 trying to find my unmute button there. Yeah, you know, I think so. It's a little hard for me to tell, given all the screens and we're in different rooms. So I'm gonna go with a yes. Okay. So I'm gonna- I thought I said Bob Percy on and as long as Bob's on, we're all set. I'm gonna reconvene the meeting of the board. And John, I see you have several members who are going to testify today. So if you could just introduce them and then I'm gonna ask Joanne to swear you all in as a group. Okay, sounds good. That's our third slide, but I'm gonna jump ahead and do that now just so you know who everybody is. So for the NVRH leadership team today, Sean Burrows, our CIO, who's actually away on vacation in Alaska. So he won't be joining us, but he was a major contributor. We don't have to swear him in. We have Diana Gibbs, our new VP of Community Health Improvement and Marketing. This is her first presentation, the Green Mountain Care Board. Betty Ann Guacan, our Chief HR Officer who is joining us also from her vacation. Bob Hersey, of course, you all know quite well, our Chief Financial Officer. Laura Newell, our VP of Operations and Medical Practices. Dr. Michael Ruth, our Chief Medical Officer and Julie Schneckenberger, our Chief Nursing Officer. Colleen Sinan, who is our VP of Quality Management Programs and of course, myself, the CEO of NVRH. Okay, Joanne, could you swear them all in? Sure, would you all please raise your right hands? Do you swear the testimony you're about to give will be the truth, the whole truth and nothing but the truth will help you bad. I do. I do. Thank you. Thanks. And Sean, whenever you're ready to proceed, take it away. Okay, you got it. I think we're gonna let Bob open a little bit with the review of the agenda. So the agenda that we have, and good afternoon by the way, we'll follow exactly the format that was suggested by the Green Mountain Care Board. So we'll go to slide four now and we'll give an overview of NVRH. We are an independent 25 bed critical access hospital. We've been a critical access hospital since 2004. Our service area, which includes about 30,000 population includes all of Caledonia County and Southern Essex County as well. Our budgeted ED visits for 2022 or 12,500, which by the way, we're down from about 16,000 ED visits in 2019. We operate 14 medical practices, multiple specialty practices and four rural health clinics. We have currently 684 employees. Of that, 80 are either physicians or advanced practice providers. Of the 684, 394 a part time and 290 are full time. And our mission is to be a leader in improving the health of our community. Next. An introduction to our fiscal 22 budget snapshot at the 35,000 foot level. We're budgeting an operating margin of just over $2 million or about 2% of our total operating revenue. We are requesting a 3% average charge increase. We continue to expand and add services in order to meet the needs of our community. We continue our focus on reducing avoidable ED visits. And for 2022, we will be expanding our participation in value-based payment programs. Next, I am going to turn it back to Sean, who is going to make a few introductory comments. Sean. Thanks a lot. The picture wasn't my idea, but the bears behind me are what I look like in the morning before coffee. I did prepare a couple of them. I'm glad that you didn't go there to make the presentation. It would have been kind of neat to have that bench. That's right. Next year. The Fairbanks Museum is one of the gems of St. John'sbury. Kevin, I did prepare a couple of new marks, so bear with me as I talk our way through these. First, I just want to open by saying just how proud I am of my staff and the whole team here at NBRH for their hard work and the commitment to our patients while navigating this pandemic over this past year. And I also want to give a special shout out to the staff who set up the programs that really helped us prevent the spread of COVID in our communities. For example, our testing centers, the vaccination programs, and the screening centuries that have become a central function of how we operate as a hospital in this new world. I think I also want to highlight something that you'll see in the data coming up, but we've been very pleased with our new express care clinics that we opened in partnership with Northern County's Health Care, and we also rolled out during this past pandemic year. They're already having an impact on avoidable ED visits and we're excited to see that result. Now, given all that positive, I'll be honest with you, it's been tough to have to prepare this presentation and this process in the face of what we're seeing with the pandemic. I really much prefer to have been spending this time supporting our staff and preparing NBRH in the community for this next phase of the pandemic that seemed to be entering. And while I believe that we have prepared a prudent and reasonable budget, there are some things that I want to really specifically call out that you may not pick up or may or may not pick up as we walk through this. Firstly, it's a global observation and that is that as a state and a system, we've done a very good job of controlling costs and delivering high quality care to the communities we serve over this past decade. And while the cost, the goal of cost cutting is both necessary and admirable, there are consequences. We, and I use the global we here, have created a healthcare system that has zero slack. There is no excess capacity. And even without the impact of the pandemic, our aging population has put increasing pressure on our system. We've got older and sicker patients who need a lot more care. Compounding that fact is the matter of our broken mental health system, which means that people who are suffering are waiting for days in our emergency departments for a bed to open up. And I can't stress this enough. Our own staff are stretched thin. Our heroes who are doing all this incredible work, our nurses, our LNAs, our techs and our clinicians, they're exhausted. For the last several weeks, NVRH has been at or near capacity with very sick people. And this is without a surge in COVID. We're unable to transfer tertiary care facilities because they are often full and we are finding ourselves in a position where we're transferring people farther and farther away. The open question I need to ask all of us is, we created the system, but is this what we want? From for our mental health patients to language in our ERs, for critically ill patients cared for in hospitals, three, four hours away from home, or for our staff to be so burdened and burned out that they're choosing other lines of work. There's another issue that I want to raise and I think it's hidden in our budget presentation today. And that is around inflation. We have presented a budget that works really hard to maintain reasonable increases in costs over this next year. But my team and I do not believe that the inflationary risks to our economy are temporary or transitory. While we've presented a budget that tries hard to control these inflationary pressures, we are seeing impacts on everything from wage pressure to drug costs and supplies and facilities improvements. I believe that inflation will have a significant impact on future hospital budgets all across our state. We're committed to serving our community and we are here for our patients, but we need the Green Mountain Care Board's help and your support by approving this budget as presented. In our presentation, I hope you see what I see, which is an extremely well-run institution, committed staff all making prudent and reasonable decisions to ensure that care needs of our community are met. We're serving our neighbors, friends and our families. We cannot meet their needs without the support from the entire system. So thank you for indulging me in these opening remarks. I'm going to now turn it back over to Bob for the formal presentation of the budget. Thank you, Sean. Thank you for those comments. We're gonna move ahead to the next slide. As requested, we have reproduced our income statement here as part of our presentation. And we'll start by looking at a bridge of our fiscal 21 budget net patient revenue and fixed payment revenue to our fiscal 22 net patient revenue and fixed payment revenue budgets. Our approved net patient revenue for fiscal 21 was 90,525,000. We're budgeting that to grow to 97,368,000. And you can see some of the major variables here. We expect our volume to return to pre-COVID levels to approximately 2019 levels in most of the areas and expand beyond that in some. And as we talked about with the ED visits to retract a bit from 2019 levels. We're particularly seeing the return of patients to our medical practices, those 14 medical practices I mentioned. Patients are coming back at least to 2019 volume levels and in some cases because of the addition of some providers beyond 2019 levels. Our 2021 budget did not sufficiently include COVID testing revenue. We anticipate COVID testing to go on into fiscal 22, probably given what's happening now at a greater level than even we've anticipated here in the budget. For example, now we're doing about 70 tests a day on COVID patients. Code Silver, ED Parkumont, ED Parkumont. Code Silver, ED Parkumont. Maybe Sean, you could just mute yourself until you speak. Yeah, sorry, I hesitate to get a code Silver or somebody with a weapon outside of that Parkumont. Based on information we've received from one care, we anticipate our Medicaid attribution to increase in 2022. And we've also included the Value-Based Incentive Fund payment here, that's a little deviation from how we handle those revenues internally, but we've been asked to include those as part of our net patient revenue figures. Sequestration is expected to come back in December or January of 2022 actually. Sequestration to us as a Medicare sequestration is a hit of about 575,000 a year. As you know, that was