Public Health, Welfare and Labor Committees - Senate and House

Representative Pty, we appreciate you carrying that side of the room for us. Um, if everybody can just get settled in their seats, uh, first order of business is to approve the minutes from the June 4th, June 5th, and June 12th meetings. The entertainment motion at the appropriate time. Second. All those in favor say aye. Minutes are approved, um, first up on the agenda, the Department of Health, is Mr. Gilmore here somewhere? If you want to make your way to the head of the table, we'll be happy to hear your presentation on tobacco settlement. Also members, they're passing around some information that would be important for some of the other presentations that we're going to see. So as you get information passed around, just know that that's it's a reference to different points on the agenda. Mr. Gilmore, y'all are recognized to state your name for the committee for the record and Oh, before we start, uh, Representative Schultz, do you have a point of personal privilege? Yes, sir, Mr. Chair. Thank you. On August 9th, paramedic Mark Gibson of Emerson Ambulance Service, a 38 year veteran died in the line of duty as the result of a motor vehicle accident while transporting a patient. I would ask everyone to please join me in a moment of silence in his honor. Yeah Thank you so much. Thank you and we appreciate you bringing that to our attention and our prayers are with him and his family, um. Yeah, and we recognize Senator Irvin for comment as well. Thank you members. Um, just wanted to announce at the beginning of this meeting for the legislators that are here. Our staff has done an amazing job of organizing all these meetings and so I just want to recognize Ms. Steele and everybody that has helped. They've just done a tremendous job and it's complicated, um, all the time, but um in September, we are going to have some meetings. I'm really excited about this. We're going to the Delta area. To West Memphis and Memphis, um, we're going to be focusing on issues in the Delta as it relates to their to the health of our citizens there the staff, along with the help of Senator Chesterfield and others have really helped us put together a fabulous agenda for a couple of days there, so we are trying to reserve blocks of of hotel rooms as well for legislators. So if you're going to be attending that. would like to know ahead of the time, just so we can get some numbers for the different things that we're going to be doing and for those meetings and their spaces. So, uh, please reach out to me if you're going to be planning to attend those meetings, whether you're on the committee or not. Thank you. OK, if there's no further preemptory business, we will go ahead and let you recognize yourselves at the end of the table for the record, and you can go ahead and proceed with your presentation on the tobacco settlement. Matt Gilmore, Department of Health. I'm Bobby McGee. I'm a professor in the College of Medicine at UAMS and executive director of the Arkansas Biosciences Institute. Thank you, Madam Chair, Mr. Chair, uh, Appreciate your time this morning. I know you'll have a lengthy agenda. I'll try to keep this as brief as possible. I do want to donate some of my time to Dr. McGee to speak briefly about the Arkansas Bioscience Institute, which is part of the tobacco settlement programs. What you have in front of you today is the 2022, 2023 biennial report for the tobacco settlement programs, um, it's a similar report as y'all see in the past. This is a biennial report, so it covers a couple of years. There's an infographic, I believe, on page 8 that kind of gives a quick overview, kind of an executive summary of the report. And then there are individual sections for each funded program, and then their specific metric and metrics and data. I'll just point out a couple of things and then I want to turn over to Dr. McGee to speak a little bit about what his program is, is, is involved in. We found it helpful in the past that y'all can hear from the programs themselves and and some of the good work that they're doing. But a couple of things I'll just point out in this report, um, the number of uh screenings, health screenings that the programs engaging across the state. This is community events, health fairs, work site wellness events, those numbers have increased by about 8000 over the previous reporting period, so that's a good increase there and we're, we're happy with that. And that gives individuals a chance that may not go to the doctor very often to go to one of these events and get a quick glance at where they are with their health and just some basic numbers and point them to a Local provider. Another thing I'll point out that we're, uh, happy about is the number of dollars that was leveraged over this time period. Um, the programs all engaged and outside, um, activities trying to leverage grants, donations, private grants, private funding, that numbers increased by about $165 million over these two years so that's a healthy increase. We're proud of that. And Dr. McGee may speak to that a little bit on what as far as his program. And then one more thing that I'll mention briefly and turn it over to him, the Medicaid expansion program at DHS that's funded with these dollars. they serve several populations over there. Those numbers have increased slightly as well, so we're happy about that. That's, you know, some temporary assistance they provide to different populations over there. Um, so that numbers increased as well, and I want to keep this as brief as possible, as I said and then turn it over to Doctor McGee, but happy to take any questions and if y'all have specifics that you need from me, I'm happy to provide that, but I'd like to let Dr. McGee speak for a minute or two if I could. Members, does anyone have any specific questions for Mr. Gilmore? OK, go ahead. You can go ahead, Dr. McGee. You recognize. OK, thank you. I very much appreciate the opportunity to be here. Um, and, and appreciate Matt inviting me to speak. Yeah, you know, the Arkansas Biosciences Institute. I, I represent a really proud component, I think, of the, you know, under the the tobacco Settlement Commission as well as, uh, as a really significant component of the tobacco Settlement Act, but, and each of you, we have our last year's report that will be coming out in the next 3 or 4 weeks so you can expect that to come to your office, uh, sometime in mid-September and it will highlight many of the things that we accomplished last year. And so I thought today I'd just give you a little bit of a brief overview of some of the things that we accomplished last year and um Our, our single number one metric that we report on is is our leverage factor, and historically it has, it has always been really, really good, and this past year we set a record. We received through the Tobacco Settlement Act, the ABI received $12.7 million and this is split among the five member institutions of our organization, and we generated 88 million in extramural grant awards. That's a leverage factor of $6.93 for every dollar that we received from the tobacco settlement and that, that's, that's pretty nice. And you need to keep in mind that these are grants this $88 million in grants are money that are generally come from NIH, National Science Foundation, USDA, HESA, etc. and these are dollars that are in federal budgets for grants, but they're not in federal budget for grants in Arkansas. We have to be competitive to be awarded these grants and the ABI dollars that we receive. Make us competitive to be able to get those, so it's really quite an accomplishment and sense of pride for our investigators. Over our 22 year history, uh, we have brought in over $971 million in extramural grants and certainly this next year we're pretty excited because we're going to cross the the $1 billion dollar threshold, and we're going to have several events associated with that pretty, that's a pretty, pretty significant milestone, so we're really proud of our leverage factor, and I think it's a Estimate to the longevity of this organization and the tobacco Settlement Act that's allowed us to do this. Um, we, another metric is publications, uh, this past year, we had over 500 publications that were related to these ABI related projects, uh, combined over our 22 years we've had over 8500 publications. Another is you can sort of think about this as a spread out across the state as a as a pretty good size small business, uh, on average, we support about 300 knowledge-based jobs. These are research assistants, postdoctoral fellows, etc. Research technicians, you know, really strong knowledge-based jobs and 80% of those are funded through these extramural grants, while only 20% are supported on the ABI funds. But if you were to think about a business that employed 3. 100 people, that would be a pretty nice sized business representing the state. Uh, intellectual property this past year we filed 5 new patent applications for provisional status, and 3 full patents were awarded. And then last, I just want to mention that, um, uh, 6 years ago, we started the collaborative project of the Arkansas all payer claims database, uh, with AI and the Arkansas Insurance Department. And that has been, that is really maturing and has really come a long ways. We've had over 73 individual projects that involve almost 300 investigators. We've received 17 grants, 13 alone of those came from NIH. Others included, USDA and one Hersa grant and uh so far just from that collaboration alone, we've, we've gotten, uh, 25 publications. So that's a brief overview and it'll be detailed. In depth in the report that you'll be getting here in the next month and be more than happy to answer any questions or elaborate if you'd like to. Thank you. Thank you, members, are there any questions for Dr. McGee? Yeah. Yeah, Representative Ray, you recognize for a question. Thank you, Mr. Chair. Um, so I just have a general question. I'm looking at the funding on page 5, and I, it, it just shows the funding for 2223, because I think a portion of the the amount of the settlement funds that go to each state is determined to some extent on tobacco sales as smoking rates decline, or is this basically a declining source of revenue? Does it go down a little bit each year? Yes, sir, Representative, it's, it's decreasing, um, I wouldn't say significantly, but we are seeing decreases every year and it's based the formula that they use to figure the amount is based on sales, it's based on some inflationary measures. It's based on several different factors as a complicated formula that the AG's office helps us manage, but it is decreasing, um, these, as a smoking decreases, so it's, you know, it's, so you're correct, it will beginning to go down. Yes, sir. You know, Approximately how much it goes down, um. The payment to the state, uh, probably 3 to $5 million a year. It's so it's, it depends. I mean sometimes it goes up a little bit, then it'll have a drop. So it's, I'd say average anywhere from 2 to 5 million a year. The last two years it's been 10%. And Richard, there any other questions? Represent Senator Irvin, you recognize. Thank you. Just a quick question, um. On the trails for life. Is that a grant program? Yes ma'am. So there's legislation, I believe it's been several, several years back, at least 10 years back, that created, uh, a trails for Life program which is grants for, um, uh, walking trails and nature trails that are distributed. We, the Department of Health uses some of its tobacco settlement dollars and funds that to Parks Heritage and Tourism, and then they issued that out in grants. Yes, ma'am. OK, so, so it's, so you're, you're passing the money to Parks Heritage and Tourism and They're kind of bundling that with whatever they have, is that corrective process, yes ma'am, and they issue those out. Yes, because one of my concerns is you've got all these different grants all over the place and a lot of Counties and towns that are particularly rural don't know where to go and where to apply for different things. So, thank you. Is there ever an