 So we're going to reconvene and the second hearing today is Montescutney Hospital and Joe, besides yourself, who will be presenting today? Dave Sandville, who just popped up. He's two doors down from me. We have a second wing person, Theresa Tabor, who is our controller, but would only be engaging if there are questions that Dave and I can't answer, but we should be swearing her into, I believe. Sure. Let's swear all three of you in together. Joanne, if you could do that. Would you all please raise your right hands, please? Do you just swear that you're about to give the truth, the whole truth, and nothing but the truth? I do. Thank you. So, Joe, whenever you're ready, you can proceed. Okay. I will bring up the slides here and let's see how we look here. I'm going to try this and one more. Can you all see the slides without any difficulty? Yes, we can. Okay. We'll move through. As we just stated, it's myself, Dave, and Theresa for context. I've now been at Manuskatni for seven years, five years as the CMO, and three and a half as the CEO slash CMO. Significant savings for the hospital to have me do both jobs. I would say it's wearing a little thin after a few years, but it remains the plan moving forward. Dave is still our CFO, and Theresa has been our controller for a number of years as well. It's been nice to have a stable financial team as well as a leadership team through the pandemic. Managing through with new senior leaders would have been pretty challenging. So we'll go through our overview, the requests, provide some financial information, talk about some of the service line adjustments, risks and opportunities, and then our capital budget. You've seen this before, drone view of our hospital. I like to point out our solar field and can't see any sheep in this picture. We still have our flag. We're not even seeing that picture. Oh, you're not? Okay. Hold on. I think I know the answer here. Bear with me. How's that? No. Okay. Hold on. I'm sorry. We went through this yesterday and everything seemed to be working. How about anything yet? We're still on that first, Mona Scottney Hospital budget presentation slide. I apologize. It looks like it's working though. I don't know if there's like a circle that's in the middle. That's just, maybe it's going to take a little time. Maybe you'll have to exit out and re-enter it. Yeah, let me do that. Okay. This is presentation one of those. So the first one might be the second one. I can't see it with my glasses. How about this? We're back at that main beginning slide. Yep. There you go. Now we're on to the slide that mentioned your names. Okay. All right. We'll do it this way. I was trying to be slick. I'm sorry. There's our overhead view. We'll move right through. Our mission is to improve the lives of those we serve. This is one of our recent rehab patients. I did want to make a note that we completed a new strategic plan in the beginning of 2020. And I'd be happy to share that with the board offline or in a separate document. In general, it adopted more of our Dartmouth-Hitchcock health system-related themes. And it was significant reworking that took about a year or so. So I will share that with the board post-presentation. Our organizational chart of where we stand within Dartmouth-Hitchcock health. And you can see us right in the middle here at Windsor Hospital Corporation. That's us. Linus County Hospital and Health Center. And I'd make another quick note around the historic homes of Runamead. That is our assisted living facility in the downtown Windsor. It's been a bit of a grand experiment over the last five years as we've moved to have a greater population of Medicaid extended care patients there and actually taking a sicker cohort of those Medicaid patients that require waivers from the state. I would say while it is an ALF, we run it in a way that there are a number of folks there that could potentially also benefit from nursing home care. But because we've got the nursing staff and the waivers in place, we're trying to provide that. And it's a by a significant amount, the lowest cost assisted living facility in the region. It's been a struggle, but we've been able to keep our heads above water there. And as we move through the sub layers of questions, we were asked to comment on our integration activities with Dartmouth Hitchcock Health. As I've said for the last couple of years, there have been, there's ever increasing momentum to become, to have a more mature health system of all the things that I've bulleted up on this slide. There are varying levels of engagement and overlap in the services, both administrative and clinical. For example, our regional lab services are 100% integrated with Dartmouth Hitchcock. Our telemedicine and telepsychiatry services in both our ED and on the inpatient units are fully integrated with Dartmouth Hitchcock. Our radiology services fully integrated. That's just on the clinical side. And above pharmacy, compliance, quality, growing shared services. Again, we've made significant progress in the last few years around integration. And please stop me if there are any questions on the content in the slides that we're sharing. Ongoing activities, both integrated and otherwise, we've made some significant changes in our primary care practice management. These are hospital-owned practices. We are not affiliated with an FQHC. We had an operational goal in 2020 to add 1,000 patients to our primary care practices for a whole host of reasons. The pandemic being one of them, we were not able to meet that goal. We probably added a couple hundred patients to our practice over 2020 so far. We suffer in our clinics around our staffing model and primary care has become much more of a part-time practice as opposed to a full-time practice for a number of our physicians. So the numbers I'll share, we have about 11 primary care providers for somewhere between six and 7,000 outpatients in our primary care clinics in Windsor. Of those 11 providers, it's about seven FTE. So you get the sense of a lot of providers, most of them part-time, not a huge patient population. It creates some stress in our clinic operations. We certainly don't have economies of scale. We've done a tremendous amount of work around quality and patient safety. I like to brag that we've got the highest quality and safety overall metrics in the health system, the highest employee engagement in the health system. And as of a report in Becker's, we already knew about this a couple of days ago. We're only one of two hospitals in Vermont to have the five-star rating from CMS for our HCAP surveys. So that's a representation of our inpatient satisfaction surveys for their inpatient experience at Mount of Skutney. So we're starting to trumpet that a little bit more widely. I think you've heard us say this before. We have a strong history of aggressive expense management here, pretty lean operation. We'll certainly be completing our fiscal year 20 with significantly under budget from an FTE perspective. And again, maybe the only upside of managing through a pandemic is our overall expenses are down significantly for FY 20 as well. And we remain committed at the senior leadership level of pulling every new position or potential higher into our position control process to make sure that we really need it and that every FTE continues to be accounted for. Our current service lines have not changed significantly from last year except for the addition of urology. Everything you see in a red font has at least a provider, a single provider or at least part of an FTE coming down from Dartmouth-Hitchcock and Lebanon. So we have a cardiologist a day a week from DH. We have all of our pathology and lab services are run through Dartmouth-Hitchcock Health. As I mentioned before, our radiology program is entirely integrated. We have a GI provider a day a week, a general surgery provider three days a week from DH, a pain management provider a day and a half a week. Urology is new. This was a provider that wanted to leave a neighboring facility. She was a DH provider. DH reached out to us to see whether we could accommodate a new surgical specialist. She came on board in the beginning of 2020 and then we had our pen, then the pandemic started. So it's been a challenge to see how that new practice will actually work for us and work for the region. Hopefully as the dust settles, we'll have a better idea. We have telehealth in our emergency room as well as telepsychiatry service for both the emergency room and in our inpatient units. And then as always, we have our community health teams which are robust. Moving through, we were asked to comment on our initial ongoing and projected impact in response to COVID-19. Year-to-date through February, we were largely on budget or slightly better, but then we quickly shut everything down. We continue to be an incident command. So that is about five and a half months of incident command at the administrative and leadership level. Our initial focus was really on patient and employee safety and maintaining access for urgent and emergent services. So that involved ensuring our supply chain for PPE, great benefit of being part of the larger system and that we rely wholly on Dartmouth-Hitchcock Health for our PPE supply chain and they've done a nice job. We haven't suffered any shortages. We had to do some very quick facility modification, new temporary walls, plexiglass everywhere, protection of our door screeners and staff. The thing I'm most proud of is the early establishment of a respiratory clinic at our main entrance. Where we screen and segregate patients that are having respiratory symptoms or concern for COVID exposure immediately and they're sent to a different part of the hospital with a distinct group of providers and nurses that care for them. We've been able to keep somewhere between 30 and 50 outpatients who eventually tested positive out of the general hospital population and waiting rooms by getting that respiratory clinic up within about, I want to say seven or eight days of when we shut things down. We had to deal with low volume and again with our ion expense management. Our nursing staff in the best of times, non-pandemic, they run a very tight ship with call-offs for low sensors or low volumes. We moved a bunch of people offsite to work remotely. That has continued, although the number of folks coming back is increasing. We had to door screen and I'm probably hitting bullets that you've heard in every budget presentation so far. So I won't spend too much time on it, but it was challenging, it was tiring. We haven't had a single employee test positive for COVID. So that's been a great success and hopefully that continues with our screening. The second phase of the COVID impact in response was again adjusting to changing standards and what PPE standards are were, what they are now, what they are likely to be. There's been a lot of adjustment for our providers, our care providers, respiratory therapy, nursing physicians, associate providers, but they've had to adjust to working with a face shield and a mask all the time with every patient interaction. Our role in the system was to continue to care for a large number of Dartmouth-Hitchcock post-acute patients and that included the COVID patients. We were the only swing unit accepting COVID patients during the pandemic that may have lightened up or the restrictions at other places may have lightened up, but we built out a separate negative pressure wing off our usual hospital unit where we were taking COVID patients post-acute after long and complex ICU stays and our staff really stepped up to the challenge there. But it's an everyday battle. The return to schools has created new stress around our workforce as every school district seems to have taken on a different tact as far as hybrid learning, a mixture of remote in-person, some going all remote, some going all in-person. So now we're gonna have to respond to that and we are actively serving