ALC-Hospital and Medicaid Study Subcommittee

We'll go ahead and try to get started here but I can find a seat sorry where a little late think staff has passing out some hand outs right now. My coach. Okay i'll go ahead and call this meeting to order. And. Members thank you I know this is our first medicaid ever site subcommittee meeting but. We we try to limit if we don't have things that need to be discussed and we're probably not going to meet but anyway we do have an issue today that we're going to discuss I want to say from the on that that we do have public comments so if you're a member of the public and you have signed up there's a sign up sheet we would need you to sign up for i'm also during the public comment if you are making if you're a member of the public and you're making comments now that members may or may not ask questions also we would ask that you would stick around and stay after you make your public comments we ask that you stay throughout the entire meeting because your questions or comments could be answered or common commented on further by the agency and ah members may have additional questions for you as well so if you're a member of the public signed up to speak for public comment we would ask for you to stay through the entirety of the meeting. Okay. All right with that we will go ahead and get started so if we can have ADH s come to the table members i'll direct you to exotic has are coming to the table. Good afternoon christie pittnem. Secretary department of human services. Good afternoon jean it may and deputy secretary of programs and medicat. Thank you for being here go ahead and proceed thank you I will just open us up we want to say thank you to alc and two members of this committee for allowing us the opportunity to be here during the january twenty sixth alc meeting we had the opportunity to present the cost report the cost study that was done uhm for assisted living facility rates and this is the cost report study that is governed by. At section fifteen of act two thirteen of twenty twenty two that also requires the secretary to report in and during the course of that alc meeting the request was made for DHS two present to this committee go over some details of the cost report process in provide additional details from response to questions I do want to make sure that everyone is aware as the chair noted that we are still in the public comment period during which time providers have had the ability to comment on the cost study that was posted publicly and shared publicly on january sixteenth so we will go ahead and we have our contractors available who conducted the cost study report and deputy secretary janet man will continue with the additional details. Good afternoon and mars and staffer is online day and dave hoverty and they will be able to talk about their report in it and give some comment after I get over just the top part of the right calculation and then I will let them go into some of the details so mars and stuff are west chosen to do this through a competitive bid of our current contractors. On staff bring your mind closer sorry that's okay thank you better. Yep so marines offer a worse chosen they do some current work for us we did do a competitive bid process with our current contractors they were chasing they had done the previous cost report study in prior to that another company had had that done in in our history so we used the same template we made very few changes that would have that were governed by the state statute that was changed or it passed this past session and so we looked at direct care staffing indirect career admin in general rent and utilities to come up with a total rate we asked them or charge the team with doing um everything that had been done in the previous year and then to come up with a draft number the discussion with the contractors were over the inflation factor in what inflation factor would be chosen and then an access fee that had been used in the previous cost report those were the only two point that I weighed in on did to know what was being used and calculated for the inflation factor we used a nursing home market back basket index which had been used previously and it came in and think of it a six point six three percent which I will defer to the contractors to tell you where they got that number because it's an it's an independent number the second inflation factor was consumer price index which was a little bit lower at five point six seven. And then i. Looking at some of the cost reports and occupancy and things around the state we chose not to promote an access for your five percent in this rate study in so given those factors we have a range of from eighty six seventy three to eighty four seventeen that is presented in the cost report today. That has been out for public comment and at this point I would deferred to the contractors to talk about their process. Dave aiming in your heart. Okay process and then anyone want this. And you want to add again. Was shared we. Costated it was captured through this survey it was distributed to the assistant facility. And they were fifty records that were received. That was the increase over what we used in the previous study the previous study was voluntary. And that received twenty four records. So it was required for dissertation so a little bit bigger data. That. Yeah. When we got the cost of the first thing that we did was broken out that car into car centers and per dm costs or costs for red day so how much it was costing to care for the resident of different areas that were mentioned earlier direct care. Interact here admit in general and then read utilities at food there's also part of that thing and. I immediately believe it's identify a few facilities that. Probably at me errors and their populations in other words like we have what. Yeah thousand dollars we use that with your followed up with those providers we were able to correct. The facilities that we identified do that process over four total. One we were not able to get a response from so we did not include that facility in the calculation. We also did further analysis to compare. Those previous calculations we got for each facility to each other and use just a standard deviation calculation to determine what might be considered an outliner so if they were more than. One standard deviation above or below the mean. Or that particular class center then they were deemed an outlier and we followed up with them as well. The determine if there is. The poorly documentation they could provide to ensure that what we add was was accurate. And then after doing that again we did not eliminate any other facility but it does forty nine of the fifty five reports in our stand so. That's what we moved to next. One thing that we did you to try to. Eleven eighty four. Outline or or just facilities different rates than others will use the medium so we wanted to use a major central capture what is the. The general cost for easily centers that were we're looking at in the direct year we actually look at wages and hours were provided. The remove that includes those extremes we just focused on the media because with the media and you're just fine what is that middle number as opposed to using average then anybody to have an extreme value is going to be stored that or bring that average after down. Accordingly so that was one thing that we did with what we did in the previous record as well. Yes we did with the data is we applied inflation to it because we knew that we were looking at historical. From a period for most providers june thirtieth twenty twenty three. And we wanted to better rate for. Period for fifty year twenty five is what we made our calculations for so looking at the mispoint of our cost period and the mid point of that project is rate period we applied. Eight quarters of inflation. And we did that yet as was noticed the nursing facility market back in index and also with the price. The nursing facility market. Is that. Is that the compiled for master the standards for medicare medicate services. And it is specific to long term care more specific to nursing facility care but but it is an interesting more too long term care than because again cancellation with both. So that way we had everything moved to that that rate stating period we were looking at. Yeah. And then beyond that or. Private calculations for direct care. What we looked at is. A number of hours. Of care. Provide in. In four different positions. Yeah. Personal career. And universal workers. And then also. What hourly rate would be for those. Position again we use millions for both of those. So for example for the LPN. We found that the difficult facility. With provide point three oh hours of LPN care per resident per day. And the average of the way the difficult way for that person would be twenty six dollars and twenty seven per hour. And then by most playing the total. Per day costs for LPN seven dollars and seventy eight ten. And then we did calculation then. The positions for the ended up with roughly one hour per day fourteen dollars is fifty one percent per hour. So again almost fourteen dollars forty nine. By the hour. Eta was the point seven hours at thirteen thirty six email dollars and thirty eight in a new year reversal worker was quite eight hours of came out to a dollar sixteen. We also clearly contracted each of those positions and so we had some days it was collected in that recording it was small amount. Or each of those positions and we didn't include allowed three to those. And then the total that we came up with with this is that was two point three four hours per day then. And I read a blanket rate of seventeen dollars and forty nine. For a total of forty dollars and. We also added a fifth past two thousand the non contracted position. Another five thousand ninety three. Which could up to forty six dollars and seventy seven cent pool. And any question was applied to that which. With the net market facility market that is eight point eight three percent earlier. Which came out. Yeah. And could our total direct your staff in forty nine dollars in eighty eight so. We used that was the core component of. The services that are being provided is that direct care stopping and so that. Was why that paculation was much more eat here yeah we focused on the media because we thought like that was a better major of the standard the typical. Service provided also meeting for the area that way we can remove the bills extremely values that you saw some of the data. By an allowance for business and fighting allowed for. Station and yeah that total with the facility market massive connection question with. Which is episode that reduced that a little bit down to forty nine dollars and forty three so maybe some different tremendous amount. We also knew that there are other costs that are that the story incur cost in the. Our certain money related to the services they provided his interact here. The admin in general services that are required to get you some way you could argue that in utility the cost of having the facility to be able to provide. Activity for the resident that also be able to provide or do you condemn conduct the administrative options that they have to do that they were allowed to calculate those things as well. Calculations we look at the total cost. Or the allowable. What was being allowable. And. Again focused on the median so that we wouldn't be. Student. Result wouldn't be by outliners. Where is wreck here we came up with a media fifteen dollars and thirty five dollars and thirty seven percent when the year that's using that nursing facility market basic inflation factor. For administrative in general costs became up with the median seventeen fifty three. And with inflation applied that the eighteen sixty nine. And there's program. And utilities we did allow a small portion again for admin general activities and then also. President activities. And the media there came out through sixty eight though we eliminate. Allowable. And this morning. With inflation seventy nine and then when you quit those score components together the direct care the interact here admin general utilities. A highest calculation came out of the six seventy three. The nursing facility market basis inflation equipment three percent to the median that we use. And including that allowance for rent and utilities. If you remove that allowance for red in you. Utilities that rough that recalculating the east court understand that he could. If you use. The consumer price index inflation at five point six percent. Including utility rate comes out the eight dollars and ninety four cents. And without that. Allow it for return utilities came out the eighty four seventeen. So there's with noted earlier our range was eighty four seventeen up to eighty six seventy three that was defended again but inflation factor was used and also whether there was an allowance included. So that's kind of a high level general explanation The. Yeah. Yes I believe you've covered everything and all the process that we went through and that's documented and they report. The. With that alright thank you thank you so much for your comments and your work and i'll pit it back to our dhs secretary and deputy secretary if you want any follow up