 So good morning, everyone. We're going to get started on the first day of four days of hospital hearings. And to begin things, I'm going to turn things over to Pat to give us a little recap. Thank you, Kevin. For the record, my name is Pat Jones. I'm Director of Health System Finances at the Greenhouse Care Board. I wanted to start by just showing a brief agenda of the day. So we will, first of all, go through a quick timeline of what the budget process looks like. And then we'll hear from four hospitals today. Gifford Medical Center, Copley Hospital, North Country Hospital, and Northeast Cermont Regional Hospital. In terms of the timeline, we received budget submissions from each hospital on or around July 2nd of this year. From July and continuing into August, the hospital budget team has done a detailed stack review of each budget. But I want to just take a minute here to thank the incredible health system finance to Lori Perry, Kelly Gero, Tom Frampton, Jenny Morrison, who many of you know, and is transitioning to Harriet Johnson's for the big health to assist you as well, and many others. But I wanted to take a moment to acknowledge them because their work is truly incredible. July 30th, we completed our initial staff analysis and sent questions to each hospital. We received responses from the hospitals on or around by August 10th. Here we are at the hearings this week, the 20th of the 22nd. We're in Montpelier and Burlington last week on the 27th and 29th. We're in the Castleton and then back again in Montpelier. Public comment. We've been receiving public comment all along the deadline for public comment on hospital budgets will be September 10th. The board has discussion and makes decisions on hospital budgets at public meetings, essentially starting as early as August 30th and going through September 14th. The board will issue decisions on each hospital's notification of revenue and rate by September 14th and then by September 20th, we'll provide written orders to the hospitals. So that's the timeline that we're looking at. This slide shows a couple of resources and this very brief deck will be on our website with links to the budget here in the schedule, type hospital budget information for each hospital and then also a link to provide public comment. I'll close this part by just briefly discussing the role of the board. The approach of the board is to, first of all, establish net patient revenue for each hospital and that includes an aggregate level of net patient revenue for fiscal year 19 and also a rate of growth. The board also approves changes in rates that are charged to payers for fiscal year 19. What the board doesn't do is set individual salaries, wages or charges or prices for individual healthcare services. That's the role of the leadership at each hospital including their board of directors and their administrator staff. So I'll stop there and turn it over to Susan for some brief comments. Thank you, Pat. I just wanted to brief the board on public comments and also to the public to reiterate that our open public comment period for the hospital budget is active until September 10th. You can do that on our website. You can send the comments in the mail. You can call Christina with your comment. To date, we have received over 300 public comments, the majority of which have been related to the EVMNC nurses contract. And again, there will be a special public comment button on our website and then to date all of the public comments have been shared with the board. So I'll turn it over to Chair Mullen at this time. Thank you, Susan. Thank you, Pat. Thank you, Hospital Budget Team. They have been working incredible hours in the little conference room at our offices. In fact, I thought that it was her office. One day I saw her going in there into her own office and realizing that she was in the wrong place. Before we get started, I do want to state publicly that the board has reviewed the well over 300 public comments. We've also fielded some calls from legislators and others asking about what will transpire on Wednesday. What will transpire is business as usual for the Greenmont Care Board. The hearing will proceed as usual. As Pat said, hospitals have the ability to manage to different events. And in fact, they do that regularly. The hearing is not the final say. We'll make a decision in mid-September. A written decision must be issued by October 1st and it will be. And every hospital has days cash on hand. They have the ability to make other changes to their operations as they see fit during the year. Hospitals also have the ability to come back to us mid-year if there is a problem with their budget. And so there is no reason why this board should not stay the course and proceed with business as usual. We expect on Wednesday that it will be a little bit awkward going in as I understand there's gonna be a lot of people picketing out front, but that's okay. We're used to that. We've gone through public comment periods after QHP filings where we have to walk through a number of people to go into a hearing. So again, hospitals do have the ability to manage their own budgets. We're looking at a larger picture and we wish both sides good luck. We want to have the best possible workforce in healthcare in the state of Vermont, but we also want to keep healthcare costs and their control and several emails have really targeted the fact that they want it all. And unfortunately, we're trying to create the all, but we're the reason. So with that, I'm gonna turn it over to Dan and the Gipper team so that we can proceed with today. So Dan, welcome. Thank you. Can you hear me? We can. Thank you very much. And I just want to echo the comments before in thanking the staff at the Green Bay Center. As usual, I forgot something. If I could ask the court reporter to square in all people who are going to testify today. Do you all please raise your right hand, please? Do you swear the testimony you're about to give shall be the truth, the whole truth, and nothing but the truth. So I'll be glad. I do. Thank you. So with that, again, I want to echo the previous comments of thanking the staff of the Green Mountain Care Board and the Green Mountain Care Board for the back and forth interaction throughout this process. This is a lot of work that you go through. It's also a lot of work and a lot of effort that we put into that. And there is good discourse back and forth and we appreciate the ability to get clarification and share information as we go through that process. So thank you very much. We are here today to present the budget for a different medical center. This is the agenda that we're going to follow. This was the agenda that was provided by the Green Mountain Care Board. So we are following that. I won't go into great detail on that. And I'd like to introduce our team today. My name is Dan Bennett. I'm the president's CEO for different healthcare and different medical center. To my right is Ashley Lincoln. She is our director of development and public relations. To my left is Rebecca O'Berry. She is our vice president of operations. And to the far right is Jeff Hebert. He is our chief financial officer. And behind me, because we only have room for four up here, is Katrina Lombra and she is our controller. So I'll just briefly go over some general information about Gippert. We are here today to present the budget and accompanying information for Gippert Medical Center. Gippert Medical Center is a subsidiary corporation of Gippert Healthcare, which is our parent organization. We also have a third organization in our structure, which is Gippert Retirement Community. Our parent corporation is Gippert Healthcare. It is a federally qualified health center. This presents a very unique structure for Gippert. We'll also see the same structure when Springfield comes to present their budget. But we are one of only a handful of organizations in the United States that have this structure where a federally qualified health center is the parent organization for a hospital and in this case also for a retirement community. This is an organizational structure that we've had in place since 2014 when we did create the FQHC. Within the FQHC are our primary care practices, which are located down at the bottom of the slide. And then within the hospital is our 25 bed critical access hospital, where we provide community-based medical services as well. And we have six locations, which are also listed here. And then finally, we do have a retirement community, where we have a 30 bed nursing home, a 49 apartment independent living, and we have two adult aid programs as well, one located very and one in Bethel. For today, the budget that we're presenting and the information we're presenting is for a different medical center. We will talk about some initiatives that we have underway that incorporate some of our other, the other organizations and other programs within our corporate structure, but the budget presentation is for a different medical center. We are also located, essentially out of Randolph and Orange County, but we do have locations throughout the upper valley and also into the capital area here in Vermont, which this map will show you. So we do have a broader geographical reach beyond just Orange County and the Randolph, the greater Randolph area. I'm getting into some of the issues that we are facing and I think these are probably similar issues that you'll hear with other hospitals when they come to make their budget presentation as well. Workforce is a big issue for us, both in terms of turnover that we've had in recent times and our physician services, general surgery, orthopedics and primary care are areas where we have had vacancies over the past few years. And in the last two years in particular, this has impacted our volumes that we've enabled, volume to services we've been able to provide at your medical center and also our revenue, which you have seen in our financial information that we've provided. We also, because of that, have had to rely on temporary staffing, either visiting nurses or loathing physicians, so temporary staffing in those areas, in this particular budget period in the year that we're in currently, general surgery and primary care are two areas that have been impacted by that. This does impact our costs, although Gifford has done a, what I think is an excellent job in our cost reduction strategies over the