Public Health, Welfare and Labor Committee- Senate and House

Chair sees a quarm. The. First up on the agenda is the conservation the minutes to prove the minutes from march twenty ninth meeting of action previous motion second all those in favor say a opposed minutes a bit approved first up on our agenda we have some discussion around the vacancies at the human development center nursing vacancies there's some folks here to test found that. If you if you hear the test for the nursing shortage race then you can press the table. Maybe there's someone outside yeah. Hey ladies if you are if you're here to test found the nursing shortages come to the front of the table and when you the table states your name for the record who aren't you with. Should be able to just press the button and I can recognize you. The. I'm katrina robertson and I made the parent and guarantee and no a robertson who is a resident at the boom bell human development center thank you. The. Good afternoon i'm carol sherman and the mother in guardian of china are resident of the orange office htc. And i'm currently died my son matthew lives at the architect yet each dc as well. Thank you later whichever one of you want to go first you recognize to present. You have to touch your mac phone or more town. It took me a better I still and figured it out i've been here like about third time it's okay you're doing great when you sread you can talk. So chairman johnson members of the committee. Staff. Ladies and gentlemen. I'm carol sherman i'm here today because of my son john. John turn fifty five last december. Yeah. A good look and guy who carries himself well. My son is non verbal and functions on the level of a young title. He's unaware of danger. And he's dependent upon others for his health and safety. Assisted by many john continues on a slow. And passaging developmental ark. And when i'm with him. He pours love. From his eyes. The. In my early journey with john. I desperate that I would ever have such a message. A college for instance to me well. We will pray. That he no shoe. And although he has never call my name. There's no doubt. John knows me. I think back to when I was a young mother and when my husband in. Or struggling. To understand the mister boy. So beautiful so perfectly formed. Our first chart. Who looked as if any moment. He might speak to us. We did not know that an unknown syndrome was at work in our boy. Which would prevent. Cognition and speech. Five years ago when john was fifty. We learned. That he and his grave conditions are result of genetic anomalies. The. I don't think of drawn as an institutionalized person. He lives where his health in safety needs are best met. When I think about his license facility. I think about faces. The faces of his housemates. That of his. Create superintended in the staff. The direct your staff the training stare. The directory behavioral medical and dental staff. I think about the safe. And spacious grounds. I'm a visit with chin. I observed it all seems right. In his world. Now i'm grateful. The. I said that I was here today because of my son. In that is true. But i'm also here to tell you about. The dedication of the state employees who work at the hdcs. I specially want to report to you about the over and above in beyond care that they took during the covered crisis. Think about it. My son doesn't understand to cover his mouth when he coughs. Is never learned how to use a tissue double is nows. He has to be prompted. Two washes hands. To stay hard reading. During that few four times beginning in early march twenty twenty. The superintendence in their staff learned new health protocols. They took extra shifts. They postpone personal time off. Administrative staff to shifts in the homes in order to provide. Coverage. I know in order to office. The. An employee name ten yaka conway who usually commute it from. Texture cannot to arkadolphia. Stay so often during those frightful times. That the superintendents set up a couple. The. In her office so she could get some rest. Nine months later. On wednesday january six twenty twenty one the architect you superintended sent out a report. Vaccinations were given to day. And everything went extremely. Amaysim. That nurses could. Provide vaccinations to individuals who have little understanding and can help in their. A health care. Think about her flagship the conway hdc. It cares for four hundred and fifty individuals to have vaccinated all those people. The report continued that. In additional booster shot would be given. Twenty eight days later. In further more than all the staff would be back sonated as well. Every day the five hdc's provide life saving care. To over eight hundred and fifty individuals who come from every county in our state. Then I would like to data recognize their work. By calling the names. Of the superintendents. Architect of your. Carry gamble. Boomball. Jeff gone. Conway. Ceremorphy. Jonesborough. Diane keith. And south east arkansas warrington mark wargo. Diane keith actually came. To the superintendence job after the. Superintended at change for a diet of coving his name was steve former. I'm also here today to report. The challenge is that three of the five htc advice for some nine years I think nine months. And that is they're inability to hire nursing staff. You have a hand out she with greater detail about this situation. The cause of the nursing shortages is the center's inability to offer competitive nursing wages the htc's in order to meet their license your requirements must have nurses. And when they are not sufficient. Hdc nurses the circumtinance have to hire contract nurses. Rans for seventy eighty dollars an hour. Lpns. Or fifty one dollars per hour. Such spending blows a whole in their budgets. Additionally hiring contract nurses causes a moral problem at the hdcs. An hdc working nurse working beside a contract nurse is doing the same work but that contract nurse is earning much more. Hiring contract nurses also means a disruption in the continuity of care. It takes heart inexperience to help take care of our htc residence. And. I can't explain. What a miracle it is that someone like john would tolerate a jab of the needle. And even a draw of blood. So. A stable experience nursing staff at these centers is critical. As I understand open the office of personnel management has been working with h s n DDS. Two are proposed of formula to address the nursing issue at the the three htc's and perhaps other state programs as well. I don't know if the reset review stable is sation act has addressed. This urgent need. I respectfully request your support in assistance when such a formula is proposed. My light has been reshermented served. In the house. A representatives for ten years. He was a single practitioner lawyer. Any created the parent guardian association. It's less lonely. And frightening to work. With other mothers and today two of our newest members are here after their brief presentations if you have questions of us will be glad to answer. So katrina are you sure. Chairman john sanna and members of the committee and staff and. Ladies and gentlemen and the audience like i'm into my name's katrina robert san and i'm here today because of my son nowhere. The boom bill human development center has been a guide send to our family and to nowhere with out this hdc nowhere would be honest rates in jail or dad. The support of these facilities must never come to an end as we will always have these complex individuals amongst us who will thrive in these settings and will never fit the narrative that community for all disabled individuals is outside of facilities i'm gonna take you back to my electronic diary. The following passages from february of twenty twenty two. Hot here streamed down my face in the anger boiled inside me as the disability rights person continued on the phone. We can help you get him to care he just needs more community supports and place everyone deserves to live with dignity in the community. I swallowed hard. But my anger was impossible to mask. Have you ever tried to care for an adult with profound and incomplex disabilities an individual with both intellectual end behavioral issues. Or what about complex medical names. There was no response from him and he evaded my question I hung up the phone feeling like a failure. Guilt overwriting me I nearly killed myself for years and I brought harm to many trying to integrate nowhere into the community. At the time of this phone call he was sitting in a gel cell after being homeless in a shelter for months and then at a hospital ER on a mat on the floor for forty five days because there were no placement options even community waiver providers were now all denying him due to the risk and liability he presented and their inability to provide for his complex behavior issues. We were nap as he sat in jail we were waiting for a bed at the boonville human development center to become available as a funds had been a made available for additional beds for these individuals with these complex dual issues. While if you found forward about nine months later he did get that bear that the boom bill human development center and I was making a trip there for a talent show he had excitedly told me about this talent show for a weeks reminded me of the date and time to make sure i'd be there and of course I assured him that I would be there. When I arrived that day and made myself made my way to the building in which the talent show was to be held I was able to spite nowhere and he hurried over to give me a hello but then scurried off quickly to meet with his peers friends residents and the other staff. I went into the auditorium and I saved a seat for him next to me but then I realized he had no interest in sitting next to me. Our my feelings were hurt a little. But he wanted to be with his friends his peers so I set toward the back of the room and I watched. Again I had tears streaming down my face as nowhere as I sat and I watched nowhere giving the participant standing novations and he danced in the isle when he clapped and he hollered and he cheered them on and then he got up for his own little part in the talent show where he's saying how great is my god. I realize no awares living with dignity in the community this community his community with his