ALC-Employee Benefits Division Oversight Subcommittee

We've got a pretty short agenda today and while siegels coming up to present II just want to make a quick note we are including the stabby study in part of our larger wellness study that we're gonna be doing so we won't be taking the action today but but feel free to. To to ask questions. To. You know make comments if you wish but we won't be doing any sort of recommendations today so if you have anything like that you'd like to recommend just wait for our next meeting center happy would you like to anything now and I think that is a good point although we've we've had the stability study we had a lot of members that wanted to do the willness part of this so we're going to kind of. Say that that's all inclusive so that's all inclusive of our original study so again if if they give recommendations today everybody can ask questions but we're going to have some additional time that if you want to bring other thoughts that you can do that do that also so thank you mister chair all right please introduce yourselves when you're ready and feel free to begin. I am doctors on a per all good with seagan and patrick client with seal and we have two members on the phone as well can you introduce yourself. Yes this is. Necessarily sent from seat car. Great. Two hundred to get started. Yes please proceed thank you so and back here most of you have heard our previous sessions and to these ideas to bring everything together how those fall things with are coming together one was the adi area to provision index study one was a mental health study one was on glp ones than the us debit and one was on commodity is that we did so we are bringing it all together now and then coming up with some next steps for us the reason I have made and set on the phone is because they did create some of the slides in the previous sessions that I would be sharing so it in case in there are some questions. So here is what we found in the series of these presentations that the prevalence and costs of dvds remain high in your health plan and they need to be addressed because if we don't address those today they are just going to go up and up mainly because the treatment options in day beaters are that are coming in the market place our way more expensive than what they used to be before so i'll touch base briefly on that. The call mobilities of debit is which is other conditions that are present with diabetes are hypertension hypothetic. Cardiovascular disease and will be city. Mental health remains where he hires well cost of newer debit is drugs as I mentioned that you ever be ones are really high they need to be managed. And members living in those deprived areas in terms of education and health goating access affordability all of those they need to be addressed more than anybody else. And why is diabetes management important. It's important because it can prevent many other serious conditions later in life. Are only actions to prevent the type to debit care actually reduce the risk of getting a disease I disease no disease and all of the other. Some ways to manage david is is making you know held the eating head their lifestyles maintaining black for their level been turning healthy wait following the instructions of your provider on the black sugar level and then taking medications that are necessary. So all of those things come together to effectively have a day be dismanagement program. So less recap way quickly what our previous analysis should this was the area to provision analysis we. Would be plotted your population in this about a giller charred where the blue is the least disadvantage meaning most advantaged area and the red was the most disadvantaged and those are dependent on the factors such as income education employment and housing quality those are like sort of some of the areas that are cdc watches to for uh certain conditions and we found that the people who lived in the most duty surventage areas had the highest direct is released held the highest obviously prevalence they had the least number of some of the programs that are available they were not seeking treatment when the cessary and they were using the more expensive methods of seeking health care which is going to the emergency room and hospitals over something like a teller held preventive visits were also very low for these populations. And then we saw some slides on the medical nutrition had AB which is a easy way to manage david and there are programs out there what we found was very few people were actually taking advantage of this medical nutrition therapy through the health plan that's available today and david is in the most disadvantaged ideas what the users least users off this understandably so mainly because of lack of health education. Obviously I think I spoke and lessly about it when we first presented it is rampant in the population there's no doubt about it seventy five is it just the right chart that I hand side charge just be attention to that almost seventy five percent of diabetics were also classified as it will be and they had the lease number of that medical nutrition terribly. The bottom chart breaks down the visiting to different classes based on. The levels of obviously three being the high est and it's the highest percentage of august day as compared in the other population. The. Same results here most diabetes this is broken by the area the provision index they live in the moderately disadvantaged areas. We saw multiple call more but it is meaning other conditions that are present with diabetes so hypertension that will be city hypothetically me average his high leopards the the life producers we call them hdl and then the mental health all of that comes together as he were fixed on when it comes to dvds. And by but it broke it breaking down by costs this is a pretty simple slide to understand every time when you look at it the total pm pm **** member per month that your health plan paid was high used for those with. Most commodity is most other conditions not just bureau diabetes so that's just i'm just driving one point home after you know every slade. Mental health that was another one where my colleagues sarah presented at the last visit and sarah who here is one slide I would like you