 We will resume our hearing of August 18th and next we'll be hearing from Mount of Skutney. Thank you all for for joining us today. Thank you for having us. Nice to see you again. Likewise, I'll miss McCracken swear in the Mount of Skutney team. You'll provide your opening statements and then I'll turn to director Lindbergs team for their presentation. So good morning. I'm so sorry to interrupt. Could you tell me who said thank you for having us at your table and how to spell your name when Brown interim CEO W. I. N. F. I. E. L. D. Winfield Brown. Thank you. And I think if you don't mind, uh, to the Mount of Skutney team, if you could, uh. For the record, introduce yourselves. So, uh, Winfield Brown, the interim CEO here at Mount of Skutney, David Sanville, uh, CFO. And Andrew Jeremy, G A R A M I is our financial analyst. Great. Thanks very much. I'll go ahead and swear you in. If you would raise your right hands. Do you solemnly swear that the evidence you shall give relative to the cause now under consideration shall be the whole truth of nothing but the truth. So help you God. Do great. Thanks very much. And the floor is yours. Okay, great. We just have a we'll start with Winfield Brown. He's our interim and he's been here a couple of weeks. Yeah, three weeks. As of today. And so he's probably not going to be a active participant, so to speak, since he's still learning Vermont Mount of Skutney. But I thought he would just mention who he is and where he's from and how we got here. So when we three here, as many of you probably know, Joe Paris, the long time CEO here has taken over as CEO of Cheshire Medical Center in New Hampshire. So I joined the team working closely with Dave and company. I'll say that in my first three weeks. I'm very impressed with the team here. Very lean, very competent, very focused on the community as I think, you know, historically, and of course, this is my first green mountain care board. I've heard a lot about it from other colleagues over the years. And so look forward to providing some benefit where I can turn it over to Dave. Okay, so we'll just roll through some slides here. I know you guys have been through the gauntlet for the last couple of weeks and shared this with Sarah Lindberg. So certainly you guys can circulate it and we'll only hit the high points. Quick agenda. We did the introduction. And we're going to really try to spend some time on quality accessing costs as it relates to our budget. And outline our request and some of the reasoning behind it. And then whatever you folks have. Sorry, we have a fly in the room here. So good. So our mission to improve the lives of those we serve and who we are. So we are part of the Dartmouth Health System. We are in the bottom left hand corner of the slide and our subsidiary Historic Homes of Ranamead is listed there as well. You'll notice for those who've been seeing our presentation for the last several years that there is a new box on this work chart and that is Southwestern Vermont Medical Center, who recently became the newest member of the Dartmouth Health System. We focus on three things here. Quality, cost and access. And that is the driver for pretty much everything we do here. And so we've recently been awarded some recognition from Becker's Hospital Review, top recommended hospitals in Vermont, top Vermont hospitals for patient experience and top Vermont hospitals for patient experience. And basically I put the questions, the indicators that we scored very high on, on there. Additionally, we received an unexpected award from Prescayne, which was just released a couple months ago for the Human Experience Guardian of Excellence Award. And so we hit the 95th percentile for patient experience. And so we're very proud of that. Next slide. We have a very strong quality department here. To be frank, we probably have more FTEs in this department than most critical access hospitals are to have. We really focus on the next patient, the next survey, the next situation. We've maintained our five star CMS rating for patient experience. We're annually in the top 15% of the country for overall hospital ratings. We're, we've just engaged with the Dartmouth Health System for continuous improvement initiatives, which is a Prescayne tool, and to provide constant monitoring and feedback on various aspects of the patient experience here at Mt. Scotty. We just recertified and re-accredited by the Commission on Accreditation of Rehabilitative Facilities, CARF. We're one of the smallest facilities in the country to have CARF certification. And we did it this year with emphasis on stroke specialty designation, since we received a number of post-stroke patients from Dartmouth-Hitchcock. It's a three-year accreditation. This year we also added CARF certification for our outpatient therapies program. And we have some of the highest rehab scores for the CMS measures, frankly in the country and certainly of the handful of CAHs who have a distinct party unit for CARF. We just also had our CMS recertification just a couple weeks ago. We literally had only one item to look at, and that was a wording change in a single policy. Everything else was scored, explained with zero concerns. And again, it just speaks to our goal of being constantly ready for the next patient and the next survey and not trying to cram every two or three years to get prepared for the next survey. So one of the things about our quality measures is they're strong pretty much across the board, whether it's radiology, it's laboratory, clinic related. We have strong measures consistently, and frankly it comes with a price. We talk about all the time in Vermont, the three stools of healthcare, access, quality and cost, all equally important. And sometimes we have to make decisions on how we prioritize those in the current environment. And so just putting in quality standards, expectations or initiating new programs, it takes management, this data and analytics. We have mock audits. There's software usually involved. And so there is a real direct cost to engaging at the level we engage at for quality. Obviously we're doing that for patient safety, but it also feeds into employee satisfaction, engagement, retention, recruitment. People want to know they're working for a place that cares about quality and safety for their patients. We, year to year, with the Dartmouth-Hitchcock Employee Engagement Survey, we've been the top scorer in the system over the last three years. And our top item is that our employees feel that we're focused on quality and safety for our patients. I'll talk quickly about access. This is similar to slides we've used in the past. These are the specialties that we offer at Mount Oscone, color-coded to reflect whether it's a Dartmouth employee-employed provider working here. It's someone that we employ or we have some departments that are a combination. We've really not changed our footprint in this regard for many years, and so this is really what we're measuring access against are these specialties. The last two years, our visit lag report, we've made a significant improvement in getting patients in the door. I wish we could say that we're doing an excellent job at all times in all clinics. It is a constant process of monitoring and managing, but we've made material changes and improvements to the statistics that we provide to the Green Mountain Care Board. So, just like quality, if you want to improve access, it requires ongoing monitoring of clinic and ancillary productivity. We periodically monitor wait times. We look at the regional need. We're in the area where we have three, arguably four other critical access hospitals that we bump up against, and obviously the tertiary care center at Dartmouth, and like the rest of the CAHs, we have providers who from time to time decide to move on, retire, and so we have to kind of look at how that affects all of our referral patterns and how we're managing patients. The other facilities have the same issues, so we have to periodically come up out of our hole and look to see what's going on in the area around us and what barriers are there for people receiving the care that they need. We identify those barriers, and we make great effort to reduce, remove, minimize those barriers. Sometimes that's with staffing, sometimes it's with a provider compliment, sometimes it's just changing hours and schedules with those clinics, and then we have a committee that meets every two weeks called SLAM, service line activation management, so anytime we materially change a line of service or we have something that's happened that we feel is untoward relative to access, we convene and determine how best to solve that problem. There were some questions with the Green Mountain staff this year regarding the walk-in services that we initiated almost two years ago, and so we've been removing people who would normally be going into the ER with low acuity problems and putting them into a walk-in clinic within our primary care confines to reduce costs for everyone involved, but also to provide the appropriate service in the appropriate location. And with all of these efforts to approve access we're always talking about what's the return on investment, what's it going to cost us to improve the access for the patients. Cost, so this is the third leg of this tool. I've listed and generally consistent with prior submission information. These are the services that relate to cost management that we engage with Dartmouth Health System on a daily, weekly, monthly, annual basis. Many of these resulted in some significant reductions in cost as opposed to us doing this on our own. We actually get Dartmouth Health pricing as an affiliate. Dartmouth also runs a group called NEA and NEAH, and NEA is a buying group for not only Dartmouth and their affiliates, but also other regional providers in Vermont and New Hampshire. And so that's the first tier of discount and if you're an affiliate from many contracts we get into another tier of discount as an affiliate. So that's probably the biggest area of cost control relative to Dartmouth. There are a couple other items that were asked in our narrative and with the staff questions that were addressed and we're happy to take questions on those. But we're also