Insurance and Commerce Committees - Senate and House

Thank everyone for coming we have a really good turn out here today and I think we're gonna get a lot of information out there to the public today so I really look forward to it and again glad for the turnout unfortunately there's a public health meeting and for smith today at the so we are missing a lot of folks but still appreciate everyone coming so much we have a fairly busy agenda so we'll try to move fairly quickly as we can so thank you for coming in sir hill anything you'd like to add. Appreciate it and being here a day representative should be a a good good chair for today's meeting he is an attorney so he will be listing closely to make sure all that dot in these are crawls so we appreciate that and look forward to the very informative meeting today. Thank you senator has anyone had an opportunity to review the minutes from our last meeting that have a motion by reps and of ubank's in a second bass in our hill all in favor say I in your post I know motion passes thank you. Okay first on the gender we have doctor charles mason doctor john watton and doctor just and why if you would come to the table please. The gentleman just take a seat you can introduce yourself and then commence with your testimony. I'm charles mason doctor just in white doctor john well thank you and and before you proceed if you would man tell us who you're with and what your role is there if you don't mind and then pursued with your testimony please. The. So i'm a charles mason i'm with the cabinet mergency hospital one of the local positions that is partial owner of that facility. And after just in white partial owner captain emergency hospital in the chief medical a. Cheap medical officer and owner as well of the fort smith you are in hospital assist or hospital the cab of the soldier. Thank you go ahead and proceed with your test money please. It is so at the so i'd distinguish senators that I guess i'll start first again we are emergency medicine physicians we probably between as we probably have close to seventy five hours of er experience just working various emergency rooms. Where were. Representing probably seventeen partners today that have asked us to come and talk to you guys. But in reality. We are. Now leave physicians that work in a hospital in their merchants to department but we're also owners. And so we've learned a different side of the business. That is now very concerning to us and that's basically what we're here to talk to you about the day is that is the pay that that occurs. We work for sister hospitals we both can have the same apparent company. We we employed between us somewhere close to a hundred and twenty or candidates and and we provide emergency care to roughly thirty thousand our candidates every year. We would be considered. Out of network physicians and this is where our problem last today and if no one knows what an allen network physician is will slowly explain that to you today as we work through this process. See here okay you got it. You know for the most part. In simplistic terms and out of network physicians one who basically has not agreed with the insurance companies. On a controlled rate. A pay for the for the services that we provide. We're here. But because recently there's been some changes mainly in the last two years. That has caused us to be somewhat fearful or skeptical whether or not. Our investments and our businesses are going to be successful because of its been a gradually decreasing rate a pay for the services that we render. Yeah. As owners of course were concerned about our employees were occurred we're concerned about the the areas that we cover lower as as providers with partners and we're concerned because as the pay starts to decrease a lot of our car leagues are looking to move out of state to where they have a better reimbursement rate. The courses in our kansan you know and the one of my other jobs is unmedical director for members we worry about the coverage that's available to the smaller counties in arkansas. So what we're going to talk about today is a very complicated. Subject it's some of it involves local problems with arkansas some of it involves payer problems with the insurance companies and some of it involves federal problems which is uh mainly the the newest law that was passed in s a law no surprise act. What we're hoping for today is. Maybe convince somebody to be interested in our problems and that. There needs to be some sort of standardization in the reimbursement process. We're looking for some way to streamline the reimbursement process so it's not so cumbersome cause we spend a large amount of our time. Just trying to do paperwork get paid and we are hoping to. That some way they're there there's a method within arkansas much like what texas new mexico has to to kind of regulate the independent dispute resolution process which is mainly federal right now and very time concerning. Uhm if you're if you'll look at this slide. Talks about their discrepancy everything that we do is based on medicare rates. For the most part we look at. An average two hundred percent or less for most places in arkansas. If you look at some reports arkansas probably is de very last as far as reimbursement goes in the all of the united states. We. As you can see up their cross most states there's going to be an average but two hundred and fifty four percent. We're just trying to get some standardization within arkansas. We're not asking for big pay raises we're not asking for anything else we're just trying to get some sort of consolidation so that we can get paid as well as other hospitals have. I'm going to talk a little bit about the no surprises act that is a federally mandated law that came into a affect on january first of two thousand twenty two. This is a law that has really changed the game for out of network providers because it basically is supposed to have standardized the amount of payment that is given to all facilities across a region so. The no surprises act again took effect on january first twenty twenty two and this was to protect consumers from surprise billing and what this is is where a hospital or provider would go in insurance company would pay one rate there would still be money left over that should have been hospitals or providers fell like should have been paid so they would have gone in and balanced build those patients for that amount so patients were getting exorbitant rates or exorted bills for their visits to hospitals or emergency rooms or for their provider just so the record is clear for smith and cabinet have never participated in balance billing we never have we never will the nsa would limit the amount that and out of network provider was able to bill and that limit is supposed to be based off of something called the qpa the qualified payment amount which is based off of a regional standard. In other words all hospitals in a region are supposed to be paid according to the qpa so that everything comes out to about the same so that if you're seeing that one facility in our region. And you come to our facility and be seen we should be paid a similar rate to what is paid at at at each facility. Uhm what we have found is that this qpa and it's not no surprise billing act has essentially been weaponized by insurance companies in our opinion to affect out of network providers. If insurers. What what they're doing is they're paying us on a exorminantly low g PA we cannot even identify necessarily what the qpa again because it's not published it's basically kind of secret of among the insurance companies as far as what that upa is in this leads to exorminately low payments for services that we provide for the citizens of arkansas. When. This initial payment or comes in to us we have the right to because we're out of network have the right to them go into a resolution where we can go into the IDR process and that is the independent dispute resolution process. In arkansas is a very cumbersome process where we will basically try to negotiate with the insurance companies for a higher rate of reimbursement base off of what we should be paid. If that doesn't go well then we can also go to arbitration according to c n s and the latest out of the half if providers in hospitals go into the independent dispute resolution process the providers when that dispute seventy seven percent of the time. What that tells me is that insurance companies are paying an exorbitantly low rate initially and so again when we have to go under this IDR process it is very cumbersome there's a lot of paperwork that goes involved it is an outdated process here in arkansas it adds hours of paperwork too billers and coaters trying to get a rate that should have been paid initially on the front end. The. According to the emergency department practice management association they have found that peer behavior has really changed after the n s a pre answer which would have been before two thousand twenty two uh they've we have seen that rates and average rate for a visit has dropped thirty two percent so that means that on january on december thirty first twenty twenty one when I saw a patient with chest pain we build coated send out the bill to the insurance company for one right we were we were paid one rate I see the exact same patient on january first twenty twenty two my rate is art automatically average down thirty two percent. So that is in midst of post covered supply chain issues increased labor costs all of the things that are facing all the the aspects and road blocks are facing hospitals these days in our state so we already have an artificially low payment rate from the commercial insurers and our face for us being out of network we're faced with a thirty two percent haircut on what we were being paid from one day to the next despite the fact that we are taking care of the exact same patient. To the to the process doctor wide area initially discussed is that. When we finally decide well you were getting paid this rate we would like to negotiate and discuss a different rate. We have to enter into a process with no surprises active independent dispute resolution we call idr. That process requires additional paperwork and information that we have to supply from our business office it applies to our back office work or we have to fill in additional paperwork consult with the chart consult with the patient and then resubmit these claims for discussion and resolution. That adds to our increased business cost because of the increased man hours in the in the billing office that we have to provide it also delays reimbursement or a closure of that claim from a period of sometimes three to six months now we can stretch these discussions out nine to twelve months. And the arbitrary nature of how this occurs where the insurance company can just say well we're gonna take your level for a claim and downgrade it to a level two or three without really much. Much a validation on why they do that. Knowing it's going to go into an industry in the dispute resolution phase so we're submitting claims that previously were level two or level three or level four and now for reasons that are unclear to us without a really clear rules they are being down coded and they were having to go back and read the arbitration to decide how we're going to finally come to an agreement on how we should get paid for that claim. It'd be okay if the rules were clear but as doctor white doctor masons that earlier the rules aren't really laid out through well it seemed somewhat arbitrary and we try to figure out what those rules was based a week in decrease the number of claims to actually go to arbitration but if we don't know the rules we can't do that very well. The process and the delay and claims as frustrating for patience is frustrating for us it's frustrating for us to figure out how to budget on a monthly basis on how we're going to get paid for claims it previously we kind of understood if we have a chess pain it's going to be at this level we're going to get paid for that level. III was going to go to a few basically if the next slide they're they they anecdotal can have been example we will see a patient with chess bank. They will come in we will do a very standardized work up we approach this from several reasons of from from medical assessment will obtain a chest ray some lab and ekg we may do cereal ends i'm testing me made to do additional testing and even an observation of this patient in the department. We would typically build that at a certain level and an insurance may come back now and say well we're not going to pay there no explanation no reasoning why that's going to car we're just going to downcode that claim. And now we have to enter into a process of appeal and and we have to go through this no surprise it's act dispute resolution to come up with a reason why they downcoated and what we need to resubmit to help with reimbursement on that claim. Why could say if we understood the rules a little bit clear we could probably decrease the number of times that occurs and if we understood the rules we could also streamline the process. All this right now is manually submitted that something doctor why it's going to talk about the next slide is the process we use an arkansas also very cumbersome it requires a lot of man hours and submission of additional information that could be streamlined and spelled up. The other danger that we've dealt with is in many of our hospitals and cabinet is a good example or in a rural area. If doctor wider doctor mason have a patient that rolls into their er that isn't in having a stroke they provide thrombolitics they provide intervention and care for that patient. With the current system those drugs and those supplies may not even be accounted for with the current reimbursement that we're receiving for these for these services in our facilities. So we just kinda need to figure it out of how to have approach this and a little bit better manner to facilitate the number of claims that go to resolution to decrease those by understand the rules and also to make a little bit easier for us to submit the required information to streamline this process of dispute resolution I was gonna let doctor wide if you could he has a little bit more information on the process that we go through. So in arkansas when we enter into a dispute resolution with an insurance company and again this is with a lot of the insurance companies we're not singling out any insurance company here today we want to make that very clear but for arkansas for this example it is blue cross who shield we have a email male snail mail process that has to occur so when they say we're going to pay this we don't agree with it we have to send an a dispute then what we have to do is go into an open negotiation period where things are sent the effects email they require line item items instead of just getting the chart they require to minisman a paperwork to try to adjudicate the claim what this does is it slows the process down for the claim to be worked by thirty to sixty plus days that means that we're third too much further down the road from ever seeing a bit of payment this also leaves the patience in limbo because the patient has seen on january first. What's going on with their built they have no idea so so their bills are sitting out there they're trying to meet deductibles and things like that but their bill from us hasn't been adjudicated because we have had to go into an process with the insurance companies once we do submit things we start getting other emails of all you got to send it here again it is it just feels like it is a shell game that occurs when we are trying to submit these claims other states have done it better and I think that's what we're asking for here today if we could look at possibly something like what texas new mexico illinois oklahoma utilize a program called availity what this is is this is a program that automatically when we have a process or a or bill that we don't bill is being paid at an acceptable rate we would be able to go in a sort of negotiation off of this program immediately instead of having all of this inefficiency through the emails the snail mails the facts and again in these states has been highly successful for the uh independent dispute resolution process for for these states. Surprisingly a lot of the insurance companies do have available available to them they're using it currently but we don't feel like they're utilizing this to try to actually. Make this idr process easier. And at the end of the day I mean we're out of network this is an in network program problem as well you know everybody knows in the news that you have major medical facilities in our state who have all gone out of network with one or two insurance companies because they've gone into dispute there's one in northeast arkansas right now that is out of network with united. Okay and so. You have to kind of sit here and think we have insurers premiums that are going up for every patient in arkansas the your employers are paying more for your insurers the individual is more responsible for their insurance we have reimbursements that are across the board decreasing two providers in hospitals in this state and we have massive incomes for these insurance companies that the the difference in the premiums that they're charging what they're reimbursing that's where again it it it's very easy to see what's going on here. As you might receive from our conversation where somewhat distressed because of the way that were were performing our normal daily duties seeing patience in the emergency department but we have found over the last two years that the difficulty and collecting for that service as a grown leaps and bounds. So so we come for you honored to representatives and standards to see if there's a way to push arkansas maybe into some of the rounds at the other states have gone to. Were commercial payments are more consistent across the board. That that payments occur timely I mean right now we we've we've gone from me and paid in a month the sometimes it's as much as twelve months now just trying to get fees collected. We we think there are to be some accountability to the insurance companies for these automatic denials that just occur randomly the best weekend tell not based on what's on the form nobody reviews it is just a computer program that that will randomly deny it or down code it. We we. We think these thousand delays are strategic and and and we think there's got to be some good faith and they're somehow that to limit that we we course we also hope that we are able to convince you guys to cannot push forward and electronics system instead of a email system emails kind of out of date already and electronic system is something that negotiations occurs in minutes and not weeks. But and in f if possible more we hope the job will will look at the legislation that the other states have passed. And maybe implement something that could be used statewide to alleviate some of these problems now we are we're ear physicians and we're out of network but this is not just as the same program affects radiologist it affects surgeons it affects everybody that. When they deal with the insurance company they feel like the rates are too low and they go out of network so as soon as they go out of network they're following these same rules that we are. And we we feel that you know if if if if we're not able to resolve some of this conflict that arkansas will suffer because they all just cannot move out the state. Questions. I wanted to say one more thing before i'm sorry if that's okay not that's fine go ahead II believe there needs to be a regional equity in health insurance for our state when you look at the surrounding states around us missouri tennessee mississippi louisiana texas oklahoma they all have higher rates of commercial reimbursement based off of the medicare rate than what we have in this state we're losing the best and righteous of this state it is hard to find emergency physicians to come into this state to want to work because they can go to texas and be compensated better they can go to missouri and be conversated better. And and so that is scary i've got a son who's a washed albatus he wants to be a doctor and i'm stating here having sent him absolutely go do it go be because i'm hopeful that something's gonna be better when he becomes a position when I was going to become a physician I had positioned some of the don't do it it's terrible it's never is never you know it's not like the good all day so of course it's not like the little days because things change but I would never tell somebody not to go into medicine because we've got to take care of your constituents we've got to take care of our neighbors and more importantly I would ask all of you go talk to your in network providers you're out of network providers in with everybody that you represent ask them they're going to say the same thing you're not hearing anything different from us today that you're not going to hear from every physician that you talk to it is bleak for hospitals it is bleak for physicians and we o at our state to provide them with the best healthcare possible we feel or to facilities go a long way toward doing that for the people in our communities when you have someone drive from little rocker yet someone drive from conway to get the cabinet or you have someone drive from northwest arkansas to get get down to john it for smith we know we're doing something right. Come to our facilities come come see us and will show you what we're doing this right again we just would appreciate to be reimbursed at a rate this commissioner with everyone else around us thank you thank you and I want to thank you for your testimonian and I do want you to know that to be frank that is the reason we're having this meeting as we know the struggles that archise hospitals are facing so warrant to get small warehouse out there in a precious testimony would you have some questions if you'd be willing to estimate some questions number numerous members would like to ask you a few questions and I will start with sinner hill thank you john muffer for being here they appreciate the presentation that the challenge given to us. I guess my first question. Not amazing after what whomever wants to answer some of these instances you are referring to with the paying method you being paid by low cost. II know that we tried to go in network where we were for negotiate with various insurance. Uh companies you were we know for a fact that you know they like the last offer I think was a hundred and fifty percent of medicare. But do mob you know course the field of emergency medicine is very small in the state. So I have lots of friends and other emergency apartments I know that slow. I know that they're being paid more than that. You know and the problem is is because of the the innocent law there's no way for us to negotiate. You keep saying no no you know i'm just going to balance bill the difference and then the have the consumer first set the insurance company that doesn't happen anymore. Now now it's you take it or you leave it and the insurance companies know that if if I don't like what they offer me that I can just be out of network and they'll just make me delay on my returns. Okay that an unaware I think it was doctor what's it long ago he didn't