Insurance and Commerce Senate & House Public Health Senate & House
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Speaker 3
5:00
I'll be right back, I'm just going to step out real quick. Okay. I'll- Thank you.
I'm gonna get going me to come to order hey senator well thank you
everybody for being here today and I think chairman Lowry is headed back in the room but we get a lot of folks here in a big agenda so we want to get started I do have an announcement that was just given to me for all legislators here and others that might want to tomorrow February the 20th from 10 to 1130 is Nurses Day at the
Capitol and is there is there anyone with the nurses here that handed this to us well they came in and gave it to us and wanted us to announce this so if you're around the Capitol please take an opportunity to visit with our nurses and we do appreciate what they do for the state of Arkansas with that and perfect timing Chairman Lowry is back at the table here and we want to thank I want thank first of all public health senator ervin and chairman ladyman and chairman i don't know if center urban is going to be here or not but if she's not you're welcome to join us up here if
you'd like to but we appreciate you for being here and joining us for this issue and with that i would like to yield to my chairman from the house insurance and commerce committee chairman lowry and to be also glad representative ladyman to hear from you if you have
anything anything at all you better probably hit the mic and i'll hit you here
Representative Jack Ladyman
Unverified
8:43
there you go sir well first of all uh thank you uh senator raper for scheduling this meeting i know that uh ambulance service in a county in
the city is a difficult thing to do and to maintain and there are issues that come up in all parts of the state so i'm looking forward to the discussion i know it's a problem in many of counties so looking forward to that discussion if i could you talked about the nurses day there is a breakfast for the house so just wanted to highlight that
okay very good thank you chairman ladyman we do appreciate all of you being here and we're going to jump right into the agenda
first of all what we need to do is adopt our insurance and commerce committee meeting minutes from january the 16th 2020 do i hear a motion for that i have a motion i hear a second i got a second all those in favor say aye all opposed no thank you very much and with that i'd like to ask if mr john roland mayor of perryville we've got several people that are on the agenda to speak to us and looks like what i'd like to do at this point is probably bring
up john roland if he is here yet john if you would come on up and then also perry county judge toby davis if he's made it here yet there he is if y'all would come and you just take a seat right up here uh in the front and since there's only three chairs i'm going to wait and bring up the balance there from amanda warren and ken kelly and jamie patford gresham bringing them up after the judge and Mayor Rowland. And just to set this up, legislators, I don't know, depending on whether
you have a rural county in your district or not, whether or not this has been brought up as a pressing issue, but we were approached several weeks ago about an issue that has been, I guess, under the surface, has been coming to a head, and finally reached a point, I've got two counties in my district a little bit of Perry County is still left in my district after the gerrymander of 2012 have to throw that in there for you judge I've got just a little bit a little bit of that county left there and of course they've been
trying to wrestle this problem now for several months and and bringing together a small group of legislators just a few days ago and bringing in stakeholders from around the state we discovered Perry County is not alone there are some other counties that are right on the cusp of being in the same situation and so with that I would like to allow judge Davis and mayor Rowland to visit with us here a little bit about what they're facing in their county and judge I would just say kind of summarize the issue where you're at it'll help bring
into picture the problem and how we might begin to address that I would say we might have a question or would welcome your input a little further but want to get basically your testimony about what you see that you're dealing with uh what some of the solutions you think may be in play there and then we'll have the folks from the ambulance services come up and testify as well so for the record if you would please state your name and who you represent for the record both of you and then we'll allow you to begin i'm
Speaker 18
12:05
perry county judge toby davis i represent perry county
Speaker 20
12:11
mayor john roland city of perryville i represent perry
okay very good judge i'll yield to you first and thank you you have freedom to say what you
Speaker 22
12:20
will first i'd like to say thanks for inviting us this has
Speaker 24
12:24
been an ongoing problem for probably close to three years and we need some help i'll summarize kind of what's going on perry county is a rural county and it's a around 10 400 people and it's a long drawn out county it takes approximately two hours to get from one end to the other end of the
county if you drive normal speed limits hour 45 two hours and the ambulance we had before us they were kind of home home owned and the county was a basic life service but they they retired so our new ambulance service came in and the problem we're having is just not enough run volume they're making it with one ambulance but to do two to cover our area it's just not feasible because they're just not we're cursed in the that point but we're blessed in the fact that we don't have
that much runs but what happens is all too often there's more than one run at one time and one ambulance is just not covering it so they approached me as a county judge to ask for subsidies and i started doing research and i found out that we had no money in the county to provide for that so i started reaching out to the quorum court and since then i've appointed an ems board and two of the members are here with us today to start studying and doing research is what we can do we're having a special meeting with the quorum court i've called it on the 25th of february
and hopefully they're going to reach a solution whether it be a tax put on sales tax voted by the people or a fee upon a personal property to subsidize some of this problem i think once we get something like that in place we can sustain but right now we're
Speaker 25
14:03
just floating okay mayor roland well i like toby have been
Speaker 27
14:10
working on this right at three years you
Speaker 29
14:12
know three years ago there were two ambulance services wanting to be in perry county
Speaker 30
14:19
Well, they found out that one of them was eliminated, and we voted on one. Started out two ambulances which would sustain us. They quickly found out that it was not profitable, and they are for profit. They came to me, said, we're running in the red, we'll have to go to one ambulance. I said, well, you need to go
Speaker 31
14:41
to Toby, and we need to get together. Things
Speaker 29
14:46
kept rocking on. my co-worker which really brought it to my attention I have a pharmacy there in Perryville
co-worker, pharmacist her husband started having chest pain she was off that day, they were at home called for an ambulance they made it to the driveway the ambulance was going somewhere else at that time we had one ambulance they started CPR on him nobody was there this rocked on for an hour. No ambulance. The family
Speaker 30
15:17
was called in. He's in the driveway. They literally draped a sheet over him
Speaker 29
15:22
while the grandkids went by him to go in the house. This is very close to me. He was my co-worker in Perryville, small town, 1,500 people. Next thing, a plumber there in town that works in Conway. He was gone at Conway working. And we have a scanner there at work, and we're listening to a call on the Homewood. Y'all wouldn't know where that probably is. It's around Petty Jean. It's remote.
Speaker 30
15:52
It's not close to Marlton or Perryville, but it's in Perry County. The first responder showed up there, and we could hear it on the radio dispatch, the scanner. You know, where's the ambulance? The ambulance has gone somewhere else. Needless to say, that was over 45 minutes an hour before an ambulance arrived. There was no help. The municipal judge that retired recently, this was three months ago, her husband was suffering from a stroke.
She calls for an ambulance. She's on the phone with
Speaker 33
16:28
a 911 dispatcher. Our ambulance has gone somewhere else. We do have mutual aid agreements with MIMS
Speaker 30
16:36
and MedTech out of Maralton, but they have to fulfill their obligations first before they can come help us and stroke victim you have a time period where you can get them into the doctor the hospital get a shot to reverse the the side effects of a stroke by the time the 9-1-1
dispatcher told her this would be over an hour and that's out Cantrell here 45 miles it's not that far she couldn't load him up you know people come to me I'm accessible not that Toby's not but they come in to get the prescriptions filled or whatever I hear this she was in there that day with tears in her eyes you know what can we do about this problem you know and me and Toby have been fighting this for
three years you know having meeting after meeting trying to find an avenue to get funding to get help uh you know another one a boy got mauled by a great dane uh his ear torn half off in perry which is three miles in perryville called 911 well the ambulance was going yet again they called mutual aid it starts coming that way our ambulance headed back it overheated they'd already turned back med tech you know and this child is the the first responder
is literally holding his head, holding the ear on. Then this is a child. I mean, not that any age makes a difference, but it touches more close when it's a child, and they're helpless. And I won't necessarily say nothing against the ambulance we have there. They're doing the best they can. They're just spread from Hollis, which is 28 miles this direction, to toad suck which is another 20 direct miles this direction from perryville and they're centrally
located uh mutual aid is is very nice and very helpful and they're wonderful but they've all always have their own obligations and and we've been having meeting after meeting after meeting and you know we don't have the money the county doesn't have the money uh this last meeting we had uh i'm thankful for senator rapert to getting that together and uh find out the funding gap uh you know they had a chart out there in how many years since they've
been had an increase well i run a business uh it's easy to see if you don't have a
Speaker 33
19:11
rate increase in in 10 years i don't i think it's at least 10 years i think everything's from minimum wage and everything's going up 18 i think if
i'm not mistaken we could have the department of health or somebody provide that information at some point but you're right i was surprised to hear that as well mayor
Speaker 30
19:30
i ramble on and on but perry county in particular we're hurting yeah the people are hurting the people are dying uh if it means a rate increase so we can afford to have more
ambulances whatever the need something has to be done to address it like i said toby said we're trying to get a personal property tax in in place or a sales tax something but this is this has been rocking on and I could literally fill a sheet of paper up with people who have been affected by this. People that went to the ambulance will tell them, meet them at Houston. The ambulance goes to meet them halfway to the hospital and the battery's dead in the ambulance. If they had two
ambulances, maybe the other one could make it. These are actual cases that have happened. I'm listening on the scanner, half of these going on and thinking, what are their chances
and it's pitiful well obviously the stories are very compelling up and you know to every single person that was involved in those events it is a crisis for them and so i appreciate you sharing those because it puts a face on the issue this is not just numbers
it's actually dealing with a fundamental basic necessity which is emergency services for people that are in trouble and need help and what's difficult for me is knowing that perry county is is literally sitting right on the edge of pulaski county the edge of faulkner county and underneath conway county which absolutely has resources and has services in those counties but your county is the lowest population in the metroplex and so i understand that let's turn a little bit i do would you entertain some questions i've got a representative that i'd
like to go ahead and allow him to ask a question and i would like us once you answer a few questions here i would like you to get to what your local resolution is in terms of what you're trying to do so that we could kind of pinpoint that and and and also articulate have you gotten a firm number now on what what's being demanded out there maybe what's being recommended from some of the ambulance services that have been speaking to you about this to be able to get proper coverage
for perry county with that representative love i'd like to hit the wrong one but i'm gonna come back and get you they don't want you for some reason there there we go i had to use a different finger
Speaker 41
22:06
there you go representative love as long as it's the right finger
Speaker 43
22:09
not the wrong i won't tell you which one i use representative love. Go ahead. Thank you, Mr. Chairman. And I thank you for bringing this issue to the forefront because for the last, I guess, six months or so, the hospital committee, subcommittee has been
looking at rural hospitals and rural clinics and seeing what we need to do because in the rural settings, I mean, this is kind of what we're seeing. Mr. Chairman, you all answered one of questions and it was when was the last rate increase and you said it was 18 years okay is there
is there department personnel that could speak up to that because i know that was discussed in the meeting
okay right we're going to we're going to she's going to be up here in just a moment to testify but we're corrected is 25 years okay which is
Speaker 43
23:08
even worse yeah that's oh wow and that should be unacceptable but i guess we could put some things in place now and then also i guess then you you can speak to when will the right review happen because what i'm looking at and i'm just looking at this um and this is not yours but this is one from ems and there's a medicaid portion and an
insurance portion and a medicare portion of this mr chair and i'm thinking i guess we could do something about the medicaid and the medicare portion i'm not i'm not too uh proud of if we can do anything about the medicare or the private pay portion i'm not sure but is that is this what we're going to be looking at
Speaker 41
23:46
and i guess that's a question to the chair i definitely think it's a factor and what i would say is that unless
you want to address it to one of these two gentlemen we want to hold that and come back to that with you representative love when we get some of the
ambulance services here and we don't necessarily have any department personnel that are actually on this agenda but we would definitely welcome some input i know the department of health was in the meeting as well as dhs that we had a few weeks ago so representative love anything further on that before no i i'll i'll yield thank you thank
Senator Kim Hammer
Unverified
24:21
you very much and with that senator hammer you're recognized thank you mr
chair and this may get into that same area but let me ask the gentleman at the table over here um if we get a rate increase on the medicaid that's not going
to do anything with your run volume uh your run volume has been what about five what's your run volume been each year for ambulance calls out there it's going to
Representative Michelle Gray
Unverified
24:45
run somewhere around 50 to 70 a month that's around the average one a day okay and of
Senator Kim Hammer
Unverified
24:51
those how many turn out to be i'm going to say
Speaker 24
24:55
about about 25 percent is not a true emergency and what happens is uh our county is is made up of a lot of people who use medicare and medicaid so uh when when the ambulance service
bills that they have a cap of a certain number so it's it's not it's not making them to
Senator Kim Hammer
Unverified
25:13
be sustainable okay because one and mr. chair i'll i'll stop
after this you want to pick it up later when we
Speaker 24
25:21
get can i answer one more thing sure one thing i believe has happened is that our uh our county citizens has when they call an ambulance nothing to do with the current service it's just we don't have one available they've decided instead of calling an ambulance now they use their pickup trucks they use their cars so i feel if we had an ambulance service in place
Speaker 25
25:37
with with enough coverage the run volume will pick back up okay
Senator Kim Hammer
Unverified
25:41
and as a former medic having worked on the ambulance by the way I appreciate the position you're in and everything but the the thing is when we go talk about rate adjustments you know you're still gonna have to maintain the overhead cost but if your run volume is not there it's gonna affect our discussion in
my opinion about the rate increase because without the runs you can't bill anybody doesn't matter what the
Speaker 25
26:07
rate is. Before we lost our other ambulance, before we lost two, we had a higher
run volume. But there again, I mean, I think people have lost confidence
Speaker 24
26:16
because they know that they may not have an ambulance. It's nothing that the ambulance services did. It's just they don't, they just don't have the coverage because they only have one ambulance. I believe
Speaker 25
26:25
if we had an ambulance service in place with two ambulances, our run volume would come back up. very good thank you thank you
mr chair thank you uh have uh representative ferguson up next thank you mr
Senator Missy Irvin
Unverified
26:40
chair i i'm trying to really pin down exactly what's the problem is it the volume
or is it the distance the ambulance has to go or both both is it a privately owned ambulance service that it is ma'am because i i know my first term uh we passed something with baxter hospital where if it allowed the EMTs to do sort of home health-type procedures to earn additional money in their downtime if being down, but you don't have a hospital closing up or a home health to associate with.