leveraging them for regional lab services, unified PACS system oversight from pathologists and reading radiologists. The CHNA, all of that gets done as a group and regionally, which I think is good for everyone involved, but most notably in pricing. And we'll just roll to the next slide. We're largely fixed expenses at critical access hospital. As low as 70%, arguably 90%, depending on what audit firm you talk to, I generally like to believe that we're about 80% fixed expense. Some of that is related to our conditions of participation with Medicare as a critical access hospital. There are certain services that we're obligated to offer and minimum standard for offering of those services. The most obvious one is the emergency room, which needs to be over 24 hours a day. So staffing ratios, we look at those all the time. How many nurses, RNs do we have for every patient on the floor? What's our minimum staffing for the emergency room? How are we staffing the clinics? What do we need in ancillary services? So we're constantly looking to keep those as in control as possible, but the large percent of fixed expense really prohibits us from moving that needle too much. We largely provide community-based services. We don't have any niche services. We don't have some specialty services here. We just provide what's appropriate for our community, and we do it as well as we can. We have monthly department P&L and FTE reports that are reviewed with department managers over the last 15 months or so. We've been shorthanded in finance, but prior to that, we had three or four finance people who would go out and meet with department managers, specifically the clinical managers to ensure that they're managing their staffing according to volume and their expenses as well. Senior leadership goes through position control weekly. We have kind of a catchphrase here just because we budgeted it doesn't mean we're hiring for it. So whenever a job opens up, there's a position that needs to be posted, we analyze how is that department doing, what changes could be made as an alternative to hiring an FTE. Over the last two years, we've been a little bit more aggressive with partnering with other hospitals in the region to share staff. One example is respiratory therapy. We hired a respiratory therapist. We float them back and forth between Valley Regional and Claremont, and here Windsor to cover vacations and lessening our need for travelers. We have a nursing pool within Dartmouth Health that we can all draw nursing from as opposed to travelers saving everyone money, and we're constantly leveraging the Dartmouth Health system for GPO pricing and other purchasing items. One of the questions that came up from the staff, I just want to touch on it quickly, is that we have been migrating for a number of years towards the Dartmouth Health benefits platform so that we can offer one set of benefits for all affiliates in Dartmouth, and we're going to be live on that January 1st, which will be the start of the second quarter of our fiscal year. Apples to Apples, our current offering versus what we'll be offering our employees in January, was about a $250,000 savings with slightly better benefit platform. We also will be migrating our retirement platform January 1st, and we'll be offering our employees a better plan with better options, and also they'll retain about $200,000 a year because of reduced fees. Administratively, we won't save any money, but we'll be passing that on to our employees, which is fabulous. And then the 340B mixed use, which is our in-house pharmacy, our savings working through the Dartmouth GPO programs for pharmacy and working with the manufacturers, we've been able to increase our mixed use savings on 340B from approximately $200,000 change to we're annualizing about $440,000 in savings this fiscal year and ongoing. There was a question about the Valley Regional Hospital, what savings do we expect, and this is what we are projecting. If this were to happen, let's say September or October 1st of 23, we expect that we would move the needle about $700,000 here at Mount of Scotty over the coming months and Valley would actually benefit even greater. Some of that would be moving from a lower level of discount to a higher level of discount as an affiliate of Dartmouth. But we will have common oversight, common management, and we'll pick up some efficiencies there as well as some more efficient staffing between the two facilities by sharing staff. So our request as you know, we've asked for a 5.1% rate increase. I put slide up that Sarah Lindberg was a chair last year and then updated for this year. The circle is obviously us. You know, we asked for 5.1% are a request year to year you can see is a pretty tight band. There's only two other hospitals in the state who have done a better job over this period of six years, managing their rate increases. What's interesting about it is I listened to the couple of the hearings and we're asking for 5.1. And as you know, we don't get 5.1. So the actual net increase that we'll be getting after deductions is about 2.4%. So Medicare we're going to realize 2.4 Medicaid 1.3 of that 5.1 commercial be about 3.4% of the 5.1. And we have self paid essentially zero. We do have an MPSR increase of 6.8% budget to budget. So doing quick and simple math taking 2.4% off that the remainder of our increase is 4.4 a relative to volume and intensity of services. Capital. As I've said, in the prior years, Matt Scott me seldom has a sexy capital project to talk about in our presentation. We're doing about $3.2 million in capital next year. Mostly facility facility improvement mechanicals. I've highlighted our most significant investments for next year. The CSR renovation and the equipment associated with that is really going to come to about $750,000 and that is a regulatory requirement that is not optional for us. And we've actually been trying to get that done for a couple of years, but with bandwidth and availability of contractors and whatnot. It's been impossible to get it done sooner. We have some rooftop units, some other major mechanical. And we do have a Dartmouth initiated project, which is rebranding wayfinding signage and all of that that will be implementing in the next fiscal year of note. We've been underspending for capital as you probably heard from most, if not all other hospitals, basically, basically because of bandwidth and supply chain issues. But maybe the most important thing on this particular slide is we will be migrating to the Dartmouth Hitchcock IT platform. Effective in FY 25, which means that we will be filing a request in FY 24. And we anticipate that that's going to be somewhere in the vicinity of approximately $9 million. So this is this is what we're all here to do. Right. This is this is what it all boils down to is functionally we've asked for a 2.4% net rate increase. Virtually 80% of our supply, our expenses are coming in with inflation increases greater than that. Travelers benefits and utilities have actually been favorable and we're projecting that would be more favorable than they've been in the recent past, which is great. That said, everything else is going up. Much more than 2.4%. And this brings us to this slide, which is, you know, we look at those three legs of the stool and every year we have to kind of figure out how to thread the needle. Just from an operating margin perspective, we have to look at what the Green Mountain Care Board would like us to do. We have expectations coming to us from the Dartmouth health system. We have expectations of our board of trustees and we look at our own financial ratios and determine what we need to fund capital and whatnot going off into the future. And at the same time, we have to figure out what our investment is going to be in quality to maintain the quality that we've achieved, but also to incrementally improve that over time. As we mentioned earlier, access same thing we look at what's it going to cost to improve access for our communities to the care that they require and and should and deserve. And then we also look at healthcare reform and what the likely changes are in the state of Vermont for that. And that's how we arrive at our request of 5.1% rate increase 2.4 net rate increase. And we try to thread the needle where we come in reasonable in the scope of what's going on in the Vermont marketplace and hitting the other things that the state of Vermont feel is important. And that's where most notably access of quality. Over our operating margin over time, I think it's kind of, I can't see that with the presentation here but I think it's one is roughly 1% over the last 10 years, which I think is very reasonable. If we were in other states we would be shooting for two and a half three as a critical access hospital. Risk and opportunity. You've heard the healthcare workforce, probably a nauseam over the last two weeks. We have wage pressures. Not only do we have the same wage pressures as everybody else in Vermont, but we're also competing against our mother company who's competing against Boston. They also opened a new tower a few months ago, hiring hundreds of nurses and other support staff. And none of this helped the employment market that we're trying to recruit ourselves. We're still suffering from the great resignation slash retirement aging workforce, cashing it in during COVID. We have an extreme housing shortage here in the upper valley, which frankly just got worse with Dartmouth's opening of the new tower. And of course we're competing with New Hampshire hospitals and non hospitals for back office staff who have a great deal more flexibility in New Hampshire to cover the wage increases that we do. Risk is the valley regional affiliation. We are that transaction is in the hands of the New Hampshire Attorney General and Dartmouth. Mount of Scott knee and Valley regional are in constants every week we have work to do in that regard for the transaction. We had hoped last year that we would have been closing on that July 1 of 23. Well, here we sit in the middle of August. And I would say we'd be fortunate to get a decision out of the Hampshire Attorney General by the end of October. So now we're kind of hoping for January 1 transaction date, but even that's a little