Good afternoon and welcome back everyone. My name is Kevin Mullen, Chair of the Green Mountain Care Board and I'll call our meeting back to order. And the first item will be an executive director's report, Susan Barrett. Yes, thank you, Mr. Chair. First, I want to announce some agenda changes. We had the first part of the meeting this morning where I announced these changes, but I want to reiterate them. First, for this afternoon's agenda, we have listed the wait-time metrics for hospital budget guidance. We took that agenda item earlier today. And then there is the item number three on today's agenda, which is the Department of Mental Health Update. We heard late yesterday from the Department of Mental Health that they were unable to attend in person to our meeting today. They did submit a written memo, which we've posted to our website for those who wish to look at that. And I do believe we'll, after we hear from the University of Vermont Medical Center psychiatric inpatient update, we will hear from, we will talk with the board about their comments. So I just wanted to clarify that agenda item. I also just want to remind folks that we have two public comments ongoing, the all pair of model next agreement, public comment. We're accepting any comments regarding a potential next agreement with the federal government. We share all of those comments with our partners at AHS and the governor's office as they are leading the negotiations on the next potential model. And then the second comment is regarding the essential health benefits plan update. And there is a link on our public comment page that directs folks to the Department of Financial Regulation page where they are collecting comments on that new proposed plan. So that is all I have to report. I'll turn it back to you, Mr. Chair. Thank you, Susan. So let's get right into the discussion at hand today which is the University of Vermont Medical Center, psychiatric inpatient capacity report. And I'll turn it over to Dr. Bromstead and Eve. I'm not sure who's leading it, but whichever one of you is. I'll start off, Mr. Chair. Good afternoon, everybody. And I hate to start with a correction, but this is a University of Vermont Health Network plan and the work has been done with lots of UBM Health Network hands on. So it clearly is not UBM Medical Center and so in a regulatory hearing like this, let's make sure that we keep that pretty clear. We're here to give an update on the psychiatric inpatient capacity project that we started in earnest just about four years ago, exactly now in 2018. Obviously a much different time. I would look back and say it was bucolic in relation to where we are and where we've been. We've been giving quarterly reports on this project, quarterly updates in writing and a couple of times we've given testimony and what we're doing today is an update. So I may refer to some things that have been presented before and not go into great detail. I do wanna thank Chair Mullen for giving us a couple of extra weeks. We're having some difficulty with the slide projection. We want just the main slide on. So pardon while we get our technical act together. And we can always help to protect them, Chair Mullen, but we'll stand by, I'm sure Kara can help with that. And Duly noted on the agenda, we are going to change that listing. Thank you for pointing that out, Dr. Brownsred. No problem. So can somebody speak to the fact that we have PowerPoint in construction on the viewer here? Anya, are you driving the PowerPoint? She's, she and others are trying. I just, I don't know why we've got this going on. My apologies. We're working on it. It looks right from here, but I understand you're seeing something different. Okay, we'll- Are you all seeing something different? Eve, are you seeing something different? You see the title slide? Don, I'm seeing what you're seeing. Now we're seeing the presenter view. I've been here before. I can't give you any technical advice. I think Susan's smiling. Okay, Natalie's working on it. I think if you wanna go to presentation view and what you're seeing is two slides simultaneously. Well, with your notes, I guess. You did trust us to build a $200 million Miller building. Thank you very much. We're better at that. Two more seconds and then please send it to, there you go. That's good. It's fine to have the stuff on the side. Let's just keep it there. Is that okay? Can we go to the next slide? There we go. So this is what we're gonna talk about today. The need for the psych inpatient capacity, affectionately known as the PIC project by us. And we're not gonna dive deep into the analysis of the need that's been done, I believe exquisitely well over time. And I'll show you some data in a minute that the need hasn't changed. Then gonna turn to Eve, who's gonna show you that we've done what we wanted to do at this point, which is to design a facility. And we have some updates on what it costs in today's world to build that. And then I'm gonna come back and meld together our current network financial reality, which you all are deeply aware of. And then how the two come together, the implications of where we are with the project and our financial health. Next slide. So the case for the need for more inpatient beds, really from the analysis that we've done hasn't changed. And again, Eve will go through at a very high level where that rests right now. Go to the next slide. And this shows that that need hasn't changed. That'll come in a minute. This is to indicate, and this is a DMH slide that the PIC project really is to address one piece of the access issues that folks with mental health illnesses in Vermont have. We're just looking at the inpatient site capacity largely that was cut in half when Irene took out the state hospital in Waterbury. And so focused project, one piece, we know that there's a lot of other aspects to access for mental health services. And I used the metaphor right from the very beginning that we had a log jam. And the log jam was around the inpatient psych needs of patients boarding in emergency rooms around Vermont. That was the real driver back in 18 to try and address this piece of the problem. And the log jam was if we pull out one log in the log jam, that being capacity for inpatient, adult inpatient psychiatric needs that perhaps the whole river would start flowing much better. And we still hold to that. But this is really one aspect of we know a much broader issue. Next slide. So these are the recent data that are brought forward. And Vaz has been doing a good job of this. This is the hospital emergency departments. And these are patients waiting for inpatient care that lower blue line are those that are fortunate enough to wait less than 24 hours. The orange line in the middle are those that are waiting over 24 hours. And some days, and we've even not some poor folks that have been there for weeks. And you've heard from many, many different constituencies including ED docs, psychiatrists, others. This is not the right way to treat these folks. It's not the right side of care. It's largely not therapeutic. And it has ramifications for others seeking care in our emergency departments for emergent needs. So this issue, this initial rationale for launching this particular project still exists. And next slide. And that's on a backdrop of overall increasing urgent needs and presentations by folks with mental health issues. So these is the UVM medical center. So it is the medical center, the academic medical center. Emergency room visits for psychiatric diagnoses. And other than the brief dip in 2020 when people just weren't coming to the emergency room because of COVID, this is inexorably climbed. And so this is sort of a denominator of if you will, of the need of the population. Tom's written about this probably related significantly to COVID, but also pre-COVID these demands were growing. So next slide. So I'm really proud of the fact that we as a component of the healthcare delivery system for Vermont and Northern New York have not ignored this population. We've actually focused on those with mental health needs and tried to weave that into everything that we do to meet our mission. So we've increased in patient beds even before the pandemic. We staff VPCH with our psychiatrists and professionals. We've developed some very innovative plans for integrating mental health care into all of our primary care sites and we actually have implemented it. And this is a unique program in that it's not just putting somebody with mental health clinical skills in a site. This is truly