ALC-Employee Benefits Division Oversight Subcommittee

No employee benefit division oversight committee subcommittee to order. Ah. Representative rich when you have any comments you want to make all versed only listen. We're on review improve the department of transformation share services exhibit b navigators help solution for a grant was. The. Yeah. The. If you would plead introduce yourself for the record in your recognized. The. Great wallace director of employee benefits division. You like to know some this amimit is. Simply we are cleaning up definitions and terms that were in the rfp and baffle really to match more operational terms and definitions that were using. So that's what's really being addressed in the that's before you regarding navities we also expanded some data security language to make that more current to work were utilizing and what we're making sure that we're protecting information and secure transfer of data in those types of information things that are going on. So with that i'll be glad to answer any questions. Thank you mr chair so we have this on our agenda today and it just says navigates health solutions lsc contract amendment to appreciate mr wallace's explanation I have asked a staff to see a copy of it I was told it was online and it very well might be but i'm not able to find it so i'd like to know where the language is so that I can actually see what i'm voting on i've you know had too many experiences work in this committee where i've been voting on things and told later I voted on something I didn't understand I was voting on so could somebody help me with that. Would you look at uh debit b. You have should have a copy. Yeah. Yeah. Okay so this is really the language. Where were we brain copy grant will bring you a copy because all this says is clarifying terms and operational condition. So like is there more to it than that I guess is what i'm asking. You have question on boy. What it what we provided is more information than what comes through on the the portal so i'm not sure how we want to get that out. Because we do we follow the office the state procurement there are minute process which does outline the details that you're looking for I just don't know what actually comes through for you all and if this is it this is just the cover sheet that comes through on the portal so if we need additional information II don't I mean I don't know the best way to get it to you right in this moment yeah I mean so that's my concern is i'm being asked to vote on something I tried to do my homework ahead of time I was told this online and the only thing I found online is a minute to says a million eight hundred thirty four thousand two ninety five five fourteen clarifying terms and operational conditions. And I don't know what that means other than what you said but we've had things in the past were i've been told something and then found out that was an exactly the case later on and i'm just a little hesitant to vote on it I don't mean the hold things up but is a member of this committee subcommittee I think I should. Have access to that before mass to vote on it and you know so. It again I will defer to state however you want me to get that information to you or I was following the process there we were directed to followed but II mean i've got it I can email it I can do whatever I need to do to get it to you. Okay come back to this staff making copies right now and and and we'll come back in a minute. Okay. So would you like me to go to the next one on the list. Okay. The. The. Yes a question. Thank you you have a question yes you recommend great wallace and I do believe through blr I was able to receive a copy of the amendment and after reviewing and I did notice that there's some significant language concerning confidential information and then also for you that tends to allow narvatives to. I guess determined what is there isn't confidential information and then also determine what is there isn't a foiable item can you speak to the necessity for that so this would be standard language around foyer that the to my knowledge and what I was informed would have been used for any state contractor and it is you know awareness that we are a government everything is foeable but obviously when it comes to phi and that information it does need to be protected so it would be kind of the natural language around how we would navigate that when it comes to being a government entity and dealing with a phone is to benefit manager or health administrative plan administrator anything like that there's going to be some information that we clearly want to make sure is protected. Follow up. Yes I understand that phi aspect of it it just seems that this the language seems to have been pretty broad given notice a lot to determine what is there isn't confidential information and that allows them to object to any foyal requests that may be subjected to which would be standard for anybody that's contracting with the state they just like me as a public employee I can object to four year and have that reviewed by the attorney general and then the determination would be made it's similar for those that contract they do have the ability to object to a foyer and it still would go through a review process in in a final determination would be made on whether it actually is releasable or not so this language here was it authored by your office or was did representatives of not as author of this document no this would be between what we offered and i'm sure there was probably some amen that I don't remember etc specifically if not what has had any recommendations on this on that particular section or not but it would have been language with that we would have presented around for you in and responding to four year requests okay so your office drafted the language under freedom of