Public Health, Welfare and Labor Committee- House & Senate

What was your own. She were ACT. Okay So. Okay I want. Have your kids want to call me. with the. All right that better. Okay want to call a meeting to order. And when you start we got a long agenda we do have some people joining from zoom. And we should be able to take all questions either here or on soon so want to thinker one for showing up this morning we do have a big agenda we got a lot of rules that we've carried forward because of our meetings that we've had in the past so there's a lot to to go over so we want to get started of one thing I want to mention. Other was a handout from the department of health. That shows the latest total number of cases for co would. Nineteen and then a break down there. So if we have time in by county if we have time we we may be able to discuss that at the end of the meeting but with all the things that we have on the agenda we may not get through that. We will just see how that goes we may have to have another meeting or carry things over to the next meeting will decide that as we go along here so with that I'll ask my cochairs as in comments senator Irvin give any comments. Thank you a yes at members anticipate probably having another meeting just because we have so many rules on this we just need a meeting for the lot of the updates that are important to the work of this committee and to the states so I've been contacted by you may miss department of health and others just wanting to really have a meeting about information and what's going on so that we can help better inform our constituents as well workforce services may also be a part of that because labor does come under this committee so just anticipate we will work to try to get that together for us in the next coming weeks yes and and then also just wanted to say we do have a long agenda we have a lot of rules on here there is a report from the buffalo river conservation committee that's on this report I'm really excited about the work that happened last week I couldn't believe how many stake holders were on the call but I'm really looking forward to that so I just ask you to stick around so that we can get through this and you can hear the information from that committee as well thank you. Thank you. All right we'll get started with the item see their adoption of the minutes do I have a motion. I have a motion second. I have a motion and a second all in favor signify by saying aye. Those opposed nay motion carries. Okay we'll move on to D.. Of this is a rule by DHS. On our choices. So mark is going to come to the table. And then we have other folks remotely going to be presenting. my community sure self. Thank you Mr chairman mark white with DHS we do have several others who are back in our office and are all and soon to present these rules this morning and I believe all go ahead and start with the item duty. Get the right page here. March yes Sir can we have the other folks that are going to be presenting introduce ourselves my soon. Yes Sir yes Sir offered those the just if you all go in introduce yourselves and we'll get that gives interactions done. The. It just did you. Can you hear us. I don't think they can years. A a. Six. Let me. I'm not sure if they if they've lost the sale there. Okay. Well the. Can mark can we go ahead and can you text them until they were ready for their presentation and they we can hear them. I did a text of them we'll see here. If you like I can I can go ahead and they say they're not muted if you like I can go ahead with the for this autumn yeah thank you for your recognized. Okay so members a last month you may remember you had a rule that you reviewed from the department of health related to the supervision of personal care aides these people who go into homes and provide assistance to individuals with your activities of daily living things like bathing eating mill preparation moving around and there's legislation you'll pass the last session the director the department of health to reduce the requirements for supervision it used to be that that supervisor had to be a registered nurse you back that up so that is now an individual with lesser qualifications can serve as a supervisor and so we did not want to have our rules out of line with with department health is required because we separately have rules that regulate personal care that's paid for by Medicaid so what we've done is we've adjusted our rules so that it is in line with those new requirements on the department of health side we reduce those requirements for who can be a supervisor as well as reducing the required frequency of those so are in supervisory visits to those clients it now in line with legislation has to be at least once per year it can be more often and there is a requirement that in our in has to make a decision about what frequency is appropriate for that beneficiary and that again that's going back to the act so we do is we we modified or Medicaid rules reflect those requirements and add some language just insuring that if there if the beneficiary does have a change of condition where their condition worsens that there that that will be re evaluated and they'll be a new decision about how frequently to the supervisor need be checking on that beneficiary I without the help with that I'll be happy to answer any questions. If you have any questions. Seeing none. Okay Senator Wallace you're recognized. I'm good items Senator. Dave you're not on the don't think. Can you hear me now yes better when Milliman did the their studies. On the day care rate they've they've made provisions for the minimum wage rate increase but on personal care. We didn't do that was that a mistake on their part or. Wanted to happen that way. Was read the personal care rate that is a separate agenda items that is later in today's agenda okay you look out for opportunity to review that certainly a denture question it the minimum wage increase was considered on both sides I think the the the there's a clear patients have been done and that the letter from a woman should been more clear about that point but my understand that no one did consider the minimum wage increases part of that. Okay thank you. All right seeing no further questions. This rule stands review. One one item he. Thank you Mr chairman and the folks the adjuster say they're not on mute they would see if if we can hear them now. I did just can you all let us know if you there. Can you all hear us. Thank you. I'll say no thank you are still muted. I can hear them as well. Okay which someone. goals did just that you. The. Okay can you all hear this. Yes there we go there we go nine okay so all our merry Franklin with the division kind operations to introduce herself and then introduce this rule okay we're on item ET so America unities yourself. Absolutely. Voting I'm sorry for the technical difficulties I'm very Franklin with the department of Human Services director division of county operations and we have a rule today that is a lot of pages that most of that rule is clean not. Of the rule were to you As a result ACT eight ninety two which which directed us to set reasonable limits for non medical expenses that are on my own and also it's. For many residents in nursing facility. that rather than being paid to the facility is allowed to be paid for these medical expenses instead and The most part of the rule is in subsection page fourteen in which speaks specifically about the rules about women non covered medical expenses can be allowed to be paid to other providers instead of the nursing home and The changes there were. Was also seeking this are sponsored plan amendments with our Medicaid state plan in this policy is now online with that law in some of the changes in that particular area or around not covered expenses it is now clear fund that they must be anchored. Three months seeking a month of application They're all even payments for cosmetic or elective procedures will not be allowed except when they're prescribed by medical professional. These are the expense that we can allow as the offset to income is the least of the free recognized by Medicaid Medicare or the average also allowed by commercial health insurance that clarification is now our policy expenses incurred as a result of the imposition of a transfer of assets penalty are not allowed. And expenses resulting from failure to obtain prior approval from from an applicable insurance or Medicare or Medicaid are also not allowed. In and it. If I procedure has been determined not medically necessary through the prior authorization process it is also not allowed. in addition to that there is clarification now on the policy that is someone who is not the nursing facility resident or the community spouse of the nursing facility resident is paying for a health insurance premium out of their own funds that also is not. In those are the substantive changes in this office now for questions. Okay other any questions. I'll I'll have to ask one question here of just for clarification. You talk about income offsets in I thank you defined it but just to clarify it that that is medically related expenses that insurance does not pay is that a ballot definition of that. Well what if there is other insurance other than Medicaid then it has to make use reasonable requirements in order to be paid and there are some things for example like dentures that may not be normally cover and dangers would be something that sounded offset if if all these other criteria are met it's Any prior authorizations overseeing did in its Recommended by medical professional so. Does that help answer your question yes in the thank you. Any other questions. Seeing none without objection this rule is reviewed. Thank you. Okay we're moving on to the. Who F. run if known right yes Mister chair may you may press the more thank you Mr chairman of this rule is released our self direction budget calculation methodology self direction is that's or independent choices program in which individuals receiving personal care services in the home they they are the they act as their own employer so they choose who they want to provide that care they pay the amount they want based on a budget this assigned to them according to formula and Jerry Sherm is at DHS and allow him to some self and write a summary of this rule. Good morning committee thanks for having us as mentioned this is about this so direction budget. Which the this rule change that methodology to calculate budgets for beneficiaries. Program if you are probably aware self direction is a program that allows a beneficiary to employee care givers of that this year is choosing use Medicaid. Fiscal agent separately contracted to assist in your related tasks so this is really just about that benefit your budget to be able to pay for care currently there will state percentage of. Personal care rate as the foundation for the budget under this revision would still be a percentage of the personal care ready but that percentage will be updated to more accurately reflect the difference between the agency based personal care model and the self direction model which is that difference being personal care rate less the administrative overhead that self rex streets not have because this rate of overhead is covered by our this lady contractor. You have been answering questions. All right are there any questions. Seventy one who's in seats seventy one. Who is. represented Miller you're recognized for a question. Mr you recognized me come over here represented Wardlaw. You can see you and see seventy one that the correct okay represented Wardlaw you're recognized we'll get back to Europe I'm sorry represented Miller he let mom like up. If you could explain to us question to on the hand out it says where does a seventy three percent hourly rate come from I read that in your response and was wondering if you could explain that out a little bit further. It says you attach the mythology but I can't find it in our hand out. Okay so the question to was there is a seventy three percent rate I'm from and as I mentioned or based on that personal care rate methodology that personal caper personal care rate was set earlier this year. Yes submitted a. Right she is along with that answer sort of the. But essentially it starts stock starts with ninety one that you're with house addicts percent benefit mode. And did not at a rate of overhead costs and that's what brought. the number two thirteen. Subsection. Great fifty five. Okay follows. Yeah you're recognized so that thirty seven percent of basically for overhead is covered by the contractor for re discreetly. That's right we we pay in the state being we we're paying a hundred percent to the contractor to contractor then pays that seventy three out in the thirty seven states with them is that correct. We are in the contractor to handle all of the administrative tasks it's not thirty seven percent exactly. Related to this taxation thank you a number of other things. Contracts so when they do things like paying taxes it will. I'm confused and why you would say it's thirty seven if it's not thirty seven I mean why not tell us exactly what it is if you're going to put a number down. Mister chairman if I'm are disqualifying may yes Sir the thirty seven percent that represents what if the services are being provided by an agency that is the assessment of what that agency would encourage administrative costs to deliver that service and so it is for self direction since the individual like there as their own employer worst track in that amount out essentially and then use that to build their budget the entries another question Mr. Yes go ahead we're paying thirty seven percent for ministry of cost for the personal that's for their ministrations for the personal care rate that is that is the amount that is included in that rate is thirty seven percent for overhead. And Mister Wardlaw are the I have a common methodology I can give that to you at any point if you'd like to Mr chair I may have a lot of questions about this rule but all yield to the other members and I may have a motion at the end of this okay. Representative Bentley you're recognized for a question. The owner. Now I am thank you thank you chairman just a real quick the question we are at what rate now. What our current rate. The current rate is ten dollars and fifty five cents per hour and we're going to what. The new rate under this provision. It's you per hour skews making I couldn't hear you on the second part. Is there. Can you move closer to the Mike we we having trouble hearing you. I'm sorry can you hear me yes much better thank you. Sorry about that it would be thirteen dollars and thirty two cents per hour. And that is it taken effect that we're paying thirties word deducting thirty seven percent for overhead for if they were under a Going to an agency correct. It. The agency right does have a third percent mistreated. Right straight it's not. Senate. Administrative costs. Okay thank you. And so I had chairman right now Representative Miller you're recognized. Thank you Mr chair just. I guess to start with I'd like to make a personal privilege motion that we do away with his own crap we had two thousand people protest ARE not hearing from the capital a few days ago I didn't see any dead bodies so I think we could all come to the meeting now that's a side note sorry for that my question is this. And I happen to know a little bit about the personal care and self direction and all that stuff. This is not. Adding up. At all I may infer one. We were promised back in the nineteen legislative session when a bill was proposed that would have mandated DHS raise the reimbursement rates to match to match the the minimum wage increase we were promises will be you know this study done whatever executive orders and and and that's been handed out this study by Milam and and I've I've read through it no we're in there does it mention minimum wage increase at all it's not in there and then also this math I mean I understand the self direct. Care process and we're talking about a hundred ten percent. Of a dollar. I don't know how you get a hundred ten percent of a dollar. without admin a dime to it but. With the. What what this math it's just not it's just not accurate and why is it that in the in the study. There's basically only a recommendation for. More or less a one percent increase. For personal care. That's what's in the study can you explain that a little bit. A certain Miller I think there may be a little confused I'm not quite sure what you mean about a hundred ten percent but let me a list of I clarify things just everyone's on the same page that. There are two separate issues that are involved in the in this one is the personal care rate itself which is the rate that we paid agencies personal care services and that is as so that's that's separate gender item but that is at is on the agenda today and we are proposing a one point four percent increase to that rate based on the the study those Dunbar actuaries for this not a specifically the the rate we pay for self direction is based on a percentage because the theory is that because that individual is administering their own services and hangs on to do that they don't have the same overhead as an agency to us and so essentially what you're doing is that you're backing out that overhead out of the rate and saying this is the budget that person on self direction and the issue that we have right now is that the percentage is fifty eight about fifty percent right now is fully paid currently for self direction and with the increased minimum wage fifty eight percent of the personal care rate is not enough to fully cover that minimum wage increase particularly when the next one hits in January and so that's why we're increasing this percentage now this percentage that will tie back that personal care rate so assuming the personal care rate goes up by one point four percent then this of direction that would increase at the same time but it's still going to be under this proposal. is good I still going to be that seventy three percent of the personal care rate if that makes sense. The following Mr. Yes thank you of and and and I'm not I'm not at all trying to be rude at all but the I want to know. Well for one I think a rain here's confused by the percentages coming in Heber springs or I attended school and luckily got a diploma. Seventy three plus thirty seven