waived for a period of time. Bringing that back will have an impact of about $143,000 before it returns in January, that's a positive. Uncomfortable. I'm sorry, this is, excuse me, this is a core report. There's a lot of background noise, so. I'm sorry, hold on. And Bob, if you could speak up just a little bit, that would help. I sure can. And I'm also re-positioning the microphone and close my door slightly. Is that it, better? It is better, Bob. And if you guys need a few minutes to make sure everything's okay, we can go into recess if necessary. Okay, our team is responding. Okay, thank you. I may walk down the hallway, but I'll be right back. Bob, you can continue. Okay. And hopefully I can, I heard better now. Does it sound like I muffled? I wanna make sure, I'm talking through a headset, but I'm not sure it's coming through that or through my computer. So is there any muffling sound? So I'm hearing you fine, but I'm used to you too, Bob. So the better question is, Joanne, how are you hearing him? Fine, but just please keep your voice up and that'll make it easier. Sure will, thank you. And again, don't hesitate to stop me. So I was talking about change in uncompensated care, which we're seeing a decline in. In part of that, we attribute to the increased Medicaid enrollment, numbers that one care has given us. Last year during the budget presentation, I talked about the cost of one drug that's only for a couple of patients, that cost of that drug has now increased to over $1 million a year, an increase of my $278,000 from last year. We have expanded several of our services, pulmonary, pulmonology, I should say, E&T and pain management services. I'll talk a little bit more about that in a minute. And the change from our rate increase we were expecting to be about $1.2 million. And we estimate that for every $1 rate increase, we receive about $401,000 of net patient revenue. The table down the bottom, trying to illustrate that if you look at routine ongoing revenue growth, it's about 3.3% of the growth, about 2.9 million. Other factors, the volume returning to pre-COVID levels, the expanded and new services, those other factors account for 4.3% of the total, 7.6% increase in our net patient revenue. But again, the routine ongoing business would have yielded only about a 3.3% growth in our net patient revenue. Next, please. The, as I mentioned, we're requesting a 3% rate increase. On average, for the last five years, our rate increase is just a little bit under 3.25%. We'll achieve that 3% average by increasing our hospital service fees by 3.4%. And as I've indicated here, we just had a complete review done of our Charge Description Master and we've had our prices for most off-services compared to those of our peer group. So we'll be using that data to help us guide our price increase strategy to help guide that 3.4% increase for fiscal 22. And we will not be increasing our fees for provider services at all. On a budget to budget basis, again, the net patient revenue increase due to utilization is about 1.7%. I mentioned our provider practices, medical practices seem significant volume increase. Our operating room revenue department continues to see to get busier. Our physical therapy department is growing as well. We, well, some practices are growing. We continue our efforts to reduce avoidably due visits here. And you can see from fiscal 2018 to so far in fiscal 21, we've gone from about 27% avoidable ED visits to about 17.5% ED visits, avoidable ED visits. So significant decline there. And as Sean mentioned, our express care operations in partnership with Northern County's healthcare are putting out significant role in that, we believe. Net inpatient revenue from newer expanded services is about 1.6%. Our ENT, nose and throat practice, we shared with Wilton Regional two days a week. That was just not meeting patient needs. The current wait time for patients seeking an ENT provider is two point, I'm sorry, two to three months. And patients just aren't waiting. So they're going elsewhere, specifically across the Connecticut River to get that care instead of waiting. Our pain management program, we're gonna expand as well. The same issue with provider, somebody waiting for pain management is waiting about three months for that care. A pulmonology provider, we had shared with North Country Hospital, that provider left. And we are other referring providers that said we really need a full-time pulmonologist. And so we are right now, have employed the only pulmonologist in Northern Vermont and New Hampshire. And she is already very busy. We, as I said here, and I could expand a little bit, are seeing ourselves really becoming more and more of a regional provider. We continue to see patients being referred from the north of us, up from North Country Hospital and from Grafton County Hospital. We see a lot of orthopedic cases coming from out north. Some of our growth and physical therapy has come from outside of our service area from out north. And to put it into perspective, compared to the same period two years ago, our revenue from Orleans County is up 29%. And our revenue from Grafton County is up 39%. Next slide, please. Here is a trend to charge increase. As I said, that works out to an average of just under three and a quarter percent annually for the last five years. Next. Next are our payer assumptions. We do not anticipate any changes to our commercial payer discounts. We do not expect any changes to Medicare's rules for critical access hospitals. We talked about the sequestration issue. In 2022, we will participate in all of the one care value-based programs, except Medicare. We'll talk a little bit more about that shortly as well. I talked briefly about our lower-on-compensity to care trend. We're anticipating that we'll continue. We did anticipate the potential negative economic impact of COVID and what that would do to our uncompensated care during 2021 that did not happen. We are seeing this decline in uncompensated care, despite the fact we have not changed our uncompensated care policies at all. Our patient assistance program, which is the free care program, did not change. And for patients that have balances that don't qualify for our patient assistance, we are expanding the amount of time they can pay those bills beyond what we normally had done. So there's no change in policies that have resulted in our decreased uncompensated care. And as I again mentioned, we think part of that is the increased Medicaid enrollment. That which, by the way, we work hard with our employees to make sure that they can make qualified for Medicaid and help them through the process to qualify for Medicaid. Next, our budget for 2022 does not include any provider transfers. As I mentioned before, we have expanded services, but there is no provider transfers included. Nor were there any material counting changes adopted in fiscal 21 and none are anticipated in fiscal 22. Next, other operating and non-operating revenue. As you can see, there's two main components of our other operating revenue, that being the 340B program and the referral of the reference lab revenue. We do operate a vaccination clinic that doesn't show up here as any revenue because it's a break-even. It's a contract with the state in conjunction with our partners in Northern County's healthcare and it just covers costs per contract. So there's zero operating revenue, but I do want to point out that we are operating the vaccination clinic. Stimulus money for 2021 projected. We're still working through the final guidelines on how that money can be used. We do anticipate that it is highly likely that the 1.1 million will be greater for the 21 projected. In other words, we will be able to recapture and record more than 1.1 million as other operating revenue for that stimulus grant money. And we don't have a final number yet and probably we'll not have a final number till close to the final deadline of September 30th. NVH does not budget for non-operating revenue. Almost all of our non-operating revenue or expense is gains or losses on our investments. And as you've heard me say before, we cannot predict that, so we do not budget any non-operating revenue. Moving to the next slide, our expenses. Our budgeted operating expenses for 2021 with 93,488,000. A big change going from fiscal 21 to fiscal 22 is the provider tax increase. As you know, the 2021 provider tax is based on our actual 2020. So Bob, if I could just interrupt you for a second. Your screen went black for me. Oh, just getting back on. Okay. Did others have that same problem? Okay. So we're on slide 14, Terry, if you could back up to 14. Thank you so much. Thank you. Yep, thanks for putting that out. Our provider tax was based on our then projected 2020 revenue and our volume came back much quicker than we anticipated and therefore our actual 2020, that patient revenue was much higher resulting in a higher tax moving into 2022. The new and expanded programs, you can see we're budgeting about 1.3 million. We talked about those on the revenue side. This is the expense side of that. If you were to compare those two, by the way, you'd see that we are expecting a slight operating margin from those new and expanded services. Talked about the revenue side again of the COVID testing. We see the expenses of that as well. Our operating room in particular, our major orthopedic cases continues to increase and we have the cost of those implants, as you might know, is very expensive. And so that volume grows our associated costs projected to grow as well. The cost side of that one drug I mentioned is 278,000. We're anticipating our travelers expenses to decrease. And we'll see shortly that is one of the risks as we encounter, as Sean mentioned, staff burnout. There's pressures on us to retain employees. One risk is that the reduction in travel expenses may not actually happen. We'll be recruiting some additional providers and