information and then disclosure at their parties. And protection of confidential information with the bulk of it and there may have been a a counter of the min meter counter language that navigates presented I don't specifically remember the back and forth around that section but we would have presented the initial language on four year and in the confidentiality yes. Copies coming we will come back there if you would receive two number two. Item number two this is our relationship with health advantage they are are third party administrator for the medical benefits this is the one year extension and there was a increase from the current year into the next year but this will be for plan year twenty twenty four starting in january. The. The. Thank you mister chair so we need to amend this contract due to inflation is that what i'm understanding that this would be we're in the one your renewal when your extension renewal process with this particular relationship so this is just that next one year extension and I was not part of the initial negotiations of these numbers but i'm sure inflation was contributing to some of the increase okay so buy it in other contracts were slashing prices in reducing it and we have built in an inflation increases on other contracts so help me understand why one industry has inflationary. You know pressure but another industry just can suck it up and deal with it and didn't have to deal with minimal wage increases or costs of suppliers going out anything like that could you give me a a good solid against her on why it's okay to do that to one industry but not another and I don't have a good solid answer for you sir i'm still learning the contracting when it comes to this what I will tell you is that this is a contract that i'm going to go to rfp for and in the process of trying to get a work on a consultant or if for it to bring on a consultant to help navigate the tpa renewal and the rfp free tpa so my goal would be uh to address the overall cost and figure out ways that we can bring cost savings to the state on this particular contract because it is the one of the largest and it is something that needs to be scrutinized that we need to review but to answer your specific question I do not have a good answer so so would you agree that pretty much every industry out there had inflationary pressures and it wasn't just limited to health insurance companies what I personally have experienced is yes that there there has been a drastic inflation pressures on everybody thank you for your honesty. Replaced the mister I think with the information center boys bring forth it's important to note that in a report from siego through the recommendations that are contract with blue cross blue shield partners in this was a good thing and it was it within cost measures. And patrick do you are you might come to the table and since sender boyd want to bring this up let's talk about it and talk about how the cost measure across the country. Direct wallace is that okay. The. If you would please introduce yourself for the record and patrick line signal yet so it's been two years now but we did do a report and we looked at how competitive the contract was for blue advantage and they're administrative fees so that's what we're talking about was in line with what we seen in the market so I don't know what's happened over the last two years I don't know what the increase was for this upcoming renewal but at the time it was competitive and we also looked at the discounts so that's really where the the bulk of the. The savings would come from is that discount relative to other networks and they were best and class for the state. Thank you patrick thank you mister chair. Thank you i'm just kind of hearing the conversation it's sounding like you just said you don't know the contract that a lot of the individuals in here are about to vote on but you hear presenting it to us. II know the extent of the one year renewal the I when I came in in february that I have reviewed it and understand that the extent to the overarching contract that was agreed to some five years ago I have not dug into that I don't know the full extent of that. Okay. This. Any other questions. If not I would do their emotion statement we have circuit. All in favor say i'll host. Well. Okay. Stay here for a little bit less come back to you we're going to get these other copies okay so we don't have that. You get so i'm getting the head of. The. The skilled resection c. All right so these would be the formula recommendations for the months of september in october these were reviewed by ebd EBRX and averages what you have before us is what we all agreed to this is an effort to move closer to the signature select that would go into place on january first again these are efforts to maximize the best possible drug and rebate combination for the plan and and again all of these have been reviewed by the advisor commissions and state board of finance. Yeah questions representative wardle. Thank you mister chair I was looking through c one I believe it is come back over here and. I'm not even going to try to pronounce these drug names but number three on on top of c one if you read the rationale it goes through the different cost analysis between certain name brands versus other name brands can you walk me through to make me understand that the patients are getting the same therapy. And I think that's important that we are covering drugs that give them the ability to either get better or are maintaining. Where they're at and I don't want to make the these decisions totally based on money and when you read this it talks about one cost more than the other but it doesn't really talk about the similarities between the two. Right so in this particular instance there are to my knowledge there are. The. Drugs that are just as good and