last couple of years that has been mitigated to some extent by additional costs that we've had to incur for temporary staffing. We also, like everybody else, in health care and outside of health care are dealing with a very tight labor market. Unemployment is low, and it is difficult to find qualified staff or many of our physicians. Some of the areas that, some of the issues that we face within that are the difficulties in our recruiting to rural areas in addition to a tight labor market. For us, that often involves when you're able to recruit somebody, having opportunities for the spouse or there's no loved one who comes with them. And also, for us, the strategy that we have taken is we do try to find people who have some connection either to our local area, to Vermont, or to the activities that our area provides, whether it's skiing, mountain biking, the arts, or somebody who just likes long-hauled winters. Things that we, strategies that we employ to try to attract people to our area. Ever this year, in our physician practices, both our primary care and our specialty practices, we implemented a new electronic health record. ECW is the software. We went live with that new electronic record in April. However, leading up to that, we had a period where we were doing a lot of training, obviously, for both our providers as well as the staff who work in our practices. And then once people go live with that, there is a wrap-up period for people to get used to using the software and for us to get all of our interfaces and other back-office functions working properly. And that has had an impact on our volumes for the past couple months, April, May, June, and the time period. We are, like everybody else, in hospitals and other health care entities in Vermont, assessing and preparing in sub-cases for some of the hospitals participating in health care reform through the health care model. I'll talk a little bit more about that further on in the presentation, but that is an initiative that we have been working on at Gippert as well. And of course, access to services is an on-voting issue. We are focusing on the increasing needs for mental health and substance use services and also for primary care services in our area. So the risks on this slide are similar to the things that I just talked about. Under the first one, the ability to enter a risk-based reimbursement arrangement. We are, as I noted, currently evaluating our participation in the all-payer model for 2019. A couple of the things that are concerning to us as we look at that are our ability as a small health care organization to maintain our cash reserves and adequate cash reserves to insure us against down financial years and also to be able to take on the financial risk inherent with this model. And as we've experienced over the past couple of years, our small size can result in greater volatility when we have staffing shortages or vacancies in provider positions. So those are factors that are weighing on us as we evaluate our ability to participate in 2019 and switch over to opportunities as I've already talked about the other two bullet points. One of the great benefits that we have at Gipperd is that connection between primary care and our hospital-based services. We are a federally qualified health center, our primary care, therefore, in light of our structure, but also in our focus. We put primary care at the forefront of what we do and we have an opportunity, excuse me, with the FQHC structure to be able to provide integrated care, integrating mental health services, substance use services, dental services, with our traditional medical services as well. So we are well positioned there to function as we should in caring for the health of our populations. Gipperd has, over the last couple of years, embarked on what I think is a pretty aggressive and successful effort to reduce cost and be more efficient. This is something that Gipperd's done for years, but we've done it with new focus over the last couple of years and we have had success in reducing our cost. As I noted before, that has been offset in some areas by some of the temporary pressures that we've seen in bringing in temporary staffing. We do have some promising new hires. One of our focuses is on getting our staffing back up the traditional levels and being able to provide all the services that are needed in our community. We do have two primary surgeons that started last week and they are already one strong. We have four new primary care providers who will be started between the 1st of September and the 1st of November. And we've had success in filling some vacant positions in our operating room, which we have had to utilize traveling staff for over the past year. So we've had some success there as well. And then later on in the presentation, Ashley's going to talk about our expanded community health and outreach programs, which I think have been a great success for us over the past year plus. So she'll talk more about that as we move on. So one of the areas that we were asked to comment on was the access to care, the wait times to get into services at Gipper. Within our practices, we do offer same day appointments for urgent or acute patient visits. And each of our specialties does offer a provider on call for their patient base so that we are able to answer patient needs as they arise. Another commonly followed statistic is the time to the third next available appointment that does vary by clinical specialty, but we are able in general to be able to see patients within five days. And we did note also that with our outpatient rehab, so PT-MT speech, we are able to schedule new patient evaluations within five days and follow-ups within 14 days as well. With that, I'm going to turn it over to Rebecca O'Berry. That's hard. Good morning. I wanted to talk about quality at Gipper Health Care. The slide in front of you is actually the all-payer model quality measures. And Gipper is feeling well poised to respond to this because we have been measuring quality, should have asked you which one, which one is better. We've been measuring quality for years in a different sort of manner. So this is a slide that shows our hospital and clinical development. Our hospital division and our surgical division quality measures. So each one of our divisions actually comes up with their own set of measures depending on sort of what we're looking to improve and what's important to our patient base and our physicians. This actually shows the other two divisions, operations and then the primary care division. So as you can see, a lot of the things that we're measuring are also on all-payer model quality measures as well. The way we present our data to our quality committee and also up to our board is through these types of slides that show the calendar quarter that we're reporting on and any other measurements that we're reporting on. We have the indicators on the right-hand side as well as the comments to let the folks in our audience understand what we're measuring and what we're measuring at least. So these are just a couple of examples to show you what we're doing. This slide is showing another way that we're looking at it as a graph form over time and what we wanted to talk about was hypertension here. You can see in the bottom left corner that we've been measuring our hypertension for the last few years and we've noticed that we're going to go up and down with our measurement. And so this year, we're actually putting a lot of effort into getting this onto our blueprint panel management to be able to spend a little more attention to this measurement. We actually have some education provided that's coming up in our CME over the course of this year with two of our primary care providers presenting the best practices and getting everybody on board to be able to respond to this measurement. I'm going to review the financials. As requested, we supplied in the presentation a profit and loss statement that we actually got from the adaptive planning program. We also did a balance sheet and a cash flow statement. We get into the cash flow statement. Just wanted to point out that we did have in 2017 an audit adjustment restatement of our financials which is showing up in our 2019 budget under other changes and under other long-term assets. So just to make you aware that that happened. But moving down to the ending cash, we ended out the 2017 actuals with cash flows of 3.3 million. We did have a budgeted cash flow for 2018 of 5.4 and as Dan alluded to, this year due to staffing issues as well as productivity issues, we have paired that back in our budget 2018 to 2.7 million. It was requested to have an understanding of overall our outpatient hair mix. For Gifford Medical Center, it's, when we take a look at overall hair mix, 3% represents outpatient hair mix when we out of state, out of state hair mix and that basically breaking it down, we have the process of 17 commercial at 34, medicated three, medicated at 42. It's low-effective. I agree. I recommend it. That means that the MD wanted to do that. So we're having a overdue for our hospital survey from CMS and it just arrived. It just arrived. It just arrived. It just arrived. It just arrived. It just arrived. What? What time is it? We just wanted you to experience what it's like to run a hospital. The other piece of the presentation of the financials is there was a request to reconcile as well as point in 2019 budget. I'm not going to go over this detail but it is in the, that it is in the, but moving into the details, let's behind our numbers, as Dan alluded to, but one of the things that we did, we got back to looking at any and all costs, but first we needed to understand what was going on. And when we take a look at our patient revenue for inpatient revenue streams, we did see that we've been behind expectations, we've been communicating that to our board as well as to our managers. The big reasons for that is the, our OR department is causing a lot of that shortfall as well as what we expected for inpatient census is not coming to fruition. Our patient, again, it's the operating department, all the insularies that are associated with that operating slowdown. And then when we get into the clinics, the again common theme was the OR, but also our EMR, we did start to get ready. We had to basically make sure we had the appropriate time to do the training, which has lack of productivity