 Okay, great. So, Joanne, are you with us? Yes, I'm here. Thank you. Great. So I'm going to call upon Steve Gordon to introduce the members of his team, and then I'll ask Joanne to swear you all in for the testimony. So, Steve? Well, it's a pleasure to see you all or at least see Kevin right now. Thank you for the opportunity to share with you our presentation today. I'm going to make it some introductions, and I would ask you all to just raise your hand and wave to Kevin and the group. So first is our CFO, Andre Bissonnette, who's in the chief seats behind. Chief Operating Officer is Ali Pederser, Ali, Chief Medical Officer, Kamal Graw, Chief Nursing Officer, Cody Stack, and Medical Group Medical Director, Dr. Sheehan. That's our group. Great. Joanne, if you could swear them in. Would you all raise your right hands, please? Just for the testimony you're about to give, will be the truth, the whole truth, and nothing but the truth. So, I hope you got it. I do. Super. And if I could just ask everyone who is not speaking to place themselves on mute, so that we can clearly hear everything that the team from Browderboro has to say. So, Steve, take it away. Okay. Can you all see the presentation on your screens? Yes, we can. Great. So the first component of the presentation is really where we're at and what we're projecting for the rest of the year. I will tell you it was a very, very difficult first five months for the hospital, where we encountered about a $2.4 million loss. We were very, very concerned. Volumes were down. They had not come back from what we thought we would see as a rebound from the pandemic to this fiscal year. So, thankfully, with a lot of hard work by the folks in this room and our medical staff and all the employees here at the hospital, we got back into the black with gains in our third quarter, which you see here is $400,000. And we're projecting fourth quarter to be another positive about $200,000. But we are, however, projecting a loss of about $1.8 million for fiscal year 21. We based our budget for FY 2022, basically on our fiscal year 19 levels, which you see in the last bullet. But obviously, as we came out of the pandemic and the first wave, this hospital provided a huge resource to our community for both vaccinations as well as testing over 20,000 COVID vaccines were given during this time period and over 15,000 vaccines. We're seeing a very substantial, I'm sorry, tests. We're seeing a very substantial increase now in our testing. And we'll say that we work with AHS in developing the model contracts for both the CIC Bro testing as well as the vaccination program and work with Todd Dulles, who's the attorney for AHS. Patients felt very welcome to come back to the hospital. And I think that really helped us regain our our our vibes back in March. So next slide, please, Haley. So this gives you a little graph of what was happening since October. We were all, as I said, including the board, very concerned about what happened in those first five months. You know, if you projected out based upon the first five months, what we're looking at, that would be an over an $8 million loss. You know, going back to 2020, if we hadn't gotten about $11 million worth of federal monies, both as to COVID as well as as being a safety net hospital, we would have posted an $11 million loss. So the party was kind of continuing for those first five months. But thankfully, with a lot of hard work and our vaccinations in our community, we started to see a major uptick in our in our volumes, which meant more revenue for the hospital and more care for the patients starting in March. Next slide, Haley. So one of the things I share with you and there's a lot of detail behind these numbers, a lot of it is confidential, but share with you. We really focused in December timeline as getting back to budget plan, which we had a really a major impact on getting us back on track to the tune of about $4 million, both savings as well as revenue enhancement. And, you know, in general, it was everything from the medical offices in each physician and associate providers seeing 16 patients a day as a goal to your senior leadership team here, taking a 10 percent reduction in our salaries. Contracts were renewed with major renegotiated major providers. And a significant number of positions were put on hold basically because of our lower volumes that we saw in the first five months. So that was a major focus for this group and our board early on and really the November, December, January timeline. Next slide. So I'm going to ask Jody to spend a little bit of time on talking about contract labor spend, because as you might recall, our last presentation, our biggest budget buster, like most hospitals, was the cost of contract labor. And Jody's done a phenomenal job in reducing that, as you can see by this chart. But we're starting to see an uptick in our contract labor. But I'll let Jody take it from here. So this shows fiscal year 2017 through what we are projecting for fiscal year 2021. So you can see a steady decrease, almost $1.8 million in fiscal year 2017. The light blue at the bottom is for nursing contract temps and the dark blue is for non-nursing. So that would be lab tests, MRI tests, physical therapy, things like that. It's important to note, I think the $242,000 that we spent in fiscal year 2021 is largely in the last quarter. So from July of 2020 to July of 2021, we didn't have any nursing contract temps. We did bring some in over the summer, mostly to ensure that our staff was able to step away and take their vacations. But when we are seeing an uptick into the fall, the contract agencies that we work with are seeing more open positions and increased bill rates. So we are seeing a trend back up and we'll be focusing on that. You want to talk about nurses? Yeah, this is really reflective of many different initiatives, both on the recruitment and the retention side. So for recruitment, this is our third year of doing an RN nurse residency program. So that's where we bring a cohort in in July. It's above and beyond our current staffing model. They take about three to six months and they'll work in our progressive care unit. So it's very focused education, even more important in the past two years as they're not getting all of the clinical experiences that they normally do. So we give them a lot of classroom work, a lot of clinical work. They work with preceptors, our clinical nurse educator and departmental leadership. We learn something new every year and I'm really hopeful with this group coming in. But other retention efforts and recruitment efforts, we read and job descriptions. We do some social media recruitment retention. We're really focused on education, professional development, communication, and we'll be continuing all of those. But I think we need to think even more creatively and and listen to the nurses and our technical staff on what they're really looking for. Thanks, Jody. I'm going to ask Ailee to cover the next group of slides in terms of access to care and COVID impact. Thank you. So starting in March, we really started to see patients resume care within our ambulatory practices in a bit way. And certainly that coincided with the onset of mass COVID vaccinations. Patients felt safe to return to in-person care. The main drivers for that return of inpatient care included primary care, cardiology and orthopedics. And that really correspond with the top diagnoses that we see for patients during this timeframe. Number three is diabetes. Number two is cardiovascular disease. And the number one diagnosis that we've seen over the last several months is depression and anxiety. And so these are important things to cover in our primary care practices. On the orthopedic side, we saw patients returning to surgeries for hip and knee problems that they had long put off. You'll also see here the rise and new patient visit