treatment as this particular wine but are available to us at a lower net case so that is part of the factor that goes in on this this was not as you'll see in the current set at its night has the evidence that is going to work better than what is currently offered so the recommendation to not move to it yet because the science was not there to say that it would produce a better outcome so that was really the core of the rationale one on that particular one so he follow me on over to page three and you look at who mark humer if i'm even pronouncing that it we need to number these so I can just call out a number daily's farmers can't do this if you read that one and you walk through the noveltars rationale and you cannot tell me a little bit about the tears you're want your two to three three four and currently they're until two by a moving on the tier for we are able to last the rebate system so why are we not able to last that rebate system on on all the tiers and and want me through why that is it and why we move these tears and then what it takes for patient to qualify for it you're one versus your do and so on so the tearing is the pricing related to the copay and all of those that a member would experience of tier one would be the lowest that would be at a zero or very minimal co pay so that's the penny drugs that you were right so that would be your generic trying to understand so that would be your generics tear to or your name brands obviously would have a little bit higher copay associated with that tier three or the name brands where we have a generic equivalent available that would be on it to your one you go to tear three where you do pay the higher co pay plus you have a penalty that's on type of it to where the member pays the difference between. The generic price surname brand price so if if. I think i'm getting there if the patience paying a hire copay that qualifies us for a better rebate with the manufacturer and that's the reason we moved to a tier for so on this particular instance with human there are a lot of similar bio similars for that. What is going on here is that one of its similars is actually at the tier for when it comes to manufacturers then what they're all there competitors they want everybody on the same tiering structure so that's why when you move when you move move this particular one up that's where you get to take advantage of the rebates out there because we're making an equivalent to the other drugs and that class that makes sense. Thank you mister. The. Thank you mister chair i'll be quick miswallace would you agree that if you look on changing a breeze value in a brex fee to the standard vaccine list of zero dollars and then the narcan nasal spray on c two are choosing to cover the less expensive over the counter are kind of the historic intelligent things that has has been known for for doing and this is good work. I would hope so in yes I would agree with you. Representative. Thank miss chairman i've taken my question I have a few questions about a approval denials and approvals in on a particular drugs especially life saving drugs. How do you educate. A reploys how to appeal a denial or do do you educate them on that yes it's all it's very public on our website anybody calls we walk them through the exact process members are more than a capable in able to appeal direct to ebd on any denied drug or denied service anything like that providers they do have a different appeal process but everything is very public facing is available on our website when it comes to forms and process in the steps that they have to walk through okay and follow up mister german in about a me I have a couple questions you cut me up to tell me to shut up at any time and i'll get back in the q on a denial. So an employee gets denied a specific drug could be a life saving drug. So they have cancer. In who is making that initial denial a lot of insurance agencies use artificial intelligence believe it or not. A lot of the employees that are making that denial it could be somebody like danny watson that has no health care experience he and he's making that based on log rhythms and and so forth so does a medical professional ever touch that request for a procedure or medication there's been submitted prior to it being denied so not prior to the denial so the initial denial is gonna be a result of how the weather it's it's so for instance on a pharmacy how we initially set up the formula which were discussing right now so that initial denial is going to be whether it's on the formula or not now for a medical procedure we have our submarine plan document which outlines what are covered services and what are not covered so again that would be the governing document that would trigger that initial denial now once that denial is made the appeal process does go for medical review and that's where you get the experts touching it in reviewing that particular case and making a decision one way or the other weather to cover it or not cover where ebd really steps in is on that second level a appeal so say health advantage or navigations issued a denial on an appeal they then can reappeal for a second level appeal it comes direct to ebd and that's where we review it and make the ultimate decision in consultation with the provider with the. The vendor health advantage navigators we utilize especially on the pharmacy in we utilize ebrx to help guide us and make those decisions on the second level appeals in case if I make mister chairman the sole the second level let's say the provider since then appeal so that's what gets involved at that point now ebd only deals with member appeals provider appeals stay within the vendor so they would get elevated through again using health advantages example it would get elevated to a peered appear review or a higher level medical scrutiny review on that