want the waiting insurance companies are the bus while I do. I'd like to hear some names which which ones are the worst ones III will give you a a discussion and not along answered your question our primary provider of insurance coverage there are facilities for smith I think it may be similar and cabinet is blue gross blue shield. Now we're a border so I get a makes of oklahoma and arkansas blue crossfully she'll be accounts for about half of our volume of our insured patients. I'll also major their doctor mason said we. We are a newer facility than cabin so our first year we were brand new we went into the process of a new. Documentation guidelines for submission of claims and billing and coding. And then at the same time we entered into the no surprises and a decrease in reimbursement so we've operated at a different playing field and a doctor white doctor mason. We actually entered into a discussion with blue cross blue shield and other insurance providers and we thought it sound like a good deal on the surface will take three hundred percent of medicare allowable. For our first year and we'll see how that goes for our billing and our final collections they they promised us it would be a smoother easier process it would be less of an idr price service it would make things smoother. It did not and I can elaborate clearly the the the issues we personally faced. We still saw a significant delays and payment we also saw a very specific tactic that i'd already alluded to in the discussion we would. Assume or code at a certain level and it would automatically be down coded. That the the contract we took of the three hundred percent medicare allowable. Was down coated and we had opted to not participate in an IDR process and the idea again is the independent dispute resolution so we can took what they pay this thinking that in good faith it would be a better deal in about killed this because of the way that they downcoated our charts so whenever that contract was. We went back to the more traditional approach similar to what they use in cabinet. Where we we went into the idr process so we complete the chart we submit it we then hope for the best that is going to go at the level we coded and those codes are are a matrix there they're not just pulling stuff out of the year those were done based on charges charge capture the acuity of the complaint it's a complex issue overly complex as doctor mason alludes to and we as he are physicians have had varying degrees of involvement that process. But but we code and good faith based on a historical data of what we've done for years and years. The double where me over change in the way we code the chart are we documented a chart. And the way it's entered into a coding matrix and then the prices of the no surprise is act has really been detrimental doctor why do they to decrease reimbursement about thirty two percent. It's probably more than that because of the increased cost to our business to submit the claim again. And in the thing that he had looked into as well as this delay we have this were in the ether of find a figure out what's going to get paid who's going to get paid when they're going to get paid it actually is so delay that people in our community you're coming to us and say in what are we owe you and we don't even have an answer because it's in this process and and in the insurance company's defense they're dealing with the new process as well how do we handle all this so it's delayed things from two or three months we're still processing claims we opened in february twenty three we haven't closed the books on charge so typically we would close after a year we're still in the process of negotiating reimbursement for those for those patients. And I apologize to have precedent so we have blue crawls who else. What what what other insurance companies I mean you you can goog I mean again who who's gone out of network where the certain provider here in this state I mean can't we regional first went out of network with united baptists went out of network with the united baptist hospital the biggest provider in this state went out of network why they go out of network I mean ask yourself that question. Because they were given an artificially low rate for their services from that facility are from that insurance company and again I it's we got laptops and not bad that we got blue crowls in sign united right now do you have another one all of them with you it's really all of them even federal blue costs who shield used to pay very well it's a federal government. Now it's right on power with everything is is terrible there is a various in the state and in all of the facilities and the state are not paid equally. Again there has been some rumblings between hospitals here locally at the end of six thirty. Okay where. A heart surgery is paid one rate at one hospital is paid ten thousand dollars more at another hospital and it's paid up upwards of fourteen thousand dollars more or twenty i'm sorry. Twenty four thousand dollars more in another state. Okay so somebody has heard surgery here in arkansas it is it is a huge difference in what is going to be paid to the certain is the same procedure there is no difference. It's just being done at once facility versus another and again a lot of that goes into their network negotiations again we feel like the the little guys that being asked north arkansas regional medical center minor you know facilities that aren't aligned with a major player are taking the bron of this we're seeing the same patience there you're constituents they are your neighbors. And let me tell you something I can we got countless cases of people who have been saved by the simple fact the cabinet mercy hospital existed. Okay heart attacks people who have heard that you know kids who have a pin aside us their diamosis has made five six seven hours quicker because we were there and so we are providing a great service to a lot of people against about compensation for that service I think we're more familiar with the blue cross blue shield component because that's our highest volume and I know we may have a different discussion or agenda from the questions. But III would not been able to speak to these issues two to three years ago until I became an owner and investor and had more involvement in the process of what we do is a physician. So it's been a very positive thing so we get to review these denials we get to discuss with patience these issues with billing. And we really just want to understand the rules of what we're being asked to do and that's not been very clear it it's a very nabulous process of what we actually have to do and then streamline that price is and I think I keep going back to blue cross we shield because again that's the that's the lines share of the patience we see we see a thousand patients a month fifty plus percent of those patients are are consultative prosperity shield I get a lot of those denials and the request for additional information that coordinate with my facility administrator in my chief nursing officer through billing so i'm more familiar with those issues we have the same issues with other providers so II again i'm not trying to I don't have any ownership in the insurance companies i'm actually trying to. Understand them a little bit better but blue crossfully shield is the line share of what we do and I believe it's the same in in cabinet so. If if we want to pick that one provider out it'd be helpful if we if if that's who we see the light insurer to learn the rules so we can communicate better streamline the process make it quicker I think that's what what I personally mask is I think that's the same thing from capitol speak for anyone else that thank you so much for your testimony i've been made aware of those discrepancies also when I found their very interesting and I don't think we'll get that answer today but I certainly want to hear the while they're set to describe and see for the same procedure i'm in the same geographic region you know I don't really understand that and then certainly a red and article on a a procedure bring down in northeast arkansas and then right over the bridge a massive discrepancy so I found that very interesting I hope we're going to get smanches on that maybe not today but something will we certainly want to loan learn more about that but we have numerous members who would like to ask questions so if you guys are ready we're going to get started with that merchant in the blood of you are recognized. The. The similar left you are recognized to apologize you more former colleague that's all right so I didn't want to get where the first of all mister chair we're going to have insurance companies coming in to to actually. Mister chair. Mr chair tap in machine or so are we going to are we gonna have insurance companies coming in to provide us with the same sort of testimony or is if there are any insurance companies that were invited to the that's a good question there are not invited today senator however if you know obsolete this is going longer already then I thought but if there are any who would like to come and speak after they're finished out welcome that but there are not any on the agenda well I would like for the insurance companies to countercome in in provide us with some of these answers because they're the only ones that can answer this but I want to go to the house the system the the ability system. Did you say that did you say that you all or did you did you say that the insurance companies are already set up with this. Will this software. And you all can already interact but it's the state law this preventing you. And I don't think there is a state law that prevents us from using the program we we believe that they already use this availity program we think that there's a part of the program that they actually do not utilize and that would be the IDR process so it's kind of like having an iphone but not utilizing a couple of the app so we we feel like they've already got at least a blue cross who shield has available whether they've got that part of the application turn on or not we're not for certain but it sure would make life easier instead of having to I mean we all know when you send a facts the like with it of anybody getting that fact is like next to zero it's amazing and so but we are forced to fax were forced to email were forced to snail mail our our negotiations with them and again this is just a much easier processing and we we do believe that they've got it available we do believe a lot of the insurance companies have available and i'm true there's other programs as well available to them so that this could be a a quick process a lot of this is coming from the state as well the state and mandated that it be an electronic process for the IDR so texas new mexico oklahoma and illinois they have mandated if i'm novel mistaken in their state that they're the idea process is required to be electronic such as this availability program so in arkansas is this is this not. Is this not a part of the system I guess on because I thought almost a thirty almost seated the state of arkasa doesn't require the sum and i'm just trying to clarify is is this something that you all have saying you all come down saying hey we will like this piece of legislation II think if it came from the state the said hey we want the ID our process for out a network providers. To be an electronic process II think that again that would that would help but I don't think it's mandated at this point anything we're not the only ones in this boat you're getting ready to see radiology and pathology who took major hits in there reimbursements I mean you're getting ready to see out of network provides II feel like it's going to skyrocket with some of the things that are happening right now in the healthcare realm. All right thank you thank you miss share thank you senator senator boyd you're recognized for a question thank you mr chair I think i've got two or three so if you need to cut me off you will but they're not they shouldn't be long questions so i'm trying to understand this over here if you didn't catch that so in the the term of the pharmacy world you have something called national average drug acquisition cost which is basically pharmacies published their price of what something costs and so with the it really sounds like this on the surface looks really good this is about the patient this is about making sure the patient is protected but it can't sounds like the federal government stepped in and forced to transparency on one part of the payment system but not the other is that of fairly accurate assessment or am I missing something. And now I think that's fairly accurate it is definitely slong the pen to the side of the payer. Okay thank you and then just at another question in that vein so the federal government has created something called three forty b i'm assuming yell of at least heard of that it's a federal program that is a government subsidy for some people but for not for other so I would assume since you're a private hospital you don't have access to three forty b so my question is though i'm I know in your market there are cus at least in fort smith. The the other hospitals there who have emergency rooms. They have access to three forty b so does that unlevel the plane field where they have access to this government hand out and you don't. The. We don't accept any cms reimbursement or government reimbursement so I would say the enteries yes they do have access to something we do not know okay and so does that affect your ability to compete because you said you're the little guy right like so i'm i'm trying to understand how the market forces are coming together with creations of the federal government that have come down to our state and now we're having a discussion of the state level because of things the federal government did right. The the thing that makes us the little guy in town as a combination of private ownership a decreased number of patient visits lack of access to let's say rural underserved federal dollars for and II will allude specifically to fort smith baptist is in an underserved area of the state so they are available for funds that mercy for instance it's not just because of geographic locations so they're always certain inequities built in the system. I don't I don't know if that's a a good answer your question but we we are the little guys because we don't really participate in cms reimbursement. We don't take federal funding we are not really we're not eligible for many of these geographic issues that you discuss were privately owner owned facility there are numerous differences between us and some of the other hospitals in town I don't even know if I would have time to elaborate all those differences but we're a physician owned hospital which is in itself different than the other two facilities now you eat you clarified it I had I missed that point that's why we asked the questions is you choose not to accept government funds in their far for couldn't so that's just your choice and there is this market in equity out there how to have rate effection in the last question again I hope it's quick again you've indicated you don't take government funds per say but one of the things on your first slide that I felt like. Maybe other health care professions face that I didn't see up here and maybe it's cause we're focused on the no surprise act but what about audit recouperates are you struggling with the insurance companies paying you and then taking the money back after the fact for things that maybe don't don't necessarily really make sense from from a clinical standpoint i'll give you a quick answer from portsmouth at cabinet speak we don't have enough historical data to speak to that we're just now in the prices of getting paid for what we built for a year or a year and a half ago. So we haven't had the undergo what you just said which taking back what they'd pay this or historically I don't have that kind of data that's not an illusive answer it just hasn't happened here you probably will but we sell in cabinet I do not believe that we have a whole that we have much of that we came in the cabinet. A lot of the reason why we came in the cable was because of the air base we were told through some back or channels that we would be able to build and we bill try care for about fifteen months i'm trying here did go through with some payment sauce and then all sudden truck I said no sorry you guys can't participate in trickier answer we're gonna need all that money back so we paid every dime back to try care that they pay us again thinking that we were going to go into cabin be able to serve there's a huge air based population again the reason why we cannot participate in these government programs is is the start laws that most of you are familiar with because we have private ownership if we would love to be able to bill medicare medicaid and try care it would absolutely make her lives easier but we don't but we are still a safety net for every patient who comes through the door they receive a medical screening exam they are evaluated by a physician not a mid level not a nurse they're evaluated by a position and if an emergency is deemed to be present in that patient is treated. Regardless so again we are still operating by him rules that are been set for for all of the facilities that do accept medicare medicaid and try care. This. Who opened a center thank you represent flowers to recognize for a question thank you and i'll also try to be brief in the few questions that I do have you mentioned earlier that. The abuses of this federal regulation on the part of the insurance companies are arbitrary and i'm wondering does that mean what can you tell me what that means. I think what we mean as it is just such a before when we were out of network before the n s a we were allowed to go in and negotiate directly with the insurance company based off of what and it was a very easy process it was a back and forth and we were reimbursed in we went on now because of the nsa there is an arbitrary rate that is set by the qpa again which none of us know I could not go and google the qpa right now if I wanted to so that is a rate that is set by the insurance companies or maybe it's set by somebody else but they're supposed to be going by that letter of the law in order for us to be reimbursed at a rate that is level with other facilities in our region i'm not sure exactly how far that reason is I do believe that forcements is in a different region than us then northwest arkansas in northeast arkansas but again not knowing we're the bar is set makes it very difficult for us to go and so when we send out a bill to the insurance company they just basically they will downcode things where they will send it back to us and say we will this we're going to give you I mean if we if we build out a thousand dollars for any are visit which I know over the well that's outrageous if you think about what happens in an er someone who gets tpa in our facility tpa is a clock busting drug everybody is probably heard of signs out of stroke as a tin thousand dollar medication or average reimbursement for that medication is somewhere has been somewhere between seven hundred and fifty in the thousand dollars. How are we supposed to keep the doors open if we give a lifesaving medication to someone who comes in one of your neighbors when your constituents they're having a stroke we give them tpa they're walking around the day they're going to walmart they're going to target wherever and we've just even nine thousand dollars on the medication alone. And so again we just don't know where the boris set and then when you go into the IDR process it is so conversation to try to recoup what you feel is a fair market rate we're not asking for the world we're asking to be compensated at a rate that is appropriate for what we're doing and this is happening on the back end right on the back in so it and i'm and I ask you that because arbitrary sounds really unfortunate and soft and it sounds like what's happening is happening in secret on the back end of a contract that you all engage in and it's happening inconsistently so for instance when you make say yes yes okay i'm just one of because they they get on me about being long windows I want to go into my next question can you tell us what the impact on rural hospitals in particular might be particularly as a relates to closures. Do you have any idea about how this might be affecting other facilities. So I even facilities that are and network mean without adequate compensation for what we do there's no way to pay for the services he mentioned that that's a standard of care drug you know every. Malpractice lawyer in town would be after us if we would decide that someone who came does for the stroke we were going to withhold that medication because they had blue cross blue shield. So but you know you and there comes a point when you just don't have the money because it's tied up in arbitration and negotiations. So. There is the problem with the facility we got two different problems facilities have a problem collecting money and then the physicians have trouble collecting the money. Now for the physicians. They'll just pick up and go to a place where they can get a steady income that's what that's what we're after we have jobs just like anybody has a job but we want to consist an income so we can pay for our kids to go to school and do all the things that that embody has a job does and if if you can't get paid. Or you can't guarantee you're going to get paid. Or you're gonna have to wait a year to get paid you're going to find another job which might less likely be in a rural hospital which might be less likely in a rural hospital it might leave those areas unserved and can you give me an idea you sound like you but I would just speak to that I mean unless someone is born in a location of rural location. At the likelihood of enticing a physician to come to the smaller town with a smaller hospital we're there on their own guess what you're on call every night congratulations. So. Enticing someone to come into that roller is there's got to be something worth it you know our ability to care for human kind and our neighbors only go so far when you are exhausted in your under compensated for what you're doing so enticing someone to come into a rural area to do obey to do primary care how many you know go to go talk to you ms how many of their residents who got out this year are going out to open up their own independent practice I can give that answer it's poly zero it is too cumbersome to deal with all of the bureaucracy of the insurance companies and to deal with the inefficiencies that are in the system. And the secret secrecy and inconsistency that we just talked about. And then finally how how might this be impacting patience because I saw in some of your remarks earlier than some you're inability to get clarity on the basis of uhm some of these abuses. Yeah. Draws from them not explaining you know where this where it comes from and then uhm one of those bullets had something to do with it got the process going back to the patients. Who are often ill equipped to understand. How to navigate around all of the regulations of their contract with the insurance company let alone their contracts with their providers so are you aware