Public Health, Welfare, and Labor Committee- Senate and House

And called us meaning to order an first and it is good friday and I know we had had this meeting scheduled yesterday it was not her intention to call a meeting on good friday however and we were trying to be accommodating because I think there was a capital for the day yesterday and when which III think went well but we are trying to be accommodating for our folks that were attending and that capital for the day of our agency directors and secretary so that's why we're here today but since it is good friday I would like to recognize that in a representative of waldridge if you will lead us and a prayer I would appreciate it. Thank you spell or thank you for this day and thank you for the opportunity to gather here is not all your servants but service to the state of arkansas and help us to be manned for of that as we make decisions that are based on the benefit of all of those that have elected us to be here to serve thank you for your sign thank you for sending him to give us an opportunity to spend attorney and heaven with you help us as we make decisions today to be mountful of that to represent you and help us to do that and everything that we do and laugh thank you for the opportunity to serve thank you for the opportunity to live in the greatest state in the nation and your name would pray. Thank you also members if you'll look at your agenda we've got basically three items on the agenda and three sections i'm giving twenty minutes for each one of those so we'll do twenty minutes on item c twenty minutes on item d and twenty minutes on e and s and we're going to try to keep to that so keep your questions to seeing to be prepared okay with that you have any other comments alright let's role so sector amateur and secretary mallory if you want to come to the table with them this man and miss cochran. And while they're coming to the table if we can have emotion to consider the minutes from the february meeting is there a second other than favorite say I and oppose I have it most meeting minutes are adopted. Thank you all so much for being here. Yeah. I'm in a asked representative built me if she will also go into them at the table. Ok if you'll just take your names for the records and we'll proceed reno malaria secretary of health. Casey car current deputy director for a public health programs. Christie peter secretary department of human services. A representative between. Thank you all right. So we've were very excited to talk a little bit about the executive order and the initiative that we're working up collaboratively on for maternal health and overall women's health we have a a health plan that was kicked off by the signing of the executive order by governor sanders on march sixth were very excited we've been working very closely with legislative partners on what kinds of things we wanted to address across agencies and with external stakeholder partners there's been a great deal of work that's been happening lots of good work happening in lots of different places across the state and renew and I kept tagging each other in and casey and jeanne at two of two different meetings so that we are as a state making a choice to look at women's health holistically so that we can improve women's health before during an after pregnancy so with that i'll pass it over to a secretary mallery a department of health hassle great deal of work that they do in this in the space so there are some very specific immediate actions that were taking and then we want to talk about some of the next steps and longer term as well. So i'll start out and then alert kc talk for a minute but when we were looking at what we could do when you look at the maternal mortality we you find they are the reasons for maternal mortality has to do a light with chronic conditions so we realize women are not healthy when when they go into pregnancy so to change that dynamic is is tough you know we're we're not a healthy state so it's like work could we do that you know might move the need all a little bit faster and um and actually help these moms have healthy babies so many of you know most of you know if not all their we actually have a local killing healthy unit in every county some counties we have more than one in in a lot of those counties we do we actually do maternal health we we do visit and what are gold liers is to get those women in that may not have a private provider erm and we see those women and and we try to if they are if they are not insured we try to get them on medicaid if that's appropriate and we try to hand off to a local provider or in the nearest provider to wear they can they can see that herson that's going to deliver that baby and so so that's our goal with our maternal health and the reason we don't do it in every county as some counties have services enough to meet the demand we just want to be that gap biller where there is no appropriate services are enough services there. So so what we deared in looking at what could what could we do to move the needle so we we had data that showed us that prenatal care in arkansas the numbers are not good we have over ten thousand women who who don't get appropriate prenatal care so too so what we deared to take a small buy and figure out you know the best approach we took we have public health regions we took the county in each of those regions that the numbers were the worst for prenatal care so those counties ended up being garland skype philip scripted and and polk so what we're doing when we're going so all the alert casey talk about what we're actually do when are hands on stuff in those countings good morning thank you secretary so in these counties that secretary mail or register read off to you we will review clinic processes in services to better align the services that we can offer in these local health units to are patients then moving from that we will also implement some pilot projects to bring community stakeholders together to review the services that are available locally and how to connect all of those parts to cover the entire women's health and then the pregnancy and past pardon part of them. Delivering a baby having a baby so that's part of the pallet project and then where we identify gaps will work with those local stake holders to identify a resources to fill those gaps locally within those counties also pulling in the health care providers that are local for educational opportunities and how to help fill the gaps that are in the county and what is needed to do that on the health care side so that's just a really brought overview of some things that we're planning to do locally in each other's pilot counties and I will say working closely with dhs with secretary pattern and hard team we have talked about you know it it's very difficult to sometimes for a woman to to do all she she needs to do to get on medicaid so we've actually talked about housing a person at from dhs in those units to at least when when a woman comes in for a prenatal visit to get started on the the application for medicaid and then if you know they'll have a person that they can contact to to keep going down that pair. And so i'd like to touch on handing off the process and that's the next part of our immediate work is you know we are immediately looking at our enrollment to process using transition processes and i'd like to ask deputy secretary man to talk a little bit about medicaid coverage of pregnancies and what it looks like and how we're working to identify where are we missing women moving into different coverage. Good morning apologies for being late at jean at me and deputy secretary programs in medicaid director so what we have begun doing is working on the details of a process map of wine woman applies for medicaid and she is pregnant what is that process where does she qualify because it is a income eligibility application and she can be enrolled in medicaid in various categories of eligibility if she does not fit those categories of eligibility and is above one hundred and thirty eight percent of the income but below two hundred and nine she goes into what we call limited pregnancy which she gets the benefits thumb through her pregnancy and that's the sixty day post pardon category and that is the area that we have identified that we need to address better that not at day sixty year day sixty one but back in that way up almost to the time of both if not at birth of helping her determine is she eligible for a different medicaid category or do we need to do some i'm outreach in assistance with what's available on the marketplace and arm and then the other area that we are diving in to to see how we can handle better is it by federal rule you cannot present pregnant apply for a medicaid and go in to our expansion population you go into fee for service it's called a newly eligible category and so but at the time of birth ken do you qualify for our home and can we do some type of automated process to get you in to our home we do have to be very careful with the freedom of choice of the plans in our home so we are looking at those rules in how to streamline that so we are looking at that entire process of of how that could be better that was one of our immediate charges in the executive order. All right thank you I think it's really really important to understand that dynamic and understand the medicaid programs the specific nature of them the timing of enrollment and where they can come in and how we can make that more seamless and streamlined and I think that's basically that the charge but it makes complete sets you on a you want to be as effective with the programs that we have but we also want to make sure that it'd be in fully utilized to the best of the best of the programs ability because also that what's most beneficial for especially the expecting mother or a woman who if we can get them in before they get pregnant into our home it's actually been a more beneficial for everybody involved and I think that's the biggest take away and the biggest thing that we need to do better at connecting the resources that are already available and and so to that point you we have local health units and every single county that is a health resource that in my opinion sometimes it's under utilized power citizens and are constituents and so I like the idea of what we're doing there and so before we go to questions will let let's do questions and then we'll go to to our big announcement so to speak. Represent a ladyman. Thank you madame chair I mean this is great this is we need to do something and that this is really good I really appreciate this that the governor and you are working on this yeah I am so tired of reading in the news how bad we are in the information and the maternal mortality. But my question is I mean these are good actions but i'm interested in the outcome I want to move from fifty to forty nine I mean that's a short term goal so how are we or can we monitor the actions that we're going to put in the place and and see if it's working and if it's not working then we need to change the program so how are we going to monitor that. Yes are you you are hundred percent correct without the data in the tracking and reporting and technology we won't be able to gauge what is working in what is not so we've set for main goals in that were outlined in the executive order it's an education campaign on women's health and pregnancy before during an after it is to increase access in quality that is aim bundles that is working with the clinics the hospitals what more can be done that it's also. I combined to but anyway but the last one is data reporting and technology we recognize that we don't have a good baseline we don't have a way to track this medicaid pays for a global pregnancy which means we do not track the visits we only pay at the time of birth into those that is part of the charge with the quality in access how do we get more encounters how do we track it so that we know what we're doing so that is a very important piece of the executive order and our responsibility to report out on what we need to be doing so that it can become a regular part of the medicaid program working with health but also then taking a step further and I think working with our other insurers in the state there have been lots of stay holders very engaged wanting to work on this and it's not just been the public sector it's been the public and the private sector so I think as we move forward with this this is a great opportunity to set a really good standard for public private partnership. The and I would just point to members of the executive order we have that in your pocket I think it's good to tell you how to share this with your constituents i've expectably better does goals are outlined here on page two and on the education peace will will announce something that we have kind of work to collect collaboratively about here and just a second after the questions but thank you representative ladymand for very thought for question. Senator salivan you recognize thank you