 Let me just check to make sure that we have all the board members here. I see Maureen and Robin and Jess and Tom, so we're all set. And I just wanna start off today's meeting. We're gonna introduce the members of the board. My name is Kevin Mullin. I'm the chair and we'll go in alphabetical order. Hi, I'm Jessica Holmes. I'm from Middlebury. I teach economics at Middlebury College and I've been on the board for six years. Hi, everyone, I'm Robin Lunge. I live in Berlin and I've been on the board for four years and prior to this worked in various government settings on healthcare policy. Good morning, everyone. I'm Tom Pelham. I also live in Berlin but grew up in Arlington. And I was the state's finance commissioner for a number of years and tax commissioner for a number of years. And I've been on the board here come November three years. Hi, I'm Maureen Youssefer. I've been on the board a little bit over three years and my background has been corporate finance, CFO and also on public and private boards. Maureen, you have a little film noir thing going. I know. The sun is like coming in right now and I'm like trying to pull the shit down. I'm in like my office in Arlington and should settle down. Well, it's better internet. So that's the most important thing. So we're going to start by just, I want to remind everybody that the chat function is not a way to submit public comment that after each hospital budget hearing there will be an opportunity for the public to comment on that budget. And that would be the appropriate time to do so. So if you could please refrain from using the chat function, that would be great. The first hospital today is Gifford and Dan, are you all set? Good morning, Kevin. We are all set. So Dan, if you could introduce each of the presenters for the court reporter and then raise everybody's right hand so that she can swear you in. Okay, great. My name is Dan Bennett. I'm the CEO at Gifford and the other presenter is Wayne Bennett. He's our interim CFO and no relation. We are ready to swear in. Good morning. Good morning. Would you please raise your right hand? Do you swear the evidence you are about to give shall be the truth, the whole truth and nothing but the truth to help you God. I do. I do. Thank you. And Dan, whenever you're ready, you can begin. And I do see that we have one of your local reps on the line as well. So representative Reed, welcome. We're always happy when legislators take the time to attend any hearing of the Green Mountain care board. So thanks. Well, I wore two hats and some on the board of Gifford as well. Okay. Dan, whenever you're ready. All right, great. So Kevin, if you can just confirm with a thumbs up that you can see the presentation on the screen. Okay, that's good. Great. So Wayne, if you wanna go to the next slide. So today we are going to be presenting all of the portions of the budget presentation that were requested by the board. We're going to do that in three sections as we go forward today. The first section we're going to cover is that we're going to provide information for the board on what is transpired around our financial improvement plan that we've had in place now for a couple of years. That will take us on a timeline that will end as of the end of February this year, which as we all know is basically the timeframe when we emerged into the pandemic. The second phase we're gonna go through is the pandemic to date. So we're going to give you information on what our strategy was as an organization for making our way through the pandemic and then give you an overview on the financial impact of the pandemic. Again, to date. And then finally, of course, we're going to go into our presentation on our 2021 budget and the assumptions that we followed to construct that budget. Before I do that, I do wanna just take a second and thank the Green Mount Care Board. You made some changes to the process this year that were helpful given what all of us were going through and that's much appreciated on this side and just want to acknowledge that. And then also to thank once again, the Green Mount Care Board Hospital budget staff, Patrick, Lori and the whole team for their work and their help as we go through this process but also throughout the year, they're always very available whenever we need them and always very helpful. So just wanted to say thank you to all. Go to the next slide. So first off, just real briefly, an overview of the corporate structure here at Gifford. As we've talked about in the past, we do have a unique organizational structure in that our parent organization is a federally qualified health center. We are one of three organizations in the country that have this structure, the other being Springfield. Obviously they're going through some changes right now but it is a unique structure. So under the FQHC, which houses all of our primary care practices, we have Gifford Medical Center which we're here to talk about today. We are a 25-bed critical access hospital. Our and our specialty physician practices fall under the hospital. The third leg of the Gifford stool is Gifford Retirement Community which consists of our 30-bed nursing home and also our 49-apartment independent living facility. We also have an adult day program that we run in Bethel, Vermont. So today, as we move through our presentation, we are going to provide some key financial information at our system level. So at the level that includes all three organizations, we're going to do that in order to better present our overall financial, the overall financial health of our organization. But obviously when we talk about the specific budget, we are talking specifically about Gifford Medical Center. Next slide, please. So as I presented to you on numerous occasions and as you're well aware, Gifford has had some financial challenges over the last couple of months, sorry, over the last couple of years. And we devised a three-part plan for us to improve upon our finances and started this after fiscal year 17 into fiscal year 18. The three parts of that plan, first off, the first part was to return to our historic volumes. And this really focused in large part around filling vacant positions and the most impactful from a financial standpoint were vacancies in our orthopedic and general surgical areas. The second part of our plan was to reduce cost. We took many actions over the last two or three years to improve our efficiency by reducing costs throughout our organization. Finally, we have made a concerted effort to expand our community outreach and our partnerships throughout our community and with other healthcare and social services organizations. And in order to serve our community, we need to know our community and we need to work with other parties within our community to be successful. Our efforts to date as we go up through the first part of our timeline to from fiscal 18 into the period that ended in February of 2020, our efforts were successful. We have achieved sustained profitability up to the period that we started the pandemic. Wayne is going to now share with you some information on what that looks like and I'll turn it over to him. Thanks, Dan. This is a schedule that shows at a very high level, the financial results for FY17 and 18 and 19 and then year to date through February just prior to the pandemic. And what we're trying to demonstrate here is what led, again at a high level, what led to the losses in FY18 and then what had to be turned around so that we could recover. So the highlighted yellow areas show the percent change in revenue and the percent change in expense compared to the prior year. So you can see that in FY18, different medical center, the hospital had a $5.3 million loss from operations compared to the prior year, there was a 10% reduction in revenue. So a 10% reduction in revenue and a 2% decrease in expense caused the gap of loss from operations. And at a system consolidated level, there was a $6.8 million loss in FY18 with a 5% decrease in revenue and actually a 0.6% increase in expense. So things are going in the wrong direction. To improve on that in FY19, so to go from a $5.3 million loss in FY18 to only a $400,000 loss in FY19, revenues grew by 3% and expenses dropped by 6%. So thoughtful efforts in reducing the expenses paid off and we saw significant improvement. You can get a sense of what the changes were to improve efficiency by looking at the FTE account. So in FY17, 341.7, 340.5, pretty much the same in FY18, but then a significant decrease, about 4% to 326.9. You know, salaries and benefits are about 60% of our total expenses. And so you really can improve efficiency or reduce expenses without reducing FTEs. So the FTEs dropped by a significant amount on the 326. So significant improvement between FY18 and 19 and then entering FY20 for at least the first five months, we again had a significant increase in revenue. So all the efforts that Dan was just describing of patient volume coming back to where they were a couple of years before resulted in a 10% increase in revenue at the hospital for that five month period. A 5% increase at a system combined level was only a 2% increase in expenses. And so for the five months at ending in February, for the just before the COVID pandemic, we actually were profitable from operations at both the hospital level and the system combined level. So at that point in time, we felt that we were really on the right path and had made really good decisions over the past couple of years to improve patient revenue and volume and keep our expenses under control and we're sitting in pretty good shape. When we diagnose our overall financial health and we try to measure our overall financial health, we compare ourselves to some key financial ratios and we benchmark ourselves to the Moody's BAA3 rating, which is sort of the entry level of investment grade hospitals. And so our goal is to always be better than these benchmarks. And so there are eight specific benchmarks. They measure the areas of profitability, capital financing, liquidity and average age of plant, average age of buildings, equipment and technology. And you can see on this, green is better than the benchmark and red is worse than the benchmark. And even back in FY 18, when we had significant operating losses, we still had fairly strong cash reserves. So even back then 164 days of cash on hand, 120% more cash than debt and fairly low debt. Debt only represented 35% of our equity. And so even back then, the problem was really their earnings and the day-to-day cash flow, more than it was our balance sheet strength. And so even when we had the losses in FY 18, because our balance sheet was so strong for many years of really successful financial results and good decisions made for a long time, because we were so strong at that point in time, we had the luxury of being thoughtful in developing the turnaround plan on a go forward basis. Back in FY 18 though, you can start to see a troubling trend of the average age of plants. What's happening is due to the losses and the weaker earnings at that period, less money could be spent on capital expenditures. And you start to see a weakening of the average age of plants are not enough being invested in the plant, particularly at the hospital side. Then you can see that it starts to improve in FY 19 where the earnings ratios are a little bit better. Then when we get to the year-to-date February, the five months of this fiscal year, all the ratios are green at both the system combined level and the hospital level, except again for the average age of plant. So things had really turned around. We thought we were doing pretty well and we started to discuss how to, the next step was trying to improve the average age of plant ratio, starting to think about putting a little bit more of our cash and positive cash flow into investments in