similar track but for navigation when it comes to pharmacy and a provider appeals it would go through a higher scrutiny with medical additional medical people in backgrounds reviewing that case okay so to your knowledge the interest of our providers are used up artificial intelligence that you know up in in the approval process not that I know of no so if you could enough and i'll all quit it at this point that I would like breed bride to me through the staff if you would the number of over that say the past year the number of denials. The. The number of appeals. The number of denials of that appeal. And and I would like I don't want to create a nightmare for you but I would also like to to say that if any of those are life saving drugs what what is raising for the appeal in what was the original claim for if you don't mind in I appreciate you being here thank you for taking my questions mr chairman thank you for your grace and allowing it to answer those who scrutions thank you may I ask of clarification on that request would you like that for pharmacy and medical or just one or the other. Representative I can. Thank you. Director wallace to kind of pig back off of the points that represent a war law brought up about the tearing issue it seems that the rationale for that is because all of these items need to be of the same tier is why these from to have to move to four is that correct of for like that he married that injectable yes. What is the rationale for not being leaving all of them at two rather than moving them up to four. I think you honestly I don't know the the specifics on that when i'm guessing it's a a newer drug coming out and kind of facing out for an older one and trying to keep them all saying but II don't know the specifics on that particular one well it seems like they're using a reference of. Try cafter as a tear for to move all the tier toos rather than using the tear too as to move track after down to tear to. And in my concern is that the copay structure for a tier two and a tier four drug do vary for the patient at the register is that correct and kind of looking at this it may be the prior authorization process as well and quantity limits that you can't do it a tier two that you do that do come into play with tear for that may be part of the case that's going on with this particular example would that increase the volume of prior authorizations if they are moved here for. I would imagine well. No because they already at the already have the prior authorizations right now. And I guess further concerning would be that i'm moving these a tear for then make some available access guidance program. After. Multiple reviews of the access guidance program that appears to be that the PBM receives a twenty percent. Cut of that program is that correct currently. On the cost saving part of it on the on this particular I think it's just leveraging cupids and helping the member navigate that process I don't know that the twenty percent kicks on the entire access guidance they are different features of the access guidance service. Okay. It just seems that the. Using a tear for as the reference point to move a bunch of tier tools upwards lends itself to. Yeah. Be more expensive for the member. At the point of sale. And then if those car savings are mitigated then they are mitigated at a twenty percent cut back to november. And II would not even pretend to try to get into the depths on that particular one because II don't have the depths on that you would on that particular example but what what I was presented is that this was going to make these all equal and that it would not be a negative impact to the member point of sale or in their premiums at the point of sale but I believe in the excuse me sir characters for one more follow up I believe the concern is that moving them into tier for the pushes them if the access guidance program that then the savings that brings it back down to tier two prices are being cut a twenty percent of that back to the PBM. The. And I think for this particular one. It's not necessarily. It appears that we are. Yeah in that fifteen I want to make sure I understand the example this used here because I think the other drugs that are similar to this are already going through that process in this was really just making it eligible for the rebates which is why the move would be made so. Honestly I don't know the detail that you're trying to get to on this particular example I would be glad to get had that conversation off line and get you that information but I just don't know it at the surface of the meeting yet with visual care before the meeting on it. Thank you I just another quick question i'm i'm being done on this so just please clarify for me we brought a prior authorizations so is it correct that november gets paid forty dollars every time they try to rash and care through a prior authorization is that a correct statement i'm going to double check because I think the forty dollars is on the appeal or is there on prior authorization as well. Let me verify that because I was under the impression that it was just on the appeal side holder miss if I can get the answer here. That's fine tell me about fact but they're. The. I'll follow up with you on that thank you mister wallace replacement cabinet. Thank you mister chair and i'm over here to your right my question is gonna can a piggy back offer representative very on these denials and they're going through the review process how long do that does the review process take so we have up to thirty days to do the review. Don't hold me to where we're right now but I know we are much under that we try to get them done within a week especially if there's like an emergency on the like medical side if there's an emergency situation those are done within twenty four hours if there's a urgent which is