Insurance and Commerce- Senate and House

Yeah. I Let's call the meeting to order. Great to see a good, good crowd here today. Look forward to uh some good information as you all know throughout the summer we've covered insurance that covers every aspect of Arkansans. And so we've covered everything from, uh, Homeowners insurance to auto insurance, health insurance, and so we're gonna expand on the uh health insurance side of today. We've covered reimbursements for, for hospitals and today we have a very good agenda and we're gonna open up toward the, uh, end of the uh session today to allow public input to agree with, dispute, or have concerns on any issues that they that may have been brought up either the last meeting or this meeting. So we look forward to that to be. Transparent with everything that's going on with that being said, we look forward to today and I'm gonna turn it over to my co-chair for any opening comment. Just good morning. Glad to see everyone here. Look forward to another productive and informational meeting today. Our first order of business today is, uh, consideration to approve the June 5th, uh, meetings that we have, have a motion by Representative Eubanks. Do we have a second, a second by Senator Boyd. All those in favor say aye. All those polls, same sign motion passed. And that also A uh We also need the uh June 6 minutes. The motion to approve those minutes as well. Of a motion by Representative Brown. Have a second buy. Who was that? Senator Warren or Representative Warren. All in favor say aye. All those pose same sign. Motion passed. OK, we got the Arkansas Insurance department, uh, we'd like to call them up. And gentlemen, please introduce yourself for the record. Good morning, Allan McLean, Arkansas Insurance commissioner. Good morning. Booth R General Council. Arkansas Insurance Department. Please go ahead. And, and I'll just, uh, briefly, uh, say we're here to just as, as required, uh, to, as we are doing an amendment to Rule 118, the, the rule, uh, that addresses the, the, uh, pharmacy benefit manager Licensing Act, uh, as required by the law, we, uh, are required to come to Insurance and commerce to discuss any changes in rules and, uh, Booth will explain what that rule looks like. Thank you, Commissioner, uh, as the commissioner indicate uh, thanks to Senator Rapert who helped draft the PBM licensure Act, um, anytime the Arkansas Insurance Department wants to issue a rule on PBMs or amend a rule on PBMs. It has to come before the House and Senate insurance committees to get them to review the rule 30 days before public comment period ends. We have not yet had a public hearing yet on the rule that is in front of you, Rule 118, that Our PBM that is our standard PBM rule, the hearing, the public hearing is set for September 10th, next week, so we will take comments about this rule from stakeholders about whether we should adopt the proposed amendments that are before you, uh, next week from the public. The public comment period ends on October 10th, and after we complete that review process, we will go over to the rules committee to get this rule, hopefully approved after we take public comment. What does this rule do? Um, it essentially makes changes to our PBN rule to conform to 2023 state legislation, which changed PBM laws. For example, one of the laws that was passed, um, In 2023, gave the insurance department jurisdiction over PBMs that were administrating health plans issued outside Arkansas, but which covered Arkansas resident citizens, so one of the things this rule does is it changes the rule to meet or conform to what the state legislature required us to have jurisdiction over. The other thing this rule does is it increases fines and penalties on PBMs for violations above inventory costs, for example, if the BBM is. Um, it's affiliate higher than it's, uh, than it does in independent pharmacy, uh, the fines under this proposed rule will change from a $50,000 cap to no cap for a $5000 per violation. There used to be a $50,000 cap for those violations, we would like it removed to have higher penalties. The rest of what this rule does is simply cosmetic and changes the structure of the PBM rule for topographical issues. There's Nothing really that significant that we're doing in the rest of this. Just FYI this is not the rule that is being discussed. It was in the newspaper about pharmacy reimbursement, OK? So I know you probably want to talk about that, but that is rule 128, that is pending over an executive subcommittee that is not what is in this rule, OK? This rule does address reimbursement, but it is under a separate rule under Rule 128, that we are going to address fair and reasonable pharmacy reimbursement over an executive subcommittee. Just to clear that up because I know everybody wants to. Talk about pharmacy reimbursement. But essentially we're just making changes in this rule, Rule 118 to conform to state legislation and that's all we're doing. I'll be glad to answer any questions. Do we have any questions? Representative Lundstrom. Thank you. Um, I'm glad you're addressing this. It's something that needs to get done. Um, how soon until you dress for 128. I think it's up for review the next executive subcommittee meeting on, on emergency basis. So we filed that Rule 128 as an emergency rule, also as a permanent rule, it was to be reviewed last week, but it's going to be, it's a pending matter over an executive subcommittee, as I understand it. OK, I would encourage you to move quickly. We have a lot of local pharmacies that are really suffering. Thank you. Senator Boyd. Thank you. Thank you, Mr. Chair. Uh, so, Mr. Rand, I've got a, I'm over here, on the other side, other side, the normal Senate side, but we've, we've moved everybody together now. uh, so when this bill that you're writing that the rule's been written on was originally filed. It was for a $10,000 fine. Do you recollect that the original law. Uh, said that, uh, for violations of the PBM licensure Act. It was a $5000 per violation with a $50,000 maximum cap. And so what we've run into with violations of BPMs is we don't think of $50,000 cap is sufficiently high enough. So what we did at the legislative session, last session is you remove that cap. The rule right now is just not been corrected to reflect that that Just fixing the rule to conform to that new state law. OK. So, but you, you don't recollect that the original bill, original proposed bill was a $10,000 fine. OK. But it's 5000, no, no cap. OK, thank you. Representative Eve Thank you, Mr. Chairman. How many fines, uh, or I guess either how many or how much have have you issued so far? Well, we've got quite a few pending, uh, I would say since 2020, probably 300-400,000 dollars in fines and we've got 3 or 4 cases pending, um, and you might read the newspaper, some of them were asking for fines in excess of $1.5 million. But we've not collected any fines. You have 300,000. How many cases would that be, the 300,000 just ballpark. I won't hold you to a number. how many cases against the PBMs that we did I'd say we have 5 major PBMs we did on all 5. OK And that was in 2020, I think, 2021. Thank you, Mr. Chair. Uh, yeah, I have some questions. Of course, uh, as far as PBMs are concerned, yes, they needed to do what's right with their pharmacies and all that, but I also want to make sure that we're being fair the other way and maybe you can, uh, uh, maybe these are wrong, but what I've been hearing is that on multiple instances it's just been a few since that, uh, uh, that they weren't there. And I actually heard of one of them, if I remember correctly, that you all charged $5000 for 168 cents mistake. Is that correct or not correct? OK, any Senator Hickey, any violation, one cent below acquisition cost is a violation of that statute. I understand where you're coming from. But we have a significant number of these payments below inventory or NAAC costs, even if it's $1.50 and the PBMs are not stopping their, their acquisition costs below Nak. I don't know what else to do other than find them even if it's 5 bucks the statute, does the statute say up to 5000 or does it actually have 5000 in there and I probably voted on that. All right, so there's not, uh, do, do you all own something that, you know, if we're gonna talk about You know, I'm gonna be honest, in my, in my mind, it's not fair that you're going to charge. For one mistake. That you all have found for 68 cents and charged from one of our somebody doing business in the state of Arkansas, $5000. That's as unconscionable as what they're doing. So I guess that my question to you is, Mr. Rand, have you all looked to see if you've got an avenue that maybe once you charge them, if there's something that's so egrecious such as that particular one, and I guess you could, if you needed to, you could bring that before this body to figure out if something, you know, where, where it would end, because you would say, well, what if it was $10 what if it was $20 but on 68 cents, do you have a way to refund that, uh, if you wanted to. We do not. We do not, um, modulate. The fine of $5000 based upon the extent to which it's below, um, a, a certain scent or certain dollars percentage whether there should be one a barometer like that would be up to this body right now, it's like I'm a police officer and you violate the speed limit. If you're going 40 miles an hour in a 35 mph zone, you violated the law even though it's only 5. I don't have discretion, but a police officer would have discretion if it was 1 mile an hour over. And I understand, but what I'm asking you, I understand where you're at, but you know, this sounds like, you know, artificial intelligence to me where there's no parameters. We have people that are sitting down here in the insurance office that are able to make reasonable decisions because if businesses across this start hearing that we're charging penalties of natures like that for some small mistake and again, I'm not taking up for the PBMs here, but what I want to make sure is if we're going to be fair and equitable on the other side, I want to make sure that we're doing it here. And if you're telling me that the only way that can be done in legislation. Come January, then of course we can look at that, but what I'm wondering also is if there's not any leeway within the statute, how are you trying to change or change the statute within this rule that you're doing. I mean, basically, if you're one cent below acquisition made that cost, it's a violation of the statute. So y'all, so once you charge it and collect it, could you not refund it by bringing it back before ALC and saying, look, Here's the deal. This, this has happened. We've had this one instance or these two instances, maybe there's others. I don't know. This one really stuck out in my head though. Where there was something that was below what the law was, we had to charge them $5000. It's not right, it's not fair. Is there a way that you all could bring that back before us this body for well I say this body in the offseason so that we could get that refunded back to them if we need to be. I don't think so, Senator Hickey, but I, I will research that. Let me, can I respond to this. If you don't have fines and penalties even for minuscule amounts, the PBMs will not fix their systems. And that is the problem. We're getting over 1500 below NAAC acquisition complaints a month and whether it's $1 or whether it's $6 or whether it's 68 cents, the PBMs are simply not fixing their systems. I think one thing we might want to try to do is try to enforce it strictly to get them to fix their systems where I don't have to do any fines at all. So they're not fixing their systems. I'm not talking about the broad thing. I'm talking about an Incident like this that we, that we need to show some common sense as a state or in the long run, it's going to hurt us as far as acquiring businesses and other people to do if if this body and you all that we have hired to do that. I mean, if I'm, if we're gonna do something stupid like that, maybe I ask staff to say to cut y'all's line item by $40,000. Which would also be a stupid. I'm just saying we need to see if there's a way out of this on these ones that are so gracious. OK, thank you. Mhm. Sir Ty, if I'm hearing you correctly, you're just saying basically use some common sense. Representative, uh, Acre disappeared. Yeah Thank you. Uh, Mr. Durant. Have you had Conversations in the past with PBMs explaining that this was coming. Have you issued bulletins to the tune of maybe a dozen or plus concerning this and letting them know ahead of time. We certainly did, and we gave them advance warning. I believe the commissioner issued a bulletin that we were going to take this strict enforcement action in March or April of this year we had told them in the bulletin, please fix your systems. You're not fixing your systems. I don't care if it's $1 or $2 below acquisition cost. It needs to be fixed. Thank you, follow up. And to that tune also, I believe the bulletin mentioned a lot about how the Law is not intended to set some sort of. This is the going rate for what you need to be paying. There is another half of the law where fair and reasonable is still left for the market to determine. This is just about 50% of the law that they are still egregiously violating. Is that correct? I agree with that. Thank you. Sandra Hammer. Thank you. Um, with regards to their systems that need to be fixed, do you, can you be specific about what's wrong with their systems that they're not fixing, Senator Hammer, um, they are. Prohibited by Arkansas state law. From paying below national average drug acquisition cost or NADAC, and, um, each day when there are dates of service and the NAAC and the N A uh amount is say $3 for a prescription drug and they pay below NADA, um, that's a system problem, um, that they're not fixing and so they should not be paying below NADA minimums. So approximately 1500 complaints a month. That we get from our Division from pharmacies throughout Arkansas wanting to know why we're not enforcing this law and why they have to each day spend 30 minutes writing a complaint to the insurance