 Looks like everyone is here, so we will call to order the Green Mountain Care Board's March 22nd, 2023 board meeting this morning's meeting will be followed up by meeting this afternoon and this morning we are just. Discussing and potentially voting on the modification of UVM MC's fiscal year 2017. Enforcement action, and so I'll turn it over to Sarah Lindberg and Russ McCracken. Good morning. It is actually morning for once. I will ask probably Russ to take the lead here, but we, as a reminder, very briefly, this is an issue that we brought before you related to. The fiscal year 17 actuals being above the budgeted amounts, not for largely due to the utilization being higher than expected, and UVM wasn't the only facility to experience that. And so the. We'll let Russ get into all the details, so you don't have to hear it twice, but take it away. Russ, good morning. Can everybody hear me and see my screen? Great. And before I start, I will say, I think maybe this meeting was set up with a waiting room for outside folks. I've seen some admit things pop up. We have been admitting everybody. It is a public meeting. I don't, well, I think clean that up. Logistical thing in the future, but everybody who's who's come up in the waiting room has been admitted here. So, I'm going to start this is a bit of a recap and. There's not a lot of new information on these slides, but just to frame the discussion again for the board. The board met to consider this question on February 22nd at March 8th. We came before you with a staff recommendation to modify what the board did and with respect to F Y 17, which was an action taken by the board in April of 2018. Our staff recommendation was to revise that enforcement action to make the use of the remaining funds, which is approximately $18 million more flexible and addressing the current mental health needs. The staff recommendation was to order to develop a proposal and consultation with a Vermont Department of Health. Outlining the planned use of funds to address the mental health needs to come back with that proposal by May 31st. And the restriction would no longer be for only additional inpatient capacity would be for additional capacity for mental health services in the state, not limited to inpatient. I have some updates, slight updates on that proposal that I'll get to. We've had a public comment period open since February 22nd. We've received a lot of great public comments. I'll summarize those in a later slide. The Vermont Department of Mental Health is supportive of this change and broadening the proposal to broaden the restrictions on the use of funds, so that it's able to be deployed to increase mental health capacity without the inpatient limitation. Sarah reviewed this in more detail at the last meeting, but we had some follow up questions to the University of Vermont health network, which said that the funds have been maintained at unrestricted investments, which is included in their days cash on hand calculations for the hospital. Um, the returns that were provided by the health network. Uh, showed about a 21.2% cumulative return, which is about 4.1% annualized. And we also noted and discussed a little bit more. There's an inflation index if you look from April, 2018 to January, 2023 shows about a 20.1% inflation. Here, we've looked at this before, so I don't want to read through it again. This is the action that the board took in 2018. Provisionally allowing you to self restrict $21 million in surplus funds with the condition that those funds be used solely for investments that measurably increase in patient mental health capacity in Vermont. Um, the proposal we're looking at here is to modify that this by taking out the inpatient. Part of this cap of this use restriction. The order just as a reminder to the board also says that if the GMCB determines that insufficient progress has been made, it may order. The UBMC use all our portion of the $21 million to benefit rate payers through a commercial rate reduction. The finding that insufficient progress has been made is something the board did do over the summer of spring and summer of 2022. Following a presentation from a UBM health network that they were not able to move forward at the current time on the planned inpatient. Expand in inpatient psych project at CVMC. So, to date, or at least as of yesterday, when I put the slides together, the board has received 14 written public comments regarding the potential modification. Of the enforcement action, additionally, comment letter, letter from UBM health network was received. These, as I said, the last meeting, these are summaries and they don't do justice to the sort of breadth and the quality of the public comments that we've received. But the general themes were an urgent need for additional mental health services. Urgent need for additional inpatient capacity, including to address the issue of mental health patients being boarded in emergency departments. I need to prioritize inpatient beds, especially for children and adolescents. The continued disparity and reimbursements for mental health services versus other health care reimbursement amounts. Some value in providing flex, excuse me, the value of the flexibility in providing mental health services outside of an inpatient setting to reduce hospitalizations. And providing better options that are available 24, 7, then going to an emergency department. And then, important note at the end, the comment from the health care advocate during the last meeting to clarify what we intended in the motion language with the phrase in consultation with the image. And to include some required input from community members. So, the public comments received 7 really explicitly supported retaining the scope of the self restricted funds and 6 were more explicit about expanding the scope of the funds that in as the staff had proposed. So, what we're coming to you now with is a bit of an update on the staff recommendation, although kind of fundamentally, I think it's very much in line with what we had proposed before. It's to revise that why 17 enforcement action to make the use of funds. More flexible in addressing the current mental health