not quite emergency but still needs to be done there's like a seventy two hour turn around so we do have those built in deadlines but like on pharmacy there's like a thirty day review and I just can't remember the urgent and kind of emergency on that but everything is we do try to get those all done within a week so for the example representative very used and they were denying a life saving drug they would have to wait up to thirty days on those that would fall closer into the twenty four forty eight hour window that we would have to get an answer back on and just one last question so when these appeals happened and they get a denial after a denial after now but if they can't take a legislator member and that legislative member context how can we get approved then. Edit really at what level does it come but that I see it and that I can get the full information in story that's going on you know there are standards that are put in place that helps advantage it here's two that navigated here's two and it's one of those that once it's bright to my level and i'm able to dig in and see what options are afforded to me that are not necessarily programmed that the appeal processes and appeal departments utilize that's where you know I can reverse the decision and sometimes have reversed the decision I would hope that it would not have to go necessarily all the time through legislator to get to my level sometimes it doesn't they they work on their own they reach out to eved and it gets up to me but that's really what is going on there is that it finally gets to the point and it should only be too levels what i've built in since i've been there is that I have an appeal committee that does those second layer appeals if there is uncertainty or doubt within that appeal committee then it comes to me but a default is understand the ultimate reviewer of the appeal in the if the appeal committees decision is again appealed that's when it comes to me and when we are able to make a different sometimes make a different decision sometimes it's a pill. What my my concern is if. Retirees plan members if they have to. Can't take a legislator for it to be reviewed by you. I don't know how many of those claims are actually being reviewed and I don't know how many actual people's lives that were hurting then be honest with the how many people are doing because that we they don't know the review process and that's that's a concern for me and it's an equal concern for me I really hate to hear that somebody would have to go to the level of contacting the legislator before they get some response out of in that that is not acceptable and that's something that we need to work on my appreciate that thank you. Senator stove feel the item thank you grant this goes along with the representative there is question he may have assessed and if you did apologize but the number of denials other number of denials do you know what percentage of those were reversed. I do not but I will get that okay. Yeah. Questions afterwards. Oh. Yeah. We congo where to item be. The. Number one. Replace risk I will recognize you. Thank you miss chair revising item be wine i'd like to revisit for the purpose of motion. Yeah and my motion is as that. We moved to delay the vote on b one. The amendment to this particular contract until friday the purpose of that the reason why i'm making this is because we just got the hand out there's considerable information in the hand out the contract in members need to have an opportunity to to review. This can't track so they can make an informed decision in the informed vote of circuit they have circuit. All in favor say are. Discussion i'm charged under discussion. The during your recognition thank you I would then suggest that we have full review of the contract in the contracting processes that have occurred through the rfp processes with siegel at the table describing exactly everything that has occurred with this type of a contract and what we've been through on this contract because everybody needs to make an informed decision than everybody's going to make an informed decision so it's not just reading the contract it's also understanding the rfp and why we had to scrap the first rfp because it was done incorrectly and then had to move to the second rfp and with the contract as the result it is today so that's fine but it's some point you're going to have to have the full disclosure of the contracting process and how it all has occurred because i'm not interested in just blowing up another contract because we don't like the company that got the award. So let's just be very transparent here and actually make sure everybody understands exactly what the issues are and what the process was because again i'm not interested in somebody who didn't get awarded the contract trying to blow up this contract because they are mad that they didn't win the second rfp. So point of discussion I will not be supporting this motion. Thank you mister chair this is maybe for staff more than anything I noticed that policy making is meeting tomorrow is this something that would have to go through policy making on tomorrow's agenda. I am being told occasionally thank you. This. Any other questions. In a second all in favor site I all oppose. No that will be heard private. Okay continue to item d. And the siegel group come and discuss. If both of you would please introduce yourself for the record and you recognize your presentation. Patrick client signal. I'm trying to get your michael now not deciding to get siegel. And I was here last if you remember this is the continuation of the same day beat this discussion that we had. Only get this in a bigger screening. And we have nobody joining from the phone so it's just a two of us. The. And you can hear me fine right okay okay i'll pull the my clothes that's easier thank you. So