integrating psychiatrists and others with mental health clinical skills into the care team in all of our primary care offices. So it's a unique model. And but for workforce issues, this would be fully implemented. We've had this largely implemented loss of professionals. So we're in the middle of that, but that's something that we've really focused on. We've created dedicated spaces at Central Vermont and the Medical Center in the emergency room for folks with mental health issues and psychiatric diagnoses, but that still is not a therapeutic environment. We all know that it's more humane than just being in an ED, bed and it's better for other patients needing the ED as well, but it certainly doesn't cure the issue. And we've made increased investments in folks to sit with people with mental health illnesses and the Medical Center estimate is north of a million bucks a year in expense just for people to help keep these folks safe. They don't add anything to the medical center. They don't add anything to the therapy. They're just there if there's a problem to get somebody to come and help. During the pandemic, we've done everything we can to keep those things going. And we've hired travelers to maintain and in the case of Central Vermont actually expand inpatient capacity. And this is in distinction with the Brattleboro Retreat and BPCH, which were unable to keep the beds open because of staffing issues. We've really pushed in this realm and in others to make sure during the pandemic that we've kept that capacity and therein lies one significant factor in our financial situation currently. So next slide. So why did we commit to take on this project in the realm of academic healthcare and academic integrated delivery systems? This is not a type of project that traditionally would rise to the top. We, me and our management team and our clinical teams really believe that this is an important population to care for. It's our mission as a not-for-profit healthcare organization to improve the health of everybody in the communities we serve. And we know that those with mental health diagnoses are vulnerable and traditionally underserved by both public and private payers. And we all know in the fee-for-service world that it's undervalued by payers. The capacity is going to not be there to really meet the needs of the population. It's one of the consequences of that system. As I mentioned before, we know since 2011, Vermont has had a deficit of inpatient psychiatric beds. I forget 52 or 53 beds in the waterbury hospital and VPCH rebuilt roughly half of those. So we've had this deficit. And we still have, again, the specific need that we were trying to address and still are trying to address to reduce psychiatric borders in emergency departments around the state. So next slide. So sad truth in Vermont, this is just documentation that psych services are undervalued and there's no solace in the fact that we're not alone in Vermont. You could put virtually any state in there, but we've got these data for Vermont. And this is specific to Center Vermont in 21 and it's facility cost coverage. Medicaid, approximately 21% of cost, commercial payers, about 58% of cost. Medicare, 38% of cost. So in our world, what we would do with this necessary service and later in the presentation, I'll give you some more numbers, we would take revenue from other services to flow over and cover this deficit and end up at the end of the day, still with that 3% plus or minus margin. As those revenues used to cover these types of services that are this far underwater dries up, the ability to cover what's in our current service mix and expense base is incredibly difficult in adding to that the difficulties is orders of magnitude greater. So next slide. So I'm really proud of this work too. Incredibly collaborative. I'm gonna turn it over to Eve, who's our vice president for strategic planning. Does our business work as a great crew that you've heard from before and you've seen again some of their work product specific to this project in our written reports. And I believe in 2020, Eve, you and Anna, maybe others presented some of the, where we were with this project. I'll turn it over to you. Thanks, John. Good afternoon, everyone. We could go to the next slide. That would be great. We're gonna touch on some of the following things. We'll give you a quick update or just do a quick highlight of the work and our needs analysis and some of the facility design. You've heard that before, you've seen it in many of the quarterly reports that we've filed and then share with you the more recent results around the project cost and the operating financial pro forma. Before we move on to the next slide though, let's take a minute and talk about stakeholder engagement. It was huge for this project. We invited patients, individuals with lived experience, some patients, former patients, representatives from the designated agencies, other colleagues from state agencies and our hospital colleagues to really lend us their expertise and advice at all the phases of this project and we're enormously grateful to them this project design is far better for all of their contributions. So thanks to everyone for their time and I'll also call out the PIPS group. You know that we met with them on a regular basis to share our progress and the results of our work and we remain very indebted to those individuals as well. Okay, and now we can go on. Let's jump right into the needs analysis. Thank you. So there were two big components of the needs analysis. The first component was that bed demand model that tried to forecast the number of additional adult psychiatric inpatient beds that we would need by 2028. And if you remember, we had a little equation and that resulted in a range of summer between 29 and 35 beds that we would need. The second component of that needs analysis went and did an assessment of the IMD statute, the Institute for Mental Disease Statute. And that statute says that there's a limit to the number of inpatient psychiatric beds that you can have for an adult population without jeopardizing federal reimbursement for all of your patient population. So after that careful work, the conclusion was very clear that CVMC couldn't accommodate more than 40 inpatient adult psychiatric beds on their campus without jeopardizing that federal payment. So we had our direction, we had need, we had the IMD assessment, and we proposed that we build a 40 bed adult inpatient psychiatry unit. A quick note, so as time passed on, we looked at our bed need model and said, okay, things have changed, let's go back to more recent data and make sure that the need for those additional beds, again, forecast out to 2028 didn't drop below 25 so that we weren't overbuilding. And every time we looked at that same kind of tip of the iceberg of those emergency department visits, those long-term stay, those long-stay patients, what we found was that in all cases, the number of those patients was just increasing over time. So we felt pretty sure that, we felt very sure actually that that 25 beds was the right number to build. Next slide, please. We wanted to give you a feel as we think about now the design phase of this facility. Here's just one slide on the number of different types of rules that get involved in a facility plan. Really clear at the top, again, I'll just underscore our peer advocates, our individuals with lived experience, our patient and family advisor, were absolutely instrumental. We thank them so much for their time. Their changes, Eileen He, who led the facilities part of this project for CVMC, just couldn't say enough about the large and many small ways that the contributions of these folks contributed to the work that was done. But as you can see, a lot of input from a lot of key players in actually making this facility and the patient experience and the clinical experience work for everybody involved there. We can go on to the next slide. Thanks. Our program design phase was, once we had the number of beds for the unit down, we went to program design phase. You might recall this was facilitated by our longstanding facilities partner, HALSA advisors. They did a masterful job of kind of convening these groups and talking about what a therapeutic care environment that was safe for patients and safe for staff, what did that look like? How would it operate? What did it feel like? And then how many staff would we need to make that happen? We actually thought about, and we did actually propose that, for example, support staff who might be delivering