peers don't we all do that gravitate towards those who are like us I left that day with those feelings that fell you're in guilt gone I had done good for nowhere and my fight for him was not in vain. If you fast forward another nine months he'd been there eighteen months and this time I stood in a court room I know is behalf and I held in my hands written by a psychiatrist advocating for nowhere to remain at his placement it was eleven pages long but it started and ended with this statement. Therefore by the very nature of his mental disease and mental defect he can be considered a potential danger to himself others and property what mitigate that possibility is that he is in the most appropriate placement possible for his diagnosies. He is in a well controlled total care environment so any potential for acting out as handled by train staff medical staff and a security team as long as he remains there he presents no danger to himself. Other persons and property. So I repeat what I know to be true the boonville human development center is a guide send to our family and nowhere. I appreciate your attention but more importantly I appreciate your public service. Characters and members of the committee staff and ladies and gentlemen i'm kimberly died. I thank you for allowing us to speak to you about the life saving work of our states five human development centers we appreciate this opportunity. First I need to tell you about my math you. My math you as twenty eight years old. He was four hats at a time. So we're a baseball cat he'll have a seasonal house like a sand a hand on top of that. He covers it with a black cowboy and he cause a great big top hat from the circus down over those four house. He loves his house. He also wears about high a black boat with this shorts and his teacher and he carries a walking step. He considers himself to be dressed up like germany cricket as he moves around and sometimes he'll even break out into a happy ticker. He just laughs his disney characters and he loves his house. Matthew joined the south east arkansas htc and warren and twenty seventeen. He was twenty one years old. In prior to this window nothing about the htcs. The. Our family had done everything we could come up with to meet matthew's needs and the community matthew attended a little rock scores he was in self contained classes and graduated in twenty fourteen. We did speech ot pt several other kinds of therapies we did psychological councilling everything we could but it wasn't enough. After high school graduation and twenty fourteen matthew started in a day program. It was a great program and they worked at matthew for two years before they dismissed him they were not equipped for his level of disability or his behavior allowed hers. Matthew started on a downward spiral at that point he was unhappy he was a defiant he was a determined and he was going more and more aggressive. Mm. In twenty seventeen we were and crisis mode all the time. What matthew was twenty one his younger brother was only nine and he was beginning to show signs of trauma. Matthew needed more services than we could give or find and no one understood nor is a willing to navigate are the complexities of math you. We turned to the htcs so on september twenty fifth of twenty seventeen. When we arrived at southeast arkansas ht and warren matthew was upset with us and he ran from us as we got out of the car we were early for our appointments on that day we had not even been interviewed or admitted and to the warrant program but we arrived on campus. And we needed immediate help. We basically locked in the front door and said hi you've never better before or almost an hour early for our intake interview. And. Your future resident just ran his gone towards the highway. Well as you can imagine they ammediately. They immediately mobilised and superintend that mark wargo was in charge. They called a crisis team or a behavior team I had no idea what this mount but I quickly learned but a blessing such a response is. I truly expected the warrant staff to sin math you away after iraqi start I expected them to say what every other place had said. We are not prepared for his level of disability or behavioral complexities. Instead they welcome tim. They talked to directly to him instead of only addressing their comments to me about him. They remained calm and relaxed while he raged and fight. They recognize to signs of escalation and descelation. They were trained and they were prepared by they were being timed compassionate and encouraging this was a new we have not encountered this before. Matthew was at the warranty htc for five years. He was there through cobin. Yes my son. My family is in a congress at setting during a pandem. Our family watched immediate reports of high death tolls and nursing homes and other congregate settings. But in the fiber hdcs and arkansas there was one resident who died from copen. It was a tragedy for sure. However there is only one because our hdc staff cared for our most vulnerable during an unprecedented medical about. Matthews now at that rocked off yet htc. The superintendent there is carrier gamble we met carry gamble in warren she was part of that impressive tea meth is very first day. I want you out to know that when I walk unto the architect yet htc campus. I'm watching. I'm watching the staff and I see them. And what I see is how they laugh with the residents. I see how they notice when someone needs a hug encouragement a high fiber if this bumped. I see the staff applied them I see them offer assistance when needed. I see my son is treated with dignity and respect. I see the meeting are the residents daily needs and i've even see how they respond when a staff is aggressive. Matthew moved to the architect yet htc because it gives him even better opportunities for employments and activities he's interested in he has a job. He's making friends and these positive experiences have filled matthew with the sense of accomplishment he's more confident and he's proud of themselves these are all improvements for him. The htc program is where a matthew has found is independence. He's happy. Matthews thriving there he's gaining skills and he's achieving goals he's living a better life because of the htcs. I know the htc staff and programs have helped him grow I see his behavior has improved dramatically and positively. I can say htc's are making a difference in the lives of people who desperately need assistance. My son needs the hdc it's where he is gain independence it's where he's integrated he has inclusion all these things that advocate speak about when they're seeking more rights for people with disabilities. I support the hdcs there are blessing to our community. It's not always easy to speak about matthew and our family's experience with artism. But I tell you matthew story. Because he cannot he cannot sell the advocate. This. I tell it because I haven't request from you all. When you are making decisions that involve people with severe disabilities. Please consider those can who cannot participate in moment such as this. Please consider them by listening to their advocates and their guardians. We do our best to give them a voice. They deserve a place at the table during discussions for policies related to their care there work in their activities. Thank you all for your time today and I thank you too for your public service. Thank you ladies for that test where would you have any questions from the committee in ecommerce. The. Sit around with your account. Well I just I just think the guard creates angels for those most phoner ball and we have three sitting at the table. The. And so thank you for I know sometimes we get so caught up in the world and we don't apologize for being late but sometimes we just don't get changed we just get to take service or yourself sweet but honestly I mean thank you so much for in the marms that you are the leaders that you are the examples that you set for all our cancers because of because of your children and in a guard just gives sometimes you've got big shoulders and guy puts a lot on you because he knew you could handle it and he knew that you could speak so adlocately and so beautifully and share that stories with us and make us more aware so we're just and gratitude to you are thank you. Senator sold in your recognized thank you mister chair and I share the comments that were made about. So in the hdf makes recommendations are a maybe their mandates about vaccines and sharts and things are you required to follow that or do you have a choice there's the advocate for your children is it a mandate to stay and there that they must be vaccinated or no it's not a ok thank you thank you richard chair. Representative ladies and your recognitions thank you miss chairman well you all know I could be sitting in another chair out there but my son ethics and john jones borrowing the bill center thank you all for your stories and come in the day and I think it raises awareness of people that aren't involved in that whirl. That there needs to be a place like that. For you know our sons and daughters that had the needs that you all just mentioned you know when when he's one end of the human development center they asked me they were what's the best thing about it as well they have three shifts at home we don't have one is twenty four hours home and you know what i'm talking about when I say that but appreciate your stories and I think that this group will hear you and work where we can and as you all know we have limitations on I mean that we have available but it's good to bring the problems to us bring your stories to us so that we can make good decisions so thank you for being. Center love you're recognized. Thank you miss ship. Oh sorry sorry I pushed the wrong sorry man. They are he trying to turn me out again man I press the room and first of miss chairman here I am of here i've been here for a number of years in you've been even even advocate you've been advocating for number years and not just appreciate the the efforts see that you and the other lady's bring to us where I do want it but what I want to ask and it's not a question to you are but mrs share and hurt miss sherman say the. They've been working with a number of different state agencies do we have a update on on what is going