to comment why did you have this particular. Box certainly and what's the take away from this lade. Absolutely what you see that their circle nine hundred and twenty five circle on the right place the screen is the monthly cost for a diabetics with no mental health condition but if you look at all the numbers while that in that column you see their all more expensive in that nine hundred twenty five dollars so that really dress all that diabetics who have mental health or substance use or going to be significantly more expensive I think diabetics you do not have these mental health conditions so that underscores the importance of the driving matter how conditions are diabetics. Great thank you sir. So mental health and pretty david is same relationship you have when you can manage that at the early on said. You do prevent these deplete david extra becoming the real debit cards if you manage the mental health condition. Oh and in this medications this is the glb one we did a pretty extensive presentation on this as well as patrick and matt presented that white paper for you guys about projecting the cost of geography once so I only have two slides on that. But the important point here is the divides medication spend on a poor member per month basis has increased dramatically at the annual rate of twenty one point five percent twenty. At the rate of twenty one point five percent for in just two years that's that's beating any inflation or any other number that ever seem. In the right hand side look for that. The the the met form in which is the standard rate when for day which is your basic generic drug that's available at for four dollars will be at most of the actual even to you as a health plan sponsored it off like. Like close to ten I would say. That. Is. Traditionally considered the first line that it be has increased only at the rate of three point four percent over the four year period why the others have in feast which are the two most expensive that is yelled into nglp ones they have increased at an annual read of seventy three percent and twenty eight percent respectively. So what that tells me is your future costs of managing diabetes for anybody in your population are not going to remain at that met form eleven. Because most more and more doctors are prescribing these expensive drugs they are effective they are more effective than the traditional treatment but not everybody needs it because other drugs work also but you can see the cost increases is very I opening and that's if not any other reason this is one reason why we need to address this head on in terms of day ready to be city management. And then similar slide here we talked about this kind of a lot last time was them big tolicity victors that I believe these are all the drug classes expense within the GL b one class and you can see there in three year old year and next terrified rather sort of be extrapolated and as well fair tricks people tried to do last time we kind of tried to extrapolate the cost of those drugs and is just a straight line up almost we are hoping that at some point these drugs will establish in in price they would be more competition and hopefully that will help us panel pick the best in class among all of them and the one that gives us the most rebates. So they state of your current windows your two vendors we blue cross has some programs and navigates has some programs but these are like the basic programs in terms of identifying people and reaching out to them and the. By dissipation in those is minimal if any because we did look at some of your previous data and we saw that not many people who are taking advantage of those but they do have the basic programs that's nearer in terms of beijing education and setting goals and addressing the gaps and care and they do have partnership with some of the point solutions that i'll be talking shortly. Seem with navities because that's your pbm that's your pharmacy benefit manager and their programs are very much geared toward. A addressing their dispense seeing of you'll be ones based on the utilization of you. Concurrent or red respective meaning after it is dispensed they go back and review and then kind of making sure that those who are described are compliant with the medication or at the end of it and they have partnership the word I heard which is one such a rendered as well. So this is the most important beast that i'm coming at now recommendations and next steps and then we can have a discussion so we talked quite a bit about the obviously causes and risk and there is psychologically complete then there is social emotional component that is met of all it which is. That insulin resistance that are body develops and learns to live with and then obviously janet extractors kind of the blame at all area and then it does put you out higher is for all of the things that are on the right hybrid infordability joint pains sleep administer these are all obviously related obviously up the government did for me the sun bosses are trying to and all of the above. So the options to address those are many. And I have a a slight on that but there are late many many of these point solution renders and it's out of job to wet them and figure out who actually it has the best in glass programs because when we like to look at. These programs. They need to be doing all of these things they need to be helping people with the well less programs with the well less component. Which involves a lot of diet nutrition held the eating advice which does address the exercise in physical activity things which does address the behaviour change that somebody needs to undertake when it comes to weight loss and managing david is in their lifestyle changes and then the some alternative medicine more more than that I as I actually expect them to be are more coming and mental health type of interventions like that it may even include like a you'll go class or something. And then you have the disease management programs that just address managing the disease modelity using some kind of world gadget. You could have a step there somebody who could. We talked about step through in one of my sessions last time where you kind of reserve the drugs for as a loss resort but everything else you do before and then there