needs by allowing the funds to be used to increase mental health capacity, not limited inpatient capacity. And then the 2nd part of this is to order UVM health network to develop a proposal that reflects and incorporates priorities from the Vermont Department of Mental Health. And contributions from community members identified by DMH, outlining the planned use of funds to address the mental health needs in Vermont. And for the board to determine that sufficient progress is being made on this, the proposal will need to be submitted to the board by May 31st. DMH will need to provide the board with confirmation that DMH is satisfied. The proposal adequately reflects its contributions and the proposal has to explain the impact on the issue of mental health patients being boarded in emergency departments. So a couple of additions in the staff recommendation and I put, we put together some motion language reflecting that staff recommendation for the board's consideration. And that was all I had prepared as a presentation to set this up again. Mr. Chair, so I will, unless Sarah wants to add anything, I will turn it back to you for board questions, comments. And discussion. Great. Thank you both. I'm just going to take a second to read the motion language before we open up to comment. Okay, great. Thank you both very much. I'll turn to board comment. If any board members have any questions or comments, please go ahead. We can start with Dr. Dr. Merman. Good morning. Thanks, Chair Foster. Thanks Russ for the presentation and Russ and Sarah for all the hard work and the team for all the hard work on this. I first want to continue to express all of our shared concerns about access to mental health treatment in Vermont, whether it be inpatient or outpatient. And all the other services related to the care of patients with struggling with mental health challenging conditions. This really needs to be improved. I do think this reconsideration of this prior budget enforcement action has brought a lot of these issues since in my short time on the board right to the top of the agenda. And I think it's been really, really helpful for this to have occurred to encourage all of the really helpful public comments that we have received. I think most of us read every single one of these and consider them very carefully. So I think this has been a really good thing to have occurred at this time to reinvigorate the conversation about challenges of capacity for mental health treatment of mental health conditions and access to inpatient care and access to outpatient care. And other services. You know, I've mentioned before as an emergency physician, you know, essentially at this point every clinical shift we we take care of patients who are being evaluated for mental health crises or are boarding in our departments awaiting treatment therapeutic treatment for a mental health crisis. And it's it's come to the point where at this point, I don't think very many, many of us feel at all surprised when somebody has been boarding in our departments for at least 48 hours. I mean that doesn't even seem shocking at this point. In fact, that's starting to seem like a reasonable amount of time for someone to await transfer to a treatment facility. And and actually we're getting to the point where sometimes weeks don't seem all that uncommon children waiting a week or two for an inpatient psychiatric bed in our departments. It doesn't feel nobody feels good about it and we all know that it's much harder on the patients than it is on us but it but watching it happen is is is really is really challenging and and tragic. And it just seems like it's the wrong the wrong way to care for these patients night and I think everybody in the state is in agreement with that every public comment. Every hospital. Nobody thinks this is the ideal way to care for these patients and the patients themselves are the ones that are they're most affected by this. And there's not clearly and I think the public comment speaks to this very eloquently there's not a single solution for each one of these scenarios. I mean from my perspective it's clear that more inpatient capacity would be beneficial because there's patients that just need need that level of service now an ideal world with improved outpatient treatment could we prevent those patients from having to come to the emergency department. And I think many yes but I don't I don't know if if at least in the near future. I do think we need more inpatient capacity the ED is just a really not a good place for these patients to to language it's not the solution. We don't have opportunities for therapy there's rare opportunities of any opportunities to see natural light sleep cycles are impossibly hard to maintain. There's other instances of dysregulated patients are very high acuity medical trauma patients that are near these patients there can be stress that's associated with those situations. It's just not the place to be waiting for treatment. It's not treatment. So as a new board member trying to understand and actually having not been through the hospital budget process yet trying to understand the subtle derivation of the normal process of of managing a hospital. Margin budget process with a margin or net patient revenue was over the allocated amount in 2017 has been a bit of a deep dive trying to understand what occurred. So looking back this appears to have been a very unique situation taken by the board as far as I can tell. There were no other circumstances when a similar situation occurred where the net patient revenue or margin levels were above the allocated amount and the money that that was not returned at least in a large part to commercial rate payers through a commercial rate reduction. So it appears to me that in 2017 as continues now there was a crisis and patients boarding in the emergency department awaiting mental health treatment and there seemed to be an opportunity and an appetite to try to rapidly improve this this crisis and it it's hard to tell. Looking through the presentations and the records what actually occurred but it seems to me to be reasonable that there was some communication between the board