So, again, my name is Kevin Mullen, chair of the Green Mountain Care Board. We are about to enter a certificate of need hearing for Silver Pines. And at this point in time, I am going to designate Michael Barber, general counsel for the board as the hearing officer and turn the meeting over to him. And before I do, Mike, is there some type of attendance that would be required that Abigail should take or are you going to handle that? I'll handle that. Thank you. Your call has been forwarded to an automated voice messaging system. It is not available. At the tone, please record your message. When you've finished recording, you may hang up or press 1 for more options. So I don't know whose line that is. If it's possible to figure that out and maybe try calling in again or something. We'll just kind of proceed and see if it works itself out. So as the chair said, my name is Michael Barber. I'm a general counsel. I'll be serving as the hearing officer for today's hearing. It is a hearing in the application of Silverpines partners LLC for a certificate of need to develop a medically supervised withdrawal treatment center in Stowe, Vermont. The docket number for the case is GMCBE-01619CON. We are holding this hearing primarily remotely in light of the ongoing health emergency of the governor's executable. The most recent of which directed remonters to stay at home and leave only for essential reasons. We do have a physical location for this hearing in compliance with the Open Meetings Law. That is our offices at 144 State Street. And we do have someone there in case someone shows up. So given that all the board members are participating remotely, I do need to start by making sure that the board members and actually all participants can hear and be heard. So I'm going to start with the board members. Mr. Chair, can you hear okay? Everything is fine on my end. Member Holmes, can you hear okay? Yes, I can. Member Lunge, can you hear okay? Yes, thank you. Member Yusufra, can you hear okay? Yes, I can. And Member Pelham, can you hear okay? I can. Okay, thank you. So representing the applicant today is Dr. William Katzperil, the CEO and managing partner of Silver Pines Partners that we'll see. Dr. Katzperil, can you hear okay? Very well, thank you, Mike. We also have a court reporter on the line, Kim Sears, who will be transcribing today's proceedings. Ms. Sears, can you hear okay? I can, thank you. Great. So as the chair alluded to, normally we would have a sign in sheet document who is in attendance today. We can't do that remotely, obviously. But I can see the people or the telephone numbers of the people who are on the call. So what I'm going to do is I'm just going to go down the list of people that I see and ask that each person I call on state their name and if they are here representing an organization, the name of the organization. So I see Amron Aberjaley. Yes, Amron Aberjaley, Green Mountain Care Board. Okay. Myself, Susan Barrett. So Susan is the executive director of the Green Mountain Care Board. Maybe she stepped away for a minute. Alayna Barraby. Hi, Alayna Barraby, Green Mountain Care Board. Abigail Connolly. Yes, Abigail Connolly, Green Mountain Care Board. Donna Jerry. Right, Green Mountain Care Board. Dr. Amondisable. Hi, Jessica Amondisable, Green Mountain Care Board. Thanks. Jeanine Morrison. Jeanine Morrison, Green Mountain Care Board. And there are members of the public present at the time. Thank you. Now I'm going to phone numbers. People who don't come as names for me. So, a phone number with the last four digits, 8-6-4-6. That's Doug Moses, William Casperell invited me to the meeting. I'm not exactly sure, Willie, do you want me part of this? Just for everybody, there's a partner in construction and Doug works for Bullrock Corporation who's in charge of the refitting of the building that we will eventually lease from them. So, Doug, you don't have to be here. I appreciate you joining in. More than welcome to have you. If there are questions about construction and construction, potential construction delays because of the COVID-19 situation, it may be helpful to have you on board. Mike, I think it would be helpful if we stayed on because there may be questions. Not a problem. Okay, thank you. So, phone number, last four digits, 4-0-2-8. This is Kylie Kuiper from the Office of the Healthcare Advocate. Thank you. Last four digits, 2-5-0-5. Hi, this is Jennifer Collis, Government Relations for UVM Medical Center. Thank you. Last four digits, 1-9-7-0. I think that might be our office, Mike. Got it, thank you. Oh, yes, I'm sorry, that's our conference room phone. Thank you. We're learning. We're learning. That's the stealth number. All right, 9-3-1-4. Excuse me, that's me, the court order. Okay, thanks, Pam. And then last four, 7-0-0-0. This is Greg Belmont from Bull Rock Corporation also. Okay, thank you. And I see Orca Media is on. And the rest we've already gone through. So now that I've asked literally everyone on the call to unmute themselves and speak, if you could please just check and make sure that you have your lines muted again. That would be great. So the order of today's proceedings will be first, the applicant will be going through a presentation. He will be sharing this presentation with the board members and others participating via Skype. Copies of the presentation have been posted on the Green Mountain Care Board's website for members of the public to follow along. The easiest way to access those documents is by going to the 2020 board meeting information tab and finding the documents for today's meeting. Dr. Catsboro, as you go through your presentation, if you could please just identify the page number of the slides you're on so that anyone who doesn't have this kind of electronic Skype access that is on just by phone can follow along. I will. Thank you very much. For the sake of the court reporter and others, I'll also ask board members to please hold your questions until after the presentation is finished. After the presentation is finished, I will be calling on board members individually to see if they have questions. Following board member questions, we will take public comment and then following public comment, I'll join the meeting, or join their hearing and turn the meeting back over to the chair. So, Dr. Catsboro, before we start your presentation, yes? So you need to swear in the witnesses? I'm getting there. Oh, sorry. Okay. So if you could please raise your right hand. Can you see it? I do. Thank you. You saw them swear or affirm that the testimony you're about to give will be the truth, the whole truth, and nothing but the truth. I did. Thank you. Okay, I'll turn it over to you to start sharing and start your presentation. Thank you, Mike. Can everybody see the presentation? Not yet? We can. Excellent. Thank you so much. Again, thank you for the opportunity. Appreciate it very much, everybody being here. Most of you, I have seen this material before. The presentation that I am going to go through is a summary of the original CON application that was submitted on November 5th, 2019, and then three sets of responses to the Green Mountain Care Board questions, 80 questions in total in three sets. And I'm going to do this a couple of times through the presentation. I really want to thank Donna Jerry, Michael Barber. I know there were a lot of other reviewers that I'm not aware of their names, but I have to thank them for the very, very quick turnaround and the very, very close read of the proposal. I think the questions that they asked were terrific. And they made the project much more solid. So I appreciate the care that they took in reviewing the proposal, the complex proposal, and they did it very, very quickly and very thoroughly, so with lots of thanks. And the summary here just would like to give you an overview of what I do think that everybody on this call is very much aware of the epidemic of addiction that we are in the midst of, now joined by another epidemic. I would like to move through that rather quickly. It's background material that I believe everybody on this call is more or less aware of, and then concentrate on Silver Pines, the vision that we have, the mission that we have developed for ourselves, the specifics of the project focusing on the very individualized clinical care process that we are suggesting, the team that I hope I will actually assemble, the timeline that we have in mind, the timeline that is pre-COVID-19, so clearly we will have to be modified. And then, I don't know if you all had an opportunity to see the formal response that I submitted to the series of concerns from ADAP and the Department of Mental Health questions that came in the last round, and so I have added them as an appendix, happy to go through them if you feel like you want me to address those specifically. I'm planning, as Mike suggested, to go through the presentation until the summary at that point, stop for questions. If you want me to proceed and go through the specific answers to the questions that are shown in the appendix, I'll be happy to do so. So I'm starting the presentation now. I'm going to, this is slide number five, five out of a total of 46 slides. We are in the, again, a lot of the language here. I just need to couch it obviously in relative terms giving what's happening today with COVID-19. But addiction is raging as you all know. We have a crisis that I think is going to get unfortunately worse because of COVID-19. My guess is that the social distancing is going to actually lead to the problem getting worse rather than better, certainly in the short term. And one of the reasons that we suggest that the epidemic has not abated, though it has been raging for at least the last decade, is that the treatment of addiction has not been particularly effective. And one of the reasons that we suggest that that's the case is that the treatment has been fragmented and not particularly individualized. It's basically a one size fits all approach. And we think that that's one of the reasons that we haven't really been all that effective decreasing the incidence of this chronic condition. The numbers are enormous. Again, I believe that you are more or less familiar with the magnitude of the problem. What is interesting is not so much the size of the problem, which is depressing in many ways, but the fact that very, very few people actually around 11% get the treatment in a specialized facility. And that is where I believe Silver Pines is adding to the landscape of treating addiction in Vermont and nationally. The consequences as you know in terms of human life is staggering. If we add individuals that die from drug overdoses to the people that die from alcohol related causes, we're looking at almost 160,000 people in this country. And Vermont actually does contribute to that total in terms of number of deaths per 100,000 inhabitants of Vermont is on the high end of the spectrum. And you can see from this slide I announced slide eight showing a trend of overdose deaths. They have triple in the last 10 years. And it is particularly a affliction, a chronic condition for males. But the trend is actually across the population. And it doesn't seem, as you can see from this graph, to be slowing down on the country. It seems to be accelerating. And it is across the nation. It is particularly bad in the Midwestern states in New England. This red circle that I have on slide number nine is the radius, the circle of catchment area for Silver Pines. And as you can see we are unfortunately in the middle or fortunately from the point of view of the need that we are trying to address in the middle, the eye of the storm. And this circle has a radius of 800 miles. And we chose that thinking that we are going to address patients within a two hour flight of Burlington, Vermont. I'll talk a little bit more about that. That's the incidence of this chronic condition. I would like to address a little bit how in Vermont we are prepared to deal with it. There is only one other facility in Vermont that has the level of medical supervision that we are going to be offering. For those of you who are familiar with the classifications, the ASAM 3.7, only the Breedable Retreat offers that level of care in Vermont. And it is a level of care that we believe is cost effective. It is an expensive care to provide, but in terms of the downstream costs that it saves, it's a very good investment. So that's the background. That's