* Arkansas PANS/PANDAS Advisory Council

You for being here today all of this no problem. Ryan and doctor smis. And help me out on the other three please announce yourself for the committee please. They call and. All right it. Which do is at USC. A resume in in can you hear so okay wave if you can hear so okay would you please. Four out of five that's a good average okay for zoom that's a good average as a okay. All right so just want to say thank for everybody that's joining us today you have the agenda in front of you you have the minutes in front of you also there should be two articles that are attached one is a copy of a piece of legislation that was provided to us I think it's out of my copy went to New Hampshire and and then also there's a article regarding the clinical study this can be referenced today in the conversation and I'll just as you're listening to the presenters as everybody sharing by just get familiar with those two documents and thanks for being here we hope that we can progress the ball down the field a little bit more today and I'm a recognized co chair if you'll go in push button there please and recognize. press seal on their. In my report recognized Representative Warren for any comments you may have. Thank you Mr chair the for should everybody being here today and I'd like to real quickly just mentioned are two vice chairs the doctor Joe cloud the and Senator Missy Irvin at both the been the down with the corona virus so we need to keep them in our thoughts and prayers. So I think both are improving so that that's good but that's the reason they're not here with us today. I am glad we're back together since we met the the one. Person that I know with pants and vendors have a serious issue and unable to get treatment we're going to deal with that later in the meeting but thank you for your presence and Mr chair back to you thanks Sir just couple housekeeping rules there should be some germ ex there for you use it as you wish the if you will I think it's pretty well done but if you will make sure there's a cubicle between you and whoever sitting next to you when you get up and move around please have your mask on if you would please and when your wanted when you want to speak push that yellow button and then I'll recognize you and the light will wait for the light to turn green and then you can go ahead and and speak don't touch the buttons after you light up your yellow button will take care of it from up here and when you move around if you would please have your mask but when you're talking to the microphone you want to take it off that is fun and also want to recognize our new staff member Emily or at least new person to the committee and late this is her first committee chair so you'll be nice to her okay I'm or try to help her and she's going to help me a lot and represent one so this is her first committee chair or to help assist you know since coming on board so we would have them only with this all right and liaising with a. Nope nothing okay. Here we go I need a motion second to approve the minutes from last me could get a motion please the motion goes second a second any discussion or corrections or anything you see in the minutes that the we need to talk about. favor for say aye. Post okay and then rest over the update from doctor Smith medical director and doctor Smith thanks for joining is by way of zoom today and if you will just go ahead and start off with an update on the clinic please. Your guy your welcome senator happy to be here update is really pretty short the clinic is up and running it runs out of the child study center at Arkansas judge on the Arkansas children's hospital campus the clinic itself is in the neuroscience at. An explanation at children's it meets twice a month and we're open available for business so I think our to medical directors handy at a doctor rainy or doing an excellent job we've got a lot of the flow issues worked out so that at sine. able to get people in in a timely fashion and and get the same so that's that's my report center I'm happy to take questions let me ask you a couple questions the members if you have questions like to ask bring up anything I know you all had a staff change who's the new contact person that you want us to reach out to in order to get information to you. can you get it to me or get it to Emily so we can get let me let me get your let me get you that are are all judgment and much on that's okay. That's fine if you get for the in the main just interrupt and we'll get it then or if you will email it back on number is still the same but I'll get that name of the person to you okay thank you what about the staffing is forced the nurse one of the things that we took action to do is to requests of money but I think you and I had all flying conversation about the med center in that position can you update us as far as the need of the nurse or what's the position of the nurse helping me the numbers we're we were operating as if we where bonding that nurse of our technical program and we don't have budget for it but we're making it happen. So if we are able to get that through some mechanism that would be great our represent warned put you on the spot would you mind taking the lead on that and talking to the we'll we'll get together but would you mind taking the lead on that please. All right gonna recognized ms pocket for question misspoke. Okay you have stated that the the clinic at children's is up and running if we have an adult that's in crisis do they go to the one at children's or is there one that you I MS that they go directly to. They could come directly to to you are Walker family clinic here it on the you I am asking oppose and that number is five to six eighty two hundred and I would job as to be referred to Tammy who who is our nurse for doctor clothier and doctor of the year is the one who will see adults. Thank you. All right induction method get Emily contact your staff so we can get that and on the handout that was provided by you and this do we need to articulate that on that hand out so that there's not of misdirection as far as where people are going for adolescent verses the adults or how would you like to handle that. Let's see well why don't we get you a new we'll get you a new handout senator and then you can distribute that. Okay and then the members will get that pushed out you own in leaf you'll take care of making sure that gets pushed up to all the all the members okay. Miss buccaneer questions were good. Okay up missed Bradford. So I was just curious if you all done any education for your just children's providers in general I had a patient contact me this week sol one of your neurologist not doctor panda four take disorder and was discussing the possibility and she was told that it did not exist and that that was not recognized at your hospital right children's and she's I know you're a mass and so I was curious and I also just sent one tear ET in sudden onset crisis and so I'm just kinda. Curious what they're gonna get if there's not been a lot of education. Well I Our I regret that There was that reaction I think that I think that is a not totally on common reaction we can make some. head way I know that doctor rainy gave I think grand rounds to that are section on pediatric neurology maybe two three months ago about and and is several of them did not agree with her about the scientific evidence for the syndrome. So We we've got got lots of doctors here and we can invest try to convince some but get in it uniformly across two or three thousand doctors is at a bit of a challenge but if you if you can get them to our clinic certainly the patients would have a warm. A warm welcome. Mr joyous so I understand that there may you can't make it doctor understand or agree on everything but I mean the statement was made that it doesn't that you're that children's hospital does not believe in it and so it's very contradictory that that statement was made when you have a clinic for it. So that's. Well I. Our by rule I regret that I would I wish we had More it more uniformity And will redouble our efforts but their their it there is just like there has been some Disagreement even with the task force there is still disagreement among physicians and They're pretty strongly held opinions. So I I apologize and that's part of the reason I think for the task force. To see what what can I had where we can make and how we can support patients especially their families. I cannot tell of doctor sharp is on assume doctor Sharma larger sharp city couldn't be here today he sent me a text last night and city could be here today yet a national Medical Center national chief medical officer meeting but I can We can get in contact with him about that response all right I will be happy to do that. Maybe a so we put on the agenda for the next many or you can have a private conversation with him about what needs to be done at children's in order to If nothing else I would think that that clinic would have referred down to the pants clinic instead of just dismissing them so do you think we can make that up item to have a discussion about. Sure I can't speak large shark about whether he could make it to the next meeting or not but I will have the private conversation with senator all right Mister Bradford got more her anything now get thank you okay the Mr Bramley. Thank you chairman In the minutes in March and June it was discuss that a child needs primary care provider PC need to help with treatment provide information and assist with pre testing went on to say that you and this will develop a flyer for adults also make it available. I'm aware that when I attended via remotely there was a hard copy that was just repeated I believe in March in June I ask for one of those copies and if we could make that available electronically do we have hard copies in do we have something electronically that we are able to provide a primary care physicians emergency room physicians and other clinicians to make them aware of resources that are available. All right. I believe that we have a hand handout an electronic version of the handout I can tell you that we have been a little hampered in that there's no direct funding for this activity and we're a little slower on getting things done especially considering the pandemic so apologize if we at job made a commitment to get something done A was that If I may that I've forgotten it so I apologize. Sharp when you I'm sorry section it's when you identify who the new staff person is it's going to be assisting in this serve Maurice is gonna be handling it if you can get them to resend that up to Emily Emily will get it out to all the staff. And represent worn I want to ask you if you don't mind taking charge of we'll have all of our conversation on the funding assistance with were in the middle budget hearings right now it might be a good time to. Go for that if you don't mind helping on that one. May you get follow up. I would just request that before our next meeting that some expectation be set is to wear a. Piece of information that is this able to be distributed so that these circumstances of not knowing where resources live for the practitioners that are faced with patients that are suspected of an auto immune and several up at the that we sent some expectation that it this date we will have something that can be distributed if we get to that date and it's not ready we at least are able to update where we are on that. All right of. Let me of. Let me visit with family to forget here because have you seen this. I haven't seen anything okay is anybody else on the committee at this email to you. Some yes some no okay. Because we were wrist we were in receipt of this so let me let me see if maybe on our end it didn't get pushed out if the Senate the US will handle that today right after this meeting is over okay thank you okay. All right anything else man no Sir all right this pocket. House six. Now try. Get yes Matt pretty much touch base on what I was actually gonna addressed as well another issue that we are currently having are these children that are going into these crosses modes and his parents have no where. To turn do we have anything on the table are we working on anything on the table to where we can actually send these kids if they are trying to self harm or hurt their parents or do anything like that is there anything on the agenda that you're gonna be working on to try to address those particular issues as well as trying to get these kids the actual help I need. I'm sorry I didn't hear your whole question is this this is a question about children that are doing undertaking self harm yes we're dealing with children that can do self harm. And that can actually start attacking people their parents you know lashing out do you have anything that you're going to have in protocol to were you know we can tell these parents what to do where to go and how to get the help they need at that particular time. Certainly certainly if there Sixteen or eighteen and under then the child study center at Arkansas children's hospital would be the place the call if it's an emergency the emergency room at Arkansas children's hospital they're pediatrician's office would be a place to go to start with that they're it dolls then if they're engaging in self harm then any emergency room in the state what be appropriate and then provincially referral if it is positions thought that this was where the provider thought that this was banner pandas then they would go eventually to our our our and and is planning but we've got there's a lot of reasons for self harm in the and that happens and kids a lot and we need to sort through that