based on what they stated or if there's any sections of the report specifically you want to highlight. Thank you so I would like to just say we did a range of rates to show um slight variation I think with having a complete. Um. This. Cost reports from all of the providers allowed us to have more cost analysis than we've then we've ever had before we were below fifty percent in previous years and even somewhere around fifteen to twenty another year so having the all of those cost reports I think gave us a clear vision of the cost for the for the alpha facilities so I think that it was helpful I do think um. One of the areas that we. Have looked at in you know working to make sure you know obviously that we looked at everything in that everything was um accounted for by using the median think. Um hourly wages are always sensitive to change and I think with some facilities that using more and more contract and then some of their own employees with an hourly wage depending on how they staffed and what level they staffed in those positions you could see higher cost and some facilities versus others and I think by taking the median versus the average we chase the middle up those in the end. And I was glad that the contractor spent the extra time to identify the outliers and work with the individual providers earn to address those outliers and and I think that there should be just some of my summary point. So just a recap for a members this was legislation that was passed in this previous session that made it mandatory for these costs reports to be submitted by the facilities that's why we now have previously there was twenty four from the report there were twenty four facilities that provided those cost reports due to the legislation making it that was under voluntary but due to the legislation that made it mandatory it was fifty reports that were submitted so just a lay that groundwork okay we will open it up for questions senator hickey. Just just one if you don't mind I want to make sure I fully understand this inflation factor in our and heard what you say about the six point six three. What what would have we been in the past because you said do you do you know about what that number's been five years ago ten years ago what factor we were using no so I don't know for five or ten years ago last year there was a lot of questions around the inflation factor that was I think approximately twelve point nine four percent so it was much higher last year then it is this year I think there is one or two factors that went into. That being is they were doing and I believe a longer term inflation factor of multiple years this is eight quarters which is two years I think previous report was three years I would have to verify that dave or may be maybe able to crack i'm wrong prior to that I don't know what inflation factor was used I would have to go back and look at who gets in this fair that in you can believe it to my neck my next question right there with eight corners so whenever we say six point six three like at work we're using that for two years so in other words we have a we have this calls and then we're just adding that one o six six three two that particular one for the for the two years itself. And then at that point we would look at redoing that again and add in another. Well the and I understand this is just a study but well yes or the statute is the statute calls for cost reporting annually now so we will be doing some form of this exercise every year to review their costs so that was also part of the reason that we didn't want to go past two year eight quarters or two years because they will be submitting updated cost to us every year. Okay then we were just assumed that those would go up and then have an additional. Inflation factor added under those I guess it's all but it's up for discussion I mean I think. I can't speak to what was done in the previous cost study about how they they chose some of those factors I wasn't I wasn't working at the time this year when we were doing this we chose that's why I chose two different inflation factors to see the difference between the consumer price index I guess as an annual as an analyzed thing with that particular one though I would assume right at a leave so but I will defer to the contractors thank you if you're on the line a dave can you answer senator hickey's question about that. It is could you receive a question about right understand II think. Yes sir if you can hear me and I guess it's just more clarification as a question not i'm here in the six point six three and issues on eight quarters. And then of course i've heard about the consumer price index which is as your state of that point six seven which I assume that's analyzed so. I guess the thing II guess i'm asking right there are we being fair with that particular thing if i'm correct on the analyzation of the consumer price because if we do a quarters were actually just say in whatever that comes to three point three one and a half a year I guess. Uh. With a quarters. Is there a is there a way to enter calculated inflation for eight quarters in both inflation before we were looking at you know the ideas where you your consumer price index do that what you buy for a two dollars today. A quarter from now will cost you two dollars and. So that's why you add the for two hours and twelve roughly. Hey quarters or four quarters. If you if you just use it we use the quarters of these places that we we went from the next. This point of our data period which was twelve thirty one forty two because most provided. Reported for one year and then do thirtieth of twenty three. The big point of that period is twelve thirty one twenty two. And then we played to the mid point of the proposed rate period with sweet treated as difficult you're twenty five. Yeah at the mid point of that was twelve thirty one twenty four so that's why we applied. Eight quarters for forty four months of inflation. Okay that's fair thank you sir thank you rabo we have. Representative miller. You recognized. Thank you madame chair and this may be a little bit alarm with with the topic of today and if it is just tell me shut up. But I just want yellow here I had this one question I know it's been being worked on in the past I know with. Whether sisters living facilities. There's been a whole issue of tex or c n as. Not being able to despend medication. Which is is part of a more kind of those into what's being discussed today is part of their bear their cost increase because of. I haven't have a nurse on staff just so they have a nurse present. When medications are desperate when otherwise they may not need one has that been resolved at all or can you all address that please. I'm i'll start in the secretary and it was wrotch our attention that that was as as programmatic change that needed to be reviewed so it was not part of this but it's in the program that we are reviewing to address we're also trying to look at other states on what they do several other states have different tears a facilities in they pay differently depending on the type of clinician required to be present in the hour's present so I haven't found an apple to apple comparison yet but we we are looking at it I just I don't have an answer today madam chair if if it would be okay. If you could just let us know maybe next month we are with that i'm. I've had several of these facilities both are out of my district of. Contacting me making me aware of this and it's kind of a. May I see where. Obviously this is a cost impact to the facility if if you're just having. A nurse there so where by also no give medicine. Yeah. I mean next month that would be great yes sir thank you thank you mapper absolutely yep will work to to get that update thank you senator galmore you recognize for question. Thank you ma'am chair thank you both for being here so much my questions are on the study it's page six toward the bottom of the executive summary. Where it talks about costs that are figured in and those that aren't and uses the word debatable I was i'm curious is to you to and I know we heard that a little bit a second ago in the presentation i'm curious as to what those are and how. You know how how it's apparently basically staying it's not apples to apples there's there's some discrepancy is on how things line up match up depending across facilities does that make sense and could you talk a little bit about that. Certainly that i'm going to ask dave and fair enough it so my understanding from the history last year there were a pretty healthy and a and debate on some expenses that should be included and I think there were actually questions posed to cms to see if they would answer yesterday now i'm gonna get dave and to confirm that. I'm not aware that cms answered so when I asked them to do this study again at a said what you'll decided on last year and i'm not looking to change we're we're looking to do the study so they put that in there in that my understanding is it comes in the rant it comes in the utilities. Um and food space special which I saw on the recommendations that seem to be basically the only differences in in those line items and that is my understanding is that that is where the category were all the questions came from last year and so was trying to be consistent from one year to the next left it in wanted to have the the range of. Rates for discussion and then gets the public comment from anyone anyone that's interested in commenting. And then at a dave or which I like to come out on any of that that did I say anything wrong. Eight eight eight I understood the conference over rent utilities and food and and what might be included in the right calculation for that area. That's correct again there was if there were considerable debate about what should be allowed and through their discussion. We landed on the idea there. Because the facilities are required to provide. Activity for the residential lady eight to do that and they are required to certain administration functions and they need to do that that is reasonable to include some allowance for that. However it's not reasonable to include anything that would be related to room and board because that's nice of course the america would allow to be included in the rate so that's why small portion. Of those costs were included and. I. Thank you do you prospect the. He told all. Right utility and food experience with actually ebid that the facilities incur. So I don't know even when we get included a portion for that. It was a very small amount of dollar seventy nine. One calculation of seventy seven with the other so we we allowed a small amount in that much and we did their calculation because where footie looked at the add the facility report to us with the future the entire facility was and then identified what where pretty used for. Added activity and what square for this use for. So that's how we determine what that percentage could be never certain expenses that that was even for the allowable certain expenses that reported in that cost and it's food that we didn't allow any of that so so that was. The discussion and how we arrived at what we ended up with. Thank you do you have any full amount of yes thank you so that's helpful at based on square footage I was sort of trying to figure out where that number came from and it's based on square footage so that I guess the final question I have is. Clearly I guess the way this this works as I understand it so I may not have a clear understand so please correct me if I get this role. But based on their they're paid for the number of days that residents are in the facility correct and so they're not paid when the residents aren't in the facility correct that is my understanding that's also another programmatic request that came with the med management when we did have a public meeting earlier this year okay so it was there any consideration as to if there I don't know if they're holding bed space available for so if someone has to go into the hospital but yet they're coming back to that bed was there any consideration in that the not currently the it's a waiver program and it's not considered in institutional service which a bed hold or holding in bed for next number of days is usually used in a long term nursing home calculation so we we took that back as another programmatic request to to consider and look at are just I don't have an answer for it yet fair enough thank you. Thank you mapchier. There's attention right on page twelve about it appears at one provider data that it could be resolved so it was an outlier was that one facility or is that one provider with multiple facilities. I'm going to have to defer to to the contractor I did not look at the detail of the facilities. In that settings of day can you address if it was a facility or if it was a. Group that separate. It was a facility suggest one one of the fifty reports were the exclusive because of the. Okay and then when the underwrite comparison there are allowances. That are made for inflation. Was there any consideration for allowances of how our state laws impact a rate compared to maybe a neighboring state that may not have identical laws and therefore comparison right to other states to ours may be a little bit skewed because maybe we're a little