Thank you. Representative Ferguson, I think both your questions, Senator Hammer, both of you, if we're
trying to dial in very specifically on the areas that are absolutely in crisis, it's the rural counties and so I don't know if we're going to have to look at a situation where we try to address something in counties that have a particular set of circumstances I would say that that's going to be one option that's one pathway obviously I would say that of all the
handling services sitting out here everybody would love to see an increase so so we were gonna have to figure out a pathway that allows us to achieve a desired result we've got two more in queue here representative lynch you're recognized if it's
right i'm over here who is 39
Representative Roger D. Lynch
Unverified
28:08
where are you oh here okay all right right got you represent so what does it cost the cost of one
Speaker 80
28:13
unit staffed per year i'm not an expert
Speaker 24
28:18
but i'll tell you what i've been told uh it takes about and the medical professionals could tell you more but it takes
about $15,000 per ambulance per month so $30,000 for two ambulances per month to sustain and that may be a little low
Speaker 25
28:32
I'm just going by numbers that's been shot to me those numbers were
Speaker 81
28:37
actually when this first started out two years ago when I went well a
Speaker 33
28:43
year and a half ago whenever I found out that the existing ambulance service was not viable and they needed a subsidy I started calling around and I called med tech and Pafford and different ones that I that I
knew and asked what it would take to bring them in the number kept coming back to around $15,000 per ambulance because they're looking at a payment service that's going in the red right and they're not gonna run and jump in there where
Representative Roger D. Lynch
Unverified
29:13
somebody's in the red so it's 15 per month and that's seven days a week 24 hours a
Speaker 33
29:18
day yes sir you'll have 24 hour coverage with paramedic level which when you if you if you go to one of these accidents and you witness a
paramedic level that you have you you enjoy here in Little Rock and Conway and Marlton you know that's what you want for your people I mean you don't somebody just to throw them on a gurney and take them to the hospital you know somebody actually to attend to them right there and when you have a paramedic level which most of the ones behind me probably all of them that's what they are they're professionals when you when they are on the accident they can stop the bleeding they can take care for that patient right there it's very impressive I it's it's
Speaker 30
29:58
very impressive to watch him work and when you're in the situation like me and Toby and you're you're looking at your people you represent that's what we want we make the 10 the county of 10,000 we still want quality service and the people
Speaker 33
30:19
that are needed quality service now what that magic number of reimbursement per run that number y'all have
Speaker 30
30:26
to come up with but I the the point is we've there has to be some increase
the county they're meeting the 25th they come up with their way of funding it you You know, I'm at an end as a mayor. I ran at an end when I went to the AG and said, can we tax water bills or what can we get a fee from? And I was told the city could not do that. It had to be on a county level. Representative Bentley directed us, helped us figure the right pathway, and we're on the right track. We're not there yet, but we have found a problem and we're trying to address the problem.
Between now and when that money becomes available, we haven't filled that gap yet but even at that 25 years was no increase I mean that that has to be addressed that's that's where the problem comes back to work begin to me if they don't get paid enough I mean they can't continue even low volume and we're not the only county with low volume we don't have a hospital we have a nursing home one doctor and two nurse practitioners and a lot of retired people we're a bedroom community there's no industry so you know 75 percent of
them either retired disabled i mean that's that's the reality of our of our county
Speaker 88
31:44
and those people are really the ones that are going to be needing a
good aim of service thank you on on that note you mentioned the nursing home situation there have they articulated to you the
impact that this is having upon their own situation obviously having people that have needs well the
Speaker 30
32:03
administrator told me that she's very cautious she doesn't want to call out the ambulance if if they have a patient in need they try to find either
a mutual aid to come to come get them and that hurts our local ambulance service I mean just like the one with the I was telling earlier they had the stroke when her husband she got her husband to the hospital well he has to go to rehab well she's from Perry County she's you know be convenient to bring her right right there bring him right into Perryville but she said I cannot take him there because what if something else happens how's he gonna get at the hospital and that's a good you know who can argue with that point when he
wasn't there the first time was wasn't there the first
time what makes things gonna be there second time you got a couple more questions in queue for you and then I'd like us again to get to that at the
Representative Josh Miller
Unverified
32:59
end of this try to tell us what your solution is representative miller you're recognized thank you mr chair and i appreciate you having this meeting and including both committees this is a i know this is a tough issue we've experienced a lot of these same issues in mine and representative payton's home area and
and around um my question is this and you gentlemen can answer where does uh like med flight and and our our airlift services and folks like in your areas that have memberships of those how does that play into effect with you know a lot of what you're talking about do they have the ability and i know some of this may be insurance type questions i don't know if an
ambulance you know medic has to call for the the helicopter or what but can you talk to us a little bit and address you know what you may know
Speaker 24
34:00
about how that affects it we do have a couple well some med flight businesses that help our county but getting the person from their home to the amp to the to the to the flat we have designated areas like the ball fields for the area back to land getting them from their home to there requires someone to do it and our fire departments are
not equipped to transport people from there to the to the airfield and so we have to have an ambulance
Speaker 84
34:30
med flight which covered our area specifically pulled out how long has it been in
Speaker 30
34:39
november they pulled out of morrowton which was their closest access the closest one that and of course feels further out from there we did have one in morrowton but it pulled out okay
thank you okay thank you representative miller and i believe the last
question on this this particular time is representative gray thank you mr chair
Representative Michelle Gray
Unverified
35:00
sorry we were we were working through some issues here um but i wanted to say you know i'm i'm actually from rural arkansas izzard county and i've got vital link is here you know our our ambulance provider and so kind of a little bit of a history but also a little bit of a suggestion as well i'm on the ems board in izzard county we actually met last night um and so we have the ems board
with the the 50 yearly fee that helps to subsidize these trucks population of roughly 13 000 and what we've seen over the last couple years we lost a nursing home a few months ago we have a hospital in some serious financial distress and expect to lose that so as of last night we were informed we're going from three trucks now to two trucks and looking at their numbers if they decline much more i have one truck in my entire county so we're we feel your pain um it's not just it's
all over rural arkansas and it's one of the things i was going to ask is have you are you have you looked at doing the ems fee um and even if you have i don't know what amount you're looking at but i can tell you that ours doesn't subsidize enough um so just make sure that you
Speaker 24
36:16
have that number right i could answer that judge smith and myself are friends isord county and uh i've guidelined through your ordinance and and that's how i've come to the conclusion that we need ems
board we appointed that about two months ago i have two members here now so we're trying to strongly because you are in the same situation we're in i mean i think batesville's your closest hospital so i'm trying to guideline uh our county to to be like your county so i have the ordinance and we're trying to get that into place so this next meeting of the quorum court uh i passed out to our to our quorum court members y'all's ordinance and we're trying to we're trying to go into like you're doing okay
Representative Michelle Gray
Unverified
36:56
good and that's without that we wouldn't have ambulance service
Speaker 24
36:59
absolutely and with your 13 000 and our 10 000 and four we're probably going to have more than than 50 dollars and that the trouble as an elected official that myself and the mayor has come across is our people we've had people that don't want taxes they don't want to have fees but it's time for us to step forward as leaders and make that decision and i'm hoping that's going to happen in in february the 25th but until then because you know as a fee we won't receive a dime until next year so we need to sustain our current ambulance that's why i've asked for help from
whoever we can get help from just to get us to that point because when we started this our ambulance service is private as well as yours but i didn't have an ems board in place i didn't have all this all the ordinances that i needed so it's taken me two years to get there because i've been trying to select and do things legally but now we're there so we're ready to move
forward good thank you and on that note thank you representative gray uh you you've mention a little bit about your plan so could you articulate for us number one have you got a number
that you think that you're going to be in need of to bridge yourself and then also secondarily whatever your plan is that you're going to propose will that be able to supplement enough that you think that you can even sustain or will you be right back in the same boat next year no sir i I think if we get the
Speaker 25
38:25
implementation fee in place, I think in a year's time we'll see a major turnaround because what's going to happen once we get the fee in place, we're
Speaker 24
38:35
going to open it up to a bid process so that we can select.
It's not really a competitive bid, it's a quality bid, so we can select the ambulance service that's going to suit us the best. It may be the one we have now, it may be a different one. I'm thinking, and right now they're one ambulance, it's making, you know, it's sustaining. They're in a shortfall, but it's nothing they can't pull out of. i'm thinking probably enough to buy one more ambulance or or to fund one more ambulance would probably be around 20 000 a month is what we'll need for probably a year because it's going to take a right at a year to get that information fee in place so you're looking about 240 000
about 240 000 but i wouldn't want to do it for a full year or six months because what we've seen in other counties is once the people know they have this it happened in conway county when their service came in 30 years ago they read you out for a subsidy well once the people got accustomed to having an ambulance service and they got comfortable with them she don't have to have subsidies anymore because it took it brought her into the red into the black out of the red and she turned the subsidies back every how
they did it all right so make sure hit this again so the
the number that you're hoping to raise with your fee is 240 possibly yes all right and so how will
that be assessed does that look are you look how are you going to to assess this how will this be done what it
Speaker 24
39:54
would be done is like i said i'm basing on desert county what they do is they right now they do a 50 when they first started 1985 it was 15 dollars now it's 50 and each year when you pay your personal property tax that personal property assessment fee is on their on their personal property and uh what that means is like me and my wife will pay one fee of
fifty dollars and my son lives with me and he has his car he'll pay fifty dollars but in return i believe theirs if you're a member and you pay your fee you get a run for free from the ambulance service now what what eric explained to me was if you call the ambulance and you don't have any insurance whatsoever your fifty dollar fee covers you but if you have insurance or medicaid or medicare they're going to build that company and that company will pay then
so that helps offset theirs okay so what you're saying is that you would assess every household personal property on their personal property yes
sir and then the the number that you mentioned is a shortfall that you're currently looking at that you may end up losing the service even if you pass your fee if you don't have some way to keep the service going you you may have another problem before even are able to continue so we need a year of a subsidy of
Speaker 22
41:09
a year is what we need and and are you also saying that's 240 what is
Speaker 24
41:13
it that you're saying 240 that'd be about because he's making it with one ambulance he's in the red a little bit but i
mean that's because when somebody calls an ambulance and they don't get it he loses out on that run so so if he had two ambulances sitting there available then he's not gonna lose out on runs anymore because when he calls he can go right now so often uh like in bigelow the other night There was a lady having a baby, and she called, and he couldn't be there because he was in Conway. Well, the other service came. They got that money. He didn't get it because he missed out on it. But if he had two services, two ambulances there, he wouldn't miss any run volumes.
Well, I'm also wondering if you're taking the steps locally as a county to put in place resources to subsidize for your county and the citizens. That's for service for them regardless of who offers it. Yes. are you also going to rebid this to see whether or not there might be a service that might end up giving you better service at a better price than what you may end up with now once we get the service in
Speaker 24
42:20
place it'll be a bid process and the ems board will govern that they're also going to
govern what he does with his money it's going to be checks and balances and it'll be open to a yearly bid each year that that service will be open to a a bid to see if someone else can offer more or better need to be up to them
to decide i've got senator hammer back up in queue i got one last question and then i think i'll be finished for now uh i think i've got it clear what you're telling me is that through your research you've assessed that you're in a position now where you feel like the county needs two hundred and forty thousand dollars for a year
yes for one year to be able to supplement so that you can keep some service in place for the citizens
Speaker 22
43:02
yeah sure because what i'm afraid is if
Speaker 24
43:05
if for some reason uh tomorrow he can't make payroll and he leaves us the other the other ambulance services in the neighbor in the neighboring counties will help us but they're not exclusively our services so they have to take care of their people before they do us so if we we have nothing then then it's not gonna matter how much money we have or
Senator Kim Hammer
Unverified
43:24
don't have we're gonna be sitting ducks uh senator hammer uh you're recognized sir thank you
Go back to what I asked you a while ago about the number
that you actually transport that are determined to be true emergencies once the ambulance shows up on the scene. What percentage of your run volume fit that category? Probably about 60%. Because
Speaker 24
43:46
what happens is, and there again I'm not a professional, but I believe that when the ambulance is called, they have to run regardless of what the emergency is.
