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HOSPITAL ISSUES FY2018 NPR Issue (Slide 4)Cerner Conversion– Impact on General Financial Systems-Reporting and AR– Select New GFS and Reporting Tools– Legacy systems archiving MDH/LV DesignationRecruitment and Retention–––– CardiologyOrthoHospitalistHospital Staff- ESD, RN/LPN, MAContract Labor/Travelers (Slide 5,6)OneCare-Risk Based AgreementsBirth Rate DeclineCommunity Needs stretching hospital resources–––––HomelessOpioidsMental HealthDentalAging population3

FY2018B NPSR ISSUE BMH removed the OneCare ACO contract risk as proposed, which was estimated as a 1,304,315 deduction from Gross Revenue.To account for this negative reduction, BMH lowered its rate request from 8.9% to 5.7%.These combined actions-reducing the rate increase and removing risk as a deduction fromrevenue- do not impact NPSR; see chart below: Upon receiving the budget order, BMH requested the Board in writing on October 18th, 2017 toamend the order and reinstate the original NPSR: 80,202,627. This matter was also discussedwith Board members at a BMH site visit on October 31st, 2017 and in several emails with GMCBstaff. See Executive Summary in Budget Narrative for additional information. Without this requested technical amendment, BMH’s GMCB-approved FY2018 Budget results in anegative operating margin of -1.5% which would not promote the efficient and economic operationof the hospital


CONTRACT RN ( 000’S) BY MONTH FY 2018***July-SeptemberProjected***Projected FY 18 Total: 1,308,0006

RISKS AND OPPORTUNITIESRisks Recruitment and retention––––Difficulty in reducing contract labor expensePhysician/CliniciansLow Unemployment and loss of young talentCompetition from NH and MA OneCare risk-based performance CMS Proposed Reductions General Financial System– Identifying and implementing new GFS and reporting tools Limited patience with long-term population health investments whichdon’t yield short term returns––––––Vulnerable Pop Nurse (Homeless shelter and Respite bed)RiseVTCare CoordinationDental HealthEmbedded BH Therapists in PCCommunity Health Team and Hub and Spoke7

RISKS AND OPPORTUNITIESOpportunities Successful recruitment effortsRegional Psychiatric Strategy Group– Retreat, BMH and HCRS Continued collaboration with DH and Cheshire Med– Evolution of Strategic Partnership Telehealth– Expanded Telepsych– HIV Care LGBTQ Initiatives–––– Policy and proceduresStaff educationCommunity engagementClinical services3 Day SNF Waiver– Right care at the right time and right place8

RISKS AND OPPORTUNITIESOpportunities Development of Dental Clinic (Medicaid and Uninsured)– BMH provides facility and employs dentist– United Way, Brattleboro Health Department and other community agencies Upside Potential –OneCare AgreementsOpioid Reduction/Overdose Efforts–––––– ED BH Nurse PractitionerAdditional MAT CliniciansED Peer Recovery Pilot-Turning PointProject CARE (Community Approach to Recover and Engagement) ParticipantBMH Clinician Opioid Task Force and community pharmacy collaborationNAS (Neonatal Abstinence Syndrome)/ Substance Exposed Infants CoalitionChronic Pain Initiative-BC and Medicaid9

THIRD NEXT AVAILABLE APPOINTMENT(UPDATED 8/20/18)PracticePhysical ExamNew Patient AppointmentRoutine Follow-UpWindham Family Practice14 days32 days5 daysBrattleboro Family Medicine33 days32 days23 daysMaplewood Family Practice38 days32 days9 daysPutney Family Health46 days32 days15 daysBrattleboro Internal Medicine19 days32 days15 daysJust So Pediatrics30 days60 days20 daysBrattleboro Orthopedics andSports MedicineN/A5 days5 daysBrattleboro Center forCardiology andCardiovascular HealthN/A7 days7 daysBrattleboro UrologyBrattleboro General SurgeryN/AN/A47 days7 days5 days7 daysBrattleboro OB/GYN67 days61 days61 days

MEDICAL GROUP FTE GROWTHBMH Medical Group FTEs vs. BMH Total FTE600FTEs500400BMH Medical GroupStaff FTEs300BMH Staff FTEswithout MG200Total BMH StaffFTEs1000FY19BudgetedFY18 ActualYTDFY18BudgetedFY17 ActualJulyFY16 ActualFY15 ActualFY14 ActualFY13 Actual