department, even if it's $5 or $6 below NDA. Right, which that's the underlying cost to the pharmacy is the amount of time that they're having to take to complete that form, uh, which has a dollar value associated with it that, that might be hard to put a tangible number 2, the, the 1500 complaints that you're receiving, what percentage of those are coming from independent pharmacists and what percentage is coming from pharmacies that are attached to a PBM themselves, or do you have any way to get that information. I would say the subs. A majority are from independent pharmacies or independent retail pharmacies, not chain pharmacies. OK, I'd like to get that. Um, and then also with regards to going back to the previous question, then if it's a systems issue. And, and maybe this is a judgment call on your part. You can decline to answer if you want to, um, I'm wrestling with is a, a, is it a part on the part of the PBM is it a matter of intent or is it a matter of, uh, this is just cost of doing business and we're going to try to ride this thing out because it would seem like they could fix our systems fairly easy if they wanted to. I don't know in, in, in all fairness to the PBMs, Um, I would suspect it's not malicious, um, the pricing and um. The reimbursement that. Follows Nak or National Average Drug Acquisition cost amounts are actually set by CMS. They fluctuate. So they fluctuate each week, each week there is a different NAE out usually for a brand or generic drug and, and so there is uh that difficulty the PBMs have in jiving up their reimbursement with something that's moving. Each week, but we feel like, uh, there's, there are significant software that makes it. Pretty accurate even if CMS changes NE amounts, um, each week. Um, PBMs have sophisticated sufficient resources in electronic capabilities to ensure that they at least have the Nyack out whenever they make the payment of the claim. Last question is, uh, with 1500 claims coming in a month, the turnaround time for you to handle those claims in a timely manner based on the help that you have. Give us an assessment of where you are, help versus the number of complaints coming in and how's that affecting turnaround time for those complaints to get. We have a staff too. 2 Uh, and we regulate 40 PMs, um. The typical turnaround time for a complaint. Um, On below night act minimums would be about 1.5 to 2 months to get the PBM to make the adjustment that they were supposed to make but did not make. Well, how quick do they then actually make that adjustment? I mean, once they get it done. OK, thank you. Thank, thank you, Mr. Sher. Mr. Rand, if you would please get that information requested to the staff and, and they'll distribute that. Uh, Senator, Senator Boyd. Thank you, Mr. Chair. So I, I know you've said some of this, but I want to kind of bring it in a consolidated fashion. His NDA a public number that is published every week. So there's no reasonable. The reason why PBM should not have that information. There's a 3 day, as you know, a 3 day sort of lag time, um. Uh, but I, I would agree with your, with your statement. They should know that PBMs given public notice that you were gonna change the way this was being enforced, and as I indicated to Representative Aker, um, we gave them notice in March. For April of this year. So are these violations that you're reporting, are they based on reported violations, not necessarily all violations. Reported. OK, so if a PBM paid less than 68 cents on one claim at one pharmacy which was reported to you. If it's A top 10 drug, say like lisinopril, then that claim might have been repeated several 1000 times over a period of time, so that's 68 cents could actually wind up being a lot of, a lot more money than 68 cents. Is that correct address one of the issues that we have is. Uh, we have pharmacies that are very aggressive and active with filing complaints, and we have pharmacies who are suffer violations but don't do anything. Simply because they just don't have the time to report that to the department. So I can tell you what we see, that's reported to us from pharmacies, but I can't see what pharmacies are not sending me simply because they don't want to spend, you know, 3 hours of there each day sending something to the PBM division director at the insurance department. So there may be a significant number of other violations that I don't know about. They're simply not reported. So in summary, we have a public number. Which every PBM should know if they have any clue how to do its job. We have given ample notice, put them on notice, this is going to change. And so when it happens, by and large, it is a choice, the PBM is making to pay below NDA. Does that make sense? OK, thank you. Sand Johnson. Thank you, Mr. Chairman. Uh. Commissioner McLean and and Mr. Ann, thank you for your testimony on this, and I. I, I feel like dealing with PBMs is like playing whack a mole. It's, uh, Arkansas is the leader in regulating this industry, we went all the way to the Supreme Court with the original act. Uh, we won, which says a lot, uh, I appreciate everything y'all are doing obviously in response to what Senator Hickey said, if you bring us some reasonable recommendations. I'm sure in January we'll accommodate, uh, the common sense tweaks that need to be done. But as uh Senator Boyd just alluded to, uh, if you And I'm gonna say this and you know, I'm, I'm sitting here immune, somebody else might not say it, but, uh, if you cheat your customers 68 cents and you've got 100,000 customers, uh, you know, pretty soon you're talking real money. And you can see it in other industries where, yeah, well, that's just a few cents. Well, yeah, it is times 100,000 people or 3000 are Arkansans, of which probably fully half are buying drugs at some level either out of their pocket or through their insurance policy. Uh, so I, I'm, I'm glad you're going after them. Uh, I don't have a problem because there's gonna be a whole lot of them, as you said, that will go unreported simply because of the hassle factor and and I'm. Uh, you know, we I've said this to, you know, to, to Colonel Hagar and people in the state police. Yeah, I, I know you can't stop every car speeding out here on 6:30. But, you know, when you get one that's really getting after it. If you don't stop a few, you know, everybody will speed, and I think it's the same way with the regulation that you have of this industry, you know, it's, and it's not just. If it's not equitably applied, then we get into a monopolistic situation that is violated of the Arkansas constitution that says that perpetuity is and monopolies are not uh conducive to maintaining of, of our republic. And so I, I applaud you doing this, but, uh, let's make this a two-way street. If you have some ways that you think that we can. Tweak the law in the other direction to give you a little bit more power and maybe even some more people in enforcement then then let us know. I'm hearing from constituents both on the consumer side and on the pharmacy side that they're feeling the pinch when you have a, a, a good size independent pharmacy in your district as I do and the the owner has told showed me numbers and said if this continues, I don't think I can stay open and I Hear from, from, uh, the pharmacy Association that in some of the rural areas it's much, much worse than it is in my district. So, so. Let's, let's have a two-way thing here, uh, certainly I know y'all will be responsive to our questions, but, but come up with prop to us with problems you see that we can fix because obviously this is technical and we're gonna be sitting there in January saying, well, how do we fix this? Well, please tell us as soon as possible that some some tools that that we can give you to allow you to do that so that that was really all I wanted to say and I I'd wait your response, Mr. Ann. your point, Senator Hickie is valid. I think The problem is, as a lawyer, just strictly reading the law. Uh, one thing you might want to consider is putting language in that says in his discretion, comma, the insurance commissioner may, may find the company $5000 per violation. Senator Hickey introduces that bill. I'll support it. I'll co-sponsor. With the approval of Pier. Indeed, indeed. Rand, going right on from that staff just brought this to me. what you referred to a while ago, it's, I'm going to read this. In section, C I says impose a penalty of up to $5000. Right, up to, we want the maximum because of issues we're having with all these violations, but that goes counteract that counteracts what you said to Senator Hickey just a while ago. You may be right. Yes, sir. I just want to bring that up. It does say up to $5000 would you like to make a comment on that since I was your question earlier if I can respond to that, I, I think that would come. That would, that would involve an enforcement decision by the legal division, uh, whether we want, uh, uh, a $5000 fine or a $3500 fine. You may be correct that we have that latitude. It's just that we're having such a significant problem with violations, uh, to, to, to, to bring that fine down to a lower amount, uh, we wouldn't, we would not feel that is sufficient deterrent to stop these practices. So, I mean, I'm gonna seek the maximum. I appreciate that and I'd like Senator Hickey to better response if that was his question earlier. Thank you, Mr. Chair. Uh, Your own I don't think I am, if I could reclaim my time and complete my question for Mr. Rand. I'll be glad to yield to Senator Hickey at that point if we could. Thank you, sir. OK, uh, so I guess if I can finish, Senator, then I'll be glad to yield to you. I just wanted to to follow one last sorry I thought you were through but I I was trying to get a follow up in, but thank you, Mr. Chairman, for allowing me to do that, um. The point I'm getting at is that when I mentioned the, the analogy of the state police stopping speeders is the idea is to make it clear to the perpetrators that they will. Be caught and punished not to try to make every fine Uh, equitable. Would you agree? OK, thank you and thank you, Mr. Chairman. Thank you, Senator Hickey. Thank you Senator Johnson, and thank you for getting that. Of course, that was a contradictory to what was said here, but I understand you deal, but you deal with a lot of stuff and that's, that's no problem. I guess that my next question is gonna be this. So we're sitting here talking about the statute and not giving you any leeway. And the statute itself according to what we just said, says up to. And then whenever you look at exhibit C right here, it says 2 of $5000 cap. Does that need to say up to or you just automatically going to change it where the you're, where, where you're going to have to charge the total amount. So it sounds like to me that we may have a little bit of issue with if, since we're talking statute and no leeway within the statute. I want to make sure that this rule is written so that it complies with the way the statute OK. Thank you, and I appreciate you, Mr. Chair evaluations. Thank you. Thank you, Senator Hickey. Uh Center Mark Perry. A representative Mark Perry. Thank you, Mr. Chairman. I thought I'd changed positions for a minute. Uh, my question is on section 7 on the pharmacy network at its adequacy and compensation in the old rule and the new rule are, are the same, uh, will be the same, but the question is, can the insurance department provide the committee with any pharmacy network adequacy reports that and and that have plans with Rule 118, sir, we have done and conducted a network adequacy. Um, uh. Program, uh, that can give you a Hey, uh, read out of where the health plans pharmacies are and whether, where their locations are and whether they meet meet the distant metrics for network adequacy that also contain any kind of complaints? OK. Can you, can you look at that and add that with it for like the last two years the complaints that we get, but that is not connected to the reports that we get on network adequacy, but we do have reports on work adequacy. For pharmacies OK, thank you. Representative Brown. Mr. Chair. um I just had a couple of questions. You said that, um. There was about a 3 day lag time. What, what does that mean? Uh, after CMS changes their, uh, drug acquisition amounts for a drug, um, before they update their website. It takes several days for that to happen. I'm, I'm told that that's what I was talking about. So it's uploaded would it count And then, so then that information is easily downloadable by the PBMs Boyd and I were talking about that's correct. Um, OK, so if one pharmacy complains. has a, there's a violation with one pharmacy. Um, what happens with this, I mean, it just the PBM have to reimburse that pharmacy and do they have to reimburse all pharmacies that were underpaid. They are supposed to reimburse all pharmacies that that's a complicated question. I'll try to answer it the best I can. If the complaint is over a maximum allowable cost violation or MAC, which is. Basically your inventory cost, which is a little diff different measure, um. A PBM who makes an adjustment for one pharmacy has to make that same adjustment for every other similarly situated pharmacy on maximum allowable cost. If it is however on Nak, I don't read the law to require all the sly situated pharmacies to be reimbursed with that mistake. But on Mac, they do. It's kind of complicated. What's Maximum allowable cost and maybe, uh, representative Boyd can explain that or Representative Aker, it's essentially, um, what the PBMs, uh, approximation of what your acquisition amount of that drug, what it costs for the pharmacy to buy that drug itself. I'm sorry, I shouldn't asked you to go into that detail. OK, um, I'll talk to. Senator Boyd, um, Thank you, you've answered my questions. Representative Lundstrom. Thank you. Um, Medicaid pays on NADA, correct? I don't know, my understanding is they do, um, and we don't, do you get any complaints from Medicaid from pharmacist jurisdiction over traditional Medicaid. Now we were private option private options different understanding is Medicaid pays based on NADA and we get very little complaints on the Medicaid