Health Services Subcommittee House and Senate

Okay everyone I'll make your way to your seats then we'll get started. Okay the meetings called to order and I have no comments do you have any comment senator Hickey of do I have a motion to accept the minutes from the last subcommittee from Justin. The. And. That a second okay the limit in the minutes are accepted. Okay were ready to do the interim study proposals which is no. With a motion the second and. I'm sorry on me that's. All opposed okay of the first dynasty is represented Penzo. We're on item daisy on the agenda. You're recognized to present thank you. Certified registered nurse in this this this have been administering anesthesia for over a hundred fifty years. In a multitude of settings in nineteen eighty one the health care in finance administration now centers for Medicare and Medicaid services connected the supervision language. At that time page CFA was very clear that this language is not a quality control criteria in the supervision requirement was solely to meet the conditions of participation for Medicare part a reimbursement to facilities. To date over forty states do not have supervision and they're nurse practice acts nineteen states including two in the past eighteen months Oklahoman Arizona helper permanently opted out of C. Mrs position supervision role. CMS has temporarily suspended their supervision requirements for C. R. entities to meet their conditions of participation due to code nineteen additionally there are no supervision requirement barriers and United States military one Arkansas's twenty nine critical access hospitals. Arkansas siRNAs currently work under the supervision of but not necessarily in the presence of a licensed physician licensed dentist or other person lawfully entitled to order Anastasia. This bill seeks to remove the word supervision and replace with in consultation with a licensed physician. The language not only has precedence and other non supervision states but most accurately describe tell siRNAs practice with surgeons when is the anesthesiologist is not present. Removing the confusing supervision language one Kerr increase access to care and decrease healthcare cost Arkansas our Kansans and our rural hospitals additionally it will clarify a confusing liability language when a C. R. in a is being supervised by a nun anesthesia trained physician or dentist finally this bill is permissive if individual facilities and their medical executive committees made up of positions have local control to make the decision to change their language and their respective bylaws or leave the language as it is. Any questions committee. A Representative Boyd you're recognized. But when. Thank you madam chair representatives of thank you for bringing that have you had any discussions arrange discussions between anesthesiologist and see our and I as part of this I'm and I just. For all three sessions this is been a contentious issue I'm just curious have you made any. Plans or have any plans to bring the two sides together and see if there's any way that it can be worked out ahead of time and and agreed to and. I can't speak to the whole history on what's happened in the past if I could bring Slade bridge will appear he's the president elect for the anesthesia nurse in this this association they might be able to address that a little better okay certainly. Yeah. Thank you Representative way for the question of currently the session for this session we have not had any discussions with the anesthesiologist on this issue would be more than willing to sit down and have discussions with them to see their side of this issue and if there's any way to meet or if there's any compromise we did attempt to meet with them last session and we just felt that we can come to an agreement at the time so that's why we went ahead and ran or bill as is in two thousand nineteen. Just follow up Sir go ahead this is Anna I don't really it's more of a point just if you have need help arranging the two sides represented Penzo please let me know and I'll do what I can do to help as well thank you. Representative Johnson. Recognized. Light headed again. Late hit hunter but again I think a disconnected G.. Get to this. I feel better it's not dismiss. There we go I was just gonna because some of the same sentiments I mean I think you know from last session course last session was my first session and I walked into the session pretty green and it's still pretty green and how I'm approaching things but it did feel like there was opportunity for compromise but but by the time the session started everything it's were wrapped up and and it felt like to be personally I was a little late to the game as well I think the rule itself as it at as it reads it is could stand being proved I think both sides would agree and so you know I think that the most productive thing would be to try to get together in some format as early as you can pre session and try to have some those discussions and again it is just like represented board if there's anything I can do to help moderate that I do think there's opportunity for improvement here and would like to you know encourage those kind of communication dollars really not just for this issue pretty scope issue that standing out there I think that's the best approach so I appreciate you let me make those comments. US senator Chesterfield thank you madam chair and thank you for allowing me to ask a question I'm concerned about liability. without the required supervision. Of the liability it seems to me would be increased by the individual who is is administering the anesthesia. How is that addressed in the bill or in in looking at it I don't see how