APM QUALITY MEASURES Patient Centered Medical Home (PCMH) allows for excellent results inchronic disease management and a focus on prevention. Theseresults are seen in our data and continue to improve. Patient access remains a constant concern, and we have putsignificant effort into recruiting providers with good success. Substance abuse and mental health data point to the need for specificplans to address these issues. We have implemented:–––––––Embedded RN Care Coordinators focusing on the patients with highest needsEmbedded Behavioral Health Therapist for primary care focused on results for substanceand alcohol misuse and depressionBehavioral Health Nurse Practitioner in Emergency DepartmentAdditional MAT PrescribersTele-PsychiatryA Regional Psychiatric Strategy GroupVulnerable Population nurse12

FINANCIALS-Income Statement with BMH FY2018BINCOME STATEMENTRevenuesGross Patient Care Revenue Disproportionate Share PaymentsBad DebtFree CareDeductions from RevenueNet Patient Care Revenue (NPR)Fixed Prospective Payments & ReservesNPR & Fixed Payments & ReservesOther Operating RevenueTotal Operating RevenueExpensesWages, Benefits & Medical ProfessionalsHealth Care Provider TaxDepreciation & AmortizationInterest - Long-term & Short-termOther Operating ExpenseTotal Operating ExpenseNet Operating (Loss) IncomeNon-Operating RevenueExcess of Rev Over Exp Operating Margin %Total Margin %FY2018PFY2018B BMHVariance 169,571,693 2)-659.54%254,950-2.5%0.3%740,0001,100,069 0.4%1.3%1,492,569(882,242)-6.36% Y2019B158,780,867 827 nce %201.70%-80.20% 5758,0001,012,9500.3%1.2%13

FINANCIALS-Income Statement with GCMB FY2018BINCOME STATEMENTRevenuesGross Patient Care Revenue Disproportionate Share PaymentsBad DebtFree CareDeductions from RevenueNet Patient Care Revenue (NPR)Fixed Prospective Payments & ReservesNPR & Fixed Payments & ReservesOther Operating RevenueTotal Operating RevenueExpensesWages, Benefits & Medical ProfessionalsHealth Care Provider TaxDepreciation & AmortizationInterest - Long-term & Short-termOther Operating ExpenseTotal Operating ExpenseNet Operating (Loss)Non-Operating RevenueExcess (Deficit) of Rev Over Exp Operating Margin %Total Margin %FY2018PFY2018B (GCMB)Variance 169,571,693 613)109.19%254,950-2.5%0.3%740,000(223,130) -1.2%-0.3%1,492,569440,957-6.36% 2019B158,780,867 827 88,382)7,023,293(665,089)106,251(558,838)Variance %201.70%-197.62% 5758,0001,012,9500.3%1.2%14

FINANCIALS – Balance SheetBALANCE SHEETFY2018AFY2018BFY2019BCash & InvestmentsRisk Reserve for Fixed Reform PaymentsOther Current AssetsCurrent AssetsBoard Designated AssetsNet, Property, Plant And EquipmentOther Long-Term Assets 4,720,330 20,662 ets 80,064,982 80,695,513 ,064,982 80,695,513 89,192,804Current LiabilitiesLong Term LiabilitiesOther Noncurrent LiabilitiesFund BalanceLiabilities and Equities 15

FINANCIALS – Cash Flow BudgetCASH FLOW STATEMENTFY2018B (GCMB)FY2018B (BMH)FY2019BCash From Operations(Deficit)/Excess Revenue Over Expense (223,130.00) 1,100,069.00 ,933,151.004,641,677.00Patient A/R2,604,969.792,604,969.79(800,382.00)Other 86.00)Cash From Investing ActivityCapital SpendingChange in Accum Depr Less DepreciationChange in Capital AssetsTotal(Increase)/Decrease:Funded DepreciationOther LT Assets & Escrowed Bonds & ,605,802.59)(1,605,802.59)8,605,420.00Change in Fund Balance Less Net otalTotalFinancing ActivityDebtBonds & MortgagesTotalOther ChangesBeginning CashNet Increase in CashEnding Cash 3,320,662.00 4,643,860.92 4,465,685.0016