capital. So that's where we were at that point. Like I said, we were feeling pretty good about ourselves. And then COVID arrived. And so what was the impact of COVID arriving? So this is a graph that shows, just to demonstrate this, shows weekly charges. It starts back in the first full week of January and goes right up until last week. We updated this this morning to go right up to last week. And you can see that as soon as we entered into the period of social distancing and patient caution and the cancellation of elective procedures, the revenues significantly drops immediately. So we were going right along in the first couple of months of the calendar year, averaging about $2.7 million of patient charges a week. And then it drops in half in a three or four week period and bottoms out in around the fifth week, right about here. I had about 50% of our normal business. And you can imagine the sleepless nights that were happening at that point in time. We really weren't sure what was gonna happen. Again, because of the strength of our balance sheet and our cash reserves, we were able, again, to have the luxury of being thoughtful in developing our action plan at that point in time. But we weren't really sure what was going to happen. Right about this same period in time, right about week five, right about the middle of April, we did start getting COVID relief funds. So that made us feel a little bit better and we'll talk eventually about those COVID relief funds in a couple more slides. But then you can see that things started to turn around as things opened back up again and revenues started gradually coming back. And this is important to talk about as we, when we get into our budget for next year, we budgeted next year that patient violence would come back to the pre-COVID levels. And we were feeling pretty confident about that as we were submitting our budget, which is right about here. And we actually were back for a couple of weeks. Lately, things have dropped off a little bit, but we'll go back to this slide that around when we talk about developing our budget for next year. I'll hand it back to Dan to review our priorities as we began managing through the pandemic crisis. So as Wayne noted, when we came into the period, the pandemic period, what we've called here, the COVID calamity, we had neither no expectation or no promise of any significant financial relief from the federal government, state, what have you. So at that time, our leadership team sat down and came up with the priorities that we were going to follow as we went through the pandemic to ensure that Gifford could be as strong as possible and that we could assist our community in getting through this crisis. We wanted to ensure that we acted strongly enough to accomplish these goals, but we also wanted to ensure that we didn't overreact. As Wayne noted, we were coming into this situation with some financial strength. We had a good balance sheet. Our day's cash in hand was strong. So we knew that we could take a little bit of time to come up with a solid plan to assess what happened and then to adapt as we went through time. So we wanted to use the time that was available to us to devise a good plan and implement it appropriately. We came up with three broad areas that we wanted to focus on. The first is that we were going to provide appropriate access to care for our community and we were going to communicate throughout this event to our community, provide them with the information and resources that they needed. The second was that we wanted to make sure that we maintain a strong and well-supported workforce throughout this event and that when we emerged from this event, whenever that is, that our employees are able to continue to come to work and do their job well and that they've been supported. And then, finally, obviously, we wanted to ensure that we maintained our financial strength throughout this event. Put it to the next slide, please. So some more specifics around that. On the first item, the access to care and communication with our employees, I'm sorry, with our community, we wanted to ensure that our primary care offices remained open for needed care and that was a combination of continuing to provide some face-to-face services as appropriate but also expanding our telehealth and our telephonic care. One of our main goals here was that we wanted to make sure that our community members, that our patients received care in the right setting. We were expecting at this point that we were going to be seeing a lot of COVID-19 patients in our emergency department. We were ramping up to be able to provide for COVID-19 patients in our inpatient units as well and we were planning for surge capacity around those areas. So we wanted to make sure that people who had other health issues or other health needs that they could receive care outside of the emergency department or inpatient settings and that they didn't wind up there unnecessarily. So we did ensure that we provided care to our community by all means necessary. We also embarked upon an expansive testing program. Our testing program has obviously included people who are symptomatic or people who have had actual or expected exposures to people, to other people who have COVID-19. We enacted a testing program for our employees and also for pre-operative patients. Since May we've also been offering community asymptomatic testing and more recently we've been focusing on some high congregation testing which is meant to represent schools, colleges, churches, other areas where people would be congregating in numbers. This program has been very successful. Through, since May we have tested 3,900 people. I'll show you a graph after that, that visually represents that but it's been a good program. It's been very valuable to our community. It's been very valuable to Gifford as we've gone through the first stages of the pandemic. We also focus very heavily on communication. Hopefully some of you have seen our Chief Medical Officer, Dr. Josh White. He has been very prominent in our communication strategy. He has been blogging. He has been speaking to local press. He's also been on some of the statewide press talking about the pandemic and frankly providing very common sense information on all things COVID to people in our local community and throughout Vermont. That's been something that we've wanted to focus on. We wanted to make sure that people in our community had the information they needed to be able to to be able to make it through this pandemic in this very scary time. One of the other things that we've done is to work with some of our partners to ensure that people in our community had the basic needs that they required throughout the pandemic. An example of that is the Veggie Van Gogh program. This is a program that we've been working with the Vermont Food Bank now for over a year. When we hit March and the pandemic started and there were a lot of changes and guidance coming from the governor and others, we had to quickly adapt that program which was needed even greater than it was prior to the pandemic. So we expanded our program to do a drive-through program. We expanded sites in addition to doing our Randolph program. We also were able with some community partners in the Rochester community to, we were able to expand it there as well. We utilized a drive-through format that allowed us to socially distance while also being able to efficiently provide needed food to people in the community. And we've gone, we've seen a significant increase in numbers of people. We just did one this week. And again, we had in excess of 500 families that we were able to serve with our program this week. And that's been consistent throughout the pandemic period. So this is a visual representation of our testing program. The map on the left shows you where, visually on the map of Vermont shows you where people come from. I realize it's a little small, but it does represent that the greater number of the testing come from our service area. The darkest block in there represents the Randolph area. So that's where the majority of our people have come from. But we have serviced people from outside of our area as well. Most of these people are people who are coming into our area for some purpose, travel, work, or otherwise. But it has been a very successful program. This particular graphic that you have up here is a few weeks old. So as I noted earlier, we've, as of the beginning of this week, tested 3,900 people. We also have been able to mobilize to do a greater number. You'll see on the far right the test by service state that we were able to mobilize on a couple of occasions to do wide-scale testing. And so we have had the capacity to do that. I do want to note that we've done this in conjunction with our federally qualified health center, which did receive some funding to help defray some of the cost of this. And that has been a significant benefit of our structure in having an FQHC and hospital working very closely together. Next slide, please. So the second goal we had was to ensure that we could maintain a strong and well-supported workforce. As you all know from the work you did over the last year, headed up by Robin on the task force on our workforce that focused the task force on rural health, which had a large focus on workforce. Workforce issues were prominent prior to the pandemic. And it's only gotten, workforce has only become a more prominent issue with the pandemic. Our leadership team decided early on that we had to ensure that our Gifford people would be safe, secure and well-supported throughout the pandemic. Our first step in that was to ensure that our people had access to the PPE, the personal protective equipment that they needed in order to see patients, in order to be able to come to work, the people who were able to come to work physically to ensure that they were protected. And we also quickly moved to enhance our infection control protocols specific to COVID-19, so that again, we could ensure that there was a safe workplace and a safe care environment for our patients. We also, once we hit the beginning of April, we offered a voluntary furlough program. I do wanna stress this is voluntary. And as we moved through the first part of the pandemic, at one point we had about nine to 10% of our total workforce had chosen to take part of our voluntary furlough program. We also offered work from home options for people and quickly deployed the technology and training so that people who were, for whom it was applicable that they could work from home. We also redeployed staff to other areas around Gifford. First, as we planned for surge, but then later on to help fill in another areas and to be able to staff areas that we needed to stand up specifically because of the COVID-19 pandemic, such as screening, working in our testing program, those areas. We also developed and then adapted quarantine pay policies if our employees were exposed to someone who had COVID-19 or if an employee should contract COVID-19, we had policies around quarantine pay. So again, they would be protected in terms of their livelihood, should they be in that situation. We also spent a great deal of time and effort on communication internally. One of the things we started up quickly was to expand upon our quarterly program for all staff meetings. We began doing that on a weekly basis, then a bi-weekly basis and now we're doing it on a every three or four week basis, doing video meetings with our employees to inform them on what's going on, to give them clinical updates, to give them updates on our furlough program and other information that was pertinent to them at that time. We had very good participation by our employees utilizing the technology that was available. We also utilized electronic communication with email updates, both clinical and