what actually led us to think about this project being a good addition to Vermont. And the vision that we developed for this facility is to develop one of what used to be called a center of excellence, a place that will be known for the quality of the treatment that we provide. We want to be known as one of the best treatment centers for addiction, medically supervised treatment in the country. And we have a very specific mission, and for us it is to create an inflection point in the trend line that we showed you. Nationally it would be a little bit too ambitious, but certainly in Vermont we would like to see us having a role to play, as many other people are already in the community trying to do so, to add to the efforts by providing a evidence base individualized, this is important, coordinated medical care treatment. Specifically the project is in Stowe, Vermont, has 16 double rooms, 32 bed facility. It is a very, very pretty private, very discreet, very nicely landscape location. It's a building that used to be a hockey academy for those of you who are familiar with Mountain Road in Stowe, used to be the North American Hockey Academy. This is a building that has been purchased by the Bullrock Corporation. They are refitting it. They're working with us to create a world-class facility. The Bullrock Corporation has a long history of experience in building healthcare facilities and in the memory business. They had nursing homes. They understand very well the type of care that needs to be put into delivering to patients a peaceful, a centering experience. The treatment again will be a 24-hour medically supervised treatment. We will actually work with opioid alcohol and sedative use disorders. We will have counseling and coordination of care in the community base setting. We are providing a stabilization treatment program that is 7 to 10-day treatment. This is important. I know that it was an issue that raised some questions and we'll be very happy to talk about why we chose this length of time, but it's a 7-day treatment modality with a very intense, customized, post-discharge planning and support that we're planning to provide. We will have a systematic tracking of medical outcomes. This is a key component of our concept. Medical outcomes is one of the areas that I have been involved for more than 25 years. I understand the importance of tracking what we do in order to improve the operations that we have in place. This is part of this organizational learning that is an integral part of the values of silver pines. The idea is to have eventually a national reputation. Again, we are going to target the northeast all the way to the Midwest, Chicago, being a two-hour direct flight to Burlington, Vermont, and the southern part of Quebec and Ontario. Specifically and intensively, within that 800-mile circle we'll be addressing a 300-mile area that contains Montreal, Boston, New York City, Albany. We are going to be focusing on that area and we are, as part of our program, providing transportation. That is, we are going to provide patients and their families the ability for us to go and get the patient back into the clinic if that's what they need. The facility is privately funded. We're not asking the state for any sort of contributions or subsidies. All the proceeds that we're raising through that the private fund will go directly to operations. As some of you may have seen from our P&L projections, we hope to break even by the end of second year. We have made a commitment also of being an important part of the environment and community in Vermont that treats addiction. We have made the commitment to allocate 1% of our profits as grants to community-based organizations. The idea is to create an independent board of seven individuals that will actually receive this 1% in profits and then allocate it as the board sees fit without any intervention from the partners in Silver Pine. The reimbursement model is a private pay only. Again, I know that that has raised some questions which we'll be happy to address. But this private pay only model allows us to deliver the highest level of care with one of the highest staff-to-patient ratios in the country and to provide a lot of other ancillary services that we believe will make the treatment at Silver Pine nationally recognized. We're investing in state-of-the-art technology. We're developing a series of mathematical models that will help us, we believe, fine-tune the effectiveness of the treatment. Very, very importantly, particularly right now in the state of freefall that the economy is going through, we are planning to create 55 very well-paying jobs in Vermont by year three. And this private pay model allows us to have, we believe, a long-term sustainability. So in terms of the state of Vermont, I think we are going to create jobs. We are going to add to tax revenues and we are asking really for nothing in return, obviously other than the certificate of need, but no financial contribution. I am moving now to slide number 16, which shows you the expected admissions. We are expecting a total of 365 admissions on year one. The number in parentheses, 31%, represents the percentage of total capacity. So we are planning to be basically a third full in year one. And as you can see, year two and year three, our capacity goes from 31% in year one to 79% in year three. And we expect the number of Vermont residents that will be treated at the facility to go from 39 in year one to 90. And if you look at the bottom of this table, we show you the calculations that we performed, the assumptions that we made in determining those percentages. I would like to talk a little bit about the process of clinical care that we are going to be delivering now. And this is slide number 18. And I think there are three basic points that I would like to make. One is that we have constructed the clinical process to deliver what we expect is going to be better outcomes. Better outcomes as measured by increased long-term abstinence, higher rates of sobriety, decreased rates of relapse, and fear medical and psychological complications. Again, I want to reiterate that we are going to be systematically tracking these outcomes for every single patient that enters our facility. The economics of detoxification and stabilization of patients has been documented several times. They yield cost savings. Addiction is or creates frequent use, much higher frequency of use of other medical services. And we believe that by effectively decreasing rates of relapse, we will have a long-term impact on savings for the healthcare system as a whole. And then part of what we do very well, I teach the course on continuous improvement here in the business school at UVM, is this notion of organizational learning, understanding what's working best, what is not working, and having a very, very quick feedback loop that allows us to improve continuously. I am on slide number 19, just showing again this notion that without intervention, substance use disorders lead to much higher costs in medical care. We hope to have a major impact again locally, at least on the incidence of substance use disorders. The one to go through this table in great detail on page 20, it shows you the breakdown step-by-step of what we are planning to do. We have gone through the process on the left-hand side, on the silver pines process. You see the six stages of the clinical process pre-admission all the way through post-discharge, and we have identified critical success factors to each and every one of those phases. This is what will drive our training, this is what will drive our hiring, and this is what will drive our assessment of quality. We will actually measure each and every one of these phases to make sure that we are delivering the specific metrics that we have identified as being critical in each of those. There are some questions as to the length of our treatment, being short seven to ten days, it obviously then raises the question of follow-up, and we have concentrated a lot of our energies in thinking about how we are going to make sure that we are providing a continuity of care to our patients and providing them with placement and treatment post-discharge. Here are some of the post-discharge follow-up activities that we will be performing. On slide 22 is the type of data that we are going to be collecting. As you know, we have made the offer of sharing our data with the appropriate government agencies that are interested in following addiction. We will be sharing our outcome measures. We will be actually reporting them, and we will be, as I said before, tracking them systematically. Slide number 23, reiterating that our length of stay, on average, will be between seven and ten days. The program will be totally voluntary, and we will make sure that every single patient will actually go through the full treatment and has a very well-planned structure supported departure from treatment. The team, I apologize for this introduction that is a little bit longish about who I am. Donna Jerry very nicely suggested that I should give the board a sense of who I am. So what I think I would like to say very quickly just to summarize all these bullet points is that I've been in Vermont for 37 years. I live in Stow. Vermont has been extremely good to me, and I would like to be very good to Vermont. I've had the opportunity to be engaged in other businesses that I think have contributed to the well-being of the state, one of my major contributions was the redesign of the MBA program here at the Grossman School of Business. We created, in 2015, a totally new MBA. I was a founding director and a major designer of that program. It is now ranked number one in the country on sustainability and innovation. So I do have a commitment to quality, to excellence. You may actually wonder how a professor of business goes into addiction treatment. I had a lot of working with a stupendous group of psychiatrist on developing what is now a nationally recognized risk of suicide prediction tool. My background in artificial intelligence and expert systems in neural networking overlap with their interest in trying to do something that nobody has done before, which was the prediction of short-term risk of suicide, where we call imminent risk of suicide. And through that work, which has won several awards, including some national awards of note, I started to realize the tremendous public health problem that suicide represented. And through my work in suicide, as we try to apply this tool to several different populations, and we start to look at the rate of suicide in the substance use disorder populations. We looked at some of the data that basically pointed to half of the death by overdose being intentional. And that really was, to me, surprising because it immediately doubled the number of suicides in this country. The official number of people that die by suicide is 42,000 per year, but there are close to 100,000 death by drug overdose. So if you take half of those as being intentional, that will be 50, and that will make 92,000 death by suicide. And that would be, it is a staggering number. And I started to put together here at UVM a group of faculty interested in what I call the death of despair, overdose and suicide. To look at the social determinants of those death of despair. And that led me to the question of how can it be, how can we have such a high incidence of death? This is, I would really suggest unacceptable. And I started to ask questions of people that are experts in this area about addiction treatment. And this is how I got involved in thinking about developing a clinic that could deliver, that could make a difference. Small grain of sand in the big beach of despair here, but at least trying to address it on a personal level in an effective way. So that's the background as to what brought me to think about addiction, what brought me to actually do something about addiction. I am putting my money where my mouth is, where my intentions are. I really would like to make a difference and I'm making a difference, I hope. Assuming that you will consider the certificate of need in a positive light in my backyard. I really would like Stowe to become known for treatment of addiction. Happy to answer any other questions about my background when I'm done. The team that I'm hoping to hire is described on slide 26. We will have, as you know, 24-7 medical supervision. We will have a chief medical officer