other positions in 2022. So we're putting some money in the budget for that. We gave our employees an increase in 21 earlier than anticipated and that expense carries forward to next year. We're starting to return to normal capital expenditures so that will increase our depreciation expense. Again, we pretty much held all capital investments in 2020 after the COVID pandemic and our concerns about cash flow. We budgeted about routine supplies, about a 2% inflation index, a little bit higher than 2%. You can see the anticipated cost of our salary increase. FTE increases, this is where FTE is not associated with more expanded services, but you can see some of the categories of expenses that we've had to carry into the budget. Other volume related expenses increases are about 320,000. And we're projecting to find ways to reduce expenses by about 361,000. Some of that is for our ongoing efforts to maximize the 340B costs in our supply chain savings through our group purchasing organization. Next, here is the trend of our operating margin. You can see we're fortunate to have the last five years to have a positive operating margin. And in fact, if this trend were to go back 10 years would show that nine out of the last 10 years we had a positive operating margin, pushing back five years beyond that, we've had a positive operating margin, 13 of the last 15 years. So we've been pretty consistent from year to year for the last several years. Next, you can see our five year average operating margin is 1.8%. You'll hear a little bit more about this, but we are preparing for a major project expansion, our West Wing Emergency Room Project expansion based on current estimates. We think that cost will be about $22 million. So we're needing to budget a minimum of 2% operating margin, 21, 22 and beyond in order to support the cost of that and the associated debt that we'll be taking on to fund part of that project. And our total operating margin is just the operating margin plus or minus our gains on losses and investments. So we don't have a number of that. As requested, our balance sheet is reproduced here. Just to go back to it again, increase from 107 to 143 days to support the West Wing project and ongoing debt coverage. We feel we're well positioned to take on our balance sheet in terms of the capital structure ratios indicates that we're well positioned to add that long-term debt. Our current debt service coverage ratio is about 5.4 times. In our ratio of long-term debt, the capitalization is about 0.1. Based on those metrics, we're in good shape to take on some additional debt at school. Sliding moving to slide 19, cash flow budgets. I'll just highlight a couple of things here. We're anticipating putting about 3.1 million into the West Wing project during fiscal 22. The details will be coming on that in a few minutes. And we're repaying about almost 11 million of the Medicare advance payment that we received last year. We've received 13 million in total. By the end of 2022, we'll have paid back 11 million of that. So if you look down near the bottom of that page, it looks like a decrease in cash of about 12.8 million. But if you exclude the repayments of the Medicare and exclude our 3.1 million investment in the West Wing project, we actually had a positive cash flow of about 1.1 million. And I'd also note that we're seeking short-term funding options for that 3.1 million. So we may not have to burn as much of our own cash for that during 2022, but I don't have any commitment yet. So I've not put that into the budget, cash flow budget. And I am going to take a break and turn it over to others on the team. We'll talk about some of the risks and opportunities. And the first will be Julie Schneckenberger, our chief nursing officer, Julie. Hi, good afternoon. I'll just speak briefly to these risks that we feel could negatively affect our fiscal year. The labor market is tight. I don't think that's news to anyone. Vermont has over 1,200 postings for RNs and over 300 postings for LNAs. Currently, we have 33 open positions that include RNs, LPNs, and LNAs across all of our clinical areas. Right now, we have 11 requests out for travelers to fill some of these positions. And we're currently utilizing eight travelers working in all of our clinical areas. In addition to this, we have 25 other positions posted for a variety of jobs across our campus. Travel nurses are asking for and getting anywhere from 125 to $180 an hour, depending on their specialty. Many of the travelers are not vaccinated. The supply of travelers has severely dwindled over the last couple of years. Two years ago, we would get 10 applicants for one position. Now we have positions posted for weeks and have no applicants at all. The new patient care tower that's going to be built at Dartmouth-Hitchcock, our understanding is they're increasing their beds by 60, 20 of which are designated ICU beds. And there's an estimate of 60 RNs plus answer to Larry Personnel will be needed to staff this tower. And we believe that that is also going to put an additional strain on our recruitment efforts. Mandated vaccines, we feel will also affect our ability to hire staff. I had a call earlier today from a nurse working in Maine where they've mandated vaccine for all healthcare workers, looking for a position somewhere where vaccines are not mandated. And she, I guess it's gonna have to look a little further south. That is basically what I have. If there are any questions, I'm happy to answer them. Thanks, Julie. I'll talk, it's Bob again. I'll talk a little bit about our inflationary pressures. Sean alluded to them. The main one that I and others I think I'm most concerned about is our labor costs. The tightening labor market that Julie mentioned is driving up the rates for not just travelers, but staff at all levels of the organization. Our supply chain, we're doing a good job, we think, in maximizing savings from our purchasing contracts. But we're not sure that we've got enough inflation built into the budget and that would be a risk if we don't have enough. We talked about the project, the impact of the current inflation for equipment and construction. Do we have enough money to, is $22 million gonna be left for that project? Our construction manager is estimating 10% per year growth and construction costs. He's not sure that that is going to come down any. So that's some of our inflationary pressures and Dr. Roos is gonna talk a little bit about some of the other risks that we have in the 2022. Yeah, thanks, Bob. So I'm gonna talk a bit on the chronic strain on our mental health system and how it's impacting what we're able to do here at NVRH. There's a couple of slides coming up that I'll show you, that talk about that. We're an acute care hospital, critical access hospital. We do not have any designated, true designated mental health services, really, you know, we have some counselors, but we've had to contract with a tele psychiatrist in order to be able to be sure and round out our care that we can give to the patients because we end up having a fair number of patients in mental health crisis with exacerbations of their chronic mental illness. The other thing we're running into are true capacity issues, and I'm assuming the board is seeing this from the other hospitals as well. A lot of our work here in caring for patients in the community involves triaging them, assessing them, stabilizing them, and then ultimately getting them to a tertiary care facility for the further care that they need. So if they have advanced cardiac problems or major organ derangement, they're gonna need a tertiary care bed, and there have not been adequate tertiary care beds available. Dartmouth is our main referral. Tertiary care hospital has been full in the 90 plus percent of the time when we go to transfer somebody. UVM has been our backup. They've been full much of the time when we go to transfer somebody. We recently had somebody quite acutely ill who needed to transfer something we could not care for here of variceal bleed, something we don't do. Dr. Sexton called 22 hospitals around New England and the Northeast all unable to accommodate, finally found a bed in Albany, New York. So we're transferring people far afield, Bay State Medical Center in Springfield, Maine Med in Portland, Maine, Mass General in the Brigham in Boston, and Catholic Medical Center in Manchester as well as Concord, New Hampshire. Those are just some examples of where we're transferring people to get care, a higher level of care. The availability of mental health beds is causing long wait times in our hospital up to 45 hours at a time. This graphic shows that 40. If you look at the angulated line, that is the number of hours. In 2019, it was averaging about 24, 25 hours. In 2020, it went to 32 hours. And so far in 2021, 45 hour wait time for mental health boarding. And the second graphic on the right hand side of the screen, the orange color or, yeah, kind of a yellowish orange is pediatric cases. And unfortunate consequence of the pandemic is we're seeing a lot more pediatric emergency mental health. And you can see the cases have doubled in the last two years, more than doubled in the last two years. You know, other consequences of the mental health crisis is we have clinical patient safety observers one-on-one with mental health patients. This is a one-to-one paid 24-7 position that amounted to $385,000 they added to our budget in order to take care of these patients. We were required to do that by CMS. Some years ago to be sure that these patients remain safe. We have to transport these patients. There's costs there. And another sort of hidden cost is our licensed nursing assistants are often assigned to be the CPSO clinical patient observer. And they have to leave their acute care assignment in order to do that. So we have less care for our acute patients and less job satisfaction for these nurses, licensed nursing