administrative and we stood up a phone information line as well that our employees could access to get up-to-date information. And then finally, we have applied for the state hazard pay program that we had about 200 employees that we deemed to be eligible for that program. Next slide please. The third area was to ensure that we came through the pandemic retaining our financial strength and we focused on what we could do around expense reductions and cash flow preservation. I mentioned our voluntary furlough program. At the height of that, we had 66 people representing about 44 full-time equivalent positions or 9.5% of our workforce who took part in the furloughs. That really was instrumental in our being able to reduce expenses in line with our reduced volumes and revenues that were apparent on the previous graph that Wayne had shared. So that program was successful. With the expiration of the federal unemployment bump, the $600 a week program that the federal government put in, that expired at the end of July. We have brought back virtually everyone who was on furlough and as Wayne illustrated on our revenue graph, we have needed people because of our volumes returning back to near normal as well as having some additional areas that we need to staff as I noted, our testing program and our screening program. We also delayed our annual wage increase program which was scheduled to take place in April. And then from a cash flow standpoint, we did put on hold our women's health renovation project which had started up prior to the pandemic. We did put that on hold although we were able to restart that in July as we started to see our return to more normal volumes. So with that, I'm gonna turn it back over to Wayne to talk about the COVID relief funds that we received. So despite the efforts that Dan just described, we were able to reduce our costs a little bit during the crisis, but certainly couldn't avoid the losses that were created from the really significant decrease in patient volume. So as that slide disclosed, we lost $6.3 million between March through July really. But we were fortunate enough to get quite a bit of relief funds. So this slide shows the at the top level, what came into Gifford Medical Center and then what came into the FQHC and the retirement community. In total, we got $7.5 million of COVID relief payments. This does not include an additional $8.7 million of interest rate cash advances. So what's shown on this slide is the actual grants that came in, the actual funding that we got. So 7.5 total COVID relief from CARES Act funds, the rural stimulus funds and some payments that came in for the Vermont Medicaid retainer payments that came into both the hospital and to the FQHC. So the hospital had $5.2 million of operating losses March through June. So at this point, there's only about $200,000 left from this pot of money that came in. We brought the rest to income. So we're reporting break even on our income statement from March and we have July results all the way through July with $200,000 remaining as we get into August. The FQHC received $2.1 million of COVID relief and only had $1.1 million of losses in the period. And so still has a million dollars remaining of COVID relief funds. We did submit our financial information to the healthcare provider stabilization grant. And I've had some discussions with that office. We don't expect to receive any funds from that because we didn't suffer losses in the period. We did think it was important to provide our information to them so that they knew what our situation was in case we need to apply in the second round of funding there. If we have losses in the next period after July and August, we may need to apply that. We just want to apply for that and we wanted to make sure that they knew what our situation was. So we were very fortunate to essentially get through the period relatively unscathed financially. And that brings us right up to today. And so now in our presentation, we're going to transition to starting to discuss what our budget submission was for FY21. Needless to say, the disruption and distortion from COVID provided quite a challenge in trying to determine what to budget for next year. So I'll hand it back to Dan before we go through the numbers and Dan can discuss our vision and outlook. Thank you, Wayne. So as Wayne noted, there's a great deal of uncertainty which has been in place since March and continues as we look forward into the next year. That being said, we do continue our work in support of Vermont's healthcare reform goals. As we've noted, we have undertaken a lot of successful efforts to reduce cost and those efforts continue. We also are continuing to invest in our population health programs in working with our providers and our practices on active care management, panel management, working with partners in our communities on a number of initiatives that are in keeping with Vermont's healthcare goals. And we will continue to do that moving forward. We are anticipating continuing in the all payer model with both the Medicaid program and with the MVP shared savings program. Those are the two programs that we're currently participating in and that is our plan to continue those as well in 2021. In the short term, we are going to continue with the goals that we set to assist us in moving forward throughout the pandemic period, the three goals I talked about earlier. And we will continue also to take the information and what we learned from this period to assist us in our planning as we move forward. So that takes us in the timeline that I talked about at the beginning from the period over the last couple of years through February and then through the COVID period, COVID pandemic period up to now. And Wayne now is going to take us to the next step and talk about 2021 and the assumptions that we used to build our budget. So to summarize, I guess our budget submission includes a slight reduction in net patient revenue. So this is the net patient revenue plus the fixed perspective payments. So we're budgeting next year 0.6% less than we budgeted in FY 20. The left-hand side of this shows our projected 20 against our budget 21, but doesn't really provide a meaningful comparison because the FY 20 projected is very low because it includes the COVID period. Normally when we put a budget together, the current year provides a base for forecasting next year. But we didn't really have a good base to go on this year. And so we had to make a critical decision early on in the budget planning process about what to use as a base. So what we decided to do because we felt at the time in the middle of the COVID crisis that we really couldn't predict what was really going to happen over the 18 months after COVID. And so we rolled everything back to February. So we used the five months ending February as our basis for projecting the next year. And because we were fairly close to budget in the five months ending February, we end up submitting a budget next year fairly close to the budget of last year. We based our reimbursement rates on the actual data through June because we felt like the five month period of October through February wasn't enough of a baseline to look at that. And so the combination of rolling forward the volume and then looking at the reimbursement rates over a slightly longer period resulted in the numbers that you see on the screen. We do have a 4% rate increase in our submission. That is an effective reimbursement rate of about 2%. So when we raise our prices 4%, the commercial payers on average pay about 65% of that. So the impact to our commercial payers, we estimate it's 2.5%, 2.4%. Actually, our government reimbursement payers Medicare and Medicaid on average, we estimated 1.8% of an impact to them. And our self-paid patients, we have about 5% of the population that has no insurance. The impact to them is 2%. We give an automatic discount to anybody that comes with no insurance at all of 50%. So the 4% price increase to the self-paid population is an impact to them of 2%. The weighted average of all that is about 2%. So our 4% price increase yields us about $2 million of net revenue. And all of that math results in a net revenue fixed prospective payment budget next year a little tiny bit less than what we submitted last year. Just to explain, just to sort of demonstrate this a little bit further about our assumptions of volume. So this slide shows some key volumes, indicators in these rows that are highlighted in yellow. So total patient census, total OR minutes per calendar day, total ED visits per calendar day, and you can see the trend. So for example, FY 18, the inpatient acute census plus the swing bed census was 14.3. And FY 19, it was 13.7. And then the five months ending February 13.8. So we were running right on budget 13.8. So our budget next year is 13.8. We rolled it back to the February numbers. This year dropped to 12.5 because the census dropped so much during the COVID period. So we didn't want to use that as a base. We just rolled it back exactly precisely to what the volumes were pre-COVID. OR minutes per day, part of the reason we were doing so well in the five months ending February is we had more surgery as we tried to get back to previous surgery volumes in the past and recruited a new surgeon. So 328 minutes a day, we budgeted 328 minutes a day. 17.4 ER visits per day, 17.4 ER visits per day. So that's basically how we did it. You know, when you go, we visit this slide of patient charges per week. You know, like I said, when we were in this zone of this few weeks, we thought it looked pretty good and that things were really going to come back. Lately they've been a little low, although we suspect that they're low in August because of more and more vacations, vacations of our providers and vacations of our population. And so we think maybe this is low because of that and things will come back. You know, there's a question about whether there was a little pent up demand that was met in the July period and maybe that's going to drop off. But I guess at this point, we're feeling it's more likely that it was the vacation season and we think we will be back to normal. So we're feeling pretty good about our budget submission at this point in terms of the patient volume. But, you know, it's really hard to predict what's really going to happen on a day-to-day basis, things change so much. So back to our summary of the budget, that we submitted an operating margin of 1.8%. Again, with just 0.7%, so budget to budget 0.7% more, net revenue 1.8% more operating expense. So on the operating expense, we basically did this similar thing to revenue. We went back to February and looked at the actual trailing 12 months of expenses in February. And we rolled those forward adjusted for inflation. And that came up with 1.8% more than the budget of this year. I mean, again, we were pretty close to budget back in February. So, you know, taking those, that experience and assuming it's going to repeat itself after the COVID epidemic with a little bit of inflation gets us pretty close to what we started with on the budget. So 1.8% more expenses. So a smaller net operating income, 2.9% operating income last year, 1.8% this year. You know, given the strength of our financial ratios, we felt like that was okay to have an operating margin of 1.8%. A total margin of 3.6%. You know, as we demonstrated before, the organization has fairly strong cash reserves that are invested in the market. So with a modest return in the market, we get $1 million a year of non-operating revenue to help with our bottom line. So in summary, that's our results than going through the detailed income statements. I wasn't going to spend a lot of time going through these numbers in great detail. On the cash flow statement, you can see here it's a little bit hard to follow the budget