that will be trained in addiction and will have a board certification in psychiatry. We will have, we think this is the numbers that you have in front of you, numbers that deal with year three. So we'll have three top-level executives. We'll have 37 clinical positions. We'll have eight admins, not here, but part of the team will be a kitchen staff. Part of what we hope to do is a farm-to-table program that, again, will highlight some of the strength of Vermont farming community all together by year three. We hope we expect to have 55 employees working at Silver Pines. The timeline is much easier to look back because that's what we know has happened. We started November 5th. The last response to the set of questions was sent on February 20th. I believe that the process was closed on March 5th. We are now having the hearing on March 25th, and so that's what brought us here. I'm going to slide 29. We are hoping to start credentialing with private insurance as soon as a certificate of need is awarded. We were hoping of hiring, licensing, and credentialing critical staff on June 1st. All of this was really based on the presumption that the construction of the building was going to be done by July 15th. Construction, as you know, right now has stopped across Vermont in most cases. We are pausing to, for we don't know how long, certainly we hope no more than a couple of months, but nobody obviously knows. So much of these dates have to be adjusted in this COVID-19 world that we are living today to recognize the reality of delays. We are still committed, we hope, to open this year. September 1st was what we had in mind. We had actually already started to identify individuals that would actually join the team and so forth. Everything is a little bit on hold now. I certainly hope that we will be able to open our doors in 2020. I do believe that in a couple of months we will have much greater visibility as to whether opening in 2020 is still realistic. The goal is there and it's just a matter of being able to have the facility in place and the team in place. So in summary, I would like to close by saying that we have built what I believe is a clinical process that will give us distinction and will give us distinction because we are going to have better outcomes that we'll be able to report and for us to be successful. We need to demonstrate effectiveness. It is an individualized and integrated treatment modality that we hope is going to make silver pines in nationally known facility. We are planning, as you were able to see from our financial reporting, that we will have a model in place that will allow us to run a very, very high quality clinical care process in a sustainable fashion. The benefits to Vermont, this is on slide 32. My last slide, unless you want me to go through the specific answers to the last set of questions and concerns from ADAP and DMH is that we're offering a treatment option that does not currently exist in Vermont. We believe that we are going to be treating up to 90 Vermonters per year. It may not sound like much, but it's 90 Vermonters that will have access to the best possible treatment that maybe doesn't exist right now. So 90 is better than none. We will create 55 well-paying jobs. We will be providing these financial grants if we are running with the level of success that we believe we will have a profitable operation and give to those community organizations. We will make minimal demands on the Vermont health care system and we believe that we'll be adding substantial tax revenues to the state. So with that, again, I am at your disposal, your discretion, and I can go on to talk specifically about the concerns of ADAP and DMH or stop here and take questions on all the subjects. So thank you. Thank you. Is there any board member who would like Dr. Casperill to proceed with the remainder addressing the concerns of ADAP and DMH? I think a quick run-through of those would be actually helpful. With pleasure. So there were five concerns from ADAP, one concern from DMH. Basically, ADAP was concerned, first of all, with silver pines creating a workforce of shortage or creating pressures on the current workforce environment in Vermont. And if you look at the numbers of people that we are going to hire, we have a very high ratio of staff to patients. We are going to be hiring around 1%, 1.5% by year three of the existing and maybe by year three, they will be even more than the 424 staff that are in Vermont today. So we believe that we are not creating any on-do pressures on what is considered to be insufficient staff to provide services in Vermont. We are aware that that may be a concern, but certainly silver pines is not going to contribute in any significant way to those pressures. The second concern was a concern of silver pines distorting in some way the salaries of professionals in Vermont. My philosophy has always been in every business that I've run that you pay the people that work for you the best possible salary. It's the smartest and tends to be the most cost effective way to run a business. You pay them well, employees are going to work hard. I want the best possible employees as silver pines. I want to have the best possible staff at silver pines. I am proud of the fact that we are going to pay as well as we can to get the best possible skill level. So having said that, the numbers that we have proposed in our financial, in our PL is completely in line with the blueprint for health guidelines. We are right in the middle of that range. What we are going to do is offer bonuses of performance and certainly motivate individuals to work hard and produce the best possible outcomes. But the salary base that we are planning to provide is in line with the market in Vermont. A third concern from ADP was this lack of connection to the rest of specialty treatment systems. Here I want to make sure that we all realize that there is a continuity of care. We are not doing everything in addiction treatment. We are doing a very specific aspect of it, a narrow one. We think we are going to do it very, very well, possibly as well as anybody else in the country. But we are providing a very limited service. And this service, I think is important, will be connected. We are going to make a tremendous effort to connect our clinic to all the community organizations that are already doing a terrific job in Vermont. I think that it's a little bit of the chicken and the egg. I mean, we don't have a certificate of need. And so we have an idea for a project. And I think once we have a certificate of need, once we know that this clinic is going to be a reality, it's going to be all hands on deck to create all of the connections to ensure this continuity of care. So we are totally aware that this is a chain. We are only a link in that chain. I will be connecting. I am convinced from conversations that I've had with individuals in this environment the ability to create those connections. Again, same, same, the next, I'm on slide 39. One of the concerns from ADAP was that we were offering too short of a treatment that there was no real evidence that these treatments were effective. We very respectfully disagree with that statement. Our thorough review of the literature or conversations with experts in addiction tells us that the seven to 10 day is the sweet spot, if you will. It is the number of days that seem to provide equal or better effectiveness of intervention for the least amount of time and expense. And we actually have given in our response, but we had already provided in our original certificate of need application evidence for this. I want to make sure, again, very respectfully to the board that the seven to 10 day detox program that we propose was not just a whim. We could have offered 14, 21. We could have gone into rehab. I mean, we chose this treatment modality because we believe that this treatment modality is extremely effective. And we provided some of the evidence in the response as well as in the original certificate of need. And finally, one of the concerns that ADAP brought up was that not all states have access to medication-assisted treatment for opioid use disorders. That is true, but it's changing extremely quickly as of 2018, which is the last reported statistic. More than 92% of the population live in a plate with at least one buprenorphine prescriber. And the number of prescribers are increasing. The number of opioid treatment centers and programs in the country is increasing. And so we believe that the individuals that will be discharged from silver pines then to seven-day treatment are at no higher risk of overdose than any other treatment. And we believe actually that they will be at a much lower risk of overdose because of the care that we will take replacing our patients into a post-discharge treatment. And then the last concern of ADAP is about neural network model that we are using. It's a relevant concern. It says that the machine learning and neural network models that we have proposed have not been fully tested on the population they will be serving. It's absolutely true, but it's not the way that we are going to deliver care. We have a parallel system. We're going to have experts, individuals that have been trained at the highest level of addiction treatment in this country coming from the best fellowship programs in this country on addiction. We will have terrific nursing staff, and they will be delivering the care, not the neural model. What I'm doing, and this is very close to my heart, this is part of my life work, is we are going to test in parallel a model that will try to replicate the expertise of these individuals so that eventually not only can we increase the consistency, that is we will actually be training staff that has a much less level of experience, expertise, and skills with this model, but that we can contribute nationally to a treatment of addiction that will be much more effective. The neural network works in two levels, please. The first one is by identifying patients. We've talked about this individualized treatment that Silver Pines is going to deliver. The individualized treatment is going to be drawn by physicians and will actually be tracked by this neural network, and eventually we hope that the neural network will be performing, quote unquote, just as well as the physicians. We will be actually adding a level of patient safety through this neural network. It will be basically a model that says, okay, physician, here's a patient, here's how it presents. The patient has a certain history of addiction, a certain history of rehabilitation. This is a substance that they abuse. Here is the type of treatment that best fit them, and the model will actually confirm or disagree with that selection, and we believe that in that the model is actually providing an extra layer of safety, an extra layer of quality of care. The same logic applies to how we are going to place patients into, how we're going to discharge them, and how we're going to actually place these patients once they're done with our clinic. We will have a post discharge and discharge experts that will be handling that, but we'll be building a mathematical model to basically confirm that those choices make sense, and over time we hope the model will be performing just as well as the physicians. So yes, they haven't been fully tested. We are not using them as the main source of care. We do hope, however, that by year two or three, these models, I don't know if we have some people on the board that understand or have worked with neural networks and how they work, but as the patient base increases, the intelligence of the model increases, and we hope that by year three, when we'll have treated hopefully more than 1,000 patients, the models will start behaving in a way that would be of help, support for the clinical staff. And by the way, on slide 43, I'm sorry, I just went too fast through it. I'm sorry, 42. Just mentioned the work. This is a very similar work. I've done it in several conditions, chronic conditions, low back pain being one, chronic conditions. We've done and followed the same model with the imminent risk of suicide project that I mentioned a second ago. So those are the concerns from ADAP and from the Department of Mental Health. Their main concern was that we were going to possibly increase, put pressure on local medical and psychiatric emergency departments in the state. The non-vermonitors were going to