of how this might be impacting patience. I'll i'll speak to a part of that and just a problem when I elaborate but that the confusion that comes in with all of this he he made at a great point when he said that the qpa what's the qpa what what's this payment amount that insurance or or the government or someone has set for the services we provide. We don't even know as partners as sister hospitals what that q PA is in cabinet versus fort smith why it's the same service if you have chest pain and I work up your complaint it should be the same as what just and doesn't in cabinet or little rock or anywhere else so that's that's part of the confusion we are also mandated to provide pricing and cost information to pay since as part of the no surprise is act which we endeavor to do we actually provide priceless we actually posted on our websites. So we're able to provide that information yet we can't get a straight answer from insurance what they're going to reimburse for this service we can't get an answer of what the qpa is in fort's math versus cabin. So that confusion comes in with paces ask us questions about the billing and reimbursement process through insurance. The second part that comes in is the delays basic comes in with the insurance they pay they they think i'm insured everything's covered and then we go into this extensive negotiation process that they're not really aware of because as you mentioned it to back off this issue. So the the insured person thinks they're done and then they realize they don't have any idea what we're going through to try to just get paid. If it was a little bit easier to submit the claim that's the first thing the second thing is if the payment amount was a fair amount and equitable to cover our services then the amount of resolution process is going to decrease. The turn around time on that claim is going to be easier and the patience involvement and have an issues repeated statements asking for their copay that's going to go down because we'll just get paid when they get their service and we've submitted on insurance. So that that increases the confusion for the patient increases the confusion for me is the physician given on the care II don't understand why it takes a long time to get paid for something that that I provided and I can clearly document and i've been doing for twenty five years so. All this uncertainty of what we're actually going to get paid what things cost but it's always been that way to some extent but it's even much worse now with something that's supposed to provide clarity. So that's a frustration and there is a physician before I never really got involved in these things and now as an owner of the hospital i'm intimately involved in these discussions because. My neighbor causes his wife in the worldnesses in a wise is taken so long they're coming to me what in the pay bills what into they don't want to have been beholden to me they know me so it's it's really different so there is a lot of confusion for the patient is supposed to provide clarity for the patient. I think though your question of what's it doing for the patience it is delaying things but the real confusion I think is between us in the insurance company. And the reason we don't know what to qpa is or what we're going to get paid is because as in any realm of life knowledge is power and. Unfortunately the insurance provider has the knowledge and we don't have the power we have no negotiation we can't ask we don't even really know what they're doing many times and the interview sorry about why it takes a lot of excuse me i'm sorry if we're getting I thought we need to little redundant and we do have a lot of other things on the agenda today but I appreciate your testimony represent flowers he finished yes okay thank you reps and wouldn't you are recognized for a question thank you mister german documents and first of all in the compliment you own your facility in cabinet its address to allow his use in the constituents and then the others in in the cabinet area we appreciate that. Mark my question deals with it I think the doctor was answered by that didn't hear it. Open then told the medicare cannot be used it can't is that correct. That is correct in because of star clause because we have a portion of our facility is physicianal privately owned by a physicians so stark laws prohibit us from because of they feel like it is self referral so medicare medicaid and try here we cannot accept we still see those patients and believe it or not many of those patients will pay us. Out of their pocket so that they do not have to go and sit in a waiting room at another facility for six hours that's exactly right but why should they be penalized it will where is that rule all the roads and they do keep you off on being able to accept me the ca medicaid medicare and try care that's called the stark law it's a federal law. Fellow law yesterday I believe it was made during the old bomb he made of assuming the nantians of the problem in medication in medicine today in the hospitals and doctors is that not the fault of the federal government which it'd be always because you know we could sit here all that afternoon and the answer questions and you give excellent test and your you work professional proceed but if you know what can we do with tell they'll tell me while we can do that would help you because laws I don't go to merge the rumor set there six to twelve hours for it for us you know we're asking that you know we're trying to get things levelised across the state you know because it because my partners that work at other hospitals get paid one thing we work at cabinet we get paid a different thing you know why keep things be equal across the state we don't understand that when I saw up somebody is the same work the same job as is what my friend does it baptist we we do not understand the process i'm also hearing. This is a perhaps for medicare that they'd pay better than the insurance companies that the insurance company drag it out dog is out right here to help take advantage of those policy held is. Is that creep pre meeting with we think that may be true now okay thank you thank you representative thank you reps of evans you're recognized for a question. The. Evans has left. The. Yeah. Senator hammer you recognized. Oh here too far left gentlemen when it comes to once it goes into. You know that the debate between you and the insurance companies is there a time lying that the insurance company has to respond to your knowledge if they violated that established timeline of which they need to respond we believe that time period is within thirty days but I am I think our coding and billing company can probably speak better for that we we do feel like there is a exorbitant delay a lot of times in getting that information back and again you know where we're talking about putting the patients in between us the when we call and talk to the insurance companies about a claim many times they will not talk to us because we're quote unquote out of network so we are kept in the light or an exactly where a claim is going or where it is in the processing okay so when it goes into the interthink you'll call there it's been called idr you don't know if there's a set time line that that it has to be responded to or you get an official response as angry. The insurance company okay they're not now. So so when it goes into open negotiation. That's that's the first problem we have because that is a snail mail problem that we either send it by email it goes to some account somewhere or it goes by facts by mail we lately actually have I think sixty days from the time that they receive it to to post an answer aren't limited let me rep because I know the chairs want to get to buddy also do you think it'd be beneficial then if legislatively and maybe that's what this discussion is all about that we set the time limit upon which two things while we set the timely upon which they have to respond and take the snail mail in the you know the the smoke signal fact out of this thing and and put that time on an insurance company and then to do something to force the discussion if you're deemed at a network because my understanding is somewhat happened deemed on a network is your at the table and you don't really have a choice insurance company play you know they play the they set the rules by which the game is played and you could be a basically eliminated from the discussion so why should they why should they be allowed to not discuss that with you with those b two things that be beneficial in the commission. I'd like to hear your response if you think does be beneficial enough they I think they would be beneficial. Thank you thank you senator repson of evant you recognize for a question that he was shared in. The. Doctor mason doctor white either one of you want to take the lead on this. I am first I just want to say is a patient of the cabin mercy hospital I know the quality of health care that you provide to our community and the statement it was made about one of you that it's not just a community emergency hospital is is I know people. Fifty sixty seventy miles away that drive to cabinet for the services that you provide there in so I want to thank you for what you're doing there in the work in the impact is making our community was I think about and I know countless constituents that I have their cabin that. Are in the situation bit have found themselves a situations where they needed emergency services but did not have the the uh the means whether they did not have insurance or they didn't have phones but they were never turned away they were treated and taken care of very well. And so as I think through that and I know that there's a certain amount in your business model to where you're going to take care of people you're going to allow for that. But if this situation is not fixed and you look at the scope of services that you provide at this hospital if this situation is not fixed does that put you in a situation where you have to look at that business model the end and start thinking about particular services that you provide there that you will no longer be able to provide the communities. In our doctors the arab comfort level is not sitting before you guys we we much rather be in the hospital taking care of someone with a heart attack but yes we we feel our business model is threatened with the current payment system. And I have six members in my family who at one time or another including myself have been a patient of your facility. And. It's not just you're coming in there for triage mean what what you provided medical services at cabinet emergency hospital to me is well above an x ray to see if if my son broke his arm or if. If if my month cutter channel open and you stitch that that's it it's way farther than that and so I can't imagine. Continually having these reimbursement issues these billing issues that clog your system but yet still providing the vast number of services so it would concern me that at some point. Are you going to have to look at all the different services that you provide there. And say you know what we we can't do this here anymore because of the disparity in the reimbursement issues and. The backlog that it takes to get that reimbursement amount correct in that you're correct thank you thank you represent events thank you graves and bry recognized for a question and members let's do try to move this along the best weekend. Text message you have appreciate you let me gentlemen appreciate you i'll be in here today and I have a question. If this was all online. All online. And you had negotiations that were online. In your hand proper colding there was online do you have under have any kind of figures that will show how much money that this would save the patient and how much it would actually help the harsh bureau. The. II don't know if we have exact figures on what it would cost or what it would save the patient what it would save the patience is a lot of heartache in knowing how quickly their bill is going to be adjudicated what it would save us and the insurance company is a lot of time sifting through papers instead everything's electronic I mean everything these days is electronic I mean when you walk into a hospital now you're filling out things mostly electronically as opposed to. Be a paper paper is the way of the old and it's the old and days it I mean again we have the capabilities these days of doing things much quicker electronically and that's what needs to be utilized and in texas I mean it has been very successful there are also mandates in texas that regulate how that process goes so there is two levels is using it electronically but also having some backup of the texas legislature to to back up and make sure that those rules are followed. Thank you represent thank you clarity reps nice to. Thank you I have two questions and I think both of them can be yes or no with the brief explanation to help the chair. So in cabit. We have lots of employees of the air force base is a correct I would assume that a lot of those are soldiers and their families. Yes so we. Expect them to love somewhere of now we know where they live. But according to the rules representative wouldn't this that question for me. According to the rules that we have if somebody sees a need. And tries to fill it. Part of our federal government taking care of our health care is but we won't pay you. Is that correct. Track tracker has very specific rules and that are similar to medicare medicaid because the star clause they they will not allow us to participate another word we cannot send a bill to track we did that the beginning and they asked for all their money back so I went to other questions and testimony though that leads to long lines elsewhere and people waiting we would love we'd love to see him we we try hardest to get involved with them but it is not been successful that that would be my point so do current federal and insurance company rules lead to a lack of care or even a desert of care of emergency care in rural areas. I can absolutely again went when your child cuts their arm and they need to be taken care of I mean what makes the most simple makes most sense to go to the place that is right by you as opposed to driving thirty five minutes down the road unless you've got a very good reason to go down the road unfortunately patience they know that we can't bill medicare medicator track here so they will bypass us a lot of times go down they will wait long lines and and so we are affecting the healthcare of our state because patients cannot get the health care that they need in their community interestingly enough we can bill the va the mandates that came down several years ago allowed us to bill the va patience the the veterans love it because again they don't a veteran this in cabinet or sercy doesn't want to drive to the VA c at the va is great don't get me wrong and no every one of those physicians but but they they are allowed to have care at our facility and I to me I don't think there's a a greater group to serve than the men and women who are serving our country I mean I think we owe it to them to be able to care for them in an appropriate manner for an emergency thank you thank you very much thank you and thank you mister chair thank you center clark reserve a recognized for a question. The. Chair for dr well I wanted to just echo one of the questions that senate avoid brought up about auditing and I thought it was very. Impact for that you mention that you haven't been paid enough on the front end even start looking at what it would be like to be audited I would argue that it sounds like this extensive delay and payment means you guys are getting audited on the front end that there's extensive auditing going on before you even our compensated appropriately the sound like there is. Extensive delay in payment is that correct. Yes this correct and do you guys as a business offer health insurance as a compensation package to your employees yes. How delayed are the insurance companies and collecting payment from you they're not thank you. Thank you or some baker sinter hickey right now for a question yes thank you for disclosure my sons in his residency and stuff and and if there's some international step down being done by the insurance company I agree with you that that needs to look at be looked at but always like to do a balance almost a different way. And I think it was used a doctor mason. Is that yes sir did did you say there whenever you are going to arbitration that you were in seventy seven percent of the time who said then I did there was an article or put out by asap which is the american college emergency physicians I believe they quoted that number that seventy seven percent of the time when a fair. Followed the providers win seventy seven percent of those cases this idr process is also backlogged by hundreds of thousands of cases across the country so the process is in in that but but I guess that's my question you know and again right here I guess that would want to get to the bottom of this of this part along with what you are talking about because from mass the important if you all have done a procedure and it's been interest correctly you know in my man almost feel like that that that should be nanny nine percent of the time so can you give me some information on why it's not her you know but because in what am I missing there as far as that arbitration process because it looks like to me that if it's fair and you have it done that procedure you've entered criteria correctly there's no fraud unless there's just been a mistake or two how you could ever lose yeah I think because again from december thirty first twenty twenty one to january first twenty twenty two we took a thirty two and average of the thirty two percent haircut we weren't here before twenty twenty one are before twenty twenty two discussing this issue I mean again you probably never would have seen us but a thirty two percent haircut based on every everything that's happened since the the nose rise billing activity and we never participated in that where we would balance bill a patient there were groups that did that and and that's what really left a bad taste here by his mouth and made this legislation come down but I can appreciate that but if you're going into arbitration on something whether something's been build correctly or not I guess that's what i'm saying if if you lose those arbitrations why are you losing is it because you build too much. Is it because there's just mistakes explain to me and i've skipped my bills thirty three percent chairman I think about brief answer. The the the place that I see a bit of wiggle room with insurance that they use is a combination of the arbitrary nature of just we're not going to pay it so they puts it in this price as we have to negotiate discuss that the ads with the second thing is there's a little work on room because we change the way we code the chart. When we code the chart we have combination of charges and in a medical decision making which is put into a narrative summary of the care we provide the patient. In that weekend somewhere subjective to how the coder interprets that so we may look at the way that that story is told the way that folds patient presents with chest pain substantly nature that we enter this cascade of treatment. To us that's curtain dry and that's up to us to dictate and clarify the medical record. Then that is sent to a coder who submits a code on our behalf of what we view that level of care represents. Then it goes to insurance and you have a second person who then looks at that data and then reads our story or tail of the care of that patient and they may enter into the questions that say well this doesn't look like the story that you're trying to tell so there becomes an argument how do you interpret that story that narrative of that patience care. Whenever we go to an idr process then it typically becomes appeared appear discussion where we're talking to another health care professional. They're like well yeah that makes sense you did this this and this and we agree you did this this in this that's why higher proceeds these I think go to well yeah you're right. But there's always that potential stall tactic is it is it worth it to insurance to potentially have enough of a discrepancy between your tale and their tale to save them twenty five percent yeah it is so I think that's why their prices occurs so you you throw a certain procedure of the process you know you may lose seventy seven percent of the time. But for me it'd be a pretty good gamble to still keep twenty five percent of that which in the past you weren't able to have any options to keep so I think that's where it comes in from my take on it but that's my view so just just one thing so what you're telling me what you're telling me is is that you feel like you're basically right every time but you're just that you're just willing to take that sacrifice because it's it's not worse the calls to pursue it is that what you're you're loading to tell you to some extent I mean II code that chart if what II think is is ethical for the care I delivered I don't know since I don't understand the rules of what's going to be thrown out what's not going to be I really don't adjust the way our document from one chart to the next. Now we're into this idr process where I then have to go back in arbitrate and sometimes I participate net most of the time we don't even participate it's a third party that's doing dispute resolution on our behalf. And again that's not an accident because if they explained to me the rules which I was trying to tell representative flowers if you give me the rules are streamlined the process to play by the rules because I want to get paid I went the patient to get taken care of when it becomes an education I don't even know what we're arbitrating fair enough and that's your you're kind of getting my point in to instead of use just doing legislation this is simple as mandating what you are talking about is you know from the electronics ten point it almost seems like it needs to be a little bit broader because you know when all fairness with the insurance companies you know they need to uh you know make sure that those buildings are are correct you know is are coming into them you know because they're trying to keep premiums were there it so maybe maybe it's a little bit broader discussion you know that before going to try to do something in session that it's not just limited to the added central of say you know the insurance companies and again i'm not for sure that maybe we don't need to have their take owner it's some port mister chairs thank you appreciate your present transfers thank you senator and certainly agree with that one I have time for that today but we certainly do when you're from insurance companies thank you sinner hammer up until you have one one more. Question direct de you referenced at two hospitals at the end of that six thirty year you are a private owned hospital correct. So there's only two at four thirty that's hard hospital and baptists which one got the fourteen thousand dollar reimbursement higher for the heart procedure if I heard your question while I go and if so why would two hospitals be reimbursed differently like that. Again I can't speak for those facilities this is information that