equals a hundred ten. Our and and and so I'm kind of stuck on that a little bit wondered about these percentages but as you just brought up recommended a one point four percent increase now can you give me a dollar figure not a percentage a dollar figure on either the hourly rate or a yet list to the hourly rate a dollar figure on what we're adding one point four percent to. So the well for both self direct and personal care okay so so for the the personal care rate this on the agenda the one point four percent increase is being applied to and I see Janet man is it DHS twice Kerr to double check me case like the speaker's wrong but that is being applied to the current personal care rate which is eighteen dollars per hour. So we're adding one point four percent. To that the personal care right yes Sir so. That would be. Of a little over what somewhere between eighteen and twenty cents an hour that puts up I believe to eighteen twenty four per hour for personal care right yet yet. The. As we know due to the minimum wage increase the cost is going up. Of the way over that per hour. Well the the rate that we build for personal heroes built essentially from the ground up that we ask the actuaries to do to look at know what are the increase is coming for but keep in mind that rate includes not only that labor cost which does reflect middle age but also includes overhead costs as well and so you we take all those pieces together no based on the actual words came up with they came up with this one point four percent is being the appropriate amount. One quick follow up question and I'll I'll yield yes when eight eight you're familiar with study. Hello I don't know if we have anybody you know online or wherever with the the Milman group but the. The the minimum wage increase is never mentioned in their study am I am correct in saying that. I believe on the at least on the initial letter that was done by Millman will also if on the blood Milliman it does not have the worst minimum wage increase no Sir. Thank you. Senator hammer you're recognized for a question. Thank you Mr morning mist what good morning let me up pick up where represented Miller closed out because a lot of the recommendations that you're giving to us in this exhibit and probably some of these others but specifically the one one now. Is it on the basis of the millions report and the recommendation to you and that's what you're basing your recommendations on the for the personal care rate yes Sir it is based on that report from element for this exhibit for item F. today no Sir Norman did not make this recommendation I don't believe this was a this was done separately from that termination of the personal care right. So you didn't use any of the Millman recommendations in setting the rates for the personal care. Rage for saying personal care rate yes Sir yes Sir but as I said that that's the best a different agenda item off for this item which is the self direction percentage. That information that it plays into it but no woman did not set this. Okay and I'm I'm sorry I got here late after Dennis point which which item is it that the milk that you willing to put this weight of the items that are on the table for today which one have you utilized Milliman in order to arrive at your conclusions that you want us to review today. That would in me include autumn J. which is the personal care rate increase okay and then also on I believe autumn G. which is the rate increase for EID T. and eighty two okay and I believe not Norman also provided some input on the rate increase for physicians which is item them okay. Then on the date on the numbers that are represented in the exhibit that's before us discussion right now how did you reach your conclusions to arrive at these recommended adjustments was it in house DHS Sir what was the basis that you drew the data from in order to make these recommendations out just to ensure complete answer let me deferred Mr Sherm to provide that information. Thank. We your start with their study with twenty eight per hour they included in their study on their way to get to the ultimate personal care rate eighty three percent wages increase assumption over the course of two years which product to ten ninety one at ten ninety one was where we start we start from there ninety one rate added sixteen percent over the course of two thousand. Eight hours not twenty six thousand three hundred fourteen we did not at eight thirty seven percent okay possibly would was added with the admin. House. So we ended with twenty six thousand three hundred fourteen and twelve cents. Including eighty hours of vacation twenty four hours of training with a billable and what hours of nineteen hundred seventy six that's how we calculated how to thirteen dollars and thirty two cents an hour which is that seventy three percent of the person you're right now to go back to it initial question about why isn't that you know why isn't sixty three percent which is thirty seven percent per hundred. Thanks. When you do the multiplication carrying four through this process thirty seven percent wasn't at right so it's sort of the difference between how these rates are calculated but we're not we're not removing thirty seven percent we didn't we just at percent was that the person you're retired explaining I without looking at this rate you just that I have in front of me but it isn't a street thirty seven percent less from the person you're rate it is just the personal care rates starting number at ten ninety one plus sixteen percent and I guess thirteen thirty two the next administrative costs if you will for some direction would be. Twenty seven percent not that thirty percent. But I just that that that's the next for how the multiplication works out I'm not sure that helps in the initial question I'm not be happy to follow up for questions. Okay I had a little trouble hearing you on the front end who did you say provided you the numbers that began the discussion. In the first place was it to providers was it to was it outside source that recommended the starting point for the discussion on the numbers every concerning number ninety one sixty. Yes. My ex. One more time if you don't mind that question directed to to me it we you cut out there could you repeat that question the the question that I asked to you all was. Who was it that you said provided you the numbers for you to begin your assumptions. Who who provide you numbers to get started with was a to providers which a DHS which is a recommendation from an outside consulting source how did you get what Senate numbers did you start with an who whose numbers did you use to get started with. Mister chairman there text me the same date they're having trouble hearing anything I'm not sure what's going on on the audio. The. Not sure what the issue is there I will say Mr Senator hammer the. So then the numbers that involved are looking at the ritual personal cure rate and then looking particularly at that overhead amount that overhead amount that was something that was term by Millman and their personal care rate study based on cost survey data from the providers the providers based they responded to the survey help gives information on their cost and Miller calculated that thirty seven percent overhead load based on the data provided by those providers. Follow Mr yes go ahead thank you okay the surveys is just the one that goes back to were only a few the providers initially sent in Report and then they set the numbers based on the few that were sent in and they went back and asked for more is that is that relevant to this discussion we had we had asked the providers provider information we do have some response I don't read the exact number miss man may have that later but we did get some. With house enough responses gives leasing good idea of it and came back with thirty seven percent now I know that the providers they produced a their own actual report that comes to an overhead load of forty one percent but I don't believe we seen the the data behind that number so we can't speak to the accuracy of that but that's that's one of the differences between the providers of us on the personal care rate is for what we saw we saw thirty seven percent overhead load they and they are saying is a forty one percent overhead load okay and we'll go back clarify one thing could while ago I asked the question did Millman have anything to do with the numbers that are represented in the exhibit that's under discussion today. I thought I heard you say no not on this one but they did on item J. and G. and maybe and but not this one but now you're coming back around and saying that. What they did you know and I apologize I apologize I wasn't clear enough but I think what I said was that although some women woman's numbers to play into this Milman did not perform the calculations or come up with this methodology the words we took some of the underlying data from Milliman but DHS staff came up with this methodology to come up with that percentage for self correction. Okay so you're you're the one DHS is one recommended the numbers that are up for discussion today for the for the self direction methodology yes Sir we came up with fourth Burke for come up to the percentage that should be used to calculate that self direction budget which is it is based in part on personal care rate wherever that personal care radius yes Sir for that percentage with DHS staff came up with that are thank you sure. Representative Bentley you're recognized. Thank you chairman I'm like represent our Miller I'm trying to do the math here so we had the ten fifty five rate that we are currently at was based on eighteen dollars and twenty four cents an hour for personal care so what is our current what are we basing. Jean dollars on what rate we're basing that on per hour. That will be based on a personal care rate of eighteen twenty four an hour at the but just be just be clear for first self direction what we're proposing is a percentage and so wherever the personal care rate that percentage will be applied to it I'm is gone by the report here in front of my face this is to date the ten twenty five is based on a personal care rate of eighteen twenty four an hour. So not increase eighteen twenty four hour this this is not making any sense at all. And I would just say chairman I I am we're green with represent a Miller that we need to have a good meeting this for affects so many of our constituents we need to have DHS here in this room so that we can have good conversations they can hear us and we can hear them so I'm just asking that they all drive over here is not that for. So I'm just asking that is a member of this committee covers thirty three thousand constituents that they take a minute drive over here were all getting screened we have a two meetings their biggest screen we're hearing from folks we need to have a good meeting this is very important and we're not having good communication of mass and they get their vehicles and drive over here. You could act is it urgent that we review this rule today. It's I have. Okay. Is not in today no Sir no Sir I think these senators you're recognized. Yes thank you I mean just a couple of different things I think so I'm receiving a draft of the time line of how we went through the steps so I think that's clear information that probably needs to be shared with the members of the committee said that they understand and I'm looking at it so I would recommend maybe we just. This to the end of the meeting for right now and if miss man and Jerry and if they could come over that might be a good idea of Gerald and Janet man could come over but that time line is important and then a break down of the thirty seven percent and how it went from a certain administrative the. I think you said fifty eight percent or fifty seven point eight percent and then it went down to thirty seven percent but that was requested forty one percent but you've already adjusted that is that correct which yes for the for the overhead load what what we proposed in the personal care rate is thirty seven percent and the providers they they're saying should be forty one percent okay but what I think what a lot of folks here questioning is they would prefer more going to the personal care aid worker themselves and less and administrative costs administrative fee so but I think it's important to have that time line of what the steps have been taken the next steps and then also just in response I understand that there is and there will this also will be revisited January one because of the additional increase in the minimum wage is that correct so we're we're incrementally taking care of getting to the minimum wage increase is that correct hi I bonded for this man on that I believe that's correct but I don't see tax or that and so since it may be a good idea just to share that information with the members of the committee and patents toward the end of the meeting okay okay can't. Can you all on zoom come over here. Yes Sir we're on our way we're leaving right you okay we will move this to the end of the agenda than so. Item F. is moved to the end of the engine yes to answer a question. We did issue a one pager or. industry on the next minimum wage increase back to January one. Okay thank you. Alright let's move on the G. we'll come back to then. So I know we had some people in the queue but will will recognize you when we get to that later. Okay Adamjee. Mark you want to present that yes Mister chairman. Give us a brief introduction of that and then Melissa stone is available to answering questions as well this is the proposed rate increased for early intervention day treatment and then adult available day treatment programs it's recognition of an increase of bleed eleven percent that we're proposing. All right. Are you all ready for questions or Melissa did you have anything to add. It wouldn't matter so these. Right. I'm sorry house so stoned division director word development disabilities services I didn't see it A earn a request and regarding rate increases for a service call day habilitation which is really a class ring hi eight and service for children and adults with developmental disabilities and the providers were actively involved in this reading of this great and and I have seen and riding side with how they rate. So there was an increase so bachelor and. I'm happy to take questions okay Senator hammer you're recognized for a question. Thank you Mr chair. As far as the as far as the origin of the numbers and what's been recommended in this unless you sent questionnaires last time did these come recommended from the providers are they internal and DHS are they from an outside consulting service Sir how did you arrive at the numbers. Yeah we I'm are contracted actuary element so we are rate eight that that providers completed and and and then we shared with the providers that. That number's right along and was looking three what factors they were looking and. And came up with the rate. But providers actively involved in the process in my case that they. Seems satisfied with the numbers that. Question for the chair please okay you're recognized are you gonna have any any providers here to speak to this or were they invited to speak to this. No I don't know we don't have any providers invited. Was there a reason why they weren't what. Go ahead senator you're recognized. It's it's a public meeting and so you know they can come they see the agenda but from my understanding and meeting with DHS they were everybody was okay a with with this from my understanding so. I assume if they weren't okay they would be here to. Testify against it or for it or whatever. Normally have people in the lobby that can come in. Man chair Mr chair yes on send a text message or to a chair do what they like to do but if nothing else I'd request this will be put down with G. until they get over here and like to text a couple people but how what you want to handle this just request thank you. Okay we can the latest one that you're wanting someone to come speak to it. The AHCF is gonna be over here anyway. Nine will delay this until they get here. Okay let's move on to the H.. Thank you Mr chairman this is a change to our Medicaid state plan related to opioid opioids The. The Congress passed was known as the support act made some changes and initiates requirements for Medicaid programs among other things related opioids and Mr might give a quick summary of this one mismanaged expert on this one certainly there any questions we can get to this one I will not say we receive no public comments on this one I don't believe this one is controversial at all that we're makes make some changes to the reviews of purchasable bill it's at that point of sale also in as new requirements regarding the monitoring and management of anti psychotic medications used in children as well as putting in new process sees a tech fraud and abuse they'll be happy to answer questions. Are there any questions. Seeing none. Without objection this rule is reviewed. Okay moving on to the item I. Saddam up of for several years we had a isn't some sloppy software known as pay is or provider electronic solutions what this was this was a program that a Medicaid provider can download and use to submit claims two are in an I. S. system so they get their Medicaid claims paid most providers use other systems we now have a web portal it can be used to submit claims and soap this this software it's it's has some bugs as some other issues and we are simply decommissioning that software and will no longer be using that going forward we had just a handful of providers who are continuing to use it we've been working with them over the last few months to transition them from this to other ways of spending claims is that this is just going back in the manual and taking out the references to that the soon to be the commission software. Senator when you're recognized for a question so you were able to identify those that were using passes and did you all identify all of them and reach out to them yes ma'am okay that's really important to me because I I don't want us to make changes to catch people off guard if they're not prepared to do that because did and and that transition for them because pass was a free software was a transition also free or did they have to spend money it's it's up to individual providers some they hire outside services to do this but there are other