risky at this point. Lastly, one of the other big concerns that that I've voiced for many years in these hearings as well as another settings is the reduction of dish payments. And that was made a few years ago is the gift that keeps on giving year to year, and the retail side of 340 be essentially those of us who are able to participate 340 be that revenue has functionally been cut in half for us at Mount of Scott knee. So the ongoing dependence on other operating revenues has come to roost. And so this also speaks to why we needed to ask for, you know, 2.4% net rate increase opportunities. Well, Valley regional also makes that one because there are some potential savings efficiencies that can be garnered with that affiliation. Dartmouth is in a constant state of rational distribution of services in the region, trying to figure out where where general surgery should be. What do we need for a urology complement within the system within the region. We will continue to pursue every opportunity in DH integration, whether it's in the group purchasing world, or in the sharing of services or support services from Dartmouth, and staff sharing. Another opportunity going forward is we're a stable organization we've been very predictable. Our board of trustees recognizes that Dartmouth recognizes that I believe that the Green Mountain Care Board recognizes that year to year we have a lot of fluctuation and a lot of change, and I hope that that's a value to you folks. In market share, we, we still receive about 26% of our business from the state of New Hampshire. We have another high single digit migration from other Vermont service areas to us. I think it's a reflection of the high quality and customer service that we provide and our employee engagement. And we are looking to improve some of the service lines that we've had for the last few years. Most notably, we lost our full time urologist during coven. And so we've kind of patch that together with local services. Now we've been able to broker a deal Joe Paris brokered it before he walked out the door. So we have about a half time urology service. They should be good for the next few years foreseeably. We're engaged and we've talked about this the last few years of succession planning for our ophthalmology professional as he nears retirement. And regionally, and I mentioned this in the global budget meetings regionally there are no ophthalmologists in Claremont, Springfield, Lebanon, aside from Dartmouth. And so we really there's a there's a need in the community. Dartmouth is backlog. If you decide to go get a cataract procedure at Dartmouth, you'll be fortunate to get in the next six months. So thankfully, our current turnaround time is very short, but our, our focus is on our communities and our patients. And there is clearly a need regionally to expand that service. So we are actively recruiting as we have been for the last couple of years. That's a tight market. And so we're hoping that we can get somebody on the hook over the next couple months. We're also working with Dartmouth on a possibility of a joint recruitment where they would hire someone and we would split the time with them, which would help them approve their throughput and help us with meeting the regional need. And so that's kind of the high view of presentation and trying to address some of the concerns that we were aware that you might have and we obviously understand that there'll be a lot of detailed questions that you'll probably want to ask. So we'll, we'll tap out on our end as far as the presentation and turn it back over to staff and board at Claremont. Thank you very much. I'll turn to Director Lindberg and her team for their walkthrough of the benchmarking tool. Good morning. Thank you so much for your prepared remarks. I think they hit a lot of what we had planned to touch on. So appreciate your preparation for that. So as you see, Mount Escutney is above the benchmark, however, and we'll update this value now that we know the commercial portion, but the commercial rate would be 3.4%. So that's the commercial anticipated realized change in commercial revenue from fiscal year 23 to 24, assuming a 5.1 charge master increase. Of note, one, the green check is a good thing, regulatory compliance. So everything the board asked for was addressed on time and completely. So always appreciate that. That helps make for a smoother process. And we also see a trend here where the operating expense growth and MPR growth are very close. And that's a trend that I think tends to show up for organizations with long standing management of their expenses to a high degree, to a very successful extent. So as far as that MPR benchmark, the 12.4 is above the 8.6. We don't have an official benchmark for the operating expenses. But we see that at 12. One thing I just wanted to give you an opportunity to talk about is in our conversations, Mr. Sanville, it sounds like you've been really trying to operate with a skeleton crew and trying to make do. And that some of the driving force here is really right sizing the labor force for Mount escutney. Is that correct or anything you'd say on that? Yeah, it's, you know, obviously nobody cares if the finance team is running short and we're grinding our staff into fine dust. I'm sure this season, you guys all can relate to that. Obviously, we're more concerned with the clinical openings. We've been running at 10% below FTE for as long as I can remember. I mean, well, back into COVID to put some perspective on it. And I don't want to be overly repetitive, but you know, a lot of things are connected, right? So we have competitive wages. We are not at the top of the market, but we are competitive. And with the wage studies that come out of Dartmouth and some of the others that we have access to. And what we hear anecdotally during the recruitment process when somebody applies for a job here and somebody apply the same person applies for a job at Alice Pecday at Lebanon. Yeah, well, I'm taking that job. They're paying me a dollar more an hour. You know, we've got some anecdotal information as well. We're, we've got a great environment to work on to work in. We have extremely high employee engagement scores for the last three or four years. We do a great job. It's a great place to work. And yet we have about 20 as we sit here today, we have about 25 FTE's worth of travelers in our organization. Historically, really up through the first year of COVID even, I think we were running at three to five FTE's at any given moment, going back as many as 10 years that I can account for. So this is a really awkward situation for us. Our, we did the first year of COVID. Generally, people pull in doubles and it was unsustainable and and so we've had to turn to travelers far less than ideal. We've been creative to the extent possible. We've altered shifts. I introduced Baylor shifts into our ancillary departments as an alternative staffing, which brought some staff satisfaction and less burnout. But we continue to run tight. And in fact, over the last month or two, our acute and swing senses. In fact, today was running, we were at 24 out of 25 beds. So, you know, we're running hot on the impatient side the last few months. And so, you know, just for maybe some of the newer members or staff, you know, we work off a staffing ratio. So the staffing ratio for that shift is five patients to one RN. Every multiple of five works really well for efficiency five 1015 2025. When you cross over into the next increment. 611, et cetera. You're very inefficient, but in order to meet the minimum threshold so we have gotten creative with sharing staff between the ED and the impatient unit, drawing people over at different times or if one unit is running hot. And we are very blessed to have a CNO here who will actually go down and do patient care and plug holes in the ED on weekends to minimize the impact of travelers and whatnot. And to be frank, I wish you would do less of that. But, but she's, she's a hero. She's an American hero. So, that's kind of how we're managing and it's been a little bit ugly from the last two and a half years anyways, but we're maintaining our quality and keeping our access up in fact, improving both. Great. And, and speaking of sharing labor across state lines. I know that's not always a trivial exercise is that also a benefit of your partnership with Dartmouth and kind of navigating some of that. Miss Jeff. Yeah, it's the catch is you have to be licensed in both states, but with Vermont adopting the. The nursing coalition and compact. That's made things easier. But restory therapy rad laboratory. And we've been, we've already been sharing managers are restored therapy manager is shared between Valley. We have managers who do some time at Dartmouth and do time here. And so we've tried to figure out how to broker things with flow staff for nursing, RT, and we're probably in negotiations every month on a new position. So we just needed a half an FTE and hiring for a half an FTE is ridiculous in this market. So we found out that Valley needed a half an FTE and so we hired a full time 340B analyst to help us claw back some of our lost 340B revenues. We were half time for us and half time for Valley. They're very happy Valley's very happy. We were able to do it as opposed to hiring an FTE and trying to find things for them to do. We also just did that with an emergency management lead. We were sharing that 5050 with Valley regional so we were able to fill that position with a half an FTE versus a full FTE. Thank you. In looking at kind of labor, I see the kind of decline that great resignation slash retirement trend that was starting to really hit in the post pandemic years and seeing, you know, the per FTE growth, you know, a little bit above the benchmark but also you started quite a bit earlier so when I look at it in totality, you know, if you're down toward the bottom so not seeing kind of any concerns from a staff perspective and the labor and your growth is within the benchmark. Not necessarily ever concerned when utilization is over that benchmark but I did notice that for fiscal year 22 your payer revenue really did not keep pace with the utilization change and I think you've kind of spoken to some of those challenges. Just