 Good morning to all of you. My name is Jessica Holmes, and I'm currently serving as the interim chair of the Green Mountain Care Board. So today is day two of our Green Mountain Care Board hospital budget hearing process. Just as a reminder, I said this on Monday, but I'll say it again today. I'll say it at the start of every hearing day that we have to conduct our analysis and ultimately make a decision for each hospital. We have to look to our statute and our hospital budget rule for guiding principles. Our review requires us to balance several often competing factors, for example, the need to slow the growth and health care expenditures, while also ensuring that our hospitals have the resources they need to recruit and retain health care workers and provide the high quality care we expect in our communities. As we're looking to balance, you know, these competing factors of cost containment, access, quality and health system sustainability, we have to be mindful of this year's unique circumstances and the significant headwinds that we're facing. We have historically high inflation rates, workforce shortages and the continuing impacts of COVID-19. So both nationally and in Vermont, we're seeing hospitals facing unprecedented financial challenges as our businesses, families and individuals. So what lies before us is not easy. I think we all know that our short term task is to set fiscal year 23 hospital budgets for the 14 community hospitals and we have to do this by September 25th. I mean, September 15th, sorry. With that said, I want to remind everybody that the board is working closely with the Agency of Human Services to begin the work that outlined in Act 167, which aims to move us closer to a sustainable hospital system that's going to ensure, better ensure that Vermonters have access to high quality, affordable care. That longer term work is going to involve extensive data analysis and community and hospital engagement to identify options for a more sustainable path forward. So as we return to the task at hand, I want to extend a thank you to each of the hospitals presenting today for the time and effort taken to submit the documents for our review. There's a few housekeeping notes for today. The presentation is a public meeting. It's being recorded and transcribed. There will be a publicly available record. If any hospitals leadership believes that there's confidential information that the Green Mountain Care Board should consider either as part of the hospitals presentation or in response to board or staff questions, please alert us before responding. If needed, the Green Mountain Care Board has the ability to go into executive session to review confidential information from hospitals. I just want to note, though, that executive sessions are limited in scope as provided by the open meeting law and they're limited to information such as contracts and information that would be considered confidential under the Public Records Act. So if an issue of possible confidentiality arises, I'll call on the board's legal counsel to determine the scope of what could be discussed in executive session and if deemed appropriate and at the appropriate time. I'll ask the board member for a motion for us to go into that executive session. So knowing we have a really tight schedule today. We have three hospitals that we want to hear from. I'm going to hold all board and staff questions until the end of each hospital's presentation. And if Grace Cottage, if you folks could help keep us on schedule and wrap up by 10, we would really appreciate it so we can get through all three hospitals today. So with that, Russ, I believe you are here today to help us swear in Grace Cottage's witnesses. Great. Thank you, Chair Holmes and Grace Cottage team. Who from the Grace Cottage team is going to be speaking today? That would be both myself, Doug Devello, President and CEO of Grace Cottage, as well as Stephen Brown, who's our Chief Financial Officer. So the two of us will be speaking. Great. Thank you. If you could both raise your right hand. Do you solemnly swear that the evidence you shall give relative to the cause now under consideration shall be the whole truth and nothing but the truth. So help you God. I do. I do. Great. Thank you. You're both sworn in and excuse me. Court reporting. The gentleman that was speaking, he mentioned two names, but not his own. Oh, sorry. Dougless Devello, President and CEO. Thank you. Thank you. Great. Thank you. I will turn it back to you, Chair Holmes, or Yep. Great. Thank you. Thank you so much. So Doug and Stephen, you are the floor is yours. If you can share your slides. If you have them, that would be wonderful. Great. Absolutely. And as we put this slide presentation together, we were mindful of the timing and the time frame and so forth. So we've kept it fairly streamlined to try and get through this as quickly as possible. I think you all know that we're the smallest hospital in Vermont and probably have the simplest budget of all the hospitals in Vermont. So That being said, doesn't that doesn't mean that we don't find ourselves with fiscal challenges and operating challenges like most organizations, but I think we can get through this fairly efficiently. We'll see how it goes. So I introduced myself. I introduced my Chief Financial Officer, Stephen, and I just wanted to make some introductory comments. I know that there's been some changes at the Green Mountain Care Board, and I don't believe in the past. I've spoken at all about, you know, the history of Grace Cottage is quite an interesting organization and has a dramatic historical story to it. And I thought I would just say a few words about that just to kind of give you some color before we start talking. Talking about numbers. I asked my assistant to pull a book off the shelf that was written about Grace Cottage. It's called The House That Became a Hospital. And I thumbed through the first couple of paragraphs for just some talking points. And I just wanted to share some of those with you. So the first thing that struck me was that it was an 1844, that's 178 years ago, that the building, which is now the main part of Grace Cottage Hospital, was built. And it was built by a local reverend by the name of Horace Fletcher, and he and his family lived there for many, many years and many generations. In 1905, the very last Fletcher family member who lived in the house shared her home with a fairly prominent mathematics professor who worked at Leland and Grace Seminary. Her name was Mary Plum. Mary lived in the house for many, many years. And in 1938, a little over 30 years after she moved into the house, she convinced a local physician who settled in Townsend at Dr. Carlos Otis and his wife to take up residence in the Fletcher family mansion. And he did so and was able to use the space not only for his own personal dwelling, but also to operate his private practice out of that at home as well. And this allowed Dr. Otis to start on his pet project of creating a cottage hospital for the southern Vermont region and for Greater Townsend. And without that dream, you know, our organization wouldn't be here today. Dr. Otis was the singular driving force in pulling together an entire community to make this happen. One of his accomplishments was that he convinced a professor of UVM, a retired professor from UVM and a local physician from New Fane, to donate significant funds for the start of the Grace Cottage Hospital, provided that we, his name was Dr. Abel Graut. And his only request was that we name the hospital after his wife, Grace, and call it Grace Cottage Hospital. In 1949, which was 72 or 373 years ago, a grand ceremony took place here in Townsend to celebrate the opening of Grace Cottage Hospital and the rest, as they say, is history. So it's quite an organization over the years. Buildings around the Fletcher home were acquired and used to expand the operation of the hospital. And if anybody is interested in touring the facility, we'd love to welcome you here and we can show you some of the old buildings and how they've been connected and cobbled together and how the facility kind of took growth and expansion over the many years that we've been here. We are a 19-bed critical access hospital with swing bed volume as well as an emergency department. This past year, we actually, this current year, we're forecasting a little over 3200 visits to the emergency department. That's about a thousand visits more than last year. So things have been really busy at the organization, particularly in the ED. Our hospital also has diagnostic imaging. We have X-ray, CT ultrasound, bone density, and we also have a laboratory. Our diagnostic imaging service is forecasting almost 5,500 exams for this year, which is a significant increase over last year. Our lab is forecasting almost 65,000 laboratory visits for this fiscal year, which is an increase of over 7,000 visits compared to lab tests, rather compared to last year for the same time period. We also have a very sophisticated inpatient and outpatient rehabilitation department, staffed by a number of very, very talented rehabilitation specialists. We're forecasting a little under 53,000 therapy treatments for this year, which is an increase over last year of almost 1,800 therapy treatments. So things are really, really growing year over year at Grace Cottage. That being said, our, probably our claim to fame is our primary care rural health clinic at Grace Cottage. That rural health clinic is staffed by physicians and advanced practice providers who work tirelessly to see the patients of our region and provide world-class primary care. We have four physicians staffing our primary care clinic. We have four nurse practitioners and we have two PAs staffing the clinic. We also have two behavioral health providers in our rural health clinic. They're both nurse practitioners. The second one was added within the last month or so. So we've gone from having one behavioral health provider to now having two at Grace Cottage. And that was really driven by our observation that there's just more and more need for patients to have access to behavioral health care. And our primary care providers see those patients in their practices and having two behavioral health providers that they can conference with and refer