laundry or delivering pharmaceuticals and medications coming in didn't actually go in the same hallways, but they had kind of an interior pathway so that we wouldn't disturb patients who were in their own environments. And so we really, there was a lot of great thought to that happening. And the final outcome of the program design was for the space plan. And we kind of replicated this approach, not only for the inpatient psych units, but for the intake unit in the ED and also for those supporting departments so that we made sure that we kind of looked at all the aspects of what care for this population of patients might look like from the minute they arrived at CVMC. Next slide, thank you very much. So just to recap, the scope of the facility is a 40 bed adult inpatient psychiatric unit that's actually divided up into three tiers. Tier one being highest acuity, 16 tier two beds and 16 tier three beds. All of the rooms in these units are single occupancy with their own private bathrooms and showers. And the other really important thing about this unit is the rooms are bigger. They're meant to be able to accommodate patients who have an accompanying medical condition if needed. And that's not the case in every psychiatric hospital that you go to. There were places to store their personal belongings. Again, a lot of care given to the patient room space and also to the group spaces, group therapy rooms, exercise rooms, access to outdoor spaces and outdoor natural light and views as well as part of that therapeutic environment. On the ED, what we learned about the flow of patients when they arrived at CVMC and up to the inpatient psychiatric unit was we needed that ED to be close. And so this facility has them, you'll see it on the next slide actually stacked one on top of the other. But the ED had an intake unit and then we had an expansion of the current CVMC ED to accommodate more emergent psychiatric cases because that's what we're seeing. In particular, a better way to accommodate the needs of pediatric patients who are coming to our EDs with emergent mental health conditions and need some private safe space. So we did, we really improved the situation to provide care to those younger patients. And we also gave our staff much better room and space in accordance with kind of the modern standards for support care to do their jobs more efficiently and take care of their patients better. Lastly, it was absolutely critical that we connect this facility to the CVMC main building to allow the efficient ability to support these units from nutrition services, environmental services, security, pharmacy, so that those things that are functioning for the rest of CVMC can easily kind of just glide right over and support the inpatient psychiatry units as well. Next slide. So there you go, in that, we tried to cram two things in one slide here, in the top right, you'll see a schematic of the facility. So the ED goes on the, and there's our little color block of the floors, if you will. ED on the ground floor, the two inpatient psychiatric floors above that. And then a fourth floor that has a little bit of psych admin space and then the building mechanicals as well on that floor. But you can see lots of access to natural light. You can't see the rooftop gardens on this thing, but they are definitely there and we're on the floor plans. On to the site. Wow, when I first came to CVMC, I thought in comparison to UVMMC, where it feels like a New England farmhouse that CVMC has its own challenges. And between a ravine in back, high intensity power wires, roads on two sides, those of you who know CVMC know exactly what I'm talking about. It became very difficult to find a place for a facility of this size and bump it up right against the main campus. But we found one. It's right there in that parking lot. For those of you who come into CVMC from Fisher Road, it's right there on the right as you come in. So you can see it in that dark orange spot. That that's where the facility will be. Fantastic for ambulances coming to RED, but challenging as we think about what happens to the rest of the campus. So we've expanded parking to deal with the displaced parking spots, where the facility will be, as well as additional parking that we need for staff and visitors for our patients. So there you can see the expanded parking there to the North ish. And then we had to go expand more parking down to the South across Fisher Road. Okay, that's the quick recap. Let's go on to the next slide, please. All right, now on to the project's capital costs. Let's go to the next slide. Thank you. All right, so in 2020, we completed an early phase of facility planning called conceptual design. That's when we have the square footage for the plan of the building. We find the appropriate benchmarks. We do the math. We have some early estimates on some key parts. And this came out of the oven in very early 2020 with a price tag of $148 million on it. And at that time, so this phase of the design in some ways did exactly what it was supposed to do which is to say if that's your plan, here's your rough estimate of the cost. And our steering committee said that cost is too high. You need to go back to the drawing board and do a lot of value engineering. And that is what we did. We shared this information with you and I think it was the 2020 February quarterly report. So we went back to work. We started with some value engineering that happened, and I believe, and Anna, you can keep me straight here, February, March, and maybe, yeah, I'll say February and March of 2020. And then we had to pause that work because COVID arrived and honestly, we couldn't have partners on our sites to help confirm or validate any of the ideas we had for value engineering. We were just working with our partners virtually at that point. So when summer of 2021 came, we brought our partners back on campus. We had our value engineering plan. We could really validate many of the ideas that we had. And we did find that we were able to eliminate things like the parking garage that we thought we could fit into the budget, which we couldn't. There was a two-story hospital connector. We scratched that from the project. We thought we could save a lot of money by creating some standalone mechanical systems for this facility because it was of the right size. And we achieved some savings, but we didn't achieve as much as we thought, to be honest with you. We also added some things. For example, we learned from the pandemic and our experience with our own psychiatry units at UVMMC and at CVMC that we needed to create more negative pressure spaces so that we could not have to close beds when we had our next pandemic or infectious disease outbreak, I think. Unfortunately, I'll realize that this is likely to be part of our future. So there were some things like that.  So number one, we were going with real estimates. We had an itemized list, no more square foot and estimates by square foot. It was itemized lists of exactly what we needed in each one of these units. The list is really huge, but the impact of inflation on every single one of those estimates was real and big. And it brought our total back up to 158 million. Dave Kilty showed me a graph of the cost of steel increase. And it's the slope of the line is just crazy, but you all have your own stories about that. Let's go to the next slide, if we could. So our capital cost estimate, as I mentioned, is 157.8 million. Here's a quick breakdown, 121 million for facilities, about 18 and a half million for equipment, some IT. Those other expenses include fees for permitting, for architects and designers and other partners and some other miscellaneous things. I asked a group if we could allocate that capital cost to the inpatient psych units and to the ED separately. And so per that allocation methodology, it's about a hundred million of that 158 million for the inpatient psych units and about 57 million related to the new ED. We can go on to the next slide. Thank you. So now on to the pro forma operating financials. I'll give you the bottom line first when I wanna go back and talk about the work we did to model the revenue and the expense side. So what we concluded was that operating this inpatient psych 40 bed inpatient psychiatry unit would add another $25 million in annual operating loss to the CVMC financials. The, our estimated contribution margin is actually a negative $29.7 million dollars. So we, I wanna talk a little bit about the work that we did actually back starting in 2020 on both the revenue and expense side