 I'm going to spend the whole team to raise their right hand and a couple of square feet left. Do you swear that testimony about your gift shall be the truth? No, it's not the truth. I don't think that's the truth, so I'll be glad. And Tim, whenever you're ready, take it away. Okay, thank you. Appreciate it. Thank you for being here to present our 2019 hospital budget. My name is Timothy Ford. I'm the Chief Executive Officer. With me on my right is Scott Wilmore, the Chief Financial Officer. To my being left is Todd Marko, the Chief Quality Officer. And also, that's our information system work. And Josh, with the frame far left, is our Chief of Practice Solidarity. The system is a little bit different than most hospitals. We are technically an FQA city fairly qualified health center. That's our parent organization. The hospital is a perplexus hospital that is a subsidiary of that FQA city. We made that change back in 2009, I believe, before I came. So we went first to the state to do that model, I think since ten years ago. That's also changed to that model. And when we saw that at that time, then we were moving. That's kind of where we are today with the ACO type setup. The integration of primary care, the primacy of primary care, and the importance to producing costs, providing better care, chronic disease management, care management policy. We're talking about today's move to that model back in 2009. So we feel like finally maybe things are going to catch up to where our vision was back then. And I think that financially it catches up as well. There's a lot of times I felt like we were never going to have a cutting edge in the organization, maybe on the bleeding edge. We have nine locations in our FQA city, including two dental practices, one in Guadalupe and Chester, Vermont, and more than that in Southern Bend. We have one vision provider from Ophthalmology Practice. We serve six different communities, not just Springfield. We also have clinics in Londonderry, Chester, Bloodloaf, Rocky Lamb, and also in Charlestown, New Hampshire, which is the past year and a half we've built a new facility partially through grant funds in local donations. So it didn't cost the organization, the FQA city, a lot of knowledge out in some pocket. And it seems to make pretty significant amount of services there to that community. Our service area is primarily Windsor County. We do, of course, down in Rocky County, get into the William County area. And we also serve as the London Dairy Clinic now, portion defending to the Brooklyn County's, also with the Bloodloaf clinic that gets a little bit into London County. And we do serve parts of Southern and Chester counties in New Hampshire. So we do RIT State Organization, two different laws and local payers. We are, I guess, one of the first FQACs or only FQACs and critical access hospitals to join all three payers in the one care convention. We did that in this past year, 2018. So, you know, a lot of folks are kind of looking at how we're doing with that model. Again, we felt like we could be an early adopter because that's kind of what our system was built for, was population health at the bottom. So we felt like, you know, let's get into that program early. I think it's been to our advantage to produce it. We'll get into a little bit of detail on that. As far as hospital issues, we have familiar with the Springfield area. It's a very challenging demographic area. Difficult pyramids. Our current pyramid is about 43% Medicare, which we'd actually like to see that a little bit higher because our cost-based reimbursement for Medicare. That's a little bit low if you look at the national averages for critical access hospitals. We do get any less than our actual cost because of the sequestration a couple of years ago. That's still in force. A lot of the allowable expenses, we used to be able to claim. We didn't know what we were claiming. So that really isn't paying our full cost. But again, if one of the most closely gets to paying our full cost, certainly more so than Medicaid, which is 22% of our business. If you look at industry norms across the state, that is extremely high. We have a very significant Medicaid population in our community to serve. Blue Cross is about 15% and other commercial insurance together is about 16%. So that is a, you know, if you look at it compared to other hospitals in my professional colleagues who say that's a very difficult area to manage. We do have the same workforce issues. When I first came four years ago, you know, we really begun to see the workforce issues as far as the bond clinicians position. Really hit us hard last year. Our turnover has begun to increase. We understand that we used to be able to recruit nurses right out of school because we would send nurses and adventure to train them. Whereas other tertiary hospitals at that time would not take the new grass and wanted to experience nurses. So oftentimes we would train them up and then they might give them to Dartmouth or UDM. Now I understand that some of those hospitals because of the peak shortage are getting kind of waived that requirement, are being able to take some new grass themselves. So that has had an impact on us. Wages, we try to keep up with our process boards and we're trying to do some wage adjustments. Also we're trying to create the right kind of environment that nurses want to be a part of. But I think this workforce issue has been, particularly this past year, has been on the provider side. Particularly for in-patient medicine hospitals, local coverage. We've had some huge turnover there. And that has impacted us significantly on our financials. So with those factors, we did not realize the budget goals for 2018. And Scott will go in more detail on that. As far as risks and opportunities, I think not only in the state of Vermont so much, I think we have a direction, we have an issue in this state. But I'm looking more at the federal level, what's going to happen to the Affordable Fair Act, keeps getting chipped away at. Vermont is set up with maintaining coverage and people will have insurance coverage. That doesn't happen everywhere. Whereas the ACO going as far as federal policy, in just amounts that they've been longer supporting upside risk loan plans. So we're looking at what's going to happen on the federal level. And yet being a federally qualified health center, we're very much into what happens on the national level and it does affect us as well. I mentioned also recruiting and protection staff. We've heard a problem from every presentation the past couple of weeks. It's just difficult to recruit, particularly in primary care. I think we've lived for two years to try to find a primary care physician. Because of the past few years we've been pretty successful in finding physician assistants and nurse practitioners. But we see a number of our physicians who are beginning to age out, getting closer to retirement. And we need to kind of rebalance that ratio. So we are giving you that difficult mark of finding a primary care physician to work with our system. We do have a little bit of an