volume. We believe that with the onset of COVID, patients found that having a primary care provider was never more important than it is now. It's really essential to establish a medical home. And so patients who have not had a primary care provider in the past reached out and we help them get connected to primary care. While the level of new patients has sort of plateaued in the recent months, we still see on a weekly basis that we are scheduling 40 new patient visits per week. Well, what a difference a year makes when we were here last year, we were sharing with you that over 75 percent of our visits were being conducted using telemedicine prior to fiscal year 20 in our outpatient practices. We were not familiar with telemedicine. It was a new platform, but certainly the COVID brought on the rise of the necessity of patients having access to telemedicine during FY 20 for many instances. It was our only option for providing care. Today, we're right around 18 percent of our visits being delivered through telemedicine. And there are many benefits to the use of telemedicine. It certainly allowed us for a creative response at a time when we had no other options to deliver care to patients. And we've really seen that it's been an effective strategy at delivering mental health services to patients. We've found that patients have resonated in receiving their mental health services through our embedded behavioral health psychologists through the use of telemedicine. But with that said, there are a lot of challenges. And for the reason of the challenges, we don't see telemedicine being our main venue of care delivery moving forward. Nothing takes the place of in-person care and where we have the choice we should be delivering in-person care. We all know that with challenges, with broadband connectivity, that access to telemedicine is not equitable in our state. We also have licensed or restraints starting in October. Clinicians will be obligated to be licensed in the states where their patients reside, where they are receiving telemedicine. And for us, with patients in Massachusetts and New Hampshire, that's costly and takes time. Starting in December, Steve mentioned that we entered into a contract with CIC and Broad Institute to start to deliver mass COVID testing to the community. This allowed patients to come in for free COVID tests and have their results delivered to them in a timely manner. In February, in this very room, we started to deliver mass COVID vaccinations to the region. We were providing over 300 COVID vaccinations per day. And this was through a contract in collaboration with the Vermont Department of Health and the Agency for Human Services. The feeling in this very room where so many hundreds of vaccines were delivered was one of complete joy. Patients were so thankful to come back here on site after months of not coming to the hospital. They felt grateful for being able to receive the COVID vaccine at their community hospital. And staff really saw the return of the COVID vaccine that a personified hope for our community. We all know that the COVID vaccine is our greatest weapon against this virus. And this work continues today, starting last month. We implemented phase two of our COVID response, which was standing up the COVID vaccination and testing center. Again, this is a collaboration for a contract with VDH and HS. This is one location located on the campus of one of our primary care practices, where we have one team delivering both COVID vaccinations and testing. This model allows us to move in one of two directions. One, to be poised to integrate these services into primary care. Or two, should the need arise, which we all believe is pretty likely, that we will need to go back into a mass vaccination center to deliver boosters to patients in need. And so keeping this team intact allows us to pivot back to that model seamlessly. During this time, VMH has really been the backbone for the community, partnering with the Vermont Department of Health, with state and local agencies to deliver these essential services. And it's been our pleasure to do that and to offer that to the community. And we look for your support and helping us ensure that we can continue to deliver these essential services. I'm going to turn it over to Dr. McGraw to talk about our immunization mandate. So as you may have heard last week, we announced that we are going to have a requirement for vaccination for all of our staff by October 1st. And this is something that we came to after quite a bit of thought. We, as Ailey has just outlined, really embraced the vaccine around here with vigor. It was really celebratory and it really required essentially a full court press from our staff to be able to do that. And given that level of involvement, people have been very enthusiastic about the vaccine. It really seemed the next natural step with respect to that. Our clinicians have been concerned from the beginning about all of the patients getting vaccinated and so extending that to our staff was important. At the time that we made that announcement last week of the decision to move forward, we had a staff vaccination rate of just over 90 percent. We have done outreach since then to all of those staff members letting them know about the vaccine and the new requirement. We will have religious exemptions or medical exemptions. But we do know that some of those folks with requirements have started to actually get the vaccine themselves. So our numbers we expect will be much higher than that at the end. For those who are not going to go through with getting a vaccination, we have had to reckon with the fact that there will be some difficult discussions. Those who are having medical or a religious exemption will require to have some routine testing to ensure that they remain COVID negative. So I'm going to have Andre go through some of the financial implications moving forward. So Andre. So our MPR FPP increase for budget to budget is 3 percent and our overall charge increase is 5.1 percent. Income statement, I know it's pretty small. I circled some of the high notes, the biggest ones as you talked about in the earlier presentation with Steve Majanek, 340B retail programs. We've got an increase there. We contracted with some additional pharmacies as well as leveraged 340B tech, which we put in place over a year ago. So that's that's gaining some results for us. And then our two biggest line items that make up 75 percent of our overall expenses are salaries and benefits. So you see the increase there. And then in the financial statement, you've got the drug spend in 2021 budget of zero and 22 budget of five million. That's kind of a little bit of an accounting well slash classification shift from other operating expenses. So overall, when you combine those two, it's a slight increase, but I just wanted to highlight that there was a variance in how we present those slides. On the balance sheet, you'll see some significant changes in the net property, plant and equipment. The 2020 actual was 25 million. We're anticipating in the 2022 budget completing our Ron Reid, or pretty close to completing our Ron Reid project. So that's been capitalized. So we see the increase there. The middle circles are other third party settlements. We have we have gotten a Medicare advance payment of roughly $6.3 million. We're in process of paying that off, and that will be paid off by the 2021 budget cycle. And the last one on the balance sheet is long-term liabilities. The increase there is the drawdown of our bond for the Ron Reid project that we're engaging in. Anticipating that will be fully activated by the end of 2022. Charge request again, other operating and other non-operating revenue. The budget change is the increase in 340B retail pharmacy. Again, we've realized some additional pharmacies which has added to those revenues. And our expenses again, wages and