FINANCIALS – Material P&L Variances Gross Revenue and NPSR: Drop in OR utilization, Medical Office visits, Birth Bad Debt: EHR implementation delayed billing and caused “timely filing” write-offsand an unhealthy aging schedule. Projected bad debt expense at FYE18 is 6,815,604.––– Free Care: No policy change; overall, upward trend in applicants with downwardtrend in utilization––– 50% Bad Debt expense; 50% ReserveLimited bad debt/collections functionality in Cerner which impacted our ability to collect patient portionof balances. Process improved in March 2018.Implementation problems will continue to have negative impact on bad debt; the FY2019B reflects thisexpectation.Charity/Free Care adjustments were not completed timely due to billing & A/R issues noted aboveGoing forward, BMH expects these numbers to be more in line with prior years and budgetThe Financial Assistance-eligible patients have increased year-over-year; BMH's Community ResourceLiaison has also been increasing the number of low income patients assisted in obtaining insurance.Analysis also shows that requests are for lower amounts than expected.Depreciation: FY2018 Budget calculation incorrect17

FINANCIALS – Payer MixPAYER MIXCommericalMedicaidMedicareTotalVT 019B91.14%9%100.00%8.91%100.00%8.86%100.00%18

FINANCIALS Expense Drivers–––– Contract LaborDrug Costs (Oncology)Benefits-Health insurancePhysician wages, fringes and feesCost Containment Efforts– See detailed Slide #10 in Budget Narrative submission: Position EliminationsExpensesPrograms19

COMMUNITY HEALTH NEEDS ASSESMENTPopulationHealth FocusInitiatives Addressing these GoalsAssociated CostFood Security Veggie Van Go: In collaboration with VT Foodbank , BMH staff offer fresh and healthy food monthly. Administrative and staff timeCoordination ofCareCulturalCompetency Vulnerable Populations “Healthworks”: In collaboration with Groundworks, BMH provides support for a VulnerablePopulations Care Coordinator and funds a shelter based respite bed for patients experiencing homelessness. BMH is alsocollaborating with Equity Solutions to bring Cultural Competency training to BMH with a focus on poverty and homelessness. 82,000Obesity Rise VT: Early adopter of this initiative aimed at promoting healthier lifestyles for Vermonters. BMH to hire Project Managerin Fall 2019 70,000Access to Care Primary Care Access: Interim Care Clinic established in 2017 to provide care to 4,000 patients following PCP retirements 150,000Coordination ofCareAccess to Care Care Coordination and Healthcare Navigation: Care Coordinators hired into the Medical Group to coordinate care forhigh risk patients as well as improve access for things like Wellness Visits 215,000Coordination ofCare Community Health Team: Additional support to provide health and wellness to Windham County through diabeteseducation, health coaching, nutritional support, behavioral health, and care coordination. 125,000 above BPreimbursementAccess to Care Medical Scribes: Assist Clinicians with documentation and enable clinicians to focus on their visit 203,000Aging population Post-Acute Care: Provides primary care to three local skilled nursing facilities 397,000Coordination ofCare Accountable Community for Health (ACH): Provide Physician and Administrative leadership to the ACH (former RegionalClinical Performance Committee-RCPC). Collaborates with health and human services organizations/agencies to provide amore coordinated approach to patient care. 10,000Substance Misuse Narcotic Use Task Force: Physician leadership of committee evaluating and managing chronic narcotic use amongstpatients served by the BMH Medical Group. NegligibleMental Health andSubstance Misuse SBIRT: In Brattleboro Family Medicine, patients are screened for mental health and substance misuse and referred ifappropriate to a behavioral health therapist embedded within the practice. 66,000Mental Health andSubstance MisuseCoordination ofCare Women’s Health Initiative and Centering Pregnancy: Brattleboro OBGYN provides enhanced SBIRT screening andreferral to embedded Social Worker. This Social Worker provides counseling and assists with coordination of care andreferrals to external agencies for things such as food and housing security. 5,000 above BPreimbursement20

HEALTH CARE REFORM INVESTMENTSInvestmentGoal of InvestmentAPM Initiative SupportedRationale for whyinvestment is necessaryNeurologist1.Keep attributed patients inHSA1.2.Behavioral Health NursePractitionerAllow patients in needof neurology services toreceive care in theircommunityEmbed Neurologist inPCP office to allow forwarm hand-off1. Decreased boarding timefor mental health patientsin ED2. Improved medicationmanagement3. Provide real-timeconsults for PCPs2.1. Depression Screeningand Follow-Up Plan2. Suicide Prevention3. Reduce mental health readmissionsCurrent lack of accessto care in WindhamCountyAllows for improvedcontinuity of care1. Lack of available mentalhealth beds in State2. Reduce psychiatricemergencies21