so when they get called to a broken shoulder and they go there and the guy when he gets there the guy says no i don't need you to call me because my wife's taking me in my car they get no money
Speaker 25
44:14
for that so that's a non-run or they're
Speaker 24
44:17
not non-paid so i would say out of the 75 runs probably about probably about 50 was paid runs and then there again if it's a private insurance he can charge around 1775 but if it's medicare medicaid they have a cap of a certain value and i'm not sure
Senator Kim Hammer
Unverified
44:32
what that is all right and with regards to the
i heard fifteen thousand dollars a while ago would you would you drill down on that is that fifteen thousand dollars per unit and that covers what you have determined through your research to be the cost of what it takes to keep
that that truck there 24 7 for one month but that
Speaker 30
44:55
I did all my research year and a half ago of course everything goes up since then you
Speaker 33
45:02
know I'm what pavers at 15,000 for one
truck med tech said 30,000 for two trucks so basically $15,000 a truck and they're guaranteeing that if the citizens won't have to pay at that price They'll take what was billed through the insurance, Medicaid, Medicare, and so forth. Roughly when
Speaker 124
45:30
we're going through their existing ambulance service, we went through their books,
Speaker 33
45:35
we've had them supplied to us. Payroll, I mean that's roughly going
Speaker 30
45:43
to cover payroll, nothing added to that. vehicle expense all your supplies gas insurance i mean that's cut to the bare minimum because they're whether they run or not because we've we've had these
Speaker 33
45:53
uh public forums you know people arguing well it's for-profit money giving them for-profit money when you dial 9-1-1 you want somebody to show up and they'll argue that i'll take myself to the hospital well your wife might
not be able to carry you if you're unconscious to the truck
Senator Kim Hammer
Unverified
46:11
to carry you there okay last question how active is your volunteer fire department services in your county as far as interacting with the ambulance services i can they're
Speaker 24
46:20
very active the only trouble is with our volunteer fire departments and we mentioned this today in our meeting this morning is a lot of our volunteer fire departments are elderly folks that are retired and a lot of the young people have jobs so during the day when you're at your job you've got no coverage right okay thank you thank
mr chair all right and we're going to take one last question for now gentlemen and move on to get some other presenters up
Representative Michelle Gray
Unverified
46:47
here representative gray you're recognized thank you mr chair um just based on my experience with the ems board the number that you kind of give us of the 240 000 i believe to be short so i don't want you to undersell yourself i think just payroll alone runs our trucks about 300 000 and that doesn't include benefits or any periphery type things
So I just don't want you to under undersell yourself there And then it's kind of also wanted to clarify that with our EMS fee It covers everyone in that as long as it's paid it covers everyone in the household for Emergency runs only no transports from hospital to hospital and no non-emergency runs So I guess and that was just clarification But also my question is I just want to make sure make sure I understand what our purpose or what your intent was are you asking us to subsidize you guys for is that what your ask is of us at one side brought
that up to mention that i don't know if it's doable or not uh i
Speaker 24
47:44
think the reason we're here today was to talk about the all the shortfalls that the state of arkansas is having with counties like yours and mine and i just wanted to share with the our our our burdens okay um but i don't you know i mean i would take our county would
gladly accept any help i guess i would say representative gray that's a great question and i think the reality of the fact is that with
you know nobody wants to get up here and have to ask for anything when money's tied everywhere
right but i do know that one of the primary regions that we have rainy day funds and we have these issues is that when we have a situation that demands a response in some way that we have an opportunity so i don't mind saying judge that it appears to me that that unless you have some assistance and the governor would allow some assistance from a rainy day fund request or if the legislature wants to push forward in similar fashion like we've seen just done with senior citizen centers and other issues that we've taken action on really there is no other alternative
for you at this point is that a fair statement that's a fair statement yes okay thank you i do have two more folks that i do want to bring in it's for your transition center bledsoe you're
Senator Cecile Bledsoe
Unverified
48:58
recognized thank you mr chair judge i just wondered if you had thought about going to the if you're going to the voters for a tax increase uh wouldn't it be possible to structure with a bond have you thought about that yes ma'am
Speaker 24
49:13
we have we've kicked that around for two years
it's not it's not going to sustain and as far as the tax goes we've talked about a special election to do a half cent sales tax the trouble we have is our county is so diverse that the people that live in the east end of the county they shop in faulkner county the people that live in the west end of the county they shop in pope county or yale county the people live in the you know it's just the counties because we have no industry so if we raise our taxes in the city of perryville because we're all interested people's
Speaker 25
49:44
going to continue to go other places because they
don't want to pay the high tax so it's kind of
a catch-22 all right thank you so much all right and actually i want to recognize senator irvin and we do welcome her to the committee she we appreciate you being here senator irvin and recognize you for comments and
Senator Missy Irvin
Unverified
50:06
questions thank you mr chair and i apologize for i had a previous meeting that ran over um and i'm coming in late to the conversation i realized but um one of the things that i i mean i'm concerned about utilizing
rainy day fund in this manner i'll be flat out straight with you i mean because once you start that it's like pandora's box right and not that i'm not sympathetic i am sympathetic i mean i live in mountain view arkansas rural arkansas stone county is or county's my neighbor i get all that but we start going down that path you have to understand um where we're at and so i mean i would just say um so let me just clarify you have or have not done a similar structure that is in
israel county we are working on that right now you're working on that right now so i understood that you are working on something in order to put together the funding mechanism for yourself at 240 000 is what i heard yep i just wanted to make sure i heard that y'all were working towards that which yes ma'am we are okay okay and then and then secondly is um is your is that through um um is this is this through the company or how are your how would that money be audited okay that
Speaker 24
51:30
would be uh um if if we were to receive money from the government it would go into i'm talking about your assessment fee okay
Senator Missy Irvin
Unverified
51:37
our assessment fee would fall under our treasurer it
Speaker 82
51:40
would go to our treasurer's department and it would be under legislative audit just like everything else
Senator Missy Irvin
Unverified
51:46
we do gotcha okay so whatever mechanism you put in place yes ma'am similar to what they have be under a yearly legislative audit yes gotcha okay and then um and then what level of accountability
do you have with the ambulance provider themselves as
of right now or in later was of right now so i mean like are they pay are they up
on paying their taxes are they we done able to you see what
Speaker 24
52:16
i'm saying the county we hired a uh a firm it wasn't an audit it was a review and we paid out of county funds to do that review and they have a shortfall with payroll and their taxes
Speaker 117
52:29
have not been met and that's one of the
Senator Missy Irvin
Unverified
52:32
things that's not so the the taxes that they have paid have not been
Speaker 117
52:36
met yet as of that time that was six months ago
Senator Missy Irvin
Unverified
52:40
he may be up to par now okay this is the ambulance provider yes ma'am uh the thing is because because i'll tell you i mean i think that's important that you have done that because
what i don't want is for us to subsidize someone who is delinquent absolutely and
Speaker 22
52:58
i don't want you to do that either i don't want uh yeah we covered that senator okay it's not previous meetings okay it's not the county
Speaker 25
53:05
or the or the state's responsibility to to award mismanagement
Speaker 24
53:11
right however when you talk about subsidies and it
scares me because because if if we ask for an ambulance service then the guy who sells tires he can say well they're a private entity i need to sell tires because you got to get to the hospital so but the thing is this is a matter of public safety and it's a real gray area it is and that's why it's taken me so long to get my ms board in place because i have been private you know we've had open forums we have public meetings we've nearly had rocks thrown at us i mean we're at we're at the ground level and people just when you say taxes they just go nuts and i know that
Senator Missy Irvin
Unverified
53:47
there's i know cleveland county a lot of my counties are dealing with this and i final question, but have you, you know, one of the things that I think when we do look at this issue is the level of funding through Medicaid, or I mean Medicare is federal, Medicaid is ours, so have y'all looked at that as far as your, the Medicaid funding portion of that? Because to me, that's an area that would be more, that I would feel more comfortable with
maybe looking at and changing versus going an alternative route which would be more equitable across the state. Does that make sense? It makes very much sense. They are going to
address that and it was mentioned earlier. It's been 25 years since that rate has been increased and I
think the next set of presenters is going to get into some real details on that funding.
Anything further sent urban no thank you okay thank you very much uh gentlemen anything further from you two before
Speaker 29
54:51
we move on to the next presenters i will say it our situation is dire tomorrow night we've already organized a meeting for a volunteer ambulance service because i don't know that the 30 days now i don't think the existing one will be there honestly we've already had the it's going to close down friday it's going to close down friday they've got another 30
Speaker 33
55:13
days funding and I'm not pleading poor man but I mean I'm trying to put together something to fall back on we were lucky enough that children's hospital gave
them out of the Perryville fire
Speaker 30
55:26
department one of their old ambulances we're gonna get it retrofitted we have I think around 50 EMTs that most of them work at Little Rock and fire departments just at another trying to get a volunteer basis up for once something happens and we're not prepared so we'll have something in place that's my worst fear is having nothing in place when 9-1-1 in the weather you'll have to get there yourself there's nobody can that that's what i'm afraid is fixing to happen
Speaker 98
55:56
so we're trying to get something in place um
Speaker 24
56:05
thank you all right anything else judge move to the next panel severe to be the severe ability of it is that with modern technology i thought if the current ambulance service if they were mismanaging that they would kind of fold and the other services in the neighborhood would come to our rescue and they will but they see the run volumes too because we have computers and technology they see that we're we don't have the volume of the money to sustain them that's all i
have on that but once again i'd like to say thank you all for allowing us to come
here to listen to our we appreciate it and and i will say i thank you for the efforts that you put in there locally there's no doubt that you've been trying to figure out an alternative to it and uh and the reality of it is is you have come and you've articulated to us a plan going forward uh but we also know that have a shortfall that you need to meet one way or another and i guess it's up to all public service to decide what's true emergencies or not but thank you for your time i'm going to move to the next uh panelists i would have okay okay uh let me call these off i want amanda warren and
ken kelly and jamie pafford grisham if you would come take your place and i'll recognize center
Senator Missy Irvin
Unverified
57:18
urban one thing to the gentleman that just left you might contact van buren county i don't know if
you have already or not but fairfield bay fairfield bay operated a volunteer ambulance service for years and the mayor there would be very helpful paul wellenberger and if you'll stick around i'll get you his phone number to contact because i mean i know that they were in similar situation and so i would really recommend that so i'll reach i'll come over and give you their
number thank you mr chair thank you thank you if you would please just state your name and who you represent
Ken Kelly
Unverified
57:55
for the record and we'll recognize you for presentation okay thank you mr chairman thank you members of the committee my name is ken kelly i'm the president and ceo of pro med ambulance in el dorado and also the
Speaker 166
58:08
government affairs chairman for the arkansas ambulance association okay i'm jamie
Speaker 168
58:10
pafford gresham i'm also a representative of the arkansas ambulance association and part of their government affairs as well as i represent the american ambulance
association in a board spot and i serve on the 9-1-1 board you helped put together but we are a pafford ems and we actually service 10 of the counties in arkansas thank you amanda newton i'm
Speaker 172
58:31
the president of the arkansas ambulance association and the ceo of columbia county ambulance in magnolia thank you very much thank
you all for being here uh i don't know which of you would like to go first but i will let you decide that and begin your presentations and comments thank you
Representative Nicole Clowney
Unverified
58:50
our goal today is to provide you guys with some information and our thoughts about some of the critical issues that are facing ambulance services across the state and as you just heard from parry county there are some issues that our our state is facing and often whenever we're here before you were here to discuss a stroke or a STEMI or a trauma patient that's usually what you've heard about how we respond to 9-1-1 calls but today we aren't here to discuss how we respond to others today we are here to actually place a 9-1-1
call to you all as you've heard there are some critical issues that our ambulance providers across the state are facing and we're afraid that the critical issues are very quickly moving toward a crisis situation as you've just heard a few moments ago there is a county in our state that is actually having to look at the life of the ambulance service the life of the ambulance service is in jeopardy and unfortunately that's not just one county and we have several providers that are behind us in the gallery and there are many counties in the state of Arkansas that are facing a very similar
crisis situation so we're here today to discuss that with you guys right now as it stands the state of Arkansas has a very robust emergency medical service the system 73 of the 75 counties are actually covered by an advanced life response advanced life support ambulance which is the highest level of service that our state licenses and having that paramedic readily available is important to those communities after five o'clock there's seldom not another resource the
doctor's offices are closed there's not hospitals in many of these counties so having the ambulance service there is vital and to the safety of the people that live there. We're an essential part of the public safety net, so funding for us is crucial to us being able to be ready whenever the call comes through. For more than 40 years, the Arkansas Ambulance Association has served the voice of providers across the state. We represent all levels of providers, public, private, hospital-based systems, and volunteers, and we have been
innovators and champions for quality care for the citizens of Arkansas for many years now. Over 60 percent of our state's providers come from the private sector, which has a significant impact on the local economies and the state's overall economic impact. Over the years, we haven't came to you with open-ended questions, and we'd like to partner with our local and state leaders to develop solutions for the EMS communities across the state, and we've taken the initiative to educate the public, our industry partners, and key stakeholders
about issues related to EMS services. In the late 1980s, the General Assembly passed legislation that established the Municipal Ambulance Licensing Act, which helped stabilize ambulance markets and ensure financial viability for providers across our state. On the national stage, the Arkansas Ambulance Association has made the case and continues to make the case to advocate for Medicare payment add-ons for rural and super rural counties, which is most of our state. I'm going to interject for just a second
because members this actually this presentation is in this folder in front of you it wasn't loose and so we would just make
sure you're aware that you've got this you
Representative Nicole Clowney
Unverified
1:02:08
can proceed. Thank you Senator and finally the Arkansas Ambulance Association has vetted the process and helped you pass legislation to establish the upper payment limit program that mirrors the supplemental payment programs that have already saved many of our state's hospitals and nursing home facilities so clearly we understand that industry viability takes a lot of work and as an
association we are here to do that process along with you guys I would like to turn the presentation over to mr. Kelly who will continue to provide some additional
Ken Kelly
Unverified
1:02:39
perspectives thank you mr. chair members of the committee thank you again for this opportunity as we've heard today we have laid the groundwork for trying to understand the importance and the essential services that EMS provides. For my portion of the program, as Senator Rapert mentioned, you have a pretty detailed packet. We're not going to go through every slide in detail in there. I think a picture sometimes says a thousand words, so I will keep my comments very brief, but I just kind of want
to give you a perspective since it seems to always come back to dollars, and we always are focusing on the dollars, which is important. Just as important as the life is to making sure that the life of the ambulance service is sustainable. Many of the ambulance services, I would say the The vast majority of ambulance services in the state of Arkansas are fee-for-service, irregardless of how they are established. Your volunteer services rely on fee-for-service. Your fire departments, your hospitals rely on fee-for-service. So when it all comes down at the end of the day, irregardless of the type of model that serves the community, we all have to have a mechanism in place to ensure, one, you have
value and you have quality, and that quality has to be reimbursed in some shape, form, or fashion. As it exists today, there are a variety of ways that ambulance services are funded around the state. In many cases, as you've heard, there are communities that provide general subsidy funding or through some form of assessment or a tax or a fee. There are certain areas that have formed ambulance districts which afford them a little bit of flexibility in how they spend those dollars. And then also hospital systems sometimes provide foundation funding.
The other sources of funding, of course, are what we call peripheral funding. doesn't always account for the true cost, and that is in the form of statewide subgrants that come to all ambulance providers through our Arkansas trauma system and through a Arkansas Citizens First Responder Safety Enhancement Act, which was a fines fund, sort of a, I guess you want to call another one of those sin tax funds, that we assessed people that did not have proof of insurance. Those dollars were also directly returned back to EMS agencies. But as we have
seen, irregardless of whether it's local revenue, state revenue, we have always been in sort of a capitated market. When you look at a payer mix for an ambulance service, and you've heard mentioned the major payers, Medicare and Medicaid, which accounts for the largest portion of any ambulance service's revenue base, there are really four primary payers. Medicare is the largest, about 56% of any ambulance service is funded through the utilization of Medicare dollars. About 13 percent, and that number has gone up certainly since about 2014 with the passage of the ACA and the Medicaid expansion,
about 13 percent now fall under the pure Medicaid bucket. About 16 percent are commercial and private insurance, and then the remaining 15 percent are usually private pay, simply out-of-pocket expenses. In this payer mix, you can see, based on just the top two payers, 69 percent of our revenue is automatically capitated, whether it's through the National Ambulance Fee Schedule that is established for Medicare as the payer, and then also the Medicaid rates, which are established in our state plan for Medicaid spending.
Three points to point out on this. Most of your commercial payers, the other 16 percent of what we consider viable payers, often follow many of the managed care principles of Medicaid and Medicare. So we're seeing more and more commercial plans having capitated revenue or capitated benefits, particularly for the non-emergency business. Maybe they cover emergencies, but we often find that the non-emergencies are what they do not cover. A national survey by the American Ambulance Association, and just looking at how effective this capitated revenue is,
For Arkansas, as many rural states, the Medicare ambulance fee schedule has actually been demonstrated in survey to be about 16% reimbursed below the cost of providing the service. So having the fee schedule is a good thing for cost control, but it has also limited the ability for us to meet narrow margins in a very narrow industry. And specifically to the Arkansas Medicaid rates, the number is actually 25 years since we've had any substantial increase in base rate funding.