contract medical specialists benefits make up 75% of our overall expenses. The other two items that have increased are drug expense. We've got cost of drugs which are always increasing. And we have some additional volumes in our oncology program that's been a program that through the pandemic really hasn't seen any volume changes as far as decreases. We've actually seen some increases in that area. And then Med-Search supplies, our volume in our joint replacement program has increased. So those are the two other expense areas that we have seen some increases. And then again, the change in charge request is 5.1%. So I'll cover some of the risks that you face which are probably pretty similar to most of the hospitals. And I'll just point out some that aren't. So obviously COVID-19 resurgence, starting to see greater positivity in the area. But as I've said in the past the last 10 years, we are the only Medicare dependent designated hospital in the state at this point in time. And that designation is a set to expire not this September but next September. And that really, I always sound like a broken record when I'm talking about this, but that is our Medicare is our biggest payer. And we're always very concerned about changes in that program. Hopefully with some of the movement in Washington that could be like critical access or Soul Community Hospital be considered a formalized program that's baked into Medicare on an ongoing basis as opposed to continually looking at sunsetting this program. There are only a couple hundred hospitals throughout the country that are considered MDH low volume hospitals. As Andre talked a little bit about one care risk-based performance. I know Steve Mugenic talked a lot about that. We won't go into that to repeat what you talked about. B40B Andre's talked about loss of provider-based billing to off-campus facilities. We will have one of our offices in Putney considered a reduction in our provider-based billing. The other practice which is in Brattleboro off-campus will be coming on campus once they're on read. The million is built but that is still a risk. And then as I've talked about in prior presentations this hospital is very committed to our community on a number of different levels. Fireball population, care coordination. We are a major sponsor of a dental program combined with our United Way serving those on Medicaid as well as those that have no insurance. It's been an incredibly successful program embedded behavioral health therapists in our primary care and our community health team. So I've always been asked the question well when are you going to see improvements related to these kinds of programs? And you know we're on a journey of five to ten years. This is not something from budget to budget. You can really look at and say well you know we had X number of patients who were diverted from let's say the ER to the dental program. It's a lot longer process. And for all of these this is a commitment that this hospital and our board has to our community. On the flip side is opportunities. We see continued opportunities in revenue cycle. We have a relatively new VP for revenue cycle programs. We've been very successful. Ailey and the medical group Dr. Sheen have been incredibly successful with new clinicians joining the staff. You see them here. We will have our first surgical podiatrist coming on board this month. And we continue to recruit in in both primary care and the surgical specialties. Opportunities continue to work with our regional psychiatric strategy group which involves the retreat and HCRS our designated agency here. And with that sort of community treatment initiative ACT initiative which we are currently seeking funding for. Continued collaboration obviously with Dartmouth and with Cheshire. We have multiple programs that are partnered with both DH and Cheshire starting with the emergency department. Pathology, radiology, cardiology, pathology. Did I miss any Ailey? Rheumatology. Rheumatology. So very strident. We continue to look at that evolving strategic partnership to continue to grow. Telemedicine Ailey talked about we did implement a new platform, more effective platform for us. And then what's really important for us as it always has been is the LGBTQ plus initiative now combined with our racial diversity initiative and the hospital hired its first DEI director this past month. So we're very again committed to that and we see continued opportunities as it relates to DEI. So I'm going to flip it back to Ailey talk about value based participation with OneCare. So when it comes to OneCare BMH is all in. We're all in for all major payers for which this program support. And we have selected to be part of OneCare because the values that are funded through OneCare and idealized are ones that we also hold true. This includes a real focus on preventive medicine and primary care. And that's really what our hospital is all about. So some of the models and payments that OneCare helps support that we appreciate include the access to embedded care coordination. OneCare provides the vehicle for payment to help support and reimburse the care that comes through embedded RN care coordinators. These are nurses who are committed to providing and meeting the psychosocial needs of our patients. Additionally, OneCare has funded a few unique and innovative programs for us. One is our cardiac prehab program. Our hope and objective is that one day this can be turned into a waiver program where insurance companies reimburse us for services like this. But this is taking your cardiac rehabilitation program, which meets the needs of patients post having a heart attack and flips it and works to be geared towards identifying patients who are at high risk of having a heart attack and then stopping that heart attack in its tracks through exercise and education. So it's really focused on improving the quality of care and decreasing the cost. We have selected to be part of OneCare and to be part of the advanced alternative payment model for several reasons, but I'll highlight the top three. One is the continued support of the community health team. Dave mentioned our commitment to that and that's a commitment to patients. This is a free service that's provided to Vermont patients and without the OneCare vehicle, this funding would not exist. Two is timely access to data. Given the unique relationship that OneCare has with insurance companies, we can get data that we would not be able to receive through other means and we get this in a timely manner. So I mentioned earlier our top three diagnoses that we've seen over the last several months. That's data that we got from OneCare. Without OneCare mining that data and giving it to us, we would really be hard pressed to have the data that we need to make important decisions or on the quality of care and utilization. And lastly, something that I don't think it's talked enough about, but I think is really important, which is because we're part of an advanced alternative payment model, OneCare is responsible for the federal requirement of our MIPS reporting, the Merit-based Incentive Payment System. Without OneCare doing that extensive rigorous reporting for us, it would mean our staff would need to do that and that's taking staff's time away from important patient care initiatives to divert to doing this. And so there are several reasons why we're all in with OneCare but I wanted to make sure that I highlighted the field. And I'll turn it over to Andre to talk about our capital budget. I think this is our last slide. This is our capital proposed capital budget for FY22. See it's 2.6 just under $2.7 million broken down by the four major categories that we have there. The CON approved modernization project, this is the Ram read project, the construction is to finish in October of 2023. The boiler plant upgrade has already been complete. We do not have