advantage. There are certain physicians out there that want to work in FQAC like the mission. And those are the kinds of ones that we try to target. And we don't try to recruit ones right out of residency or big city physicians. We do try to focus on those. They have a strong sense of community service and have done some work in low income, difficult areas. We want to continue that. We also see consumer expectations changing rapidly. Mark of disruption competition. Now you can see that we're focused in on primary care. We've made a strong part of our mission to get everyone in our community tied into a primary care practice to go see their primary care practitioner on the regular basis. Now we're beginning to see that people are making appointments and having a business to do their laptop or cell phones. What happened? We see that the Alizons of the world are beginning to get into health care. That could be a very dangerous disruption to us in our mission, trying to provide a primary care home for patients and not only having some disruption with the emerging character of also these business computers that people are doing on a national level. That may be a good thing, but normal, we think it's very important that people are focused on primary care and consistently getting that continuity of service in order to prevent further deterioration of chronic disease, et cetera. Also, as a risk and also an opportunity is the one care participation which I mentioned, early educations. Very early educations the first couple of months is getting positive. Again, we've built our model of Ram population health. So we feel that's going to benefit us in the long run. We are looking at expanding the neurology practice. We currently have one provider who is through our contract with Dartmouth. She's there about four days a week. Currently she wants to come back to three days. So we're able fortunately to find a resident who's finishing up at Dartmouth at the end of December. We will join that practice and that'll be just a little over one full-time position. And really that's one of the only areas we have in the hospital practices that we do have wait times in this chair in three to four months to get an appointment. It's not urgent cases. So that is a growing area that we're trying to address the need. You may ask, is that something that can be provided through Dartmouth or referral to another facility? Well, we're 45 minutes to an hour away from any other comparable hospital services sort of in that particular specialty. And we're getting kind of growing. Telling the population generally requires more neurologic care. So we're trying to meet that need because there's a little bit of a station there where you have had some challenges with the orthopedic program. As you may recall from the previous testimony in the past years, we've been very stable with two orthopedic surgeons for a couple of years. We dropped down to one. We had one practitioner that moved back over to Dartmouth. We did recruit, from Dr. Clare Clay to get recruited in Dartmouth physician who was an editor in the trauma program. He's now been working with us almost a year and took him about six months to kind of revert the brain by the orthopedics. He's been a trauma specialist that's all he's focused on and he wanted to get back into doing traditional needs, his choice, general clinic type practice. So it took time for him to ramp up and kind of hone his expertise again in those areas. So that's another reason why we did not get our financial departments this year. We have, you know, I think we have continued an opportunity to enhance what I think is a very sound mental health substance abuse service that we provide to dialogue through our FQAC. It also has been the 10 additional inpatient psychiatric beds at the William Center in Rocky Hang. So again, looking into that slide. The access, you know, it's an issue of our wait times are minimal. We have same-day visits to our baby through our FQAC practices at Rocky Hang, Ludlow, Springfield, and Charleston. So I think, you know, for a non-emergent case, you can get in to one of our practices, except for neurology at this point. So with that, I'll turn it over to Mark and to discuss all of our quality measures. Thanks, Jim. I'll just mention, and we've already heard a lot of discussion today, I certainly agree with a lot of their comments regarding the quality measures. We consider quality measurement extremely important for our organization. We always have. We believe that if we can't measure things, we really can't have a discussion. We can't define them. By measuring them, it helps us communicate to our patients and to all of us and our providers, you know, regarding the care that we're giving, so we know what we're doing. Quality measurements not new to us. These measures have been hard not new to us. We're very pleased that we all pair model a line with our UDS measures from HRSA as well as the blueprint measures, the definitions have become the same, which is great. It comes down to the work for us to be able to understand the data. We do have concerns about the data that comes from blueprint and one care. At this point, they're giving us smaller populations. There's problems with data transfers from our hospital to the state sometimes. We're very confident, though, in the improvement efforts we're making through the UDS data, which is pretty much the same data as the all-payer models. We actually look at our entire population and so we feel that that data is actually a better and more accurate reflection of the work we do. We use the data every day. We talk about it frequently. Our amazing teams are an organization to measure, to analyze, and to focus on performance improvement. Our goal is always to educate our staff to the quality measures. We want to standardize how we provide care to our patients to be able to meet the demands of the measures. I think all of the measures we've agreed upon as clinicians, they're really important to us and really relative to our patients in terms of good outcomes. As I see in the end there, it says, you know, quality indicators guide and focus our clinical improvement efforts to our aim to provide patients the highest level of measurable, reliable, effective quality care we truly believe is certainly very supportive of the work that one care is providing right now. And I think even though the measurements may not be totally accurate at this point, certainly the tools that are being provided to be able to focus on areas in our populations that are in particular risk in terms of utilization and quality outcomes are really important to us. And our goal as we work with one care from one is to be able to apply those tools, these measurements to our entire population, not just as small volume and attributed lives. I'll turn the number to Scott to get into our financial statements. We asked for a 5% rate increase this year. If you look at the 19 numbers versus 18, you can see inpatient is basically flat. If you took out the 5% rate increase, we're actually projecting down from the budget for 18, as far