for just a quick sec. So we convened a reimbursement group with lots of folks from inside the network and from outside the network. And we're grateful several folks from the state, some representatives from VAZ and other places, but we wanted to build a reimbursement model that we thought was fair and accurate. And so we're indebted to those colleagues out there who helped us to actually build that reimbursement model. On the expense side, we were really careful. So staffing as you can imagine is a big factor on the expense side. We were careful to reach out to our colleagues at VPCH at Rutland to benchmark staffing per to patient ratios. And so got a lot of feedback on that, lots of, lots of iterations on that. But as we all know, our expenses are being driven by increased staffing costs. We also updated the percentage of travelers that assumptions that were in the original model to be more in line with what we're experiencing currently. And so this does reflect about, this expense reflects about $7 million in premium pay. So that's pay above what we expect to pay permanent staff for travelers to share that. So that was a very, it was very sobering. I think you have to get the idea that we checked and double checked our numbers, but this all gave us pause. John, let me turn it back to you. Technical difficulties today, I had to find the mute button. So project gets to that point and something that we've talked about all along is engaging with payers to make sure that we can have a reimbursement model that will at least allow us to break even. And I will say that our work with Secretary Samuelson and with the Department of Mental Health and their leadership and staff has been great, been very engaging. And in the January, I think December, January and maybe even into February timeframe, we had folks meeting together, sharing in much greater detail, the pro forma and the cost side. And for the Medicaid program, which of course is a significant part of the payer mix for a unit like this, but not the only payer, there was conceptual agreement that we would try and get to break even payments. But it's very clear that there is risk in that because you have to go through a legislative process and appropriations to actually have those payments made. And so at that point, we need to step back and assess the affordability of this and all other major capital projects. So this is back to where we are in trying to take all of the incoming information that we have on the revenues that we can expect our current expense structure, our service mix and try somehow to get to a FY23 budget that gets us back at the UVM Health Network on a solvency path because we're not on one now. And so this presentation, fine to give it, but it's a little bit out of context because we're going through all of our capital projects, not just this one in our current financial situation and we're going through our programs and our service mix as well. Again, trying to get to a place where we can craft a achievable budget for 23 that puts us on a sustainable course, but I don't wanna look past the fact that Secretary Samuelson and her team have been engaged and have been very willing to listen, learn, kick the tires of what we put on the table and to try to help. So next, next. So this is where our financial situation and the projects start coming together. The current carrying load from a financial perspective for UVM Health Network for inpatient psychiatry is that we lose 13 million a year. And again, in sort of state usual times, there are revenues from other services that we provide that we can take and we can use to cover these sorts of services that are part of our service mix. As those revenues have dried up, it's created incredibly difficult decisions for our clinical and administrative management team on what and how we cover those services. And as I said before, it makes adding incremental services. I won't say impossible, but orders of magnitude more difficult than even trying to figure out how we're gonna cover what we have. When you add in what Eve gave us on the pro forma for inpatient psychiatric care, we would be looking at covering 25 million expense over patient care revenues for this project.  You've got plenty of this a couple of weeks ago, but we have thin or negative margins since 2018. So we really don't have the financial resilience that most academic integrated systems have. And I've actually fielded the question from our folks as I've been talking about the rigors of creating a budget for 23 and the tough choices that we need to make. And they say, John, why are we doing this? Are we different than other organizations? And other organizations like us have had really, really tough, particularly late calendar 21 and into January, February, March of 22. We've got data from Kaufman Hall and others that showed that not-for-profit, particularly academic health care has taken it on the chin. What I tell our folks is that on a backdrop of good solid financial metrics in bedrock, you can weather that and come out relatively quickly. Our difference is, and I'll show you some graphs. I promise I won't beat it too hard in a couple of minutes. We've had expense inflation not covered by allowed revenue. We do have our age of plan increasing, which is a tough place to be. Folks, when we talked about mid-year rate increases, we're clamoring around for us to use our reserves. Well, we've gone down almost a month in days cash since the beginning of the fiscal year. And this is clearly not sustainable and should worry all of us. And we've got significant workforce shortages, 50% vacancy rate. We usually chug along at about 7 to 800 open roles in our whole network. That's, we've got about 15,500 great folks that work for us in all of our organizations. So we bumped up to about 2,000 open roles. And even though we're filling those at a greatly accelerated rate, it's really being on a hamster wheel here. It's tough to get ahead of that. So these are really significant stressors, which are the backdrop, not only of this conversation, but of how we're trying to put together the 23 budget and how we're looking at all of our proposed capital projects. Next, this is presented a slide that was put together by your staff a couple of weeks ago. Note that 21 really bumps up, but that's all one-time money. And we all know the difference between one-time money and money that is in the run rate or expense that's in the run rate. And so those are the federal dollars that came in. And it's important to stratify that and pull out Center Vermont. In this context, any depreciation on that building and really the operating losses or expenses need to be on the books at Center Vermont because that's current regulatory structure. Anytime you wanna go to managing and regulating our budgets as one large network, we're there with you, but that doesn't work right now. So Center Vermont pulled out is, I think it was characterized as a sea of red. Onto the next slide. So I'll show you a few graphs and this is work that we've done because we're gonna be out talking to lots of folks about our financial situation just to help them understand where we're coming from as far as any changes in our service mix or our capacity. And you'll see a couple of slides, very simple, be quick. Slides have two lines that I'll point out. One is a financial sustainability threshold. You're above that, everything's hunky-dory and ducky, you stay there. And there's a second line financial sustainability at risk and no news to you.  