there is our waste through the web portal another means that providers can use to submit without any additional cost okay that's that's important thank you. Right seeing no further questions without objection this rule is reviewed. Okay moving on to item J.. Yeah we probably need to delay that until with the other two so we'll move that down. Okay item Katy. Thank you Mr chairman autumn K. this is a rate increase for vaccine administration again part of the regular use we've been doing over the last last year and be happy to answer any questions. Interview recognized. Do you know if this covers the cost of their overhead and purchasing the vaccines and immunizations. It I don't believe so and that this is strictly for the cost of actually administered at the cost of the vaccine itself and those other lady cost those are covered separately okay thank you. And it's for all of all folks that are. And is this for all so that is it gonna be the same that's being paid whether they're at a pharmacy or a physician office or at a health unit. I believe so there there may be a couple of. Differences on pharmacies just cause pharmacies have a different race schedule bubbly they can access this in some situations. Well I just wanted to be all the same. It's up my memory is that it is I can I can verify that for you can verify that for me I just think that we need to all be on the same playing field on this this so I understand you have a different. Rate fees for different folks but to me I just think it's really really important to me for immunizations the vaccines particularly because of the coronavirus we have seen a lot of kids not get their immunizations and I just feel like this is going to become very very important in the upcoming months thank you Mr chair thank you. Seeing no further questions. I'm sorry we have one Representative Gonzalez you're recognized. Thank Mister I get in there kind of late Why is there a difference in the cost of of flu vaccine versus any other. I would for the administration yeah. Because the the the rate at which are beneficiaries receive the flu vaccine is not as high as we'd like to see it and so with this is we could say also experiment of work up a little more for the flu vaccine ministration see we encourage and up takes the we have more garbage officiers getting the flu vaccine so you think that's a problem with with people not wanting to give the the back saying well we we know we get we do get we have got complaints from providers that the the rate was just not enough to justify it and so forth that's part respond this rate increase anyway but we thought was was probably more the flu side to see if I can have an impact and we'll come back and re evaluate the next year or thank you Mr. Any other questions. Seeing none without objection this rule is review. Okay item L.. Thanks chairman autumn L. this is this is a rule that it we brought it to the exact subcommittee a few months back as emergency rule this relates to the right we pay for durable medical equipment we discovered that there are some items of DMB particularly auction we're over the years Medicare has reduced their rates and other federal law we cannot pay more than Medicare to us as a right now well before the mercy rule we had we score we had a situation where there's some race that we were paying their higher than Medicare so what we're doing in this rule is simply adding some language to say that we will not pay more than what Medicare pays for the inmate. So that have entered motions basically mayor is laying. This rule that we brought it to the exact subcommittee a few months back as emergency. That was me. isn't speaking it was neck of what I said. All right. With. All right any any questions on this rule. Seeing none without objection this rules review. Okay atomism. An item in this is a no the rate increase this is a rate increase for physicians and sickle sickly for their evaluation and management codes we are providing for a five percent increase for those rates we're also in talking with medics Saudi about providing additional three percent increase that may be done through the PC CM program or the patient centered medical home program we're still in discussions on that additional parts of that part is it is still in the works but what this does is does provide a five percent increase for physicians. All right Representative Bentley you're recognized for a question. Okay was a last year that this is reviewed. Right well the last time this rate was reviewed it is been several years let me see if this. These rates have not been reviewed and fourteen years so were several for fourteen years you give us a little five percent increase for physicians I'm just I'm appalled by that when I look at my district out there and I have very few physicians out there I'm desperately trying to get more physicians to come out to rural Arkansas in a vast majority of my constituents of you know my area covered with Medicaid and I just you know we with over here over and over and over again that we can't get every other because they can't make any money we can't make ends meet they can keep their doors open so I just I need to have more information where we get to the far percent how do we get to five percent because in fourteen years. Everything I purchases gone of a whole lot more than five percent everything I pay for more there my employees even at my plastics business or sure get more than five percent increase and I need we need physicians out there. Take care of our folks so where do we get the five percent from an how to resolve on that and I'm just saying now I'm very much opposed to just a five percent increase. We will certainly get you a copy of the the study was done to reach that five percent and I apologize I don't have a lot of the children that minimum is met with his man gets here she can provide some additional details would like I will say I think just from our discussions medical society after I think everyone was satisfied that this was a a a fair amount we've let's not leave her the objections to the amount from anyone that I know of. I'm just hearing objections from my administrators hospital ministration those folks that are trying to get physicians out there to real Arkansas seven. Representative Miller you're recognized for a question. I'm sorry. Yeah are you on absent a Miller. Okay driving in. All right here we go thank you Mr chair just. Real quick Mr why and I'm of. I hope you don't feel like we're all picking on you personally not at all you're just the poor skate. That was sent over here Anyway so on the five percent but we paid err err I'm here by in here knows you know Medicaid is it it's of of of place seventy thirty MAX basically this with forever so we talk about adding five percent to what the state is paying so we would that would be an additional. An additional actual five percent. On a dollar that is paid to a physician. It would be so that would be getting a hundred and five percent of what they were getting before or is this some other kind of actuary methodology. Big word after big word top of process that arrived at this no so this would just be an increase in the rate this paid those positions just simply Dale so were we would be pay and so we could say that we're pay and. Moving forward we will be paying thirty five percent. Out of state money as opposed to thirty that we were pay and prior is that correct no Sir this this would affect the the split between the with what the federal government pays what Arkansas pace and that and that does very depending on the population from ten percent thirty percent or actually less than ten percent but none the less know that that split stays the same it's just so of the additional five percent that were painted that would be paid physicians under this rate increase it would be that same split so in most cases the federal pick up seventy percent of the cost and the state would pick up thirty percent of that cost. With federal government so pick up seventy percent let's do a lot more. Well if a with more stage all revenue we could do that. Well thank you very much. All right Representative Gonzalez Mr I'm of follow up with what I represent a Bentley was was talking about what. I don't think anybody is going to turn down any top a raise or or complain about that at all but that may not necessarily be exactly what they want have they asked for anything more specific than that and we're as a state where we fall among other states on on our. Payment CPT codes are to my knowledge no one has asked us for more of an increase on the position side and this further person of the state's offered to miss man on that. If you would the in addition so at yes Sir thank you Janet man the director of medical services at DHS Arkansas. To answer your question We did look at an eight percent increase for the physicians we are talking physician okay. And we we propose splitting it between the evaluation and management codes that are before you today and then using the additional three percent to bolster the PCC M. and the PCMH program we have not begun that work and we have not started that it was slated for January we've got a little bit behind with public health emergency we did have a meeting with several of the physicians with them medical society and the pediatricians they did ask us to consider the eight percent complete to be on the an M. codes and we chose to stay with the five percent with given every everything that was going on in trying to have a budget so that I think that was your first question that you had asked and then As we relate to other states. I can get you the specifics we were in we were in the middle to the lower end in some of our surrounding states but several of those states have gone and become a very heavy managed care state so I don't have very specific Mississippi and Tennessee are seventy percent and hunter percent respectively managed care so I don't have their exact CPT codes Louisiana is a make sure Oklahoma. Is mainly fee for service and I three Texas out because it's taxes. Because it's large I can get you the specifics it was in the rate review I just don't have it with me today okay I would like to see that you know on under were amongst the bottom of the state Senate and health care and it may make a difference if we if we are willing to pay a little more to the positions out there of people. Providing the care thank you yes Sir so question of about the budget that's come up a number of times and the part that the state would pay. But in the situation that we're in we're we've got money that we've transferred to cover budget and we don't know what's going to happen it's it's kind of an unknown right now five percent on the physicians would have a bigger impact on our budget and some of these other increases that we've talked about is that correct because it's based on a higher. Base salary yes Sir physician services are large part of our budget and I don't know that I know of specifically the dollar amount that and knew that it would have a higher impact on some of those codes than other sections of our budget. And I don't mean to say that they don't need that I I agree with what represent Bentley in some of those folks have said about rule Arkansas but right now in the budget situation we're in I think we need to be careful about. When you know the the rate increases that we would talk about approved. okay we have some additional questions did you have a question senator Irvin you're recognized. Thank you I know in February when we on that five percent was less than what we discussed but because of the budget problems you know I think we all we're trying to add the understanding with that I say we as in the medical society that academy of family physicians pediatrics but also there are other providers that fall into this category so we have a lot of a PR and stuff are working in that capacity under in that so that would affect them as well I I just want to go on record to say to nine I know I spoke to you privately about this but I really do believe that it should the three percent needs to do be a part of part of the five I mean not part of it but in addition to the five across the board and the reason why is because those I I support the PCMH models and I do support those the you have to have a certain number of Medicaid recipients that you tree in order to qualify for those programs so to me do you know your that's that's not fair because you may have some positions. It's just as important that they see the Medicaid patients that they have on their patient rosters as others that are bigger and so you're favoring the bigger people the bigger provider groups when you're doing that that three percent and not yours smaller folks so that's why to me it's really important that it's again kind of across the board. treatment so that there's some fairness out there because that could be disproportionate to people in very very rule areas like what represent a Bentley is talking about that And and also the physicians are only seven percent of the Medicaid budget. So again taxes represent of lady men's points. This portion is only seven percent of the entire Medicaid budget so we need to be real careful we're talking about you know making sure that we understand where the big percentages of this money goes and sigh I guess it's important for the question that you asked no of this is only seven percent of the Medicaid budget not larger so anyway to me I would just echo what Representative Bentley and Representative Gonzales has said is that in order to recruit. People to rule parts of the state of Arkansas to provide health care they have to be able to cover their overhead and make money and they cannot do that when predominantly those areas are Medicaid recipients but to put another point on what Representative Gonzales Senate is the fact that Medicare rates we are lower in Medicare with the federal government pays the most all other states and not is that correct. I apologize there is a differential and I do believe in this region of the southeast it is lower yes we are we are at the very very low end when it comes to Medicare so you have to look at the whole picture and it's not our job to cover that in Medicaid we can't we have a state budget we have general revenue we have to balance our budget but it is true Arkansas is lowest paid the only other place that gets paid lower in Medicare is Porter Rico. So folks need to understand that's where we are in the country every other state around this is getting paid more Medicare and to make another point on this when the federal government through the cares that gave money to the hospitals it was based on our Medicare rates so we got less money from the federal cares act in response to the corona virus because we are getting paid less in both Medicare and through to self and three insurance companies so is based on Medicare and commercial rates and because we were getting paid less a commercial rates the Medicare we got less federal money. Again that's incredibly disproportionate to a very poor states like Arkansas we have very rule areas and generally you're gonna find populations of Medicaid you're also going to find large populations of Medicare patients so to me you know this is this is critically important and and I would just echo that thank you thank you. Representative Miller you're recognized for a question. Thank you Mr I just wanna be. Clear for the record because I have several people back home in in mine and represent Payton and and center ridge district that this affects what are APR ends. Included and the five percent raise or not I just want to be on the record extremely clear on this issue yes Sir any any physician or provider type that is paid off the physician fee schedule I believe a PR ins are paid eighty percent they will see that increase in addition but it will be an effective rate if we increase the valuation management codes five percent for the physicians and then we pay eighty percent of that to the A. P. R. E. and they will not see a straight five percent increase they will but they will see an increase yes Sir. I would say eighty eighty percent of a five percent increase correct. Yes Sir okay so that is the way that's what occurred thank you. Senate Bentley you're recognized. Well thank you chairman this man is a look at this report here for this far percent increase is going to be one point three million dollar increase to the general revenue is that correct. Okay so why look in C. mask what you're looking at specifically so I can I wanna make sure I answer it on AM which is our exhibit and. Third page financial impact the financial impact for the rule was four point five million which we will see three point two million from the federal government and one point three in general revenue here. Yes man I and I'm going again reiterate to my colleagues here in this room that one point three million my goodness we can improve that the one point three main which spent eight hundred thousand dollars for a state school election money how to write a funds we spend three million dollars on a movie theater just to me this is pitiful I'm just being honest this is pitiful to think this positions across the state don't need more than one point three percent increase to take care of our patients. That's not too much to ask I think a percent is definitely doable if not a lever percent one eleven percent upon our duty to providers here for day care treatments I'm sorry I just don't think that one for three one point three means to I think we can go up to two million for heaven sakes at least we can do that much year for physicians across the state and this is our job here guys this is where the rubber meets the road this is what our job is and I'm I'm saying. That we need to go out more than five percent is not enough and it's not it is not adequate I'm sorry one point three million is not too much to ask me go up to two million a year out of general revenue we sure spend it wasted on a lot more than that and I can sure find a lot of places if you need me to find it for you. I would like response on it is that's one point three me is not that much were saying a word about the root word about our budget but one point three million is not that much we know how much we spend every year. This is where we need it is where I need this is work constituents needed to get treatment. To improve we know we're at we're at