assistants. And unfortunately it's harder to maintain them. They are moving on because they find a better work arrangement elsewhere. This second slide again demonstrates mental health visits and the average boarding time. You can see it varies. We had a real influx around May. And the slide to the right is actual patients. You can see based on that there are patients who come in repeatedly volume by age. The majority are adults, but you can see nearly a quarter are pediatric. In the further lower right-hand corner, you can see the difference between a voluntary and an involuntary. Fortunately involuntary patients don't have to wait as long. An involuntary patient is a little easier to place. Voluntary patients staying for about 59.55 hours, involuntary patients can stay for as long as 96 hours, four days in an emergency evaluation position. These are the most volatile level one patients and they've been somewhat difficult for us to handle. So we've had some real difficulties dealing with some of our mental health cases. And as you may have heard, security for us here in the Northeast Kingdom has been a difficult issue. Our Caledonia County sheriffs have not been able to staff and provide our coverage. So we're having to find alternative security arrangements as well. So it's a tough time on the inpatient side but we are trying to make it through. The other issue is post-acute care beds, the nursing homes in our region. I think like most places, it must have been very difficult to staff a skilled nursing facility during COVID with isolation beds and limited ability to transfer. We had to hang on to patients a little bit longer. We've undergone ownership changes in both of the skilled nursing facilities in our region. They're having trouble with both nursing staff as well as medical directorship for both of these facilities. So struggling a bit at that end. Next slide. So again, continuing with the theme on risks, the COVID-19 resurgence because of the Delta variant is just, I'm sure you've heard that in your hearings but it's just disheartening. We've been working hard to try to provide excellent care for all of these patients. And now we find that it's coming back despite the fact that we have a high vaccination rate. And now we're facing schools returning. They likely will not be doing remote learning, unfortunately, but they will have a mask mandate. But the risk of the Delta variant affecting our employees is gonna affect staffing. When a child comes home sick, the parent has to stay home with them. And then we're essentially out of staff person. We're looking at supply chain disruption again and the availability of personal protective equipment. We're having to re, because the pandemic's been going on so long, we're actually having to refit test everybody for what now is a different N95 mask. So the logistics of maintaining in the Q care hospital through all this has been quite burdensome. Bob, why don't you talk about the... I will, why don't you continue to talk about the designated agency and then I'll come back. Okay, well, most of you have probably heard that the Northeast Kingdom Human Services designated agency in our region had was cited for a number of deficiencies and was on the verge of possibly not being able to continue with their contract. They are undergoing a rejuvenation plan to try to get back on their feet. They've had to curtail some services and are barely meeting the needs of the mental health patients in our region. And that just adds to, because where do most of these patients end up is in our ED and at times they end up on our inpatient service. So that's just another risk for us. I would say fortunately, fingers crossed, we have not had a lot of patients with mental health crisis or COVID positive because that presents another whole set of problems but we've been very lucky there. Thanks, Mike. So a couple of other risks that we'll talk about is the 340B Revenue Program. I'm sure you've heard about Detroit manufacturers pulling their drugs out of that program. The risk is that others will continue to do so and we've got about 2.4 million budgeted in that 340B Revenue and there's a risk because of additional withdrawals that that might be overstated. I mentioned that we're going to expand our participation in the one-care value-based programs. We've budgeted $812,000 of risk. That is not our maximum level and so if our actual risk exceeds that, our actual risk liability exceeds that, that's an additional risk to us achieving our 2022 budgets. Moving to the next slide. Some of the risks and opportunities. I'm going to turn it over now to Laura Noel to talk about a few of these and Laura. Good afternoon, everyone. Thank you for hearing us today. The first bullet there, one of the Vermont did an excellent job of navigating this COVID pandemic and one of the unintended consequences, a good consequence is that Vermont became a place to be. People want to come to Vermont. They see it as a safe place to be. I think throughout the pandemic, people came back to their roots and valued their time with their family more and realized that Vermont is a great place to have a great work-life balance. So we've seen this happen with our provider recruitment. Normally, we may get a couple applications for our provider openings, but throughout the past year, so we've had an influx of applicants for all of our provider postings. So that's been really great. We're happy to see the high-quality candidates that are coming through and that are moving to Vermont and staking this as their home. The second bullet, we've entered a contract with Alpine Telepsychiatry and we're super excited about this. Alpine is providing telepsychiatry services throughout our organization. So not only in the ED and emergent situations and in our inpatient situation, but also they're providing services to our medical practices. So this will really help with the continuity of care and supporting patients throughout their touches within our organization and the care continuum. We'll continue to use telehealth services. We had kind of an abrupt start to telehealth last year when the pandemic hit. It's proven to be a great resource for patients and providers alike, especially for our counseling providers. It's working very well. As Bob mentioned earlier in the presentation, we plan to budget for 10 telehealth visits per week in our primary care offices and we'll utilize telehealth services as appropriate in other specialties. Bob, I think it's back to you. Thanks, Laura, yeah. So we will continue to use the 340B program to reduce our outpatient costs. That is an opportunity. Our pharmacy director does an outstanding job in making sure that we're getting every possible drug under the 340B program and maximizing those savings. I talked about the manufacturers pulling out of the 340B program. We're working and we'll continue to work with our medical providers to find alternatives. So drug A has been pulled by a manufacturer. The drug B is manufactured by somebody still in the program and has the same efficacy and patient outcomes. The providers are often willing to switch to that drug that's still eligible for the 340B program. So we are working on that to minimize the lost 340B revenue. An opportunity, I mentioned the downside risk for the one care value-based programs. There is also upside risk. We budgeted a downside risk of 812,000 but there's a potential for upside risk as well. So almost that same level. So that's an opportunity as well. Moving to the next slide, I'm gonna turn it back to Laura to talk a little bit more. Yeah, the first bullet point there. I'm talking about the one care data analytics. We've had the opportunity to really leverage this information for a variety of reasons. We use it to identify areas for improvement and take action to improve where we can. We also use this information to ensure that no patient gets left behind that could benefit from care coordination in our connected system. Improving operational efficiencies through cross-departmental collaboration. We do a really great job of this at NVRH. We utilize work groups when opportunities are brought forth. Recently, a group of employees started something called the collaboration tank. This is a group of employees that gather together to vet projects, ensure that all the stakeholders are at the table from the inception of the project and get projects from start to finish efficiently. So we're very excited about that. We're also focusing on introducing new patient-centered technology and integrating it across our healthcare system. Things like continuous glucose monitors, as probably many of us have our Apple Watches on today that provides a lot of health information that can be beneficial to our care. So looking at how we can integrate those into our healthcare delivery system. Thank you. Hi, Julie. And I'm just gonna talk a little bit about our nursing education program that we continue to expand and develop. We've got a nursing, RN nurse educator on every nursing unit now. They all work collaboratively together to provide education across the units. And they provide education for nurses, LPNs, LNAs. And this education keeps the staff up to date on their skills and current practices that are out there. We offer mental health de-escalation training and restraint training in the event we need to apply restraint, review equipment that they use, medication administration, keeping all providers and staff that are needed to have ACLS, BLS and PALS. That's all done through the hospital. And we have a great simulation lab that we share with this VTC nursing students that come here to use our facility for clinical practice. The staff have found this increase in free education great. They don't have to travel, keeps them up to date, helps them with their certifications. They find this to be a good retention, retention products, I'll call it. And then we also started an LNA