and and people at UVM. To that that there was a that there was potentially a solution that this could that this could work out quickly. And and I think that there was all the best intentions of this occurring as a rapid improvement to addressing the in patients mental health capacity challenges in Vermont. But it if this unexpectedly high margin was dealt with in the same manner as any other unexpectedly high margin was in 2017 and this money was returned to commercial rate payers in Vermont by a rate reduction. Well we would not be here today talking about this but it it also would have reduced the commercial. Rate reimbursement to UVM by approximately by twenty one million dollars in the subsequent year and a rate reduction of approximately 3% is what it looks like back then from looking through slides that it was about $7 million per percent at that time for UVM budget. And if that 3% rate reduction or twenty one million dollar rate reduction occurred in twenty eighteen. It may have actually continued through twenty nineteen twenty twenty twenty twenty one twenty twenty two. It continues because the rate would have been lowered and the and that rate would have been down and that that would have that's a large amount of money. Now that may not have been what happened. It's it's hard to to reinvent the past and predicted forward. The board could have said OK well UVM took a rate reduction coming into twenty seventeen because of twenty sixteenths performance. And so maybe the board wouldn't have thought that a whole 3% rate reduction was the appropriate amount. Maybe they would have been a one and a half percent rate reduction or maybe in twenty eighteen. UVM would have asked for a commercial rate increase from from what it would need in twenty eighteen plus what it needs in twenty seventeen. So it's not necessary that it would have been twenty one million dollars a year for each of the last five or six years. But but at the very least they're not having a commercial rate reduction in twenty seventeen for UVM was financially very good for UVM. Well financially good to very good for UVM depending on what would have occurred again. It's all hypothetical but it clearly was was better to take to try to figure out this solution for the hospital. And at the time it looks much better for Vermont to try to figure out the solution because we needed to deal rapidly with this mental health boarding crisis. Now we all know what has happened since then and that did not pan out. But that's my best understanding of what occurred then and what the potential the potential ramifications of this of this money work. Additionally there was this money that that Russ had described about the earnings associated with investing this twenty one million dollars. So the twenty one million dollars was appropriately put into the I believe the general funds at the Medical Center or the Health Network along with other money like funded depreciation. There is I think some things like endowment are put in there as well and this money is invested in that. That's the smart thing to do. And this money the twenty one million dollars has earned money at this point. And so to me it would seem that this approximately four million dollars that the twenty one million dollars has earned because it had not been used for the initial intent. And it had really not been used. I think with the intent was for this to be used fairly quickly although it wasn't really defined in the enforcement action. I think that four million dollars seems reasonable to me that that be added to this twenty one million dollars for use to improve mental health capacity whether inpatient or outpatient in Vermont. The other pot of money that I'm trying to understand what happened to is the three million dollars that was spent designing the new hospital complex and parking garage at CVMC. I think the intent was again the best intent for this to be used to increase mental health capacity. There was going to be some beds shifted from the current capacity at CVMC to this new facility and then some beds added to that. But unfortunately because of a twenty because of a net operating loss of approximately twenty million dollars a year this this project has been put on an indefinite hold. So you know strictly speaking with the language that says this should be used I think to I don't have in front of me measurably increase inpatient mental health capacity in Vermont. This three million dollars did not do that. So so I do I do think we should consider whether or not that three million dollars should be used for measurably improving mental health treatment capacity in Vermont. So again thank you very much Russ and Sarah I really do think this is an incredibly important topic for us to spend more time on. I really would look forward to speaking with DMH to understand our state's priorities on how to improve mental health treatment capacity and treatment in Vermont. I think this is a great opportunity to rethink about how to use this money in a an effective way and in a rapid way to try to to try to alleviate the problems. So look forward to hearing other people's comments. Thanks so much and back to you to our foster. Thank you Dr. Merman. Jessica Holmes Miss Holmes. Sure questions or comments. Thank you. I think I'll be I'm going to focus on the motion. But I actually you know I want to thank the team Russ and Sarah for thinking about this and putting together some you know motion language for us to consider and also like my colleague Dave. The I also want to thank the members of the public for taking the time to really submit some really thoughtful comments very very much appreciated again read all of them and really appreciate them very much. I would say that I support this motion with the language that's been suggested for increasing the flexibility. I really think it's important that the language says to increase capacity of mental health services. That's you know but giving the flexibility to not limit it to inpatient capacity but again still focused on increasing capacity. I think you know as as Dr. Merman just outlined we have we have a mental health crisis we have it today. We need to deploy these