any additional CONs teed up at this point in time but the non-CON capital again is just under $2.7 million. But we have asked for an extension on our approved modernization program. The program has not changed in scope but obviously we have significant delays through Act 250 and then we delayed as we went through COVID. So I know one of the things in front of you, I don't know when you'll be able to rule on that is a request to extend the project as well as an increase in the dollars approved for this project. So that concludes our presentation for this year. Thank you so much. We're going to go in alphabetical order starting with board member Robin Lange. Robin. Thank you. And hello to the Bradbro crew. Good to see you. So I have a couple of questions. One question I wanted to ask you about is on your slide 14 and also in your narrative you mentioned limited patients with the long-term population health investments and I think it's always good to remind folks in general that these sorts of investments aren't a one-year return. So that's helpful. But I'm curious whose limited patients you're referring to. Are you seeing that in your staff and you're within the hospital in your community? Like who's laughing at patients? Yeah. Don't take it personally but I'm referring to the Greenmont care board. Okay I wouldn't take it personally. Under prior chair we were asked a couple of different times. But when do you inspect returns on these investments? Is it a one-year deal? Is it a two-year deal? We're talking a five to 10-year deal. Great. Thank you. In terms of your recruitment it sounds like there's good news around some successful recruitment efforts and could you just remind us I know I remember in the primary care area there are a number of retirements that you had mentioned last year. Are you seeing your openings driven by retirements, pandemic related? FBMC was saying that they feel like they've had some success because folks are looking to move to Vermont. Could you just give a little more qualitative information about that? Yeah I'll wait. Ailey and Dr. Sheen might want to address that. Absolutely. Is there a way that you could turn your camera back on to Steve so we can see the people responding? That'd be great. There you go. Can you see us now? We can. Yes. Thank you. So our primary care clinician recruitment has been somewhat been driven by retirement but it's one of those fields that's important to perpetually recruit. As I mentioned during the presentation primary care is an important service for us. It's important to our community sort of as the heart and the foundation of what we do here as part of our hospital. So we've had a few retirements but I wouldn't say that's the main driver for it. On the other hand in terms of our the ability for us to recruit clinicians we've had more clinicians reaching out to us as opposed to us searching them out than we have ever had. Clinicians are very interested in moving to Vermont. They see us as a safe state. They have been really responsive to all of the safety initiatives that we've had in place here and they want to be part of that culture. So from a clinician recruitment standpoint it's been it's been great because people are seeking us out to want to come here and be part of this. Yeah we'll say Robin I think what's probably what you're referring to is it was several years ago we had three independent primary care physicians retire all at the same time very very little notice. And that was 6,000 patients from those three full-time docs that we had a really hard time placing we couldn't place them. So Ailey and Dr. Sheehan and the medical group leadership clinical leadership have really focused on continually to recruit primary care both MDs, DOs and nurse practitioners and physician assistants. Great thank you. And my other question was relating to the first healthcare advocate question. As Mike Fisher mentioned we have been trying to collect this ratio between related to Medicare and I believe I can see if I can find my tab here that that was a question that you did not answer. So I think to Mike's point I think we do have to figure out a way to start being able to make these apples to apples comparisons. So I wondered if you could speak to that. So Robin you're talking about the the original questions with the the DRB weights. Yes. Yeah that is something that we we have not historically captured. It is something that we can look at doing for future years. Okay but do you have a general sense of it even if you count do you calculate it in a different way? You don't sort of use that as a metric at all. We don't really use that as a metric at all. Okay. Thanks. And I think in interest of time I will stop there. Thank you. Thank you so much Robin. Next we'll go to board member Tom Pelham. Well thank you for a crisp presentation. And hopefully we can bring this in for a landing before one o'clock but it looks like we will. I just have a few brief questions. My first one is just an observation. I mean last year we talked about the provider tax. And this year I'm happy to say that the across all hospitals are all coming in at a plus or minus six percent of their 2021 projected net present revenue. And I think that your presentation comes in near the high end this year at six point five three percent. And I'm just wondering is there something magical about that number? Because if it were to drop down to say six point one percent or so you'd have a few hundred thousand dollars falling to your bottom line and enhancing your operating margin. So I'm I just you know other some hospitals are five point eight percent five point nine percent. Many are right at six percent and you're at six point five three percent. It's just a suggestion to to make your operating margin appear a stronger than it might otherwise be. Unless there's something sacred about that six point five three percent. So that's just an observation. In terms of fixed perspective payments on the on the income state income statement you have that at thirteen million eight hundred ninety two thousand eight hundred ninety four dollars. But in appendix six it calculates out for a twelve month period at thirteen million seven hundred and forty five thousand hundred and sixty dollars for hundred and sixty dollars for a difference of one hundred and forty seven thousand. And there again I'm just wondering which which number is the one that we should look to. But overall either one of those numbers you use it's about fourteen point five percent of your NPR FFP which is just about average across hospitals for the state at least given you know the recent numbers. You know southern Vermont as you know is up at the highest in the state at twenty four percent. So I'm just wondering do you have any kind of conceptual game plan as to how far you would want to grow your fixed perspective payments. As a as a percent of your your total revenues your net net pressure revenues FFP's. Well I would think our game plan would be to maximize that as much as possible like southern Vermont or southwestern Vermont. We're in Medicare Medicaid and the commercials as well. So it comes down to attributed lives and how those lives get attributed to Brattleboro in our health care health service area. I don't know the magic to get to twenty four percent versus fourteen percent with attributed lives. Other than the location that we're at and other hospitals that patients could potentially go to the tribute to another hospital. So what I hear you saying is that you don't think you plateaued what the horizon looks like you can't you can't you don't you you don't have a specific trajectory to get to get to some future number. I do not know and I don't I don't know if there's any way to you know the magic of attributed lives is different for each pair. And being able to identify and quote unquote redirect those patients to a hospital is not something