In 1993, we were successful when the ambulance fee schedule was coming into existence. We were successful in taking Medicaid rates from $59.11 for advanced life support. Well, actually, it was for any level of ambulance service. We were able to make the case that because of the expansion of advanced life support services, we needed a rate increase. and we were able to get that rate from 59 11 to 86 percent of the medicare amount which we thought was based on cost and back then we had the process of call reasonable charge you could go and you
could make a case that that was a reasonable charge that lasted for one year unfortunately we did not codify that increase in any form of legislation it was simply by a memo at the end of the session in 1993 that we would raise these rates for one year because we had ambulance services that were struggling. Since that time, that honor agreement to keep it at 86% of the Medicaid allowable has fell by the wayside. And now we see that our rates are anywhere from 57% to as much as 215% below the areas around us that have similar demographics as well as the
national fee schedule. And when you look at the national fee schedule, the way that we got some that disparity in the medicaid rates and the medicare rates is that we as jamie mentioned she's been on the national stage and we've certainly in arkansas been at the forefront of arguing that for rural states the cost of readiness the cost of having this in rural communities has to be subsidized or has to be supported in some way simply not by volume i often say we can only run so many people off the road but uh that's that that is a joke by the way
um but uh there there has to be some way to supplement that and so the national fee schedule does account for what it determines to be rural and super rural areas and then there are payment extenders that are added onto that for example in the medicare fee schedule in a super rural area they get an automatic 22 percent bump in medicaid in medicare rates excuse me and then the rural areas also get a bump and then if you travel for more than 17 miles or more than 50 miles beyond your service area there are some mileage bonus extenders on there as well
if you look at the demographics of arkansas better than 81 percent of the state fall into the rule or super rule category and for the purposes of our discussion today i don't want to get bogged down into what's determined by rule and super rule but just to say that 81 percent of our state we feel would fall into the category that would require some form of supplement simply because of population density and call volume if you look at the how that breaks down across the counties there are about 11 percent urban and those are typically your metropolitan statistical areas
around the garland county area extends down into the pine bluff market a little bit hot springs in garland county in and of itself as well as the area in northwest arkansas so typically that's the areas of the state that fall into the urban everything else even the the small percentage that have some urban areas in them count for again better than 81 percent rule the next two charts if you're following along in the packet these are the ones that really tell the tale of why we're here today and how we think you can help and this is a 27-year snapshot chart comparing the medicare
the blue line medicare ambulance fee schedule and then the orange or red line that shows the medicaid reimbursement for similar services and this just compares the one reimbursement code and that is for advanced life support ambulance service which is paramedic level ambulance service that most of our counties enjoy around the state the gray line in the middle is the agreement the 86% of the Medicare allowable and showing where we should be so if you look at the top line where we'd like to be and you have the gray line in the middle where we should be
unfortunately as in medicine we are flatline we are the orange line and that rate was increased in 1995 and it has remained the same since 1995 if the next slide compares our second payer code which is the bulk of what is paid beyond a cost of readiness or a base rate code and that is the mileage code and you can see the graph is very similar in that the Medicare line has steadily increased as cost of increased if we were to match at 86 percent allowable you can
see where we would be instead we have a virtually flat line with the exception in 2009 we did receive a small mileage increase this is when fuel prices hit almost five dollars a gallon we were able to get a mileage rate increase only but that has been flat since 2009 so other than the one bump It has been 25 years since there's been any substantial increase in change in funding for ambulance providers. Ken, on that point,
Speaker 11
1:11:51
who makes that decision for the state?
Ken Kelly
Unverified
1:11:54
I assume that that is part of the state fiscal budget plan, and it is presented to DHS as part of their budget to make recommendations for rates for all classes of providers, and then that is codified in the state plan amendment that's
Speaker 183
1:12:10
submitted for approval. Okay. Thank you. proceed the
Ken Kelly
Unverified
1:12:13
the next chart we won't spend a lot of time on this this is just showing how not only are we flatlining on rates in some ways we're also declining this is the trend line for the the Arkansas citizens first responder
safety enhancement fund this was the special fund that was set up that provides assessments against those that don't have proof of insurance just to show the impact of the new online insurance verification database. As that moves into the electronic age, there will not be as many fines assessments for people that do not have insurance. Now, we know they don't have insurance because we see that when we try to reimburse for our ambulance bills, but we will not receive that funding, and so that fund is virtually fixing to go away. Over the life of this fund, it's provided about $3 million. We have funded well
over 70 ambulances every at 70 ambulance services every year through what we call ems development grants that's everything from buying new cardiac monitors to new stretchers to upgrading equipment on the ambulance buying new ambulances we it doesn't pay for it all together but it certainly goes a long way to help ambulance services but that fund is also going away and then we've heard a lot about you were asking lots of questions and i can't thank you enough for trying to drill down to the cost of the ambulance service we have put in your packet a one pager that has the ambulance
in the upper right corner and i broke out just a couple of things on this the rising cost portion just to kind of give you a perspective of where we were when we set these medicaid rates in 1995 and and 2000 and 2009 and moving forward in 2000 ekg monitors would run about 13 500 those are well over $30,000 pieces of equipment now. Ambulances, if you remounted an ambulance, you took an old ambulance and just put a new set of wheels under it, it would cost you about $45,000.
That is now $85,000. And you can see in that last column, those are hundreds plus percent increases in cost. And some of those, you say, well, we'll just push it a little bit longer. Unfortunately, as an example of the cardiac monitor, that is no longer an optional piece of equipment. As we have expanded our systems of care for taking care of heart attack victims in the state, we have now made it mandatory that all ambulances, all paramedic ambulances have 12 lead equipped EKG monitors. So when you thought you could hang on to the $14,000 heart monitor for
maybe another five years, now that has to be upgraded to meet the current standards. Same thing on our ambulances. People that would remount ambulances over time, new safety standards now require that they, if they are remounted, they have to be upgraded and added specific to patient safety equipment, which is a good thing for patient and crew safety. So many of the costs continue to go up. Medications, the opioid crisis is certainly hitting us, just like it's hitting other segments of health care. Our medication costs have gone up more than 800 percent in the last few years. Our airway management equipment continues to go up, and so we seek cost all
across the board but probably the next biggest thing and as jamie's as amanda said we're moving from critical to crisis and this is the one that we as the arkansas animal association think is the most detrimental and why we're here today and that is the rising wage cost particularly associated with the minimum wage increase prior to this last three years wages in arkansas for paramedics increased over a 20-year period about 54%. For EMTs, they increased about 47% over that
period of time. And really, we only have two wage segments within the animal sector. It's entry level, which is an EMT, which is the basic level of training, and then paramedic. There are a few services that use the advanced level EMTs in between, but for the most part, your wage structure is based on entry-level EMT or top-level paramedic. And since the minimum wage increase, year one it doesn't impact the industry too bad most providers reported about an 8% net increase in payroll and that was primarily only associated with those new
entry-level workers maybe that came in below the minimum wage year two there was about an additional 28% increase that hit this year January 1 and that 28% affected mostly again entry-level workers going up one more notch maybe services chose to go ahead and spread some of the cost to their higher level workers at the same time. But year three is going to be the critical or the crisis point. In year three, for the vast majority of most rural ambulance providers in the state, entry-level EMT wages will equal high-level paramedic wages. So there's going to have to
be some pay parity there in order to make those differences. And providers are seeing that in loss of employees, seeking other jobs that they can be recognized for their skills and their talent. Many are moving to other segments of health care, such as nursing. And so we really think that in this three-year period, where it took us 20 years to get 54% to 47% wage inflation, we're going to see 58% come January 1 of next year. And many providers are not prepared for that massive wage increase. So we're very concerned about it.
But as Amanda said, we have had some innovative solutions through the years. We voluntarily raised our fees and permits and license fees on ourselves in 1993 in order to fund the Medicaid increases. That was part of that agreement that if you raise it to this rate, we'll help raise the money. And we did that through federal matching dollars, and those matching dollars continue to flow to the health department today to fund that 1993 level increase. and the most recently in 2017 with your help we passed the ambulance upper
payment limit program and this program is the same program that is used for our hospitals and our nursing homes and has been for more than a decade this is a voluntary assessment by ambulance services across the state there were some exclusions in the law at the request of the providers we excluded municipals and government-owned services and we excluded hospitals that were already part of another cost reporting or another UPL program it was not intended to carve out any ambulance provider because we didn't want them to benefit in the program it was more a timing issue for the private sector we
could move faster through the decision process than cities and counties could move through that process but they are certainly still eligible to participate through intergovernmental transfer of funds and this could be something that for Perry County could be done immediately in the form of sending up an intergovernmental transfer to match those federal dollars and bring them back to the community through the UPL program. 43 out of 50 states have UPL programs for health care, particularly hospitals and nursing facilities, and 17 states, and you'll see the map in your packet there, that shows 17
states that have specifically implemented ambulance UPL payment programs. And you can see Arkansas in the center there, we're surrounded by states that are very active in this process. There are really three different strata of programs that take place that. The green is the public-private partnerships where public entities and private entities contribute to that program. In the orange states, that's the ones where the privates are now being added into what was already existing public programs. And the pure red states, they are public. There are discussions
about adding privates there. They just haven't taken active steps. And then you also have to look at the demographics of the states that are public only providers many of those states are heavy fire based ems systems that there's not very many privates in the states that operate in the 911 arena whereas in arkansas we're better than 61 percent private sector so we think the upl program is is an absolute must to get some critical funding flowing these are also dollars
that cost the state nothing. These are self-assessments by the ambulance companies sent up to the feds for matching and brought back. And we can talk more in detail if you have questions about how that program will work and how it would benefit the state. And then lastly, before I turn it over to Jamie to kind of give perspective of where we think we need to move, is our Medicaid rate rebasing. You've seen the chart. You've seen the 25-year, the flatline. The demonstration of the inequities in Arkansas Medicaid are very clear. We have known it for some time. We very seldom come
with our hat in our hands, but today we have our hat in our hands saying we've got to fix this problem. We met with DHS in July of 2019 to go through the numbers. The next chart on the next page shows how we compare. Again, if you look at just the pure numbers today as DHS records them and the codes down the left are our reimbursement codes, everything from advanced life support to basic life support, you can see that we're about 172 percent below the six states that surround us. If we were to add in a rule modifier, as is recognized by CMS and what we think is absolutely
critical for Arkansas, we would be 215 percent below our neighboring states that have some of those modifiers. And so we absolutely think that we need to make that adjustment. We have gone from first place in the region to now fifth place in the region and in addition to pure base rate codes there are also certain other technical aspects in the reimbursement rules for Medicaid that we need corrected it's not so much that we need to find new dollars we just need to be able to collect the dollars that are
already rightfully due to us but we have technical problems in the manuals that need to be corrected for better than 15 years we have pointed out that two base rate codes are actually flipped you actually get reimbursed more for a non-emergency service then you get reimbursed for an emergency service and that code has been flipped for I know at least 15 years if not the 25 years that existed and we have to get those kind of corrections done there are also some modernization of the rules that need to take place we have two sets of rules on getting physician certification statements Medicare allows for
physicians and nurses that are caring for patients and discharge planners to authorize certain levels of ambulance service where Medicaid strictly requires it be the physician at the time of service. Well, in most cases, the ambulance does not get to hang out with the patient. We only have about 40 minutes of patient contact time to get information, and then we have to either go back to our service area, as Perry County would state, and return to their service area, or we have to go back and chase down paperwork later. In many cases, small ambulance
services lose track of those claims those then become non-billable claims because either the lack of timely filing trying to get the information or they simply just give up trying to track it down so there's some technical clarifications that we could certainly use your help on in getting those rule changes fixed and with that I know there's a lot of detail there and I talked very quickly but I was told that I had to get it all in and I appreciate your patience and your time I'm going to turn it over to Jamie who kind of will give us the overall perspective of where we go from here we told
Speaker 50
1:23:27
him he had three minutes it really is a lot of
information and again thank you for the opportunity to sit before you you can
pull that mic a little close to you there that'll help you
Speaker 166
1:23:41
sure again so again we thank you for the opportunity to sit before you and discuss our ambulance issues across
Speaker 168
1:23:47
Arkansas you're here today about the rule issue but what we want to also make sure that you understand that this is an issue across all 75 counties of our state because as larger providers as smaller providers go out larger providers are having to take up the slack and meet in the middle to make these transports and
take care of these communities so it's very important to look at the overall picture and as you can see from all the information that ken has put forth before you today we've been working and hustling this for quite some time this isn't something that we just decided this year oh there's a minimum wage increase we've got to go do this we have been you know we've had the forethought to go forward and try to work with um dhs to see if we could make some changes on our own um and we really are a group of people that like to solve their own problems and we've not been able to solve this one and that really bugs us and
i want to i asked this question earlier and
i just want to hit this before you close down on the presentation uh 25 years no increase this is not something frankly just happened overnight who has been the entity or the agency that you have been discussing this with that you've been sharing this data with that you've been trying to wrestle this issue with is that DHS or is that the Department of Health who has been sort of the direct contact for you and your entity with the state as it relates to these policies so we've had more than one
Speaker 166
1:25:07
but I will say first and foremost that the Department of Health behind us
Speaker 168
1:25:11
the division of ems has been very helpful and very supportive with everything that we've went over to the other side to the division of medicaid and worked through dhs and their programs to try to get these things fixed i mean we have had a lot of uh overturn and heads of of the departments we have some folks that have been there for long periods of time that know these issues are there but yet their hands are tied at some level i think that they really you know they want to listen to our
problem but i'm tired of holding the hat in my hand and ringing it because i have ringed it and i'm not we're not getting any
results at this point that's interesting to me so on a regular basis you've been pointing out the funding issue in the flat line for 25 years is that correct yes sir and and when you articulate that issue what is the response that you're given we're in line they just we're not we can't do anything right
Ken Kelly
Unverified
1:26:08
yeah i mean they've been receptive to you know
provide research and and but it's just like we know we know you're in line we're going to do something and and we go general fiscal to general fiscal every year with making the case uh as you said i've been this is my 35th year in the business my first day as a member of the arkansas association board was to pick up the letter that gave us the 86 match to Medicaid and I've trended that since that time and every two years when we get to a general fiscal session we think we're going to make the case to get an
increase and it just keeps just flatlining all right I want
to I want to go on here we've got some people getting in queue I'm gonna let you close down because I know you're about finished and
then if thanks Center urban's back in the room, Senator Irwin, I would love to hear from you and Representative Laideman if they've brought this issue before your public health committees on the flat line of the funding because I know it hasn't made it our direction. So with that, I'll let you finish and then we will pick up and hopefully get some responses and some questions asked. I'm a little bit faster talker than Ken
Speaker 166
1:27:15
and I will say that the 25-year number
Speaker 168
1:27:17
comes very easy to me because while he was running around, I was nine months pregnant with my daughter 25 years ago, making sure this happened, and she turns 26 next month. So this is long overdue, but, you know, we've already told you guys that we really feel that we're at the brink of a health care crisis in our state, and I can actually attest to the fact that due to low reimbursements and the inability
Speaker 166
1:27:41
of our communities to properly be subsidized, as you've already heard today, or fund the ambulance systems properly,
our providers find themselves living from Medicare check
Speaker 168
1:27:48
to Medicare check just like the Perry County gentlemen, especially our rural providers in the underpopulated counties. Myself and others on the board have received phone call after phone call from different providers around the state just looking for relief and asking for help. What do we need to do? What answers are there?
Speaker 166
1:28:05
Just like you guys are looking for answers. We've been looking for answers for quite some time. So again, just having this conversation with you has elevated it to
Speaker 168
1:28:13
the place we think it needs to be.
But although our providers find themselves short on funding, they are not short on compassion. And I think that you will hear this no matter if it's
Speaker 166
1:28:27
public, private, for-profit, not-for-profit, hospital-based, they provide excellent care for our patients across the state. Across the state, as you heard earlier, we work with the Department of Health
Speaker 168
1:28:36
to strive to bring a level second to none in the nation. When you think about it and you hear the number that we have 73 of the 75 counties in Arkansas
that receive advanced life support care. That's amazing. And to be clear, for anybody that is still wondering what that means, that means you basically have paramedics in the back of the ambulances with advanced life-saving equipment, with basically many ERs on wheels, to put
Speaker 166
1:29:02
it as simple as it comes, in 73 of the 75 counties. And so I applaud them for doing that. But I want to point out the importance of that EMS provider.