as volume is concerned. Help patient, you take out the 5% for about even and I would get into some of the reasons why you think outpatients are going to pick it up a little more compared to inpatient. Bad debt is budgeted to go up and chair the care for now a little bit. In total, I think they're about the same. And again, that's the same thing that other people have mentioned. We think we may be going away starting in January and some people will drop their insurance and end up in bad debt versus chair the care. Total deductions are based on gross income, so that's not much movement there. Other income is our adult day care mostly, 1.4 million. There's some grants in there like also about their name cut. Expense-wise, we are up less than a million dollars. I get into the reconciliation of 18. I've explained what the issues were and what steps we've been taking to control the expenses. So our bottom line from operations is pretty conservative. Less than a million dollars. And even last year, it was pretty conservative but we're not going to come close to that. We're going to report the FQHC to the 2,450,000 again and then the investments are kind of at the end of the line. We're in total return approximately 1.6 million compared to estimating for this year 2.3 million. You might get a negative sign in front of that and it will be a little closer to where we're going to end up. The cash flow and balance sheet are in there. These are right from your software. I will skip over those for now but if there's questions, we can back to them. The Pyrenex index. This is our hand versus out of state. Medicaid for us. Yeah, it pays about the same for hospital stuff but for the psych unit. It pays for a couple hundred dollars a day less than the amount Medicaid does. Pretty high percentage coming from out of state. 35% to 65% in state. The others are pretty much in line with any board community in the month. The main reason, other than volume, that we're at an issue of 18, two expenses which everybody, I think, is talking about local coverage and I'll throw travels in there as well and self-insurance. We really got to meet up on self-insurance this year. We do have a plan moving forward and we're planning to join the NIA Group which is the Diagnostic Limit Alliance for Health Purchasing Group. They also do insurance for some of the hospitals participating in self-insurance plans so you can spread the risk out, especially for high cost expenses. This year we have to be ahead of the very high cost for one procedure, cost us about $600,000 which we're going to avoid if we ban this plan. Other things that we do is local coverage. We're working on hiring another, we want to hire two more hospitalists. We've got one, we think, is on the hook at the moment. And then we, I think, have the only fully-physician anesthesia group in the state where we're going to change that next little and put a couple, see a lot of names in there and reduce another NBs that are in there and that will save us approximately $10 million. For local coverage itself, there's a variance of approximately $1.4 million this year. So the reconciliation fund, we have, we guess, a revenue by 6% percentage-wide from most people is on inpatient and even though inpatient days exceeding budget, it's a mix of what type of patients they're in. They're mostly in medical, less surgical, so dollars per patient, the patient they are now, even though the days are quite aggressive with their budget. How patient, part of that is the OR. And we just had to come back and we hope to do it. Contractuals in and cherry care, all follow pretty much the decrease in revenue. Moving on to the next page, it's what tells the tale of the fight with the COVID-19 virus there. We've got employee benefits over by $1.2 million. Physician fees which includes welcome over by $1.4 million and travel over by $230,000. We had all those up, it's about $2.88 million. If we were on budget ago, it was to an athlete of old loss would be $300,000 a day and as you can see, most of the expenses are down. Some of the things we're doing is we're looking at every contract we have no matter how big or how small. And to give you a couple of examples, we looked at copies. We had copies rent a lot from lots of different places while we consolidated on to one place and we're saving annually $100,000 in copies. We also looked at pagers, telephones, systems and those aren't anywhere near as big compared to that, but $10,000 or $20,000 in last week's and that is just real money. We're just being 10% away reviewing those contracts. So we've got a lot of ways to go on and some big ones coming up that we're looking at right now. So those are a few of the areas we're addressing in the 18 now but some of them are reflected in the 19 one. So Constantine, it is our focus because that's one thing you can control to some degree. And that is going to be a continuous thing. It has been for a few years but now it's more of a systematic approach. Once we're done with all the contracts we're going to go right back into the six. Kind of like being able to meet Bridge once she's finished, she'll go back and start at the other end and we'll set our approaches to these contracts. So we're trying to get away from any evergreen contracts that we do automatically and sometimes you miss the date to terminate and you're stuck with it for the next year. We're just going to have one call and Emily, you at least are aware if you want to be able or don't want to be able to contract and that will make us sort of more efficient than we have been in the past. So our discussion about our community health initiatives from the community needs assessment is really where you can start to dig and understand the population to better make sure that you're aligned and better to serve the community. For roster top three, not surprising, substance abuse and mental health ranked out as number one. It's not really a shock to our community. It's not a shock to reply to our America, obviously. So the thing that we're going to place to help with that is really working with members of the community. We have a lot of community partners and working through the community health team as well as the community collaborative and making sure that we're not overlapping the same services and making sure the experts have done their job and we're not reinventing different services. So the thing too, it allows us to do is make sure that we fill in the gaps that many other areas don't have and, for example, we got to be putting pediatrician at HCRX which is our role as a community agency. That's just one day a week. That's an area that they don't currently have resource. So when they're seeing some of the kids there mental health issues, they're also going to see competitive issues and that's something that we're working forward to right now. Substance abuse work, we're doing MAT. We do a pretty big amount of MAT. Those calls to the mod and that's in the group setting. We find the group setting works pretty well. We also have individual MAT services that are online by clinicians that tend to take care of