payments. Yet Fortune 500 companies can't seem to get it right. And am I missing something? because it sure seems to be a shell game. I think at Whack a mole was referred to earlier. It doesn't look like whack a mole. It looks like cheating is in response to Senator Hickey and others, um, I don't want to go out and find companies like this, but the systems aren't being fixed. And so I don't know what else to do, um, in terms of getting these multi-billion dollar companies to fix their systems to ensure that they're not paying below NADA acquisition costs, to me, they should have the resources where that shouldn't occur one time, in my opinion. overcharged consistently 68 cents, make customers get pretty upset and they call the bank and the bank, of course, responds to, to fix it. It doesn't seem like the PBMs after 1500 complaints, they don't seem to care. The message is Screaming, not there's a computer system, not that there's a glitch, not that we didn't read our mail, not that we didn't notice the public meeting. It screams, we don't care. We're gonna screw those pharmacists no matter what. I don't know how else to read it. Am I missing something? I, I think it's unfair that they can't fix their systems, but, um, I, I granted 68 cents is not that significant in grand scheme of things, but you add up 2 or 3000 transactions at 68 cents. That's quite a lot. Well, the 68 cents is one part of the transaction. Um, it actually ends up costing the pharmacist $10 to $20 because now they're underpaying and so it's not 68 cents, it's the whole process. And then you've got the cost of compliance, you've got 1500 people trying to figure out what where they're supposed to be paid. Or if they've been paid the right amount. We're not calculating the cost to the market. Or to us as taxpayers when we have to pay you to go find these guys and get them to do their job that they've agreed to do. There is an economic cost associated with you having to spend the time to report this to the department. It's spent, it takes quite a little bit of work to get mail and the. They have to send us an Excel spreadsheet and there's a form and it's got to be filled out and so there's a, uh, economic cost about that the cost of doing business, you either have to fight government or fight the PBMs. And There's a reason that PBMs often have a moniker in front of their name that isn't very ladylike and I can't repeat here, but you can guess it's something blank PBMs because this is a problem that continues to go on, right. Thank you. Representative Baker. Thank you. And I, I think to piggyback off of some of the things you've said in addition to the uh economic and administrative burden put on the pharmacist that's also removing the pharmacists from their primary duty, which is to care for the state of Arkansas, those constituents are removing people from that counter where their real services, honestly, where they do their best work. Um, I, I, I like your timeline where we have in March where we let them know, hey, this law that you should have been abiding by, we're giving you 90 days of a heads up that we're going to be enforcing it, and I believe you even quoted. If it is one penny. Um, July comes, you get a ton of continued complaints, um, As a pharmacist myself, yesterday I spent several hours filing 280 violations just for the month of August. For a company that had 90 days of a heads up to become compliant, 30 days of receiving actual hearings. And yesterday I filed 280 violations at one pharmacy location. The administrative burden on you guys to enforce that. We haven't even touched the tip of the eye. Central hammer. Uh, are there any PBMs talking about pulling out that you know of right now because of the action being taken by this legislation and after the notification is being sent out. I'm not aware of any. OK, and if a pharmacist makes a mistake in the 1500 that you reviewed, how many of those 1500 complaints that were filed was it determined that it was actually the pharmacist that made the mistake and not the PBM or were there any I'd have to talk to our PBM director, uh, Senator Hammer, I don't know, you get that sometimes are made. And, and if you, if you don't mind, maybe if the chair allow send that to the chair. The reason I'm asking that is because if, if, you know, less than 5% say is a pharmacist that's making a mistake. That's, that's pretty damning evidence of where the problem lies, but to Senator Hickey's point, If, uh, uh, if a pharmacist in particular maybe is being abusive and taking advantage of it, we kind of like to have that data to raise that above the stream if you could do it. And where's the money go from the fines? Ultimately, where's general revenue and how much are we talking about so far? 300 and something, what would you anticipate, um, I. It varies each year, depending upon the enforcement actions that we take. And the, um, Let's see, uh, OK, total the last one, total amount of money. That that's one factor, but The negligence. Of the intent of them not fixing their systems is a totally different factor if they, if they don't fix it. Then the reality is, um, and, and I mean sometimes we hold people accountable for, for what some might deem as small infractions, uh, whereas others interpret it to be big, um, so as far as your ability to, uh, without overstepping your limit of power to determine intent from uh. Neglect. How, how do you feel about, about what the PBMs are doing. Maybe you don't want to answer that question, I'm ask you anyway if the fine amount is up to 5K. Um, My decision as an enforcement regulator would be how How often are you violating the statute? Um, I might have some leeway to go below 5, but if you have historically paid below NADA over and over and over and over, um. I think you go for the maximum amount, which is $5000 for every one of those violations, otherwise they're not gonna fix it. So do you feel you're exposed to liability that if a PBM came back and said, hey, he's picking on us or they, I mean, you, you're OK with that. OK, thanks. Senator Boyd. Thank you. I just, as we're sitting here, how many PBM owned pharmacies file below NADA violation complaints. I mean, have you received any? I mean, are they paying themselves below NA? I have not received any of that I'm aware of. Thank you. Representative Wooton Thank you, Mr. Chairman. Mr. Booth on the, um, 1500 a month. How many of them are like, uh, alike each other or similar. They're quite similar, very, very similar. all of them, the way it works is a representative, uh, a pharmacy will send us a spreadsheet or Excel spreadsheet for that day's transactions. Showing us every time they dispense the drug. The extent to which they were paid below the NAAC acquisition cost. And so our PPM director will get an Excel spreadsheet. From the pharmacy that lists. 902 M. Jones, not Ms. Jones, you're, there's no patient information, but, but basically, it will be a spreadsheet showing the numbers of transactions that that day they showed were paid below NADA, um, much like, uh, Representative Aker was just describing he had to fill out and so we get that spreadsheet. And we identify the PBM who paid below acquisition cost. We send the complaint to the PBM. They review it if they determine that they made a mistake, they make the adjustment and pay the pharmacy what they should have paid the pharmacy but did not. For all those. So, so you, you're telling this committee that there are 1500 violations a month regarding what the pricing should be and what the pharmacist was paid and in and of itself, does that not tell you that there's a problem with the PBM system and again, this is why I want $5000 fines, not $1000. And again, why, I don't care if it's 68 cents or a dollar. There, it needs. To be fixed. I don't want to do this. I don't know what else to do. I shouldn't be getting that many complaints. This should be a fixable situation, in my opinion. Well, what do you feel that they think they can get away with that? Do, do you, do you think, if I may, Mr. Chairman, do you think that they're just ignoring Until they get so many, and then they decide to pay them. I mean, it just, it just appears to me aren't they covered by federal law? They are subject to federal law in various aspects, but not on this particular area this area. Not yet. I mean, Washington always wants to run everything. I, I don't understand how they can let a system exist where one state has 1500 a month. I think there's federal legislation that, uh, the FTC's release of reports about BBMs. So there may be, um, Um, activity in the future about more federal regulation over PBMs instead of state regulations. I understand vertical integration as it relates to the petroleum industry. To me, that's entirely different than what we're looking at today with CVS and some of the others and some of the insurance companies owning everything. From the, from the making of the pill down to the very existence of selling it to someone. Right, and it's not insurance companies necessarily owning PBMs, all of that. It's now PBM's owning insurance companies, so flip that, um, PBMs are, are buying carriers right now, so thank you Mr. Chairman. Thank you, Representative. Mr. Chair, I'll just gonna. Representative uh Pilkington. Yeah OK, thank you, sir, with that. Mr. Chair, yes, yes, sir. You don't have. I was just gonna say any enforcement action that we do finds. Yeah, whatever amount is, they the the PBM in this case has an opportunity for a hearing, so we, they, it's not like we issued the fine they send a check, you know, they, they, they will schedule a time with to come in and and plead their case so why it might not be a reasonable process. Who do they plead their case to? Who do they plead the case to front of the hearing officer or insurance commissioner. The insurance commissioner, uh, would preside over the hearing unless he appointed a person to actually preside over it called a. officer or an administrative hearing officer. That's who they plead their case to. So the same ones that are prosecuting them are hearing their plea. That is the way state government works with with agency, uh, adjudications. in many cases we will hire an outside hearing officer that that hasn't been exposed to all the facts have been a part of the decision. So yeah, there, there's a, a, a lot of times we do have to hire an outside hearing officer. Thank you, sir. Seeing no other questions, I need a motion to show this rule reviewed. We have a motion Uh, OK. We'll have another question then. So the up 2, are we reviewing the rule? Are we reviewing the rule with the $5000 or are you changing that to the up 2 because it doesn't read that way. It says 2. He doesn't say up. So what, what are we gonna do, I guess before I will, I will pledge to you, Sarah Hickey is I will change that up to 5 during the whole process and I will, I will remind you and show you that I have done so when I get into the rulemaking changes of this rule. OK, and again. I've heard, I've heard some other stuff here about this 68 cents. I want everybody to understand that this was one company that had one filing. That they were found. It was one company with 68 cents. It wasn't the aggregate total of this whole thing. Are there other violations? I don't know. But if they haven't filed them, then you can't go out there and say that somebody's guilty of it and start making those accusations. If so that, that's my only thing that I want everybody here to understand is that there was one of these PBMs, one company that had one of these violations for 68 cents that they got charged $5000 for. And I believe that that has to be changed so that you have that discretion and it sounds like the legislation does that. OK. They have a right to a hearing. I know which company you're talking about. Um, in fact, I just emailed them and so, um, they have a right to come protest this and take whatever. Plates and we'll take that into consideration. Thank you, Mr. E. Representative Maddox. Thank you, uh, very briefly, I just want to touch on, um, this has really been covered, but I have numerous independent pharmacies in my district that are struggling. Um, they've shown me data and shown me how they're losing money, um, and frankly, they're worried about their survival. Um, so I appreciate what we're doing, um, but I, I really want your opinion. I don't know if you want to give it or not, but, um, I don't think the majority of these are good faith mistakes on the PBM's part. I think they're willfully violating known Arkansas state law. Um, and I'd like your opinion on that. I'd have to look at each particular transaction Representative Maddox to see whether I feel like it was just a negligent system violation or whether it was intentional so. Have a follow up. Yes, sir. Would you agree with me then though that there are certain, there are some, um, that are willfully violating the law as they know it to be. I'd have to, again, I don't, I, I, I'd have to look at each case. OK. Thank you. I thought we were through, but Representative Rose. Over here and you're right. Thank you. Uh, over here on your left, sorry, commissioner, um, I kind of just wanted to, uh, thank you, by the way, I kind of wanted to just follow up on uh Representative Maddox's question, and I don't really mean to put the screws to you here, but I would say of, of everybody who's seen the inside and out of this, you should have probably the best sentiment of what's been taking place and the intentions uh of, of those PBMs. And so I'd just like to ask again, do you not have a sentiment on whether there's will violation of this? Do you, do you think it's, do you think it's all just happenstance? I Representative Rose, I just don't know the answer to that question. Um, I think some of it's just a system issue, um, I mean, in response to Senator Hickey's issue, that was 68 cents. They missed on 68 cents. So I mean, if you're missing the NDA by $60 and, and you're missing it only by 68 cents, it seems sure to me that this may be a system issue more so than some malicious willful intent. Um, but I don't answer. I, I don't know what their mental state is when they're doing these