come into the state and actually divert some of those resources and the numbers that we are planning to have if we execute perfectly on our plan, as you can see, the numbers are insignificant in terms of the total annual ED visits, both at Copley, which is a hospital that is closest to the clinic, or to UEMMC, where they may actually need inpatient psychiatric care. So a very good snowfall in the middle of winter will bring more people to Vermont and will bring more people possibly to the emergency room because they break a leg or the heel of a tree, skiing than what we are going to do at Silver Pines. The numbers that we, and the numbers that we're predicting may require the emergency department attention are all based on the literature across national programs and the numbers would be very, very small. The last thing I would like to say to that effect is that we believe that on the country, right, if we are going to bring up to 90 Vermonters to Silver Pines and treat them effectively of an SUD, that we will decrease the impact, the pressure on the health care system in Vermont. We believe that the more the Vermonters we treat, the less the impact we're going to have in the state's medical system, certainly the emergency medical system. So taking all together, we believe that the impact that we're going to have is not really one of increasing pressure on emergency departments in the community, but that ultimately what we will do is have a beneficial effect and free resources in emergency departments across the state, certainly in the northern part of the state. Happy to expand on any aspect of the presentation or these responses to the concerns from ADAP and DMH. Okay, thank you. And now I'm going to turn it over to the board members for questions. And like I said earlier, I will, just to keep things understandable for folks and the court reporter be calling on board members one at a time. So, board member Lunge, do you want to kick things off? Do you have questions for the presenter? Sure, yeah, happy to. Thank you very much for your presentation and the materials. There's a lot of good information in the packet and I appreciated getting the thorough information. My first, I have a couple of questions related to your reimbursement model. So, I wondered if you could give me a little more detail around the self-pay versus interaction with insurance. When I was going through the materials, I did note that in answers to the questions related to bad debt, you had indicated that you're expecting self-pay upfront, which would obviously minimize the bad debt. And in reviewing your patient financial policy form, which was page 23 in response to question three, it does look like your plan is for folks to individually ask for reimbursement from their insurance company after paying with whatever documentation you provide. But I also noted in some of your other materials where you were explaining what would be included in the upfront cost versus what would be billed separately that you had indicated that labs, for example, might be billed to insurance. So, I just wanted to get you to expand a little bit on how that's going to work. Well, I think that, you know, we hope that the charge that we are going to make will include every service that we deliver, including lab services, including medication. So, it is a, as you said, self-pay. They will actually pay upfront. We will provide all the documentation needed with their insurance company of choice. But all the lab costs are going to be included in our original charge. Okay. And so, could you explain a little bit then why you'd be credentialing with insurance companies? That's so when a patient submits the reimbursement information that you're already credentialed. That's exactly right, yes, to facilitate the process of reimbursement to the patient. Okay. And who on your staff would be working on that piece of it? Well, we're going to have the executive director that is going to be, let me just go back. Mike, do you still want me to keep the slides up? I don't know what the process is here in terms of, if you want to see my face, if you'd rather see the slides. I mean, I don't know what the protocol is. I can actually see both. So, I'm okay, but whatever Mike prefers. Awesome. It's kind of up to you. I mean, I think it's helpful for me at least to have you be able to go through the presentation, but I can see your face and it might be weird if you can't see board members' faces as they're asking questions. So, it's really your preference. Right. Well, I cannot see you, so there you go. Because the slides are ticking over all the screen. So, if you look at our team, the executive director, we have an accountant that will actually be tracking all our relationships with the insurance company. And we will have what I hope is a good relationship with this insurance company. There's not going to be that many, but we will have actually the executive director in charge of credentialing. Okay. And who would be in charge of the reimbursement like getting the paperwork together for the patient for reimbursement? Yeah.  The business at the beginning is not going to be all that busy and complicated. And so the accountant will be the person that manages that process. Okay. Thank you. I wondered if you could speak a little bit more generally about why you chose the self-pay model as opposed to being open to all payers. You know, it's a matter of a business model that what we started, the concept from the beginning was a concept of providing the highest level of care. For me, that was absolutely critical. You know, after discussing what was needed in Vermont in particular, but across the country. You know, I actually went and visited many, I think I visited 14 different detox clinics across the country. Seeing all sorts of models. And I realized that the ones that I wanted to emulate were fully 24-7 medically supervised clinics. It is an expensive model to sustain. There aren't many across the country because of that. And to me, in order to be able to sustain the highest possible level of quality when it comes to clinical care, we just needed to have the cash flow to sustain it. And, you know, for us, the point that there is, as you said, so well, no bad debt that we really don't need to be worrying about cash flow from that point of view, it gave me, gave investors into this facility a level of understanding of how we could be sustainable in the long term. Thank you. My next question is around the upfront patient payment. So I know that your model has a real emphasis on individualized treatment. And could you explain a little bit about how you're going to know prior to someone getting to your facility how much to charge them, whether it's seven days, 10 days, 12 days, eight days? No. Thank you. This is a good question. The idea here is that we are going to assume that the treatment is going to take 10 days. And we are going to plan on a charge for 10 days. If the patient for whatever reason, whether from a voluntary decision that they want to leave halfway through, we will actually prorate what we charged them. But the assumption is going to be that they're going to be with us for 10 days. And we are going to structure the treatment on that basis. Does that answer your question? Yes, thank you. All right, hold on just one second. I got to shuffle some papers around and find my other notes. Thank you. So my next question is about the discharge planning and is really a follow-up on some of the ADAP concerns. So I hear what you've said about ensuring that you're just a link in the chain and understanding that your service is specific and narrowly tailored for its particular purpose. But I was a little concerned when I looked at the projections that you had provided around the number of hours that people would be spending post-discharge with your patients. So hold on just one second. There is a chart that you provided in response to question three that is on page five. And it indicates that in year one you would expect that the average number of follow-up per person would be an hour for the first month, half an hour for the next two to six months, and then less after that for a total of five hours. And it just seems like when you're trying to work with providers within a two-hour flight radius that that may be challenging to do in that little time. So could you speak a little bit more about how you came up with those hour estimates? Again, thank you for the question. The question is for us, whether we specifically know how long it's going to take. I ask how much time is being used to discharge. You know, again, I talk to other operators that do this type of discharge planning. We've got an estimate of that amount. For us, it is a very... We believe that we are going to distinguish ourselves on the way we actually discharge patients and we place them. That's going to be a priority for what we do. It may be that the number of hours may be greater than five. What I can tell you is that early on we are going to have only 30% capacity. We're going to have a lot of time on staff hands to actually do placement. It may be longer than five hours. We will actually assess them after year one. This numbers that we showed are numbers that were based on interviewing people that have spent time on discharge. It's an estimate. I think it's an estimate that makes sense for us and that reflects the type of care that we want to put on that task. I think your implication is that it may be low and you may be right. We will know very quickly, but we think they're reasonable based on what we heard from other operators. Okay, thank you. I'm good for now, Mike. I might have one follow-up question later, but I suspect somebody else will ask it. Okay, thank you. Next, we'll go to board member Yusuf. Do you have questions? I do. First, I'm really glad to see the MDA program is going so well. I was on the inaugural board of that in 2015, so I'm not sure everyone... Good to see that take off. Clearly, there's a need for additional addiction treatment in the U.S. We'd like to see success here in Vermont, but I definitely have some concerns on the success of this model based on some of the assumptions, and that's really going to drive several of my questions. I want to look at the landscape in both Vermont and nationally. So just first going back to something that Robin was talking about, about reimbursement, there was something on page 21 of the original con talking about contracting with Blue Cross Blue Shield of Vermont for patients. So are you planning for Vermont residents to do that, or what was that? Again, what we wanted to do, and this has evolved, but yes, I mean, for us, having relationships with insurance companies, looking for this credentialing of our program with Blue Cross Blue Shield of Vermont is important. I mean, we believe that they will be one of the main issues in Vermont, and being credentialed by them will be important for us. So the answer is yes. Again, we will support patients by providing all the documentation required by the insurance companies, but we will not take insurance directly now. Okay, and then since some of your comparisons and benchmarks were against Brattleboro, the Brattleboro Adiction Center, and you talked about the 10,500 was kind of I think the average there. And just wanted to get an idea is that gross or net, and do you have any idea of the mix of payers that they have in Brattleboro? How many are really self-pay versus Medicaid, Medicare, or commercial? No, you know, I really don't know the breakdown. That is their published rate for the type of medically supervised treatment that they offer. So we will be offering our services at a very similar, at least their published rate, whether that's a published rate that they negotiate, that they lower, you know, I really cannot tell you. I don't know what the mix, the pair mixes for them, but it is their published rate. Okay, that's typically what we see when we deal with published rates, and I can't speak specifically, you know, talk about, you know, in the hospitals, but typically a published rate, the insurance company would pay about 70% of that. Medicare would pay about 45, and Medicaid would pay about 35. So just from a perspective, it's probably lower what they expect, what they actually get. Yes. So when you're basing it on that. Again, for Vermonters, do we, do you have any idea that the 70% of Vermonters are self-pay for detox versus, you