probably before they get to the Klan act especially yours there and then also for harm to the parents or the caretaker. So there's and I they've. So that's enough said thank. A follow up. Yeah. To. All right the server. And maybe Mr Ryan can give us some insight as far as what they've been able to do in Ayers on. Well of we'll see how it might be adapted here in Arkansas so we're gonna move on to letter AT which is discussion the pace foundations role in the Arkansas children's hospital of clinic in Arizona and so missed right thanks for joining is in today and let me just open up the microphone to allow you to give some introductory comments and just to talk about subject matter on the agenda please. This run can here's are your your muted. I just wanted to see if there was uh video available of you Senator hammer and Representative Warren and maybe matter whoever's in the room I can't see them so. Is there just let me know who is who is in the room. Thank you see videos of some folks but length rank in the. Other people but. Is it a video that you want to play you you just want to see who's in the room yeah I just want to see you as their strike a read dressed you go wow. Thank you. As great talking to a dark screen sometimes is not my favorite thing so Senator hammer thank you for inviting me and I wanted to also think Marie's for his invitation kind words and the work doctor Smith has been doing before I. enter into some general remarks I think we can Rick and I can have a conversation after to see if there's something we can provide it up from there is on the as to what a primary care. Kind of a check list if you would of what a primary care doctor we get up the kid with cancer and is suspected kid comes into their office so I think that that's something we worked on for awhile it but it's I think it's available on our work with him after to make sure he gets up on your hopefully your your website of PM clinic website thank you do you have one okay so I think that's probably the best answer to the questions or asked about primary care there is generally a checklist of the kind of things you would look for and test for if the kid came and suspected so that's just kind of a general idea for pediatricians think and educate them as to what to do when they they get a suspected a kid the suspected pension plan to stop provide that the M. they can put up on the website and and the other thing that we do in Arizona on that particular question is we have a pretty good a range of with the department of health and I ate yeah was there it when I was there December I think shortly after we provided a link to that department of health website which talks about our clinic talks about the disease as a bunch of videos on it that explains the disease the primary care physicians so that's size very well designed to address primary care physicians there I give me an example there are three videos a mug stop budget other papers are three videos out there one is what is pants pandas on the second one is diagnosis liquor bunch treatment and they're all like five to seven minutes because of all the pediatric thousands of pediatricians action now that I've met you know they don't have a lot of time to sit down and read papers so we also want to be around a little bit to give them a and a general overview of what this looks like and and how to treat you and so we'll we provide that the DHS also give it to wreck along with the right up so we have so you guys have a more robust Avenue for pediatricians in primary care folks actually look at this disease in kind how to react to it when they get a kid their office so with that. I will I just wanted generally thank you committee for asking me to appear I think there were three subjects that Maurice put on the agenda one was our relationship with the clinic I sat down this morning it kind of went over all the correspondence is been a lot of I think a lot of it's centered on the clinic itself and congratulations for your opening I think in June we were not able to have the the and I think record of like to have a little bit of more of a real people could actually hugged each other K. what a ceremony up there but because the pandemic like this change a little bit for everything off the factions will come soon enough and sometimes it and twenty twenty one we can actually about their visit you guys we had a thoroughly exhilarating trip out there met a whole lot of really good people and some which differ with this is Rick mentioned earlier beside most don't and I think we made huge progress and yeah and in Arkansas in Wisconsin and other place that open cut UCLA. so it's I think the critical thing is spread while in instrument throughout the United States and I know later on you want talk about the global IPA G. study which you guys for a major part of both in sending a protocol and be one of the few sites in the United States that actually will take these kids I can explain that for me a little bit later so thank you again I mean I listed out all the you know the things we've been acted about I just sent Recca new paper this morning on well Walters one of the top infectious disease people was the champion of the Wisconsin clinic so I think you got to every which the medical industry that how are all doing these clinics in back in our efforts this young things eight the idea and you study so generous when I have to the an opening if you want to have some more detailed discussions about those communiques and be happy to. To tell the committee let me ask you a couple questions and we have miss rice of wanted to enter into the conversation. So. How did you overcome or what did you do to overcome the skepticism among the medical field in Arizona and are you meeting that in the other states where you are. Rushing the college and. In Arizona have you do you feel that you're over the the milestone of this being accepted because that seems to be from the previous conversation comments made a minute ago by ms Bradford of one of the obstacles that we're up against. Yeah and and it's a good observation and I'm sure she's under percent right In Arizona up and first of all we did and we decided as a as pace and all as the folks at the university of Arizona that the best strategy would be to ignore it and I'll tell you why in age for twenty five years is gonna symposiums and argued the case of bands existing. I thought that was not a prudent way to to do it I think the way to do it is open a clinic and treat the kids and all of a sudden the success validates itself inside your state so when we opened our center in twenty sixteen in Tucson and then it is and the second clinic and mesa Arizona which is a suburb of Phoenix you guys though. so we have to clinic centers on a ever our partners along the way and I wrote this in one of my letters I think earlier to you guys are part as long the way was the department of health so when I mentioned that they had set up a website the act of them doing that alone validated the disease I mean from a perspective of a medical reality if you go up in the N. I. H. today and type in pants by golly there's a write up on it and it is a disease so I guess I kind looked out like the browser. Argument there is still in in reality a platter society believe it or not and I kind of look at the the arguments about pans band this that we should probably not spend a lot of time on it we we will spend time on during these kids on on documenting how on doing global IBA G. studies which in fact will be the seminal moment of of essentially proving that cure for a disease or cure for that some of the symptoms of that disease in the extreme up so we we just kind of got on our train it went up a little health center I mean to be honest in brief about it I don't find a lot of profit and all like corporate indentures around the world and spending at some time arguing about something that is actually a fact so if the other recognize it we have centers of excellence and world famous infectious disease doctors all saying it exist that's enough for me and I think we spend really on a percent of our time yeah and and addressing these kids are and probably zero going to seminars argue the case we've had the house grand rounds all over the country because pediatricians run into these kids they are not strict OCD they are they got a symptoms that align with pants and pandas right down the line and they're quite believed to have a formula by which and and you guys a clinic two which is serve these kids the second thing I'd no to you center is the one in Arkansas much like the one in Arizona that is really going to be a section of the country clinic regional clinic we see in Arizona now how we see eight kids that clinic we started with for that we're up to eighty now of each time we have a clinic and a half of those are from out of the state and a bunch of those from out of country so the rest of the world kind of believes it enough that they get their their kids there to get the don and I I think that's probably our general attitude is just keep all over going because it it helps kids arguing the other way and joining in the world of Bob spinal taps and all the brutal things that kids go through and this disease is not recognized correctly is to me inhumane gets my dander up so the answer to that we essentially just say let's go and get it done and that's we didn't sixteen and we've taken that tack ever since I would recommend yes sounds almost simplistic what I would recommend that you guys you know kind of take on that platters analogy and and kind of believe it that way and go where you're going. All right of miss rice. I actually had that earlier when doctor Smith was still on but I do have a question that kind of rules and so what we're doing in the Arkansas clinic as well with the Arizona clinic you just mentioned that you are you were seeing for kids in clinic and now you're seeing eight how often do you see. Kids in clinic like is it a once a month thing or what is the consistency. No we actually two clinics now so each one sees eight a week it's a it's a week clinic one stage of the ones for the next area and there's usually the ones for today would be the one to the Tucson center of excellence we also have a full time staff and there's an interest rate to should we be involved to that because our our medical provider banner which is one of the largest ones in the country has seen fit to adopt this disease as one of their major causes long with Alzheimer's and so uh they have funded both under centers practitioner at both of these clinics in addition you know and most of our clients we have a new one we have a primary care physician a psychologist or psychiatrist and and neurologist for NBA G. prescriptions and a nurse editors practitioner in the wanted to some we have a we actually of college fellows probably two or three is Rick is seeing the band there that attend those meetings and researchers so this pretty rough probably ten people in a room when you get that multidiscipline crew together to see these kids so it's pretty robust yeah but if we take the eight pre clinic were house Jean sixteen week. Anything else mistrust The how often typically do you see these kids like is how many visits to they typically do through the clinic versus how much they get treated by the primary Kerr's after you have the initial eyes on them. That's a great question It depends on the severity of the child when they come and to be honest with you the idea the principle of the clinics is there we we believe a primary care doctor really is should do eight should be benefited by the clinic but not the sole recipient of their but happens with that child so our primary focus is to return that child to the primary care position with about a plan of action that the parents also get a copy of it said that primary care then supervises that kid anybody who's around this disease after while even lay people like restricted determined that they're fairly defined courses of action with these kids is not rocket science every time so you can take a kid give um uh be and probably eighty percent eighty fifth five percent one time they're analyzed usually at a fairly early stage in their has cancer and this development and then returned to the primary care physician with you know whatever prescriptions they have for antibiotics and as steroids your and says and then so I was a pretty high the other fifteen typically would be older kids I mean a higher percentage of the word difficult cases are older kids are kids who had not been analyzed quickly at AT balls into service cases were you know I B. I G. or some other repeat treatments were necessary we also have I would gas one of the nation's leading cognitive behavioral therapy clinics that a lot of these kids go to whether it's in Phoenix or or in Tucson so that it that's kind of a off shoot of the clinic if you will so we have that C. B. T. both in both cases in both places we have clinics so the kids are then referred to that as a subsidiary treatment I. And I think that's what highly important it is one of the reasons I think back to center embers question to a wide how do we handle the argument we have the argument by a believing in both sides of the argument I mean if you look at the classic papers that state has your past doesn't exist there are there are Remedy for that is highly CVT or yet what we have that I mean it yes we recognize these kids get some psychological damage to so therefore we address their bad habits that they learn from hiding this disease or or not hiding this disease so to the interval part of the clinic itself but is basically any repeat repeat things from the children would