program not too long ago and we've put quite a few people through that program. Some of our staff that worked in the Environmental Services Department took this program past and are now working as LNAs. And then we also extended to our Home Health and Hospice neighbors and they have a few personal care attendants that are now LNAs and are now able to provide an increased level of care for the patients that they're looking after. Thanks Julie. Next slide please. So value-based participation for 2022. The slide says Medicare will be determined. We have determined that we will not participate in the Medicare program, but we'll participate in all the others. The budget at risk again, you can see is 812,000. And our monthly budgeted fixed payment, fixed prospective payments is 752,000. Total attributed lives, we're budgeting for is 12,400 per month of 2022. And I highlighted here the Medicare downside risk is just too high for a critical access hospital. If we were to include the Medicare, the risk annually would increase to about two and a half million dollars a year. Again, much too much for this or my opinion, any critical access hospital. Next, our capital investment plans. So we have about 2.6 million of routine capital budgeted. The larger ED West Wing project, we're hoping to fast track a portion of that and we'll be in touch with the CEO in office shortly to discuss this. We need to expand our capability to handle patients with mental health conditions. Part of the bigger project is a dedicated mental health support waiting area. We'd like to fast track that and start that ahead of the main project. So our budget includes $2.8 million for that phase called phase A of the West Wing ER expansion project. We've also included money for the CON preparation about $300,000 of the phase B of the rest of that project. The actual CON for the entire project we will be filing this fall in 2021 dollars, as you can see, a little over 19 million. Our target, again, based on 10% inflation a year, targeted project cost is $22 million when we anticipate starting construction in 2023. One other, if you look at it over our five year, a four year capital spend plan, another major cost will be upgrading our Meditech system. We've put budget 2.5 million for that. I'll just note here that we also have a committee of the Capital Budget Committee that reviews our capital plan monthly. Plans change, priorities change during the year and this committee helps us readjust as necessary throughout the year, our capital budget planning process. Next, the impact on COVID. I think, Laura or Mike, you're going to start talking about the impact. Yeah, so, you know, how have we fared with COVID-19? Well, you know, what a 18 months it has been, I can tell you. It's gone by, well, like a whirlwind. We thought we were winding down in June. We had a very few cases. We actually went some weeks without cases and we stopped having to do monoclonal antibody infusions and no inpatients and we really thought we were on the home stretch and then the fourth wave came through and we're back in business again as far as dealing with COVID. But I think the impressive thing about NVRH is how we've handled it. We have shown that we can stand up programs quickly and efficiently. We converted our day surgery unit into a respiratory intensive care unit in a matter of a couple of days. We took care of a few patients down there and then gradually got our upstairs second floor med surge and ICU ramped up to be able to take care of COVID patients in the negative pressure environment. We put in four new negative pressure rooms on the med surge area and we converted our four ICU beds to negative pressure. We made the donning and doffing areas for all these and ramped up in really efficiently being able to get in and out of pepper hoods and PPE very quickly and efficiently. We were really proud of that. It was homemade videos of how to do it. People using their smartphones and downloading them onto our system and people were really studying them. It was really impressive to watch. We were one of the first hospitals in Vermont to fully adopt monoclonal antibody infusions. We were fortunate we had a vacant office suite that we were able to add negative pressure to and began doing monoclonal antibody infusions within weeks of it getting emergency use authorization. That was in light of actually Dr. Levine not fully endorsing it, but we felt that it made good sense and it's since become adopted as a standard of care. We've given over a hundred infusions and we really think it's made an impact in the number of hospitalizations of COVID positive patients in our region and probably a real impact on mortality of those hundred patients. If you went by the statistics 10% of them probably would have died. So we're pretty proud of that. We continue to give right now it's Regeneron infusions now with an added indication of post-exposure prophylaxis. So we're ramping that back up because we expect we're gonna have patients that get exposed and are gonna wanna get the infusion. We of course have become experts at remote meetings and as expert as you can, we still forget to hit the unmute button occasionally but we actually have improved attendance at some of our med staff meetings because people don't have to drive. We remember we're in the Northeast Kingdom. We have health centers for our field, Danville, Concord as well as all around St. Johnsbury and Lindenville. So providers are able to tune in and get back to work pretty quickly. So remote meetings are probably going to be here to stay. We've actually invested in some state of the art equipment to make them a little more efficient and a little easier to attend. Telehealth visits are very likely here to stay. There of course are elderly patients where travel is difficult and we do get bad weather and we can still check in with patients remotely. So some of these things are actually going to continue. We have looked into having employees work remotely which gives the added benefit of increasing office space here. We will likely be able to shuffle around and more maximally use some of our square footage here and improve the space. So we're looking into that in a meaningful way. Our maintenance crew have become experts on negative pressure. It's really impressive to see. They've installed meters and fans and we really have, I think, gotten quite good at that. As you can imagine, it's been hard to get equipment and get contractors in during the pandemic and fortunately we have a top notch maintenance crew that's been able to do a lot of the work on their own. So that's another amazing benefit and the ingenuity here in the Northeast Kingdom is truly amazing. So we have focused on staff wellbeing. This is, I think it's been mentioned, been very difficult on staff and we're very committed to focus on staff wellbeing. We have a Luminos wellbeing program for all of our providers twice monthly. We get regular emails, we get check-ins and we've expanded to the nursing staff as well and we're very hopeful that everybody's gonna hold up okay through all this. The other really amazing thing is we've stood up this really not very pretty building but a fairly large building that is our drive through COVID operation center. And I think we thought it was gonna be a temporary building and we're gonna be able to use some of that space for maintenance type activities but we since have purchased the trailer and it looks like it's gonna be around for a while I think for a few more years in fact. So we have now a fully blown COVID operation center where we do testing a few days a week. We give COVID vaccinations a few days a week and it seems likely we're gonna be doing flu and COVID boosters a few days a week through there and we've really optimized that space. So a lot of great innovation, a lot of really heartwarming to watch people working hard doing a great job but we're really disappointed that we have to go through this again. So we are running at capacity. We're having to delay transfers. We're having to take care of patients longer than we would like to here at our facility. We're having staffing issues. We really are, we're working very hard to keep this place running smoothly but it can be very disheartening to find that we're having to cut back. We can't provide as thorough a care as we might like. We're having to turn some patients. We've had to limit the number of patients we could admit to our hospital because of staffing issues. We've had to close our emergency room to ambulances because of capacity issues. We've had staff hurt because of out of control mental health patients who are in crisis. So it's a tough time. And add to all that COVID protocols and provider burnout and then now we're in the midst of trying to decide how we're going to deal with unvaccinated healthcare workers and other staffing issues like that. So I think in closing, I mean, we're, this is a tough time to be doing healthcare as you probably heard, but we need the resources to be able to provide our mission and keep going. Thank you very much. Thank you. That concludes our formal presentation. So you turn it over to the board and staff for questions. Thank you, Bob and everyone. We're going to start the board's questions with board member Holmes, Jessica. Okay, great. Thank you. Thank you for the presentation and thank you for all the hard work. I share your disappointment in where we are today. The pandemic has obviously had a profound effect on our healthcare workforce. And I really just want to say that to you and I'll say this to all the hospitals I really appreciate your staff's efforts and continued efforts as we battle this virus. And I do wonder how much more we can take. So I appreciate your presentation and where you are. I've been trying to assess from all of the hospitals so far, updates to where you're thinking the 2021 projections are going to be. And I know Bob, you