their own panels. That works pretty well too. We've moved into vitro. Initially, primary care didn't really want to do vitro. There's an interesting cultural piece about primary care and also having psychiatric and union providers within our system. So being able to work together, you also get a nice educational system by people that primarily work with psychiatric diagnoses. They can co-operate in education and as you know, we know the recruiting issues across the state and the country are difficult. So being able to have our own psychiatric team be able to co-manage patients really helps with efficiencies and helps keep costs down and have patients have better outcomes much quicker. So vitro is something that we're doing in summer clinics. Needle exchange too. We're doing that. That feels pretty good and I was actually not sure I wanted to do that in the beginning and there was some thoughts about it and there was a lot of hypertension about it too. Surprisingly, however, starting that system up we have had continuous patients coming in and receiving needles. The nice part is that there's counseling that goes along with it and we have had some folks come in for needles and say, oh, I think it's time I stopped this and getting them into MAT treatment which is really the legal part. Our MAT group too is not looking to have something addicted to human organ response and for the rest of the life. Also working towards the radion. It's not easy but it's something that we are looking for and hope for for a more outcome if they are going to be on this maximum as it went for us. We've also stepped into the world of ECT so electro-embolson therapy within our hospital system. That's something that we've had at UBM and as well as free chat to us and say you know we could do some help with what we need. We specifically did that and we had some training from UBM to use our psychiatrists. We're going to be operating that service within our system now. Something that can be very effective for ongoing mental health needs especially depression. So that's something that's where we're moving into. You know we have struggled with this within our primary care group and part of the reason is you have 10 minutes to set some goals and pull people accountable in the coming. That's tough and I don't know anybody that's made life change over 10 minutes. That's a difficult piece. So what we did is we thought outside of the box and we have hired a lifestyle certified physician for lifestyle medicine. Scott Durga who was a our physician for us years ago and came back with a certification. Relatively new so if you haven't heard about it it's not surprising because I've got a program that's been going on for a bit. Scott himself is definitely taking this time with patients and that's something you don't necessarily see in primary care because of the fever service models that can exist for a long time. Getting away from that is a sight we're still not totally away from that. Scott spent some really good time with patients and died in a weapon level part of those folks at how can we exercise and eat better and how can we minimize any kind of pharmaceuticals that you might be on with any adverse type of reaction. So we know a lot of those side effects that you come along can cause other medication or medical issues so we try to stay away from that as much as we can. I also look at it's kind of the capstone piece of blueprints that I'm working on. So the nutrition piece, this is a physician that is able to really guide that program and get people in and make huge changes in life. We have seen that. We have had some great observations and it is really, really important to know how that happens. So lowering the cost by getting them off their medications also focusing currently on and getting them involved. That's the nice piece and I'm breaking it further along working with schools so we just set up four FQHC sites in our schools and that piece is really very nice to you by World Health Ministry actually moving forward into the school system so having a high jazz within the public schools and now we're having a nutrition within the schools too. So that idea is to really become as proactive as we can with delivering care the way we know the dog through the tail. So that's what we want to get away from that. We want to make sure that we are starting young. We talked about ACEs we talked about ACEs already today making sure that you're having an eye on children. TGTB will have a cook. It sounds pretty basic. It's pretty valuable. TGTB will have a shop and showing you where they can shop and be more healthy at reasonable costs and make quite a choice so that you're really starting to pull away and you're working with water patients that are focusing on the cold and making sure that we do everything we can and keep themselves healthy for as long as we can. So I'm going with the CHNA we have it and having and I talked about this a little bit but the CCB or community collaborative meetings and all the lab and cloud services this is something that we've worked on with the cancer patient I think would be one of the biggest positive outcomes from this as well as also working with B&H and other community partners that have dental appointments is higher for patients to get to medical appointments and being able to help with transportation we've got a couple brands actually that came through from HRSA and we've gotten some other LTE but local companies that say can move patients back and forth and they can reverse sometimes has been really helpful and it allows us to make an impact with those patients in the exam room and it's much better than an impact with a phone call. Second. Most of our reform efforts as I mentioned are embedded in our daily FQAC operations on primary care practices we, as I mentioned fully participated in one care from the law and Medicare and Medicaid and Blue Cross we've had since before 2009 certainly in 2009 we became an integrated system we've used care coordination and essential tool to reduce costs and provide better outcomes we have a very active community health team just 40 to 50 different agencies represented in our local community that meet on a regular basis and we work together very well we have working on trying to reduce our emergency department visits that's very intense we've seen some reduction in the past few years made with the addition of walk through the availability of improved access to primary care but also I think having people embedded in our emergency department that can address issues right away with folks where they need mental health behavioral health issues or they need to get the timing of the primary care provider that's such a big piece of what we do there's development people accessing the system and on an episodic basis we have about 30 2,000 individuals in our community which we have in our primary care practices after those challenges in our population so we have a very strong market presence and we think we're doing a good job of getting everybody tied into the primary care provider in the community to be served and now