we look at doing. Well the reason I ask is I just I know at the board we're trying to figure out where the tipping point is you know where the level of participation in these value based programs gets us to the point where we truly are generating the innovations that that the system promises. And as we saw with Southern Vermont this morning that's also a risk. You know so there's both sides of it and I'm just hopeful that you know we keep we keep growing that number. I'm looking can I answer a little bit on my end you know strategically is what I've been talking about with Medicare dependent hospital designated status always a question mark. We do want to drive towards more value based payments that is for us a more secure way of sustainability for this hospital as opposed to every year wondering from our biggest payer how much we're going to get paid. So we're very different than every other hospital. And as I said MDH is slated to go away next September. That's a very concerning situation for us because MDH gives us how much more four million dollars with low volume that's a lot of money. So that's why we have from day one been in value based payment through through one care. That's unique you will not find that with the other hospitals whether it's critical access sole community which is what Southwestern is. Thank you for that. I only have two more questions one has to do with payer mix and again I went in and kind of trended your your different payer mix categories your gross Medicare Medicaid and commercial from the from 19 from 2019 through 2022 budget. And I noticed that your the growth rate for Medicare is 9.1 percent. The growth rate for Medicaid is 10.4 percent over that period. And the 20 for Medicaid the 2022 budget over the 2021 projected budget is a 71 percent increase in Medicaid payments going from 7.7 million to 13.1 million. And commercial is down at a negative two tenths of 1 percent. And it just I'm just asking what insights you might offer as to that kind of specific mix of payer mix. So let me when Springfield hospital shut down their OB program we've got the majority of OB cases coming out of Springfield which is a significant number of those on Medicaid. So that was a pretty big factor as well as other specialties that Springfield did not have. So that and as you as you know Medicaid makes up a very significant portion of our OB volume here in Bridalboro. So that's that was a big jump. Yeah. Yeah. So with Springfield having come out of bankruptcy do you see a migration of services migrating back to that hospital or how do you see that relationship unfolding? You'd have to ask them. I think once you lose OB it's pretty hard. You know we lose four million dollars for an OB program. That's both inside the hospital here for our birthing center as well as the OBGYN practice here. We we staff an office in Springfield on the campus Springfield hospital. I don't think you know personally and you're going to have to ask Springfield is but I don't think they're going to be interested in taking on a four million dollar loss when they just came out of out of bankruptcy. We you know I would like to see enhanced payments out of Medicaid for OBGYN. It is a significant loss for this hospital but it is a major service that our board wants to make sure we have in this community and you as the Green Mountain Care Board want to make sure that there's not a bigger OB desert in southeastern Vermont. We're the only one left standing right now in our area for OB. That is a huge driver both on the Medicaid front as well as the you know when you start looking at services on the loss fund. But we are committed to do that but we'll be asking for additional help from AHS on at least the Medicaid front for OB. And my final question is I think it's appendix six or seven the one that profiles your payment for the Medicare Advanced Repayment Program. And as I followed it you have at the end of 2020 there was still a six point three million dollar liability and that that is liquidated in 2021. Is that the right understanding? Partially 2020 yes we did have that balance deal Medicare started recouping those funds in April of 2021. There's a 12 month run out for that recruitment at zero percent interest. Once the 12 months is over unless they change anything the interest rate I believe is like 18 percent annually. At that point in time if there's any balance left over we will send them the amount of the balance. Right and so then they won't be deducting it from their payments to you anymore. Correct. Right that's my questions. Thank you very much. Thank you Tom. Next we're going to move to Maureen Yusuf or Maureen. Thank you and thank you for your presentation. Just to talk a little bit more about where Robin was going with and where the healthcare advocate has been asking about the ratios between Medicare Medicaid commercial and the payer. I'm kind of creating a proxy based on the information that everyone's sending us and we have in the details your gross to net for each of the polar types and it doesn't break it out by inpatient and outpatient but for those hospitals that calculate like Southwestern the calculation works out very closely. So you may not have those materials in front of you but it's the data that the staff provides and you provide to the staff. So for your data your Medicare ratio of gross to net is 38% so what the gross charge right and then what you actually get you yield 38%. For Medicaid you yield 34.2% and for commercial you yield 58.3%. And then you just index those Medicare is one Medicaid becomes 0.9 and commercial becomes 1.53. So I mean it is a way to use as a proxy and what it helps us do is look at what that ratio for your commercial is to Medicare. And so because it's very hard to look at the price pricing across all the hospitals you know it is a way to kind of at least say how does that benchmark and the only other hospital we've seen today is Southwestern and you know they were at 2.1 for commercial compared to their Medicare you're at 1.5. So you know it just kind of positions things. I mean it's not obviously there's a lot of different spending and you know what you're doing in Medicare Medicaid and commercial but you know it is a way to index. So I know I'm doing that for each of the hospitals to kind of at least look at that as a benchmark for those hospitals that aren't. So just want to make sure everyone's on the same page as to what I'm doing and I guess you know Andrew could you speak to that as far as does that make sense. Yeah I think that makes sense and it will be probably different for those hospitals every hospital actually you know that's a pretty drastic difference between us and Southwestern which exhibits the difference in our reimbursement models. It'll be very different when you look at it with a critical access hospital who can't possibly reimburse and all but two of them are only in Medicaid they're not in Medicare and commercial for the ACL. So I think between our MDH which gives us meant enhanced reimbursement for Medicare and the you know that we're all in with the ACL I think the 1.5 ratio for commercial makes sense. Okay. You know I think the question I could have is what's the end game? You can't really change your payer mix it's your what's in your community. You know what I'm saying? So if you if you want to give us you know an extra percentages for charge increases that that's fine but we've got to go back to the basics is the payer mix reflects your community. Right. Absolutely absolutely payer mix is another critical piece if you're if you're a hospital that's 70 percent reimbursed by commercial you know your payer mix versus 30 percent you know that that's obviously a big difference but you know I just think it's a data point when you're looking across hospitals but there are a lot of factors that then would go into any decisions being made there. But right. Okay