resources today. I think the deadline of May 31st seems reasonable so that a proposal must be submitted. We need to know where this money is going to go and how it's going to increase mental health services in the state with that flexibility added. It was good to hear and I appreciate that DMH is involved and supportive of this motion to increase the flexibility and that they will be involved in developing that proposal and incorporating DMH's priorities into that proposal and we will receive confirmation that DMH in fact is satisfied that was important to me and I'm glad to see it in the language here. Also you know I think important that that the proposal reflect communication from stakeholders you know that the public comment that we received was really helpful. One of the things I think we should do is submit you know in case that public comment was not read by the Department of Mental Health and UVM Health Network I think we should share that public comment with the folks that are developing this proposal. And to me I think that third bullet item is really important that the proposal include an analysis and explanation of how this investment of resources is going to impact the patients who are boarding in EDs. And I wonder actually given some of the public comment we received about adolescent borders in particular in the need for better treatment paths for our children and adolescents. I wonder whether my one minor thought as I'm looking at this language is whether we want to just specify that we want to understand how this proposal will impact mental health patients being boarded in EDs separately adults and children. So we understand if there's going to be an impact in reducing adolescent borders or is it just going to address adult borders. I think that would be helpful to understand. Given the priorities for getting treatments for particularly children and adolescents it would be helpful to understand that and hopefully however these dollars are allocated will alleviate some of that. The issue among children and adolescents. But again I for me the really important thing is we're not the experts DMH is the are the experts here with a full view of the system and how best to create impact with these dollars. So to me that was a really important component of this motion so I support the motion and I appreciate all the hard work that's been done here. Great. Thank you very much. Member Holmes. Member Walsh. Sure. Thank you chair. Thank you Sarah. Thank you Russ. Thank you Jess. And thank you Dave. I really appreciated your thorough walk through the dollars and the three million that it seems hard to say that that went toward mental health care and the four million earned in interest. I think those are really key points that I'd like to come back to. In regards to the motion here I think it's an improvement from what we saw a couple weeks ago. I'm not quite there yet to go with it the way that it is worded. I read I've reread every one of the public comments last night and this morning. You know and I think Russ did a nice job saying that we can't summarize them in a slide. Right there. They're profound. I think we we say that seven were in favor of keeping the focus on inpatient care. Six supporting you know widening the scope. But you know one of the one of the letters was from the emergency department directors across the state. I think that was 11 people. They described our current situation. These are their words as inhumane and unethical and Dr. Merman does a nice job. But in an emergency departments calm emergency department doctors calm demeanor. Right describing kids being kept inside unable to go outdoors for weeks. If you were not in a severe mental health crisis when you came in you would be in one by the end of that time. Any one of us this situation has languished. It was discussed in 2017. It's only worse now. The suffering is worse. The situation as a whole is worse. Another another item from that letter. 30 patients in boarding in the E.D. for a day or more. On any given day there are 30 patients in Vermont. Who are in an emergency department for at least 24 hours. Sometimes weeks. For every 24 hours that one of those patients in the emergency department. Six concerns have been raised. in the emergency department, six non six patients without mental health disorders are diverted. So the simple math would be that at least 180 patients a day are diverted, but but that's inaccurate. That number is way too low because some of those 30 patients have been there for multiple days or weeks. And this figure from Dr. Smith and colleagues is that for every 24 hours, one person is in the ED six are diverted. So this isn't a problem that's only affecting people who are suffering from mental health issue. This is a public safety issue. Our emergency departments are clogged. So I don't know how to create more urgency around this other than saying words like inhumane and unethical and public health emergency. We've been told there's been a lack of action because this is doing something about this would not be profitable. I don't know if that's true. But as an excuse, it falls woefully short of the mission of a nonprofit system. The part about this motion that I appreciate the most is the proposal to include analysis and explanation of how the proposal will impact the issue of mental health patients. I could imagine extending that to say that it would need to include an assessment of inpatient capacity need. The best evidence that I could find two weeks ago was that we need a few more beds. Not a lot, but a few. And because they're deemed not profitable, I worry they will never be made. So I think we need to keep some focus in our language on assessing what the need is and right sizing our capacity. We have some measures of. Boarding doctor Smith and colleagues advocated for having ongoing assessment of boarding numbers, quote unquote. I think we should add that to this motion. And I'd suggest wording like this to the third bullet that there is work in consultation with the emergency department directors to develop a parsimonious set of boarding measures that includes, but is not limited to the number of patients