Porter Hospital Narrative FY 2014 Budget Submission

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1 Porter Hospital Narrative FY 2014 Budget Submission Summary: Porter Hospital s FY14 budget represents a continuation of the significant and positive financial turnaround commencing from January, 2013 and projected to continue for the remainder of FY 2013 and throughout FY The return of Porter s primary care practices to pre-emr volume this spring/summer has helped drive revenues closer to expected levels. Significant changes in senior management in January resulted in a thoughtful review of staffing and FTE consolidations in many departments, as well as careful scrutiny of all capital and operating expenditures. These changes are key drivers that will allow Porter Hospital to regain debt covenant compliance in fiscal year 2013 and sustain this status throughout fiscal year Examples of key consolidations and FTE reductions include combining the director positions for surgery and obstetrics into one, reductions in laundry, food services and maintenance achieved via the collaboration of these services with the Helen Porter Nursing and Rehabilitation Center, and the planned outsourcing of switchboard services in a joint effort with Middlebury EMS. About Fiscal Year 2013 performance: The projection for fiscal year 2013 includes an operating margin of $1,048,357 and a total margin of $4,592,105 (including 340B Pharmacy), offsetting earlier months poor performance when the productivity of certain physician practices was hindered from the implementation of their EMR systems. One key driver in achieving a positive margin is the hospital s anticipated attestation for Medicare Stage One Meaningful Use funds. This important milestone will be recorded as a receivable worth approximately $2.5M in fiscal year 2013, while cash payment is anticipated during the first quarter of fiscal year Aside from the resurgence in physician and outpatient revenues, inpatient volume continues to be strong. Year to date average daily census of 17.9 is consistent with the performance in recent years and careful management of expenses and the balance sheet have Porter Hospital poised to achieve a Debt Service Coverage Ratio of 5.64 and Days Cash on Hand of 70, both measures in full compliance with our debt covenants, in fact these accomplishments will be met with the issuance of the organization s financial statements for the interim year to date period ended June 30, 2013.

2 Community Health Needs Assessment (CHNA) Porter Hospital is in compliance with IRS Code Section 501(r) in general and more specifically Section 501(r)(3)(A)(ii) as it has completed a CHNA which is adequately accessible to the public as well as available to our community via our web site. A copy of the CHNA along with a draft of the implementation plan was included with the budget submission. IT/CON Project Status: As Porter closes in on successful implementation of our EMR system, we have taken steps to ensure that the project will be completed for less than the revised CON amount of $7.1 million. Our independent auditing firm, Berry Dunn, has confirmed this in their independent review of past and anticipated project expenditures; further noting that Porter clearly has the resources necessary to successfully complete the implementation. This report will be shared and reviewed with the GMCB during the month of July. About the budget for fiscal year 2014: Our proposed budget for Net Patient Service Revenue is 1.4% higher than the fiscal year 2013 approved budget and therefore is in full compliance with the Green Mountain Care Board budget to budget comparison requirement. As previously mentioned, both physician and outpatient revenues were substantially low in the first quarter of 2013, and the most significant cause of the year over year increase is simply the return of those revenues to their pre-emr pace. Porter s budget also includes a request for a 6% increase in gross charges to maintain core infrastructure and certain quality, patient safety, and reform initiatives. Certain significant changes are included in this budget submission such as: Sale of pharmaceutical and drug services to Helen Porter Nursing and Rehabilitation Center Outsourcing of communications services through Middlebury EMS Significant and continued investment in IT to support EMR and to build for success as an ACO participant Budget to Budget Expenses Changes: Overall budget to budget expense changes represent an increase of 4.4% (approximately $3,000,000). I. Staffing Changes: $1,440,000 a. Porter s Leadership took great strides in scrutinizing its staffing needs to both facilitate our efforts to engage in healthcare reform initiatives and successfully implement our new EMR system. When comparing Budget FY 13 to Budget FY 14, Porter Hospital has a net growth of 15 FTES with an impact of approximately $1,440,000. i. General Services: 7 FTES 1. The single most challenging initiative for Porter is the ongoing implementation of our EMR system. A robust IT/Clinical team and project