when that happens, as well as getting onto the new system. Moving down into the expenses, looking at the salaries and wages, we've been really focusing on making sure that we're using the right productivity minutes, given the revenue shortfalls, using tools like low census. And whenever possible, looking at attrition for employees that lead the organization. Our benefits overall are in line with our 2018 actual expectations that we brought forward in our 2019 budget. When we took a look at advertising, that was one of the areas that we started to look at any and all expenses. One of the recommendations was to look at the paper reports and take a close look and understand what was needed. So in regards to this year, our annual report, which is a very expensive proposition, we decided to go electronic with that. We also looked at print ads and reducing those. And we have held on an internet site and rework and we brought that forward in the 2019 budget. Depreciation, depreciation is lower, but that is not a reflection of our cost-cutting efforts. It's actually a reflection of IT. When we went into it in 2018, we thought that our EMR was going to be a server-based application. After working with the vendor, they recommended that we go cloud-based. And so what you'll see further on down below is those expenses actually live in our purchase services. Other, other basically, again, gets back to our cost savings initiatives. The areas that we're able to really look at was our dues, our break, our postage. We're able to reduce those expenses. We have on this list as well as our network printer and copies. Right now, we're working with our vendor to look at revamping the whole fleet. Just like it seems like with different areas, it's always this creek that happens. Everybody likes to have a copier next to them. And so when we look at it, we have a lot of copiers within our organization. So we're carrying that back. We're making sure that we're right-sizing that copier fleet for our organization. The other thing that we're doing is we're saying, hey, do we need color? Basically very simple, but going through, making sure that everybody has the appropriate copying capabilities that they need. Purchase service, as Dan was saying, this is up substantially, primarily due to the use of locums as well as the use of traveling nurses. The other thing that is in there is we did have an orthopedist contract which went into play as October 1st in our 2018 budget that orthopedist was actually in our salary budget. But we did contract that service for this fiscal year. And the other initiative was the move to cloud-based IT. That's also up. So the appreciation was down. Other purchase services was up due to the IT services. And then utilize our utilities. One of the things that we have been doing in the last few years is working with efficiency one. And they've been very helpful in us looking at any and all cost and saving another cost. Thank you, Jeff. So this is our third year of completing our Public Health Care Needs Assessment. This is mandated by the federal government. And our goal this year was to try to reach more people. We did indeed use a survey online, we used Survey Monkey, and our responses came in at 392. Interestingly, this year compared to last, more of our responses were folks that had commercial insurance. But you will see that the responses still are in line. So what we're seeing year after year is for a healthy community, much as what Dan spoke to, we need to have good jobs. Folks, we often talk about our ability to defer to be able to hire the first job, but finding the second job is often difficult. And a lot of our providers, our clinicians, our managerial staff, they need to go somewhere else for their spouse to have a partner. So we often lose those excellent candidates to the Burlington area, the Hanover area, because we can't provide that second job. But folks also wanna have good schools and access to healthcare. Of course at Gifford, access is not an issue. As Dan pointed out early on, we are spread all through the White River Valley from Montpelier down to White River and over the mountain. Gifford years and years ago found out that the problem with healthcare is that folks couldn't get to it because of mountains. So we opened up clinics in Chelsea and Rochester. We brought primary care to the people. And of course they do get their follow-up treatments at Gifford, but we have a nice partnership with Stagecoach, which is our local transportation. As far as health problems in our community, I have no doubt that the Green Mountain Care Board is gonna hear these trends throughout their budget process with addiction, mental health issues, and obesity. You'll see in a later slide that I really like to focus on, Gifford is doing an excellent job in responding to these issues that are being noted. Our areas of focus, as we have shared with our board and our entire management team at the hospital, we are gonna continue working and looking at the drug addiction, obesity, mental health issues, and preventative health care. Folks also noted that sometimes they have struggle and making an appointment during the day. Everybody's working and oftentimes they're working outside of Band-Aub. So right now we're looking at having those evening appointments because we know for working moms and dads, that's what's important. And folks also talk about not having dental insurance. With our FQHC, this will be the next slide, we are able to expand our dental health and our mental health services. Before I go to that, we'll stick to the obesity and preventative health. Gifford enjoys a very collaborative relationship with the blueprint. We have our blueprint team embedded in all of our primary care practices, and they are now on our main campus to work with patients that are in the emergency department. So when there are folks that are utilizing the emergency department care as primary care, we know that's not the relationship we want to establish with that patient. We want to work diligently to make sure that patient is actually established with the primary care and creating a relationship that's gonna help manage these chronic conditions. Our blueprint team also has self-management programs and again, much like primary care, we bring those self-management programs to the people in their communities. We go to the low-income housing in Chelsea. We go to the Park House in Rochester because we know that transportation is always gonna be an issue. So we bring the services to the people. We're thankful for our FQHC status and we have always partnered with Claire Martin as part of our community health team, but we ourselves are hiring folks to provide the substance use counseling, again, right within our clinics. And this year, we did get the MAT waiver increase, allowing our MAT providers to see it to 250 patients. And in September, the state has designated our Kingwood site for a Narcan distribution site. With mental health, as I mentioned, Claire Martin. Claire Martin has a clinic in our Chelsea facility. So again, when folks access primary care in Chelsea, they can also access mental health care as well. And at Gifford and in Berlin and White River, we also have services. But our community health initiatives, this is an area that I'm very proud of. Two years ago, Gifford received a generous grant to really revamp and reinvigorate our community health programs. When we look back at that first slide and we talk about drug abuse, we talk about obesity, it's very hard to change the habits of an adult. We clearly have to be working with youth. Youth is where we're gonna be able to start changing mindset, where we're gonna actually be able to teach them differently. Because when you are, your environment, if it is one that eats unhealthy, doesn't exercise, and you see your parents using illegal drugs, that's all you know. So if we can actually get to those students in a safe place at school, that's where we can make a change. And Gifford is committed to doing that. We installed a drug kiosk in January. We reached out to other hospitals that have a drug kiosk and they said, oh, you'll probably change your bag three times a year. So good enough, we're ready for that. We changed it every three weeks. Gifford has actually taken over 600 pounds of medications off the streets since January. In addition, we received a $10,000 grant from the state of Vermont to again reach out to youth and do education about the importance of prevention around drugs. We called it our dose of reality series. It was a six weeks session at our Chandler, easy access, it was off-site. We used all of our local talent within the hospital and we brought in our pharmacist who talked about the effects of drugs from a pharmaceutical point, but she brought it down to a level that everybody could understand. And I will share with you that there was one woman who came, sat quietly in the back every single session, never said a word until the last one where she walked up to us and she said, thank you. She said, I lost my daughter. She overdosed on opioids. And she said, I always thought it was my fault and now I know it wasn't. So that impact itself, we know that's where the difference is gonna happen and that's where we have to focus. In addition to all of our outreach reach, we are also partnering with our local law enforcement on a program called LEED, which is law enforcement against drugs. And we have our local sheriff and deputies going into the school and working with fifth and sixth graders to teach them about the effects of alcohol and drugs. We have now been able to secure funding and they're gonna now go into the junior highs as well. Again, we're trying to get to the kids when they're young to try to break that cycle early on. In addition, we are now working with our local schools through an athletic trainer program. It's mandatory for high school sports to have an athletic trainer on site. We're very happy that our schools are looking at Gifford to provide that service. So we're going in early and we're teaching kids about the importance of concussion safety, the importance of stretching, the importance of good nutritional habits before they hit the field. Again, trying to prepare them for a healthy season. Our skin cancer screenings. Last year we saw, I think it was with 10 clinics, we provided over 100 free full body skin checks. We had people calling us saying, my