mentioned you don't know what the updated stimulus money is actually gonna be and it's hard to make those projections. But I'm wondering, to some degree, have you been able to make any projections given the return to volumes? What you're thinking 2021 might end up like and any of your best estimate about what the stimulus money might be. Yep, so I think our 2021 projections are still solid other than that stimulus money, Jessica, the... Okay, but so you in the 2021 estimates that you submitted in July, the 92 million, you anticipated the volume that you're seeing now in June, July, August? Yes, this time of year, we did anticipate most of those volumes to return. Yes. Okay. Not all. Most other hospitals did not seem to do that. So it seemed like they were all increasing their projections based on what they're seeing now. So maybe just to clarify, so the projections that we just did in July seem to be holding. The original budget, I think we maybe underestimated what the volume would be in 2021, but the projections we just completed as we submitted the budget, I think are accurate. Just to clarify. Yeah. I appreciate that. The stimulus money, all I can tell you is that everything I see right now says that we will be able to record more and not less of the stimulus money in 2021. The amount is still uncertain, but I would not be surprised if it was at least another million dollars. Okay. Thank you. That's just helpful. On the bridge table, if you could just clarify for me, the bridge table, it's I think slide eight on your presentation, taking fiscal year 21 budget to fiscal year 22 budget. Yeah, that's exactly it. I'm trying to understand the uncompensated care change, the one million dollars, that's a shift from uncompensated care to Medicaid enrollment. And then also there's another line item above that in the change in FPP, which also is related to increased Medicaid attribution. So can you just explain to me a little bit that that's not, that that's not counting the same people moving from uncompensated care into Medicaid and therefore being attributed to Medicaid getting a more fixed payment from them? So, sure. So we're seeing that the Medicaid fixed perspective payments will be increasing because there's more people enrolled in Medicaid program. And because of that our uncompensated care is going down. So our deduction from revenue for uncompensated care is going down as well. Okay. And it's not being somehow double counted in there. It's not double counted. No. So the uncompensated care write offs are decreasing and we're seeing a shift to that again, the Medicaid. Okay. And then actually what's interesting to me as I was thinking about it, as I was thinking about the shift from uncompensated care to Medicaid enrollment with the new increases in the QHP subsidies and the new, you know, more outreach at the federal government level about, you know, opportunities for folks to enroll in healthcare under the Affordable Care Act, health insurance under the Affordable Care Act. Are you expecting any of this uncompensated care movement to also shift into commercial as more people gain access to health insurance because of the subsidies? Yeah. I did not anticipate that in the budget, so. Okay. It's possible, but yeah. Yeah. Okay. It's not predictable enough. Got it. Okay. One of my colleagues might also ask you about this, but I just was curious, you didn't fill in the HCA's table breaking down the commercial to Medicare reimbursement ratio by payer. May I ask why? So there's two pieces, right? They wanted to broken down between inpatient and outpatient, then by payer. And it just, the way our systems can report out, it just lumps all of that together as one payer. They could break out major payers, maybe Blue Cross from the others, but so those are just bunched together. And at the time, I couldn't pull all that in. So have you not had the most updated version of this, but I don't even have it by Medicaid and commercial lumped together. So I might not have the right table in front of me, but I don't have any, I have the whole completely the table empty. So perhaps I have the right version of this. Do others have it on the board and I should just- Well, maybe I just didn't fill it out correctly. Okay. Would it be possible for you to fill that out? So we could fill it out between in total, but not between inpatient and outpatient. Okay. And as I said, I think you should have it in the response. We are able to calculate that on average, our commercial fees, about 160% of Medicare, which- Okay. Question. That's helpful. Thank you very, very much. Sure. And I also just wanted to note that I really appreciated the effort that Northeastern has made to reduce the avoidable ED visits. I know that was something that had come up in prior board meetings and we did hear a presentation last week about these potential, potentially avoidable utilizations across the state. And it was just really refreshing to see that you are trying, working hard in this area and actually calculating that metric yourselves and seeing the progression there. So I just wanted to kind of give you a shout out and say thank you, really appreciate that. And I hope that you'll continue to track that metric, especially as we're moving to value-based payment and trying to improve population health and get people into care in a timely and appropriate setting so they don't end up in an inpatient setting or in an ED when they couldn't, perhaps we could have avoided that. So I just thank you for that, appreciate it. And I hope you'll continue to track that. Thanks for mentioning that. And we have made a note to include that in next year's presentation as well. That's right. Thank you for the shout out. We're really proud of how that's gone and we're excited to see the results. And I think what we're finding is that our patients really like the option. So it's a win-win. Yeah, that's fantastic. And I'm just gonna telegraph that I would like to see all hospitals start to track that. And there might be some lessons that maybe you could share with other hospitals going forward about how you calculated that in your EMRs or in your data records. I also appreciate your focus on the issues related to the strains and mental health capacity in the state. The data that you're sharing is really troubling. It's, I've been on the board for several years now. This seems to be an issue that will not go away. It's only exacerbated. I think the pandemic has exacerbated it in so many ways, whether it's the increased acuity of our mental health patients, whether it's the shortages, whether it's now we're reaching capacity because of pent up demand. I mean, this is really gonna be a crisis mode, I think. And I'm just wondering, there's some light at the end of the tunnel perhaps in some small ways with respect to, I know UVM Health Network is considering expanding inpatient capacity, but that's gonna be several years off. There's work to be done on that front. Do you have any thoughts around short run solutions or short run mitigation strategies for this crisis that we're in? Is there anything that the board can do? I would say, and is there anything the legislature can do? What can be done that you all think about? My thoughts on this, it's a wicked problem. And it's not a problem that developed overnight and it's gonna be a problem that's gonna be with us for years as we work through it. I know there are a lot of people working on these issues. We've kind of come to the conclusion that we've really gotta make the investments here. You're seeing that in this build out of behavioral health or mental health space in our ER. We really need that. What we have today is absolutely unsafe and it's really not good patient care. So we really, from the board's perspective, what we want is your support so that we can build out the facility so that we can care for these patients when they are here. Longer term, part of the problem of the state is not only the facilities, but it's the workforce. And even though we're making investments and building out facilities, for example, what UVM is doing, I remain concerned long-term about our workforce challenges. I don't have a good answer there. Part of it is reimbursement. You look at the costs that we have trying to just support these patients when they're here and the reimbursement isn't there to cover the costs. And that's part of the compounding problem for us as we deal with the issue. When you say reimbursement, reimbursement by who? Medicaid in particular, Medicare? Yeah, Medicaid, yeah. Medicaid, largely Medicaid reimbursements. We're getting the number of Bobby, are you inside in that? Sorry, I'm here. Yeah, I don't think, I didn't hear, but I think what you're asking is the costs associated with that were the clinical patient safety observers. I think Dr. Roos pointed out it's close to $400,000 a year. I mean, that's built into our ED visits. We don't get paid more for those ED patients to cover that $200,000 additional cost. Yeah, I know VAS has been looking into this. We get paid for an ER visit and the patient stays for 45 hours. You can't make money doing that. VAS is looking to get the state to provide an additional payment for some of these patients, mental health patients that are boarding in our EDs. And then the workforce issues, we still have about 30% of our mental health inpatient psychiatry beds that aren't open because they can't staff them. So there are capacity issues because of staffing and they're just gonna have to raise salaries and they're gonna have to make those jobs more attractive. There isn't any other way around it. You can't staff a position that nobody wants to work in. Is there anything that can be done in the pipeline prior to an acute episode that ends up in an ER or a in the hospital? I mean, what can we be doing at the community level to prevent some of these acute episodes that we don't have capacity to handle? I'll