be probably more or is it going to C. B. T. therapy for awhile but most of them go back to the primary care physician that's why I think we spent a lot of time and effort and money on awareness campaigns in the pediatric world because I think really is you know our goal in some point is to eliminate these clinics right discussion from Needham I'm should always be a a bunch in the country a few in the country but honestly we're trying to get to where the primary care folks up have the ability to fix these diseases very early in the game and never get to a service case. Long answer but essentially that's what we do that's our focus. Anything else thank you. All right of let's go to represent a warrant and then go to spread for. This run. Warren how you doing I'm doing great yourself. In healthy. Me too and that's a good place to be right now of of are you have to grow the bar so. First of all thank you so much for what you're doing because to me the everyone of these. Kids that has this that we treat. Is a statement that we got something that is working. And that's testimony that no one can refute so thank you for what you're doing. I would love to see Arkansas become a regional facility. So you talked about two clinics that you have you seen eight a week. Yep so what kind of waiting list do you have for those facilities. We started we set a goal just so I kind of want to make sure reference get service you guys have the same goals because of what I think a work release in Arkansas. We set a goal that we would never have a waiting list longer than eight weeks at that which is cruel and unusual to me right now we're down to probably a month maybe at the Max we actually blow through pretty well we kind of went as a general principle and I I'll probably give you guys too many of these but we we cannot I'm a big baseball fan and you there is a movie out there that was because you know the kind of build it they will come all I see well we built in a K. and I think the same teams going after with yours the problem I had with once a month clinics is that it's yes unless you fund something every week I think that the ability to see these kids in a timely fashion you've seen these kids. sure sure Matt has and the books that room I did you know you want to get treatment right now eight weeks is your. misery for the parents of the child so we actually try to rotate ourselves and not no longer than a month but that kind of the buffer again is back to the pediatric world if you have a knowledgeable pediatric world that months that you think this kid or maybe as a back up and getting to actual clinic really is kind of a necessary if you have a robust pediatric care so what you'll see commonly when you guys need to develop it and I if they just involves is a where doctor panda and and doctor ready go out and do virtual grand rounds in this case or grand routes to pediatric groups hi I'm here is my telephone number you get a kid I don't want I don't want to see many clinic is back to the kids back to the parents by putting in a CD can the car an airplane for crying out loud and so you you have a relationship built up with that community that allows pediatricians to call doctor me or call Dr panda and say I got this kid here's what's happening I don't think I can handle it can I send them to you so motor all of our Ferrell's if you look at our website and this is been going on for I'll be the two years out of the four that we've been open is we have a pediatrician referred that kit it is there is not parents with and the reason we do that is because a parent's age should be communicating with the pediatrician and the pediatrician said have instructions that of the kind of blood tests that you wanted observation should you want before he even goes to the core so that's kind of the linkage it's a benefit to both sides to have that linkage to the pediatric world so my answer to backlogs is you know we we actually tell the folks yet if they stay have a severity kind of leader so when we get a call referring physicians physician. That severe they'll see the kid that I expect out right away they would wait for clinic the the you know the more severe the it's instantaneous but second on the kids that actually go to the clinic if they're severe they are seen within the next clinical cycle which is one week in up there not severe you know it that that backlog gets a little longer for the ones that aren't as severe hopefully we're communicating with the primary care folks at that point in solving that the problem will so it's a very much an integrated system that way and I know that you guys that isn't probably the case right now but I think you need to kind of look at it look at your website to look at how roll blast you need to address that pediatric world to make friends out there that they're looking for an answer to right I mean you're you're kind of a god send we just need to get it out there so I don't want to talk about money too much today I have a couple comments at the end but Rick mentioned that we had an awareness funded we talked about him and and you and represent a warrant a member all we we had that discussion and ideas to try to get some funding not only for the nurse overhead but for awareness campaign and we certainly will help you with that when you get some funding to reach out a lot of it has to do with again personal contact with and a rainy get not listening to pediatricians and becoming accessible so. All right let me let me ask you a quick question and I've got to. Natalie Matt on board okay but missed run when it comes to your funding streams are you already set up in Arizona to where you are getting reimbursement because you listed off about how they needed cedar PCP before they get to the clinic and other things but do you already have the battle one with the insurance companies out there Medicaid out there so that when they do go to see their PCP that part of the. Removal of the obstacles you very got it were were those PC page or if they come to the clinic can get beer were reimbursed by Medicaid in the insurance companies. Yeah I know we don't have a problem with that the role of again banner health care is a fairly large medical provider here and they own actually lot of facilities at the university as well the bottom out for I was one point two billion dollars two years back so they actually provide the clinical portion of it and the the Arizona universe there's like doctors may and those banner clinics and then the other half of their life they're all doing research at the university level so we honestly don't have that I've ever really of anything that has to do with primary care of that kid including antibiotics and all the prescriptions you would normally get except I V. I. G.. really are not a problem. All right Should not be a problem either by the way all right Jason are you on the resume yet if you are wave your hand so I can see if you're up there Josh Miller. Okay. He'll be joined in just a second because he's with one of the passes and I wanted him in on the conversation to the topic you're talking about raising awareness all right Natalie. So Mister I and you had mentioned that the department of health website that you had and also a an article from one of the internal medicine and gurus for lack of better term that you're going to get to doctor Smith is there a way that you could get those to our committee so we can review those as well. Sure there thank you A rex probably already got the link at I think I may have sent it to Maurice's well but I can structure which said that if it's okay with you guys Senator reckon reach that heat they can distribute that so you want a link to the website the DHS website and then also the the paper written by defections disease doctors fairly recent thank you two thousand two twelve twenty twenty and it refers essentially it's a commentary on Thanks to read articles about depends on the exist type articles I will to the detail of it but essentially she took that on as a in two ways one to kind of point out a few flaws in those reports and the second one is to say you know let's get on with treating these kids the validity of that paper just scientific papers should you guys know an academic you can go back like Rick said thank you got any meeting and you know are the audience will party on and they'll get very close of course about act the only thing I think we get closer first round is actually treating these kids of not leaking about Cole by but that paper is a really good example I'm seeing an argument but it's a good district Tatian on let's go treaties kids that's how it ends up and because so who only walled is right now she's in Wisconsin so they're going through holy Dickens in that place with that because it is you know so she agrees she's busy twenty eight hours a day I came region right now because it's just she's just overwhelmed but essentially she's been the chair of pediatrics of their universe is constant for over twenty five years and one of the heavy which the industry was that one of the editors of the infectious disease journal for a long time so yeah what an extraordinary she kind of a female doctor about you if you will of the Midwest and so I. There's a lot of credibility which you write something and in the medical. Thank you cannot as too quick follow ups you so also on that list could you add the the forms that you provide the primary cares for them to send back to your you made mention the Johnson handouts for them as well and and then the second thing is you mention and antibiotics and steroids or whatever need to be covered do you have B. I. G. coverage in the state of Arizona currently we have let the ridge IV IG. Do you have a V. I. G. covered in Arizona. But we do I don't but that's a long discussion because it's not mandated anywhere both I think we're going to get that a few minutes of by and finally did your agenda so if. Less you want to enter into something else that I can get into. Can we hold that one if you don't mind but we will get on it is absolutely okay all right of man. Mister Ryan thank you for all that you do for the interest of time I won't kind of bundle leave the you mentioned you know eight weeks gosh that's I can be a long time in whatever disease process you have been obviously you need to intervene on what's going on right there so we may look very different when they're in front of the multi disciplinary team than it did in the PC peas office have you seen any use for telemedicine or at time of is it if somebody is acting out in the PC peas office they could then Weatherby steroids is in says whatever that is kind of question what's going on that they don't present the same way in that multi disciplinary clinician office. So good good how are you doing Trent really good thank you yet excellent okay so we kinda added to that a little bit differently I just texted the center now to what they're backlog was right now it's two weeks so we're handling it I think robust the that's great restart out of much longer stuff but on a will to down to that by increasing staff and opening a second. So I just show that in for you were your comments in earlier questions folks that I think and Repeat your question government madam strive seeing opportunity to use telemedicine to increase the ethical. Yeah I know I'm glad you brought that so wonderful so it has its benefits one of ms to home at so yes we we actually love it because the doctors use something called Microsoft team I think it's they found that the best tool but what they've done now is the even the first time kids they see them all they even did kill any reservation recently and actually have wifi the interposition and so they're loving the fact that this kid the doctor state when did you have to be a kid yeah right just like the parent does your twenty minute chapter barmy you're taking into a medical facility which in the kids mine is loaded with germs I mean it's just not a good experience so. What telemedicine done is allow them to develop techniques of seeing these kids even first time kids which is the toughest ones but even the follow ups the primary the follow ups were extremely well on telemedicine problem with tele health we your regional center like you guys essentially are right now by the way Your folks commitment out of state at you. That the problem is two full one apparently lawyers and I haven't heard the detail yeah but they're very concerned about liability for the health facility on people from out of state I mean there's licensing stuff that you can kind of get around by having states cooperate with each other but I for some insurance from some reason insurance is not there were I think they're worried about when that emergency goes away the liability insurance for company kid out of state would be come difficult so that's one thing you want to kind of start investigating about why that would exist outside the emergence of an emergency right now which kind of allows everybody to be seen by everybody. So that's that's gonna be a major concern that's over seven to do without but that aside telehealth is absolutely the way to go I mean I I honestly is and huge fan the doctors are huge fans I know it's getting a lot of play with the elderly people like me. Being a good thing as it is a boy that to the kid's standpoint is just is just as good for this matter is a great question and we're a hundred percent for it and uh will be using it specially in state all we can because there is a tremendous tool for these kind of clinics out of reach yeah thank you and the last part of a. Comment question it goes with. Tell education of the physician that you have in Arkansas with