on on this issue all in this matter. Even come to the table if you let his just slide to the side and I don't think in better when you leave yet let these two folks come and give us an update. The. You can just when you get seated there just state her name for the committee so we can have your name for the record. Yeah. Pay more as the weather turn director of medicaid specialty populations. Tommy tarpley and am director for the division of developmental disability services. The. So we do are so grateful that you guys left these lady scam come today to talk about the htc's rate we think they did really good work but it's nice to hear it from people who have lived experience we have been aware I mean as you guys know we've done so many different. Types of career ladders and grades of the htc's ever last probably nine years really a lot of them have stabilised after cobid in terms of our cna ladder right we have very little vacancies right now but we continue and as you guys had their hand out from insurer men those numbers are an accurate reflection of both the lpns and the vacancies we have at each one of the centers we calm to alc I guess it was the fall of last year the fall of last year and we had asked for two things to try to have some relief on this issue we had asked for a ten percent geographic differential for registered nurses at the architect yeah human development center in the conway center because those were the two we were really struggling with with registered nurses and then we had also asked for an additional ten percent geographic differential for lpn's at all fab of our centers in it has helped I mean it really has but we still have to utilize an at well contracts for those two types of employees there is a request that has been sant we've been working very closely not only with opposite person on management but this is not unique to asset dhs rate it's also happening at DHS that are state hospital at our arkansas health center it's also happening at better and affairs corrections has nurses the health department of course has nurses and so as you know when we change something on a nurse position it affects all nurses in state positions across the state so we had to be mindful about so we've been working for several minutes where veterans affairs and arkansas department of health to come up with a proposal that we felt like we get all absorbed within our budgets. So that we could make a real difference but we didn't want to put something out there that may be wasn't going to go anywhere because they weren't going to be able to support it which is never helpful to so we have been working for a several amounts we will be bringing to alc in june I propose or for a request for increase in salary to both lpns and registered nurses and current. And current lpns and registered nurses because as you guys know when we do entry level increases that sometimes only compounds the problem because then they're coming in much higher than our staff that are there which is a real moral killer so we'll be bringing that to ALC n june for hopefully and review an approval for a july one start date. Happy to answer any more questions and think you are. The. Said loud you have any more comments no mischair chairman I think sufficient update thank you representative barely recognize thank you and chair and thank you I will be in here today and we have when knows the problem across the state where they were working do we have any specifics yet are you want to share those who want to wait to june to share what you're working on that. I'm happy to share them with you represent a bentley i'd prefer not to share him from the table since I don't think a pm officially reproved them and but i'm happy to talk to you about them I have them with me thank you thank you. Send yourself so then you recognize you thank you so I know the staffing is really difficult right now the competition is just unbelievable that that agency's face and provider face are there states that have programs that have different licenseers in this then we do here in arkansas that allow you representative bentley is looking at midwives we're looking at another form of care that's trained and professional limited and their scope. So are there other limitations in scope that other stages are using to provide some of the as much needed care. So hours they have not dent other state research but what we have been kicking around and discussing internally and with the other agencies is a different type of nurse designation ray of a direct care state nurse and II talked to representative ladies and about this I think yesterday when he called really trying to make that distinction of direct patient care at our facilities vs nurses who are valuable still but i'm doing more of our claims review process or may be doing another line of work across the state night direct patient care so that is being discussed and we are mentioned with brought that up to OPM and of course we are continuing conversations with their group that stewing arkansas forward so i'm very hopeful that we can make a move in that direction in the near future glad to hear that because we if we're only trying to solve current problems with current solutions we're not going to catch up oh the pay scale for nurses and apns and such as where this can be difficult to compete but if we have alternative sources of care who are still professionally trained that may be another solution so i'm glad you hear you're looking at that thank you thank you very much representative all in your recognize thank you mister chairman and I will thank you off of being here today and thank you for your passionate testimony very passionate I have requested you mentioned doing a testimony that is high for you to compete with contract nursing so it was contract noting the same as traveling. The. It's yes here it's it's a it's nurses it's lpn's ends that we we have various contracts that we can call from but yes they are much more expensive than if we hired a full time employee. Thank you. Image of any other questions comments. Ladies yes representative is certainly. Thank you thank you chairman then idea about having a category for those direct here because if you look at the list that the ladies gave us and the the amount of medical care the issues that these direct care nurses have to deal with is much more difficult than some of the other nursing jobs that we have so I think you know it's it's a matter of paying for the difficulty of the job and I think most people can agree with that so i'm looking forward to seeing your proposals on that they. You recognize center thank you just one last question do you adjust all of your health professionals according to what the market is happening so your physicians are there are first name now. Okay. Let his app pludge a courage hard then can they make testimony on these kind of issues i'm a parent of a child with adult with the intellectual disabilities it's hard as a heart thing and it's difficult to find the right environment for your child to live in and certainly for a subsidiary kids this is the least restrictive environment right and this is that their community and so that I deal pretty judgment is being placed on you point i'm in pathetic with that and in really appreciate you take the time to come and testify this is eight hundred and forty one individuals this is not going to break the bank of arkansas you know we should do the right thing and do the best we can to take care of these folks because it's a very limited small group and people that we that really need this kind of intensive care so they can for comment and thanks for your testimony day. Senator boy. You have an eyes peter present. The. You recognize presentation thank you mister chair so fellow committee members i'm here to ask you to refer this isp to public health health services subcommittee from both the the house in the senate and I just want to give you just a little bit of background on it on cradom or cradom and so i'm a start with some people pronounce it cradom some people pronounce it craddom they're both acceptable depending on where you are but in america it's probably cradle so the crayon plan is a tropical ever green tree in the coffee family it is native the cambodia thailand indonesia malaysia mind mark and papua negini depending on the dose it can have caffeine or opinions like effects it is a potential it is a partial operate against which can produce opinion like effects but it's touted to have less concerned with negative effects such as risk record depression. Some sources talk crap credit on is a vehicle to assist opened attics with transit transitioning off opinions cradle miscurrently a schedule one in the state of arkansas schedule one means it's likely habit forming and has no medical value however twelve states have passed the great on consumer protection act which is what this isp is a hearing in the health services subcommittee with all sides of the debate on access and legality will provide clarity on benefits and risks of providing a legalized structure or not for distribution and possession of cradom in our great state so i'll move that we assign this isp to house and senate health services subcommittee for for hearing thank you. Members there any questions for center boy. With that objection we will sign that to said subcommittee. Thank you. See next step is adam army okay me members staff to clarify this is a rule that we had been asked to review at a prior meeting and i'll have some questions just around as it processed different because we're in session is that the same process is when ratified session i'm told the process is the same so we have four things we can do with the rule just for everybody's review we can review the role. We can not review the rule to not review the rule you can do that only only two basis one is it's against the law in the other is if it's against legislative and tear if it's not against the law not I guess legislative and ten in that those the only two reasons not to review we can take no action. Which is we don't give any opinion back to the rules committee in which case it goes to the rules committee or we can choose to do what we did before which is hold the rule in at I think I have that correct with staff. So if there's any questions