that is addressed could you tell me that. Yes Sir thanks for the question it what people don't realize is that certified registered nurse anesthetists carry the same amount of liability insurance as the surgeon and anesthesiologist as well we all carry the same amount of liability whether we're working in anesthesia care team setting or working individually with the surgeon so there's no increase liability that falls upon the sea are in a because that liabilities already there and that's one of the things we're trying to eliminate is one liability for a surgeon there a surgeon being liable for C. R. in a you know we are to carry our own liability so there were there wouldn't be any increase liability that's. Pretty much but I didn't make the cost of the premium go up because of the increased amount of independence no ma'am not at all I've been practicing for sixteen years I've been practicing and I've practice two years in anesthesia care team setting in fourteen years either under the supervision of a surgeon or supervision of an anesthesiologist and it's a little bit different than being medically directed my insurance premiums don't change in fact insurance premiums have and have continued to decrease over the decades for our specialty instead of increase showing the safety of nurse anesthetists in anesthesia profession as a whole including is these challenges we're both doing a great job I believe alright thank you thank you madam chair to allow me to ask questions. Senator Hickey you're recognized. Thank you ma'am and I believe that to represent Johnson represented board both give some good advice I think that This needs to be worked out prior to the session I've told people that time and time again during the last session whenever this didn't go through we said what we need to work together so as they said if we need need any help on trying to get those groups together there's multiple ones of us that will help with that. One thing that I do see with the bill. And I had an issue with this is before it had under the suit supervision than we didn't define what supervision was so now what we're doing is we're putting in consultation with and we're not defined in what in consultation with means that doesn't mean anything to me and it seems like to me all we did was separate circumvent was supervision was before because somebody's thirty miles away or somebody's on the golf course I don't really calling super supervising but. You know that seems to be what was probably transpiring so whenever we do get together and do that I'd like to see a definition as it relates to that port so that we'll know exactly what we're up against in the future so just a suggestion thank you. Of seeing no further questions do you have any closing comments. Of I would just like to say that I do echo all of your I respect all of your opinions about getting together with the anesthesiologist and getting this work out ahead of time we should take note of our anesthesia colleagues over in Oklahoma who recently removed supervision and said you and opted out of federal supervision they did come to the table with the anesthesiologist and both were in agreement and the vote was all greens up on the board because everybody was on the same page so we're gonna try to use that as an example we will reach out and see if we can get some things done so we don't have a big contentious issue in next session. Yeah could liquid at. Thank. I don't know this is there's no by for will it be the and this these to people but we don't have anybody from the Anastasia association here do we I haven't not that I'm aware of no yeah okay a yeah eight thank you again I know that the anesthesiologist sissy organize of all of it on the front lines of this kind of it so we appreciate you all okay thank you A yep try to maybe get with them and have a. We'll check two men have a discussion thank you okay. The next agenda item is E. of Dan Sullivan R. Justin Gonzales either. Of representatives of. I guess send to be senator. Thank you madam chair. You're recognized as your we ran this bill last session and it didn't pass out of committee I want to introduce it again what occurred in the last session it I don't think we really have an opportunity to share all the information that needed to be shared and ended up in debate at the committee it was just very difficult so I wanted to run it in as an I. S. P. E. to give the members of the committee an opportunity to ask questions or dig a little bit deeper. I have talked with DHS I have had conversations with the provider group and I'm willing to compromise on the bill if we need to change it I'm fine with that I just would like it to pass when you talk with DHS that a nothing there someone from DHS here I think they will admit that there are some structural problems in how the process works right now we have businesses that Enter choose would like to start but can't you have businesses that would like to sell their building but can they may distribute the patients may go to other facilities but buildings that are built specifically for a an industry like this their stock holding the building with nothing they can do five a and again there are structural problems with our regions are designed how regions are allotted and how needs are determined some very willing to compromise on those and come up and maybe it's just a rule change we do rather than a bill but I did want to give the committee an opportunity to ask questions and and decal bit more in depth for me the reason for the bill was to allow patient choice right now patients and some counties have very little choice and I think the best thing for consumers is that have an opportunity to choose