forty eight and forty ninth and health care across the state you know across the nation and I want to get better. This is what we've been looking at work meet you know we'll go to work every day we can't get paid we got a peep at a make over head more more my clinics are shutting down because physicians don't have money to make it and that's what I'm worried about I want you wanted to clinics left I don't wanna lose those. Well all all furnish response than ms may may want to add in. Certainly you're absolutely right about the importance of the critical importance of primary care physicians and how important they are to our Medicaid beneficiaries and our state we do recognize that and yes one point three million is a small percentage of Medicaid budget but I would I would only add to that just put in context of that our Medicaid budget is very tight we do not have a lot of fluff Medicaid budget Medicaid trust fund is it has been dropping for several years as we of work to to wean off departments reliance on one time funds for Medicaid and of course with other increases in cost coming down the line going particularly the next year there is going to be a need to find additional state general revenue so I started so don't want to minimize what your sex you you're actually right about the critical importance of these positions but it it would finding that money that that is the challenge is finding that additional state general revenue well I said let's do it and what why are we so low on a making explain to me why were so low one up on Medicare basin who do who decides what our Medicare rate is to CMS decide who decides that right so we know why were the lotion I have no clue why with the lowest I am happy to do some research and get you some answers off the top of my head it comes from CMS in and some body there I I don't have a direct answer for you Representative Bentley I'll be sure to reach out to center caught into center Bozeman defined at one in the world because that's not fair to any of us we know that are the rates based on that I'm asking my colleagues not to review this today that we need to use more study on that we can look and find some more general revenue I'm just asking you guys not to review it so thank you. Is that a motion Representative. Yes. I would say yes Sir it is you know we've got Henderson we get aspect for their six million we gave them if we need to cover but I can find some other spots and I make a motion that we do not review this rule today we go back to the board we find some money anybody call the governor will but we need to increase one point three million is not too much to ask and I'm we have got to get things better in the state and I'm just saying I make a motion. Okay have a motion on the floor to not review this is there a second. That motion. I have a second. In discussion on the motion. The notice question I'm sorry represent Gonzalez. Thank you Mr I had another question for DHS sensors a motion on the floor I guess all Alaska to the chair anybody else I can answer it I believe this was supposed to go into effect July first of this year so what if what would happen if we went ahead and approve this got this rabies in place and then continue the discussion to add more on and in the future. Of the three percent when is that due to kick in is that January one yes Sir the the right before you today is scheduled for July one if you approve the three percent was scheduled or being looked at for January one. Okay. Okay any other discussion. All. Senator hammer go ahead. Hammer thank you and again to the fallen represent Gonzalez is lead a more direct this to the chair because the weird discussion the motion I'm curious as far as I think there's an ongoing work rate review study that has or has not been completed I'd be curious to know of the legislatively directive rate study review how any if that plays into this discussion about this particular item and and what bearing it may have on the decision we would make. I mean this is the product of one of the write reviews that we have been conducting and we have done the evaluation and management codes for primary care we have not done the specialist codes yet for the physicians I think I'm answering your question but it is an ongoing process but this this right right right review in our this rate increase before you today is a product of the write reviews that we are trying to do systematically over the next I believe two years to review all provider types. Mister chairman okay latitude to ask a question or two under the where we are in the process or yes you're recognized thank you. So what kind of feedback did you get other providers if this is the by product that is now before shin this item for us to be voted on today what kind of push back feedback did you get all the providers while arriving at the numbers that we're voting on yes Sir we did do surveys and we did get responses and we have been communicating and I think the largest statement made as I reported earlier they had requested the full eight percent rate increase and we had all we had recommended splitting it says and I do think they had some additional questions on some things in the survey and the rate review and I believe we answered most of them I want I don't want to say all of them because then I'll find one that I missed said to but ongoing conversations we do regular meetings with the medical society and the pediatricians and I think there was a letter in comment to the state plan amendment into the rule before you today from the pediatricians that and they are appreciative of the five percent would have preferred the eight and all right so we're getting five percent what they wanted which was the eight and they get the other three in January is that March fair stating that that way yes Sir what we were looking at doing was looking at the PC CM program and the PCMH program but and that is always up for discussion as indicated today from the feedback from from this committee of looking at different things. And what's the price tag to given the other three percent. I don't know off the top of my head I would have to go back and look at the spreadsheet I mean it the one point three is the state share of the five percent I don't have my calculator with me all the Senator hammer spot my very quick calculation it be an additional seven her eighty four thousand five hundred twenty six dollars a state you'll revenue all right so first to give the eight percent now we have to come up with that seven hundred something thousand dollar number you just gave or in January they're going to get it in January anyway. It's just going to be delay between now and January set and I'll interpreting that correctly I believe sensor yes okay thank you. I get turned thanks to the to me. Representative Johnson you're recognized. Thank you Mr chair I'm glad I figured that out almost push my buttons can talk my question really is important to the motion so it was related back to some of the things or comment on before I don't want to delay the vote on the motion but when you talk about engaging stakeholders I've heard you mention the Arkansas medical side in the pediatricians which is great do you have a sense for what percentage of the payments out of being in in code you're going directly to physicians and Iberians verses entities that employ these providers because you know a lot of our physicians in the state of Arkansas a lot of funders practitioners they're not seen direct impact on the in in codes revenue back to them they're employed providers here and and the professional services are being billed for the hospitals by entities that own multiple clinics especially clinics specially hospitals and and so those are the people who are gonna stand to benefit or not benefit from increases in the in the in codes and I have a feeling in our state that the largest percentage of positions in the respective centers or employed and so if you're gonna be engaging stakeholders in the process I think is very important to reach out to some people besides jest the medical society the pediatricians particularly may the hospital association some of the other folks in the community that are gonna be stand to to benefit or not benefit from an appropriate rate increase so do you have been in an idea of what that percentage is break down necessary I do not am I made some dates to to go back and see if we could look and I do not know the breakdown of an individual independent clinic or at a clinic that is supported by provider base or entity or if they're employed by a hospital we've we try to send it out to everybody we try to send the survey through several different means that the medical society through the pediatricians therapy CCM and PCMH program we tried to open it up to anyone that wanted to participate but I don't have that breakdown okay. I'd like to see that if you can get that that be great I will try yes Sir. Okay at I'm and Mr it one thing I just wanted to say yes we they've had good meetings with stake holders the Milligan that studies came back I I would say it's fair to say they didn't agree with the studies but they were a lot of good discussions and meetings with DHS and so and and but that all kind of stops because of the code for the situation you know the the meetings had to had to stop the stakeholder meetings because of the the situation with cove it so. You know I think I think in speaking with a nine a and can fairly for certainly say everybody is Khan talk cognizant of our economic situation in the state and I just appreciate those stakeholder groups understanding that however you know we do have to look at economic growth in our state and health care is tremendously important so I do appreciate all the work I've done with the stake holders I think you know there's discussion about the three percent and and that's appropriate I just wanted to add that that the other thing I wanted to add to is that the carriers acts the corona virus money from the feds that came there was direct money that did go to different providers and doctors that pediatricians because they do not see Medicare patients did not get any of that federal money so again just kind of another thing to think about right now because a lot of folks are really struggling to keep their doors open to to represent abilities point that's real that's very very real and so they're taking out the PPP program they're they're taking out additional loans they're applying for every thing that they can they can order PP because I don't have a history of ordering PP if they're a small clinic generally speaking so that cost is been encouraged they're going further into debt because they're just trying to stay open so but I just wanted to add all of that different information but I think it's just ongoing discussion I just thank you go ahead representation thank. Representative Payton you're recognized for a question. Thank you Mr chair we back on the motion now there's a still a motion on the floor there's still a motion on the floor the discussion is on the motion thank you well my question would be to represented Bentley I continually heard you mention one point three million dollars that we need to find and the way I understand this if we review this rule they've already found the one point three million dollars it's in there so could you clarify your motion or help me understand what you're done. By Representative Bentley your answers representing pain there is one point three million I'm saying let's make it eight percent at least let's make it a percent so one point three million let's make it two million I'm saying that there's a lot of money you know as well as I know that we waste money on across the state and I have small clinics that are going to shut down if we don't get this at rate where it needs to be they've not seen an increase in fourteen years so we're given these positions a five percent increase from fourteen years ago to now and I'm saying and so the one point three million and the other seven hundred thousand it's make it a little over to me and and get these physicians what they need okay my motion is I'm saying let's not review this rule this let them go back to the drawing board and come back with this body with an eight percent increase in the different things to right there either the motion add seven hundred thousand or the motion takes it to zero which is. I would like to. I make my motion that we add seven hundred thousand I make it a percent okay so the motion is that we. Modify the language of the rule to get the insurance we can't represent Bentley we can't change the motion that's on the floor we have to vote on the motion and the second somebody tell me what the motion the motion is to defer to did not approve or defer. Back to the agency so that has the effect of making it zero those those places they're shutting their doors are now going to get zero instead of five percent it has my motion is that I want to not review this rule and to send it back for them to give us a percent I didn't know that I could make it eight percent today I've been happy to do that and that we can do that I would certainly take this motion off the floor and have a new motion to increase it to eight percent and make it two point two mil market a staff. Good I a staff felt what the time frame is on that. Could I a staff with the time frame is on not reviewing this and then coming back with an adjusted proposal okay if we don't review this he can go on the rules if we defer it goes back to the agency that's my understanding. Okay so we don't know the time line that we're given on zero but we want to give on zero instead of five percent because we want eight percent. Thank you thank you yes represent a pain because I believe if we don't we will just get the five percent I don't trust them to make up make it eight percent if we don't do it today and stop the rule. Right this moment discussion. Representative gray you're recognized thank you Mr chair I apologize I missed part of the first part of this discussion and the eight percent. If that's what Milliman came back with it makes me question the rest of the write reviews that they've done because I can quote quote G. the fee schedule for multiple insurance companies and what's considered breakeven or cost would be Medicare rates and so these rates for the most part really almost needed to I'd say it they need to increase by about seventy five percent just to get to the Medicare rates which we consider breakeven was a cost report done how how did these rates come to be. Physicians do not complete a cost report regularly so we did a survey and we sent out a survey asking for their expenditures and we we treaded a very careful line I did not want to get into confidential information but I needed percentages enough of what they were comfortable giving us to to look at the cost surveys so we asked for percentages of revenues for Medicaid Medicare and other we asked for percentages and details of their overhead their benefits and additional cost for delivering care at I did not bring the actual survey with me and we did work with the stake holders on the survey because the first survey there were several questions that came back on confidentiality they thought we were trying to obtain some information that we really had no intent we are trying to get some cost information so we did go back and forth with the different stake holders on the survey questions and things of that nature then all of those were compiled and looked at. And so that if if you're getting G. forgetting the revenue you're getting their expenses how exactly do you come to what the rate should be per visit per level how did you take that data and actually use it to come up with the eight percent increase. I hate to say this but my actuaries worked on that and I answered some very specific questions of looking at urban versus rural looking at the types of clinics trying to get some down to some granular level I did not actually crunch the data so I I don't want to mislead you okay well five percent a percent is better than nothing but it is no where close to actually breaking even which is why you know you can only schedule so many Medicaid patients today because you have to make up for it with your commercial payments not your Medicare but your commercial and it just it makes me question the validity of the rest of the reports that they've done thank you. Thank you Representative hammer. Senator hammer I'm quite right thank you madam chair. The who who is your actuary just refer to the actuary who's actuary. Milliman. So everything that you're. Basing your recommendation on is coming out of what Milliman says is best based on whatever formulas they use to arrive at these numbers is that accurate it was Millman and a combination of staff this was not done in a vacuum by Milam and I do have staff that worked with the providers will on the call surveys meetings and things of that nature so yes they did do a lot of the data crunching I don't have an actuary on staff okay at so if I did misunderstand sent was said while ago it's been fourteen years since a race is being given to the the of of physicians what direction did you or your staff give Miller man as far as how to arrive at what is a of current sustainable number. In order to catch up over fourteen years. We asked we asked them to to use the data I I did not direct staff with the percentage or a certain preconceived idea or anything of that nature and. I was we did try to take into account what we are under a consent decree with the physician rates so I did I did have to a and give that to staff and to Milliman that with all of the write reviews we've not given any direction to anyone working on it for a up or down or type of percentage or any type of rate increase. We wanted them to do the data and crunch it and give us some recommendations I I'm in my answering your questions are I'm you are at the center if if I may add to that of windmill is building these rates in certain this man concurrent if I misstate this what they're looking at is what is the cost provide that service and so generally they're going to start from scratch and see okay what are the what are the individual pieces there needed to provide that service what is that cost and then come up with right based on that so it's in the maven fourteen years since the last rate increase was done for positions mill in their official