American Association of Community Psychiatrists

Board of Directors Meeting

October 1, 2008

Present:

Hunter McQuistion, MD

Walter Rush, MD

Beatrice Kovasznay, MD

Jules Ranz, MD

Charles Huffine, MD

Steve Jewell, MD

Jackie Feldman, MD

Wesley Sowers, MD

Mark Ragins, MD

Dick Christensen, MD

Jeffrey Geller, MD

Anita Everett, MD

Curtis Adams, MD

Alan Radke, MD

Ramotse Saunders, MD

Eddie Maxwell, MD

Charlotte Hutton, MD (Arrived 2 p.m.)

Tony Ng, MD (Arrived 2:30 p.m.)

David Pollack, MD (Arrived at 4:15 p.m.)

Steve Goldfinger, MD (Arrived at 4:15 p.m.)

Ken Thompson, MD (Arrived at 4:15 p.m.)

David Cutler, MD (Arrived at 5 p.m.)

Michelle Clark, MD (Arrived at 7:15 p.m.)

Linda Gochfeld, MD

Absent:

Cheryl Bowers-Stephens, MD

Warachal Faison, MD

Russell Lim, MD

Fred Osher, MD

Stephanie LeMelle, MD

Jamae Campbell, MD

Paula Panzer, MD

Brinda Krishnan, MD

Guests:

Kathleen Clegg, M.D.

Darby Penny

Vernon McDaniel, M.D.

Nada Stotland, M.D.

I. Call to Order:

Meeting called to order at 12:30 p.m. by the President, Hunter McQuistion, MD

II. Announcements:

There will be guests from APA leadership dropping into this meeting so the agenda will be interrupted from time to time. There will be a guest presentation Darby Penny, who co-authored a book about the possessions and belongings of people in state hospitals. Ms. Penny is interested in our collaborating with her on a project on shared clinical decision making.

Membership Reception at 7:30 p.m. on Friday and Membership Forum at 6 p.m., Friday

The disclosure statements for Board members to complete for 2008-2009 were circulated for execution.

Doctor Everett reported an issue from Nada Stotland, who has been looking for a way to do a public psychiatry initiative while she is President, one of the issues is thinking about the future of our profession. How to prepare ourselves to work in some of these settings? Preparing psychiatrists to work in community mental health centers? The issue of getting the field to train psychiatrists appropriately is before us. In GAP, the MH Services Committee has published an article on this and that will be follow up on with one about mid career psychiatrists and how they are spending most of their time in public settings. Programs will be sought who have access to residents to train and validate this. There are six competencies and one is systems based learning. The RRC has added six or seven items that are psychiatry specific.

All of these will be submitted to Doctor Stotland to add to the summit on these issues.

We are going to translate LOCUS into Japanese and there is a group of Japanese mental health professionals to work with some of us.

Doctor Huffine is interested in seeking grants specifically for consumers to attend some of these meetings for parents and youth consumers. It is difficult for consumers to attend and it is a real deficit in the meetings not to have consumers in these meetings. Perhaps the AACP could partner with another like minded organization to pool resources. Doctor Huffine will talk with Federation of Families and NAMI about this. One possibility to help with this would be to get a consumer on a program and the program support their attendance.

ACTION:

Doctor Huffine will work with a grant writer in the next six months to work on this process and Doctors McQuistion, Sowers and Everett with work on this project.

Doctor Ragins announced that he is working on a book for popular audiences on process of recovery and am looking for contacts in the publishing world.

Doctor Radke announced he is working on a presentation on transformation of the Minnesota adult mental health programs, gap analysis and lessons learned.

Doctor Radke announced that the technical report on strategies and education of people with SPMI will be out this week and available on the NASMHPSD web site.

Doctor Ranz reported on three new public psychiatry programs and how they were formed with the core elements. There are 16 fellowship programs in existence and of those, 11 are represented on the program, “Practical Pearls of Psychiatry.”