bit more stringent and other states little bit more lenient or was during consideration for that. No sir and programmatic. Uhm definition was not considered for allowances this was a pure cost rate analysis of asking the facilities to provide their costs and their occupancy and square footage as we discuss so a programmatic change as to compare to another state was not part of this rate study. Strictly cost of doing business at you know again when you start looking at other states and comparing other states there are so many differences in what medicaid covers there even some states who do not cover us as a living facilities period so compare and and what is included is very different from state to state it's very challenging to try to do a state by state comparison. This. I understand I guess when i'm trying to get my mind around is if another and this has been age old argument this industrials and other state might have more leniency as far as the expectation of the regular you know that is directly going to be attached to the cost because of was expected and maybe that's things that need to come through legislative change but that's greater effect. That would intern effect the price so it might raise it or it might lower it or would it create. An additional for like a bear term profit line to make it sustainable if we were to look at those areas yes sir it could do all of those what we've seen. From looking at some other states is they have several states have tears you can have a base tier and then different levels of intensity or acuity depending on the service is being offered or the clinician covering those services I know there's been a lot of conversation about border states or neighboring states that do have tears but their programmatic base we just we have not a studied to be able to answer exactly is it apple to apple ma'am chair can I get one more i'll be done. Thank you yes please one more I have one more person in sure page nine it says the rate of eighty one fifty nine which calculated based on wage rates paid to direct here staff by their so health center. So. The the benchmark for that eighty one fifty nine part of it was taking consideration the cost of operation if they are are so health centers that that true statement i'm trying to find page none where you're we're it's the middle it's the middle lane of the paragraph that says current rates appendix k amendment. On page nine of what we've been. I do believe during the pandemic and I may have to ask director hill to confirm this but my understanding is during the pandemic the rates for the assisted living facilities were scheduled to go down again so we we that was start and then further into the pandemic a new emergency rate appendix k great as it was called was calculated in an end from reading this statement they used some of those different scenario wage rates paid to calculate that rate but I was not I did not calculate that rates I keep. But if it's that's the rate that we just put before your in the appendix k to make permanent so that it would not go back down after november eleventh again while we were doing this rate study so I would say yes okay and in the reason I bring that out is I know the difficulty they have getting staff out there and we have given pay increases and etc and if it's if it's that hard out there which I know ideas it's got to be that hard in the private sector if we're going to use that as a benchmark per month looking at it wrong not I don't think you're looking at it wrong but I would also add that is why we added contracted staff cost to the rate study because the health center will use a mixture of employees and nursing contracts or different types of clinician contract so that we can meet our staffing ratios as required by statute to maintain our accreditation and patient care in I would say that that would be the same one the same lines that they had contracted staff therefore we looked at those costs in addition to employee cost in calculating that direct care costs for in this rate study okay thank you member okay and then yet another page thirty one thirty two thirty three thirty four can it outlines there's those costs of labor costs including a contracted cost okay i'm gonna go back to I think I have senator chesterfield. And then to senator hickey senator chesterfield you recognize. Thank you madame chieron are we dealing with living choices assisted living waiver comments in questions are we dealing with that at all right now. I have repairs there well were were specifically trying to discuss the the the cost report the rate study report that we have before something's a bit basic I prefer to limit our community to that okay because i'm I was very much interested in in the methodology. That we that was changed by not including the ad on it was concerned about that but if we have passed that particular part then I will just visit later about it okay okay deal to the chair okay thank you thank you if it comes up or get back to you thank you senator hickey can you push her button. Thank you man's just another clarification no her heard some welcome go down the when we're asking about the square foot cost. Op and I understand maybe this is a small part of it but I want to make sure I fully understand it because on page fifteen it says it is allowable it's under the three the number three right there they say well we'll square footage ratio was calculated. As administrative. Space. Plus activity space. What is what is considered activities space is that the rooms and everything or is that that would be the common areas so that would be the areas that are not covered by room and board of the individual residents so it would be recreation space it would be common dining facility space and it would be admin offer space okay in the end just for my benefit the reason that we use those particular to. Two is why I mean because if somebody has a gymnasium for an office I mean in that administrative. I can understand the activities but i've just I guess I wanted are those actually being excluded then is that is that the thought process or is that used to or is that used to increase the rate because it sounds like to me it was being used to increase the rate. So it was included as one of the I think it was listed as debatable inclusions but the the thought process behind including the common spaces because those are areas that are used by all residents were also used by staff and not attributable to the individual residents under the room and board and i'll let every secretary clarify any further if that. Apologies it's it's common space used by all member all the difficulties living in that facility in it had an applicant allowable cost even though that it was small to be added to the rate and again i'd like to say I understand it was smile issues so let me ask you so well we took all these and then we just took the median whichever won the median ways as far as the office in the activity space is how we how we come to their own on that particular category also believe the median was used in all categories yes. Okay thank you. Alright thank you so much and if you all are will go to public comments so at this time we'll call a filler spell. There are you are gonna come up together or individually okay so fill spell tbarks lorry cooper skyte. Kingsborough and ed homeon. And I believe the hand outs that you received members are from them is that correct. All right if you'll just all state your names for the record when you sit down also just a note. Our microphones are a little wonky so only two can be lit up at the same time so you may have to monitor that for yourselves just so that you're able to be heard. So if you're each state your name for the records then you may proceed we'll just go down the line. Good afternoon every one my name is phillips bell i'm the executive director for arkansas residential assisted living association. Hello my name is laurie cooper I am the chief operating officer for health mark services representing todd high tower I am scatkings were on a operator of the manner assisted living in little rock arkansas. Ed home and ceo in iraq village. Terabox owner and operator of to this is to livings and in northwest arkansas. Alright thank you my proceed. Yes my am thank you madam chair. And thank you legislators for hearing us today a couple of providers couldn't be here. One was taken to the u this morning and the other one had serious life threatening medical issues and so they send our regrets there regrets that they were not able to be here on their behalf. They are under immense stress in this situation. David cook with alzheimer's association also since his regrets for not being able to attend but has provided information in your packet relevant to today's meeting. Just to get go back and a little bit of history you've heard all the data that was put into this report. Uhm we're gonna talk about the people the people that these providers serve. According to arkansas assisted living act passed in two thousand and one most of us I don't think we're here the department of human services was required to seek federal financial participation to increase access to home and community based services. Provided in assisted living communities. The law required dhs to seek permission to serve a minimum of one thousand persons at a time the purpose of inten of the law was to provide the least restrictive home like environments for elderly persons and adults with disabilities particularly those with low to moderate incomes. According to the dhs data that we've received page three of your packet the assisted living recipient account and in the state fiscal year twenty three in the facilities as nine hundred and eighteen and the number of providers has declined with their most reset data to at least fifty one there were sixty one providers in two thousand and eighteen. Some of you were around and and don't see representative demandics here but the oaks was built and astablished and meaner in poll county to provide services for low income individuals as a thirty bed facility. It has now been used. I think against college students but community. Apartments for college students because it was not sustainable with the rate because of the decreasing over the past few years of reimbursement to those providers. The. Can you pull your might close their sorry thank you you have to just really yeah get close to it so everybody can hear a go I don't have any problem talking loudly I don't know that I think. So if you look at the bed need in your in your document on page ten you'll see that polt county. Shows a need of eighty seven it's projected in that state report. We had thirty beds there they're not available now because in two thousand nineteen that facility had to close. I received a call this morning. From a provider in east arkansas that is drafting his thirty day notice to DHS. This is not sustainable for the people use serve. Since this number show arkansas are kansas age sixty five and older have increased from four hundred nineteen thousand nine hundred and eighty one to five hundred and twenty eight thousand eight hundred and sixty seven from two thousand and ten to two thousand and twenty. The number of our kansas receiving care through the living choices of assisted living waiver. Is it keeping up with the increased aging population in our state. According to the most current the h s arkansas state plan on aging. I put a couple copies in your in your packet page as five thirty seven. Just over twenty one percent of our kansas. Are aged sixty and older. There are more seniors in region five central arkansas. Closely followed by northwest arkansas of those senior seventy five thousand four hundred and twenty three are considered low income. The number of our cansons needing assistance with daily living activities continues to increase. But the number of people we are serving is following beh. The attached hs map page four of your packet. Shows all assisted living providers. It might look good but if you look at the other map with the red stars we had to create this and we have asked the agency to make it available on the website and II hope that they can do that for us but if you look at this map we created this to show you where living choices assisted living providers are look at palaski county look at northwest arkansas but more importantly look at the delta. The. Where are the services for our minority communities. And people that are in poverty. There are deserts in our state for services the arkansas health services permit commission in their state fiscal year two thousand twenty four report pages eight intent of your and these these reports are lengthy that's the reason why did not include them in your packet but i'm sure that we can get those two if you want to look at them and more detail pages eight through ten there is a significant assisted living bed need across the state plasky county as the states most populous county. And has fifteen. Facilities containing eleven hundred and thirteen beds yet only four percent are available to waiver residents the list can go on and on and i've included that in your in your packet craig head county. There's only a few beds available in the jonesborough area. In that. Population i'm not sure that