jump in. That is actually something that we're working really closely with Northeast Kingdom Human Services on is catching those as soon as possible when things start to escalate for a patient, meeting them at the primary care offices and bringing in Northeast Kingdom Human Services as soon as possible so that we can prevent the ED visits in the inpatient stays. And I'll tell, I'm sorry, go ahead. Go ahead, no, go ahead. Honestly, I think adding telepsychiatry program to build in our practices could help that effort. Early in the community. Well, that's all I have. I applaud those efforts and I hope that we can move the needle on this because it worries me, but thank you. Thank you so much. Thank you. Thank you, Jessica. Next we'll go to board member lunch, Robin. Thank you. And I just wanted to echo Jess's thanks about including the data on the ED utilization because that is really encouraging and a real success story. So again, thanks. I had a couple of questions around the utilization data that you had mentioned for services folks coming down from the North country service area or from Grafton. And Bob, I think you said that over two years you'd seen a 29% increase from Orleans County. And I think this was in revenue and 39% from Grafton. And was that just for the four services that you were mentioning ENT, audiology, pulmonary and pain management, or was that overall? That's overall, Robin, yeah. Okay. We don't have it by service yet, but we're working to capture that. Oh, great. And do you have any sense, and again, this may be data that's not available yet, how that translates into like episodes or number of visits, things like that? Nope, not yet. Okay, all right. I was asking because our data team had done some work on patient migration and which was helpful for us in terms of being able to get a sense of that in and out migration. And certainly that's been an issue in your budget for a few years. So I'm just looking to see kind of forward-looking how we might be able to crosswalk the data that you have with the data that we have and understand how they fit together. So thank you. Is that the VQ status that you're... It is actually VUDS, so it's a little bit old. Okay. I think some of it's VQs and some of it's VUDS, but the patient migration, the one that would correlate to what you were talking about was VUDS data. Okay. That is on our website. Okay. Yeah, once we can drill down a little bit deeper into those numbers, we can maybe do some better analysis. We'll share what we have in more detail. That would be great. Thank you. Hold on just one second. And I think, I think Jess asked all the other questions that I had on my list. So I'm good. Thank you very much. You're welcome. Thank you. Is it me, Kevin? Kevin, you're on mute. And I answered your question and everything, Tom. I introduced you and answered your question and I was on mute. Thank you. Well, move it along to Maureen then, you know? Go ahead. You know, the farther down the line you are, these are your guests because, you know, the people before you ask a lot of questions and they ask them better than I would. But I have a couple of here. I'm one, I'm just interested in your value-based participation. I noticed, and I know it's an unrealistic objective, but in your narrative, you were saying that the tipping point in terms of value-based programs, hitting the critical mass where the benefits of the value-based programs was in the 50 to 60% range. And I'm looking, you know, at where you are now and you're at a little over 9% participation in terms of NPR FFP. And so I'm kind of looking at that at a point in time and also thinking about rate review that we just went through where we were talking to the carriers about, you know, their participation and Blue Cross Blue Shield was, you know, they were very open about it that they said they would kind of jump in deeper if they had some willing participant, willing partners, you know, referencing hospitals. And so I'm just, I want to kind of understand that tension or that conflict a little bit better that as you kind of work with OneCare and work with Blue Cross Blue Shield, a setting of programs, do you, how do you foresee those, see that evolving at a pace that the benefits of value-based programs in terms of efficiencies and economies and innovations get realized. What is your kind of two or three year outlook in terms of your hospital participating in value-based programs? Sure, we are participating or will be in 2022 in all the value-based programs except Medicare. And the issue there is the level of risk that we would have to take on. I would point out that we're participating in all the programs, but it's only a Medicaid that has fixed payment, prospective payment revenue. So we'll be participating in the other programs, but that other programs do not appear as fixed prospective payments. So that's only one piece of the value-based, total value-based revenue that we'll be realizing in 2022. So, I mean, this is just a wild question, I guess, but where do you think you'll be in 2024? And in terms of participating, and I understand value-based programs and the risk quarter type programs. Much farther down the road than you are now. I would say the other program left is currently available is Medicare. I don't anticipate that the risk level is the same in 2024. I don't anticipate participating in that either Sean, I'm sorry, did you say something? Yeah, I think that's a really difficult question to answer. I think as more programs become available, we have to evaluate each program on a case-by-case basis and determine whether or not it makes sense for us from a fiscal perspective and from a patient care perspective. We've been committed to the journey. I think our budget this year demonstrates that we continue to expand into the programs that make sense. We're in every program except for Medicare and I anticipate that we will continue down that path as the programs mature and expand. But like Bob said, that risk quarter for a small critical access hospital is really challenging and we cannot put the fiscal health of our institution in jeopardy simply to be able to say we're participating in these programs. Is that a reasonable answer? I get that, I'm more interested in trying to pull Blue Cross Blue Shield and the carriers into the mix a little bit more than they have been. And they readily admit that they're an incredibly small piece of the pie and that they wanna do more but they kind of point the finger at hospitals saying that they can't find willing and that's their words, willing partners. So my next question was just a while. I was listening to you talk about people coming to out of their health service areas to into yours for physical therapy, for example. And so that's there and you're garnering some revenue from that. But why is that? Why are people traveling so far for physical therapy? Well, of course we offer a great service. So in addition to that, we're hearing that especially from the North, they're having trouble retaining physical therapists and there aren't any available in some of those service areas. So they're coming here and liking what they see from our physical therapy providers. I'd also add that we're getting major orthopedic referrals from North of us as well outside of our service area. So those patients come, get to major orthopedic surgery and then come for our physical therapy services afterwards as well. So that's part of the physical therapy piece. I'd also add that in terms of pain management a North country hospital gave up their pain management program. So that's why we're getting referrals for that service. To my knowledge, they do not have a neurology. My knowledge, they don't have a neurologist and don't play to have a neurologist. So our neurology practice is bursting at the seams from our own service area as well as trying to accommodate patients from outside of our service area. Tom, often what you see and I think what we're experiencing is neurology is a good example. I believe Littleton regional recently abruptly lost their neurologist really tough to recruit for neurology. That's a tough service to bring to rural area. So when that neurologist leaves the area people get referred to the next closest and we happen to be the beneficiary of that. And so with a lot of staff turnover and especially turnovers, there's a lot of that going on out there than the marketplace people just kind of going to where the service is provided even if it's a long drive is what you're saying. And pulmonology is another example of that. Yeah. And so my last question is in terms of the COVID advance money in Appendix 7 you had a profile that there was 4.45 million of CARES Act money and it's kind of recorded as a liability now in both 2021 and 2022. But I'm quoting here about what recently published financial final guidelines allows. So you think that you're gonna be able to convert that to a revenue? Yes. Some of that I'm anticipating converting to a revenue. That's the piece we're still trying to determine and don't have the final answer yet. Do you have a guesstimate about what some of that means? I estimate it'll be at least another million dollars. At least what? At least another million dollars of money I can keep but we're still going through that. That's real money. Yep. That's on that after this process is completed that's on next priority. Okay. Those are my questions. Thank you very much. Thank you. Thanks Tom. Thank you Tom. Next we're gonna turn to board member Yusuf or Maureen. Thanks and thank you for the presentation and all the work you've been doing. I'm just to follow up on Tom's last question. Why do you think you wouldn't be able to recoup the rest of that if you're only gonna get a million dollars there? So we have to find COVID related expenses. In other words, the expenses related to the prevention or detection of COVID and lost revenue because of the pandemic. So