just to talk some about reserves on your balance sheet and you know just trying to align with when I look at the it looks like the ACO reserve you have on your projection for 21 is a million and carrying that through to the 22 budget is also a million and just wanted to understand do you know what your settlement is going to be in September as we you know as we saw with Southwestern they're obviously getting some favorability back this year and and just how is that reflected in your projections and in your reserve. Yeah so our settlement in September will be for 2020 overall we've got an AI-PVP issue with payback to Medicare so we've got some money in there for that the reserves that we generally build here are the report of our maximum risk with all three payers that were involved with the ECO so as far as getting any payments back we were favorable with Medicaid and then with the AI-PVP it's unfavorable with the Medicare so overall it's going to end up being probably a pre-significant hit to our reserves I'm thinking that remember quickly it's like six or $700,000 with that AI-PVP payment so is that reflected in you know anywhere in here as far as your because your reserve of a million is just kind of carrying over from the prior year but should you have a net hit to that you'd have to replenish that reserve so are you assuming that six or $700,000? Yeah as we're for some of that we're replenishing through 2021 okay yeah and then on other reserves for any any COVID cares money anything that's still on the balance sheet that you may actually be able to to move not hold as liability No we took all of the CARES Act funding into down into the P&L last year in 2020 Yeah okay and the only other thing that's on there's a liability is a Medicare advance payment Oh and the AI-PVP grant fund have it out we have a million for that Did you get any? That won't be right down to the bottom line any PPP loan money and is that all resolved? No we did not qualify for that we have too many headcounts for that Yeah you're my headcount Yeah Okay great and now for 2021 the income statement it looks like you're going to move from what you were projecting to be a $4 million loss to a $1.8 million loss is that correct for operating income? That is correct and how should we think about that favorable $2.2 million as we roll forward into 2022 it's going to help you obviously in your cash and other other pieces because that wasn't considered when you did your current forecast correct? Correct Okay Well I shouldn't say correct it was the forecast carried from 2021 now that the budget piece for 2022 yes And then I appreciate the chart talking about the $4.1 million in revenue enhancement and expense reduction plan and I guess a couple questions one can you talk about how much of that you've already accounted for in 2021 how much of that will be incremental in 2022 and are there any additional plans for 22 a 22 financial action plan? Well you know from a high level on most of the position holds since our volume has come back we have now recruited for those positions so that that's that was a savings in through this year we have contracts vendor contracts that we renegotiated pretty significant rate reductions and that will roll forward and is already baked into the budgets for 22 in terms of visit volumes expected by the medical group that you know 16 a day has already been baked into the budget for 2022 so it's kind of a mixed bag one time hits or one time actions that really reflect that really were taken in 2021 by the number of these are obviously rolling forward for us and are there new actions for 22 that you can talk about and additional cost savings and efficiency that you're looking to achieve? I think one of the the biggest challenges that we face and is what's what's going to come with contract labor that Jordy talked about that is that is you know the biggest concern I have and I think our group here we're recruiting for a number of open positions right now I sent to Kevin some data from one of the firms that we've used they can't fill contract labor positions so that's probably the big a bigger concern that we have here but we're in a constant state of vigilance in terms of what what savings every position whether it's budgeted or not budgeted is reviewed by senior leadership before that position is turned loose so we continue on a daily basis to look at our operations but there's no you know I think the key is we can also be nimble enough to respond to what's going on in our local community as it relates to the pandemic and any resurgence of COVID we've got to you know stay pretty flexible but we're we're doing what we need to do every day okay thank you that's all I had thank you Maureen next we'll go to Jessica Holmes Jessica great thank you the good part Kevin of me going behind everybody is that a lot of my questions have been answered but can we just speak a little bit to the the projections on NPR or the you know the budgeted 2022 NPR relative to 2021 projected and 2019 actual so for 2019 actual net patient revenue and fixed payments I have here for about 84 million for the 2021 budget as submitted and I recognize this has been adjusted it was about 93 million but the projected was 87 million right so there's a deviation here between what's what you budgeted in 2021 and what's been projected for 2021 and so I recognize then that the 2022 budget is 96 million roughly so there's a 3% jump from 21 budget to 22 budget but if we use the projections from 2021 as submitted it'd be about 10% increase and so I'm wondering if you might first of all update the 2021 projected NPR so we really have a sense of really what is the projected updated projected NPR to the budgeted 2022 NPR and then speak to going back to 2019 the actuals are only about 84 million so 84 million to 96 million is a pretty big leap and so I'm just want to make sure I want to understand some of the thoughts behind those jumps I'll start with the projection to budget jump if you recall forget what slide number it was that Ailey went through when we had the first five months of our year where we were we had lost 2.4 million dollars yeah remember when we when we actually do the initial projection and budget for this is the March April timeframe sure I totally understand yeah sorry again that number and going from projection to next year's budget is basically taking you know starting to see our volumes come back and then benchmarking the volumes back against 2019's volumes so what would you say right now is the 2021 projected knowing that the volumes have come back would you still say I mean you know you went from a four million dollar projected loss to a 1.8 million dollar projected loss so what is the equivalent if you know the now new projected NPR for 2021 I have not calculated that I don't have the number on the top of my head Jessica I'd have to go back and take a look at that okay I think that would just be really helpful for us to understand then you know given what you're seeing now you know what you're projecting out for the end of 2021 presumably it's not actually going to be a 10% jump from 2021 to 2022 but I'm trying to get a sense of what that actual number is do you see what I mean yeah it'll that's okay yeah if I go even close to our 21 budget off the top of my head and I'll hold me to this if I say in the 90 million compared to the 92 million for the budget okay okay that's helpful and then my second question actually and this is something I'm really just trying to understand I asked SPMC the same question I'm really trying to unpack these changes in charge requests particularly you know into some component parts and you know as you you submitted some information about inflation so the inflationary factor seems to be about 2% for Brattleboro based on your submission of sort of the breakdown of wage inflation and supply inflation and drug inflation and