 Yes, thank you for being here. My name is Jeff White, I'm the interim CEO at Copley Hospital. I'll tell you a little bit more on myself in the next few minutes. To my left is Deb Durene, who's the CFO at Copley. And to my right is Dr. Dawn Dupuis, who's the chief medical officer at Copley. So we will be the primary presenters today, but I want to call your attention that we have a number of supporters in the audience. Kyle Slahetker is our board chair, who's there in the audience. We have a number of our active staff physicians and retired physicians. Dr. John Macy is currently chief of orthopedics, and will be available for any questions about our robust orthopedic practice. We have a number of members of our management team, and there may be other people who are trickling in as some thought that this program was going to begin in 1915, but we love it when we start. So let me give you our slide number one, an overview of some of our leadership changes. So in the fifth of the year, 2019 has been an unusually challenging year at Copley. Our long-time chief financial officer, Rasmus Ramgives, died suddenly in December of last year, which left an enormous hold in our Copley team and Copley community. Very fortunately, he had worked diligently on succession planning over the years, and so Dev Durain was able to be promoted and step in and become our chief financial officer early this spring. So this will be her, I believe, her first full-time presentation to the Greenland Care Board. Dr. Brian Huber, one of the founders of Mansfield Orthopedic, was unfortunately diagnosed in January with cancer, and he has been fighting a courageous and diligent battle with his disease since that time. I had a chance to chat with him last week. He has a positive spirit, but he has a diligent battle to fight with his disease. We do not anticipate he'll be back until early in 2020. Very fortunately, his five colleagues at Mansfield Orthopedics have stepped up intensely to attempt to fill his gap, see our patients, and keep our service moving forward nicely. In March of this year, I got a call from Vera Jones, our chief operating officer, on a Sunday evening while I was enjoying a martini, indicating that Cotley was in the need of an interim CEO. I have been retired since 2013, but I relented and came and met with the board leadership, the medical staff leadership and the management team, and so I've come out of six years of retirement to accept this job as the interim CEO. I had a 46-year career in health care, 25 working in hospitals, in Bain in New Hampshire with CEO of two community hospitals, and then my 21 years as a consultant at Elms & Company. I had multiple opportunities to work throughout Northern New England. I know the Vermont landscape very well. I was the, my last job before I retired was the, as the interim CEO of Grace Cottage Hospital in Townsville, Vermont, so I was able to present their budget in the fall of or the summer of 2013 to this morning, so I'm not unfamiliar with the process. And the other major change in our community is, as you may know, Cotley does not employ any of the primary care physicians. All of our current primary care physicians are employed by community health services like the Loyola Valley, known as Cheslev, and they have a number of changes in calendar 18 and resulting in spot-and-pray joining them in the fall of last year as their full-time CEO. Scott and I have been meeting weekly. We understand the importance of forming a close and independent community collaborative, so it's been a year of some significant changes. Our tagline at Cotley is exceptional care, community focused. We will, throughout our presentation, you will hear more about that because we believe deeply in those phrases. Cotley, perhaps more so than other hospitals in Vermont, has had four years of financial challenges. We will end FY19 with our fourth year in the role of operating losses. I'm old school enough to remember the phrase, no margin, no mission. It's difficult to plan for the future when you cannot generate an operating margin. Non-profit is a tax status, not an operating status. So we presented and will clarify for you what we believe is a reasonable FY20 budget with the objective of improving our financial health. I believe strongly in Cotley, T has believed strongly in strategic cost reductions. We're balancing revenue and against costs. We have far less control over revenue because of pay-o-mix, because of demographics, because of the uncertainties of the outside economy. But we do have the opportunity to manage very efficiently and control our costs. And you hear more about that in the slides that follow. We have complied with the budget requests of the Green Mountain Board. We need to achieve a positive operating margin in FY20. We need to build cash reserves for needed capital investments and for risk mitigation, particularly including our future participation in OneCare. We have submitted our application effective July 31st to participate in OneCare Medicaid program effective January 1. But that, as you all recognize, implies certain financial risks, particularly at the hospital side. So we will try to answer your questions. We'll talk more about these in the slides ahead. So I'm going to pass the microphone to Dev Durand to talk to you about the budget. Good morning. Bear with me while I juggle. I need a third hand. So our proposed net patient revenue for Cotley includes a 3.5% increased budget to budget. That increased most deemed necessary after taking into consideration so what we consider to be significant cost savings for an organization of our size of 1.2 million in FY20. And incorporating trends that we were seeing in an unfavorable payment and increase in back debt and charity. The 3.5% increase is necessary in order for us to achieve a positive operating margin for the first time in four years. We do recognize that this request is technically an exception request in that our FY19 projections are currently forecasted to come in below our budget and that we would hit the cap of the 5% growth limit. So we are requesting an exception to that in this budget filing. Looking back over the last five years, we think our proposed net revenue is reasonable. If you take a look at this five-year trend, it boils down to a five-year average annual increase of 2.8%, which is below the state average and lower than the willing-developed pair model goal of the net growth to 3.5% a year. Our proposed change in average gross charges in this budget is a 9.8% increase in charges and it's the equivalent of an 8.5% increase in the commercial rates in that we're not expecting any additional reimbursement on professional fee schedules. That makes up the difference between the nine. Over the last five years, our average annual, not average annual, our cumulative rate increase is only 3.2%. So while 9.8% is quite a bit higher than what we've requested in an individual year, over the last, there's extra for a while, we think it's reasonable and necessarily look at it in a five-year trend. Out of our total $72.7 million worth of net revenue that we're proposing, only 1.2 million of that is actually funded through rate changes from the last five years. So we don't believe that it's a significant burden on the rate payers over the five-year trend. With the benefit of hindsight, the graph that we've provided in our five-year industry, we've been reducing rates regularly, 4% in 6 FY16, 3.7% in FY17, 3.4% in FY18. I think with the benefit of hindsight, looking at our NPR trends now, hindsight is 20-20, we believe we've been overcorrected in our rates and that this proposal is trying to get Copley back up closer to its peers and recoup some of that rate adjustment in order to help us achieve a positive operating margin. I think later in this presentation we'll demonstrate that we've really done our best in terms of cost containment and put a lot on the table and just haven't quite been able to get all the way to our goal and are asking for your help in getting us there to secure our, sustain our financial future. So this slide, both Dr. DePuy and I are going to chat about but the point we're going to make in the next few slides as we talk about issues and challenges, opportunities and risk, I suspect that by the end of next week you're going to hear similar themes from each of the 14 reward hospitals on the areas that are challenging us in our local communities and statewide. So I have a hunch that these are all themes that will be familiar to you. In terms of our people, recruitment and retention is an enormous challenge both in terms of skilled professionals but in every position in the hospital, whether it be a laundry worker, clerk at our front desk, there are very low unemployment, there are lots of opportunities so we are continuing to be challenged as our peers are in recruiting and retaining people. And we have, the law has an aging population that partly and others have an aging workforce. We'll talk more about this in a later slide, particularly about our primary care positions in our community. These themes you will hear from Dr. DePuy and I, I suspect will bring truth. Dylan? Sure, like the rest of the statement, perhaps the country, the nursing shortage certainly affects us. We deal with that by being a clinical training center for both BTC and Norwich and I think it has something to do with us going reasonably well with young new nurses. However, it's certainly a significant challenge to find mid-career nurses that have an abundance of skills and experience. Likewise, surgical techs are a specific problem for us. We deal with that by putting them through school over in Concord, New Hampshire. We currently have our second person going