wanted to give an opportunity if there's anything else you wanted to flag related to that trend. Yeah, I mean, there's kind of a couple key drivers in that one is we had a higher Medicaid as a percentage of business. Part of that was Medicaid extending folks coverage during the pandemic. But the other piece of that was just more people qualifying for Medicaid on an ongoing basis with the employment issues that they were dealing without the marketplace during COVID. The other thing is we took, we took some hits on our provider compliment relative to surgery and last year for budget we were conservative because the outlook for, you know, recruitment relative to urology. Dartmouth had pulled back their pain provider. We have a lot of, you know, incremental I called death by a million paper cuts. But it really hit the OR and so the OR is one of the better payer mix departments within the hospital so that kind of takes care of 80% of that discussion Sarah. We also had a lot of borders in the hospital that year. Yeah, thank you. And I swing senses versus acute. Yeah, we had I think we averaged something like six borders for most of last year. We're thankful that as of this week we're down to four. And nobody over six months or only one person over six month they just crossed. So. Thank you. And I would just note that maybe people aren't staring at these graphs as much as I would say that this very low consistent operating expense trend is unusual. And I think is a testament to some of your focus on those areas and might indicate some catch up that's going on in the current environment. So obviously your border hospital. So according to our data, which is certainly not perfect about half and half in terms of who's coming from the White River Junction HSA versus from out of your on HSA. But one thing that I just want to note here is this is one of the heaviest population mixes for Medicare. So, you know, you see how low the bars are for Medicaid and commercial and how high they are for Medicare. So that's saying of all the dollars that were spent in the White River Junction HSA. Most of those folks are going to be Medicare beneficiaries and of those dollars. Most of those do are spent outside of the White River Junction HSA. Since it's dollars, that's probably generally some tertiary care probably going to the appropriate facility across the border. But do notice that there's been a little bit more volatility in terms of the dollars over time and just curious if you think that might be pandemic related or if there's other kind of trends and utilization and what you're observing. Yeah, I guess, you know, of all the of all of the Tableau data presentations, this was the one that was maybe the most concerning from a just kind of what is it perspective and the issue and I break this up and other many other state settings. The White River HSA is a is a horrible measure for us. So the biggest practices in White River Junction are independent. They are not affiliated with Madison in any way. They refer to Alice Pecday and Dartmouth mostly Dartmouth for ancillary testing for surgeries for inpatient stays. All that goes across the river. It does not come down to us. Once you get below Hartford into Heartland now, which falls into that now you're talking about us, but really we bump up against the spring field. And we're in stone store distance of Gifford. So the White River Junction HSA actually goes above White River Junction and we don't even know who those people are. So we should, you know, I don't, I've been complaining about this for 10 years. I don't know that there's I don't have a productive solution to offer. So I apologize for just ranting, but you know, really this is this is Dartmouth experience. This is Alice Pecday experience at large. Yeah, that's fair. Yeah, I do think that moving towards maybe a Dartmouth Atlas or another indicator that isn't so hung up on these state lines that patients maybe aren't would be beneficial. So I totally hear that. All right. And then everyone's favorite page is the cost report. Lots to say about what this isn't isn't. But as far as we can tell from what we've got here. Now, escutney is somewhere there you are a relatively small critical access hospital among the peer group. And we see that you I was a little bit surprised that your case mix index was as low as it is here in fiscal year 22, given your service mix. So just is that I mean you're probably closer to this than me just wondered what your impression was of that indicator. Yeah, so actually if you just move your cursor ahead. Thank you. So, so, you know, we went and actually looked at this to see how we were running this year versus last year. So our rehab are the highest case mix index, because they're medically complicated and required great deal of rehabilitative services swing bed is super low. And swing bed is essentially, I think rehab and swing are 75% of our of our inpatient universe. And swing is about 60% of that business, which is generally a case mix in death somewhere between 0.75 and one, you know, on a few were to look at the range of case mix. So this actually tied out to what I would expect to see on here. Pretty darn close and it is what we're running this year. I think last year was 1.18 and this year we're running at 1.17. So it's pretty tight. And that probably is a good segue to, you know, obviously, this would be an outlier at the 29,000. But if this were a peer mix of other of other hospitals that primarily are doing rehab services, my hunch is that you'd be if not at close to the median. I didn't have a chance to confirm that, but well, but just. Yeah, go ahead. I'm sorry. Yeah, so, so you you alluded in your question your staff questions that are are inpatient service mix. It's the same issue as the last conversation except it's more accentuated statistically so Andrew and I went and just kind of looked at the Y-22 bus report and looked at our discharges and we did the math and I tied within less than $1,000 of your number looking at it and aggregate. So we're comfortable with that. If you look at rehab by itself, the numbers more like 37 as opposed to the 29. If you look at swing, I think it was somewhere around 34 or 35. And so that's what's pulling everything up. If you look at our inpatient acute, which is again, very small percentage of our business. You know, we fall within the range very easily. But as soon as you add swing, which are, you know, those are all multiple week stays for swing and rehab. And, you know, swing goes, we have folks in here, you know, now crossing the six month line. So not a lot of discharges with a lot of charges in patient days. So, yeah, to your point about comparable critical access hospitals, there are less than 10, I think distinct per rehab units with critical access hospitals in the country. So, yeah, if you could share that list, I think it seems appropriate to have a different peer group given your unique bimodal service situation. Sorry, I missed that. Could you say that again? Yeah, I believe there are about there are less than 10 distinct part unit rehab hospitals part of critical access hospitals in the country. So critical access hospital is allowed to have a 10 bed distinct part unit, which is generally either a psych unit. Or a Q rehab unit. Or. Yeah. Yeah. And so you, which you'll most probably see would be psych or Jerry psych units. And especially with the Jerry site with the, the Medicare population, most CHS have high Medicare population as Sarah pointed out earlier. But to have an inpatient acute rehab unit. It's, you know, when just commented that, you know, we're a bit of a unicorn and that's definitely true. It is very difficult to manage the quality in a 10 bed rehab unit. So the people we compete with, so to speak, you know, we don't have any immediately close to us, but UVM has a 20 bed unit. Robin had a 10 bed unit that closed it. Cheshire has a 20 bed unit. There's around 140 beds down in Concord, New Hampshire. There's some down in Nashua, then you're down in Spalding in Boston and there's main med has one in Southern Maine. So, but they're all much larger units. And so for us to be knocking car surveys out of the park, compared to those folks is really a testament to our rehab director. And they did a tremendous, you know, flagship service for us, but it is makes us a unicorn and creates us having a weird dots on whiskey charts. So, and then we've kind of been over the limitations of this indicator any thing you want to highlight in terms of some limitations of this indicator that we're trying to get at. Yeah, I was a little bit surprised by that. And to be frank, maybe it's worth a sidebar discussion. After these hearings, just to see how people were reporting. I kind of laughed at some of the benchmarks who were running down at, you know, near zero, zero and near zero. So you know they're part of an RCH part of some system and everything's back office at the mother ship. They're not counting anything, which is really a possible. But it would be interesting to see how people, what people were putting in that bucket. I feel like when I look around at other CH's and with the exception of the quality department, we're pretty tight here. We have our billing department is runs two thirds of what most CH departments run at. I mean, I just, you know, look at the, you know, it's a handful of departments, it's not 100 it's, it's maybe a dozen. And I look at that. And what I know, and I've been able to look under the hood. I've had the privilege of being part of Dartmouth's integration work and performance improvement work in London and aspect a and sprint field and valley. And so I'm coming from Gifford fairly recently. I kind of know where everybody's at for staffing so I was a bit surprised. But we can definitely clarify that. I appreciate your thoughts on improving that indicator. So it measuring something that matters versus maybe some just accounting. I just think we got make sure we're all reporting it the same, but I don't feel like we're egregious on there, but it's, it's, I understand the concern. Yeah, you know, for the cash available at the end of fiscal year 22, I'm seeing, you know, 44 million knowing that that's maybe not all unrestricted, but, you know, within the kind of middle 