opportunity, and I know you probably could speak to this too, for y'all to look at what you're doing and reshuffle the deck or um to see if this is, you know, where we want to go or do we need to put because of the declining revenue, is there, is there ever a time where the commission looks at that and says, you know, we We really need to consider this more as a priority more than this. So they, they receive quarterly reports that we bring to y'all and they look at those on a quarterly basis. They also look at the biennial and annual reports. The commission then votes every 2 years to make a recommendation to keep the funding as it is, but it's a legislative, you know, governor's decision as far as the actual funding that's set in statute. Um, I think the commission feels like that, this is my perception, I think the commission feels like that the funding is, um, is being used appropriately at at the programs it's at some of the programs are very broad indicators, and it's, it's, it's difficult to, um, I know one program has, you know, decrease in mortality, and I don't know how that's that's kind of a tricky thing how you keep people from so and so, but they do adjust the indicators occasionally. They do adjust the metrics that are that are that the programs are required to follow, so I think they do watch it pretty closely, but, um, you are right, it is going to go away at some point and it's just a matter of time, I think. You know, I don't know how fast that will happen, but to your point though, or to your question, I do think they monitor that. I think they do look at it and watch it. I think the programs also, you know, um, do a good job trying to show their value and their worth. Well, and I wanted to tell you thank you for, I appreciate the leveraging statistic because I think that's so critical and important and those research opportunities. We don't value that research and that leveraging that occurs and thank you so much. For tracking that and reporting that to us because it's one of the big reasons why I'm a huge supporter of us getting NCI designation for UAMS cancer Institute is because of that huge, you know, just benefit all the way around, but the leveraging of whatever our investment is is really amplified with the idea and the ability to attract other investors and stakeholders into that research. So thank you so much for tracking that and I appreciate the. biosciences Institute for doing that and it's something that we should probably consider. I mean, I love, I love walking trails. I love that so much, but I also know that we need to really sometimes take a, take a hard look and see what's working and where we're getting our biggest bang for our buck and the biggest impact and moving the needle on these different issues. Thanks. Represent Representative Rose, I think you had a question and then Representative Bentley, I'll come back to you. Yes, sir. Thank you. Uh, Matt, I was looking on page. 402 it's the infographic on the front page of the tobacco Prevention and cessation program. I was just curious if you could speak to it looks like all these other smoking rates decreased except for pregnant women smoking, which was an increase. I'm just curious, um, with all the data that's here and I know this may be one of those you get a follow up with at a later date, but if there's something you could share about why we think that that increase was taking place while the others were decreasing the. I can get more specifics on it. I will share. We've got more recent data than this. These reports are a little bit, as I said, 2022, 2023, the, and I can, I can get more info on the pregnant women, the actual adult smoking rate though just about two columns over. It's dropped about 2 points, so that's a, that's a significant decrease. So I, let me, I don't think I've got the more recent data on the Pregnant women I don't. I can look and see if we got more recent data on that, but overall, smoking is going down, but we do see bumps occasionally, but I can get some more detail on that. OK, thank you. Yes, sir. Representative Ben Lee, recognized for a question. Thank you, Chairman. Thank you, uh, Matt for that and give that to the whole committee, please, if you don't mind. Also just, can you give us an update because we got some new members here. What exactly we're doing in that program to stop smoking? What are we doing across the state and have we changed that at all in the past few years, several years back, you're speaking to the tobacco cessation program. Several several years back, we, we brought the, um, quit line that was a call center that was contracted out. We brought that in-house. We've seen significant improvement. And I appreciate y'all providing some input on that as that was going down, but we've seen an increase in our quit rate with that, with that call center being brought in-house with Arkansas individuals answering the phone and providing that, you know, that one on one connection to Arkansans. Um, we have a significant program with our high schools and what's called Project Prevent, and that's a program that we go, we have chapters in individual high schools across the state's close to 90+ across the state where it's, um, uh, high schoolers working with. Their colleagues providing some leadership, and sometimes they listen better to their colleagues than they do an adult or, you know, a teacher saying, hey, you don't need to engage in vaping or smoking or whatever. We've also have a, uh, a children's program that we've we've rolled out in the last few years, um, and it's a cartoon focus, but there's a literature that talks about vaping. We've realized that, um, you've got to start sooner. You've got to catch them while they're young and before they get into their teens and see the, you know, and get exposed to the habit of Smoking or vaping, whatever. And so that's been successful. We've gone into numerous high schools, I think, in the tens of thousands of kids have been educated through that program, so that's been impactful, um, we have the for pregnant women to representative Rose's question, we have a program just for pregnant women called Be Well Baby, and it gives some incentive incentives to moms that are smoking, um, and, and provide some one on one counseling to them, and we've seen that number increasing as well as far as the numbers that are engaged in that. So we try to be innovative where we can, and I think it's, we're starting to see some movement there, just like I mentioned with the two-point decrease there in the number of, um, individual adults smoking. So, vaping is always going to be a challenge. I think that's the new frontier if you want to call it that. I don't like it. I, I think we're going to have to battle that for a while, but, um, I think we're seeing some inroads and some progress. Quick follow up chairman, if that's OK. So these numbers do include vaping because I know when I go to my different schools that's really the number one problem that they're having. There's a vaping with their students and that it's really kind of overwhelming them. So do these numbers include vaping? I guess that was my question. We do break out the vaping numbers there separately, um. OK, so yeah, we have, we have, we tracked the smoking, the vaping, and across different age groups and demographics as well. Great. Thank you. I appreciate the report. Yes ma'am. Representing Pilkington, you can ask for a question. Thank you, Mr. Chair. Thanks, Matt, for being here today. Thank you for this presentation. Um, I guess my question is, do we know how that we are comparing in our drop and smoking rates compared to other states. I mean, obviously nationally we see it going down. I practically in every state is my understanding, and so it's just culturally smoking is less and less prevalent, uh, and so I guess there's a kind of two questions. One, how do we do compared to other states and dropping their smoking rates and then of course the other one. is, you know, how much do we think that's actually the programs that we're implementing and how much is that just a cultural norm of people are just less interested in smoking. There's an uptick in vaping, um, you know, I mean, what's in some ways, what's our ROI on this? I think it's so do your second question. I think it's a mixture. I think the cultural norms, I think that is shifting. Um, I do think that some of the programs we've done here in Arkansas are innovative, you know, we're the only state to have a, uh, a lot of states, I say most states, I think Have a quit line, um, but we're the only one to have it that's, you know, not contracted out and based with Arkansas staff that are, you know, employees doing that. The, uh, program that we're doing with the children I spoke to, the cartoon-based, you know, and, and going to the schools, that's a little bit innovative. I don't think any other state has that. So I do think there are some things that we're doing here that are making a difference, um, to your first question, um, as far as how we track, we still are in the One of the states that have a higher smoking rate, I think that has a lot to do with being a rural southern state, um, you know, there are some, I think we're not the highest, but we're close to the highest. But that decrease that I mentioned a little while ago, that's the largest increase I've seen since I've been working around this program for the last 7 or 8 years, you know, when I started working around this, it was in the high twenties, so we're, we're making progress. It's slow. It's not as fast as I'd like it to see it, but, um, I do think that, you know, um, you're right, it will, it will continue to do. Decrease. It's never fast enough. So I don't know if that kind of answers your question or not, but yeah, it's a follow up to clarify, yeah, I guess what I want to know is how much do we attribute that to the efforts done by the state and these programs and how much is just do we attribute to just the cultural change, yeah, I think that I can see if we've got any data on that. It's going to be a little hard to kind of pull out and and see, you know, it. You know, I want to think it all works together, but we can see if I've got specific data from the College of Public Health at UAMS or, or through our own, uh, folks to see if we've got a way to pull out and see that, you know, um, our youth numbers are going down, so I want to think that's related to our efforts we're doing in schools, and I want to think that's also efforts to that we're trying to reach that younger population. Um, but I can see if we've got specific data as to, you know, if it's a specific program or if it's just something that's trending across the nation. You know, I can I can look and see, yeah, because I think what I'm worried is we're spending all this money on these programs and we're seeing decreases, but we're, you know, we're attributing to something that's actually not actually moving the needle and so I just want to make sure that we're spending this money wisely. I think a lot of things we do in here is good use of that money. Um, I'm just always been extremely, you know, skeptical of, uh. Some of these campaigns and ads and even just programs that actually effectively get to people and change behavior because I don't think we see it on other. Other programs, but you know this one says we do, but then it's like, well, yeah, but culturally we're just smoking less, so that's fair. Yes, sir. I'll look. Members of any of the questions. Sing and gentlemen, thank you for your time. There are other legislators in the room we have some people that are standing in the back if anybody wants to come and take a chair at the table, you're welcome to. Um, there's always the possibility a member will walk in late and tap you on the shoulder, but if anybody wants to come and, uh, sit at the committee table, other legislators are going to come and set to make space if you'd like. See, next up on the agenda, Mr. Davis here? Yep. on. You come on up to the table and recognize you're recognized to present on the discussion of Arkansas Medical marijuana impact assessment. And