II think it's all out there but the heart hospital was paid less again but but those hospitals are in network with these providers and again. We see time and time again where these hospitals are going out of network they're being forced out of network by certain insurance companies again I almost think it's easier for the insurance companies sometimes to go out of network because then the the rules are kind of much different and so that kind of discrepancy for the same type of procedure I think is where everything needs to be brought to a level playing field between all the facilities whether they're in network out of network and I think if we could get to that point I think that that is it more importantly if we could get to a point where we are compensated at a rate commissioner with what we're seeing in the states around us when a patient goes across the border to tennessee are the physicians in tennessee any better than the positions in arkansas I doubt it okay I mean are the physicians in oklahoma any better than the physicians in arkansas no we're doing the same thing were paid at a much different rate and again that's where we are fiftieth we we should you know there is something we should not be proud of it all that that our rate is around a hundred percent hundred and seventy percent of medicare according to the citizens as you can find what we're paid. Thank you thanks in hammer sinner urban you're ignorance. Alright. Thank you actually listen to your testimony as I was driving down sorry I was like to the meeting but I got to watch your presentation online quick question on this side where it talks about the variance and just what you were referring to where you have the seven states that are below the two hundred percent of medicare prices but the other states were above three hundred percent of medicare prices was that as a result of just negotiations then by choice of the insurance companies or was that legislation passed. I i'm not for certain on that I think that's it I think that's a question that has to be answered by the insurance companies as far as wise arkansas deadlast when it comes to our commercial rates and for what are hospitals and providers are paid in this date. So I think that's a question but i'm not sure if that's a legislative thing or if that is just an insurance thing well and and I think you know also we when we're having this discussion rightly so I just traveled from fort smith and public health committee where I think talking about educating and you have college of osteopathic medicine you have the go score and turns broad mass and then you now have a new off alice walton school of medicine in northwest arkansas you can educate all the doctors you want they're not going to go two places where they do not get paid bottom or throwing a ton of money at. Rightly so at educating work force at. More residencies which we need but if they can night cover. There's their medical school debt. Which extends in a residency if they cannot cover that with the population that they serve. And if it's primarily track here medicare and medicaid forget it you're going to close your doors. And then commercial insurance has the caveats of being able to pay way less than other states I can just tell you the applications that we're getting to for the medical board to approve for new doctors coming into the state are so far behind and it's because darkers are leaving the state going to other states where they can get a higher reimbursement rate from all of their payers and so you know and it's not it's it's not helpful on our state medicaid program to have that tremendous amount of pressure because we are we can't make up the different medicaid we are say we medicaid can't make up that difference because it's not supposed to be that making up that difference so it's a it's a good conversation that have we need to have all the figures of all the money the state of arkansas investing in the workforce development education residency etc for physicians and all health care providers to be frank. You have to have that p service to really understand the full economics of what's going on here because we're never going to solve rule medicine rural health care or make a difference if we don't really attack this issue and it's a medicare is a big medicare issue I know center boy didn't have helped and worked on a resolution with me because our medicare rate we are only write above porter rico. Arkansas about porter rico and our medicare reimbursement rate in the country and that is horrible and we should demand a we should demand better you know are our state should demand better and a greater level respect thank you for the lattitude thank you for answering the questions thank you sir in the last the last member there speak on this matter he is represent flowers thank you so much mister chair and I just wanted to number one thank you all for coming in speaking as today about this issue because I had no idea that um this is something that was bubbling up and early reminiscent of the pbm abuses that this legislature has been trying to address for several sessions even with a taking the lead in this country on finally regulating pbms we're still dealing with those issues and so i'm extremely disturbed in while we've had a lot of great conversation here today I don't want it to be lost on this body that that comparison exists also that it struck me that you said that when you do go into arbitration you went seventy percent of the time I think that and that this issue only came a occurred in and and began happening after the federal regular regulation. The other thing that I that struck me that I want is to remember is that you keep the example of a ten thousand dollars medication that you are being reimbursed seven hundred and fifty dollars for so to me these are clear examples and patterns of abuses that must be addressed with some some kind of response legislatively in terms of penalties for dragging out the administration of reimbursement for services that have already been rendered with some sort of patience and providers bill of rights in this state because no matter what we're talking about when it comes to cms or federal rules of federal regulations insurance companies are regulated on the state level so it is our job to address this very clearly and decidedly and I hope in pray as I won't be here and I know that there will plenty of folks clapping in banking guide that I won't. Um because of my response to this but I hope in pray that we don't take years to address this in the way that we have um pbm of users thank you thank you everything for hours and gentlemen I want to thank you for your testimony has been very helpful today this is something that came to my tension months ago and this is just the first step to get information out there very helpful and I appreciate your patience and taking all of our questions but. That that's all happy today and and thank you again. Thank you thank you very much thank you next on the agenda is sammy robertson if you would like to make your way to the table please. The. You can bring any board members or whomever you like to bring with you. You can just impressed those microphone press that was buttons and then each of the introduced yourselves if you don't mind and just proceed with your testimony. I'm doctor steven beeler i'm a board chair at north arkansas regional medical center. Kirk campbell board member of inner or mc also. Semicrips robertson ceo and president and north arkansas or regional medical center afternoon everyone. I am incredibly grateful for the opportunity to be here with you today and appreciate the time you were devoting to discuss the challenges and health care as you've heard from the physicians this is not an isolated issue I am here to talk about the impact that the challenges and healthcare are having on our community. I started by career and health care over twenty years ago I certainly wouldn't call myself old but i've seen a number of significant changes I started at north arkansas regional medical center as a prn or as needed nurse and you can see where I ended up a few challenges a long way in a few opportunities but at the end of the day i'm still a patient i'm here representing the patience that we take care of the team members that come to work every day to provide health care and the communities that we serve. I'd like to start by highlighting a bit of information about north arkansas regional medical center in our community mostly because I think what you will hear me say is that sounds like the community that I represent this sounds like my family my mother my brother my sister my dad. Most of you know where her son is located were a town of thirteen thousand people in the north central part of the states boom county has a thirty thousand residents and our organization sirs serves over five counties with the catchment area of over ninety five thousand people or a not for a profit hospital fiber one c three sole community hospital license for a hundred and seventy four beds we have fourteen position clinics and thirty five employed providers to remote clinics and tell the medicine services we are a level three trauma center designated by the state we see over twenty two thousand patience annually in our emergency room. Over six thousand surgeries annually with twelve percent growth from prior fiscal year so that tells you business is growing. We will deliver close to five hundred babies this year and have seen an increase of six percent from prior you we provide general surgery you're ology orthopedics on college home health upstate direct scan ecology pediatrics and won't care auspice hyperberg's cardiology usual things you would expect we have a hospital owned ms service with three substations that's a bit unusual on the state I believe there are less than ten from a quality perspective we are rated as AB according to leap frog that's an a through f scale a being the best and a four star according to cms star ratings that will be updated in july. I could continue for days about the patient experiences and incredible staff that work at n a rmc however as I look in the audience I see my fellow co code colleagues and ceos and know they have the same stories we are all here to advance the health of the state of arkansas and ensure sustainability and financial viability for the organizations that we serve. These organizations across our state and the nation are economic drivers for the communities that we serve npr has done a couple of interesting reports about communities that have lost their hospital they're devastating naramc is the second largest employer in boom county and we employ over six hundred and fifty people dedicated to the service of health care. We provide over fifty three million dollars annually in salaries. According to the data collected by arkansas hospital association and based on twenty twenty two data namc provides an estimated total annual economic impact of a hundred and eighty nine million hundred and ninety nine thousand. The dollars earned by namc employees are spent on groceries clothing mortgages etc they generate approximately ninety nine million two hundred and eighty three thousand and economic activity and create an additional six hundred and forty jars throughout the community. Narmc's spends approximately forty six million per year on goods and services to provide health care. These dollars spent by name c generate approximately eighty seven million for the locally economy in twenty twenty two we spend over one point four million on buildings and equipment and this generated approximately two point seven million for the local economy in a town of thirteen thousand it's a parent that the hospital provides a significant economic impact to the viability of our community as well as economic growth across the state. The concern remains a house sustainable as healthcare that's what we've been talking about today correct. In the past ten years we have seen a twenty two percent increase in wages utility cost have increased by twenty five percent insurance has increased by thirty seven percent. And supplies have increased by twenty percent. Postpaid we've seen exponential increases in the ull service lines not to bring up a sour subject postpander make. But the cost of toilet paper has increased in two years by twenty three percent and a case of starrer phone cups has increased by fifty two percent these are necessary supplies and despite all ebida improvement efforts we still sign increase of four percent in total supply cost from calendar year twenty two to calendar year twenty three inflation rates were nearly seventeen percent and as a result of incredible efforts from the leadership team we only saw four percent increase and supplies in one year we sigh seventeen percent increase in benefits and a four percent increase in wages. We also had a thirty six percent reduction in contract labor we know that's killing us post pandemic our volume increased by over nine percent in the outpatient setting we had six percent increase in birth five percent in surgical volume and our gross revenue reflected a nine percent increase however. Our net revenue or the dollars we actually collected the money that came in the door to pay the bills was only three percent. As you can see within flash and expenses significantly outpaced the revenues. Despite aggressive attempts to reduce cost sadly. There's a minimum cost to providing the standard of care and we've reached a pipital point where state federal and commercial payers are not even covering the actual cost of providing the health care. We've seen cases where an implantable device so something that goes into the body it can't be repossessed we can't bring it home with this. The device itself costs twelve hundred dollars. For the total case the facility was reimbursed three hundred dollars that means we have lost nine hundred dollars before we even turn the lights on pay the staff provide the medication produce the images or process the claim we've heard already how difficult the claim is to get paid this is not sustainable it's simple map arkansas ranks at the lowest and reimbursement rates from payers across the nation in multiple studies. Arkansas medicaid rates for inpatient care were last changed in two thousand and seven and that was from six hundred and seventy five dollars per day to eight hundred and fifty dollars per day for a patient in acute car. The average rate of a starting ears is around thirty dollars an hour. If we have one nurse to care for the patient that is seven hundred and twenty dollars in salary alone we never even paid for the medications the patient card imagined therapy or the employee's benefits at twenty five percent sure we have one nurse carrying for more than one patient but when you look at drug cost radiology there are pre salaries you can quickly see how the reimbursement of eight hundred and fifty dollars per day is not covering the cost of care as for outpatient services with medicaid this includes our emergency room. Those rates have not been adjusted since nineteen ninety two. And those were a decrease. As many of you know sixteen and seventy percent of rural hospitals are based on state and federal payers. Federal payers being medicare medicare advantage hospitals are seeing patience convert to medicare advantage plants and an alarming rate. These plans are not paying. Are not paying medicare rates and are imposing very challenging requirements for prior authorizations and creating numerous denials for patient care that's already been provided and it's absolutely necessary for the patients outcome. Patients are struggling to receive the care they need hospitals have extended length of stay and increase cost because these medicare advantage plans will not authorize long term care skilled nursing appropriately and physicians are spending exorbitant amount of time trying to secure prior authorizations or peer to peer requirements the administrative barriers to these programs are cumbersome and costly. We have recently seen facilities in the state of arkansas go out of network with these plans and attempts to negotiate better rates as we've talked about. However this creates a huge imposition on the patience these facilities are trying desperately to take care of. Hospitals are also struggling with commercial papers as they're sending out reduce fee schedules yet employers are challenged with the rising cost of providing health care to their employees small businesses are impacted significantly. If the hospital attempts to negotiate these rates and the employers plan goes out of network. There is now a challenge for the employer to insure the employee has access to care as well as on the employee who has now charged with finding a new provider or absorbing the cost of out of network providers when the employee or the patient can't do this what are their result to. They shall for the emergency room they get emergency care and that is the most costly plan costly place to provide non emergency i'm certain are you are positions in the room would agree. In addition these patients don't get necessary follow up and chronic conditions aren't appropriately managed and now we create a more costly healthcare bill the next time they in our system a great example of that is stroke here. Each of you are familiar with someone whose experience to stroke we have done a lot of education across our state about act fast for stroke. Stroke intervention as time sensitive and access to curious essential for optimal outcomes why. Because there are medications like we talked about tpa that can be administered to these patience that have a specific kind of stroke and the effects of the stroke can be minimized and in many cases eliminated however if this medication isn't available because the hospital can afford it. Or is an administered within the gold an hour the patient loses this opportunity and will suffer life long effects if something that could have been prevented for example in our organization we have seen patience who come and our facility they're unable to speak they can't move the right or the left side of their body they give us we give the medication and the patience are talking to us and holding their families hand at narmc we've done a remarkable job with stroke here just to put in perspective the average door to needle time which means from the time the patient arrives at the hospital and tell the medication is administered is a goal of sixty minutes on average in twenty sixteen it was sixty five point eight minutes for our facility in twenty twenty three was forty six point five and our fastest time was twenty four minutes think about how long we've been here today twenty four minutes is pretty quick during this time we started an iv we got a cat scam we performed a stroke assessment obtaining a consent gathered the medication at administered we couldn't know this without education preparation and personnel. In two thousand and eight less than one percent of stroke patients in arkansas receive stroke here and we were the absolute worst in the nation for a stroke mortality. Now after we the implement implemented the arkansas saves program and provided funding to support the necessary infrastructure or rank ninth and the nation this is a clear demonstration of the relationship between access to care funding and outcomes. However just this year we received notification that are funding for this program would be reduced reduced by thirty three percent. At narmc this program has impacted many lives and in a rural area these patients don't have time to be transported to a facility sixty ninety miles away. Totally care facilities are available for the sustained care but these rural facilities must be able to provide immediate intervention to support optimal outcomes. Rural hospitals are being forced to make difficult decisions about the availability of care due to lack of funding in adequate reimbursement and with inadequate funding to support necessary programs is programs go away. Many of you've heard from me in regard to the concerns related to maternal and infant mortality across the state. Sadly arkansas leading the nation in the infant and maternal mortality this means we have more moms and babies dying and the state that across the nation. As a nurse that hurts my heart. We have a larger maternal desert in the state of arkansas then the national average according to the mortgage it was last reported and event in march by the maternal mortality board that ninety two percent of these deaths were preventable we could kept these mummers here with us this is frightening. This is at a practice problem this is an access problem. In twenty twenty three we saw that the maternal desert erie in the state without adequate access to maternity care increase because we had five percent of the hospitals delivering babies discontinue the service. There are currently thirty five hospitals that deliver babies. And the two that closed last year both sided financial challenges as the reason for closure. I've spoken with a number of ceo's across the state related to maternity care and we are all experiencing significant financial losses related to this service however all of us feel that this is a sustaining service that is vital. There was a great article in arkansas business that detailed the concerns and I won't repeat those but I want to say this is an imminent concern and immediate action is needed from a funding perspective to support the hospitals that are currently providing this service to ensure that we don't lose more access. Once a service is interrupted or start. Like senator irving said these doctors aren't coming back they're not staying in arkansas it's unlikely that service will return the clinicians leave the area they find other positions the equipment becomes obsolete and it is exponentially more expensive to resume the service than to maintain it. Again this is a service that patience may not be able to travel for various reasons or may experience any mergency these services must be available to have optimal outcomes for a future generations I need somebody to take care of me. At naramc we deliver around five hundred babies we've seen this increase from six percent prior you it's not uncommon for us to receive a patient from a facility that doesn't offer obstectorical services with an emergent case. Recently we had a baby delivered from a critically young mother within forty minutes of a rival and we spent the next five hours on the phone attempting to secure this mother a critical care bed within our state. We had a number of health systems that wanted to help. They didn't have the availability i'm certain they had the physical beds. They didn't have the staff to take care of the patient this is an increasing problem because patience health systems and position clinics are struggling to ensure financial viability this is the result of a closure of we're closing staff beds were closing units were closing programs they continuation of inadequate funding across our state is going to exponentially increase this problem arkansas one of the lowest states for reimbursement rates with payers the failure of reimbursement to cover the cost of care is now decreasing or states access to health care hospitals in the rural communities that we serve or the economic cub and are essential for the communities