A guest, Darby Penny, Advocates for Human Potential (AHP), discussed a project on shared clinical decision making. She is working on a CMHC funded project on shared decision making. This is an interactive and collaborative way to make decisions about things that affect people’s lives. How this differs from past efforts is that it basically emanates from IOM reports concerning physical health decision making. This has not been widely used in psychiatry. There is a common ground computer based program to help people indicate their preferences and may be printed out to carry in oder to make decision with practitioners. What AHP has been charged to do with CMHS is to come up with materials that will explain the concept of shared decision, making this clear to consumers, practitioners, administrators, and payors to recognize the benefits of this approach. The group is working on two videos, one targeted to consumers and one to professionals, with printed materials with tips on how one could do this in their own practice. There would also be material to help guide people with their decision making, with a web based tool that would focus on medication issues. Ms. Penny is looking for ways to approach psychiatrists to interest them in identifying the barriers, etc. The AACP expressed an interest in working on this.

Doctor Geller noted that shared decision making is far superior in community mental health centers. What is the base line to move to improvement? What is the current standard? What is happening now? Where are the gaps?

Also noted was that the younger the patient, the more on top s/he is on his or her situation: they want to understand what is going on with their care. Older patients may be more passive. Therefore, it is possible that these tools would be more focused on younger populations Doctor Ranz noted that there needs to be a scale developed that could be completed by the patient and the doctor to measure the extent of the problem but also measure what the doctor can discuss with the patient. This tool could be a great discussion point.

III. Minutes:

The minutes were circulated for review from the May 2008 Meeting.

Motion: Doctor Sowers moved the minutes be approved as circulated.

Second: Doctor Feldman

Minutes approved as circulated.

IV. Report from the Treasurer:

The year to date information budget versus actual was reviewed. The finances are stable and Deerfield has been processing the checks and running the reports. The Executive Committee will meet and discuss how much to invest.

Doctor Rush has outlined three options for investments and the Executive Committee will work on this at this meeting and report. There has been $30,000 earning interest in a CD. The goal is to have one year of operating budget in reserve. In our budget, the net income will be re-invested. There needs to be a point at which the goals are set and no money from pharma is received. In the short term, the amount of pharma money has been reduced and the board is looking toward a point for pharma money to sunset. There are mixed feelings about accepting pharma money. However, the membership has been interested in reducing the amount of such funding from a philosophical stand point

ACTION:

Refer this to the Membership Committee for discussion.

The question was raised as to whether there are reliable sources of income that will take us into the future. Doctor Sowers noted that another part of the plan was to develop an endowment fund. The money from pharma could be used to build the reserve fund. These are all of pieces from the strategic plan.

The Board welcomed Nada Stotland, M.D., President of the APA. Doctor Stotland’s mission for her Presidency is to try to develop projects that will last at the APA. The investigation by Senator Grassley has been distracting, asking for detailed information for every penny the APA has received from January 2003 to date from pharma. It is a 60 page document. This inquiry is very hostile. The APA gave a copy of their response to the New York Times and met with the newspaper about the inquiry.

It is the aim of the APA to provide our patient population with the most recent and advanced treatment and medications. The APA wants patients in the public health sector to have the same access as all patients.

Doctor Stotland reported she has written a letter to Secretary Gates at the Department of Defense stating that the APA is against interrogation and torture.

The issue of psychologists’ prescribing might be related to increased scrutiny about the interrogation issue. Dr. Stotland stated that there are Scientology activists who dig up every piece of ethics violations and report it. The psychology prescribing issue is at the top of the list for a number of the leaders at the APA. Dr. Stotland appointed a work group, “Life after Psychologists Prescribe,” to give a message to APA members that psychiatrists are “still who they are.” The need to define roles is very important.

The AACP is interested in a sketch of a master plan to see how the AACP fits into the scheme. Doctor Ranz has written an article about this period of transition as psychiatrists into systems of care. How do we conceptualize ourselves in the systems we work in? How do we define ourselves?

In the past, psychiatrists were afraid of losing patients to primary care doctors but now psychiatrists want to help train those people in mental health issues. Organized psychiatry has a commitment to recovery.

V. Winter Meeting:

Doctor Kathleen Clegg attended this meeting to discuss the 2009 Winter Meeting, March 20-21, 2009. The theme for Friday is integration of services, while the theme for Saturday is trauma and disasters. Travel and accommodations will be covered but no honorarium. All submissions should be sent to Dr. Clegg.

Doctor Ng reported about the Winter 2010. There could be a joint meeting with AAEP and AACP.

ACTION:

Doctor Geller will work on this.