it's given to our capital budget employees so our capital budget it sounds very similar where you just heard it's a pretty small budget 1.14 million nothing exceeds what comes close to half million and there's no ceiling projects I have listed some of the larger items in past history since I've been here 20 years we've never bought anything that's on the capital budget and we haven't bought some things that weren't on the capital budget some from the ranks and places and just horse training nothing here is too exciting there's some power sets for the OIR it's one of the biggest things 145,000 that's drills and things that you want to be certainly used on the X-ray it's under 60,000 and even in a good way the largest I've ever seen on a capital budget so about 2 million but you have to live with your capital issues so nothing controversial nothing exciting pretty boring west and it's all routine replaced by nothing new so the long range financial outlook the poor pair of myths on the hospital side we anticipate overall basically inflation rate I don't think what's bad for the hospital is kind of better news for the FQAC because Medicare and Medicaid actually pay pretty well the FQAC pay better than who crosses the commercials cost containment is a big issue because we have pretty good amount of control over that fully participating in one year in a month this will be our second year coming up and I think we're going to go down about one year in a few minutes I did put a couple of graphs in here on the on the budget or compliance kind of laugh now I'm back at 15% we came in a little over and we got beat up for it I think I can take that nowadays so bouncing around a lot of this is dependent on the cost of work settlements when they took away the the light attacks came out as an expense I took about two and a half million dollars off the table for a lot of expense and that's really affected our reimbursement from Medicare since that ruling came out several years ago our actual results from operations kind of follows the the income to more exaggerated degree if we're making all the loss that you see in both 14 and 17 I mean the absolute bottom line of loss from operations in 17 is really well in 17 there was a negative effect on the defined effort play that really impacted us to all the line in multiple years I did want to talk a little bit about the ACO because I think we just need to state a question about what we improved for what we're going to improve for what we're going to improve for anything in any direction and the reason being we were back in June and at that point we were in a slight loss situation on the fixed payment side things but we were in a game situation when you look at the lowest spend for your community lives because if you're under you share the savings with the different payers even though it was June 1 through February so they said don't take anything through May it looks like you guys are going to do okay if I don't look at anything and we talked to our auditors and said if you look like you lost and we conservatively improved something if it looks like a game we conservatively improved anything and because they're so far behind even at year end in September they may be through May and that's only five months because they have a calendar here so we've worked with our auditors and they all agreed to be conservative and so that's why we haven't improved anything we definitely haven't improved on the upside because they expected to screen flash even though we've gotten through flu season which is what you think a lot of your expenses will be incurred because it's time of the year we'll be getting the flu season began and then we're going to send it we've got the other side of it so right now we think we're in a positive situation but is it enough to think of the bank we're not looking at anything and we don't think we're going to get in the main situation so we need to crew any reserves that puts our presentation to the committee pretty much thank you Jim so could you speak a little bit to I know this is not a huge driver in your budget given your percentage of Medicare and Medicaid but could you speak a little bit to the your commercial contracts and how much your percentage of fee schedule versus percentage of charges and where the range is for you just to give us a sense of that similar to what the amount of spending said we had a lot of fee schedules for almost all the imaging and to the lab I'll talk about Blue Cross because they're everybody's familiar with Blue Cross their discount is about 15% so we'll collect around 15% from them the issue we have being a border hospital is some New Hampshire insurance companies don't like to pay under law in a hospital and sometimes you find that out before you're treating them and sometimes you find out when you submit the bill that's an issue because I know you're getting zero and some people come a long way to our hospital and they're too often you wouldn't sign up with them or they won't let you sign up with them actually that issue with our vision plan they wanted to draw up everybody in the month but we constantly let them allow our vision ophthalmologists to be in their plan but that was a 5 month or 5 months so that's a little bit of an issue especially now that we're getting more and more into New Hampshire that new FQAC site is attracting more people from New Hampshire and more labs or x-rays generally they come to us and not go up their own valley so anyway short answer 85% from Blue Cross a little less from everybody else thank you I haven't paid for this thank you it was close I've been told that you came here so thank you for your presentation I when this budget project is over I will call you and we'll come down and visit your facility and spend an afternoon or a day there getting to know you better I have just two or three questions I noticed in terms of your expectation your written application of request a rate increase that you, unlike most other unlike most other hospitals expect some additional revenue from the rate itself in Medicaid and I'm just wondering what you're thinking was behind that I sense that most hospitals don't expect the fact that they have a don't expect I missed a word here sorry most hospitals don't expect the fact most hospitals don't expect the revenue increase associated with the rate increase we've met with my cost a few times and he is very interested in us keeping our childbirth center open if you are down in our area the state now stuff he doesn't deliver grace doesn't deliver and valley doesn't deliver and one that doesn't deliver and the PD doesn't deliver so he and we and him are working on a plan to keep some babies from going to the NICU endocrine floor getting them back sooner because he says every baby that goes there costs 100,000 dollars for Medicaid and so he's giving us some extra Medicaid money from the childbirth center to make some things happen we have worked out all the details and that's what we're having and so you booked that for revenue of 174,000 on the associated with the rate increase I didn't know where