random chair appreciate the recognition for the problem in the efforts and strategy or usually get there so in the last month we've done the state of arkansas done all that can to reduce our medicaid roles and we have really examined those closely at enrolled people off of medicaid and now we are seemingly in what number of our percentage of the babies born in arkansas are on medicaid. It's approximately fifty eight percent but it's more than half each year yeah so we're. That's not a good trend. Does your plan include a strategy far reducing the number of babies that are born on medicaid. The. Not currently with the goal is with the healthy pregnancy to have a healthy baby and then if the economic opportunities don't think there's anybody going to vote against healthy babies and we all agree we need healthy babies but if the trend is that well over half of the baby's born in arkansas are on medicaid if that's not a good trend than our plan needs to have something in it to reduce the number of babies that are on medicaid it's obviously better for clothes thank you if I may respond briefly so sender sold into your point the workforce cabinet I think there is a lot of work being done around economic self sufficiency work for economic supports working to ensure that people have connections to work for us opportunities but also learning transportation child care all those pieces are being discussed by the work first cabinet in all of the cabinet members are working very closely together so you have the education as a key point of it and what what I failed what we didn't mention on the beginning in the beginning a introduction is the strategic committee includes the education secretary also includes dr greenfield and doctor shandler and we have a met informally twice as a committee to plan for a larger stick holder meeting that we're going to have on april twenty second that is the plan that will be going out beginning of next week to all stakeholders it is not exclusive it is this is a. Any and everyone come to the table but to your point we do want to also connect all individuals to better opportunities to make sure that we're working to support them along the way. Thank you and I have got two more questions a representative of it. Thank you madame chair I want to thank everybody for their work on this I do have a question since mertality in mertailed martet material metality affects african american women at a higher rate do you have numbers about the number I mean of how that effects people they look like me. We do have those numbers for maternal mortality yesterday okay and do you have them and are you mentioned the five counties that you're working on but do you have the numbers for a palaski county in particular we do i'll get anything you show that with me sure okay thank you. Okay senator hammer thank you ma'am chair. Do you have to have the numbers which use parts to break out of the number of teen pregnancies number of pregnancies by single mothers in the number of pregnancies by married mothers do you ever have that with you or if not can I get that. Good morning center eight we don't have it with this week and go back and and look I don't know if i'm going to have all three categories but I do believe we will have teens and we will have single and i'm trying to think through the questionnaire in my head so we should have married bad default if we have single but we will get back to you okay thank you and then a second question would be the areas that you the five carriers that you go identified. Does that include an assessment of the resources of properly trained medical personnel regardless of whatever their scope of practices cause I know one issue is the number but we want that are no longer delivering babies because of the legal liabilities and responsibility could you just kind of give us a brief enlightenment of how you're going to address shortages in those five areas. Yes thank you for that question so you are correct on the obguined coverage in our state so the educational comparing it will pull in health care locally in these counties and we will assess the skills that are present and maybe what needs to be expanded of fine so doctor chandler and doctor greenfield will be a part of this pilot process in these counties to help without assessment and also identify the appropriate education that might be needed for these providers. Okay thank you and representative bentley ran a bill regarding. I've lost a term midwives lottery blood resistance came toward that and I think that's gonna have to be in your plan there's going to be some teamwork that we're we're not within in the days what we used to were we're gonna have to adjust the model as far as make sure we got personal otherwise everything we do is going to be for not so appreciate the fact that's included in it thank you thank you I and I also know you know how do you utilize people that are already trained and that's been a part of the conversation to your primary care physicians are are already trained through medical school and residency to deliver babies but because of the liability issue they cannot afford the malpractice insurance to have they they can't make the overhead cost of carrying in that liability so we've got it also attack all that as it stayed and figured that out because that would open up a lot more points of access as well. So good questions i'm i'm gonna go ahead just if you have quick questions i'll go back to representative ladyman because there's one other topic i'd need them to discuss thank you mentioned while it may not be that quick i'm sorry if it's not but. But we've got a maintain our focus here our focus is not on just medicaid department the health is here they work with different people in front mortality does not just affect poor people it does not use the fact people on medicaid it does not just affect people of a certain group in order to get better as a state we have to move focus on all groups and that means I hope the private industry is listening because there are people that are not in any of these groups that have been mentioned. That have problems with them for more tality. You know we've had that affect this group right here within the last two weeks. It's not a poor person problem it's an everybody problem so we need to keep our focus on the babies that's what it needs to be and I think the things are to put forward will do that so I hope the private industry is listening and the members of this body if we can do something to get the private industry to move toward improving our numbers we need to do that would you agree I would represent into validity and we so to your first point about this effect in everybody that's one of the reasons that we pay our counties state wide you know one in every public health region be instead of just focusing on a region or two that had you know major issues that talking about the private industry you know when we have our large stay colder meeting and even our local stay culture meetings I mean we're going to engage everybody and we have actually had private. Companies reach out wanting to help so they're out there we've just got we just got to coordinate what we're doing when and get them get them involved with us to how it that points the the lack of prenatal visits is really concerning and so we've got a look at that from a from a private payer medicaid payer everybody to get women in the door quicker and the data showed I think that they were not even scheduling their first visit until late in the first trauma well that's too late you got to get in the door as soon as you know your pregnant you got a start prenate of items as soon as you know your pregnant you gotta start drinking and stop using alcohol and tap using drugs as soon as you know your pregnant but we have to talk about these things and we have to make sure that our policy aligns with that and make sure we are paying for a women to come in and have a full scale of prenatal visits and what that looks like and what scope that is and so those are great i'm so glad you brought that up because it it it really is policy that needs to be adjusted but we need to lead you know obviously from the stay but engaged all i'll private and public partnerships with that so am with that i'm i'm going to turn it back to you to announce something that we all as they we have been working on and this team and then we've expanded that to our women legislators and so we're kind of excited and excited to announce something with everybody here today so i'll turn it over back to your. Well thank you so much for allowing me up here so on the theme that if we will have healthy marms and pregnant mom so we have to have healthy women so I may the second which begins women's health month across the nation we're going to have a big event here at the capital a mama vent to bring in a stake holders from across the area for a woman to come that day and to launch a new journey into being healthy so will have opportunities there for women to get a blood pressure check budgeter checked as this is a new health activities what we can i'll do together as a journey because as all of our state together to recognize that we have got to get help these are whole journey we need to begin now and so when we have moments they get pregnant they're healthy then we're going to healthy baby so we'd love all of you to be a part I made the second heart the state capital at four o'clock we're in a launch a mam event a huge amount here to make sure that we're kicking out of women's health month and meta as we have legislators we can be so impactful in our own community so it will be event with our and our local communities as well each of our health departments will have a health journey book so we can even though people aren't here at the state capital they can launch that journey across that month of may to make things happen with our local business owners and i'll let the center to give some more details because really was was her idea so i'm thankful for her in general to hear a making this happen on my second so give some more details in. So I mean part of their education and peace said the executive order is something that we have been working on and and so my niece is a small business owner she ends a bit ticked he's got to young kids she calls me and you know about her health issues I mean and so this effects everybody to your points that were made and so we're gonna partner with any business out there to really promote an advertised and promote women's health month the month of may which stands for which is marm the month of may and so it's really about raising awareness about your own health as a woman and getting healthy and it's not just about physical health it's about mental health emotional health then you know all kinds of all kinds of good things and so we're going to celebrate a women's health during the month of may and we are encouraging an inviting partners who want to help us promote this and advertise this my niece and who earns friend insurance and all in literally is going to partner with us and offer a discount if you come into her store and bring your health journal that you're going to get a at a at the event or at your health unit so I think that's a really cool idea and we've talked to the women legislators you are all on boards helping us and we would invite our mail colleagues to help us as well will have flyers available if you want to go to people in your districts and want to approach them about helping us promote women's house months in your communities we will have all the information available for you to take to your chambers of commerces your hospitals your healthcare providers in any business at once to come up with some promotion that they might want to do it could be a hair slot announced on anybody but to help us raise awareness rates education about women's health and offer some sort of a an incentive to participate in this program that we're going to light through the department of health and d h and and as as a legislature. So were excited about that event and we encourage you to count and participate with us so. Anything else you guys want to say about it if I can make one closing remark before you keep it over them you know we know there's not a silver build to solve this material health issue we all so I know we're all retired to hearing we'll react we want to improve things which can take out of us working together so this to me as a key a symbolism of that we have argued to work together take every stake holder on the state to make a difference that we are all on but when i'm excited about the executive or to bring some organizations that make and some things happen so thank you all for what you're doing and I would just say if you're a stake holder out there in the audience or listening online please fully engage in participate with us without event on my second and here at the capital in the front of the capital on the front lines and front steps and so if you want to participate just contact the department of health. And I thank