population of people who have received some care in this case in 2018 and who carry a debt has now come of that care and what happens to their ability to come in the door or the likelihood of coming in the door or whether there's any I don't know any thoughts you have about that population of people I don't believe that any of them feel any hesitancy to use our services if they need them if they have a bad debt or not you know we do everything we can to collect a bad debt we don't go overboard our collection agency that we use follows all the HFMA you know we do not threaten people or intimidate people in any way that would prevent them from telling you anything they needed a service the other thing I've often wondered about and I don't have these numbers after today I'll try to find them but I feel like we do a really good job of connecting people to Medicaid and other health insurance through the Vermont health connection I don't know if we do better than you know how we compare to the state we're very aggressive about doing that and we have lots of resources to help people a frequent policy requires that they apply for Medicaid first for their health so thank you and I look forward to continue conversations with people from the board or from the hospital association about the system statewide and just about the sort of the number of Vermonters that have bad debt as a result of the care that you see and trying to do a better job of understanding just who they are and how their lives are impacted by that debt we are very generous in setting up a contractual payment program with those that have bad debts I will tell you that we take $5 a month from some patients thank you Mike at this time I'll open it up to public comment if you wish to make public comment about the specific budget please stand up and when I call on you if you could state your name and direct your comment towards the board would anybody like to make a public comment Dale clarification first does it have to be the specific budget itself or can it be about the theme of bad debt or a specific budget but since that has been raised by one of the board members every time go ahead so talk me through this because I wanted to be totally appropriate I grew up in an area where I lived on the board so I heard that theme I'm very familiar with that whole issue of what is that when you're trying to decide where to get your care Dartmouth is right across the board and you got somebody practicing in my case it was what rubber junction where do you get your care what I wanted to point out is that became a really complicated issue more than I was hearing my employment is in Lebanon New Hampshire their insurance company prefer Dartmouth over any buddy that delivered care in my river because they saw with my epilepsy that was the care that was going to give the best benefit that's not totally up to me at that point if I want to keep the employment and here's the other issue I want to get to there's a sprawl effect around these issues it affected my day care where my kids was going to go to day care because they had to be on the way to work Dartmouth becomes key to where I can get the medical care which makes it possible to stay employed they all connect one falls apart they all can fall apart it's not really an option necessarily if you're trying to keep your employment they're going to get to have your care in Vermont and spend your dollars in Vermont I was making them in New Hampshire but it just doesn't work that way it gets much more complicated and the bad debt issue well if you lose your care because of bad debt that can cause you to lose your employment that means your kids lose day care the whole issue of bad debt becomes a problem of like me with epilepsy I can't afford to lose the care whether I can afford it or not because it's just going to make it worse I just wanted to comment that I think this is a very big issue but I don't think we've totally captured it in terms of how this plays out for the consumer thank you thank you Dale other members of the public who wish to comment yes please stand up and state your name so my name is DJ Russo I'm a resident of St. John'sburg and I have a vested interest in NBRH I was born there in 1972 five weeks ago I had a cardiac arrest and I was treated by NBRH so that's kind of like my book and story so to speak I have done pretty much everything I think you can do regarding a hospital service I've worked pre-hospital I work on the fire service and I'd be curious to actually see some of your numbers NBRH's numbers as far as avoidable costs seem to be going up and other ones are going down one of the fire departments I work for we have the busiest in the state so much so that we have to employ a third ambulance service we're running 24-7 365 a year and I have transported numerous anonymous people who have avoidable ER and other things one in particular a college woman very young called and complained of abdominal pain she met us at the door I said what's going on? had abdominal pain, how long has it been going? 15 minutes taking anything for it? No going to the hospital? Yes dressed like any of you are right now no stress, no issues and she just walked herself right over to the ambulance sat in the stretcher and she was three quarters of a mile away that's something that she could have easily seen her primary care doctor or she could have gone by I'm not worried about my phone that's okay she could have gone by Uber she could have gone by Lyft you name it, she could have gone by Lyft this is the kind of society we're starting to see more and more so I don't really see a decline in that I see an increase in that people that are being requesting EMS services for things they don't really need I think some of that is an educational thing I really do the department I'm on I try to do a lot with their social media and I do that as a way to educate so in the fire services a lot of people that do not understand what we do and some of the posts I put on there I'm often getting comments from readers I didn't know that you guys do in the fire service now I understand why we have to do this we're having a traffic and we have to go around we have to stop and wait, whatever it is we're talking about for that particular thing I think the hospital service is no different people do not truly understand what the purpose of some of the hospital services are and what they can gain from the primary care provider again, that's great you want to keep it to bring your phone as a matter of fact so I don't think people truly understand the difference between what they need to get from an ER visit versus what they can get from the primary care physician I think that needs to be spread out I don't care if it's end-gare reach or fletch around or colopy or whatever I think that is a systemic issue that's going on so I'm curious about that as far as the cardiac side of it again, that's the most recent thing for me I've seen some cardiologists through end-gare reach and now I have to go through Dartmouth I'm glad I got a letter from them saying they're coming up which is great and that saves me an hour commute one way a two hour drive not counting my visit so I think that's fabulous end-gare reach, I think it does a great job as far as education goes with the community could it be better? yes, of course, everybody's education could be better a great example is the CPR issue you know, I would not be at your table as a part of my life but that same concept I understand, just something as simple as compressions only CPR that word needs to get out well, how do you get that out? it's either the fire service because they're the ones that show up the ambulance service because they're the ones that show up or they're the ones that are going out to these different social community events and end-gare reach is one of those as well they're trying to get out there it's one of those things we just need to promote more of for other people so education is huge