goodness, will you do it again? We wanna come in. So now that we have general surgeons on board, we're gonna be kicking those off. Again, we're trying to do the early detection so it doesn't become the chronic problem down the road. And we're very pleased with the work that's being done at Gifford. Gifford has been doing a number of investments for our health reform. And in the past, we have been a member of the CHAC, ACO. That ACO ceased operations at the end of 2017. So currently we are not participating. In one, we will be, we are currently evaluating participation with one care in the air model. So there are no expenses budgeted for 19 in this budget at this point for that. We did, as we noted before, we did implement a new electronic health record this year. And that is a tool that we believe will help us in our population health management capabilities. We will be able to receive data, understand data more quickly, and also understand the different needs of our patient population, and then be more proactive in reaching out to our patient population with services, with resources, with education and support that they need so that we can help them, whether they have a chronic disease or multiple chronic diseases to live a more healthy life when they're dealing with those diseases, but also to work with people so that they don't develop chronic disease and can stay healthier throughout their lives. We also have a number of quality management activities that we're engaged in, and many of them are tied together towards working with people, either people who utilize our emergency department on a high rate, or people who come to our emergency department and don't have a primary care provider. We're working with those people through the blueprint program, through our care coordination program to help them become established with a primary care provider so they don't need to utilize the emergency department for care that can be provided in a primary care and less expensive setting. We are working with the people who utilize the emergency department to a high degree, again, with our community health team with the blueprint program to help them to get linked up with other services that are in the community, whether it's through us or whether it's through other partner organizations. We are also working with our partners in the community and with our primary care, with people who do have multiple product diseases who are considered on a clinical risk scale to be high risk so that they can have assistance in managing those diseases, self-management and being able to stay out of the emergency department and stay out of the inpatient setting where possible. Gifford did start a post-acute care clinic which is a clinic that is staffed by one of our physicians and our goal there is to see patients who have had a new patient stay or in some cases emergency department stay within 48 to 72 hours after they're discharged. Some of the things that we work on with patients in those visits is making sure that they understand their discharge instructions, make sure that they are able to get appointments that they need, they don't already have them before they're discharged with their primary care provider with other specialists that they need to see, making sure that they understand what restrictions they had, that they were able to fill those prescriptions and that they understand how they're supposed to be taking their medications. Ultimately, the goal is to make sure that people are not having to make return visits to the inpatient setting or the emergency department setting and that they are established with care in the right environments, preferably primary care where we can. And then the second item under their panel management, it's important that we get people into primary care and then we work with them. Again, if they have chronic diseases, if they have other needs that we're able to help them to get the services and the resources they need, then we're working proactively with them to help them manage their own health. So these are some of the initiatives that we are making to ready ourselves for health care reform and to be able to serve our nation as well. And this is, again, from the community side, a listing of the investments, some of the investments actually just went through this list so I won't do it again, but this is definitely a part of our investments in health care reform, in population health management. And we'll go back to Jeff. All right, looking at our capital, for this year our capital overall, both for building services as well as major movables, just making sure that Gippard was, you know, its capital needs were on either upgrades or replacements. Looking at the first project is a lighting upgrade. And again, we communicated that we have been working really closely with Efficiency Vermont and making sure that we're appropriately setting the organization up for the future. So that's one of our big projects at 320,000. The other projects for the most part are either replacements or upgrades, fuel tanks, rooftop replacements. We have a gamut banner, which you will see in the major movable. It's a very big project, but that is replacing an old gamut camera. Security badges, interior, exterior camera upgrades, a burner replacement, again, working with Efficiency Vermont to make sure that we're doing that appropriately and refrigerator upgrades. Looking at our major movable, throughout this list, you'll see that either we're replacing or we're upgrading current equipment. The first is the gamut grab camera. We have an endoscopic system, access to mobile, EMI. All of these are replacements. Baco, pulmonary, and cardiac. And again, one being the Baco's and upgrading the other to a replacement. So one of the questions we were asked is to comment on our financial outlook and also link that back to the goals of the all payer model. As we have noted and as you've seen in the information that we've provided, we are having it down here, which as we've talked about is related to the vacancies we've had in provider positions and also in some of our other positions and the impacts that's had on our volumes. Moving forward in our financial outlook, we are in the process of building back our vacancies, building back to historical levels with our providers, primary care surgical services. And also, as I noted earlier, we have had success in being able to add back permanent staff in some of those areas where we've been using temporary or travel staffing, which does have a positive impact on our cost. So we are looking to get back to our historical levels in terms of our volumes, but also to our historical performance which has been steady for years, excuse me. So in looking forward to how that aligns with the all payer model, we've talked about some of the investments we've made over the past year and beyond in focusing on primary care, in focusing on preventive care, in focusing on community health, the integration that we have between our primary care, mental health, substance use, dental, specialty care, hospital services, all of these activities and all that which is near and dear to what the effort does. These activities are consistent with the goals of the all payer model to be able to provide preventive health care, to be proactive, to be able to provide care in the lowest cost setting, to help people in our community to remain healthy and to improve their health where that is needed. In addition, Gifford has also, as we noted, had a strong focus on cost reduction efficiency, reducing our costs where we can, and also being as efficient as we can, utilizing resources like Efficiency Vermont to reduce the cost of our utilities throughout our organization. We also believe that it's important and necessary that we collaborate with our local partners and also with our regional partners. Jeff, in going through our costs and before, noted about orthopedic surgery and moving the orthopedic surgeon from salary to contract, we did establish a contract with Dartmouth-Hitchcock last year to have orthopedic coverage in our community. That is something that we did in collaboration with them in looking at what the needs were for the area. They're making sure that we weren't duplicating services, but we were collaborating and utilizing the existing physician who was already employed at Dartmouth-Hitchcock to provide some services up in our area. So this is an example of what, of our philosophy of providing care in our community, but not duplicating, not bringing on additional costs to the system where we can avoid that. So we feel confident in our ability to meet the goals of the LPR model. We feel that what we're doing is consistent with that. And as I noted before, we are actively evaluating right now our participation for 2019, the process for getting all the information that is necessary to make those decisions does not really ducktail well with this process. We're still getting information from OneCare working collaboratively with them to get the information we need to make these final decisions, but that timeframe is very compressed. So that is not included in our budget for this year, but we will be deciding in the next couple of weeks what our direction there will be. And we have had numerous phone calls and meetings with OneCare. We've had presentations to our board of directors from OneCare and also from other hospitals that are currently participating in the LPR model to better understand how that's working, understand all the different pieces of it, and also understand what investments and what capabilities we need to have in place in order to be successful in that. So we'll have, as I noted, decisions on that within the next couple of weeks. I believe the deadline for us to get back to them is the 1st of September, so as all of us are starting to go, summer's almost over, so we will make those decisions very quickly. So one of the final requests was historical compliance with the budget orders. Looking at the net patient revenue, the green line will be the budget expectation, the black line is the actual experience. To start the presentation, we went over how GIPR is structured and we communicated and GIPR healthcare was apparent and then underneath that was GIPR Medical Center and GIPR Retirement Care. Prior to 2014, it was just GIPR Medical Center and the nursing home as well as the primary care clinics were actually