50% of the data. And then the only other place where you kind of are broaching the upper values is related to this earnings her adjusted discharge from what you've said about the very high unit cost for your services. So that's mostly what that is picking up on. But please correct me if I've got that twisted. Yeah, we I actually didn't do the math on this one, but my gut was exactly what you just described. So thank you. Yeah, okay. Wonderbar. All right, so cost coverage. So we see here that over time. And he's got an unusual pattern in terms of the cost coverage for Medicare allowable costs. I'm guessing that some of those funkiness is going to be the unique services that you're providing, but also guessing your commercial populations very small. So some of that volatility is likely due to small numbers are seeing again less of a kind of downward trajectory, more of an even trajectory among the Vermont Medicaid payments, although we see that starting to creep downward from 21 to 22. And, you know, providing generally a higher cost service as you described, but the cost coverage, you know, not, not really meeting that Medicare allowable costs for Vermont Medicaid and that kind of being made up on the commercial side overall. So just don't know if you have any comments about this indicator or if you think we're not getting the signal. No, I think when I looked at that, and I looked at the comparative actually do you like the presentation in looking at the comparative. I wasn't surprised by anything I didn't feel like anything was was way off. We clearly aren't getting costs on on Medicaid and we are all coming in at 99% is the ages with the sequestration, basically, and I felt like when I looked at the commercial. I was maybe surprised by this graph at the variation. And because this is this is really a percentage of costs associated with those services commercial services so it's, it's really not so much a demographic discussion. So I was, I don't really know what my, my conclusion was when I looked at it but I didn't, it didn't feel wrong when I went back and looked at our revenue model and compared it. Yeah, and I don't know if we've done this, but I just notably these have gone way down since fiscal year 17 and I just think if people didn't know that that's an important thing to know. So as far as Rand. So again, I think this standardized price per inpatient stay is really just measuring the services you provide and seeing that on the outpatient basis, you're in that, you know, near the 25th percentile. So I think that this is mostly just measuring service more than the price per se. And again, if if you're able to provide those comparators happy to kind of make sure we're doing you justice in terms of a comparators. So that is all staff had happy to hear any other reactions you might have before we turn it back to the board. Yeah, if you could go back to the ran data please Sarah. So, you know, and what's interesting about this is, is I'll be curious to see how our patient looks going forward, because we did our large price decrease. So that was outside of the Green Mountain Care Board approval in 2020. So that was probably the better part of $2.5 million in the ancillaries that we repriced in 2020, which obviously trickled into 21 22. Jessica Holmes astutely asked in our hearing. Like, are you going to be able to pull this off because we had a very low ask for a rate increase that year, I think it was two might have been two and change and, and, and, or you're going to need to come back, you know, and reset. And so we were able to, you know, our estimates were accurate. And so we were able to absorb that decrease as well as continue on with a low price increase through that period. So I would expect that that would get better in 21 and 22. Thank you. Appreciate your. Straight shooting as always any other reactions generally before we turn it to the board for their questions. No, I think we're good here. Thank you. All right. Go ahead to your foster. Thanks. I'll open up to my fellow board members. First, if they have any questions. I just have one, which is, could you speak Dave a little bit to your thinking around Medicaid redeterminations? Yeah, you know, so those those, as I understand it, you know, start rolling out in April. We have definitely seen a small change in our Medicaid percentage over the last couple months. I don't know that it's statistically valid, but we're seeing some movement on that. We last the beginning of this fiscal year FY 23. We liberalized our free care policy a bit. So we're trying to kind of glide path to next year's mandate. Right. So we expect that the folks who are coming off the Medicaid schools will migrate to commercial or free care or bad debt kind of in proportion to where it has been historically. That's kind of the bet we made. We don't think it's all going to bad debt. We don't think it's all going to commercial. One of the issues is I don't know how the exchange is going to handle mid year terminations. To me, this is a one of the life changing events that allow you to open and roll the middle of the year is losing coverage. That's the way we offer our program here and most of the other lawyers as well. So we just kind of figured we're going to be spreading it based on historical and it's not going to be overly radical for any payer group. That's our bet. Thanks, Steve. That's all I had. Thank you. I have a couple questions that I can jump in. So a few things I picked up from your narrative and a few things in the presentation that I'd like to just expand on a little bit. And one was you talked about the telehealth services for emergency medicine and neurology. And I was just wondering if you could describe sort of the frequency those are used and the impact that they are having. It's fairly low frequency. So it's, you know, it's when you need it, you need it. Right. So I think tele-sign has been the most utilized and we utilize that in the ED as well as the inpatient unit. Neurology, we literally just signed up for that. So other than test testing, we don't, we don't really have any practical experience with that. But it's, it's, it's been a, it's been a help in a small hospital to be able to get a sub-specialty consult on the fly with folks standing by. We, you know, one of the things is Scott Rody, who is the ED medical director at Dartmouth, used to moonlight at Gifford when I was there. And he loved coming to the CAH to work without a net. That's how we refer to it. When you're at Dartmouth, you can get the kidney specialist. You can get, you know, whatever you need in short order. If you're at a medical access hospital, you are working to a degree without a net and this reduces that and improves the, the outcome and the quality. And frankly, sometimes we're able to not have to transfer a patient because we find out that they can be safely managed locally and not put them through the rigmarole of being sent to Dartmouth. I think the other piece of it too is our ER in particular runs on APPs. So we are, we don't have positions typically in our ER. So we need some backup to provide them clinical expertise in decision making and course of care. So that kind of thing, the tele-support and the ER in particular is supportive of how we operate. I'll throw a caveat out because most people don't realize this, that those telehealth services are not billable. And mainly because of the complexity of the process and the credentialing. And in fact, when we just recently signed for the Neuroservice, I pushed back with Dartmouth a bit and said, we've got to push back a lot. Okay, that nobody agreed. Mound Care Board is surprised by that. But thank you for pointing that out. So yeah, so I did push back a lot. I forgot I'm under oath. I should, I should not exaggerate or minimize and said, you know, you, we've got to be able to, to bill for this. So Dartmouth is building us on a per encounter basis for that. But we're not able to build a payer for compensation. And they're not able to, you know, and it goes back to for those of us who've been around a long time. The Nighthawk services for Rad reads, right? There'll be somebody in Australia reading the MRI at 2am and we'll send back a read for the ER provider or whatever. And then the hospital, you know, would bill for that because they enrolled that provider into their group. So we would write a check to the Nighthawk service and then we would bill the payer. And that, you know, wasn't always one to one, but it was pretty close. Nobody complained about it. This is this, this service, the way it is designed in a way is rolled out at this point is unbillable for anybody. So we're just writing a check on a per encounter basis. And it's well worth it for the infrequency and the need. Okay. You talked about some volume changes associated with your walk-in clinics and avoiding patients having to go to the ED. Do you have any idea if you can quantify those at all? Yes, it's approximately 700 people have been redirected from an ED setting to the walk-in setting. And that's with, that's only Monday through Friday for four hours. So we're actually been discussing just this one year about what's the appropriate expansion for walk-in just because we, we took all those 700 patients out of the ED. And those were identifiable. Yeah. Thank you for posting that graph. This is kind of what we've been tracking. So we talked about ongoing monitoring about services. This is kind of the stuff we do on a regular basis. So the ED was growing very quickly. A lot of that covers the COVID time period. And then you can see a big drop off in the ED volume, which is the red line. And now you can see it's climbing up again. And the walk-in clinic is the light green, sage green, whatever line on the bottom. And that's been trending up since day one. So we figured it would alleviate some of the staffing in the ER as well as do the right thing by payers and patients and whatnot and take care of the patient in the appropriate setting. And guess what happened? Well, the waiting at the Mattis County ED is low. So now we've got this organic growth back to the ED again. So now we're having to go back and revisit and say, well, now we have to again walk-in to shunt some more patients over from the ED. But it's