that's adequate for the need. So I would like to introduce a terra box who is a provider and she'd like to give a few comments and then lorry cooper following her. New technology to me sorry I actually don't bring that mike real close to your mouth thank you you can move it you can I think i've actually been in this business since nineteen ninety eight since I graduated college it's very true to my heart and everybody in my facilities would tell you that. I'm also a nurse and I can fill mini issues enough facility which I often don't get paid for but that's okay. I'm here to discuss the waiver program i'd like I said I do own two facilities and north and northwest arkansas one of my facilities is private pay only the other facility is one of the biggest providers in arkansas providing we currently have a hundred and six beds at that facility and over half of them are a medicaid provider medicaid beds we are fall at the facility with over a year long weight list our average private payee at our facilities run ours around a hundred and fifty dollars a day. For me quality of care is my number one priority one of the biggest differences in my facilities is how they are staffed. My private pay facility currently has twenty four hour nursing staff and which mister miller over there was talking about nursing staven a facility and then in my medicate facility were not able to staff that twenty four hours a day just because a cost. The notable difference is hard ignore when providing care for your residence as you know when you're staffing is stretched thing the restaurants are the ones who suffer. In in private pay facility the staffing is about a 1-7 ratio and direct care staffing where the medicate facilities around one to ten I would not go any less than that because it's it is needed in these facilities as you know when staff staffing is stretched then the restaurants are the ones who suffer increased false medication errors skin breakdown due to residents not being changed as frequently as well as employees safety and burn out or just some of the few things that can happen when you do not have adequate staffing. The minimum staff in requirements that the state encourages are simply not sustainable and more only I do not want to operate a facility room as even consider this as an option. In two thousand and fourteen the state's medicare rate from our facility was eighty two dollars and eighty six cents this was ten years ago. The steady show that the cost of living has increased thirty percent in the last ten years although our rate is currently eighty five dollars in sixty seven cents this isn't even in a three dollar increase in ten years. Based on the increased car still living our daily rate should be more reflective of a hundred and eighty dollars per day with wage increases inflation cast three three dollars doesn't even begin to cover those increases. In arkansas twenty two percent of residents rely on medicaid services for a long term care that is almost one in four that number is concerning when trying to prepare for our future. In a february twenty twenty four publication from the summers association predicted that by twenty twenty five there will be an estimated sixty seven thousand are kensans aged sixty five and older. That will have alzheimer's disease. We do not even talk about this and our regulations we do have ask you but lots of facilities can't even operate and ask you under the medicaid rates. David err let's see sorry david cook director of the government affairs with the association stated that in his letter that as the prevalence of alzheimer's rises is crucial that the state turn best and home and community based services and enhance access to care especially a long vulnerable groups with the baby boomer surge that we already experiencing this number will increase exponentially unfortunately with these rates there's absolutely no way that medicaid waiver program will be sustainable let alone effective provide to provide effectively for those who desperately need that this type of care to live facilities will be forced to close our elderly will have no where to go and more than likely no access to care. They'll be forced to stay in their home with without help or missing or are nursing home where they might even not qualify for this services. We need a system livings we need them for our future. I would I would like to invite you all into our homes to see what their lack. We we put a lot of heart into our homes. We need to invest in our residence our caregivers and our facilities at my medicaid facility we do have a year long weight list the need is there are population keeps growing but unfortunately the number of waivers is not reflective of that is getting harder and harder to be a provider and unfortunately it will get to the point where are our facilities were have no choice but to stop being medicaid providers we must protect this program and invest in our state's future not destroy it there are many laves at stake and I hope you will take this to heart. The. Okay just need them yet there you go bring that micro close to you thank you excuse me if you're way i'm going to go ahead represent a war law you have a question you want to wait okay go ahead okay i'm back well thank you all for the opportunity to come speak with you today on behalf of the elderly arcans that we serve in our communities across the state health mark services we operate communities and waldron crosset malvern share it and van bureau and harrison and you know additionally the owner of health mark services partners with another provider that offers services in mina four days star city and benton just so you have an understanding of where we. Who we who we are representing and who would care for thirty one of the states counties have no access to assisted living and nine of these counties had poa issued that were terminated relinquished or in fact had a facility that closed. In addition there are eight homes that are the only assisted living facilities in those counties. So if these close fifty two percent of the stay or have no access within their county. Your life and my left they'll go on but what about the people we care for your constituents. Umm our facilities care for five hundred and seventy five seniors on an average day and three hundred and thirty nine of those are resident are medicaid recipients so i'm here because I care about the people we serve. Armado for help work services is live well and be well. Are care giving strap staff strives to provide the highest quality care and services we treat our residents individually to ensure that they have what they need and the things that will enable them to live well and be well and I know you know that the last few years have put a financial strain on those who care for elderly and disabled our candidates and assisted living providers were no acception inflation cost in everything. It takes to ensure the quality of life is provided to a residence has been unreal rather utilities insurance staff benefits they're all on the rise additionally we continue to face labor shortages labor costs have increased even though we have mobilised recruitment retention strategies we've have increased our starting wages we had pretention bonuses. And we were flexible schedules and we do this to offer services. To those who are no longer. Able to provide them um excuse me let's see. Um. We do this to maintain our staffing standards and if. These assistant late a living providers who offer these services. Are no longer able to provide them due to an unsustainable reimbursement rate the state will have no alternative but to put these residents in a higher level and more costly level of care. As I mentioned earlier our communities are located across the state. Where there are individuals who do not need skill nursing. Care. Currently but they have access to assistance with their activities of daily living in assisted living. Unfortunately the most recent DHS report will decrease the asset access to our state's most vulnerable citizens. And we were hopeful in twenty twenty two that state leaders recognize the health and fiscal benefit of providing assisted living services to low and moderate income are kansas when we left the table with DHS and the mayor store for group. Am we provided input in data on the arkansas. Living choices assisted living program we all came together to ensure access to necessary services is sustained especially in rural and minority communities where access is limited and even non existent the eligibility application process is another deterrent and delays access to services it can and should be addressed in another setting. Expediting services based on an individuals need can positively impact their overall well being in twenty twenty three the process was different in that twenty five or so providers who didn't participate in twenty twenty two had only an introductory meeting about the cost reporting process. The elimination of the access add on in the current draft report contribute to a decline in services available to arkansas most vulnerable elderly the combination of increased cost reimbursement rate instability and medicaid pending status will affect not only quality but the ability of existing facilities to remain open as we try to continue and continue to decrease costs to a point that the reimbursement rate and the room and board component can add a minimum cover the cost of caring for our seniors. As legislators you have an opportunity before you to make your constituents who need assistance with their daily activities daily living activities but they can remain in their community with improved access to assisted living services especially those who qualified for medicaid you also have an opportunity to help those currently residing and assisted living communities to not have to move out of their home. And move to another assisted living apartment further away from their family and friends I respectfully ask that at a minimum the access add on which was included in the twenty twenty two rate methodology be consistent and included in to help low income archanics to have access to the services they need thank you okay thank you I appreciate all the comments I think just for time and that wanna be specific about the report I know we've brought up eligibility issues that's not what we're here to discuss today and and I appreciate the kind of background but try not to repeat what others have said and then the access add on I think was one specific to the cost report so I just want to per pin there that may be something that dhats might want to come up and or the the survey wanted to uh the folks that conducted the survey might want to address. So as we get moved forward thank you thank you madame chair comparing the two reports validates the point that a state wide cookie cutter approach leads to decreased access in many areas of the state this is particularly true for black are cansons regarding access when reviewing waver service availability and counties more densely populated with black are kansas. If you look at page fourteen and then page eleven through fourteen actually in the packet that we have provided a david cook with the alzheimer's association regrets that he could not be here he was out of state and did provide comments he did say in his. In his letter to the committee as the previous of all cymers rises its crucial at the state invest home and community based services to enhance access to payer okay so he's not here point of order taken so it's in the packet yes matter but he has not here to be able to answer any questions I don't think thank you and so I would like to pass it on to mr holman and scott to mister king's borrowed to discuss maybe a little of the details from the current the twenty twenty three report thank you out of absolutely. At home and i'll say this both has a assisted living operator in the skilled nursing operator and doing both for a long time nursing homes over thirty years. Never once I had anybody say I want to move in your nursing home some day not even my parents. Sister living they all love it. It's great product great service and. That's we need it the study shows that our room and board cost is forty dollars and twenty nine cents a day that has to be paid out of the resident social security. The maximum they can pay out of that as twenty eight dollars and sixty cents state does give us a little bit of assistance there three dollars and forty four cents but we still have a huge shortfall so in an average facility with twenty one residents. The operator was visit the table have to come up with three hundred and forty one dollars a day in savings somehow we've got to pay that where does it come from comes out of the rest of our reimbursement so it's not something you make up in volume or anything else. So we bella real tough road we need help on that looking at your chart there study they show the daily hours of care twenty seventeen we are almost three hours of care per resident last year we were down to about two hours so forty percent drop like that's right. And is terror said. Bad thanks can happen if we can't have staff we've all had to make cuts we've had to cut our staff as down to the minimum to stay open and that's just just not right I would