departments of the hospital. Going into the 2014 budget, we did meet with the Green Mountain Care Board and asked, how would you like us to present this? We didn't know when the actual FQHC, we'd get it's approval. We knew that it was going to be in 2014 at some time. At that time, the recommendation was that we would then budget the entire primary care as a full year and then just explain when we came to this group on what the differences were. So on July 1st, our GIPR healthcare primary care FQHC became into existence and that revenue then went to GIPR Healthcare instead of GIPR Medical Center. In 2015, on the same situation occurred, we actually finished construction on our nursing home. We were moving away from a hospital based department of the hospital nursing home and had a standalone. So we had to create a new corporation called GIPR Retirement Care. Again, we seek the council of Green Mountain Care Board to say, how do you want us to present this? Going in, we knew at some time that this would happen and it ended in two, I believe, around July or March. Actually, the nursing home came into existence and so that was the reason for the reduction in net patient revenue. Also, when we take a look at our compliance, we do look at our operating margin. FY17, you're aware that GIPR Medical Center did have a down year, but prior to that, when we take a look, again, the green budget, the black is the actual experience, we feel that we've gotten very tight to those expectations that we can afford to this group. And with that, we'll turn it back to the board and then we'll interact with our follow-up questions. Thank you. At this point, I'm going to open it up to the board and to our hospital budget team to ask any questions. Who would like to start? Robin, you look like you're itching. I'm happy to start or I'm happy to wait, either way. But if you want to go down the line, I'm happy to just kick it off. Well, I think we'll go down the line and let Pat go last. Okay, great. Thank you for coming. It's good to see you again. First of all, before I jump into some questions, I wanted to say I really appreciate the expansion of the MATH program, the net patient treatment program that was highlighted in your budget materials, my notes and my recollection is that you've tripled your capacity. I think that's terrific. So I just wanted to give you a public kudos for that focus. I did have a question around mental health. It looks like you're staffing on mental health. You had a vacancy. So I wondered if you could talk just a little bit more about your recruitment plans and also how that interfaces with the tele-site services with the retreat that you mentioned in your materials. So we have just recently hired a new counselor, a new psychotherapist who is working in our main, on our main campus. So that position is posted. We also have another position that we're looking into, Phil, to actually embed, we're hoping to embed that person in our emergency department and also do some clinical hours. We have, our site in Bethel had an external psychologist who was there, who has recently vacated the premises and we are looking to put somebody, embed somebody in that practice as well. So that's how we're managing the operation services. The tele-site is going to be focused with our emergency department and we're working with, grab a little treat in collaboration with them to provide that service. So they're distinctly different services that we're trying to have. The person that we're trying to embed in the emergency department is really to then direct the patient where they need to go. Thank you. That's helpful. In reviewing your blueprint practice profiles, one of the areas that stood out to me is that you're actually the highest in your HSA, you're the highest per capita cost for the state. So I wanted to ask you when you are doing your community health needs assessment and you're looking at what services are needed in the community, how you consider the fact that it looks like at least for price, because quite frankly for the resource utilization you were right on average, but the price you were an outlier compared to other hospitals. So I was hoping you could speak to that in terms of how you determine what services are needed on the inpatient and outpatient setting and also how that, we should think about that in relationship to your 4% commercial rate increase. So when we're looking at that, we talked about the different investments we're making in terms of primary care and preventive health care. We think that is the area that we need to be focused on in order to drive down the cost of care throughout our health service area. We work very closely with our blueprint program, our community health team and our establishing new ways of reaching our patients, people who are the high utilization of services, ensuring that we are getting people established in primary care. We think that is the, that's really the pathway to be able to drive those costs down. We have had, we alluded to earlier, but we have had since about 2015, 2016, we've had some turnover in our primary care areas, which we think has impacted that, those statistics, those numbers. We, as I noted earlier, we have added back for, we have four new people coming in in the next two, three months. We think that is going to accelerate our capabilities and our access to services for primary care. Again, we think that is really the pathway to making an impact. We've also made an investment in a new electronic health record. Our former system that we used in our practices did not provide us the capabilities to be able to track down to provider-specific levels and patient-specific levels what the needs are for people, for us to be more proactive. But also to say, okay, do we have any outliers? Do we have areas where we're over-ordering tests or whatnot? Our new data capabilities and which we are just developing again, this system we just brought behind at the end of April. There are more capabilities within that system and we are building capabilities within our organization to be able to utilize that data to better understand what's going on there and be able to impact that. Your commercial rate increase, could you talk a little bit about your payer arrangements? Obviously, when you have an increase to charges that would impact your payer arrangements that are a percentage of charges. I'm assuming with Blue Cross, you're on their community fee schedule. So could you just talk a little bit about kind of the range of commercial contracts that you have and how that commercial rate that's approved as per your budget flows through down to the net cost? So really for the commercial rate increase, it's Blue Cross and the MVP that we have, that we have an arrangement with. In regards to the rating increase, we utilize this forum as a discussion with our payers, making sure that we are appropriately reinvesting within the organization, within our staff, within the organization. And we look to your guidance to communicate with them that that is what is the needed rating increase for a different medical center. And so that's, honestly, some of the conversations that we'll have when they give us a holler and stuff and we'll have to oversight and stuff. And I just have one last question. I was also noticing in your Healthy Vermonters 2020 report that your coronary heart disease death per 100,000 rate is on the high side and I'm compared to the state average and also has increased in the two periods of time that they measure. I wonder if you could speak to that statistic and if you're not prepared to do that today, certainly you can follow up later. I'd be grateful for a follow up. Thank you. Okay, Tom. Thank you. Thank you for coming and thank you for the tour a while back. It was a very nice hospital and it just felt like a nice place to be if you had to be there. So I just have a couple of questions. It looks like 2019 is a very pivotal year for you folks. And I'm just looking at some of the financials here. You're looking to, and this is a 2019 budget over 2019 as we're tracking at a 4.9, almost $5 million increase in revenues in the 2019 2.9 million dollar or 5% cut in expenses so that you can change your bottom line from a negative 3.9 million to a positive 2.2 million, which is a $6 million shift. And that just seems like an extraordinary task and the more extraordinary task becomes the higher the risk becomes. And so I'm looking at your revenue projections and so you're looking at overall a 9.8% increase in NPR, a commercial rate, commercial increase going up 9.6%, the Medicaid 15.5% year over year in Medicare at 9.9%. And from your rate increase, I think it's your only predicting just from the pure rate increase about a $1.6 million increase in revenues. So what worries you the most about not hitting these targets on your three different major kind of payers, commercial, Medicaid and Medicaid? So I'm just gonna get to the more existential part of that. I just want to jump in some of the specific numbers. One of the things that we talked about here a few months ago on hearing on rebasing and one of the things that we focused on during that conversation was building back to our historical levels in terms of our staffing and volumes and whatnot. We have had, what I would say, a significant turnover within our surgical services in the last couple of years. We are getting more stability on the orthopedic side. And as I noted, just last week we had, we filled our two vacant general surgery positions which we have been filling for the last several months with low pump temporary positions, which is a higher cost and you do not get the same level of volume and referrals through there. So we feel that in those areas we are going to get back to meeting the need in our community, getting back to our historical levels. Primary care has been really the other side that we've been building back on. We had a number of retirements. We had a number of people who left. We had a couple of people who left for love. We had a couple of people who left because of the opposite of love. And, but we have had success over the past couple of years and building back in those areas. We have a great team of physicians and nurse practitioners and PAs in our primary care side. And again, we are adding two physicians and a nurse practitioner and PA over the next three months getting us back to our historical levels. Again, we're