let's talk more divides that's what we are here to do if you remember last time I presented this analysis of your claims by the area the provision index if you remember we had those three search of areas where you know there are the social determined soft health then based on which some of the morabilities and disease prevalence of the people differ to theory are going to talk about more of the. Nutritional basilian lifestyle management aspects of diabetes and somehow how they differ in those areas as well as kind of what works for. These diseases in population health management so we'll talk about some of the programs that actually help contain those prices or those incidences. So this was from your data we pull your data from our database and refound that your average day redisrevents but evidence is the number of tight two diabetes that existed in your population and also keep it in mind that this is coming from claims data that means those who are actually seeking services so we will not know any diabetical is not going to the doctor or who doesn't have a prescription medication so those obviously we are missing so your prevalence is around eight percent hour ignation dw shows six percent if you pull up the united states national leader for buries is around ten percent so keep that in mind why i'm seeing. This is. Actually at par with what we are seeing nationwide is because these people are actually seeking some sort of treatment and hence we found them in the claims data. So the diabetics are around it person the rx which is the pharmaceutical span just heard the big discussion on your divided euroformacis phone has increased from about thirty five percent in nineteen twenty nineteen to forty five percent in twenty twenty two a lot of third we discussed last time about the glp ones which are the ex newer expensive drugs that are used for diabetics is maybe because of that then I many many other factors for that as well. Members were debiting a conformed twenty one percent on an average of the total medical spend for your plan and that is very much in line with our database as well around twenty twenty two percent. Somehow debited here in this population are female and that's kind of fine there's no known statistics as well and most different excellent each fifty plus. So let's talk about nutrition and lifestyle management and we had the cities of diabetic talks and this was one of the topics that was agreed upon to be talked for debit. Medical neutician heritage is a very technical world wood that. The. The clinical side of the practicing physicians started using essentially what it is is really a dietary advice for somebody to manage their disease just by diet and lifestyle management and the direct focus is on low carb diet so low sugar low study foods more vegetables. More produce that's what it is medical nutrition therapy it's not therapy it's really directed the advice. I always took objection to the sword mnt and and why was this not just all today to advise one first of all ement is a code haha it's the ice code there a doctor's office can code to get paid to get reimbursed because their direction in the hot in in their clinic or a stand alone direction can actually use that court to get reimbursed from the insurance and from medicare and that's why that complex stone was invented mnt as a therapy. For courtifying it but it essentially what is it it's a day to the advice. And in my opinion I did adverse can come from many different sources it doesn't have to come from. A doctor's office or e somebody who is able to program it so that they get reimbursed it could come from one of those health coaching well less type of initiatives that i'm worth a talk about later so just wanted to give you some based on that. And. There is because it's a reimbursed civil core we could find from your data that some people are actually utilizing mnt and that's a good news the bad news is. It's only a fraction of the people that are utilizing this so that's kind of the badness and there is opportunity for us to go up in that number so this the second column or the third column from the left which shows the number of utilisers percent of utilisers off the debit is in single digits and four percent five percent. And what i'm. Inferring from that is it's not like everybody is not managed by mnt they probably are getting that directed advice is just not getting reflected in the claims data it's possible that the doctor when they are talking to them one on one they are giving them several nutrition and somebody from their office might be doing it too it's just not getting courtified so that our claims read a reflects that. So claims that I don't have a lot of shortcomings when it comes to that the the only inference from this slide I can she is that. Those who are getting the mnt advise and then if you kind of move to the arm on the bottom right column where on the pm pm basis which is the cost of those off the day readings who utilize any nutrition periphery in twenty twenty twenty twenty one sort of drop in pm PM so maybe that's some good news that they are managed well and they'll be in is getting dropped but they've gotten a the other take away from this as there is a huge opportunity to fulfil the gap and whether that gap is full filled by. A doctors offers giving having a registered direction or whether we have a external head coaching type of program so this is another analysis where diabetes is the in the most disadvantaged area where we talked about that area the provision index so the red ones on the right. Are the most deprived areas and their deprived off not only health education and access but they are in general living in a very rural areas with without a whole lot of three sources for them to access any kind of a decent care so you can hear it does show that they are getting you know