patients to. Really helps with the continuity of care for the patients here in Townsend. On the hospital side, we have a hospitalist team that consists of four physicians and a nurse practitioner and they provide all the bedside care for our patients who are in either an acute bed or a swing bed here at Grace Cottage hospital. And I mentioned the emergency department and the tremendous volume we're seeing in the ED. We have three physicians in the emergency department and four PAs, both full-time and per diem working shifts to keep the ED staff 24-7 here at Grace Cottage. We also have something of a unique entity here in Townsend. We have a pharmacy that's owned and operated by the hospital called Messenger Valley Pharmacy. And that pharmacy was located right across the street from the hospital. And it's a tremendously important and convenient service for our rural health clinic patients who can walk right across the street and have their prescriptions filled within a few minutes of the provider writing the order. And the success of that pharmacy continues to astound me. We're forecasting almost 54,000 scripts being dispensed this year at Messenger Valley Pharmacy and that's almost a 1,700 script increase over last year. So it's just amazing how more and more people continue to use that pharmacy for their medication needs. And I think part of the growth there was contributed by the fact that one of the community pharmacies in Brattleboro closed this past year. And we've been seeing a number of patients actually coming up from Brattleboro to fill prescriptions because of the massive challenges that the commercial pharmacies are having in Brattleboro maintaining their staffing. And providing efficient service to their customers. So we welcome those new patients to our pharmacy and I think we're doing a great job of meeting their needs. Next slide please. Catherine, you can go to the next slide please. Thank you. So it wouldn't be a complete presentation without us talking about our mission and vision. I think it really speaks for itself. Our mission is to serve the health care needs of our community to promote wellness, relieve suffering and restore health. I think it's really important to note that the mission of promoting wellness is really, really important for a rural health clinic. You know, we don't provide specialty care services here at the hospital. All we really do is primary care and rehabilitation. And we really believe that expanding access to primary care and taking care of the patients who rely on us and keeping them healthy is really the key to our success and keeping patients out of the hospital and keeping them from having to avail themselves of more costly health care services. So I really believe that a well functioning and successful primary care practice over time really, really helps to lower health care costs for Vermont. Our vision is to provide personalized, competent and accessible primary care, which I mentioned, rehab, wellness, inpatient care and emergency services. We collaborate with other community agencies and our goal is to make sure that anything we can do for the wellness of our community is an opportunity that we jump on. And we really believe in taking care of the entire person as part of our vision. And we also focus very closely on the culture of the region and make sure that everything we do is focused on making sure that we're meeting the needs of our culture and our diversity here in Southern Vermont. I'd like to turn the microphone now over to Stephen Brown who will start with the net patient revenue portion of the presentation and the summary of our budget request. Stephen. Yes, thank you. Quite simply, 2022 thus far has been a very busy year as Doug alluded to in a couple of his comments, particularly in the emergency department, but throughout the entire facility. Inpatient census, primary care, all of the related outpatient services that come as a result of that diagnostic imaging lab outpatient rehab are all above budget for the current fiscal year. And our gross patient revenue and net patient revenue projection and budget for next year is based entirely on that volume. We have no reason to believe that our current volume of business throughout the facility will not continue at the same rate that it is. All volumes for the coming year are based on what we have done thus far the first seven months at the time we were preparing this budget. And those have continued in May, June and July. Since that time in all areas, the only slight variations from that is within the provider clinic, our primary care clinic and the mental health clinic. We have additional volume in those for the providers that have either come on partway through this year, such as the second psychiatric nurse practitioner that just started, as well as the three to new primary care mds we have arriving in October. And correspondingly in the retail pharmacy, a slight increase in number of prescriptions being filled for both those providers, but more so for the increase in volume we've seen over there. The last couple of months in that time period that we were looking at when a local retail pharmacy in Bratibro closed and the extensive issues that the major retail chains in our area have been having both in Bratibro, Wilmington and Manchester. In fact, we've been seeing a lot of patients coming to our retail pharmacy as a result of those major chains. You might have seen the article that was in the newspaper recently about complaints being filed with the pharmacy board about those chains closing their doors unannounced for days at a time and patients not being able to get their prescriptions. So that accounts for where our numbers come from. Again, no major no changes really not expecting any huge increases in volume from where we're at our requested rate increase is a 5% to charges across the board. That while that doesn't really keep up with anywhere near inflation across the board, nor as you're well aware, do we begin to collect even part of that 5% increase in the bottom line. It's the minimum that we feel is necessary to try to meet the continued increases in operating expenses that we are experiencing. The next slide Catherine which has the income statement. What you all have this is your form summarizes all of that and as you can see our 22 budget was pretty much the same numbers as where our 2021 actual ended up. However, our projection is significantly greater than that. Due to beyond our control, we are just taking care of all of the patients that are walking in our door and short of not taking care of those patients. We have no control over the fact that that volume is increasing. And again, I expect that it will continue. Next slide balance sheet. And as a result of that you can see that our balance sheet has continued from 2020 through now and the projection be one of the most positive balance sheets. Actually the most positive balance sheets I have seen in my almost 40 years here. The previous 2020 and 2021 as into 2020 early 22 had a lot of funds in there, you know, you'll see the large fluctuations in cash balance as well as liabilities as a result of all of the COVID funds we received. Both prep in the stimulus act funds as well as the Medicare advanced payment funds, which we are currently in the process of paying back and will all be paid back at the very beginning of fiscal year 23. All of that cash is still sitting in our account and will be paid back soon. Next page cash flow just gives you a quick snapshot of that and you can see the corresponding cash balance and that decrease is strictly either returning our unused CARES Act funds. We returned about $1.8 million earlier this fiscal year of funds that we did not need as well as the fact that we have been for the past year and a half returning the Medicare advanced funds. Next slide I already talked about the change in charge and the 5% that we requested overall. So I don't see any more to add to that. Next slide on other operating and non-operating. Our two primary amounts in the other operating revenue line are the 340B Retail Pharmacy Program, which net about $730,000 in the current fiscal year and is budgeted just under $800,000 for fiscal year 23. Primarily the Retail Pharmacy Program is strictly related to billing prescriptions at our Retail Pharmacy for the patients we take care of. The second part is the Retail Pharmacy overall gain or loss, which unfortunately in the current reimbursement scheme of Retail Pharmacies will probably always be a loss going forward. It's roughly a $200,000 loss for the current fiscal year and due to that, can you continue to increase in prescriptions being filled roughly $128,000 loss next year? Non-operating revenue for us is all a result of our very supportive community committed to assuring our continued excellence and the excellent work of our foundation, the Grace Cottage Foundation and all of their efforts to keep in contact with those donors. And we are happy to know that those donors are always there for us when we need them, whenever there's a need, they're there for us and has been what has kept this organization in business throughout its entire history and definitely the 38 years that I have been here. Next slide on operating expenses. Our, I'm sure what you see on here and what I'm going to tell you is no different than anything you've heard from the hospitals you've heard from on Monday and we'll hear from the rest of the hearings. Travelers is by far the biggest expense variation. For us, it was a million dollars over what we budgeted in the first nine months of the current fiscal year, both due to need continuing in our case to have five nurse travelers in the building pretty much all year. We are our average. Sometimes we get up to two, sometimes three. And never do we get up to five and stay at five for an entire year, but more importantly, the dramatic increase in cost of getting those from rates around $65 an hour, even a year and a half ago to $200 an hour for that same position. Fortunately, that has slowly started trending back down a little bit over the last couple of months, as well as we are filling positions with the goal that we are hopefully going to decrease that number down to if not zero close to zero within the next few months. Having done that by