you with that appreciate you i'll be in here today i'll let you sit right there for just a second representative but when you'll get back to receipt but wanted to and via medicaid if there are any additional updates that unite need to give us a now it be a top a good time for us to get there updates thank you so much for that so earlier this week the alzheimer council met and it was reported that the association has spent the respect grand grants which we are excited that they could expand those fines and and give some brakes to care givers very important but I also wanted to let the body know that their additional funds housed at dhs specifically in dip square and so they're remaining funds to be spent this year about a hundred and fifty thousand dollars so we are not out of respite grant funds and so I just wanted to make sure that that everyone knew that so i'm as as we finish out the year so members if you know of anybody in your communities or your districts you want to get the word out will get if you'll send just a little brief statement to our staff will get it out to the whole legislature about this but there is about a hundred fifty thousand dollars left and respect grants so you need a contact dhs for those okay and then you have another update. I'm sorry we have that one for now we only had one thank you alright that's it thank you guys so much appreciate it. Okay item d on our agenda if mister call clays are mister bennett filled mr adams jones cannot come to the table really appreciate your time here. At numbers as as we have been reviewing some of the. Financial funding requires that have come through a lc it was kind of evident to me that we as legislators need to know a little bit more about the our water plan and are kind of then update on our state water projects and programs and so this is really just a time for her education about like what we've been doing it's been expensive and exhaustive but you know sometimes it gets peace mailed when it comes to us and just funding requires so this is an opportunity just for us to be educated about all the different things because we hear a lot about the need and water wastewater infrastructure there's a lot of moving parts and yard dealing with a lot of moving parts right now so I just think it's a good time to to could give us a an update about where we are also in it ever seof you'll just recognize yourselves for the record and then you may proceed. Alright good morning members chris called laser director of the natural resources division at the department of agriculture right and benefit debbie director natural resources lay exchange the director of engineering health part done adam's cheapest day I felt department. All right good morning i'll start out with the state water plan and what we're doing there so if you may recall in august to governor sanders issued an executive order really charging the department of agriculture in the natural resources division with updating the state water plan so the state water plan is really a comprehensive look at all of our water needs across the state. So it's going to dive into things like supply how much water we have available. What our demands across the state so that could be municipal demands agricultural demands industry demands it will look at infrastructure will take a deep dab in the infrastructure we know that's a big issue across the state especially with population shift is we've got some areas that are losing population some areas that are gaining and just the overall age will also look at flooding as a component of the accident how prepared we are for flooding in a lot of our infrastructure related to flighting. And so one of the first things we did as we partnered with the US army core of engineers through a planning assistance to states program so they're actually our partner in this they're helping us they're actually paying for half the cost we went through a contracting process with them and we selected as a group michael baker international as the contractor to do the water plan update and then they have subcontrade subcontracted out parts of that to fd in an associate to local firm here. And so right now the process that we're in is we're looking at the the goals and objectives and the things in the two thousand fourteen plan that was the last time it was updated was two thousand fourteen prior to that it was nineteen ninety. And so we're looking at what what were the goals and objectives of that plan what are some of the things that have changed since two thousand fourteen what do we need to be looking at now I mentioned population shift that something that's happened relatively rapidly and so we'll be looking at all of that to develop a scope and a work plan that will basically drive what the state water plan will look like into the future and so right now we're in public engagement process on the scoping side so we did two meetings this week one in literacy when in fayette bill and had you know a lot of our stakeholders come and provide us input will also do five other public meetings as part of this scoping process in may and then our goal is to deliver a work plan a cost of what it's going to cost to update the word the the final water plan and then a timeline and schedule to the governor and this summer and so that is where we are right now long term the actual water plan itself will likely not be completed till twenty seven some time out there because there's a lot of work that has to be done. Research and we think about infrastructure I mean we will end up serving a lot of our communities across the state to get a better feel of their infrastructure needs so there's going to be a lot of work that goes into that will also look at reports in studies that have been done since two thousand fourteen to address all sorts of water issues across the state so that's a general overview of the water plan in the water plan process if it's ok manager i'll turn it over to ram bitterfield talk about our are water waste more funding program if that's yeah absolutely and I remember in twenty fourteen actually attending a meeting and stone county in mountain view and so about the water plan I just can't believe it's been ten years ago but anyway yes please do I really I really appreciate that the process and the engagement we had tons of stake holders and people there and I thought it was very very good old the input that was the the two thousand and fourteen plan I think had over two hundred and fifty engagements presentations public meetings. And it's and so we've done two polite meetings this week one presentation already to the state technical committee on water waste water sort of issues with nrcs and a lot of our partners and we're getting asked for to get presentations left and ride on the water plan so it's going to be a busy time will stay caused but i'll turn it over to run thank you guy alright thank you so yes I am round benefit deputy director natural resources i'm going to give you a quick overview of our water and waste water funding opportunities we have at the department as the chairman mentioned it is it is kind of complex and you'll see why we actually do operate five different opportunities for funding for water and waste water projects across the state along with usda roll development I think we are the largest funder of water waste water in the state so we have two federal capitalized or funded programs which are two largest programs are clean water state revolving loan fund and are drinking water state revolving loan fine and then we have three state funded programs too smaller programs and then our general obligation bond program that we fund some larger projects. So we primarily find a water drinking water infrastructure whether the treatment of it and or the distribution or waste water the collection and then treatment of wastewater but we're not limited and I should have mentioned hopefully you have a copy of this hand out in front of you it's something we created it's a two pager that hopefully you can give your constituents or your cities that have questions on finding it would take them through our process in so while we primarily find a drinking water and waste water we do primarily to our smaller state programs we can find such things as solid waste disposal irrigation erosion and settlement control and other projects pretty much if it involves water we can find it through the state programs those that those are traditionally smaller projects traditionally or eligible entities are public entities really get your cities you're water utilities your counties across the state so well before I get through the process of real quick overview of the process I want to give you a little bit of a statistics on what we've done recently so we had a record year last fiscal year we actually funded our did approvals for funding for one point one seven three billion dollars and projects across the state in three hundred and two separate projects that was primarily added federal programs which was eight hundred and ninety one million out of the two federal programs two hundred and seventy million and funds from the american rescue plan act funding and then twelve point nine million from our state programs one thing we do like to stress is that we are primarily a low interest loan agency we do have some small number of available grant dollars or you'll hear us called them principal forgiveness but for last year we actually were able to do more than usual because of the american rescue plan funding but we were seventy one percent loans and eight twenty eight percent grant roughly so well you can see primarily our funding that one point one seven billion went out his low interest loans to communities. Which is a great benefit for communities because we're able to borrow and loan the money at rates that they much lower than they could get if they could get a bar were at all so just to give you an idea though why that was a record year the four years prior to that we did four hundred and twenty two million combined so you can see in one year we did one point seven billion and previous four years a third of that but we've seen this trend continue I think already this year were over half a billion in approvals for forty or fifty different projects. But and also I would say he traditionally we are actually closer to a ninety percent loan program in a ten percent grant or principle forgiveness historically. So we do have a a very simplified process though it is a multiple step processes to apply for funds so we do have facilities need to get on in your seat on that hand out the project priority list it's a list of all the projects in their ranked according to a scoring system although I will tell you we're able to provide low interest loan so far to everyone who's applied no one has been turned down for low interest loans however the grant or principle forgiveness dollars are a little more competitive so we do score and offer a principle for given this according to that project priority list for entities that are eligible so once they go through the project party list they need to go that's do something called the water and waste where advisory committee it's just were all the major funders in the state including ourselves sit down and look and try to find the best funding package for the entity and then once they're through that process they can proceed with funding through the agency so in addition to that process we do offer you'll hear occasionally some special funding traditional usually it's from federal money that we get we do have special funds right now for cyber security for a systems that want to put in cyber security we do have special interest rates and fines for projects that we call regionalization where a smaller system might decide to consolidate with a larger system in that usually results in savings and we can also incentivise that emerging contaminants we have special finding for if you're treating what's considered an emerging contaminant a lead service lines and lead service line inventories we have special finding an opportunities and then we also provide special opportunities and some of our high priority water sheds including the buffalo river water. So with that I will close that we do have a list serve on our website where someone can sign up to get notice anytime we make an offering or any news we have we encourage all communities in the state to uh to sign up for that list of. Thank you some at. Go ahead. My instruments are directed at the health care to our office works with the just over one thousand public water systems that serve ninety nine point seven percent of our cantains. Umm those utilities rely on the numerous water resources of the state to supply their customers and therefore you'll protection and judicious use of those resources is crucial for insurance political health in economic growth for those communities. The. So we are oversee the uh both federal and state requirements for these water systems in the drinking water quality we do that through a conducting routine inspections