I think we have, do we have a handout for that too? Everybody has their hand out for that. Thank you, Dr. Thompson. If you can state your name for the comedian and who you're with. Thank you, Mr. Chair. I'm Dr. Joe Thompson, CEO of the Arkansas Center for Health Improvement. Appreciate your time today. We want to bring to you the first report on the impact of the Arkansas medical marijuana program. This is a unique report based off of the transparency initiative that Dr. McGee just mentioned, funded by the National Institutes of Health, the Institutes for Drug Ad drug and alcohol addiction, and candidly, I think this is probably the first population-based report to a public health committee anywhere in the nation. So we want to bring that to your attention. I've got on the 2nd slide here, let's see, get going. What I hope to do fairly quickly today is is bring to your attention some of the changes underway nationally and in States on cannabis legislation. Quick profile our program and then look at the data to describe who in Arkansas participates, what conditions are they qualifying for? What products are being purchased? How much, how frequently, um, what physicians are certifying individuals. Is there evidence that we are having medical marijuana truly integrated into the health care system and then speak briefly to one of the conditions of several that we're looking at for what the impact has been nationwide 38 states have now legalized cannabis in some way, 14 states, including ours have restricted it to medical use only. The use nationwide has risen over the last decade from a 1.2% of the population to 2.5% in Arkansas we're at about 3%. I'll share those numbers shortly. Historically, the federal government has restricted marijuana as a Schedule I substance, meaning it had no medical use. This year, actually last fall, the Food and Drug Administration requested the Department of Justice, and now the Department of Justice through the Controlled Substances Act is considering changing that from Schedule 1 to Schedule 3, meaning that it could enable research to happen with federal dollars and other inquiries. Up to date, there's been very limited clinical research because there's no money flowing for clinical research, so we don't really know much about marijuana other than anecdotal reports, small studies. I'll give you one piece of information that will come back to the studies that have been done, a dose of medical marijuana has usually been tied to 10 mg, which is the amount that California, Washington, Oregon have estimated is in a joint of marijuana, so 10 mg of THC is a dose, if you will, of medical marijuana. So we'll come back To that in a few minutes. This, as I mentioned, is the first NIH funded population-based study of medical marijuana. We worked together with the colleges and pharmacy, medicine and public health at UAMS to accomplish this. Uh, our research team included Dr.s Hudson, who's here with me this morning in the audience, Dr. Martin and Gowdy and our AI analytic team, um, just a quick overview of our program. It was authorized by a constitutional amendment which limit some of your ability to make programmatic changes. The first dispensary opened in May of 19. As of August of this year, we've got 38 dispensaries and 105,000 active medical marijuana cardholders. The participation process to get a card, patient submits assigned form by a state licensed physician. The first visit is required to be in person. The state then issues a card that authorizes the purchase from a licensed dispensary. It can be renewed annually by phone. Uh, the card holder can purchase the equivalent. This is going to be important a little bit, the equivalent of 2.5 ounces of flour, um, every two weeks, the cultivation, the transportation, the dispensation is highly regulated and we have 18 qualifying symptoms or conditions that physicians can certify individuals for. Some of these are very specific diseases you'll see glaucoma, hepatitis C. Some of these are a little more vague, intractable. Pa, that's a symptom, not necessarily a diagnosis. Uh, the data sources that we use for this inside of the healthcare transparency initiative include the Arkansas Medical licensure data, the qualification data from the medical marijuana cardholders, the dispensary data, and the all-payer claims database which includes about 80% of all the paid claims on individuals in the state. Importantly, we don't have any individual persons identifiable information. This is all blinded information. There's no individual information. I don't. Who bought what, who has what condition? I'm in there, probably you're in there, but we don't have the ability to find anybody if we were asked to. So who is likely to be certified? You'll see the Arkansas adult population in the middle column, you'll see the cardholder population on the right. It's younger folks, those 18 to 44, the most likely 45 to 64 year olds. There's a slight predominance of women that are cardholders and Caucasians are much more likely to be a cardholder, not depicted here, urban residents are more likely to be cardholders than our rural. Residents when we look at what are their qualifying conditions in 2021 we had 76 77,000 individuals that qualified for over 98,000 conditions you can qualify for more than one. That's why you have 98,000 conditions, 76,000 individuals. PTSD was the most frequently certified condition within 3 pain conditions that followed that intractable pain, severe arthritis, and peripheral neuropathy. If you combine those pain conditions, they become the majority. So pain is the most frequent reason that people certify PTSD, the next most frequent, and you'll see it falls off quickly from there. This is the trends in transactions, so the dotted black line or the number of dispensaries that have been opened, the red line is the amount of plant-based marijuana or flour that has been sold. The vape or the is the uh solid black line, edibles, the teal line, and then there's a A number of tinctures, oils, other things that are sold, so you'll see the monthly transactions we have somewhere close to 3000 to 400,000 transactions that occur monthly at a dispensary by those 100,000 individuals that have a card. Here's the amount of THC tetrahydrocarbonanoid is the is the active ingredient inside cannabis. So this is the amount of THC purchase. You see again the flower-based plant marijuana being the predominant source. Followed by vape and edibles, and then the dollar spent, so we individuals in Arkansas spend somewhere close to $20 million a month on medical cannabis. The purchasing characteristics, and you'll remember I said that 10 mg per dose, the average amount of THC that somebody purchases per day is 160 mg per day on average, an individual goes to a dispensary 30. 3 times a year, so about 3 times a month. Uh, and the average Arkansan spends $3300 a year at a dispensary. For those that purchase flour, they go 3 to 4 times a month for those that purchase edibles, it's about one time a month. Uh, so these are characteristics of your consumers in the medical marijuana program. This is an interesting chart. I mentioned the average of 162 mg per day for those predominantly purchase plant marijuana that averages 206 mg per day. For edibles, it's far lower at 35 mg per day. vapes 120 mixed types, the tinctures and others 35. So overall it's 162, the average, but if you look at the maximum amount we have individuals that are purchasing 900 mg of medical marijuana a day for plant, 752 for edibles, 900 for. I mean, so this is really, I mean if you think about a 10 mg dose. These are 90 doses a day that individuals are purchasing, which we clearly think represent. Probably not personal consumption, but diversion to other sources. Um, when we look at how many physicians certify, so to be a certifying physician. You have to be a licensed physician with an active DEA license of the 6871 actively licensed physicians, about 12% certified and individual in 2021, or at least one, the majority of those certified fewer than 10, between 1 and 9. We 7 individuals. It certified over 1000 when that plays out, the ones that are doing it kind of judiciously with less than 10 certifying about 4% of the whole population that are cardholders, the 7 individuals represent over a third of everybody who got a medical marijuana card in 2021. When we look at the evidence for whether a physician that certified an individual is actually integrating that into their health care, so we're going to look at the 1 through 9. Certifying physicians versus those with over 1000. Um, well, sorry, I jumped ahead of the individual 76,000 that were qualified, we could find about half that had continuous coverage in the all-payer claims database for which we could look at whether they had the condition and whether the physician was using it in their care. Uh, what we found was about 92% of individuals with a card had seen a physician in the previous year, about 62% had a paid claim with a physician visit with the diagnosis that they Certified for, 32% had a paid claim with a physician that certified them and about 27% both saw the physician that certified them and that physician gave them the diagnosis in a claim that they qualified for. So about 27%. We've got pretty strong evidence that the physician who certified them also saw them and also gave them the diagnosis that they certified them for to an insurance company. When we look at the differences between number of conditions on the left. You have the physicians that certified between 1 and 9. On the right, you have the physicians that certified over 1000. The dark blue bar are the patient, so the patients in both circumstances saw a physician anywhere about over 90% of the time in the year before they got their card. The brighter red is the proportion of individuals who had the same diagnosis in a claim about 75% of those that were between 1 and 9 certifications, had a diagnosis about 50% of the physicians that certified over 1000 was there a diagnosis in the claim. But then on the teal, you'll see it really drops off. The visit with the certifying physician. In other words, you were seeing that physician for a regular basis. It's over 60% for physicians at certified 1. 9 it's less than 5% for those with over 1000 and when you look for both a certifying visit and a concordant diagnosis from the physician. It's over 50% or right at 50% for those that did less than 10 and it's very few for those that did more than 1000. So clearly we have two different groups of physicians here. We have physicians that are trying to integrate this into their care platform, and we have physicians that you see the billboards for which are gateways for individual access points along the pathway. So we looked at is there evidence of a clinical impact on select conditions, and this is the first of several that we will look forward to bringing the other results back. We looked at PTSD first because that was the most frequently qualified condition, and we found individuals that had diagnosed PTSD in the all-payer claims database, and then we group them into those that were purchasing medical marijuana or not, and we paired them up tightly matched on profiles, demographic profiles, clinical conditions, amount. Health care utilization and we look at differences between the medical marijuana users and the non-users. Differences in ER visits, differences in hospitalizations, differences in medication use, PTSD frequently use antidepressants or anxiolytic drugs and changes in outpatient visits. Our preliminary findings, which we have put out for peer review to make sure that others believe that the path that we took is a legitimate path with a legitimate findings. We did not find any changes in the prescription. That were used between the medical marijuana users and the non-users. We did see and observed increased hospitalization in non-users compared to users, so people who were not on medical marijuana ended up having more hospitalizations in the year after than those that were using medical marijuana, about 4 hospitalizations per 100 individuals. Now these