market adjustments to both retain staff and recruit staff, hopefully it will work and we can dramatically increase that coverage. But right now it's a cost of doing business in health care. As you're well aware, inflation across the board is beyond anything I have ever seen. Some areas are 10, 20, 30 percent above where they were. The cost of supplies particularly are just way up if you can get them and continue to have all kinds of charges out. I mean, almost every invoice I get now has a fuel surcharge on it. There's just continued inflationary constraints. All of that said, next slide, Catherine. Our overall operating margin and total margin, while the charge increase is not adequate to produce an overall operating margin, the total margin is a minimum, minimal excess as a result of our strong community support. We would very much like to have requested 10 percent or even higher in hopes of getting a positive operating margin, but are doing our best to keep costs in line and again, relying on that strong community support and non-operating revenue. And at that point, at this point I will turn it back over to Doug to talk about the equity question. Thank you, Stephen. I think it's important on the non-operating revenue side to highlight the fact that the stock market has not done very well as well. And that's had dramatic impact on our non-operating income as it relates to our foundation and our investments. So a lot of things stacked against us and hopefully we will see a return to some normalcy in the coming year or two or three. I know the question of equity is an important one and it's been asked in prior years as well and rightly so. In 2019, we made the strategic decision to create an equity committee and to make this work of looking at equity as an organization, a major strategic plan for Grace Cottage. That committee was formed through the collaboration of hospital employees with specific interest in this topic, as well as active members of the community and folks from the region who represent the LGBTQ plus community. And this team of individuals, I think did an amazing job and did some really significant work for Grace Cottage and highlighting the culture here. We really believe that every patient who comes to Grace Cottage, regardless of their beliefs, regardless of their culture, despite their diversity, be treated the same and be treated like everyone else. And that's something that we believe in. It's something that we demonstrate every single day. And the equity committee really helped us to highlight that piece of our important culture here. And they set a goal to achieve recognition by the Human Rights Campaign and getting Grace Cottage listed on their Health Equity Index as a leading organization in the state of Vermont. And we went through that process. We went through the self-assessment and then ultimately we were surveyed by the Human Rights Campaign as part of that nomination process. I'm really pleased to say Grace Cottage scored a 95 out of a 100 possible points on the Health Equity Index, which is the highest score achieved by any hospital and matched by only one hospital in the state of Vermont. And as a result of that, we are now proudly listed on the Health Equity Index, Health Equality Index, as an organization who people can go to with confidence knowing that their unique beliefs and their unique diversity will be celebrated and they will get the very best care possible when they come to Grace Cottage. We've taken that work and we've done extensive education for members of our team, our staff, our leadership, and our medical staff as well. And we continue that strategic initiative going into 2023 as well. We're going to do another self-assessment in the next month or so to make sure that those goals and objectives that kept us from scoring a 100 versus 95 become part of our work plan and focus so that we can be the very best we can as an organization that celebrates equity and equality. Any questions there? If not, I'll go to the next slide. Another important topic that you wanted us to talk about is the issue of wait times. And as I mentioned earlier, Grace Cottage is a primary care facility, primary care organization with behavioral health embedded in our practice. We do not provide specialty services here at Grace Cottage. So that kind of makes us a little unique when talking about wait times. But I can't speak to wait times for primary care. We're actually quite proud of our success in this area. We have a team of central schedulers here at Grace Cottage who do nothing but take referrals and answer the phone from patients who call to make appointments for primary care. And they have access to all of the provider schedules and they have permission to schedule patients with any provider who has an open slot in their schedule. So at the time that a request for an appointment is asked for, the majority of the time that appointment is given with no wait time incurring as a result of that. If the patient needs a follow up appointment after a visit to one of our providers, we have designated slots that are held in their schedules for weeks after the day of the initial appointment. So a follow up appointment is given to patients at the time that they finish their initial appointment with their provider. So we're very successful in getting patients in to see their doctor or their advanced practice provider and get the appointments that they really need. We also have a designated specialty clinic with a separate schedule for those patients who have acute care or respiratory symptoms that need to be seen immediately. And we also have a triage nurse who works with our scheduling team to talk with these patients when they call. So if a patient calls and says, you know, I'm not feeling well. These are my symptoms. I really want to be seen. I think I need to be seen right away. That triage nurse can look at the schedule, can put that patient on the schedule the same day as the phone call if there's an available slot. If there's a late cancellation or no show. Or if the triage nurse feels that the patient needs a higher level of care than just seeing a provider in the clinic that nurse can make arrangements for the patient to be seen in the emergency department and we coordinate that visit with the folks in the ED. And as Stephen mentioned, we've been really successful in recruiting primary care providers. And while all organizations do see change and people come and go, we've had some providers leave Grace Cottage, but we've been successful in recruiting replacement providers in excess of those that we've lost. So the net result is that we continue to slowly grow the number of physicians, PAs and entities who are here on our staff to see patients and we'll continue to stay ahead of the curve to make sure that we can handle that steady growth that we're seeing year over year so that access is successful and that wait times are minimized. Any questions about wait times? I think it's important as we go to the next slide, risk and opportunities. One of the things, one of the bullets I've mentioned here is delays in ED patient transfer due to delivery stress system stress. I think you're going to hear from hospitals how difficult it is for them to get patients into their organizations that need specialty care, particularly from organizations that like Grace Cottage, who don't have specialty services here on site and need to transfer patients, whether it's for cardiology, whether it's for pulmonology, whether it's cancer care, or just a general trauma surgery, trauma surgery, for example. Many times we see patients in our ED that require a transfer to a higher level of care that can wait significantly longer than we would like them to wait here at Grace Cottage for that transfer to occur. And oftentimes we have to call multiple organizations to locate a transfer opportunity for a patient that's in our emergency department. And that's a real problem. I think it's a problem for all hospitals and I think it's a system issue that we as a state need to figure out how to address. I'm really glad that the Green Mountain Care Board is focusing on wait times. We've got to figure this out. We've got to make sure that we've got the specialists statewide that can meet the needs of the patients in a timely fashion. Another risk, and I think as Stephen mentioned in his comment, reimbursement. Reimbursment is a real challenge at Grace Cottage. Fortunately, the number of Medicaid patients we see here is not overwhelming by any means, but it certainly creates a physical challenge for Grace Cottage in that we receive less than 50 cents on the dollar of our costs for taking care of Medicaid patients. We also don't recover anywhere near our costs for Medicare patients as well. And that's a real risk for a hospital like Grace Cottage that does primary care. And we've got to figure out how to push the lever of reimbursement reform so that we can just get a little bit more of our costs for taking care of Medicare and Medicaid patients. As I mentioned earlier, primary care is so important to keeping healthcare costs lower. Lowering healthcare costs are going to require us to keep people healthier and out of the hospital. And we need the funds to do that. If Grace Cottage closes because of its inability to function financially in a healthy way, that's going to impede our ability to keep people out of the emergency room and to keep costs lower than they need be. And then the staffing cost and nurse traveler issue. We talked about that this year has been a real challenge. I'm hopeful that a supply and demand shift will occur in the next year and that rates for travelers and agency staff will return to what used to be the normal expenses that we have budgeted in the past. We're doing everything we can to recruit nurses who want to work here full time rather than coming here as an agency staff member. We lost a couple of two, three nurses who left Grace Cottage to go work for travel agencies when they saw how much money could be made. Two of those three nurses are now back at Grace Cottage and working for us again. And I think that's a testament to the great place this is and why people really want to work at Grace Cottage and why our turnover rates for staff are really world-class. People want to work here and people