This is just putting in relatively simple, digestible graphic terms, some parameters on that. And these parameters come from standard industry metrics, largely from rating agencies. Next slide. So just looked at the operating margin in these slides includes some straightforward, digestible, understandable definitions for these things. But the green line, just look at the graph on the left operating margin. Green line is the financial sustainability threshold. You're chugging around that, everything's great. You keep going and we've been at the network level the 3% range and these are just the UVM health network Vermont affiliates and it's just Porter Hospital. It doesn't have the nursing home because that's the way you look at it. So this doesn't include the New York affiliates. Trust me, they don't make it look any rosier. The orange line is the financial sustainability risk threshold. If you're consistently below that on any of these graphs, danger, danger, danger. And really, again, we all should be concerned about that. And you can see since 2018 operating margin and the real issue for us, particularly as it pertains to capital projects, the EBITDA margin has not only been under that sustainability, but for going on five years now. And that if it doesn't correct, which is why I'm being so hard on our folks on the 23 budget, if that doesn't correct, then all sorts of terrible things happen to these organizations that are part of the UVM health network. Next slide. On the left, age of plant, again, deferred maintenance and equipment needs. And we're really for the second year, 21 and 22, our capital spend is break fix only and break fix specific to things that are primarily directly patient facing. Obviously, if it's a boiler or something like that, you can't deliver care if it's below zero, but we're on break fix. We're not spending capital on anything. Days cash on hand, again, really troubling below that threshold, the risk threshold. And again, from end of 21 to the end of March, the end of March, we've burned 28 days of cash just to keep things going. Not good, not good. So how all of this comes together, the original plan, as you're well aware was to put in a certificate of need for this project with some significant caveats. We can't do that, go to the next slide. When we put a certificate of need in, really the first thing we do very much at the beginning is, is there a need? Yes, there is. Do we meet the criteria to need a CON? If yes, do we have the ability to meet and exceed those criteria? Because we don't put CONs in that are gonna not be approved, you can't go back then for a set amount of time and it's all sorts of work that doesn't go anywhere. So right at the top of the box, the cost of the project is reasonable because each of the following conditions is met and the applicant's financial condition will sustain any financial burden likely to result from completion of the project. Right here today, we can't meet that criteria. Next slide. Project is needed more than ever. The cost now with the inflation that all of us are experiencing, you know, go to the grocery store. Even shopping for one or two is an eye opener. The inflation on building costs astronomical. We have thought in the past of citing the facility in Burlington, I'm not, I don't think we have the site coverage capacity to take on this unit. But even if we did, it would take much longer and the construction would be even more expensive. And this is just reiterating the annual loss with the current set of measures. Next slide. So we can't responsibly carry forward the project at this time given the costs and our financial status. As I've said several times, we've pulled this out. You appropriately wanted this update. That's fine. We're going through this with every single one of our proposed capital projects. So go back to the 22 budget we put in and run the list of things that were in there. We have the team really looking at each one of those. And if it doesn't meet a significant patient need and have a margin until we get back to where we need to be financially, it's going to be probably irresponsible to propose those projects. The same time we made a commitment, I feel like when we make a commitment, I personally make a commitment and I pride myself on doing what I say and keeping my commitments. So we committed and you gave us a budget order to invest $21 million and this was in 2018 to improve inpatient psychiatric care for Vermonters. Paraphrasing a bit, but it's got those elements. And we've used, Eve, correct me if I'm wrong, 2.3 million and we obviously can account that down to the Nicholson dimes of that 21 million. So at this point, nothing would make us happier than to be in a position where we could take the rest of that money and move forward with this project. There are three absolute prerequisites in our mind that health network and central Vermont have to be on a firmer footing. I mean, we have to see those lines going up and we're not writing any checks until we see that EBITDA margin that creating cash back into the organization. Because to do otherwise puts at Jeopardy all the services that we do that Vermonters and folks from Northern New York depend upon us for. There needs to be a capital partner. Way back in 2018 with the financial strength that we had a very moderate matrix actually between those two sustainability lines not even at the top one, we had several hundred million dollars more capital that we were in line to generate that could be used to reinvest. And that's exactly the way that we've reinvested in the Miller building in Epic, both approximately 200 million dollar projects. And we did that without a rate increase specific to those projects. And that's how this works. When you follow the metrics and you have a stable financial platform. So at this point, we couldn't possibly generate the capital to cover all of those costs. And we must have the rates, but again, that's something that we could continue to work on. It will take a lot of work and legislative work, good work, but unless we really can afford the project and run that glide path, it's probably not work that we need to do at this point. You all gave us the budget order. If there's another way that you wanna use that 18 point whatever million that's left, we stand to improve inpatient site care. We stand ready to invest that as you see that this is how we would see using it for that project. We left at 33 minutes for questions. Usually when I in my past took oral board exams, I tried to get right up to 14 seconds before the exam time was done. So they couldn't ask me any more questions, but we're giving you 33 minutes. There you go. Thank you, John. Let's look at the cash flow analysis that you did and I guess it was 4.5 million in existing loss for your psychiatric use at Central Vermont within a delta of another 25.2 million. Help us understand that number for that 25.2. You had on a slide that you believed there was a good chance to get cost-based reimbursement from Medicaid. So the 25.2, is that based on that cost-based reimbursement or is that based on if you didn't get it?  Thanks, Chair Mullen. It's based on current reimbursement. And I'll just say at least from, and this is not throwing stones in any way because everybody's willing to work on this, but planning and getting a project of this size going down the path requires that if there are risks, they are risks that we can take and that we can cover. Okay, and so if we got two years into this and we're building it, or even if we're opening the doors and that still isn't there, a financially solvent organization could roll with it, even if it was just half of that for a year or two to get those reimbursements up. We're not at that point. And a lot of my job is identifying risks and taking the ones that are reasonable and mitigating some and not taking others. And so that's how I would put it into that. It's not that we couldn't get there. It's that that's a risk on a project that is essentially we don't need the criteria to put a CO in it right now. How many additional dollars would the cost base reimbursement from Medicaid net you? Sir, Mullen, I don't, sorry about my clock. I don't have that number handy right now, but we could get that for you. Just look back at history and I feel like we're in a similar place to where we were when Rutland was considering doing inpatients like beds and they made it very, very clear that they could only do them if reimbursement was such that they didn't lose money. And I don't think that your request is unreasonable. You can't lose additional money. So it's a reasonable request and I'm just trying to figure out what it takes to make that project viable so that it could happen. Well, again, it's those three criteria. If it would be a project that UBM Health Network would take forward, we would have to have the financial strength to deal with a lot more than the $18 million of capital costs that we have and be able to absorb whatever the margin is. And I'm sorry, I'm from the show me state that for a project this size and the track record of how we've not taken care of people with mental illness until one of my colleagues says, why don't you just tell them the money has to be an escrow before we would go forward? I wouldn't quite go that far, but you know, the answer is in the case mix, payer mix, and I don't know what the payer mix is on that service right offhand. But, you know, say there was, it covered all but eight or nine million and the UBM Health Network is already under water, 13 million for our our units currently, it's still something