our director of quality and safety and our pediatricians are working with our surrounding school districts on their reopening task force. So we've taken a large role in the schools and we'll continue to do so on the, as I mentioned on the next slide here, what I didn't put a, I didn't put a bullet on here but I should have, but as we move toward the flu season, early and aggressive vaccination is really going to be a big push from a public health standpoint, hopefully in all communities, but we are now aggressively working with the state and the schools so that we can do what New Hampshire does, which is do all their pediatric flu vaccinations in the schools during flu season. It is a big change in operations and we're gonna need some wiggle room within the regulatory and environment around immunization so that we can actually pull this off but I think it's an imperative. One thing I haven't mentioned yet is at the DHH system level early in the pandemic, all the system members made a commitment to not pursue furloughs or layoffs. We've been able to maintain that. So it was a time to recommit to our employees that I think has been pretty well received, although I think most employees at all of our hospitals are getting pretty tired of life in COVID at this point. So at this point, I'll pause for any questions on the first 12 slides and then I will hand off to Dave for the next few to talk about some of the financial impact of COVID and what we've had to do. Joe, if it's okay with you, the way that we always do it is hold all the questions till after the presentation is online. Sounds good, perfect. So Dave, I'll keep my presentation up and you just tell me to advance as needed. Okay, can you hear me? Yes. Great, good to be here. So talking a little bit about the financial impact of our COVID response and the pandemic in general. So net revenue to date is running about $5 million behind normal. If we remove what was done through February and just look at March through current, our net revenue was actually down $7 million. So COVID specific, we've taken essentially a $7 million haircut on net patient service revenue. And so I know we've applied for everything we could get to be honest with you. We get about $5 million in stimulus funds, which were great. We got about one third of what we should have gotten on the Medicare Advanced Payment Funding. We're trying to get as much funding from FEMA, SHIP, Flex and all the other sources that we can. Kind of the, just like our other patients were not coming into our facility during this time. Well, guess what? Our employees weren't going out and getting a lot of services either. So we actually got a little bit of a benefit on our benefits cost. Kind of an unexpected issue that came up that has affected our finances is we had a lot of folks who came in, post-acute stayed for a swing bed stay, sniff level kicked down to ICF level. And because of all of the facilities and locations, we would typically discharge these people to be in lockdown. We've had to maintain what we call borders here. And we've got seven or eight as I sit here today. And we've got a reserve built on that because there's no reimbursement for those folks. And the reserve that we're carrying on our receivable right now is about $700,000. So it's fairly material. We've worked very aggressively with the ombudsman and the Medicaid programs and the local facilities and trying to come up with creative solutions for some of these folks. But to be frank, nobody's really been able to accept these patients. Even we have some that probably could go home but there's no family support given the circumstances. So we've got seven or eight residing in our unit. Financial decisions, Joe referenced. We did not do a layoff or furlough. We reallocated employees. We did exercise call-off, low census, encouraged ETO usage. So that kind of took the edge off some of our staffing. We've really managed all of our open positions. So I won't say we have a hiring freeze but we've been incredibly selective on the positions that we've posted and tried to fill. We were scheduled to do some raises this year and to make some retirement contributions based on budget. Those have been postponed indefinitely given the circumstances. And we have only done the capital that was in process when COVID hit, emergency replacement of equipment that we feel put us or patients at risk and capital that would be beneficial to manage through the COVID pandemic. Next slide, please. So how did this impact our budget? We're working through recovery. We did a few different iterations of the budget, probably at least three full efforts to put a budget forward as things changed. If I were to assign a number of, how close to normal volume wise are we for budget 21? I would say somewhere around 94, 95%. Things that are emergent, urgent or absolutely medically necessary, which is most of our inpatient business, infusion for chemotherapy and things like that. We're expecting that those are gonna stay pretty close to 100% of normal. The more we move down the scale of things that are elective or preventative where patients do have choices to push off certain services, we're expecting that to be more like about 90%. We're keeping tight staffing. We've definitely added some positions to facilitate our recovery and execution of safe care and for our patients and for our employees. Most notably is door screeners. You know, we're the classic old Vermont farmhouse. We've got a bunch of different entrances and we've really looked at how we can consolidate that to the fewest number of entrances and still not grossly inconvenience our patients. But that is gonna be probably somewhere between seven and 10 FTEs that will be added ongoing. And so we've tried to look at all of our other positions open or otherwise and tried to limit those going forward. Yesterday, we had a very detailed discussion in what we call position control and tried to figure out, how can we integrate the screening staff with some other people that we would normally staff and move them around and try to develop some efficiencies. We may have found a couple FTEs worth of improvement on that total, but I don't know that we're gonna be able to do much more than that. We're expecting this flatten curve to last through most, if not all of FY 21. We have budgeted no raises. Thankfully, our benefits have been running pretty good for a number of years now. And so we expect it to be essentially flat. And we have what we call limited retirement budgeted and there's actually kind of two drivers on that. One is with the termination of our pension plan this year, we had a very favorable termination. And so we actually had $50 or $100,000 left over after everybody got bought out. And if I don't give a retirement contribution this year through 403B, then I send half of that money to the federal government. So I would much rather give our employees the $100,000. And additionally, Dartmouth has told us that they as a system want to make sure that while we've had to tinker with people's income and whatnot for the last several months that we should be committed to doing retirement. So we're expecting to do about 2% of eligible employees' salaries. Obviously volume's changing by the week. We track this daily, weekly, our efforts to recover. And we try to throw some time and effort at managing some of the departments that are lagging behind in recovery. And as Joe referenced earlier, best practice seems to change just about weekly. Next slide, please. So we'll talk about this later in some of the other financial slides, but essentially we've asked for a 4.3% blended rate for the year, 2.1 would be what I would call normal and gets us to the 3.5% growth. And 2.2 is to manage the effects of COVID for this year relative to cash and next year going forward. Next slide, please. You guys are good readers. So I don't plan on talking about these other than to highlight our operating margin for 21 will be $351,000. Our total margin will be 1.1 million. And that's about a 1.5% operating margin for operations and almost a 2% margin for total margin. Balance sheet cash is definitely take, I'm sorry, this is cash flow. You know, we're expecting to lose a positioning cash over the course of this year for any of the number of reasons you've probably already heard, decreased volume, decreased net revenues and hoping to bend that degradation with reduced capital spending and some expense management. Next slide, Joe. And then kind of a balance sheet, the takeaways really are that, you know, we've lost some value in our receivable, it's starting to come back now. You know, cash has definitely gone down about 2.7 million from our last fiscal year and to where we are today. We expect that to improve a bit and our liabilities change radically with buying out our pension. But that also resulted us in taking on some long-term debt that Dartmouth was willing to afford us with some very positive interest rates. Next slide. So again, a total volume if I were assigned number approximately 94, 95% of normal for our budget next year, a 4.3% blended rate, 6% for most of the hospital departments, 0% on pharmacy and 3% for our clinics and provider billing. And as I mentioned earlier, 2.1% blended gets us to a 3.5 MPsR growth budget to budget and the 2.2% that we assigned to COVID really covering supplies, equipment, some replenishment of cash and the concern about capital funding. And because we've pushed off so much capital funding this year, you know, we were kind of just getting to a place where capital was kind of a normal and routine reinvestment year to year and we didn't feel like we had a lot of pressure for failing equipment or mechanicals and things like that. And so, you know, we're a little bit concerned going forward that we've kicked a couple key facility capital projects this year down the road, but we'll see how that turns out. Next slide. Our payer mix is essentially the same, you know, we've kind of had to make a lot of determination in not only managing this year's financials or the budget, but looking at some other things as well as, you know, how much do we count our COVID experience going forward? How much do we discount it? And so essentially we've proposed a very similar payer mix going forward as we had prior to COVID. Some of our more fragile patients are found in the Medicare and Medicaid programs. And so those volumes went down during COVID as a percent of business which made Blue Cross and commercials seem bigger, but in fact that was still less than normal as far as revenues went. We have seen a change between Blue Cross, Blue Shield, meaning New Hampshire, Vermont, not a state and an all other commercial. That's, I don't know that it's really material on our bottom line, but it was just kind of curious that some of the policies and plans, there seems to be some movement within that. Changes in reimbursement by payer. We did get a clean PSNR at the very end of June. We immediately filed our FY19 cost report within a week. And but we did not have enough time to run our interim year to date to change our budget. So we've taken really no risk or on that projecting into next year. As a critical assets hospital, our fixed expenses are arguably 70 to 80% of our total expenses and with units going down during this COVID period. In theory, you would garner more cost per unit in the Medicare cost report settlement. Unfortunately, we lost a lot of Medicare business as a percentage. So Medicare will share in less of that increase in cost per unit. So we really need to do a full blown interim cost report not only to close this year, but also to have a better handle on how we can expect all of this to roll through in 21. Medicaid moving from this year to next year projected budget 21 is actually going to improve as far as reimbursement percentage, mainly because we're hoping and expecting not to have seven or eight borders in for six, seven, eight months. I mean, some of these borders were here before COVID hit and some of them have come in during this time but they are a huge material hit on our net revenue for Medicaid. So we're keeping a positive attitude and hoping to find some creative ways to place them in the next few months. And commercial is largely an immaterial change budget to budget. Next slide, Joe. Deduction, so again, we didn't have an interim cost report to really evaluate our current reimbursement experience with Medicare year to date. To be frank, I'm not even sure really how much value that would have given that we had some departments that are high cost departments that were down 50 or 55% in volumes and high Medicare. So again, we took no risk. We didn't really take a gain. We really didn't take a loss. We just kind of took the same percentage and applied it going forward. Our budget only represents a first quarter participation of one care Vermont Medicare because that's a calendar year contract. We do have a full year of one care Vermont Medicaid including the risk reserves and whatnot built into our budget. We do not have any commercial participation listed for those last nine months of FY 21. Our payer mix, we're not expecting big changes and there were no material changes in bad debt or free care as a percentage of gross patient service revenue. Other operating revenue, there's been some questions about whether blueprint funding will continue in its current form going forward and if so, how much having no specific information or final information on that. We estimated a 50% reduction from our current levels. 