know, using their, you know, going to a place that uses their commercial insurance work? You know, that is a question that we try to answer. I look everywhere. If some of you have a tip to give me here of what may be a good source of information, we look very, very hard at how many Vermonters leave Vermont to actually get this type of care since it is not available in Vermont, the type of, you know, very personalized individual care, high staff to patient ratio type of care. And we didn't find any information. You know, the information that we actually, the assumptions are based on conjecture. As I show you on that table, you know, the percentages that we think are individuals that are looking for specialty facilities, specialized facilities, and that's the extent of it. I am not aware, and again, I would love for one of you to suggest where I could look at the number of Vermonters that leave the state to get that type of care. They cannot get it in Vermont. So for those individuals who are interested in that type of care, where do they go? And I think that's, you know, kind of one of the underlying things, both from Vermonters and nationally, where I just have concern about whether you'll achieve your revenues that you're projecting, which is, you know, how many people for a detox seven to 10 day type of facility pay self-pay, knowing that right now, the current model, and I know you're changing the model a little bit, but the current model may be that they would go to that type of facility, you know, at a Betty Ford or something, and then go into, you know, continue on in that facility for another 30, 60, 90 days. And so I'm not sure how many standalone detox that are not affiliated with something like a Betty Ford or Hazelton, you know, how many of those exist, because for many families, this might be the first expense of a much bigger expense if they're doing it, you know, if they're looking at it as a detox and then moving into maybe a 30-day or 60-day, which could be another 30 or $45,000 for something. So, you know, that's kind of my concern about this model is that you're expecting the majority of the people to come from out of state for a seven to 10 day and then need to filter back into their communities either into a longer term or something like that. So I'm just, the concern would be, you know, as people research this, are you going to be able to make that case so much early on, right, right now before you have evidence yet, and we don't have a facility for them to go to right after. So, you know, the question is really, you know, how many standalone detoxes are there that are completely self-pay that do not affiliate with somebody else? Yeah, there are many. There are many. There are obviously a majority out of state. Also, again, you know, not everybody needs a 30 or 60-day rehab program afterwards. I mean, we believe that our program will stabilize patients to the point where they may actually have access to an outpatient clinic or some other sort of non-residential, you know, not everybody needs to go through 30 and 60 days. Obviously, we will have arrangements depending on where the patient comes from and what their preference and their family preferences to place them in other states. There is no doubt that this is going to be an expensive first step, but, you know, for us, again, the whole notion behind the business model and the treatment model is that it is expensive but it's a great deal. And that we are how long is it going to take us to collect the data to prove that is obviously an excellent question. From my point of view, the sooner, the better. And this is why we are going to be prioritizing and putting a lot of resources on tracking medical outcomes because we need to prove effectiveness and we need to prove that though this is an expensive 10-day stay in the overall treatment of your chronic disease, it's a very effective first step. But, you know, we all know the proof of the pudding is in the eating and we need to actually collect data to support that statement. And then, you know, that brings me to really some of the financial statements and I know there's a bunch of the model changed a bit so I'm not sure, you know, if I try to help with answering some, but it looks like at the start it looked like there was going to be maybe a million capital contributed, but now it looks like it's going to be 2650. So is that correct? That is correct. So, you know, it's been a process of refining the model, the business model, the debt component, the extent of the work that is being done to retrofit the building. You know, the type of facility that we want to build, a facility that is going to compete with facilities across the country at the highest level requires a much bigger investment in the rebuilding and therefore the rent that we have to pay. So, you know, for the contractor to actually engage in the risk of rebuilding that facility, we needed to sign a lease with a rent that was required for the first year and that's what actually then change the lease for capital.  Okay. And when you talked about the retrofit of the building and the rent, and I know there were two leases in there, so are we now at a lease where it's about $500,000 a year? Because there was a lease where it's $600,000 and then $600,000 pre-payment? Yes, you know, the amount, only one lease, I think that there was an early lease that was just a model of it. The second one that came, I believe, with the third set of questions is the one that actually applies and yes, we are paying $50,000 per month, I believe. That's the amount. And are you still paying up front? We are paying, and this is what I think is important, right, that the $2.6 million is really, the proceeds are going to be used all for operations. There's absolutely not a single send that is going to the partners of this LLC. So the money goes for rent, goes for salaries to start the operations and we have, as you saw from our projections, we need around $400,000 as cushion in the first four months of operations. So all of the proceeds are going to go directly for working capital and nothing of it goes to the founding partners of the venture. And do you know how much the retrofit of the building is going to cost? I think we have Doug Moses. I know if Doug is still, are you still online, Doug? I don't know if you're here. I'm here, really. Greg, they are, they'll be my landlords and they are the ones that are keeping track of construction costs. So Greg, I don't know if you want to comment on the cost of retrofitting the building, please. Before you start, Greg, this is Michael Barber of happy to have you answer the question but I do need to swear you in if you're going to be providing any sort of evidence. So do you mind doing that? Absolutely, Michael. It'll be the second time I lifted my hand as Willie was being sworn in earlier but not on Skype, so let's do it again. All right. Do you swear or affirm that the testimony you're about to give will be the truth, the whole truth to nothing but the truth? I do. Thank you. And could you just spell your last name for me, please? Sure, it's B-E-L-D-O-C-K. Thank you. As we had done in the past and we have built assisted living facilities, independent living facilities and were innovative in the memory care, the growth of memory care and a change in the way memory care and Alzheimer's treatment was done throughout the country, beginning with the facilities, we suggested and offered to Willie that the most successful way for his financial plan to move forward, which would provide the greatest likelihood would be if the landlord provided all the internal fit-up to the building, including the medical equipment, the software, the phone system which speaks to an attenuation system which also allows for scheduling models, and all of that will be provided by the landlord. It's about a $3.6 million internal fit-up. Okay. That makes some sense then in what the rent payment maybe is, because I was looking at a purchase of the building. In addition to the purchasing of the real estate, the real estate would be on top of that. Pardon? $1.2 million for the real estate, right? There was $1.250, so we're talking about a $4.7 million capital event. A good portion of that is very specific. The furniture is high-end. The beds are specific. And obviously the software system and the attenuation tracking system. When I say tracking, we actually tracking labor as they enter and leave rooms. Not unlike we did in many memory care facilities which has now been adopted nationally. Thanks. And really my last question that brings me to is then the financial statements where and will you just refer to it a little bit about the additional cash that you have and just that's where there's concern for me looking at your financials where, and I was looking at your three-year performance balance sheet as of 220. I think it was under question one, so I don't know if that's since change, but it had you I'm sure the timing has changed but it had cash getting down to about 214,000 in month four and that's assuming that you had generated already about a million dollars in accounts receivable that's going to offset that. So what is your ability going to be to raise additional capital or to fund a shortfall in cash if you hit the revenue assumptions that you've had in here? You know, it's pre-COVID-19 I would have told you that my ability to raise capital is absolutely excellent. I cannot tell you how motivated I have raised money for many ventures. You know, I've been lucky enough to be successful in those ventures and my investors have always been very very loyal to me. This project is a project that people understand as doing very well by doing a lot of good and I do think that the COVID-19 situation has made everything a little bit more model. I can tell you that I continue to because these are individuals that have backed me in other ventures the ability to go back to them for extra cash again, I am under oath. So before COVID-19, 100% sure. Now, you know, a little bit less sure but I do think that this is a type of project that has always generated on people that want to make money and this is a model that eventually will have I believe attractive returns for investors but more importantly are committed to make a difference and I think that again, I've been involved in a lot of business, lots of them have had this do well, do good. People have always been very responsive for, you know, a capital call that is in an emergency situation I mean when, you know, for reasons that are not predictable at this point, we have a shortfall I feel that my investors are going to be there. One other point that I want to make is that I have no debt, right? And so at this time, I mean talking about again a post-COVID-19 world, I think banks are going to be so incredibly pushy trying to get people to borrow money, they are going to, you know, everything is right now leading to much greater liquidity and I believe that loans are going to be at plenty at ridiculously low rates. So though I have built the model on a 100% equity no debt in case that there are some issues with the capital call viewing what has happened with the markets right now, I feel that banks are going to be extremely pliable and will have plenty of funding available for us.  