Sacramento is not off of the table but Doctor Lim is not in attendance

VI. Liaison Reports:

Ortho: Doctor Sowers reported on Ortho: not much activity. Doctor Scotty Hargrove is the new President and Doctor Andy Pumariega is President Elect.

APA:

Doctor Everett reported on the action papers in Assembly.

“The Use of Antipsychotic Medications in Patients with Dementia,” calling for a policy for using antipsychotics in the treatment of patients with dementia. This is a significant public health issue.

ACTION:

Motion: Doctor Goldfinger moved to table this motion.

Second: Doctor Huffine

Motion: 14 in favor

Opposed: 2

A paper on the consideration of a publication of a Standard of Care Guidelines for People with Psychiatric and Behavioral Disorders for people with intellectual disabilities.

Asking for a guideline oriented toward people with intellectual disabilities.

ACTION:

Motion: Doctor Goldfinger moved for the AACP to support the development of treatment guidelines of people with developmental disability/MR, and with co-occurring psychiatric disorders.

Second: Doctor Geller

Motion passed.

CMS Medical Home Program: advocate for the psychiatric practices having to do with funding for places designated as medical homes. The Medical Home is a concept involving as a physician centered program as a way to recognize and provide some structure around primary care practices. There are seven elements. One of things worked on is to make sure that CMHCs can be designated as medical homes. It is a team based approach, with care management.

Doctor Radke pointed out that the opposition is coming from the behavioral health care companies and the carve-outs. The AACP supported pieces of this but strongly urged Doctor Everett to suggest deleting the monitoring requirement.

ACTION:

Motion: Doctor Geller moved that the AACP supports this action paper with the proviso that the monitoring requirement be deleted.

Second: Doctor Pollack

Motion: Motion passed.

Doctor Hutton opposed.

ACTION:

Doctor Everett will submit a proposal for the Board to review to submit to Doctor Stotland.

Doctor Everett reviewed the papers on the agenda for the November Assembly Meeting.

NASMHPD:

Doctor Radke reported the Medical Directors’ Council will meet on Friday. The issues on the agenda are finalizing/releasing the obesity paper, a draft of the health indicators paper and looking at the role of psychiatry. There will be a collaboration of academic chairs creating strategies for people who run state operated services as a member of a university and for promote residency training and medical student training. The Council will be working with AAEP on a document about crowding in ERs and with AACAP on on antipsychotic medications for kids.

NCCBH:

Doctor Everett reported that the leadership program going on with AACP members involved. There is a new state policy director and he is interested in discussing the mentoring project.

AAEP:

Doctor Ng reported that the AAEP is tackling the overcrowding in emergency rooms. American Academy of Emergency Room Physicians is asking that psychiatric patients be taken out of emergency rooms. The AAEP has been working with APA, NAMI, and NCCBH to educate the AMA about these issues. There is a decrease in resources and people are presenting in the emergency departments. That is, there are so many other patients coming in with co-morbid diagnosis and they are being dubbed as psychiatric patients and most emergency rooms do not have psych ER’s.

Doctor Ng is interested in a developing a joint position statement with AACP and AAEP.

Doctor Radke noted that NASMHPD is interested in being a part of this collaboration.

AAPA:

Doctor Ranz noted The New York Chapter Regional had proposed to refashion itself as a joint chapter of the AAPA and AACP Chapter. Communication has been held with Arthur Lazarus, M.D., President of the AAPA, requesting information from the national organization to join AAPA and Regional Chapter of the AACP. The local chapter of NY has been operating under the national organization and a parallel chapter of the AACP NY Chapter is being proposed. With the dual memberships, there is no allocation for the NY Chapter. The AAPA has local dues payable to the local chapter and there is a fee for the NY Chapter. The group will come up with a proposal for the dues, and discuss the use of the national the tax id number.

CPR:

Doctor Sowers reported that the Coalition of Psychiatrists for Recovery has not been active.

ASTART:

Alliance for the Safe and Therapeutic and Appropriate Residential Treatment of Youth. This group has testified before Congressional hearings and a bill has been passed and will go the Senate. The principle of oversight of the residential industry is in question.

Meeting adjourned at 7:45 p.m.

Thursday, October 2, 2008

Meeting called to order at 8:00 a.m.

Present:

Hunter McQuistion, M.D.

Beatrice Kovasznay, M.D.

Jules Ranz, M.D.

Charles Huffine, M.D.