things. I just don't know. All right, thank you. Thank you, Representative. OK, I have a, I have a motion, seeing no other questions for this rule of standard review without review, without dissent. We'll say this rule is reviewed. Thank you. Commissioner McLean, I guess it's back to you. That that review was based upon the testimony he was going to do the up too so we do have that contingency in with in with that, correct? That is correct. Thank you. OK, thanks, sir. Uh, and I'm, I won't take more than 60 seconds on this, but I obviously available, uh, answer any questions. I'm gonna, what you have is a part of your packet is a required annual study of the workers' compensation insurance market in Arkansas is required under Act 796 of 1993, of which I was around when that was passed and, and, um, so it is required under the statute that, that you get this information that basically tells you the workers' compensation market in Arkansas is strong, is profit. Uh, the rates are very competitive. They're among the lowest in the country, uh, the, the act, uh, passed by the legislature in 1993 when in fact July 1, 1994 is doing what the General Assembly wanted it to do. Uh, this is required under the law that we make this report. There's some consideration, uh, to, to maybe even remove it from the during your next session, uh, whether depending on the will of the body, whether you want this report every year or not, but that's good news for the workers' comp market. It is good for. The business is buying this coverage for the safety of their employers, employees. So that's really, I'm happy to answer any questions. Thank you, Commissioner. We do have a question for you, Senator Hammer. Thank you, Mr. Chair, Mr. Chair, I want to ask the commissioner for a piece of information that would be sent to all the committee meeting, committee members and myself, if you don't mind, um, commissioner Booth, I think just walked out the door. Here's something I'd like you to find out for me based on the previous discussion of the previous rule, and that is of the 1500 complaints that are filed or as complaints are filed, can you determine how many have gone? through the appeals process prior to filing a complaint with the insurance department. And I'll get with you offline, but I want that sent to the chair if you don't mind because I think that'd be relevant to our ongoing discussion about the PBMs. How many actually filed an appeal. Prior to filing a complaint. With the insurance. Department. And I'll get offline with you afterwards. OK, sounds good. Thank you, please get off the line with the after this. OK. Go ahead, commissioner. I say no other questions. Your next. The state of the line report. Yeah, and that that's actually all included in the same, um, workers' comp report and, uh, as far as how they market in Arkansas is doing, uh, it's for in workers' comp and so it's, it is like one of the most. Overall, it's one of the most profitable insurance lines in this, in the country and then that's the case, Arkansas swallowing that. That's what that state of the line report sort of gets into and it's a report by the National Council of Compensation Insurance. So, uh, it's just more, uh, backup that, that that line of business, uh, unlike some of the other, uh, lines that we're dealing with nationally is strong and in, in Arkansas, it's, it really set the model early in establishing this legislation. OK. Thank you, sir. Are you open Any other questions? Councilor, uh, what, what is our current count from the, uh, March of last year, March of 23 tornadoes at the claims have not been settled yet. I don't, I don't know that you're talking about from all the insurance carriers that might have open claims from March 31st. I don't have that at my fingertips and, uh, but I don't know. I think I, I just don't know the answer to that. I, I hadn't had any reports that, that there are still some that are open. Obviously there were some things, uh, you know, more severe ones, but I think the A car carriers have done overall, overall, uh, and there are obviously outliers, uh, getting, getting unsettled. But I don't, I can, I can try to get that data for you. Yeah, if you could get that information for me. I don't know if anyone else wants or not. I'd like it on the, uh, March 31st tornadoes along with the April straight line wins that we had, we, we would could specifically do a data call for the carriers to, from the carriers to get that. That's not something they routinely report to us in their normal reporting. There'd be some good information to have. I'd appreciate that. OK, thank you. Appreciate your, appreciate your time today. Thank you. Up next, we'll go to, uh, to Max Greenwood with Blue Cross Blue Shield. You can both go at the same time. Before we get started, uh, with, with y'all's testimony and comments that that you have to ask someone kind of back up for the committee to let them know, uh, last time we heard from several hospitals, about things going on and in Blue Cross and some other, uh, insurance companies were actually not here to, to give their response back to what was said so today we've invited them to come and give their testimony, Representative Maddox said the last minute that we'd have them at this one to come back and Counteract or answer any questions that anyone has. And so that being said, if y'all would introduce yourself for the records. Yeah, I just like to make a distinction that I am not Blue Cross Blue Shield. I'm a Centene Corporation, so for, uh, ease of understanding our products in Arkansas and better, uh, quality choice. Arkansas Total Care, where a minority owner of in the past program, um, and then our Medicare Advantage plan is, uh, Well Care by all well. Would you please introduce yourself for the record? Jack Hopkins. Thank you, Jack Blue Cross. And Max, if you would when you speak, talking to that, uh, pull that down just a little bit where you can hear a little bit better. If you get closer to it, it will be. There you go. OK, I'm sorry. Thank you. Go ahead. Um, first, I want to thank you both Chairman and members of the committee for giving us the opportunity to appear today, um, as Senator Hill mentioned, um, last June, uh, you guys heard testimony from some providers about the no Surprises Act. And what I wanted to do was to give you all a little bit more information about this federal law that was discussed at your last meeting. The No Surprises Act or NSA for short, protects only those facilities that are outside of our network. Um, we, Um, Arkansas Blue Cross have more than 10,000 healthcare professionals in our network. So obviously most healthcare providers in the state are in network. Ms. Greenwood, if you would pull that. A bit cloud, just pull the whole thing toward you. There you go. OK. Is that better? That's a lot better. I, I can hear you now. OK, I'm sorry, um. The entities that choose to be out of network do so for a variety of reasons. Some, it's just their business model, not to be in-network. Others are not licensed by Medicare or Medicaid which we require to meet our credentialing, um, requirements to be in our network. It's also important to remember that the No Surprises Act was passed by Congress to protect consumers. And it was to protect consumers from being, um, balance build or surprise build for services that they don't really have any control over. So you go to an emergency room and you receive services from a doctor, a radiologist, a pathologist, an anesthesiologist or even an emergency doctor. Who maybe does not have network privileges with that actual hospital. The hospital may be a network, but the providers aren't. So what was happening was consumers would get treated, they would get home, and a few weeks later, they would get these astronomical bills by out of network providers. So the no surprises act was put into place in order to protect consumers from those types of bills. What it does not apply to our pharmacy costs, ground ambulance or any in-network facility who just happens to disagree with the amount that they're being reimbursed. Now, During your meeting back in June, this was happening when there was a national breach. There was a huge information data breach by an entity called Change Healthcare and change healthcare is basically a clearing house that is used by providers all over the country. To they send their claims to this clearing house and then this clearing house basically sends their claims to the appropriate payer. So there was a glitch and it was a national glitch and it caused a lot of cash flow problems for providers and it caused a lot of headaches for everyone within the health area tell you that we have, um, had to go back and reprocess a lot of claims from that were impacted by this data breach and that we have reimbursed, um, those facilities over the past few months, hundreds and thousands of dollars, um, to try to make them whole, um, because we weren't paying them properly during the period of this breach. So let me quickly explain to you how the No Surprises Act works. As you guys know, most of the time you're in-network benefits are 80/20. Your health, your health insurance pays 80% and you pay 20% out of pocket. If you use an out of network provider or an out of network facility, you're out of pocket cost is going to be higher. Generally 40%. Your health insurer pays $60 you pay 40. So when the NSA applies for those narrow services that I spoke about, we basically pay the out of network provider, what is called a qualifying payment amount. And that is an amount that is an allowance that's based on an average of all of your in-network payments that you pay across your network. So you average that all out and you come up with that qualifying allowance. And that's the amount you pay. For a no surprises, um, episode. If the provider that you're paying says no. I don't want to accept that amount they can then, um, go to a process that's called open negotiation. And in short, what that means is it's basically a negotiation process between the payer and the provider that occurs before the issue goes to arbitration. So let's say they can't agree, it then goes to arbitration. All of this is being done electronically. It saves time. It saves administrative costs and everything is being done electronically. If it goes to arbitration, there is an independent dispute resolution and Arkansas Blue Cross and Blue Shield, we use a third party vendor that handles all of that for us. Whatever the determination by that independent dispute resolution individual is that is binding on both parties and it's the end of the situation. Are there any questions about Before I go on Senator Boyd. Sorry, it, it's related. I'm just curious. Any idea how much the market changed healthcare has? Like, is it 100% of the market? Is it 90% of the market, 50% of the market? It's a lot. I don't know the there's not a lot of competition in the market for that service? OK, thank you it's, it's, it's, it's huge. I mean, it, it had a huge impact on the. There are just a couple of other issues I wanted to bring up before I turned it over to Jack. We do have another question for you here. I'm sorry. Representative Ferguson. Yes, thank you, Mr. Chair. Just a quick question, Ms. Greenwood, that third party vendor you talked about it is that an arbitrator? And that arbitrator is paid by who? Uh, that arbitrator is paid by us. Baboros. Correct. So they are employed by you guys to arbitrate something between Blue Cross and the provider? OK, all right, thank you. Thank you, Mr. Chair. Thank you, Representative. Go ahead, Mr. Greenwood. As I said, there were a couple of other issues, um, I wanted to raise. We've all seen the daily stories, um, pretty much every day now about the rising costs of health care. Um, we will have rate increases for 2025, uh, just like most, most carriers, we're seeing is um. A sizable rate increase for our small groups. These are the small employers in your districts, the mom and pop. Companies, um, and stores that are really struggling to pay for insurance. The drivers of these rising costs primarily are the surge we're seeing in medical claim trends and the huge spikes in prescription drug costs. In our lines of business, we have seen, um, over the past decade, our total spend for drugs increasing from 17% back in 2014 to more than 35% this year. So there's been a huge increase. We've also been working very diligently with the providers out in the state. We've been listening to them. We've been working closely with them, um, to try to shore up a lot of the issues that are surrounding reimbursement. While we are still having conversations with lots of the various specialty groups and other provider groups. Um, we have made some adjustments that I wanted to bring to your attention. For a 2nd year in a row, we increased our outpatient hospital fee, um, To over 3%. Um, we had a substantial increase the year before and we will likely increase it again in 2025. We've also, um, updated our fee schedule for ambulatory surgery centers, double digit increase this year beginning in August, we wanted to demonstrate our commitment to promoting cost efficient sites of service when it's clinically appropriate and there are many, many services that can be safely and efficiently done in ambulatory surgery centers. In January of this year, we began hearing a lot of concern from oncologists about the cost of oncology drugs. I know some of you in here know how expensive those drugs can be. The drugs, these drugs were their costs were rising faster than the reimbursements were. So what we did was we developed a uh special pricing methodology for those oncology drugs that were, um, negotiated and we increased the reimbursement for those drugs by 33% and we also. Prorated it back to January so that we were able to make oncologists whole from the point of time where those costs started going. And in addition to all of those statewide adjustments we have also negotiated and adjusted inpatient facility rates for 36 hospitals this year and an additional 9 hospitals that we are still actively in negotiations with. And then finally, earlier this year, Arkansas Blue Cross