340B income will remain essentially flat. There'll be some inflationary increases. We do have a material increase with the PNG grant that came from the feds through the state of Vermont and extended to Mount of Scutney. And that grant is about $450,000 and essentially it's an offset between expenses and other operating, pretty much dollar for dollar and we'll talk a little bit about that later. Staff sharing is increasing. What is staff sharing? As we've kind of worked through some regional things here and are starting to develop some partnerships with other providers in the area, we've began to rent staff and this originally said staff renting, which really is inappropriate, but we didn't really have a better term. So I believe that Joe wordsmith this and said staff sharing. So we are sharing, we are renting a couple small percentages of FTEs from other places and we are also renting some folks out and that is increasing and that's both staff and providers. So next slide please. Other operating revenue, non-operating revenue rather, we're expecting 5% returns and we have kind of an annual placeholder of $250,000 of fundraising that may be challenging. We lost our director of development. He passed away a few months ago and so we're still trying to figure out how we're going to work those development plans that were in place and part of our strategic plan going forward but we left the placeholder for the moment. Next slide please. And so kind of getting through the expenses as quickly as possible. So our FTEs are essentially flat. They're up three quarters of an FTE and that is despite some expansion of ophthalmology and psychiatry, which Joe will talk about later, new services of urology which we implemented this fiscal year and also a 0.6 neurology service that Joe will also talk about later. But those were, even though those were gains we had a lot of reductions because of the expected volume decrease currently and going into next year. And then we added back COVID related FTEs which as I mentioned earlier will be somewhere between seven and 10 FTEs once we figure it out. Purchased labor is up budget to budget. Part of that is the contracted DH urologist and the rest is travelers. We've done very well over the last few years with minimizing travelers but that seems to be a growing concern here at Mount of Scottney. And so we took our current level of travelers and projected that into 21. Again, benefits are flat and we talked about the retirement contribution and the termination of the pension. So I won't belabor that point. If you look at the comparatives on the five or so sheets analysis sheets that you guys are looking at you'll see there's a large movement between purchase labor and other operating expenses. And so there was a change in reporting there and nearly $5 million of that is just a reporting change from one category to another. So medical surgical drugs and supplies. So again, because of COVID everything's goofy. Well, supplies are going down because volume's going down but then we're buying COVID supplies that we never bought. So that increases it. We also had some other supplies for the new service urology which included pharmaceuticals as well some of the procedures that she's performing here. Inflation is kind of all over the board. Some things have become more expensive because of freight and just normal inflation as with any other crisis. Some manufacturers and vendors take an opportunity to bounce up their pricing and we don't have a lot of leverage on them especially at this particular time. Additionally, as I'm sure you've heard elsewhere already, there's that ongoing increase in standard of care for infusion chemotherapy and otherwise and it's impossible for us to offer anything less than best practice. And so it's not even just inflation on the pharmaceuticals. It's the upgrades to more expensive medications. Provider tax is essentially flat. Appreciation is going up a bit mainly because of the age of the capital that we expect to be doing next year. Interest is up significantly due to the pension loan. When we did the analysis of this approximately a year ago as to whether we were gonna be able to do it and whether it would be a good time in the market to do it, the internal rate of return for this transaction was 9%. So it was as close to a no-brainer as we could get and Dartmouth because they've been working as a system to try to reduce the exposure and risk associated with the pension, they realized that offering us a low interest loan, which was very small to them but very large to us was in the system's best interests. Our employees are completely secure and taken care of and the market minimized our expense to get out of it. And so I think it's a win-win as far as the state goes as we look at this, we've cut down a lot of expense risk going forward and we've shaved off a couple of $100,000 a year guaranteed expense going forward in the benefits section. So I think this is a win-win-win for everybody. Other operating expenses, so there was the removal of purchase labor that I mentioned earlier and that was assigned into the salary fringe and physician cost line, utilities were reduced, purchase services were increased, equipment rental, some service contracts. The other thing that's not listed on there was the PNG grant. Again, about $450,000 of that increase was related specifically to that grant because most of what we're doing to fulfill that grant for the state are contracted services with other organizations or individuals or consultants to help facilitate the execution of that grant. Next slide, Joe. So the change in charge, we've kind of talked about this. You can see the changes of gross charges are higher on the hospital, lower for the providers and essentially zero for the drugs and basically what we're doing there is with the drugs is we mark up on actual cost so we don't inflate the gain on that markup year to year. So we just, we felt like the most fair way with the medication of pharmaceutical expenses and the changes in them is to make sure that we're being consistent in our markup with that and being consistent with what gets pushed to the payers and ultimately to the employers and patients. Next slide, please. Just some quick financial history. If you want to look at this, I always like to look at things kind of quick and dirty and what do I see? And kind of really from 2013 to 2021, we're basically trending slightly up, a little bit better than break even. If you look at 2008 to 2012, those are the dark years. They were horrible and prior to that kind of a little bit better than break even. And I always like to look at this cumulatively and if Joe would flip to the next slide. So the orange line is kind of what we had budgeted to do historically from 2000 until now. And the blue line is how we have performed cumulatively since 2000. And then, and again, if you look at 2012, which was the horrendous year for Maniskatni, it's when Joe and I got here, not that we did that, but we got here later in the year. So before Joe, before Dave, we've kind of been break even and trending slightly up. So I think, I don't think it's a great story from a business perspective and managing to margins. But I think with all of the change and the environmental issues that we've all had to deal with over the last several years, this is probably a pretty good story for a small CAH. Next slide, please. Great, and I'll take over here on this slide. This is for our service line adjustments. I already mentioned our urology, new urologist that we have. She is 0.6 with us, 0.6 FTE three days a week. She is not a new provider to the larger health system. Because we hadn't had a urology practice previously, we had a significant investment in new equipment to bring her on board. This is what we are projecting for new NPSR with this new urology practice. That said, the pandemic has significantly set back our plans for growing that practice and actually trying to keep her busy. Neurology is a new service that I have been clamoring for, for as long as I've been at Mount of Scutney. We are a rehab hospital. There's only two acute rehab hospitals in Vermont, us and UVM. The vast majority of the cases of the patients on our acute rehabilitation unit are neurology patients, post stroke, post spinal cord injury, traumatic brain injury from multiple traumas or MVAs. We finally identified a candidate in conjunction with BH, a graduating fellow in neurology from Dartmouth-Hitchcock. That would serve both Mount of Scutney Hospital and the VA. Unfortunately, because of new administrative pressures at the federal level, it has been incredibly challenging to get this woman, the H1B visa that she needs to continue working in Vermont. So I was reluctant to put the neurology service on our service line slide earlier in the talk, but we've had some good news this week that we've had approval at the federal level and we're hoping that we will have this neurologist who will be about a 0.6 FTE at Mount of Scutney serving outpatient inpatient starting, we're hoping mid to late September at the latest. In ophthalmology, we are the only non-DH ophthalmology service really in our communities for surgical ophthalmology, specifically cataracts. That is the vast majority of operative cases that our ophthalmology service performs. We have two providers that are closer to the end of their career than the beginning of their careers that have started to plan for succession as they inevitably slow down their practice over the next five years and we are actively recruiting for another optometrist and hopefully we'll have some success there. In psychiatry, I think this is a real success story for us. We hired a 1.0 psychiatrist earlier this year during the pandemic in addition, who's in addition to the 0.80 0.9 FTE psychiatrist that we already have. And we just sent an employment contract to another psychiatrist who is leaving the New York City area and moving back to a family house with his family in Woodstock. So we will have a growing psychiatry program which is much needed in our region and I think would certainly qualify as a essential service. We've stopped talking about having a psychiatrist and now started describing it as actually having a psychiatry program with three psychiatrists, social worker, licensed counselor and dedicated nursing. This is all outpatient. They will certainly help provide inpatient consultation and