in evaluations of all the public water systems and stay. Um would a routine testing for over ninety regulated contaminants including things such as learned bacteria test asides and emerging perform p fos chemicals. Among many others with also license the water operators of the drinking water systems make sure they have qualified personnel operators systems we also conduct. Erm playing review on approximately fifteen hundred infrastructure projects for water and waste water each year. The. And we also provide what a bit of technical assistance to the water systems both in their operations and compliance erm strategies. The. And with the the extraordinary resources and water resources in the state along with the dedicated water professionals and both from the regularly the service and most importantly the other operators and managers across state. Or is I was able to provide exceptional drinking water quality to to our residence and we have one of the highest compliance rates in the nation discover numbers there with health of our program in our public health laboratory we work for the systems and have a ninety nine point nine percent compliance rate on monitoring of all the regulated contaminants for drinking water and have a ninety seven point three percent compliance rate on mortar quality standards. The. Excellent thank you. Go rather have adams cheaper stay out I have nothing to add madame chairman oh okay alright thank you thank you that's as exactly what I want it although I love the status etc you shared I love the general overview that you shared I love this because we always love being able to post things and share with our constituents to make it some seamless and easy for them to apply for available funding so really appreciate this very much I will move to questions of members of committee and then to other members represent of ladyman thank you madame chairman here you know I believe that water is the most valuable natural resource that we have and I believe in arkansas we have abundance of that in appreciate your presentation you know in certain parts of the state we have excess water rally of the northeast arkansas or northwest west arkansas water short so we'd love to ship our water over there at times during the year when it floods up there but my question I have a water treatment license and I have always worked readily so i've been in this business for a while but as I go around the state of the country to environmental and safety meetings and talk to other representatives of senators from other states i'll always tell them that well I tell them where number one in water supply and quality but is that true I mean I know you mentioned ninety nine percent in our quality and and that's got to be pretty close to number one but am I telling the truth or am I stretching the truth when I say we're we're better than other states can give me an idea how we stack up against other states yes you think you're you're on point we uh. We do get we. Have to do our reporting to epa for the federal requirements and inconsistently get high marks on our compliance rates there talking with the uhm. Other state programs you know there's they have face face a lot of additional challenges that fortunately we we don't have to fight face in arkansas. Um. Many those have more contaminated sources that have to deal with or they have significant shortages of short of sources and your I think whilst so we have a strong program and have a history of a strong program of focusing on safe drinking water in in the state and trying to promote that for the communities. I also wanted to shout out to all of your for the work they all have done with us on the buffalo river conservation committee and I represent ladyman it's been very much involved with that as well from a but one of the big focuses of that spinned we were able to receive a million dollars and funding from governor hutchinson but one of I think the most important areas of spend that we did was replacement was like a partnership leveraging state dollars with existing federal dollars with a partnership to replace outdated septic tanks most of rural arkansas utilize subject tanks and they need to be updated and replaced and so there was a federal program and we leveraged state money to maximize and that federal program for people to replace an update their subject tanks which does lead to all types of water quality issues seabids and it's not just the tanks it's the it's the lines and everything so I just wanted it to say you know we think about water and waste water infrastructure but we we sometimes miss the the the very individual systems that we also need to pay attention to and the fact that there are programs out there that are available for people that can qualify and so really appreciate a doctor make million with the health apartment and these gentlemen in here mr benefit mr cole pleasure for really bringing that together and and and partnering with the feds on that there was a great great use of funding and resources at the point that represented ladyman was also making senator love you recognized for a question thank you good morning gentleman I just want to follow up with some things gives mr co pleasure you were here last time and I asked you a series of questions in regards to kind of senator chester field in others kind of posed the. How are we getting the word out so thank you all for the for the the two page or some. But i'm among unfamiliar with your. Beyond can. Programming. Are you are still working through the planning to development districts I mean how how do you mainly get the word out in regards to making sure that our constitution sees our informal on these programs. So so I mean we we will work with every group that there is out there and so as i've mentioned for and in fact that right after I left this meeting I guess a week ago I had a meeting again with the municipal league that the conference but I mean we do work with the planning the planning districts across the state we work with a lot of other groups that are just solely focused on water and waste water whether it be the water and waste water managers association so we try to work with every group that we can in fact about three weeks ago four weeks ago I had a discussion with blackmailers association about led service line phoning and in provided them the liest of all the projects that had been signed up so far all the community so we're constantly incommunication with folks across state run you get anything else no I think that the covers we we present at every conference every meeting whether it's rural whether it's municipally you know that that there is and we have that list serve and we also routinely just send things out to the entire list that lance has of water systems out there also we have a better list of water systems and waste water system so I think we can get word out better but but we're closely looking for better ways to get word out also okay I was going to say one of the thing to is is it right after we've I left the meeting we we basically took a lot of our older fact sheets and created a simpler factually that easily shareable that's easily walks people through the process and will be distributing that and trying to get that out in the hands of of all of our folks across okay so are we pretty comfortable that we were pretty saturated are getting the word out to the mayors of the county churches you know or for the water systems we only are pretty comfortable about that I feel comfortable but you know turnover is always the challenge and so as new mayors come in as new administrations come in on a local level we can't ever stop. Doing the education process we have to continually do that because we have new people that show up in new communities and and a lot of times they're calling you all like you know i'm a new mayor i've got a water waste water issue and who do I call and so we're constantly doing education on a on an annual basis or thank you yes sir thank you representative then you're recognized. Thank you membership my question is for I guess director call close your deputy director benefit and under one of you talk about the funding for special projects I guess mall communities but my question is was to start it do we have a possibility of new round of funding coming down the pipe what what was the status on it. Actually when I was here. Okay sorry about that. So when I was here appear the funding that was coming down that day that I was asking for appropriation for was infrastructure investment in jobs act finding and so that was the third year of a five year commitment of finds to the state of arkansas both for water and waste water project so we will continue to receive that was fines and try to get those out the door and within that there are also very special last categories of funding that we can tap into but it's very specific so for example. Ryan mentioned led service lines we'd like we have led service line funding but first thing we have to do is determine you know who has a lad issue and so that's why we're trying to do the lead in the tory with all the communities we're working with health department to do that and so as we find some of these new issues hopefully it can unlock some fines there that we can have access to and provide those to communities but we're heavily dependent obviously on federal phones that the come does. Okay won't want one followed men married here and for me with the late funding program because one of my communities I think it's involved in their going through a process to try to see if they qualify but the other thing so they are no funding coming down the I four infrastructure wide projects for other rural communities is that what you're saying now no actually I mean we will we will receive traditional infrastructure finds for traditional projects but in addition to that we will have the let service line and dollars for emerging contaminants but we do expect to to receive new funding for water and waste water projects through the infrastructure investment jobs act but also we have a base a grant that we get every year it's not much but but we get that every single year that we can we actually take the infrastructure dollars and the base screen and combine those and then we're limited on how much of that can be principle forgiveness and how much of that can be loan and that's limited by the funders the federal government tells us is that like eighty eighty twenty maybe eighty one or twenty now I wish that it was ninety it's actually forty nine fifty one or forty nine fifty one okay thank you thank you matter yes there are senator hammer you recognize thank you mapchier in your assessment just one day if you're gonna have a few things considered in that number one determination of ranking as far as when the studies done what's the process for making their decision because there's always going to be more need than there is money for a long time become so could you speak to that for a second idea I definitely can't so under the federal funds were required to have a project party list that mentioned so it is a system that under drinking water is actually scored by the department health and under clean water score by our agency so it's a list of questions that gives you a score in a rank however to qualify for principle forgiveness we also do another factor we look at the median household income for the community. The loader moderate income level for the community and their existing rates so once you're on this priorities list if your rates get high enough where you qualify for principle for given us we then go to that list in fundamental order of eligible applicants until we run out of funds each year so as director cole clinton played your mentioned you know we get this next year I think we're getting maybe thirty five million and additional drinking water dollars behalf of that can go out as principle forgiveness so you're looking at a very small amount seventeen or eighteen million relative to the whole state of dollars that we then look at what are you eligible for principle forgiveness based on your mhi element your current rates and then we find based on that ranking you know of all the eligible entities. The in the in the master plan. The word consolidation often gets people a bit on the defense of side but the router is sometimes that's the best thing to do. Care speak publicly about what your thoughts are about how we might encourage some systems to consolidate sure knowing that I think we recognize it as the reality but we've not forced anyone to consolidate that's not something we have the authority to do but what we've worked to do is to incentivise and work with communities to find their best solution so in a lot of cases a community we can offer them lower rates in better water a better waste water if they decide to say consolidate with a neighbor and once again consolidation for us means a lot of things it doesn't mean hostile it could it doesn't mean that you lose all control it could mean that you come together to form a new energy that