through that program. The trade-off is a period of community employment. So for our community, Vermont's an aging state and our local service area is certainly no different. An aging population has special requirements as people age, their joints give out, making joint replacement and orthopedics differentially more important. And likewise, basically all new cancer, I can think of, age is a significant risk that your fourth oncology needs with an older population are more important. We partner with CVH to provide every other week oncology at Copley and we have a busy infusion center for that. The other community need that we feel is very important is our birth and center, women's health center. I certainly think if you ask anyone in LaMoyle what the community hospital, what college they should be doing, you're going to get the answer of birthing babies pretty high on their list. So the opioid crisis has certainly hit us as it's hit everyone else in the state. Our response to that has been many different strategies. Our practitioners, like everyone else in Vermont, have done a serious rethink about the place of opioids in treating pain. And I think as a group, we've done a good job at decreasing the amount that we prescribe opioids. Is it working yet? Is it working yet? Yes. Okay, great. So additionally, we partner with the North Central Vermont Recovery Center to do both inpatient and real-time referrals in our ED and in our nursing forms. We also are working with them with a program to actually dispense Narcan directly to at-risk people. Studies have shown that the more Narcan you have in the community, the more lives you save. That's an important risk reduction effort. And we are in the early phases working with several community members on tooling up for a rapid access to MAT which is the medical aid treatment which is what CVH and UVM have piloted and we hope soon to be joining them. Certainly dealing with mental health challenges in our hospital are difficult. The regulatory and funding changes for the role of law enforcement to assist in behavioral challenges with mental health issues has certainly been difficult for us as it places a larger requirement on our resources to effectively deal with. We recently retooled one of our rooms in the ED to allow safe and appropriate care of mental health people. A significant problem happens after the hospital has taken care of the acute needs of our patients. Particularly with mental health direct treatment and skilled nursing or rehab needs. The ability to get them to the new facility in a timely fashion has certainly gotten more difficult over time leading us to care for people that really would be better cared at another facility. This goal in digital space, we have at our hospital space challenges. We have some absolutely recently renovated modernized terrific spaces. But we are at a max. We are maxed out in many areas of our hospital delivery system and that will need to be addressed in the future. Additionally, if you walk in partly you will come away with two impressions. When you walk in the front door it is immaculately clean. Many parts of the hospital are tight. The flooring, the paint, the ceilings and that is all part of deferred maintenance that will need to be addressed in the future. And we have a number of inefficient layouts that should not be as surprising because the emergency rooms when I was here in 06 and 07 the mental health crisis, the opioid crisis those problems were not emerging but today they are relevant in every hospital. So we need to modernize, enhance and expand certain spaces. Digital space, this is the first for me and that partly has currently four components of its electronic medical record system. One for the hospital, one for the rehab service one for the emergency department and one for Mansfield Clinic and the multi-specialty practices. So if those of you who are familiar with electronic health records moving from one system to a new system is always a challenge. Assessing how to interface and connect four different systems is more than a challenge. I would characterize it as a bit of a nightmare and a major need for us to capitalize where we go. Our current hardware is at capacity and maxed out. We have some software systems and accounting and pharmacy in other critical areas. We have 187 personal computers that need to move from Windows 7 to Windows 10 by the end of the year. So we have many challenges in our digital space at the same time as I alluded to because of our operating losses over the past four years we've necessitated investing in infrastructure and necessary investments to make sure we have enough cash on hand to keep the lights on and serve our patients. In terms of opportunities and risks I'm going to turn this over back to Dr. Dupuy who has provided some excellent information. So we recently joined the New England Alliance for HealthNIA which is a Dartmouth run by our group. We're certainly looking forward to achieving cost savings through economies of scale through that. But beyond that it also serves as a forum to share knowledge and experience between varied hospitals. The second thing we're doing is expansion of community services serving our community as well as we can is completely important to us. At IntelliMedicine we're partnered with Dartmouth to provide rheumatologic pulmonary and nephrology services to our local community without the commute of the patients to Dartmouth instead the electrons do most of the work. Sleep medicine is a difficult area statewide. The need for sleep medicine badly outstrips the capacity of all the hospitals in the state that provide it. We used to have an active sleep medicine program we lost our managing physician and so that's been mothballed until recently when we believe we have found the new managing physician and we're currently getting ready to restart the program. Looking forward to that. We recently hired a new young general surgeon at Copley who has brought surgical breast care back to the community which has been very well received. Physician engagement at Copley as the CMO is obviously something that is important to me and I'm always struck by the commitment of my fellow practitioners in their commitment primarily to quality but also into the efficient running of the hospital Surgeons are particularly expensive doctors in the hospital but we can in fact contribute to cost containment in several ways largely through consolidating and making our equipment and implant needs consistent between surgeon to surgeon allowing us to bargain more effectively and stock more efficiently. Because Copley is a small community hospital strong community partnerships of course vital for success that we're going to serve the needs of our community for an active member in the UCC the United Community Collaborative and one of the ways that that's manifested itself is joining with Cheslow of our local agency in placing a social worker in our emergency room and this has really been a tremendous success in two ways first it allows the loop to be closed for people who come to the emergency room but don't have a primary care positioner to follow up with the referral specialists make sure that the loop gets closed on that and there was a program recently that dealt with super users in the ED it turns out that there is a small select group of patients who keep coming back to the emergency room day after day, week after week their needs are usually very complex both medically and socially and they require a great deal of focused care to corral all the different and disparate organizations to really meet their needs it could be something just as simple as getting an air conditioner fixed and someone has COPD and every time their air conditioner breaks their COPD exacerbates and they're back in the emergency room so you can keep the air conditioning used running they're going to be able to stay out of the hospital which is good for them of course good for the healthcare system as a whole we studied that program for three months and we found out that if you paid enough attention you could actually save almost a quarter million dollars in three months just on decreased ED visits and hospitalizations so clearly that model of care which I think is basically in line with the principle of one care actually can work another partnership is with our local skilled nursing facility Morrisville Manor we regularly meet with them to review all our readmissions so we can improve our communications and optimize both of our practices to better serve the patients to make sure that we're remitting the people who really need to be remitted and catching the things that might become a readmission early which is certainly again better for them and better for the healthcare system as a whole I think I've spoken about partnerships with opioids with the zero suicide endeavor all of our patients that present that are not small children that present to the ED are screened for suicide risks in the appropriate referrals are then made let me pick it up here regarding the category of risk one care participation for the Medicaid population as of January 20th is both a risk and an opportunity and we are hoping that we will have the financial resources available to move forward with this the dues for us will be $195,000 a year the potential downside risk is another approximately $200,000 on the plus side of this by our participating with one care and Cheslev, our federal health center and the primary care position will have an opportunity for enhanced reimbursement we recognize that having a robust and active primary care base is vital but it brings some financial risk the LaMoyle County's primary care landscape is changing I arrived I think I said