are some electorate accession that's usually reserved at the last one and there are some things that we don't like to talk about them so i'm not going to read those out. But basically the this is from a very scientific journal this is a divert is clinical medicine journal and this is a slight from that but it's really the goals of care they go i'm not going to read all of those points you can read and I mean i'm here to have available for answering questions but it's really working with the patient meeting them where they are and then understanding their other conditions call more about it is and then addressing the program based on what you see in that individual journey and there is a shared decision making about what I can't really cut this from my diet okay then don't get that but eat that within limitations or add a more exercise when you do that there is something that that helped go ching that works with the beach to help them understand the goals of their care to prevent a complications. So the top point solutions in these and these are why they were one of many that at eight thousand vendors today in the point solution space I would say twenty five percent of them are just in the day we decide will be citizens virtually impossible to list them all here so we have. Veteran out many of them and the ones that you see. Are kind of on this chart window very much everything about so there are vendors out there who can help you prevent the diabetes so in the bidders. A predatory space then you have the diabetes. Management wenders they overlap a lot with the week lost windows as well mainly because the interventions you undertake for diabetes and weird loss are pretty much very similar to each other so these vendors play a good role in there so we know everything about most of them. And we cannot know how they stack up in themselves. Umm addressing the population. So because these point solutions are not that all in terms of their existence redon't have the data that I can see or signal to this analysis last year after five years of somebody having this window and this is the results because they are simply too new but what i'm i've listed here is what they tell us is there findings and we have kind of see in anecdotal evidence that they are pretty much so they are actively engaged in managing the g plus of drugs they include health coaching some of them do have the physician letter management physicians on the telemedicine teller helped platform that will manage the betin they do charge the best thing is that they charge the fee as a ppm which is a poor participant per month so you're not paying a pm pm you're not paying for all of your population you're only paying for those who are engaged in the program. And. They do offer performance get into and we can hold them accountable for that and what instead are all I have somehow somewhere between one point five to three I would like to always believe the lowest are that the render tells you even if it is one point five one one to one it's still worth doing it because. The future cost savings is something that the plan will realize. So some of the reporting that outcomes and these are simple outcome these are not even taking into account how much it's saving but they're telling us that they were able to drop their each be even see which is the sugar metric blood figure when it comes to. Three month average that's what he's been see catches a drop from eight point eight percent seven point two it's pretty done good. They need to drop it to even six now but let's see if the patient journey continues the blood pressure drop they were able to reduce split pressure of seventy five percent of their at response disciplines college roll rob was average seventy eight percent address reduced the college role tobacco secession and then the weight loss too people with bmi better than thirty lost on an average of thirteen point four with every pound of weight loss in there will be there is direct impact on getting the person better and hence their by saving you money in the future. So and this is my very last slate which is the next steps about what we think the plan should do here. With recommended you need a day reading program that also addresses the everything else there be a listed here which is mental health and other commodity that controls the jail p one drugs and that also offers performance guarantees and all of doing all of the about the diabetes program will address they will be the issue as well. You need to do a competitive bid for that because these vendors they offer sometimes it's not easy to procure just by looking at their presentation we do need to kind of hold them accountable for apples to apple's comparison. When it took from a compared to vendor fees get some allowances for credits and negotiated the best offer that there is there are some legal considerations that when it comes to wellness type of programs or any kind of far diabetes or busiest management program that we have to apply by. And then obviously communicate and then measure the roy on ongoing basis this will address one aspect of the wildless program as well because if they are addressing somebody from preventing them from. You know either putting on weight or helping them with a weight loss that's a one huge component of a willingness program we will address by doing that and then we'll we'll see how it takes us from there but I think that's a good start so I don't almost twenty five minutes to cover this but I think we can take some qne's now because that's where we want to spend most of the. Most of the rest of the time. In the last light is just talking about it's just a twenty big so some drugs that realistic earlier. The. The. Alright consider higgie of click just just wine I know you said a lot but manages to want to focus on what you said about the oral return on return on that how how how do we and I heard you say ongoing which happened I believe in that but can the world do you do you measure that how are we going to do that across this entire problem to know that that though that specific thing is creating that return that we're looking for. Great questions so we have done many many are always studies that we have a pretty good solid foundation as to how we can fill it