between providers that's just a basic principle that I believe in and I think the bill out lines that. But it is a unique situation there are certain county certain districts that have different needs than others so again I'm very willing to talk about those with the groups just wanted to give you an opportunity to ask any questions and I'll take him at this time. Representative Boyd you're recognized. Thank you madam chair and I would just want to reiterate the first of all I wanted to clarify the goal but it's did you sounds like it's patient choices is the goal for the purpose of the legislation so you already answered that not number two same thing I just asked Representative Penzo have you had opportunities to bring the two sides together and try to work this out before we work it out at the you know the committee table yes I've talked to them today and again I'm very willing to do what we need to do to move forward two. First take care of the patients and the consumer and second take care and this is not in any particular order to prioritize but to take care of the businesses and third to be responsible with the use of the state's money and your ex and expanding population are contracting population what impact does that have on I'm very willing to work with DHS to help control the does that answer your question. Absent the board does that answer your question okay and okay. Representative gray you're recognized thank you madam chair and I know I was on the other side of this last session and one of my issues was especially in these rural communities essentially what you're doing is doing away with any type of certificate of need or any way that you need to show need in the county. So especially in the rural counties there small where you just have one provider I understand where you're saying it should be patient choice free market what healthcare with government payers are involved or not always free market My issue is in these communities that have one provider if you come in and had to a second provider and there's barely enough need for one you're gonna end up with two facilities that can't make it. And they're gonna both go out. That's my biggest concern is addressing in making sure that I have a facility in my counties that currently just have one that we don't do something to undermine the one that's there and I have no and sure and I'm very willing to compromise on that you know we need to agree with you a hundred percent if if it's about patient choice and there is no choice that's not a solution so what if we need to a compromise on things for work that out again it may just be a rule change and how they defined under served I think many of you know I was in that industry not a business owner but a business CEO of a company that did that I was in that situation several times for a competitor came in what it cost us to do was build a new playground of offer a new service and I'm not aware of any instances where that's occurred. I'd be instances I'm aware of it's improved choice in the community it's improve the quality of care but again if it if we need to write a special wrecker select certain areas I'm open to doing that I just want to see something passed we have people That have a building and several of our county if I don't know if it's still true but I know for about a year and a half they couldn't sell their building five hundred thousand dollar building I know of a company right now that has invested over a half a million dollars based upon what the rules were are we're told to them and now they have a half a million dollar business going on that they can't operate and they're operating all of that business at a loss every day so there are multiple problems out there and I think we need to get all the people around the table and come up with a solution. That is best fits best for everybody. And I'm I'm very willing to have that conversation I thank you nine I would I'd like to work with you to see we can't get what you want accomplished while still kind of making sure that everything is protected in a certain way so we have services sure and I do have one follow up one of the that's fine and on page two it's on be it talks about a it's eight be the healthcare provider's described in subsection a eight a of this section include without limitation. I noticed in there you've got a couple of things that currently do you also have certificate of need like the hospice care are you I know this is still this is in the legislative intent section but that still shows legislative intent to do away with any top a certificate of need in the I'm not stuck on that you know if we need to there's certainly a need for protections far certain industries and our state we are unique state what does works may work another day other states may not work here so and certificate in the of need is certainly one of those that you know I'm if I'm I'm not solid on that are hard on that okay okay thank thank you and you've got that on record now on video. Senator Hickey you're recognized. With the yes of Senator let solemn of the. Mine made of tell exactly with what you are just talking about on page eight. Just were. Section four mainly lines nineteen through twenty seven it you know it just says that they'll develop rules which we all understand how that works the only thing is if we could get a little more detail with some of that port I'd appreciate it because I don't I prefer it be in the legislation whenever it comes out you know because we just got for the creation of a newly formed business you know if we could have that detail within the wall itself if I remember correctly when I pass this to DHS to see if they would approve it