looking at that fourteen year further looking at today what is the cost for this provider to provide this service. And do they taking consideration to comment that was made awhile ago that physicians can only see so many Medicaid patients day they have to have allowances to have commercial patients to make up just to keep the doors open when they go about setting these reimbursement rates for Medicaid patients do they throw that in the formula. Because to me that's a contributor why were in the poor state of health that we are that if there's a bottle necked that physicians cannot see Rita you don't financially if nothing else only so many Medicaid patients because they can't afford to keep the doors open and we're set the rate what we're set in it and that's not gonna open up that bottle neck for them to be able to see more Medicaid patients what that tells me is we've got Medicaid patients not being seen because physicians can't afford to CM somehow note of that needs to be thrown in the discussion with actuary if we're going to get what we want which is better state of health for Arkansas. What. Yes Sir at I'm trying to think back to the survey in the different questions on the survey I think we asked for patient Break down of percentages I don't know that we asked for it by day so I think we asked for you know if you give us your revenue percentages commercial Medicare and Medicaid we can deduce what what your mixture is and then we can ask them to confirm it but I did not ask for their daily load or their daily scheduling patient I don't believe I just I'm trying to think back to the survey it was quite a few months ago and and on the right survey I know that we do the initial rate review we did look at access we look to see how many providers are there providing this service how much access to beneficiaries have to a provider provides that service so that. That access issue generally it does play into this and that is something that we looked at the less saying the consent decree referred to while ago how does it play in the mix of what you're proposing today as far as the rate increase. I am not a lawyer semi understanding of the consent decree is that and we have a requirement to meet and with the medical society I believe and medical society and I have exchanged some emails and and working on meeting that portion of the consent decree the consent decree is tied to a current BlueCross BlueShield schedule at I guess from the fourteen years ago as referenced by Representative gray and so therefore the lawyers have said that we are in compliance I did at would like to keep us in compliance with the consent decree wearing wearing complies with the five percent and the projected three percent or were in compliance with eight percent. The guy that there's apologize I don't know that there's a percentage tied to the consent decree there's there's not with consent decree requires a requires the regular consultations with the medical society so that because we and it does require center right this consistent with what federal law requires in federal law looks of those elements of access no to beneficiaries have off axis compare build other payor sources so all this was thrown in discussion when you came up with the numbers that you propose in today. It being in compliance with federal yes these numbers keep us in compliance with federal requirements yes Sir yes okay alright thank you yes this does require state plan amendments. So yes. Representative Miller you're recognized. Thank you Mr chair of our question can we make it I don't represent Bentley has a of this emotional floor discussion. We make a I don't know how this works we make a substitute motion at this point. yes as a matter of fact if you yield I want to go represented Wardlaw. Would you. Mr Miller. I reckon I'll yield for Wardlaw thank you. Representative Wardlaw you're recognized I didn't ask for that. Just all Representative Miller know that I have a couple questions first Mister chairman is that okay you're recognized I'm confused you guys testified three different things in the last five minutes. Mr why you referred to general revenue be an ex and you didn't have it so that that's why this number was what it was and the lady to your right I I missed your name and I'm sorry but you you testified that you answered questions for Millman your actuary who also did the store the study. And that's how the number got down to where it is so what I want to know is was it because of budgetary reasons why we answer those questions we we did is that why we're at the percentages were at or is it because that's the percentage that it should be from the study no Sir I and I apologize for giving Christian that the the five percent will I apologize for giving present five persons tied back budgetary considerations because it was not the task that was given to Millman was to arrive at what is the cost provide this service so that we can calculate appropriate you may you said earlier that general revenue did not allow for a higher percentage was your words used our general revenue yes yes I did use words revenue in reference to Russian Bentleys question about the increasing them out and go ahead and providing an additional three percent now and I told her that the base my very quick calculation it was roughly seven or eight thousand dollars in general revenue so here's what I'll tell you guys before you come to the committee we set their numerous of these rules while I've been here today and you guys of set down and stumbled all over everyone of them we did while ago on the on the itemized question on earlier here we are again it seems like we need to our homework before we come to committee so we can answer questions and we can tell the committee exactly what's going on and with that Mister chairman I'll make a substitute motion if you all out you're recognized all makes sense to a motion to allow this rule to go is reviewed with the understanding DHS will be back in front of us before we get to the end of the year with the other percentage that minimum recommended for this of provider. Their second. Okay. All right we have a substitute motion on the floor. What your question right Senator hammer. Would you repeat your motion again absent a Wardlaw motions to review the role as stated by DHS with the understanding that come back to committee with the percentage increase the minimum recommended in the original study which would be today percent if I'm understanding percentages correctly I may be off I had a lot of numbers in front of me last five minutes. Senator hammer you're recognized thank you can addresses to represent Wardlaw Mr yes thank you you mentioned the end of the year are you talk at the end of this fiscal year are you talking about the end of this calendar year the calendar years we understood the rate was going going to affect on January so we need to have this resolved before January okay thank you thanks for the thing Mr. I'm sorry I'm being told July Mr chairman. The the five percent is July one the three percent is January one of next year Senator hammer. This will make sure that motion. That's tied into that. Yes it is. Okay I have a Representative brown did you have discussion on the substitute motion. Okay. Is a pertain to the motion on the floor. You're recognized. I would see. I just want to clarify a couple of things that you said early on he said that this rate our our rates are limited by the Medicare rights correct yes this is five percent bring us to the Medicare reimbursement rate no. Thank you. Okay is there any further discussion on the substitute motion. Senator Irvin you're recognized. See the five percent will go into effect July one if this is approved and then the again we the three percent the the substitute motion was to bring that back before this committee but that also does not preclude you from bringing an emergency rule tales the executive subcommittee just I'm throwing that out there. Because that is an option. So I'm I'm I am throwing that out there that we get to what represent Bentley I think. That could get you to the eight percent box a lot one. Am I correct in that Representative Wardlaw okay I just wanted to clarify or just started out there for comment thank you. Center center Hickey recognized yes I just I guess I need some clarification I don't I don't really have any issue with what the substance of that motion it is but can this body do that. Because. Are we saying that we're going to do the five percent and that were requiring them to come back with three percent we can't require them to come back with three percent came. I mean it's just. May we can have a recommendation the recommendation okay so if they don't come back they just don't bring it back is that as long as long as we all understand that we we can always bring it back our sales for. Or for discussion in this committee okay thank you. All right I don't see no further discussion. So we're voting on the substitute motion no further discussion all in favor say aye. All opposed nay. Motion carries so this rule is reviewed. All right list Sir move on to in. Thank you Mr chairman this next rule relates to our children with chronic health conditions program and west miss bliss miss Melissa stoned come up and present this rule. And okay let me. Please introduce yourself. in. Yes Senator you're recognized. Thank you thank you miss stone for driving over here and to miss man thank you for driving over here we do appreciate that just want to recognize that sorry for the difficulties and and I do appreciate that as as well as Gerald that is here with the thank you all for driving of income and do that Mr chair it since it looks like we are going to run out of time I don't want folks to sit here and wait that may be on the agenda but I would just go ahead and recommend that we take items. Q. R. S. T. U.. And put those two at a meeting for tomorrow at one o'clock. I think because we're gonna run out of time that leaves all the DHS rules here because we have more work to be done and then those folks can go ahead and go on to do in their business and then we come back tomorrow one I think that's a good suggestion because we're not tomorrow afternoon it will want to one o'clock education has a meeting in here at one I believe or one thirty not today this meeting room is not available this afternoon and will be available to them tomorrow at one o'clock. So that's what we'll do so. If you're in that group is going to be carried over. In your you're free to leave. So we're going to basically do the H. S.. Okay members. Right he. Items Q. R. S. T. U.. And if they can come back tomorrow at one. Okay that going to be okay with them doctor Cochran. Dr com is that okay with the presenters can I get and not the man secondary wacky is to go with that AT queue okay. Yes Sir as question Representative Payton. What we get senator garner question. No Sir this was to the in agenda item I don't have a question this morning. Representative Payton. So my question would be to the chair and the staff I mean can we schedule an unscheduled health committee meeting with less than twenty four hours notice. It's not we. yes we can go allowed to do that thank you. Okay. Okay alright we're back to item in. Yes I'm my name's Melissa stone I'm that division director for developmental disabilities act and DHS. Item in is a request to review a rule of a hundred percent federally funded grant that is administered by a and. IDT gas it is for more than just kids with intellectual and development disabilities it's for all children in Arkansas that have chronic health care needs so although we administer it and many children on the program do not have intellectual disabilities they might have physical disabilities or some I'm pretty serious medical conditions so the rule and is being amended to outline exactly and what services and what categories and limits we will pay for each child under this grant so and the grant not only provides nurses that are on my staff that helps families get connected with services but then we also pay for and things like and vehicle modifications for requires for a wheelchair ramps adoptive equipment pharmaceuticals many medical procedures if there's no other medical coverage and and and medical camps which can be very expensive but there's and there's camps across the United States and FOR specific illnesses that many children like to attend on an ordinary summer so I'm happy to take questions. Okay so this Already exist for some of this equipment is covered but this just modifies that yes Sir it's just and we want to clean up the rules around at the people who are aware of exactly what what the benefit package was in this grants Right. You're recognized thank you Mr is this isn't related to the role I was waiting till we got to the end of the DHS rulemaking process to ask his questions is unrelated to the rule making process and now that we shifted the DHS to more important issue toward in I think the appropriate time to ask if it's okay with the chair to ask a question that's not related rules with that be appropriate. Yes ma'am thank very much mark thank you so much right me my email back I don't know of many people here heard but I've heard from probably a dozen nurses to last week about the direct care payments they were getting from the cares act the number one concern here for people as as their colleagues in the hospitals and other settings or start to get that additional pay the people at clinics the EM teasing the other folks or not receiving that pay now your email explain that to Legislative Council that wasn't approved to the steering ACT and they weren't included I think it's clear that we need to let people know why they aren't being paid because there is a bunch of resentment being built up right now with nurses all across our districts to see their colleagues who are working in a hospital some of which don't even have an active cove it move on covert nineteen patient but the day at the clinics or the people that put their lives on the line every single day who or exposing myself to the wheel on cover nineteen virus. Are not received a pace that I need to beat communicate clearly because I think between DHS and the governor's office unfortunately that message has been muddled and I'm here for people who do not understand that can you explain clearly now for the people to understand they will not get paid or who will get paid thank you. Yes yes senator let me give I can't use little background but how we got to the program and where we are today win the pandemic began back in March one of our concerns was that some of the healthcare workers. Whether not they would show up for work essentially because of the risk the pandemic with people wanting shelter in place and and not be further exposed there is a concern of will we have enough workers who are coming in so that Somers critical facilities and operations can continue areas where it is truly a lot for death risk of for the not a worker shows up for work and so that's why we're doing what we proposed was some payments for these direct care workers number one in L. TSS settings select nursing homes as well as people riding in home care I know that Medicaid waiver money that went to them initially that the governor also believe tort in the March yes Sir yes that was funded through Medicaid and then separately we also proposed for direct care nurses working in hospitals in the in patient section of hospitals again because the critical nature of of that area and how it is of law offered at the importance that those employees continue to report to work and so the steering committee had approved that proposal for that for that group and they can Legislative Council legislative counsel prove the preparation for it and so that's where stands today is that we are using Medicaid dollars for the long term care side using carriers act dollars for the hospital inpatient side now that does leave open the question of what about other areas hospital so outpatient facilities clinics other things like that certainly that is something that could be considered it is not been approved to date by the steering committee or by legislative counsel but that's certainly is of eight a possible use of the Kurds ACT fundings and it's be a question of prioritization of with all the different needs that are trying to be met with those carriers act findings it is that something that for which those funds should be used I will miss one specific one for the EMTs we're working with the able to association on a proposal there and I do expect to see a proposal come to the steering committee within the next few. X. two and institute similar payments for EMTs thank you that that clarifies allied I think that shows the kind of power the steering committee and how there are been lapses in that because I can tell you these nurses from from two months ago understood they were gonna get this pay and now they aren't they are upset they feel like they put their lives on line the same way as something that we definitely need to think of the solution to to protect those who came through but I just thank you Mr chairman for allow me to ask that question I've been inundated with people this week you want to do it in the city thank you so much. All right getting back to Adam in was there any other questions. Seeing none I without objection this rule is reviewed. Okay the let me see okay we're gonna go down to the ones that we moved. So we're gonna go to item A. F.. Back to item if. Do not. The. So this is the item on self direction. Care yeah. Mister chairman A Mr does have copies that methodology if you wanted district that members the Russian copies yes if you have companies recently. Yes go ahead. Mister chair. Yes Senator you're recognized members if you just don't mind going through your packets and separating out exhibit and leaving that at the packet so that would help staff out. So if permit exhibit online just pitch a rubber band around that that would help them so that we can be prepared for the meeting for tomorrow. And then discarding your other exhibits that we've already gone three that would. I'm just going to ask a little housekeeping. Are you guys to do that. And we are on F. G. and J. R. the three exhibits that we're gonna go over now for the rest of those tossed to the side and pitcher reprimand around exhibits so. I'm sorry. Yes. Okay and also you getting hand out here that