about the process would be happy to answer those before we start here in comments about the review of the rule. The restaurant ok we do have some people signed up for the rule and I guess DHS is here to preset. He wanted to come to the table and preset first sector something new that. Fingers state your name for the committee. It's a mystery to us until you state your name go ahead afternoon elizabeth hitman medical services mitrous chief there janet man deputy secretary of programs and medicate you recognize to present the rule. Yeah. Hello and this is the continuous glucose monitor role that is a result of an act three ninety three that was passed in the last session. And this rule is the same as what we presented before and and this is to comply with that act which to DHS required two things one to expand the continuous glue coast monitoring benefit to pharmacies and the second is to collect rebate for the provision of that service so this rule would and allow both pharmacists and the me providers to provide that benefit it is still being built through the magellan system which is the point of cell pharmacy system. And paid paid at a wholesale acquisition cost and i'm happy to take any questions members with any questions for dates about this rule. The. Representative of your recognized that you miss chair thank you offer him today and for presenting the yes I know we've had some discussion about this a few weeks ago so a couple things that I wanted to clarify that I was at. For me or are sure on when we left that first of all how is this being build so currently historically how is this being built to the fair federal government to the cms program how are we currently doing sure so staying that's probably better at explaining this than I am but we uh we claim federal match for the services we provide and just like anything else so on this when. We try it down after the fact that we do we always we we match and and pay the bill when the claim is filed so I think the question is too far the service is currently delivered as a medical service claim through dm which I think is what you're asking representative and it is currently reimbursed I believe in a hundred percent of the medicare rate it is reported in through the cms sixty four quarterly through the expenses under home health benefits in this with this change that we are proposing today it would be billed through the pharmacy point of sales system which I will due to cake the claim immediately put it in the queue to be paid and then it will be paid out. Weekly just like a medical service claim if it goes through and includes all the audits in its deal will be reported in the home health benefit that's where it is required by the fed the match rates i'm not aware will be changing it is just the delivery system that will be changing could I have followed it was due you recognize from potentially a couple so is this going to continue then to be build in the damage benefit at the cms level but then paid or build locally through the pharmacy can it be done through two different things. It it can and I will say that after we presented the first time we had several conversations with dme interested parties and think an association was formed and in mrperiod good and others were part of that conversation and we continue to have that conversation with them there are some states that do do a dual benefit we are not proposing that today because that puts a burden on the agency to pay and chase and that does offer some concerns with fraud and abuse also it would put the dmes at a disadvantage quite frankly because the point is sale adjudicates at the time that the prescription is filled in at the time they send a medical claim in those get processed every week and pay there's always a risk that they will have fulfilled it through a medical claim and not get paid for it. In an or if there's a dual and both are paid then i've got to go recoup from the last one paid the first one that would have been served we would have gotten the payment in ensure faith so that is a concern for the agency while we are not proposing a door benefit okay could I have one more follow up this few minutes there's someone else in the book i'll get back here you get more follows okay but my other question would be and what I was unclear on so there was talk about a a rebate and you guys don't know what that rebates going to be but currently we do know that the me is being charged a certain level pharmacies being charged a certain level and it's about a hundred dollars increase to go the pharmacy route is that correct. It has been reported that it is for that specific service or that specific vendor if they choose a different vendor I don't have those specifics on the differences okay but with what we know between me and pharmacy there is a hundred dollar difference very from day to day but it is around a hundred dollars that history so we don't know what the what the benefit will be back to the to the department so there were some discrepancy also the way this is written that goes back to the beneficiary but you said that goes back to the department but I don't see that's changed in the rule. Well I know so that the benefit was always the rebate not not the benefits he's me the rebate is always designed to go back to the agency we do not pay any benefits to any beneficiary but the statute says to the beneficiary correct. The statute was I think there were questions about that last time about the way it was written and we had interpreted it that it would be going to the agency and i'm not aware that we had changed our position so the agency has been a few questions so the agency has a beneficiary then. No sir but it it. Yeah. I'm gonna let the lawyers answer that lawyers told me that it was going to the agency and I went with that while they're looking at it well they're looking at the estimate may take another question represent billion recognized thank you and thank you for giving a slighter to done this and been steading a little bit so give us the I know there's different points that point a sale throughout there's no one time dispensing vehicle so he goes opportunity for them to how they're going to recoup their funds on that for me real quick and appreciate certainly so the point of sale system is used for all of the pharmacy benefits to the beneficiaries in the state of arkansas there is dispensing fees paid for each time that is filled I believe that dispensing fee for the um glue cost monitors would be ten dollars and fifty cents each time that it's filled and we do have a rain digital believe the range is nine or nine to ten fifty for all pharmacy local reimbursement for a dispensing fee. Do we have an answer for representatives yes so representative walls are just to answer your question the way we interpret that statute is that coverage is the now and there so when we say coverage for a continuous glukos monitor show allow the beneficiary to obtain a continuous glocal smarter and in the coverage shall be eligible for rebates as a pharmacy benefit. So that that's the difference in the interpretation I know last time we were here the question was when it says be eligible for rebates. There was a question of is that the beneficiaries or is that the coverage and answer from our interpretation is that coverage is the now coverage is what it means when covered shall be eligible for rebates meaning the medicate program. So you're classifying yourself in that statute as coverage. Correct the coverage that we provide is what gets the rebates because we like janet has said the there would never be a situation from our program where rebates go to the beneficiaries that's not how the program works the rebates would come back to the system so in the other programs that get rebates their worded exactly like that they use beneficiary and coverage. I don't know the answer as how it is worded in other sections of the statute that all pharmacy is subject to rebate that do go to to the agency I guess my question would be for the chair then is there a way that staff could get us that information about other things with rebates we want to be in electrically consistent I assume and interpret though all the same across the board so I would I don't know how many times it's mentioned in statute we can try to look that up and get that information back to the committee representative research I can speak for a state plan the way our state plan works is the way pharmacy benefits flow in they go back to the state plan as well they don't go to the to the employees in that situation that are covered under state plan. So that there works similar to how our state plan works for pharmacy rebates nominated keep moving to the key i'll come back to you if you have more there's there's center boy do recognized thank you mr chair I just wanted to clarify you mentioned there was a hundred dollars more in payment. I think you answered this when you talked about the ten fifty the non dollar to ten fifty dispensing fee but it's not like you're you're not saying pharmacies are getting paid a hundred dollars more. Na gross profit since you're just saying the payment is more and then rebated back to medicaid right yeah yes that is what we're saying through through the conversation and through developing the rule they're their different rate schedules where the glue coast monitors are sent to the wholesalers being it in dma or be it in pharmacy there's a difference in price the the entities are reimbursed for the price and then the dispensing fee so that's where the hundred dollar difference came in from different schedules so that the ones that go out and are distributed that have an ndc number also get a rebate and we would anticipate that. After the claim was paid and then the rebate came back to the state that the net spin would be less and saved that whatever fiscal impact they they showed earlier correct we hope for it to be we do not have those details they are proprietary so I can't give you a definitive yes or no we can follow this in come back and if it's night then real value at the rule I think her contractor provided as some estimates that were given here as about close to a million dollars a year and and that's based on what they have done another states but as doing it said we don't have an agreement