that was language they put in there so I'm very willing to clarify that I agree with you a hundred percent okay well like I say this that's my suggestion on that thank you Sir. Represented lighting you're recognized. Thank you manager I'd like for the H. just come up the table. Mark what would be edge's I'm sorry you're recognized thank you meant that a patient Marc one. Tommy Tarpley deputy director for TVS up mark what. I just want to for you all to give us your input on this and now that may affect what you all do so. The sure against real briefly then we can go on or the self we need to we're certainly open to discussions on this and would be glad to work with the center like Solomon with providers on on come up with a solution there I will say one of our concerns is that the statute as it is is a little unclear there are some difficulties in trying to administer what's there presently and so I think I think we're certainly welcome some improvements along those lines but we we we saw a work work with both sides and we glad to help out where we can. One question I've got Representative gray talked about this the certificate of need and and I know that's a difficult thing to answer but the all have any ideas on how this bill could be modified to were you don't have a county left out there without a a provider I mean in the capitalist world if you have two people in the same business strong ones going to survive. I'm not sure we're on the same playing field here but the all have any input on that I mean how would you protect these counties that and maybe can't support to operations. At this time I would want to speculate on a specific thing we just have a look at it in in depth enough another some discussions two years ago in the session lot of times as passes then lost law water going to the bridge inside bill has to be give me specifics there were certainly willing to look at that see what can be done. Thank you thank you Mr chair of saying no further questions the. G. like clothes for your resume for the ice. Turn the Speaker Representative les eaves point the definition of under served it's very difficult definition to rye hi if you balance that against what markets forces do that's very difficult but I think again if we all come together and everyone is willing to compromise a little bit Yeah that I I think there are solutions that we can find and that's what we brought a before this committee so we can have this conversation before the session when we start the session I think we'll have a language that everybody can agree on or I promise I will run the bill I don't want to fail again. Okay thank you thank. Of the next agenda agenda item is a off of doctor Johnson the point. Thank you madam chair committee members of the Senate study proposal the idea behind it is to empower paramedics in the pre hospital setting to provide medication that patients may carry in the case of rare disorders so there are certain conditions and disorders that people can have the best example I can think of to give use their certain kind of bleeding disorders clotting disorders repeat patients bleed readily indeed certain factors to give themselves to stop bleeding many of these patients carry this medication with them but as it stands right now paramedics in the field can only administer medication that they carry on their trucks so in other words if you're carrying medication that your prescription that you have in your in the presence of the paramedic understand look this is a medication I need for my rare disorder the paramedics can't give you that medication and so this is a bill that's modeled after legislation has been passed in other states to try to provide a mechanism for these rare situations for paramedics to get potentially life saving medications in the settings I've discussed it with our same list association I have not yet discussed it with in this section of DHS the public health I'm sorry but I will there are some things as I read through the version of the bill right now that I still need to be worked on but as a as a proposal for a study I think it's a good idea and and that's the general with intent and I'll be happy to answer any questions. Representative Ladyman you're recognized thank you madam chair of represented Johnson the you know you have any idea how many states have done this and and they have any success rates or anything I don't I can get that information and I this this came to me as a constituent of an issue from a group of people that work with the rare disorder organization under that pass legislation like this in Missouri but I can find out how many states have done that have that information for you and and hopefully be able to get some some ideas of numbers house affected them thanks I guess I don't understand enough about what ambulances are at. Hello out today were they not allowed to give a patient any of their own medications is that the room correct yeah they can only operated the so they're operating in the physician he then they can either off product operate on and offline direction which is the written protocols in emails is because these are rare disorders most services are not gonna have written protocols to to address that issue they can administered things through online control so they can call a physician and talk to them lifetime and then operator that positions direction but even then they're only going to be allowed to get the medications that they carry on the truck that's the way I understand the law and the rules. Represented board to recognized. Thank you madam chair there any known opposition to this the to my knowledge no again I think I think there needs to be you know some I need to