else to put it within the rate increase because it's not a volume thing to say it's trying to avoid sending people somewhere I'm bad debt I think you're probably going against the trend looking at 2019 over 2018 projected which is the more recent number you're expecting your bad debt to go down in 2019 and with other hospitals the concern is about the individual mandate I'm just wondering what you're thinking was behind that sorry sorry a budget nice showing going up 500,000 on that budget so I'm looking at a 2018 projected we have a bad debt at 5 million, 10,000 dollars and for a 2019 budget we have a 4 million 624,000 well I think our thinking was the bad debt for this year the beginning of the year it's always a high number because everybody's working through there through their deductibles of 5,000 or whatever it is and towards the end of the year it's also likely that the projected will be higher than you should for the major standard lives instead of factoring in that people have through their deductibles to have their insurance taken out I can probably answer this question but I just I'll ask it anyhow the question is do you use a collecting agency to collect a bad debt but the question is do you when a a debt is not collectible do you send that information to a federated agency and I know that I'm quoting you in a presentation you said we select the softest approach offered so I guess is that you don't well actually we do our softest approach is a couple of letters from a phone call not like a credit card company that normally lets you go and we do reverse it because people could call us and say I may pay the plan or I'll pay we'll give them a discount for cash and we remove it from that credit report so that it's more of a house or car or whatever that's usually what gets them to come to the table and finally how would you characterize your relationship with the remind insurance companies in terms of the negotiation I think you know in the past before I came to a hospital and I've heard that for several years that Springfield Hospital did not raise rates in the back of the days I think before the green amount of credit report was active in controlling rates so that kind of set us behind the charges in a lot of areas I think it's been 30 years so we could probably speak to that in a setting way behind the site in the 2020 we went six years about the rate increase and you used to come having a factor on that and even if we got 1% we'd probably be in a lot different position in where we are now we thought we were doing the right thing and I remember the 7th year we asked for a 6% rate increase for that we asked for zero but the price 6 years in June I ended up but you know that's you know while I run the bridge but I wouldn't do it again but it's an amazing question that you anticipated I really just want to talk a little bit about your financing model because it's not really sustainable with the losses you've had in 2017 and the new losses you're projecting now in 2018 which you're already in for about $2 million and when we went through the actuals you know we looked at rebasing some of the budgets and you know we rebased higher but the concern on some of the ones that are lower is and you guys really resisted being rebased but you're coming in to date 7% below now in 2018 you're only asking for 1% increase year over year on your budget but on your actuals it's going to be up more like 7% and I'm just concerned that we're going to be in the same place last year I challenged your estimates that you were going to be for the top line and you didn't hit them and I'm just concerned that the same thing is going to happen that you have some optimism still within your top line estimates that you have now for 19 and if you don't hit them you're not able to react quickly enough on your expenses and your loss continues to be a big loss so it's really more just a concern for what your financials look like and how they're now attracting an 18 and the potential that 19 could go the same way if you still have optimism in that top number and understand you're replacing some people and you think you're going to get that top line that's what we heard last year too so it's just a tough one it's like how can we help you because it's not sustainable to continue at losing 2 to 4 million dollars a year and you just don't have that much on the margins so I certainly agree with that and to you we can't sustain these kinds of losses continually as I mentioned before we have a 30% below budget on our competing cases and that was due as I mentioned we finally got our second board competing surgeon the demand is there it's just they started to lose some of our obstacles or they were choosing not to have left of procedures maybe 32 insurance deductibles and so on and I think in our testimony from other hospitals particularly critical access hospitals that one or two provide a huge difference on your weapon certainly in our case so if you have where we reject the need for two important competing surgeons that are very strong important competing program as the population ages there's more need for competing services and also being part of the ACO population panel who's thus in the ACO to have those services provided globally and more cost institution rather than people giving cover so the next closest to single which because of the tertiary hospital cost structure so I think we're serving the optimistic we're serving out and leaving this pie in the sky we're going to get back to where we were before so I think our budget shows some increase but it's not the moment over the optimistic similarly with the urology we're seeing an unmet need there that is our one area that people are even waiting a long time or if they're waiting a long time they may be going to a doctor and yet they have a higher cost which is going to cost us through the ACO so we're trying to meet those needs in specialty areas and I think the budget shows that it is cautiously optimistic and that we can sustain these types of losses continually and if this continues to look at those programs we need to find a way to support one and a half share with other organizations so one very fragile program as Scott mentioned is the obstetrics program we're kind of tracking the smaller rural critical access hospitals in making strong effort to try and maintain and actually grow and improve that service recently I think it was announced that we were one of the first places that we wanted to have a station where others would come and express mail if we could store it and share so we're putting a lot of effort into retirement child health I think that as I mentioned I think I mentioned yes we have some problems with other nearly half 40% of our others that deliver on our organization have a condition and we are working hard to reduce those numbers and I hate to think from a population health standpoint if we had to get out of that service because of the high cost and low reimbursement and what a testament that we have the ACO of the population but the people themselves and the community so hopefully we won't