was the first insurer in the state to follow your lead and expand services and access to basic testing and treatment services that were delivered by our local pharmacists. This was huge. This expansion has resulted in more than $300,000 in new revenue paid to pharmacists through the end of July of this year and has increased services To thousands of members at our health fairs that we do, um, across the state. We hand out flyers, informing the public that they can now receive these new services at their local pharmacists. Um, Some of those services include getting tested and medication for COVID, flu, and strep throat. They also have medicines to combat opioid and, um, tobacco dependency. Our internal team spent, uh, made a substantial investment, not only in training pharmacists on how to medically code for these procedures, but also learning, getting them credentialed in our medical network and teaching them how to submit claims through our medical portal. In closing, I want to thank you again for your invitation to speak today, but I also want to ask for your help as we prepare for. Well, I look forward to working with all of you to give Arkansas the best care at the best value. I also want to impress upon you the importance that we also focus on addressing the unsustainable escalation of. But that I'll take your questions. Appreciate that. We got, we got a que full over here. We'll start with Representative Aker. Thank you. Um, thank you guys for being here. Um, you mentioned the premium increases and the primary drivers being, uh, what you're having to pay out for providers and also in the pharmacy space, um, who sets the drug pricing in y'all's plan. I'm asking how are the drug prices determined for. Your company. What you spend with our PBM and we negotiate a rate for our drug costs. OK, and I appreciate you bringing up, um, The oncology drugs, um, that's something very sensitive to me. I have someone who has sat up on the 6th floor in Kartai inside of a recliner receiving these types of medications. Um, I'm very sensitive to those providers still having access to provide the care that they do. Um, one of my primary concerns is I see on. It looks like either through CVS's website to oncology drugs can range anywhere from $250 in the Our Hos plan up to $5000 in the commercially insured space. So when we talk about these small plans. Having rate increases, is it because they're paying $5000 for a drug that Other plans are paying $250 for. Not to my knowledge. OK, we'll go to the other one. we have another oncology drug where in our home space, they're paying $141. And in the commercial space, it's quoted on their website, your vendor, $4,436. Are those commercial plans see premium increases because they're paying $4,436 for the same drug. That in other plans they're paying $141 for. No, the premium increases are due to something else besides the, what you testified as drug costs. No, what I, what I. I'm questioning is what those numbers are representing, and I don't know. They're representing your vendors price quoting for drugs. For our plan. Yes. Well, I'll be happy to look but, but we don't have that kind of I would encourage you to look into it before you arbitrarily increase premiums. We don't arbitrarily increase premiums representative our premiums are approved by the insurance department, and they have third-party actuaries review all of our information. Our premium increases are actuarily justified. OK. I've got a question for you, Ms. Greenwood, on your, uh, qualified payment amount. Is that published on your website or where is it? Where can that be found? the amount that DHS reimburses the plans for their partimburse whether it be a hospital or whatever. Is that it found anywhere proprietary, OK. Mhm. Center hammer. Thank you, Miss Sher. Let me pick up on Representative Aker's line of questioning, if I understood it right. One provider is paying, um, 250, um, another one is paying upwards of $5000 for what I understand to be the same drug, having not looked at what he's got over there. And Would a third party actuary that is representing you should they pick up on that price difference and present it to you for you to engage in why is it one price to you and different price to another? I, I don't believe that that's accurate and accurate depiction. So I, I can't really respond to that. What is inaccurate or just so I can understand where you're coming from, what would be inaccurate, what he is saying as far as the information or the way I characterize the question or framework the question. We have different products. That have different copays, co-insurance, and, uh, Pharmacy Um, uh Plans And people pick and choose, employers pick and choose plans that best meet the needs of their employees. All of our, um, individual plans use the same formulary. All of our, um, Group plans have similar formularies, so the swing and prize that representative Aker, I have to check with our pharmacy folks because that is not anything I have any information about. OK. After the last session and I'm glad that you recognize that some of what we did was good and that, um, from the, uh, testing, you know, being proactive, preventive instead of waiting for some disease to occur and then reacting. Which I think contributes to a higher cost is because of preventive medicine is cheaper than treatable treating medicine. You put out a flyer, uh, that said that we cost, and I'm going off memory here that our legislation costs, I think, over $100 million now it is, uh, significant time since the session. Do you still stand by that statement? If so, would you be specific as to where you think the legislation we passed actually costs the plans that much money. Senator, if you remember during the session we put that information out to you as you were deliberating those bills we had our actuaries review the proposed legislation and based on the new mandates in those bills, um, there were cost analysis done. We gave members that information while you were all debating that information and yes, we do stand by that information and we do stand by those numbers. Um, we cite that number, uh, those. Many of those numbers in our. Uh, rate filings. OK, and that was in anticipation of what the cost was going to be based on the legislation we were passing. Now that there's been time gap since that, and there ought to be some historical data. Can you produce anything in the way of evidence that shows the actual data proves out what your statement was. I'm sure we have some data and I'll be happy to pull that together for you. Yes, sir. Yeah, I'd like to see that because I think that would actually substantiate whether or not that statement, those statements that were being presented were, were accurate or. Or, or not, so I'd like to get that last question, um, the conversation about the arbitrator a while ago and the, and the failure in the system, um, did I understand it right that that arbitrator that had the system failure is somewhat works for you or clear that up for me, would you failure was a a national independent, um, clearing house completely separate. With Anything other than they other than providers use the clearing house to submit their claims to then get processed by. People like us. OK. And is there anything within your systems that should have detected earlier that there was a problem or are we just totally dependent upon that, that one entity, uh, and just by chance it came about that somebody realized there was a something going wrong. Yeah, I mean, it, it, it was a national, I mean. It was It didn't affect you, it affected everybody. Yeah. OK, thank you. Yes, sir. Thank you, C. Uh, Ms. Greenwood. On your qualified payment amount that I asked you about just a while ago, who calculates that for Farm Bureau, third party or y'all do it yourselves? When you're negotiating When you say qualified payment amounts, Senator, are you talking about the amount that we reimburse providers. In general, it is a combination of. Um, Their information, the provider's information, cost information. Other information that they share with us and our claims experience are cost experience and we sit down with them and basically negotiate. So y'all y'all actually figure it then. You don't have a third party, OK. OK, thank you, Representative Rose. Uh, yes, thank you, Mr. Chairman. Uh, thank you for taking our questions, Ms. Greenwood. Uh, I had a couple of questions. You said, um, When you were discussing oncology drugs and and working with. Uh, kind of all the parties involved there. You said make oncologists whole. Did I understand that correctly? For the cost of the drug. I was gonna say, could you just explain that a little more thoroughly and I'd have a follow up with that, Mr. Chair, at your, at your latitude. Rose, what I meant was make them whole for the cost of the drug. The concern that the oncologists were voicing was that the, the amount of reimbursement that we were reimbursing them for the drug needed to increase to keep pace with the increase of these oncology drugs that they were experiencing. So what we did was we raised our reimbursement to them. So that they could cover their costs. OK, I, I, I interpreted it to be something along those lines, but I wanna make sure I had a pretty good understanding. Um, and I'm, I'm no expert on the, uh, No Surprises Act and, you know, all the ins and outs of that. But I, I had a cur a curiosity of what kind of protections you have built in, uh, for the patients or for your members, um. Because you're talking about making the oncologists whole, which I appreciate, um, uh, like Representative Aker have very, uh, personal experience with cancer, uh, with my wife in the last 4 years. Um, So With with with regards to when some of these bills come in and they go through, uh, you know, the health insurance filter and they're either declined or they're negotiated at a significantly higher rate than what they end up being paid at. What, what concerns are being taken into account for the patient and the stress that they go through, going through that process. Sorry, I don't think I'm understanding, for example, if, if, if a service or a drug is declined. Oh, OK. Um, or, uh, in the case of, uh, Newasta, is that, is that a medication you're familiar with. So it's a white, white blood cell treatment that, uh, a lot of cancer patients will have to take a day or two after they receive their chemotherapy because it zaps their white blood cells. Um, you know, every country has different pricing for drugs. I understand that. I think the standard rate, and this would be after every chemo treatment for these patients. The standard rate is about $6500 for one of these shots. In our case, um, It was $19,000 19,454 dollars, I believe. And so the insurance. said, hey, yeah, we're going to pay $2500 of that. Or, or whatever it was. So it left us on the hook for a significant chunk. And so me and then along with a number of many other families who have gone through cancer I've talked to, have to do this back and forth, back and forth. It's a lot of mental anguish. It's a lot of stress on people already going through something. Just curious, if you guys are taking into account the, the anguish and and the hardship that those kinds of things, the toll that takes on your members and on your, your patients. I mean. You know, It would be great if we could pay for everything for everyone. Unfortunately, there's just not enough money to do that. Um, I don't know who your insurance is with, you know, if you're with the state employee insurance group, you know, they, they have an entity that handles their drugs and they make the determination of what drugs they're gonna cover and what costs they're going to pay for those drugs, um. And, and That's just the way insurance works. It doesn't, it unfortunately, it doesn't cover everything for everyone. We do recognize the toll it takes. I think that's why all carriers try to minimize, um, any kind of, um, administrative hurdles for the consumer. I mean, we want people to get their health care as easily, um, and safely as possible. Sometimes questions do come up. And, and they have to be answered and addressed to make sure that the patient is getting the right, the right treatment. Final follow up, Mr. Chair. One more. Thank you. I think, and I went in a roundabout way to get there, but I think what I'm, what I'm trying to get at is, um, I appreciate the, the sentiment of making the oncologist whole in the, in the costs and, and the reimbursements, and that's very important. And the and the thought that goes towards that. I just would like. To encourage Um, Your company to take the same thoughtful approach or increase the thoughtful approach, uh, for your, for your members or your customers in terms of denials or maybe um second reviews before denials because a lot of times, as you and I've spoken with in the past over uh personal interactions or other constituent interactions that a simple follow up is all that's required to make sure that that patient receives what they need and it just may be that there's room to improve. Um, To protect your patients, customers, there's always room for improvement, and I appreciate your comments and suggestions. Thank you very much, thank you. Representative Rose, if you have any more questions, just get back in the queue, OK? Uh, Representative Mark Perry. Thank you, Mr. Chairman. This is for, uh, both Max and Jack. I know, uh, of course, I deal in health insurance every day, but. The utilization, uh. When the primary utilization is the prescription benefit. Is there a way to Have a report based on the number of prescriptions filled at an independent pharmacy versus a chain pharmacy. And something like that, if y'all could do and report back to the committee. Yes, absolutely. I'm glad you get to participate, Jack. Yeah, thank you. Yeah, yeah. No, I am happy to answer any questions for our products as well, um, uh, generally, uh, our, our. Statements would be the same as Max's opening comments, uh, differ a little bit on the NSA and the QPA payments, um, but that's a standard between plans. Thank you, sir. Representative, uh, Fred Allen. Thank, thank