growth without adequate reimbursement these services will not be able to continue as we look at industry to move to arkansas we continue to focus on tourism the quality of life. Each of those have a component of healthcare employers need to work force work for us once and access to health care and visitors want to know when they have access to emergency services if needed there is a direct correlation to access to healthcare funding and patient outcomes. On april thirtieth of this year walmart announced it would close all fifty one of its health centers as well as his virtual care centers. The reason stated was the challenging reimbursement environment and escalating operating cost create a lack of profitability that make the care business unsustainable for us at this time. Look at how wonderful walmart has done with their business and they're saying. It's not profitable. We cannot afford to ignore the glaring discrepancies that undermine the very foundation of our health care system it is not merely a matter of financial viability for hospitals it is the system staying ability. And growth for the communities that we serve. In conclusion. Ten years ago commercial payers were paying nearly a hundred and fifty six percent of medicare rates today were seen ninety eight percent. Despite expenses skyrocketing reimbursement has only grown by twelve percent this is around half of the expense growth rate the discrepancy is clearly unsustainable thank you for your attention your time and your service. Thank you misrept and that was that there was excellent testimony shining the frankly a lot on the whole reason the reason that we want to have this hearing today is there the struggle facing arkansas hospitals I mean I stated as a fab and have a very close relative to the hospital in my district but the the business model is not working park into a hospitals and that's something that we want to dressed and in channel it on today so thank you for that testimony we do have some questions if you would like to take some questions senator hammer you are recognized. Yeah. Yeah. The. It's not just use in. This. Right thank you you may no one answer this question but you mentioned while go that you're in a twelve percent growth rate in your area which means you're increasing capacity to your hospital but yeah I got the impression your profit margins not keeping up with the growth rate that what point do you see yourself in the future being in financial distress. That's a tough question to at to answer but i'll i'll take it this way and say that what you start to do is you start to look at service lines and if we were running a business and we had a widget we would say we'll just discontinue this. And so you start looking at service lines that are not profitable but then you make difficult decisions about the services that your community needs and for example we've all talked about maternal care the terminal care is is a difficult service line to sustain most hospitals are reporting losses but can these communities go without maternal care and so what you're not going to see is a hospital just put a close sign on the door you're going to see these services whittle away with all way and people move out of your community you lose economic resources you lose work force and pretty soon your community is gone. And they least the same question malpractice which mind her saying he on a lot of the birth in units the reason they're getting out of his because the malpractice and the expenses to the hospital the risk to the physicians can you speak on that as far as how it's affecting your bottom line in your ability to stay open. Absolutely malpractice rates for physicians that are delivering babies are obviously higher so that that impacts the rate of the training for the staff is extensive and labor delivery is a unit that you always have to be prepared because babies will come when babies will come and sometimes they show up as twenty nine week twins and we're just a well mom well baby and we take care of healthy newborns but we have to be prepared for stabilising shipping those babies and so when we pull those resources out of those communities you obviously have bad outcomes but to sustain those in that community it's very costly because whether you're delivering five babies or fifty babies you have to have the resources available. And then a large question is this the listening to your testimony the previous testimony maybe this is the enough for the insurance department when they get here. But you you've got you know when it comes to the reimbursement to the providers were either going to be increasing the right to the citizens the states can be kicking money somewhere along the way there has to be some pressure from the federal side to give more on the reimbursement rate or the insurance companies are either appropriate at a fat line or a thin line you know sometimes it's hard to determine or the provider groups have to trim their ability to operate the most effective level so I mean it's kind of mixed bag of a lot of things. II hear your concern but what you're proposed solution. Obviously I think there has to be some adjustment in some of some of the rates that were getting paid the ability for hospitals health systems physicians continue negotiate with commercial payers is very difficult and when we take those steps the person that we put in a bad position as the patient and so I think I think some more. Some more direction on how we are able to negotiate those rates and try to try to help from that perspective because I agree with you this all can't come out of one bucket I mean it's not the state can't absorb all of it the fed's can absorb ball of it and we can't expect the commercial payers to pick it all work but we've got to have a peace out of each part to make this sustainable for health care and I think that you know i'm i'm a nurse by trade I also think that there's an especially with maternal mortality I think there is some quality metrics that need to be assigned with that if we're going to getting issues some funding in some subsidy to make sure that we sustain these thirty five hospitals that are currently providing care we also need to see those quality metrics improving. Thank you center representative wouldn't your recognized for a question thank you mister chairman. Thank you miss robertson tourier informative test morning robbed alive alone things that. My colleagues myself need to be aware of my question he has the reimbursement rate of eight hundred and fifty dollars that you mentioned is that just for the nursing call stories that have cover all the calls that you reimbursed for a patient that's all cost that's that's eight hundred and fifty dollars for whatever service care that patient needs for that weather it's a hard attack or do board or whatever my next question is what your calls. III don't have that with me certainly we can break that down and it depends on a lot of different things as far as what the patience admitted for what they're come more bit conditions are what specialist are on the case what resources they need so that varies but you can see from the nursing costs that even with just nursing cost you you've exceeded the rates for getting paid good your nursing ghost is is it seven hundred is so so the way I had done that math is if you average aurion rate is thirty dollars an hour you figure you'll least have to have a nurse taking care of the patient so thirty dollars an hour multiplied by twenty four hours in the day and so then that's seven hundred and twenty dollars there are long time we figure out benefits are some more around twenty five percent so if you had that on you've almost hit your your eight fifty and we haven't even bought any dressings we haven't bought any meals we haven't turned on the lights we haven't provided any medication do you have do you have that cost available. On a parapatian average cost you you could do that but you'd have to look at it by diagnosis code because every patience a lot of it have some average costs that we know on average can you give can you provide their to the committee. I can get some detailed information back to you yes thank you one more question. Who can make the biggest difference. In the operation of your facility from a governmental standpoint can it is it to federal government or is it stake. Both both. Equally. Yes we're work and we. Do more. To help maintain the health care the currently in rural areas. So and I think funding is is key whether that I know that I have the medicaid fee schedule is a is a huge monster in itself and I certainly are runner a budget and I understand the need for a balance budget but some adjustments in the in the medicaid fee schedule would be helpful some work with commercial payers on these rates in arkansas that that are less than others across the the nation would be helpful. Follow up chairman in the rule the same in an urban setting also. Would you say or would you do the insurance companies about hammer hold on your all relative to what you are going to be very imposed. Could you ask that again so i'm sure that it's certain that i'm asking answering your question. Stay dead again repeat your question for them a rephrase. Are the insurance companies in control. Of re embarrassment to the point that is hurling the operations of hospitals yes sir thank you thank you thank you in response to your previous question I did get a message back my cfose in the audience behind me and she said the average average rate run somewhere around eleven to twelve hundred dollars per so you're losing about four hundred three hundred four hundred dollars when the embarry walks to the lower correct is the cast the reform you've had a few follow ups but let's make sore. Is is the cost that it exceeds what you are reimbursed for a they'll secure patient or maybe. Is that cost then spread out among those who pay. Or have insurance coverage if they're there is some car shifting and in the past the car shifting from commercial payers to state and federal payers was a little bit more that that has decreased there's also as you all know there's something called AUP l or an upper payment limit that is designed to help off set the difference between medicated medicare reimbursement the problem with that as it comes about a year and a half late and I will tell you that we took a significant reduction on our uple payment this last december and then again in march I understand there are some recalculation going on to try to help with that and i'm certainly that helps but but it doesn't offset the losses thank you thank you very much german thank you reps and wouldn't sir keen your recognized. Thank you mister and representative would make good points so you know same in when we talked about this for several years and going back couple decades from ever from when I came first came back down here about how the reimbursement rates so. Looking at like you know we're looking at we don't know what these blue cross blue shield reserves are like we don't know what their situation because it's protected but yet. In my opinion or monopoly and if you look at what's going on in national ever with the. The swifties in the in the ticket master and all that i'm not sure that we don't need to have some people looking into what's going on with the insurance companies and you know how much reserves are have what they're paying out or or look because they are monopoly but in your situation up there how much of your businesses with blue cross blue shield how much is it with other insurance companies and in how much is medicaid or just even private payout of a pocket just generally. Easy enough for me to give an we're about sixty percent sixty seventy percent state in federal payer and then the rest of that is a mixture of commercial payer self pay those type of things but at the sixty percent state and federal and we talked about the feds and the reimbursement rates are low on that and and now you're having the other part of the thirty percent it's that's what's really punish extra panches on you in trying to make things work is because the insurance part is not reimbursed where the lowest in the nation. I mean that part right there is something you probably count on a little bit better because you would expect that those reimbursement rates would be better than the government run. We just need all payers to cover the cost of providing the care were here to you know it were a five or one c three were not for profit so every dollar that we make is turned back into our community or organization buying new equipment staff raises those kind of things so we just need payers to cover the cost to care okay. Thanks in a king singer urban you're recognized thanks i'll be quick when you talked about the medical devices we remind me is the medical device tax still on the books at the federal level under the affordable care. You cannot answer that but I can get back with you okay II think it may be but that was a huge issue so let me just kind of play out that scenario you you gave it an example of where a medical device so we're talking about a total hip or a total need desert device and plants that generally are going to be put inserted inside your body by an orthopedic surgeon he said it went from a twelve hundred dollars down to three hundred dollars so let me just play that out for members. When that happens smith and nephew striker whomever are now gonna start manufacturing those devices in the cheapest place in the world where they can manufacturer where is that china. Those devices are horrible and the technology that we've developed in the united states of america for these different types of antibacterial coverings that to make sure you don't get staff infection and don't make sure that your leg doesn't get amputated because of a bad device. Those instances have gone up the cars you're using really crudy devices now in sight of people so now you're repeating the surgeries they're happened to reduce surgeries and that's liability and getting sued and all of these things are just huge problematic so does the trickle down a fact for these decisions are tremendous I want it I want to ask you about the the codes and that the kind of conversation that we had here on the arbitration I thought when we all went to him at like tronic medical records that there was going to be no discrepancy in coding. That was what we were sold because now using electronic medical records there should be no arbitration. Right. And that's a problem so it's not just reimbursements that the issue here it's also the processes around payments. Timer payments and II would ask the insurance department to give us an update at some point mister chair with your permission on these laws about processes and payments. Also in your mind. When you call to get a prior authorization for a surgery. What does that mean to you. Means that they are proving the service to provide payment. But that but actually no. Right so you you would think that a priorization means I authorize you to proceed and do the surgery and then you go okay or doctor i'll go ahead and do the surgery thinking okay it's been authorized by the pay your. That this is going to be paid and covered but then that does not mean that. And so then comes the discrepancy between what is medically necessary and what is not medically necessary and and II find the testimony by the er doctors extremely problematic because they are literally making decisions and a life and a situation as quickly as I possibly can't in order to save the life of a patient there's no way they can get on the phone and dear protestation you would not want your ear doctor trying to get on the phone with some you know and I know that doesn't happen but the problem is on the back into that. How all of this is extraordinarily detailed so it's the codes are very specific and they've exponentially increased they've moved to something called icd ten and it is all geared around specificity severity of illness intensity of service and so many times there's also a idea that the same patient we took care of five years ago that was deemed to be impatient receiving the same level of care now is out patient and and that is according to the payer they're still in the hospital bed they're receiving the same here but they're out patient and therefore now they pay at a reduced rate in addition to that we have challenges with as you mentioned the the denials we appeal the denial then we only get 60-70 percent then we have an auditor come in and then they may take that money back and then we're caught in this tail wind of trying to explain why we provided the level of care of why it was appropriate and we've got someone with a retrospective scope reviewing the care that was provided and admittedly we've all looked back at something in life and said well in the moment it seemed like the right thing but in the in the back it looked a little different but for the cost to hospitals that means they take back all of our reimbursement and many times we don't get that back or it's delayed for six months or a year and so from a cash flow perspective from a business perspective it's really hard when you get paid ninety twenty days after you provide the service and then six months after that we come and recoup all the payment and if i'm not must taken there are provisions in state la that say when payments are supposed to be and I insurance department can update us on what the sales are as to when you're getting supposed to be paid and then what's for happening as i'll this other bureaucratic. Processes as slowing all that down I think that's the violation of the law. So that's where we really need to be paying attention thank you for the question thank you thanks in and we will try and get that information. Center board you're recognized. Thank you mister chair so first of all I just want to say thank you for being here today I understand it can be uncomfortable to come talk about your payers while they're all watching and that takes a brave person to be able to come in and do that and at the week with a legislature need to know that so my question is pretty specific you've talked about we've talked about federal government have talked about state government so are you familiar with the employee benefits plan how how they import employee benefit stacks up versus other payers versus medicare we do in our eye we we set an example in doing the right thing or we underpan any any insight into that would be appreciated. So are you tiring up from a state perspective with state insurance state employees public school teachers and then you know if you have any idea about minister lee or or any of the others that they would use a similar or the the same payer in our organic we setting a good example and go on this is what's fair and reasonable or we yeah sending a signal to everybody else that down and the dumps is the place to be. I will just say there's opportunity. It's good to answer thank you there's always opportunity. Thanks to the boy senator hammer you were recognized. That was very politically correct answer that was good uhm the. You know united health care there only payers is that correct yes okay and I do not recall hearing in the news that when it came to your negotiation with them that they put you out a network and my correct on there. Like that as hospital was put out. Well in understand that that hall has to do with when contract contracts come due for renewal. And so maybe this is all too accountable for you to answer also but why is that that one hospital can negotiate. With united and the other one cannot. When you're both doing the same thing well to nonprofit some i'm just trying to get understanding. Why. I can answer generally I think when you look at scale you know how many how many insured lives do they have in that particular area of the employers in that area that that have that as they're as their insurance company and then also from an insurance perspective I believe they have something called network adequacy which requires them to have a providers in their area so depending on on the health care systems position if they have you know a a large market share that may impact their their negotiating powers okay and then do you know what percentage you see that have coverage through the minister league represented boy brought that up do you have to know my II do not know specifics I can get that but I don't know specific and do you know do you have personal knowledge as to the experience you have. Dealing with those that are covered by the minister believe. That information would come better from our cfo and i'm certainly happy to to follow up on that conversation okay coz I would because I mean they are a payer of sore they are a payer and in they seem to do a good job for my understanding they seem to do a good job and then the complaints were here in our primary along the lines of the insurance companies and i'm wondering if we need to level the deck as far as what do we need to do to be more like a municipal league approach versus deal with traditional insurance companies that seem to have a strong hold on things so I would appreciate that conversation thank you thanks in a hammer and last question for this group is from coach air center hill you're recognized only issue the same questions I asked the the other doctors I like that though the insurance company done the bus won't get a chance so name either companies that are the worst payers. He volume into blood craft falling out unadded we made another name you know obviously some of the to be honest that some of the medicaid rates are really low we've talked about that I have to have to say that I realize it's a state issue but I feel that i'm just told that you're your regular insurance company not your medicator medicare. We have significant challenges with humanity man. Yeah so just about let me just put it this way just about any insurance company that has a medicare advantage plan as a struggle what's your solution. Thirty words or less. We need payers to cover the cost of providing care. Thank you. This. Misrobson thank you very much for your testimony I don't see any further questions that was very helpful again we want to shot a lot on the struggles facing all of our arkansas hospitals particularly smaller midsize and and I really want to pay to to move forward to something you touched on his ob services and the challenge is there specifically with rural health care so thank you so much for coming all the way from harrison to testify in we hope to see you again so in it and you can help force moving forward so thank you. Okay next on the agenda is all the claim you guys want to come to the table and. Yeah. The. Borrow alan claim the state insurance commissioner with me booth ran our general council and most of you know. All of on their schedule for just to general update the department but we're happy to stick with the theme of health insurance if you want to do that talk a little bit about the no surprises act and sort of. In the rules we've done there anything else to all round this topic and will obviously you know it's time discretion we can come back if you want to take deeper travel anything but. If with your permission will just go straight in those surprises act if you that's what you like us to do. Yes that's great thank you thank you mister commissioner listen both