have some discussion still within that section of the department of health and and sit down with the endless association in spirit I think everybody agrees this is a good idea just the details of how it works out there's some language in the bill that would allow for transport alternative destination so right now if you picked up on the ambulance they have an obligation to take you to the nearest appropriate facility there's language in this bill that would allow you to be transported to a more specialized facility so let's say you're picked up in Conway and you have some rare neurological disorder in your reduce justice charge from you I am mass their obligation would be to take you to the nearest hospital there in Conway this would allow for cabbie ought to say okay had just got discharged from you have mastered you transport me to UAMS and there's some questions about payment who's responsible for that that I think still need to be worked out those are the two facets the bill I think the medication facets pretty clear and straightforward I think the destination transport there still some phasing areas there that need to be sorted through. One follow up statement manager yes go ahead just just like with the other two are speeds if you identify any opposition groups and you need help bring on together please don't hesitate to reach out thanks thank you. A senator Hickey yes Sir seems like common sense thing just the couple questions that maybe should be addressed within the legislation whenever you all get there. The patient dosage if the I guess is of course of it's on the bottle what they're supposed to get that's what they would administer what if what if the patient just word I have it within. You know an overnight bills Monday Tuesday Wednesday Thursday are we just going to go with what the patient says that that's our dosage or how how could we do that in our center Chesterfield mention liability earlier how would all that tiny and and this goes to I now have and that's a fair question I think that needs to be fleshed out some of the details legislation because you'd want to have you know you'd want to be going off the specific labels on the medication so the medication if it's prescribe should have some dispensing directions I wouldn't want the paramedics operating outside of that dispensing direction and so we may need to clarify that I think in the language thank you Sir. Seeing no further questions do you have any hope I once are represent Ladyman. Thank you up to just come to mind and this may be a statements it'll question but might there be situations with certain medications that might have potential reactions at the EMS might not be trained to recognize or handle I mean do you think there might be some exceptions that need to be added yes ma'am I'm saying a lot it's it's a fair question I think you know you have that situation potentially with medications they carry already on the truck right because there's always a little bit of and I know me working in a pre hospital setting so it's hard to remove all of that risk these are by definition rare medications that even someone like myself is going to be less familiar with the generally you're leaning now on the patients to have that familiarity in that does create some risk of as far as how you mitigate that and still get the value of the bill something I'll have to think to a little bit but I think it's a fair point and that's something that the MS may be able to that yeah I think they should be should be able to help me with that some thank you. Representative gray you're recognized thank you madam chair and you alluded to this when you talked about the right we some issues with payment but I think currently the no insurance will normally pay for transport to the nearest appropriate facility in so that I think it would behoove you to talk to some of the insurance carriers and Medicaid to figure out. what language would work for them and that something that they would actually implement into their plans I think there is some cost savings to it would be much easier are much less payment for me to pay for transport thirty more miles than to pay for the first transport and then a second transport so I think there's a way probably to fix this but we just need to make sure that payment is part of it yeah I agree I mean what we don't want it is one of six in the past with a big bill their insurance won't cover it just because we're trying to do the right thing thank you. But let me clarify their only can be giving the medication under the direction of the physician so that would be talking to this with well no this with the medication so maybe that the patient has the medication they need for their and on this day no this is how they treat it they would normally under any other setting just take their pills or administer the medication but because they're now in an ambulance and not in the house where they would normally take that medication there's some restrictions on that so the girls try to remove those restrictions so that what it in again whether it's with the assistance of the with the assistance of the paramedic you know even if it's just them handing them a glass of water and now they're taking this pill that that needs to be clarified so that the paramedic can can you absolutely have that potential so this would not be creating a situation where they're doing this necessarily under the guidance of the position online that would be allowing the patient to have the medication that they already would normally take it is a good example would be if you have high blood pressure and you had your blood pressure medicine with you presently you know they're not. They're not