Speaker 168
1:29:11
in many of our communities, we really are considered the health care safety net because, you see, ironically, of those 75 counties, 20 of them are without hospitals,
Speaker 166
1:29:22
and you have to wonder what do they do at that point in time. An example of what I would mean is, you know, whether it's Mariana, Arkansas, clinic closes at, you know, 5 o'clock on Friday or maybe it's Thursday, whichever day it is, and then from then until Monday, who is the health care provider in those communities? It's the ambulance service. And when you have an incident happen after five in those kind of communities without hospitals, everyone depends on the ambulance service. And this is why it's so important, no matter where you live, that we really pay attention to the problem at hand because we are the last safety net at the end of the day.
You know, it's pretty much obvious that the statewide trauma system has been a huge benefit to our state. you know this body passed this into legislation years ago and that our state works very hard hard to offer and encourage additional education and training for our clinicians to take care of the patient and they're always going to do what's right and you know many times that means that our rural ems systems find themselves taking our patients out of our local counties and our communities in order to get them the proper trauma treatment they need for their specified injury
you know whether it's an emergency or a transfer because i feel like both calls are just as important. A transfer is just as important as an emergency, especially with a lot of our STEMI and stroke patients. But, you know, transporting them to the most appropriate facility enables the patient to have the best recovery opportunity in the end, and that's what we should all strive for. But, you know, to recognize our medics at this time, and I really appreciate a lot of folks coming in today just to be behind us, supporting us, letting you guys know how important it is to us. They, the success of that system relies on them and their total, their triage of the
patients in the beginning, and the triage and treatment that they provide, making sure that they're getting to the right location at that time, but realizing that we're asking a lot of them to transport these patients, sometimes very long distances. Coming from Hope to Little Rock is not easy. Lake Village to Little Rock, all over the state, we bring it we call it the little rock bubble no offense but that's what it is and you know we ask a lot of them and we test their skills and our equipment when we do something that long but being ready at a moment's notice is the challenge
and the cost of readiness which several people have actually pointed out seems to be an afterthought to this process but allowing access to care and preventing patients from being hospitalized rather than the inability to be transported is a concept we do feel that we need to embrace as we move forward and I think it was Senator Irving that mentioned that while ago but you see we're only reimbursed when we transport the patient there's no other funding unless we actually put the patient in the back of the ambulance and transport them and whether there's we feel that there's other options
available not only is we looking on it at a nationwide at a nationwide level we should be looking at it at Arkansas alternative destinations treatment without transport and community paramedicine as someone else mentioned that could be tapped in producing better patient outcomes and then show an overall savings to our program in the state and and we have discussed this in previous meetings with the department as well but to be the primary ems provider in these areas many who don't have hospitals and experience very low call volumes is a challenge and and i appreciate someone who said earlier i
think it was the county judge if you have a provider in your area struggling don't pass judgment on them it is most likely that they are running on fumes and from old rates and they're tired they're overworked they're trying to make ends meet and they have the compassion to take care of their community and that's why most of them are holding on is like I can't leave the gentleman that keeps making his payroll he's just keep making his payroll because he realizes that there's a community there that's in need they need help you know I spend a lot of time in washington advocating for ems issues across america and um i off i like to say we're
special and i believe that i absolutely believe that this group of people is special because you know unlike some providers we treat the patient regardless of their ability to pay we don't get to opt out of programs we don't get to refuse service you call 911 and we're going to be there and we don't question that you know all of that is after the fact we take care of the patient and the poor billing office has to worry about it in the end you know public reliability on our ems systems actually across the state is at an all-time high and although you have the pockets
that are struggling people really do rely on their ems systems and and most of these systems are locally governed and regulated with charge fee limits and response time requirements to take care of the patient when they call 911 regardless of their ability to pay but very few counties offer subsidies like other states i actually provide ambulance services in four other states in the u.s virgin islands and the fact is other people get very creative on how to get those funds in but the fact is arkansas is a poor rural state and there's not a lot of money to pull from
the fear that someone in your area could soon call 911 and not get an ambulance i believe is real as we continue to move forward and we continue to get phone calls from the ambulance association standpoint we're concerned. With that being said we answer the call every day and today as Amanda said you know we're here before you get calling 911 asking for you to help in this crisis and taking care of the patient has become one of the easiest decisions that we make and the difficulty really comes with how do we continue to provide the same level of care with our diminishing revenues
and the skyrocketing expenses that we have. And, again, that number, you just can't believe it when you say it. You have to scratch your head. We have not had that increase in 25 years, but yet we've been paid the same amount, but there is so much more that's expected of us, and there's so much more that we want to do for the patient than we did 25 years ago. You know, how this continues to ensure that the true safety net provider of health care in our communities is protected is before you, and you have definitely answered that charge. As you heard in the beginning, the Ambulance Association wants to help be the solution to the problem.
One of the things that we really recommend is that when you have problems in your area, that you reach out to the Ambulance Association. And we have a toolkit that can go to communities to say, you know, these are some opportunities. These are some things you should look at. You'll have better information. You'll have better numbers. Most of the people back here were having a heart attack when they were hearing the numbers a while ago of how much they thought they were going to run an ambulance service on because we're like, can we get in? We wished it cost that little these days because the numbers are high, and I believe one of the representatives over here spoke up about the payroll not even being correct, and it will go up again in January.
You know, we need DHS to realize that we need help and that there are opportunities to enhance the health care in our communities, and while saving money in other areas and being fluid with the market, as the market changes, we must do that as well. and our ask today is very easy and direct and there are a few things that cost you absolutely nothing that Ken's talked about so there's no physical notes attached I see you've got your pen pencil handy so go ahead let's we'll
write it down here what what I need you to do but really y'all got you it's in the yeah you have it in the packet but just to reiterate we have to ensure that the legislation that you guys passed nearly three years ago the UPL program is properly enacted and it needs to be enacted soon and it needs to make understanding that helping bridge the gap with DHS and CMS on our supplemental payment program providing assistance with that upper payment limit process is is our number one ask and it doesn't matter to me if it's a phone call a
letter of support but we need it on the top of your list and amending it so that it includes non-emergency transports with partnerships with local governments we feel like is a solution to the rule issue and making sure that those patients require our professional treatment and access to care just the same as the emergencies. And when you talk, the judge talked about them losing calls, you know, if they were gone and they lost a call, every transport counts to make that gentleman's payroll, and that's why it's so important. You know, later on you're going to hear about the mental health crisis. This is part of that realm, making sure that those transports are taken care of.
You need to instruct DHS to work with our association leaders to correct our errors that we've already talked about in the billing process and this is actually inhibits us from properly billing calls in a timely fashion and that opening some dormant payment codes and allowing us to maximize not only our UPL payments but our opportunities with community paramedicine and things like that would be very helpful in this state you know it's in the biggest thing that I feel like you know you guys need to institute the long overdue rate rebasing of the
Ambulance Association we financially need your support to do this to have our rates increase across the board to be compatible with our neighboring states when he told you we were fifth that was one of five you saw the map that the people touching us you know we're one of five states and at the lowest it it and we used to could tout that we had one of the best systems and and we're just on life support right now mentioned rural health representative love mentioned rural health clinics rural hospitals rural physicians in Arkansas you have all of that and they get an additional bump in some type of pay but you do not
have a designation at the state level for a rural ambulance service and that has already been something that Medicare has set precedence for and we should absolutely look at to take care of these rural communities if you think about the helicopter I heard someone ask about a helicopter while ago you know I have a brother that has a helicopter and I'm not they're great when they're needed but a lot of times they can't fly and when they can't fly everybody's turning around and asking where's the ambulance well you've got to make sure that you're properly funding that ambulance that's in the ditch waiting on the helicopter
to land at the nice safe zone before we can move forward with that so making sure that their designation when they go to that rural area they get a 50% bump from Medicare when they when they land in a rural community that's why you see a lot of landing zones in those areas making sure that those patients can get out you guys have had a lot of information thrown at you and you may ask yourself like where does this fall in your priorities and I love to tell the story and I'm gonna leave you with this thought you can put it in the
scenario of a car wreck going back because when I drive all over Arkansas just like you guys do coming back and forth to Little Rock I always think about what ambulance is gonna pick me up if something happens to me and there's a wreck on the side of the road who are they gonna call what kind of coverage am I gonna have what's gonna happen but if you put it in a different perspective and you leave here today and you head home and God forbid only to find out that your home is on fire and you think you know what I wonder if the fire truck is on its way and will it be able to save my house and you go on down you turn down your street and you go into your neighborhood and you see someone running down the street and they've got some of your
belongings and you go oh my god I hope somebody called the police and I hope he gets my stuff back and you know you keep driving on and you pull up to your house and then you realize you guess your house is on fire and some of your belongings just went down the street and then you realize you have a loved one that's in distress and they're on the you know front yard the front lawn and maybe they're passed out um your immediate thought is where is the ambulance and at that moment your number one priority come becomes that your family member and it's not
is the fire truck going to arrive am i going to get my stuff back but you're going to really care about your family member that's in distress at the end of the day and wondering where is the ambulance and can someone call 911 and get the ambulance there and you need to make sure that we all properly fund it to take care of it so that we're ever put in that situation and that phone call comes in that all of us can respond to you in a timely proper fashion
thank you for your time today thank you excellent presentation members do remember that everything that was shown here is in this packet in the folder that was on your desk we do have several questions
here for you and members just remember we do have a follow-up with senator hickey and representative perry on the non-emergency side of this so if we could get our questions taken care of senator hammer you're first in queue if you're still want to ask a question sir thank you you uh ken you made
Senator Kim Hammer
Unverified
1:41:46
a comment a while ago and used the word mandatory and just for personal reference i started as a volunteer on the des arc ambulance and then before you probably got out of high school i worked for paford out of lone oak so yeah i've been around a while on that side of
of things then finished up with MEMS but my question is this how much of what has been mandatorily put on you is responsible for the increase of cost and do you agree with all the mandatory things that have been put on you that we as legislators or the federal government has put on you and do you see any room to eliminate some of those mandatory things and I and I get whether you're getting the guy out of the combine that got his leg caught in the combine
or your CPR on a two-year-old kid going from a rural area to a hospital 30 miles away. We all want the best for everybody, but how much has been placed on you mandatorily that you don't agree with? I think it's safe to say
Ken Kelly
Unverified
1:42:48
we are well-regulated. I mean, we are a regulated industry, as most health care are. I don't think that I disagree with some of the mandatory requirements, particularly such as the cardiac monitors, very important to be able to identify those heart attacks and get people to the right place at the right time. Some of the medications that we're
now required to carry with regards to stroke management and respiratory, I don't think that we're arguing the mandatories as much as we are sort of policing our own industry and saying this is things that we should have done years ago that providers took the easy way out. So I don't know that there's anything that we can reduce as far as mandatories. I think it's a good thing. I think it provides for protection for patients. I think it provides for protections for communities and the providers themselves. The mandatory things that come from the feds have to do with the
capitation of the rates. We continue to make the arguments. Now, where we're at in that process of the national fee schedule, and I didn't touch on this in the presentation, we are unlike any other segment of health care that has to do cost reporting. Hospitals and nursing homes and and durable medical equipment all do you know cost reporting the ambulance industry has always been based on anecdotal survey data to know what our costs are and our true cost beginning january one of this year the federal government cms has started mandatory cost data collection for ambulance
providers that is going to be a five-year process before that data is collected analyzed and and and any meaningful way make adjustments in those schedules 25 i think there's 16 providers in arkansas that are required by next year to report their actual cost of doing business so i think in five years we will see some of those what we consider mandatory pressures today where we'll probably see adjustments but i don't think the industry i know certainly the small rural providers in arkansas we can't wait five years to prove our cost data we have to live under the mandatories
Senator Kim Hammer
Unverified
1:44:42
as are given to us today and a whole lot of conversation today has been based around the argument you need an increase in the medicaid reimbursement do you statistically know how many patients that you transport are actually medicaid patients because we've got to have a number to aim for you know because if you're talking five hundred thousand dollars that's one thing if you're talking 25 million dollars that's another thing so what can you do to help us understand what the true dollar impact would be if we were to get your rates up and what's the
comfortable level that you need to know it's it's going to get to to support your argument today
Ken Kelly
Unverified
1:45:18
correct we we have those numbers actually dhs has provided those numbers through the upl process we had to survey ourselves we had to do cost survey uh and calculate the amount of medicaid business that we do and amount of crossover medicare and medicaid business so those numbers are readily available uh by through dhs to say that you know if we were to increase this this would be the volume of business that ambulance providers consume and we are on the federal budget we're
less than one percent of the federal cms budget for ambulance service and in arkansas i'm assuming we're still a very small piece of the pie even though we would be looking at some significant increases to overcome that minus 215 deficit but we have those numbers the ambulance providers that participate in the upl know their own numbers and we have had to roll those numbers up to dhs so that they could submit that to cms for approval now where we are in the upl process is we had to answer some nine questions in december for cms for approval unfortunately those questions
were due in september and we didn't make the september deadline and we went what's called off the clock so now cms has it under review but they are off the clock there is no deadline for them to give us an answer but we are anxiously awaiting to know what that impact will be to
Senator Kim Hammer
Unverified
1:46:34
arkansas's budget mr chair i got one more brief question but in response to his do we have that in this presentation anywhere as far as the number the medicaid run or how can we get access to that information please i
just would say there and you probably know that for sure but there is a slide
Speaker 48
1:46:51
or a section of this presentation that has a payer mix is that was that
Speaker 161
1:46:56
the 13 percent payer mix number that would be pure
Ken Kelly
Unverified
1:46:58
medicaid that is that well i say pure medicaid that's the medicaid and our medicaid expansion or our past program uh be about 13 of net revenue for the ambulance service would be that as far as a roll-up number i'm pretty confident dhs could give you that total expenditure right off the top of my head i want to thank total ambulance expenditure in the 2018 fiscal budget was 15.6 million roughly but if you're total
Senator Kim Hammer
Unverified
1:47:23
yeah what i'm trying to get to is
if you're asking you got to know what percentage you need to get it up to to survive and then attach a dollar number to that so we know when it comes budgeting what we're talking about and and we work on that but the last question is this with regard because you mentioned the statewide trauma system with regard to the sustainability of our statewide trauma system level and being able to maintain that status what what part of the ambulance service impacts that
Because if the ambulance service diminishes, does that also pull down our status as a statewide trauma system? Because I know the golden hour, those people get paid less than anybody else involved in that patient in the golden hour. But I'm curious about how what happens with you impacts our status as a statewide trauma system. Well, not that we're not any
Ken Kelly
Unverified
1:48:19
more important than any other segment of the trauma system. But if you look at the geography of the state and where accidents and traumas happen,
without an organized EMS system, your state trauma system collapses. We are the only segment of the trauma system that has to have 100% participation. Hospitals get some buffers on whether they have surgical coverage and neurological coverage, and we have strata levels of 1, 2, 3, and 4 for hospitals. You have one designation for EMS. You will be there, and you will be the backbone of the trauma system. Without that, costs are going up tremendously because you're going to have to move patients longer distances with fewer resources, so absolutely essential.