you I think peer education is very effective and I know that there's a timbre system here in the state of Arkansas that offers see in these to clinicians on a regular basis weekly basis also we have a engaged group of and that is educators nurses at schools and so I just wonder your experience in the pathway of getting to that multi disciplinary clinician have you seen that education in schools and other places is brought about the identification of the young person or an adult that may be suffering from autoimmune encephalitis that the and how does that pathway look going forward. Another great question that I've We used basically grand rounds to do that to medic to nurse associations as well as doctors as so one in southern Arizona was attended by two hundred fifty nurses so they were pretty robust organizational education I think the one area we're still working hard on I guess are hard to reach as a group and that's school nurses which really are cut again a first line of defense right so one of the projects we had this year was to have a pretty robust program with the school nurses the now you have to do with telehealth most like it but it's not you know everybody has conferences we're gonna have one and December our second one of the year national conference for all university at the and that'll be virtual I mean they're not impossible to do after subject like this I think you if. We can certainly make available all the presentations that doctor dancing Dr rice who are cold directors Barkley got here have made but we've also done even from the primary care we have a primary care doctor is one of the conditions at the multidiscipline clinic in Phoenix that he's given up to other hospitals as well so I mean I I can certainly if you guys when you get have designated a doctor any doctor panda somebody rector runs a clinic I I would recommend gives these two under two under several connecting your them towards what they'd be interested and say well primary care folks I mean I this is the one there's no point inventing the wheel when the wheels already been invented just take we have modify it and and just give it a half hour virtual that whether you sugar coated was CM is or not I think this subject is interesting enough for folks taxi just a gender lease we found that to be the case so I would. Your right Madame message again to preside offense the pediatricians of nurses and the quicker you can get and educate them. So that they also know they have a clinical resource to go to it just is absolute the way to go. Thank you and I just want to point out collegiate do can Paisley Butler both educators nurse at the didn't school district and I counselor thank you all for being engaged in these conversations for the kids in your community. All right the medium. Let ME segue and I'm on a Jason we got you now we had to we had to double muted or something while go can you here's okay. Yeah can you hear me yes we can. okay good. So not bad note no prog Jason is the plan president summit community care one of the pastors here in the state and your other less mean let me let me ask you taking on to what Mister Ryan just said the population that the past to serve or what population just for the benefit of everybody in the room. Of behavioral health and I DD and age groups to serve. I'm sorry what they're eight the age group eight. children adolescents the bill. I think the limit two years and up primarily but children adolescents and adults with the neighbor health substance abuse ride ET. And you know the total population of and miss me and actually if you would make your way up to the table if you don't mind the total population that are represented in all the passes what what is that number now do you know. I know you know years what what what is yours. You were about fifteen thousand to over fifteen thousand right now against this year probably compare my I think it's somewhere around forty thousand mark between all three passes roughly okay in did you hear the conversation of Mister Ryan was contributing to as far as you know the need to get it out there and get promoted among the the provider so as to raise the where awareness level in education level did you were you in on that part of the conversation. Yes I heard back to the okay. So hold on second for the benefit which all mine go ahead and introduce yourself for the record please. A Janet man and the director of medical Janet man the director of medical services at DHS. A bill golden medical director of the Arkansas code medical services in there since two thousand eight and professor of medicine and public health at the university of Arkansas. And mark quite chief staff for DHS okay. This man how many what's total population in the past is now do you know right off it's approximately somewhere between forty three and forty five thousand I believe okay so Mister Ryan hang on I'm come back to you in a minute but I want to get Jason on this part of the conversation duration or what speaking only for your pass what could be done to raise the awareness level and the credibility of pains to the providers with a total of forty five thousand being represented what are some of the things avenues in the four match that you have that we could tap into. The number one with another and this is the conversation your state of the the one that must be I know we don't have a lot of our any amount ACT and pandas beneficiaries we haven't had any service needs there but what we are doing a certain kind reaches me because we can across the state certainly big issue important for for Arkansas. We we have the advantage in the past program to be able to submit to the state request to use some of the dollars four community investment endeavors and so we have put for our proposals already there and I think it's coming out of approval this week I think one of the other past thirty has an approval but ares one of our initiative is to launch a training education platform for the state that not for the state before anyone providers and members across the state to use we we received a lot of feedback from our providers who said we really would like to educate more provide more education but we don't have the dollars to put it into a system or platform to do that on on a routine basis so what we're looking to do is is a significant amount of dollars in to that is committee best Mister I do not think that again as in our presentation conversation with state look like a book being approved so what we would do is loss that your multitude of of Avenue is going to be available on a platform we proposed also beards direct direct course you'll near a similar to what compelled to be used in rely at I have a lot more avenues in and out but the manager of it is going to have kind of a plug and play a sort of process where you've got the models built in what hundreds of things available only watch it we're also putting together a committee that will look at additional training opportunities that we ninety to have over time so and that expanded rolled out and gives more more people the opportunity to Speaker staff and train their staff to this platform that they choose that will be at no cost to providers and will not be mandated course it is they use that it is a nice vehicle either complement other programs that are out there or you know continue as it grows to put more models in there so there's a and the training course or there's something that we need to educate. There's teachers nurses physicians other folks across the state we would be able to help support that in terms of building a module or having a watch in the platform thank you be used across the state we're very proud or so would prevent especially to code environment lease for awhile prevent the inability for folks to be loud and on site we probably can help. Checking on how would work in the office in the world the way that and I'm saltine guide know these people are using in them but we could even potentially line some of those like the or certainly weapon hours of training and wants them on the platform so it's a compliment to whatever else may be out there but because we're we're putting imports all of our providers have access we thank you certainly can be helpful if you we we want to A bill to partner with some of the folks rolling up to manage training. Okay. Is so is it was like watching a Japanese movie with his mouth moved about five seconds behind you sit on our guard eight does not your fault issues that's what is miss man let me ask you you've heard the conversation and what Mister Ryan contributed and then what the Jason just shared with regards. A kind of put you on the spot but it is is there anything that you can think of. With regards to utilizing the platform they put forth to you all that we could marry these things up and use it as a platform to get some education out there about Pan Am pandas. I feel sure that that isn't as an option senator that as that committee that's my proposal goes through the different approval levels at DHS and I think it is cycling three days and just so United that and and and am willing to work with them on that I just I can't definitively say yes or no today okay but there is an option anyway that I believe say okay all right so I mean if they could reach if we could make that a target goal and represent warm one low job today if if maybe we could follow through on that because that would give us access to you know forty five thousand and and how many providers are in your pastor ation. Get the number but it I mean thousands of providers to keep in mind even even though we have been ever health and I these are primary provider primary membership we cover the the patients full spectrum of healthcare needs minded dental so vision providers the hospitals are all in our network including your MSN are special so you know we're we're pretty expensive from a provider standpoint that we and we have no really no particular limits to the average despite form would be rolled out so it it may be an opportunity for to and we all we are also going to want to work out of a proposal to prove just to launch workstations why we can't do that everywhere our plan is to. After the state with places that don't normally have access to training methodology or or computers we've got money in there to fund workstations so that we can put those up libraries are schools and are places for employment skill training but also can be used for other other types platform launches and worker training so a lot of opportunity there to really get to the training and education needs the really new provided that needed and father beat again a multitude of models and that people can use to try and including trying to connect it to them the required training that they may require for new ratified William new model would would be relatively straight Courtney B. committee understand all right well just second I'd be a fast way to xcelerated if we can get worked in where we could marry the two together are merge to together that would be one way to get to a master group of providers fairly quickly to to get the word out there anybody have any questions on that. And just for the folks that are in the room my goal is no later than three o'clock because I know we've got a lot of professionals tied up in the room that have patience to seek center all right let's bring let's bring Mr Ryan back into the conversation and did you have anything with regards to the clinic in Arizona that you want to share that you didn't get Mr page Mr run before we go into the discussion about Medicaid. No I don't think so I center I I would just add one comment in your planning for the distribution of that educational information is I think whoever said set up or creates those should of that those true Rick and his staff at their clinic so because they they've got the most modern medical treatment so that you're gonna make sure you got the the really is the greatest but the second part is I I think what you should have as part of that component tree is again trying to build a relationship between these physicians and primary care folks for any questions that may have that with that would have on. Kind of an inference of not having to bring those kids to a clinic right so again as primary care physician or even nurse practitioner position where you've got a you've got some answers but places to go to get answers rather than having to take a kid to a clinic all day long the other part I think it if you integrate those two approaches into your presentation you always stay modern but you can also have any grab our DO was and all that is part of it again because the audience we find a primary care will they just don't have the time so when we make things kind of straightforward and on a video they at least get educated and quickly and then can go on to the next thing so I just suggest that you cannot coordinate that with the your clinic so that modern stuff gets out there and that also integrates the full path of treatment that is available to the children. Okay A miss Parker. I just have one question concerning add the education and getting the information out there have you dealt with happened to give any information to any type of law enforcement officials concerning the children or at the adult population that actually has fans and pandas. That was activity yes. No not law enforcement no okay is that something that you could recommend that maybe we do that we do educate. More outside of just the providers not just nurses in the medical facilities but we actually need to educate. You know law enforcement and all those involved that may have to come across to an individual. And the