all that overall weighted it seems to be about 2% so the charge change in charge request is 5.1 so we can see that one some component of that 5.1 is clearly inflation which makes sense I as I mentioned in the earlier hearing I think about changes in charge as having to reflect not only the inflation but also cost shift because the public payers are not reimbursing right and then a need for margin so I'm wondering how you might think about the 5.1 obviously 2% is clearly accounted for by inflation how do you think about the rest of that change in charge request in terms of justifying it so the change yeah it's all connected like you said the change in charge request does come back to like you said we're not going to get much out of Medicare and Medicaid from that change in charge so it falls to commercial and then that that then flows down through to cover inflation any potential volume increase related expenses and then to maintain a margin and our margin for next year is a 0.65% so majority of that change in charge is to cover inflation but inflation is only 2% so 2% of the 5 I mean you know we know what an inflation is so I'm trying to get from the 2 to the 5 right yeah the 5% is gross so then when you net it down you're at roughly 2 to 3% increase in our MPR okay and net it down largely because of the cost shift right the fact that not everybody is not all payers are actually going to right yeah we're not going to get that 2 to 3% or much out of that if any from Medicaid or Medicare got it so okay that's very helpful those are my questions Kevin thank you thank you so much Jess next I'm going to turn to the health care advocates office for their questions no sorry Kevin I wasn't keeping track and brought me off guard no questions from from the chair huh thank you Brattleboro I guess maybe first let me ask you to I heard your recognition of your DEI director I think you called the position I'd love to hear you expand a little bit more about what that position what your goals are for that position and what what you hope what they're working on sure you know we started our LGBT Q plus council several years ago and we worked with the Fenway Institute in Boston we did major training of all staff here at the hospital and at that point in time we actually brought on a DEI coordinator that individual actually has gone to AHEK and this organization made a determination that had such an important position that we made it a director level position the individual who we hired is Gail Summers Gail joins us from CNS Grocers pretty big employer and we're pretty excited that she has now come on board and one of the things that I think she has a high on her list of priorities is we have the LGBTQ plus group and we have a court group which is council on racial equity and being a small hospital how can we work together and how can she serve both entities at the same time being effective so she's right now kind of just getting her feet wet she came on just about what three weeks ago so that is one of the key points here and then the other piece of her role right now is getting to know folks in our NAACP the other folks in our local community representing the BIPOC community as well as at the state level she also is going to connect with Dr. Abola Abola who we've all taken training from here has done excellent programs so it's that's kind of the start right now and it's really to the position really is to make those connections with both our local community the BIPOC community the LGBTQ plus community as well as on a state level life thanks since you mentioned it do you have a sense of what percent of your your leadership or your staff have have been able to take that Dr. Abola training well I've gone through twice you get to count right try to get it right but the entire remedial class I enjoyed it so much I think the last one was the previous one was through the hospital association and then I forget the group that sponsored her AHEC sponsored her the entire senior leadership has gone through and in terms of we've done a lot in terms of our staff here in terms of training as well and I think it's an ongoing I can't give you a number per se we do have our modules training modules within our annual training program through HR that people have to take so it's part of their employment and that's part of Gail's focus is how do we continue to disseminate information and being a more responsive organization to both the BIPOC community and LGBTQ plus great thank you a question or two about your free care and well I think really just about your free care numbers from 1920 and projected 21 if I'm doing the math right it looks to me like in 19 as a percent of your gross patient care revenue you have a relatively high free care you had a relatively high free care you were actually one of the leaders in having a high amount of free care at 1.19 percent if I do that same math and 21 projected you fall pretty much to the bottom 0.47 percent of gross patient care revenue what happened you know what do you think is going on well a lot of times the free care gets triggered from patients coming into the hospital and actually reaching out or we're reaching out to them as they come through capturing them as a self-paid patient and helping them start the process and helping through the process of the free care application what we saw through the pandemic was the patients weren't coming in so that became a disconnect and outreach to that population became for us very difficult we are seeing an uptick in the free care again this look I just told Jessica you know we put this together back in March April when our volumes are still down we were still not seeing volumes come through that's since changed and we're seeing more applications being done and being signed off on so I'm hoping to see but that continues we'll see how things go with our current resurgence but you may have to reevaluate how we reach out to patients if we go back into a resurgence and patients aren't coming back into the hospital because those dollars will just sit there over time and what I've seen in my past history is patients have bills out there sometimes they just won't come in for care for fear that they haven't paid their bill and it's just becomes a moral decision form and I don't like to see that happen yeah thanks for saying that that's the story we hear as well well that's why I I did it as a percent of gross gross patient care revenue because I recognize that you had fewer patients through the pandemic and I was trying to normalize it for that I guess I would just ask that you pay attention to it because it it there's something going on that's I have no way of evaluating but you know as a percentage of your of your gross patient care revenue you you went down significantly and and I don't know exactly what you have to do in order to stay at a relatively level we of course would want you to go increase but at least maintain and anecdotally the other thing I can see happening is a lot of these patients that are self-pay who haven't been working and haven't come in may also qualify for Medicaid so we may see a shift from pre-care to Medicaid and again that's anecdotal but I can see that actually happening in the next next five six months so it's something we need to keep an eye on enough I'll ask our navigators to start tracking that and see if we see it uptick in Medicare enrollments which may go back to an earlier question of ACO attributed lives down the road so yeah I'll just echo what Eric said in the last hearing you know to the extent that you're interested in taking a look at your policy we would be happy to partner in that okay thank you thank you Mike next thing we're going to open up to public comment does any member of the public wish to offer comment on the Brattleboro Memorial Hospital submission does any member of the public wish to comment hearing none it's almost