also a benefit. The walk-in's been a benefit for our primary care clinics as well to take care of those same day acute requests that come in because that's what they do. They're set up to do that. And we haven't had, we've had a challenge for primary care access. So it has allowed access for people who typically would get an urgent appointment with their primary care on any particular day. But there's no capacity in the clinic because we don't have enough primary care providers. So we're working on that. So it's in tandem with primary care and it creates an opportunity in the future to bring some of those patients in to get a primary care with us as we bring on some new providers coming up. And that 700 patients is what timeframe? A year and a half. Great. I just have a quick follow-up question that relates to this day care. Yeah. I'm just wondering, one of the things that we've heard from primary care providers is that when there's a long wait times for imaging, whether it's referral lag or visit lag, that primary care providers will basically send their patients to the ED to get that imaging done. And I did notice in the referral and visit lag that you do have some wait times for some of these CT scans and whatnot. And I'm just wondering, could any of that increase, you've got primary care access concerns, but you also seem to have wait times for the imaging? Could some of that also explain some of the uptick in ED? No. I don't know how to say this, so I'll just say it. You guys should be used to it by now, right? I would kill somebody if they did it. I'd be like, what are you doing? What are you doing? This is not how we do business. So no, so I am unaware that that has actually ever happened here, unless a primary care provider on call over the weekend when the clinic was closed needed a follow-up on somebody they saw during the week. That would be the only exception in my mind that would be acceptable here as a practice. And even that's, boy, that would be once in a blue moon. So now I have to go look, Jessica, when I leave this meeting and find out if that's happening. But I have, we do look very tightly at the ED sources and I get reports from radiology actually reports to me. So I look and I look at all the referring providers and the sources of all the referrals every month. So I've never had any whiff of that whatsoever. Okay, well, thank you. Looking at that data would be helpful just to make sure that sounds appreciated. Thank you back to you, Dave. Other Dave. So one thing you kind of answered part way through from a question that came up that I've had, which is you talked a lot about the savings associated with Dartmouth. Maybe if I was to sort of eyeball my memory of the presentation, a million and a half, $2 million between shared savings associated with Valley Regional benefits programs, 340B. But as we know, there's costs associated with affiliation as well. And you talked about a $9 million IT upgrade that's going to occur here in the next two years. Are there other expected costs that you have that are associated with the Dartmouth affiliation? Yeah, we have we have a shared service allocation that comes down for the services that they routinely provide for us, which to your point is standard affiliation. And so you'll be seeing that with Southwestern. You know, right now we're the only Dartmouth Vermont shop. So, you know, it's a little bit different for us than it is for the other affiliates on the New Hampshire side. But we do have a shared service allocation that we're not at 100% allocation, but we're going to be running somewhere is probably around 600,000 and change, I would say off the top of my head for the upcoming year, and it incrementally goes up as and sometimes it's offset by direct expense leaving our shop. You know, so, and sometimes it's a half and half like for our IT staff, half of them are employed by Dartmouth, and half of them are employed by us as we migrate to this platform. And so what what we do is we take all of our direct expense, we send it up to Dartmouth, and then they reallocate it through the whole system. So, I can't just take my share of shared services and then my own share of local, it has to be all thrown in the bucket, and then dispersed by metric. So, there's never a good way to do this. I've looked at some other systems they're all doing it the same way to varying degrees they might use different metrics but to determine what everybody shares share would be. But that will that will grow as we become more and more integrated and the goal is that we're able to alleviate direct expense here to offset that as much as possible. That's kind of what we're trying to do here. And again, access to higher quality services like cyber security. Yeah, cyber. We couldn't afford to provide the cyber security that Mount of Scotty enjoys as a critical access hospital we would we would, it would be just a ridiculous endeavor for us. So in that case when we get a shared service allocation for cyber security. It's actually beneficial to us because we're getting an amazing product. It was such a small piece of the system that we get a very small disproportionately small allocation for that. So that one actually works for us both ways. And where's the 9 million expected to come from for the HR. So it's at last, we're supposed to have an updated pricing actually this month by the end of August. Essentially, the short story is that going on to epic. The HR will probably be 3.5 to 4 million of that 9 million. And at this point, probably about two and a half million for the HR and financial applications. Those are the two big pieces. And then there are some other smaller pieces and some infrastructure requirements but that's that that's the 80% of it. And the source of those funds to pay for that. Interesting. You asked that. So, if from an accounting perspective we will be required to depreciate that entire project on our PNL. However, it will be funded 2575 so we'll write a check for 25% of the 9 million and Dartmouth will fund 75% of the 9 million. But the entire project will be required from an accounting principle to be expensed on our PNL. Which is beneficial to us as a cost for triple axis hospital recognizing the cost of the cost report. Okay. Thank you. Thanks. A couple questions from me as well. I'm wondering. One of the costs that you reference related to the transfer expense you did a great job of articulating how much the loss has been for some of these patients that you are unable to transfer. You know, once they no longer need a acute care setting between, you know, 2.7 2.8 and $3 million a year in losses for unreimbursed care. You know, we've heard from that there is going to be increased capacity of SNFs in the state. And I'm wondering if you've factored that in. Do you think that that will impact 60 new beds coming online sometime in the next year? We understand trying to find more about that. But will that impact your ability to transfer patients will have any impact on your net patient revenue. If you can replace those beds with higher paying acute patients. So the theory would be yes. You know, so the problem is that some of the patients that we cannot place. They would be hard to place, regardless of the number of SNF beds available. They have complicated social issues, behavioral issues, whatnot. So those are the ones that we truly call borders because they're there. You know, I would report on the board on a border stat. The person who had stayed three extra days waiting for a bed to open up a Genesis. We wouldn't really consider that in our in our discussion with you or even internally because that's just the complications of doing business. But when we talk about these long, long stay patients. I don't know that 60 beds in Windsor would necessarily do anything but move the needle a bit because most of the nursing homes they're still under staff like we are. So they have closed beds. Most of them now have a pair percent caps, right? I'm only taking so many medecades. I'm only, you know, so it's going to be a lot harder over time. I don't see any material change in that to speak of it would be great to get a couple people out of here. We do get the care management team each of me for an hour every Wednesday morning. And we go over every patient that that could be a problem is a problem. What are the barriers to getting them out? What creative solutions can we come up with to assist that process? It's pretty robust and we're happy that we're able to move some of these patients. I'm not sure every other place would be able to, but we've been able to be as effective as possible. But what we're left with are near impossible to move to any setting. So just as a quick follow up to that as we embark on this new Act 167 hospital sustainability work. And there are going to be some recommendations that presumably will come out of that. We've been hearing from multiple hospitals about this concern about transferring patients and, you know, beds being utilized for subacute care. Having a cost to the system. Is there a recommendation that you would make system wide? For example, if you were pitching to the legislature, what would be your recommendation now to solve this problem? What do we need? I think when we look at some of the geriatric site needs, we need to open some beds for that. Alzheimer's unit, those types of things, those are the people that are just, no one can take them. So there's not, there's a facility in New Hampshire called the Ray of Hope that we send the very complicated behavioral patients who would normally, they didn't have the behavioral issue would be a nursing home placement. But they can't because their behaviors, you know, are really complicated, difficult. And so, you know, they'll go up there in medication management and kind of get them into the sweet spot of what makes them easier to take and what medication regimen do we need to establish for this patient to make them more takeable. Those specialty, you know, memory units, I mean, those are the types of things that I think would solve a lot of problems. As you guys have probably heard, the VNA has been running radically low in staffing and now has reduced their footprint in New Hampshire and Vermont. So, well, we had some patients