earlier my first day at Coughly was January 3rd excuse me, June 3rd however I was able to come up for a day in April and a couple of days in May to get some orientation meet with key players to facilitate my joining the hospital between my visit on April in April and my visit in May we learned that three active positions at Cheslev, community health center that offered their resignations and were intending to enter private practice the good news for our community is that they are opening private practice in Morris so Tamrat family medicine three family positions three of the most full-time productive positions will be opening their new office in October 1 in downtown Morris so that if they had decided to leave and go outside the community it would have been for a shower because we've had continued loss of primary care practices in our service area one of our nearby towns, Johnson which is the home of Northern Laoyle University in a vibrant small town this past year lost its community provider Hardwick health center in the town of Hardwick within the past year has had two of its long-time family physicians retired so we anticipate that there will be other primary care physicians retiring in the not too distant future last night at Copley we had a special board meeting Kevin Mullen and Robin Lunge were with us and we heard about what's happening in Vermont and in fact the nation in terms of the supply of primary care physicians and advanced practice providers so all of us are facing enormous challenges everybody is recruiting for primary care either to add or to replace and we're no different so and finally a risk we have is funding vital community services can Copley continue to provide the services the community needs without a positive operating margin and do we move service lines to maintain a positive operating margin while meeting our care that's a question that at least three other critical access hospitals in Vermont have faced resulting in the closer of their birthing center on my second day at Copley on June 4th during our finance committee meeting Dr. John Macy who's a member of the finance committee shared with us a wonderful article that I will make copies of the board published in April 19 by the Federal Reserve Bank of Boston that talked to Northern New England named New Hampshire and Vermont and the effect of primary care physicians leading to these hospitals leading or not any longer providing a birthing service and what that provides is a barrier for access so this is a wonderful study reiterating many of the things that we're talking about others will talk about so there are in sort of narrative term we've laid out our opportunities, challenges, risks Deb will talk with you here about our financial health indicators and what we need to move forward Hopefully we monitor a plethora of key financial indicators I've only displayed a few on this chart just to kind of keep the conversation simple I've characterized them in three categories to talk about our trends and profitability our leverage position and also liquidity looking at the operating margin we've already discussed that trend four years of operating losses in a row our budget is looking to try to turn that back around total margin also trending unfavorably the one solid year in FY17 with a 3.9 percent total margin was really due to tremendous philanthropic support from our community for our OR project without which we would have had a loss that year as well generally we'd like to target a 3 percent operating margin we feel that that would be reasonable and to allow us to make certain proven investments in our infrastructure and other capital needs in FY20 this budget proposes a 1.4 percent operating margin getting us halfway there in terms of our leverage I've presented long term debt to capitalization and debt service coverage ratio which I think displays a satisfactory level of debt I think we're too highly leveraged our debt service coverage is trending unfavorably but that's more a result of our favorable profitability trends in terms of liquidity Dave's cash on hand is something I monitor quite regularly remains an unfavorable trend we've been continuing to pay our bills very timely and I can show the AP days ratio on here but you guys have that at your disposal you can see that we're a quicker than our peer group but in order to keep that Dave's cash on hand something more tolerable we've had to defer capital investments which we'll be talking about our proposed financials and the loop as we said earlier a 3.5 percent increase in net revenue just to touch on a few other key elements to provide a little additional explanation our other operating revenue is proposed to decline nearly $400,000 big chunk of that is the termination of our support service agreement with the Vermont State Psychiatric Hospital that was contributing to about $590,000 reduction in our other operating revenue and operating expenses have declined in coordination with that amount as well this is not a significant hit to our bottom line simply off of our revenue and off the bars Vermont Psychiatric Hospital actually hired our pharmacy staff and no longer really needed to outsource that support offsetting some of that $500,000 decline are some other revenue opportunities that we've seen some gain in particular interest to you might be our industrial rehab program where folks from our rehab department or out in our community provide support to various corporations within our community to help them keep their employees healthy and evaluate their job readiness also we do receive grant revenue research revenue for some orthopedic research programs that are under way that are total operating expenses in our budget are proposed to increase only 1.8 percent and that's the lowest that Comley has put forward for proposed 1 year increase in operating expenses and we're very proud of that actually it took a lot of great work to keep that in tamed which we're going to talk about shortly bringing us to operating margin operating surplus of a million dollars and a total excess of revenue for expenses of 1.3 million in our proposed budget and not quite the goal we hope to accomplish like I said a 3 percent operating margin presented the balance sheets just want to highlight a couple of little items of note in here four designated assets of 4.7 million that represents our funded appreciation account we do continue to fund appreciation however we've been significantly understanding our capital budget to preserve our cash position in case needed and we see the decline in our property and equipment and an increase in those 4.7 million funds that are available to spend at our discretion under the board's discretion which should be done I want to focus the majority of my conversation I suppose on expense drivers and cost containment because I think perhaps in the past we have maybe not spent enough attention on this subject with Comley expense drivers I think you're going to hear some of the similar stories for many of the hospitals we certainly struggle with the inflationary pressure on wages and benefits not just related to the individual wage that folks are requesting and trying to keep up with the cost of living in the state of Vermont but also the cost of turnover and the cost of recruitment and retention that keeps people with high skills in our organization also significant inflationary pressure on drugs double-digit increases at times for Comley in particular oncology drugs make up actually more than half of our pharmaceutical spend those half inflationary pressure in that bucket is quite significant and also inflationary pressure on supplies and plants in particular those are things that we've been contending over several years another element to add is that maybe we haven't talked about enough in the past is our service mix and the complexity of the care that we provide at Comley and you've heard we have a renowned orthopedic program we certainly provide more orthopedic care than our critical access peers do in the state and that does have an impact on our cost structure I've presented a chart here I'm trying to walk you through it showing our cost per adjusted admission has been one of the ratios that we followed that Comley has not trended favorably in over the last several years in particular compared to our critical access peer group I'm going to try to explain why so the cost per adjusted admission is the blue line on the red lines are case mix index that's a measure of the complexity of the care that we're providing in a patient setting as you can see that has grown tremendously over the last five years 1.15 and FY15 up to 1.37 currently in FY19 when you case mix adjust our cost per adjusted admission and factor in the complexity of the care that we're providing that's the purple line at the bottom it's really a reasonable trend in cost compared to the intensity of the services that we're providing it's an average annual increase over that five year period only 1.6% cost containment efforts at Comley certainly to me in the day to day in life have felt significant but we've done it in a more thoughtful maybe slower strategic approach we really want to have it be a part of the culture at Comley and not an event where we're forgive the expression but cutting off our nose to spite our face we've really been very thoughtful and strategic about it over the last several years displaying this chart is the trend each year since FY17 of the cost savings initiatives that we've targeted and built into each budget of those years broken down by categories labor supply chain and other costs through the three buckets labor cost and supply chain being the two areas that we've really struggled with cost strivers