a minor miracle I was so paranoid that we'd never be finished by one and here we are looking like we're ahead of schedule and so I will ask one question Steve and start by thanking you and your team for being here today I know that you've been asked a lot and you were asked to do more at the end of last week and you know you agreed to go forward with your hearing today which is really very helpful and it helps us to understand your story better but the one question that I'm going to ask only because I like bringing the story around to Ron Reed and I tell so many people about this story and how somebody living within their means can and if they're prudent and thoughtful on their investments really can create a little bit of a nest egg and so the way I'll blend this all in together is to ask you well first I'll confirm that yes we have had some initial conversations about your request concerning your CON and we're working on that as fast as possible but my question is given all the stories that are out there about the increased costs of doing any type of construction whatsoever are you feeling any of that or were you locked in enough that you won't feel any of that pain well I think if you look at our budget for the project you'll see some of that pain in there I think we're budgeting about $700,000 of additional costs of just the unknowns and the unknowns are focused around PVC sheet rock labor costs for their contractors but thankfully we locked in pre-pandemic to the major items such as steel HVAC heavy equipment and all of our equipment for the ORs which is the major driver for this project those three ORs the replacement ORs all of that have been locked in with POs so I think a very substantial portion of this project has already been locked in to really minimize the risk but there is a risk out there and that's why you'll see as you look at the budget that we've submitted the additional $700,000 I will tell you you know as you know it's been a long journey back four years ago when we first presented this project and you know as I mentioned we haven't had any scope increase in the project it is what it is it always has been but it's these delays that have really hampered us whether it was Act 250 or whether it was the pandemic but I think we've done the best we can you know we look at I looked at it a little differently that if we had if we had a 4% increase every year in just costs in general for this project it would have been about a $28 million project we're bringing it in now at what 20 26 27 million so we're a little bit ahead of that that gain but I do appreciate the patients that you all have had my patients is worn pretty thin on this but you know you go back to sustainability this is such a critical project for this hospital because we've got to have new ORs to maintain patient safety as well as to recruit all the the physicians that we have been able to recruit as well as and you know bring back to campus primary care as well so it is a critical piece of the puzzle for Brando Barrow's future which I think you saw when you initially approved this project so it's a long answer to a short so I never know where the noise is coming from when we're having these teams meetings but I did hear a little bit of a construction noise is the project going smoothly right now? Yes you know you never know what you did you know what you find out but you know we one of our challenges was as they were doing the footings they found a lot of sand for the project and that hit us for about I don't know $250,000 of increased expenditure but we once you come out of the out of the ground we get our footings the steel is up all of the the siding is being installed right now so it has gone very very smoothly as we kicked off this project actually in September we delayed this project until last September because of COVID it's never been an issue of do we have the money it's been an issue of you know the governor's emergency orders it's been the the board saying let's wait until we get through a little bit of this pandemic so now it's it's a full steam ahead with hopefully a complete completion date a year from now so we're excited about that great and just in closing I did want to thank you for mentioning once again your collaboration with a nearby hospital and actually several because you've talked about Springfield you've talked about Cheshire and that's really something that really has to be part of the solution for Vermont healthcare moving forward and and you've been a leader in that so thank you and thank you to everyone on the team for the presentation today and we'll be back to you with our decisions in September you got one hand up Kevin oh I do Dale Mr. Dale sorry about that I had my mouth full and I was not going to raise my hand while I was still eating my salad can you give me a quick rundown I thought I heard you say the OBGYN was not profitable for you either it costs more than you bring in can you elaborate on that a little more is it we have such a alert of birth rate what's going on that's me sorry all right you chime in Dale you chime in so I don't know any hospital that really makes profit on OB unless you're doing probably 2,000 deliveries then you can spread your fixed costs over that this is a this is a very fixed cost significant program both in terms of the physicians in terms of midwives in terms of the nursing staff and as I said you know our numbers are filled we're below 300 births and to spread those costs over a Medicare reimbursed Medicaid reimbursed program is a big problem from a financial standpoint so you are you are not going to make money on OB I don't know many hospitals that make money in the state on OB potentially the ones that are bigger programs but there aren't that many that are over probably you know a couple hundred maybe UVM which also has neonatal services which wrap into OB but it's not one of the leading profitable services but it's much more of as I said a community service and if we don't do it here there's gonna there is a big OB desert in southeastern Vermont the deal that follows up really my words to the team in Browder borough about the collaborative effort that they've undertaken by they call it being a the lone person in the desert for delivery but on the other hand if multiple players were doing that the losses would be greater because you would even even have less of an efficiency and if these cases had to be sent to Dartmouth it would be more expensive care so Browder borough it really is to be commended and just confirming what Steve said Dale that nobody's truly making money when it comes to to Burs and yet we expect as Vermonters that we will have that care and we should have that expectation because we want to have Burs and we want to make sure that we don't have any further population decline so yep could I ask one other quick question is what is the main reason that is dropping down our birth rate? Well it's a drop it's a drop in population of folks having having Burs it's a major drop in the the pandemic this isn't you know one or two night lights out situation it's a long-term issue and people are very concerned about their economic status and our delaying I think but I think much more of it is related to the population and the you know we in Browder borough and in Wyndham County it's one of the oldest counties in the country getting older every day so what you know we just aren't attracting the younger folks and that trickles then down to deliveries that's what I was after thank you if it was social economic or just a demon graphics in this state thank you very much sure thank you Dale enjoy your salad Dale thank you so with that we'll close out this hearing and could I have a motion to adjourn from a board member so moved second all those in favor of the motion please signify by saying aye aye any opposed thank you everyone have a great rest of the day thank you