that we can't absorb at this point. John, I think we hear you loud and clear that you need to be on better financial footing. I'm trying to get to the numbers at hand for the specific project. For the four and a half million that you're losing now, are you being reimbursed differently than your peer hospitals? No, well, I don't know. I'm assuming that for Medicare and Medicaid, no, for the commercial, you know, each hospital negotiates its own commercial reimbursement. So, and I'm not allowed to know that figure, but for Medicare and Medicaid, everybody should be, I'm assuming the same. Okay, so, so, you know, just to excuse me, Chair Mullen, just a comment that, and we're more than happy, you asked the questions, we'll get to the answer, but what we were prepared for today is an update and not the deep dive that, you know, if we really were testifying about the certificate of need itself, so we can get, I'm sure Eve can have you that information. Sorry, Eve, by the end of the week, if that's what you want, we're happy to do that, but we were prepared today for an update and not really the whole enchilada that comes when you're talking about the CON application. Well, clearly we need the information so that we fully understand what's at hand here. You made the statement that you're more than willing to make sure that the $21 million gets invested in inpatient psych bed, and again, I'll look at something I'm familiar with, which is Rutland, where they rehabbed an existing floor. You have some space, I believe at Shep North, I think. I could be wrong there. Have you thought at all about investing those dollars there in a rehab into that space? So with the volumes that have come to the academic medical center that haven't much been the consequence of the pandemic, some, but not much, most from population growth, aging, and the fact that services in the smaller hospitals are declining before our eyes, there are rough estimates that were many beds short, actual physical beds short at this point on that campus. And I'm talking like several floors short and that right now, one of the capital projects we're looking at is a neonatal intensive care unit incredibly needed. One we have is very undersized and we can't find a place to put that on the campus. Going along with what I just said about looking at the capital costs for every single one of our projects. So the likelihood that we would be able to do what Rutland did and that actually was on Tom's board when we started talking about this. So I know at least the beginnings, I wasn't there when it came to fruition. We don't have the situation because we don't have a space. We have acute patients everywhere. And remember what happened to our capacity when the rehab at Fannie went down and we had moved those patients over and we've come back to you all with a request to allow us to not close beds, which was part of the Miller Building CON that we would. And so there's a master facility planning process that's going on at the academic medical center now and several other of our facilities. And there, I'm just telling you that there's no space for that right now. It would be new space. Okay, so should I just work with Eve to get those numbers over the next couple of weeks? Yeah, I think, you know, staff to staff. Susan, however your staff reaches out to get those sort of financial metrics. You know, we can do that Eve and Rick Vincent shop, Mark Stanislaus, we can get you whatever numbers you want. And Eve, I think it really breaks down around the service mix or the payer mix assumptions that we have. If another hospital were to step forward and say, we think we have room for inpatients like beds at our facility, would you be willing to give them the balance of the 21 million? Yeah, it's at your discretion. It's a budget order. And you know, I take the legal aspects of the regulatory environment pretty nice. I'm sure you could find me for a yellow or an orange jumpsuit if we didn't. Well, we don't want to see you in any jumpsuits. So that's not an option. The option is to figure out how to get this project done. That's what I'm focused. I, you know, Chair Mullen, I could not agree with you more. I'm not even gonna tell you the emotional struggles I've had to get to the point where I've been able to even get these words out of my mouth. You know, this is a project you know, how much going back to 2018 and 2019, I wanted to get this done, including a lot of the people around me at this fine organization looking at me like I was nuts and that it was just in the too hard to do box. But I really, really, really wanna do this and I would love to see it get done at some point. And, you know, another organization could really meet the need. And it does have to be a hospital because of the IMD thing. I mean, that's the other thing that we keep dancing around that was again, a big driver for us and for me to keep going to really get those reimbursements. We've got to hook it to a hospital. The Brattleboro Retreat is just suffering mightily because of not having that. So, yeah. Well, I'm sure with Humeter on that board, they're probably exploring all options, but maybe they should be talking about an affiliation with a hospital, but that's a whole nother topic. We won't try to solve all the problems of the world today. So, I'll open up the board questions and start with board member Pelham. Tom. Well, thank you, Mr. Brumstead and team. This is a helpful update as a start because all these numbers are kind of intermingled and so just to see it in such a short period on a few slides, it's not totally comprehensible, but to me, so, but one point I'd like to go back to is that you mentioned at the beginning of your discussion that the loss of the psychiatric beds in Waterbury because of Irene and that, as you know, was a facility that had 150 beds and as a matter of public policy, during the 90s, it was downsized to 50 beds, 52, I think actually with, and then pushing the money back out to the designated agencies and kind of making that kind of shift in policy and programming. And so when Irene came along, those 50 beds were taken out of service. They just weren't recoverable. And so my simple logic says that here is the state of Vermont. They had a facility that they were paying for both capital and operating those, you know, those 50 beds, a natural disaster wiped them out. They rebuilt 25 of them up in the Berlin facility, which are totally state funded, both capital and operating. And so why are the next 25 being treated differently? There might be a, you know, kind of a, unless I'm missing something, I mean, part of that I was part of the history. More recently, I wasn't part of the history, but I don't see why the state, one might argue that the state should basically cover the cost of replacing those 25 beds because it was a natural disaster that took them out. And shifting that cost onto rate payers would just be another avenue of the cost shift as opposed for the state taking a reasonable level of responsibility for building the 25 beds that they lost that they haven't replaced. Is that, am I missing something there in that line of logic or? The only thing you're missing is how impatient I am. You're absolutely iron clad in your logic that at some point, the state of Vermont should absolutely invest and increase back up to the appropriate compliment of inpatient, adult, inpatient psychiatric beds. And we can talk about the pediatric adolescent piece too, but waiting for that to happen when you have your emergency medicine physicians coming to you and telling you that we're not treating patients appropriately because of what's happening is how you get impatient. And so it's not Mr. Pelham that we haven't had those conversations. I've had it with several governors. I had a relatively heated conversation with the governor who made the decision to rebuild half of the beds. But that was the genesis of us jumping on this and trying to get this forward. We've been overcome by events and we can't do it right now. But your logic is solid. Not worth that much. I mean, I thought it was solid, but it just seems unfair. I mean, it's just not, but I thought that it might not be happening because I was missing something in the intramers. But other than that, I think I'll work through Susan just to kind of clear up from my notes. I'm looking at the $100 million in capital expense for the IPP beds and the $57 million for the ED. And I'm just not quite sure how to break that down on a per bed basis and allocate it and then follow it through the cash flows. But