in those areas but over the these four years Comley's committed to nearly $500,000 in cost savings significant formalization or size a great endeavor a lot of hard work and teamwork in our organization to do this in a way that it would feel attainable and thoughtful and not to cause a significant morale problem really put your organization at a jet be able to continue to provide a high quality to date we have achieved 3.5 million of that nearly 5 million in savings as I said before we still have we still have more work more work to do some of the if you want to know more details about some of the examples of these cost savings please ask 20 our proposed operating expenses if you look back over the three year period reflects an average annual growth of only 2.8% I'm super proud of that and that's it's sort of like finally you know the efforts that we're putting forward we're starting to see last several years past future patients though I think our cost containment efforts have been significant we still weren't quite able to achieve writing our rates to continue our work in future years to get to that 3% so highlighting some of the cost drivers related to labor and related costs I think these are not maybe surprising to you and all we've heard this from us year after year we continue to have in the last several years continue to have a name for travelers we will always have a name for travelers we are I'm going to skip around that slide a little bit but we are actively collaborating with academic institutions and making investments and growing our workforce from within and we're going to help address some of those cost pressures related to the need for travelers but it will never be eliminated in our F420 budget and in our F919 actual experience we are seeing a reduction in travelers because that has been some cost savings that we've been able to put forward market adjustments when we have turnover or in order to retain scale quotes we will definitely apply applying pressure to our wage and also again servicemen the mix of services that we provide and the growing complexity of the patients that we care for not just for the pedigts but also with mental health and substance use disorder patients who need areas of cost pressure and coupling and you look to the chart on the right-hand side where it comes from the historical actual growth represented in that dotted trend line has been at a 4.7% annual increase if you kind of take a look at F919 and F920 the blue bar there being our projections in proposed budget we're sort of bending that curve coming in under that historical trend from the work that we've been in in addition to trying to grow our workforce from within to address our challenges with travel and retention we've also over the course of these several years been able to identify with course efficiencies and reduce FTEs largely through attrition we have a paring action committee whenever a position becomes vacant where the leader of that department has to provide support for why they continue to meet that goal and are always looking at vacancies and an opportunity to create some efficiency that they have to justify replacement of FTE I think that activity has served as well over the last year or two in addition to the workforce efficiencies that are built into our cost savings NIA will also provide us some savings on that one benefit as well as in criminal education working forward to that working forward to the relationship the other things we're going to gain from that affiliation that are not cost savings but will add value to our organization for the care that we've provided in our community taking a look at the chart on the bottom right related to productivity I think with our case mix adjustment conversation trying to reflect and demonstrate our FTE structure compared to the complexity of the services that we've provided we have shown FTEs per hundred adjusted emissions which historically not a favorable trend on the surface when we look at Cobley however when your case mix adjusted we're actually trying to keep it real we're kind of flat in the down a little you can see this as a positive sign of the work that we're doing related to the supply chain this is also a significant area of cost for Cobley especially given our concentration of orthopedic care and our concentration in oncology services both of those service lines come with high cost of drugs are necessary to serve our community and our surrounding communities related to drugs we've seen a history of double digit inflationary increases and have been challenged like everyone else to contend with drug shortages that require you to find alternative drug that often is not cheaper and to incur additional cost and spend resources within your organization to mix and make the drugs that you need if you look at the drug cost trend chart off on the right-hand side FY15, FY18 that dotted the trend line represents a 12.8% average annual increase very difficult to contend with about three and a half percent of what we're trying to manage to part of that has been inflationary pressure but another piece of it has been the growth of our oncology and medical infusion care program that we run in conjunction with central remote medical center we've seen grow over the years and actually represents about half if you look at FY19 largely due to our purchasing power that we're going to gain as a part of our NEA affiliation and we're seeing the bending of that cost for related supplies similar charts that trend line shows a 7.6% average annual increase from FY15 to FY18 and FY19 and 20 are showing us coming in under that that historical growth trend has been not just due to inflationary pressure but also the increased demand for orthopedic care as we see our population aging I have every reason to believe that the demand for that service is going to continue to grow that confidence to be ready to make that also we do have patients who come from all over outside of our service area outside of the country attracted to the excellent program that we have is a fantastic reputation and some of those folks are you know have heard about custom made implants like the conformist need are interested in that type of an implant cost over the years and we've made some changes in that related to cost savings efforts in the supply chain Neal we've already talked about that'll be about a $200,000 savings in our supply chain area also we do continue to participate in 340B we expanded that participation I believe last year and a year before into our infusion center and expanded that in our patient settings that's accountable to $70,000 worth of cost savings for Coffley and since I know the question may come up for a point of clarity Coffley currently only participates in the cost saving side of the 340B program a retail pharmacy 340B program so there is no other operating revenue associated with that in this budget in the past we've explored the opportunity to pursue that several years ago and we've actually explored it two maybe three times and Coffley simply does not attribute enough prescriptions for us to be able to effectively run and gain a benefit from having done that program in the role of Coffley hospital having a program, Cheslaw Park QHC and our community has a benefit of that program therefore our community is benefitting from it and from the cheaper we just don't get the revenue another area where we're anticipating cost savings has to do with inventory management improvements and physician engagement in that process we have a very caring very engaged group of surgeons who are impressed by day after day and are able to thin that cost and are able to do more positive news on those subjects to come in our future budget presentation an update on our FY 19 performance so in the slide deck I have given you June because it was due before July as of June our payment was down 2.8% we submitted a projected budget or projections for FY 19 indicating that we expected maybe 2.6% decline in our net patient revenue that's largely due to unfavorable payback shift that we're seeing in FY 19 from less commercial payers to more Medicare beneficiaries Medicare previous year was 36% of our business and it's now 40% of our business and so it sounds small but it's actually a very significant amount that really has reduced our net revenue by over a million dollars we've also had a challenging experience in the beginning of the fiscal year that I know you've heard about during our enforcement hearing related to the medical leave of Dr. Hoover that Jen referred to earlier that has been an impact however we're seeing the rest of the orthopedic team are going together making up a significant majority of that surgeon's workload not 100% of it but in addition to his medical leave we had retirement of a dental surgeon that has had an impact in pediatric dentists at the state I believe and also slower than expected ramp but the most significant impact really being that paramedic shift and we've also seen an increase in bad debt and share of the care that's higher in the budget those trends have both been appropriated into our FY19 proposed budget on the expense side as at the end of June we were below budget by nearly a percent projected to maintain that essentially through cost control measures that we've put in place and heard about that not only our enforcement hearings but just recently in our cost reduction discussion I'm hiring action committee and we've also incorporated extra purchasing approvals and made the purchasing process a little more challenging and have a little more input feedback on how we're spending on it but counter balancing that with continual wage pressure that we've experienced and on our drugs