are people that were diagnosed in the claims with the PTSD 2500 individuals. You'll remember he had 39,000 that Qualified with PTSD. We have quite a few claiming to have PTSD that have never been diagnosed with PTSD in the claims by a physician. So this only represents those that were known to have diagnosed PTSD in the claims. Finally, these are the additional questions we have underway. The first two are I think an important one with pain, does medical marijuana change your health care utilization if you have intractable or chronic pain, and importantly, does it change your opioid utilization? Are people substituting medical marijuana for a more risky opioid pain medication. We have that study underway. We're also looking over time to see whether the use of medical marijuana want increases the diagnoses of cannabis use or other substance use. Disorders and we're looking at the population as a whole to see did the introduction of medical marijuana cause increased hospitalization, utilization, motor vehicle accidents, or deaths. Finally, um, Major findings over 3% of Arkansas adults are currently certified, purchases on average visit every 11 days, spend $3300 a year. Edibles represent a far lower intake point than flour or vape. Some of our purchases we believe do indicate diversion because of maximum amount that we see of licensed physicians, about 12.5% are participating. Most appear to have cared for the individual, but there are also those that have certified Fewer. We have a few high volume providers that are access points, I think, for individuals. Uh, and final early findings of our PTSD may show benefit, but we're looking at longer efforts for pain and other outcomes. We did note something, and I think it's important to draw to your attention. I think this is in our Constitution now, so I don't know that you have much option here on this, and I would validate that when we looked across the states in constitutional acts. This has been the way that others have written it also, so we're not. But you'll remember that in our act, people can avail themselves of the equivalent of up to 2.5 ounces of flour marijuana. So if you look on the top, You can have 2.5 ounces of 7 g if THC, the active ingredient, makes up 20% of the flour that gives you 14 g of THC. So on the top is what our constitutional Act says you can have the equivalent of. When you start thinking about the production of derivatives from that flower. A gummy is 10 mg, so 14 g of THC represents 1400, sorry. 14 g of THC. And a 10 mg gummy represents 7000 gummies. You can buy 7000 gummies every two weeks. Uh, when you look at the vapes again because it's tied to the weight of the flower, you can buy 140 500 mg vape cartridges cartridges every two weeks. So this is where you get to those upper limits of the THC purchase by individuals is the governor on what we can buy was tied to the weight of the flower, not the amount of THC. So this is actually kind of a loophole that's consistent across almost every state in their initiated acts that have been put in place. So for your considerations, you know, strengthening the documentation requirements for patient physician relationship in the certification process, potentially integrating certifications in the PDMP so that clinicians could be aware if their patients are a medical marijuana user. Strengthening the anti-diversion messaging. It is in your card reckon you have to recognize that you won't share it or sell it with anybody else and when you get your card for clinicians, consider integrating medical marijuana screening into your regular practice because your lack of awareness of who may be on it. Uh, and if ever given the opportunity to consider using the total THC amount for purchase limits as opposed to the weight of the flower which then gets changed into derivative products. And I guess final With the Schedule 1 to Schedule 3, and the lack of clinical research, I would anticipate major federal funding coming into the research space to study medical marijuana and with the Biosciences Institute and the researchers that we have and the data that we have available, this may represent a true growth opportunity for the state. Thank you. Dr. Thompson, thank you. That's fascinating, uh, data. I hope everybody on the committee was paying attention and sort of been comprehending some of the points that were being made. I know we have at least one question, Senator Love, you were first in the queue. Thank you, Mr. Chair, and I think my question was answered. Because I was gonna ask how um How are people, you know, referring back to your slide, I think it's slide 15 when you began to talk about the the max 900 and I think you just, I, I think you just actually described that in regards to the loophole. Is that what you were trying to describe here the maximum amount is what was over on that far left side because it's tied to the weight of the flower, 14 g of THC, 14 g if you're selling 10 mg gummies. That's thousands of gummies. So that's how people are able to get more people are getting to the maximum amount, yes. OK. Let, let me ask you this question then, because me and and Representative Gonzalez, we don't see eye to eye. Many things, but I think we're seeing eye to eye on this, man. So, so, um. The sky's pardoning something's falling out. I don't know, but let me ask you this, do you, when you began to look at the prescription. The prescription drug use and then also with the medical marijuana. Are you all, are you, are you all cross referencing any information in regards to like the drugs that people are getting. So for instance if somebody has PTSD and they're saying, you know, they're getting a prescription drug for pain, and then they're also getting medical marijuana for pain or, you know, are you all cross referencing any information like that, I mean, like, what are you seeing there because I would think that if I'm getting medication for pain and then I'm also medical marijuana like something should give to where I'm not getting both. So your question's a great question and just for clarity, we are cross-referencing, using your term, using our research term, we are matching people up that look exactly the same or using the same medicines at the same level, at the same dose, and then one group has medical marijuana and one group doesn't, and we look to see if their pattern has changed and what medicines they're using. For PTSD, at least for anxiolytics and antidepressants, we did not see much change. We are looking now at people with pain that are on opioids to see whether the opioid amount of somebody that is using medical marijuana for pain or not whether the opioids go down. That's, that would be a contribution of medical marijuana in our opioid epidemic if that were true, we don't have those results yet, but I look forward to bringing that back when we do, OK, but, but I guess you're not seeing any change in the the the prescription and then they're also getting The medical marijuana, I guess, to treat the same thing is that for the 2500 people that we have done the research on with PTSD diagnosed, we did not see a change in their medications. Thank you. Thank you, Mr. Chair. Representative Bray, you recognized. At least somebody has their mic on. No. Thank you, Mr. Chairman. Um, my question is, do you, do you have any policy considerations for this chart at the bottom of page 8, maybe, um, correct me if I'm off base here, but It seems a little bit alarming that out of 860 Physicians certified to issue medical marijuana that 7 of them. Prescribe a full third of the amount of marijuana prescribed. You have any thoughts on that? I would say, I would suggest some of my colleagues have been very entrepreneurial. I do have, I do have concerns. I mean, the fact, the fact that that 90% of people had a physician visit, but for the, the people that were certified by those 7, they had such a low rate of their physician certifying them or having given them a diagnosis, um, you know, I think we've got two different pathways here. We've got some people that are going to these high volume positions, and then we have other groups of physicians, the majority, far majority, 500. $700 if you add the next group that are trying to legitimately integrate it into their practice. Yeah, I mean, the thing that you said about the the billboard advertising seemed odd. I mean, I just don't see billboards for other types of medications like that. Is that? I think your observation is correct, OK. Thank you. I think it's a great point. I mean, I think there's there's going to be a lot of questions on this issue. I want to get their base questions. This is some really, you know, I think, um, informative, maybe transformative data that we're looking at. I know that there are some, uh, Constitutional challenges around how we regulate this particular industry, um, but you know, challenges are not it doesn't mean there's not options, right? Uh, and so I think, yeah, I would encourage everyone to thinking about this, to ask the question, you know, Representative Ray's asking what, what is it that can we do? I mean, for instance, we could talk to the medical board and ask them to do a specific review and report back to us on prescribers of medical marijuana. You know, there are different things that we could do around this, Mr. Chair. Yes, this is a lot of information and it's new. I'll be glad I will be glad to stay here as long as your members would like. I would also be glad to come back in a more focused effort because you got a heavy agenda on everybody's, this is interesting. Everybody's interested in this. We'll stick with it for a while. Representative Pil continue to recognize. Thank you. um comment and a couple of questions. I do find it ironic. You could probably take the dates off this, these charts, but everyone could probably pinpoint when everyone was sent home because the rates just shot up, but Yeah, I'm, I'm curious on the providers that were licensed. I mean, it seems like clearly there's ones who are wanting to do it, but I'm kind of curious being a provider yourself, I mean, were there. You know, this would seem like if you're a primary care provider, a family practice provider, and you saw individuals who wanted to get relief for their pain, wanted to try out medical marijuana. It to me it would seem that you would want to add an additional service line if you could, um, but it doesn't, and maybe I'm not understanding this correct, but it doesn't seem like as many physicians signed up to be a provider. Is it, do you know what that kind of lack of it just because it's federally banned. Is there, you know, legal concerns. I just, I, could you kind of walk me through that? Share with you anecdotally from my conversations. I don't, I'm not surveyed Arkansas providers, so I don't have, you know, hard numbers. I think most providers, because there has not been the research that's needed to know that it's safe or to know what dose to give or what type of flower to purchase, and I think most providers are uncomfortable because we just don't have the same amount of knowledge that you have if you look up any other drug, you've got a complete clinical trial, you know what the Adverse effects are, you know what, it's drug drug interactions are, you know how to watch out for adverse side effects. We don't have that on the medical marijuana side. Um, so I think that that's the biggest piece, and I think that's why if the federal government switches it to Schedule 3, you're going to see NH be forced to actually invest in that research and well. Naturally see an uptick of providers who are offering that. OK, um, good to know. Thank you for that. And then on the, you know, you said there's a decrease in hospitalization. Do you have a dollar amount? What we figured the savings would be to with the decreasing we did not in this research study look at at at the dollar impact this, this funded study was really first to look was there an impact at all. We are going back to the National Institute for Drug and Alcohol Abuse, with another grant application to continue this work, uh. I think because of the