overseas your water and waste water with that into the so we have two things one we offer a special interest rate if you are consolidating so the carrot type approach and the other were able to work with them and say hey you know if you were to stay independent you're probably going to pay a higher rate and it's not because there's not a punishment thing it's economy of scale if you have two hundred customers you can't be as efficient as someone who has say eight hundred customers so taking two small systems emerging together typically results in better water at a cheaper rate for the rate payer but it is a decision every community has to make on whether they're interested in doing that sort of consolidation and on that point sometimes politics is very much involved at the local level for those systems that really out of consolidate would be better. Suggestions or would you incorporate in the plan. So that may be the members should have the ability to vote on that or can you educate me that in these water systems like the two hundred for example do they have the ability to vote in order to override what might be the political structure in place I think the legislature has already put a very good tool in place and given us through what we call act six or five and as it's been modified in the last session which is the retail water provider oversight law so under that law the first thing you did is that no new systems less than three hundred customers so if you're a new you can't form a new system right now per state law if you have less than three hundred water customers the other thing it does as it makes every system look at their system and come up with rates that are adequate to fully fund the system so we're no longer gonna have systems that are not funding their maintenance not raising enough funds so what that's going to trigger though is some communities are going to end up with rates that they feel or not you know affordable to their their customers and that would per the law trick them in a trip into what we call physical distress and at that point I think we'll start working with communities to say hey if you're not able to raise enough funds to fully maintain your system then we need to start looking at other options with you on what how you might be able to consolidate or work with another system tell be able to have rates that are for affordable to your community are thank you thank my. We have representative in it thank you ma'am chair representative ferguson touched on the lead can you and them will be ignorant to the late situation can you talk through how you figure out which pipes of which areas still may have that problem in the second question would be is there a list of projects that you have slated for plaski county that's. The. It's so the first part uh of a trying to address the the potential led issues trying to identify you mention so we're looking at utilizing contractor with a partner with the natural resources using the federal phones to have a contractor that's working with this uhm smaller water systems across the state. To help them identify going through their their records um and in some cases going out and actually physically um investigating service lines to try to identify the material that that's used and then if there's lead service line components that are identified. Then under the federal rules they'll be required to address the borders be required to address and replace those eventually. And also would have. But then allow the water system to apply for the infrastructure fines to help them get those replaced. Go ahead. The. Oh i'm sorry can we request that you go to a certain area or. It's it's required of all water systems and so we we were working with the water systems across the state there is a initial deadline the federal deadline requirement for october this year for them to have that completed and so were trying to work on getting that completed for everybody. And and then once we get those initial inventories and we start working in trying to focus on which systems indicate that they have. That was away components that need to be addressed and will there be a list that we can see i'm getting probably of a public about public information that will. Yeah. Doctor is chairman limits to this create. Now you say that there's one point seven billion it's ninety percent of this this money is going to loans in ten percent of can you explain exactly why it is. The situation is far as a way that has find it through a grant is it done according to amount of money that it centralizes a dramation in side of an area. Also. Do you not go on in there and say look someone's applying here and they hadn't had no papers for a hundred and twenty years. What what do you do in a situation like that to get that i've just no open health these people get along. So so first question was related to the to the one point one billion that we funded uhm. So that was that was last fiscal year so that was the previous year and that was based on all the applications that we received and and going through the process of then approving the fines for them so. Whether or not we'll see that level this year I think this year we're at close to five hundred million is what's been approved so far this biscuit here and we have. Uh commission meeting scheduled in may where will take you know applications that we've received and and will process those. Um. You know to answer some of the other questions related to just old infrastructure one thing I think there all of this talk about infrastructure and in new funding and in all those things has created a ton of interest related to real taken a look at our systems I think axic so far that right mentioned where you have to look and do a rate study in your heaven to project out what are your capital needs into the future and so what are the things that we're going to have to replace in the future has has also generated a lot of interest in a lot of planning efforts and a lot of work really and a and so I think those are the things that are going on right now that are really helping communities kind of. Focus on taking a look at their systems to see what they need to do into the future and then where do they go to get the funding for that. But for a message yes quickly we need to move on recently may ask you this is something in there that says it's got to be an income of lesson a certain amount before an actual one hundred percent grant to come back do you have one hundred percent certain area we don't so when we offer a principle forgiveness that's on a seventy five twenty five of fifty fifty or twenty five seventy five and so we we won't find a hundred percent grant out of those programs that don't you miss you absolutely thank you for the questions please visit with your colleagues obviously to come back and watch the committee meeting if they have questions just direct them to watch this committee meeting and the presentations that were made today and the questions in the answers that were given thank you so much really appreciate yours is exactly what we needed thank you moving down the agenda i'm going to go to item f first I think we've got two rules before us and at I think we can go ahead let's start with the f because I think I have some people have signed up to speak on that one so we'll go with at first. And if you will do state your names for the record we will proceed. Good morning elizabeth pittman division of medical services good morning janet me and DHS mitros cheaper staff. And i'm ready I am starting with f this is the rule for the children's advocacy center reimbursement we were approached and buy that organization was with poorly and her organization of cac is to at work with them to create a reimbursement in particular for sexual abuse so or sexual assault nurse examinations in physical i'm abuse examinations this ad role is a result of those conversations and it does reimburse them for those two services for registered nurses and their clinics as well as for their medical directors apr ins or positions to provide those services and happy to take any questions okay are there any questions for members of the committee. Great seeing none this rule stands review thank you are ademing. Item ee is the continuous glue coast monitor and diabetic supply coverage room this rules a result of acts three ninety three from the twenty twenty three general session. That actual required medicate to to do two things one two increase access to continuous glucose monitors or cgms to farming through pharmacy providers also to look at ways to collect rebate on the cgms through the state medicaid program. Um to accomplish this we worked with cms in and pharmacy and the me providers as well as our pharmacy at vendor at magellan to create the rule that you see before you now this expands that access to both pharmacy and durable medical equipment providers both provider types can provide the service. But it does require it to be built through what we call our points of seal system which is our pharmacy billing system so we're creating a portal and we will be a training terrible medical equipment providers on how to use that portal it also requires that we change the pricing mechanism for these services to wholesale acquisition cost which is how we typically price pharmacy items and not how we have historically priced terrible medical so that is a wholesale acquisition or whack pricing plus a dispensing fee of ten dollars and fifty cents and i'm happy to take any questions on this rule. Okay. So lets see will go with a representative or rich. You recognize and we do have a three individuals that are signed up to speak on a and we'll get to you after we take questions thank you i'll try to be brief I think for being here today and thank you for presenting the rule I guess my question would be and i'm basing this off memorandum that some members I think have received is the rule as it's written in is it contradictory a federal regulation would be my first question. Good morning thank you for your question no it's not in contradiction a federal regulations the cgm I believe the memo came from a lawyer I do have a copy of it just to address it the cgm is considered a home health benefit is required under the medicaid state plan that is where it is to be reported for our expenses but the delivery of that through the medicaid program is allowable through pharmacy thirty four other states have some combination using this with cgr and so we are thirty fifth with mississippi and florida coming online after us and it has we have gained approval from cms okay good I have one follow up minimum to. So cms has approved the current rule at the federal level yes or they have thinking ma'am. Representative bentley. Thank you chair and thank you over being here today i've got them i'll start with this question we're here in some concerns that this is not a good working for a dmese whether the pricing is now so can you answer this concerned on pricing how it differs just give a more clarification of that for me please I will do my best to try to explain the different pricing methodologies we can also follow up with some information if needed. And so we currently price terrible medical equipment under our state plan at one hundred percent of medicare so read that means is for example continuous glue coast monitor receiver we don't look at brand right now in it there is a max price so the provider can build us there cost. Up to a max price which I believe for receivers three hundred and ninety six dollars under the new methodology. And there's also codes limit let me finish there's also codes under the existing manner methodology that are bundled codes so they bill what is called a code and that includes that receivers it includes the little desks that includes multiple items that how we bill today add using bundles and one hundred percent of medicare when we go to the new pricing methodology it is not priced that way it's priced by brand so each brand has a wholesale acquisition cost and that is based on several different market factors it is a national average price and we are an add to that a ten dollars and fifty cent dispensing fee and so if you look at those different brands of receivers there are different prices I believe one is three hundred and sixty five dollars one is it two hundred and ninety nine there's probably others that I don't know. I'm additionally we cannot bundle using the wholesale acquisition cost methodology so where is before you were able to bundle different things together and now each of those items will have to be built separately so because of this it's very hard to get out at apples to apple's comparison of what they are billing us today which is what they'll be less in the future it's very dependent on what brands their providing and what bundle link are doing right now but that's that's the difference and again happy to provide you with some written documentation at that kwik file up chairman of this okay yeah i'm just concerned that we're. Just from here and there were limiting