my questions aren't yet clear enough for me to ask. So I will get them back to you via Susan. Thank you. We'll certainly answer those. Tom, you and I are starting to think alike and that's a bad thing because I was looking at that $100 million, dividing it out by the $40 and coming up with the $2.5. $4 million of bed. I did the math too for my little calculator right here and I'm going $4 million of bed and the $2.5. And there's a metric floating around out there that psych beds only cost a million dollars of bed. Not when you make them med surge capable and not when you build them in 22 going forward. I mean, you wouldn't believe if you look at the spreadsheets what just the inflation costs on the construction have done in- We do believe that we're hearing from every CON in the state what the price changes have been in their project. So we believe it, it's unfortunate but we definitely believe it and it's a reality. So next turn to Dr. Holmes, Jessica. Well, thank you and thank you for the presentation. I recognize this was not an easy presentation to make or a decision to come to. And I also recognize all the incredible work that's been done on this project in the last few years and all the efforts that were made. And I also recognize the financial situation that you're in Dr. Bromstead. And to be honest with you, I understand completely the decision to pull the plug at this point in time given the financial pressures that you're under. So I guess my brain is already trying to problem solve and it's not like I can problem solve this some way that you all happened, right? Because I'm sure that you've looked under every rock and done everything that you possibly can. Along my colleague there, Tom Pelham's lines. I mean, I do wonder about conversations with the state on contributions to the investment costs of building. I had the same sort of reaction to those 25 beds. And obviously the Medicaid reimbursement is gonna have to be critical to any eventually moving forward on that as well as Medicare. And I don't know whether there's some stipulations or something that we might be thinking about in the next federal agreement that would help along those lines. So I just will plant that seed. But I'm also wondering, as I was thinking about this, there are a lot of cost savings that if this unit were put into place that other hospitals would experience in terms of lower costs for their borders, patients that are in their med search, potentially in their med search patients that really just need to be transferred that could be replaced by a more acute patient that would probably have a higher reimbursement. I mean, I'm just imagining other hospitals would benefit clearly from the building of this, not only financially, but clearly for their patients. I mean, there's a clear public need in my mind for this. This is really gonna, it's only one step, but obviously would make a huge difference in the mental health crisis that we are facing. And it seems to me that could we initiate some conversations more broadly with the state, with the legislature, with other hospitals to build a contribution pot to help make this happen? I guess is what I'm wondering. Are there other hospitals that might be willing to contribute? Are there donors out there? Where can we find the financial resources to make this happen? I recognize it cannot all come from the UVM Health Network, Dr. Bromstead, given the situation that you're under. But I guess I'm just wondering, are there other resources out there? So I just will throw that out there. You may not be able to answer that, but... I can't answer it other than to comment, give opinion. We have, as with any capital project, we do have folks from our philanthropy development team that have met with Eve and others. And but really in the starting blocks, they haven't gone out to seek donors or anything like that. And it gets really, really complicated if you have an asset that would be on the license and owned by Center Vermont, and you have other not-for-profit organizations contributing to that. I mean, I'm not even gonna play a lawyer here, but I'm thinking joint ventures and how do you do that? So it gets really, really complicated. I mean, the most straightforward way to finance this, an asset of this size in our environment is go back to 2012 through 18 and look at the metrics of the Academic Medical Center and the UVM Health Network. And that revenue and expense and service mix, all those run rates added together is how you do these size of capital investments and operating losses. And so that's one way. The other way is with state or federal money. And there's a bucket of federal money around, I didn't get really specific, but I did make several pitches that fixing the mental health system in Vermont would be a very reasonable piece of the infrastructure that we could make once in a lifetime investment in and get back on the right track, Mr. Felham, to your point. But I see those are really the two pathways. There isn't another healthcare organization that has the scale or scope to be able to make this size investment. And so that's how it's worked for my whole professional life here until the last four and a half, five years. That's, I mean, again, that's how we did the Miller building and how we've got Epic now for a million people in our catchment area. And you do that without a specific rate increase when your financial metrics are all lined up. Have you done the math on what the commercial rate requests would be with and without this inpatient unit for your next budget and your next five budgets? Thanks for the next three budgets. I don't believe so. That would be a planning question, Eve. If you looked at it from that lens, yeah, I'm mute. Oh, we still can't hear you. So sorry, everybody. So nothing that I could share at this time, I was playing around, but. But, you know, that's something we could model. Let's look it out and talk about it. I mean, we certainly can parse that out of the other ways we look at how we, I mean, we solve for the required commercial rate increase on the Vermont side. We could just pull that piece out, look at it. Yeah, that's what I was wondering. I guess my last question is, I know you're reevaluating all your capital projects and understandably so. I'm wondering how you prioritize those projects. Specifically, how do you balance the financial margin potential of a capital project against the population health value of a potential project? And, you know, because clearly this has very, very high population health value and low financial margin value, right? So I guess my question is, as you're going through your capital projects, how do you weigh that? And how does that calculus change if you're living in a fee-for-service world versus if you're living in a global payment value-based payment world? So I'm starting, you know, I'm wondering how you're making those calculations now and are you making them assuming that you're in a fee-for-service world or are you making them assuming there's gonna be a movement towards a global payment where there's gonna be more accountability for population health? And does that change how you evaluate those projects? If my question makes sense. Yeah, I mean, and it is incredibly multifactorial and requires diversity of opinion and thought. And we have all sorts of factors that we throw into the mix, including all of those. And as an organization, we are always looking to the value-based world. And again, that makes this really difficult, but was a rationale for the putting several million dollars into the primary care mental health integration. Right now, where we stand, I would say the most important factors are need of a patient population, margin, at least covering costs. And third, which is really important, if we don't do it, what happens? And if we don't do this, we're in a position that we've been in for a number of years, it's painful. We've made some accommodations. There are other things that would just give you a, for instance, our lease runs out in the end of 2026 for the Fannie Ellen campus in Colchester. Anything that's there is gonna need a new home. So, that sort of weighs in pretty heavy in our decision-making for what's right in front of our nose. The other thing that's increasingly is the impact on disadvantaged populations. The health equity equation, which embarrassingly over past decades hasn't been, it's been known about and understood but hasn't been at the top of the list as determinants is now very close to the top of our list, which again, makes this project