unique aspects and what we've accomplished, I'm optimistic that they'll support that, and we can add dollar amounts not only for the 2500 PTSD that we saw, but also the other conditions that we're teeing up now to look at whether there was a change. Yeah, I just can imagine, you know, name of the game and and savings is, you know, reducing hospitalization, so anything we can do to add to that, I would just be curious and if there's a way to reverse engineer the study to maybe get a potential number, I would just be curious to see that if you guys could get that to me so, I've got more questions, but I'll wait for another time. Yeah, there's a, there's a pretty long queue. We'll try to limit everybody to one question if we can until we get to the queue. Representative Graham link you recognize. Uh, thank you very much. Um, so real quick, when you mean diverse, what do you mean by diversions? Diversion would be an individual that has a card, makes a purchase, and either gives or sell it, sells it to somebody else or it's taken like where I'm at, so I teach middle school, um, I know. be stolen, fair enough. So I mean that's a real concern for me though is, I mean like I know I've had kids who have dropped THC vapes in the halls at schools. They hid them in deodorant, deodorant containers, like, I mean that's a real thing. Kids are getting access to it. We know that when THC is hitting a developing brain, there's not good things that happen with slows brain development and stuff like that. So I mean, I am also concerned that as this expands, kids are getting their hands on. Stuff and we're seeing it in the schools and other kids who would never normally be around the sufferer now getting connected to it. Like what are, what are we doing to make sure that we're protecting our kids in that capacity. So I would say with respect to the medical marijuana program, uh, I'm not aware of any protections that are in place or necessarily identification of cardholders who have kids that could be at risk for either unintentional or as you as you imply, teenager access to those issues from talking with superintendents and school teachers across the state. I mean this is a huge the substance use, the mental health issues, the ability of both school personnel and parents to stay on top of this is a real challenge. Representative Ro you recognize. Thank you, Mr. Chair. So You had mentioned earlier in your presentation, and I think we've kind of touched on it, just that there's an amount being purchased that far surpasses the amount that could be consumed maybe on a on a daily basis, I believe so, yes, and then you mentioned additionally there and we see this chart now, 7 physicians who are doing over what roughly 3 of these prescriptions, and I think can come to terms with there's going to be bad actors in every field. Um, one of my experiences was showing up at my church on a Sunday morning and seeing a bunch of signs in front of our church during primary season, and I thought somebody had put campaign signs. When I got closer, I realized there was 52. Um, hey, come see me, I'll get you your medical marijuana card signs in our church, you know, parking lots and our our walkways, so I would consider that. I would consider that being a bad actor because they weren't our signs. I'm saying all this to say, do you have data you mentioned having blind data, but do you have data that you can cross reference the amount that's purchased by patients as they're prescribed. By these physicians like the physicians who prescribe to 1 to 9 individuals. Do you know the total purchases by those patients versus the 1000 plus that are prescribed by the 7 physicians. In summary, can you tell if the Patients in the large group are buying more per patient than the. Person, the patients in the smaller subset, can we attribute the amount or the dollars to the physicians who certified them, that is possible through the transparency initiative. We have not done that yet. A brief follow-up, Mr. Chair. You recognize I think going along the lines of with the bad actors and with with the understanding that some of these are being purchased beyond what could be consumed, and we're not sure exactly how to handle that. I'm Just wondering if you can also correlate purchase beyond consumption from which physician, which subgroup, does that make sense? It doesn't. I can see the value from an oversight or an enforcement perspective, and you know if the committee wants us to try to, what I'd like to do is find the questions of the committee that you would like for us to answer and then we'll try to start working on answering them uh to your, to your satisfaction. I would be very interested in that. I'm sure he could help me formulate the question more, but uh, thank you, Mr. Chair. Thank you. I think that's a great of information that would be good to have Representative Gonzalez, you recognize for a question. Thank you, Ms. Sher. I have a real quick question starting out is, is there a minimum age for acquiring a card? Uh, you've got to be, uh, 18 or older to have a card yourself. You can get a card for a minor as a parent or as a legal caretaker and we have a, we have about 100 children that have a parent or a legal caretaker that are certified. We've not studied those kids. We presume that those are, well, we just haven't studied this. Well, Representative Grandmother's question just got me thinking if there was a minimum wage, so these are not really prescriptions, right? So the doesn't prescribe marijuana. They just recommend a card and then it do they recommend a dosing as well, or is that just up to the cardholder's budget as to how much they buy, and that's why you're seeing this supposed diversion. So excellent question, and I'm going to be very, very clear. These are not prescriptions. This is not the physician with any knowledge saying, here's the amount. Here's the frequency. Here's the maximum. There's no pre here like you would have on any other drug that your physician would give you. The physician is just saying you have a condition that in the Constitution of the state of Arkansas says the health department gives you a card to then go to a legal dispensary and buy up to 2.5 ounces of flour-based marijuana. So there's no guidance, there's no limit, there's no recommendation from the physician. Now the dispensaries have Supposedly, uh, pharmacists, available for or they are required to have pharmacists available for consultation. When we look at the pharmacists that are signed up, we see a few pharmacists signed up for a lot of the dispensaries, and they're almost all remote available for a phone call, so there's no in person kind of consultation going on with a licensed clinical individual frequently. If I can, it's up to the budget and up to the budtender. Senator Irving, you had a comment, so just excellent question by Representative Gonzalez and Senator, I mean, and Representative Pilkington, and the reason why I actually ran that legislation so that physicians don't prescribe this because of what his answer was. There's no clinical data. There's no study. There's no recommendations of dosage and and how that equates to solving the ailment or whatever like you have with other prescription drugs. Um, also, are regulated federally by the DEA. This is a illegal substance federally and so that creates a jeopardy for your physicians. They cannot prescribe something federally, that's illegal when they're they're regulated by the federal DEA. So, uh, so they certify only the condition, but he's absolutely right, and I think it's really an important point that needs to be you know, understood by everybody. Yeah, this, this, the idea that this is medicine to me. I mean, again, medicine for me is something that we study, we bet through traditional measures of research. This is a federally illegal drug, so this is not something that's been open to those types of research. So I don't really have an educated opinion as to how many milligrams of THC might actually help your PTSD or might actually help your muscle spasms. It may. I don't know. The studies aren't there for me as a physician to make those recommendations. And until we have that information, I wouldn't feel comfortable, you know, making a recommendation for a milligram amount. I mean an analogy would be if you could just go get hypertension medicine, right, and you could get, I don't know, 5 mg of lisinopril or 5000 mg of lisinopril, and we just said to you as a doc, hey, you know, you have hypertension. We certified you just run down to your hypertensity medicine store and grab whatever you want and just take it, however you feel like it. That's sort of the same analogy for me with this, and I could never sign off on that. Personally, Representative Wilridge, you have a, a question. Thank you, Mr. Chair. Um, I guess my question would be, do, do you all study the percentage of folks that seek a card from these providers that Representative Ray mentioned that are declined. Or do 100% of the people that seek a card get a card. I think it's a very high percentage. It may not be 100, but if they get the paperwork right, they get a card. OK. So I guess, can I have a follow up? You can, you can, so they're. The qualifying symptoms, those kind of things, there's no thought process to whether somebody's been treated for PTSD prior to all of a sudden this now becoming accessible or any of the other qualifying things of 55 year old can all of a sudden have a qualifying symptom that they've never been treated for in their lifetime and we're approving 99% of those requests. I would say yes, more specifically, there is no validation step in the certification process that the person has the condition. It's just the physician's attestation and signature is that by constitution or is that something that the medical board would have oversight of? That's the exact question I had Representative Woldrich is, you know, is this, I don't know the constitutional constraints around certification, it would be nice if we could create a certification process that required, you know, at least a prior diagnosis of one of the qualifying certifications before. You got a medical marijuana card so that you could say, hey, look, if you have this diagnosis, you're being treated for this. The treatment's not working. You're wanting to try something different, OK, versus I want to get a medical American want a card. Let me call one of these 7 and see which diagnosis I can get shoehorn into to get my card. That, you know, that's the idea. And, and I think it's worth looking into. I think there's a lot of these things we ought to ask some good questions on around what are our freedoms within the constraints of the Constitution. Do some different outside the box thinking around the process. Thank you, Mr. Chair. Um, I don't see any more questions. I have, I have at least one or, uh, Senator Chetfield, did you, did you still want to ask your question? Thank you, Mr. Chair. One of my major concerns is the industry itself. And uh I think that's something that we're going to have to look at, um. We continue to see a collapse of management. More and more, um. One entity is managing so many of the Uh, of the, of the, uh, companies. And so we're almost developing a monopoly. We have the individuals who are still in essence, owning it, but they're not managing it. And so that's one of my major concerns that I share with the chair quite often. Also, making sure that when we are dealing with it. That from sea to sail we are making sure that the product is a good product, and we haven't looked at that. We had a lot of difficulty in the medical marijuana oversight committee in making sure that the people who are invariably out of state. are indeed being responsive to the needs of this individual state and the people that it is supposed to serve, so that's my comment on it. I don't know if I necessarily have a question, but that concerns me greatly because if we're going to have an industry, I think it's flying under the radar. Because more and more, more and more we are having a monopoly of management which I don't think is