like you to look at sure the back page of your hand out their page fifteen and it shows my reimbursement for my nursing home. Since twenty eleven then it shows my reimbursement for my assisted living. Notice one goes up like a missal and one's flat. But during this time i've had to absorb four minimum wage hikes obama care cost of insurance that covered me in dates everything else and it's just not getting recognized them. We've got to do better folks we've had a number of providers go out of business. As phillips said we've got one more sim in the letter in this week. II don't know what's going to take to get the program to work we've got to do something. So i'm closing our legislators I would appeal to you to look at the reports that are referenced in the document the report that was provided by DHS in the new cost report and as legislators are leading our state and representing your communities. This. The people that need the services. Are they available for the wines based on the bed need report are your communities able to provide the services. The quality of life services for the people you represent. The proposed changes. That i'm seeing in this report make things worse not better for access to assisted living services for our most vulnerable citizens. Thank you. For hearing us. Thank you so it won't well move to questions I appreciate that I have a quick question when you say there's some security social security pays for the rim and the board but is it that is per cms is that correct I mean that's I mean if they're. The yell rumoured board can't be paid for with medicaid funds so that were maxed at twenty eight sixty a day other than the little bit that we get okay so that only we can't change that that was my weekend there there is an optional state supplement thirty seven states make those payments to assist in that shortfall and that's something the state really needs to look out and then also just quickly the the report referenced a couple of. Err what is your your address an average of your capacity. I mean it if you're not at capacity with your bads. Then I guess my question would be wine wouldn't you be at capacity if you're not at one hundred percent capacity. And and that can be for any facility are are your facilities all at a hundred percent capacity right now no they're not okay so I guess that's really more of a a business decision I guess but is there a reason why they're not at one hundred percent capacity I part of it getting qualified for the services that can take a while and eligibility frequently what happened somebody has an incident needs to get care and they can't step into an assisted living because they won't get paid right but that's that's just maticate because they're you do accept other people that other payers rather than medicaid so you're just that the eligibility process is only your medicaid reception but you could fill those bads with private pay. Self pay insurance that correct. In northwest arkansas central are console that's the case but when she get outside the the major areas the year the funding gets real difficult for people can ford for five thousand a month okay. Alright I will go to represent a boiler thank you madame chair. Miss box you. You went through some staffing requirements and you said your private pay was wonderful seven and your medicare was one to ten can you walk me through what the minimum requirements for medicaid are. The minimum daily staple requirements are one to fifteen during the day time and one to twenty five overnight. That's what the rate pays for a correct yes okay. So when I was reading through the cost reports and I think the lady from the right at missed your name i'm sorry miscooper or recover miscooper. You represent. The ford ice in store city holmes correct II do not I represent help work services we have the ones in um cross it melbourne waldron mountain home okay. If you're in and scott you said you represented the man are correct so when I looked at the cause reports there's a minimum requirement for orient. And in the cost report there is a few holmes in the state that employee no are in and when you look at the cost report the biggest cost of the call should be the cost as the highest. Degree that employed in assisted living typically. And if you reported no cost to an area you're robbing yourself for that ability to raise the rate because your rates going to be smaller your costs are going to be lower. There was five homes at reporting no orient usage the manner actually reported sixty hours for the whole year. The minimum when you divide it out comes out to about thirty hours per month. So can you explain to me how you overseen the home with sixty hours over the whole year with an orient. I guess i'm i'm not aware of a requirement for our ends we have are an oversight and we cover I have the requirement I can send it to you okay. It's not necessary in it in an assisted living to my knowledge or we aren't used or ends for overseas and we use lpn's on a daily basis so we have nursing coverage but no orient coverage correct I didn't say no orange coverage we've got apparently sixty hours in the report as what you had for the whole year was sixty hours. Okay I can add to that if I have the floor sure. I am an arian and and we do have to provide we have to do care plans on all the residents and so lots of facilities do not employ and are in they just contract with that is correct but if you didn't show that contractor your cost report your rob in yourself to your cost in that's my point is you guys are sitting at the table saying we're not covering all your cast in your very hand out you had a question number two on page two says. Many of the providers are still not currently being reimbursed for the cost it's harder reimbursed you for the cost if you're not turning that cost in on your calls reports and there was a number of homes it didn't turn out in at all and then it was a few homes that turned it in on a very minimal basis so you're coming here told us that we're cut you short and we're killing our constituents but the fact that a matter is you guys didn't do your reports correctly are you didn't report all your calls. And then you're asking this for race. So we need the information adequately to be able to do and make proper decisions. And we're not getting that we're getting it from some homes there are some homes are reportedly. A huge amount of staffing and a huge amount of nursing. But there are others it did add and it's hard to set here and make decisions when we're not getting all the data. They just can't afford to hire those areas on the wages that they are getting right now okay mountain chair all yield and come back in the queue. Thank you. I added I think I wanted to say this too about staffing and I think it was a comment that you just made but you know I look at what traveling nurses. Were being are being paid still but were being paid at the time and are still being paid because of the inflex of federal monies. Which provided that ability for them to be paid more but that you know those federal dollars because of covered. They run out and we can't maintain that same level of air of rate because there's not there's not going to be a federal you know dump of money to sustain that type of era so. I think that may be a question more so for the people that did the rate survey because that's been an a long time question for me is how do we recalculate how do we recalibrate back to you a normal a normal set of circumstances for the different rates of different health care workers so you know because the weak the state can't. Any open and pay what what was being paid and some of these scenarios so you might when a comment to that but I think it's just something important to know you know we we can't go back to the days of of what we were trying to do for covered that was a specific situation and circumstance which we were trying to provide um the ability to build a state open but to sustain the ad is a completely different I think scenario. I will go to senator. Yeah. I'm gonna go to senator love. Thank you thank you madame chair I think my questions are going to probably. Nat far on the providers but more on d HI want to pick up we're represent of what i'm left off but if I can just get back in the light for my phone this ticket certainly that sounds good to me send her hike you did you have a question okay can you push her button. And in its long lease along the same lands maybe a community here I mean if we use the media and then I don't know as far as like orient or whatever. Or that would fall within there we were using an average maybe some of the nothing would be. So it may be a question for the right providers right here is if there's not some guidance if there is some type of federal requirement you know should there be a factor you know is there any analysis of factors out there that they give us to help work with that. My question do you all is this and I heard you ma'am on the hand apologized with the names here but I heard you mentioned of course you're the nursing that you rely in your in your one facility that was not private pay. So for all of you all and I guess you could take issue for like the better word maybe with most of these things on page sixteen of the of the report but water if you could just give me like the top three that you see that you found would be the. I'm i'm I want to say the word a great she said I don't know the test of a correct word or which ones do you find in most out of line. Because I heard her new man on the end sighs up about a hundred and eighty dollars a day I assume you all had to go through this to come up with something like that but yes or I did we we currently receive a hundred and fifty dollars a day at our private pay facility and then our other facility that is medicaid those its half private pay at that facility and does and residents are basically. You're covering all the cost of the ones that the medical account cover basically on that facility we did come up with a rate of hundred and eight to be feasible to medicaid doing our own our own work I do have um twenty four hour nursing care at the private pay facility I do not at the medicaid we just cannot go cannot but. As it relates to just this and I understand if you did your own thing you had I would assume look at the comparison and said well lpn's not even right I heard the gentleman that presented said they were given caught three hours per resident per day. Basically six seventy and a third of that was what they were giving sell is that when we all for is the next one or have you all looked at that if you haven't those fan is just I have an basically the one what can I got me on this report what is saying that the cna's are only provided in two hours of care per per resident per day that seems really low to me if any base needing any care of whatsoever whether feeding you know. Transferring assistance you know walking beside them to the dining room back and forth you're going to provide more than two hours of care the lpn's they they work endlessly to make sure everybody has our medications correctly in on time at our facilities we staffer we staff approximately two lpns four a hundred residents you know I would like to have a third one but it's not feasible at that facility. So we have staff I heard the deal with rear I think is in urban went over that of course and you did too that kind can't cover there so we understand that's a big experience but it's not something that equates to this the study route here right everybody's providing lots of worry were all universal workers you might catch me doing dishes one day you might catch me run in the facility the next day and that's you know it's hard to whenever we we pay everybody to fill in any shoes they might be a housekeeper one day they might be laundering one day so that the c n a's there they're doing the bright but in a system living you do not have to be certified to provide career you have to have a certified employee in the building but you do not have to be certified to provide care to a resident and I want to make sure that I understand they have set up assume you can answer this question and we can ask them so this these cost were calculated based the phone which you're past experience has been over the last. Two years is that correct so you also what your cost was for. Yeah. An lpn or whatever. And then died they put everything together and then their use in the mid point is that correct yes sir and what what i'd like to note about the study was i'm in northwest arkansas i'm in one of the highest. Are are cost of living as a whole at higher than in down south so I just black the rates are not fair for the whole entire state that's for sure. Well I don't I don't respect but I mean you if you want to start driving back in the segments it'll really really will get medicaid doesn't do that though like you mean you have to understand health care you know healthcare in general medicaid is not going to be the payer that's going to make up the difference I mean that that is a consistent thing throughout you use their private pay pays more well yeah private insurance pays more than medicaid and medicare mean that that is a that's the landscape and and that's the business that you're in right