as I understand it then allow to administer that medication for you even though that something you would normally take everyday. But so they're not you're not going to the physician at the admitting A. R. R. L. online with the what is the new programs I have for today Communicate with a or where they're taking. Yep I'll say it's not it does not go be a part of it is just going to be at their it in another situation correct corrected it again the idea is not to get they're not giving medication is new to the patient this is medication is familiar to the patient this medication than prescribed by the patient specialist already for them to take on a regular basis you know that would be the and that gets back to cities point making sure we can have the details of that in the legislation so that it's clear that the paramedics or are only to be administering the medication that the patient already has in their possession has already been prescribed to them in administering it the way it's been been prescribed. Okay yeah it's as a side note to our chairman I think it would be interesting to hear about that they pull Serra program at some point it's there's a lot of exciting things happen in pre school medicine and that's a part of it so. represented gray. Are you. Trap lord the area thank you madam chair one more question I know on here you say M.. Emergency services personnel may administer prescription medications that are approved by the emergency medical services is battery Advisory Council so is that council actually going to delineate what types of health here issues I would say this falls into the category of interim study proposal I probably need to study that part of the proposal a little more because as I read that today this morning that was with the questions I had is what exactly is that gonna be in such again I think there's plenty of opportunity flushes out a little more than I wanted to get in from the committee to give you the idea under this setting of what I'm trying to accomplish and hopefully we can clean up the legislation so that it meets that purpose okay thank you that's AB I'm not sure I'm actually go back and forth we do we leave it open and let that be at the discretion of the paramedic or do we define you know you've got type one diabetes or you've got the no eight a bleeding disorder ABCD these are the things the parameters that you can work with the in yeah and I think there's I think there have been other states that I mention their pass legislation I think it's worth Wallace is represented Ladyman said to go back and look at some of the states and see how they address some of those questions and answers thank you. And I'm I mean I'm sure you thought about that but I guess my concern would be if if the patients in an emergency situation you don't want to be giving on the medicine and I just took you know you don't want to give twice in our there had does some have to be some discretion there for the paramedic and and and you know we give discretion permittee's every day and decision making I mean the make life and death decisions regarding medications on a regular basis of some of that's gonna fall under their judgment which you know hopefully we've we've trained well that contrast okay Representative rye. Thank you one more question do they just keep coming. What's the reasoning right now there had to be a reason why they said paramedics cannot give the patient's own medications because I think any to flush out the reason it's been this way all these years to figure out how do we move forward I think some of it is just the progress of medicine right I mean if you'd look if you'd asked me twenty years ago how we treat certain conditions we just didn't have medicine we should have these things accessible you know medicines progress so fast over the last decade there's a lot of medications now that did just weren't truly there and so this is this is an issue this new in the sense you didn't used to have people carrying around clotting factor for von Willebrand Sir some you know new neurological medicine FOR must any gravis just because that there was no treatment you just put pressure on when you cross your fingers and so I think this is a part of the reason for this press it is I mean if you'd I don't know the history of the rare disorder organization that approach me but I have a feeling a hundred years ago there probably wasn't one you know it's probably grown out of this idea that we're better at diagnosing illnesses than we used to be you know some of these rare disorders we just chopped under a big broad label and we're able to really hone down and decide what they were and so I have a feeling it's it's less about trying to control safety of the patient more about progress getting ahead of some of the rules we have thank you you might explore at the is it's my understanding that hospitals also don't allow you to bring your thanks give the medication for the hospital they won't let you take your medication from home so sometimes I cannot and to be in at least in this setting because we we've had we have a patient our community with the bleeding is or he always comes he comes with a nose bleed he brings his medication we start a half block in. Drop this medication get it sent him home so I don't know that strictly the case but I think there is some opportunity where where that can addition lord with that hospital says here and say sort of why they have those rules for hospitals okay I don't see any other further questions you have any closing comments no I appreciate a raise questions and comments is could get into it. Okay thank you any other business from anyone. If not we're adjourned until public health.