Yeah, the structure is very typical, you know, we are going to give back to investors 80% of profits until they get completely paid out and after that they will get 20% of the profits down the road. So, you know, they get preferential treatment until their investment is paid out. Okay, thank you, that's all I have. Thank you. Okay, next Member Pelham, do you have any questions? I do. Let's see. Just on kind of a combination of data. One second. At least I was having some trouble hearing you if you could start that again. Yes, that would be helpful. I'm sorry I had my phone on mute like was saying something and nobody heard me. So I'm looking at some of the data that is on slide 6 and slide 16 where there's these topside numbers of in Vermont of 54,000 people older than 12 with a substance abuse disorder and only 13% of them in treatment and then for your third year on slide 16 you expect there to be 90 Vermonters in that population of when you're fully up and running and I'm just wondering where you think those 90 people are coming from. Are they coming from existing providers in Vermont that would be diverted toward your program or would they be coming or would these be new people to this kind of my sense would be that they wouldn't be new people if they could afford to pay cash or pay up front for this benefit. They're probably getting it somewhere. So I'm just trying to get a sense. I know it's at the margin but part of the focus here is this helpful to Vermonters and I'd let your sense of whether or not those 90 people are new to the system bringing fresh money into Vermont or is it just rearranging the provider. Right. Again, I appreciate the question. The answer is that we don't know. We don't know how many Vermonters are living Vermont to get this type of care. I mean, that's the bottom line. I wish I could actually tell you and again, if any of you could guide me to where I could find that out. But where do individuals are looking for a high staff to patient ratio small facility with individualized care go? What is the number of patients that leave Vermont? Because that number would be very helpful. I could actually say that we would retain those, right? Let's say that a hundred people leave Vermont every year to get this kind of treatment I could argue that I will then bring that money that they're spending in other facilities out of state to Vermont. But we don't have that number. The number 90, you know, is based on looking at the percentage of people that and we know that here in Vermont have actually paid with private insurance or cash. And they actually have gone to a residential treatment facility. So the number 90 is what we expect to treat given who has seek treatment in Vermont. And when you say is it new, is it a reshuffle of the number, you know, what we hope is that 90 patients in Vermont will get the best treatment possible. Are this 90, 90 that were treated before by someone else, somewhere else, and they're coming back after I relapse to see us? I don't know if they're going to be 90 patients that are totally new.  So I really cannot answer your questions specifically. What I do know is that I'm hoping we're going to treat 90 patients in Vermont very, very effectively. And could we treat more? I hope that more Vermonters would come. But we expect that those 90 patients will be treated as well as anywhere else here in Vermont. So again, the key answer to your question, the key data to answer your question, unfortunately I don't have. We've looked, and that is how many individuals go out of state for this kind of treatment. Thank you for that. I think it's pretty certain though that those 90 patients are the ones that can afford to pay upfront. I mean, it's going to be a condition, right, for us to treat them. So yes, you're absolutely correct. Okay. Next do you have any you mentioned, I think, to treat on slide 10, not explicitly, but I'm sorry, I missed something there. You mentioned, I think, about two. Okay. You mentioned that the internet out here, Robin, I'm sorry, I'll speak slowly if I can. On slide 10, I think the reference was to the Brattleboro retreat as the only other ASAM 3.7 class facility in Vermont. Do you have any sense of the percent of their patient load that are doctors? It's again a very, very good question. They don't report it. So we don't know, you know, they offer as I'm sure you're very well aware several different treatment modalities and they don't break down their number of patients in each of those modalities. So they offer the highest level of medical supervision, but they don't report how many patients they have at that level. Thank you. You mentioned, I think, when we were looking slide 14, that your intent is to build a world-class facility that would attract people who have world-class patients, let's say. And at a staff analysis a while back, this may have changed that your fixed cost investments in the first year would be about $1.2 million, which divided by $32 is $36,000 per dead. And I'm but the range of what were fixed cost property taxes, etc. And do you have any sense from a construction point of view how much per dead will be invested in making this facility a world-class facility? Again, we have no role in construction, but and Greg Beldog, who is the CEO of Bullrock Corporation in charge of construction is on the line, so he may correct me, but he mentioned that if you don't take the price of the real estate, which was $1.2 million and you look at the construction, which is $3.6 million, it is if you divided by $32,000, you're talking about $120,000 per bed, basically. And $240,000 per room, 16 rooms. So if you want to make the calculation based, I don't know if it is a fair calculation because there are so many other facilities, I mean spaces, kitchen and so forth, but if you actually look at the total amount of construction cost, which I understand from Greg is $3.6 million, then you're looking at $120,000 or so per bed. Thank you for that. This is Greg Beldock. Willie, if you're looking at your operating cost and your initial loss over the first 19 months and you add your capital costs in total, you depreciable capital costs, it's identical to a memory care facility. It's about $160,000 per bed before your cash flowing. Thank you. I'm Paige on slide 15 you referenced that 1% profits will be grants to a community-based organization addressing addiction. And I'm just bringing what in year three when you're fully up and running in terms of dollars, what is 1% equal? That's a very good question. I mean again, from my lips to the years of God, as they say, if we are successful in the way that we want to be successful, the 1% is going to represent in terms of profitability, is going to represent around $60,000 to $70,000. And that distribution would be before distributions to investors? Sure. I mean this will be a built-in distribution that will be seen as a basic let me just call it a cost of doing business. So we will actually be investing that 1% we think that obviously it will be to everybody's benefit here. It's very important again, I don't know if I was clear in the description of how that money is going to be spent. That 1% will go to an independent board. We are going to invite people from the community. We have names already that have been suggested to us and that board will actually have full authority and independence on spending and allocating those monies as they see fit. We will have a mission and the mission is that it has to be invested in community organizations that deal obviously with the treatment of addiction and we will actually earmark Northern Vermont as the area where we will like that investment to happen but that's the extent of it. Then the board independently of us will be spending and allocating those monies. Thank you. I want to make that clear during your presentation. The next question I have is maybe just a follow-up a reiteration of one I think Robin raised which was in the responses to question the third response to questions on page 5 you showed a distribution of the types of benefits that after-care benefits services that people would get after discharge and I just want to make the point that not only were there time amounts on that chart on page 5 but dollar amounts and the dollar amount was $131 per patient for the entire year after discharge and I just it's interesting to look at time but it's also what the expenditure would be associated with the time I can't get my arms around $131 per patient so if you could speak to that a little bit more I'd appreciate it. It's a little bit difficult to really put out a number of dollars because ultimately we have staff that is working full 40-hour shifts a week and they will spend whatever time they need to spend on making sure that the placement and discharge of our patients is appropriate. The number that we actually provided and this was in response to a question. We responded to the question not really questioning whether the question made sense when we actually responded to it but we are not allocating a separate amount of money to the follow-up. This is going to be an integral responsibility of our aftercare specialists. This is going to be a responsibility of the executive director. I am sure that some patients will require less. There's going to be some patients that require more. I just want to put the caveat that the dollar amount was really based on an average salary of an aftercare specialist but it is most likely undercounting the salary for example of the clinical and executive directors that may get involved. Maybe the direct case staff and the counselors will get involved. The number that we provided was based on the question that we were asked. They said how much time do you think that you are going to spend? As you know from Robin's questions it was five hours on average per patient and then the question was how much money you think you are going to spend. We multiplied by the hourly rate of an aftercare specialist and that's how we came up with the $130. If you are interested in the mechanics of how we got there that's how we did. I believe that because this is such a high priority for the reputation of silver points, for the success of silver points and for treatment it is basically a floor. $130 or five hours per patient is maybe the minimum amount that we are going to spend but it is a good estimate and just as I answered before I think with time we will be able to refine these estimates much more specifically. Thank you. Just to go back a little bit to this $90 per monitor number that is on slide 16 as well as on slide 32 what is your definition of a vermonter? Do I even attempt to define a vermonter? I have been here for 37 years and not a lot of people consider me a vermonter, not even with my accent from Sherlock here. So, we consider them residents of vermonter. That would be the definition of a vermonter is someone that actually is a resident of the state. Thank you. I'll just as a side note that the chair of our board because he comes from Roblin I came from Arlington he does not consider me a vermonter because I'm from Massachusetts in his mind. The last question I have is on slide 6 and I note that kind of the way you did the math in terms of 424 L.A.D.C.'s and then you have a projection in the first year at the three that you will be using you're breaking up. Okay. Let me let me try again. So, you reference on slide 36 of 424 L.A.D.C.'s in Vermont and that you in year one would be employing three of those, plus or minus and year three, six and so the percentages that you derive are quite low at seven tenths of one percent at one point four percent but the actual incidence of those hires would probably be not be spread evenly across the entire state and that they might have a much more localized impact on service providers that are in your same field that are you know, more closely located to STO. So, I'm just wondering if you have a concern that in the more immediate area of STO that your ability to pay more would be any of the specific organizations located in STO. You know, again we are thinking here of some game. We think that we cannot attract more licensed alcohol and drug counselors to Vermont. I am confident that if we have the type of facility that we want to people will actually come to work here. They will come to Vermont. They will come to STO. One of the reasons that we decided to create this clinic in STO is that we do think that it's an attractive destination not only for patients but for people to work. You know, this notion that there's only 424 counselors in the state of Vermont and it's a zero sum game and there will be no additions. I mean, this is an area that we all know is looking for work and jobs and this is like an area where I can bet we will have more individuals coming into this area. So, you know, I haven't really done a census of where this counselors live and deliver services in the state of Vermont. I do believe that giving the quality of what we are attempting to do and the quality of the staff that we're going to have that people will actually move to be close to this job. We're going to pay well. We're going to make them proud of what they're doing. They're going to be associated with one of the premier treatment centers in the country. I think people will thrive from, you know, move from Bennington if need be to be associated with us. As a business professor here, I have a little bit of trouble seeing how the workforce is static, right? I think that there will be some dynamics here that will make the numbers that we are hiring really not particularly significant in establishing pressures within the state. Well, thank you for that. I just raised that because you may know, for example, many of our hospitals are breaking up again. Yes. I wonder why that is. So that many of Vermont hospitals are running red ink significantly. So these small marginal impacts are much more significance because they don't have cushions on their bottom line. And so I think one perspective would be that you're projecting a very, at least by the second year of a very healthy relatively third year with net revenues that are in the black in an environment where healthcare providers in Vermont are in the red. And it's just a thought that I want to keep in mind. That's my question. Okay. So sorry, did you want to respond to that? Well, I mean, I think that the point is very well taken and I understand it. And the reason that we have this model is precisely to avoid being in the red if we can. So I understand the challenges and difficulties of the hospital setting in Vermont for sure. And our pay model is based on trying to avoid those pressures, those financial pressures. But the point is very well taken and I hear you. Thank you. Okay, next we're going to go to Board Member Holmes.  