boarding for more than 24 hours, more than 36, more than five days. And that we stratify that by gender, the proportion male female by race and ethnicity is very much likely an equity issue under scoring all of this as well. And the age distribution and average, and that those numbers be updated weekly and provided to us. And we post them on our website. If we can do that, I can support the motion. The way that it's written right now, I can't. Back to you, chair Foster. Thank you very much. Member lunch. Thank you. And I echo everyone else's thanks to the staff and the public and my colleagues. I just wanted to say one thing in response to Dave's sort of summary. I would say I would use the term. I'm not sure I would use the term quickly that there is an expectation that inpatient capacity could be expanded quickly because of course anything that involves construction quickly might be three to five years, which is not, I think, quick in most people's time frame. So I would just caveat sort of that with at least my own personal expectation on the timeframe for increase in inpatient capacity. Most of my questions are actually for our legal team and involve legal advice. So I think once chair Foster once everyone has finished their questions, I would like to make a motion to go into executive session for legal advice. I can do that now. But if you'd prefer to ask your questions, happy to wait. I think I'll make my comments and questions because they may be relevant as well to any potential legal advice. And then the other question I have for you member lunges, would you prefer that if the motion carries for executive session for the purposes of obtaining legal advice that it come after the HCA in public comment or before? I don't have a preference. So I'm happy to do it after so that we can have the full information that might be best. I think that's my inclination. So we'll do that. Okay. Did you have any other questions or comments or just the executive session? Just the executive session. Thank you. Great. Great. Thank you. All right. So I don't have a whole lot beyond what my fellow colleagues said. The one thing I wanted to note was that back in 2017, this was a crisis and it's today a crisis as we all know, and it's likely a much worse crisis. So, you know, the board took opportunity to create a solution to a problem and that took some boldness and it was a good idea. It was a huge problem and there was a creative solution that the board took. And if it had come to be, it would have been a huge positive for all the points that Dr. Merman made. It would have helped patients get the right care in the right setting. It would have helped ED doctors, staff, nurses who are dealing with a huge number of borders. It would have helped the hospitals with their costs. It would have helped for monitors with the cost of affording health care. So had it come to be, I think it would have been a huge, huge, huge benefit to the state. And so I'm glad that the board took that opportunity to try and come up with a solution to a very important problem. Unfortunately, it didn't come to pass. And the proposal that UVM put together wasn't financially feasible. And then, of course, we had a pandemic and now we have hospitals with severe financial challenges. The board and UVM or nobody could have predicted all of those confluence of things happening. To Dr. Merman's point about the $3 million being used for improving, measurably improving mental health capacity, I don't think it's clear that that $3 million was. It was never built. So, of course, it didn't help in that regard. And then second, we pulled or received in response to requests of ours some of the documents relating to the architectural planning. And I want to just share one or two of those and raise a question about them. In UVM's letter, it didn't explain or identify that some of this money may have been used $3 million for things other than strictly inpatient mental health. And so I wanted to raise the question if anyone knew the answer, perhaps someone from UVM is on so that we have a better, clearer understanding. Mr. McCracken, do you have that document 3A? Could you share that? Yes, hold on a minute. And if possible, blow up project scope. So this document is the UVM Health Network CVMC EDE4H fee proposal that was executed. The date is June 18, 2019. And the project scope here indicates that CVMC wished to construct 107,000 square feet of new building to house a new 40 bed inpatient psychiatric hospital and relocate replace the emergency department in new construction. The new building will be three stories plus mechanical space in the basement level and rooftop. The building will be designed to accommodate three additional floors of medical, surgical, inpatient nursing units in the future. There's additional option being considered for based on space for the emergency department. It's anticipated that the new building will connect to the existing hospital on the ground floor and first floor levels only. The inpatient psychiatric hospital requires secure exterior space for patients. And so from the project scope from this document at least, it looks as though it wasn't strictly relating to inpatient psych. It looks like it included some work to the ED that maybe was desirable or maybe was needed to do the inpatient psych. The second document, Russ, is the PIC project workbook. And here we see the total cost for the project. According to this document of 157,786,167 dollars. And if you go to the medical equipment page, and you just scroll down to the bottom of that page, you see that there's equipment for OBGYN, Covery, all sorts of equipment that I'm not sure would relate specifically to inpatient psych. And Russ, if you go to the design drawings, the CVMC SD drawings, selected pages. Is that sharing? Oh, great. Thank you. And you can just scroll down from my review of this. It looks, again, to be quite broader than inpatient psych. It's quite an extensive building. So the 157 million dollar estimate to my eye based on these documents appears to be quite a bit broader than inpatient psych, which potentially I don't know the answer because I wasn't here, but was one of the