good for the industry either. Because we said we were going to have various people owning it. But if we're collapsing management, it doesn't matter if they're different owners because you've still got one person or one entity managing all of the industry, and I think that that's something that we've got to look at as a state and make sure that we're not letting that happen. So that was my concern. I am concerned about what we're talking about with that, but I've always been concerned about the industry itself as much as those who are prescribing within the industry. Yeah, those are great comments and great insight, and I think this A matter that deserves some attention and I look forward to giving that just briefly two other quick questions. One's more of a personal experience, anecdotal question hyperemesis, cannabinoid hyperemesis is something that I feel like I see now, uh, with some regularity in the emergency department as a practitioner that I didn't see 5 years ago, and I'm curious if there's a way to track that diagnosis through the all claims payer database, uh, specifically through emergency departments department visits for cyclical vomiting. That we, we see patients regularly now and that was something I never saw. Um, and I suspect quite a few of those people it's related to that. That is a condition Dr. Hudson specifically wants to look at, you know, in our future studies, but yeah, I think it's really an issue and then the other question I had was around the geography, do we have any data around like where, where do people live in Arkansas that have the medical marijuana cards, is there a distribution that matches the population? Is it skewed in one way? I didn't. If you had any information on that. It is statewide. I mean, there are medical marijuana cardholders are in every county in every corner of the state. There's an urban predisposition, so you're more likely if you're in a more densely populated area, and I think if I remember correctly, I'd want to get back to you. I think there's a little bit of a Northwest tendency compared to the southern and eastern parts of the state. Thank you. One other ask would be a big presentation, lots of slides. I thought there were some very salient bullet points like I would love to see, you know, what percentage of patients are one time, first time diagnosis. This information about the high prescribers, the information about how many milligrams of THC are actually being purchased per day per consumer. If you could get sort of a, I mean, you may already have it like a one pager for the committee with Of the more headlines, yeah, headlines, some of the some of the more grabbing points that you've alluded to today, that would be much appreciated by myself and everyone on the committee. Thank you for your time and your support. Thank you, great information. Thank you. Now, Mr. Davis, sorry to try to tap you early. If when y'all get seated, if you could just state your name for the committee and I'll let you, you recognized to present as soon as you state your name for the record. All right, thank you, Mr. Chairman. Andy Davis with UAMS. Paul Phillips with UAMS. Mr. Chairman of the committee, sometimes in internal meetings, the UMS, I get to see a presentation from an institute or college that I just strikes me as particularly interesting and I saw Dr. Phillips do this for the Jones Eye Institute a couple months ago, so I asked him if he would come and present to you guys. We don't have a particular ass today. We don't have anything groundbreaking to share. This is really intended just to be informational and educational for you guys. I think the I Institute is something that, you know, Depending on your perspective, we don't talk about a whole lot, and so I just thought it would be interesting for you guys. And with that, I'll turn it over to Doctor Phillips. Well, good morning, everyone, and thank you for the opportunity to tell you a little bit about our world class eye institute. Uh, my name is Paul Phillips, as you may gather, I am not a native Arkansan. I did my accent has softened over the 20 years, but I grew up in New York, subsequently trained at the EREI Center as well as Johns Hopkins, some say the best eye center in the world and was recruited to the University of Arkansas Medical Sciences, as well as Arkansas Children's Hospital and have been privileged to be on the faculty for the past 20 plus years and to serve as faculty member, program director, head of the residency program and now chairman of the department as well as director of the Jones I Institute. There is a handout. I hope everyone has it. You can follow along because we'll be going through it pretty quickly. I think, um, you know, what inspires me to join a place like this, and one is the academic mission, I think, you know, what does that, what does that mean in terms of emissions statement? I think everyone knows that physicians treat patients. You see patients in your office. You might treat 100 patients or 50 patients, but part of the academic mission also involves education, treating the next generation of physicians. as well as research and consequently your impact factor is much greater. You can see 100 patients, but imagine you train 100 residents who themselves see 100 patients. You've now affected thousands and through research, even millions, and you benefit the state of Arkansas as well as nationally and beyond. Now, what allows us to achieve the status, our most precious resource, is our world class faculty and you can see on the next page pictures of many of them. We have over 26. Many may not be aware, you think the eye is so small, but the eyeball is too vast for one person, so we actually have multiple, we divide it up. We have glaucoma, cornea, retina, all parts of the eyeball as well as general ophthalmology and what you can see on that handout is we cover every subs subspecialty. There is no place in Arkansas that provides this extensive coverage and in fact there are only a few places in the country that provide this extensive coverage. You don't get it in Tennessee, you don't get it in most of the surrounding states and indeed we have patients who come from all of those places to seek care as well as Arkansans. Next page is CB service 3 hospitals, of course, UAMS, but as well we have the VA and we have Arkansas Children's Hospital, and you can see some of our clinical volumes, basically thousands of surgeries, over 60,000 visits. What I tell people is we're up to our eyeballs and eyeballs, and the bottom line is there's plenty of Work we do A lot of visits and a lot of surgery. I'm going to highlight some of our specialty services that put us on the map nationally and internationally. When is our ocular Genetics Center. So we have the Leland and Betty Talet Aylogenetics Center. This was established in 2009 by our first chairman, Dr. John Shock. It's now run by Dr. Sammy Udo with geneticist Dr. Brad Schafer, and once again this was established with a donation from the Tala family. And if you go to the next page, you'll see this structure. The patient comes in and in the same visit they'll see an ophthalmologist, a geneticist, a genetic counselor, again, all in one visit, much better than having them come back 5 or 6 times to get the information because as you can imagine this is a very, it's a touchy subject you're providing genetic information sometimes you find out by the result that the that the who you thought were the parents were not the parents. You really need a group of People in the room. And if you go to the following slide, it's really a list of some of the rare conditions we see and without going through all the fancy names like retinitis pigmentosa and a whole host of others. Suffice it to say most places see one or two of these a year we see several 100 a year. So again, that's what puts us on the map nationally and if you go to the following page, it's gene therapy. Now this is something when I was training in the 1990s, I didn't think I would see this in my lifetime. This was futuristic, so I thought, well, it turns out the future is here because we now have some blinding conditions where we can inject the gene in the eye and in fact the eye lends itself to gene therapy because we have access. We can inject it. This is done in the clinic and the gene gets incorporated into the retina, and that is now allowing children who would have been previously blind for life to have improved vision. So it's quite a, it's quite dramatic and it's only going to Expand and we're on the forefront. We're one of the few centers that do that. I'm going to just highlight a couple of things with clinical outreach. One is our marshal Lee's gift of sight, and you may have seen this in the news, but I think many know that the Marshall Islands, middle of the Pacific, a small atoll, and nuclear weapons were tested there. Consequently, their ecosystem was damaged and many of them have migrated to northwest Arkansas over 14,000, 1 of the most in the country, and it turns out that um even though they he legally over the years they've had limited. Access to medical care and consequently, They're walking around with cataracts. They're typically a blinding. cataracts that you do not typically see in the United States. Most times when we go to Guatemala or Honduras. That's where we see these cataracts, but it turns out there's a group in the US that unfortunately is walking around with these, and we've established a program where at no charge to the patient, we evaluate the patient, we bus them in, we put them up in a hotel. We do their surgery and if you look at, uh, again, if you roll through the slides, you'll see this Lady who is now reading 2030, 2040. She couldn't see the big E, so we drove them here on a van after we do a 30 minute surgery. They want to drive the van back themselves. So it's quite a quite dramatic. Now this was in the news as an annual thing, but I didn't want this to be just a news story. There are 14,000 up there, so I've established this as a cyclical thing. We've now done 7 groups over now over 80 patients who now see we do a group every other month and my Goal is to increase it to every month over the next year. Our other big outreach program is with telemedicine. I think as we discussed earlier, Arkansas has public health issues. You were discussing smoking, but in addition we're typically in the top three with regards to diabetes. It is the most common binding condition in people over 65 treatments best if done early. Unfortunately, only 50% even get to the eye doctor. We can't even get them in to look at them and with telemedicine, we now are able to get a picture of the retina when they're seeing their primary care physician, so they go to get their insulin. They not even an ophthalmology specialist. He hits a button, gets a picture. We review with the picture about 40 or 50 of these a week and if you look at um slide number uh. Slide number 27. You can see what we've already done over the last several years since establishing this well over 1000 patients have been screened over 200 were found to have diabetic retinopathy that otherwise would not have been detected and treated. So this directly results in sight saving treatment. In addition to diabetes, we found another over 300 who had other conditions that needed to be treated. So by getting the exam to the patient as opposed to getting the patient to the exam. Obviously has great impact with regards to access. I'm going to slide 29, you see the research we're doing with artificial intelligence, so maybe the next generation, there'll always be a room for doctors, but you know, we're not so far from having machines analyze the pictures. Finally, I mentioned the marshallese, but we do have an international rotation where had to go to Guatemala and Honduras. OK, a final two things. One, education. We have to train residents. They train. That's important to many of them practice here in Arkansas. It's the next generation. And one of the challenges of training residents is they have to do surgery, but we have to train them without sacrificing quality of care. We need to make