and antibiotics new this year because we've actually had favorable health insurance claims that's been passed this FY19 marks a significant and favorable year in this area not just regular claims experience but also we've had a couple of significant catastrophic events for some of our couple of our employees in particular causing on our stock loss insurance to raise its limits essentially adding $50,000 of benefit costs to coffee that we we didn't build into the budget so it brings us down to an operating loss of nearly a 1.8% operating loss FY19 that's the again fourth year in a row of not generating a positive operating margin which has deteriorated in our cap six days as of the end of June so as of the end of July our number of years slipped a little more it is now 3% below below budget and we're not anticipating any significant gains or improvement in that between now and the end of the year tend to be vacations, times, I don't have a boom in utilization in fact that all this is probably going to change we have a number of slides to review with you but let us move quickly through these so that this is sort of a summation so you'll have ample time for questions and clarifications so you know I these points are from once eight critical access hospitals are all unique to me and your respective communities you understand that, we understand that the Kotli is not the typical critical access hospital we have a center of excellence in the orthopedic care five now full-time well, Brian is a medical lead full-time fellowship trained orthopedic surgeons withdrawing patients from all over the state and region Kotli is an engaged community partner we are the largest employer in the community we are active in virtually every facet of wellness initiatives health initiatives we work with our academic programs and we intend to be engaged in collaborative part of it so this is the exceptional care community focused slide the top bit is to remind me that we are AT all our commitment to having a community center and a women's center both in service to the community's needs measuring quality in health care is an extremely difficult thing to do as you know almost certainly the best way to do it is through, at least for surgical care, the national surgical quality improvement program run by the American College of Surgeons under the rubric quality access and affordability is desirable health care goals what often hears that there is an implicit tradeoff between access and quality and this data, which is our Nesquib data from Calvary 18 is basically presented as an emphatic like that's not just not so at all if you're interested I'll be happy to explain the whole thing in excruciating detail we'll just move right to the chase Nesquib requires a little bit of money but quite a bit of effort for hospitals really only hospitals that have an above average commitment to tracking and improving their quality participate in Nesquib at all so even if you're an average Nesquib hospital you're doing pretty well in this slide, average if you move to the odds ratio column average is one if you're below average if you're below one, you're above average if you're above one you're below average this particular data is presented yearly by Nesquib and it takes into account the differences in patient risk factors before surgery it takes into account the relatively small sample size we only entered 1300 cases opposed to about a million cases overall for Nesquib all of these things have statistical consequences and Nesquib has worked this all out so what you're getting here is really an apple to apple comparison between the work that Copley does in providing outcomes to patients from our surgical care versus the rest of the Nesquib world and as you can see if you go down the odds ratio column we're just below one in pretty much everything we're dramatically below one in fact we're in the first quartile in morbidity and morbidity is basically a synonym for complications here for UTIs associated with our surgical care and for readmissions not only are we an exemplar which is Nesquib's name our confidence limits our 95% confidence limits on the odds ratio is actually below one which actually makes us an outlayer which is really I guess maybe you could put two stars there the next time so when we tell people that we're not your average little hospital it's not just our boast Nesquib thinks so too our capital budget plan in FY 19 as I alluded to earlier we significantly under spent our capital budget in the interest of preserving our limited cash reserves needed investments in FY 20 we have proposed a capital budget that limits our spending to the amount of our depreciation none of those items are over 500,000 I just need to say and hopefully you hear it we cannot continue to defer capital investments we are going to need to be able to fund these investments for the future there are a couple of major capital investments that we see in the next couple of years is being important of fully functioning and integrated health information systems since we do have four and we're relying on interfaces and a lot of manual interventions working with these four products to calculate and also challenge the continuity of patient care it's not ideal for patient experience it's not ideal for our staff as well and productivity we're also looking at opportunities to replace our MRI we currently use a 20 year old mobile unit that only has refurbished parts available we're evaluating our options of a fixed site versus mobile site mobile MRI and are really looking to improve the quality of the images that the MRI could provide and to provide a better patient experience it's not really a great experience with mobile MRI long range financial plans ultimate goal is to strengthen Copley's financial position and our flexibility it's imperative that we achieve a 3% operating margin in 21 and beyond we intend to continue and strategically manage our costs I think that we've demonstrated today that we're capable of doing that and intend to continue that work however it will be unrealistic to expect that we're going to be able to have a million and I have every year across data at some point that rate across data's opportunity is going to decline we continue to focus on operational efficiencies at Copley that's a hot topic since we're largely surgical we think optimizing the utilization of that fixed capacity and an appropriate utilization is what will help keep costs down in our organization we do anticipate seeing a growing need for services and do the aging of our population but also while county has seen a population growth with an operating margin we intend to renew efforts to improve funding capital investments we also will be working hard to improve integration of services of primary care and other hospitals and the community at large we'd like to participate in the one care Medicare program Medicaid program for good reason however we're discussing that with our board and ways that we can fund those dues and manage the new financial risks on behalf of our primary care partners that we don't employ we also certainly intend to continue efforts to improve care coordination that's very important to caring for our population we think all of these plans tie into the goals of the all care model I think it's it's certainly maybe an achievable goal statewide to contain our growth to three and a half percent but I do feel that individual hospitals need to be evaluated on a case by case basis because we are all unique we have different service mix we have different utilization trends and demographics we all have different capital needs and overall financial health position needs to be factored into NPR goals for each hospital historically taking a look back at our NPR compliance over the last three years we've implemented the 11 percent rate reduction or reduction in gross average course charges as we call it now the lowest in NPR is only cumulative with 4.4 percent which is a one and a half percent average in billing certainly lower in three and a half percent and cumulatively our budget is within compliance taking a look at the overall total cost of care for patients in our community I've highlighted the Morrisville service area we have the lowest growth rate at only 2.3 percent likely due to the 11 percent rate reductions that we've implemented over the last several years this is probably one of the largest contributors to this outcome including other efforts and cost containment efforts that probably an excellent coordination of care between our community partners I think it's an awesome outcome 2.3 percent growth however if you look at the next chart taking a look at where we ran in Paris into the other hospitals within the state we're way down there at the bottom with the lowest annual expenditure of the capita and also the lowest total resource use so we are not over-utilizing services and those services cost the least in the state I think that's wonderful news however given our financial conditions maybe we have been over-corrected and need to be pumped back up a little closer to some of the rest of the hospitals in the state and want to secure our financial stability finally let me close sorry respectfully we understand the very challenging job we have we ask the remote care gear to approve our budget as requested with the ability to earn a modest in 20 operating margins pledged to control costs promote quality access work with our partners have a robust primary care contingent in our community which is vitally important and let me bring a totally outside perspective so this slide shows a very unique statue in the slide it's called the Forest G. McGaw Prize this prize sits in the lobby of the hospital and