we have to find expenses and the lost revenue to meet the criteria and we may not be able to find enough to meet the entire 6.2 million that we received from that stimulus money. Okay. Hopefully you can find it. Well, believe me, we're working on it. And Bob, what was the date certain that we could find qualifying expenses? It was the 30th, right? June 30th. June 30th. So the period just ended, right? June 30th and the guidelines, well, the final guidelines came out June 30th, but I understand there were more changes yesterday to those guidelines. And that's one of our other challenges is I believe since the first guidelines have printed on how we could use these funds, the guidelines have changed at least 15 times. So that's our other story goal is the every changing guidelines that we're using to quantify what we can keep. Okay. And on your ACO risk accrual, I think you have 812,000 left. Are you expecting any money back from any of the programs that you're currently in? One care is telling us we'll get money back for the 2020, but there's not an amount certain yet and there's not a date certain yet as to when we'll see that money. And if you get that money, will that change? How much you put into an accrual? If we get that money, my plan is to put it into a reserve for 2021. We don't know how we're doing in 2021. I've put into our projection a $300,000 risk, but it could be much higher than that. So I will take any of that money we receive for 2020 and reserve it in case the 2021 estimate is understated. Okay. And then you've talked a little bit about some of the ER volume being down and having some express care in the community potentially. So do you see that that may, the people are going to other places, whether it's express care or primary care and that maybe that will continue? We do, yep. So part of the decline in ED volume this year in 2021 was especially early on attributed to patients hesitant to come back into the hospital for care. We've seen that mitigated somewhat and seeing patients coming back to the ED. Unfortunately, in a number of cases, they waited too long so their conditions worsened, but we are seeing patients coming back to the ED. We're appropriate. Okay. And we're seeing, as we've said, those express cares are up and running just to make sure everybody's aware of that. And we are seeing those volumes increasing consistently. Every month we're seeing higher patient visitations to the express care locations. So we expect that to continue as it becomes more popular. Great. And the other factor is we see a lot of outdoor activities that draws a lot of people from Canada and some of them get injured and the course of boards have been closed. So we're anticipating that that will return next year as well. And then can you talk about cost saving programs and any initiatives that you're working on now and how they're going to impact 2022 and beyond? So there's a few of the maximizing the 340B savings for our outpatient drugs, something we continue to do and do a great job that do to primarily our director of pharmacies efforts. We continue to maximize our supply chain savings, converting to our primary vendor onto the food purchasing organization is one. We continue to work with our orthopedic surgeons on standardizing implants wherever we can so that we can maximize savings opportunities and volume, give them more volume, we get from one vendor to lower the price. And part of what we talked about specifically lower and normal was our cross-departmental collaboration efforts to look at ways we can do things more efficiently throughout the organization. So that's our fourth effort to find some savings. Just as a benchmark, I've been calculating based on your gross to net, what the, in total, because we didn't have all the details of the inpatient, outpatient, where each of the hospitals stand relative to Medicare and of the five hospitals now that we've done, you guys come in as the lowest. So on my calculation, the way I'm doing it, which is consistent with everybody, it's 1.4. So it's a little bit lower than what you were saying on the 1.6, but even on the 1.6, that would put you in relative to Browlboro, it was at 1.5. So, I mean, it's good from a benchmark. And I just wanna compliment you on your, I think your balance sheet looks strong. You're ending with quite a bit of cash. And it's one of the, I guess positives of COVID if there is one, right? That maybe these plans from the beds and state work to help keep things afloat. So. Well, for sure. Sure. Yeah. Thank you. Thank you. Well, thank you. Thank you. Next, we're gonna turn to the healthcare advocate. Yes, hello. Can you hear me? Okay. Yes, I can. Good afternoon. My name is Kylie Kuiper and I'm here on behalf of the Office of the Healthcare Advocate. First of all, I wanted to thank you for responding to our pre-hearing questions. We got your responses in writing this morning. So, I just have a few quick follow-up questions. My first one is that you specifically mentioned your ability to provide materials to patients in Spanish. And I was wondering how you assessed that that was the appropriate language to offer to your health service area. Hi, this is Diana Gibbs. I'll help respond to that. So, in our service area specifically, our diversity is mostly in the way of socioeconomic status. So, there is not a significant need for language translation services or other languages. But specifically, not that we chose or identified Spanish as the other language are up-to-date subscription provides patient materials in that translated language already. So, certainly not something we sought out or informed. It's just available through the product. There are other translation services that we could seek if we needed to. But I think it's worth noting that according to the demographics in our region, as far as the Hispanic population, we're looking at about 1.6%. So, Spanish would be an appropriate second language choice. And then the other thing just to mention is that based on our most recent community health needs assessment, English only being the language spoken at home is roughly 95% of the households that we're serving. And then the other question that is represented in there are all other languages or all others who speak English less than very well. And that percentage is only about 1.1%. So the need is very low for language. It's more plain language and helping with the understanding of whatever information is trying to be provided. Okay, thank you. So my second question is that, so you noted that your bad debt and free care have recently declined in comparison to your overall gross patient revenue, care revenue. This is the dynamic that we're seeing across a number of hospitals. And it's a bit counterintuitive in a way to see these numbers decrease during an economic downturn. You did note that it could be due to Medicaid uptake. I was wondering if you would agree that it's also fair to assume that both bad debt and free care are down right now in comparison to overall revenue because those who struggle the most to pay for healthcare are those who are most likely to avoid care. I don't think I would agree with that. We open our doors to everybody. And maybe somebody else has seen data to support that, but I'm not aware of any. That is not something that we've seen, but I mean, anything's possible. We have a great world transportation service here that helps those that have difficulty getting to facilities. It's a great transportation service that comes to all of our practices. So, and access should not be hindered by not having transportation. And certainly we take everybody that comes. We have two connections, which is open to patients to sign them up with the health plans. And we actually have a fund that they can get them services that they might not otherwise qualify for. So, we really do cater actually to disadvantaged folks that, and I think they've learned that this is a welcome medical community. So, I don't think that is a major issue here. Okay, thank you. And just to be clear, I wasn't trying to say that you're trying to avoid low income patients. I was more referring to people with high deductibles, or people that are uninsured perhaps are the first groups to avoid care when there's economic issues. Okay, thank you. Yeah, our patient assistance program I think is good. We work hard with those patients and they don't qualify to extend payment terms topic discounts. So, if they're delaying care, we're not hearing about it. Okay, thank you, that's all. Thank you, Golly. Next, we're gonna go to public comment. Is there any member of the public who wishes to offer public comment on the Northeastern Vermont Regional Hospital budget? Does any member of the public wish to offer comment? Hearing none, I wish to thank the team from Northeastern Vermont Regional Hospital for a thorough presentation. And at this time, I would entertain a motion from a board member to adjourn. So moved. Second. Second. All those in favor of the motion signify by saying aye. Aye. Aye. Those opposed signify by saying nay. Thank you, everyone, and have a great rest of the day. And I'm glad that it was, Sean, I've gotta tell you that we've had some strange things at hospital hearings but never a code silver. And the strangest one prior to this was when we were doing the hearings at the Pavilion in Montpelier when all of a sudden all the phones for the people from Gifford started pinging and Jacob had arrived in Randolph to do their annual unannounced inspection. Yeah, needless to say, they were both troubling, but yours scared me more. Yeah, well, thank you. I will say the issue was resolved for my state police came quickly and everybody's safe. But I wish I could say that was an uncommon occurrence but maybe that particular situation but that's what we're dealing with today. Have a great rest of the day. Thank you, everyone. Take care, bye bye. Thank you for your time.