adult population that actually has phantom pandas. You bet I think the major folk we call them chill child protective services here at or what you call in Arkansas but their their job is to you know check out of child abuse and that kind of stuff and Matt probably know this is really well and is you in his group knows or really well I think one of the great fears of parents trying to admit that they have got a kid with this got problems autoimmune problems are not necessary psychological the evidence that way but they're actually physical problems on a mu problems that The first thing that will happen if you tell some doctors in the state is they'll call their your child protective services office and you get a knock at your door stand you know we're here to investigate you're using your child as the worst thing that could happen to those parents at that particular time so the education of those folks. To understand the disease understand when they see it how it evidences and I I think probably that is parents could probably for the best education is is to you know don't walk into their thinking the kids being abused when you the evidence presents itself that this is some kind autoimmune and step office the case I don't assume bad things when you walk in assume that you want information and that information should be again coordinated with this whole learning program about what is paid fantasy houses go up again this stuff is not rocket science it really is not and when you see in this over and over again it's pretty obvious that this kid has been affected by that disease as not just the you know that the parents or are being unruly and their treatment of a check of the calendar side of that is some of the parents some parents the with that need education on as well because a lot of parents will think the kids at this point problem and you know take on their parental role in a in a in a in a way that's probably not too acceptable to try to understand what this kid's going through and what it can do to all families so I think that's education on both sides of that with the protective services folks I think they're they're education is vital to not getting this family in trouble for just trying to help to get a house. Thank you. All right let's move into a discussion on item if which is the discussion of errors on Medicaid doctor run you want to give this inside as to what and and miss man feel free to weigh in on this because I think there been discussions between you and the director of the Arizona Medicaid in my correct on that. The. Yes Sir we did talk with Arizona Medicaid in conjunction with Mister Ryan and some of his staff in September to have a conversation of the the pants pain that center of excellence in in Phoenix okay so let me yield Mr run first can you go ahead and give us the background to give us the current status of how Medicaid in Arizona is dealing with reimbursement of any treatment associate with pants or just give us the overview police. Sure when we open the click I think it was action twenty eighteen so good open about a year and a half two years we sat down with the Medicaid folks in Arizona and with the correct that clear thank you explain does they they were knowledge of this anyway explain what we're doing the concept of a major clinic and how they were leading kind of the medical information and treatment about those diseases and after awhile we decided that we should they decided that they were convinced that we were knowledgeable about that that the pediatricians we're educating were knowledgeable about that and I think it became acceptable in their mind to authorized Medicaid treatment on ideologies for these children that in a simple case as what happened we also had the N. H. joint is in that room but they really didn't participate so it was it was some based on a couple things Senator hammer one of them is a letter of medical necessity that we drafted in concert with the co directors of the center and the Medicaid CM all that was basically would get submitted every time we had a request for IP IG we also I decided such that everything was submitted on expedited basis which I think legally gets the insurance companies every two hours to respond. So we want to expedite all these things that take forever so those are kind of the principals out of that meeting and we also because the concern was brought up by Medicaid that they were very concerned about shortages in I. B. I G. they were very concerned about over prescription that a couple of doctors in the state were noted I will repeat their names but they had they were tracking doctors that were OVERPRESCRIBING in their opinion or suspected OVERPRESCRIBING. More appropriately ideology for kids and we volunteered at the center and I would encourage you to have your your clinic there do the same you should be a center by the way at some point so that they would offer their services to give a second opinion about cases where the department suspected there was an over prescription or inappropriate prescription FOR ideology which you all know is fairly expensive and and you know is is a fairly major product to be introducing into any human beings body I kind of but refreshes their automated system is action the purpose and also reduces a brain information as. So that was the general gist of what we talked about it think in the meeting we had with the Arkansas folks is to educate a little bit on the process and sort of the way we agreed at the base the gentleman's agreement to require a law didn't required of a change really and in the notification and so that's how it preceded ever since then we've had hundred percent success with with Medicaid folks which is in Arizona is a forty five percent of the kids run it on Medicaid so it's you know it's it's work great it's a it's really had no problems on the other side what I would tell you the secret to no problems is that we're pretty conservative right we we we apply a IDA G. to probably less than ten percent the kids of the get the last number I saw the seven percent the national averages twenty percent. So in some ways to save money for the state as well and I think they recognize that but it's a component you need to be aware of IBA G. is is got to be carefully handled I it is gonna be is gonna shortage going the United States which is predictable because blood draws for a lot less with coated and blood draws of the of the home base of by how you get I B. I G. the market place so it is something you want to be extremely careful of I don't like talking about it separately as a big time issue because if you get down to seven percent of the kids you that the object there is to get down to seven percent against the the first first window lemonade that is thirteen percent go away if you have a robust primary care and quality but anyway that's the that was how what happened in eighteen since then what's happened on the other side of the fence mostly private insurers the Blue Cross blue shield United kind of folks they see that seeks sass and they stay understand a little bit about how again conservatives most of the practitioners have become in Arizona you know things like CPT therapy and other drugs have really kind of taken the place of the national average right BA G. that's how we've lowered it down to a very little amount the notice is success of that program and I would get to the psychological influences that includes insurance companies but essentially we have about a ninety five percent acceptance rate overall whether it's Medicaid or Blue Cross blue shield is very high I would add to that because these are not simple questions senators are amended carry on but it it's a very it's a difficult subject matter so the university of Arizona we would have to sit in the probably already have made available to the Arkansas folks their counterparts we have the. Up the nation's first ability to do pre testing of IVI G. and post testing post meeting after every idea G. so insurance companies are not bad all right so what they're looking for as proof and so what these tests do rather than mom and dad say and it's better or some anecdotal evidence they actually run psychological testing for these kids before the IBA G. in right after the I I first application and that there's a second one they run the second the third to try to get at is this year and. Measurably up for improving on ideology so it's a it's a again a fairly simple formula but we wanted to make sure that the folks that were blessing this we're confident by evidence of this child improving such a yeah could you could program isn't something you just turn on I. B. I G. you really need to. Kind of be careful about but there are steps there that are they're very workable that you can adopt on based on what we're doing so that's kind of our view of it I I I I I I talked to the Medicaid people little bit more just an informational meeting I don't know if they talk to doctor salik afterwards or not and talk to Serra for awhile but I plan to the next week or so I would just wanted to hear that they had decided not to go ahead with that it should be there are there right I mean I I have written recently there are just see of the committees where there are five states that have approved it in total and I think I sent more reach this morning or last night a link to the the lockdown this mostri forward is in New Hampshire and it's a it's a is not much writing it's one of the members of the legislature for five years it was so state and to appoint but it it allowed idea Jean stated in Hampshire do I recommend the legislative route mandating that yes you know from my last and there I'm not stand I think legislations guidance place but as you guys no more anybody it's fungible right to change from year to year so I think the the way of agreements the way of proving that the treatments effective again ninety five percent rate of approval here and and I think every case that you would draw up they can show you the improvement a degree of the kids and I think that's the way you do it you do it by evidence in medicine not necessary by law but it but if it becomes it is a tool that's why I suggested and I'm not you know in favor of it but I I think if you read out options and service of the applicant. Hi miss man let me give you an Dr golden a opportunity to respond if you would where we as far as our Medicaid in Looking at this is a viable option for you all to get involved with amend make some comments you can start now finished yet so you know part of my role is the medical director is to advise her staff about the effective use of resources and the appropriate care for the populations we serve. As you can imagine we have a lot of folks with a lot of conditions a lot of needs and the we have to be also accountable to of the state as well in the budget we have with the state. we have been I've been tracking the literature on hands and pandas and it is evolving and maturing and believe that it is a difficult spectrum of conditions which is can be dramatic within a family certainly Causing a significant issues with the disability of the child stress within the family. And in and the appropriate care and support is very important. I think the creation of a clinic here in the state and the potential for clinical studies he is a very good and strong idea as well as the educational efforts that we're moving forward. I am I spoke with the medical director of Medicaid in Arizona. Who tells me that she herself is not involved with the decisions about coverage four specific and treatments for pans and pandas in Arizona but it is basically the province of the managed care companies and state and managed care in the state handles about. I guess ninety five hundred percent of the cases in the state. Their arm I think multiple ways of treating it I think the disease or the condition is under diagnosed I think it is over diagnosed I think we have to make sure that we identify the right kids for the right treatments or the right adults the older children as well the older adults. And I think we're learning more I think the literature is a lot more nuanced and sophisticated than it was say five or six years ago when it was to allow debate about is this real or is it not reveal that kind of thing. golden can I interrupt you for second we have a real barrier between you and us good job pull those mikes down just a little bit I'm sorry thank you notes not thank all trying to be you know socially distance with the microphone I understand thank you The literature on IVI G. is is pretty mixed if not not particularly strong I have read a few studies I've also looked at the national coverage criteria for humana seventeen in other companies some of them have sent done synopses of existing trials of IV IG. Most almost all of the national coverage decisions of view ideology four pans and panda this is unproven an experimental. and I can mean they have for example seventeen or health net has a seventy three conditions that they review for IP IG et that they consider experimental or not authorized of which pans and pandas is one of them. so I believe that it's important for us to carefully diagnose and document of the condition I think that having clinical studies in the state to look at the effectiveness of a different therapies is extremely important as well as to identify where or which patients within the spectrum of the disorder would benefit the most from different therapies. so at this point given the Weakness of the clinical evidence in the literature in the published literature. As well as the national coverage decisions by major national insurers. Hi is difficult for me to advise that Medicaid