when I asked our department leaders the other day how many have noticed this or seen this we got a lot of blank looks with the exception of two of our employees who have been there 30 years the Forest McGaw Prize is the highest award by the American Hospital Association been made since 86 we were awarded the second prize together with Mount Sinai Hospital in Hartford, Connecticut in 1987 recognizing distinguished services to improve the health and well-being of communities and with your help we will continue to fulfill this noble work when I went on the website to look up the prize because I had seen it I had noticed it and decided I would share it with you 2017 this prize was awarded to Yale and Raven Hospital 2015 it was awarded to Mass General Hospital 2011 it was awarded to our colleague hospital in the state of Vermont Lotus Company Rehab Center hospital 2004 it was awarded to the Henry Ford hospital system it's a prize that you apply for a very rigorous panel and we will always be proud to be a recipient of the Forest McGaw Prize and we hope that we will continue to do this noble work thank you for your patience your attention and your consideration of our budget and we will be happy to try to respond to your questions thank you Jim we have never apologized before we can't help it sometimes so we're going to start with Dr. Holmes thank you I agree very thorough and I want to first say I really appreciate all of the costs I mean we can talk about that for a few years and it's very clear the numbers that we've done in a very intentional and thoughtful way and it's really happening and I'm glad to see you're in a purchasing group now and we've talked about that over years and I'm glad to see that's happened I also just want to applaud the total cost of care for capital numbers and I'm suggesting the resources and we should maybe have a similar correction but we're in the quadrant you still want to be low I appreciate that and the quality measures a couple questions about that in a second but I would still say I'm worried about hospital probably as one of the hospitals that I worried about we've seen over 100 hospitals since 2010 rural hospitals and over my time at the board the hospitals that have turned themselves around and moved from red to black than those hospitals that have either affiliated or have informal ties with other institutions so that they can share services and bring the assets and specialty care into their regions so that they can spread those costs whether it's IT or other types of shared services you know, Brattleboro quarter of those were a couple examples that we heard about in Brattleboro yesterday and we heard a great presentation here from the outside experts that said really the path to sustainability of rural hospitals involves acquiring and having primary care in the hospital network and also affiliations, collaborations with other so you have some affiliations or some agreements going on with CBMC on ecology, you have telemedicine happening with Dr. Pitchcock can you talk a little bit about what other initiatives you might engage in to try and enhance some of those opportunities and two, on the primary care part we talked about the loss of primary care in your area and extended area are there any opportunities for potential recruitment you've been probably hospital of primary care and to, you know, supply and attraction in the hospital two excellent questions and a thank you for your positive notes one would I have to be living in a cave not to think about affiliations so I've had the good fortune of being this is my eighth interim CEO role so it's unusual to see a small critical access hospital remaining entirely independent so in my earliest of days I reached out to colleagues at Dartmouth and I've had an opportunity to have some discussion with Dr. John Bromstead at University of Alabama Dartmouth, frankly at this point has its plate full in terms of how it's looking to affiliate particularly with hospitals outside of the state of New Hampshire for those who don't know major merger with Granted One which is the Catholic Medical Network so they're putting their full attention now on that affiliation however they're reaching out with telemedicine specialists and we will always pursue that at University of Vermont Medical Center they, as you all know have relationships with the Center of Long Medical Center the quarter with a number of hospitals in Vermont and the message I add to John Bromstead is I am the interim guy here for three or four months the door will always remain open for continued discussions but one suggestion I offered to him is that one size does not necessarily fit all so at this point with University of Alabama Medical Center the relationships they have with the other hospitals is essentially an ownership position because of my in 2002 or 2003 I was the interim CEO of the London hospital just south of Hanover and we affiliated with Dartmouth in a brand new model that they created which was a three year management contract where we were able to keep local community control of our core services of our board we employed our CEO jointly with Dartmouth and that model was so successful that after three years in London became a part of the Dartmouth system willingly and successfully so I've asked Dr. Bromstead if he would consider if they would consider other models for affiliation other than their current model and he indicated to me and I don't speak for him that he would talk about that with his leadership team et cetera so we have other independent hospitals to the north and east of us for hospitals and it's not would not be untoward that we could not find opportunities to join in combining services or sharing economies of scale with those other hospitals so I as the interim I can't speak for our board or our leadership but my advice to our board and leadership is being fiercely independent as the ship is sinking is not a sound strategy so that's and I'd be glad to try to rebel or something in terms of primary care we became aware of Dr. John Dunn who's an independent physician in Jeffersonville Cambridge who's been in private practice now for a couple of years and he is having financial challenges so we have referred him to Cheslet we have suggested he talk with his colleagues at Tamrac family medicine to open a new practice we have said that we would want to continue discussions with him about how we can maintain his primary practice in the Cambridge, Jeffersonville area including the possibility of him relocating to Johnson which is a larger community a more robust community so we will help Cheslet we will help Tamrac primary care physicians to the best of our ability thank you I really appreciate that we respect to access I appreciate also the access to quality sometimes tensions people argue that it's hard to have access and have quality particularly in small rural areas I want to stop that there is there is a empirical evidence out there that the number of cases can be tied to quality your data suggests that you would have an excellent job of maintaining quality on surgical outcomes so I wonder do you have minimum volume standards that help you choose the types of surgeries and procedures that allow you to have that quality standard meet that quality standard I guess the most direct answer to your question is no of course there is a little bit more to it than that it is true that in selected cases volume tracks quality interestingly enough it's mostly based on the institution not on the surgeon so low volume surgeons and high volume institutions tend to do better than high volume surgeons low volume institutions so that is true however none of the things that we do are really captured in that month that we don't do things that have been shown to have quality track volume so the cases that we concentrate on a couple of things that we do fantastically well and that even though our entire case volume which is somewhere in the low 2000s is not very high we actually do do quite a few of the things we do and I think why we do those things so well we're not trying to be all things to all people but the things that we do offer which should be 80 to 90% of our community's healthcare are things we do not even just well extremely well hopefully that sort of answers that the birthing center I recognize people who want a birthing center in their community and hear me but I also worry about right here in the 280s and here there's some evidence that there's some quality so if there are things that I recognize so again we see the same world that you do most of the risk can be foreseen and dealt with appropriately so we definitely do have a birthing center so if we continue it and the people who live near us definitely want us to continue it but we don't offer that service to everybody we have fairly strict criteria for low to average risk birthing at our facility so you're exactly right there is a concern we completely share your concern and we feel that we act appropriately to maintain the appropriate parametric show looking about the cost savings and one of the things that struck me this might be for you there but you put a chart on there on the FTE for adjusted admission one of the statistics that stood out to me was your FTE for adjusted bed so your FTE for adjusted bed is 11 state average is 6 so I don't know how that tracks with the data that you had about FTE for adjusted admission but that's to that to me is how is that staffing working that you're so above the average and may yet again be a factor of our service mix as a critical access hospital we're looking at in the 25 beds inpatient services really are not the significant driver of revenue at our hospital where we do more outpatient