I mean you choose to be in that business and you choose to pull it where you're your facilities are because of your business model but I mean I read in one report that ninety percent of the residents are medicaid I don't know how you could ever sustain that business model because I just don't think that you can but you know that's a choice that's a business choice obviously and so i. You know and where but medicaid doesn't pay a different rate based on geography right yeah I mean maybe a business choice but in the states it may not be like where you live you may not be able to make that you meant they may not be able to pay that rate so they need to have the access to career which is not available in southern part of arkansas right now sure no I thank you yes i'm just just one more cousin since you equated to I heard you talk about your private your private facility and then you have a separate facility I guess for the medicaid patients is your private pay facility is it a newer facility then your other one I would assume it is yes sir it is a newer facility we've been in business for to approximately two years we have approximately eighty five residents there we are full at that private pay facility so you filled them within six months so your capital calls it all fairness on that particular one are going to be are going to be hired for that so I want to make sure that we are curved with that II understand the situation you already know that not and wanted to do this but also wouldn't be fair with this stuff because to me down here you know as with most everybody in this room a promise you would want to be fair but the problem is always fan in the truth for like the better word and that's the hardest hardest part down here whenever it comes to either deal with the agencies or the providers or things like that uh so you know I know sometimes we'll throw that tap stuff out there but then there's more more to the story and you know that's if we could just ever get nailed down with what the truth was and I understand everybody wants to make more money that want to make more for their administrative they want to have a higher dollar facility you know so it's a it's just one of those things that I would like for us to. You don't make sure that we're trying to get to an exact number so that we can be helpful thank you. I think it's is providing access to that career facility has to start somewhere it might be a new facility or an old facility. The. True and and again i'm the please don't misunderstand what you hear but whenever you're sitting in a meeting like this and you throw out a hundred and fifty dollars per day like that it'll it runs up a red flag from me cause I might well what how how much during the facility or have we got to grounds keepers are we providing you know landscaping services and things for that one whereas we're not having to do it for the other so it's just that those tap things make it hard to compare apples to apples from me correct but even at my meta keeps facility I charge that same private pay rate at that facility and then I do it my new facility okay but do you have any there. Anyway do you have any private pay at your medicaid facility yes i'm half half private pay half medicaid yes sir that's helpful thank you. Thank you mountain and i'm i'm just gonna judge a little bit daver but that I asked you to look at some just a little bit different but. Okay i've heard there's a okay there's two reports I get to report one report you guys put together great report in one that we got from the DHS and evaluation and market contacted there's obviously a gap between those two reports and looks like there needs to be money to the between the gap I sell my question do you guys are simple. Are you saying that the gap between your report to finding in your report and funding in the dhs is result that DHS is not paying enough for the individuals that are required the caregivers. And their report they're not that the rights are take day I used in their reports are not high enough is that what you're saying. Or are you saying that the number of orients we were talking arients are there the number of rains in the allocation for our ends that's not enough so there's not enough rns in their former that makes me except for the gap. In a suspect is probably a percentage you know part of it is we're not paying enough and part of it is that they're not enough. Arians are all pianes or whatever in the government nor wanted the DHS has prepared for so how she could you quantify that for me in sale kay yeah the gap is twenty five percent that you're understanding us and in the and the seventy five percent that you're not paying the stap there's none of allocation of funds. The staff that you're requiring for us representative back if I can address that question. To um we did request data from the study and did receive some information on last night from DHS and we've not had an opportunity to review from the most resent arm study the data that was provided the the twenty twenty three report shows that provider cost an urban areas are substantially more than rule provider cost in I think we just have to again focus on we want to ensure the access and sustainability of the waiver program for eligible are kansas. Is. It's a stained that's the whole reason we're here we want we believe there are gaps are we paying. Providers more than their costs are because we've taken the median those were things that need to be considered in these guys are the numbers people because it's their business model but is legislators you have to consider or need to consider that. The data that's before you is evident that there's a gap and we have evidence that facilities are going to close we have had letters and i'd we didn't get into that and that's that's a concern so the reason we're here is we want to be good partners with the state in insuring that the people that were carrying for in your communities has access to that service if that's the level of care that they need and that's the reason we're here at this table. So we are in a line ever everyone here would say we'd love to see that there was no gap and everybody was happy and there were lots of facilities everyone saying that my question was is what i'm looking for data this is okay where do I start digging if I need a dick for this where that starting or more importantly maybe the heck here there since okay you you've got your allocations for our ends are helping ends up way off it's going to be more we got it more than more in btw you're not paying them enough for or whatever that is does that that's the information because that kind of tells you where to go start looking. And I mean i've heard at absolutely and I will I will mention that through the process of data being submitted we had one meeting with myers and staffer this year and we in twenty twenty two had several for providers to present questions and we did ask dhs for providers to have that opportunity this year and we they were given one meeting and I know that myers are stuffer did follow up individually but in twenty twenty two and cms does encourage this stake holder involvement at the table so that the the providers can provide input on the services and ask questions about the process. But but the report is based on your data for that I mean this is this is a this is on a rate study that we did just file like arbitrarily picking and choosing a number yes me and I mean you you had incredible input because it's based on all your input whether you're. I mean so fifty you have I mean I just want to make sure that we're careful and saying maybe you didn't have a face to face it down meeting but but you were it's based on your information you submitted her to us that created the right study yes yes may I am in if I had to me is like ultimate I mean I don't i'm not sure if that happens in some other areas of medicaid medicaid could tell you that but I don't I know for a fact it's not uncertain areas of medicaid to where you have that you know. That level of input based on actually what your providing in your costs are actually so I just want to make sure that workers make it understanding clearly that that this this report is based on what you'll gave to us in it if I may add there were twenty five or so new providers that it had not participated in this because of the legislation and so II understand that in the they complied with the law but I think that there could have been some questions that could have been answered that could have helped the process be a little easier and I would respond to you by saying since I was a sponsor of the flegislation and that we was we were fought on this that that it was lobbied against very vehemently lobbied against. For passage of that legislation under voluntary we are twenty four that voluntarily submitted their information but it wasn't until we actually mandated it by law that we got a full response but previous attempts at passing that legislation were defeated by a very strong lobbying effort from your industry that is various I want to state that clearly for the record so you know II want to make sure were speaking about you know this. And very truthful and honest terms. Yes ma'am and I wasn't here for that. Earlier in that process and I know that you were and if you recall in committee I said at the end of the table for heartedly supporting transparency so that providers can be a reimbursed for allowable cost and we we came to the table and supported that legislation. I'm going to move on to questions I don't have folks from the committee but i'll go to senator hammer. You're recognized for questions. They came out of chair the the issue of some reporting the cause civilians and some night it would seem that those that are not reporting they are in cost. Are adversely affecting those that are in that in the overall picture it would pull the reimbursement rate down could you help me true statement in accurate or a help irationized understand that. Senator we don't have a requirement for our ins and the building it's strictly in use for the care plans so in my case I have an addressing care plans only the rest of the year cares directed with through the lpns which is also not required but most facilities try to provide as much helping coverage as I can. Okay. And for those remaining utter young legally on the place the in your case where your providing oriented service do you have any other orients in your facilities or you kind of bear in the whole load there. This. At the medicaid the half medicaid facility amber and that responsibility but at our private pay facility I do have three other orange and the building they are acting you're doing an lpn job but they enjoy the work and so they they will they will be there as an arion working in the facility. N. And you may know an answers question about the hundred and fifty. That you stated a while ago if you had to extract. What would be the cost affiliated with having to pay for a new two year building. Do you have any idea what that would drop your comparison rate down to against the hundred and eight. I probably wouldn't be able to answer that write off right here but you know it's just it's hard whenever the other facility it it is is an older facility but you know the. Your you are having to pay for the cost of a new building but. The. It is that that would be hard I would have to get back to you on that unless saying if you're if you're providing our insertions for the private pay but you're not providing or in services for the medicaid population. It is probably a softball no brainer but the reason you're doing it. At the at the page facility is because you can apport to pay those area because the citizens are are paying for. Through it through the right that you charge yes they're paying their paying for that extra care. Okay thank you. If I may in our four of our seven facilities we have orange. The. Question quick question are are those are ins physically there or by contract they're physically there they're the directors of care. Okay. Question under cms. The. It's required to have an. Not physically there but to be and contract overseas. We have that. For the facility said don't have one that is physically there okay so have you set four of the regional rn that overseas those those buildings okay. And so i'm assuming that that cost then as spread throughout your different. Whether whether there's an orient there are not. That is the cost that spread throughout your system yes we would have captured that cars you are capture that cars but but you didn't necessarily report it. Correct. I don't have the copy of the report in front of me i'm not i'm not sure but it's contract is there a contract or in in the report we don't we don't have a contract or in we have rs that are staffed by the facilities the staff and we have a corporate not a contract. That works for health mark services okay okay thank you. This. When that's a cms. Broad. You have to have AR in oversight at your facility it does not have to be a physical a physical they could even volunteer their time but they do not have to you do not have to have to make physically in the building as an orient okay even in you do not have to have somebody twenty four hours a day in your facility but if you