cover IVI G. at this point in time only because it begins part of the role of being an effective steward and trying to get the right care for the right kids at the right time. What we'll have an open dialogue so I'd like to hear. Mister Ryan your response and doctor golden I guess. Our what of a struggle with the is. When you hear what Mister Ryan says in the advances they've made in Arizona and the other states that seem to be progressing further than what we are as a state in acceptance or becoming a believer however you want to terminate And. But I guess I'll have a little trouble understanding why were not. Up with the other states that are out ahead of us. But I approach. When I approach my work is with Medicaid. hi take I do this with. All requests for care for whatever condition pianist your cancer be it a funny blood disorder. Hello people the staff will come to me and ask what do we do with this request what we do with this condition. So I go to what is in the published literature I look at a what is being used what has been recorded what is in pub med and what other large national companies do for covering a condition and I look for opportunities where there is promise and I look for evidence for or against treatment of a condition and so that's what I've done here I've done nothing different than what I've done for any other condition that is brought to me for review and consideration. Miss man did you want to weigh in. I would just add that doctor golden does handle every every review of case by case and there have been cases that have had a diagnosis of pander panda as a secondary diagnosis as we testified to earlier in the year and I the I. G. has been prescribed and has been administered and by Medicaid given the diagnosis so given that we had a very good conversation with Mister Ryan in Arizona we've had good conversations with doctor Smith and the clinic being established we are very encouraged by the clinical trial and additional evidence and continuing to work with that developing said that as case by case is developed and reviewed by clinic clinical staff we have the opportunity to to treat that case by case so while there is some evidence that doctor golden has addressed on a national in in different studies I do want to emphasize that we take each case by case each child is as a child and has to be reviewed individually not in not in a spectrum of everyone else so and I think we are very cautious I do I do appreciate Mister Ryan conservative apprentice to addressing any type of clinical diagnosis and the letter of medical necessity was very encouraging to us doctor Smith had and has indicated he and I have not had a follow up conversations I hate to put you on the spot doctor Smith of trying to you it implement that letter of ethnicity here in Arkansas which medical necessity excuse me which I think would be a very which would be very good because everything that we do at Medicaid has to have a medical necessity component for us to even begin to do our work and so I would just. Say that we are you know we are open and we're trying to work with everyone at the table given the studies given the new approaches given the new clinical study coming and we want to treat child by child yeah I think that Mister Ryan so comment about all of that only five seven to ten twelve percent of the cases were getting IVI G. is interesting and the you know what when I reviewed the material was more of a general approach to the condition as opposed to a targeted approach to select cases all right of got a couple questions on the board but let me ask one four go to them because one of things I am going to ask you for what we get out here what's our pathway Ford of. So the thing about that but let me ask you if if a PCP are the river watch has determined that a child or an adult could be treated by the I. V. I. G.. And do you do you then in the Medicaid department take it case by case to determine whether or not you deny or what do you pay educate me as far as what you do. You know I I think that given the current structure of what we're developing in the state and my conversations I've had with a doctor Smith I think that the the best way to handle that kind of approach would be going through their clinic and their assessment and have it kind of a a very targeted approach with the with a center of excellence to consider that the treatment. A doctor at a sharks and give you doctor status or Mister Ryan you mention center of excellence Lago something you need to think about the county was that what you're referring to or what what exactly was at about. I I think is kind of a consensus of something maybe you should try and that is if if the validity for Medicaid can be proven by this is a primary care physician says I think this kid needs IBA G. I think you would be wise because it is new in the state to have a trial program maybe make it six months or some reasonable year where a child who has a of desire prescription for the IB IG goes to the clinic you get a validation that that is the proper last resort of treatment for this child which is by the way what it should be Medicare right now and and that. blinded validation by the physicians is then tracked and tract with these tests I was talking about to see if this kid approved that way you have a scientific management of improvement not anecdotal I thank you you guys sound like you're already kind of the year in your thinking which I applied is very open minded to say okay and you to Senator hammer that that I the question is what do we do now I do we go forward and be because you want to come for on the Medicaid side there doctors to they they want to help these kids there's no question my mind so this isn't really all that much of by and disagreement it's more like let's prove it together and I think you can prove together by just joined forces in setting up a program a robust program with doctor Smith and and saying you know let's have it here's what we do and the little Johnny has it and he's the other forty miles away the trip to the to the clinic is a one trip they validate the that's the right the prescription for the GNU you enter into your trial period he gets one two three six ten twelve two years soft some application of ida B. I G. that's track all the way through and then I think we could also work and something with there's only if you need double validation that they would review some of those cases I make that off for that without asking but there might be mad at me but that's our that that we go through the ballot is you guys are comfortable because it if that comfort level is there you know you don't need laws you don't need lawsuit you don't need for you you just we're all trying to help the kids and you guys later today are down that same pass so I would suggest that trial really defined robust trial done at the one kid or two kids could be a lot of kids that you have evidence of that working that also by issue say at a year and a half period where we get to the subject of the I. B. I G. H.. Trial that truce medically affect it's a phase three trials so if it succeeds to what we think it will succeed to insurance dissertations about experimental all goes away there is no argument anymore about whether works or not and and just regular positions can prescribe it but I think in some ways this trial has an advantage right you guys get to prove to yourselves whether this thing works or not and I think you've selected the cases to make sure they're valid trial subjects I think it's the way to do it I thought and I think Rick and you know he he's the he's one of my favorite people in the history of mankind is at and you guys it Medicaid can sit down and come up with this trial this robust takes care of these children the really do need IP G. and I don't mean just wanted to let me just look at him and that that the clinical folks say yeah these or candidates that the let's go I mean that's what I do with it you can use and I think you have a peaceable integrated approach and everybody gets the monitor be happy with an is scientifically validated I'll just be clear though I it is the science is still uncertain about the effectiveness of this conduct the treatment. Of I think we still have a lot to learn so I think putting this is part of a study and to make sure we understand with it if it works and with whom is extremely important going fully. Okay let me go to a couple questions Natalie. Miss manning you mentioned okay I'm here he's talking that and so just for you to know I'm Natalie Bradford I'm a PA and been and that in Arkansas and I've been treating these kids for about three years and and I would agree with Mister Ryan by the numbers of what I would like to get out of a G. R. under ten percent of my patients that I treat so I would agree with a conservative you know there are a lot of other options before you get to IT IG but my question is you said these cases are reviewed case by case and any time that I have tried for a Medicaid patient with our first line of however we normally go through processes we are told that it's covered but not reimbursed and so there's no way to appeal or anything else so my question is how can I as a medical provider get to someone to review a case by case I need to talk to my staff obviously okay In the case yes I know that the pharmacy staff sees them before you do so that part of my concern I know how to read and not being paid is I'm usually not the answer it Medicaid okay usually the complaint I get is we don't pay enough and so I just at this to be transparent right so I would like to follow up with you sure afterwards just because obviously it's the process that I am testifying that should be working is not working in this case and I would like to rectify that sure thank you though it wonderful. All right ms rush. I'm over here thank you I'm sorry I know you're. I I I. I give a little bit of my story last time when you were here about my son I actually have a son that is diagnosed and one ms Bradford was probably also kinda talking about my son as being one of those ones of the case by case so that was my first question is when you say case by case how has that happened because I will tell you I've fought we were about to lose our child and for those who didn't hear a little piece of our son's story last time I was here our son is eight years old and up changing over night this site facility we had to put him and they said he was the most suicidal eight year old that they've ever had hallucinations like overnight we got him out got him on heavy and about ex did a little bit better Blake slowly but I think it gone too far that we needed a bigger punch to him. Natalie it actually put in an order for ivy IG in February so his first day was in September she put a border and FOR IVI G. in February January under January February and knowing that we needed this punch to his gut to like hopefully overcome this because he was not going to get completely better on his own no matter they were thrown psych meds out hand they had him on how it all at one point We need to A went through the hospital they would only reimburse up to a hundred and forty dollars and they said it was a nine thousand dollar treatment I did have connections to call someone with in Medicaid and I'm sure you know Tim Taylor two he set me up the chain he fought and talked on the phone with me late at night many nights knowing we were losing our child fast and he was fighting with me and when we say case by case basis no one heard us no one he ended up back in a facility and so there goes another twenty two thousand dollars I recorded for that stay and not only that but we've added the trauma now of my then three year old daughter who's watching her brother completely psychotic now I will say we had to go through a couple years a trauma and throwing meds and changing minds in cycling methods and playing this roulette game my child is now then off of all men's for a year and a half completely saying in a straight a student but we could have saved a year and a half of trauma possibly. And a whole lot of money that the state paid for psych stays in the therapies that even my young age my younger one is still in because of all she witness with him going crazy of a first let me and apologize on you did not get case by case handling and I will look into that and and knowing TM I knew that he and did did everything that he could date when I refer to case by case I am referring to the prior authorization and the and the re retrospective and utilization management review that we haven't Medicaid and renting when items that are ordered are have to have a prior authorization that they are handled case by case with the doctor's note in the clinic in handled peer to peer for a review and said that is what I mean when I say a case by case when we go through. Different trials and different things that are coming from the doctor I cannot speak to your son's case specifically and and let me say I apologize that you went through a year and a half of of that and what we I knew working with the different clinicians and the different doctors. They may request one thing and one another I don't know if that happened in your case I'm not I'm not trying to say they did not request IVI G. up front I just I don't know at the I would have to go back and look at your son's case but in the proctors ation we have a preferred drug list and we have prescribed and protocols for children doc and adults going to the hospital and then things get reviewed and we try to bring in peer to peer review I don't have them on staff it's actually a contractor that several contractors because of getting the clinical