generally stay when they come to work at Grace Cottage. On the opportunity side, I mentioned the addition of primary care providers in fiscal 2023. We've got two really stellar physicians who will be joining us in October. And we also have a nurse practitioner who's joining us in September. One of those physicians is a local new grad from UVM. I was talking to one of the professors at UVM who said to me that they tried to do everything possible to keep this young man from leaving UVM. They wanted him to stay, but he chose to come and practice rural medicine here in Townsend, Vermont as part of the Grace Cottage team. So we're really happy about that. The other physician is a practitioner in Brattleboro who has a mature practice and will be coming here and probably bringing a good portion of his practice with him to Grace Cottage as new patients. So we're doing well on the staffing side, despite the challenges that other hospitals seem to be having in attracting primary care members to their teams. We're really having a good run of success. And then the last opportunity bullet I have here is the design and construction of a new clinic building. You'll be hearing about this project in the coming months. Ultimately, we'll be submitting a certificate of need request to the Green Mountain Care Board where we'll be talking to you about our plans for a building that will be new to our campus that will consolidate the current clinic work that's being done in a disassociated fashion. We currently have three distinct clinic locations with three registration points. And patients with many of the provider they're seeing have to go to the registration point that corresponds to that provider's practice. And so obviously that's not the most efficient way of running the rural health clinic. It duplicates staff. It duplicates registration. To some extent duplicates nursing support and so forth. So we really want to create a building that can allow us to run the clinic in one location to take advantage of economies of scale, take advantage of operating efficiencies and ultimately provide care to our patients at a lower cost. And so that's our dream in the next two to three years. We hope to have that building become a reality and we look forward to talking with you later as we coalesce our application and our formal submission for that new building. If there are no questions, I know you, I know, Jessica, you want questions at the end. So I'm not going to ask for questions. I'm just going to turn the mic back to Stephen who is going to talk about our capital plans for fiscal 2023. All right. Included in the budget capital section for capital plans are not any particularly large projects for fiscal year 23. I outlined a couple of them here. Excuse me. The biggest one is probably replacement of our diagnostic x-ray room, the table and all of that stuff. The one we have is getting is end of life and time to be replaced. We have a few small IT projects, nothing large. We've done most of our large IT projects over the last two or three years, including replacing all of our servers and wireless infrastructure and are amidst replacing our phone system this fiscal year. And then some boring things like resurfacing the hospital parking lot. As Doug just mentioned, our biggest upcoming project in probably 24, but most likely 25 will be replacing or building a new primary care and mental health provider clinic building. Currently in the fiscal year we're in, we are, as I mentioned, replacing our phone system completely. We are also working on a small project to expand our, not expand our ED, expand the space, not expand the number of ED beds, but to improve security, provide better patient privacy, improved increase efficiency, essentially making a more formal entrance for the emergency department with a secure formal entrance with the emergency department, with a place for the security guard to sit and registration clerk. Instead of coming currently our front door, if you haven't been down here, but for both the emergency department and the hospital walk right into the same space and essentially registered for the emergency department are sitting in the hallway outside of the emergency department room. So we're excited about that project and that's pretty much it for capital plans. So at that point I will turn it back to Jessica, I guess, and continue on with the process. Great. Well, thank you very, very much. I appreciate we're definitely on time today. So I appreciate that. I will open it up to questions from the board and again I'm starting with Robin. Great. Thank you. Thanks so much for your presentation. It's nice to see you. I hope you're doing well. First of all, I just wanted to say it's great to hear about your work to move away from travelers and that you're hoping to reduce those number of contracts due to the expense, the expense pressures that you mentioned. So I just wanted to applaud you for that. I did have a couple of questions about some of the details related to that budget item. Can you speak in a little more detail to how you budgeted travelers for fiscal year 23? We budgeted the way we normally budget is to have two people in the building and that generally in the past has always been more than enough. And the way I actually budget them is the presumption that all of our positions will be filled. So if I've got two vacant RM positions, the actual positions are budgeted in salary and benefits. And then what I budget on the actual travel line is the premium above and beyond what the cost of those people would be if they were here full time. Great. And so that makes sense to go back to the two that you typically do. In terms of the traveler rates, can you speak to how you estimated that? I know that's going to be tough this year. I believe that I would have to pull out it out, but I think it was around, like I said, we have had been up almost to $200 an hour. I think I budgeted around 120 or 30 because it was on it just started going back down in May when we were working on the budget. And I believe our CNO said the other day, the last one she did was around 130, I think. Great. Thank you. And could you also give a little more color commentary in terms of the wage increases and retention efforts that you've done in fiscal year 22 to keep folks and how you're anticipating that flowing into the 23 budget? We always force wages around here in the facility look regularly at we participate along with most all other Vermont hospitals in an annual South wage survey done by the Vermont, New Hampshire and Maine hospital associations. And we always, when we're hiring, look at those salary surveys to keep in line with market and try to keep somewhat reasonably close to those above and beyond that for the current year. However, we particularly in nursing did a department wide market adjustment to try and remain competitive within for both the surrounding facilities but nursing rates in general in this area. So that was a significant change for the whole nursing department. We've also had to do similar things with housekeeping food service staff. We actually just increased our minimum wage from 15 to $17 an hour in within the past month for the whole facility which didn't affect a lot of people but it was mostly the most of the housekeeping and food service staff, primarily. So, in most cases, the nursing rates are all include that increases all included in next year's budget, the increase from 15 to 17 is not that's not going to be a huge additional expense, but because that was just done in the past month. But it's just a matter of trying to, you know, keep people from thinking oh I can earn a dollar an hour more by driving 20 miles down the road and turn. Yeah, it's a tough environment. It certainly is it's definitely by far the toughest I have seen in all my years here. And it looked like in the material that we received the budget submission materials that you were estimating like about a 5% wage increase in 23. Overall across the board, yes. So one of the questions I'm going to ask all of the critical access hospitals is to speak a little bit to the higher fiscal year 22 expenses that you've experienced and how those how you would expect those to flow into your Medicare cost reports and then hit Medicare reimbursement and when you would expect that cost settlement process to be completed. The cost report is required to be submitted by the end of February for the current fiscal year so the September 30 21 cost report is submitted by February 28. And then they generally Medicare generally processes though has to is supposed to process those within 60 days and usually takes the full 60 days or sometime around the end of April. You will see the interim rate adjustment and any settlement coming back one way or the other. It flow the costs flow very differently depending upon which departments it's in. Fortunately for us that one of the biggest of variances as you're well aware is the traveler cost. And that is in of course the acute and swing bed area and that has our highest Medicare percentage. I'm not sure up top my head at the moment what it is it's probably still around 85% Medicare patients so fortunately they pay a significant portion of that. It may be dropping. It actually may be less than that now because so many people are switching to Medicare replacement plans and those don't actually count as Medicare patients count as commercials so. Right. Still got those same patients they're being paid differently. Most of the rest on average for our facility Medicare is roughly 60 some odd percent of our overall business. That being said we are in the an unusual situation this year where because our inpatient census is so high that we probably are not going to expect a huge costs report reimbursement when we submit because we've got more patient days so our cost per patient is being divided by a larger number of patients so most likely we are not going to see most of any of that money come back. I'm just hopeful actually that we don't owe Medicare money this year because of the fact that we've had those additional patient days and been getting paid for those throughout the year. It's a very complicated system this cost report. Yes it is which is why I appreciate you walking us through it and having a better understanding