David Cutler, M.D.

Steve Jewell, M.D.

Curtis Adams, M.D.

David Pollack, M.D.

Richard Christensen, M.D.

Mark Ragins, M.D.

Jeffrey Geller, M.D.

Charlotte Hutton, M.D.

Kenneth Minkoff, M.D.

Anita Everett, M.D.

Alan Radke, M.D.

Michelle Clark, M.D.

Ramotse Saunders, M.D.

Ken Thompson, M.D.

Jacqueline Feldman, M.D.

Tony Ng, M.D.

Walter Rush, M.D.

Suzanne Vogel-Scibilia, M.D.

Eddie Maxwell, M.D.

Annelle Primm, M.D.(Arrived at 10:15 a.m.)

Guests:

Tony Carino, M.D.

Allison Grolnick, M.D.

Kathy Clegg, M.D.

Vernon McDaniel, M.D.

Delegation from Japan reviewing LOCUS

James Scully, MD

Clif Tennison, M.D.

Mentorship Project:

Doctor Pollack reported on the project that was begun by Doctor Minkoff and Stu Meyers to support psychiatrists who are hired into community mental health programs. Doctor Pollack has done a fabulous job with this project, focusing on their psychiatrists with the newly recruited main focus. Over the last year we have developed a concept and business plan describing the project.

There will be a pilot of this project starting this month at an agency in northeastern Maine. Doctor Pollack has taken the role of the coordinator and the first mentor for the first project.

If this Board votes to move forward, the Myers Group and the NCCBH will be notified. There is a connection with support and a mentorship with a national leader. One of exciting aspects is that it fits into our strategic plan on work force and leadership development, a way to connect to our membership and generating revenue that decreases our dependence on pharma funding.

Dr. Pollack pointed out that , one of the things that concerned the Board members about this project was the liability and contract issues. Contracts was developed between the agency and AACP, between AACP and the mentor and between AACP and the coordinator. The mentor is not responsible for clinical supervision. We are ready to sign on for the insurance piece of this business. We need to move ahead with the contracts and to create a mechanism to select a coordinator and identify people’s interest to serve as mentors.

The question of how to market the program was raised and it was noted that the referrals will come through the Myers Group and the NCCBH. The Myers Group will market it as a recruitment opportunity.

The APA is developing a similar program more focused on advocacy issues and the NCCHB is in the process of delivering PLDP. There is a description of the three different programs. At the so-called bottom line, is there enough potential market that all three will be utilized?

Doctor Everett reported on the NCCBH program, Psychiatrists Leadership Development Program. All of these programs are heavily influenced by the AACP. Knowledge, skills and abilities are the three areas worked on. There is a one week class held at the NCCBH meeting and a follow-up meeting nine months later. There is funding from SAMSHA for a second year but the funding is year to year renewal. There were 15 psychiatrists in the first class. The PDLP is targeted to executive directors, encouraging them to send their medical director for training. It is narrowly focused on medical leadership.

While the APA program is for medical directors, in which they work on a project over a year, the AACP program, by contrast, will be a year long consultation with the agency. The AACP consultation program will be fluid and flexible, with the mentee being coached in an ongoing manner.. The target audience for our program is the organization, not the individual. There will be a coordinator and mentors. Mentors will be the heart and soul of the project in terms of mutual supervision and support.

The other issue built into this is sustainability over the long haul. The AACP really wants to be the fabric of community psychiatry. Over time, this will prove to be added value for these providers. Doctor Radke expressed the positive aspect of the AACP initiative as a team effort. This has to be a team effort to teach the skills and competencies.

Doctor Thompson noted there are key differences in the three programs; the APA program is targeting people right out of residency into public service, the PDLP is a one year program and project driven and the AACP will need to carefully think about how to simply mentor the psychiatrist. It is inevitable that there will be some competition among the various mentorship/consultation programs (AAACP, APA, NCCBH) but this can be worked out to minimize overlapping goals

ACTION:

Anyone interested in being a mentor should contact the Executive Committee.

ACTION:

Motion: Doctor Minkoff moved to approve the mentorship proposal business plan.

Second: Doctor Everett

Motion passed unanimously.

Doctor Pollack will continue as the interim coordinator.

The general liability insurance policy will be purchased.