expertise they can be an individual contractor they can be and. Secured through a vendor they are all licensed in the state of Arkansas just for the record it has to be peer to peer review seven A long winded answer to say aye I have some work today. To I just don't want to see it happen to another I mean I it was a year and a half of me not sleeping taking doors off literally I mean that's what it's like to live with one of these kids so none of us will ever be the same so you know we have PTSD in our house now I mean everyone's good right now but we can't take back the possibility of there could have been an answer but we couldn't get it in our state. I understand. Our our. How to better. Man. First of all thank you all thank you all for your work I V. I. G. was spoken seven percent maybe of one population who knows the percentage here I've always been of thought that I look forward to the day when I'm talking about IV IG that we are recognizing diagnosing and treating this prior to that. And that day is not here clearly. So in regards to case by case basis for those patients the present early on in the stages that we have. Multiple other we're able to be treated and see great success way before I V. I. G. was even need. Thanks to are meeting. blockades as far as the the a facility saying yes we we love to treat you without reimbursement but we just haven't found many of those and so my question is is they come in for for blood draws for for prescriptions of antibiotics and said the. Steroid whatever that whatever the pre IVI G. regiment and or treatment may be. How how is that reviewed is it reviewed is there a condition code for something like that. I don't believe so I'm gonna deferred to doctor golden and believe so of the children you know there The. My perception would be as of these patients present a presents with clinical issues and they will be a clinician making decisions about how to treat the child or treat the patient. I it is I am not aware. Of System issues that would block payment for some basic interventions if there are specific episodes B. like and love to hear about it but I do not think at least of from our standpoint it would be an issue granted there other papers I don't know if they don't accept any code or something along those lines but I a I would be surprised if there would be major issues in that regard thank you and in respect to just Medicaid payment would it be reasonable to thank you Mr Ryan you may or may not have that we have some sort of nomenclature of condition codes that says if you are a stage one autoimmune encephalitis at the stage two stage three stage four much like any other sickness or disorder diabetes cancer whatever we do we just don't go in and say we caught prostate cancer on day one and we need you to have chemotherapy that doesn't take place nor would you do that to a diabetic with that makes sense in this case is you see it today. You know I'm not sure where we are in terms of the ICD ten coating and all and that's we'd be on the pay raise of everybody here at kids I think to a discussion somewhere in Geneva or something like that but you know there are Yes a world of difference between billing and taking care of people and I think that you know you can take care of people and described things and there are ways of getting services paid for so I think that you can describe clinical presentations in a way in your building codes that allow for treatment okay in for up I think this is all that I have the to your point of. billing and taking care of people we just want taking care of people to be sustainable and what we find out is sometimes is not sustainable and maybe a one and done and and we certainly don't want that he was described in the previous meeting that the reimbursement rate for IVI G. changes daily. in that was in regards as I read it to Medicaid. Would it be reasonable to ask what an aggregate over a year with the we we know that it was much less than even the cost there of. With that be a reasonable request. I can I can ask my pharmacy director and when it changes from day to day we use a wholesale acquisition cost and that's it the cost is not set by us it's it's set by a larger entity in the in the field of pharmacy and I can I can ask her and get back to you I I don't know how to answer the question okay thank you. Alright members just so you know what the intent here for. Expected time Natalie who has a question and then one one do is give Mister Ryan well actually I'm not sure if it's gonna be Mr Reiner doctor Smith the two together to talk about the Of lost word. The. We call trial the the trial thank you and maybe that's going to weigh in on some of the discussion that we're having here to kind of give a little bit of a sense of a path forward and then Okay there you can what state did you wanna bring up anything. Okay all right. This man I respect your time but I think a couple people may want to get you and mark afterwards if you could okay yes Sir all right thank you Natalie. I was just gonna follow up with what Matt was saying I will say on my end for the patients that I've had Medicaid has covered lab work for diagnosis which is a clinical diagnosis but lab helps rule other things out so I have gotten coverage from Medicaid on labs and I have not had any denial for antibiotics steroids or anti inflammatories from Medicaid I've had to jump through some PA hoops depending on the anti inflammatories but that's manageable and we can make it through those it has been the commercial insurance like Blue Cross tricare United that have not reimbursed appropriately on labs to my knowledge and most of the time if they get a bill for labs I've I know about it so I will just I know you all weren't sure and Matt as far as lab work and antibiotics we've seen got good coverage it's for Medicaid it's been the RBI G. issue now for non Medicaid that's a whole different ballgame we need to talk about another time but. Maybe that's where we can look at the legislation was passed under the stage because that applies private insurance so all right let's do this Mister Ryan and doctor Smith I'm not sure if you two are going to weigh in together on this for Medicaid on the trial of the did you referenced earlier. You know me go Rick I'm a yield of Paul okay all boards with Paul created the truck. Yeah that was the when the journey Quick comment about the the mom that spoke at it I didn't get her name so I'm sorry about that but I just wanted to reiterate our grandson came down with the years ago and that's why I got it in in the best in this she's a hundred percent right of what it does to a family and I would just respond by saying I think to that mom and to match that into Senator hammer and Representative warned that you sit down. Come up with that trial that moms child with the then the perfect candidate for that trial that and and the Medicaid folks that think would appreciate the information that we now have the new modern techniques of tracking the success of that I think you would please everybody's desires and I think I agree with her you don't want that to happen happen to her to happen to any family I mean suicide all those things that happened I see no I see them hundreds of times in the families we. Met over the years the they need to stop and people I think like yourselves at that table who are open minded. Jean Jett real created within about an hour's time we come up with that trial and that everybody would be happy to participate and that would prove the effectiveness of that and I I would just leave you with that thought I think it you have an opening to do that I would jump all over as the IBA G. tried as an interesting trial it is the largest trial ever run on I. B. A. G. fort specifically for these children. We went to short story we went to every farmer company in the world actually six of might think now maybe seven. How long how long chat with them and to to say that we think this is going to we think anecdotally of not even so much at all about our proof of you of A and the success of this is pretty soon significant and and they we have a lot of chats around the world and the company call octapharma still not that the idea. you know from a commercial site obviously they would like a market but full I'm a patent standpoint we decided to go with the trial started with just a result and then the like the plan so much it went to the United States and then they like the plan so much that and we kept pushing of prior demographic of both ethnic and racial and and also geographic that we wanted a sample of a large part of the world because it really is the only thing about I was a scientist I want to have recognition that no matter where I went this had good effect and so al last Christmas day actually I got a phone call from Austria say and that their board had accepted the fact of doing enough a trial throughout the world largest trial retentive wasn't blinded or any losses sixty kids this one is going to end up being ninety two we ranged in we have protocol discussions around the world for months and months and months the university of Arkansas participated in those because you're a clinic as part of that network and they were doctor of panda doctor anywhere significant contributors to the kind of design we have is a double blinded study which is the highest you can do it's got site testing it's got medical testing it's got it's a list of test would blow your mind it's also we then went for an F. T. was called up phase three trial phase three trial skip stays one to which is kind of experimental and says this is a ballot enough drug it's been around ideas you've been around for I don't know a hundred years and extremely safe drug. and so with line sketches of the FDA day except that this is a pastry trial what that means is if the trial is quote unquote successful shows an advocacy for the drug and safety for that the drug application that will be immediately approved by the FDA. And therefore that we are discussions about insurance go away because it it becomes essentially FDA approved and everybody in government approves and so therefore an you don't get arguments the insurance companies so in a nutshell that's what that is it was a long journey to get there you can imagine the protocol meetings have been days not hours they have been review by the FDA a three month review question answered back and forth where now go through the same process in Europe and agents of she called the EMA which is that their equipment at the FDA in Europe when it gets approved probably in the early first quarter of twenty twenty one will start recruiting kids around the world that this trial it is about a strict to trial and and dented a trial and to give you an idea each university gets trained on how to that these kids are valid how to treat them ideologies happen at the chosen sites again which show Arkansas is one out in the world and the reporting is done by ACT crew it's audited by three different companies the results are are Bennett to make sure don't cheating went on that nobody knows what was of the Seybold a trial the kids or their names are hidden we made sure in the trial this was one of the contributions paste made that even the kids who don't get it happen get it happen get a placebo basically is saline solution that those kids at the end of that nine week period of trial period. Also will get treated with up to three applications of ideology so that their no kid goes untreated I guess I'm trying to see which is rather unusual for the sample by that was one of our demands of the former companies to do so in a nutshell it is a big deal in the world of science is the norm is due and I think for the university of Arkansas it means a couple things one you get revenue because you get revenues reach patient recruited but you also get revenue for the medical side of it the I. B. I G. ease that's all reimbursed you're gonna get visited by teams of people both auditors and up trainers before the process started so again it's quite conforming rather standardized every place is going to have will we have seven university sites that are in our coalition or participating in what else can I say it's probably I asked him last time with the budget for this thing is thirty million Bucks so arsenal it's not a small deal and by the way the medicine is being written up as one of the one of the great trials for children because it's so uh we've got a pretty safe drug there again I B. I G. is not out a dangerous drug or dangerous process. So anyway that's that's the not shell of it I'm really happy that Arkansans in there I mean I told you how much I admire doc B. Smith but that the to doc's the leader clinic there are just. Fantastic people an open minded and very talented in their fields so we that each one year in the you're in the kind of big leagues of colleges with UCLA harbored stand for the you of A out our little hospitals out in the desert and and Arkansas which happened to be my two favorite places so anyway then I show that's it if you have any question be happy to answer of the trust just two mornings for the trial starts in the first quarter it'll be the pandemic will dominate a little bit of that as you can imagine but is schedules during the first quarter of twenty twenty one we're asking all the the parents that may have a candidate for that trial to contact the Arkansas clinic we will start recruiting tool of first quarter what I don't want to do is have them calling out the pharmacy and I have a kid is I'll just refer you to the clinics anyway so we have to be a little careful about getting too excited about it because it's still got the yeah may have probably go through