has information so you are an anti in you thank you. All right I think you're a unless you had something entities yourself please I thank you Mr chairman my name is Cheryl chairman the director for the department of Human Services division of provider services and quality assurance A of did you have something you want to add or do you want is open up for questions I'm happy to open up for questions Mister chairman I was going to the reason why set out that hand that was just to explain the calculation numbers I think there's a lot of questions about that okay. All right we'll just move into the questions in. Represent Wardlaw you're recognized. Thank you Mr chair earlier I asked a question about the percentages and my ask it again now that you have this handout what's in that thirty seven percent is that mileage or is that a ministry on the. For agencies that it over it cost and I use my ledges example by the way is a is a that that is one example so for example they may have trouble calls for the pay employees trail from one works not to another Medicaid does not pay for that directly we only pay for the direct service provided to the beneficiary so yes over it we could include those mileage or the travel cost for an agency employee to travel from side to side it includes their back office operations it would up to now with included using a registered nurse to make supervisory visits to those individuals and as your call earlier you all review approved a rule in which were lessons requires but it would also have the supervisory business as well. Okay thank you. All right of the other questions on item if. Representative Bentley you're recognized. Okay I just want a clarification so we are currently now before this rule reviews at what rate per hour ten dollars in here I'm sorry ten dollars and fifty five cents is to self direction rate what's the personal care right right now before we do it and I don't I know that's based on the of the rule but it is connected to this because we do percent so what is the personal cure rate now before we increase. It if I if I may as of December thirty one it was eighteen dollars an hour we went ahead and increased it as of January one to eighteen twenty four an hour so those we would have put that one point four percent raise into effect because under federal rules we can do so that retroactive even though we're in the process and you have before you today the rule change to formalize that we would head and may that effective back to January one two again this rate has been in place for how long how long is the eighteen dollars an hour banning percent was has been in effect I believe since two thousand and sixteen. What was it before that Marty now. I don't know offhand we can find that out for you. And so one from eighteen dollars and that's our increase now so now the rate for personal care raise eighteen dollars and twenty four cents an hour with the one point four percent increase yes ma'am with all the minimum wage increase and everything yes I eighteen point two four. Okay this so I can go back in the queue this all I have right now look at my numbers thank you. Thank you Mr chair Even this handout you'll and I appreciate you being here of. The. I know I cannot get comfortable. With with any of this especially with the I mean the self direction. Not a minimum wage. January one minimum wage will be eleven dollars an hour okay I understand with the personal care there's another agency there who we assume is. Is it is making somewhat of a of a profit under center nonprofit but they're but they're they're covering their operating costs and so they might have a little bit of wiggle room to make up the difference albeit we're going to discuss that on Jay I know but in the in the sump race all this is so linked together. I can't get cover for the I mean where's the extra money going to come from I know you may say well it's only nine cents an hour. Was still is gonna come from somewhere. Our our these what was the deal on this certain that that ten ninety one that is where it is that right now and so that's what we're asking to increase is that we're asking to increase so that rather than the self direction rate being fifty eight percent or so of the personal Kerr rate increase that so that is seventy eight seventy three percent of the personal care rate so soon this rule was approved and went forward then the rate which would be paid to the self direction budget would be thirteen thirty two. That's correct Representative Miller the current rate is ten fifty five we started our calculation methodology with ten ninety one which you can sort of see on that first or second column is where the personal care rate really started with before dad at the benefit load and the administrative overhead cost so we definitely appreciate that minimum wage is ten dollars an hour now to be eleven dollars an hour in January so this goal was to first tie it to at the personal care rates so we can have some way of having automatic appropriate updates based on rate reviews without having to go in and adjust this number every single time the problem with the current methodology is that it was currently at fifty seven point eight percent of personal care rate which doesn't make self direction of viable alternative for beneficiaries because it's just too low on the first I mean it's below minimum wage at the at them at the moment or when it goes to eleven dollars an hour but will eventually get to about seventeen percent of beneficiary hours they can't afford unless this rate is increased and once he gets a thirteen thirty two what will be able to accommodate that that second minimum wage increase okay so just for. Just. Sample five this. For the common red necked please. Right now your your ten ninety one an hour ten fifty five okay ten fifty five that's right okay list on the sheet or I haven't seen. What with what we're you're asking us to do today it will raise it to. Thirteen. Yes Sir it'll raise later thirteen thirty which most the time if I'm not mistaken palco. Our our They may have a balcony of everyday is we have another outside coming because god for bid we not outs or something Or somebody else can make some money but there are so they're they're they're covering their operating their operating expenses will be covered and the the The aids the into attendance employees in the self correct we'll make a minimum of eleven dollars an hour come January one that's correct on record for sure yes. All right. No further questions thank Sir. Right. See no further questions. This rule stands reviewed. Thank you Mr chairman thank you committee. We were very. Okay we're on items G.. So it is your self again for the record. Was this town and division director for developmental disability services. So I told Janet AT handle item G. E. It said DMS rate review but it's for our DD providers so am I and G. is a request to review a rate increase for a service called day habilitation so we offer day habilitation for children and adults with developmental disabilities it's a classroom type training setting and FOR adults the rate why is ten dollars and sixty cents per hour and the increase is now eleven dollars and seventy seven cents per hour for children it was sixteen dollars and forty six cents per hour and now eighteen dollars and twenty seven cents per hour this rule this rate did go into a fact earlier this year at the request of that providers they were pretty desperate to get the rate at so that they can remain open. I'm happy to take any questions it's an eleven percent increase. Wardlaw you're recognized for a question. You tell me the rules already into effect that you're asking for today. It was it was an emergency rule approved okay by the six I just wanna make sure we're clear on that well the route the rule itself was not in fact but the way things are structured we were able to go ahead and implement that reading crease retroactive back to January one we'd come to council to get some additional funds we this rainy day funds that was used because it was not part of the budget but for that for that rate increase to be permanent there has to be changed and the rules and that's why this before you today. Thank you Mr. Any other questions. Senator when you recognized. Yeah just to. Comment a little bit further on that I think. The part of the reason for that was because we were struggling to find people to work. In this arena is that correct and we wanted to really kind of keep people in their homes or keep people where they were at as much as possible. yes this particular Provider type and service had not been reviewed sense. Two thousand and ten I believe this hourly rate for this service and yes this is a service that intellectually disabled individuals go to during the day that's right and it's a day clinic so in addition to this service than they often also get nursing services and occupational therapy speech therapy and physical therapy. And this was one of the first I'm per but first services that were reviewed and after the governor put out his executive order where we've been talking about earlier today so this was one of the first providers selected at their request if you remember they were pretty vocal during the last legislative session and then there was a lot of discussion around this particular service and what they were being paid and they asked to go first in that rate review and we felt like and that it was part at that would put them their first so if I could just make a request I mean because. I think the big picture I think it would be very helpful to have a spreadsheet of all the different write reviews and how long it's been since great because what what I don't want to see happen is who has the loudest voices yelling the loudest okay and because there are some people that are gonna work hard and check are gonna try to. work with you but then they they get kind of. Cut because they're not screaming louder than the other people or whatever so to me this is not a good way to do it so let's really try to look at this from a large perspective so that we know okay this is the provider group this is how long it's been since I've had a rate increase this is the process and just a real simple spreadsheets and then it says what it is currently and what it is going to whatever and also what percentage of the Medicaid budget are they so that all those things can be answered and we have real clear information about that does that make sense and then what the fiscal impact is and the why I mean I I think it's important because a lot of provider groups are trying to work with you but they're not happy they're just not yelling louder right and so in the grand scheme of things we as lawmakers have to sit there and go okay this isn't more important than this it's just that these people are yelling louder than these people that's just not a good reason to make policy we've got to be able to make policies and FAQ's in so and we also have to see the cumulative picture of that and how that affects you know economic growth and how that affects the people that we serve and how it affects the budget so I think that's really going to be important if we have that are next July meeting if you all can get that together I think that's really important for as we move forward thank you. We'll get that together for a. Absent a Wardlaw you're recognized for a question Mister I don't have a question I was wondering we have discussion about review of add something to add to what senator Irvin just said go in. You know we've said here today and we heard all these discussions about rate review and what we heard was there's budgetary reasons we answer questions a certain way for mail on to the are actuary when they're they're rate study as well. What we really need is an independent. Rate study we we have no clue as a legislature and we've learned this today how you guys are actually going through this data how you guys are manipulating this date of whether it's budgetary manipulation are because somebody's louder than somebody else or because they stood in session and try to pass a bill I'm not comfortable where we are today and this is been very in mind breaking learning how this process is actually taking place so we as legislators. Need to step up at some point and figure out how we want to move for with this because it's not going forward in a constructive way at the moment and that's my discussion thank you for those comments. All right seeing no further questions with the. Without objection this rule is review. Thank you so now we moved down to J.. Hammer. Sure I believe I handed to the staff two ash the chairs that they would consider passing out a hand out from a independent consultant that had comments reminding a rich pertaining to item J. could wood chairs allow that to be handed out. The what Senator hammer would you explain what this is a little more detail share it is a it's comments I propose reimbursement rates for sought former here services personal care services which is got my. Story right that's what Jay is about yes it is okay and so he identifies who is it's pretty transparency farce to retain him but he is an independent consultant would have been here today a sentiment siege but he was under the impression that because it was a closed meeting that he would not be allowed in to testify and actually have sent a message to see if he could be here tomorrow in the that the chairs may want to add J. to the list of things we're going to deal with tomorrow but there is a two page handout that expresses his concerns regarding how the department has arrived at the rates that are represented in the item J. and some concerns and so I would just simply ask maybe if we're gonna get in discussion this today that that handout be given to the member so they could maybe do a quick standing considered in the questions that might be asked about exhibit J. okay all right of. Centerton your question just quick question Senator hammer did this individual cement those comments under the public comment period and if so what they'd be included and our handouts manager I do not I'll look through here real quick but I do not believe they are. Included in the public comment they were of additional items that were added after the. Comment was because it was closed. Well I think because there might be some confusion and closer open meeting I think allow this to be passed down so thank you later passes now. All right of. The. Your issue self one more time. At Jana man the division director for the medical services Arkansas DHS may may I ask a quick question yes. I just need to confirm if I have the same two page document that you'll mass maker so we promise on my proposed reimbursement rates topline. I review proposed reimbursement rates by Arkansas department Human Services for personal care yes Sir I just want to be able to refer to it if you ask me questions back right to page yes Sir yeah that's it. Actually what we have. We have the report that this is alternative pager I. Okay Representative Gonzalez you have a question. Yes thank you Mr chair I guess this is directed toward you or or maybe I need to make make a motion but a lot of work Senator hammer said about this in the confusion of the open or closed public meeting I would like to ask that we hold this till tomorrow if some the public is willing to come tomorrow to testify on this. To hold this item it was more. So. If I need to make a motion on that I will but I'm. Nope whether other people I would like to hold it till tomorrow. Center you. Okay yeah I don't see a problem with that you all can be here tomorrow. Yes okay. All right so we will hold item J.. Along with the other items that were hoping for tomorrow. We need to pull item J. al you stack and put it into morals stacked thank you Mr. Okay I think that's the last for department Human Services the correct. All right thank you. Thank you Mr chairman thank members thank you. Okay we're we and Okay a committee were down to item Department of health. Thank you Mr chair can you hear me that this large to yes of this you I can hear you would you all introduce yourselves this for the record. We lost. We lost the feed. Where are you general counsel and I'm here to present the rule on at administration of vital records. And I have with me other witnesses that'll be representing either rule the doctor Delahaye in here to present and health update on Kobe and if we get to other business at the end of that agenda. Okay you may proceed. Thank you Mr chair with regard to the rule this addresses changes pursuant to three ACT that were passed in the twenty nineteen legislative session ACT three fifteen of twenty nineteen eliminate the unnecessary references to the word regulation ACT nine seven five at twenty nineteen amend the death certificate registration process and this requires a medical certification to be completed using an electronic product that I that includes all medical thirty fires in case of death including corners medical examiners physicians and hopped the nurses it also amend the rule you add that the language for ACT eight a one and twenty nineteen this requires a report on it do you termination of pregnancy to report whether or not the abortion resulted in a live birth add the rules were amended to add the draft with promulgated by our board of health back in August of twenty nineteen we had a public hearing public comment period we receive no public comment. That concludes my presentation I'm happy to take any questions. Any other any questions. Seeing none. Without objection this rule is reviewed. Thank you. Okay this move on the item P.. Shared Matt four can you hear me OK yes we can hear you man. Thank you Matt Gilmour aboard the commission your department health the rule we have for you today is for the Board of examiners in speech pathology I have miss Elizabeth Williams she's the board chair and I think she is them down now and we're gonna have her present the rule we can take questions if you all have after she gets to present in the rule. Okay maybe. This is Elizabeth Williams can you all hear me yes we can okay I'm good morning committee I'm the chair of the. Board of examiners in speech language pathology and audiology and some of the highlights are proposed rules and in the interest of making the licensure process move more quickly and be more cost efficient we have first delegated or board director the authority to issue licenses