I'm on mute. Sorry, now can you hear me? Yes. Okay, perfect. So thank you very much. It's nice to meet you virtually. Thank you. I'm going to start, I think, and I'm going to try and be somewhat brief given we've had a lot of time and a lot of my questions have been addressed already. But I wanted to focus on Vermont need a bit, because my colleagues on the Board have already addressed a little bit, but I want to take it from a different angle. Since our focus really is whether this project meets Vermont need, or that's one large part of the focus, there is one other ASAM 3.7 facility in Vermont that's available. So one of your comments is this would be a good addition to Vermont in the second facility. And you claimed earlier in the presentation you want to have a major impact locally. So when I look at your number you gave, the 9634 that was on slide 16, those are the admitted patients 18 and above. And we look at your 18% of that number that needs residential treatment. We're talking about about 1,734 Vermonters that need help on an annual basis. And you're building capacity for about a thousand, right? If you look at your year three capacity it's over a thousand although you're only going to have 900 or so. So you're only taking 90 of the 1,734. So that's about 5% roughly speaking of the actual need in Vermont despite the fact that you're building capacity for much more than that. And I recognize that that's largely because of your pay model, right? Because of the self pay. As soon as you add in Medicare, Medicaid out of the payer that's not your business model that eliminates a large fraction of the need in the state. Is that right? That is right. I just would like to make sure that when you say take we will take anybody that wants to pay. So the 90 is what we think is the floor. And it's based on the census data that we have. But it could be much more. How much more? Again, I don't think anybody really knows. But yes, what you said is absolutely true. You had put in there about 14% of patients admitted are either private insurance or cash. That means 85% are probably either uninsured, unable to pay or on Medicare or on Medicaid, right? From your assessment. Yes. And I understand the financial model that you've designed is to avoid the financial pressures by having self pay and pay up front. But I'm wondering if you to some degree consider externalities that you may be generating. The way I'm thinking about it is you had talked about in the first year having about 15% of the market share of self pay up to by your three having 35% of the market share of self pay. And this is just in Vermont. So we're talking about just the Vermont self pay market. Is that right? That is correct. So my concern is that as you increase market share there are other facilities in the state that rely on the self pay population to cross subsidize the underpayment of our public payers. That's not an assumption. That's a statement that is not proven. You just said is possibly true, but possibly not. We don't know how many people that actually are willing to pay leave the state. So your assumption that again it's a zero sum game that I'm going to actually have all of the patients that self pay from other facilities come to silver pines may be true, but what we think we're doing really is providing something that the state doesn't have. And that the individuals in the state that currently go out of state will stay in state. So it's not like I'm actually taking patients away from Brattleboro retreat specifically. I am actually hoping to keep for monitors that are going out of state for the type of treatment that we're offering in state. And what evidence do you have that you will not be taking any patients from Brattleboro retreat? We have actually again the question is how many to answer your question directly I have no evidence because Brattleboro retreat really doesn't publish how many individuals are actually going for ASAM 3.7 treatment modalities. The numbers that they treat may, again, I don't know if they self-pay. So the question that you're asking me, we don't have data on, right? What I would need to know from the Brattleboro retreat and they don't publish this and don't share this data is how many individuals are being treated at ASAM 3.7 are actually self-paying. And we may or may not obviously attract them. But again, the whole concept here is to bring individuals out of the state and taking their dollars elsewhere to keep them in Vermont. And I guess this is the same line of questioning around you refer to and this has been brought up a little bit before but you refer to the creation, your words of 55 well-paying jobs and I think that I understand your point that it may not be a zero sum game and the labor force is dynamic and there may be some out-of-state employees who are willing to come to Vermont to work at a high quality facility that's paying well. But there's also the possibility that ADAP brings us up that you could be depleting some of our much needed workforce that's caring for the more vulnerable populations largely those in Medicaid and Medicare. So I think there's a concern about that and I hear what you say and I hope that if this CON is approved bring in folks from other states certainly we need an increased workforce in the state of Vermont. But there is a concern that you would be taking your you have 37 clinical providers four providers, 12 nurses and four counselors and that combined group of individuals would be serving 36 to 90 Vermonters. My question would be if those even 20 providers were deployed in other Vermont addicted settings could they serve more Vermonters and have more impact? And again I know it's a hard question to answer but if you look at the number of clinical staff that you're going to have there I almost think about the provider to Vermonter ratio and I think about it that way a little bit and it concerns me especially when we're getting you know letters from ADAP and the Department of Health that are concerned about the impact on the Vermont system. The question I mean again is a very complex question that you're asking. It's a philosophical level right and that is whose responsibility is it to provide that kind of care. I mean it is hard to argue right that you want to keep salaries low so that you don't put pressure on the state. It is actually hard to argue from an economical development point of view that creating jobs and good paying jobs is bad for the state. So actually providing jobs that serve the under, serve under privilege socially challenge economically speaking population. Whose responsibility is that right? We have a model that is doing what I think in addition to the environment in Vermont. We're not detracting, we're adding. Are there some needs that we are not addressing? Absolutely. I mean we are not trying to serve everybody in Vermont. We have made a choice. We think that we are going to deliver a service that is in great need in Vermont to maybe some very few individuals but it's a need that they don't right now fulfill in Vermont. And the responsibility for taking care of a lot of other patients may fall onto someone else. The notion that we are going to create some pressures by hiring 20 people. If I take the numbers that you mentioned which are the numbers in year three so this is not like it's going to happen like a switch from one day to the other but it's going to happen over the next six months. I mean there's a lot of graduates of programs around the country certainly around Vermont. Certainly a university of Vermont that will be looking for jobs and I hope that the state and I hope that other entities in the state will take the responsibility to develop jobs for those individuals. We need them to stay in Vermont. We need them to create and yes I'm using that word because right now they don't exist these jobs. I can hardly understand why that has a negative impact. I mean I think that if I hear what our governor is saying what we need is jobs, good jobs jobs that actually address a very important need. I appreciate what you're saying a workforce shortage in the state of Vermont so if we are not currently facing a workforce shortage in Vermont it would be a different story but I hear what you're saying and I don't want to belabor the point. This is important because this is really economic policy here so you mean that because we have a workforce shortage we shouldn't create new businesses. Are you saying that because we have a workforce shortage in healthcare we shouldn't come up with new treatment that could help people. I mean again for me this is thinking of a zero-sum game if we believe in the ability of an economic system to grow it will create jobs, it will create really great jobs and you talk about externalities for me the ability to create 55 very good paying jobs in a little town like Stoke or Montt where I live I can tell you that that will have a huge impact on convenience stores on gas stations on grocery stores I mean we're talking about making not only on the addiction population here but to add to the economic landscape and this notion that we have a workforce shortage so please don't open anything else because we may actually create a negative result you know it's a hard argument for me to understand. I hear it I understand that is a challenge and I do think that this is public policy much more than you know a certificate of need for a new business well we just have to ensure that what we, the decisions we make don't compromise access to other Vermonters so that's the line of questioning is around that you I just want to ask you a little bit so you talk about the cost of non Vermonters straining the emergency rooms and inpatient psych capacity less than the benefit of avoided ED visits that Vermonters would gain if they sought the treatment at the Silver Pines Center facility I didn't really see an attempt to try and quantify that cost benefit analysis my guess is that would be challenging I just want to say that you know even 8 inpatient psych non Vermonter needs 8 non Vermonters needing 8 beds in an inpatient psych facility seems small but it's actually significant we have a huge issue with mental health borders in our emergency rooms and not enough psych capacity in the state so it may seem like a small number but I just want to articulate to you that this is an area where we're already struggling in Vermonters so we have to be concerned about exacerbating it I am fully aware of that I want you to know that again I am extremely familiar with inpatient psychiatry treatment I have again in my work suicide work with three of the best psychiatrists in this state so I know the challenges that they face every day I'm very much aware of that challenge I want you to know that the timing was not right we have a letter of support from Dr. Toby Horn who is the director of inpatient psychiatric services at UMMC and Dr. Horn very specifically would be very if I don't know Mike what the limitations of the protocol are here of adding information and so forth but this letter came in at the beginning of the week and it was beyond the deadline of Friday when I needed to submit the presentation and other documentation to the board but in that letter he actually supports the creation