HEALTH CARE REFORM INVESTMENTSInvestmentGoal of InvestmentAPM Initiative SupportedRationale for whyinvestment is necessaryEmbedded Behavioral HealthTherapist-Primary CarePractices1.1. Depression Screeningand Follow-Up Plan2. Suicide Prevention3. Overdose Prevention4. Reduce mental health readmissions1. Focus on early detection2. Cost savings related tohigher levels of careBMI Screening andIntervention Plan1. Improve outcomes forchildren’s health andwellness through bettercoordination of communityresources and leadership2.3.Project Manager-RISE VTIdentify early signs ofmental health concernsand substance misusethrough enhancedscreeningReduce mental healthcrises through provisionof brief intervention andreferral to appropriatetreatmentReal-time referralsto/from PCPs1. Improve health andwellness for children inWindham County2. Improve communityinfrastructure as itpertains to health andwellness for children inWindham County22

HEALTH CARE REFORM INVESTMENTSInvestmentGoal of InvestmentAPM Initiative SupportedRationale for whyinvestment is necessaryEmbedded CareCoordinators1. healthoutcomesReduce unnecessaryER visitReduce patients’ overallcost of care2.3.Increase access toMedicare WellnessVisitsDecrease A1C rates forDiabetic Patients3. Focus on HTNcontrol2.High prevalence of‘very high’ and ‘highrisk’ patients inBrattleboro HealthService Area (HAS)Known high cost of carehigh risk patients23

CAPITAL BUDGET INVESTMENTS The Non-CON capital budget:FY2019 Non-CON CapitalAmountPatient Care equipment replacements 319,760Medical Practice equipment Diagnostic Department equipmentincluding Echocardiogram unit 461,583Plant Services repairs and upgrades 132,536General Financial system upgrade 200,000IS projects and infrastructure upgradesincluding data archiving system 878,669TOTAL84,581 2,077,129 CON-Approved Modernization project construction to start in Spring2019 with completion in FY 2021. Boiler plant upgrade commencingAugust 2018 with completion Fall 2018. No Budget impact for FY201924

LONG RANGE IMPLICATIONSSUSTAINABILITY AND PROFITABILITYOver a longer time frame, our objective is to try to return to an averageoperating margin of at least 3%. At this point we have dropped to a negativeoperating margin of 0.6% for the 5 year margin. This level of return does notrepresent a sustainable return for such a capital-intensive operation as acommunity hospital.As previously stated to the GMCB, BMH is the most reimbursementchallenged hospital in Vermont. We do not qualify for designations forCritical Access or Sole Community which receive preferential reimbursementunder Medicare. Our Medicare Dependent/Low Volume Hospitaldesignation is continually under Federal funding pressure.One of our expectations in being an early participant in OneCare is toprovide some stability and upside potential in our Medicare and Medicaidreimbursements. However, it is too early in the journey to determine whetherwe will be successful in our efforts.25

LONG RANGE IMPLICATIONSINDEPENDENT TO EMPLOYMENT OF MEDICAL STAFFOther than challenging reimbursements, the major impact on BMH’s marginis the necessary employment of the majority of the Medical Staff.In 2010, the Medical Staff was mostly comprised of independentpractitioners who “hung up their shingle” in the 1970’s and 1980’s afterresidency. These physicians, who practiced in solo or 2 person offices, havenow entered retirement over the last few years.Consequently, in order to provide access to primary care and appropriatespecialties, BMH has had to create a new clinician employment model andenterprise for our community. Currently, approximately 30% of our total staffare connected to BMH Medical Group; which has also required significantcapital investment such as an integrated EHR, office space developmentand new staffing models (eg. use of scribes; care coordination).26

LONG RANGE IMPLICATIONSNEW MODEL FOR BMHThe continued financial pressures on BMH have created opportunities toimplement new ways of delivering high quality care. These efforts haveresulted in the creation of the Progressive Care Unit, our Post-Acute Team,Scribe and MA programs; etc.We are also leveraging our relationship with Dartmouth-Hitchcock andCheshire Medical Center in Keene, NH to begin developing a regional healthsystem for our communities.27

Practice Physical Exam New Patient Appointment Routine Follow-Up Windham Family Practice 14 days 32 days 5 days Brattleboro Family Medicine 33 days 32 days 23 days Maplewood Family Practice 38 days 32 days 9 days Putney Family Health 46 days 32 days 15 days Brattleboro Internal Medicine 19 days 32 days 15 days Just So Pediatrics 30 days 60 days .

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