work on our EDs. We are not planning on building an inpatient psychiatry unit. This is purely to meet the community need both in Windsor areas of Springfield as well across the river over in Claremont communities that are in significant need of behavioral health resources. Dave, do you wanna take service line adjustments for one slide here? Yeah, so we were asked to provide some kind of an oversight on what our expectations are for those two brand new services. And essentially, it was really hard to estimate because urology started was two months into a new practice when COVID hit. And so those are kind of sketchy numbers looking forward. And additionally, we've had zero neurology. So we were able to estimate the clinics but when you start getting into what is the neurologist ordering for ancillaries and we were a little bit more dependent upon external sources of data. But essentially both practices will functionally lose money which is probably no big surprise to you folks. There are very few hospital-owned practices that within the actual practice itself are positive. However, the ancillaries and in the case of urology surgery and ancillaries that we expect to garner from their presence will push both of those into a positive margin if you were to think about it holistically. One is a 1.2 increase budget to budget for FTEs and the other is a 2.2 increase in FTEs year to year. And I'll take the next few. Our risks moving forward as they always are, we're a small, we have small practices. And as Davis mentioned previously when you make small changes with contracting risk or otherwise you can have big variances. And then we're also looking for succession planning around various service lines that we've historically been quite strong in with ophthalmology being one of them. When you lose a provider at a small place the ripple effect is substantial. We have continuing questions as everyone else does of how long we'll be with COVID, my medical and public health opinion is we'll be reporting on how the dust has settled at this time next year for next year's budget. I think we'll be fully reliant upon a vaccine as the upside of living up here is our community prevalence rate is so low. The downside is we'll never have herd immunity. So we're gonna be really dependent upon a vaccine and we'll continue to be dealing with the costs and lost opportunities in our practices through COVID. And the concern that patients are not coming in for the care that they need. We've been really aggressive in reaching out to our communities, direct mailings, emailing them social media ads and local papers describing our safety workflows and protocols to get patients back in the door. We've very quickly built out telehealth services and at one point got up to about 40 to 50% of our outpatient visits were telehealth. Not a huge satisfiour for either our patient population or our providers. And we're back down to probably about 5, 6% of overall visits in primary care being telehealth delivered. For ACO engagement, I'm sure we'll talk more about this. At the time of our budget submission, we did not have 2019 performance data or the risk quarters that we would expect to see in 2021. We certainly did not have a board of trustees who was who were willing to support the same footprint in 21 that we've had in 20. So we chose a conservative path in our budget submission. We will be presenting all of the options for 21 for one care to our board of trustees and to DHH leadership, functionally my boss on 9-7 during a special board meeting and we'll finalize our contracting with one care on 9-11 based on those discussions. And I believe that is the deadline for contract submission with one care. We've prepared a lot of data for both our board for DHH leadership and for our own good regarding what our total cost of engagement is with one care. And as I said, I'm sure this will come up with questions after we finish our presentation. Ongoing risks are recruiting and retention, both provider and staff wage pressures that continue to increase. We have real risk in our anesthesia staff as our providers are aging and it is an increasingly expensive service to provide internally. You can see why a number of hospitals contract with third parties to provide their anesthesia care. It is also tough being a border hospital when virtually every person that we recruit whether it's a secretary or a doctor is asking us what premium we're gonna give them because they have to now pay Vermont income taxes whereas right over the Connecticut River, they do not. Dave has already mentioned the inflation around pharmaceuticals. We've really built this culture of quality and patient safety and that requires a significant amount of investment, best practice training, equipment, how we do things. We say this every year, there's an increased dependence on other operating income such as 340B. And then we've already emphasized the issues that we've had especially during the pandemic around discharge and placement pressures. One note I did wanna put out there for maybe discussion later or follow-up offline is as we start to move into responding to the sustainability questions after the budget season here, and we've really tried to focus on essential services for our communities. We don't have neurosurgery or orthopedics or other lower volume, high reimbursement service lines, but we have found even within our own health system and in our neighboring hospitals that the folks that do have that have a little bit healthier bottom line which then translates to higher wages for LNAs, certified medical assistants, mid-level providers, associate providers. So it's something I think we're all gonna have to keep in mind as a statewide health system that as we focus on essential services, we don't wanna get into a situation of winners and losers and the winners who get all the surgical services are able to pay their staff better. And I'll say it's a real concern of mine because we are certainly living it. We've lost some staff this week due to pay discrepancies across the region. And that's despite having, like I said earlier, very high quality and safety metrics, the highest employee engagement, really in the 85th percentile nationally around employee engagement, but at the end of the day, if it's a buck or two an hour when you're lower into the pay scale, folks are gonna make that jump. So as far as opportunities go, we continue with regional planning, three critical access hospitals within 20 miles of each other. It is unclear at this point from my perspective if Springfield Hospital will be a partner or a competitor in our region. That's just an honest assessment. We are working very closely with Valley Regional Healthcare in Claremont, New Hampshire. We're starting to talk about distribution of services, sharing leadership. Ultimately, that will take some cost and expense out of Mount of Scutney, but I think all of us are wise enough and experienced enough to know that just when you bring places together, you never get the savings that you expect on leadership and managerial costs, but we expect to see some over the next year to 18 months. I've mentioned our new service lines already and then we're gonna have both opportunities and risk within the system. At some point in the next few years, we are going to go to Epic as a medical record. That's really one of the foundations of Dartmouth-Hitchcock Health. So that's gonna be both significant opportunity and risk and cost for us. We'll continue to lean heavily on DHH for things like supply chain, quality and safety, compliance work, and the clinical benefits of being able to afford a one day a week cardiologist as opposed to trying to hire a full-time one and try to find business for them. We'd be dealing with that for any extra service beyond primary care. So it has been a great benefit to be in the system. And Dave, I think you're bringing us home here. So again, capital, 2.5 million. There are no CONs obviously given the amount in that nor do we have any scheduled for the next few years. Kind of really mostly routine for us. And as I reference every year, there's nothing sexy in our capital, nothing exciting or interesting. It's just replacement of rooftop units, aging equipment and beds and the like. So nothing really to talk about there. One of our issues, next slide, Joe, is again, we were historically underfunded for many, many years here. I feel like when you walk around our facility, it looks good, it functions well. Our equipment is good. We're offering pretty excellent services for a small hospital and the providers are happy with the equipment that we're providing to them. So I feel like we've gained a lot of ground over the last seven or so years I've been here. Our biggest issue is bandwidth, throughput of those types of projects. And obviously we don't know, we've done a lot of COVID-19 related capital. We've changed air exchange units in the OR so that we can turn cases faster and have a higher level of safety for our providers and staff and patients. So we've been a little bit strategic in how we manage the COVID-19 capital. And we're really looking to, every time we do something, it's okay, great, we need to keep people safe. And then what opportunity do we have to improve our ability to recover and regain volume that's been lost and make sure the people get the services that they need when they need them? Next slide. I think this is you, Joe. Yeah, we embedded the two initial questions from the healthcare advocate. And I think I saw Julia handling questions today. So we're ready for more after the presentation. But the question was, would we be applying for the healthcare provider stabilization grant funding? And the answer was no, we feel like our recovery efforts are proceeding very well as well as further expense management over the remainder of this fiscal year. And into the next one. So we feel like we're not gonna have a significant hole to fill when all the dust has settled over the next half year. And again, we weren't comfortable at the time to commit to our current one care Vermont footprint, which was going to be a requirement as well. How much weight was going to be put on that? We weren't sure, but either way, those were the two compelling reasons why we did not apply for that funding. And that's it, that's our presentation. So I will stop sharing my screen. There, I think. Well, that was a great final picture. Thank you. We're gonna start with the board member Holmes, Jessica. Great, thank you. And thank you for the very clear presentation. Also, I wanted to start by thanking you, all of you at Mount of Scotland for the dedication, clearly that was demonstrated, came through in the narrative of your staff dealing with COVID and all of the Herculean efforts and it really came clear in that narrative and just a heartfelt thank you for that. It's a crisis unprecedented. We don't know how we're gonna deal with it. And it seems like you all really handled it well. So appreciated. I maybe I'll start with some of that recent last few slides and a little bit in your conversation you talked about in the narrative about the work that the leadership team is doing with Springfield and Valley Regional to try and think about regional allocation of services. And you've also talked about in the presentation, the integration with Dartmouth-Hitchcock. And there have been recent conversations around the growing consolidation in Vermont of hospitals and affiliations. And I'm just wondering if you could just talk briefly about what would the but for world be if Mount of Scotland was a standalone independent hospital in this particular time and what is your perspective on affiliation and consolidation just in general? It seems like you're moving in these directions with increasing integration, increased affiliations, shared services must be a reason for that. So can you tell us about that? So, Dave mentioned the dark days before he and I and some of the other senior leaders