Thank you, Mr. Chair. Thank you. Senator Bledsoe, you're
recognized. Okay, I hit you. I don't know why it's not coming up there, Senator. Hit your talk
Senator Cecile Bledsoe
Unverified
1:49:18
button to see if that hit. There you go. Okay, thank you, Mr. Chair. I was going to ask about the UPL program and why it hadn't been implemented, but I think you answered that. Someone missed the deadline, and now you don't know when you would be able to make application again.
Ken Kelly
Unverified
1:49:36
Is that correct? Correct. The state plan amendment was drafted and crafted. We met on April the 19th of 2019 to go through the draft proposal that would be submitted to CMS, anticipating that we would have questions. We went through the public comment period through the month of June and July. On August the 15th, the comment period closed. We had no public comments against the program. It was 100 percent supported by the industry and no negative comments.
And we had a September the 25th deadline, I believe, to submit the draft plan. There were a few questions from DHS on some of the numbers, making sure that we had properly surveyed. DHS wanted 100 percent of the providers surveyed for the sample data. We were only able to achieve about 86 percent of the providers that would participate. Still a relatively valid sample for sampling data, but they were uncomfortable with the 86% or 88% that we had surveyed.
And so instead of submitting something that they felt like would get denied by CMS on face because we didn't meet 100%, we elected to go off the clock. So it wasn't that it was a punitive decision to go off the clock. We agreed to go off the clock. But now that we're off the clock, I guess we
Senator Cecile Bledsoe
Unverified
1:51:02
need help getting a final decision. All right. And then my other question would be, what, in terms of dollars, will that mean to Arkansas, to the Ambulance Association, if you are accepted for the UPL program?
Ken Kelly
Unverified
1:51:16
We literally feel it is the lifeblood. We feel that's the lifeblood of the system. It will vary based on providers. When you're talking about, you know, rural providers that have a high percentage of Medicaid utilization, some of the rural providers, they have a 17% mix of Medicaid. Some of your more urban areas may not have quite as much. The purpose of UPL programs, certainly there are winners and losers, but the way the program is structured is exactly the same as the hospital UPLs and the nursing home UPLs we crafted.
Senator Teague was very diligent in making sure that we crafted those programs exactly the same. So it could mean anywhere from $100,000 to a half a million dollars for a small rural provider simply based on their mix and how much money they're able to draw down. And that goes directly back. We also, DHS, also gets to keep a 3% administrative fee right off the top for the dollars they draw down. In most of those other states that have ambulance UPLs, that administrative fee is 1%.
We were agreeable to take 3%, just help us get this done. that's how important it is to
Speaker 168
1:52:27
us I think it's a bad thing to add but I'm gonna add it the Hospital Association did theirs in six months I'm on my 32nd month to try to do this so I'm not sure where I fall on the totem pole but it's not at the top
yeah we'll check on that yeah I think that I could safely say that you
just got a lot further up the totem pole here today so thank you
Speaker 214
1:52:50
Chairman Lowry. Thank you, Mr. Chairman. I really don't
Speaker 215
1:52:56
know who to direct this question to, but I remember before I was in the legislature, I was executive director for the National Association of Insurance and Financial Advisors. We had to get involved in issues related to the funding of the trauma system statewide. At first, it was going to be a fee on reckless driving because that seemed to account for so much trauma and then that got pushed
aside and it then became an extra fee on liability insurance across the state. Whatever funding mechanism we ended up with, we do know that we fund a trauma system, a trauma network across the state. Here today we're talking about where to come up with money to subsidize what you're doing. there any subsidizing or any subsidy from the money that is raised for our trauma system our trauma network statewide because it seems like you're
the boots on the ground for it for our trauma system and I think Senator Irvin said
Ken Kelly
Unverified
1:54:02
she can answer that yes you want to answer it more so than me probably well we currently receive trauma grant sub grants funding that goes to all ambulance service irregardless of provider type so and that number of course the maximum appropriation has remained flat so we we're not losing money as far as trauma grant funding but it may be that there could be a reallocation of some of those funds to rural areas versus those that are in the
more urban area I think currently we use it like the 45 minute rule to kind of decide you know if you're within 45 minutes of a level 1 or level 2 trauma center and then there may be some additional rule bumps that may could come through that but currently we are receiving trauma dollars senator erving i'll defer to further explanation
Speaker 216
1:54:48
senator ervin do you have anything you want
Speaker 16
1:54:51
to add to that let me go ahead yes i am right now
Senator Missy Irvin
Unverified
1:54:54
there you go okay thank you so lots to add to this conversation um as far as public health i
I mean, it's a big public
health issue. And so to start off, we passed Act 8-12 when I reorganized the Trauma Advisory Council. And we added the ambulance service at that time to the Trauma Advisory Council as members of that. And so I, along with Representative Hammer at the time, was my co-sponsor on that. Because at the time, you know, there was a lot of, I would say, misappropriation.
those funds that are being brought in through the funding is through the cigarette tax for the trauma system and at that time there was no oversight over the way that those monies were being spent and appropriated it was an it was an unelected group of individuals who then broke into subcommittees and then appropriated money actually back to their nonprofit foundation so we changed that because that was unbelievable in fact there were bills I think that were
submitted by the Ambulance Association for education that y'all put on that you never got paid for and there were bills that were outstanding bills that were paid that were not paid to the Embassy Suites in Northwest Arkansas to in Rogers there were $7,000 bar tabs it was it was unbelievable $1,500 for s'mores i'm not making this up this was all part of the audit so uh there was some restructuring that needed to take place obviously with that fund so um adding y'all to the trauma advisory
council was a big deal for me because i mean absolutely you're correct you're absolutely correct on you are the front lines and that is a very good um view of being able to look at that funding and to see how exactly those things are being funded and where that money is being spent because that's a good argument that you could make as to that is a very appropriate usage for ambulance services and funds and grants
for that purpose I think is a very very good argument there and there's probably flexibility and room to do that so we move that oversight to the Department of health because at that point there was no state agency which we have direct oversight over those funds there was none so if there's no state agency oversight of those funds then there's no legislative oversight over those funds so that was a problem we fixed it so it's under the Department of Health and
I think you know we've got new leadership there at the Department of Health as well which are great and they're wonderful and they've worked incredibly well with us so I'm so grateful Department of Health for taking that whole thing over with that said I think I wanted to comment and ask a few questions we also passed legislation so you're correct the CPL program obviously I think that needs to be right at the top of the list that is absolutely the the solution here in my opinion and I would to a couple different things I
to comment on though when we talk about the the rates and the fees and the increases so you know it's it's easy to have this conversation within just one but it's difficult to have the conversation with everybody at the medicaid table so there are lots of different areas for the sake of the legislature there are lots of different areas where people have not had rate increases for 25 years they're not alone in that there's a lot of people 20 years the in-home home health aides that we just gave an increase to hadn't had one
I think for 13 or 15 years so you're not alone in that and so it's difficult to have that conversation just as one and not denying that it's necessary I think it's something that we should absolutely look at but you came with a creative solution of the UPL program which I totally appreciate we also passed legislation to create the community um paramedic program which mountain home actually initiated and put in place so that was my legislation and my bill that we put in place but you can make a
comment on that last question there aren't people that are paying for that though right and so that so that's another example of we tried to help and we created a program for the community paramedic program but not a lot of people are paying for that service and so it's incredibly frustrating because it's people that are in the community stepping up to try to address the problems that you're articulating very well but you can't get paid for it but we put legislation
in place but it's still not happening so can you elaborate on that for
Ken Kelly
Unverified
1:59:57
me yes and thank you Thank you, Senator Irving. That was a very important piece of legislation, and we honestly feel that community paramedicine and being able to treat patients on scene without transporting them to the ER or to the hospital for that high level of treatment for something that can be handled in alternative destinations, that is an important piece of how ambulance services are going to evolve in the future.
CMS has also just recently taken applications for what they call their ET3 model, which is the triage, treat, transport, and release, basically, is what it boils down to. And so we think that in the future that will be important. The problem with community paramedicine is large departments that have reserve resources can have extra personnel maybe to staff that. Rural providers covering large territories, they may still wind up with a staffing shortage. So they're going to have some ongoing costs to have to hire additional, maybe single-resource paramedics instead of full ambulance crews.
But I do think that it is important that we get alternative destination codes added at some point. And this is probably going to become an issue, and to get to Representative Perry's issue on non-emergency transport behavioral patients, our CSUs, for example. Knowing taking a patient to a CSU is the proper thing. However, in the establishment of the CSU, that is a non-covered destination for ambulances. If we don't take them to the ER, the ambulance is not going to get paid.
We know that's the right place to take them to limit the overburdening of our ERs and also to de-escalate the situation to keep them having to be in the right place. But we're prohibited from billing for that. So ambulance providers are doing the right thing. We are just not getting paid for it. So I think it's absolutely critical. We look at alternatives, community paramedicine, alternative destinations, has to go
Senator Missy Irvin
Unverified
2:01:50
hand-in-hand. And that's a division of medical services within DHS, which I think
was a question, which department are you working for?
But commercial payers are adopting, I think, this one right here. This is a good example. And you made a comment about there's a bump in additional payment to rural providers. that's not the case if it's a private like if it's if it's a federally qualified health center provider they do get a dramatic increase but that's only for them and I would argue that that needs to be rebalanced because they're doing the same exact work that a rural provider out
there is doing so were you referring to the helicopters I think you mentioned actually get
Speaker 168
2:02:34
50 percent bump from Medicare when they land in a rural area and the same with our mileage we get an additional bump for taking a patient up to the first 17 miles if we're considered in one of those rural counties we listed okay and then for Arkansas purposes one of our maps earlier we basically feel like when you look at Arkansas and you wanted to simplify things and not use one Walmart or less in a community, just jokingly, but populations with 15,000 or less is basically
where we feel like the level would be for Arkansas counties that we see that will struggle in the future. And that number didn't just come out of a hat. It's just the fact that we realize what the call volume in those communities are going to be and what the payroll in those communities should be from an average from any providers and what it would take to sustain an ambulance service in that community and we backed into that in that method um i would i do want to point out going back to the trauma system i mean we all buy in we want a great trauma system
in our state yes but the fact is just to put real numbers to real things you know most of us most of our communities get less than twenty
Speaker 166
2:03:45
thousand dollars a year if that and to participate or to be mandated to participate and we want to participate but when the funding when somebody's shaking the hat around and it's falling out it's not falling out to the ambulance providers and we're
Senator Missy Irvin
Unverified
2:04:02
carrying a huge huge load well we were spending an absorbent amount of money on education which benefited us anyway it's a long story but again i think there was a better use of that money
so that's why we did that whole transition um and i don't disagree with you i think that's but i do think it's important that you have the slide that you said commercial payers are are adopting similar policies that fail to reimburse above the cost of providing the service we're seeing that really across the board in all health care aspect all health care areas and people
Speaker 166
2:04:35
have to understand you know a community paramedic is not knocking anyone else out of their current job it's
Speaker 168
2:04:40
not pushing uh home health or anything it's more specifically driven and when we're able
to open up codes because we all believe in that and the fact is that we feel like the struggle becomes when we don't have the workforce to do it. But if you were able to access something like that in Mariana, Arkansas, and over the weekend offer those services to help mitigate some of your expenses you have for your medics not making calls during that, then that comes very valuable to that community, and it's a resource that everyone around gets to utilize. So I think having some common sense about what we're talking about and being on the forefront of finding out where there's funding, because other states have found funding for
other other commercial payers actually pay for
Speaker 166
2:05:18
some home uh for some community paramedic type stuff so there it's out there and it seems like you know
Speaker 168
2:05:23
you guys have done a great job of trying to to carry our flag and our water and support us
Speaker 190
2:05:29
but we're just not able to get across the finish line on some
Senator Missy Irvin
Unverified
2:05:34
of these issues i have one last question so if
if it's a volunteer fire department and they purchase an ambulance or they get a grant for an ambulance can they bill and can you run me through that
Ken Kelly
Unverified
2:05:47
yes absolutely I mean every provider you have to be a participating
provider for Medicare of course and and then of course the Medicaid would follow as a separate approval process but I have a billing services company I've done billing for volunteer fire departments that can be very lucrative as far as providing the ongoing operating cost it just it just takes uh it takes time it takes like jamie said we're special we're we're a unique form of reimbursement uh and we're finding that it's hard sometimes to do that but yes they
Senator Missy Irvin
Unverified
2:06:19
can yeah great okay thank you sir
thank you members i've got three of you left in queue representative cloud
Representative Joe Cloud
Unverified
2:06:25
you're recognized sir thank you mr chairman a lot of discussion about money today and in light of that mr kelly i'm just astounded by the fact of what i learned on the non-emergency and emergency codes being flipped so it's a very simple question who's responsible for that happening there's no telling how much money that has been lost over many many years with that so why wasn't it caught who was responsible for that thank you well i
Ken Kelly
Unverified
2:06:57
i can't speak to responsibility because i can only
control my own self and my own service but we have made the case on more than one occasion and jamie and i just pulled red line markup documents from three meetings where we pointed out that going back to 2012 13 and 16 respectively presented that to dhs and made them aware that the codes were inaccurately reimbursed and much of this has come around trying to come up with a total dollar number uh because they they will throw out you know well you're doing so many non-emergencies
maybe we give you some increase on emergencies and we argue that you know there are actually providers that down code calls that would legitimately be tracked for statistical purposes as emergencies but they listed as a non-emergency so we have pointed out on numerous occasions that those numbers need to be
Speaker 208
2:07:52
corrected it's 55 difference 50 yeah
Representative Joe Cloud
Unverified
2:07:56
55 per call difference quick follow-up mr. sure thank you so just to be clear those codes were
applied by DHS yes those code
Speaker 208
2:08:06
those codes are active in the the reimbursement system by the descriptor code and then
Speaker 161
2:08:12
there's a dollar value associated with that code thank you
thank you representative cloud senator Johnson Thank
Senator Mark Johnson
Unverified
2:08:23
you, Mr. Chairman. Ladies and gentlemen, thank you again for coming in a couple weeks ago and coming in today and helping us on this.
Since most of Perry County is in my district, the part that's not is in Senator Raper's district, but he's a resident of Perry County, we're obviously focusing on this today, but it became clear in our previous meeting that this is not just a Perry County problem. This is a statewide problem, and when you showed the map over here, even I pointed at Representative Maddox and said it looks like your county's in there too. The commonality, there it is, the commonality is low population density.