away so some of the things that I listed right on this slide here which is. Once you drop off one point a blood pressure drop off experts in a college will drop off expression we apply that to there is research out there that for every person that drops go to strong by experts and you are avoiding future reverse events by y percent so there is a way to actually really project that because you now control your diabetes and college on your not going to have a future advertised event that otherwise you would have had so that's one future avoidance two is we have a way of also calculating auto I wear people in the program and comparing them with people who should be in the program but they're not in the program and then be kind of just compared their healthcare costs with each other and there has gonna be here in dumbs of emergency room utilization hospitalization and their drop course and stuff like that and. If the program is working well those in the program will tell you get that there will much cheaper to the plan so that's actually tad back into the specific to the specific yapoko so that's right and you said have you all you have done that in the past not with this particular program but with other programs we have done it yes thank you something battery sir boy you're recognized. Thank mr chair i've got three questions but the first one is just the hand out can we make sure we get those online so other people have access to them as well sure then just in slide twenty or page twenty two in our slide pack it you have a list of four year trend of utilizers by diabetes class and your home that increases I just was curious of those increases were before or after rebates or those you know the part that the pharmacy would pay where the part that ultimately the planner somebody would see with those up increases. The. Drop out of yours off. The. Yes so. That grocery bad so the the rebates would help offset some of that trend yes okay so we don't really know how much the increases cause we don't really publicly know how big the rebates are. And where all the rebates are going thank you just want to clarify that and the next point is is one of the things in your solution was what can we do to manage the g o p one cost so I see a lot of compounding pharmacists that offer this stuff a white less why are we not going there why are we not looking at glp ones from compounders and just cutting a deal and bring in those into this state thank you. So. There is no regulation on the combounding part of the pharmacies. If that section was regulated then made sure that the drug that's coming into the compounding is the real drug and it's dispensed in the right way then we can be assured that those are something that we can confidently say will help your people what's happening with this compounding pharmacies and then our pharmacies lot of times is compounding solutions are dispensed from medicines they call them since medical sparse and they are all over the place and all over the country and there is no regulation. From where the obtain these drugs there was a documentary on this topic that I saw I just a couple of weeks ago where they actually interview some of the manufacturer and asked them to verify it is this your drug and none of them could verify so when there is this section is not regulated we cannot say okay go and get it from them that's the problem if if everyday I ever decide to regulated we can revisit it. He understand add to that so I mean members they have they can go to a mats buy and they could get the compare cash price and they could get but pbms aren't gonna offer compound medication through. Through like the health player let's it just doesn't happen right now. Senator clark you recognize for a question thank you mister chair. I was listening with great interest. Are. Heard a lot of things that are hurt all my laugh the. Do these thing these top of willness programs dealing with obviously which is really what you're dealing with to try to deal with that do they always work. Do they work for everyone. It's a very important question. If somebody is more developed enough. To lose their weight they definitely work but the person's motivation needs to come from within because that intrinsic would have and that's something that we just need to message hammer the message home with communication about how this is going to impact your life in the future and get that person motivated and in that case when they are motivated enough. It does work with all these interventions and sometimes these drugs are good in terms of putting them on the right track so you get that initial boost and you just have to maintain that lifestyle. But not doing anything is not an option either so we have to help the members achieve their goals if they need it I didn't suggest not do anything my question was that is doesn't always work there's a. A part of medical science that says it does it I know this is mainstream the animal center doesn't work for lot of people not saying it doesn't work for most people. But as someone who heard this solve his life. From a family that has. What appears to be a genetic wait problem playing sports almost overnight until my. Early fifties walking twenty miles a week. Doing everything you know I can tell you that some of us can go down to a twelve hundred calories a thousand calories and still gain wait and you're not in this part answer for people who don't experience that. Is actually offensive used to assist the way we talk but it's just not true and is a guy who is now sixty pounds water. Oh after try and was in was actually six weeks from buriatric surgery when the doctor said let's try one more thing of so no it doesn't a question your expertise when you say that it does. I'm i'm sure that exceptions do every research thing to. The. Senator chesterfield you have a question. Thank you one of the things that I see ultimately happening if we are able to. To control. The weight game. And the diabetes and the other co morbidities is a reduction in the cost of health care. Am I correct and assuming that will happen. The. That's the whole bs that is the hope. But unless we insist. On our healthcare providers looking at a reduction in hypertension a reduction in obesity unless they are committed to saying