of an entity like silver points for the reasons that we're speaking of and that is that though effectiveness the cost benefit of how many people are you actually helping to avoid emergency department services is challenging Toby is saying hey you know I think the impact that you're going to have on the substance used disorder population is significant the only other thing I'm going to say and again you know that that goes it's not my research it's not the work that I do so I need to quote just the sources in the literature is that a dollar that is spent in in detox environments actually generates 12 dollars of savings in emergency services down the road you know that's a number that has been used so it's a number that you know I am actually quoting in the presentation and I have not experienced that but I am actually using that as a point of reference as to what the impact of our services will be okay and my last question is actually on the slide that you have up on the screen now your chief medical officer can you just clarify addiction fellowship trained and or board certified psychiatrist or primary care physician I ask that because I know you had mentioned in the application that best practices really integrate mental health services into the treatment so it seems to be having a psychiatrist would be really important particularly if you're going to be administering medications but then and or could be a primary care physician seems like there's a big difference in primary care physicians capabilities and mental health and a psychiatrist so can you just clarify that for me yeah again let me just tell you what my preference is right board certified psychiatrist with an addiction fellowship I mean that would be what we are going to be looking for and trying to recruit for again we all you know just to your previous question this is Vermont there are a lot of individuals that actually have that profile the key for me is the addiction fellowship is to have the specialty in addiction there are many primary care physicians there are many family practice in this country that are dealing with addiction directly and if there is a primary care physician that we will hire would be someone that has extensive addiction training we will then have a board certified psychiatrist on the staff but maybe not as a chief medical officer but ideally right I would like to have a board certified psychiatrist with an addiction fellowship that will be my ideal candidate okay thank you thank you so much okay will you ask about the procedure for submitting the letter of support you can do that after the hearing at the Donna we typically consider those as essentially public comments which so yeah just send that to Donna after the hearing thank you thank I will do so thank you so much Mr. Chair do you have questions if you're talking you're on mute okay can you hear me now yes I can that's okay great so it's like I started to say it's always good to be last because my colleagues have focused on some real key areas that I had been trying to hone in on especially as it relates to the impact on other facilities in Vermont and other force and also the financial conditions so questions will just be some tweaks around the edges of what you've already discussed previously and I want to start by saying I truly appreciate your confidence in this venture if I were in your shoes I would be probably a lot more trepid about moving forward under the current conditions and also I think I would have a lot more fear of success but with that being said first let's start with the financial end of it your monthly lease payment is that gross or is that triple net and what confidence that you have moving forward that there won't be significant increases on the additional charges I mean this is a public record once Listers and Stoes see how much money is being put into the facility it's likely that there will be an additional assessment have you calculated those type of assumptions into your projections so again just to make sure that we all understand I'm just a tenant and the implications of change in property taxes valuation of the property and so forth will be absorbed by the developer and I believe Greg Belduck is on the line so he can address that directly for us we have a lease that actually sets our rent very specifically we have a limit on the amount that they can increase that rent for the first three years so and Kevin I appreciate your comments about the courage that it takes to start a venture entrepreneurs are sometimes seen as foolish but it is a business that I believe will sustain the projections that we have based on the need there is no doubt to your comment that in this particular environment raising capital is challenging there is absolutely no doubt in my mind the mind of the people that I've spoken to Kevin that says that addiction will get worse because of the circumstances that we're going through so nothing in the environment since November when together this application has actually changed in a way that tells me that the assumptions that we've made on demand for this service has in any way diminished in all the conversations with professionals that I've had through this four months it's been a confirmation that the need is there and so I hope that we're right and I certainly this COVID-19 world though it has made financing, private financing private equity financing more challenging I think all the assumptions on demand have been actually strengthened. Okay so there's been a lot of questions that focused on the impact on the Brattleboro Retreat I'm more concerned about also the impact it could have on other facilities as you know I'm a former legislator and a lot of times I had to go to the mat to try to make sure that there was assistance to programs like Serenity House and other recovery programs in the area that I represented and I'm not so sure that this is strictly a silver pines versus Brattleboro Retreat as far as the type of patients I think people enter into recovery programs for a number of reasons and most importantly based on what they think their personal success rate will be so I'm curious if you've really given thought you know you spent a lot of time talking about do well but do good and I just want to make sure that you know I the 1% for recovery is great it would be greater if it was 1% of revenues not 1% of profits because as you know profits are an elusive target at times but with that being said are you confident that you're really not impacting existing programs in the state of Vermont we are offering such a different program you know I do believe that we are offering something that is not being offered right now when you talk about courage Kevin to start this venture and again a lot of people on this board have started ventures of their own I know you need to find a service a product that has not been offered right the chances of success are always I think in entrepreneur based on a need that is not being fulfilled and I believe that we are offering in silver pines and that an addition and this is you know when you mentioned the word against bridal board retreat you know I really don't think I don't see the bridal board retreat to be very fair as my competitor I don't want to beat bridal board retreat because I think we're looking for different type of patients and our service is going to be very different from anything else that is offered in Vermont so I see it as additive some of the comments that we've heard and that we've had is that we are detracting that we're going to take away from and I cannot tell you how from where I started this vision and this venture was about it was an additive to Vermont and you know better the state I will no way I will question that you have a much greater understanding of the needs of some of the serenity house a turning point you know I really don't know the financial status and state of those organizations but I do think that it will help and look you know you mentioned that one percent is not enough with success comes generosity and you know right now what I can afford is to think about one percent if we are really successful and we are more successful one percent may not be the limit I am actually making a commitment and again I'm under oath and you know that I will at least provide one percent and I can assure you Kevin that there will be no hanky-panky accounting wise one percent profit will be one percent profits and you know you don't know me but I can tell you that for me a lot of what is driving the creation of this venture is to feel that I'm contributing and that will be we will start with one percent and then you and I we can talk maybe three years from now and you can convince me to move more and I think it will be my arm will be easy to twist I'll hold you to that one other question that a lot of concern was on post discharge and the follow-up there wasn't a lot of questioning on that so I just want to what assurances can you give us that this isn't a scenario where somebody comes in they put their money down they get their 10 days and then they're kind of left hanging as it goes out in the future I'm curious what type of post discharge plans would you have as far as communications with family providers etc that makes this work on the long term you know it's obvious but let me just state it explicitly is that we are going to live or die by our medical outcomes you know we are going to live or die because we're charging a lot of money for a service based on the effectiveness of our program and this charge planning and placing patients it's a key metric of success for us so we've been asking the questions of how many hours we're going to be spending on post discharge and so forth I can tell you that it's a critical component of reputation for us to be able to attract new patients I cannot make a living attracting a patient taking their money and then not succeeding because this is a community where that kind of reputation gets known very very quickly we are going to make the placement the post discharge part of our treatment it's a critical component of the model that we have I wish I could again give the board all of you I hope we're going to have this conversation a couple of years but I expect a 100% placement in a program that will actually support what we did in the detox part of the treatment and make us look very good part of what we think we are doing here is that we're preparing patients for greater success at rehab and the only way that we're going to prove this is by actually placing our patients in environments where they will get the same type of treatment that we are delivering very effective long answer to your question placement is key for our success priority for us from the beginning thank you that's all the questions that I had at this time I'll turn it back to Mike thank you so we are running a little late but did want to give board members a quick opportunity to ask any follow-up questions that may have been spurred by other board questions so if any board member has please identify yourselves and make a quick okay I don't hear anything so I'm going to assume there are more questions and we will proceed to the public comment portion of the hearing so same deal for public comment if you wish to make a comment please begin by stating your name if you are here on behalf of an organization what that organization is and then provide your comment okay I don't hear anyone so like I said doctor if you want to submit that letter of support after the hearing to Donna and unless there's anything else I think we'll close the hearing and I'll turn it back over to Kevin or to close out the meeting thank you Mike thank you doctor and for the board I know that we have a board meeting coming up in less than an hour so at this point unless someone has anything that needs to be discussed we'll convene this hearing and I'll talk to all the board members again at one o'clock thank you Mike for your excellent work as the hearing officer and thank you doctor for very good presentation and answering a lot of the questions that we have had thank you Mr. Chairman Maureen Goetsing you has been a while and and Donna I just want to again please for all of you you know what a fantastic staff you have but I cannot tell you how helpful Donna has been I want to thank her publicly she's been just terrific thank you so much for the opportunity you're welcome see everybody at one bye bye thanks