care than we do inpatient care in our facility and so that statistic may be just changed by that service mix what would be your average daily census per staff bed what would that be on average in the middle of that if our average daily census is around 15 I think it's a 14 right now and that's how we staff we staff to that so you're not staffing to 25 no no we don't staff to the beds we staff to our average daily census and our expected demand for services they're adjusting that based on the surgical schedule and you might be able to see more to that than I can I've seen hectic heads now it's basically true basically true I mean average is of course just average it actually changes if you're doing a significant surgical volume the actual census can change quite a bit from day to day it can be 10 and then 20 so average is a 14 but the day to day variation and therefore the staffing requirements change dramatically and we work hard at making that great I'm sure that's a chance I heard from other hospitals that a quick question about the investing in the sleep so one of the things when we hear about community needs in the sleep I'm just interested by your comment that needs are far exceeding capacity community needs we hear about mental health we hear about dental substance disease I don't think until this presentation I've heard a lot of sleep center needs I'm just curious about that to reinvest in the sleep yeah I don't think our community has an especially high volume no they sleep me and more stuff but what actually happens is that the backlog for sleep studies in the state is impressive to the point where hospitals are just renting hotel rooms and equipping them so that's really the problem it's a generic problem it's not just us yeah and we already have the facility because we used to have this service and it was just a staffing problem at the MD level that I think is correct it's basically just space that was kind of being used not very efficiently will now be used efficiently and as it happens there's a terrific need not just in a little while but really everywhere for sleep medicine got it okay and then I think this is about the last question there was a chart you answered one of the HNA's questions about the ratio of commercial reimbursement and Medicare reimbursement and I just want to make sure that I'm understanding that the Medicare reimbursement would be accurate to say that your commercial payers reimburse between 156 you can get back to me on that but does that sound about right that the ratio is about 156 percent it's unique for critical access hospitals as well we don't have fixed Medicare reimbursement it's cost based reimbursement so what Medicare pays is not a fixed amount that really can be compared to the commercial pay so I just used an average when I provided the chart that was actually very helpful it's all the lower and the ratio so I want to make sure that my interpretation of that is okay thank you thank you first I want to thank you for really framing your story well and the situation that you're in you know and I'm also concerned about this hospital and you know operating margins in the past 7 years and one thing I wanted to do is just kind of go back to last year and flood your word and kind of ground a little bit this situation is pretty similar which we said we're concerned the hospitals are not too much of a commercial rate increase to address how this would resolve on-door financial concerns but considering other business changes such as buying and spending reductions and financial operations efficiencies to achieve a positive margin and most of what we're concerned about the hospital's sustainability and utilization continues to decline and expenses continue to exceed NPR and really if you can go back two slides to 23 I'll bring the plane which is where you've been the past 7 years actually and what's really concerning when I look back at your history and I agree you know there's been some commercial reductions that have been caught in the past you know I'd also say you're a hospital that's a little more favorably positioned than a lot of the other hospitals and let you talk about 60% of your revenue coming in from commercial insurance base so when we take a 10% increase you know you get a large part of that hitting commercial increases more so than other hospitals because of your base is so large but when I look at your history there in 16 you actually exceeded NPR by 1.8 million dollars yet when you go to your profit you're actually unfavorable 900,000 when you go to 17 and they didn't have the expense numbers for 16 and they switched to expenses but in 17 you increased your NPR by 200,000 and your expenses went up by 800,000 in 18 you had a 1.8 million dollar decrease in revenue but your expenses went up 700,000 in 19 you have a million and a half decrease in revenue with only a 600,000 increase in expenses and you know that concern is that even in your forecast that you have for 20 if you don't hit the top number regardless of what we do with the commercial weight increase you haven't been able to manage your expenses even with all the cost reductions that you're doing which are odd life efforts that are there so to me that's been really the biggest driver of your change it hasn't necessarily been the commercial increases that's certainly able to that but once you want to budget your expenses continue to be higher than utilization changes even when you have favorable it favorably increases on the top line so I really want to challenge you on how do you feel about the increase that you have in for 2020 you know large part of the road the 6 point increase year over year where you're tracking it's pretty significant you're falling a little bit short again on 19 and when that happens you're not able to change your expense so we just want to get to your point of view on how you feel about the forecast what's going on with that that could be something that's certainly challenging for an organization of our size according to your volume we're a critical access hospital designation is really established to sort of recognize that we have limited ability to flex our expenditures when our volumes do go down the sort of foundation of why other classes that are secure are financial stability because we have a high degree of fixed costs in an organization of our size I think we do an excellent job in terms of operational efficiency and trying to utilize the fixed capacity that we have particularly in our O.R. as much as we can to help cover where we maybe don't where we are more challenged in terms of where we have low volume in our E.D. or in our living center our invasion services there's a point in which you can't really go further down I mean MRI there's not so far I could reduce that right so you sort of come to that challenge I will say for the organization that understanding our cost structure in each individual unit throughout the hospital is something that we do a better job of we are limited by the technology that we're using I have the hope that some of the investments on the capital side can just allude to a decision support system something that we need to be investing in to help us dig a little deeper and then be able to do it with the resources that we have to see to do a better job of evaluating the fixed cost the step cost that's really the biggest job I have whether or not your top line if it's not because we are so fixed and then it's the spiral if you continue to just wait where you're going to get I think your point is an excellent one and it's hard for me as the interim guy with two and a half months on deck to answer comprehensively we have on Friday of this week and Monday of next week our community is interviewing two CEO candidates both experienced, seasoned CEOs with critical access hospital experience both looking at their resumes and from the feedback I got from the interviews I've not met either candidate during this process but cost containment is stamped on my left forearm in order to survive in health care for 46 and a half years I understand the importance of the revenue side but I have a high level of confidence even though the budget was adopted on my second day at Cobley I had seen four or five prior iterations having seen dozens of these budgets I have a high level of confidence that we are we've under promised and we can over deliver I think this is not pie in the sky from my outside for you I look at that state and I look at gross revenue that you would expect to raise over 2020 in comparison to 2019 and then the contractual allowance is retracted from that and once you do that math what you find is that of the 4.6 million plus or minus that you would expect to raise including your 9.8% rating increase that 83.1% of it will come from Medicaid that's right 7% to 16.2% will come from Medicare when I go to the blueprint and look at your population around it's 24.8% Medicaid from 31% Medicare and I'm just wondering if you can speak to that because it's not something that we call but something that you have to live with so I think one thing to consider that the Congress is always serving particularly in our orthopedic program or we're drawing from Chittenden County I think it's over half of that program that tends to end up being commercial volume not always I think that that has a factor in that difference between how much commercial coffee has versus what our community demographic looks like another factor in this proposal it does appear like a significant increase it is a significant increase to the commercial payers in this particular year with the rate ask however our history we've given that a significant amount net revenue in FY20 that's actually being funded through rate