FY21 cash flow statement because there's a big impact in here of the payback of the interest-free loans that we got. So you see that in this line, $6.4 million. We project to end the year still owing $6.4 million to still holding on to that cash and owing it back and then we pay it back next year. So although this appears as though there's $7.3 million of negative cash flow in the year, there's really only $1 million or so of negative cash flow. And that's because we assumed a larger capital budget spend of $4 million, which is about 1.7 times depreciation. Normally that would be a little bit more than you would expect to spend in capital, but we're trying to improve that average age of plant ratio that we talked about earlier. So if things go well and we stay on budget, we'd like to spend a little bit more on capital, trying to improve our average age of the plant. I'll hand it back to Dan to talk about the service line adjustments. Okay, so the service line adjustments are one of the questions that were asked. We were asked to address in the presentation. We are not planning any service line changes in 2021. As I talked about at the beginning of the presentation, we have seen steady progress in our original improvement plans over the past two to three years. And we believe that our current model is solid. The budget that Wayne just presented as well builds upon those plans. And so we are not anticipating any changes to our overall service lines in the coming year. Moving to risk and opportunities. On the slide we focused obviously heavily on the pandemic. We are not finished with this yet. And obviously none of us can predict how long it's going to be with us and what impact it's gonna have going forward. So that is the obvious risk that we have at this point. As Wayne outlined, our budget assumes that we are able to avoid the types of disruptions in care and the types of disruptions to life that people experienced in that period. March, primarily March through June or March through May, that that won't repeat. Obviously if it does repeat, all of these assumptions will need to change. Moving forward and we'll have to take the same sort of actions we've taken to date. I do want to focus a little bit on workforce. I noted that before coming into the pandemic period. This was a difficult environment to both retain and recruit employees, particularly in rural communities like ours. So we continue to have those same pressures. Competitive, this is a competitive market for employees. We have seen upward pressure for wages. Obviously with the COVID-19 pandemic, there's some other challenges that did not exist previously. This includes some additional childcare issues. And I think we could all agree that there were greater needs for childcare. Somebody could mute their phone or laptop, please. Prior to the pandemic, we needed more childcare options in the state of Vermont, particularly in the rural areas. That has only gotten more difficult with the pandemic. Add into that the different plans for kids going back to school and the impact that has on their parents who are our employees. This causes a lot of additional stressors for people. And we are concerned about the ability to be able to, of our employees to be able to show up on a day-to-day basis with all these things that they're dealing with. So those are, I think, the biggest risks that we have right now. Obviously there's environmental risk and the healthcare environment that we faced. And I think that have been well discussed. But we feel those are the general risks that we face for this budget year. And now back to Wayne. So wrapping it up here with our capital budget plans. So due to the uncertain environment, we did not put any major capital projects into our planning for next year. We restricted our planning to just routine replacement of equipment and medical mechanical systems because we wanted to be flexible should we need to sort of shut down again. This year we were in halfway through our construction project that we had to put on hold. And so we don't wanna be in that situation next year. We wanna have the flexibility of stopping our capital spending if we need to hold on to cash. And so we're really just looking at routine replacement of basic equipment and mechanical systems. We just wanna let you know though that we are looking into trying to take some of the surplus grant funds, COVID relief grant funds that the FQHC got and perhaps invest in expanding our broadband capability to support telemedicine a little bit better for the future. So that wraps up our presentation and we'll open it up to questions. I think you're muted, Kevin. Yeah. Can you hear me now? Yeah, thank you. Before I turn it over to a board member lunch, I just wanted to say that two years ago, if anyone had asked who would be the biggest fear after the Springfield debacle, it would have been Gifford based on your operating losses that year. And I think that you and everyone at Gifford is really focused on keeping your organization alive and healthy for the long-term and your efforts are paying off. And I just wanted to acknowledge that before we started our questions. So keep up the great work and we'll start with board member lunch. Thank you. Hi, good morning. First of all, I just wanted to say thank you for all of your hard work and dedication during the COVID-19 pandemic. We very much want to recognize just the lengths that all our healthcare providers had to go to, including all of your staff members who continued to come to work in faith of the pandemic and do what they needed to do for their community. So thank you. In your narrative, you mentioned that you are starting to do some short and long-term strategic planning, both related to COVID, but also entering into a longer term strategic planning process. As you know, the board has been working on sustainability planning with hospitals to try and figure out a path to move forward there. How can our sustainability planning that we are doing together and your strategic planning work together to really incorporate that kind of thinking into your community strategic planning process? That's a good question. Thank you. Thought I'd start out with a bang, you know? Softball. Yeah, so much for the softball question, but no, obviously that's something that I know the board, the Green Mountain Care Board is wrestling with. And we obviously are trying to make that connection on how we're going to go through this process, which I think it's still in development with you and do appreciate your keeping the lines of communication open as you do your planning around that process and including the hospitals in that. I think my first comment would be as I think similar to what you're saying is that the process that the Green Mountain Care Board goes through should not be duplicative to what our organization does for strategic planning and the responsibilities of our board of directors around their governance, their governance of Gifford. As you're well aware and you've heard from us and you've heard from other hospitals, we're stretched a bit thin right now and taking on another large scale project while we're dealing with all these things that we're dealing with, in addition to the normal work of running a hospital, taking on an additional task like that is difficult at this time, so we do appreciate your flexibility around that. So I think the work that the work that you're talking about is the work that the board and our organization does. Sustainability is something that we look at, looking at what services we're providing, matching that up to a community health needs assessment, matching that up to the demographic level matching that up to the demographics of our community which tends to trend to more of an older population, tends to have transportation challenges some geographically based but also based on socioeconomic factors in our communities. We look at all those things and in our strategic planning process we try to match that up to what the needs of the community with what we should do as a community hospital. I think we do that very well. I don't think that we have services that go outside what a small community hospital like Gifford should be doing. We don't try to do things that we shouldn't do here. We provide the services that we can support and it's not just as much, it's not only having a physician or a surgeon who's skilled in a particular area but do we have the support around them? Do we have the capacity in our nursing staff? Do we have the ancillary staff? Do we have the equipment? Can we afford to be doing these things? We look at all of that. So I think there is consistency with the strategic planning process with the governance. Again, I guess my plea would be to to not duplicate that process as we go forward because we are doing that and my assumption is that the other hospitals are doing that as well. So I don't know if I answered your question but that was my comment. Yeah, thank you. You did. I wanted to talk a little bit about your reimbursement assumptions for 2021. I know you said you looked at the actual data for how reimbursements were trending. Did you make any assumptions around changes in Medicaid prices or Medicare reimbursement and related to that? Did you factor in any of the temporary changes removing sequestration for Medicare? Yeah, so our basic assumption of government payers, Medicare and Medicaid was that they would increase their rates 1.8%. With Medicare, we're cost reimbursed. So the reimbursement goes up and down when our costs go up and down. So we had a little bit of inflation there in cost. So that was the initial basic assumption on Medicare and Medicaid. But then we also assumed that we'd have more Medicaid patients enrolled in the ACO and we are getting reimbursed less for that. So then it went up 1.8%, but then down a significant amount with more people enrolled in the ACO. On the sequestration, we did assume that sequestration would still be in place next fiscal year. In FY19, the effective sequestration was $234,000. So it doesn't move in a little lot whether it's in or out. But because we rolled forward from the past and it was in the past, it's in the budget. So that was our basic assumptions. Okay, thank you. I was interested in hearing a little bit more about your telehealth experience. In particular, I mean, obviously it's, the FQHC would have the primary care component of that. But I was interested to hear, do you have a sense of percentage and visits in different settings that were happening by telehealth? Has that started to go back down with the reopening? What do you expect moving forward? So I'll start there. So, yeah, I'll take it. So we did see a significant jump. So, and I'm gonna, I'm gonna, this is gonna include both video telehealth as well as telephonic. But we went up as high as about a third of our visits went to, we're in those media, so telephone or video appointments with patients. That did, that has gone down since that was at the peak of it. We did have to do, it took us a little while to get to that level with being able to expand the technology and all. So that has gone, actually it's gone quite well as I noted before, one of our pieces of our strategy around our community was we wanted to ensure there was access to care, but we also wanted to do what we could to ensure that people weren't coming into a care environment where their potential to be exposed to somebody with COVID-19 would increase. And so this technology helped us immensely with that. We are continuing to explore how we make this more of a long-term part of our care environment. And so one of the, one of the positive things that came out of that and that will impact our strategic planning going forward is that we now have greater numbers of providers who now have some experience in using this and hopefully