if this happens we are going to reduce cost. It's not gonna happen is it. Possibly yes haha i'm i'm worried because. Everybody in this health business especially those of us who are dealing with these issues have got to think that at some point in time if we are able. To horness better health then we should look forward to lower costs and i'm not sure it's going to happen unless this committee or some other legislative committee is working to make sure that that happens I thank you for your work because I think this is one or more important conversations as one who has been wrestling with this one of the more important conversations that were happing in the legislature in one of the more positive lines so I thank you so very much and I thank you mister chair for allowing me to to speak as i'm not a member of the committee. Any time sandwiches bill center stuff will you have a question. Yes I was chairman do we wish to use their address to the linked time and individuals remains on these drugs. That was part of our last paper now I don't remember off the top of my head. Yeah could you repeat the question so you're you're looking for on average how long people take a narrow pc many of the targeting drug driver. I mean how many different brands are this is my last light here but yeah these are all the divides classes how many. How many of the electrols are looking at classes yet if you add in the number of drugs within each class I mean. And how many of those were manufactured and in the US. The. No idea. I can see that no idea where their fact I mean I am and I have to look up I don't have the number of the top of my head. Well you know her what's sent for clark said. And. If you if you skip these drugs. And you have the whirlpower enough to exercise in eat healthy. You could you could buy past correct. Correct. So there's another avenue that we could take to get around having to take because do we make long term studies only. Some of them there have been around for a long time the microphone but but they were not formulated for this particular thing. As forced white loss correct. They were formulated for a big okay. That's all I have run out of the insurer thank you soon so filled a center urban do you have a question thank you right here i'm thank you so much for your presentation on page eight. Just wanted to ask you really quickly about that page and then the map of course is on page seven but one of the data analysis of your edi amount that you put together showed that preventive visits were also the lowest for the most disadvantaged group is that directly related to the type of payer that is predominant in those areas. It's more to do with the industries my hypothesis because we have repeatedly seen that in other forevolutions too. It's more to do with lack of education on what is prevention and the preventative visit and two is provided availability. Are. Telehealth is a very good option that your plan makes it available but people are simply not aware of it that I can actually get myself. Checked by having a what you provided so is this data just from the members of our plan or is it state is that everybody in the states it's our plan yes the paired is the health plan so so that doesn't have a difference between i'm in the raise my asking as because if you lay like the medicaid map yeah but the matter came out could be part of the lack of preventive visits but that this is separate from that and then then finally is it just are you getting more are they getting more information and there's different areas and education because of maybe the presence of more. Health care organizations or me what do you think it is other than just. What other like what other societal factors are playing into you the idea that the actually getting more messaging more education more information. In certain areas of the states. What what are your thoughts about that you hope there is a whole arm area of social determinance of health that we study so i'm just going to give you some observations from other studies that what doesn't happen in these deprived areas is one is that in a lack of education maybe it starts at the school level or or if you are simply even if it's in the school level. There is lack of schooling too so that's also possibility that you know that availability is there for they didn't take advantage of that all districts having free parks open for people less another one that we have seen it's more obvious in the urban setting then in the rules setting where there's free access to a lot of these community activities transportation is a big one to where if it justice too long to get anywhere so or sometimes people simply don't have transportation more available that is one card for family with somebody who goes to work and then the rest of them cannot go anywhere so it's a it's a plethora of things that's a separate presentation on its own which is we have studied that extensively social determined would it would it be your opinion that a more robust physical education curriculum requirements in our public school system would actually benefit our society and health care. You know that's not my area of expertise but i'm sure there is research on that as well that that we can look up but II would I would see logically makes sense right well I mean I think if we were going to look at this whole listing that we need a consider of that first it's just to be nurtured from the childhood right be nurses for a childhood but we're missing such a great opportunity in school because now pe has gone from. Just actually doing fiscal activity education to just sitting in the bleachers and texting on your phone for thirty minutes or an hour so. Um I think. Appreciate your comments thank you. The. Thank you center representative richmond you have a question. Thank you miss chair center urban hit on a lot of what what my concerns are in the fact that. In our public education most of the education that we have right now concerning diabetes is kind of a reactive type thing i'm sick what do I do to get better. And you get down in the public schools and even college and stuff like that it's in effect I used to teach health and physical education. And too much of the physical education was practicing the three hours of physical