with the manufacturer to tell you what specifically. That would be but you would do your do diligence and verify that you're really saving money correct we do thank you. Representative pill continue recognize thank you thank you chairman. Switching gears a little bit you know after I last meet at heard from several my colleagues that they thought that there's somehow violated federal law despite having cms approval can can you talk to that and explain why there is no violation of federal law in this rule yes sir I will start an elizabeth and mitch will follow up when it if I message up I mean cms is known for violating federal all the time you know that a joke so bs has approved this plan we do not feel that we're in violation of law what the original state playing a moment that we did submit sms did deny I think we came to the table and disclosed that and it was primarily the difference between a required benefit alternate benefit and so where you have to report it that was the reason there's been a lot of discussion of reporting it in the home health section which is required under the medicaid state plan in pharmacy at and don't mean to shock anyone is not a required benefit in this in the state health plan state of arkansas as most states in the country have adopted it as a benefit in their state plan so we have to report it under home health. Thank you for up. You're reckon as for follow thank you and it's not really far because more of another question but. I'm going to keep talking anyways. Though weren't they going to make sure clear and this is another thing I heard after some of the scheduled was they said they they they liked having two lanes they like to have in dear me being able to fill this they like pharmacy being a fill they didn't want to shut one laying down for the other. But what we're talking about here is how they get paid not the ability for a dear me to fill this and I want that to be very clear so could you reiterate that. To the committee cause I think some of some people can confuse on this they think that somehow were in other dme company wanted to still do this they wouldn't be allowed to simply by the fact that there are dme company which is not true. Yes I stay to be clear where changing the billing from a medical billing claim to a pharmacy point of sale claim but we are encouraging dmess to to enroll and bill under that pharmacy adjudication point a sale process so that they can all be build but we're trying we're changing the billing method we're not changing who can bill thank you appreciate. Senator urban you recognize for a question so just follow up because I you again we don't want to close the line I think that was a good analogy. But from the testimony are they being priced out of is dme being priced out of being able to provide this and other words. There is a dispensing be built in for a pharmacist is there a dispensing fee or a. Service. Code. Associated with this for dme and how how or where they also receive a dispensing fee. Because that was the testimonies that. Yes they can but if you know if they're not. Being an ambulance are not able to like you know provide it then that's just going to cost them out of the market and honestly don't think anybody in the legislature had have any. Um intentions of two thing one over the other you know we were trying to open up a path and open a bit door not shadow door on anybody so could you just respond to that so i'll start on a little is a bit finished but also then would defer part of it to some of the test many of it of the dme companies yes if the dme and the pharacy both bill through the point is sale they are eligible for the same dispensing fee for every prescription that is filled so that is true they will be paid the same going from the medical claim to the pharmaceutical claim in the point of sale you billing differently different rates under the dme they bill one hundred percent of medicare usual in customary which I believe is two hundred and sixty five dollars a month. This. Ish. And then that's where previously question was asked about a hundred dollars difference with being told that the retail pharmacy under the wholesale acquisition cost will be approximately a hundred dollars more that will be reimbursed plus the dispensing fee I will I will defer to the. Dmeas to talk about what they do with the usual and customary that they will not be billing this time but they there has been testimony not by us but by others that there is a difference in the ten dollars and fifty cents versus what they were getting in the usual customer. Yeah and i'm in that that's just information I want to know because. I mean and understand the way the bill was written but if it's effectively putting them out of business on this issue. I just don't know how that's. Beneficial to us. So I i'd like to know the specifics of how those billing processes are structured. And then what exactly are the dollar amounts. Between the two yes I make a notes thanks ordered to recognize thank you miss chair and I think I wanted to follow up on senator ovans point that was my question to some extent also but what caused you to choose the farmers you pay out instead of the current dme path that's a stablished and in place you've got a network across the state so they've been dispensing this product through the dme portals why not allow pharmacy to dispense that the same way is they're not that not it is far billing through the pharmacy through the point of sale is the only way to obtain the rebate it per cms. With that benefits that benefits dhs correct but that benefits dhs correct so so the decision to bill farmers overdme was because of the rebate that comes back to the hs I would like to just preface that we were trying to implement the statute and be compliant and so to part of the bill is to obtain the rebate in working with our federal partner with cms in the manufacturers that the rebate agreement which is at the federal level the agreement to obtain it is only through the pharmacy. Point of sale system okay when far work mr i'm sorry go ahead I was just going to pick a piggy back off what jane it said there which is to clarify the the the reason we chose this path is to satisfy the act that's out there we're trying to come into compliance with the state law and the only way we could get to rebates was through the point of sale system on the pharmacy side which is why we've done it their way now there was mention of of doing the door path and and you heard why we didn't choose that there was really our two options which is to go point of sale through pharmacy or to do the door path and we have our concerns on doing the dual path which is why we've we've done it point a sale via pharmacy ramp in my followed to their chair would be II appreciate that and I understand and we no one needs someone else creating them more work I understand where your comfort there the thing that I do have concerned with though and and great concern with is that dme companies that i've spoken with the demands of my district do not like the path of having to build through pharmacy and you know I feel like to send it urban point they feel like this prices them out of business in ultimately the only people I see that win from this are not our dme captain were providing more access for our kansas and I appreciate that and that's obviously the girl but it seems to me that DHS is going to benefit substantially from this and then whoever provides the the monitoring system will benefit substantially from this because they're going to charge another hundred dollars per unit correct and they're going to give some unknown rebate benefit so we don't know if that's a dollar it's fifty dollars if it's four dollars so ultimately they stand a benefit. More than our arkansas countnies is would you agree I think two points after that hoping i'm answering your question here which is one I wouldn't describe it as dhs benefiting necessarily it's more that we save money right that the plan saves money so over all the state saves money the the pharmacy benefits and that's the hope right and what and the ideas once we get those numbers we could we could be able to show that there was through these rebates there were some level of savings and that really just flows back into the plan and is spread out throughout the plans it's not really a ADH s benefit necessarily and and the second point is you know our goal is to nart price out means I don't I don't think that's our goal in this are goal is to satisfy the act and these dme providers can we welcome them up here to talk about how it impacts their business then we've talked to them then we've tried to work through some of these issues in the the truth of it is is is is we may not write a really are goal is to try to satisfy this act and capture these rebates and hope that we get to something that provides benefits for everybody. Represent pill continue recognized for a question. Thank you you brought up savings and a wonder iterate we have the second report that shows that we had an annual estimated total savings of four point three million is that correct. There are you told about the siegel report for the state plan no for it when we did the single report during session for hb ten oh eight. It showed her savings and annual estimate total impact saved four point three million with the state share of one point two million. We're a digging through I know it's but we'll take you for your word on the copy of it right here yeah and that was one of the reasons why we did this bill during the session was because obviously trying to save medicaid money when we know that we have you know we've got to take budget and we need to provide more services was part of it and of course two you know we weren't billing medicaid or sorry dear me was a billing medicare for continues because monitoring if it wasn't for a two session to go when senator davis and myself ran the bill to allow that to begin with so we're just improving on policy that we enacted that three four years ago and now we're just honest it in making sure that we get more benefit to more beneficiaries and then save the state more money because obviously we have large concerns about what medicaid needs to do to say more money in the future would you not agree that that's how we've got