arrived. So our decision back in 2013 and then finally ratified in 14 to enter the DHH was really an existential one. And we needed the security of being part of a larger system. We also knew that we had resources that Dartmouth-Hitchcock wanted. I think I've mentioned before I was on the DHH bench when we started affiliation talks and finished on the Scutney bench. And there was a pretty good match of what DHH wanted and what we could provide. And it's that match and resource need is not always there. So I hate to project our experience as the right one for everyone. I've had the opportunity to present to the Green Mountain Care Board. This might be my fifth one. And it was a lot bumpier in the beginning because service lines were changed. We lost orthopedics, ears, nose, and throat. They went back to DHH in times of crisis because they had a departure of physicians and that hurt and it took a lot of management and staying on message that affiliation is good, integration is good, despite these bumps and bruises. And we still have those bumps and bruises. It's far less on the clinical side now, more so on certain administrative projects. We still sometimes deal with the, well, how do your people work with our people? And our people is me and Dave and Theresa and it's, we don't have a deep bench to do some of the work. But so I would say for us, being part of a larger health system has been net positive and more net positive every year. So we started work over the last 10 months with Springfield and Valley, the work with Valley Regional predated the work with Springfield, but Springfield had kind of jumped to the head of the line due to its entry into bankruptcy and we spent a significant amount of time, myself, Dave, folks from Valley, Alan, Mike, who just finished their presentation, but ultimately didn't get to a point where folks could agree on terms of entering Dartmouth-Hitchcock health, what that would mean organizationally, administratively from a leadership perspective. So the work with Valley is ongoing, that's still going to happen. We're, you know, we're 18 minutes from Valley Regional in two remarkably different environments between Vermont and New Hampshire, certainly. But I think a lot of potential there. And I do think we'll continue to work with Springfield as we move forward, but it'd be dishonest to say, if I didn't say, you know, we took our foot off the gas in Springfield because of just the way the working groups kind of ended. Can I add on to that, Jessica? Is that okay? Sure. So I think one of the things that we're, we talked about how rational we're going to allocate services to staff and, you know, we've already been tinkering with this, contractually with them on a case-by-case basis. But, you know, no CAH can really, in theory, ever be 100% efficient, you know? We can't hire a 0.3 respiratory therapist. We just can't make it fit volume versus FTE. And we manage to that every month. I mean, we measure that constantly. And so we find, well, you know, there's a run in speech therapy right now and we really need 1.2, not just one. And so we've been able to contract with Valley, who's really running at 0.8. And so they send over their speech therapist every Friday to manage some of the outpatient volumes. So our person, you know, is not hair on fire week after week and they're offsetting some costs. So we just brought in a traveler respiratory therapist for COVID due to some issues that were going on. I don't know what's going on there with if I'm the only one seeing that. Maybe, I don't see anything. Yeah, some kind of weird outlook thing going on there. So, but, you know, we felt like we were a little skinny if this thing got really out of hand and we started taking more patients than we ended up taking. So, you know, I called Valley and we split the traveler. And so there's just spent a lot of those types of things and then looking at, well, you know, do we all need to have a one day a week oncology service? What if we had the oncology clinic centralized but did the infusion in community specific locations? And we're seeing there's not only a financial benefit but there's a deeper bench. You know, we had an ultrasound tech who had a personal issue and had to leave for a week. We had no ultrasound for inpatient outpatient. We're done. We're done for a week. Got to shuffle 40 patients out. And what we were able to do was contact Valley and executed a rental staff sharing contract and to take care of the patient need here and push off the non-urgents but keep the urgent, emergent inpatient people taken care of. So those are the things that are gonna make a difference to the patients but also financially. Yeah. And all of that makes a lot of sense to me. I appreciate all that hard work you're doing. A question about your volume assumptions. I just want to understand, you know, every hospital is so different and partly because we don't really know what's happening with COVID understandable so much uncertainty. So I'm trying to get a handle on what everybody's assuming. And my understanding now is that so you're assuming 95% of normal values, 100% for emergent, urgent and 90% for elective and preventative. Does that 95% of normal values? I'm trying to figure out how that includes or doesn't include the additional providers in, you know, urology and psych and by the way, psych I'm so thrilled that you've got two psychiatrists so important, obviously we're such a shortage there so congratulations. But I'm trying to, is it 95% of normal without those additional providers or 95% of normal now inclusive of those providers? So I'm not sure if I'm clear on my question. Yeah, it's, you know, 95% of normal and then added neurology and urology. And there's a little. It's like a 5% effect. Yeah. And so we just kind of normal, we re-normalized and then added the two new services if that helps. That helps tremendously. Thank you. I wasn't sure if it was actually a larger COVID effect that was just overshadowed by the additional providers. Yeah, and Dave and I had innumerable meetings around what kind of volumes we thought we were going to get to with new practices, with our existing practices. You know, our current recovery dashboard, every week we do volume to budget what we expected. And we're, you know, primary care is about 80% of what we expected in a non-COVID world. Our emergency room is 120%, or 110% of a non-COVID world, our inpatient volumes right on budget. So that's really what triggered, okay, let's just, our emergent, urgent inpatient business, that's all going to be the same. ED volume, again, has come back because I think a lot of folks aren't coming back to clinic despite our efforts and we're getting them in the ED, unfortunately. But primary care is going to lag. There's still a good population of folks that don't want to come back and really don't like telehealth for whatever reason, they don't have Wi-Fi. I mean, I live in Norwich like Susan, I can't do a Zoom call from home because I've got, you know, over-the-air Wi-Fi beamed from a mountain top. It's so patients and providers just have not embraced it after the initial, when it was really necessary, everyone got on board, but as it became less necessary, telehealth unfortunately has dwindled. With respect to the rate, I just wanted to say that I really appreciated the effort you made to separate out, you know, the sort of the normal rate requests and then the COVID specific rate requests, recognizing that not all COVID expenses are going to be ongoing. So I just, not all hospitals did that, but I wanted to let you know, I appreciated that effort. I am trying to get a handle on medical inflation. I've been asking all the hospitals this question, just what are the assumptions that hospitals are making about medical inflation? And I've been thinking about three buckets. So you've got your compensation bucket, wages, salaries, benefits, and then you've got medical supplies and you've got pharma. And those are the three that I've been focusing on. It sounds like you're flat on wages and benefits for next year. So 0% price inflation there, although that would not be a normal inflation, but for next year, that would be the expectation. And what percentage of your overall expenses are, would you say your compensation bundle is? As a percent, so I kind of look at it two ways because I overly complicate everything. But if I look at it- I'm trying to tell you something simple here, so don't get too complicated. But if we look at labor, you know, what that is defined as at Mount of Scutney has changed as we've contracted for management from Dartmouth. And, you know, so if I look at it from a just the people we employ plus their benefits- All labor in there, it's okay, all labor. Yeah, it's 60%, just for our actual employees and benefits. And if I look at total labor costs, it's more like 70, 72% somewhere around there. Perfect, okay. And then what would you say is your assumption about medical supplies growth, you know, the inflation rate on medical supplies? Well, I guess the, you know, I always try to find those little advantages we have because we don't do a ton of surgery. When you get into some of these surgical supplies, you know, titanium implants and things like that, you have zero control over inflation. I mean, very little negotiation power. So because we do less of those things and more routine things, you know, I think our inflation on medical surgical supplies is actually fairly small. I would say, depending on the type of item, one to two and a half percent, somewhere somewhere in that range. Okay. And then pharma. So actually, what is the bucket size of medical supplies in general? Do you have to guess? I'm sorry though, the overall blend- The advantage of your expenses that are medical supplies. Off top of my head, I'd have to do the math, I don't know, I can certainly get to you. That'd be perfect. And then pharmaceutical, I'm wondering what your expectation is on growth, price inflation for pharmaceuticals? Well, the problem with pharmaceuticals is it's got two issues. You've got inflation, which I would say is running three to 5% and it changes quarterly because it's also a supply and demand issue. So when you talk about a med like IVIG or something like that, supply and demand, that price changes daily. It's like a commodities discussion. And it's grossly unfair to everyone involved, except maybe the people selling it. But the other piece of it is, especially in the area of infusion, the best practice changes. So it's not even an inflation discussion, it's the new latest, greatest, shiny thing. And so we have to throw in a factor for that. And that growth is running three to 5% a year. Okay. And pharmaceuticals is what percentage of your overall kind of budget? Would you say? No, no, kind of roll them up internally. So I don't really think of them as seven. Okay. Okay, that'd be great. Okay, perfect. So you assumed a 1% rate increase for Medicare. Is that because you're expecting a favorable Medicare cost report? Is that the tie in there? Yeah, just the way we ran the 2019, we didn't get a chance to run to 20. And we just kind of smoothed the difference through. We've got the temporary canning of sequestering. We've got a couple of things like that in there. And that's kind of how it came. There's a bit of movement and services. We had a higher, we were experiencing higher acuity as a percentage of our business. We used to be three acutes and 15 swing beds and now we're five acutes and 11 or 12 swing beds. So there's a lot of levers there, Jessica, to be honest with you. I'm not trying to call back. Yeah, I was trying to get a sense of it, but I appreciate that it's multifaceted. And then I guess my last question, knowing that there's other people waiting, is just what is the rate assumption you're making on Medicaid? Well, Medicaid, I think that's on the, your sheet in front of you. Okay. And so as a percentage, the reimbursement ratio, I think you folks call it, goes