of what your expectation is around that reimbursement. And then lastly could you speak a little bit to any cost savings efforts or expense reduction efforts that your race either currently or expect to pursue in 2023. Truthfully we do not have any significant or potential cost saving efforts. I mean we have always done all we can do to reduce costs. I mean we continue to look for ways in areas such as energy efficiency things like that. We actually intended in July of last year to undertake three on that particular note install three different HVAC upgrades many split systems in three different buildings. Paid the deposit for all three of them and thus far have only had one building completed and are currently looking for a provider to do the other two buildings because there's not enough people to do the work you can't get it done. In fact the large company that we use for all of our other work. We finally asked them to come and give us a quote about three weeks ago and they're coming I believe the third because September to even look at what we want to have done so you know it's we're trying you just can't get it done. But for general expenses now I mean we we run a very tight ship if you will when it comes to operating expenses and all of our department heads are very good at looking at every line item on their reports and we provide each department with detailed line items every month of their both revenue if there are revenue and revenue for producing department as well as expense lines and Doug and I meet with every department had every month and review those variances. And they're all very conscious of not spending any money they don't need to spend. Thank you. Back to you just those are my questions. Thanks very much. All right. Great. Thank you. Number Palom please. Well good morning. It's nice to see you again. I remember my days in the Leland Gray gym. And down the soccer field that had a class four road that ran through it. It's still there. It's still there. So, I'll try not to be too redundant here. It's in looking at Grace Cottage's budget. It's kind of interesting because there's some big percentages for very small dollar amounts. So like the entire budget to budget increases three point three million dollars. So, you know when you start to break try to break that down there it can be get pretty noisy I think. But I was looking at your payer mix table and where you were looking for the growth to fund the 15% overall increase was a 24% and this is budget to budget I'm sorry about that. But as a 24% increase in Medicaid revenue and a 30% increase in commercial revenue. And if I were to guess what your answer would be as to what's driving that it would be we are projecting off of our projections through July I guess or or. So, if that is your answer what what do you think the risk is that you won't hit a 24% increase or 30% increase 24% increase in Medicaid and a 30% increase in commercial. You're right those are. Looking at budget to budget that is correct but it is based out what I budgeted next year is based on where we're currently at so the increase from projection is not that and what's really accounted for that is. As you can see Medicaid particularly. Excuse me, you'll see is continued over the last three years as people have lost jobs and normally in the previous year or two. The commercial has either stayed relatively flat or gone down as Medicaid has increased, but what's accounting for a lot of that this year is as you heard me just mentioned, a lot of our patients. Are now choosing Medicare replacement plans which are considered commercial insurance. Both we're seeing significantly more of those, but also what's skewing our numbers somewhat and you'll see a decrease in Medicare is that prior to the current fiscal year. The commercial plans for the people we had, we're still included Medicare revenue our computer our billing system didn't have a separate financial class so those Medicare replacement plans were part of Medicare revenue. They have, I think I think she started it earlier this fiscal year, set up a separate financial class so they are now being counted as commercial as they should be. So that's part of the reason why the commercial looks like it's going up and Medicare is going down. Well thank you for that. And related to that I was looking at your utilization table. And in terms of acute bed use, increasing from 285 patient days in the fiscal 22 budget to 393. For the observation patient days, increasing 60% from 81 days 230. And so I, I can accept that that's kind of what the track record is through fiscal 2022 and this is off of projections. But behind that what what do you think the dynamic is, you know that's that's driving that increased utilization. Two things, primarily what has driven it up until the time that I did those projections. As Doug alluded to you'll, if you look, you'll also see that the emergency department is way ahead of volume, like up 35 or 40%. Again, small number is not that that's a huge number of people around here. The average of eight a day to now nine point something a day. But more, most of our acute patients come through the emergency department. And so there's more patients here to be admitted. The other thing that is going to allow us to continue to keep, whether it's acute or observation patients is we have implemented over the past few months. Tele services with Dartmouth, two different contracts, one for telepsychiatry and telestroke, so that we're able to get help assessing some of those patients. And in some cases keep those patients here that would have been transferred someplace else to be assessed. And then of course ended up staying there. But most of that change in volume is simply the fact that the ER has been so busy. And I think a little bit, you know, maybe, you know, nobody really knows why the emergency department has been staying busy. One possibility or few of those patients might be the fact that the local urgent care center has been closed as much as it's been open due to staffing, just like everybody else. So we get a few patients from there. But for people who are just traveling and more people in the area, it's hard to say. So if that urgent care facility started to get fully staffed, that might be a risk? If that's where they're coming from. Truthfully, I don't think a lot of them is. I mean, they are because I think most likely if you wanted to go there, you'd probably go to BMHCR being as it's in Brattleboro, the urgent care facility. But, you know, I think it's just a combination of things. So looking at, I was looking at your provider tax number, which is a 29% 30% increased budget to budget. And I just, you know, the methodology that hospitals use, I know varies across hospitals. But I took 6% of your 22 projected NPR FPP and that came to $1.4 million, which is, and I think what you budgeted is $951 million. So I'm just wondering what your calculation approaches that you used for the provider tax. Because provider tax is not calculated on swing bed revenue. And that, if you look swing bed is a significant portion of our inpatient revenue. So for instance, in 23, our swing bed revenue is about the gross 7.7 million of $40 million gross. So that comes out from there. Thank you for that. And I think lastly, So I was looking at your trends in terms of non operating revenue and I recall from our previous discussions that had a lot to do with the generosity of your community and your your fundraising effort. And looking back at the trend in terms of non operating from 2021 actual to 2023 budget. It was trending down at about 11% a year. And I'm just wondering if you I think you said during your narrative or during your presentation that you know you have folks out in the community that you can call when you need them. And so is the number then that you have, which is a higher number in the 2023 budget. Is that assuming, what is that assuming about, you know, the, the, the folks that are on your, your on on your contribution list. I mean, I guess I'm getting trying to get a sense is do you feel. What might make it a little easier to understand or make a little more sense is that the non operating revenue also includes, as Doug mentioned, market, market change, market value change of investments is of course on that line. And I don't generally budget, the number budget number going forward doesn't usually include that because who knows if it's going up or down I usually budget just the actual contributions. The 23 contribution amount is the same as the 22 projection amount. So what the difference is is the current projection amount includes huge negative market value changes to with any luck we'll be going back up but you know this point who knows if it will between now and the end of September, but the actions are higher. Well, that makes sense to me. Thank you for that. And for me, I think that's it. So I will pass it back to Jess. Great. Well, that just allows me to pass it back to Tom wash. Thank you, Jess. And good morning, Doug. It's nice to see you again and it's nice to meet you, Steven. I first wanted to just commend you on the work your organization has done with equity. The achievement that you've made there is outstanding. Similarly, the your wait times are remarkably good. It looks like a success story from IHI. I wonder if if you can recall a time when you had longer wait times and if you would describe for us the effort that it took to get to where you're at. Yeah, I think that's a great question. I've been at Grace Cottage now going on the four and a half years. And, you know, I remember talking with my team when we began to look at how to make sure we develop a strategic plan that's going to allow us to be successful in the years to come. And, you know, one of the things we talked about as a group is, you know, how do we focus on and monitor access to our providers? Because I truly believe at the time that the key to our success, aside from the fact that we have really, really great people who treat people, you know, with their hearts and, you know, and we have wonderful community reputation. It was really all about being able to give patients appointments when they want them. I mean, it's as simple as that. It's simple business. People who don't feel well are going to seek care wherever