not looking at shooting the moon here. We're looking at getting back to historical levels, meeting the needs that exist in our communities. And we think that is going to be, we don't think that that is risky in terms of what we're predicting now that we have the people in place. What any hospital and healthcare provider of our size deals with in terms of risk is that we have those, we have that turnover. We have that somebody in people in crucial provider positions leave. We don't have a team of 20 surgeons if one leaves, they can just pick up the volume. We have in a lot of cases in our practices one or two people of a particular specialty of one or two leave, that's a huge hit. So that's where the risk always lies. But we think that we feel confident that in the people that we have and the people we have coming, I personally feel great about the caliber of people who are coming both in terms of their clinical skills, but also, and I'd say almost as important or maybe as important is that these are people who want to be here. We talked about the type of recruitment you have to do for any staff. You need to get people who want to be in this location, in this environment, and who bring the right, the right attitude, the right convictions to what they do, and I feel strongly we have that. So what I sense is that, and you can see from your timelines that you have lost in recent years, you acquired a bit of your historical volumes. Given that, where do you think that volume went while you were going through these staffing concerns and what is your strategy to regain what you have lost in recent years, other than you actually providing the people that can provide the service? So there's a number of places where it could have gone. I don't have the definitive data on that, but definitely urgent care has been something that I think people have relied on more, and obviously there are other providers within particular distances from us. Our strategies for winning people back, if you will, Ashley talked a lot about the community health, community outreach initiatives that we've undertaken, expanded over the past couple of years. I feel strongly that those are activities that benefit the community, but they also, I think are a clear message to the community that we're here, we're here for them. We're doing the things that are in their best interests, and I think those are activities that will go a long way towards helping people want to come back to different if they die to seek services elsewhere. I also think that it's important that we be flexible, and the model that we have employed over the years, or any other healthcare entities have employed over the years might not be the model of healthcare that resonates with new generations or generations that have been with us for years, and we have to be flexible in offering access, different access, different ways to access services, different types of services, and just those are things that we're looking at as well in terms of having expanded hours, expanded days, when services are available. So that's important to me. Two more quick questions. The, I saw in your presentation, you mentioned that as many hospitals in Vermont seem to have any suitable traffickers, and that you're trying to reduce that. But when I went to the utilization tab, it was, you know, going back to 2015, it had a zero rate of travelers kind of building into your staffing profile. So I'm just wondering if you can, you'll provide us with a history on the travelers that kind of tracks the money, that what you've been expending in 2016 and 17, and where you're hoping to be in 2019, that seems to be a big item. And finally, you told us in your materials that you wrote off about $2.69 million in bad debt in prior to 2016, bad debt that had been accumulated up to then. Do you have any sense that all of them, because you have free care, do you have any sense that all of that bad debt is truly bad debt and unpayable by folks? And so there's no reason if the strategy could be found to continue chasing that debt. Start on the bad debt questions. Overall, our bad debt, we do closely monitor that bad debt that we have to, because eventually, for our cost reports, we have to discharge the debt, meaning that it is truly 100% uncollectible. We utilize outside resources to do just that, and they then come back and say, okay, this one, you know, we're pretty much at, we can't find any other alternatives and stuff. And so then what we'll do is in the system, we'll actually indicate that that account's been discharged, we report it on our cost report, and then that means that we cannot at that point select additional money on that outstanding debt. So yes, I think we feel very confident that when we get to that point, that we utilize all our resources. The travelers, one of the big things in the 2019 budget, this year definitely we had locums, we had travelers that we had a lot more than we've ever experienced in years past. Prior to 2016, you know, our travelers usage would be, you know, very insignificant in stuff. 2018, it definitely came on strong. We're basically, I believe, and I constantly check in around August and September, we'll be seeing the last of the travelers, you know, the contracts being non-extended and going into the 2019 budget. We do not have that traveling experience. First of all, I want to thank you guys for really adhering to the presentation. I'm putting in all the charts that we asked for because that was really helpful. I want to ask you about the audit adjustment that you had. The, like you wrote off, it was like 5.5 million. It was hitting in 2019, minor cash flow. And did that represent, you know, material weakness or significant deficiency through your audit? And does it have any impact on the future? No, it was a deferred compensation entry when it went out on our ballot sheet. And it doesn't, you know, be honored if you're not concerned at all that it would have any impact. Another thing I want to talk about is really, you know, we focus a lot on NPR and on, you know, hitting the targets for NPR. And one of the things we talked about at the end of 2017 was rebasing. And part of the reason we looked at rebasing at not only the hospitals that were above, but below, was because of the financial risk that some of those hospitals have, specifically in the losses that are being generated. And, you know, you guys kind of resisted, you know, that rebase. And when we didn't end up rebasing the hospitals down, but the concern is more that you guys potentially are setting yourselves up for the same thing in 2019. We had a very similar conversation last year when we looked at your budget and where you were going to come in and that you were going to get new docs and things were going to get you up to the number that you had put into the budget. And now we're running about 15% behind your budget and a $6 million operating loss against a million something operating loss last year. So, you know, I appreciate your chart where you said you've pretty much been sticking with, you know, the operating losses up to last year. And so, I guess the question really is just, how can you insulate yourself against future downside risk? I think you're, any of the year you're projecting in 2019 to have about $2.7 million on cash on the balance sheet. If you have another bad year, you could wipe that out. You know, Tom pushed on that before about how you're going to get there. But I just, you know, really question, you know, yes, your NPR is down 6% to budget, but it's up 10% against the way you're coming in this year. And so, how much optimism in there? How much did your board push you to really, you know, prepare yourselves in case there is a loss? And how can we help you? Because, you know, I really think the concern for hospitals that are losing money and continuing to lose money, you know, could put them at jeopardy in the future. She's right, I know. So, I'll, there's a lot in that question, obviously. I'll, I have a couple of board members in the room and they're not sworn in, so I won't ask them to swear. But I'll tell you that our board is very close to, monitors very closely how we're doing. We have a very active board, we have a very involved board. They share the same concerns that I do, that all of us do, that you do, about our need to improve our financial results. And we also understand the timing of, our timeframe of how and when we need to do that. You know, we are, you know, we have been rebuilding that, our staff. And I do feel confident in our ability to do that and the impact that that will have. But we also have been very, taking very robust efforts to make sure that we get our costs down. And our costs are lower this year than they were last year. And we expect that our costs next year will be lower than they are this year. So it's not just a long prompt effort to look at improvement. We're looking at both sides of it, both the volume and the expenses. We are continuing to look at the different services that we provide, making sure that we're providing the right services that we're not overreaching. And also getting more information on, to help us make strategic decisions as we move forward. So we are, you know, we're saying the same things that Tom's question really, but we feel confident in our ability to do that. We also understand that we need to continue to be very diligent and making sure that we get to where we need to in terms of our financial results. What you can do to help us, you know, I noted that we are going through our deliberations in deciding where we, you know, what we do in terms of the all payer model. We are very interested in all the roles of that initiative of health care reform. We are very, you know, we're definitely looking at being a part of that. What we ask you is for patients, you know, we do need to make sure that we have the stability and the reserves in order for us to take on the financial risks in that. That might mean that we take a different life path than some others, but that is not an indication that we're not, that we don't buy into the walls of that and want to be a part of it. So, you know, we, I think Chair Mullen noted at the beginning that hospital boards make these kind of decisions and ours will in the next few weeks. But we, you know, we ask for patients and understanding that there is greater risk for smaller entities as they go into this and you