presenters afternoon I would encourage the presence to fall complaints with the insurance department I don't think they have not that they're required to but is certainly when interest may and I would love to handle these compliance we do have jurisdiction at the interest department over the no surprises act. And I believe we would more than willingly look at insurance companies that are not being transparent that are being dealionatory and as to their qualified payment amounts and are being abusive or discriminatory as was presented by the presenters in the first by the first group I would enjoy receiving a complaint and pushing that forward this body does have jurisdiction to improve the no surprises act procedures or processes sooner hammer at a point two maybe expedite the process more quickly to make it go through electronically or just a pure love electronic basis within thirty days the insurance commissioner can issue a rule on that if we want to so you've got jurisdiction in the interest apartment has just action to improve the no surprises act process but I do encourage the presenters to present us with a complaint be more than willing to go forward. We've heard a lot of out of network providers complain about reimbursement the pharmacies are not getting reimbursed that we'll talk about that line of providers are not getting reimbursed just sort of educate and remind this body of the insurance department in the insurance commission do not set reimbursement rates they're over a thousand or more different cpt or d r g codes we do not set those rates since i've been at the department for the last thirty years we have allowed the open market the private market negotiation process to be the vehicle for the contracted negotiating fee scheduled rates maybe that's not working so we've seen a lot of complaints from providers who are just not able to not willing to agree with in network rates because they're not sustainable and it's made more frustrated by the fact that allowed the health insurers approached the negotiation process some work like it take it or leave its situation here's our rates and they reply back maybe they have some disagreements in the response back is taken or leave it so maybe we need to encourage a little bit more better of good faith negotiation either through rules or bolts and to try to encourage more out network providers to be willing to agree to network terms to improve reimbursement across the board but up but I do say that issues that you're having with the no surprises act can be dealt with by the insurance commissioner either through a role report and or through an examination or audit. I'll be glad answering questions. Thank you sir. Start to hammer again. Miss share may be the sale you're real house i'm just trying to absorb it also give me a little letter to for being ignorant. The when we talk about the insurance companies that are nonprofit. Our limitations to be able to see what the reserves are that they are holding. We are not able to look into that as that corrector do you know the answer that question. Is it this to me yes yes you can look and see from their financial statements they're surplus. So it's not hidden it's not secret and they're not a nonprofit I don't know why everybody thanks for the process which it was a non profit they're not they are for profit okay so adding out to that point listening to the discussion day you've got you have to providers. That are saying they're not getting reimbursed enough. If we can look at the insurance companies. And and see what their reserves are or how much they have in reserve when i'm trying to get my mind around here's how do you close the gap because going back to the question asked earlier we got kicking in mars a state. The insurers are going to have to pay more the employers going to pay more for their insurance some of the head of pay more and when i'm trying to get my mind around here's where's the balance between looking at insurance companies and what their reserves are because we don't we wanted to be healthy to be able to pay those claims but yet at same time at the pound and on the providers. And and cutting the providers it's a catastrophe in the making can you give me some first week we can consider surplus. In our evaluation on whether we want to approve a premium rate from the insurance company it is part of the listed number of characteristics or items the insurance commissioner in his or her actuary review so that is something that we do look at in addition to medical cars reimbursement impacting right we have an actuary it reviews the actual report and submission by the insurance company our actually looks at their surplus or excess in financial statements in including all the medical to rough at a premium rate that we feel like is is economical when we try to keep premium rates as long as we can state so whenever you raise reimbursement. Okay you start increasing reimbursement medically it might have an impact on right so we want to make sure that we let me make the right analysis when we do that calculation or at last question and is one of those providers have been saying that the table is where the lowest in the nation for reimbursement but when you compare the insurance cost of other states that may be reimbursing higher than what we are how do we compare in the insurance. Rates there being charged to those insured because you got a factor that into it they may be getting more reimbursement in other states but also those people may be paying higher monthly premiums because of that so can you speak to that. I am not studied the border states doctor bruce murphy hard hospital has got a project program for this body there others his visit with us he's got a lot of data showing are just how far behind we are in commercial reimbursement with this surrounding continuous states but I have not stated I do not know of calls for that maybe one cause its population but i'm not sure so I don't know thank you thank you thank you so hammer sir to boyd. Thank you mister chair so. I guess I want to go back to what you had encouraged providers to report this to you I think it's great I understand you're an enforcement agency you you have to have the information but what kind of assurance can you give the providers I mean you're they're complaining to you about someone who is both a competitor and the payer it seems like we're we're putting the providers in a sense of severe risk of retaliation in a very. Strange climate where again the person who is paying you somewhere along the line is competing you may maybe less frequently and doctors offices in arkansas but other places you know there are definitely insurers to have doctors offices who have hospitals. What what reassurance can we give them that we're not all that that happened well I would take very severely retaliatory action undertaken by health insurance company. I am in response to a complaint being filed the nets not just bought medical providers at spot pharmacies as well so we would look upon with great despair and insurance company that would retaliate against a medical provider for following. But I would encourage that I can't do really much anything unless I get a complaint to gives me the data so I can go forward with a legal prosecution II understand it's it's a it's a burden but it's also you don't give someone a speeding a ticket that you don't catch speeding so so I got it it's the challenge of how the system set up so but thank you. Thanks senator representatives you're recessed and give you either one you can answer this question and not probably should know the answer but when the testimony earlier was that a doctor. Get up a prior authorization to do a certain procedure or perhaps it's already done the procedure as in the case of the emergency room doctors and the insurance company comes back and says we don't believe that be medically necessary who had an insurance company is making that determination is it a doctor and it's all is today or or medical professional in the same field well sooner than could probably answer that as well as me she has a pioneer and prior authorization law and the answer that question is our only license doctor in arkansas allowed to make a denial of priorities asian claim and also if they have made a prior authorization approval they're very hard to to go back and resend and apps they may be doing at all medical necessity reasons but if there's an other basis than that they cannot go back in resent that prior authorization under the prioritization act out again i'll extend an I will personally handle any prior authorization complaint or slow pay complaints that any of the presenters would like to present to me and I will be more than willing to go forward with looking into it thanks. Thank you repeated wooden you reagnessed thank you as chairman. Continuing questions mr both related to a representative. What happens if can't application occurs in the surgery and it costs more. How hello is that determinative will be covered by the insurance company I don't know the answer to that question representative wouldn't I would suspect the medical provider would have to go in and recode the service that was done because of the complications that submit an additional claim I believe sender urban on there I don't know question is. Do you all look at the average caused. For a house bills in the state well to the amount of money that they're reinversed we do not would you not there's no considered is that not part of the market without a represent we do not regulate a hospital's contract on fee schedules with health insurance companies in any way shape reform we do not. The interest commissioner is not authorized to get in the middle of that negotiated contract rate discussion. We just don't do it thank you thank you richard flowers you're right now thank you mister or mister reclaim commissioner a claim. There were a couple of things that struck me in the previous testimony that I wanted to ask you all about just as it relates to current. Um state regulatory standards and one of those things and you kind of spoke earlier about how if you know in a circumstance where. Uhm. The reimbursements. Go up then it's likely that costs would go up but what about when there is some consistency in terms of reimbursements in time and then as we have heard you know what the physician that the providers believe is happening in response to federal regulation there is this arbitrary change where now the reimbursements are decreasing on the back end of a contract without any real consistency or understanding why and then you have you know the providers are having to go into arbitration so what you're seeing is possibly a pattern of abuse you know in response to this federal regulation that's impacting the the reimbursement right you know then what well we still not regulate the rate at the insurance department so if you have a surgery it's the safe bt five one two eight and the provider. Wants to get thirty five hundred dollars for it and the fees schedule mount by the health insurance company's twelve hundred dollars that's being offered they disagree about that right and so there's nothing in the arkansas insurance code rules regulations that authorize the insurance commissioner to step out and say. It's forty two hundred dollars okay aren't you too need to quit arguing is forty two hundred dollars in fact i'm gonna set out all three thousand of these fees at the insurance department and that's going to be the negotiate right so they answer questions we still would not get involved in the setting of that rate or that qualified a payment amount or whatever comes out of idor. But we still have processes in the law that govern how long it takes the insurance company to pay the claim and it's thirty days for electronic claims so that rules still holds true so I would encourage mac providers to go to the architecture support website and click on the length to rule forty three it is our claims handling practices rule it clearly sets out that insurance companies have thirty days to pay electronic claims if their coded cleanly. And their code correctly so we do have state laws do a help I represent a flowers but we still don't get we don't have the authority to jump in the middle and sought what the rate is. Well and i'm in america suggesting that i'm what I heard is that. Basically things were going along swimmingly before this regulation and now all of a sudden we're having issues after we negotiate at all of that the rates i'm hearing that the problem is in process and what I what I heard definitively is that there is an abuse taking place because now there is sort of a portal through which a company can say well you know this was coded wrong and so we we shouldn't pay that you know that's what i'm hearing and i'm wondering if because it could be could be a process issue if there is any will room for providers with the current law to address this as it relates to process versus rate I don't have any complaints at that's the problem you know it so I would encourage the presenters to file a complaint this these concerns that are witnessed today or the first time that i've seen these for me to so real quick and then the second one is was about the ten thousand dollar drug with the seven hundred and fifty dollars reimbursement agreed as prepasturous okay thanks thank you represent senator urban you are recognized just a quick question hi tax attorney question you may or may not know that when you have a loss like that can you write it off for a doctor i'm afraid of even trying to answer that I don't know the answer that question either but I think this important way at one point you were able to write off certain losses but I think the law has changed either at the federal level of the state love i'm not sure where anyway that is something that we asked for me to kind of add to the conversation and I appreciate all your hard work alongside have been able to do and appreciate you very much sir thank you center hammer who recognized him technically just too quick once the test my while ago if I remember right was that upon appeal. The providers were winning seventy percent of the appeals and minor scene is the insurance companies have their medical. Individual that makes those determinations a seventy percent wind rate is a pretty high rate and what i'm wondering is. What I mean. **** it should we look at how the insurance companies and their medical personnel that they're using to make those decisions. And is that affair is it a fair plane field when you got a seventy percent wind rate on the providers that would tell me there's something wrong with the medical team that the insurance company is depending on I know it's changes like you know two preachers two lawyers two doctors you're going to get different opinions but what are your thoughts on that II think that's a troubling statistic it seems to favor that the provider was right alone so why waste time doing them at the aliar. I think what will do sooner hammer commissioner and I and our market conduct. Team will be glad to study that sort of process issue that you're talking about and try to make improvements the rules regulations that we would provide to this body cause I wonder if there are to be a penalty assessed. I don't I don't know and maybe you know maybe something else needs tell me is if if you if you go into an appeal and you win and your successor is safe percent there i'll be some sort penalty waged against the insurance company because you can almost be to their advantage to pay the stall game keep that money tied up do whatever they do with it while the providers are on our hung out there waiting an opinion about that II think you could you could potentially address some of that in a proposed rule if you want to make improvements to the the nsa process you certainly can like texas and mexico the first presenters describe texas in the mexico adding tweaks and improvements to their n s a process I think this body in the assuming executive leaves the greens we could we could look at making me maybe making improvements for his health network providers last thing would you give quick update on the pbms as far as the penalties where you are with complaints and just give us a year let me let me address pbms we we are the insurance department making doing significant pb reviews right now we're getting about fifteen hundred. Complaints on mine for pbm's that are paying below night act night act stands for the national average drug acquisition costs this legislature are passed a law several sessions ago that are prohibited pbms from paying below night act minimums the architects so insurance department he receives about fifteen hundred a month complaints about from pharmacies there are being paid below night act amounts yeah what we've been doing over the last year and you're in a half. Is simply taking the complaint in requiring the paper pm to pay the or level as make the payment upward to just to what it should have paid. For night but did not and we have not been a fining companies for those violations and we've just been making up our adjustment requirements the commissioner several weeks ago sooner hammer it may be three weeks ago we should have bought turned to the pbm's advising them and after june thirtieth this year we will no longer just be making upward adjustments for night act they will have to pay a five thousand dollars fine for every our payment is blown eight act levels even if it's nineteen cents they're going to get fine so we're about to ramp up that strategy. And we're also adding a. A pp done or start a limited scope exam on the average and are looking at doing several others to look at affiliate payments and to look at the reimbursement of practices so we'll be quite busy with pbm stuff thank you claim issue thanks center center boy you are the last one for these presenters thank you mister this would be very quick so the state of arkansas growing thankfully we got more our kansas now than we did you know ten years ago um clearly the work in your office is is increasing with all of the complaints you're receiving I thank you heard from some other health care providers that maybe you've encouraged them to report back to you can we have at some point in time in some forum at an honest discussion about staffing to to make sure you're you're keeping up. We quit our mikes on the same time we were say yes absolutely left talk about that because those responsibilities mean if you can know how important it is for us to have these enforcement opportunities and and there's only one booth unfortunately we can cloning we would that we need to be able to pay for some more than yes yeah we've got. Three pbm on staff and I think tennessee in our home I have over twelve for pbm so we're doing the best we can with what we've got so that's just an included hospitals are this is pbms that doesn't include what you might start receiving from other health care providers is well right. So you'll write and the from the other health care provider complaints and then and we could really stand in as the pbm opportunities continue to grow we need to be able to audit these these companies and and do it with our own auditors and so it would have some staffing opportunities for that as well thank you i'll be in touch thank you actually there are two more representatives you're recognized for a question well first I want to say thank you for bonning putting some teeth behind what we passed every years ago and doing something about these pbms I think we don't do this and go down this road we're going to lose our rule pharmacies so to senator boy's question how many more auditors do you need just for pdms. So we have forty pbms of their license by the insurance department so what I would propose a good idea would be to have an auditor that's assigned to twenty each and so anything coming in the door one argor a we get a twenty in those companies to manage in the other argument would have twenty which is about forty so each would have twenty and they would do day to day enforcement and reviews and audits to make sure of their complaints with the pm laws and how many complaints did you say you get each month about regarding a PD fifteen hundred fifteen hundred and how many auditors or folks do you have addressing those fifteen hundred three three enough to handle fifteen hundred yes I think so yeah thanks thank you senator urban the recognize for question just a quick question and you can get this to me later but on your processes for approving premiums is there a medical last ratio that is considered and at what level of article do you do worth the insurance company when you approve the premium request. We do get medical loss ratio and there is actually all report it is reviewed by our actually higher percent II just I don't know the details of the analysis but we do get mlr it is part of the rate approval request it's a very important part of that so our actually who is in dallas does our health insurance stop not sure can go into too much detail I just not see much I don't that we do have access to their funny adjuster okay believe this is the last reps and wouldn't you are recognized. The. Thank you mister chairman mister move that man here insurance come in his own bb. How many insurance companies own pbms I would say probably eight or nine maybe ten million national ones. How many her own. This. Let me refer to his how many of the operating changed drug changes like cbs and while greens and others have an interest in quite a few hours deferred mr vents and whose I think going to speak after me he might know that I don't know the answer to that. Do what II think that the pharmacist association might be able to provide that information I don't know which you have either not at home approximately eight or nine national health insurance carriers own pbms. Everybody's familiar with you not health care owns option at their own I think yes II forget I forget I forget all what rules are regulations apply to the pbs find and pay the plan all of all of our state laws apply to them they're not very regulated yet how many heavy plans are lately not any this year that i'm aware of but two years ago we've had we find apt and esr in cvs over fifty to seventy five thousand few times so did you do what representative won't could wait we really have to move this along with sub tear from the pharmacist though if you could make this one breakfast appreciated. Okay that was very very far representative out on this is the last question for these presenters thank you mister term my question meals what action can be taken if the pbm does that pay to fire. You were done you would revoke their certificate of authority their permit and they would not be able to transact business in arkansas not one sent not once until so you would issue an order it would come through an administrative order which would remove their license just like a lawyer not being able to practice lower the doctor not being on practice medicine follow up is there a date line is there a deadline for them to pay the fact yes it would be set out in the order it usually are ten days is usually the the time that we put in order for payment of so you've answered my question thank you thank you in center hill you're right next mister randy if you would would you please get with the the german test fat earlier