3 management support has been put into place to support the on-going operational IT/Clinical needs of our clinical staff. ii. Strategic Healthcare Quality Enhancements/Alignment: 6.5 FTES 1. Porter has added additional leadership and clinicians as prescribed by the Blueprint for Care program and to support our Community Health Teams throughout our primary care network. II. Inflation: $780,000 a. Expense budgets were developed initially without consideration for inflation using a zero based approach, with inflation assumptions estimated as follows: i. The approach resulted adding inflation as follows 1. $300,000 in supplies and expense based on an estimated year over year CPI increase of about 4% (effectively 2%) 2. A provision for salary increases of $480,000 III. Group Health insurance: $420,000 a. Porter has received preliminary information from its health care benefits consultants pertaining to the policy year beginning January 1, 2014 which suggests an increase in members, taxes and rates. b. Porter anticipates receiving quotes in the next several weeks, which will include possible considerations for design changes so as to limit the amount of expense growth in the fiscal year As a result, Porter Hospital has proposed a budget with an operating margin of $703,689 (about 1%). Porter Hospitals covenants will continue to advance forward from fiscal year 2013 results, as Debt Service Coverage Ratio is anticipated to be 5.32 and Days Cash on Hand of 101 by the 2014 fiscal year end. Helping to ensure the continued growth in Days Cash on Hand, Porter Hospital has greatly scrutinized its capital requests and plans to limit spending to $3 million, mostly on replacements of existing equipment, noting that depreciation expenses are approximately $5 million. This compares to Capital purchases for fiscal years 2011 and 2012 of $3.9M and $2.4M respectively, while we anticipate fiscal year 2013 spending to be less than $3M as well. Porter Hospital also anticipates another successful year of participation with 340B contracts, with a year over year increase of about 9%. Continued expansion of new contracts and the resurgence of volume within Porter s physician practices are the primary drivers for this increase. Combining the operating margin, along with the non-operating revenues of 340B and investment income, Porter s FY 2014 budgeted total net income is $4,314,204 for a total budgeted margin of 5.94%.

4 ICD-10 Preparation: Porter Hospital has developed a plan for addressing the October 1, 2014 implementation of ICD-10. Key components of this plan include the identification of a project leader, plans for a readiness assessment, identification of key steering committee members, identification of software and other necessary resources, along with a communication plan. The project leader will perform a readiness assessment including coding staff, clinical departments, and fiscal departments along with employed and nonemployed physicians. A draft of our readiness assessment will be available early in the first quarter of fiscal year The costs of the project leader and initial estimates of training costs have been included in this budget, and total approximately $125,000. Overall budget net patient budget to budget increases Utilization Porter very carefully reviewed its core assumptions for admissions, length of stay, and emergency visits by comparing to the rolling 12 months, October to April annualized and known Porter Hospital seasonal trends to set these utilization parameters. This approach produced a marginal, but realistic, growth in routine services of approximately 2%. In concert, ancillary services were budgeted to correlate with these core utilization factors, thus resulting in the same growth pattern. Porter performed a thorough review of physician practice volume recognizing that its 5 specialty practices would be going-live with the implementation of electronic medical records. (6 of Porter s 11 physician practices have already gone live with EMR.) As outlined in the executive summary and the expense section of this budget narrative, Porter has enhanced training and support services and thus is better equipped to handle provider training and user support as the remainder of the physician practices go live. Visit thresholds for FY 14 were developed taking into account the phase-in months for EMR along with specific considerations for visits per provider. For the primary care practices, visits were developed by reviewing each provider s patient panel. The individual visits per provider calculations factor their individual trends towards rebounding from go-live EMR dips as well as reflect a steady staffing pattern during FY13 there were staffing gaps due to FMLAs and retirements. Ergo, the FY 14 budgeted physician visits reflect the upward volume trend for primary care practices rebounding from EMR implementation, less physician transitions i.e. less gaps in staffing, and remaining go-live in EMR. i. Revenue assumptions: Medicare Porter Hospital prepared an interim Medicare cost report for the year to date period ended April 30, This report was used for the purposes of projecting fiscal year 2013 results as well as a basis for determining effective budget rates in fiscal year Porter Hospital will continue to qualify as a Critical Access Hospital and will continue to benefit at the rate of 101% of allowable costs based on Medicare charges as a percent of total allowable charges. While there is a year over year increase in allowable expenses which would increase Medicare reimbursement, the benefit of this is offset by a reduction in reimbursable capital costs relating to the anticipated certification for Stage One Meaningful

5 Use in fiscal year As a result of these factors, and given the presumption of continued 2% sequestration on total payments, the effective rate of Medicare reimbursement as a percentage of charges has been conservatively estimated to drop by about 1% vs. fiscal year ii. Revenue assumptions: Medicaid Porter based the FY 2014 Medicaid revenue on current proposed law which provided for a 3 percent increase effective November 1, Below is an excerpt from Vermont State Legislation: Act No.50 An act relating to making appropriations for the support of government H530. Sec. E REDUCTION IN MEDICAID COST-SHIFT (a) Beginning on November 1, 2013, the Agency of Human Services shall increase Medicaid reimbursements to participating providers for services provided by an amount equal to three percent of fiscal year 2012 expenditures for those services. Rate Request: Porter Hospital reviewed its charge structure, utilizing among other tools the data available via the Department of Financial Regulation website which shows the results of a 2011 charge study. Whereas Porter Hospital s charges are highly proximate to the mean for the State of Vermont, a nominal increase request seems appropriate in addressing the issue of cost shift. We have estimated that a 6% increase in charges will yield additional Gross Patient Service Revenues of approximately $7.3M resulting in a Net Patient Service Revenue yield of approximately $760K based on Porter s payor mix and payment methodologies. The result of this additional Net Patient Service Revenue is included in our budget submission. As mentioned previously, our resulting Net Patient Service Revenue budget request is well below the budget to budget compliance requirement 3%. Porter Hospital s intention is not to apply and across-the-board 6%.

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