you, Mr. Chairman. Max, thank you for being here today, and I appreciate your, your presentation. During the past, during the last uh General Assembly, we passed the bowel marker testing bill, and I have received phone calls from A few oncologists and they're saying that Blue Cross will not pay for the biomarker testing. So, are you familiar with that? Are you familiar with that? That we are not paying for it? No, sir. You're not familiar with. So would it be possible for you to check into it and get back in touch with me and let me know what's going on with it. OK. And the second question is that we talked about, you talked about what it costs, Blue Cross, when these new laws were implemented. So it costs Blue Cross some money, but I behind every cost is a savings. So can you tell us what the savings were? OK. So follow up. You're recognized. Do you know how long it would take you to get back uh with the General Assembly and tell us what the cost savings were. I have to get with our actuarial folks, so, um, and I'll do that. I'm hoping a week or so. OK, thank you. Welcome. If it's longer, I'll let you know. How's that? I just don't know who's on vacation and who may not be. Representative Allen, are you finished? OK, go ahead. I OK, thank you. I think the most important part is that when we pass bills up here, I don't believe no one is maliciously trying to hurt Blue Cross Blue Shield. Or any insurance company because if you look at it, we all are in this together. And what we're trying to do is make life better. For those that are struggling with any type of catastrophic disease. And if we can make life better for them, I think that's the most important part. It's not what it costs. It's if you have a loved one that's battling cancer fighting the, uh, a life-threatening disease, the most important part to that person. It's to save that person's life or to prolong that person's life. And when companies come up here and say, well, it's gonna cost us money. Well, If you've never been in that position before, cost is not important. When someone is dying and people want to make sure that their loved ones get the best medication they can get to get the best treatment they can get and cost is not important when you're going through that. And I know that you all are concerned about cost. But let's start focusing in on the patients, and the ones that's receiving the drugs because when you're receiving those drugs, you also have to worry about how you're gonna pay for it. You also have to worry about how you're gonna live because I have seen people spend their last money. Just about medication to stay alive. And that's important to them, and I want you all to, to realize that you have to have that same passion about helping people as we are about helping people too. Thank you. Representative Brown. Thank you, Mr. Chair, and both of you could answer this or either one of you, um. Miss Greenwood, you mentioned earlier that the cost of drugs are going up. And My question is. Is that just the overall cost of drugs in the hall or is that because, uh, I, I've read recently that Patient are seeing their doctors. And the doctor's prescribing a drug for them or wants to prescribe a certain drug that that doctor knows is tried and true and safe, whatever, and it's not costly. However, they're seeing the patient is seeing lots of commercials for, uh, different drugs, um. That have a very high cost associated with them and may or may not be as effective or as safe as what the doctor is wanting to prescribe. So is the cost of drugs going up because patients are demanding what they're seeing advertised on TV or is it going up because the cost of all drugs is going up. Yeah, I mean, that's not a far stretch. I can't make that. Statement with certainty. Um, I do know the United States is one of the few countries in the world where you can advertise for drugs in that manner. Um, so, uh, perhaps. And Full disclosure, I used to work at Arkansas Blue Cross Blue Shield. Now, I wasn't intimately involved with this particular group, but at that time, I know that there was an office that was, um, The staffed with nurses and probably some doctors that would review, if I'm under, correct me if I'm wrong, that would review a patient's uh stay in a hospital and then meet with that patient and determine, does that patient need to be cared for in the hospital or could they easily go home and receive just as good or better care at home. Um, Now, I may not have all the characteristics of that program. Correct, but it seemed to me that Blue Cross Blue Shield was trying to not only minimize costs for hospital stays versus staying at home and getting care, but also looking at where the patient is going to get the best care. Or does Blue Cross and Blue Shield have some mechanism to look at these drug costs or to look at the drugs that are being prescribed and say, you know. This other drug. Accomplishes the same thing for a lot less cost to help keep these drug costs down. I think we're always reviewing for a member that. What, 90% of our job, I mean, the, the, the, it's a very small percentage overall of the drug costing the high spend, OK? So most people because they are more affordable and they are just as effective. So we encourage our members to use generic the same um appropriate, yes, of course, yeah. I mean, obviously there are certain drugs where there's not a generic available, um, and in those circumstances you absolutely want that individual to use the brand drug because there isn't an option for them. But for the most part, most people use generics. Just one quick follow up. Um, so actually, the pressure is on the position if the patient is demanding. An advertised drug versus over what the physician thinks is. The appropriate drug that really would not, so if, if that's the prescribed drug, Blue Cross and Blue Shield would, would cover it as long as it was in the formulary. Thank you. Thank you, Representative. Next, uh, Representative Pilkington. Thank you, uh, chair. Thank you for allowing me. I appreciate, uh, Max and Jack being here today. Um, One of the parts of the mission statement for Blue Cross is to improve health, uh, in Arkansas, and I was curious, as you mentioned, next session, and I was reading over that flyer that was sent out about the trends you guys are worried about for next session. Do y'all have any policy suggestions in which we can improve the health of Arkansas without increasing costs, um. That you're concerned about? Are there any policy suggestions to help guide us? Thank you Representative Pilin, that's a, that's a great question, you know, uh, um. Of course, there are things that we see operationally day in and day out, um, specifically on our programs in the past program in our home that, that, you know, we, we work collaborating with with DHS every single week to, to improve those programs and improve the outcomes and the quality of healthcare in Arkansas. So, uh, aside from that specific legislation, you know, um, I, I don't think I'm prepared to make a statement on recommendations just right now, but, uh, happy to look into that and work with you on that. Thank you, Representative. Representative Lundstrom. Thank you. Um, first of all, Blue Cross Blue Shield was extremely helpful and a constituent issue where the, um, no surprises Act was being implemented and evidently not handled well and you stepped in and said, not so fast. So I appreciate the help and, and I know my constituents do too. Um, Blue Cross and Blue Shield and Centene both have obviously pay out with PBMs. And have a, a seat at that table. What would your recommendation be? We need both the independent pharmacists and the big pharmacists. We need them all to have good competition, get better rates as customers. What would your suggestion be on this PBM issue? You've heard the discussion before. Yeah, so, um, Multifold there, um, you know, we contract with the PBM because it's necessary to remain competitive, um, in our pricing that we put out on the marketplace and in our commercial products, um, and to the state, um, when, when the states, uh, uh, our client or our vendor, um, you know, I can't speak for Blue Cross, but I can speak for us. We've, we've looked at the PBM thing before, um, as far as ownership of how these other companies are doing it. For the record, we, we do not own a PBM. We own Centene pharmacy Services, which is Not a tried and true PBM like Express Scripts or CVS or anything like that. Um, To that end, um, The market is so, um, tight at the top or competitive at the top, there's really uh not space for us to enter in and make corrections to that level. It's more of a, uh, a national issue that that needs to be addressed. OK. I would agree with Jack. I mean, it, it is they are looking at it at the national level, but it has to happen there with regard to the PBM I mean we used as representative Achor pointed out, we use CVS Caremark, um, we do not own it. We do not own any PBM, um, but what I will say is, is if our PBM is not following the laws of this state, we want them held accountable. I mean, it is very important that the. Um, pharmacists. Um, Are, are treated by the rule of law, they're paid what the law states they should get paid and if AID finds that the um PBM is violating those rules. We strongly believe that they should be held accountable. OK, thank you follow up, um. So y'all use CVS and Care Mart, but you don't care if I use an independent pharmacist that's still going to be in a Blue Cross Blue Shield plan is that we have no dog in that fight. OK, I just wanna make sure. OK. All right, right. Thank you. I think that answers my questions. I think mentioned in the June testimony too, nor are we allowed to steer direct towards, um, One or the other. Right, OK, right, right, good. Thank you. Representative Wooten. Thank you, Mr. Chairman. I have 3 questions if I may. First one is you mentioned to uh Representative Anchor's question regarding, um, The negotiation. Who, who do you all negotiate with. On your, do you, do you negotiate with the pharmaceutical companies or do you negotiate with the PBMs. You, you, in other words, the PBMs are sharing. Determining your cost for you just as they are the independent pharmacist. In other words, it's, they're the third party. They're the third party for us, for you, and they're a third party for the pharmacist also. Independent pharmacist. So let me ask you this called a PSAO. That negotiates on their behalf. Well, they negotiate on their behalf and you know, you negotiate on your behalf with the PBMs. That's my point. OK. The next question, if I may, is If an independent pharmacist is confronted with the PBM price and then they're confronted with what you will pay. Is there a collusion there or does the plan take dominance? No. There isn't a separate, there isn't a, a PBM Arkansas Blue Cross payment and then our negotiates on our behalf. So, Yeah, that, that I think you're, I think you're where I am, I'm frustrated about the PBMs. It looks like they're controlling the medicine prices, the medical, the, um, prescription cost throughout the total medical chain, is that correct? No, not necessarily. I mean, there was not necessarily now let's let's be exact because this is, to me, this is a serious situation when you have one group that's controlling the price structure for Blue Cross Blue Shield independent pharmacist, and also for the chains. And I don't guarantee you if you ask the Insurance department that the majority of the claims that they get are from independent pharmacists and not the chains. So we've got a collision here. Then the consumer is the one that's suffering from it. Would, would you agree with that? Oh, is that putting you on the spot too much. Because you have to negotiate with the PBMs, but it's, it's, you see where we are. I can understand the front frustration, um, uh, PBM's, um, are still one of our vendors, right? I mean, we work with them every single day to deliver care to all of our members here in Arkansas, so, um, as far as their practices or the, the supply chain of pharmaceutical drugs that's below, uh, where we end up with it. Number 3, Representative does that answer your question? I mean, the, the, the, the, the cost of drugs are set by the pharmaceutical manufacturer at the top and then it trickles down from there. sent by who? The pharmaceutical manufacturer manufacturers, they sent the cost to the PBMs and then the PBM set the cost to y'all. And then and they're the third party which raises the price to the consumer because somebody has to pay the PBMs. That's right. That's assumption, OK. Follow-up question. The state is in the process of looking at a wellness plan where we will provide X amount of dollars to the benefits of the employees for them to secure wellness. What do you have a wellness plan within Blue Cross. OK. What, what is their savings, wellness, cost of the wellness plan to the cost of claims that are filed by your recipients. You know, Representative, I think that depends on each group. Um, You know, it's up to an employer. To decide whether or not they want to offer that type of benefit for their employees. If you have a mix of employees, for example, that have a lot of diabetes or a lot of high blood pressure. A wellness program may save you money in the long run. It may help your employees lose weight, it may get them more active. It may teach them how to eat better, so you may see some savings, um, and you'll have a healthier workforce, but I think it's, it's really, uh, It it's, it's really a personal decision among the employers, whether or not they think a program such as that will benefit their workforce. OK, for our plans we have what's called a, a My Health Pays program where we reward our members for engaging in healthy activities, visiting their doctors, uh, prescription adherence to where we assist them with over the counter drugs, uh, paying their bills, etc. There's, there's several different things that qualify for those payments. So we're incentivize incentivizing our members directly to, to participate in our wellness program. So it's really by individual employer relative to whether