a greater comfort level in using this and how to introduce it to patients, how to ensure that patients are comfortable with it. So that's been a good thing. And we will be setting some goals on what component of our overall encounters will be done by these means. We haven't set that yet, but we are working on that. And we'll continue to ensure that we have the technological infrastructure to support that. Great. And did you find, I would kind of make a guess based on your catchment area and some of the rural areas within it that some of the patients, the phone was really the more realistic medium given their broadband or lack thereof issues. Is that a good assumption? That very much is a good assumption, yes. And we support all the efforts in the legislature with the administration and also on the federal level to expand broadband to rural areas that obviously has an economic impact but we can see where it has an impact on someone's well-being as well. Okay, great. What would you attribute your success in the quick implementation of telehealth too? Do you have any lessons learned or things that you think are worth sharing with other folks? Well, again, boy, you're getting the questions I didn't prepare for, Robin. Sorry, Dan. But I think- I've been asking the same question, so I'm sorry that whoever should be telling you this in advance so that you're prepared didn't know. All right, so you just showed that I wasn't as attentive on the other hearings as I should have been. Okay. So I think part of it is we are, one of the benefits of being a smaller organization like this is that we are flexible, we are nimble. We were able to get people, get our IT people in front of our clinical people, be there at the elbow to get them established. So I think that that was very helpful. We did have, I think, probably from what I've heard from some of the other hospitals and some of the other FQHCs. I do think we had a greater number of people who were physically coming into work on a day-to-day basis and at least at the onset of the pandemic that did allow us to get people together so that they could trial the technology here. And again, this was something that a number of people had not done previously. So that was good. I think good leadership as well on both our medical and our practice administrative structure was imperative here as well as on our IT side. So again, it's just a good alignment. I would go back and just in general, the ability that we've had over the past couple of years to make positive change, to get people to embrace change, having that be a part of our culture helps to deal with these kind of crises when they come up. And again, if I can just put in a plug, every single person at Gifford pulled their weight and then some throughout to this stage of the pandemic and just, I can't say enough, wonderful things for our team. Thank you. I wondered if you could speak a little bit about the status of travelers. We have seen with some hospitals that they were able to decrease their number of travelers over the course of the pandemic. So I was wondering kind of where you were at before, what happened over the last few months and what you're expecting for 2021. So it's like some of the graphs that Wayne showed, it goes up and down. Yeah. We've seen, particularly on the provider side, we've seen improvement. So as we've been able to fill some of our vacant positions over time, we've transitioned more from having locum physicians be here on what looks like more of a permanent basis. We've been able to reduce that significantly and where we are utilizing them in some cases, it's more just for periodic call coverage, which is fairly routine in a rural environment and a small hospital environment like ours. We do continue to see on the nursing side, particularly with the OR, that that's something that is a pressure that we feel. When I talk about the workforce concerns we've had, a lot of it's been regarding the OR, our nursing and surgical tech positions there. So we have seen, we get that back almost to full staff and then we have needs that arise. And I think that's going to be a continuing issue into 2021. Again, the childcare issues, the back to school issues only exacerbate that. And so how many travelers? It's only two to three. The nursing numbers are remarkably small. It's two to three in the OR at any given time. Right now there's three. Okay, great. Yeah, I was going to ask you at what numbers you budgeted for travelers. So it sounds like it's a small level. Two and a half, yeah. Great, thank you. And then my last question was life two. So the first is it looked like, so you mentioned that you pushed off your salary and merit market-based changes from 2020. Do you have that same assumption in 2021, a 3% wage increase? We do have that, yes. Okay, great. And then we, can you give us the information on what you budgeted for ACO dues and your risk? If you don't have that handy, you can submit that. You can follow up with that. Yeah, I don't have that handy. So we'll take it as a follow up. Great, thank you. I will pass it to the next. Thank you, Robin. Next we're going to move to board member Pelham. Tom. So my name is next. Good morning. I want to add my applause to Kevin's in terms of when I first came on the board, your declining financial situation became very present. And I remember looking at lists of reductions that were as small as $100. And I thought these people are going to be okay. There were no excuses. And obviously we're seeing the result of that now that you are in much more stable footing. And I applaud you for that. Because I know how difficult it is. I mean, those are very difficult things to do. So my first question has to do with fixed prospective payments in that you're looking at a 14.2% in the 2021 budget over 2020, which is still only 6.1% of your NPR FPP. And so I noticed that you were appointed to the ACO board in 2019. I think April of 2019. And I'm just wondering now, when in wearing both hats, how you would see and at what pace do you see the continued integration of Gipperd with one care? Thank you. Yes. So we are and continue to be very much supportive of the health reform effort. I'm not going to say that. I know you know, but somebody needs to mute. So we kept the travelers to help us get there. So someone's having kind of a rowdy conversation there. If they could put themselves on mute so that we could actually hear what Dana's saying, it would be very helpful. Just for the record, that wasn't part of my answer. So we are committed to continuing our involvement in the all payer model. Really for us, it comes down to a risk analysis. And as you noted, we've had a rough patch the last couple of years. We've taken a lot of efforts to improve upon that. And to this point, me, our leadership and our board have not felt that we were at a point where we could take on the level of risk that we would need to continue to expand that participation at this point. Obviously, the pandemic has only amplified that in the activities and just the whole unrest around what's going to happen moving forward. So that's where we are right now. That being said, we are investing in the activities that we think will make us successful in a population health, value-based purchasing type environment going forward. We will continue to do that. We think that our structure as a federally qualified health center and a hospital that that structure will be beneficial over the long term as we continue to make investments in this reform effort. It is, I will just, I'll get on the soapbox a little bit since you gave me the opportunity that I do think that it's important that the state and continue to invest in health care reform. There were delivery system reform dollars that were in the original plan, some of a very small amount of that has been appropriated but the vast majority of it has not, which then has resulted in hospitals having to pay much larger dues than we would have otherwise to invest in the activities that will make us successful, the whole system successful in this environment. So that as well is an impediment, particularly for small hospitals like Gifford to make the more rapid move into this program. Thank you for that answer. My next area of is having to do with bad debt and free care. And on a kind of a combined basis, Gifford's bad debt and free care are projected to grow a budget to budget by 36%. And if you look at it going back to 2019, it's a 50% increase over your 2019 actuals. And that stands out a bit to me. The system wide averages is a budget to budget is a 13.1% growth rate. So I'm wondering and it's, the increase that you're looking at is 1.3, 1.4 million over the 2019 actual. So I'm just wondering what you see that might be driving the increase in combined free care and bad debt. You know, over the last two years at the, at the pace that we're, we're, we're you're showing. Yeah. So it's hard to compare to the 2019 actual because those numbers are a little bit depressed because of the volume in COVID. But we're like everybody else. That's 2020. Oh, yeah. The 2020. Yeah. I jumped, I jumped over the 2020. Yeah. The 2020 projected. But we are seeing growth in bad debt, just like everybody else related to higher out of pockets. You know, the, the copays and deductibles that people have. So we do see that as a little bit of a trend. We're trying to give away a little bit more free care. We simplified our process for applying for it. And we're trying to screen people to qualify because those numbers seem a little low to us when we benchmark to the, you know, the rest of the industry. So we've expanded that a little bit. But other than that, I can't really explain the growth other than sort of what's happening economically around the country. Thank you. Next area is the provider tax. This isn't a huge amount of money, but I'm was looking at your 2020. The provider tax related to 2019, and it was just about 6%. And what you budgeted in 2021 relative to 2020 projected is a 6.6% increase in the provider tax. So I'm, I'm wondering if, if you're hoping that there's a little bit of a cushion in that projection. Or do you expect it to actually grow to buy 6.6% or, or to 6.6% of the 2020 projection? The budget, the budget submission for provider taxes is zero based budget. We know that number because the state has told us what it's going to be. And so that's, that's done fairly precisely. You know, that it's a function of our revenue. So as you know, revenue. So let me just understand what you're saying. So you were saying that you're in your 2021 budget, the number you have there is, is a number that the state has told you, you will be assessed. Yeah. The FY 21 budget is a known number. A known number. Okay. Thank you. I, I was going to ask a question about Medicaid and Robin started it. And as I listened to you talk, there's so many moving parts in terms of your, your Medicaid projection in terms of attribution. It looks like you're, you know, accruing some from the rate or at least you're expecting some from the rate and charge increase. The payer makes differentials. And so it's too much to unpack here. But I will make a point that last week when divas admitted to the legislature, they announced that the 2021 rates will not increase unless it's a federally mandated increase. Does that change your Medicaid? Does that pronouncement change your Medicaid projection at all? Well, it probably would a little bit, but you know, a significant portion of our Medicaid book of business is in the ACO part of it. And so the rate increase that they're talking about affects a fairly small percentage of overall payer mix. So, you know, every assumption in the budget. Yeah. Yeah. It's, I mean, we have a little bit of an effect. Yeah. Yeah. I mean, overall you're projecting whether, whether you look at the budget, you were looking