they can get it and wherever they can get it quickly. And so, you know, as a team we said, you know, we've got to stay ahead of the curve. We cannot wait until providers leave the organization and leave us with a hole to fill and then start trying to recruit someone to replace that hole and to rebuild that capacity. Because as you know, it could take upwards of a year between the time you start recruiting a provider, to the time you sign them, to the time they give notice, to the time you get them credential insurance carriers. It takes a long time to replace an outgoing provider, physician or otherwise. So, you know, we really work diligently to focus on what our providers need, what their future plans are. We've had some people leave, but it wasn't a surprise to us because we had conversations with them for many, many months about their plans and what they want to do and where they're going to go. And so, to the extent that you can, you know, have advanced notice about when an opportunity might develop that you can begin recruiting for early rather than later. It allows you to maintain your ability to provide that capacity and to give people appointments. And so that's really been a focus of ours, making sure that we don't fall behind the market with regard to access, making sure we stay ahead of the curve. So come October, we're going to have capacity at Grace Cottage that will need to be filled. And we believe that when you build what they will come, if you create capacity and then promote the fact that you have immediate appointments available and you're accepting new patients, just give us a call, patients will call. And we know there are a lot of patients in the community who are looking for providers that want to establish with a practice and cannot find anyone who's taking new patients. We have a few providers of Grace Cottage who are still taking new patients, which is good, and we're building on that capacity with our new hires later this year. So really it's about planning, it's about staying ahead of the curve, it's about watching the horizon and being prepared. And then finally, I just want to say that when I took this position four and a half years ago, folks warned me that, wow, it's going to be difficult hiring people to come and work in towns in Vermont. And yeah, it has its challenges, we've got housing challenges, there's not a lot of retail locally, people have to travel to groceries and other retail needs and so forth. But what we lack in everyday comforts we make up for in other really spectacular ways. And we focus and we promote the good and the positives of having a practice and a work life in southern Vermont and all that comes with it. And we believe that we have a great thing to offer here and that's helped us recruit people who have been looking for just a change in their lifestyle. I received a call from a provider yesterday who left to go to Burlington, Vermont for a job opportunity and has been there a little less than a year and he called and said, you know, Doug, I'm thinking about coming back to southern Vermont, to Townsend. I miss it, I miss the lifestyle, I miss the quality of life and if you have any opportunities or any openings, you know, that you may need somebody to keep me in mind, I'd love to come back. So it's just, I think, just one of many examples of where we've been successful in attracting people to come work here where other organizations have been having difficulty. Thank you for that. I'd also, I'd like to try to explore the increased utilization of the emergency department a little bit. And Stephen, you'd mentioned earlier that it may be closure of the urgent care, but that's unlikely because there's another opportunity, there's another place pretty close to that. But have you started or considered starting efforts to try to understand the needs of those patients? Those patients oftentimes, a few different projects I've worked on in different places. Increased volume in the emergency department is not a huge increase in unique individuals. Yeah, repeat visits and a few. And so understanding the needs of those patients and bringing the care they need in order to not need emergent or urgent care. It can often end up being a savings to the system. So can you talk a little bit about where your thinking's at with exploring the emergency department utilization? We can certainly look at that. I'm not aware that we have a big issue with repeat customers in our emergency department. We can certainly talk to our ED director about that. The other thing I didn't mention, which I think has been accounting for some of the volume increase here is particularly in this area. Pretty much every second home of which there are lots and lots of them in this area is currently fully occupied by people who either have decided to move here full time into their second homes or have been living here full time in their second home for the last couple of years more or less and likely have not necessarily decided to change their primary care here. So when they need to have something done, of course, they're ending up in the ER. We do know that that's what some of the patients have been. But again, with a small number of volume, we certainly could look at those patients and look at them. It's still, as I said, only an average of nine-some people a day. I think one of the other factors that's hard to validate is the fact that in the last two to three years, we have essentially replaced all of our emergency room providers with new providers. And the providers we have now working in our emergency room are our local individuals who have been working in Vermont for a good portion of their careers and are now working at Grace Cottage and they have reputations. They're well known and I think people are very comfortable coming here knowing that they know who they're going to see and they know they're going to get good care. And I believe that our reputation for providing quick and timely access to care in the ED also helps our clients. When you come to the emergency room at Grace Cottage, you're going to be in a treatment room probably within 10 minutes of your arrival. And the majority of those patients spend less than two and a half hours here start to finish on average, which is dramatically different than emergency rooms and other full service community hospitals around the state of Vermont. So I think that that has a big, I believe has a significant role in why we see, you know, we're seeing more people come to the emergency room. I agree with Stephen, second home owners are either more people here in southern Vermont than ever before. That's a function of the pandemic and I think that's probably not going to change anytime soon. And so, and then there are other people who don't have primary care providers that are not established with primary care providers. And they use the emergency room as their doctor's office, which is unfortunate. But what we do in that case is when we have a patient in the ED who does not have an established care provider in the area, we ask them if they would like to have their care established with one of our family medicine or APPs in the rural health clinic and we facilitate a follow up appointment in the clinic for that patient, particularly those where the ED provider has determined that a follow up appointment is necessary. We make every effort to schedule that follow up appointment in our clinic before the patient leaves the ED. And so, you know, to begin to try and jumpstart that relationship so that ultimately we establish them in the clinic so they don't need to use the ED in the future. So we work very diligently at that. I think another, speaking of the pandemic, another possibility could be as well that as we all know, especially in the first year, year and a half of it, a lot of people were putting off healthcare. They're not being able to get preventative care because of all the times the hospitals were closed, but a lot of people were just scared to death to go anywhere near a healthcare facility or even a primary care practice because they just were not getting their work done. So there's probably a number of people as well that now all of a sudden have urgent conditions that might in the past have been prevented. And I still don't even want to go into a primary care practice. So they even though they could get an appointment, they don't schedule and then all of a sudden they need to go when they end up in the emergency department. George, your unit was up earlier. Yeah, I don't think I'm sworn in. I was advised. I'll speak for George. He wanted to remind me that we've seen quite a number of patients coming here from the Springfield area. You had some operating operational difficulties the last couple of years and are still working their way through some of those challenges. They had some pretty substantial upheaval in their emergency department. And in fact, some of the providers that ended up here as a result of that. And so they've attracted some Springfield patients to our emergency room. And as George points out, you know, there are sicker people in the region. People were getting older. You know, Vermont is not known for attracting young, young, healthy people. We're an aging state where Southern Vermont's an aging region. And as people get older, they just have more health care needs. I think that also plays into the ED as well. I think those all make sense, I think. There's also, and I understand or hear the small volume that you're talking about if it's like nine people a day. But I also recommend just thinking about trying to understand this increase through your equity lens. Some of these patients may be underinsured or uninsured. And so they're forgoing care not because of the pandemic, but because they're afraid of the cost. And then they become very sick or have an accident and need to go. And so, and those patients, those individuals underinsured and uninsured, they're frequently from historically marginalized groups, women or single family, single parent families, low income individuals. And so there's an opportunity through that equity work that your organization has done to try to understand the needs of the people that are behind the increase use of the emergency department and make sure that the resources that are necessary