volunteer you still have to capture that as recorded in order to meet the requirement right. For cmass. Now. The. Okay. Are only requirements are for the cnase in the pca is not for an lpn or in the orange only requirements to be able to be accessible and help with to sign the care plans. Okay we'll move into more question. Thank you mansion I think everybody I wasn't going to write the question to you but I think everybody danced around the questions that I want to ask and so. I'm gonna go to the I guess are are. Guessed it and zoom to ask. In regards to the rates. We were using the median right versus the average can you can you tell me what the median radios and they can tell me what the average is a more a more curious about the average. The guest dave are you online could you did you hear that question at the question yeah the question is could you just outline the difference between what a median is versus what an average is. No no I don't know what the definition is just give me the the the media right versus the average rate. Okay did you hear that. It is yeah that is in the report for. Verify that. Sorry. Alright all right media for twenty twenty three was twenty six thousand twenty days I guess i'm looking at I guess when i'm looking at the overall rating i'm looking at your comparison between that I guess the fifty. The fifty. The fifty group sort of the fifty that she looked at. Overall. There's fifty simples that you have in the two looked at in the state I will look i'm i'm asking you what was the the the median it was the average of those costs between those those facilities. I got the car boards been issues with all car yes the expenditures of what they did you not look at that. Yeah I have that right in front of media may just show those that would be great okay so we actually have that for two calculations that the total cost so we have total allowable which would be in those costs that we used and calculated the overall rate he average pretty and was eighty one dollars and sixteen sets. And then the media was. Seventy one dollars in two steps we also have that record by total cost but that you know it was all that really where that we just allowed the differential with average at a hundred and thirty three dollars and fifty nine cents. And the median was a hundred and seventeen dollars in seventeen I believe that's what you were asking for okay that's yeah that's that is what a massive for in so when when you begin to look at them in an exam in kind of the services they were provided. Just in the outliers what what were some of those services that increased those cost. Because when you when you're looking at outlaws you can have some data just like overcost some that are under cost i'm just i'm curious as there too what were some of the the services or just different things that we did. Possibly made for some of these outlines that we look at we did look at what is a visible car might be writing eight years out why are we looking at what the total. Per day clock team to. For each car better and then determine from that. Which of those look like outfires okay so so. I guess i'm curious is if you didn't look at what would dram those costs in. How could you I get how could you make a true assessment as it is into I guess from what was allowable what was not i'm trying to figure. What i'm trying to figure out is this is that if we had some facilities just didn't they came over the average what drove those facility what drove those cast up you know so for instance it could be here you know would ask some I said they don't have a rein or then they have two areas and three areas i'm just trying to isolate some of those things that you are may have looked at it there were to drove those cut those cost. And so are you are you saying that you are did not do that. We didn't look at that level of detail one we were limited on time we did you know I again we identified those that might be considered outliners followed up with them to make sure that they had the forty documentation. Worried what they had. Admitted to us and that came in the form of their financial statement you know maybe sure that hard back to what we saw the report but we didn't do what you're forgetting where if we see a tight facility idea I ability that way. My tire then what that. And that mean was really big okay where is the cost driver of that particular area okay then the beauty out what what what I was I was thinking about because they kind of crossed my mind when said it a hicky was was asking questions in regards to like northwest arkansas the the thing came up were. No price of square footage in northwest arkansas different maybe from in the dealt or so that they can't cross my mind when the issue so you if you want and look at that in. Yes you just didn't let me let me then. I guess madame share our own. Sir I have some more questions in that same vein so I get back in the I get back in the queue thank you okay we've got two more and then I want to bring dhs back up because I think you have maybe okay representative ry. Yeah. Thank you madame german have a question for your. In comparison to our hospitals across the state. The nurses in the lp are we in line with what they are paying in those places and number two within the man of money that you requestion is this going to be a cost to live in built into this for our nurses and our locations. The cost or not that there are sellers are not the same. There are you know we try to be competitive but no there are nowhere near what the hospitals are paying. We don't necessarily build a cost of living into a medicaid rate so I just made him chairman the reason I asked question is I know that it did go up and I just wonder if a forekeeping up with the term if it got passed on well that's a consoke very much for let me yes but I mean that's a question that can take it answer perhaps if if they increased their. Salaries are raised based on their increased. Titue is salary increase dr have a cost of living adjustment that you give to your employees. Perhaps. Most of us appear probably had to give one or two raises every year especially with the copied it was really like a revolving door where we may have done three percent reasons previously. Ten fifteen percent was not unusual at all and realizing we had the four minimum wage hikes too that we were not. Compensated for sure if I may since two thousand and eighteen are cna wages have increased twenty five point zero six percent. Thank you absolutely representative okay senator hammer you're recognized and then i'm gonna bring ths back up okay center hickey. Senator hammer you're recognized that they commanded her. Cmash. This. Require the orient uh cms requires you to have them. Or to have some oversight capacity as an in the medicaid facility but not the private pay facility is that correct. It's an all his sister living level two facilities the regulations are the same so that it's a it's it's required about olt. Based on a regulations that there is arian oversight in every facility. Private payer or or medicaid it doesn't matter or the differences in the private pay you can adjust your caused in the medicaid for a miller you're locked in at what ever gets agreed upon in this room but you're required to do it. You don't have the recovery unless. You report it or you calculate that into what it would cost you into your rate information each providers that correct. Yes sir okay right thank you. Okay senator hickey center love i've got you you're for dhs right okay senator hickey. Just just want more based on something you said you are mentioned something about utilizing volunteers is that minimal in nature or do you all do that on a regular basis as far as your nurses and things like that because somebody down here mentioned that sometimes that you had someone to volunteer. Well as said volunteer but what I meant like in my role capacity i'm not getting paid but basically volunteering my orient services for our facility and not including that out on the pay you will count since you own it but much like that's what i'm that's what i'm yet by volunteering sorry I miss that's that's fine I just that my reason for asking that I wanted to make sure that you all were not that there was a people volunteering and yet you were given them some type of credit or something to that nature because and then it not not have been included in the cost estimate so that I will because of that word was a reason sorry about that no problem thank you. But but just to be clear as the owner you do receive compensation from this business you're not a volunteer that receives no money at all from your business okay I just want to make sure that that was clear okay thank you alright dhs if we could have you guys think there are no other questions thank you all for your time also just quickly I think that the public comment period for this closest the sixteenth that that correct so you'll be submitting i'm assuming these for public comment I just want to make sure that was stated for legislative. For the legislature. Ok dhs if you want to come back to the table. I'm not let senator love and senator rice as in the queue. This. Okay senator love. The. You recognized thank you thank you manchester take several to a putting them you heard the questions before and I was I was just a little the final question I guess I had because everybody kept talking about the orient pieces there. When dave went through kind of. The I guess a staffing they they did mention in mitchell and cna's assistant and I mean they mission like four four I think different areas. Or so our are we not compensating them for arnaments but requiring. Cause i'm i'm just confused on on the aspect most they bother parents. Sure and and I will start and then debit secretary man had to go to another meeting but direct triple is a weatherton is here to help assist with some of the questions to but if you look at page twenty the top of page twenty seven in the report before you the very tap speaks to the requirement for an orient. Are in oversight is required the facilities are required to employ and are in and that can be through contract but they're not required to have an orange physically present at the facility and so that's why you haven't heard the rn hours out of facility contemplated in the rate study. You want add to that. No I would I would like to say there was I think a lot of talk about cmass so federal requirements so actually that is in the medicaid manual erm the language that's the section that's in the the medicaid manual itself. For arkansas so her address to get back to the question about the rain so so in this in this formula this right formula. The arian is not actually. Figured into that in its because they're not it it is figured in it should be figured in and it should have been submitted as part of a cost because there is a requirement to have an rn employed but they don't have to be physically present at the facility so the cost of employing the rn or contracting for the orange oversight should be something that's figured in should have been submitted as part of the cost report okay so if if that was figured in as part of the cost report in when he went through like the lands of lpnc that would have been one of the the figures that you all would have compensated them for against i'm just trying to figure this out if it would be the difference between direct current and direct care correct yes dave do you want to speak to that I believe we had that as a line in the cost report. And that would and so that's part of the right review is is that that orient but since they did not. Submit against that information if it wasn't subso the cost reports submitted by the facilities should have included a cost for or an oversight that would be part of the indirect the direct care staffing is the lpn's the cnase the the those who were at the facility okay so they're not it's not part of the direct your staff and issue support of the indirect okay in the end I get I guess just just my final statement because you know I was very curious about them the median. You know they were talking about they wanted to use the median rate in the in the average rate and and I wishes. Is very conversation and we can take it off line there was those little confusion to me in regards to she did give me the median should give in the media and the. In the average rate. I'm just talk with you all of line in regards to what i'm really trying to get so that we can get that answered okay and and paid just page twenty has the total cost analysis on it and that has the average predium cost the median the minimum in the maximum so it gives you the full range of all the total costs that were submitted on the cost reports by each facility set on page on page twenty yes sir. The total cost analysis and that's what was referring to when she was giving you the average compared to the median art this is the cover this what I need thank you thank you so much thank you questions for clarification send a rice recognized thank you very much. So button again up always appreciate your excess ability and and we visit over there so over many march. Oh. And i'm pretty soon plastic and my thought process trying to take in the. Who rarely and your task. It within certain parameters so I