who would be, you know, okay, get them to a certain point and they can discharge home. They have some oversight, but they need some home health. Well, now we've lost a good percentage of that as well. So, I would go with the specialty units would be my first recommendation. If you guys could take care of that for me, I'll call it good. Well, I'm going to throw it right back at you for a second, because, you know, you, you all are in this unique interesting position where you're working on an affiliation with, you know, Valley Regional. You're a part of a larger system. Dartmouth-Hitchcock and it's all of its satellite areas where the system is constantly looking at the rational distribution of services and what the needs are. And you mentioned earlier that critical access hospitals have this opportunity actually to add on a geriatric psych component to their service line. So, I guess my question back to you is, why doesn't Dartmouth-Hitchcock writ large the system and the potential affiliation? Is this on the table to add a geriatric psych, you know, unit that would take care of this, you know, for the rest of the state and presumably for Scottney? So, I have, I have been in meetings at Dartmouth over even the last two months where we've talked about what could be done. One of the fears that they had was opening this new tower that we were just going to take all these subacute nations and fill the new tower, right? And they have the same problem we have, which is getting people out. And sometimes we're able to help them. Sometimes we're not, but they have been discussing this. They have been speaking to their affiliates. They have been working with the local nursing homes. These are all things I actually can testify to. But setting up a distinct part unit is a level of complexity. There's a moratorium in New Hampshire on nursing home beds, right? Most states have moratoriums on adding new beds. So, even with Valley, this has come up multiple times. They have an old OB unit that is largely unused. And so, I've been involved with three meetings of what, what can we use that for? And of course the Attorney General of New Hampshire, you know, they're interested in what, what, what, how that resource so that that space might be used. So, those are real ongoing discussions. Jessica, if it were up to me, it would be done faster, better, but it's very complicated politically, especially with the affiliation and the AG looking at that. And as the cost report guy, I'll, I'll add a piece to that distinct part units are generally cost draw from critical access hospitals. So, it reduces Medicare reimbursement. That's why there are so few in the country. So, it will draw cost away from our reimbursement and reduce the margins. Yeah, I think the, the, well, we had the hospital based nursing home when I first got here that was in the process of being unwound. And I think that was 22 beds or something like that here. Medicaid was adding a little bit to recognize the cost issue that Andrew just referenced, which was great. Grace Cottage got it, Gifford got it, Madison got it. I believe those were the three at the time. The nursing home took $2.4 million in today's money back then it was like 1.7 but 2.4 million dollars off the table. Because it was attached to a hospital so the hospital lost that much reimbursement so that the nursing home could lose money. But now the world has changed, you know, 10 years of role by and now there's a greater need for these nursing home beds will be aging population and all the things that you already know about. And Andrew's point that a lot of not a lot of CAH is saying sign me up for taking $2 million off the bottom line. But I will say that I have developed a proposal that's being kicked around where if Dartmouth is able to fill a subacute bed or a bed with an acute patient versus a subacute and subsidize the facility that's losing the cost. These guys stay even and Dartmouth puts margin up. So there is there is a play there. It's very complicated. But the problem is you can't get permission from the state of New Hampshire, which is where most of their affiliates are to open a nursing home unit. And had an appendage to the hospital. So it's just, I think it personally could be done. But it's it's a it's a political hot potato. Well, hopefully we'll have maybe more conversations about the possible solutions here. You know, as the stack 167 work continues and I'm sure you'll be tapped for your creative solutions. Let me just ask one final question and it relates actually to the rational distribution of services that Dartmouth Hitchcock undertakes as it's considering all of these affiliations. Does Dartmouth Hitchcock use minimum volume thresholds to ensure high quality and low cost care other minimum volume thresholds for example for orthopedics or for other types of service areas that are deployed when they're evaluating those rational distribution of services. I'm very confident that that is used everywhere at Dartmouth. And even in primary care where there's no procedure minimum volume per year to maintain competency. But it's come up in our in our discussions about joint recruiting an ophthalmologist for the region. Here there is a minimum number of cataract procedures that you should be doing in your or the not only maintain the competency and quality of the provider, but also the nurses and texts assisting them in the in the or so it's really a two level competency. So I'm, I'm very confident to say yes they are and I know that they're doing it in primary care I know that they're doing in orthopedics I know that they're doing in general surgery. I think it's an easy assumption that they're, they're using it globally. Fantastic then would you be willing to have them see if you'd like to share that with us. I would really appreciate seeing what those minimum volume thresholds are to ensure quality and efficiency in the delivery of care, particularly as we're embarking on this act 167 work. So if they would be willing to share that that would be super helpful. Thank you. Any other board questions. I think I just have one really little set on slide 19 of your presentation, you have the request, and then you have the various realization percentages and then what I think in brackets is the net rate that you anticipate. How do you anticipate through the math on these, like how you anticipate Medicare realization 47, like where these numbers coming from. So out of the 5.1% increase Medicare will recognize 47% based on our historical reimbursement rates. So 40.47 times 5.1 equals 2.4. And Medicare typically recognizes 47% of our rate increase. And I know that that may slightly differ from what the staff has put together for you. I'm using a model that gets cut differently than how Sarah cuts the data. So I won't say that hers is wrong or that ours is wrong. It's just cut different. It's going to be reasonably close to to what the staff has produced. And so Medicaid base 27% of that 5.1. So we realized 1.3% in our payments. Now I will comment on the Medicaid because that was one of the questions and subjects that came up in our narrative as well as the subsequent staff questions is. Medicaid did you guys pick up for Medicaid's improvement of professional billing. And so we are very happy that Medicaid through some money at primary care and surgeries and specialties that's great. We really appreciate it. However, we didn't get an increase for inpatient outpatient inpatient rehab and certainly not swing. So when you look at this number, chair Foster, you'll see that that 1.3 is assuming we were going to get something from Medicaid in all lines of business this year. So we've actually made a bet that's not going to be fulfilled. So we are actually our expectation of Medicaid realization is actually lower than our model would project. Okay, sorry. And I might be missing something, but so your, your change in charge request is 5.1% and you're saying you're going to seek 5.1% increase, but Medicare is actually only going to give you 2.4% rather than 5.1. Correct. That's when the dollars come in, it's going to be 2.4% on any given service with a 5.1% increase that was a Medicare patient. Okay. And he may have said this, but where did the 47% number come from? It comes from our historical run rate of reimbursement percentages. And it's not to the penny because we have anticipated cost report settlements coming in and, you know, but it's it's it's pretty darn close and it has served us well over the last 10 years of budgeting. We were seldom surprised. Okay. And so then on commercial, if the care board were to provide a 5.1% increase, you're saying that historically you get 67%. So therefore, if we give you 5.1, you're going to get 3.4 in reality. That's what this is indicating. Yes, that would be correct. Okay. And then you had said, I think in your opening that the net would be 2.4. And that's just taking all these numbers and waiting them. And that's how you come to the 2.4 net that you had represented. Based on our historical service mix, what we budgeted for a service mix, our payer mix when we're budgeting for a payer mix in our historical reimbursement rates and other deductions like free care, bad debt. Yeah, we'll get 2.4 of the 5.1. Okay. All right. So the free care, bad debt impacts your realization rate. You're even looking at our P. Yes, if you look at our P and L and look at take that patient revenue divided by gross patient. It's going to be less than 50%. And I don't think that's atypical. For CH's and so the 67% for commercial realization. That is not directly representative of how much you end up. Obtaining in your negotiations with insurance companies, isn't. That's based on our current terms. So if we had to. So if we had to renegotiate with a payer effective October 1st. And you guys agreed to the 5.1, which would seem like a great idea to me. Then I would be negotiating with the payer to ideally maintain or maybe even hopefully improve, which like never happens in this day and age. But, you know, our percent realization. Okay. And so is that because you have a negotiated discount off of change in charge with the insurance companies? In a couple cases, but mostly not. Chair Foster. Could could I ask a follow up? Please. I'm still a little