here today. I would just say I remember when you ran the bill a couple of sessions ago because we were doing lucas monitoring by pratherization so the that's right that's right yes he had been offering it prior to you the bill being passed back if sorry that's a good clarification there was four years ago but yes. Senator king you recognized some mister churches to be as you said earlier so basically we either approve the rule down approve the rule which means it's basically still going to be a rule or the only other option is to make emotion to not approve the real because it's contradictory to the legislation which actually may do so yeah I think there are four options as I understand we could remember the rule we can not review the rule which was only on two basis one is if it's against federal or state law or if it's against legislative internet we can take no action in which case we're making no recommendation in the review moose to rules or we can hold it search for the four options okay. Sorry. Sorry I did not mean to catch you off if you had it. You don't. All right I had there are several people in the huge representative i'd recognize representative can ferguson future thing you know tapia. You think you message you one quick question you talked about the door benefit process. With that. Provide a more clear part to with the dmease what i'll understand that's the process they're thinking use the term pay and chase. Yes sir I do I do benefit or dual pathway is whether topic of discussion that we discussed with with the association. But with the dme association our part with their kind of. Be a happy medium. With the dmess. I can't answer for them I believe so but I can't II can leave though okay but that. The process that you. That don't want to use because it's a problem of collection. It could be it could be yes sir but it also could be but it also could be a problem of if they fulfill the the. The benefit and they bill it under a medical claim in that medical claim is processed there then it runs a risk I don't know the I don't know the percentage of risk of the being denied because it's if it was already filled as a pharmacy benefit so this is a possibility they could happen could happen yes sir we don't know if it would be there's a possibility that I think it would happen I just don't we would help or could you just on the other percent yesterday if I may just to give a little background there and I don't want to get a really complicated and systems language between run too completely different systems with different vendors and they don't share information with each other right now so there's no way for there to be real time auditing of those claims so if you go in to buy a dme from a cgm from a dme provider they don't know that you've got into the pharmacy and gotten it or the pharmacy doesn't know that you tried to call the dme to get one and the dme wasn't answering so you left a message so they can't look at what you've done it's all up to the beneficiary to make sure that they're telling those two providers you know who they've communicated with them with those other provocations that were less questioning mr cheers who so what you say ended this process there's a door process would be problematic for dhs. Right that's what you say yes or as I did state that it could be burden some and it could it could cause us to pay in chase and then when we pay and chase and we don't collect that money sims still makes us pay it back. So. Yes so that that is my. That is why i'm cautious. I'm also concerned it would be burdensome for the provider who was on their second the second to the door so to speak the second to the computer to build the service could be burdensome from them because they've now built a service that they may not get reimbursed for okay and in members of and want to be ween it with people on follow up questions but we do have quite a lot in the so we're going to try to limit follow up to one question and i'll just take people in the orders they come up so representative ubank should recognize thank you mister care do you have a britain permission from tms in order to make the changes that you're you're proposing here. Yes we do we received that I believe the nineteen th of april on march but we have the letter and we can forty and follow up sir the going back to represent ferguson's question so it the beneficiary he got the monitor from a dme and also went to a pharmacy they'd be violating the law correct the beneficiary would yes thank you. Representing ladies and your recognized for questions thank you miss chairman going back to what was said earlier about the you're just trying to implement the the act with these rules correctly correct and what a representative pilkington said that that would generate four million dollars plus savings correct. And that's what the bill said that's what his report and we don't know exactly because we don't have the rebates yet but to the senators question while a go if we don't get that we can change that later on but it was there that then only benefits DHS we just got through talking to some ladies that we need our ins and lpns we need money to pay them so this form million could go to words a need like there are some other need so it really benefits the clients or the taxpayer I mean DHS is not hoarding this money in an account somewhere early no sir we are not hoarding the money we use our pharmacy rebates every year as part of our operating budget we spend approximately five hundred million dollars plus annually on prescriptions for the medicaid program in part of that match it money used every year every week when we pay claims is is you is funded from pharmacy rebates. So that savings as projected in the the act would go to other services that are needed as they're correct. We do try to use the matching principle so we do try to use the pharmacy rebates to help fund pharmacy which does allow us to use our other sgr and our other funding sources for the for the other portions of the program. Representative million recognize that thank you mister chair I just have a motion at the property do you recognize for motion to make the motion that we do not review this role due to it is not in live with legs live in ten. We have emotion on the floor not to review until that's a propromotion do we have a second. Discussion on the motion. The legislator who you reckon is getting under legislator who wrote the bills I can probably speak to legislative intent this rule is within legislative and ten of my piece of legislation. So this is a voice vote for others in favor of voting this is to not review based on not meeting legislative intent all those in favor say I opposed to knows have it. Do. Representative ubank's we're going to take one question because there's one question the key before you. Senator love you recognize your question thank you miss tree so. He can look into this issue I want to asdh. Can I think I guess one of the issues is that i'm at the dispensing fee did you all ever think about modifying the dispense and features for dmese. Was that was that ever was that ever thought our ideal are. That was not really considered I don't believe now we have never modified a dispensing fee for any particular product before we have standard dispensing fees across our program and so no that was not really considered as an option. Um nor could we do it for justin providers it would have to be based on the service so we would have to do it for anyone that built that service so under we see a miss ross so okay are so we have more we we have multiple dispensing fees but just because it is a pharmacy benefit i'm just trying to get. Since this is a pharmacy benefit just to ten dollars and fifty cents. Is what we just need for the pharmacy benefit at that was you there's levels of the dispensing fee based on factors that I can't remember right now this one falls into the ten fifty bucket it's in that class and we can get you all that information I just don't have it in front of me today and and that is everything that gets that gets that we don't separate it by who's billing in it or you know the different types of drugs in that generic versus non generic versus this first is that type of classification. Hello let me let me check on that for me to get back in a key sir range of dispensing fees I believe is nine dollars to tin to ten dollars and fifty cents so this is the highest level of applicable dispensing fee did that help at all. No I can I would I was going to add it earlier I didn't bet you know we had testified in the previous hearing that some codes were bundled in some were night and in an under the dme and nothing can be bundled in the pharmacy so when you unbundle that you get a dispensing fee for each of those things so if there's four products than that bundle you now get for dispensing fees and I don't know if that's been made clear so in that case you'd get a ten fifty dispensing fee for each of those four items that you dispensed. Representative ubank should recognize. Mr chairman I have a motion to hold this till the next meeting to allow senator urban to get the information she requested. That's a proper motion they're second. Members I will remind you there are people that have signed up to talk to give testimony we have not heard testimony today. My inclination would be the whole the vote on any of these motions until the people that have at least traveled here today to speak averaging a speed if there's no objection i'm gonna hold the vote on that motion i'm allowed people who signed up to come in. Talk. Guess we really haven't had what I would consider a public debate because people have signed up and we haven't had you haven't afforded them that opportunity. Will slide just up aside if if if we need to back we'll bring it back. Runousy three people signed up to testify morgan butler jennifer sellers. John barres i'm happy to take you wanted to tomorrow together if you're wanting to come together what it be prefer. If you could just state your name for the committee. My name is morgan butler i'm a registered nurse and certified diabe's care and education specialist. John berros would capadisers group representing dexcom. I've done it for sellers also on a registered nurse and certified care and education specialist who recognized