I mean, there's other issues I know, and distance to a hospital with whatever level trauma center. But I guess probably, Ms. Gresham, I'm aiming this more at you, but anyone can answer. You serve multiple states. Are there any states that use some kind of model that has, my term is probably a more sophisticated term in the industry, but a standby fee, a fee for more or less what a taxi would do if you ask them to wait
when you go into some place that they've given you a ride somewhere. All I'm saying is that you're standing.
Speaker 237
2:09:50
Yeah, it's a cost of readiness is really what you're starting. Exactly is what I'm looking at. So for
Speaker 166
2:09:56
a cost of readiness for most communities would actually be considered a subsidy of some sort. I think it would be. with the association of counties attorney yesterday and picked each other's brains a good bit appreciating being here today just looking for some solutions for some of the small counties they have a great handbook that's out there we'd like to throw a few other type things on the table of what other
states are are doing and trying to come up with the funding and and you mentioned I forget which one was about the subscription program historically that was a great program and and we were able to you know glean a good bit of funds off that for community ambulance services and that's just not the case anymore because people don't buy in so then the cities and the counties actually end up charging for it you know to work through that that's a little bit more complicated than what it was presented but there you know there's some caveats there but it is a it's a nice program to have but the cost of
readiness really comes from subsidies in the communities and what they want the ambulance service to look like and when someone asks for a second ambulance it's not the same amount of money you got to realize the situation in Perry County county that first ambulance had additional it has ambulance calls to pay for it that second ambulance is only going to make a handful of calls therefore you're going to have to take care of the full expense of that unit 24 7 365 because it's not going to have the revenue there so it's not the same as
Senator Mark Johnson
Unverified
2:11:16
you walk through that how do our neighboring states deal with this in a
let's compare and contrast what they do and how we do
Speaker 166
2:11:25
it in Arkansas Arkansas getting on down that list pretty far unfortunately we receive subsidies in our most of our other states in Mississippi I receive subsidies from the communities in the same way in Oklahoma Oklahoma does more of an a water meter surcharge for community members they do something like that they pay subsidies but that's their regulations and that's how they approach it so making sure that Arkansas follows their guidelines of what they put forth is okay for ambulance
services to do is important for us to realize but I did find out yesterday that we're pretty far down on the list when we talk essential services and you know dr. Bledsoe back here he and I have many many phone calls we really feel like we're an essential service whether you want to realize it or not there's three legs to the stool fire police and EMS and when you think about it we're the shaky leg on the stool and it's time to you know solidify that portion of it and be considered an essential service for some of these communities many of them it's a second thought it's only a second thought until when your family member is actually injured and you're like where's the ambulance well who pays
for this who runs this and I don't know if it came out earlier or not but see over 60% of the providers in Arkansas are private providers and then you add another 10% that are hospital based providers that are private providers we're not a state that is run on municipally municipally owned ambulance services because it's very complicated and over historically over the last you know 30 and 40 years communities have invested in private providers to be a a part and have a partnership with private providers to make sure that these things happen so um just kind of wanted to address that today too
Senator Mark Johnson
Unverified
2:12:59
okay and i appreciate you again you coming and
i i realize we're not through with this uh we're probably just now scratching the surface but but thank you for your this is a great presentation and at least it puts us in the right direction and thank you
Ken Kelly
Unverified
2:13:16
mr chairman mr chair if i may represent johnson this map that we referenced here these are not necessarily distressed counties not all of these are distressed counties some of these counties have already addressed you know local options and subsidies and i represent one of those that subsidizes the ambulance service but this is just if you had to pick a number
and jamie and i haggled over this and reason there's red and yellow on there i wanted to go 10 000 or less and she wanted to go 15 000 or less and so the yellow is getting right up at the 15 thousand threshold but if we don't do something we'll be adding a third color an orange that's going to add more if if we if we don't start to
Speaker 166
2:13:51
stop the bleed and then somebody made my point earlier because they said they had 13 000 and someone else said for us like see my
Speaker 184
2:13:59
15 number was right senator hammer you have the
Senator Kim Hammer
Unverified
2:14:01
last question sir thank you mr chair this is a request of the
chair you know at 55 a
pop per run that potentially could blow up dhs's budget maybe that's why that didn't get somebody forgot to flip the switch but i'd like for ask the chair could we get some real dollar numbers as far as if that had been switched in the last year based on the call volume dependent to medicaid and maybe that's in the presentation i don't know but could we get a little digging on
that yes and that sets up perfectly there's going to have to obviously
will be a follow-up to this we would like to hear more from the agencies involved DHS and Department of Health and I know they're sitting back here listening and so we're gonna need some feedback if there's anybody prepared for some of that feedback today I'd be happy to put you on the end here and let you say your piece but we there's there's no question about it Senator Hammer we're gonna have to wrestle this number and I think there are some members here that have been involved in some different aspects and i think that the following report from
senator hickey and representative perry is going to be pretty enlightening in regard of the non-emergency okay so uh senator hammer we will definitely be following up and asking for all those numbers okay can i ask them one one question i wanted
Senator Kim Hammer
Unverified
2:15:19
that to the chair can i ask them a question yes thank you so i'm doing some work volunteer fire departments and we've got an interim study that's coming out going to address part of the issue in the volunteer fire department world is that 80 percent of their runs average are medical runs they're not fire runs they're medical runs we passed a piece of legislation this past session where if you're a fire protection
district those dues are mandatorily collected as as they have to be mandatorily collected they can't be ignored have you had any discussions with the volunteer fire department organizations associations in these counties because one of the big things that's going to happen is that map's going to change dramatically in the next five to ten years as populations move out of the rural areas and and we see the direction this thing is going what dialogues have you had with the volunteer fire departments knowing that their dues now can be collected mandatorily if their
fire protection district to see about partnering with them
to work out some sort of arrangement with providing the ambulance needs we have
Speaker 166
2:16:21
not had any we have not had any discussion with the Rural Fire Department Association so we can reach out to them but you know they're just like us they're struggling for their funds and and they got those funds for on their behalf and then I want to clarify on the the $55 so that you don't see some big number in your head that actually was for a basic non-emergency that means not a paramedic transfer being from emergency to
non-emergency and that's not a lot of what we have in our state but it still affects our return trips that we come back from Little Rock or go back from the hospital to the nursing home those type things those are the trips that were affected by that so I didn't want to throw you off there and if you ask me what amount of money you should be looking for we really feel like we had a handshake deal back in 1994 saying that we would be at 86% of the Medicare allowable and that we were given a bad bag of goods
Senator Kim Hammer
Unverified
2:17:15
all right but let's point out that was under previous administration so the current
Ken Kelly
Unverified
2:17:18
administration. That's a long time ago. That's a long time ago. I was trying to go back and remember all the administrations but and one thing on the flip code it does affect the UPL because the UPL is based on as it exists today it exists on number of emergency transports. If you've got people that are downgrading emergency calls to non-emergency so they can get the higher $55 they're not capturing the true emergency so it wouldn't be calculated for the UPL which could be matched three to one. That constitutes fraud. You're leaving money on the table.
Senator Kim Hammer
Unverified
2:17:47
If somebody's intentionally doing that does that constitute as fraud that they're not classifying it as what it
Speaker 192
2:17:51
is you have to wonder you have to wonder you have to wonder i mean that's been our discussion we're not and
we've had those discussions all right thank you thank you mr chair thank you i appreciate you for being here you've done a great job with your presentation uh members uh and you can be dismissed at this point um welcome to stay if you want to follow up with any members afterwards mark wyatt uh i don't know where you were at when you sent me your message sir uh since you are here and you do have a couple of comments would you mind to come up for just a moment speak to a couple of the issues because had i been able to see through that wooden
fortress there in front of your face i probably would already called on you so thank you for speaking up mark and i do appreciate not only you've been here today i do appreciate everyone that was present a few days ago just when we were trying to get our hands around the issue so just state your name and who you represent for the record and we are going to be brief with this so we get to the point because we want to get these other members up here for their presentation. Thanks Senator Mark White with DHS. Hi I'm Elizabeth
Speaker 249
2:18:53
Pittman I'm with the Division of Medical Services. Okay and Senator of course I
Speaker 248
2:18:57
know we've been here for a while so don't want to delay things unnecessarily. Happy to answer questions now, later, or certainly in between meetings. Any members welcome to reach out to us. I do want to give you some very quick updates about where we're at on a couple things that have been discussed today. One is on the rates. We are in the middle of a rate review process as I'm sure many of you know. In years past, Medicaid addressed rates on a very ad-hoc basis. It was just here and there depending on what the perceived needs were, depending on what the expectations from the legislature were, and we recognize that that is an
issue. That is not the way the Medicaid program should be run. And so the governor did instruct Medicaid for us to begin a prolonged effort to review every provider's top's rate at least once every four years. And so we're in the middle that process ambulances were in the first group that we looked at and so when we did our initial look we agreed and recognized that their rate needs to be rebased needs to be revisited so that's in the process right now we've done a lot of the work to determine where we think that should be at this point we're working to make sure that that can be fit into the budget for next
year and so that work will be finalized by the time we have our budget hearings coming up next month when the governor will bring you his but his balanced budget recommendation and our recommendations for how we will fit that within our funding so that rate it is in process is coming it will be coming to you for decisions here very soon second point on the UPL issue yes that is with CMS right now and we appreciate the help of the Ambulance Association in putting that proposal together we got that submitted I believe we have met the
deadlines that were set but CMS did have another number of questions that's why CMS decided to stop the clock so to speak because they had questions they wanted answers to and they wanted to investigate this a little bit further I believe we have another phone call scheduled to CMS coming very soon in which we'll be talking with them about that and then hoping to get a decision from CMS here in the very near future on the UPL issue so that's that is progressing and we're just waiting to see what comes back on them and then the last point of course certainly we'll do everything we can to assist this I do
want to emphasize no as you notice one of the slides earlier medicaid is a small part of that payment mix about 13 of things what the slide indicated and so certainly there's there's lots of room we have to improve on the medicaid side but i would emphasize this is a problem that's bigger than medicaid there are a lot of challenges when you look at population density that is going down in counties population losses the tremendous increases in the cost of health care equipment and supplies and again and they and the previous witnesses they went to that in very painful detail
about those increases and so there are lots of issues facing this industry and we certainly want to be a partner in addressing those and making sure we can address this in a
way that helps the citizens of our state thank you that's very good news that you're hoping to include something even as early as this budget that's important in terms of senator hammer's question i don't know if you have any information available for him now but we appreciate you working on that to to get that information back to the committee anything further that you have no sir that's all
Speaker 248
2:22:11
i have and be happy to answer any questions or as i said discuss with anyone afterwards all right uh center urban i believe
Senator Missy Irvin
Unverified
2:22:19
you're up next yeah thank you so the rate review process it's coming before public health so i'm happy to call another meeting um of public health and insurance and commerce we appreciate it when that time comes up or invite insurance come to that um and that's been a process that was started like you said by the executive order and this is in the first round and so um if you need additional information about that you can come
talk to me or to them um one of the things that um so you're at the milliman they're reviewing their milliman report and all of that right now is that where
you're at yes okay and then um and so you'll bring that to public health committee what next month before fiscal session are you thinking we can
Speaker 248
2:22:59
check and see it's i think the i think the the financial side of in terms of the rate i think that is largely very very close to completion it's the budget side that's still in process uh and of course as you know between now and the physical session lots is going to be
Senator Missy Irvin
Unverified
2:23:14
happening so can you just also walk through we did actually approve a rate increase for in-home health workers yes but that was just go through the funding mechanism on that one just so we're all clear how we did that one sure we
Speaker 248
2:23:31
we put in a rate increase for two provider tops and we made it effective going back to January one one was for personal care which is hands-on assistance to individuals in their homes helping them with activities of daily living things like bathing and
cooking and in standing and toileting we also provided increases for early intervention day treatment and adult developmental day treatment providers which provide some similar hands-on type services but in in a center location and those are two areas reason we did those initially at first because more than any other provider top those are the ones that are most directly impacted by the minimum wage increase and so we recognize there is a particular issue you there wanted to address and that's why i wanted
Senator Missy Irvin
Unverified
2:24:16
you to talk about that because they did
mention that in their side and even though
that was not something that the general legislator the legislature did not enact that the people enacted it yes and i i was you know i wish people would have organized a campaign against that because we knew that this was going to happen the codes can you just talk about the codes and the non-emergency transportation and emergency transportation discussion can you are you prepared to talk about that from medical service side i can
Speaker 248
2:24:43
talk briefly and ms pittman may have some additional detail to add in my recollection is that we have of course there are several codes for ambulances for an actual ambulance run there
is the highest level which that one is as it should be rate may not be correct but it is accurate between emergency and not emergency in the level below that cms will allow uh it's no it's not it's not that high i mean it's certainly we need to address the rate okay gotcha but in terms of the difference between emergency and non-emergency it's not an issue at that highest level okay it's at that level below that that the non-emergency rate is higher than the emergency one and we we frankly have no idea why that was done again as as was mentioned earlier some of
these things go back 20 plus years yeah i know there may have been a rationale in the 90s when that when that was done we just don't know it was done in the 90s that's that's my our best guess okay i'd like to
Senator Missy Irvin
Unverified
2:25:37
follow up with you on the time frame on that and why it was done that way but sure um okay thank you thank you senator all
right any other comments that you'd like to make before we get to the next section i do appreciate you speaking up appreciate what you do and look forward to working with you and the rest of the members on the issue thank you senator
thank you uh representative perry and senator hickey i don't know if you both are going to present but appreciate your patience and i'm sure that this has been very very interesting from your perspective because i know you both have put in a tremendous amount of time on the non-emergency side and with that i will yield to you and let you make your comments thank you mr
Representative Mark Perry
Unverified
2:26:27
chairman i appreciate it very much you want everybody to introduce themselves well i think we we know you
and senator hickey uh but uh won't let your your your third party introduce himself for everybody and mr chair members my name is
Greg Brown
Unverified
2:26:40
greg brown i'm the branch chief for our trauma program at the health department for our stroke and stemia and for our emergency medical services program thank you you're recognized sir
Representative Mark Perry
Unverified
2:26:51
thank you thank you members on behalf of senator hickey myself we'd first like to thank the department of health dr nate smith for their willingness to staff
and to host this task force and additionally the members of the task force and the many interested parties who've attended all the meetings and given all their free time and knowledge and resources and we thank them as we listened in the first task force meeting to ems law enforcement mental health professionals and even family members share stories of some of the events that have occurred just in the past year including the death of a young person who jumped from the back of a moving ambulance we quickly realized there's a very real
issue that needs to be addressed we also began to learn this is a very complex problem with many different touch points we have initially divided them into two buckets first bucket being transports went from one facility to the other such is an ER to a behavioral health facility and then secondly transports from everywhere else to a behavioral health facility like many issues the General Assembly faces we began by reaching out to other states to see if they had
similar issues and what were their best practices we learned was this is this issue is facing virtually every state and like here more difficult in states with rural populations which was been discussed previously today while we found no real best practices we did review a couple of pilot projects that have started in Virginia and Oklahoma as we began looking at potential solutions we identified eight primary factors that will have to be addressed within any
solution mental health resource identification patient patient placement opportunities, facility acceptance, timeliness of transfers, resource allocation, custody issues, appropriate reimbursement, and, of course, liability. You will see in the report several additional areas that will need to be addressed, including regulatory oversight, centralized communications, appropriate vehicle needs, data needs, and, of course, funding.
so statutorily our task force has ended however as you can quickly tell we don't have enough information to even make recommendations senator hickey and i along with the members of the task force and the department of health have all agreed that we will continue meeting and working in an effort to bring real recommendations back this fall for next year so during the regular session and we can begin implementing these policies that make a difference for EMS, law enforcement, hospitals,
providers, and most importantly, patients and their families. Now, if you'll look at the last page of the report, you will find the names of the real brains of the task force. But Senator Hickey, Mr. Brown, and I will be happy to answer any questions you may
have for us today. Thank you. Thank you very much. Members, do you have
any questions for Representative Perry and Senator Hickey at all members you do have if you've probably already found that there is a report that he was referring to in your stack of documents
Senator Hickey do you have any comments that you'd like to add or mr.