whenever you when we finish it with the amount now that them so they're concerned with you absolutely thank you thank you prepared it misrepresented ubank's address of the. Sir sin scared me sinner hickey you're recognized. Yes thank you I know there's been a lot of discussion about you know possibly you are doing a rules and I think you all have that authority through some legislation however especially as it relates back to our ebd and things like that we actually have legislation that requires fiscal impact studies. Prior to us running those bills you know so I guess the thing is just so that uh senator hammer has been hitting on his all day you know if we're going to do some raw changes or whatever I would like for us are or let me rephrase it if we're going to consider doing some rule changes I would also like those physical impacts to be done with that rule because that's much is the same as if we were to do legislation I know that there was something suggested here while back we get with the b d in the cost on that we're going to be huge but I do believe that if we're going to go down this route and some of it's needed but I think this body needs needs to know everything because. Sooner hammer was suggesting. In which we've said many attempt is it's not just going to come out of period we they're going to have to take it out of the states call uppers. Our members if it's the ebd or a possibly our other constituents may have increased premiums or we're going to figure out if the insurance company is going to eat that so I want us to have the whole story whenever we start looking at this and i'll be more than willing to do a cost impact premium impact analysis before we do any rule appreciate that thank you sir thanks to her german thank you for no further questions in the queue thank you for your test money. Okay next on the agenda is the john vents and with pharmaceutiation if you make your way to the table. The. Just where we know you bet if you don't mind introduced yourself for the record just proceed with your test money please. Thank you mister chair thank you miss share thank you members of the committee i'm john vincent ceo of the arkansas pharmacist association. Appreciate you allowing me to speak today share some information. Lot of what i've got to say related to pharmacy I think was said. For the hospital presentations in the physicians a lot of similarities between their testimonies and what's going on in in pharmacy when I originally put this presentation together it was going to be educational and others many of you have been here through the acts that we've taken in the state that have lead the country and reform in the pbm space and I thank you for that some of you weren't here at the very beginning and I have slots on that i'm going to move through those slides quickly so we can talk about the more cute issues that we're hearing about since there are questions about the rule in about something emergencies. The three largest in this goes back represent wooden's question to you and i've got slide to on the vertical integration a minute but. The three largest recvs at optimal x which is owned by united health and express groups which is a philly I was signal. There I can't wake up at any day and not open the newspaper and there's not just an article from arkansas but a national article about. Declining an unfair reimbursements that are not allowing pharmacies to take care their patients so just want to point that out this is an article just yesterday in forty five hundred. There is by partisan support across the country in every state or fifty states now have passed some form of pbm reform when arkansas was one of the very first states and the very first state to have a comprehensive pbm wasn't your bill so this is just an example of something from our current attorney general tim griffin where he lead an effort across the country to work federally on this issue and there's several other examples. This slide really want to just share some examples of. What has happened in right now in arkansas that is just completely unfair and not sustainable. So we are seen observations in our office and I know the interest commissioner's team just told you they're investigating some of these but we are seen examples currently where pbms compensate themselves more than their competition somewhere to what we saw in arkansas and two thousand and eighteen when we saw that with cbs and and our state of course has passed laws that have made that act illegal we've also seen drastic unfair and unreasonable payment curts some of them implemented on april first by one particular pbm on national contract rates and their their stated reason in rotting for the reason that they're doing it is that our laws made them do that. But it's not consistent because they're not doing it in every network and they're not doing that in every pharmacy it appears to us that those cuts from what i've seen in data shared with me our primarily in arkansas only and and applied to arkansas a smaller pharmacies. We in one example we have members and I know. Representative several heavy center hickey have heard some of this. But we had a pbm sand contracted in them that said retroactive nine months later. Are done months earlier we're applying rates to pay you exactly the cost of the drug and not a penny more for your services for your costs to operate your pharmacy on every single coin and we're going to make it retro active. Nine months ago and a passive adendant pass through with no negotiation or not contract been reviewed are taken. And in that same pbm that I just described we have data than in a state funded plan. That they're paying chain pharmacies at least on the explain I shouldn't benefit of what the patience pay in there might be some backing and call back or spread nationally that we can't see but the chain pharmacies and larger pharmacies in that particular plan even though they've said they're making these kirds the comply with the law in to our insurance commissioner they're paying other pharmacies much much higher rates for the same exact service in many cases directly across the street. To outstate companies. We've also seen examples where in another spins of discussion about what is should be a proper dispensing fee worked what might be what shouldn't be and we've seen examples even recently where the pbm is not you know I just talk about a paying themselves more there's also examples of them paying other insurance companies pbm owned pharmacies. Fourteen dollars and thirty seven cent dispensing fees while paying the small and local pharmacy zero to fifty cent dispensing fees in the same point so it's not just I feel like it's not just the pay in yourself more but it's also seems to be. Pbs who own pharmacies pay each others pharmacies at higher rates than smaller market competitors like they're trying to squeeze out competition. The. And then last we've also seen some examples where manufacturer coupons this does not directly impact the pharmacy but it indirectly does in other questions about worst the money going to come to pay for these counts at things I do think there's some issues where. There are savings that ought to be going to premium reductions or to the patients that are certainly being staffed off by the middle man. There these next couple of slots are some breaking information it's not arkansas specific but I expect it to be published if it has an already today and and a major national news outlet. And I know this heart this slide is hard to read and the audience I know you have copies of front of you but what I just want to say is that in washington and these are where the pharmacy association and employers of washington work together and shared data and headed analyzed by data analytics company out of ohio and they found that. Independent pharmacies chain pharmacies and. Grocery pharmacies that are not owned by insurance companies. Compared to pbm owned pharmacies primarily those that through mail order are literally being paid thirty five times a glass on margin compared to the pbm owned pharmacies and on generic drugs is much as four times less or four times more if you're a pbm owned pharmacy that's in the state of washington. And this is compared to that night act that senator boy was talking about earlier which is a benchmark of invoice process that are surveyed in and are as close to what the real cost of buying the drug is as there is a benchmark. Uh published. That same report also looked at medicines that are more like specially drugs are expensive and more rare to be used that aren't used enough to show up in that need actually they benchmark versus whack. And on those drugs they found the almost every market competitor was being paid adder below their costs but PBM pharmacies were literally being paid twenty two thousand times more than their market competitors. Self dealing way. That's pretty staggering data and I think that to your point about is complaint driven versus is audit do you go look and for it the you set power state knowing that this is going on because these are national contracts if it's happening in washington it should be happening or could be happening in every state in the country. Here are some remarks back to the boparks and part from the current federal trade commissioner we call there is an active ongoing investigation by the federal trade commission first time and my career that that has happened into the antarcompetitive acts of pbm's and the market place that are distorting drug process and destroying access for our patience. This was large and two thousand twenty two but it could take up to six years to complete the latest comment that was made in the white house to the round table just in march. We commissioner conscious that and chaircon shared that. The ftc. It in their investigation the pbms are not cooperating. So we talked about earlier how difficult it is for the insurance commissioner to enforce the laws even the federal trade commission is having difficulty enforcing federal anna trust laws and is not getting cooperation from the. The companies that are required under federal heart compliance. Here's the slide that senator i'm excuse me representative wouldn't refer to your asked earlier. All of the major insurance companies the six largest ones all own pbms now that was not the case twenty years ago some of these not the case ten years ago but all of them do now and they also all own either mailed retail pharmacies. Narvatis is not one that is owned by an insurance company that the state poise program. Current or users but they do have affiliations where owner mail order specially pharmacy and costco which is a fortune fifteen hundred company in cooperation or collaboration business model with ssm health which is a non profit hospital does own the PBM naftas from a ownership perspective so there are some times with costco and with women's area builder with them also change health care if you find it far in the sober tax is part of a billing platform that's part of united health care and that's also under a lot of scrutiny right now both the federal state level anti trust concern. I just wanted to to share like edit at a hot level those laws that were passed by this body give the insurance department the ability to enforce the the safety net claims on individual claims in case there's a a single claim or a few claims that would pay below the cost of to purchase the drug that need act that he was talking about or a mac appeal that's only one part of the laws there's also the part that booth represents are talked about about affiliate pharmacies that are owned by or have interest. In the pharmacy from the pbmm insurance company that they cannot pay a single penny more in any network compared to other market competitors that has to work in conjunction with the first part of the law in the third part I think is probably the most important in terms of what is the solution we have to have enough. Reimbursement to cover not just the drug but also the needed finances to operate a pharmacy and actually provide patient care in our communities and if that rate is not fair and reasonable which in a lot of cases has been to be honest with you between two thousand and eighteen in two thousand and twenty four in a lot of plans at the state level think that the laws have made a difference but there's been some recent drastic changes where they're either blatantly ignoring the laws altogether or they're blightly not being fair and reasonable I don't think any in a love for the insurance commissioner come back up your boot but I don't think anybody in that department thinks that pay an exactly night act on every single claim it's fair and reasonable ever. I just don't and those previous slads are showed you from washington they were paying the pbm owned pharmacies literally on on every claim on average I should say not every claim but average a mean of forty seven dollars above need act to pbm owned pharmacies and in the four or two fourteen dollars range to other market competitor pharmacies on average just for perspective. We talked earlier about that I think senator hickey reference that the insurance commissioner could do a rule to address compensation. And even though they may have not historically gotten to the middle of rate setting or or referring on exactly what should be fair and reasonable in the PBM space and in the pharmacy reimbursement space the legislature did give them the authority to do that as part of the conversation. This is just a little bit of a math this is pcma is the national trade association for pbm's and i've seen some of their literature floating around about how much do they keep for what a drug cost how much does the pharmacy keep that kind of stuff and if you look at the green part that would be what a community the pharmacy according to their own literature keeps and that shows that if a drug is a hundred dollars. Maybe the entire reimbursement is a hundred twenty five dollars the pharmacy would keep twenty five dollars that would be a gross profit of twenty five dollars that is consistent there's a range of gross profit across generics and brands between I mean from time I was in pharmacy school it was somewhere in the twenty to thirty percent range and the national community pharmacy is pharmacist association average across the country in two thousand twenty two which is the most recent data was twenty one percent pcma are saying it's twenty five percent and their literature when they're occurts to exactly need act that takes it from twenty to twenty five percent gross profit to literally zero to one percent rose profit you just can't provide care at those levels. I've had a lot of questions from members about what is this really mean in terms of how much does it cost to operate a pharmacy how many prescriptions are failed how many pharmacies are there this is just a real example of a typical pharmacy that fills somewhere between two hundred and fifty and three hundred prescriptions a day that's just typical average pharmacy there are some that are half that says there are some that are four towns that says. But for a typical pharmacy it costs to operate the pharmacy about eighty thousand seventy to eighty thousand a minute. Out of that national statistics are the about sixty percent of those in labor so pharmacies pharmacy technicians other staff community health workers who ever happens to be working in that pharmacy and then the rest is operational like equipment insurance technology riot all the things that are in addition to your labor and benefits. And I think what I want you to take away from the slot is that and I use twelve dollars as a number I talked earlier how to pbms in some cases in washington or paying themselves forty seven dollars about the cost of our drug per drug. If a pharmacy was paid about twelve dollars. That would mean. If you do the math on that then you would make enough revenue to cover your expenses and have a net profit left over. And if you look at the next slide every time that number drops off it drops from twelve dollars to eleven dollars or weapon to teen or twelve to eight is a four dollar drop for every dollar that's about a seven thousand dollars drop in gross profit so it doesn't take very long for a month. For those of you her math wizards to figure out that as it drops from twelve to eight or eight to four per prescription gross revenue or gross profit. They're only think you can really do is either sell. Way off employees. Or cut services I think somebody asked earlier about the hospitals about would you cut services or the physicians. And so those are the decisions that are being faced is every single pharmacy facing those decisions I believe yes but I do believe in some areas where they're big employers that have some of these points that are being agreed and I believe breaking the laws I think it's even worse in a poice like gas bill or in stuck there are literally I could see a scenario where every pharmacy in arkansas county and I don't know about walmart cause they do have one chain there but the rest of them are all independently owned I could see a scenario where everyone have em did not survive till the end of the year of seventeen change with the points in that county as an example. Some of those services I know there are mailed our options there chain options their independent pharmacy options there's a lot of different options I just want to remind this is something that in a visit with speaker matthew shepherd when we were down in his area that there are some things about some of these smaller pharmacies that are unique and don't forget the hospitals care and of course pain management associated with the end of loft career assisted living nursing home same day delivery after hours and weekends emergency tap staff compounding those are more likely to be done by smaller local architects our based pharmacies so as they leave her or sell offer don't exist you also lose some of those services that really aren't not available in my order or in some of the larger pharmacy so just keep that man. The. And then these are the sides i'm just gonna go through quickly I know you guys are familiar with legislation in in the past there was a map that came out this week in the paper and one of those articles where they're now tracking pharmacies per capita and I would just point out that west virginia can turkey arkansas louisiana some of the states that have been more aggressive with PBM legislation it's worked it's helped it has helped improve the market but that doesn't mean there's not loopholes that are exported that that threaten the market as time goes on we have had sixty nine per minutes and arkansas that don't exist since two thousand twenty some of those pharmacies be honest I mean there's been some startups that have come in behind them so that numbers not you know easy to track on. There's a pharmacy not exist at all or did it pharmacy replace them but we have said some recent closures in moralton and marshall takes arkana and greenwood that there hasn't been I mean in greenwood there were two that left and one start up that came back so there was a network is what i'm trying to say and some of those communities. Need act we already talked about a minute ago but I just want to say that there's been a lot of talk today about has federal government interfered and I would say absolutely yes not just in hospitals and physicians but also in pharmacies pharmacies when they are paid in medicaid programs there is a where you basically put your cards out on the table from a transparency point of view you turn over your invoice is some cases it's voluntary and some states it's mandatory and there's congressional while that's going to move through either later this year sometime next year it would make it mandatory but you have to show your invoice process and they're published on a national cms website and then our market competitors who set our rates but also feel prescriptions themselves are using that data I believe against smaller market competitors to push him out of business are also suspect I can't prove this but I suspect that the recent cuts to exactly need act those are to me those are retaliatory those are saying we don't like the law we're not going to be fair and reasonable and we're going to push every claim to pay exactly the cost about the drug because we can get away with it I don't think it's bear in reasonable and I do think it's retaliatory to the point earlier about taking retailer to reactions first seriously. I've had questions to about dispensing fees and medicaid about arkansas in a nine to ten dollars and fifty cent dispensing fee plus night in the fee for service medicaid program. And those rates were put in place and are studied in two thousand fifteen put in place at two thousand sixteen and that cost plus system did save the state over fifty million dollars a year so it was tracking out it a quarter of a. Billion dollars over the first five years during the a such and administration so our pharmacy saw big cut in pay because of that but what they got out of it is they got predictability something they understood and consistency and knowing what they were going to get paid so this just kind of gives you an idea tennessee and west virginia and can turkey have actually passed laws recently to require that methodology to be used in all plans commercial state boys outside of medicaid so there are three states congress passed a similar similar law through the house recently but not through the senate yeah it the federal level for managed care medicaid that's not done yet and we don't know when it will get done but i'm just saying there's about parts and support not just it statement it. Federal so this just gives you an idea of of where we compare there. And then as far as policy solutions go. I think there's kind of three pieces somebody said uh. Thirty words earlier less as a way to to describe that and. Policy solutions are believe we need a rule now I don't think we can wait until the legislative session I think we need to work on a rule figure it out what is fair and reasonable to provide a fair market I do think we need enforcement but I fill out without fair and reasonable it could make the situation and will make the situation worse our retailer to reactions by pbms and then the last fees were PBM and insurance own pharmacies paying themselves more and driving up the price for consumers and an intercompetitive act that's a real problem for the market for consumers. So i'll leave it with their and take any questions thank you so much for testimony that was very insightful that something we've all been talking about and working on a precise your work on this there are a couple of questions in representation you are recognized thank you mister chairman. How many can you enter the quote how many years have we had a family probably owned for this is in the best two years three years held are concerned. I don't know the exact number that are small independent because there were also some berkshires that sold and most of those have been are still opening by wall greens but there are some stores that have closed the. We would you might consider to be a small chain the majority of them are independent pharmacies but over four years there are sixty nine permanents that don't exist anymore there are some other independent marmand pop