sure our outcomes are not at any expense to the patient. And if you look at the surgical sim lab, you can see what I was trained on back in 19 70s, which is the operation game where I'm trying to remove the funny bone here without wringing the nose. Fortunately we've advanced quite a bit. The next step is we used to work on pig eyes. You could see the pig on the following slide, but we've now advanced quite a bit. We have a surgical state of the art surgical simulation lab where the residents can practice surgery. They can do a simulation of several 100 cases before working on a human being, and we monitor our outcomes very Extensively and we now have with the training of our residents outcomes equivalent to our experienced faculty. Obviously that's what faculty supervision through their training, but the bottom line is you get superior care and we simultaneously train our residents to be expert surgeons. Our residents then do go on, many of them stay in Arkansas. Some of them do fellowships, even from Duke to Baskin Palmer, many of them come back about half of the faculty a previous residents, and I'm proud to say we have a very stable faculty. Um, with regards to research where internationally and nationally known, you can see over the last 2023/60 papers, 42 presentations. This is dramatic for ophthalmology. It's for a small subspecialty. These presentations typically win awards, and if you go to slide 42. You'll see everyone knows the US news report. Well, they get their information from doximity, and in ophthalmology, it's really a population. There's no objective data, but the one objective data that that proximity does collect as research output, and you can see I put the list there, we only have the top out of 150 plus programs when I'm in the country, number 9. OK, if you go, you can see Mass General and Wilmer, Johns Hopkins, a 1 and 2, but the bottom line is we are now in the league with the best of the best, and Ali and if you go to the next page because I can't fit it all in one slide, you can see where who we be, who we do better than, I mean that includes Vanderbilt, Emory, Duke, Iowa. These are world class eye centers, and I can proudly say we are up there in the in the big leagues. Finally, we also have Basic science research which evaluates diabetes and stroke. So even in the lab from the patients to the lab, um we are productive and impactful in terms of future goals, as always, we went outreach throughout Arkansas. We know that Arkansas is relatively underserved and we're all very busy taking care of patients and with telemedicine and these programs, we look to maximize that. The second parts of genetics clinic. I only one of a handful, 567 places in the country that do that. Once again, this is a sight saving surgery and we're in a good location being in being in a place like a, like a FedEx was looking at one point being in a place in the middle where people can get to. We actually people can come in and get their surgery as well as Arkanskansans as we provide this world class genetics care. Um, we're expanding our fell so that we can cover all parts of the eyeball as well as our basic science. So on that note, I thank you for your time today. I am happy to address any questions and being the chair at the University of Arkansas for Medical Sciences. You all know how to find me, so if anyone even after this presentation has questions on any one of these programs or any other concerns, I'm always happy to talk. Thank you. Thank you, members of the questions. Senator Love, yeah, you're recognized for a question. Thank you Mr. Chair. Doc, I just wanted to clarify something with you. When you, you said you were talking about gene therapy. What was the, what is what, what did you say after that? Did you say that? People that could not see can now see, so right now this is, I mentioned that we're at the very beginning of this, so this is something I didn't think I'd see in my lifetime. So the condition that works best for is something called what we call labor's congenital ammorosis. That's a, that's a condition that children are born with. And we know the gene that's not working properly and we can inject the gene in the eye. The gene gets incorporated into the retina and the child and the children can see. And this has been on the news nationally and there's quite dramatic. We're doing a lot of research to expand this to other conditions and we participate in those studies, so it's quite dramatic. The best example I can give, it works best now if uh the cell structure is intact. So the condition we use it for, it's a little bit like your computer. If the software is down but the hardware works, the gene is like replacing the software. It'll be another step to repair the hardware, which is of course so if a neuron dies, how to get it back and functioning, but yes, we inject genes for a limited. For a limited number of conditions, but over the next 10 to 20 years, this is going to expand. And once again, I, I did not when I heard about this in the 80s, I didn't think I'd ever see it. I thought this was 100 years out. Well, it's now. OK. All right, Dr. Phillips, the condition you mentioned, can you say that name one more time? Labor's congenital ammorosis. Yes, and how long have we as a medical community been aware of that as a condition? 50 years, 100 years? How long have people recognized this is well, we knew the condition over 50,100 years, the condition, so for 100 years we knew this condition existed. When, when would you say we identified the gene? Oh, I'd say in the last 20 years, yeah, yeah, and since we've identified the gene, how long from identifying the gene to a treatment that cures the problem, yeah, to treatment that improves it markedly probably 1010, 15 years. I just think it's important to point those those time frames out. I mean this is a condition that's existed as long as human beings have been around, and we've we've recognized it in the last 100 years we've identified the problem 20 years ago and in the last 10 we've figured out a way to It's an amazing arc that we're on with this with these kinds of therapies, and I'm with you, you know, we, when we started doing the human genome project back in the 80s and 90s. That was when we sort of had this idea that hey, maybe some of these conditions can be treated that we never would have dreamed we could be treated before. We just thought you were wired this way and there was no fixing it. I think this is a great example and there are other examples out there of these genetic disorders that were on the cusp of this frontier of being able to radically change lives and you know turn people Who would otherwise have difficulty and challenges with their, you know, with with a variety of different medical issues, some of which terminal, and now we're able to save lives. It's great, great, great story for that to even highlight the arc even further. We only knew about DNA since 196 Watson and Crick 1960. So it's quite amazing from just even figuring out DNA and and the genetic to the genetic project and identifying diseases and curing them. One other question. One other question I think is Senator Love's asking, I think it's important the cost of this gene therapy, some of these things that we have identified, we've produced drugs that can treat it, but the drugs are sometimes millions of dollars a dose. What's the relative cost of this gene therapy? Oh, it is, it is probably about $1 million now, which when you talk about the cost, the patient doesn't actually pay that. So at this level we get it to the patient, the company is interested in getting it to the patient. So it's quite expensive, but Again, as you know, with any kind understanding a medical bill could take and the meaning is a whole other subject, but, but the bottom line is that we will get it to the patient, the patient that needs it will get it. And, and I certainly, I know it's intuitive to know the cost of, you know, helping a blind person maneuver through life versus a sighted person, $100 treatment on the long haul maybe a bar you. Yeah, you're talking about a child who can't even find his way to the door who can now make his way through an obstacle course, so absolutely, it's fascinating stuff. Anyone else have any questions? Representative, you recognize. Thank you, Mr. Chair. I'm not a part of this committee, but I just wanted for everyone to know that I attended the graduation services for the University of Arkansas for Medical Sciences, and you all had a number of graduates there in all the colleges. So if you would kind of share with us so that we can be aware that we have a lot of things going on here in Arkansas, and we are graduating a lot of doctors, researchers, and that sort of thing. So if you would just please tell us that, and I'm just So proud to be an Arkansan and to know that we have a facility a college here that graduates these types of doctors. Thank you. Absolutely. No, it's, it's a privilege to be part of the University of Arkansas for Medical Sciences. That's why I came. I had no connection here back then. I'm now here 25 years and and I'm 62, so I'm finishing it up here. Um, as you mentioned, we have 150+. People graduate serving all portions, of course I focus on the ophthalmology care, but there's also a huge emphasis on primary care, getting a lot of these graduates to rural areas to provide care and there's just enormous benefit to our Kansans. Thank you very much and I just want to give a shout out. I had 2 members of my sorority to graduate this past May as well, so I just want to say thank you so very much. Great congratulations. Thank you for your comments, Representing Pocadire can ask a question? Yes, thank you, Chairman. And sorry, I think you mentioned this and I miss it, but on the telealth services you're providing when you are I love that. I love bringing the exam to the patient as opposed to bringing the patient to the exam, who is with the patient when the exam's being performed? Does it? I missed that part. So it's the primary, well, the primary care provider, it's at the primary care visit. It could be it could be a specialty nurse. The person who takes the picture could be anyone you train in your office, so you could train like a medical assistant, an LPN. OK, great. And then we see the picture and of course we have a doctor analyze the picture, figure out. He's in trouble and bring them in. Gotcha. OK, thank you. Great, great points and great presentation. Thank you for your time today. I appreciate all the work you're doing for us. Thank you. Thank you. Committee members, we have what looks like a really long rest of the agenda, but it's, I think we're going to be able to get through it relatively quickly. Most of this is rules to review. Next up on the agenda would be Representative Graham Lake's two ISPs without objection, and if it's OK with Representative Gramley, do pass. I would move the I would entertain emotion. to pass those, see the motion, all those in favor say a congratulations, your eyes, piece of past. Do we need to do this one at a time or is it OK to do? Yeah, we're without objection, we'll count that for all of them. Perfect. All right, next up, uh, we have some rules for the Department of Health, whoever y'all want to bring to the table. Uh, we'll try to get through y'all's rules as quick as we can. Just when you get to the table and you get a chance, state your name and for the record. Thank you, Mr. Chair. Members of the committee, I'm Laura S. I'm general counsel for the Department of Health, and we have a few rules to present to you today. We'll try to move through these quickly and we're happy to take any questions. The first rule we have is rules for home caregiver training in Arkansas. The proposed changes amend the aid training requirements in order to comply with Act 70 of 2023. Uh, this would require a specific number, um, uh, at least 4 hours of training for dementia and Alzheimer's. The rule mirrors the original. 