so that applicants do not have to wait for our boards need we need six times a year and then second we have lowered the licensure fee to reduce the cost the licensee's. And next based on public comments regarding tell practice our board decided to pull that section. And not make changes at this time we planned a thoroughly fleshed out the issues in public comments and then also consider what we're learning due to the situation with cover nineteen a new aspects in that area we will have those discussions with stake holders and make changes at a later date also due to extensive public comments that we received In the area of the speech language pathology assistance registration process. no changes were made to that section I have appointed a committee to study the regulations and standards in this area and then make recommendations to the board at a later date Also in the proposed the Arkansas was rules when institute automatic licensure to certain military applicants. And that concludes and some of the highlights and I'm happy to take any questions. Committee on any questions. Seeing none without objection this rule is reviewed thank you. Thank you for your time. Thank you Mr chair. All right committee I think that is. Everything except doctor deal Hey. If you. It that a few of. Give us a update on the co with nineteen. Situation can you hear me. Yes thank you very much Jennifer deal Hey that epidemiologists at the Arkansas department of health. I would like to give a brief overview of the situation regarding cope with nineteen in Arkansas so to give us a contact we have well over seven million cases in the world and over four hundred thousand that. In the United States we have one million nine hundred and twenty. Thousand plus cases in the in our country with over A hundred and ten thousand that. in Arkansas we have currently nine thousand four hundred and twenty six cases. And we have one hundred and fifty four at. that case have been increasing recently over the weekend we had seven hundred and seventy five new cases. and they seem to have from what I know at this point we're still looking at the data from the weekend we're seeing the most rapid growth in northwest Arkansas and then ten and Washington County. And and we are also seeing at in the population of increase and art Latino population in that area but also in some other counties around the state. We're working hard to increase our testing capacity in Arkansas so far we tested Over one hundred and fifty eight thousand folks or run that many tests. And over all our test positivity rate is five point nine percent so there's a a balance that we want to make sure we're testing adequate numbers of people to find any cases that are present and at so this number help the keep given have an idea if our testing is adequate we are wanting to find cases quickly the offering tests that are convenient and easy for people to access is important and then any cases that are dent that have contacts we traced those contact and also get them tested. So to increase our capacity in Arkansas the health department has acquired a high throughput testing machine and are I laboratory we're able with that machine to test up to a thousand at test at the a day and our hope is to sent acquire as second machine so that the one of the machines need servicing our maintenance they were able to keep the capacity up. we are also now providing test and local he health units around the state so people can call make an appointment and come get tested and we do not require add people to have any at known symptoms are contact but people anyone who wants to be tested can detect it we've also been partnering with other organizations that just the community health centers around the state to increase our testing capability. Up with regard to the case investigation at this time we have a approximately two hundred and forty health department staff involved that includes the nurses who do the initial interview of the new cases and contact tracers who work with them to follow up with the contact we are wanting to increase our capacity in that area and also to make our efforts sustainable so we have a request for qualifications out to partner or to contract with A organization or company to oversee the testing and the acting related to that in the meantime we are working with organizations to provide that and at if it's that academic institution it may be faculty and students who are also involved in contact tracing in the fall it's not likely that the academic institutions will be able to continue at the same level and of course eventually many of the health department staff who are working on contact tracing and case investigation will need to continue on with their other usual functions so it's going to be important for us this summer to have a sustainable contact investigation and tracing in place. The health department has also continued with a call in line at so that the public may call with questions we receive about a thousand calls a week and they're mostly about clarification for guidance and direction as well as a large number of people with complaint about going places and people not adhering to the guidance or the recommendations are the directive so we feel those and try to work with the call are as well as the businesses that we may hear about to help them be educated and make it a learning opportunity for them to Know what that guidance and directives are. I can stop now if you would like to see and try to answer any questions you have. Senator hammer did you have a question yes Sir I do you're recognized thank you. On the total number of test given do you include in that number those that go to get elective procedures that are now required to have the code that tests taken are you including notes numbers in that total overall number. Yes so if the test is Apart in Arkansas we receive reports from both positive and negative Pat and that's in the overall number that we calculate if it's not reported to the health department we would not know that number but our understanding is that almost all tests are reported to the health department do you know how many of the tests that have been given that are reflected in that I think it's up to a hundred thousand plus test are the result of the mandatory covert test associate with elective surgeries. No Sir I don't have a way of tracking that I could see if it's possible to get that number. And I'd like to get that because to me that potentially could maybe skew the images being given that people now that elective surgeries have opened up and people are having to get that test even though they're not showing any signs or symptoms I'd like to see that number split out just to because that would separated from the rest of the general population that's kind of a captive audience so I'd like to get that number and then the other question I have we have a handout that was given to us that shows the number of positive covert nineteen cases by county do you have a copy that. You're referring to the map yes ma'am. Yes yes Sir okay sling county shows a hundred and thirty five positive covert nineteen cases. Is that a voter is at a hundred thirty five as we sit here today or is that a hundred thirty five cent you started testing. We started testing. Why would you not put out a map that would show real time because to the general public they look at that map and they think a hundred thirty five is how may we have now what are the current yeah what are the current number of active cases in sterling county today. So that would be about thirty one cases. And how. I have a list of county what they're total number of cases they had over time how many have recovered and how many that that are I just selected an overall map to provide you today okay and the reason I'm asking for that is because as we try to get these businesses open back up if they see this and they hear those number of cases that you know were added but at the same time they need to know the number of cases that are rolling off so we have a real time the the push back on getting my community about getting the business is opened and turn them loose they they are drawing the resistances that they see numbers like this and I think we got a hundred thirty five the real the real number is thirty one and that changes the discussion or the nature of the discussion that occurs yeah. If I'm not mistaken I believe that is available on our website so if someone goes to our website and click on the county they will be able to see the total number in the number recovered so let me check to see what I can do to produce such a map that we can make that more clear because we do want people to have confidence in their community I can go about and and you social distance thing and so forth to carry out their business. All right I'd even go so far say on this map if you had it grafted to wear a hundred thirty five total code cases today thirty one would would be a good snapshot but that's just a layman suggestion so thank you thank you appreciate that. Representative Gonzalez you're recognized thank you Mr chair of five point nine percent positive rate is that just health department test or is that private labs as well. They're all the tests together. So we have And that's a cumulative total at because of the increased numbers the last few days of. For instance yesterday the positivity test with seven point one we had four thousand two hundred and twenty seven attest and three hundred and two were positive that we received so that was a seven point one percent positivity It includes all the tests. So so if I remember correctly the health department had a much higher positivity rate than that at the beginning of this and private labs were were around five percent. way back to the start so does that mean that we that we have this spread through the community we weren't doing another testing to identified then and and this is maybe not as serious as as what were made to believe. So the health department initially when they were doing their testing work testing hospitalized people and the people who are most highest risk because we can have a very quick turnaround so it's not surprising that the positivity rate would be higher in that population commercial lines were able to test the more the general population so of course if the number of cases in increasing then you would think the positivity right would go at if a worker that number of cases is not increasing in your increase in the number of tests in the positivity rate would go down as so what we see in the last week is a positivity rate around seven and it's been fairly stable during the last week so that leads me to believe that we're having both increased number of cases as well as increased number of attacks. At a little bit of both and so what we would really want to do is make sure that those people at highest risk can be tested and then they're if they're positive their contact be tested even if they don't have them and because of those are going to be the one that would be more likely to have cobit nineteen and if we can isolate the cases and I have the contact quarantines for the needed fourteen days and that's how we're going to break the chain of transmission in our community. If my memory serves me correctly the the positivity rate was all a lot higher if you combined the health department. Rate with the the private sector rate way back at the beginning of this and it is not what from what I'm saying gone up so that would lead me to believe that the problems of the cases are are going down but I don't have all those numbers. Directly in front of me five yeah we're increasing the number of tests so in that case is we're not going up the positivity rate would go down but it's actually staying kind of stable so I'm thinking it because we're increasing the number of tests but we're also seeing increased and at cases in some parts of the state. All another question if you will allow Mister yes committee unrelated to that band and probably not one that you can answer somebody there sitting at the table my I know that the health department people have been out harassing business owners and stuff over over some of this in complaints that they've trying to follow up on at restaurants and hair salons and everything else have you all issued any finds any type of punishment license revocation anything like that. L'arche general counsel I hop with our and environmental health and investigators on a regular basis and it's our right now we have not issued any find. Or citation. Okay thank you. Representative Johnson you're recognized thank you Mr chair so my question about the testing of asymptomatic people before elective cases we've moved that back to seventy two hours from forty eight under we're testing a symptomatic patients presenting to labor and delivery as well do you have a sense of how many what the positivity rate is for those test in particular those are those are patients were testing that are presumably a symptomatic it's is a separate subset the the the stipulation for testing before elective surgeries is still you know still burden on our system and I'm just curious how long you think that will is as of the we're gonna do for an extended period time are we looking at you know what kind of results were getting are we seeing a lot of people come in and having cancelled cases because of an suspected positive test or are we going to this exercise and just everyone we're testing turns out negative. So I haven't looked at those numbers but Klay I have heard of cases being positive that did not receive surgery and I recently heard of a case that was overlooked and did receiver procedure so I know that it can happen but let me see what I can do to hold those numbers and give you an update. Yeah I would like to see those numbers because it it does feel like even at seventy two hours you know I I just question what we're accomplishing with that particular task because we all know that within that seventy two hour time frame the person could test negative before their surgery in contract or test positive on the day of surgery so you're still you have a pretty big loophole there for people to to come in and in that window and and you know there is a cost to reducing the number of elector cases that we have an and and we're still having difficulty at the hospital level in getting the turnaround we'd like to see certainly's certainly not getting the rapid turnaround for the same reason is because we don't have the re agents to run the quote the machines we have plenty of test wives that turn around time of the commercial labs still is lagging behind many times what we'd like to have it have it. Get be ideally is so I'd like to see is at least look at that consider that if you're not another question I had if I may Mister chair yes I have a question about vaccinations to you know I we talked earlier about raising the rates FOR vaccinations for healthcare providers in the state which is good that most of the kids in Arkansas get their child back to nations to the local health units I know that the crisis we sent most of our people at the local teen is home to work remotely I know a lot of our people of diverting their attention appropriately to contact tracing we have a sense of how far behind we're getting with our vaccination schedule for these kids do we have an idea of where we are year over year you know when the started were two three four months and now you know a lot of that I'm I'm hearing from my community that some people having trouble give their child a vaccination schedule throughout local health units and presently you know the healthcare providers or even with the rate increase it will take awhile before you start seeing pediatricians offering the service that you have a sense of those numbers. Yes Sir we have looked at those numbers specifically for the younger children spoke children and under two years of age we find what we've done is we compared the number of doses for the each month for the first four months of this year compared with that last year and the year before for ad hoc for and March and April we saw about a seventeen percent decrease in the number of doses that were administer and also we've looked at the doses for children over all and there's been another off that would be great although I don't remember that percentage off the top of my head this is something that we're actively looking at and making plans to at help communities get called up one of the considerations would be at could we potentially have a drive up clinic so that families and I don't have to bring their children inside the clinic can that wait in the car Arkansas children's hospital has done a pilot and that it went very well we think we may be able to model that and other clinics may be able to do it adolescence are eligible to be vaccinated and the pharmacy if they have a payment towards that were working with pharmacy to also And. Hi what in the potential models for and delivering vaccinations and I drive up way is well so that will help with the adolescent but you are correct we are behind and it really concerns me about our risk for a measles outbreak I certainly do not want means will and because of it nineteen at the same time and so we are taking active steps to try to get people caught up. Thank you. Representative Payton you're recognized. Thank you Mr chair out this is really not about the report I'm not sure I can be here tomorrow so I'd like to move for immediate consideration of a of item T. on the today's agenda and that it not be reviewed. The hope for more to. All right I have a motion. Item T.. Third. I have a second. What I. M. T. that it not be reviewed unless the hog for farm moratorium thank these. Okay have a motion on the floor that item T. not be reviewed. Correct correct and I moved for immediate consideration meeting separation and there was a second it was a second. All right since media consideration. Call for. All right so out repeat the motion is I item T. not be reviewed for immediate consideration so there is no discussion so all in favor of the motion signify by saying aye hi. All opposed nay. Motion carries. Identity is not review. Hammer you're recognized. Because it had immediate consideration associated with that can I ask a chair questions relevant to what we just did yes. Would you refresh my memory as far as a while ago when we I don't think we took a motion