competition the last thing on earth that we won't do is limit competition to make sure could to me this was going do the best for our patience and ask me to make sure that my patience are going to be able to get in rural arkansas what they're getting now and make sure that being taken care of as we I did not want to bod for this one and decrease any competition at all to make sure we're not going to have the providers that we have an out to make sure those patients are getting taken just because our state so so different and where were her provision where we don't so I don't want to limit what folks are getting some concerned on that and didn't you know for sure I don't want to make sure reason one provider and do it you know and every service is one could smarter has been out there to me we're going to be detrimental to our patient scare in the end so I have some real concerns with it but that's offered now thank you thank you okay I will let you guys respond if you like as well we do have so three individuals we have no more questions we have three individuals here that are out senator love we do have one sorry yes thank you mary insurance and in representative being we were on the same wave these are some of the questions that I dear present to to miss pimme but explained to me why can't we bond or when this system that we're moving to versus the system that we had for sure so that is all based on the manufacturers agreement with this so we are looking to get the rebate which is where we pay the pharmacist or the dme provider the cost that the normal billing the wholesale acquisition the full billing price and then we sit with that claim back to the manufacturer and then give us money back and to be able to claim that money back we have to know exactly what we provided so you can't lump all of those things together into one bundle so that we can provide that information back to the manufacturer and get that rebate back. Okay all right and then and just just as an asar how did we come up with the dispense and fee of of ten dollars and fifty cents. That is our current phone received a spencing fee that has been in place for quite some time we looked at it recently and we're actually we're on par with all other medicate states around us and actually one of the highest and payers in the state for a dispensing fee okay and in what what comes in what comes what is what calculation comes with the dispensing thing what are we thinking about as far as ten dollars and fifty cents and that is what we pay the pharmacist for a packaging the drugs giving it to the client giving them the handouts and all of that information so would they get the drug billing price but then they also get that ten dollars in for descent dispensing fee for all of the things that come with providing that drug. The. Okay are thank you. Yep okay and then the the different prices that you you at said that one was at three sixty five one was at two ninety nine is that the wholesale cost yes me and that's the whole seller acquisition costs today or as of the date that we pulled those those changed pretty frequently because as I said they're based on market drivers okay. Alright one one more question. Is that over there you are occasionally represented richardson good morning I think you guys for being here so the question from senator love kind of spring upper another question that I have about this it's it you said that the rebate is what you're looking to get back from to apply to this but it's my understanding in the bill the rebates are going to be are specifically written to go to the individual and not to dhs is that in accurate no sir the rebate program with and medicaid is a program where we make enter into contracts with the manufacturer and for every drug that we provide that they have injured into a rebate agreement with us they provide us money back at the end of the quarter and I pulled it recently for a question signature left it asked me we had recently our last quarter we got eighty four million back and drunk so it's a huge saver so what is the in the law itself what is that rebate a roof referencing so that rebate is the the rebate for the medicaid program we were charged with creating a program where pharmacies could provide that service and the medicate program could collect that rebate back but the laws written to go to the individual. Not this was this lies specific to earn medicaid. We can review the statute but we we have an educate program has never done rebates to an individual or to a provider and I don't know that we would actually be allowed to do so and I appreciate that i'm just wondering from a legality perspective how how we're going to negotiate that I mean the reality is if it's written now that it's supposed to go to the individual then that creates a challenge for us obviously I believe I have the statute let me check I can read at least the line i've got it here which says. It's supposed to allow the beneficiary to obtain a continuous glue coast monitor through a prescription out of pharmacy and to be eligible for rebates as a pharmacy benefit right meaning cgms to be eligible as a rebate for a pharmacy benefit. Yeah. I actually had a question about that too because it says been officially and it uses the word and and so that that rebate actually should it is. Not specific to the agency their specific to the beneficiary because I mean that that was a question that many members have asked me that as well I think there's no way for the medicaid program to do that so we've always interpreted those as beneficiary gets a continuous glue coast monitor through medicaid program and then the medicaid road where i'm becomes eligible for a pharmacy rebay where there are those medical supplied just to add to that the majority of medicaid members have no copays at all in those that do you have very small copies of four dollars and seven years answer I think nine dollars right so there is really night and mechanism by which we could rebate a medicaid client right bed yes and I understand all that i'm just II think the way that it was written is is a little problematic. One quick follow up do we know how much those rebates are going to be we don't we have and entered into any agreements with those. Manufacturers at this time we have to have the mechanism set up to be able to do that and right now they're requiring that point of sale and wholesale acquisition cost okay. I would also add that those rebates or proprietary agreements we will not know what the rebate is until when until it's collected an insent to us that it is a proprietary. With each manufacturer and that is the standard business practice okay thank you do we know that information after we receive it is it reported it I don't believe it's reported by actual individual rebates it's it's a it's a consolidated number like last we send those rebates and invoices every quarter and I think last quarter where's eighty four million dollars as miss pittman reported yes we we don't pull by individual manufacturer because of the confidentiality around those agreements we pulled holders and report those to see a mass around what we we collect and rebates and for the pharmacy program last quarter it was eighty four million and that and that's that that's information that answer the public it and we get right the eighty four million of the aggregate number. Representative again thank you very much motions property let me go ahead and hear from uh folks that have signed up thank you so much thank you and if I could have these individuals come to the table altogether just in I mean i'm outside of my time sat forwards but I want to try to get us through the succinctly we have if you'll just come to the table or three and state your names for the record and then you'll be recognized. And I would just ask like make individual make. Don't repeat what the other person says just to try to get us through this as quickly as we can thank you madame chair members of the committee my name is steve good and I represent a. Newly formed reflect we don't have over our s paperwork back yet so II newly formed association in the arkansas medical equipment providers of which these two gentlemen are members. Bradwin pitagin medical supply. My name is sean mccoy and the president of eclipse medical and also the president of architect medical equipment providers are new association steve just mentioned thank you all for being here please receipt. Okay first of all I want to think the committee for allowing us to come before you today to presert again I am the president of eclipse medical we are small architel based durable medical equipment provider here in central arkansas where a family own business we employee approximately ten individuals I think that we were very excited back in twenty twenty one to see the expansion I am access to continuous glue coast monitors to the medicaid population they're an extremely vulnerable population and getting them accesses is key because these these devices change how they manage their diabetes and entire that manages the outcomes and the outcomes or where the real cost star when it comes to diabetes so the more compliant we have these patients to be the better their long term prime notices the better quality of life they have and the better outcomes in the lower cost ultimately to the state so I think that's an important thing to point out act three ninety three is something that we broadly as a dme organization and other fellow dme owners embrace we embrace access to patients we don't have a problem with the additional competition as it were from the pharmacy we think that that's a very positive thing because any time you have choice that's good and by opening up access to these formancies around the state now you can get your products at your local pharmacy if you choose or if you choose to have a higher quality level of service you can go through ADM e provider well how do we provide a higher level quality of service we do that in a merit of ways and I won't go into all the details but a couple of the big things are we shipped directly to their patience home meaning these patience don't have access their home bound they don't have reliable transportation perhaps the nearest pharmacy is thirty minutes away so it's not excessive for many of this vulnerable pipulation we also speak and engage with these patients on a monthly basis we provide education. Direction answer questions are instant were more than just a provider we are a resource center for this patient population so what I want to do today if I can is focus on a little bit on the math listen we fully welcome again the pharmacies having access in being able to distribute these products and I think as a dme group where our frustration has come in is that we have not been fully involved in the process I don't think that there's been necessarily a lot of transparency so I wanted to speak very specifically to the numbers this is a complicated topic I will be the first to admit there's a lot of moving parts so I don't want to go down in any rabbit holes but they proposal under this whack pricing model which is the wholesale acquisition caused our cost as an organization our product cost which is currently around a hundred and fifty dollars for a month supply of sensors is going to go up to three hundred and fifty dollars three hundred and fifty five dollars so we're gonna have a two hundred dollar increase now are reimbursement goes up but guess what the reimbursement under this way pricing proposal I reimbursement is three hundred and sixty five dollars and our cost is three hundred and sixty five dollars so we're going to get a ten dollars in fifty cent dispensing fee to cover our shipping a processing are handling all the administrative requirements that are involved all of the time that we spend on the phone with these patients were paying to be in business were a small company we have been serving our cans as you have a built in distribution model that's currently in place and has been serving arkansas medicare patients for two of two plus years now and again we fully welcome broadening that access but if you limit it and we get priced out which is what will happen under the water pricing model now you have eliminated one business channel it's already been built out over the last two and a half years you wipe it away and now you're forcing people to go through a pharmacy. Are are represented and presented some of the challenges that exist currently with farmers he's in access so I don't understand why we would want to lessen access by carving us out of the market and while I appreciate the intent from DHS to allow us to participate and funnel our claims through an entirely different mechanism that's never been done here in the state it's completely foreigned us the numbers don't work and that's the bottom line but you're asking us to to process an adjudicate claims in a way that's never been done for a medical supply this is not a pharmaceutical product okay the other thing is what is the real impact of the state we don't know we don't