in Europe and with that have to have clearance from the coded thing that we can actually robustly recruit kids so any questions that you guys have. Is at ninety two kids among all the locations are to be utilized in the testing. Did you say. Did you say ninety two. I need to be total patient up population of that test yep ninety to the total. So essentially in a scientific role you have forty six getting di BA G. forty six getting the it may not be exactly those numbers that this the ideas to try to try to get a placebo group that isn't getting them as you can get some time was called the placebo effect she gets at I. B. I G. or invision always said you know I'm better and it did not know change so it's scientifically you want to understand that the placebo had X. of fact and the drug and expected you can present to us and just wanted okay so let me say this because we're in a we're a try Sir ratcheted up the so will be in the case study we don't know how many of our kids in Arkansas would actually get accepted the ninety two it'll be a screening process is that correct. That's great it can be disproportionate though for clinic because if you've got ballot cases in Arkansas they they will count is not like were you there's not like it has to come a quarter from the west coast quarter from the east of that kind of thing it's if you've got a a bunch develop cases they'll get in and nobody will know that by the way except the monsters the auditors because they're the ones that actually track each kid is done independent really have you been up your doctors they will know they have to turn the results in and and they're audited and entered by out completely different entity so it's pretty blinded. But yes you can have more than more than just a portion of bill all right so let me ask you for where we are and you to let trial is done and I guess I'm asking you miss manning your team there in the mean time. What we do. In the meantime add I think Medicaid's role is to work with doctor Smith on medical necessity and the protocols for the clinicians to be able to diagnose and treat and then my job is to work on that the PA process and any reimbursement that I can. I am thinking off the top of my head senator. Gold not agree with what was just said I know that I've I've had to work with doctor Smith and for many years and sure that we can reach a sense of philosophical agreement and scientific agreement as well so I'm comfortable with that working through things with their team okay and then let me ask doctor smis and doctor golden and Mister Ryan radiant weigh in on this one. Doctor golden in the position that you're in and the things that you share today. If. What would it take for the center at U. M. S. be recognized as a center of excellence so that if they referred out of that clinic say a PCP out and Benton or does arc or whatever referred a child to the UAMS clinic in the U. M. S. clinic doctors said you know we think this one rises to the level this child rises to the level. And then that child would be referred for that request would come down to you at Medicaid. Do you need to have that Senator be a center of excellence or what are you going to have to have in order to be able to say okay I I'll treat this I think that the fact that UAMS doctor Smith in his team have a center speaks for itself and you know what we when we look at approving therapies he always looking for whether the person who is putting together that therapy has a you know has a volume of experience and and can make a a strong recommendations of that so I would go with the with isn't Fishel designation or not is at least in terms of our decision making not important now you may be important in terms grants and ship of the other places in other venues but and official title I think the fact that there were you a major referral regional referral site for this condition speaks for itself okay and miss Ryan is there any benefit as far as any grant dollars or anything out there that if we work to go through whatever process to label you M. S. as a center of excellence in this does that open this up to any grant dollars potentially out there any funding. All right yes I I can't go into the details but doctor Smith and I have had robust discussions about further. I adventures into the world of science including major attempt to actually cure this disease someday I will go into details because I'm we're still mulling over Jan we even that tent that I it's very durable according scientifically but it's gonna take obviously a lot of money to do that so because I would love to see you name in the center our definition of the center by the way is that you would treat these kids diagnose these treaties because you educate positions in your university about this disease and you research happily so one of the criteria is the research part because of Arkansas's police especially its unique talent in them and in psychiatric. A medicine I thank you that's why we. And I reckon I first started talking but I think you labeling it is a center in that case would be very appropriate as long as Rick was teaching at or have this folks teaching at the university you're already doing heavy research I mean you're one of the pews places in the world to even get out this site B. I. J. G. test your obligee treating the kids so I think Senator hammer I I think you're already there and I I name at that I think the only other things I had written down as notes is kind of a redo of are always discussion back and. December of nineteen doesn't seem like a year ago seems like a few months ago but I I enjoy that kind of our conversation we talked about two things I want to just kind of follow up if you guys are in your bill of your budget process one of ms I think we had targeted a hundred thousand Bucks four of the nurse position and also some money for that awareness campaign that's one the other is I will tell you from there is a legislature when we first opened up hours I asked the legislature for two hundred fifty grand you can make whatever number you think is. A good bet is an investment in the the clinic in the center right off the bat in the area of research so not to get I have a lot to be a lot to talk about but essentially we have other projects green imaging with MRI eyes on these kids is to find out the end of the source of information on the effective insulation we have a whole brain imaging program study that's being headed up by one of our partners stand for that Arkansas is already been included in but they're gonna need some money for that kind of a research effort so I would ask the legislature on top of that starter kit of a hundred just to get the clinics open that you also think about a research grant the procedure to get them started on some of these have your topics I think the state supported that is is something everybody notices and it it ballot days again the existence of this disease in your efforts to cure it so those that you asset make again I cannot tell you how important Arkansas is to our whole program but it is being touted right now by are gonna or organization at all are sister organizations like the positions that work and there's about ten of all where we we told them you guys are the regional clinic for the south and we already have so I think you've already has some folks in Georgia call you and things like that I think that's what you should be you you have the talent there and your legislatures been very interested in this and your parental groups have been marvelous so that's what I would recommend you guys do and and I. I think again I I I will I consider you already a center and an angry and important reading of what we're doing start thank you for let me speak today sorry I a lobby hard because actually believe this. The importance of what we're doing so alright thank you got my Irish at my wrist learning as of this stuff and it's all actual so good it is appreciated too all right John Vincent with the pharmacy association thank you the presentations been excellent thank you very much right here and I was just going to ask to clarify to comments Janet made earlier about working with sent the into how awful and pharmacy program it would be helpful for me the as we talk about these therapies to see maybe as she'd paper and I don't know who put that together but the drug the quantity the size these immune immunoglobulin products which products are being prescribed and I think you even there's some discussion about the compensation or the reimbursement earlier sit in this chair I don't really know what that looks like it be helpful to be able to see that I know you said you're going to research it so we appreciate you on that. DO a bill the deal we're gonna try we're gonna try I'm sorry. Thank you all right. The. This book. I just have a question concerning the case study that you have under way sound like a broken record I'm here for the adult population it says is for ages between six to seventeen is there any talk about have been another study done for the adult population. Did you get that Mister Ryan. I think it but we not at this this study carries six to seventeen I think she age range but I will tell you what our views are on that and and we're going with it I yes it is an adults you don't just lose it when you become eighteen so we have a very robust program in association with the university of Wisconsin to transition people from pediatrics so adult care right it's a very important thing it is the population ages a little bit you got all these kids on this disease that they require treatment four of the Senate pre time so the answer is yes for addressing that a we will address it with the same bigger in Arkansas given Rick's experience with the adult population as well we we understand it's a necessity the I. B. I G. treatment is for the disease of hands it's being applied children but that doesn't mean that is not effective in adults right I mean it's the same concept so that I B. I G. treatment under the pants diagnosis if you're twenty eight it would apply this is that the it's not it's a given I I have a primary immune deficiency they call of some sort common very bottom so I get I B. I G. every month. and I'm very familiar with the process and and I have obviously I I know I don't look it but I'm on Medicare and it covers of falling so what I think the world is changing a little bit on the worldwide B. I G. but I would give you that called for that we're looking at transitional care but then also don't care is much more accepted in the world of ideology that it is in the world of pediatrics right now okay and whenever you get all the information together kids some of the adults information be included in the package that you will send over to us. She wants to know if you could send over the information on the adult with that package you were going to send over is that what is our I eight. I'm happy to do that I mean we'll we'll see folks we'll see adults right now at the psychiatric research institute so we're happy to do it thank you. Okay anything else. All right one of thank you all for being here today Dr gold what do you teach over at the university what what area do you teach and you said your instructor over there hi Sir the of general internal medicine them primary care doc had a general telemedicine their twenty something years ago okay forget put these dates on your calendar November. For. Okay just. Okay for sure put December fourth on your calendar at one o'clock as far as having Medicaid back and who all will have back we'll work through that we've got some homework to do represent worn I do and we'll circle up individually doctor Smith with you and want to get with the J. ation Medicare's will have some off more conversation so miss rice additional you blood of the question. Just a really quick question this is to our group more so what ever happened with our subcommittee groups that we were going to implement that. The bill that that's represent weren't gonna head that up and that and I hope that after today especially the conversation on the educational signed we've got a little bit of a vision how we can go forward in the conversation that happened with the Jason Lago I think maybe opened up a new Avenue so which subcommittee were you on it it's been so long I think it's B. okay movie all right represent Warren is going to be given the diligence of other subcommittees I will tell you this this work is not going to finish by the end of the year almost become the half represent board and I we're going to figure out how to transition this of Ford because I know some were concerned about ending and I think based on the conversation I don't see that being a practical solution one and he nice Representative centers will figure out that pathway Ford okay so we have official recognition anything from a thing from up Medicaid or doctor Smith missed Rigney final words. I just wanted to thank you for inviting me I it is great to actually hear and see you guys again and okay well this pandemic it's over what will come out of persons with we plan on being in there and Arkansas number times during the next few years so if you have any further questions you know feel free to ask is you know I'm not shy about giving some facts or opinions out but I think they're all based on something we're actually doing it there is all that there's no reason you folks cannot do the same so I look forward to working with you thank you again senator and Representative or appreciated thank you very much thank you all for being here today and thank you for Emily she did a great job under first committee meeting I think so thank you all very much and with that we're Jr.