her testimony thank you mister chairman thank you members I will try to be brief but I do appreciate the opportunity to speak these are to registered nurses at children's hospital here on their own behalf though we did have some doctors who were all going to be here to testify the change of time affected their ability to attend I know it was no fault of any of yours we all know the score that the dynamic of session but I just wanted to make that clear you even have a letter I believe on your desk from one of the doctors that's the chief medical officer of interconnect your wife didn't regional who sent a letter that I think summarizes the issue very well if you would like to read that instead of listening to me it might be a better use of your time but that is on your desk I would like to hit quickly on policy and process you know and will obvious there's been a time where I was more hesitant to testify on things just out of respect for the legislative process but over the years i'm become a little bit more comfortable with it because I thank if we're going to you know call you email you text you and tell you things in private we ought to sit here and say a publicly and answer questions and that's what i'm happy to do that i've tried to make an effort to answer all of your questions before this meeting over the past thirty days at them some of you have made contact with some of you I have a but I think there is some clarity needed so I will hit quickly on policy and process if you are I think there's one very important point on on the policy because I think in the end we are here to protect patience and tax payers first of four hours or not proper business models and so I think the more we can focus on patience and taxpayers the better off we are I think a very simple way to put this if any single one of you or diag were prescribed continuous groupoes monitor you would go to a pharmaceutical fulfilled virtually all commercial plans including ebd the employee benefits division of the state of arkansas or state and poolies they go to a pharmacy to fulfill this claim you as a commercial plan member will go to a pharmacy to fulfill this claim. This rule simply aligns medicaid worth what commercial policies do what over thirty states do and what again virtually every payer does it provides access it does not prohibit anything it's simply the state saying we're going to pay the best price and we're going to get it at the best rate and we're going to save taxpayer's money and we're going to make it more excessive will virtually all of you I would expect could remember the last time you were in a pharmacy virtually none of you I would expect could remember the last time you've dealt with the dme. That is not the fault of dmess they are good companies they play a very important role that that is why they are not prohibited from fulfilling this prescription. But the state is saying they will only pay the best price but everyone can still do it but you're going to be paid the same sometimes I think it's helpful to look at things in the end burst if dhs were to come in here and ask you as a legislative body too. Pay off for the same product but pay one vendor more than another to supply it you'd laugh them out of the room you'd probably would probably have the JPR hearing if they said we want to sell the same product to different prices one vendor gets more than the other that would not be good public policy and so here what the status saying again is that the state is simply going to buy the product at the best possible price claimed the rebate in compliance with the statute and allow patience and option to get it at the dme through the me or at a pharmacy and I think that sometimes it's helpful to bring it back to that point some look some of you I don't know if you ever had to deal with deal with the cgm I know some of you have because of my conversations with you talked about it some of I know you're some of your family members have one of that if you started texting friends and family you'd be surprised how many people you now have on these are life saving and life altering devices as the technology has developed their more accessible they require very little training and I think that's a heart of the issue here why the state can offer through a pharmacy and i'm at this price point again can't stay enough dms can still sell but there's no customisation there's no there's very little training involved you know he might be mad at me for saying it but i'll tell you my father who's about the least medical person retired from the post office runs a tire shop in here some arkansas called him as a little bit of a spot check on this case he'd passed out in the field a couple times working in the summer to heart didn't realize it after a couple ambulance calls when you got him a cgm get picked it up through blue cross federal picked it up at his pharmacy I called him and ask him what did they do on the training he basically kept saying what training you just stick in on your arm you download the app if you have it used one that's how these work it's it's truly that simple you go you get packed last every ten days you stick it on your arm they continually read your glue costs and have warned you of spikes of drops and it helps you all to your behavior and real time so that diabetic patience have real time real life information into how their lifestyle insurance is a. Behavior is affecting their blood sugar levels it is major cost avoidance for health plans as I already pointed out and that's why commercial plans and our own state plan fulfilled this claim to the pharmacy and this rule would simply allow medicaid to do the same thing while claiming a rebate that saves a state millions of dollars that's why it's already been approved by the federal government that's why the signal report is representative helping to mention that says it saves four million dollars at least to the federal government and at least one million dollars to the state government. I would say again perhaps in closing and and then allow these two narces to tell their stories I would encourage you to read the letter from the interconnector just a chief medical officer washington regional again there was a couple doctors that babies would be here there is no fault with the dmes these products have simply become easier to use and more accessible and people have continually realized how truly life saving they are so the more that we can make them available the more money medicaid saves the more lives we save and again the means can continue to supply they can continue to fulfill prescriptions they will only be paid at the rate at which the state that the whole sell acquisition rate plus a dispensing fee so that's why it saves the state money but without an encourage you to read the letter and all be up and answering the questions at the end but i'll present these two nurses giving their comments to thank you. Thank you so much for your time I understand this is been kind of a a link the issue so I appreciate you letting us kind of speak from the the medical perspective as you kind of heard from the dmside mostly throughout this process so as imagined before my name is morgan i'm AR in and certified each care and I just take education specialist I care for percent with diabetes as part of their health care team to educate them on their diagnosis medications treatment plans and technology options to aid in their daily management my drivers also to be a sounding board in emotional support for families as their day to day routine shifts dramatically with this life changing diagnosis i'm here today because I have been following act three thirty nine for over a year it directly impacts my patience and the work idea to help them access the benefit of continuously cost monitoring it as our responsibility to help them through the insurance process understand the steps we take as part of that process and the clinical side and how long things are expected to take currently for a patient utilising medicaid services the process for submission is lengthy and involves a lot of back and forth between us in the dme companies it can take upwards of thirty business days for a patient to receive and start wearing a cgm typically commercial insurance is on the other side with pharmacy benefits take two to three days for a person to start using their cgm this is often right after diagnosis and during a role vulnerable time as they learn to navigate a life changing diagnosis that requires constant vigilance and block click coast monitoring without timely access to seizing him the alternative is to monitor with daily multiple fingers it can be difficult to associate blood sugars with sometimes right after diagnosis so a process is drastically altered and improved with the use of cgm sooner rather than later that earlier we can start cgm the better the outcome and increase time and range for the patient I certainly am not here to condemn dmeas we use them on a daily basis. I know they are bound by the rule set before then we are lucky to live in a time where patients can pick the technology that best suits their needs but i'm asking you to please utilize pharmacy benefits as an option for these patients with medicaid thank you so much for your time today. Hagged afternoon again I am done for sellers I am also and an RN CDC e s my career as a nurse has been twenty eight years with twenty two years being and direct patient care of patients with directions in that time that I have taken care of patience with diary these um I have seen a lot of changes in an advancement and technology in the way people are able to care for themselves and their family members. And so keeping that in mind not getting their similar sake i'm sorry guys uhm. We've we we still wanted a folks that where these am from adults to very small children. Yeah. N miss morgan pointed out that the lengthy process that we have with medicaid right now and I would like to point out that. When we have a cap a child let's say a two year old maybe your grandson your granddaughter or close family member that has been diagnosed with diary these those those people they're taught how to check a blood sugar they're taught how to take care themselves at that time. But if you have a little child who is unable to tell you I