pharmacies that were sold to either chains or community health centers there may still be there but they don't provide the same services like the services are different so maybe they provided like in green wood I don't know from fort smith there I know senator boyds here but green word and fort smith helped depot it all kinds of things they did compounding they provided durable medical equipment they provided after hours access they provide nursing help services and they completely closed and so in some situations even when a pharmacy still opened they don't provide those same services that help phone bs and have immensely it makes the point exactly the big hounds or control in the marketplace competition and raising prices and have rised for their wholesale customers. How many how many companies do we have now in arkansas. That's a good question in terms of sterile compounding there's only one left in the state I think there is a possibility of of others but there's only one and in terms of just traditional compounding I don't know the exact number on that I have a compounding account to me presidents in the room there's something get back to your answer there but it there's a because of federal regulations in that area they're disappearing I mean it's becoming extremely more difficult even things like magic mouth washed to treat a simple mouth also that you were seeing pharmacy stop doing that because a federal interference understand is my experience just one thing outstairs compounding or you can make stuff in the could be put in the are injected there's only one how many how many candidates do you think will be like are console carely if I understood what you're saying people who live in the winter let her places like they are there be probably those but. They have to drive thirty to poorly miles to get to a foresters that correct. Yes and uhm marshalls the same situation where there were two security how many how many other countries do you know. That's a hard thing to qualify but I would say. T fifteen of having no pharmacy in other words these are requirement. Places have business for people to be able to make their health care and those who can't drive well for the two go. And cover you to to be able to have former. To be able to have a former correct thank thank you president wooden okay thank you represent flowers you're recognized. Thank you mr chair can you give us some idea on what's happening with regard to patience choice to purchase their drugs at a drug store versus mail order because I know for it for a while there were some issues with regard to patience being steered in two or four two use male order is that still an issue that is still an issue and. But we have the **** day thanks this legislature has passed on. All the. Address that but they're not perfect because of. The. Or was yeah better are there federal preemptions that cast it but one thing the state could do that has they haven't done that was one of the thanks to consider on and a competitive acts. If you wanted to set some rules I know we talk about insurance department rules you could have a statue in pharmacy world in the pharmacy permit sad too where these companies have licenses that own and operate pharmacies so if if patients are being harmer there and I believe they are. If there are antarcompetitive acts in terms of payment or they're in a competitive acts in terms of steering against the patience choice of where they want to access services. Then the legislature could take action not just in the insurance department laws but in the board of pharmacy permit laws if you would like to do that to answer your question and I believe that came up at the end of the last session and I know that something that could happen I won't be here but then the accession will be right to do that you know earlier you mentioned the timeline involved in the ftc finally investigating and addressing these issues on a federal level but don't we have an anti trust law here in the state and and if we do you know we still have. Um regulatory laws and a body that's helping to address these regulatory law so if we have you know pbms. In all of them aren't doing this but if we have pbm's who were at the helm setting the prices but then there also getting into the pharmacy business and self dealing and then they're also in the insurance business. You know how is it that we aren't or a cant utilize our own anti trust laws to find some sort of court relief for pharmacists being negatively affected to the point of closure. There'd be there'd be a question for terry general tim griffin but I believe that could happen I mean I do believe that is also a possibility and find that it would take time to be a long process in thank you finally access to the doubter um. To know you know to determine whether or not there is self dealinger and fair impunitive reimbursements against independence and chains and. Might for my understanding that. Data is not accessible to us not accessible to the pharmacies actually engaged and contracts with pvms is that correct and if so how can we address that word yes it is not accessible for the pharmacies to be able to see that the interest department can through audits or through exams they can get access to that. And I would just say where there's mystery there's margin. I mean they need more transparency thank you what we have to move along singer boy you recognized thank you mister chair these are very quick questions number one so when pharmacies. Consolidate into wall greens across the state what is your data imply about increasing costs to the to the state employees in public school teachers when that consolidation happens yeah so I don't have access to the claims data firm state proper your your data what is your data implied yeah so. The cost is definitely higher based on the data that we saw I don't know on the back in in fairness I know I said earlier there is that really what they're payed or is there some national backing in spread that's being caught back I know we have a person here from wall greens in the room they're not fair don't think to come up here test five but they're interested in this because wall greens and walmart and kroger i'll tell me that they are being ripped off to you so they it looks like they're being paid a lot more and then they're actually not because there's some backing in but but it would appear that the either the state employee or the plan are paying more for those prescriptions they definitely are compared to based on the data that you've got yes now the next question is johnson and johnson was sued due to its failure to provide a judiciary a fiduciary duty to its employees regarding the PBM contracts that it hill. Are you familiar with that lawsuit have you read about it do you think that arkansas companies might be at risk of being sued as well for failing to have fiduciary responsibility over the the i'm gonna just call on games they were played in the non transparent way in the background I think there's risk to that they're also lawsuits out there related to the affordable care active. Represent flowers this question earlier about a patient be enforced to mail order and those lawsuits or about okay if I have this disease I can pick it up locally but if I have or have this other chronic illness like cancer I have to go access my care through the mail so you're discriminating against an employee to say if you have cancer you gotta get your treatment through the mail but if you have a a different disease like in a cut or maybe not even a disease but need something assessed. At the local level of different patient with the different condition can get locally so yes I think that's true that thank you can ferguson your recognized thank you mr chair a big couple of my questions have already been answered representative flows their issue a one question about the male order situation mass is a simple question in madistric wong rings bought me particularly in pimbler about all of the super wine pharmacies we only have one super one pharmacy there which is now by walgreens but it's a half or block from the original while great i'll look for there to be close pretty soon does your association have any idea of how many closures we may have in small pharmacies by the end of this year. I don't know the answer to that we could certainly survey it's a good question I know there's national data that says that up to thirty percent could be gone by the end of this year and studies that were down by ncpa that that were at risk. I don't think I don't know they answered that question in terms of is the reason why in the reason why I did question on the other part of my district which goes down to do missouri and so I think they only have maybe wanted to pharmacist if they close that would be a great void of four that part the shake out is my district I was just curious to do I have an idea of the number of small pharmacies that would probably close because of it thank you mister chairs thank you senator hickey you recognized yes would now be quick again you heard me to do the same thing with the mister ran and missed my client also and you brought up to deal with the rule that you think that we need to do something and I understand the situation you're in but I will say the same thing to you all as we do this and I notice you skipped over slad thirty years but I think you're they want to talk to you that's why I put it in there sure yeah and I appreciate that but you know the thing is is I understand if you're having these issues the same as the the positions or the hospitals or whatever but the thing is is we've got to know especially how ward from these call store what we're getting into whenever we pass a rule. Of course we try to do that with legislation and I think you know it actually went back just for our state plan you know if we are to pass this to the dispensing fee alone was going to increase it was gonna increase our cost on just a state level of twenty two million now the other one where you just had the ten percent call start thank you know there was a little harder for us to calculate but it was like a four point four point eight me in a year but I didn't know what you were what your current. Percentage cost was so when all fairness it would be a little less I think i've been saying I assume twenty four twenty five million dollars. So the thing is as I understand that you know yes you all cannot operate if you're not if you're not making any money but we also are going to have to have all these numbers because either we're going to have to put it in home said again either we're going to put this in and start putting it in on a annual basis it's not a one time thing or we're going to have to pass it on to our employees and again there's going to be also a larger cost you know across the you know the ones within the state that are not on our planet or you know are their premiums going to go up or what so if we go down this road with with these roles that were talking about before session I think required to treat it the same way that we would in the session so I just want us to be cognizant of that and and not. Trader bring that stuff before is without all the information that's all I ask on this so that we can make some some informed decisions on the stuff I put that in there specifically we want to be trained sure sure and I appreciate it thank you sir thank you in the sixty dollars is the reason I put that number in the slide is because nationally that is what the average drug is in a total and that's been and that's where you all to sell across this legislature and if this body was to want to to go that way there's fine it's just everybody needs to know what they're up against because we as far as ebd as you know we as we have spent less basically. Two and a half three years you know making sure that we've got this back solvent back dissolving committees and getting reserves set up with and i'm not looking for it to go back the way it was so that's why i'm always so adamant when it comes to this. That thanks center thank you resident of acre your recost. Thank you mister chairman i'd like to ask if both ran could come back to the table. Can I make a comment to wise came and out mr analysis that senator hickey was talking about I haven't seen that particular analysis yet and I would you know and even business with governor's office and other individuals involved in this process. It's. You know when you figure the numbers is it just add the dispensing fee to the existing reimbursement or is it a you know what I mean like getting in those details out love to be a part of that thank you. Your recognized reptile thank you this is hopefully for both you guys know that you've mentioned a lot about taking metallical reaction seriously and even taking. Basically the communications in the relation if you've had with helping to just enforce current law very seriously. I know in april you issued our commissioner issued a bolton station about the five thousand dollars fine that you were going to start imposing if they got even to one sent below made account. Following that what has been the pbm's response as far as the new contract say the issue i've not seen any reaction yet so again we're going to start at enforcement process of at the after june thirtieth so i'm not gonna let as far as the contract said have i'm not forest cbs care mark majon express trips prime those are not paying need access to nickel or need exactly i'm not i'm not seeing anything change. The app john have you heard or have any data concerning contracts that have renewed or been altered starting in april moving forward for this year. Yeah the I mean in specifically cbs is the biggest concern of they made changes in april first and put in rotting to pharmacies and two psa to the insurance department that they specifically made those curts to comply with the state or to pay exactly name account every single coy. And in my opinion not be fair and reasonable. And I don't understand it at all and they've not made any efforts to fix that my point is that I think it's very concerning that is soon as we start to reveal to them just tell series we're going to take this their answer is work in a plummet street to just what that limit is. That's maybe that's what's going on I don't know. Not sure thank you thank you representative cinera urban you're reagnessed. Yeah I follow up on a that's what the lol allows the correct the way it is currently written it would allow that assuming that they're paying CVS pharmacies on every claim and they pay it work that exact same amount which I think the chances of the zero percent is in the legislation is that also extend to not just the cars but also the administrative dispensing fee is that specific in the law that they have to pay themselves the same. Or dear i'm saying like if. Or is it just on cost of drag. It's okay the neighborhood amount it's required it's a minimum it is just on the cost of the drug I don't see anything else if they're paying themselves twenty dollars a distance in fee but somebody else could think they could leave that's not prohibited that's not prohibited it's not really not yet but I agree with john that. When this body pass night act minimums it was not intended to be the commercially viable rate that is now being offered by most of the ppms the premiums have now interpreted that statute to me in arkansas you have to pay minimums that was not the internet the affiliate pharmacy piece I don't have the law pulled up in front of me but it does not talk about ingredient cost expensive fees it says you shall not pay they pharmacy or pharmacist services and then those two words are defined in other places which is a combination of did anything dispensing fees delivery fees any paying failure with pharmacy your pharmaceutics services a penny more and in a philly at her pbm owned pharmacy then competitor pharmacy so so it would have never read of the law they're breaking a lot yes and what beyond the the five thousand dollars fine what other enforcement is in the look if they continue to violate that statute then we could revoke or suspend their permit to operate because it's an architect okay so we can share him down OK and then we could always increase the fine amount as that correct end it increasing the fine amount is that my rule it's it's important to bear mine that this five thousand dollar find amount has no cap if you could be a really bad by the it give me whatever is set by the insurance commission right if you had twelve prescriptions violated the law that's a seventy thousand dollars that's just twelve prescriptions two times five seventy but you could change that amount by caveat not by a rule change or look think you would have to change it by lobb I would have to check its five thousand dollars right now with no care. Okay I gotcha I got a no cap on the number at fines I see I think that the amount okay well i'm i'm just curious because i'm i'm. I'm more interested in the enforcement of them following the laws that we pass and processes and tweaking the language to prevent or closely polls versus china that you know just like the previous decision discussion as far as setting you know. Profit margins are rates that are that gets real tricky rock fast and then app for everybody but uhm okay well I appreciate it and for the record I am fully supportive of. Making sure that we enforce these laws and hammer them if they are a night following the lot thanks in a reps of flowers you're reagnessed thank you mr chair I just wanted to be clear. Are we saying that right now if a pbm. Owns. A farmer see and the pbms are also in the position of setting reads but there if they also own a pharmacy and they are determining what pharmacies get reimbursed. But they pay their own pharmacies more. But then these pharmacies that have contracts with them that they're paying less can't say anything about it and don't get the data. That that's already not self dealing and doesn't go against existing law in terms of anti trust or whatever else might be out there we're saying that's legal. I can't say anything about anti trust says the ages office that you would need to talk to. I trade your griffin but if if if your pay you can't pay enough filling it farmer see more than you're paying an independent pharmacy that's in the state law so that's in the insurance department's jurisdiction so I don't know if i'm answering your question but in terms of anti trust that that's that's the ages office of that but so I just heard though with when senator urban was. Trying to get ascertain. You know whether or not the existing law allows them to do what I just describe are we saying that the existing law allows pbms. Their own pharmacies. To pay their own pharmacies more for the same prescription they're not supposed to do that and not just for independent pharmacies they're not supposed to do that for carton kroger or i'm has spoke that I can confuse with I think the question but no you cannot pay your philly it's higher than you that's already illegal that is already illegal there has nothing to do with antitrust is already illegal and we know what's happening what is what are we doing i'm again we we are investigating against one of the pbms with allegedly doing that we are up put them under an audit exam so I will react a complaints on there thank you represent flowers reservies directness I think they may have already just answered my question I was just sitting you're thinking if we've been getting fifteen hundred complaints a month and and we have evidence to see that they are breaking the law. Why are we waiting until july one or later to start issuing fines I think some of the reason is we wanted to be fair to the pbms and provide them with advance notice so that they've got system problems your if this electronic or they've got some issues waited to compliance we've given them notice so I don't want them coming back several months from now saying gee now the insurer's department find me hundred and fifty thousand dollars for five thousand dollars on twenty of the claims that we're not incense below netache so i'm warning them that if it's a penny below neither act they're going to pay a five thousand dollars fine so I just want to make sure email reasonable regulator giving them notice but you're right or if they are paying where they're affiliate right but there I think the assumption would be that they're already aware of the law that fifteen hundred complaints it we're getting or not affiliate related complaints representative flowers as indicated they're need at complaints which is entirely different issue thank representatives last question in the queue today is sinner hicky meant i'm sorry to prolong this but I want to make sure that we've got the whole information you say you get fifteen hundred complaints are they fifteen hundred legitimate complaints but college I was told some information at one point two that is far is paying the nadec there is it is it under medicare or medicaid if they're not actually required to do that. I don't regulate the medicare so so but but I guess the thing is are some of those complaints as it relates to that you know because the thing is are you saying that these fifth fifteen hundred complaints that we have to restriction over the percent and for complaints that we get from pharmacies there for example and medicare van each medicare plans pure medicaid or a risk narrows track here we turn those back because we don't have jurisdiction over so there may be some complaints that we get that we do not that we reject cause I don't have to restriction over but when i'm saying fifteen hundred i'm talking about ones we do your about legitimate complaints at once and and how long has this been going on your set for two or three minutes so if you had a chance to look at him and see how many of them were or actually valid yes they're all valid I mean i'm looking at whatever I say valid that they're they're actually well the walls we have that we have authority over for sure and a while has been broken with them you've looked into on that way yeah and i'm again i'm giving them advanced notice I work the I work the part about the phone yeah I think a personally I don't know you wait to june thirtieth but that's your deal to do or I mean I understand you're trying to get to the fiscal year as thing is what you're what you're doing but I mean you know from my standpoint I think that's the way to do it because I mean the legislation that we've got there that is the way it is and although I understand the thing with them with this need act that is exactly what's in the wall yes so I mean whether whether or not I agree with that or don't agree with it you know if if we're going to go with this rule before we go into a regular session that's up to this body but up but I want to treat it the same way as we would legislate. I recall representative war lot saying to me about this that once you set a minimum and state law it's where the market is going to go in that's exactly what the premiums are doing sure and agree thank you sir thanks sooner hickey there's no one left in the gentleman thank you so much for your testimony that was very very helpful and members thank you for your patience today and it was a very extended meeting and look forward to seeing everyone soon is there a most to adjourn motion motion in the second motion