bit confused. So if my organization made $100 last year. And I applied for a 5.1% increase to my regulatory board and it was granted. This am I to understand that the, the extra $5 that I made that year. 67% of those new $5. Would come from commercial payer sources. No. Okay. So really, if I may try to take your example and change it slightly. If you had an x-ray that you were billing for, and it was worth $100. Right. That was your bill to mount gross charges. And you send it to Sigma. Let's say Sigma paid the average of our commercial realization rate. I think it would send us $67 feeling about copay deductible out of pocket. Then next year, the Green Mountain Care Board approves your 5% rate increase. So that x-ray is now $105. Depending on the length of the contract that's hanging out there and the type of contract, right? So if you were to say that Sigma wasn't being renewed and it was a standard percent of charge. Then they would pay you 67% of the 105. So let's call it three and change. So they, last year you got, you got 67 and this year you're getting 71. Does that make sense? Yes. We talked about that with hospitals last week. How the negotiated reimbursement with commercial payers is on a multi-year contract. While the budget is changing year to year. So I do understand that. So that's helpful. I still want to think about the rest of your math, but that's very helpful. Thank you. You're welcome. Yeah. So on the Medicare part, does Medicare change their reimbursement to Madam Scott need based on. Our budget decisions. Yeah, Medicare. Sorry, Medicare doesn't give a Rax fan. They just pay us what they ask after audit of our cost report and our legitimate expenses and our annual audited financials. Right. Sorry. I guess I'm still missing how it goes down 53%. Because they don't pay us, they don't, they only pay us cost. That, that 47% is the percent of charge that they typically pay based on our historical run rate and we use that run rate to predict the future. So Sarah talked about earlier, then if you look at us historically our expenses and our net revenue, one pretty tight. And as long as we stay tight with that, then, then this number becomes applicable to the future. Okay. If, if I decided that we were going to pull off a 5% margin next year, then there would be a break with that patient revenue and expenses. And I wouldn't be able to use that predictor for Medicare reimbursement because our expenses would not be growing in line with net net reimbursement. And Medicare pays by way of interim payments for outpatient and, you know, per diems for inpatient and then get settled at the end of the fiscal year. And an ideal cost report settlement is close to zero. So, you know, we like to maintain a very solid interim payment rate. Okay. Any other board questions? Just, just one more on this same thing. So the, the calculations that you shared with us on the slide that you use those to monitor your expense growth. And keep your expense growth tight to your expected revenue. Is that correct? No, no, they relate them and we compare them, but they don't drive them. So if I were to answer how do we budget, I asked my people three things. One, how busy are you going to be in your department next year? How many people do you need to perform that level of volume, which we test against historical productivity? And how much stuff do you need? Paperclips, bandages, whatever. And then we, we, we run that data through. And then we look at what, what amount of price increase do we need to cover that expense growth? And, and we do that based on our historical reimbursement rates from all payers. So they're done in concert, but they don't want expenses drive the bus more. But net revenue growth. You know, sometimes we have to go back and we keep revisiting the expenses until we can line those two things up and decide what we can live without and what we need to have. Thank you. Hi, thank you, Chair Foster. This is Charles Becker from the health care advocates office. Just have a quick question about your pharmacy charges. On page four of your narrative, you said our pharmacy prices are based on acquisition cost. So no price increases are applied to pharmaceuticals. And that stood out to me in a really good way. And I was going to ask you today if that actually meant your pharmacy costs are flat. But then on one of your slides today, you said pharmacy is up two to 8% with the highest cost meds up greater than 4%. So I'm just trying to reconcile those two statements if you could speak to that. Yeah, fair. So this is one of those examples where two things can be true. So we, when I got here, we had a multiplier for drug costs 100 bucks, we do a multiplier and it's this and so it's high. And it's just tasteful. And so literally for 10 years we have never increased our pharmacy markup to cover now every year we just zero literally every year I've been here at zero. Now, if there's that product gets replaced with a new and improved product that costs more, which is usually what happens, right? We use the same markup. We don't change it. We don't, we don't, we don't take last year's $500 med and make it 505 this year and none of that happens. That said, in the inflationary question that you referenced secondarily. So yeah, depending on the, the drug that we're talking about. So infusion drugs, whether chemotherapy or medical infusion those are all the higher end of the inflation spectrum if you were to go back and look at the trade journals, and the others not so much. So if they're, if their pricing changes, that's our acquisition cost, but we never change the markup it stays, it stays relatively flat and what happens is as things become generic, or not the bleeding edge right then there's actually a regression and price. And on top of that we go after the 340 be mixed use discount which is roughly 20%. Does that help or does that make it more murky? No, it helps actually and one of these days I'm going to figure out pharmacy pricing, but probably not today, but I appreciate your response. Thank you. Thank you. And we have no further questions. I'm sorry. Any public comment. Mr. David. Thank you, Mr. Chairman. The sort of made this comment before but the today's activities and the keys of the, the, the budget discussion so far just made it seem much even more, more important. And that is it there we just have a huge air or of unreality here. It's a it's particularly difficult of course in the in the valley which is just a tangle. It's going to be hugely difficult to make any real sense out of that because Dartmouth, okay, is is so huge and Dartmouth should be doing has to has to do all of the tertiary care and tertiary care is where all the money comes from. So the small hospitals, especially in Vermont, but they have small hospitals everywhere have a terrible time making enough money doing the stuff they have to do. So they try and make up the revenue problem, revenue deficit by by doing as much heavy stuff as they can, they can manage. This is all actual that there's a huge amount of data to show this. No, but this board has not looked at it at all. It's they have not looked at stuff like the leapfrog tests for surgical volumes they have not looked at the problems with the quality problems of the Vermont system as shown by the PQI and data. They have not looked at cost per capita in the service area which is the real the real the real way we pay for health care we pay for health care on a per capita basis, not an individually on an individual basis. And nobody has said anything about all the consultant work that shows that Vermont needs 154 at least, at least 154 fewer beds that would accomplish six whole critical access hospitals. And the problem about this, of course, is that it's so painful. I mean, it's politically painful, but that is the reality. And until it's because we don't need 14 hours, we need maybe four, maybe less than four. Okay. And the ultimate I think of it I've never seen the first really, it's interesting the first thing I've ever heard that got started to get at this area was member homes today, wanting to know from DARPA. Well, how are you going to get enough volume to get make your service areas look service lines look reasonable. And you have to find out from that with with you tell us what you have is you have, you have a pile up to the ceiling of data in your archives to tell you exactly the answer to those questions. Okay, and the problem is not that the data isn't there, but that is the political will isn't there. Thank you. Any other public comments. Okay. I'll turn it back to the mouse cutting team for any closing remarks you have. I appreciate your time and it's always fun to see you guys every year I look forward to this, then I look forward to my post cream on care board vacation. But I think the one thing that really I think we should think about there's nothing to determine here today is, you know, our volume is not because we're marketing. Our volume is our volume. It's because we have community based services that we're providing at a high level of quality with a high degree of patient satisfaction. We don't we don't have an orthopedic subspecialty we're not doing plastics here. We're just providing good quality community based care. And I think our rate increases is very reasonable. The issue with the net patient revenue growth is primarily volume, which we actually can't really stop from happening and I'm pleased that people want to come here and use our services. I think it's beneficial to the state of Vermont. It's beneficial to Mount of Scutney that if we're able to enhance our volume from outside the state. It's a benefit to everyone involved here in Vermont. I can't say the same for the person losing the business on the other side of the river, but there, it's increased the provider tax it's an increase for jobs. It has a multiplying effect over time and I would hope that you guys would consider that in approving our budget. We're not generating new business. We're just taking care of whoever shows up and doing the best job we can. We appreciate your consideration and look forward to a favorable response. Thank you very much. And Mr. Brown is nice to meet you and we will adjourn. Thank you and we'll adjourn till one o'clock.