not but I don't think there was I think it was without objection we would move those items to tomorrow and we dismissed members of the community that had come in to talk about it. And I'm just curious as far as procedurally what with with what we just did how did what we do earlier. Tie into that. That's a good question because we did dismiss those folks. But I think it was without objection is what I'm. And my memory may be wrong but. Well there was no objection from the committee. That was the. Does that. According to the rules did that automatically make it a dead issue to be brought back up for discussion because the question was. What can we have a public meeting within twenty four hours that was the question that was asked earlier and so to me that brought into the discussion are we are we procedurally handling this correct. Okay we're not going to adjourn we're going to recess. Until tomorrow one o'clock. So that is allowed okay. So I don't know whether answer your question there but we can have that discussion later about with this. the people in the audience but it's my understanding that committee is one voting here in the one objecting. So that's my ruling on that what's your were there any members of the public signed up to speak. Which she taken up that had members of the public signed up to speak no okay. Or I'll leave it at that thank you. Representative Johnson Jeff coming I have a question for the Parcells back on the topic at hand had another question about the code crisis and testing okay you can you also here is there. Yes okay go ahead so so I should have asked this question followed earlier the map that you've referenced it it's change them in format to originally the map was showing positives and negatives in each county and and now just shows the positives which is fine but is still as we move forward it sounds like an important component of what we're doing regionally may be tied to testing per ten thousand population to determine that statistic you need to know obviously the total number test done per county as the map currently stands I can see the positives I guess to the active cases but I'm not seeing the negative cases or the total number of cases done per county I'd be curious at that date is available and if there's a way to look at that it is only in the in the map there's a county just just after Mississippi county I think not known as missing county and and there's a lot of tests parked in that there was at one point over twenty thousand negative test park to missing county at my understanding is those are tests that are missing county data I'm just curious what would and try to recover those are we trying to figure out which counties those are in and so that we can add those to the current county statistics if if testing for ten thousand is going to play a role in what we're doing I just wanna make sure this test are located in credited back to the appropriate counties. She at the yes Sir we are having some data challenges with the negative path when that many of that tax reports come to us from their laboratory and often times they do not include that at county of residence so for the positive test we can easily determine that information when we do our case investigation would call the patient interview them and not hard for us to get those data but because our focus is on at case investigation and contact tracing we don't make phone calls to determine county of residence for the negative at result what we do is we tried to work with electronic means can get all of those and at a county of residence and it takes some time and so we're consistently behind on the at we hope that we can resolve it but I do not know at this point what the solution is going to be. I'm asking follow do you have a sense of how that's affecting the data with regard to testing per ten thousand per county do you have a sense of because the you know that one point is a pretty significant number tests that were missing county data eight again if we're not gonna be using the testing for ten thousand it's a data point to determine factors regarding re opening or if we got a regional approach than they maybe it's a moot point but if this is gonna be tied into a regional re opening strategy then we need to make sure we're reflected accurately needs for counties as best we can if it's you know a hundred two hundred that's fairly negligible if it's tens of thousands that are missing county date at that could be significant depending on which county so as a reference to. At a point well taken my understanding is that the lack of county is fairly well distributed so the error would be the same in most regions but that is something that we will definitely look at because if for instance one of the company and that's not reporting county is there's more heavily tested in one area and then that would make it different so that's a point well taken and follow up to them to yes so it I mean it's hard to say if the relative well distributed if you don't know the County Board gin so I don't know how you can say that the missing county data is is real well distributed across the state if you're not sure which county is from I think I think a better approach would be to seek out the counties if there's a particular commercial lab our core lab core quest care which everyone it is this not reporting cabinet county data you know as soon as well. Then that that might like to a certain region or hospitalized region different in another region that I know Francis said that Baptist Fort Smith we primarily use of our core I know that mercy for Smith primarily uses quest care so I know that community health centers use lab core so there are different you know different testing commercial testing entities that are preferred by different hospital systems and so yeah I think I think that some point to try to drill down on if we can. Yes Sir what we know and tracking back the ones that we have found that they are fairly evenly distributed but you are correct as the at testing environment changes more last come on board more entities as developed and at business relationships will need to monitor that carefully. Thank you. Senator hammer you're recognized thank you Mr. The. Okay you're back on thank you okay I'll try to keep shorting the share as as I understand the pecking order of things the governor makes decisions on the basis of what you recommend to him when it comes to his decisions about whether how long we stay in emergency status how businesses should shut down an open back up that is in my is that a correct statement or in like me if that's wrong. The health department does at especially doctor Smith makes recommendations or give input that provides answers to the governor's questions and we'll work with him so that he can understand that data and information so yes the health department give the governor input and will make recommendations to the governor from time to time okay and I'm sitting here listening to Representative Johnson's question who seems to have a pretty thorough understanding of you know input to the data and some of your responses back in and I'm just a little bit concerned and I'd like you to address my concern that if the governor's making decisions about how long keep businesses open you know allowing protest go on but limiting other businesses from opening up all this debate that we have to deal with those legislators out in our community the information that you're giving him how how accurate and how dependable is it if he's depending on that information from you based on some of the dialog this just occurred here in the last twenty minutes. Well we provide the governor would is accurate data as we can provide and we are constantly working to improve the quality of our data we at can we they are the data do have limitations to them and we try also to make sure that the governor understands what the limitations to the data are. Information is power in the information you're giving him so who who's actually the point person to make the decisions that are impacting the businesses in the citizens in the ball teams and churches and everybody else I mean it is it coming from it are we going to give you the credit are we going to give the governor credit. No. I would give the governor credit we whenever we make recommendations such is the directive for the guidance that we try to get is brought input as we can and we work with the economic recovery group and the at key stake holders so it's not just the health department coming up with recommendations to the governor it's with input from all kinds of stakeholders and he'd get input from those groups independent of the health department as well. Thank you they measure. All right of. There's a lot of questions about this and I have one incident Irvin has one but can you know be available for a meeting tomorrow. One o'clock. Somebody answer questions. On the call with nineteen. Ask here. Because we we need to close our meeting because education is in here plus we have a lot of people have left that may have questions about this so what I think it would be good if you all could make it tomorrow. Well you're checking your counter there I had a I had a question long term care units or facilities I know the goal is to do a hundred percent tests on all those facilities and I know a lot of that's being done human development centers are doing each one two days ago and everybody at the facilities but my question is what percent of that is done where we add on that getting to that hundred percent. So as as you were of no the health department is in the process of doing baseline A testing of all of the nursing home and assisted living facilities in Arkansas what we would like to do is have a baseline to give us a way to safely opened the nursing homes and assisted living for visitation as you know that's been a very difficult hardship for families and their loved ones so if we can open face plate of by sharing ourselves that there's no cases in a facility for example that then we'll at be able to implement a process and procedures for people to visit their home their loved one in those facility at detecting has started but I cannot tell you today what the percentage completion is that the plan is for them to be completed the whole state by the end of the month and and as far as I know it and. Going well you know at the same time well this testing is going on the health department is working with the Arkansas health care association and other stakeholders so that the procedures or the process is needed to allow visitation is at developed and understood and there's broad input from the industry as well as family members and those who have at key interest stars a stakeholder in this so that I may be able to get an update with some numbers by tomorrow I will certainly try to do that. Okay yeah I would appreciate that and you you already answered I answered my second question was when can these facilities re open and you already stated the reasons but I'll just tell you you know I've heard some really really sad stories from people who have relatives in you know nursing home or long term care facilities they haven't been able to see for three months the I think there's actually people passed away when the family was not there so it's really really getting to be a bad situation. And in some of these facilities they have these A mentally challenged people that are maybe they're fifty sixty years old but mentally there five or six they haven't seen their parents their brothers their sisters their friends for three months and they don't understand and so this is an area we really need to put a push on I believe to open up and I think as you said we could come up with some guidelines that would allow. People to visit their relatives I think that's really some critical that we will need to move on Senator Irvin you're recognized. Yeah and in even if and we're going to go into recess for tomorrow's meeting that I'm a look at trying to schedule a meeting on Thursday and we have a three o'clock meeting scheduled for the pans panda that we may have a Thursday meeting just to discuss these kinds of things you a math of like for you I must be able to cut off the present and we have some information from a chi Arkansas center for health improvement and unemployment so we I'm able to work with you Mister price just for the folks that are here we may have a Thursday meeting that's just policy based. At. Representantes isn't like if not Thursday will try another date but we'll we'll try to find a date that we can get some of these things because a lot of this discussion needs to happen one of the things for the department of health that I just wanted to say is on testing we have to have clarity about testing because it is not accurate to say that is free that is not accurate. It may be free for a patient. But it is not free necessarily for the hospitals or for a clinic or whatever said that needs to be clear and you have a lot the difference as as Representative doctor Johnson talked about. You have lots of different players in this kind of in this scene and so I think that's really important for us as we are speaking to constituents as were putting information out that it's clear information if you're dealing with classed it's this if you're dealing with Blue Cross blue shield it's this if you're dealing with this plan it's this if you are I would like to note is that because built into the RG to the hospitals it is not this is an additional added things that is not part of what was the norm in January so they're eating that cost so I'm really tired of us saying these things are quote free when they really are not and for some patients it's not free and so we need to have some real clarity about that again a spread sheet that shows or something that says that so testing for me is coming critically important we got to get that right but we we got to put it all on a page of papers we can see it and then we make adjustments if we need to and policy to make sure that people have the ability to get tested but that Where that cost is being covered and how that can happen so I just I will work with Mister price the members of the committee we'll figure that out maybe next week but thank you very much members of department of health. Representative Johnson gets land yeah I was just gonna have a comment about the scheduling the meetings I mean the and I understand it was logged into today I understand restaurant do their best but you know we all are trying to metes busy schedules of busy lives away from the legislative body we all create our calendars based on the meeting notice is that we get so you know you carve out time to be here for a meeting today and plan to be here all day I'm here as long as it takes to work to this agenda that's my plan today this is what I've dedicated and then just recess and have to come back tomorrow one unexpectedly is a hardship on us as members of the committee and I I feel like it I feel like I'm not doing my constituents and a service by not trying to attend those meetings as best I can and there's challenges involved with that these report discussions I was looking for to be involved in this discussion with eighty eight I'd like to be involved in more discussions down the road I it's just it's a challenge to have this schedule sort of abruptly changed when we bought we away again we're all have been busy lives we ought to lots of things we're trying to do I want to dedicate the time to this I want to be here for this so you know in the future if we can if we see any gender like this that the clearly any of the steps at the meetings is gonna be hard to fit into the time frame we have with lots of comments you know anywhere I I'm not trying to beat a dead horse I understand you all know I'm reasonable I'm not trying to be a I want to try to attend and I'll try to do everything I can to clear my schedule for tomorrow but it did not my question specifically would be what does the gentle look like now tomorrow one is a DH gonna be on the agenda do we have a time frame for that so that I can kind of look at that agenda had a schedule and and sort of make a make a plan. Now you talk about tomorrow. Yes they're gonna you all are able to attend the moral right. I think we I think we can make it tomorrow we'll okay what one okay okay thank you. Well let me let me address what you said Representative Johnson and and we knew the chairs we had this discussion a number of times the the problem today was that education has this room we can't use the other room that we normally do because of the social distancing and all that so we were kind of in a corner and didn't know what to do we were going to try to get through it our fall back was to schedule another meeting this week and one o'clock tomorrow was the best fit but but we didn't want to schedule that not knowing whether we can get to the agenda but but you're absolutely right the agenda looked like we might not be able to make it and we were not so I I understand your your concern I have the same concerns with folks. No I under I understand. Yeah that's right but basically that's about all we could do and we don't want to wait till next month to cover these issues so that's that's three behind it. So okay. So what we're gonna do is recess until tomorrow at one o'clock. And. Since we've had some suggestions today. About having people here to comment on some of these issues tomorrow will be an open meeting and and I know council as had open meetings where people I want to comment can stay outside and they can be called in in the agencies can come in and sit in the audience so we're gonna make this open tomorrow. Open for people to come here. Okay. I will are coming out ask a question yes. But it be appropriate that is not related to the address the committee first with the appropriate First thing tomorrow evening. Yes Sir she's got a lot going on in our by the other element from that favor for the plane time she's pretty busy lady right now. Yes you can do that. Yes ninety first mark and and that's the only change to the agenda to answer your question represented Johnson and the reason for that is I think that's important that we be able to ask questions about that so that's the only change to the agenda. So. With that we are recessed until one PM tomorrow of check the web page check your emails and we'll try to keep you up on things if anything changes so.