have to get into those hard decisions of what programs to be cut or live back as many hospitals perhaps have so again I think to be interested in your questions certainly these are you think are reasonable and we'll have to look at other areas for the matter of cuts but there's also the cost report effect like other people said if you're in the ACO normally by now I have a pretty good idea of where I'm going to be on the cost report I have no idea because of the P.S. scenarios I told a mess I can't even estimate it but back in 21 or 2 million dollars one way or the other I have struck some paths and with revenue you can volume me down with expenses being up I could expect some kind of pick up there but I couldn't give you a legitimate estimate of what that's going to be thanks so I was actually to be back on some of the Maureen's concerns without going into detail but I am a little worried about your optimism in the top line whether your expenses are aligned with that optimism or whether it's in some ways fictitious and VR hopes to some degree fictitious really high expenses and not sustainable and the rate asked last year was 6.5% and the rate asked this year is 5% I appreciate that there was no rate asked for a while but these again are not sustainable rate requests did you want to jump in? yeah just to mention going back to our payor mix a rate increase 1% of us is fast to different what events are going on in London rather than before you begin because we have such a high percentage of educated so you know I think Scott has developed a 1% rate increase extra events to the bottom line which is very helpful I do appreciate that the other so I struggle a little bit particularly in smaller rural areas with this tension between increasing access which I think is admirable particularly with primary care incredibly admirable when it starts to get specialty care practices I think there's a tension or a trade-off between everybody would love to have every specialty service in their back yard so they don't have to go very far to receive that care the trade-off to me as I think about it is you know what is the quality of that care that's going to be delivered to the extent that there are other enough knee replacements and hip replacements in that area so that the providers have the experience to be provided the highest quality care with enough procedures and similarly we're seeing as an example from the media supply costs are very high and small rural hospitals not benefiting from both purchasing of supplies now I'm hopeful that this media is purchasing arrangements that are helping them trade-off and I'm wondering as you're thinking about adding specialty practices or expanding specialty lines and service lines given you know some of the financial difficulties there's a hospital we have faced how do you make that trade-off? yeah that's a challenge you're right oftentimes what a small hospital needs the volume may be there for 1.5 but try to find a 0.5 in the future it's hard to do we certainly think that the need has been proved in the past to be there with the population numbers it should generate the next number of procedures yeah my personal philosophy has been throughout my entire career and I'm just a sprinkler but we can't do a high quality job at a service to provide, we need to find a better way to get that service somewhere else to provide our sales but you know playing field we don't look at extending to new service lines in particular particularly to specialty areas for example this past year we were able to negotiate with the Chester Hospital with the failure you know I felt like our cardiology services were locally inadequate we got one cardiologist from the company and we were able to have this cardiologist come from a team once a week didn't cost the hospital anything that they they didn't charge us for themselves and they didn't submit increase in ancillary business for diagnostics but the bottom line is people got to care they were the same cardiologist and potentially they would have had more problems down the road who would have required more expensive MSI so that's an example of a program that's working to win for them, to win for us and to win for the community so we're looking at creative ways to provide some new services and then you're up to what's that sweet spot that can be provided by quality and low cost for example follow-up from our community had some new development because from the back down on the work meeting program hope they understand that the cost would be much higher because if the cost structure and cost was could be much higher than our facility so yes it's a challenge but we're in a high B community we are getting an hour to an hour and a half away from another hospital so we're taking those and we're getting to feel that and we can see others around us starting to eliminate the program and services and I think the pressure has gone for us to find creative financial feasible ways to continue to provide services for our community you mentioned your statistic about maternal percentage of your loved ones that are doing right to the different babies our people most 40-50% I have to tell you of all the hospital budget periods from last year they all mush together that is the one statistic that I thought about and this kept me up at night literally this year I think about what are we doing and are we doing enough than we've done in the past year specifically with that specific statistic are you seeing any inroads in reducing the percentage of mothers getting rough? we have seen somewhat of a reduction I think of those that we bring in getting the statistics I don't have right in front of me but I think roughly a third of those mothers that are having an issue once confronted they do make an effort to try to get off during the pregnancy at least we try to get them into programs and I can go back and get some specific information for them what was last year it was I think it shows a number but I don't want to see but we have a list of questions because it did stay with me stay with us so strongly we are trying to improve our internal child health program to maintain the statutes of that community because it's a very easy target as you've seen around for hospitals to just cover because of the high expense in the rebuff my guess would be that numbers are so troubling and so high that granting agencies would be willing to grant innovative ways to reduce that looking of course to Scott I shouldn't try to work with my customers to reduce I think we have the capability and the capacity without any cost to perhaps get those babies that are born prematurely after a couple of days of a week or two they can come back to Arkansas and we can continue to allow them to feed and grow until there are people being discharged and yet in a lower cost structure they aren't close enough because it not only saves costs for the health care system but also for those individual families who have to make that day return to the dorm for a hundred miles for health care but I think we're close enough I just wanted to add a little bit to