are being driven in that direction, just like the equity work elsewhere. I see you nodding your head, George. So I'll stop there and pass it back to Chair Holmes. Thanks for that recommendation, Tom. We appreciate it. Great. Well, thank you. Some of my fellow board members touched on some of my questions. I might dig a little bit deeper in some areas, but I appreciated their questions already and your answers already. One of my questions is regarding the 5% change in charge. In the narrative, you talked about fiscal year 22 and how the approved fiscal year 22 rate increase was 5% as well. But that 5% was only recognized on a very small percentage of the commercial payer charges that are reimbursed on a percentage of charge basis. And then it goes on to say that the majority of commercial payer services are reimbursed on a B schedule that is generally updated on an annual basis and almost no instances, if any, where any of those increases close to the 5%. So I appreciated that insight. And I guess my question was twofold then. So looking back at fiscal year 22, the year that we're in, what would you say the actual effective commercial rate increase you experienced in this year is? In other words, for the commercial, the average commercial patient between 21 and 22, what is the effective commercial rate increase that they experienced? And then how do we think about the 5% that you're asking for 23? What would that actually translate into in terms of an effective commercial rate? Not quite sure how you'd calculate that. Just pulling a number out of my head. Well, you can also, you know what, I mean, I'm asking all of those to do this. So I would say to you, you don't have to pull it out of your hat. You can follow up with Sarah with, you know. We can try and look at them. But I mean, yes, you completely understand what I was trying to say. So, you know, you'd have to look at the, you know, I don't get an idea of buy insurance company, you know, look at the ones, you know, Blue Cross is a good example. The majority of what they pay us on an outpatient basis for all of lab and x-ray are all fee schedules. So, you know, what did they increase their fee schedule? Was it 2% or 3% or whatever? You know, there's a very small volume of our business where they pay percent of charges for say some of the emergency department work and things like that. But it's two different percent of charges depending on which type of a Blue Cross plan it is, managed care or not. So, yes, we can try and I'll talk to Sarah and see if we can come up with a number that makes sense. I think that would be really helpful because at the end of the day, we're trying to understand what is the real impact, right, to the commercial patient in your community. And so, recognizing there's not a one-for-one correlation at all, you know, between change in charge and what people truly experience. We're trying to unpack that a little bit and understand what the, you know, what the impact is. Yeah, truthfully, you're right. I mean, truthfully, whether we increase our rates 5% or 25%, there's really no impact for the commercial payers for the majority of the work. So, there's no change. For all of the work that's done on a fee schedule, there is no change. You know, they have, you know, for the ones that are on a percent of charges, yes, if they were, they're either going to meet their deductible quicker or they're going to, you know, if they haven't met their deductible, still no impact because it's really no impact. Even if they're, where they're paying 20%, you're right, they're paying 20% of a higher number. So, it's still a pretty minimal impact. But yeah, we'll try and come up with something. That would be super helpful. And I think as we go forward, you know, in the hospital budget process, I think, you know, we're going to try and at least my hope is that we'll try and ask hospitals that calculation in advance so that we can really better understand. Yes, we want to know what change in charges, but I think we also want to understand the effective rate. So, if there's a way to discuss that, but I think that would be helpful for us to understand. On that note, I mean, along with that kind of going back to one of Doug's major discussions on risk, you know, what we increase our rates or what we charge isn't even relevant. For instance, on Medicaid, which is a significant portion, as Tom pointed out of our patient revenue, because everything they pay is paid on a fee schedule, which is not adequate. I mean, I just was looking at our 990, which we filed last week, and the Medicaid shortfall for this little tiny facility is two and a half million dollars. And it's 9% of our expense budget is what Medicaid is not paying this organization to even cover costs, not below what we charge, but what they're paying below the actual cost to provide those services. So, you know, and truthfully, I know you don't necessarily have control over this because you don't set Medicaid's rates. Hospitals should not be expected to be financing the state of Vermont Medicaid program. You know, if they're going to have a Medicaid program and expand a program, which is great, you know, we shouldn't be contributing two and a half million dollars to that program. I mean, and if that's what Grace Cottage is contributing, I can't imagine what the other hospitals in the state of Vermont are contributing toward what the state should be figuring out how it should be paying. You know, I mean, and you're right that that affects the commercial insurers, you know, I mean, the reason we're having to charge those rates in hopes that met the commercial insurers will pay a little tiny bit is the fact that Medicaid's not. It's a topic that's come up every year and the board has in various ways made reference to, you know, the fact that Medicaid should be keeping pace with inflation. It was part of our, for example, long term sustainability report to the legislature is one of the recommendations that we've made is keeping pace with inflation on Medicaid reimbursement rates. But as you just said, we don't set Medicaid rates. Right. So that is something the state needs to understand. You know, they're they're sitting there expecting you to keep hospital budgets in line and they're expecting you to keep commercial insurance rates in line. Yet they're the biggest contributor to the problem. Well, let me let me probe a little bit around that. So you know, you have talked about low reimbursements from Medicaid and from Medicare, in fact, and an inability to cover costs. And I think that many hospitals will echo that sentiment. And I wonder if Grace, you know, with, frankly, you know, your average daily census of 10, an ED volume of nine, and yet you're keeping your ED open all the time. I just want to ask you, you know, given today's inflationary pressures, the workforce pressures, the high costs of technological innovation and your low, low volumes and the expectation that you're going to keep an ED open all the time. And the fixed costs of running that you're not benefiting from economies of scale. And, you know, how are you know, as we start to think about this, what is the plan to be able to do that, given the payers reimbursement rates and those fixed costs that you are facing? You know, it's a good question, but also it's a little bit of an unfair question. You know, because we're not we're not talking about, you know, the fact that we close the nursing home in our history, we're not talking about the fact that we close the maternity and OBGYN program and our history. Grace Cottage is here to serve the needs of our community and those that rely and depend on us and we're going to provide the services that we can provide as long as we can provide them while keeping our doors open. And paying our bills and recruiting good staff and paying competitive wages. And if it comes to the point where we feel as though we cannot succeed or survive because of the weight of an emergency room or because of the weight of a small acute care and swing bed program here at Grace Cottage, then we'll have to have those tough discussions about whether or not we change again. Our our our biggest revenue, you know, a generator and and I think it's our biggest revenue generator. It's our rural health clinic. Maybe not. Yes, Steve is nodding. Yes. Thank you. I'm glad I get correctly. That's our that's our major service line and something that is probably more important to our community than anything else we do. We're going to continue to do that. But to the extent that we can we can weather the challenges and provide as much care locally and close to home for our patients. That's what we're going to do because failure to do that means people that need emergency care are going to have to drive a half an hour to get it and people will die in that period of time. That's that's the reality. We have people coming from all over the state of Vermont for for post-acute rehabilitation because Grace Cottage is as good at providing that service as almost any organization we believe in the state. So, again, it's really about meeting the needs of our patients and doing it in a way that, you know, shows them we care and that we're not going anywhere. And they support us every time they send us a check. It's because they want to make sure that Grace Cottage doesn't go anywhere that Grace Cottage stays open. That's a loud message for a small hospital to generate $2 million a year in donations. It speaks loudly about what our community is asking of us and we are open by the community. Well, you know, I appreciate that passion for your community and the caring. I just worry about the numbers as I'm looking at it. So, understand, I appreciate the care and the passion and the desire to to provide for your community. All the hospitals are remote if you're worrying about the numbers. We worry about them every day. You know, just a little further, as Doug said, you know, if our emergency department wasn't here, it's not just patients would be driving a half an hour to get care. Some of them have already driven half an hour or 45 minutes to get here, and it would be an additional half an hour. It's the, it's, you know, people look and say, well, you're only 17 miles north of Brattleboro. This is true, but it takes a half an hour to get there