reasons why it wasn't affordable. And if anyone knows the answer, I'd be curious what it is, whether or not that 3 million that was spent was just for inpatient psych development, or if that included some of the work that related to some of these other things that are depicted in these documents. I can speak to it at a pretty high level. So this was understood that the project was more expansive than inpatient psych, specifically part of that has to do with the complexities of reimbursement as governed by the IMD, which is connected with capacity at the hospital at large. Some of it had to do with stakeholder input about how to kind of make this all work in a cohesive way. And so, you know, I think that that was kind of part of the vision there. And just to be clear, I've never heard that the construction cost was the prohibitive part. It was the ongoing operating loss that was prohibited given their financial change in status. The $21 million that Dr. Berman referenced. That was the estimate at the time. I do believe that, you know, given the precedent that particularly our Medicaid program has set in its work in expanding beds at the Brattleboro Retreat, that's probably, you know, could be navigated in partnership with them, potentially. But that is, you know, the cost that was cited as prohibitive, not the construction cost per se. Great. So in any event, some certain was $21 million and it didn't come to be. And that's where we are. And we have an order from 2017 that is our guiding document in terms of how the board can address this issue today. So I have no other comments other than I would support Member Walsh's addition to the potential motion. I think getting the information to understand what the boarding situation is is only beneficial. I don't know if it's particularly burdensome, but I think it would be beneficial. I support the need for that data. Sorry to interrupt, Chair Foster. I just don't know that it's appropriate places in an enforcement action for one hospital if we're asking from data across the system. That just seems a little tricky from where I'm sitting. Oh, and I'm sorry. It wasn't clear to me actually if the suggestion was across the system or just at UVM. Across the system. Great. I have nothing else unless any other board members have any other questions or comments. Can I make a comment regarding Member Walsh's suggested motion language, including the demographic data? If we were to do this, I think we should just be very careful about the specifics of the demographic data being reported on a public website. There are You could potentially have identifiable people. So I think we just want to be very mindful that it would need to be vague enough to not potentially identify specific individuals. Understood. It's a good concern. Could I ask a follow up question as well? Sarah, do you happen to know what DMH is already collecting on this issue? I do have that in the back of my mind. I know there's some robust information that they do have. I don't know specifically on boarding. I'm happy to follow up on that. I think it's really important to understand that. And again, just welcome their expertise on what might be missing and if there's anything we can leverage to get more if it's helpful. Yeah, it appeared to me that there is some data because the physicians in their letter cited 30 patients of at least 24 hours. But acknowledge that some are considerably longer. So I think that one data point isn't sufficient. But there seem to be numbers somewhere and it's a statewide concern. I understand that putting the onus on one facility may not appear to be fair. But it's a public health crisis. We should find ways to work together. I just don't know that we even need that mechanism to do that. You know what I'm saying? I'm not sure, but I'm open, right? It's I'm open to learning more and it's the suggested language was in consultation with the emergency department directors, DMH and UVM and have that part of the reporting requirement and have that operational by the end of May. The numbers don't have to be created. They're there. It's pulling them together. Any other member comments or questions? Great. Okay, I'll turn to the health care advocate. Morning, Jeff Oster. Morning, everyone. Thank you for the really high quality conversation discussion this morning. The HCA supportive of the revised or amended language that was presented and thanks, Sarah and Russ for all the work and incorporating a lot of really high quality feedback, I think for members of the public. I think that's reflected in the motion. And we also support member Walsh, your proposal. I think any kind of stratified system level analysis is going to be valuable here, particularly for assessing health equity. And we also second member Merman's concern around doing this in a really sensitive way. It's responsive to me. A lot of this information is identifiable and sensitive, particularly when you look at race ethnicity. And so I think that there is a way to do this in a thoughtful way. I'm not sure if that's I defer to legal about how to incorporate that into a motion that is not my expertise. But I think the intent and the quality of discussion is in a really good direction. So we're supportive of it. Thank you. Thank you. And I'll open up to public comment via the raise your hand function. Mr. Hoffman. Good morning. Go ahead. Good morning. First, I think the public would thank the board for taking the level of detail and granularity in its analysis of this urgent crisis in a way that to this day has been remiss. The fact that this sat year after year without any type of persistent follow up. It should be memorialized that this won't again occur, particularly in matters of urgent public health crisis. It's very likely that in the last number of years, actual lives were lost because this crisis wasn't attended to individuals who sat for days and weeks in E.R.'s ended up going on to take their lives as a result of not receiving the caroling. I can recall in 2018 sitting in a board meeting with LaMoyle health partners, rather 2019, I was about to leave the organization to return to my home state of Pennsylvania, and telling them