the cost for visit is comparable however the member cost share appears higher in the most disadvantaged areas. Possibly because it's lower significant you'll volume of utilities in that area so that's a mnt is not simply available or offload it's possible that's our infidence from that. Let's talk a little bit about the benefits of meant any kind of medical nutrition telephone by that I mean a dietary advice for a divided to undertake. The hell they foods which are considered held less sugar less processed foods more vegetables and more protein oriented foods so it does reduce the risk of in a chronic disease it reduces medication use and improves the patience outcomes lot of david excan be maintained without medication just on losing rate and like stand changes I see you have two physicians who are going to talk after this and they're pretty much going to talk about that because I did see their presentations and they were very I would say in line with what we are talking about here continuous usage of medical nutrition periphery does impact all of those go more with conditions it will lose patient will lose they really dropped their blood pressure. Managed their lipits well and obviously that has a positive outcome on. The entire divides. Related set of diseases. The american hard institute actually disc did conduct a study on there and reduce medication use for the cost saving of additional eight hundred and eighteen over patient per year was there estimate of every single person on mnt so it does have a lot of benefits obviously an art even counting some of the other complications of baby days and hospital admissions because of that so all of those are like positive outcomes. And now obviously obviously we talk in less little hours about would be city we talked about the glp one drugs last time they are now really. So we talked about the day bit is drugs and the same drugs in a higher doors how the former companies are selling as obviously the drugs okay so just to give you that a little refresher as you know no one artists which is the highest I would say that one of the first ones that made the gill be one drug has there two drugs up ruled for it will be as well so oz counterpart. In a would be city which has gone a week over and they just came up with a bit study that showed how it reduced all of the other call mobile and then you have victors which is the david is drugs at seven days it's or business under part I know in our risk and then the one by a limitee that was just caught up rude last week so they're their diabetes drug which was my girl and they just got approval for obviously with the higher does of the same drug. Call zap I either think that was the new name they came up with its a very non catchy name anyway but we are getting a lot of help but from the drug stern point foot will be to an extent that it is used wisely for those who really need it will help a lot of these costs as well so we have that will be city class obviously classes are dictated by bmi bodymas index. One two and three those are the known classes of obesity anybody over thirty bm my bmy's avoiding us index based on your you know height with an ender there's a formula anything anybody over thirty is considered obvious that will be certainly one thirty to thirty five thirty five to forty is will be city class too and then there's a four third largest or more widly obvious which is obviously class over forty via my forty. Which is that class three and both definitely need help in turns off everything because most likely just the directory advice is not going to work for that so then we have been at a surgery as we have some other things that are disposal and these will be city drugs will help that and you can see that seventy five percent of the diabetics were also classified as albeit in your population and that's not surprising at all that's how it works if you are always your very likely to be divided. I don't about four percent off those day readings had at least one medical nutrition therapy from the data that we found the mnt is going to be annoying again like a certain is minimally used and many really cool it too in the data. Prevention of a visit within the debited population has care of increased in the past three years or the sorry the previous of obviously has increased and you can see that you're over the year in your data is gradually going up. And the. Ah more will be classed it had the highest person individual for these day and a cost comparison is not quite reflecting here in terms of higher but i'm pretty sure. Through the few years of analysis it will be higher as well. And then it's the same ways class we are now breaking down in terms of the area the provision index and. They are kind of comparable when it comes to the cost but the. Most of the august population does reside in the moderately disadvantaged areas they had the highest obviously prevalence of the plan diabetics of seventy five point five and they're all very much at barber. Area revolution in the dust player rule in how we treat the members so some of you know you can see the medical pm's lower balance mainly because these people probably don't even have access to good care in the area that they live in. And then this was a spotload or billion trick surgery we did for you back in twenty twenty one. The reason I don't have the latest day down there because we pulled the data and it had a minimum number of videotape so it is in your population last year and I am attributing that to one thing which is post covered. Impact of elective surgeon is because covered in twenty twenty one and twenty twenty two was just only twenty one was a pretty bad cool radio so most of the elective searches were not even happening and that was one of the reasons why twenty twenty two day dollars very low too so we thought that was