at a 16.2% decrease in Medicaid. And I think on your approach to the 2020 being based on, on the five month period, you were down to a 12% decrease in Medicaid. That's what's in your narrative. So that that's a big drop. And I wish we didn't have to talk about it, but you know, that seems to, that seems to be the method of the cost shift, I think. Yeah. Yeah. I'm looking at your 2020, non-operating revenue. And you, it's a one point. I, for, it's a one point, a $4 million increase over the 2020 budget. And you said in your narrative that there was a single $400,000 contribution, you know, that kind of affected that. But that still leaves a million dollar increase, budget, budget to budget. And I'm wondering if you can address that, that million dollars as well. Yeah. So we have a, you know, $30 million investment portfolio where our cash is. And so there was a significant market gains in the year that we don't expect to repeat next year. And we wouldn't budget for that. And that market changes in the bank. Yeah. Okay. And just in terms of your capital budget, agent, plant, $4 million that you may or may not get to do. Is there anything critical? If you don't get to do it, any of your, you know, you know, normal replacement. The decisions, if they don't get done, what might be the opera operational consequence for the hospital? Well, the consequences that something breaks and we have to, you know, cancel surgeries, you know, that kind of a thing. But, you know, what we plan to spend that $4 million on our, you know, IV pumps, scopes, those kinds of day to day pieces of equipment that are getting older and could break, you know, they all have service contracts on them, but that's the kind of disruption we'd be talking about. Well, thank you. I'll pass you along to next, the next next. Thank you, Tom. Next, we're moving to board member use for Maureen. Thank you. First, I do want to echo everything that you've done through this pandemic and how you've managed your financials, both now and how you did pivot after some big changes that happened between 17 and 18 and the focus that you've had on, on costs. So starting out with costs. Can you talk about any cost saving programs? That you currently are working with and, you know, kind of what your long term strategy is for, you know, keeping those costs down. So I'm going to, I'm going to talk about process a little bit. And please keep in mind that everything's, everything's sort of been disrupted a little bit with the pandemic. But one of the things that Wayne has really done a nice job in incorporating is putting process to that very goal that you're speaking about. What are we doing on a day-to-day basis, on a week-to-week basis to evaluate what we're spending money on? You know, so we set up a structure whereby we were reviewing our labor costs on a bi-weekly basis. Looking at RFDs, looking at, and then benchmarking them against what our volumes were in areas. You know, are we over-staffed? Are we under-staffed? What do we need to be focused on? Looking at our contracts with outside vendors, our contracts for service on equipment, all of those contracts on a regular basis. We had a, we have an affinity group that's working specifically on that. We have groups that's looking at our supply costs, our pharmaceutical costs, medical supplies, those areas, which obviously has become more of a heightened need beyond just cost, but around making sure that we have access to PPE and other equipment during the pandemic. So we've developed a process to look at all these areas, and we've had some disruption in that over the last couple of months with people being out with the pandemic and all that. But we have that process in place to be looking at what we spend money on, what we need to be spending money on, where we can be more efficient, how we can do things differently, looking at that on a regular basis. So it's that process that's going to continue to drive our ability to become more efficient over time. And one of the things we had allowed in this year's budget process was in your commercial rate ask to bifurcate it, to COVID ask, and kind of normal ongoing ask. So can you talk about, A, I guess why you didn't use that option, and B, if you do have some incremental costs, just during your process, some of the things we've heard is it's a little more time to prepare for patients, people have actually hired screeners, things like that. So do you have incremental costs in your budget for 22 that were kind of a carryover for COVID? And then adding to that, why didn't you choose to use that option in your commercial ask? We don't have anything in the budget next year specifically related to new incremental COVID related costs. Like I was saying earlier, we went back to the actual costs in February and rolled it forward. The reality is that the incremental costs associated with COVID are fairly immaterial. We do have screeners at the front door, so that's a little bit of a cost. There is potentially an increase in basic med-surg supplies, but if you really look at our med-surg supply spend, it's a fairly small percentage of our overall spend that's in day-to-day med-surg consumables. I calculated out about 3% of our total spend. 3% of our total expenses is day-to-day med-surg supplies. So it would take a really significant increase in those med-surg supplies to make a really big difference in our total expenses. So we didn't attempt to try to guess what the impact on those costs would be and ask for an increase in our rate to cover it. And we'll try to manage through it. Okay, great. And one area I want to probe into a little bit more is your kind of gross to net as you look at what you're asking for in 21. And specifically, and I agree with you, looking at 20 projection, it's not really the relevant number here, so I'm going back to the 20 budget. And you have an increase in gross revenue of $7 million from the 20 budget to the 21 budget. So you're going from 114 to 120. Yet what you're retaining on the net is you're actually declining. You're going from a 51.8 to a 51.5. And that's on top of a 4% commercial increase, a 1.8% increase for Medicaid and Medicare. And looking at the percentages, it doesn't really look like you're having a big shift. When you actually look at what you're projecting at the gross level, you're actually projecting your commercial increase at the highest. So it doesn't look like you're having a pay or make shift there. So Tom touched on a little bit, an increase in bad debt would take some of that away, but that's only about a million three. So it seems to me there's quite a bit of conservatism in that gross to net. So there's a 7 million increase on the top line and losing all of that. And even if you compare it to where your 20 projection is, you're looking at an $18 million increase from 20 projection to budget, and you're only carrying about 6 million of that on NPR. So obviously we know there's, you know, we know you don't keep all that, but can you help reconcile that? Because I'm looking at maybe if you hit your gross number, you're probably a couple million dollar conservative in your top line. And I'll just add one thing that also then carries to what your expenses are, right? Because your expenses are growing faster than your NPR in your projection, which makes sense when you tie it to the gross number, but not to NPR. So help me unpack that 7 million increase getting nothing at NPR. Yeah, so there are a multitude of factors in there. So part of it is that, like we said earlier, Medicare pays on the basis of cost. And so we don't yield as much from a price increase on the Medicare side. We're assuming that there'll be a higher number of patients on the Medicaid ACO for which we essentially are getting reimbursed less than a regular Medicaid patient. So that kind of erodes it a little bit too. We continue to see declines in commercial reimbursement as a percent of charge, despite of the contracts that we have. The commercial payers are pushing back harder, trying to disallow charges. And so the yield is eroding a little bit. And we've factored all that into our projections. And I'm sure there's a little conservatism built in there too, yeah. But that's what we came up with when we ran all of our numbers. Right, because when you actually go back to like 2019 to 2020, you were projecting a 4.7 million increase in gross and a 2.4 million increase in net. So, you know, it's to have 7 million on the top line and nothing on the bottom line doesn't seem realistic. I mean, I'm not too overly concerned. We don't know what's going to happen with COVID and everything. So my expectation on this one is maybe if that came through that you really would end up with more an NPR and then a little bit stronger operating margin. The last thing I want to talk about is just cash flow and where your operating cash seems to be ending for your projection. So it looks like from your 2020 budget you were projecting about 241 days in cash. Obviously you got a bunch of COVID money, which is great. But as you now, so I'm kind of skipping that piece of it, but in 2021 budget, it looks like you're now going to about 263 days and probably, you know, a lot stronger cash position even as we exit 21 and just if you could talk to that a little bit. I guess if you agree with that and it seems like you're getting some care, you know, benefits to cash from the money that you received for COVID. Yeah. So our cash flow projections at the end of next year, we don't hang on to any of that money. So right now there's $8 million of cash sitting in our bank account that we owe back to Medicare and to Cross. And that will get paid back over the next six months. So it's a little confusing. You see all that cash in our balance sheet now but then it goes away at the end of next year. But, you know, we did start the year with about 160 days cash on hand. So I'm looking at the cash flow that was in some of the backup and it said that in your 2020 budget, your cash and investments was 3.6, 21, 20 projection is 13.6. Get it. It includes a lot of one time 21 budget is 6.2. So and then from one of the charts you showed, I think it was on page 22 of your presentation, your offering cash, you know, it seemed to be netting up a couple more. I mean, that's okay. I'm just trying to look at, you know, where do you think you're going to be when the dust settles us and you pay back everything? It still seemed like you're going to be in a stronger past position at the end of 21 than where you would have trended without COVID, COVID money. Yeah, well, we had the big run up in the market at the beginning of the fiscal year in the first five months. So yeah, at February, right before COVID hit, we were stronger than where we were at the beginning of the year and the market dipped way back down in the middle of COVID then came all the way back again to now be worth more than it was in February. So the cash has come back. Yeah, okay. No, that's good. I think it's good for you guys to be in a strong position. We don't want to get to what was happening between 18 and 19. I just wanted to try to understand, you know, where things are settling out now. So, okay, that's all I have. Okay. Thank you. Thank you, Maureen. Next, we have Board Member Holmes. Jessica. Thank you. I hate to sound like a broken record, but I think it's very sincere from all of us, you know, thanking you for, you know, all of the preparations you made for the pandemic to ensure the safety of your community, the safety of your frontline workers and the congratulations and a kudos for the turnarounds that we're seeing here. I think, you know, we all are sincere in those sentiments. No, you're welcome. Thank you. And your presentation is very clear. I want to appreciate that. And it's very obvious from all of the budget presentations that we've had so far, how much