up 34%, which is commensurate or close to what we budgeted for 20. Unfortunately, our realized rate this year to date has been tanked by the borders and because the Medicaid's the primary payer, but we're getting 200 bucks a day on a cost of 800 to 1,000. So that's kind of our assumption to kind of go back more north to the normal. Yeah, I guess I'll use the reimbursement rate on a fee-for-service basis. Like what would you expect there? Like, you know, their overall average rate increase. Well, I think that's what you're reimbursing. I'll look at it again. Yeah, I think that's what it's calculating. So 34%, and if you want to sit there and say, what's your cost? It's about 50 cents on the dollar is our cost. And so they're running, you know, whatever two thirds of cost. Okay, I will look at it. I won't take any more time. Thank you. Appreciate it. Thank you, Jess. Next is member Launch, Robin. Thank you. Thank you, Joe and David. Do you actually anticipated a bunch of my questions? So I only have a couple. On page 12 of your presentation, you talked a little bit about changing hours. Could you just give us a little bit more detail about what that was related to? I know it's COVID related, but... Yeah. So a couple of things jump out. We used to provide clinic hours in our Woodstock-Fermont Clinic on Saturday mornings, but because of issues with door screening and the need for additional staff and the inability to get additional staff to work on those weekends, as well as the need to reallocate the providers that were working there in the weekends to at least for availability for inpatient service. So we brought those back and reduced those hours, held those clinic hours. Those will go back at some point after the dust settles. We also wanted to, in our recovery efforts, wanted to push out for more evening availability for patients in our clinics here in Windsor. We also had to add hours for what we're calling our swab and go process for folks that need COVID testing, but don't necessarily need a full evaluation. And that group of people are our OR patients. We are testing and need a negative before we bring them back to the OR, even though we're practicing the same standard of PPE, whether they had COVID or not. But that was a response to state mandates around testing. So we had to stand up weekend hours and availability on Saturdays and Sundays for COVID testing. And Dave, I'm not sure if you wanted to add anything else around hours, but those are the big ones. Yeah, and then we've had, you know, one of the big issues with the ancillary services is trying to decompress waiting rooms, right? And not have them so packed. So I oversee lab and radiology and a couple of other services. So we've expanded the hours that folks can make appointments. So we have fewer people in the waiting rooms. Our rehab folks have also been very creative in moving a space and reclaiming space as well as changing the schedules that they're available, just to have fewer people coming through at the same time. Got it, thank you. That's helpful just to give a little sense of what that was about. Could you talk a little bit more about your travelers costs? Some of the hospitals we've been seeing like a pretty big-ish reduction, in travelers costs. So I was just curious what's going on there. It's a little harder with your budget because you do have the contracted services with Dartmouth. So it's hard to tease that out. Yeah, and you know, so I can give you the overall kind of understanding and if you require anything else beyond that specifically, I'd be happy to provide it because it does get thrown into that contracted labor line. But we've done very well year to year on that typically. We're struggling a bit now and some of that is the wage or recruitment and retention issues that Joe referenced. That's one piece of it. But the other piece of it is, I think as our services have changed a bit, how we do things, the types of people we've got an aging workforce, retiring harder and harder to replace. There's just a lot of little factors. And again, we're a small end. So one traveler in here for the next two weeks is a big change in the percent of travelers. That's the way it's been working, unfortunately, but I'd be happy to break that out for you. Thank you. That'd be great. Thanks for talking about the telehealth. That's an area that I've been interested in sort of learning more about how that's flowing through. It seems like there's quite a bit of variation around the state. So it was good to hear your experience there. Let's see. Oh, the other question I had was related to the loss of the blueprint funding. I was a little confused about that because quite frankly, I sit on the blueprint executive committee and I haven't heard anything about it. I can speak to that. I think there's concern and even concern at the one care level. Yeah, and I'm in the middle of all these different groups, either hospital or one care or elsewhere, where I guess we haven't felt secure that there'll be the same amount of level funding in blueprint year to year. And as the funnel for blueprint funding has moved over to the one care side, I know I personally have been waiting for a few years when blueprint would be a carrot or a stick to get people into more folks into one care, at least some of the programs and tie it to blueprint funding. So we, again, I think it's just that level of uncertainty that we've had from year to year blueprint funding. And it seems like every year the same thing happens and we get level funding and that's great, but there is a level of uncertainty that we face each year when we think about it. And is that uncertainty on the Medicaid and commercial side? Because on the Medicare side, it comes through one care, but it is distributed to any provider, regardless of participation, and that's not gonna change. That's right, but a good chunk of blueprint funding is funded by shared savings. So you don't have shared savings. Where does the funding come from? That's probably the insider pool, which is no longer, you know, insider pool since we're testifying publicly, but that's always the concern. If ACO performance isn't as strong as we'd like it to be, then how do we fund it? How do we fund blueprint? Right, yeah, I think that there's some misunderstanding there because the benchmark is increased by that blueprint funding. So while it's technically out of shared savings, if it comes out of the program, it comes out of the benchmark. So it would be, I know people connect those because of the way the language works, but our current ACO budget order wouldn't allow for any change in blueprint funding. So I get the uncertainty, but I'm not sure that that's a real uncertainty from a legal perspective. So I'll just put that out there. I think that's all my questions unless I missed something, so thank you. Thank you, Robin. Member Pelham, Tom. Well, Joe and David, welcome to my dining room. This new era is something, I think. So I just, you know, in describing the pension, I think the termination of the pension, I think you described it as a win-win-win. I didn't hear a loss in there anywhere. And so that's probably true, but I'm just interested in this arrangement. I mean, I can see in terms of your non-operating money, you can see it in 2020 projection, you go to a 9% total operating month margin because of that, but who is carrying the actual real risk associated with your employees? So when you terminate a pension, basically an insurance company is the usual purchaser, they say we will buy your risk for a hundred, and I'm making up a number, but it's somewhere in this range depending on market, we'll buy out your risk and your liability for 110 cents on the dollar. So if our total liability was $13 million, then we can get them to take that for $13 million times 1.1. And they take the risk, the pension recipients get to choose between a fixed annuity solution. They can actually lump sum their way out and take their money and put it into an investment or cash out altogether, taking the tax hit, but they've got three or four choices to make. And so the more conservative you are than you take the annuity and the guaranteed income, and if you're a little bit more of a risk taker, you'll take the lump sum and reinvest it yourself in a vehicle and avoid the tax hit. So does that answer your question? Yes, it does. Yes, it does. Regarding the borders, I just wanna make sure I understand this, that you have seven to eight borders there and there were some borders there when we visited and have a meeting there last year. And so what I'm understanding is that you don't get any reimbursement associated with them as long as they're bordering in the hospital. But if you find an appropriate place for them, then you will get reimbursement or you will just not have the expense of caring for them in the hospital. And so that $700,000 reserve you have. And I think, is that in 2021? We're talking about the $20,000. That's definitely now, but we reduced it for 21. Okay, we reduced it by 700,000. Correct. You're assuming no borders in 2021. Right, so that's why the Medicaid reimbursement improved as a percentage in 21 from current. And then to get to the prior part of your question. So, we often will get somebody who has Medicare and Medicaid, they come into our swing bed unit, they do their sniff level stay, there's usually a delay in getting placement or appropriate discharge. So we're kind of used to people moving into an intermediate care level of care. And Vermont Medicaid will pay a nursing home rate to us for 30 days to facilitate that discharge or placement to a nursing home or home or to get home health arranged. So we get like making up the number, but it's probably within $3. We get like $242 a day. So if you think about like just the nursing care, $242 a day is done, just for that, regards of heat, lights, medication, food and all the rest that comes to it. So we lose money every day they're here even when we're getting paid by Medicaid. We do have some patients that actually are in the process of applying for Medicaid. So they actually have zero insurance or zero ability to make payment of any kind to us. So that reserve is kind of like what we're getting dinged for with Medicaid and what we're getting dinged for from a self-pay standpoint. Complicated. Yep. I'm looking at your rape proposal and I see that combined between the basic rate increase and the COVID rate increase, you're assuming $61,000 in additional revenue, Medicaid revenue off that rate increase. And I'm just wondering maybe it's similar to a question. I think that Jess answers, what is your assumption that getting a rate increase will increase your Medicaid revenue? For every point of increase or? Yeah, either way for the total 2.2, whatever it is or each 1%, there's an additional margin that you have on your rape profile that says that your Medicaid amount will go up and between the two at $61,000. Yeah, I only just see what I've got here in front of me. I'm not so concerned about the number. I'm just, what is the basis for assuming that you get more money through an increase in charge? Yeah, I think it's really just the factoring of, I mean, we grab a percentage and we study, determine the percentage and then apply it against the gross revenue increase. And so, I get what you're asking and I'm not sure I can answer it sitting here without ciphering a little bit, but I'd be happy to get back to you. I think I understand what you're asking. Well, in most of the charge rate documents that we have as part of the budget process, when people are getting a rate in charge increase, they don't attribute any revenue coming in from Medicaid. And so, that's why you're stood out to me because you were attributing revenue coming in associated with the charge increase from Medicaid. Yeah, I'm not sure why anybody else would have zero. Mainly because we, you know, Medicaid does give us some form of inflation year to year. Occasionally that is