have visibility on what those exact reap rebate amounts are i'd like to know exactly what those are I can tell you this is being pushed by one manufacturer specifically there are essentially four manufacturers that exist in the united states for c g products two or nine players i've never had a refural in two and a half years from our hundreds and hundreds of patients on either one of these other two products so there's two players in the space one of the manufacturers is pushing this rebate program to the state and I welcome the estate the opportunity to receive some additional rebates from additional funds back but not at the experience of the existing distribution channel and I have to question without knowing the rebates what is the cost to the state because right now the states reimbursing us roughly two hundred and fifty dollars per month for supplies. The new rebate program guess what they're going to reimburse us roughly three hundred and sixty five dollars so now it's a hundred and ten dollars increase on the reimbursement by the state is that amount being offset by the rebate maybe I don't know but we don't have any visibility into that so again I wouldn't I we are not trying to be contrarian we're trying to be part of the process it's been in place and established in this state for two and a half years and I think that were somewhat offended that an out of state manufacturers coming in telling us how to run our state medicaid program what patience are going to get what product in the last thing i'll touch on the two manufacturers that currently provide these products in the state they're not involved in this whack pricing model so now you've eliminated the competition so you have one out of state manufacturer that's come in and they've said we're gonna tell you where you get your products and we're gonna tell you what products you have to to take so as a as a as a clinician they don't they will have a choice with the medicaid population they will have to go on this one specific manufacturing product because the other ones aren't participating in the process the other thing is now the patient has no choice so they've lost access to the dme channel that's already in place and now they're limited to one product category I thank you for your time this is in a very important i'm very impassioned about this subject this will have potentially devastating impact on our business we're small family on business we have ten employees we're looking at you know having to let employees go and set us back on two and a half years work that we have done serving this particular population thank you for your time thank you thank you for being succeeded and well third i'm i'm actually not sure if you want to add more to that or not I thought he did a very great job of covering it but go go right ahead we do have some questions a as well that will get to the questions I think you did a great job on thing I was going to add is I think everyone here. The the we have great legislators in arkansas the questions are that you guys have asked even like earlier on another talk doctor lead ladyman mentioned I want to see is get from fifty one to forty nine and we need improve outcomes is how we win this and I love the state seizing opportunities with rebates but what dear me is able to drive with compliance that i've seen and i'm here only because I care about my patience my patience right now arts on medical patients that are getting their continues googles for parts to me that they think it's their sincere that's messing up but actually it expired and we're on the phone with them saying you know we we need to get you your next month supplies and what that does to drive compliance is going to more than outweigh whatever rebate I know eighty four million was mentioned but that's not in the cgm the the lack of transparency for me and international manufacturer that's looking to get monopoly is connect needing to be honest what I want to see is our kansas beat diabetes and when i'm thomas seventy year old serb or challenged fifty five year olds that have never lost weight in their in since high school who walking in and say you have i've lost twenty pounds and we start talking about how that's happening and no one realizes that the way arkansas diabetes the way the world's fault diabetes is trying to get the cat back in the bag you're trying to clean up speak mill. We'd even had physicians using a ninety day review mirror with a one c scores. Where you beat diabetes is in the moment these continuous glucose monitors are feeding the a one c predictor to the patient real time they're checked their finally able to apply what the doctors been preaching for years and we're seeing patience lose way we're seeing patience turn the corner on a diabetes so the I don't want to say there's a there's a road where arkansas will be to diabetes. Though i'm really want to do but if there is a road where we be diabetes the beginning of that road is right here with cgms and what we're able to do in the home and with this case management every month and we can't even bill without case management whether it's medical record case management or contact with the patient indeed doesn't get the bill for that it's not work not reimbursed does we can't do it for a farmers is ten dollars in fifty cent dispensing and the state would lose that case management that dimmy brings if we're forced into a model that was honestly built for pharmacies it's a pharmacy billing mechanism it's pharmacy numbers it's this was all communicated as an expansion but it's going to push us out so I i'm i'm excited to get to here the the questions and and i'm honored to stood to be here in front of great legislators thank you so much mister manager and members i'll be very quick I just want to point out a couple things one representative richardson was correct I mean the way the bill reads is the bett rebate goes to the beneficiary it's very clear. The second thing i'd like to point out is we're talking about moving this to pharmacy because again as you've heard our members of our association say this will eliminate them from this medicaid market it's it's going to happen yet for those of you that that own business as you know you have to make money and then and they the money that they aren't they do it by providing a service. But in the last three years I talked to john curtley yesterday in the last three years there had been sixty nine pharmacy closures in the state of arkansas. And so we're trying to move a benefit now to an industry that is actually closing stores instead of opening so again the bill talks about expanding access that's not going to expand access representative bentley talked about rural pharmacy. I want a pharmacy in the masters. Very we don't deliver we can't deliver it that the cost of insurance to put a delivery truck on the road offsets the benefit that we would get so north art or north fallen county it when d m es go away they won't be covered by our pharmacy I can't I can't afford it. Finally and I guess this is most telling we it we have continually as the hsa and I appreciate security putting and chief staff rouse and and they're great team that they have over but we have continually ask what's the rebate going to be you've just asked them and I think you heard. That they will never know the rebate because it will be bondled in blended. Well then how in the world are we going to go from a two hundred and fifty dollars allowable to the state to a three hundred and sixty six dollars allowable to the state and not know what that rebate is we're costing taxpayer's money potentially there because we don't know what the rebaters and the rebate may go up from eighty four million if this passes to a higher number but we'll never know that it was from this. We'll never know today we know what the allowable is. And finally i'll say this we are four pharmacies we one hundred percent think that there should be a pharmacy channel but there are many states that allow dual billing they allow billing through pharmacy and they allow billing through dme and I know that that will propose that will pose a challenge to the to d h but I think that the great teammates that we have in the state over DHS or much up to that challenge of being able to bill through a pharmacy portal and get a rebate for those and through a dme portal for those who are taking right here their patience today. Cgms were built on the back of dmese over the last two and a half years when you all passed a bill in twenty twenty one to allow that to happen to medicaid these folks are who built that and announced company who is only only interested in building their bottom line is trying to change that today with this rule thank you very much. Thank you we're going to go to questions representative poking tone. Thank you. I would say I appreciate your comments but I do not I think it's very disrespectful to say that there's been a lack of transparency on this rule I fire bill this bill november twenty twenty three I have not heard from you once until this will happen we were supposed to pass it in january it's now almost april I know dme has our dhs has been sending you guys training about magellan so for this idea that they haven't been working with you. Is ridiculous this bill was aimed to save the state four point three million dollars. I am concerned about the taxpayer and the patience first and foremost. That is why we did this bill ipassed the bill on twenty twenty one that allow cgms. To be paper by medicaid center bringing davis with us me on balance as well this is all designed to help the pages and when I feel like is your muddling the water to start a bill there went into place to help esave the state but also help save the pages what you'll hear from people they say I would much rather work with the pharmacy that a deemi company which makes it way too complicated so that's essentially what we're doing here but I take great offence to say that there's been no transparency on this because that's just completely ridiculous it's not true and I take offence for the legislatures who ran as but also d h who I know has been working with you and in conversation with the well so first offer to that also seem that we're going to limit access somehow by allowing farmers it was yes there have been a farms is that close I mean you can talk to the foreign association but as well but at the end of the day we get pharmacies they are able to direct ship medications including cgms and north falconer county will be covered there's more pharmacies currently right now despite the closures and there are companies in the state of arkansas so to say that we're going to somehow limit the amount of access as ridiculous we've actually expanded the amount of access here in the state with this piece of legislation so they're just not accurate II really find these comments troubling because I don't I feel like the I feel like you'll have tried to muddle the water on this rule and I ought to be honest I just do not appreciate it i've got more questions but all it's on my colleagues answer as well but you know I have a motor the proper time that we adopt this rule. The. Uhm. Yeah. Okay let me get a representative built lease is on committee and then i'll come to you. Represent evently you're recognized thank you chairman and can you over here when we when we'll we're talking about the money going from one fifty to three fifty five instant key to the whole thing as i'm a small business so and I know if my price is double I was an admiral. Actually whole lot less would put me out we don't want to put you guys at the lesson want to do so explained to me when you were saying the price will go from one fifty to three fifty five can you explain to us again how that happens nothing that's key to the whole process here yeah it's it's it'll it's a complicated space but unessentially right now the way we reimbursed his off the cms medicare allowable in miss pittman alluded to that accurately earlier about that dollar amount of reimbursement are called spaces right now what happens is the manufacturer that's in question here has two has the exact same product but it is built around two different pricing models they have one for the government's side which would be the medicare in the medicaid and then they have their commercial or their pharmacy side of the product that cost bases on the pharmacy pride is considerably higher for us to acquire so where our cost basis now might be a hundred and fifty dollars it jumps up two hundred dollars to the three sixty five if we have to adjudicate process to claims through them through the pharmacy the major important and then the reimbursement that they're paying us is equivalent to exactly what our cost is to do that I answer your question. Yes you did thank you. The. All right thank you and. If you hold once at my minute i'm sorry representative war lower your own committee so representative war lawyer recognized thank you madame chair. Bread this questions for you I mean you enough talked about this numerous time this week. I