excitedly about the news I was reading that there was going to be an imminent building of an inpatient facility, and that we wouldn't have to run across the street to Copley to try and de-escalate somebody who is dramatically decompensating and worrying that after they had been given some benadryl to calm them down and shipped out in a couple days that they wouldn't be found dead somewhere in our community. Since then, many folks that I worked with tragically have expired in that area. Vermont is a uniquely heavily regulated state, and this is the model your constituents through their legislators have chosen for years now, and it's incumbent on you all to make it work. If this were a private sector paradigm, you all would essentially be the board of trustees, and in this situation, UVMHN with 21 million on their books would be directed to invest, reinvest those funds in a project, and you would be following up quarterly to see what the progress was that was made on that. And while that money was sitting in an interest-bearing account, you would be monitoring that it was earning its best return possible with the lowest amount of risk. I would suggest that the motion as it stands contains no language around what becomes of the earned interest, nor does the motion address what becomes of the 3 million that was not exactly invested as the spirit and letter of the statute required. So I think that when you all go into executive session, it would be wise to discuss if and how that language should be added. And then a final point that it was incumbent on this group when they said our plan is not feasible to come back and say, what is feasible? No CEO would approach its board of directors and say, sorry, it doesn't work. And then the board of directors says, I guess that's too bad. It won't work out. No, you push back and you say, okay, let's get back at the table. We need 36 beds in this state. How are we going to figure out to get 36 beds as quickly as possible? If Elon Musk can build a million square foot factory in 18 months, can we build a 100,000 square foot stopgap boarding facility inpatient facility to get these people the care they need quickly? How do we do that most quickly and urgently? And that just wasn't there. And it needs to be. And this can't be five years from now, we're finally going to have those beds that I was telling people in LaMoya County that we would eventually have. This needs to be how are we going to get there in the next 24 months to solve this crisis before we lose however many more dozens of people to suicide? Thank you. Thank you very much for your comment. Mr. Dave Ham Davis, good morning. How are you? Please go ahead. Thank you. The the I think that it's been a huge the nature of this problem has been laid out an enormous detail. Many times I had a transcript made of one of your one of your recent meetings that was 15 pages single space. And so the thing I the thing that I think needs to be addressed and I don't hear from anybody really that everybody everybody recognizes the problem is really huge here. But the question really is is is where's the money going to come from to support the where's the money going to come from to support the operations of these inpatient beds? And unless you have that, okay, then you really don't have anything irrespective of how much you belabor the problem of well, it's terrible for these people to be waiting. It's just awful. It's the worst thing ever. It's illegal. It's immoral, etc. Somebody is needs going to have that the job here is going to be is going to be to find the money to make the operation work. And I think it's the only way to get that to do that is to get it through UVM. The reality is that they got the one bid you've had for actually doing something came from Bennington that they obviously just that's not obviously just not going to work. And so anyway, I just think that the as regulators that they that's the job you need to be looking at. Thank you. Thank you for your comment. Any other public comment? Mr. Davis, your hand appears raised, but I think it was just left out. I'm sorry, Mr. Chairman. I'm challenged. No, no, so am I. Thank you. Thank you. Sorry. I just want to make sure if you had another one, you got the opportunity. Great. Member Lange, if you have a motion. I do. I actually have to. The first motion is that I move that we find that premature general public knowledge regarding legal advice of our council about the board's hospital budget enforcement authority in this action would clearly place the board at a substantial disadvantage in any appeal or other challenge that arose out of our decision. So that's a motion that we have a finding, which is a requirement under the Public Records Act for executive session is that there's a finding that premature general knowledge regarding the matter would put us at a disadvantage. Open meeting on right. Yes, thank you. Thank you, Sarah. I second the motion and I would ask if there's a vote that Mr. McCracken take the vote. Is there discussion or are you ready for a vote? Do any board members have any discussion on Miss Lange's motion? No discussion, Mr. McCracken. Okay, so I'll take a roll called vote. Board member Holmes. Yes. Board member Merman. Yes. Board member Lange. Yes. Board member Walsh. Yes. And Chair Foster. Yes. Okay, so the second motion then is that I would move that we enter into executive session to consider confidential attorney client communications regarding the board's enforcement authority for hospital budgets under the provisions of Title I, Section 313A1F of Vermont Statute attendance at the executive session would be board members, the board's legal team executive director and staff working on the hospital budgets. I second the motion. Is there any discussion of the motion? Hearing none, Mr. McCracken, would you take the vote? Yep. Board member Holmes. Yes. Board member Lange. Yes. Board member Merman. Yes. Board member Walsh. Yes. And Chair Foster. Yes. So typically I'm not sure if we've done this with everyone yet. So I would just say that typically what happens is that the board members and staff will exit this meeting and we have an executive session calendar