eaten away with with a DRG value reset or an APC reset or whatever, but generally they give us a little something every year. So that's where the 61 is coming from, but I'd have to go back and cipher the actual percentage that we anticipate. So, I mean, and we don't need to get into a discussion of why it's a negative number, but in your pay or mix proposal, you show that Medicaid is going down relative to the 2020 budget by $325,000. And so my question is, if you're wrong and it goes the other way and you get Medicaid revenues at $325,000, so you have this $650,000 swing, where would you put that money in your income statement? What line item might you consider as a higher priority or would you let it fall to the bottom line to operating margin? Well, the only other place I can do would be to build reserves. And so unless I felt like there was a reserve that needed to be built, increased or changed, we would roll it. I mean, we have to go through audits. So all of our reserve levels have to be justifiable based on experience and documentation. So to answer your question, if we had a pickup from that, it would trickle down. And Tom, just to add, I think, our population given what it is, it's really zero sum game. If we had far pair of mixed changes, it's coming out of something else. We'll have less commercial business if we have more Medicaid business. I don't expect an influx of folks to our neck of the woods that whose primary pair would be Medicaid. I would suspect it's folks who have lost their job and are hopefully getting on the exchange, but if not moving to Medicaid, that'll be the primary push and change in pair mix, I think over the next probably six to 10 months. Well, thank you both for joining me in my dining room and I'll turn you over to Maureen's office. Okay, at my office here. I just have a couple of questions, a lot of what was already asked, but first, thank you for the thorough presentation. Just wanna touch base on where your cash position is going post the COVID relief because it looks like on the cash flow statement that you provided, the 2020 projection is significantly improved and some of that will come back in 21, but it seems like you're coming out in a lot better place and just wanna talk to that a little bit. So I guess it's kind of a three point answer. The first is, we've tried to, as best we can predict what funding we're gonna be receiving and that we have received stimulus being the big $5 million gain. Initially, if we had presented or submitted our budget at the beginning of July, like usual, we would have had a less optimistic outlook on that. And we would have had no real idea on our efforts to recover. And what really seems to be happening is we're managing the expenses, we are recovering quicker and better than I think we would have anticipated two months ago. And so I think that we're gonna be less tragic than we would have thought about May or June today. So unless there's a really large surge or our COVID exposure radically changes, I think that our current course, we changed the cash flow in our balance sheet literally the day before we submitted because we went back and studied how cash was working and our ARs growing back up appropriately because of revenue and we're liquidating. We also worked down our ARs the third piece during this year. So we're hoping to maintain it at that level. Because you did have in your 20 budget, you had about 8.1 million estimated for cash, 20 projection is 15.4, and your 21 budget is 10.6 because obviously that's returning some of the money that's owed that's probably in your cash flow. But and the reason is that I'm kind of pressing on that issue is fortunately, it seems like several of the hospitals, the money that they received or going to receive from COVID, barring the NPR reductions has made their balance sheet stronger because of the cash that was received. And you are looking as we had asked, which I appreciate that you did separate out a request for COVID for 2021. And I would just like to push back a little bit on whether there's a need for that in 2021, the incremental 2.2% that you were requesting based on where you're ending up, where you're projected to end up in COVID on the balance sheet side. Right, and part of our gaining cash is our underspending of capital. And so, as we mentioned in our presentation, not doing all the capital that we had planned does provide us some risk to deal with. And when I look at it internally, because our stuff doesn't always fit nicely with your stuff, we're looking at, we're down $2.7 million from last fiscal year end. And that's likely where we're gonna finish up. So we're down, we're gonna be down 10 or so days. And then, boy, I've got this risk of capital. So our thought with the 2% COVID was, let's split that, not even necessarily in half because every percentage point's worth about $450,000. So two points is worth 900, 2.2 is worth nine and change. So we're not looking to make up $2.7 million, we're looking to make up roughly 900 to a million as security going forward. And my biggest concern is your NPR projection and where you think you're gonna net out for 2021. And just looking at some of the numbers and some of the discussion that we've had, your year to date through February was tracking 7.5%, 7.4% down on NPR. Actual compared to 2019, it was projecting 2.5% down. You've talked about believing you'll be running about 95% and I'm not sure whether that's 95% of the trend that was seven where you were already down or that you were considering that. And then adding in the incremental that you'll get from some of the new services as well as all the rate increases you had. And I think there was about a million for each of those. So you might be getting plus 2 million for your rate increases that you've put in and for the incremental services. Having a hard time getting up to the 55 million that you're projecting. As you were in 2019, I'm sorry, 56 million, you were at 50.8 million, your budget was 53.8 million. And if you look at where you were trending, you would be trending down towards, I think about 49.6 million if I take the, where you were trending pre-COVID. And so, again, it's really just trying to push back on you guys about what your numbers are there because, again, you end up building your expense base on there and I would hate to see you end the year around a 52 or 51 million, which would still be increased over the prior years, but down three or $4 million. So I think you've tended to, and I know maybe it's just in your explanation, but when you explain part of your NPR, part of it was also, we have a budget, you give us a three and a half percent cap and then we added the incremental, on top of the three and a half percent cap that we're allowed, we added the incremental COVID number and that's why we're coming up at this 5% rate. And I know you also are building it from the bottom up, but I get concerned when it seems like we're just taking the budget, the three and a half and the COVID and we come to a number. And yes, you would be allowed to be at that number, if you will, but my concern isn't whether you're allowed to be there or not, it's whether you'll actually get there. So at the end of the day, with the commercial rates you have in here, assume that goes through, will you really be at 55? So that's really my biggest concern about you being able to hit these numbers. And I guess one of the questions to support that would be, where are you trending now in July and August, September as you track those months, you'll be able to get a better read on where it's gonna be. So it's nothing about what you're doing or what's in there, it's just really saying because of COVID and if you only come in at 95% and you were tracking behind, adding some of the incremental things you will get, I don't get to 55, actually 56, right? I think there's, so there's a lot in there. A lot to unpack. And I'm happy to have an offline, but I'll give you a couple of quick responses. The biggest gain is that we're not gonna be booking risk. Okay. And so that's a huge chunk. Our settlement for 19, you know, really, the cost to play last year was really, we just got those settlement numbers just recently, is about 1.5 million. So 1.5 million is in your 2020 forecast, if you will. And what was in 2019? Was it about that as well? It was about that. It was maybe 1.3, you know, I have to go back and look, but bottom line is that changes net. So... Even though I hate it, changes net. That was always, you know, I've always been against it, I go in net because of this very reason, but... Yeah, so that's the big contributor to that change. And then the other one is, you know, we have greater confidence because we were at least able to get that 19 cost report done to kind of reset our instrumentation because we had been kind of flying blind for 18 months or so. And so we weren't gonna, I'm not gonna take a lot of risk flying blind. So now that we had a little bit better information, not perfect, but better, you know, we could really go back and look at what's the impact with Medicare. And in our cost per unit for Medicare patients actually did go up significantly in 19, mainly just because of the payer mix by service and whatnot. Not so much our actual costs went up, but how it got assigned to Medicare changed. And so those are really the two big factors. And I share your concern that you'd hate to see us not make it. Well, guess who also would hate to see us not make it. But I feel reasonably confident or I wouldn't have presented it to be quite frank, I would have painted an uglier picture and asked you for more. So, and I'll add on to, you know, what May, June and July have looked like from a recovery standpoint in May, essentially on budget because we use some of our stimulus funds. June and July on or ahead of budget without the need to use any of the stimulus funds. It's not something to pat ourselves on the back on, but when you don't make much money, you don't lose much money. I didn't have to shut down three orthopods for two months. We didn't have that. The people that needed got, that had surgeries needed surgeries. So, while we certainly dug a hole, five to $7 million hole due to COVID, we were still able to recover again pretty quickly in the end, I suspect August will look similar to July, which so it's been pretty speedy recovery. But we get back to the uncertainty of what the fall brings. And I share your concern about the numbers. Dave and I went back and forth for weeks and 95% recovery still seems optimistic to me, knowing what we're doing in primary care and how that serves as the engine for the rest of what we do. But our experience thus far in our current community state, as far as recovery goes, has been strong. Okay, I mean, time will tell, right? So hopefully it will come out that way, but yeah. All right, that's all the questions I have. Thanks. Thanks, Maureen. How many full-time employees do you have, the equivalents? About 320. And talk us through your thinking on PPP. We don't qualify because we're in a controlled group, which is the Dartmouth-Hitchcock Health System. And we actually went and got a legal opinion because the regs were unclear. I read them two or three times and said, well, this one kind of indicates we still qualify because we're small enough. But when they took the controlled group, look at it, which we are part of the controlled group, Dartmouth is far too large and their number of FTEs are far too great for us to qualify. So we were precluded from even applying. Okay. And walk us through the seeming inconsistency and the statements that were made in your presentation that you didn't think given the amount of dollars that came in that you would qualify for the AHS CRF funds. But then you've built in a component of your rate for taking care of COVID related losses. So how do you justify those two statements? Are you talking about the Vermont stabilization funds? Yes, the CRF funds. We were told that