think he's important to committee understands how this rebates going to be paid who's paying for the rebate and I think that's where to water is kind of mudded today so few would kind of walk us through. The cost difference from your agency morton respiratory better jean medical and what that's going to look like for you guys when you have to participate with magellan and the mountain chair I may have a follow up I just I want to let him play this out first okay. I. No great question and I think the reason why it's tough to wrap our head around his because we're moved the states wanting to move towards a more expensive claim so I does that we've been following cms reimbursement but this new whack pricing jumps the price to increase experience and. Even you'd say all that from a business standpoint if i'm gonna get reimbursed more money I should be excited right well except for the fact that the second that happens to the manufacturer this international manufacturer gets to with the same product i've been ordering they get to increase the price. More than mirror imaging the increased cost to the arkansas taxpayer so they increase the price in reduced the margin so in sales you pay the rebate correct I would say me in the arkansas taxpayer pay the rebate but you be in the small business in arkansas paying the rebate back to the state of arkansas which instant saves the four and half million that was claimed by the representative of man in the pharmacist back that did engage in the program but it can kind of difficult it's not out of the goodness of the manufacturer's bottom line they're not sharing their money back to the state whatever money that turns out to be though it's preparatory and they won't share the that's not from the manufacturer that's from from off the backs of dme and and pharmacist and our console taxpayers and I don't go against the reimbursement rates that were already facing with the audits and all that india me correct correct thank you thank you. So can I just follow up to that so there's no so if if they increase it by fifty dollars in essentially we're paying for our own rebate. But if they increase the back of it there's no guarantee that we're getting one hundred percent of that fifty because it's proprietary that is that correct that's correct matter insurer and so again we don't have transparency from the manufacturer on what those rebates are because they're were told that it's proprietary but the only way of right now they're not offering the rebate to us to the forum is using the right doing that because there's no additional they would have to give up their current margin in order to do that so the way they offer the rebate appears they raise our price in this case two hundred dollars now obviously I just national distribution partner is in that mixed right but by raising that cost now the manufacturers selling in a much higher price point than they are currently and that's where they're able to pull those rebate dollars from by raising up what they're selling it into the market place for. Okay and soon urban if I might either in represent pill cannot filk into that point this is where I want to be clear please accept my apologies on behalf of myself and our members if. The the lack of transparency was only about the rebate DHS we have had numerous meetings with them you and I have taught numerous times via text and then again this week so there is no disrespect intinity we again we love the bill we just don't like the rule and so frankly the transparency or lack of is just simply on. The rebate part. And I might add II don't know that I would have known exactly how to reach out you know when I first heard whack and i've been doing and been in the space for twenty five years and had an own small business for twenty one wack pricing came up I thought it was a west coast athletic conference or something I didn't even know what that structure was and when they said we're gonna have to submit our claims to magellan i'm like what's the major and I learn that in history class but you know mark our portal is a bright tree cyntric it's a building platform specific from my medical claim submission and I don't know that I would have ever known to really ask intelligent questions and and I believe doctor representative pilking and would have been eager to work along with me II don't know that anyone in my industry has had any experience because this is unprecedented there may be thirty five other states would do benefit only know of one other state that's forced medical to try to go through pharmacy and that's california. I could just add one last comment I again I want to echo both steven brad in the comments of the representative of talking to we love three ninety three again we fally welcome broadening access again it's it's our frustration in the lack of transparency around the rebate and how that's actually going to work and what that actually looks like so we met no disrespect in that regard. All right thank you representative for the. Didn't think you map chair I think there is one piece that needs to be brought out in this walk us through the reimbursement rates in medicare versus the reimburse and I will talk a loud not billable in the reimbursement rates to the proposed medicate rule and what those p and ls would look like profit loss on those two different cost bases on the product as it stands currently our cost basis and i'll talk in terms of the sensors that's what the patients on their arm are on their abdomen and that's the monthly supply component to this that's our cost is roughly a hundred and fifty to a hundred and sixty dollars depending on the brand each month the reimbursement under architect medicaid is a currently two fifty five I believe and so that that delta is what allows us to ship the product so what's the allowable for medicare for that same product on a monthly basis it's which to the allowance to fifty five so they paid medicare and medical i'm sorry i'm sorry you have medicare I think is now to sixty one sixty four so medicare is about six dollars higher than medicaid currently to members just throw it by its clear that hundred dollars difference is not clear profit there that's how you fight in audit that's how you pay for delivery that's how you it's it's a lot of money spending that hundred dollars so there's very little actual profit there so what's the new reimbursement rate looked like from medicaid when this rule goes into effect if we were to go with the wat pricing structure that's being proposed our car spaces goes from a hundred and fifty two hundred and sixty dollars for a month supply it goes up to three sixty five I just confirm that with our national distributor yesterday the reimbursement for that same product is three sixty five now we would get the ten dollars fifty cent dispensing fee which is not going to cover our shipping essentially so if you get audited on one of those new claims how much staff would it take to satisfy that audit in one audit just kind of put a dollar for your to it so the committee understands out works yeah I mean i. So it's a great question I think from a staffing perspective it takes about two people working on this pretty consistently to get depending on the size of the odd I tend patience yeah yeah ten patients it could easily take an hour for patient it with two people working on it we currently have about two staff members that are fully dedicated to processing medicaid each month of our of our ten employees so they're spending you know a lot of time just processing them and that's without an item. Thank you thank you march. Thank you so much last question representing gonzalez they made a chair and this may be question more for you is there anybody from pharmacy here that has dealt with these rebates and this type of of billing before because it seems like they don't know exactly how that works I would like to hear from somebody who's been involved in it and in those that. So. You know II don't think we have anybody here at or make maybe dhs can. And explain that later if they get back up okay. I mean I think pharmacy is as one thing i'm not sure about the pharmacist themselves so as a distributor I think that's more of like an apple apple comparison of your question to be to be honest with you because they deal with you know the portal that you're talking about whereas these gentlemen have night so I don't think I have anybody here from the pharmacy association. Or from a pharmacist perspective point of view I mean mr good owns a pharmacy so. I don't know if he can speak to that or not no mail mayor it's just in my building and I have a pharmacist that handles all that stuff it's complicated so I want to try to okay all right no no further questions. Members of the committee we do have this rule before as i'm going to recognize and steel to to go through the administrative process of what we can and cannot do as a committee and to lay out our options before we move to take any action on the rule because it is controversial i'm not going to rule that it is reviewed without objection. Madam chair with steel if you're i'm sorry are we done yes thank thank you madame chairman members thank you let's deal with your recognized making matter of chair so the committee has four options one is to review the rule the second is to not review with a basis so the rule must be inconsistent with state or federal law or inconsistent with legislative intent the third is to take no action and the fourth is to defer or hold the rule with incom. A representative johnson you're recognized is just for clarification on the first three options in the result and still the rule moves to rules committee analysis so. The last option the rule does not move to rules subcommittee is that correct to my knowledge it would remain within committee okay all right numbers those are your options before a year I think representative mcgee. You said you had a motion at the proper time you're the first to ask that question i'm going to you. Representative thank you manager I just listened all this test money in. Looking back on the way the bill was written and and all of the. Seemingly problems we might have with access I would make a motion that we deferred hold the same committee and discussed as far there at a future date. That's a proper motion is there a second second is their discussion. Okay represent of gonzalez you recognized they manager and so a question how long can a rule be held up and like represent her copy to say this this has been passed as as law for a while now misdeal so has a. We're going to get some notes on the topic okay just want them it. If you'll just take your name for the record thank you back a million rice administrator with the rules review section here at the bureau so the subcommittee can hold the rule and there is a provision in the rules of the rules subcommittee that. Would allow the chairs of that subcommittee if they were defined and trying to find the provision i'm sorry. Either chair of the subcommittee this is the rules subcommittee may determine that there's an under delay in the review of the rule by a subject matter committee to which it was referred to recall the proposed rule. So there is that option. Okay so so to be clear there is no time frame on how long public health committee can defer or hold it however there is a provision that the chairs of the rules subcommittee can recall it from public health if they believe that that is an unnecessary longer. Tom frank correct okay. All right does that answer your question. Representative but it's just based on. It's based on the action of committee not necessarily the whole process. To you they determination yet to the role by the rules chairs yet yes whether it was just the rules just say whether it were resulted and do delay. Okay all right that present specific as the rules are okay representative because also the manager so so the law still stands without the rule in place. Right so so what happens if DHS decides to enforce the law without this for rule being in place. Unfortunately i'm not able to give an opinion on that. Okay. And basically what i'm saying is is the pharmacies being able to sell it at. Distributed whatever at the wholesale acquisition costs and they proceed with that portion of it. Any idea what. That would work. I mean we have a lot of laws that don't have that are still lols but don't have rules in place so. That are still enforced correct. The. Wow I don't I don't think you can info okay thank you it's a very good question all right any other questions in the other discussion all right. We have a motion on the floor all those in favor say I and opposed i'd have it and the rule will remain here for further discussion we will try to schedule a follow up meeting on this rule next month. So that we can get it going thank you. Ok members anything else I need all right thank you for sticking with their song at friday very much appreciate it and I hope you have a blessed and wonderful easter and thank you so much for attending today and with that we are adjourned.