going into a new home. A phase of indefinite hold, incredibly painful for us. And that's just not me, this whole management team feels this way, so. Thank you. That's it for me, Chair McMillan. Thanks. Board Member Launch, Robin. Thank you. Well, there are some benefits to going last because most of my questions have been already asked. I did have some questions related to the assumptions but I think it will make sense for me to also send those to Susan so that we just send you a package related to that. I was just noting that as you just indicated, Dr. Bremsted, it sounds like what you are saying is that you're putting the project on indefinite hold. I haven't seen a request for relief from the budget order. So I just wanted to clarify that. Yeah, let me be really clear that it's a budget order. From my perspective, the balls in your court, that either sits there and simmers until hopefully someday when we can resurrect this project or if you find a better use for that and I'm sure that there's some legalistic way that Mr. Barber to Mr. Miller paper goes back and forth and we comply with your order. So our ability to go forward right now is what's on hold, not that commitment. If that whatever it is, 18 and a half million, you find a use to improve inpatient psychiatric care. That's our commitment. And again, I'm sure that there's legal ways that that request flows to us and then we comply with that request. But does that make sense? Does that answer your question? Well, it doesn't legally make sense to me but I haven't talked to our legal team about it because I think actually as typically if there's an inability to apply with the order, there would be a request for relief or to change the order from the regulated entity to the regulator. We're not usually in the habit of Sue Sponte changing our orders without a request but I'll talk to our legal team just so that I can see what they have to say about it. I'm not sure that the ball is in our court but I'm happy to talk to our team. Okay. Well, and I have had some conversations with Eric Miller about this but not with this degree of specificity. So we certainly can work that out but I want it very clear that we keep our commitments and if there's some other good use of these dollars other than having that commitment live on until we can resurrect this will comply. Thank you. That was my only follow-up. Everything else I was interested in has been asked. So Dr. Brumsted, I still want to try to figure out a way to make this happen. So I will have the staff work with your staff to try to figure out the numbers more one of the things that I was just looking at that was the HMA Burns analysis that was conducted on behalf of the board and surprisingly mental health in that analysis showed that Medicaid was actually the best payer and was the only payer that was paying at cost currently and looks like there's a real shortfall in commercial and even bigger shortfall in Medicare reimbursement. So these are all the things that we can work out with the staff and try to get all the facts in front of us. You know, I also, you know, I don't want to rub salt in the wounds but there probably would have to be a discussion about whether or not there was any interest on the money as it sat for the three years and or four years, whatever. But that's not what's important here. What's important here is getting in patients like Beds and I hope that you haven't thrown in the towel and that you're willing to still work towards that goal. Globally, yes. Always willing to try and figure out ways to meet needs for Vermonters and people in Northern New York. You know, the presentation speaks for itself where we're at right now with this and all of our other capital projects, you know, so. But always willing to talk and bring our expertise if that's asked for. Sometimes things always look the darkest before there's light. So I'm still hopeful. Thank you. So with that, I'll open it up for public comment. Is there anyone who wishes to offer public comment at this time? Is there anyone who wishes to offer public comment at this time? Hearing and seeing none. We will be in touch and we appreciate your candid update and your honesty. And let's see if we all can work together to try to find a way to get this done. Thank you. Thank you all for your time. Let's appreciate it. Have a good afternoon. Thanks, Susan. I know that on the agenda is a discussion for the Department of Mental Health. Obviously, there's a lot of questions that are raised by this discussion that would be helpful to have. But I don't think it's fruitful for us to have a discussion amongst ourselves. And I really think it's imperative that we get a firm date for the commissioner to come in and to have the discussion and so that there can be a back and forth. But other board members, what are your thoughts? I just had some questions. Sorry. Go ahead, Tom. I was saying that that makes sense to me. We got that memo. Well, they last night and it just seemed some time, you know, we better have some time to let us set in and to have the folks here to, you know, engage in a discussion about it. Yeah, and I'm fine with that. But I think that, like, what I would hope the discussion would, I would hope the discussion would be a little bit broader than the information we had around, we received around the wait times and EDs, which is obviously a very important component. But I was hoping that they could talk about inpatient psych in the context of their overall mental health plan and mental health needs, the impact of the global commitment renewal on, for example, the IMD rules and those sorts of things because there is an intertwining there. And I know we're not final, final on the next global commitment, but just having that context, I think could be helpful. So I was, so I just wanted to put that out there so that there's maybe a little more context for when they come in. And Mr. Chair, can I just respond to... Certainly. I will follow up. I don't know if there are going to be the people to answer those, all of those questions. So I will... Well, we should try to get all the people that are necessary to answer those questions in the room at the same time and have a panel discussion. I will put out the invitation. Thank you. Yeah, I'm fine with that. I agree. I mean, to me, I'm really interested in understanding, you know, we heard on the wait times, you know, project, we heard a lot about psych services and waits for psych services all along the care continuum. To Dr. Bromstead's point, there's a log jam and there's multiple places where there's a log jam, whether it's counseling services, crisis beds, inpatient beds, EDs, it's all along that spectrum there. So I really want to understand more from the Department of Mental Health where they see the biggest issues, you know, their understanding of capacity needs, their understanding of the log jam. There's some interesting information in what they sent us last night about new value-based payment models for the DAs and funding changes for the DAs. I'd like to learn more about that. There was some conversation. There was some point in there about funding for nursing supports at the Brattleboro retreat, but that ended in April. So what's happening after that?  And I guess I want to understand more broadly beyond just the ED, what's happening and what's the solution. And I want to say, in part, you know, I've been on this board for many years and we've been in a mental health crisis for many years. And it seems growing. There was a New York Times article about youth mental health crisis nationwide. And I just want to, you know, get a better sense of what we're going to be doing as a state to try and address these issues. And now, you know, this is now, the news today is more concerning. There's, you know, there was some path forward that we saw. And now this looks like it's at least temporarily off the table. So what are we going to do about it? And what are some new paths to explore or new funding sources to entertain or seek? I don't know. But it's deeply troubling to the state that we're in.  Okay. So at this point, I don't think that we have another agenda item. So is there any old business to come before the board? Is there any new business to come before the board? Is there a motion to adjourn? I moved. Second. It's been moved and seconded to adjourn. All those in favor of the motion, please signify by saying aye. Aye. Aye. Any opposed signify by saying nay. Have a great rest of the day and stay positive. And sooner or later we'll figure out this path.