that there is a lot of hope and so I can appreciate you not speaking about that statistic we didn't either because we had to specify last year the places in the clinical social worker and the women's health center which is our application of statistics and they work very closely with the nurse practitioners and psychiatrists around the nation who also do a majority of the outpatient care for the FDFC they actually round the unit too and so they're in direct communication with the social worker to take the place in the outpatient visits if we need to have some sort of intervention even if we need to so there's actively work that's gone on and some of that is going to come into the state of Vermont so there is a huge amount of resources going into that and it's our hope that when we come next year we have even less of that the last question is about the general hospitals but I see it released and asking about whether you have thoughts about contributing those lives with your carrier to treat those lives in one care and it sounds like you're moving to joining me and may change some of that dynamic for you and I'm wondering does that include you from contributing your employees' lives to one care? We kind of our plan is designed for services to be done for those in COVID-19 etc the issue with it is only people that see a physician can be attributed and we're very happy with the good levels so if I was going to concentrate on this anywhere I'd be in and it's meant to be here until around the good levels and until they won't see why they're not if they get a triple or a number of attributed lives so until that there's not going to be much of moving our people over because we're not able to see physicians because we don't have any it's just a matter of minutes Thank you Can you share with us your experiences as being at full risk with an ACL over the past year what is pleased to you what is displeased to you? Well I like to be the most in pain if they're in front of you a month they can count on that show now which is a big improvement with some of our other bears the quality stuff that Bob answered but it's been pretty painless after the there were some kick ups to be getting Medicare was not prepared to go with that so there was no payments until February Medicaid has been on the ball the whole time Blue Cross was really painless after the service I don't know why they're going to switch over for the F3C it really helped out it was a pick up of about a half million dollars due to some tremendous pain on the F3C side of things so that was a nice pick up I get one great with Tom Tom I guess Bob can play in on the quality stuff that was actually a little bit too early on the quality measures but I expect you're going to do well with these quality measures and they will continue to help our favorite model you'll confident you'll do well because we've got so much experience in our actually really our model of care at the hospital and the Health Center working together really supports doing well I expect you'll do well if your colleagues at Nippert for example with Salmon Center came to do it we're considering one here what would you say we did attend their last board meeting Scott and I spent about an hour discussing after a topic we were first on the agenda I think we were very straight and said you know it's not something that you're from a business perspective you're not going to see a definitive business plan this is what you're going to get at the end of the experience and benefit some of it is just a good thing you've got the infrastructure in place you're ready to do this you know for a hospital is a great and a fee-for-service side of operation if you're not ready you can definitely say not but then the similar to us being an FQAC in a hospital I think the benefits of the financial right out of the gate that you get the group cash flow and the payments per month payments being FQAC providing primary care I think it's overall beneficial the early results are encouraging so I was didn't give a recommendation yes, I was going to know you should but pretty much lay out the tax personally I'm on the board on the executive committee and I can say they have listened to my concerns I feel I'm a representative of critical access hospitals and the FQAC providing primary care and I think they've listened and responded very well do you have any questions just a couple just two questions thank you for your presentation for working with our staff I noticed in your narrative that your average daily census for the window centers about 6.8 just under 7 beds there yet there are also some significant times in your ED for mental health patients and I'm wondering if that's related to are you getting a lot of level 1 patients in your ED or is there some other factor there that is part of the issue because level 1 is another part is you get some people with more than one issue we have a lot of dementia patients that need a long term solution not our succument and once a while we have somebody who comes in and they need a guardian and there's no family to work around so we have to especially if they're from New Hampshire it takes a lot longer to become the guardian so you can place them somewhere for a lot it takes a little bit quicker and the succument in the last 3 or 4 months has picked it up substantially it is running around 9 pretty consistently now thank you and then the only other question was I noticed that for your private pay segment that's where your highest out of state patients are and wondering what are the drivers of that does that increase your uncompensate care in any way just wondering what happens there well it is 35% but it's 35% of 4% so it's a pretty small number I think it is because the new FQHC site that was built over in Charlestown was attracting more people and the FQHC so we'll get fantastic trades so I think that's what's drawing some more New Hampshire people than you had in the past so you've seen that increase last year or the year before yes so this point I'm turning the question over to Julie Shaw from the health care advocates office thank you I just have one question I'm wondering if you consider the commercial rate of providing the board in your budget order do you see a set rate or a starting point from negotiations with commercial chairs well the bills will go out with that 5% increase Blue Cross last year did not come back to us and ask for a bigger discount this year they did and I agreed to it because the average last year in this year wasn't much for change at all I haven't heard much from anybody else and then they start negotiating and now I'm going to negotiate because Blue Cross is enjoying the business in our area I'd like to say the New Hampshire ones we're lucky if they even allow us to bill so this year and from Blue Cross last year it was a little bit of a discount and the others would certainly determine thank you this point we'll open it up to the public any public comment on the Springfield budget I'm not seeing anyone come forward so Tim we thank you very much thank you very much we're going to take a brief