Senator Jimmy Hickey, Jr
Unverified
2:30:21
Brown yet yes sir I do actually I'd prepared a report but to be honest since we're so late in the day I'm fixing to throw that away and I'm gonna just go off the cuff with you all for just a moment uh as far as a non-emergency transport i want to explain to the members what we've looked at because it perfectly dovetails with everything you've heard here today all of the members with the entities that were up here today they are the stakeholders we've been working with along with multiples others and i hate to start listening i'll forget
some of them but dhs is involved the ag's office is involved the counties are involved just one after another we've got a whole group of people to be honest with you i wish i was not involved i like to say as far as this subject that i'm the least educated for that subject representative perry reminds me i'm the least educated at all and that's the truth this thing is really from a redneck way of saying it is a pile of coat hangers what the non-emergency transports that
we're looking at is different than what we hear about down here and struggle with all the time these are not scheduled transports and although there's multiples i guess the best example that i had heard during the task force meeting whenever we started this is this is an individual that's possibly standing outside of a convenience store that may be talking to themselves and they under we all understand that something may need to be done because people are worried about what's going on 9-1-1 may be called law enforcement shows up no crime has been committed but law enforcement's
either got to take them to the jail and then they have to try to transport them however far that they need to go or as we've been hearing today our ambulance services are being utilized and then of course we have that service tied up and then an emergency happens such as in your county where have one or two and then somebody else dies so we're trying to figure out a way to put all of that together in it and again it is akin to a startup business there's no doubt in my mind to
be honest with you that the members of this task force can come up with this but i want to be a little blunt this task force is supposed to go away representative perry myself have agreed to stay on just because and of course all the members because it's it's so critical especially what you've heard today all ties in together but here's the thing there is so much work that's going to be required the hospital association is also included in that ever everybody is included in this there
is so much work that's going to be have to be included what i don't want to happen is that we come down here in the next regular session and representative perry and i are holding some bill and all of you are saying what is that so i would suggest and would hope that a motion would come out of here that would would require representative perry to come every two to three months to tell what has happened to involve not only public health and would love to have insurance and commerce so that you all that are going to have to be involved in what we definitely know
will be a funding issue issue as it always is and other legislation have been involved with the thing and that we have truly vetted that because i don't think we can vet it in the session and again it's not that representative perry would wants to come down here i'm just afraid if we don't do that along with what we've heard with the other issues we have we may get bogged down that's
Speaker 267
2:34:06
what i had to say thank you sir that's that's
great comments uh i just want to mention
something it's an idea and and i appreciate actually i believe it was mark whitmore that first gave me your name because we were we were not tuned in that you all working at this hard on the non-emergency side of it and so this is a situation where the committees have come together we've we've come it from another angle on the ambulance service itself and we're finding out this is a treasure trove of work that you've been working on i i don't like to put words in my
colleagues mouths but i'm going to suggest this is a joint meeting and center urban is about to speak but i know that i know that in our committee structures we have the ability at least in in the senate to to create subcommittees for specific purposes i don't know if senator urban would want to do that as a sub to supplement and allow there to be structure for you to continue that work i don't know but i just know that that's a possibility and and i think that that's something
that the chairman can discuss and i suggest that for public health because you've been doing the work from public health and and i would defer to to their judgment on how to handle it but i think absolutely that there can be some structure for you to continue that i would hope there would be and so there i said i didn't want to put words in my colleague's mouth but i almost did and i apologize but we're trying to think on our feet because this is an issue that does not need to die you you do need to continue the work and you also need to have the support of blr and the other
agencies in doing the work so i do appreciate you saying that i've got two people in line here But, Mr. Brown, do you want to say a word at all before we
Greg Brown
Unverified
2:35:59
go into the questions? No, I think just from our perspective, the magnitude of the problem. I mean, we see approximately 40,000 transports a year that are categorized as behavioral health. So it's not a small issue at all. I mean, it's a significant magnitude to our
Speaker 10
2:36:15
EMS providers. All right. Thank you. Senator Irvin, you are first in queue.
Senator Missy Irvin
Unverified
2:36:21
Thank you. Yeah, I mean, I need to
process through that. but um i think it is critical i mean we've known this for a long time and we know that this is a huge problem and we've got well not a long time but thank you for digging in thank you for your report and thank you for the work because i've i've i actually told cindy gillespie the other day at a meeting with her i said we have to address this immediately we have to have a working group behind this immediately and it's not just the transportation component it's actually beyond the
transportation component because what are you hearing from the counties the most jail reimbursement issues right and so a lot of these people get stuck in the jails that's not where they need to be just like what you're talking about so you know it is a this is you've you've hit on a specific big portion of it and it actually is a huge impact because we can continue to increase reimbursement for county jails and we can continue but we got to solve the problems right and we got the crisis stabilization units are incredibly
important the work that's been doing on the forensic evaluations with the Department of Health and that what they have done with the Arkansas State Hospital and the mental state hospital all of that and that is continuing in this comp I mean you're right it's a big pile of coat hangers and it's incredibly complicated so um yeah i i'll work with senator hickey we can work together and figure out how we can and representative perry and figure out how we can do that with the health committee um as well and i'm i'm happy happy to continue that work and need to do it one of the things i
also wanted to talk about is or ask i've i've often talked about because my husband's in a he's a family practice doctor in rural arkansas everybody knows that but he's also moonlighted in the emergency rooms for years just because they need doctors right and he's also worked at the north central unit in calico rock in the prison system because they needed a doctor so yeah they call he goes um but one of the things that is frustrating from their perspective when they're
in an emergency room and a patient like what you just described presents right and into the emergency room the difficulty in trying to find a bed for that behavioral health patient is incredibly difficult and they are literally on the phone calling you know old style calling to figure out where they can place that
patient and so i don't know if y'all discuss that with your committee senator ervin that
Representative Mark Perry
Unverified
2:39:01
is that's been a hot topic of conversation in fact uh one of the
things you'll read about in in the report is possibly even having a centralized call center can you similar like trauma con can you piggyback on the trauma call system yes
Senator Missy Irvin
Unverified
2:39:16
that's what i think because i don't want to create a new system and if we can piggyback and we've i've said that for years we need to piggyback on the trauma system but we couldn't do that until we brought him in to the department of health so based on what we've seen i think we
Representative Mark Perry
Unverified
2:39:32
can okay and that's but it's going to take a buy-in from all parties right i know i mean it's well and we just we honestly
Senator Missy Irvin
Unverified
2:39:40
didn't have that until dr bledsoe and and y'all were able to bring y'all into the department of
health so i to me that's that's a that's at the top of the list that needs to occur
Senator Jimmy Hickey, Jr
Unverified
2:39:52
that was actually one of the things in my
report and you're exactly right representing perry's right we've already talked about that there's other implications and again when i say there's a startup business because the thing is with like the call center we have to staff the thing and whoever is there there's even so many aspects of that because we have to figure out and we've discussed this
we have to figure out not only who's going to that who's that going to be assigned to because the thing is that may that person may need to go in this new vehicle we're talking about that person may need medical help so it may be that it may be that they need the ambulance service or it could be that law enforcement needs to be involved and there's so many subjective things with that and you know the other part that we've had with like the transport and exactly with what
you're talking about with the call center is that individual is also you know they're not in custody so they can get out at any time so we're looking at trying and the ag's office has been involved that's why they've been there to see that if there's some way that when we drive by the capitol if that person wants out they can get out we're trying to figure out if there's some way that we can get around that part but then still protect those that person's right also so there is and
along those same lines like even if we do have a time when law enforcement and we've already discussed some of this i'm going to go into it just a little like if law enforcement does need to be involved the other part is is whoever's manning or i'm going to use that word that call center what we don't want is that person to think well this is kind of my responsibility I don't want to assume any liability if this patient was to kind of get a little out of line so then they assigned all of those to the law
enforcement and then we're not able to acquire those cost savings we're we have delved into the weeds even that much with that particular aspect and again Again, I'd like to say there's thousands, but there is literally hundreds of things that we're going to have to do. And thus, that's why I want to know that we have the buy-in at least to make sure we get all this vetted beforehand or otherwise whenever we get down to the session, we will crater with
Senator Missy Irvin
Unverified
2:42:19
it. Yeah, I mean, if you want a formal motion, I can do that.
I mean, I'm the chair of public health, so I could entertain a motion. It looks like we've
probably passed it. I can entertain a motion from, okay. And your motion, excuse me,
Chairman Ladyman, you recognize her? So we're in the discussion phase here, I hope. Yes. Well, you know, I've been
Representative Jack Ladyman
Unverified
2:42:44
quiet about this because this is a big problem, and, you know, there's a lot of tentacles involved here. I appreciate your work. You know, I agree with Senator Raper when he says you need to continue your work,
but we need to be more connected and coming and telling us where you're at on a regular basis. I think it's a great idea. I think we should work through our subcommittees. I think in the House we can probably work through existing committees, I think. But we, yeah, I think we can. And we should work through that structure and use all the resources like BLR that are available for you. So I would support that. i would support having joint meetings with the house health public health committee be glad to
bring those reports all right well and and as you see just today yes today as we've done from the ambulance side you know a
lot of this immediately ends up who's paying for it and that's where the insurance side comes in and ambulance issues around the country we're dealing with them at in koala as well and so we're here just to make sure we give attention like we've done today to get some help and so i'm satisfied that we're progressing on that i'm very happy dhs has already
taken up and understand i guess they've been working 24 years on that rate review but i'm glad it's almost ready so i didn't mean that as a dig but i'm just saying 25 years is a very long time uh and so i'm very happy that we're now at a point where where the new team is going to take some action and so um yeah i would let
you make your motion regarding the situation with your
Senator Missy Irvin
Unverified
2:44:28
members okay well senator i guess i'll just take the reins for one second and senator wallace made
a motion is there a second second does in favor say aye and opposed eyes have it so from the public health side we'll put that in one of our subcommittees mr price yeah okay very good uh senator hammer do you
still have something there sir yes sir i wanted to ask in your
Senator Kim Hammer
Unverified
2:44:51
report and i'm going to leave you live senator urban for a season here as we're finishing um maybe
if we can get a copy if you have prepared notes about your report there senator hickey but
did y'all split out and look at the va transport as a separate issue or separate item or did you give any attention to that or you just group it all together no we have not it's a different we didn't we didn't include the va okay either for
Senator Jimmy Hickey, Jr
Unverified
2:45:25
transport reimbursement or any of the above right because again what we've been dealing with is the non-scheduled type transports only uh so we we haven't even looked at that part
okay all right thank you all right um without anything further i want
to appreciate the members people have been here stayed in their seats it's been a long meeting what i do want to say is since we've covered so much ground we need to remember that we've got one but we have some others counties out here that are an immediate critical situation so i don't want us to forget we've got to help figure out a way to make sure that we don't have counties that absolutely don't have any service whatsoever because i don't want any of those scenarios playing out in which we
all regret that we didn't do something to keep some base service so i'm happy that we're looking at the long term and i appreciate all of you that put efforts into helping possibly with the short term as we can thank you members for being here with that we're adjourned
Agenda
A. Call to Order
B. Opening Remarks
C. Consideration to Adopt January 16, 2020, Insurance and Commerce Committees’ Meeting Minutes [Exhibit C]
D. Rural Arkansas Ambulance Funding Crisis
E. Findings and Recommendations of the Task Force on Transportation of Nonemergency Behavioral Health Patients Created by Act 1041 of 2019 [Exhibit E]
F. Other Business
G. Adjournment
Documents
| Title | Type | Pages | Source |
|---|---|---|---|
| Agenda — INSURANCE & COMMERCE - SENATE, Feb 19, 2020 | Agenda | 2 | Official source ↗ |
| EMS CRITICAL ISSUES PrPt | Exhibit | 23 needs OCR | Official source ↗ |
| Exhibit-C Draft Minutes for 1-16-2020 | Exhibit | 4 | Official source ↗ |
| Exhibit-E Act 1041 · Findings and Recommendations of the Task Force on Transportation of Nonemergency Behavioral Health | Exhibit | 4 needs OCR | Official source ↗ |
| Handout 1 AR Ambul Assn Critical Care Issues | Exhibit | 2 needs OCR | Official source ↗ |
| Handout 2 Rpt Trans non emerg behavioral hlth patients | Exhibit | 8 needs OCR | Official source ↗ |
| Minutes Approved for 2-19-2020 | Exhibit | 4 | Official source ↗ |
Speakers
Speaker 3
Senator Jason Rapert Chair
Unverified
Representative Jack Ladyman
Unverified
Speaker 18
Speaker 20
Speaker 22
Speaker 24
Speaker 25
Speaker 27
Speaker 29
Speaker 30
Speaker 31
Speaker 33
Speaker 39
Speaker 41
Speaker 43
Senator Kim Hammer
Unverified
Representative Michelle Gray
Unverified
Senator Missy Irvin
Unverified
Representative Roger D. Lynch
Unverified
Speaker 80
Speaker 81
Speaker 88
Representative Josh Miller
Unverified
Speaker 84
Speaker 124
Senator Cecile Bledsoe
Unverified
Speaker 82
Speaker 117
Speaker 98
Ken Kelly
Unverified
Speaker 166
Speaker 168
Speaker 172
Representative Nicole Clowney
Unverified
Speaker 11
Speaker 183
Speaker 50
Speaker 48
Speaker 161
Speaker 214
Speaker 215
Speaker 216
Speaker 16
Speaker 190
Representative Joe Cloud
Unverified
Speaker 208
Senator Mark Johnson
Unverified
Speaker 237
Speaker 184
Speaker 192
Speaker 249
Speaker 248
Representative Mark Perry
Unverified
Greg Brown
Unverified
Senator Jimmy Hickey, Jr
Unverified
Speaker 267
Speaker 10