Dr. Scully. The Board welcomed Jay Scully, M.D., APA Medical Director. Doctor Scully discussed the future of the profession and the trajectory of the next generation. The Office of the Medical Director thanks the AACP for shaping the IPS Meeting and this is a great meeting and the APA is very appreciative of the efforts.

Where is our profession going? There should be health care reform in the next few years and look at the systems of care and the APA is working on policy on this issue. The APA is in a tight crunch with finances, at the conclusion of the Annual Meeting there was a $1.9 million shortfall. There is a freeze on hiring and the Board is taking action. There is a committee for appeals for filling positions and the APA is down 40 staff. No increase in revenue is seen for 2009. Seven percent of the annual budget comes from dues and the meetings and publishing are big revenue sources. In 2008, there were 1000 fewer international attendees and that may occur again in 2009.

The APA did succeed in its advocacy in obtainingparity for Medicaid in this rescue bill in the Senate and this affects patients. Dr. Scully asserted that “we need to fix the system of health care in this country. We have to work closely with primary care doctors in the future.”

Dr. Scully went on to discuss DSMV: it will have $20 million appropriated. The field trials will begin in 2009. There are lots of complicated intellectual property issues. ICD XI is underway and the APA is interested in the two manuals being equivalent. DSM has become the world’s diagnostic manual.

What they will do with the Axis II disorders is open for discussion. He noted that concerning personality disorders there is a disability piece that needs to be included. There are lots of scales to determine disability and that will be covered in the DSMV.

The early childhood issues are also of great interest. They have become a developmental diagnosis and the child psychiatry practitioners want this changed. Doctor Clif Tennison noted the successful collaborations concerning people with developmental disabilities. Is there any ongoing work with updating the DDID?

Dr. Scully also discussed that there is funding from the three institutes (NIH, NIAAA and NIMH) for a lot of science background.. There is work with the primary care field about integrating psychiatry into these specialties. The APA has been asked by one of the US presidential candidates to discuss expanding primary care and funding of primary care. The APA wants to influence health care policy.

Committee Reports:

Membership:

Doctor Jewell reported, there are several new area reps. The area reps will be following up non-renewing members. Ms. Bell provided the area reps with the list of non-renewing members.

In recent years the booth has not been cost effective and we are not sure if the reception actually nets new members. The Membership Committee feels strongly that state meetings should be held for recruitment. The issue of establishing state chapters was discussed briefly. The Committee is interested in developing an electronic recruitment to go along with the brochure.

Doctor Saunders will be doing membership profiles from each area.

Some data will be gathered on membership numbers of those who transition from training status to regular membership.

How successful are we at recruiting members from the Public Psychiatry Fellows?

There was a suggestion made to offer informal mentoring for new members. When a new member joins, it might be helpful to pair them with someone who has been in the organization more than ten years.

ACTION:

Doctor Osher will write a definition of community psychiatry to be posted on our web site.

ACTION:

Doctor McQuistion will pursue with Nancy Delanoache about getting AACP involved with the Fellows.

ACTION:

Doctor Jewell will follow up with Warachal Faison on the membership issues.

Scholarship and Training:

Doctor Ranz spoke about “Practical Pearls,” and education in public and community psychiatry. The Committee is interested in developing a certification process from the AACP for people who go through formal programs. Doctor Tony Carino has developed a work group and looked at what is needed to develop and implement a certificate process. The work group is working on a shared web site developing this, outlining the competency domains. In the process, a literature base for competency domain is being developed, and experts is the field will be identified for input and to recruit them in developing an exam.

Doctor Carino has developed the knowledge domains for the committee to start looking at and identifying people who have knowledge in each area (so they may be contacted as experts). Doctor Minkoff noted this can be a “slippery slope” in terms of excluding competent practitioners in the public sector and perhaps the AACP should be working on developing a platform for community psychiatrists to be certified and not merely establish a set of academic mastery areas.

ACTION:

This issue will be discussed with the Membership.

Clinical/Quality:

Doctor Rush reported. The committee re-examined the summarizations of listserv discussions. A paper was written at the Winter Meeting but has not been completed.

ACTION:

The listserv summary is a viable idea and Doctor Rush will edit the paper and circulate it on email. A one page summary will be written for CMHJ.