changes is quite small under 2% I'm just wondering I've listened to other hospitals they try to manage the relationship between those two programs of kind of encouraging bad death people to do their financial assistance get some revenue out of that revenue I've done something that we definitely do at Coffey as well can't really answer why it's not necessarily reflected in the result but I would even use the word push financial assistance pretty heavily any private paying patients is sort of cold called we review our bad debt before sending it off to a collection agency to identify folks to pursue to reach out to but it is a process to apply for financial assistance that everyone is willing to take on we do provide ample support that will fill out the application income and we'll fill it out with them we're encouraging them of course to exchange program during that process as well I think it has a very intensive and involved for a supportive financial assistance program at Coffey in fact our financial counselor will take care of one month this year every time I'm again not sure why it's not necessarily reflected in those numbers but we push pretty hard it has to do with possible risk that from 2019 projected over 2018 actual that seven of the position metrics were negative and only two were positive with that in your projections from 2019 prospective to 2020 we have seven positive and to worry you might have a negative trend in utilization we'll essentially positive trend in utilization for example when we project utilization at Coffey where we're looking at historical trends that isn't always the singular approach that we take we also evaluate medical staff changes that plays a pretty big role in some of those estimates folks who are new and are ramping up may have estimated their ramp up to happen a little faster than they did in reality we also factor in but an average of being for the most part we're trying to look at our actual utilization and scramble in those this particular budget cycle I feel like we were pretty conservative with those projections actually based on the changes that we have I'd say our 2019 budget was probably a little too aggressive and if you look year over year versus budget to budget you may see a different trend of the realistic nature of the utilization assumptions there are some folks who are saying they could do more, they could do more and I've been waiting counteredits when they're here counterediting service new programs the loss of that contract and new opportunity if your other operator left you I'm just wondering how did that decision happen what was the contract well it was intended right from inception to be a temporary support agreement they're not in our backyard we it came out of the hurricane Irene and they set up a variety of local psychiatric care facilities there was one placed in Morrisville and that was when our support began we were right there down the street we did more than pharmacy support for them we provided a lot of other support services all the support services that we provided it was quite a bit more and when they moved to Barrie the idea had been all along for them to be able to provide those services for themselves and just kind of working with them slowly eliminating services that we provided they were able to take that on themselves so it was just it was never intended to be a permanent thing and with the other operating revenue to come expenses it wasn't the sort of pass through it wasn't something we were working in we go about a month or two of the late times that we were recording in the spring it's part of the reporting that we collected and in particular I wanted to ask about OB because it looked like the late times on OB we're on the high side compared to some of the other hospitals and I know that you noticed in your narrative you mentioned that you're looking to increase your midwifery support so I'm wondering if you can speak to that a little bit midwifery support so our member free program in our community is very well respected they're a great group of folks they were three full-time midwives and in this budget proposal in order to help solve some coverage challenges and some call coverage to change the model to four part-time midwives so it's like a point step increase in all total midwives in order to supply that coverage a lot of it has to do with the nature of their business and being called in in the middle of the night and the call burden is being spread and when the stroke are reasonable and people preserve their sanity and provide a quality service I know that we have people that have the impact the other area that actually unusually high compared to other folks is cardiology but it was I think it back to you cardiology at Coffley is somewhat interesting as it's certainly one of the late stage bastions general cardiology we do echoes and stress tests and the ED and the floor and all other emergencies they come up with and one person does all that we did try a model with a physician assistant in the clinic along with Adam unfortunately she left for I don't know about greener but other pastures that's almost certainly something we're going to look again at some point but unfortunately hiring another cardiologist more fantasy than practical you know I might also comment that Adam Funen was serving as a co-cheat medical officer with Don Cui in this spring he gave up that appointment which both provided him with some of his time was administrative time he also served in a number of community activities he is now focusing his time on his clinical practice and I suspect that that will have a positive impact on his availability the other thing that happened about the time that those numbers went out is that at Newport they changed over having their own cardiologist to being supported by Dartmouth and right at about that time we were deluged with phone calls because it was a little uncertain for a while exactly what was going on and those numbers almost certainly reflect that although I don't think they've gone out a whole lot since then your slide on labor costs with 4.7% grant is there anything you could break that down for us all that goes across like admin docs nurses not off the top of my head Kevin what slide number is that your page I think we have different numbers that you have so there you go no not off the top of my head that's something I could follow up on I don't think that our administrative costs have normally high that's probably I believe you have a ratio that looks we're not doing that one anymore on overhead the percentage of your total operating expenses I may have to follow up if you want more specificity that'd be good there was some discussion on your charging increase if you factor in the professional service charge you really had 8.5 talk to us about the methodology that you used what would that request so the way we would normally know about this we initially project our NPR trends without a rate in it look at our utilization look at our pyramids, our bad debt charity etc come up with our net revenue investments first based on that industry and reimbursement and also in the case of Medicare cost structure we go through a very laborious process on the cost side of the budget it's not a top down budget but a bottom up budget budget starts at the department level in this way we take a look at the expenses that folks are proposing compared to that net revenue without a rate in it we go back 2 or 3 or 4 some years 5 times to get those moves asked on costs down once you feel we have pared down what we can on those expense requests we look at that remaining gap of our expenses and determine what the difference would be to attain a 3% operating margin which is really our goal that we haven't been there but the equate to in a break would be our ideal rate request at that point however sometimes like certainly in FY20 it would just be a ridiculous request we simply can't get as far as 3% solely on those expense reductions and rate requests and so we went half way there this year that's a 1.4% operating margin while keeping it under at least the overall 1.5% cap I don't know if that answers your question but that's sort of the logic of how we tend to set our overall top rate of gross, average change in gross charges and then with the majority of our commercial agreements their percent of charge with the exception of Blue Cross we have an outpatient fee schedule with them our models are change in charges so we do get together and appreciate that each year but professional fee schedules tend to be staffed or controlled by the payer not dependent on our charge request so one of my concerns was when there were discussions about trying to do the interim change the carriers at least I believe they indicated to you that you were unlikely to get that they didn't outright say that but based on the fact that they wouldn't be able to it would essentially be that that insurance company putting the bill in it wouldn't be something to pull into them pretty good but realizing that what we do is really account and not a guarantee do you have any confidence that you would be able to get and negotiate that larger than increase with the carriers I hope to make a compelling case looking at that five year trend of what we've given back to them over the last four years I'd really just like to get something back I'm going to make a compelling I'm going to do my best I can't guarantee an outcome okay that's all the questions I have thank you do you want me to use the microphone or do you want me to how do we make sure so people on the back can care for you I think they're going to need that to answer I think we can try the other one okay we can have this one thank you