can be your support in helping us to make those big decisions. Yeah, I did go ahead and apply to you guys on your cost savings and I think you really have mined out a bunch of cost savings and looked at, you know, probably downsizing in some areas and cutting back staff where not everyone is doing the same thing as other hospitals when they be showing they're gonna get an increase in keeping their expense levels up but they may not get that increase in NPR and if you put them in for other risks. So, do you think there's risks in your budget? But we'll see you next year, I guess. We're out, it's quite out of place. Okay, just. Okay, so first of all, I'd like to share some of the concerns of the air already, I won't repeat those, about the mental risks in your budget and meeting the NPR targets that you're setting to yourself. I do want to applaud you actually on a couple things. I think the access and the fact that you can have patience in your ability to getting a scene within five days, I think that's fantastic. I think some of your, looking at the all care model quality metrics, you're at the state average or even better and at the target levels along most of those. Target's the one that you didn't mention which I'm hoping that you will move the needle on the percentage of adolescents on Medicaid, getting well childhood visits, and so that's something I didn't hear anything about specifically strategy to target that, but hoping that that's on your radar screen to improve on. But in general, applaud you for the quality metrics that were seen there and your attention to that. And also echoing some of the cost savings that I see that you're doing are impressive. One of the questions I have, and this actually relates to this all care model and one care in particular, and I realize that you're currently traveling at participation and you have concerns about reserves and the risks therein. But one of the things that actually is a response to the HCA, when they asked you about moving the Medicare payments to a capitated ACO, the response was it would put at risk our ability to offer new community services and cost-based reimbursement offers a buffer to ensure that the care will be paid based on actual costs. I'm just curious if you could speak a little bit to that answer that you gave in the sense that other critical access hospitals under a cost-based reimbursement are in the model for Medicare and so I'm wondering what is different about GIFR and your concerns about losing that buffer of cost-based reimbursement should you decide to join the board of care. I think part of that is a point in time. You look at our performance the last two years and the cost-based reimbursement was put in place by the critical access status and the cost-based reimbursement was put in place by CMS for the very type of situation that we have encountered in the last couple of years with a small provider, seemingly small changes in personnel and providers can have a significant impact. The critical access status was meant to protect against that and it has helped to protect against that. So really for our point in time, it is important that we have that as we're going through this improvement process that we're going through. So again, when I talk about patients, when I talk about the light path getting into the out-of-air model, when I talk about making the right decision, these are all things that we have to weigh within those decisions. So again, critical access status was put in place for a particular reason and it's to make sure that small rural providers like us can weather these kind of storms and have some security so that we can continue to meet the needs of our communities and that is our concern. Again, as we're able to go back or have the reserves, that situation may change, but that is a concern that we have by present people. Is there any, I mean, so some of the advantages people argue about fixed payments is that it actually reduces uncertainty and reduces financial volatility if you know what you're going to expect from a fixed payment in advance. So how does that play into your concerns as a hospital about risk and volatility potentially getting involved in a fixed payment, value-based payment, reimbursement system? Well, so I think one of the real difficult things that we've been dealing with in terms of this decision of when and how to get into the out-of-air model is the timing of information and the method of receiving the information that we need to make those decisions. And I'm hearing my board members talk in my ear as I'm saying this, but there is a really tight, compressed timeframe within which we can get the information that we need to use to make these decisions. We are two weeks out from needing to make this decision. We still don't have, we have a phone call later on today to get some more information to better understand what we've been given. So I still don't have all the information I need to answer that question to be able to understand where there's greater risk, where there's less risk, how it impacts our patient population, what happens when patients who are attributed to us go to a different organization for a tertiary level of care or what not, how that works, you know, what costs are in, what's the cost of care at those particular places, et cetera, and how that impacts us. So it's a very complex, difficult system to understand and that's, I just want to be clear, I'm not criticizing anybody. One care is under the same time pressure as we are. They have to get information in a very compressed timeframe as well. They have to put together a budget that they bring before you and bring before they're boring that they need to be able to make very difficult decisions on as well. But for us, we haven't had all that information that we need to make these decisions. We're free to answer that question that you've asked. Great, well, I appreciate that. Thank you. That explains a lot. Just a couple of more questions. This is actually a small and minor point. As we think about integration of healthcare, that's going to be a key element of our healthcare reform and one important step is to get more patients on to VKI. We've been hearing a lot about the number of patients on the VKI and therefore we have to get to a critical mass so that mass, so that providers will go into the VKI to get patient data and have a better sense of all of the care that patients have been receiving. So one of the things I've learned recently is that hospitals can actually play a pretty critical role in implementing electronic consent through their ADT interface and their EHR. I know you have a new EHR and I'm wondering, do you have the capacity in your budget this year to be able to commit IT resources which I understand are about 48 hours to help ensure that we have more patient data on the VKI? Just a question. It's just good. I would have to take a look at, you know, obviously going back to stuff. I know that the information with CPSI wasn't a simple, easy solution. It actually was going to involve individuals, bodies doing that and I don't know what the capabilities of ECW is at this time to be able to answer that question. That's fine, we can get back to it. The last question related to EMR is, you have mentioned you have an EMR that allows you to understand where there might be over-ordering of tests, I think is what you had to say, and assessing outliers in what I would call over-utilization. And I'm wondering, we have a new legislative mandate, this is actually a selfish question in part, but I'm really curious about your answer, to measure over-utilization through our newly imagined EHR. So I'm actually wondering, since you did say something to the effect that your new EHR will allow you to figure out where there may be over-ordering of tests, how do you measure over-utilization within your hospital, what are the specific metrics for which you can say this is over-utilization? So, again, we implemented that in April, so we're not quite there yet. Okay, I'm going to take you, you asked me why she's like this. I'm curious about, how do we figure out where there's over-utilization? I think you have to just compare. You have to do comparison, for us, we only have access to information within our own entity. So, comparing amongst our own people is the simplest way of doing that. We will assume, once we are at whatever point, we are participating with one care in the health care model, that there will be additional information and resources that they'll be able to bring to bear in regard to that as well. So, I think those are the ways we've been, they will be able to compare to a wider care group. Okay, thank you. Thank you, Jess. So, being leery of the clock, I'm going to not ask you my questions. I made you follow me up and writing to you again. Do want to make a couple of comments. One is that last year when you came in, you were a new CEO and clearly you have settled into that. I think if I had CMS back at the shop and I was sitting here, there'd be sweat pouring up my cheeks. The other comment I'd like to make is that wouldn't it be a wonderful world if we could come in and someone would say, rather than it's a down year, say we had an absolutely great year, our primary care providers did such a good job managing the population that our total costs or revenues were down significantly and we've made adjustments to our expenses accordingly and I hope that somehow we can get to that place where we're creating a healthier population and we don't look at revenue as being the indicator of a good or bad year. Pat, before I turn it over to the healthcare advocate, are there any questions that you or your team have? We'll defer given my time. Thank you. Thank you, Pat. I appreciate that. Over to Julia and Eric. Can you hear me okay? Can people hear me in the back? Yes, okay. My name is Julia Shum with the Office of the Healthcare Advocate at Vermont Legal Aid. So our office advocates for consumers both in healthcare policy and access and also for individual Vermonters who have problems accessing the healthcare they need. So I wanted to thank you for your presentation and also for your answers to our written questions that you provided before the hearing. So I'm wondering, so our office here is regularly for Vermonters who have trouble affording the healthcare they need. I'm wondering if you would agree that affordability is a problem for