on a good day. Trust me, I did it many times driving in an ambulance. I did that for years here. But quite off, it's the people that live north and west of us that the next closest hospital once you're north and west of us is Rutland, which is now are in 15 minutes away or Bennington or to the west, which is an hour plus away. I mean, there's it's if you look at us on a map, it's not just that we're 17 miles north of Brattleboro. We're the only thing in this huge area. We all hear you. Yes, we look at numbers every day and it's like, how, you know, how can you do this? Yeah, well, you know, the other, you know, the worry that I have to is the budget projects a, you know, negative 3.7% operating margin and near zero total margin. And I have always appreciated the devotion, frankly, of your community and supporting you through donations and all of that. And I just worry a bit about, you know, fears of recession, right, that folks are talking about and investment losses that we're seeing to the degree that your community that is so dedicated and so passionate is going to be able to continue to help you meet that bottom line. So these are the things that I'm thinking about. And I just wanted to articulate them to you as I look at, you know, your day's cash on hand falling from 123 projected at least as far as I can see down to 109 in the moment when you're when you're making this thinking about making some big capital investments in a new medical building. And so, you know, as I'm looking at these numbers and I appreciate clearly every year, the passion that you have for your community, just thinking about how that's all going to roll out given the headwinds that we face. Let me just see if I have any other questions on here. Actually, just one other ones that the delay in ED patient transfers that you mentioned due to the delivery system stress. I can appreciate that and we've heard that as well from, you know, the bottlenecks in the system we have been hearing about and I've been reading about in all the narratives and I'm hoping that we can through our long run sustainability planning efforts start to think about that. And I'm wondering though in the short run with the new bed tower going in at Dartmouth Hitchcock, you know, with construction completed apparently this fall and opening up in 2023, do you think that will help you given your proximity, closer proximity to Dartmouth Hitchcock than some other hospitals in the state? Will that relieve some of the stress that you're facing in terms of the delay in patient transfers? I think it will. I think it will also also help raise cottage as it relates to referral for swing bed patients and helping Dartmouth, you know, keep the lower QT folks moving through. You know, we're here with open arms and we have a very close working relationship with Dartmouth Hitchcock and they know that we're able to accommodate a fair number of their post acute patients who are tying up beds. So I think it will help us more than hurt us. Okay, great. I'm going to pass it over to our staff. If there are any staff questions, Sarah Lindberg, pass it off to you. Good morning, Sarah Lindberg, head of the hospital finance team here with the Green Mountain Care Board. I just had one question this morning and that is the final rule for the inpatient perspective payment system ended up being a little bit higher than the proposed rule. It was effectively going to be kind of a cut, but now it's a modest increase. I also know that Grace Cottage tends to have not average service mix compared to a typical Medicare primary hospital. So I was just wondering in your estimation, if that would change materially the revenue you were projecting for 23 in your budget. No, because we are not a PPS hospital. It doesn't affect the critical access hospital reimbursements. Yep. The cost will eventually hit the cost reporting. I know down the line, but yeah, so just wanted on the record. Thank you very much. That's it for staff. Okay, great. Circling back. Are there any board members that have any follow up questions? All right. Why don't I, I'm just trying to see we're actually ahead of schedule. Why don't I just allow folks will take a brief if there's no objections just a 10 minute recess before I kick it over to the HCA so that folks can grab a drink stretch and possibly if needed. And so we'll come back at 1020. And then we'll hear from the HCA and thank you, Grace, if you can just hang on. We're almost there. Wonderful. Take it away, Sam. Awesome. Good morning, everyone. Sam Pysh, Health Policy Analyst with the Health Care Advocate or the HCA. Just a couple questions from our office this morning. Want to start off by highlighting Grace Coddard's the work that you've done, your real leader in updating your PFA bill or updating to come to compliance with the PFA bill that was passed in the legislature, changing your eligibility guidelines, changing the different ways that you reach out to people through phone calls to get people on PFA. If they could be eligible. So want to appreciate and commend you for that work. And also recognize and a member of WALL has pointed this out too, but also from our office recognize the work you've done with the Human Rights Commission in the health equity focus requirements you've implemented, like your real leader in that area as well. Our first question on page 10 of your narrative you talked about not participating in the ACO model because of the lack of potential financial benefit. I'm wondering if you could elaborate on how this decision was reached and what if anything could be done to incentivize your participation in any of the programs. I'll leave that for Doug. You know, in order for us to consider joining the ACO and taking on the risk and expense involved in meeting the participation requirements, there's a lot of work involved in being a participant in the ACO takes a lot of staff time. We're a very small organization and we don't have a great depth in terms of financial analysts and staff members to do that kind of work. So we've looked at what the requirements would be in order to meet the participation objectives and looked at what the cost would be for us to participate in that endeavor. And otherwise, and we just it just doesn't make a physical sense for us to do that, given the fact that we're not a full service hospital we don't have the, the ability to impact your health care costs across the state as the larger full service hospitals do. It just doesn't, you know, for a variety of reasons doesn't make a whole lot of sense for us to jump in now also given the fact that there's such uncertainty about, you know, what the future, you know, payer reimbursement models might look like and you know, the direction that Vermont might go in in terms of looking at other opportunities and other models, whether it be global budgets or what have you, there's still just a lot of uncertainty out there. We want to participate, obviously, we care greatly about lowering costs for care in the state of Vermont and we want to participate every opportunity we can to to contribute to that endeavor and plan to stand by our colleagues and do that when the right opportunity presents. We just don't believe that jumping into the ACO at this late hour given the uncertainties that certainly are ahead of us in the next year or two. Make a whole lot of sense to us. We continue to maintain our conversations with the leaders at the ACO we have a good relationship with them. You know, we're collaborative and we've explained our thinking and they certainly understand where we're coming from. There's no hard feelings. We just we just want to make sure that we make good sound fiscal decisions and make sure that we're positioned to help lower costs for care in the state of Vermont every opportunity we can. Thank you. Appreciate it. And just following up a bit on the CARES Act and Medicare advanced monies that you returned. I heard in your narrative and when you're testifying today a lot of the increased costs do seem to be pandemic related. So I'm wondering what went into the decision to return those monies and why they couldn't have been used to offset some of those costs or if it was a matter of integrity and the specific intention of the funds misaligning with the strings attached from the federal monies. It was the fact that the money that we had received had to be used by a certain period of time by June 30 of last fiscal year. So we did indeed that's what we use the money for was revenue shortfalls during the beginning through the June 30 of last year as well as some capital projects and expense increases. But if we couldn't get expenses for this fiscal year, for instance, wouldn't have been eligible under those months. Okay. Thank you for all my questions. Okay, great. I think at this point then we will open it up for any public comment. If anybody has any comments I'd like to make if you could use the raise your hand function on teams. I will see you. Or if you are on the phone and you'd like to ask make a comment, you can see you can speak now. Okay, I am not seeing any hands raised or hearing any questions from the public. Okay. Well, thank you to all the grace cottage team I know how much work goes into preparing these budgets and for frankly taking care of all of your patients in your community and there's a lot of gratitude from I think all of us on the board for all the work that you're doing to make sure that care is delivered to your communities. And appreciate all the efforts you made in submitting this budget and allowing us to review the materials. Thank you Jessica we appreciate it if you have any other questions. Thank you Michelle. Okay, great. Thank you very, very much. I do appreciate it. Have a great day. You too have a great day. I think what we'll do is I'm going to keep on our schedule. We're going to have an early lunch, I suppose is what I would call this because I don't think the Springfield team is prepared to start before noon so I'm going to keep, you know, our commitment to starting on the schedule for them in case they have other commitments to be back here at noon to hear from the Springfield team. So I'm just going to put us in recess until that point and so eat lunch, take a walk, do that and we'll all be back here at noon to hear from Springfield.