Communications:

Doctor Thompson reported on the website. There is an interest in moving to a more interactive web site. The decision was made to obtain competitive bids. One bid remains outstanding and Doctor Lim is responsible for obtaining the third bid. This will be pursued to increase the technological capability. Doctor Thompson believes organizing the threads on the list serve is very important.

Doctor Feldman is the new editor of the journal.

Doctor Saunders reported on the progress of the newsletter, Sarah Altman has agreed to be the Associate Editor. The newsletter will be used as a promotional tool. Doctor Saunders wants the newsletter to have its own web page or blog, members could contribute more actively. A spotlight feature on members is a new idea, an education space, a space for Fellows to discuss their programs, a medication update section, a research update, and a health care policy section.

ACTION:

The next issue should out mid-November

Minority/Underserved:

Relevant conference presentations were reviewed and the 2009 Annual Meeting presentations were announced. The Committee worked on the New York IPS program ideas.

The AACP needs to have more involvement in child and geriatric representatives in the APA.

Clinical Tools:

Doctor Sowers reported. There was a presentation from a delegation from Japan and LOCUS will be translated into Japanese. There was discussion regarding the differences in the systems of care between Japan and the USA, much of Japanese care is focused on hospital based services: large state-type institutions. Japanese clients would use LOCUS about initial decisions concerning admission and identify clinical problem areas and to facilitate treatment planning.

Deerfield update: the development of LOCUS and the fact that it continues to draw a lot of inquiries. There have been some recent sales and $20,000 in royalties is expected this year. Deerfield has experienced a lot of transition. There has been some disruption in completing a pilot for the revised language version and the treatment planning instrument. One of the problems is that new validation has not been completed.

Behavioral Health Policy:

Doctor Minkoff reported. Doctor Geller brought up the IMD exclusion and how AACP could provide input into the IMD advocacy for creating more flexibility.

ACTION:

Doctor Geller will develop a survey tool to get a broad sense of the issues. Pros and cons for IMD will be gathered state by state and will be circulated on email to the committee and to the Board.

There are no work groups that focus on particular populations of patients. It might be helpful to have work groups on these subsets of populations.

There was discussion of transformational recovery oriented services, Doctor McQuistion is leading one of the only hospital-based transformation projects known to this Board. This issue is something we may need to pay further attention to.

Program:

Doctor Pollack reported. The program, submissions for the 2009 IPS were reviewed and the submissions for the 2009 Annual Meeting. The 2009 APA will have only one official presentation. Doctor Ragins had an idea for transitional age youth symposium.

Submissions for the 2009 Winter Meeting will go directly to Doctor Clegg.

Executive Committee:

The Executive Committee focused on the investment policy. Doctor Rush has gotten three proposals and presented these to the Executive Committee. Doctor Rush did confirm that the mutual funds do not contain any alcohol, tobacco or fire arms companies. The AACP would have ability to exclude any particular area from fund investment. It was acknowledged that the more one limits oneself in terms of acceptable investment products, the lower the potential dollar return.

The Executive Committee decided to take the money available right now and put it in a $75,000 CD for a year. The remainder is in a money market. There is currently $15,000 for investment and the Board will be investing $60,000 more. The Executive Committee has a fiduciary responsibility to the organization. It will be verified that all funds are FDIC insured.

ACTION:

The Executive Committee will move toward socially responsible investing but for now will not invest in equities, only cash.

New Business:

There was a letter circulated to the House of Representatives. concerning kids in residential facilities The outcome has been successful and we are being acknowledged by ASTART. A law was passed by the House and has been given to the Senate for the next Congressional session. Doctor Huffine will continue to follow up on this issue.

Iraqi psychiatrists: Doctors Everett and McQuistion have been working on a letter to engage the psychiatrists in Iraq. Things are getting more stable there and there is a conference scheduled in Baghdad: a national planning meeting to try to create the behavioral health services that are identified as needed.

Strategic Planning:

At the May 2008 meeting, there was a board proposal to create a Public Relations Committee.

ACTION:

The committee structure will be reviewed at the Winter 2009 Meeting and this new committee will be a part of that discussion.

CMHS:

Doctor Thompson reported. The main issue is the US presidential election and what will happen with federal mental health policy. The head of SAMSHA resigned. The concept of transformation is at the forefront.

If people have thoughts around engaging foundations around this transformation work. SAMSHA is working to increase their availability to do international work.

Meeting adjourned at 12 noon.