invite that we will use for the executive session. And then we usually try to give an estimate of when we might reconvene for the general public, which is a little bit tricky, but I would say probably 10 to 15 minutes would be my estimate, rest of you. What do you think? Yeah, it's always a little bit hard to gauge the scope of the executive session is narrow and limited to what was covered in the motion. Hopefully 15 minutes would be sufficient. Okay, it's 1130 so we can reconvene the hearing and thanks for your patience and many thanks to Russ for handling a number of naughty legal questions quite deftly. Thanks very much, Russ. We're lucky to have your guidance on these issues. So we've obtained some legal advice and Russ, if you could pull up the motion language, I think that would be helpful. And prior to the break, there had been some discussion about potential additions to this language or modifications. If any members have any additions or modifications they'd like to make, please, please go ahead. This is this is Tom. I'd like to to amend the third bullet slightly to include analysis and explanation of how the proposal will affect in patient capacity in patient care for patients with mental health concerns and will impact the issue of mental health patients or patients with mental health concerns being boarded in EDs. And the fourth bullet that I spoke about earlier would be to work in consultation with the Department of Mental Health and ED directors to develop a set of boarding measures as recommended by the ED directors in their public comment. And that include but not be limited to the number of patients boarding longer than 24 hours, longer than 36, and longer than five days. And the analysis to include the gender distribution, race, ethnicity distribution, the age distribution and mean and that these be reported to the board weekly and that whatever we can display publicly, we do. And just for process, what we'll do, I think, because this will take a little drafting, we'll receive any suggestions from members and we can work on the drafting prior to an actual vote, but we can get it drafted before we so we all can see and read it and then have a vote later. And I think what I'll do is I'll put this meeting into recess after any suggestions from members and we'll reconvene this meeting at one o'clock in connection right before our next meeting. Thank you, Member Walsh. Do you have any other suggestions or do the other members? I would just throw out an alternative to the amendment made by Member Walsh just for contemplation. The saying what's currently written, the proposal must include an analysis showing that the investment will reduce the frequency and length of time, adults, adolescents and children experiencing mental health episodes are boarded in EDs in Vermont. So that's just another way to think about it. I think thank you, Jess. That's an improvement over what I'd said. The one piece that I was trying to loop in that I did not hear was the effect on inpatient capacity. I remain concerned that without some directive and follow through the evidence that I reviewed suggest we are under capacity slightly and we do not have a history. The state does not have a history of addressing that. I don't want to lose sight of that. The evidence telling us there's a need for more beds. So I would like something worked in about that. Can I offer a comment on that? Robin pointed out that it does take three to five years often for construction projects and health care. So the rapidly getting inpatient capacity out of this is likely unlikely. That said, I mean, definitely during COVID, we really saw how health care facilities can be repurposed really rapidly. And so I think actually maybe the initial intent was to try to repurpose a facility as opposed to build a facility. That is a possibility. My hesitancy in including inpatient capacity at this time and this redetermination of the enforcement is that I feel that and I agree with you, Tom, that there probably is a need for more inpatient capacity. But if but I wouldn't want it to delay other projects that could decrease e-boarding and improve access to care for patients who need mental health treatment. So I don't know if this is the appropriate time to sort of discuss the subtleties of these, but I guess in my in my view, I think that having flexibility for DMH and the community partners and UVM health network who are are more directly represented from the network who are more directly attuned to these subtleties and what can happen quickly and what can happen effectively, maybe better than to prescribe inpatient capacity at this time. Yeah. Thanks, Dave. I tried with my my wording. I'm not very artful, but I tried that it's an assessment of the need for capacity that we have in the proposal so that we're not losing sight of it. Not that they're proposing an inpatient facility. Sorry. Sorry, I miss and miss the the assessment word on that and not rewarding. I apologize. Thanks. I have one addition which would be and when it would be that these funds on a prospective basis be held in an interest bearing account and that any proceeds from such interest should be applied toward the purpose of the amendment, which is to increase mental health capacity. And I can I can help with some clear language, but ultimately my intent is that if this project doesn't happen for two years or three years or four years that the money is held in a low risk interest bearing account so that it grows in the future. Do any other members have any other suggestions? Great. OK. I'll put this meeting in recess and we'll take it back up at 1 PM. Oh, sorry. Go ahead, Miss Barrett. Thank you. I just wanted to clarify and make sure that the public knows that we will start the meeting at 1 PM. As you said, Mr. Chair, using the will the public will use the link that's available on the press release. And because we have two invitations going, my concern is if we're putting this meeting in recess, recess, folks might pop onto this meeting. What we'll do to make sure that we don't lose anyone is we'll monitor this meeting at 1 o'clock. But for board members, please use your 1 PM invitation. Thank you.