or not they feel that they have a savings and individuals as individuals that take advantage, a big segment of the population that we target. Our pregnant women. Right? We want to make sure they're going for their checkups. We want to make sure they're taking neonatal vitamins. We want to make sure if they're having mental health issues, depression, anxiety, that they're getting the help they need. Through the course of their pregnancy so that they stay healthy and have a better chance of delivering a healthy child. OK, thank you. Thank you, Mr. Chairman. Representative Wooton. Up next, I think it's the first time we've heard from him today, Senator Boyd. Thank you, Mr. Chair. Uh, so the, I think, I think maybe Representative Aker was referring to the drug Aatinib. Uh, so the other day in the, uh, board of pharmacy, there was gold card legislation that was reviewed and there were PA requests for certain drugs. And so, you know, I think the, the concern might be, at least it's my concern. I can answer that without a doubt, and he can answer for himself. But there was Request for $1700 PA limit for a Matinib with Blue Cross plans. So, but when you go in and you look at this on the, you know, what's publicly available at the, the in-store price presumptively in-store means in a physical brick and mortar pharmacy is 14,130. And then presumptively when you go to the specialty pharmacy. It's 4,43698 for a 30 day supply of that drug, whereas then Centene, it's roughly $130 for the same drug. So we're talking about a cancer drug that is a generic. You mentioned, you know, generics in your testimony, it's generic Gleevec is what this drug is for, for cancer. And I think that's what we're trying to understand is what is really driving up the cost of drugs. We know it's multifactorial. I mean, we, we do, Um, we know that a lot of drugs are generics, but when we see such pricing discrepancies, it's not always clear what's really driving up the cost. You know, we know that in with brand name drugs, there's a rebate in there that's not overly transparent to the public, we know it exists if no other reason than the EpiPen example that was presented in Congress and there was this missing roughly 40 to 50% that nobody knew where it went. And so So, so all those things are going into this, but we're trying to get to the bottom of it. So if there's going to be testimony that it's drug prices. I mean, we want some context on is it. Because we're choosing to direct certain generic drugs to specific pharmacies that charge a higher price or or paid because, you know. Or is it that? The, the brand name drugs, I mean, I know it's all of it, but like somehow it's proportionally is so as a pharmacist, we learn about rate limiting step. You know, until we get to this, we're not gonna really control anything, you know, we can speed up the faster things in the, you know, the enzymatic process, but it's not really gonna do anything. You got to get to the slowest one. So what is the biggest driver? What, what is causing the prices to go up? That, and you might not know that today, but I just, that example really stands out and it's especially concerning because it's a cancer drug. Um, so, thank you. Senator, would you, what was your question? My, my question is, what, what is the context for the price difference and what is it that's really causing prices to go up. That was part of the testimony is that there was a 35% increase and to make sure we have the correct, yeah, thank you, sir. I just wanted you to be clear, there was a question in there. I'm sorry, it was not clear. Senator, would you send me the name of that drug, please, so I could check on that for you. Thank you. Representative Aker. Thank you, direct questions piggyback off of Senator Boyd, so I believe what he's referring to is that at the goldart meeting and. Blue Arkansas Blue Cross Blue Shield requested that a PA be in place because the drug costs $1700 although on the publicly available NADA listing, it's actually listed at 60. $60. Yes, ma'am. OK. So that's, I think the point of the concern is. If premiums are going to go up and we're Suggesting that drug prices play in large role in that. Um, it seems that we have, we have certain plans that are paying $140 for a drug. You've requested a $1700 exemption for one, and then at a specialty pharmacy, you're paying over $4000 for one. For the same drug. Yes, ma'am, for the exact same drug. OK, and that's the drug that Senator Boyd's going to send me, correct? Yes, that's, that's the same drug that was on your request with the State Board of Pharmacy for a PA gold card. I'm sorry, I'm just not familiar with that list, so I'll look into that for you all. And as we pi In NADA. Obviously you guys are well aware, or if you weren't, you are today of the mounting number of complaints and violations that your vendors are under, I guess, review for. And I just want to know what's your take on the fact that we have the two largest, 2 of the largest PBMs here, um, you know, again, I, I alluded to how yesterday I filed over 200 complaints just at one pharmacy, 80% of those came from. Y'all's PBMs. What is your take on the vendor that you've hired and the way that they treat Arkansas state law. Yeah, I mean, if they're breaking the law again, we, we think that they should remain compliant if they're not those complaints should be directed to the insurance department for, for review and uh adjudication, um. As far as the our our vendors, um, their compliances in-house, uh, obviously, uh, we have oversight over that contract, um, And My understanding is that, you know, the, the 3 day thing lag is real from Nak. I know that's, that's hard to grasp, but it is. There is a lag there. We've talked about that since 2017 or 2018 when we did the first special, uh, special session on PBN that that there is a 3-day lag that causes those discrepancies, so total adherence is going to be an issue, um, from, from day to day on that NADA list, uh, beyond that, though, again, they should be subject to the law and if they're violating the law, those complaints should be directed to the insurance department for review and adjudication. And again, the, the 3 day lag is really only significant if the goal is to pay Nak exactly, correct? If there's a fair and reasonable rate above NADA, then those violations won't trigger. The uh Well, is that accurate based on the ingredient cost? Is that I'm not not sure how, how the insurance department reviews that if violations are getting caught because there's a 3 day lag in the NAA. That's only because of the goal of the PBM is to pay exactly the invoice cost of the drug. If they have a fair and reasonable rate above the invoice cost of the drug, then as those lags happen and Raynaak fluctuates, they won't trigger as a violation because again they won't actually dip below. Those fluctuations. I should. So I just would encourage both of you to take those into consideration. You guys are the risk bearers. It's like the PBMs. You are the ones who write the checks and the vendors that you've hired have treated state law with I mean, complete disdain. Understood. Yes, I can appreciate that. Representative Brown. Thank you, Mr. Chair. I'm trying to understand. And I think that there's some confusion here. Others are trying to understand also. The drug cost. Are we talking about overall drug costs are we saying each and every individual drug, generics or. Or the others. They are all going up in price. Are we Uh And I, I'm more interested in wellness. I'm not a nurse or a doctor. Other people in my family are, but I focus more on trying to stay well, um. Our drug costs going up, I've I've read that people, younger and younger are getting cancer than they used to. My own personal observation is. It was Uh, uh, uh, it really stood out as something significant if you saw a morbidly obese individual when I was young. You didn't seem morbidly obese children, young people, or elderly adults. You just didn't see very many of those today, it's everywhere. And that carries health costs. Uh, so many people eat nothing but processed foods and junk foods and eat out and all that sort of stuff. And those things are probably driving many, many of the health issues that were, that we're having to deal with. Is that part of what's driving drug costs. And because we are looking at a wellness program for our employee benefits and so we need to determine if this wellness program might actually help our employees be healthier. Bring down the, the cost, we always have to think about cost. Of our employee benefits. So I think it's important to understand when we say drug costs are going up, what is causing, you know, if my budget for drugs is this amount of money and next year it's got to be more. I need to know why it's going up. What are the what are the parts, the components of that that are driving it. Can you give me some sort of an idea? Well, I mean, Am I, am I on track with, with some of my observations I have to, you also have to. Realize that every day elaborate much more than I. There are new drugs coming out onto the market every single day and a lot of them are very expensive drugs. That will save people's lives. Um, so you have that. So let me interrupt. So you're saying it's these new drugs, the cost of prescribing those new drugs that is driving it not necessarily the price of the generics is going up astronomically. I don't think the generics are going up as OK, so it's these new drugs, the cancer drugs, OK, lots of, I mean, lots of dips. So you, so you have that. I don't know that there's only any one particular factor. You also have the situation at the federal level where Um, and it has to do with patterns. So a new drug comes out onto the market and the comp and pharmaceutical manufacturers that have the patent, they want to hold on to that as long as possible, so they tweak it a little bit so they can prolong that so generics can't come into the market, so there are a whole lot of levers, I think that can be pulled to, um, Prevent the cause. Now, you know, regarding wellness, you can't make people want to take you can try to incentivize them. Um, or you could hope that they just enjoy living so much that they want to do it, but, you know, Arkansas is not a healthy state. We have some of the highest morbidity rates. In the country. Um, our obesity is sky high, uh, is high, maternal deaths are high. I mean, we are just not a healthy state. So our costs overall are higher than most states, but To to come up with a single reason. I, I can't. Well, I'm not really looking for a single reason, but it seems to me that wellness or unwellness could be the, I mean, It's my understanding that cancers are occurring in younger and younger people than, than they used to. It used to be it was an old person's disease, and now it's a, a, a young person's disease. Is that correct? I mean, that's what I've read. I mean, our younger people are, are, Not as healthy as they used to be. They aren't as active as they used to be. They don't eat as healthy as, yeah, there's a lot of, there are a lot of, uh, External. Thank you, Representative Brown. Thank you. Representative Rose. Thank you, Mr. Chair. Mr. Hopkins, thank you for taking our questions. um. When Representative Aker is asking you a question a moment ago, you guys were talking about compliance and I think you said, I want to make sure I characterize your statement correctly, that certainly, if these PBMs were not in compliance, that they should be held accountable, pay a fine, do something correct. Is that, is that accurate, um. So in regards to selecting PBM vendors, uh, does history of violating Compliance with states. Is that taken into account when, when selecting a vendor? I can't speak with certainty to that. Um, I think we switched, uh, switched PBMs effective 11 of, uh, this year from CVS to Express Scripts, uh, whether that was evaluated in the selection at, uh, our corporate offices. I, I, I don't know that's something that I could absolutely find out for you. Um, I, I will say that, um, due to this body's hard work, we are the most regulated state in the nation. For PBMs. So, you know, I, I don't want to cut them, you know, overwhelming amount of slack, but it it it's a, it's a brave new world we're all in down here, um, and again, our intention is total compliance with the law. Follow up, Mr. Chair. So I understand what you just said. I want to make sure. Were you suggesting that because we're so regulated, there's more violations. Uh, theoretically, there's more opportunity to, to, to, to, uh, create violations, yes, or to to subject them to punishment for violation, yes. So I understand your suggestion at the moment is that the violations being higher is because of regulation, not because of practices that Um, maybe are unfair to the. To the pharmacies or the customers can't speak to, to the, the day in and day out actions, nor can I speak to the intent of a of a PBM, you know, uh, uh, that's not for me to say. I, I. Do know that, that we, uh, found those violations a couple of months ago and the insurance department, uh, levied a fine of $1.5 million spread across the, the, uh, PBMs that were subject to that. Um, I think that that's a move in the right direction for compliance with the law. I understand and I know, I know you're saying you can't speak too. I was just trying to make sure I understood you. You said that we're so regulated. And your belief is that's creating an environment for more violations as opposed to the regulation is catching things I'm, I'm sorry. No, the regulations are capturing. Uh, uh, mistakes or bad actions, yes. Correctly so. Yes. Final follow-up and it's just a yes or no, Mr. Chair. I can't speak to whether they're totally accurate. That's up? I'm sure. So you said you, you couldn't, you couldn't say one way or the other if uh history of violation was taken into account when selecting a vendor. Do you think that history of violation should be considered when selecting a vendor moving forward. Oh, that's um. That's a good question above my pay grade, but um, um. Of course, you know, as, as someone that is a state vendor, we, we want to be faithful