don't feel good. Or I think my sugar is low these cgms are imperative for them to be able to care for their kids and actually have some sort of quality of life and be able to sleep at night. Uhm I would ask you guys to keep that in mind where we're not asking for a change in all of them the money that goes behind it what's there is there what i'm asking for is for these kids to be able to have their technology and that piece of mind in a two to three daytime span as opposed to a thirty day time span also without laps of characters often these kids. Go with lapses of a week to a month without without their their sinceres because there has been a hold up somewhere along in the process of being able to get them out. So again I would ask you guys to please keep that into to consideration when you're looking at this rule thank you very much thank you after your test money center while as you recognize. The. There your recognized again. How that we got you know what they were going on. This question is for mr map my wife karen has one of this devices in this wonderful device. Now I resolve him I guess a murther over six weeks and she has to go down and she goes through a local pharmacy in legible or any money it. Half a mile away and she picks it up. We're fortunate because we've got. Good vehicles. We're still able to get back and forth but there's folks that are old they're not gonna be able to drive. Thirty or forty miles. The. And there's some folks who just don't have the ability. To drive their distance in into me I believe that this. Now he helps our patience it helps our keep our rules pharmacies in our small towns at my right. Yes sir and you I believe you are and I think you hit on an important point I may have said it it is important to remember that these are prescriptive devices that you have to receive a prescription from an authorized provider with prescriptive authority this does not touch that it's all is an important point to me but you have to have typewater type two diabetes to have this device according to medicaid rules so you you are on insulin you are in grand in a pharmacy channel the these are the europe if you're a patient receiving a prescription for AC g m you are at the pharmacy on a regular basis you know and and I would again repeat cause I think it's very important to be said because of confusion if you want to use a dma dme you can still use the dma the states are going to pay the the best purchase price but you can still use a dme but every single one of these patients who receive the prescription for a cgl or well and grand to a pharmacy channel I would assume just like your wife soon. And if I may i'd like we are aware of pharmacies in the state that are able to ship as well so if there is still a concern of shipping being the the concern or being able to go to the pharmacy. It is our understanding that there are pharmacy secondship. Represent order to recognize that you must share a small declare for mister barrest you keep saying the best price but does it go in the pharmacy route increase the price of that product about no sir not according to the third party single report commission by dhs and presentative legislature last year it saves the state of the federal government over four million and the state government over one million. Okay I guess I guess i'm talking about unit price you keep saying unit price so I thought missed me and said earlier that it was about a hundred dollars increase through the pharmacy route and I have not said unit price what I think maybe they're factory is the price before rebay you know I think it's really difficult to get into these I don't know you're in the provider feeling away because you know medicaid terminologies very can be complicated acronym heavy I would rely on your dhs officials who told you it will save the state money in the third party single report who have said it would save the state money I believe most of the savings are come in to play on the rebate again that's why commercial plans use the pharmacy channel why our state uses the pharmacy channel of it yeah the third party single report commission on behalf of the state so that the savings to the state of a revenue is over one million dollars annually. Representative richardson you reckon asked for a question I think mr amount make money really quick I caught a thirty day window to receive the the monitors in the in the update or the patches on an ongoing basis could you speak to why that he as wanted to take that long to to make that happen. As. Okay they're a good think you that is as long as we've been dealing with dear dmess as part of the service that's just been the length of time in order for us to receive the paperwork from the from the company as you fill out that paperwork get it back to them and then then submit to medicaid my understanding that it's the medicaid part of it that takes that one with their waiting on the approval process and versus felt mischerickness and versus the pharmacy were out which is going to take almost immediately correct they could have that leaving the hospital thank you very much thank you for your question member seeing no more questions thank you for your testimony we don't have anyone else signed up to speak for against this rule we do have a motion on the floor and a second the motion is to hold this rule. In our committee. Which would be held till the next put near the next appointed public health committee me. So all those in favor of holding the rule in this committee say a opposed nose habit. Does it to hands I get two hands. Senator scott flipper senator scott flipper. Senator david wallace. Senator david wallace. Senator david was votes now. Senator bryan king. Senator branking. Senator clinton pinso. Center pins of votes now. Senator justin boyd sinner just in board but now. Senator frederick love. Senator frederick love. Senator dance eleven. Senator dan sullivan. Senator missy irvin. Senator missy urban. Moving on to their house. Representative jeff word law. Her prison of jeff word law. Senator john ubank's representative i'm sorry. Representative of ubank's voda. Representative stephen mcgee. Represent mcgivots yes representative richard well mac. Representative richard well mac. Representative deborah ferguson. Representative deborah ferguson votes yes. Representative ladyman representative of leading involves now. Representative mary bentley. This. Representative may have been votes now. Represent their just in gonzalez. Representative in dollars foots now. Representative kenneth ferguson. Representative kenneth ferguson votes yes. Representative fred allen. Representative allenvas yes. Representative errand pickington. Represent a poking ten votes now. Representative mark perry. Representative mark period. Representative bart shots. Representative shots votes yes. Representative kindermore. Representative kind of more votes yes. Representative ryan rose. The. Representative random rose votes now. Representative gramlic. Represent exact grammar. Representative scott richardson. Representative scott richardson. Representative rigids and votes yes. Representative jeremy waldridge representative watch first yes representative josh miller representative josh miller. And so it's both failed in the house in the center. So we still have this rule here in the committee without objection. The rural stand reviewed. Members I think what is yes. Yes. Yeah. Would you can object and make an alternative motion we just had the motion to. Holding committee that failed for lack of a majority on either side you could vote we could we had emotion earlier not to review the on legislative and we've heard different testimony it would be reasonable to hear that motion again we could have a motion to review. Or we could have emotioned to take no action which would mean we don't make any recommendations so you could object to make a motion that we take no action and that would require another vote so there would still it was still advanced to committee. But it wouldn't advance disasters reviewing it or giving any recommendation. This is the. Yes representing me you object would you like to make a motion. So we have emotion to take no action. And does it understand it from staff this means we give the the rule would still go to rules committee but we would have no connotation from us is the way of a judgment for against the rule. No recommendation from our committee. They've already understand so if you vote for taking no action we're sending it to rules without any recommendation from the committee and if you vote and at the senate side I don't think there's enough. Yeah it depends on your role call yesterday you have a questions that are wallace. It devote as I understand that the votes automatically split yeah if it's roll call. She I was told by staff that the when we roll call we divided separately this is w. The. So so for a separate committee as opposed to a joint committee for joint budget that's what. I mean it quickly blamed them for any procedure layer so we have a motion and we have a second. We have a second. All those in favor of taking no action on this bill and senator rules committee without any recommendations they are opposed. The as habit. Members thank you recommend close to the end of the agenda we have a couple of more items if you could just be patient we have a couple of announcements I know a representative binly did you have an announcement. I do thank you our car I just want to remind us that we will be having a great moment of this thursday four o'clock in the capital on her begins when join us for women's health match kickers are women held the united states would love real to be there thanks represent pilkington did you have a point of personal privilege reversing pilkington digit okay members high I do anticipate of letter more known advance are doing to spend having a meeting in june june fourth and fifth in fort smith the sheriff's association is embodied us to come there have been there annual meeting there when you come and talk to us about the habit of this you so just plan ahead I will send an email out but the fourth and fifth we're gonna have it out of town meeting will make plans to you help everyone with the accommodations reimbursement that kind of thing and with that said this meetings journal.