uncertainty there is and how difficult it must have been to create a budget for this year. I mean, I think we are all living in this unprecedented time of uncertainty. So, I appreciated the clarity with which you made the assumptions and made those assumptions clear that I think we all know may or may not materialize but not through any fault of any hospital, right? We just know things are happening beyond our control. So, I just want to note my appreciation for that. A lot of my questions have been answered. Thank you for the presentation or through other board member questions, but I do have a couple. You talked about the drop in FTEs as one of the biggest drivers of the cost savings that you've seen over the past few years. And I'm just wondering if those FTE drops were across the board or whether there was an area in particular that seemed high in FTEs? Are there any learnings that we might that you might share with other hospitals going through a sustainability process that you've noted was an area where maybe there needed to be fewer FTEs or technology was, you know, replaced people, which is not always a good thing, but I appreciate that, you know, the cost savings you've made through FTE reductions. I'm just wondering if you could tell us a little bit more about that. Well, I think, you know, I think first and foremost, I just want to note that, you know, the numbers there, you know, when you look on the paper, even me looking at the number year to year is, you know, it's pretty telling. However, we did do almost all of those positions through attrition. So, you know, again, I talked about a process to look at change, a process to evaluate what we do in every aspect of what we do and that is something that we've done as positions have become vacant. And a lot of those a lot of those changes and reductions in staffing that we've had have been in administrative areas. So we have done that in a way that we think does not impact patient care. And as we've gone through changes throughout our organization, we've looked at are there things that we can do more efficiently by utilizing technology, by just embracing data-driven decision-making, those sort of things. And that really has had an impact on how we operate and has allowed us to make a lot of these changes. And I do think we run pretty thin at this point, but I don't think it's impacted our ability to provide the care needed in our community at a high level of quality. One of the silver linings if there are any of COVID, I'm not sure there are, but one of the silver linings perhaps that we've heard is that Vermont in many ways has become more appealing as a place to move to. The real estate market seems to be having a little bit of a surge. People are looking to Vermont as a model, as a place to take cover, all of those things. And I'm just wondering in terms of your workforce recruitment, has this been something that you've been able to take advantage of in terms of attracting new providers or new staff to the area as a Vermont as a safe haven from the pandemic. So I think anecdotally we've seen an uptick in some people applying for positions here who come from outside of Vermont. I think it's a little too early to say it's a trend for us anyway. But it is a promising potential area for us in the recruitment side. So we will continue to look at that as we go forward and try to find ways to make sure if people are thinking of coming to Vermont which all of us here know is the place that someone should live. But as people are making that decision we want to make sure as well that Gifford is at the forefront of the places they're looking to make a living. Well anecdotally I was on a bike ride and I bumped into literally two former students of mine that work in Boston. They've been telecommuting now for six months to their Boston offices and have just decided to relocate to Randolph area or somewhere around your neck of the woods. So anecdotally it does seem to be potentially a possible draw. If they want to ride a bike Randolph is the perfect place. Well they were offered our bike gear actually so that's exactly how we met. And I hadn't seen them in about five years so it was quite fun. So this is a I mean you probably anticipated this question from me Jan so I'm going to ask it because I wouldn't want to let you down. But it's a follow up to Robin's questions about strategic planning and sustainability planning and I want you to know I have deep empathy for leaders of Vermont small hospitals and margins are falling we're seeing that headwinds are growing you face higher fixed cost declining populations shrinking public reimbursements work for shortages I get it I really do and I'm wondering I know that you're trying hard to balance the desire to keep services local especially given the transportation barriers for vulnerable community members within need to ensure that those services are low cost and high quality so I'm just wondering if you can just talk a little bit more we talked about this last year but a little bit more this year in the eyes of sustainability planning how do you balance this desire to provide local access keep a margin maintain quality with you know in some areas we've got declining populations so your volumes are shrinking so especially in your surgery area where despite you talked about efforts in ortho and surgery to get those volumes up there's some still some areas where your volumes are low so how what criteria do you use to make sure that it makes still makes sense for the hospital to provide that surgery versus say providing the transportation to a center that has higher volumes how do you think about that in your strategic planning process well I think first and foremost you have to look at the interconnectedness of all of the all of the services and all of the skill sets that are required to have a hospital that are required in order to have a birthing program all of those things we cannot have a birthing program if we don't have a surgical program because we wouldn't be able to respond in an emergency situation to do a C-section we wouldn't be able to attract OBGYNs to come work in our community if we don't offer if we're not able to provide those level of services so you have to understand the interconnectedness of that core that you need to provide and it's not it's not valid to say that you can just split apart all of those parts and look at them individually you have to look at how one supports the other and what you need in order to build upon the services to ensure that you can remain a viable hospital we what one of our approaches and one of the things that I believe and strongly is that we can't sit here in a bubble and often say we're going to do everything by ourselves we're going to meet every need in the community and it's all going to be only Gifford doing that so we've looked out to other partner organizations and I've talked about this with you in the past so you know this but we work with Dartmouth-Hitchcock to supply cardiology and some orthopedic services here at Gifford we work with Central Vermont Medical Center and the UVM Health Network for chemotherapy for pathology for those services we're looking at ways to expand our telehealth offerings so that we can be a base where someone can receive other services but not have to travel long distances so we're looking at ways that we can provide for our community understanding that we're not going to build upon infrastructure in certain ways or understanding that if we're using an orthopedic or if we have an orthopedic surgeon from Dartmouth-Hitchcock who's going to work here two days a week you can't just look at the number of cases he does here at Gifford because he's doing a lot of cases at Dartmouth-Hitchcock so from the standpoint of quality and his skill set and the currentness of his skill set and the currentness of the technology during the Bayer, it's far greater than just what he does here at Gifford and so it's all those things that we look at and then obviously you have to do a financial analysis as well and again but you have to do that financial analysis within the process of looking at the whole and what do we need in order to be here viable and we're going to go through that process we're going to go through it internally again every time we do strategic planning to ensure that we're providing services that should be provided here we can do it as efficiently as possible and that the quality is going to be at least as good as it is other options that people could go to and our leadership team will do that, we'll do work with our medical staff and then ultimately our board will be responsible from the government standpoint of deciding what our service rail will be long term that's how we do it with respect to the all payer model and healthcare reform I appreciated your investment your commitment to the all payer model and your investment in population health programs also respect the need for more healthcare delivery reform dollars and I understand that risk obviously was going to weigh into your decision about which programs to participate in you're currently participating in Medicaid and the MVP program my my recollection is that most hospitals that choose to participate in commercial tend to participate in both payers and so I was curious about your decision to participate in one payers program but not the other payers program if you could talk about that so our decision to participate in the MVP program and we had originally we're going to I think when we talked last year for our budget hearing we were in the process of preparing to participate with Cigna as well that did not come to fruition between Cigna and OneCare so those were shared savings programs so we did not assume risk in that there was change in the Blue Cross program that occurred during this fiscal year during this calendar year for this calendar year given when it occurred given everything else we had going on we chose not to jump in at that time if that program were to continue as a shared savings program in 2021 we would consider it but the decision that we had reached for 2021 was that we were not in a situation at this point to assume significant risk moving additional significant risk at this point so that was the thought process we went through. Okay, that makes sense and to follow up to that question many folks believe that there needs to be a critical mass of a provider's panel or the group of patients that a provider is overseeing that needs to be in an alternative payment program before you actually start to see delivery reform happen so I'm just wondering how I believe you're committed to delivery reform and I believe that you're doing the population health investments I'm wondering how do you work with your providers to get the boots on the ground delivery reform happening given that you still have a very low percentage of fixed perspective payment in your NPR so how do you kind of combat that foot in both canoes kind of thing in terms of encouraging the kinds of reform efforts on the ground that we would love to see so the I'm going to this isn't the right word but the tasks I guess or the programs that we put in place we don't put them in place just for the just for the populations for which we're in health care reform we're building a system we're implementing care management programs we're implementing quality improvement programs around particular issues that large groups of patients have we're implementing panel management programs we're implementing those within our practices we're not implementing them only for the Medicaid population so we're building out the capabilities to provide this on a wider for a wider population so that's how we that's how we approach that and again that's part of the process that we need to go through in expansion is making sure that we have that