partners, uh, with the state in our, in our, uh, state programs again expansion in the passes. Um, I would hope that those, uh, those violations are taken into account when we're selecting our, our PBM, but again, we're a, a very large corporation with plans all across the United States, those decisions are made well above for who's selected as our PBM. Thank you for your latitude, Mr. Chair. How feeding the end with Senator Hammer today. Thank you, Mr. Chair. Uh, that statement you just made though, Blue Cross Blue Shield of Arkansas when it comes to PBM choice, do you make independently? Are you independent of your choosing of the PPM or you have to comply with Blue Cross Blue Shield at a national level. We're an independent plan senator. OK. So you can't pick and choose here in the state. All right, next question, um, do you annually or on a regular basis, do anything. To qualify cost savings, and this is in response to the representative question a while ago, uh, do you do anything annually, periodically, where you take the laws that have been passed, the practices have been in place and attach a, a solid number that says we're saving money because we did this and if so, how much money are you saving? I'm not sure that you're, you're saying do we quantify the savings from a mandate that you guys pass? Well, a question was asked a while ago by the rep over there. Do you ever quantify savings based on decisions that are made and the answer I thought was no. And if the answer was no, then how do you ever know that you're saving money or remember that question. That was representative. Yeah, well, do you, do you do anything on an annual basis where you say, man, we are able to save money because of a law that was passed or because of a rule that was changed. because of a decision that you were made and if not, how do you ever know that you're actually saving money, you know, sometimes that can be a tricky question for us to make a statement one way or the other involving ourselves, say, in a scope of practice fight, we're not going to take a stance one way or another with the provider perhaps I mean that's an easy way for me to explain that as far as reviewing year in and year out, what the regulations impact were. I think you can see that in our filings with our rates for the Increase, um, but no, I don't have anything stock about the savings created from what you guys passed. Maybe that's something that we should look into. No, I think it's definitely something you look into because you'll never, I mean, you come and ask for rate increases, but if you don't do anything to quantify where you save money, we're never going to see where you save money that could otherwise keep the cost under control because you've, you've done a checks and balances in business, you look at this and you say, this is saving us money, we're gonna keep doing it. This is cost. this money, why would that not be what you would do as a insurance company also when it comes to the rates. I think we do it in certain. In certain buckets. But as far as looking at. Legislation or or. AID regulation and trying to quantify that Senator, I don't think we've done that, and I agree with Jack, you know, maybe it's something we, we should look at. But obviously, there are internal things that we look at and say, is this working? Uh, it's not, we need to scrap it, um, because you're right, if you don't look at those things, you don't know if something's saving money or actually giving you a return on your investment. So we do it, but I don't think we're doing it in the. Area that you're, we could be probably a little bit cleaner about pointing to that, but yeah, we look at our costs year over year for each service, um, that, that we reimburse for and, you know, year over year it might be different and that just gets baked into what we're going to request of the insurance department. So it's something that just happens without thought, but perhaps we could look to, uh, the laws you guys are passing and point to those savings. OK, I'll tell you we will, we will be taking a look at that. Last thing is this, and I just don't know I'm asking, so like somebody. Players that they're a smoker, you charge a higher rate for them. Do they, they bear a higher cost or spread out across the board to everybody else? I don't think we did that anymore. I is it, is it, why can't, why can't you do that? Why can't you lifestyle choices that I choose to be a smoker. I, I don't know why you can't do that. I a federal law or what is it? And don't hold me to this, Senator. We used to do that you're absolutely right, but I want to say it's federal law. I may be wrong. But I wanna say. Obamacare or something that was done somewhere. OK, Sandra, how about if we have her to get that information, that'd be fun. Love to have it. Thanks. OK, thank you. Our next session, uh, is, is public comments that we have, and I'd like for the two of you to stay there that way if someone has a question or comment, they would, they, they could, uh. Address it to y'all. We had no one to sign up, but is there anyone in the audience that, uh, like make some comments today or questions for. For the two of them. OK, we do, do have one. Come, come on up, sir. Right there, right beside them. Please identify yourself for the record. Sit down, please sit down and push the button and there it goes. I'm sorry, Mr. Hopkins, you may have turned yours off. I don't know how to deal with more than so, so my name is Charles Mason and I'm one of the physicians that came and testified the other day about the No Surprise Act. Um, You know, everything that Miss, uh, uh, Greenwood and Milter Hopkins says it's true. It, it was made to protect uh. Uh, patients from surprise billing. That's, that's absolutely true what what it has done. And what they don't mention, uh, is it prevents, uh, physicians like me from negotiating what is a fair price for my service. And that's what we're complaining about. Um. Before the No Surprise Act was around, uh, they would pay the bill 80%, 20% would be for the patient to pay, and that was, uh, sort of standard practice. Now, um, and, and she mentioned one of the things that she mentioned was Blue Cross and Blue Shield does not, um, allow physicians that are into their network if we're not Medicare and Medicaid, uh, if we don't accept it. Well, I can't me and my partners, we decided to build our own facility in Cabot. Uh, so we're independently owned and because the Star claw, which is a federal law, I'm not allowed to build Medicare and Medicaid. I cannot play in those, those services. So, but yet I, so because of that federal law, I cannot be a member of uh Blue Cross Blue Shield. I cannot participate in that. And since I keep participate in that and their QPA they qualified payment amounts. Or propriety. I don't even have a way of asking what it is. Or how much I'm going to get paid for that service. And what I've seen over the last 2 years, despite the, the problems we've had with the clearinghouse is about a 30% reduction in my pay. And that problem is what other providers like myself, And radiologists and surgeons and other people have seen is this decrease in the payments. And there's no way for us to argue it. We can go to open negotiations with them, which takes 60 days. And if that doesn't work, then we can go to the federal system which has several 100,000 cases pending, and we have to wait another 6 months to get paid. So that's, that's the problem that we were trying to discuss during our testimony. It's just this. Difficulty that now exists. They have a very hard job. I appreciate what they do. I'm a Blue Cross Blue Shield member. So I pay, I pay them a lot a month. They money every month. But the, the ability to negotiate with them is extremely limited now and it's not just us that are having that problem, but everybody that is not in network with them and Somewhat, you know, not to complain too much, there is a little bit of gamemanship going on too because they can, since they figure the QPA on their own. And they do the negotiations with every group. If they kind of lower the amount they pay percentage-wise based on what Medicare pays, with the QPA lowers a little bit, so, so they have a great bill of control. And I have none, and so that's what we're complaining about last time. Ms. Green, would, would you be willing to sit down with, uh, with Doctor Mason and y'all work this out. I mean, be two adults. I mean, let, let's work this out and y'all, y'all get, get, get something taken care of because I have heard the same thing not just from. From, from the cabin facility I heard from Fort Smith. I've heard it from Ter Ken. I've heard it from several other places, including Mountain Home. Can you sit down and y'all work this out? Senator happy to try to visit with our folks who actually have the authority to work it out with, with the doctor. I, you're giving me way too much credit if you think I can work this out, but I'm happy to set that up for Mason and any other ones that need need this set up. Let's let's get this taken care of because we don't need to see our local hospitals going out of business and so You could, if you would do it, is that, is that fair enough for you, Doctor Mason, if I would do that, we would love that. I, but I don't think I'm speaking just for me. I know you're not other places position that is not in network or a radiologist, a surgeon, uh, uh, they all have, have the same problem with the no surprise Billing Act. It's just taking away our ability to negotiate, and that's what we came to talk about during our last test's nothing wrong with negotiating. I feel like this meeting is. Really didn't cover what we covered at the last meeting. We spent a lot more on, on PBM this time, uh, which they didn't get their fair share of time last time we started running short on time, but, uh, I think that part has been more than covered, but if we could handle the, the part where we're discussing here, that would, that would be great if y'all could do that. Absolutely, I appreciate that very much. Is there any other public input from the Central Hammer, I thought we were through with you. just, I'd, I'd almost like to hear Max's response because it would seem to me and Doctor Mason, have you, have you reached out to Blue Cross Blue Shield before these meetings and ask for a meeting and what has been the reaction that you've received, um, that you're having to come for a legislative body and. Get to get this. Have you, have you had any discussions at all or y'all met with them before now? I promise you this is a, uh, if not a daily occurrence, uh, uh, monthly occurrence. The, you, you know, there's. Well I don't know how to answer the question, but, but, but yes, we have had discussions we've tried to come in network we've tried, uh to modify the QPA that we've tried to get, get them to publish the QPA we, we, uh, you know, just trying to figure out when somebody comes and sees me for abdominal pain, uh, and I see a Blue Cross uh shield sticker on it, uh, you know. So I, I often wonder, am I going to get paid? Am I gonna have to go to open negotiations? Am I going to have to send this to the, the government for federal mediation. I never quite understand, um, it, it occurs almost with every patient now to the point. That I actually have a company called uh Halo MD that will take every case and take it to adjudication just because we cannot seem to find a way to mitigate this problem. And, and so from my understanding, is this a, is this a matter of federal law interfering with your ability. To work it out with Blue Cross Blue Shield, or is this just negotiations between Blue Cross Blue Shield and Your provider group. And Mx can weigh in or you can answer the question. I don't care. You want me to answer that? Yes, ma'am. I don't really know the answer to that question, Senator. I, I don't know who the doctor has been talking to, you know, I know that the No Surprises Act is a federal law. So there are certain Um, There are certain things that are prescribed to the health plans that we must follow. Um, Is there a middle ground? I mean, you know me, I'm one of those people, the glass is always, you know, half full. I can always try to find a middle ground. Um, all I can do is bring his concerns to the folks that actually work with providers in our company, um, and ask them to give him a call and see if we can. Make his life a little easier. That's all I can do, Mr. Chair. I'm not a member of this committee. You grant me a lot of latitude today, but this is of an interest to all constituents, whether you're a member of this committee or not, I'd like to request or suggest to the chair that you bring in those people from Blue Cross Blue Shield, bring in some documentations, some of his, and, and set a hard date for them to be in front of this committee, uh, to give an explanation and to give, um, an accounting of the results of their discussion, I think. I think there needs to be some pressure applied. That's just my simple request and I appreciate your latitude to me today, I think it may be on to something with pressure being applied, but I want to actually give them the opportunity to, to see what they can take care of here first and then we can look at that later if we need to, but I don't, I'd like to see Miss Greenwood and, and Doctor Mason, go forward and see what they can work out themselves without without us being involved if there's. If there's any possibilities because they've both given us their word, they'll try to work together on this and get this taken care of. I know for a fact this goes back 2 or 3 years because Centry Hickey and myself worked on a deal with the Texas can facility. Probably 3 years ago, try to get something worked out on some issues and I would like to see y'all step up and let's let's get this taken care of because this has been, been going on long enough. Yes sir, I give you my word. I will do that. I will take care of it and I appreciate the latitude. Thank you. Thank you very much. Appreciate your time and seeing no other questions from the public, no other texts or comments from anyone. This meeting is adjourned.