there were, well, there are a number of criteria to consider at the front end. And the first was need. Do you need the money? And we just heard Maureen say, gee, I don't know if you need money and we're recovering well. So I don't think that we passed a straight face test with that. And then the other piece was one care of Vermont participation. So that was also our understanding at the time these materials were distributed for our consideration. Okay. It just almost seems like you're trying to put it on the back of commercial ratepayers versus accessing the funds that are on the table. But that's just my perception of it. I'm very fearful that the hospital systems in Vermont are not gonna access enough of the dollars so that dollars are gonna be left on the table there and will be used elsewhere. And in the meantime, Vermont ratepayers will be paying more. But that's my thought on the issue. Yeah. So Kevin, I think there, the requirements to get it as initially outlined definitely coloring the decision-making process for the hospitals that are saying no. If it was purely, this is the deficit caused by COVID-19 and we'll one-to-one match it with the financials that we share, I think it would have been a no-brainer. And everyone's balance sheet would look significantly better. But it's what rode along with the dollars that have scared some of us that we have uncertainty around our one-care engagement in 21. And we may have missed the first cut-off of the Vermont stabilization funds, but there will be, I think, another crack at it. But I've gotta navigate our hospital through the next month, a little less than a month, with discussions around one care before we would then potentially even require significant reworking of our budget depending on the outcome of those discussions with our board and Dartmouth-Hitchcock. So we, outside of the uncertainty of COVID, there's still a lot of balls in the air before we'd say, no, we're just not going to try to take advantage of the funds available to us. And to be honest with you, Joe, that's another troubling aspect. As I said, you're listening that one of the founders of this organization is your affiliated entity. And yet you seem to be walking away from it and it just, it's perplexing. Well, we haven't had a great experience in one care. There have been a number of issues and challenges that we've had from the beginning at Mount of Scutney. And DHH, my boss, you know, has been very forceful in pushing us to stay in all three programs. And, but I have to navigate both that and my board who actually gets to review our experience financially in one care. And our board asks great questions. My board shares is a retired auditor. So nothing gets by him. And I'd be violating my oath if I didn't say if I said we had a good experience in the ACO thus far. And I'm trying to balance, you know, I had a discussion with a reporter last week and she brought up the same issue that you did and called me on it. And I said, you know, I wear, I wear a lot of hats. I've, as a practicing physician, I believe that we need to change the way we deliver and finance healthcare. As a one care board being a, I'm on the board of managers of one care Vermont. I believe that we are trying to do the right thing and that this can be a vehicle for change. You know, but as the CEO of a hospital with, you know, 400 or so employees in total, largest engine in our community, I have got fiduciary duty to the hospital and to my employees to make sure that we're doing everything we can to be sustainable. And we've had a significant amount of growing pains locally. It just, maybe our experience is unique, but it's been a rough road. Thanks, Joe. Turn it over to the healthcare advocate. Can I just ask a quick follow up question to that? Yes, go ahead. So Joe, I'm just wondering, and this is a question I've asked at least one or other hospital. I'm trying to remember to ask more hospitals, but it's with respect to you said, you know, trying to think about how we change, how we finance healthcare and also how we deliver healthcare. And, you know, payment reform happened first to some degree. I'm wondering if delivery reform has run in parallel with payment reform. So some of the growing pains that maybe, you know, some hospitals are experiencing, maybe a lag in the delivery reform. So I'm wondering if a random physician in your, you know, organization were asked, how have you changed your delivery practice since the organization joined the ACL? What would they say? Yeah, I think they would say they have access to better data. At the same time, they would say they're drowning in data and drowning in clerical work to check boxes and struggle to meet the demands of the EMR despite us having a pretty mature one over the last eight years. Hopefully they would notice the increase in support staff around nursing, the work of the community health teams. But it's beyond those two things, data and improved care management, which I think we have seen. Now we don't know if that's changed outcomes significantly, but we do know where the resources have been placed. I think that's what you'd hear. But would they say, hey, because of the data, I've changed how I'm delivering care, I'm ordering different types of tests I'm bringing people in who haven't been in for a while. I mean, is the data actually providing? Yeah, I would say yes affirmative to those two things that we have had better, as I said, better care management of our more complex patients. And we have changed practices in our clinic specifically around the care of our patients with COPD, that's been a real bright spot. And you can see the data very clearly on one care of what COPD admissions used to look like and what they look like now with a market decrease. Some of our, I'm very cognizant of layering on more administrative burden on our providers. And we often will have our nurses run interference and do the patient registries and build the dynamic worklists that tell us about how all our diabetics are doing, how our COPD patients are doing, our heart failure patients are doing. So I would say that providers have more tools, but I'm not sure that it takes away the overwhelming sense of the burden of working inside of EMRs. I mean, we know what a driver of provider burnout that is the drowning in data and the need to do all the clerical work. Unfortunately, your data coming out is only as good as the data going in. So it can be challenging for folks. I would agree with you that delivery changes have lagged behind payment changes. I think we see that in most ACOs. I think the data coming out is only as good as how much you use it too. So, okay, thank you. Okay, Julia. Sure, yeah. I just have a few follow-up questions. So first I wanted to just ask for some additional clarification. I apologize if I missed this elsewhere, just on the interaction between ACO participation and the Vermont COVID funding. I'm not clear on what that requirement is that you're not meeting. So we are currently for both 19 and 20. For 20, we're in all three programs in the ACO, Medicare, Medicaid and Blue Cross Blue Shield. And as part of the Vermont Stabilization Funds, I believe this is the case. And if I'm wrong, someone please correct me. You had to maintain your current footprint in one care in 2021 to receive those funds. And we at this point have not committed to anything beyond Medicaid in the ACO for 2021. Okay, thanks, that's helpful. And then second, I'm wondering if you can just give us a little more clarity on where your board members or where your concern is lying with the ACO. Is it the target or the risk quarter or generally just taking risk in general that's causing problems? I think initially we were most concerned around downside risk in a time of great uncertainty. Our risk quarters have increased each year. If we're talking about a million and a half of downside risk in Medicare for a hospital that has a 0.6% operating margin that's about 300 grand, it's five times our margin. So that has always been a concern from the start. And we've been very conservative around how we reserve for risk, probably more conservative than we needed to be. But now we've got the pandemic on top of that. We have, there have been issues along the way that we have struggled to resolve, whether it be at the CMS or CMMI level that have led to what Dave referred to earlier in our discussion as flying blind. The inability to get accurate cost reports really affects how, which is the foundational, the foundational data of everything we do is the cost report and having to fly blind for a significant amount of time also hurts. And even outside of the downside risk quarter, there are significant costs to providers to engage in the ACO. And again, in a time of uncertainty, we did not feel comfortable. And I know our board did not feel comfortable in committing to all three programs for the upcoming year. And I, again, freely, we'll freely admit that that is not what Dartmouth wants us to do. So I've got to navigate that with leadership at DHH, my board leadership, and then internally. I'm happy to share with board members and healthcare advocate, our running tally of what our experiences has been financially and otherwise. And we can do that after the presentation. We've got all the data because we're preparing it for our board. That would be great. Thank you. That's all my questions. Okay. Thank you, Julia. At this time, we're gonna open it up for public comment on the monoskutney budget. Is there any public comment? Question. Dale. They mentioned that they had seen 50 COVID cases and in fact, they were one of the first places to actually have COVID show up. I think Bennington area was their first one, but the upper valley was next to Burlington, one of the first. That's a significant number of cases to deal with. What is their impression from that experience with schools opening up? What do they feel, especially being in the upper valley area, is I'd just like to hear what they're thinking the fall is gonna look like. Yeah, Dale, that's a great question. So the majority of those cases really were early on and the majority of those cases were also asymptomatic carriage. We've only had a handful of COVID positive inpatients and post-acute patients in the hospital. Our community prevalence has remained very low for COVID-19. And I think overall Windsor County cases have leveled off total number of cases around 70, 75-ish, according to the last dashboard. I can speak from the Dartmouth-Hitchcock standpoint. They're daily dashboard. There are currently three hospitalized patients with COVID-19 within our health system, two at DH and one with us. And ours was a patient that probably received it and during the community before getting admitted to Dartmouth-Hitchcock and then coming our way. So the risk still remains incredibly low. Over the last couple of months in our respiratory clinic, there've probably been a handful of positives at the most. And as I said, our employees have remained COVID-free. I think that if any region of the country can open schools, it's this one. My wife is a school nurse and handover and know the work that's going on in the task forces up in handover and know what we're doing down here in Windsor. And there are different plans in place at each district. I also think that best practices will come to the surface very quickly as schools reopen. And within a month, we'll have a lot of clarity on how learning should progress for our students, whether it's remote or in person. It's not gonna take long for us to know what's working, what's not and what's safe. But again, I'm for school opening and that's not just because I've got one in high school and one in college. I think, again, if anyone can do it, we can do it with the right planning. And I'm confident that our surrounding school districts have done that. But that's a great question and a real concern. Okay, thank you. Other public comment? If not, thank you, Joe. Thank you, Dave.