infrastructure in place we've just in the past several months improved upon our own internal data analysis capabilities that's going to help us move forward in the future and again that's not that won't be just one patient population that'll be our ability to look at our total patient population and panel and we're building that infrastructure we're not building it only for those particular programs but we're building it for our system of care so that we can implement it within our system of care and make those changes that we need to you've built in the infrastructure and then as your financials get a little more short footing as you're coming out of this you may be able to take on more of the risk and do more of the alternative payment methodology but you'll already have the infrastructure in place for all patients in some sense right I think you have the financial risk you have to you have to address but if you don't have the capability to be successful in it then that financial risk is amplified and I think that's you know exactly what you said build the infrastructure and then be able to expand that makes sense my last question is a very very simple one it's more of a curiosity than anything else and it shows my ignorance and how average age of plant is determined but on slide six not knowing exactly how average age of plant is calculated this is just really a curiosity but from fiscal 18 to fiscal 19 the average age of plant increased three years in one year I'm just kind curious how what is the computation there and how do you have an average age of plant increased three years in one year the ratio is net property plant and equipment divided by depreciation okay so it can be affected quite a bit by your depreciation going up or down got it okay and it can be adjusted sometimes based on assets being retired and dropping off your balance sheet okay so it's not a super precise number but the direction of it is telling I guess you know about where your plant is getting older yeah that makes sense it's just really was a curiosity I was trying to figure out quickly as you guys were going through the slides how that might work but I appreciate your answer it makes a lot of sense to me that's all I have thank you thank you Jessica Wayne in your presentation you talked about how you calculated expenses for this year and you talked about just using an inflation factor and I'm curious which particular measurement of inflation did you use and what was the numeric value yeah so we we used 3% for salaries 0% for benefits 3% for supplies and drugs and then 2% for all other expenses except for interest depreciation and taxes which were zero based I came up with a weighted average of 2.4% for inflation which equates to about 1.3 million dollars so that's our assumption of inflation okay in your presentation you talked about a change in the way you factored in your revenues for commercial reimbursement because of denied claims and I was curious if those denials were justified if you had to change the way or what you were billing or are these just tough denials well there's a couple factors in there the commercial payers are getting more aggressive about going in and looking at the detailed bills and then challenging individual charges because a lot of our contracts are discounts off charges so anything that they can go in and sort of strike from the bill causes them to reimburse us less kind of aggressive on supplies actually you know if we can't document an individual supply was individually using that individual patient they try to kick it out we've also had an increase in denials just in our sort of billing processes so we're trying to modernize our billing processes and try to eliminate those denials so we've done quite a bit of improvement in our revenue cycle processes just trying to be more efficient with our billing so hopefully that'll help us too okay Tracy at North Country it's going to be a little bit longer on this presentation maybe you could help us by stop sharing your screen okay Wayne you talked about why you didn't believe that you were eligible for the state CRF funds have you applied for the FEMA funds that are available no I don't think that we did we got so many other relief funds that we did not and my last question is what is the revised completion date for your woman's health project we're expecting that that'll be finished up in December with the ability to move the practice into there in January okay yeah I didn't see anything in your 21 budget but obviously there's three months there that it's there did I just miss it it'll be that'll the component that goes over will be in that four million the vast majority of it will be in 2020 as we had budgeted in 2020 okay those are the questions that I had at this time we're going to move to the health care advocate and again if I could ask Tracy at North Country if there's any way she could stop sharing her screen we're trying to focus on Gifford thank you thank you Mr. Chair Mike take it away good morning everyone and add my voice of appreciation and recognition for you and your team in responding to your community's needs and Vermont's needs I think it's really important to recognize it in the middle of this hearing I also want to appreciate your answer to Tom Pelham's question about bad debt and free care I think I heard you saying that you recognize that there was some bad debt on your books that really could be or should be free care and that you ramped up some of your efforts to help people apply or to help in that application process could you say a little bit more about just what you did to accomplish that yeah it's actually an FQHC requirement that we screen our patients when they come in we're supposed to ask every patient once a year what their income level is to see if we can qualify them for free care and as you can imagine folks are somewhat reluctant to give us that information so we're trying harder the way we talk about that when we talk about it with our patients to try to get the information and we streamlined our overall process of application just to make the form easier to try to make it a little bit easier for people to apply we still base our free care on a percentage of federal poverty level guidelines we really didn't change that and we think we're have that level set at the sort of community standard of what the other hospitals have it set at but we're trying harder to make the process easier for people because when you look at our percentage of free care again it's a little bit low and we would like to increase it a little bit again thank you for your efforts on that you may know that we the health care advocates office put some energy into this in previous years but due to our own capacity focused on the larger hospitals which you were not in that set so I appreciate it I also want to echo what member Holmes said about clarity of your presentation I've sat through a number of these and I just want to say yours was particularly clear in both layout and description so I appreciate that on slide seven I don't know if you can pull it up I mean I can get to it on my own screen well I'll ask away because I can get to it on my own screen I also found this slide particularly interesting in its clarity but I am of course curious about what the colors represent I can make my guesses but if you were able to walk us through a description of at least the major ones that have changed I would be interested in that yeah the most dramatic one is the yellow one at the bottom which is surgical services you can see a really sharp drop right away when we canceled our elective procedures and you can get a sense of the proportion of surgery to the whole and it essentially disappeared except for really emergent procedures so that's the surgical services the one above that is the ER and the ER dropped a little bit so you can see like some things drop more than others the red is inpatient which declined a little bit right here in the middle but then kind of came back to normal and the gray also looks like it came down yeah the gray includes physical therapy so a lot of physical therapy was elective during the period and patients really didn't want to come in and so there's quite a bit of physical therapy in that the pink area here is pharmacy so a lot of that is chemotherapy and infusion which is relatively unaffected by COVID because if you need that but that fluctuates up and down even normally you can see back here pre-COVID that fluctuates and it fluctuates again yeah okay thank you that's helpful and then lastly I don't know if you've heard this or if anyone's told you I've been attempting to talk about race and racial disparities more in my day to day life given the national and state discussion recognition of this issue and and so I really wanted to invite you to talk for a minute about what you think the work is in front of a small hospital like yours in terms of recognizing and addressing the the structural racism or the implicit bias that's present in here in Vermont and whether you've taken any steps or whether you plan to take any steps on this area so sure I'd be happy to talk about it and I have a board meeting tomorrow night so my board members are going to hear some information right now that they're supposed to hear tomorrow night so I'll give all of them your phone numbers so they can call you about making me talk about this later I'm happy to talk about it so there's a number of things small statements that I made and others made here at Gifford over the last several months and then I mentioned in my presentation about our periodic all staff video meetings that we've had so the last one we have I have a request to our staff for people who are interested to volunteer to take part in an effort to ensure that Gifford is a welcoming environment and that is definitely in keeping with the issues of racial racial disparities in our culture so beyond that what are we doing to ensure that anybody who comes through our door feels welcome and is provided with the same level of care and treatment when they come through our door so there's two things we're doing one is I did get a group of volunteers who we're going to be sitting down I'm going to be sitting down with my leaders to do a focus group to identify what specific items we should be focused on dealing with here at Gifford to ensure again that we have that welcoming environment so we're in the process now of setting up that initial meeting and that'll take place in the next couple weeks the second thing we're doing is that we are actively researching implicit bias training which we are going to begin to roll that out with our leadership team which we are going to extend to our board members which again they're hearing that for the first time right now and we are then going to look at rolling that out with our medical staff and then figuring out where we take it from there how we incorporate that into our employee training education continuing education how we get that implicit bias training and acknowledgement and focus throughout our organization so that's where we are right now Mike I feel that we're we have a good start but we're only at the very very beginning we've got a lot of work to do but we are going to do that work very good thank you thank you Kevin thanks Mike at this point we're going to open it up for public comment if anyone would like to offer public comment on the Gifford budget this would be the appropriate time so hearing none again I wish to thank the team at Gifford the Bennett brothers we won't say which one's older for doing a superb job of really communicating your budget and really your mission for your entire community forward so at this time we are going to take a brief bio recess we will return at 1040 and commence with North Country so see everyone again at 1040 thank you all thank you