Vermonters in that sense? Obviously, that is a challenge. Thank you for giving us a preview of your questions as well as give us a chance to consider those. So we do see that as an issue. We have seen that as an issue. There's really been a switch over the years for people who have had no health insurance and when people have no health insurance, obviously when they do need care it becomes very difficult to pay for it. It's been more of a switch with more people who are covered with some sort of health insurance with expansion over the years and the Affordable Care Act. However, there are more high deductible plans in play now which people have coverage but they pay the first dollars up to a, in some cases, a very large amount. So those challenges extend to those plans as well. At Gifford, as we noted, we are a federally qualified health center in addition to being a critical access hospital. We do offer care to people regardless of their ability to pay and we do work with our community members to try to assess whether they qualify for reduced or no fee care based on their income. One of your questions was, does this affect people's ability, the cost, affect their ability to access care? What we can't ascertain is when people choose not to seek care or delay seeking care because of the affordability but obviously that exists. Thank you. And so I'm wondering if your view curve from your providers of instances where people are not accessing care because they're unable to afford it. Maybe they're over income for their financial assistance policy but they still can't pay for care of anything. I think I talked earlier about our post-acute discharge clinic which again somebody is an inpatient, somebody's in the emergency department or has frequent emergency department visits. We tried to get them into a post-acute visit within 48 to 72 hours. One of the things that we tried to do there again is ensure that they are able to follow up with care because in some instances they might be in that setting because they didn't seek care in a primary care setting or in a less expensive setting. So we tried to work with them to figure out what resources they have, what resources are available. Try to work with people so that they can access some of the prescription assistance programs so that they can afford their drugs when they have prescriptions again. So they can avoid those higher levels of higher cost levels of care and also get them aligned with primary care and some of the other resources that are available to them. I don't have specific instances to share with you but I think that is something that the providers will hear from time to time. People won't fill their prescriptions or whatnot. So we try to put every resource in place so we can make sure that's not someone's reality. So some hospitals in the past have qualified as money that people are unwilling to pay or in pre-care as money that people are unable to pay. I'm wondering if you agree with that characterization that all that debt is due to unwillingness of patients to do that kind of thing. Well, I think there's an accounting handling of that and I assume what you're getting to is more of a philosophical but there's an account of in doing our accounting, having our audit, we have to handle it in a particular way. Yeah, because that is where bad debt, how different types of carersons that are available and the money's in pursuit of bad debt. But no, I can't sit here and tell you that everything that's classified as bad debt is due to some of our abuses to pay. Obviously in some cases people don't have the funds to pay for it. I mean, the other thing that I would like to say is affordable care is a driven process, i.e. the patient comes in, pulls out the application, supplies us all the information on, so they're engaging us to say that distance care that they can't pay for, that debt on the other side is not that long-term service. I'm wondering how you assess for wonder's ability to pay when setting your prices for services and also study eligibility for both types of services. So, unfortunately, RIO master is over 7,000 lines of data, when we set the pricing, we don't have a study in there that says that fees are out of four, this type of patient versus that type of patient is four the most part across the board in all the money-severed prices. But I need more in terms of, so if you're looking at a certain service and setting the price for that service, whether it's, you know, assuming it's for all patients, do you take into consideration the affordability to people at that service when you're setting that? Yeah, I would say that this, you know, we don't have that ability to get down to that level and see if those understand how they interact with it. Thank you. So, when you get your commercial raise through each by the board, whether it's the amount you requested or not their amount, do you consider that to be a stat rate or a ceiling rate? So at that point, you wouldn't have that in the grocery or the insurance and end up at a lower price. That would be the rate that would be important to you. That would be October 1st. I just have one more question. So you mentioned the, I mean, our hand distribution program, we're going to talk a little bit more about that. So we have a site that's located in a place we call Kenwood. It's right off the interstate off of 89. And we provide, we provide addiction medicine services in that clinic a certain number of days a week. So what we've agreed to do is work with the state, they're supplying us with some number of Narcan packets. Anybody can come in off the street, ask for it and it's handed to them with no questions. So the directions are in it. They're there to answer questions. And as long as we're open, there's people in the site, we're able to hand it out until we're very long. There's a little bit of a tracking mechanism, but not anything that's requesting your name and information about your, why you're asking for it. And does that say offer, or others in your community offer other harm reductions or is it like surrogates change or healthcare services specifically targeted to people which is what seems to be happening in the city? So Ashley did note that we did implement a drug disposal unit at our hospital this past year. We also asked you to set up before we do offer wound care services. We have had a concerted effort on HPV immunization, and have done a good job with that as well. We do have a full service substance use addiction medicine program. One of the key characteristics I think for the Narcan distribution is that that is occurring at a clinic that can provide treatment and services for people as well. So they are coming in the door, we're not asking them to engage in services, but they are there and they have access to people if they choose to. So that is what we think is a potential benefit to being able to provide access to services for people who maybe say, well, maybe it's time. So yes, there are addresses. Yeah, that's a lot of questions. Thank you. This point, we're gonna open it up to the public for public comments or questions. Please stand up and state your name and address your questions through us. Go ahead, Dill. Dill Hackett, from Berger, Vermont. Here's your question as a consumer. When I was looking at your information, there's something that has been bothering me and maybe can help me figure this out. And that is I keep looking at the quality measures and I keep reading articles and data from other places as well. And it's not aligning with how well the measures say they are doing. The more I look at it, especially when I look at and trying to compare what is my workforce, I see the workforce shortages. And when I start looking for how long does it take to see the patient, I'm getting feedback of experiences of one, two, three weeks. Unless they're seeing just anybody. And then when I look for the quality of the experience and the care deliverer, I don't see that aligning with the measures as well. So it's got me wondering about the measures and the risk assessment. I think the risk is higher than is being talked about. I think there's a great deal of risk and not having enough workforce. And that's what I'm getting at is seeing things in reality that don't play out the way the measures show them to be. And I'm not sure that we build in an illusion is it catching up to us. I don't quite know where this all goes, but I don't see it aligning. It's falling apart. Thank you, Dale. And Dan, I thought that actually Gifford did a very good job of answering the questions as it related to access time and workforce. I think each of us on the board hear those same things that Dale are hearing. But from your submission, it really didn't appear to be a significant problem at Gifford. So is he a lacqueric in this assessment or in your particular hospital service area or do you have a different story? No, I don't think I have a different story. I think one of the comments that Dale made, I think is apt and I alluded to it earlier is historically, I think all of us when we had a primary care provider, we had that primary care provider for years and we had that relationship and that was the way healthcare was delivered. And I think in general, it worked pretty well. That's really not, you don't see that as much anymore. There's more turnover. People not, primary care providers not staying in one place as long. There aren't as many of them. You have situations, Dale noted that yes, you're getting to see a primary care provider. You're seeing the person who has openings in their schedule that day. Those are changes in how services are provided. And that is I think something that in some cases, patients are fine with that. In other cases, they're not fine with that. So it's striking that balance, having that flexibility, being able to provide consistent, steady primary care providers for people so they can see the people they want to see. But also understanding that if you have a, if you need, you may need to see someone other than the person you normally do and making sure that people understand that and ultimately you're okay with that. So it's a continuing struggle I think for the whole system. Okay, other questions or comments from the public? So I guess that will wrap up the presentation from Gifford. We thank the Gifford team and we're gonna take a five minute break and give coffee the opportunity to get set up.