haven't appreciated for your task. But what what the public seas. They see. The. Right now that stayed employees. We're working owner cost thirty for wages. The judiciary always has needs for. Judges to have a certain increase of some of them pretty happy. The exact branch has been asking for wage increases. You got a compete with the private sector. And i'd say below try to refund adequately so most paid more and were worth in some of the plan I think we're nerve but I think that that's taken care of. The lady that testified ten years ago they were being paid eighty two dollars would you psych at a correct statement eighty dollars and change I would need to go back and look and will do that in their public statement and will take that. Is correct. Do you think that. Ten years later the three dollars and some change. Increase replies a. Correct increase of what we're seeing an economy in these other things that are mentioned that were having to take care of the uc. The problem. That. These businesses. Are having. With talking about they have had four minimum wage increases. Over a bier pair. With cover yes blue thanks after the roof. And again not not directly. At you you're your day with but you see. What they are talking about. If that is a true statement. They really be an overpaid a lot ten years ago. Or it's actually factual that they've had what three percent increase in ten years. Am I wrong. Well respectfully we would like the opportunity to go back and look at what that rate was ten years ago and what that included to see if we are if there's a difference in what is covered today versus what was covered down but in that that's the deal we can and that was covered in test more return weekend fine. What we say we can pay for. And in our versus before. Or the cms says we cake pay for their certain things to say we can't pay for some points I don't know for asking if we can pay for and maybe we don't have to ask maybe it's with the gentleman that gave the. The tough was it thirty something states or paying states are picking up some car. So the state can do that the state if it the legislature chose to. We could right legislation say pick this up. And in here my bottom bone and I require. We've made increases in from better and stuff in your. Talked about that and heard about the bedroom to the increase there they needed to. Some right. Well I feel like we're disrespecting. The elderly in the infirm. That relation is facilities again not. Not ready for nursing home yet. Nobody's looking forward to go into nursing home. I think god for my mother's in one four and a half years after you paralyzed and wanted. With these facilities greatly needed not your fault not your lacking. But there's some something in the middle here let's go there it's gotta be true and I appreciate. We can't meet its owner I think we're seeing that now. So i'm thankful for this meeting today these people have been waiting long time for him to be able to speak in public meeting I hope they get their comments in before the sixteenth. In our hope to learn my bowers certainly when trying to ring a bale I don't know if it's underhammed. If I write all factual information all that but when i'm here in the day. There's definitely a lacky night of what we have to do but what we should be doing. To add that up again appreciate you being appreciated containing communicating with me and others and thank you manager. Thank you said it arise one of the comments was the access add on and I think that was fraud that was added continue just a clarify that or speak to that so the excess add on was part of the twenty twenty two rate calculation and again david i'm going to defer to the two of you to speak more specifically to that but that is an add on and moliso also has more information on that but that's an add on for accessibility of a facility are being able to access care would you like to expand on the access on whereas you'd now send a urban we use that terminology when we're looking at if we have enough providers across the state or in certain areas and I would like dave to expound on that there was a lot of back and forth on you know we have a certain amount of waiver slights on the living choices waiver for assistance living that waiver is not for so that was one thing that we considered so so the access would be to open by more access to probably more access but if if it's not all the waivers not for so there was no need for an access that on that what you're saying that was part of the discussion yes okay. David anything additional and access add on. You know that that was included in the last calculation because it was very expressed about. Recalculated making sure that it was support or what he courage providers aren't currently a part of the program to join the program for that with out of the last side we did the madical analysis this time again focused in all that because the there was brought up earlier that. It's basically called us as well they're not for the moment and also costco I mean in the s was pointed out earlier look at what the average comes out to. Is around eighty one so the calculation we're coming out for that so because of those two statistics we felt like it wasn't really supported to continue that idea okay thank you for the clarification. All right senator hammering of a question you spam the speed for david did he just say eighty nine or what david what did you say they're at the end. Debit card when I was. Twenty two is that I think the average cost is eighty seven earlier. Overall program costs. Well eighteen in our rate calculations were coming out to be four eighty six so would see that average. And then also the point was came out of seventy four point nine percent I think was the average of the. Participant. Quote. Okay ma'am chair can I ask him a question and I just the clear fish was it. And and day but i'm looking at the report on page twenty two and I just need clarification on something. On page twenty two the report on the orient hourly rate it shows the maximum of two thirty six forty five I would assume that's probably for contracted oriented services. Is that is that correct or do you know. I would just do the same. Yeah that's going to be contracted we probably cleaned out any like a data element that were. Fairly wrong that one still looks concerned that but I think it's probably just contracted okay and that I notice the minimum is seventeen seventy six when you try to arrive at a medium on the r and even if you throughout the extreme and I assume that two thirty six forty five was either thrown out or you were able to support it. Was such a wide variance. And adding arrive at what is a fair. Go ahead. Right that's that's the reason for using the media because the median you know again the idea and even when you have it out to thirty six in the seventeenth you're not more you use those new year you're just finding what that middle number is as opposed to calculation average and you've got a really big number on the end it's gonna the store that average and bring it up. Which appears to be made indication in this situation where the average came out the thirty nine eighty two but that's why we focused on using the meeting we felt like that would be a better major of what is typical. So the seller recommended rate that is coming forward others report is using thirty three seventy five on the are in our rate is that a correct statement. Yeah. Yes okay because i'm thinking what you have to pay or in in northwest arkansas which might pay for an oriented down in south arkansas if you can find one is that a reset a reasonable realistic expectation. To achieve that then maybe some you can ask i'm just so on that out there for consideration that that would be a pretty tall tash considering what we're having to compete with on the hospital level and even out there at the health service center all the other places so okay thank you. Thank you very much thank you all right I see no further questions is there anything else to come before the committee. Do you have any last statement. Thank you madame chairman just a couple things in closing acknowledging senator rice's concerns and comments and you know most of the folks in the room we this is the beginning of work that needs to be done on the living choices waiver in general the rates are part of it the requirements from regulations other parts of it so we have the ability to do a cost said the annually per statute dhs can also initiate and request cost study at other points during the year if needed and so we have the flexibility within the statute to continue to look at an address these concerns II do want to just make sure I wanted to point out a couple of things on page three I believe it's page three of the reports i'm in the executive summary just the utilization rate of the facilities that were in the participated in the cost for reporting process there's a pretty even distribution of high medicaid utilization medium and low medicaid utilization facilities so there is there's a pretty even distribution of that you know and as was stated earlier by damage secretary man medicaid is a portion of you know there's private pay in there there are other sources and so taking into consideration in a medicaid we are looking at all things medicaid for sustainability of the overall medicaid program now we certainly wanted to have a starting point with looking at this particular rate and the last point i'll make and i'll defer to director weather to know if she has anything else is during the public comment period one of the things that on page seventeen where it includes what costs were included in the in the cost study in the rate recommendations and what percentage of those costs were included that is one of the things that I think one of the other members asked about you know if there were any of disagreements with the amounts at which these were calculated and that is something that is that can be submitted as a question or a comment during the public comment period if any of the facility providers are take issue with how these calculations were arrived at so. Want to make sure that we clarify that as well and then direct your weather to anything. I would just add then although we're here to deal to talk about the the car survey on the current program like secretary pattern and mentioned I think one of the reasons that they asked me to take on the role of overseeing all of the specially populations is because they recognize the emphasis on the work we have to do around all of our home and commute based services so I just want to emphasize with what sender races saying no one you know people want to go to assisted livings you know they want to be able to live in their homes we have to get programs set up to assist them we're doing that and so not only looking at elderly bit against all the populations on how can we improve what we have right now and I think we would both agree that there's a lot of room for improvement on their services that were offering aging an elderly in their homes thank you and finally just I know it's brought up and this is about the cost of four and perhaps later on we can talk about those program changes however the thirty day notice was brought up I believe and by them so i'd like to know have you received any thirty day notices at all in the past year we have not you have no in what about you wouldn't be able to say previously but you might molitate up now i'm not aware previously but it was reference that some have closed over the past several years we can bring that information center i'm an hour so called up in dd from a policy perspective I think it's important that we understand how that thirty day process works and and I want to make sure that notices aren't sent to residents and families with out being sent first to the state because I know that that has happened in the past at am not sure which but you know I would get phone calls from time to time ahead of you from constituents we get phone calls that's just not fair we we've got to make sure that that. Processes very clear so that or not scaring people unnecessarily and that there is an actual process you know that we can follow that starts with the state so I just as we're dosgusting that that it's something you can put on the table for a policy situation but or a program change but that's important to me you know for for the sake of the residents and the family members as well yes and in that thirty day notification is a requirement of a medicaid provider but it's that's at a minimum so it does not have to be a thirty days that can certainly be at sixty or at any point that the facility becomes aware that they you know they intend to be out of business okay a certain period of time I think that's important alright senator rice uh unless they made interest like to ask. If. The department does receive a close your notification thirty day sixty day while about. And there's not some legal reason that they keep forward that to the committee I would ask that that would be done for so to a monitoring this process right now i'd appreciate if that could come to the. Committee letter but I know that involvement in this we will absolutely make sure you are updated on on any developments around this thank you thank you okay with no