education which is roll out the ball is relaxing read newspaper. Instead of having kids actually engaged. And I think this is just the bigger christmas. This. That we have as teaching math and signs. Because the health of her kids are deteriorating and has deterred to the point where this is a crisis when they get older and are getting younger when they have diabetes and other diseases affecting them. And have you seen any other I know it may be outside but have you ever have you seen any other in your states that have a better or have addressed this situation properly or any other country that has possibly addressed this situation better than what we are here in arkansas. I mean we we can look at the diabetes gravelands across other states and we know that arkansas on the higher end as far as. What they're doing in terms of statewide policy and schools I don't have a ton of information on that but to your point I mean II think you are sing a lot of that and it's a major issue and not only in the scores it's when they get home from schools and kids used to play outside with their friends and now it's you're just on your phone your ipad so. Yeah you can see how that that's gonna impact their health down down the line so we're probably gonna have a bigger issue than we do now as they transfer into a dotton. Thank you representative richmond I i've got a few questions real quick and then the queues empty so we can wrap it up after that but one of the issues is on the compliance the medical nutrition program when members typically take that up I mean how how many of them stick with that program I didn't see a number in the slides we we don't have the mnd very few people were even taking advantage of this and that's II actually blame the provider community for that to providers are not addressing the medical nutrition therapy the way it should be addressed for somebody who walks into their clinic for something if even if the person is walking in for like a small curtain bruise that injury if you if that person happens to be obvious they should start that conversation and that's simply not happening in the provider community so II don't blame the patience for not taking advantage where the providers are not even talking about it that's kind of the yes to go back to the I think what I saw that there is like a seventeen dollar part on the state of each visit I mean I do imagine if you're you know. It'll be or cans and low income. You know thinking every month you've got to pay seventy dollars to go into doctor's office and be told to eat better and you know I mean. Which great is an issue in itself but I just I sometimes wonder if that copay they were putting on the patience for this is one of the reasons why we're not seeing a compliance that we want to see with the point solution they would as I imagine we could do something as with our health but if i'm logging in on a television that I got seventeen dollars if we do the program the previous program said I mentioned the for the day central beside that we be on a part of the program I mean that is the beach and will not have to pay anything thank you for that clarification and then the other instant thing was I saw on our mental health with active members you know obviously the lowest is when they have no mental health condition but actually the next allows is users who have an alcohol disorder is that are those are alcoholics that are in current recovery programs are just current alcoholics that are on that are not currently managed in that condition this is from the data so this is something because it popped up as a coded diagnosis for alcohol use disorder so in my opinion that number is usually under represented because it's just doesn't happen it it it should be higher than that but if it's getting coded and I expect that they receive treatment for alcoholism these are the ones that are appearing because they're seeking treatment so i'm curious too because i've noticed this with some of the medical sister treatment programs is when you use certain medications even for helping treat alcoholism likes a box owned things like that you're doline receptors in the brain which also dole cravings for either their opinions or alcohol does it I mean is that also been seen to have a side effect of dollar cravings for that for food and so people are eating less because obviously. You know if you get an overeater's anonymous meeting they'll tell you that they use food just the way out the holidays alcohol and so i'm curious yeah I mean if we're not I don't feel like we're treating over eating disorders the way that we're treating alcohol is addictions but obviously if you're treating that the same way you're going to see reduction in way which sees a reduction in diabetes i'm just. No you have your on the right track here so it traditionally be considered swalking and alcoholism and up your it and any other drugs as a bigger place kind of created programs for people to quit those all the while not being attention to this other epidemic that was building in the population which is obviously so we are just now I would see in the last ten years or so just so weakening to the fact that actually the commodity issue is bigger here in the responsibilities than any of the other ones that that we have addressed effectively but I mean you your euros observation is correct that if you are on certain. No drugs are alcohol they do end up eating less so it's but it doesnt mean that you should start drinking because you want to know you're taking the medication to help you drinking it's also going to help you today some study on that about the glp ones that once you are on the drug you you don't have any attraction to any of these alcohol auto point type drugs which might be added benefit yeah in that thank you briefly that. The. Seen no other questions is there anything you would like to add from your presentation. The. No I think we covered everything we wanted to cover fantastic like I said members were because this is part of our larger wellness study we're not going to take any action today just reviewing this but please if you have any recommendation in the future please bring them to our next meeting is there any other business. Senator bye we are journal thank you thank you thank you.