13 law and Act 70 of 2023 we had this rule approved by the Board of Health in January and had a public comment period in May through June of this year and we received no public comments. We're happy to take any questions. Members have any questions? See none without objection. This rule stands for review. You just want to state your name for the committee, you recognize that you state your name. Thank you, Chair Craig Smith, attorney for the Department of Health. Rick Maha. I'm an environmental health manager for Protective Health Codes, plumbing, and natural gas. Committee, you have before you a proposed rules to consolidate 4 rules into one as well as incorporate acts of 137 and 457 of 2023. Um, the rules pertaining to master journeymen and restricted plumbling license, plumbing and gas inspector licenses, restricted hospital maintenance and water and sewer line installation as such that also includes the repeals of the three other rules that have been incorporated public comment was period. held and expired on June 2nd and no public comments were received. Members have any questions? Seeing no this world stands reviewed without objection, this rule stands reviewed. So In the states were named for the committee you recognize to present? Terry Paul, Environmental Health branch chief with the health department. Can be members, we have the next item is the rules pertaining to on-site wastewater system. The proposed amendments are intended to comply with Act 137 and 457 of 2023 to remove old language, proposed changes to allow additional use of good management practices and subdivision review and incorporate changes regarding incept interceptor drains, a public comment period expired on June 3rd. Written public comments were received and responded to in the report before you. Members have any questions about this rule? Senator Love you recognize. OK, I wanted to try to catch what you said at the end. You said the public comment period expired and was there any Was there any objections? Was there any feedback? We received several feedback, several things that were noted that were not um did not affect the proposed amendments, but were things that the department will take under advisement and continue to discuss with the industry for the next changes that may come forth at the next time. OK, Mr. Chair, I'm not gonna, I'm not gonna object to this. OK, thank you. Members of the of the questions. Without objection, this rule stands reviewed. If you can state your name for the committee. You recognized to present as soon as you state your name. Kelly Kersey, Arkansas Department of Health section chief for cosmetology massage therapy and body art. Committee members, the next item are the proposed rules for massage therapy in Arkansas. These proposed amendments were to comply with Act 45 regarding licensing permits that were sponsored by Senator Irvin, Acts 137, and um W 67 as well as Act 531, uh, public hearing was held on June 4th, and the public comment period expired on June 5th. Public comments were received and included and responded to in the report and pursuant to Senator Love's previous question, no objections were required changes or Or review by the or restart by the promulgation process. Members, do we have any questions? Seeing none without objection, this rule stands for review. Do you recognize to present the next role? All right, committee members, the next two items are tied together, pursuant to Act 900 of 2021 and as a significantly revised by Act 688 of 2023, the rules for body art establishments were incorporated into the roles of cosmetology before you, uh, also changes pursuant to Act 137 457 516 of 2023 as well as 135. 725 of 2021, um, and so you have the combined rules in front of you and the corresponding repeal of the rules for body art establishments, um. The public hearing was held on July 10th which coincided with the end of the public comment period. Comments were received, several noted as um requests by the industry that will be reviewed and work with the industry members to further address those concerns as well as incorporate in future world promulgation. Members, do we have any questions on these two rules? seeing none without objection, Adams KNL stand review. Um. Looks like you'll have One more on the agenda? Yes, Mr. Chair, members of the committee. Again, this is Laura Suu. I'm general counsel for the Department of Health. This is the rules pertaining to dental hygienists serving under underserved areas. Um, and we also have our, uh, director of the Office of Oral Health and she can introduce herself. Sure, I'm Dr. Rachel Sizemore, director of the ADH Office of Oral Health. And these rules were recently amended to update the original act was passed in 2011, Act 89. It was amended in 2013 and again in 2019. So we are amending these rules to change the method of prioritizing the communities in which a dental hygienist may practice under a dental hygiene collaborative care permit, um, we, uh, had a public comment period. It expired in June on June 30. And we received no public comments, um, to the extent that we received comments from the Bureau of Legislative Research will make sure that the typos and any language that needs to be corrected is is corrected and make sure that that gets to the bureau in order to correct any concerns, and Dr. Sizemore is here to help answer any questions. Members, do we have any questions? Was this, was this role, uh, was this the result of a legislative act that was passed. No, sir, this is just updates. This rule had not been updated in in some time and we needed to change the priorities pursuant to the original act. And so the Department of Health is tasked with the, with the uh formulary and so it was updated to keep up with the times. Any other questions? Seeing no without objection, this rule stands reviewed. Thank you all for your time. Director Mann, are you still here? or someone with DHS. Sounds great. Yeah. You just state your name for the committee, uh, once you say your name, you recognize to present as many of these rules as you would like. Uh, Mitch Rouse, uh, Mitch Rouse, DHS chief of staff. Uh Well, there we are. All right, first rule that we have up is the vaccine counseling rule. This provides coverage for standalone vaccine counseling. We got no public comments on this. We had our public comment, uh, hearings in June and July, and with that I'll take any questions. Members have any questions? Seeing none without objection, this rule stands for review. All right, our next rule up is the disproportionate share hospital audit rule, so that's DH for short. This allows those overpayments, those DH overpayments identified by an annual audit to be redis redistributed to other eligible hospitals, so it helps us best utilize those funds and it's a it's an efficiency change, and I'll tell you we got no public comments on this. We got one BLR question and we address It was really just a technical question on a CMS citation, and with that, I'll take any questions. Members, do we have any questions? Senator Love, you recognize. Thank you, Mr. Chair. So what is, what is our current practice? So unfortunately I don't have Miss Mann up here with me, and she'd be better able to answer that question, but the way I understand it is it takes a little while for us to try to redistribute that money and maybe in certain cases we actually lose that money once the audit comes through and we have to pay it back. So what this does, it allows when that audit happens and we've identified overpayments to certain hospitals we recoup that money and then we redis. distributed out to eligible hospitals that didn't ask for a more dish money and didn't get it because we had to redistri redistribute distribute that money based on a formula. So the way I understand it, this change allows us to re redistribute, man, I'm struggling with that word to distribute that money and as I understand it right now, we, we don't, we just lose that money. OK. I guess this is money. Through Medicaid. OK, so. We recaptured the money in and then we, we have a opportunity to lose it, so then we redistribute it and so it has this all been approved? Yes, this has been approved through CMS. This is, uh, now before y'all for approval, but essentially it's an it's an efficiency measure where uh the the the way the money is distributed, it's distributed out in advance, so that's when the audit comes back in and says, hey, you, you paid too or too little or whatever the case may be. And this allows when that recoupment happens for us to make sure that we get it out to those, to those other hospitals that would have qualified for that additional money. OK, all right, Senator Urban, you recognized. Just to say, this allows us, Senator Love, to keep those dollars here in the state versus sending it back to the federal government. Which we all think we want to do, yes. Good question. other questions or comments on this rule? Representative Rose, you reckon that. Thank you, Mr. Chair. Just briefly, I was just looking at the financial impact, says the estimated cost to implement is $10,000,900,000 and change for the current fiscal year. Um, could you just speak to that a little bit? I'm, I'm looking at, I'm trying to digest all of this. It's redistribution of overpayment. For DH funding, but it's also going to cost us so the way I understand that is essentially we get more federal money that way. So that additional money is a is a cost, but it's essentially us redistributing additional federal monies that we're capturing, so you see it as a cost, but it's primarily federal funds. There's a little bit of state match in there and luckily on this particular one UAMS actually pays a big chunk of that. So it's a, it's a very little state match. On our part, but that's really just us recapturing that fiscal money and then distributing that by her money and net gain, is that what I'm hearing? Yes, yes, sir. It's better for our hospitals. They get more federal money that way. Thank you, Mr. Chair. Members, do we have any other questions, seeing none without objection, this rule stands for review. And then let's see what's next up on the list, uh. This is Medicare and Medicaid crossover billing, so this adds a new field to our Medicaid management information system so that we can improve how we report and pay those claims, so it will result in some savings and efficiencies that way. So that's a, that's a new thing that we're implementing. We got no comments on it, no BLR questions on it, and I'll take any questions. Members who have any questions? Seeing none without objection, this rule stands for view. You have one more, one more and I'm Mr. Hill up here with me. Jay Hill DHS division director for division of Beijing Adult Services. So we're presenting a rule to you this morning. This is pursuant to Act 198 of 2023, which requires the agency to complete cost reporting for assisted living facilities in the state as a condition of participating in the Medicaid program. DHS. retained Myers and Soffer to collect data from all of our assisted living facilities who do participate in the Living Choices waiver program. Uh, we are proposing a right adjustment to 8673, which is an increase from the current rates of 8567 or 8159, which is a differentiated between rural and urban facilities. We are proposing to end the difference in those rights. It will be a rate increase for all assisted living facilities, uh, public hearing was held on April 24th. Public comment was conducted and concluded on May 13th. This has been approved by CMS and pending approval from our from from. ALC this will retro back to July 1. With that happy to take any questions. Members, do have any questions for Mr. Hill or? Seeing them without objection, this rule stands for review. Members, I believe this conducts all the business on the agenda for the day. I want to remind everyone of our meetings in West Memphis, Memphis area on the 10th, 11th of September. Uh, I believe there's also an insurance commerce meeting scheduled for the 12th. Uh, we do have a block of rooms that we're working on. So if you intend to come to those meetings and need to stay overnight if you can let one of the chairs know, uh, with that, if there's not any other business, This meeting is adjourned.