irrelevant maybe we're not looking at some other things it's not coming out right so showing you. From this last presentation this is from twenty nineteen we did a pre enpostered accelerator analysis for your population and what that shows is actually a reduction in their total medical cost and totally medical rex pharmacy spend brilliant post surgery that's the only take away from that so when somebody actually lose the suite whether it is through the drug or whether it is through the surgery they do have a positive impact on their overall held and hence. The post surgery medical cost to the plan is also less for them but again so if you do that only deserve for those who are on the motorbid class and not everybody so we did look into your current vendors for the activist which is the blue cross and narrators and we just was we asked them what programs do you have for addressing the diabetes issues. This is just the blue cross slide that she was the overall number of common but i'm not sure going to go in the details of that because we will be covering that very much indeed in our next session. What the programs blue cross has is they do have there. I call them the case management programs from there are your case management entity that reaches out to the members. And it's it's a very high level program so they do identify members through the data you don't have to read the fine put in here but they do it in the friday to members of the data they reach out to them. Most of the patient declined to participate but they're like who want me getting this call or letter if there is a letter that centered on the what even the reads it. Most people don't really react to these plan outreaches that's been my experience I come from a help plan background too in fact my colleagues at united heads get a can ouch for that of that when the plan that reaches out with the members that is hardly any response usually but they do outreach the identify the gaps and care they tried to educate the member and then the goal is to again get them in the medical nutrition terribly or get some directly advised and blue cross does have partnerships with these what we call the point solutions. Point solution is something that freeze the gap between when your bigger plans like your pbm and your help plan doesn't meet and that's where these point solutions are and they do have partnership with on dual water and strive hell. And i'll pop a little bit about what this point solutions do in my subsequence lights. And then we also found out from navigators what program would they have and now it is being a PBM they have access meaning they can actually do something maybe at the point of sale but some of the programs that you heard earlier that I was listening to you guys as questions they go through that same kind of a process that is your lisition the review there is a prior authorization and you can institute or sorry you can actually buy some of those programs from them to stop the sale of some of the drugs at a point of sale. Provided you can stop that meaning i'm there is that you can make a requirement at the patient participates in a weight loss program or a help coaching program and only then the drop can be dispensed and things like that so they do have. Of availability of those programs will have to think about how do we actually administer some of those without any member desert option you don't want a member disruption. When somebody goes to get a prescription full or if you and having it stopped at the previous either so somehow the pharmacy programs are usually very hard to administer they also have a a partnership with one of the point solutions that blue cross also works with worder which is a well known solution in that space and let me just most of that so what do we do in terms of these are not like recommendations hard enforced first time working on it what i'm going to talk about is. Why do some of these point solutions actually work. So the reasons for all city causes and risks are all listed over here I don't need to go through all of them one by one but. Causes in triggers of severe obviously not of them are psychological social. Emotional. There is a metabolic syndrome meaning somebody really have a metabolic syndrome which is called in swilling the resistance which the boy develops after a certain. Lifestyle adoption and how the body just learns to use garb sources fair accumulation offers and then that's what causes the motorbolic syndrome the genetics is coming now but we are not hundred but insurance or whether there is a one g in solution or or if there is any at all. But because your obvious you could be also add higher is for hypertension day it is stress john's problems gold stones live up near carter vascular disease deep when tom bosses and what nor basically eighty percent of what you see in your claims costs. So we see a step wise approach to weight loss and that's something that we highly recommend the first three just considered on the bottom chart the the first three steps are really getting that medical nutrition terribly through direct nutrition exercise it's hardful people to commented those in your lifestyle daily so then you have the drugs that help you do that and then the finally the surgeon is it is for somebody who doesn't respond to any of these statements so there are many many inventory of options out there there are wildness programs that teach you about diet and healthy eating but I mean coming to think of it is hard to be. Somebody has to be motivated to the highest level to actually work and act on the nutrition otherwise that somebody gives them it's just sometimes not part of your social norm your cultural norm it's hard to accommodate those changes in your daily lifestyle once so they do work. But I don't have that magic bill that anybody can give me off this works if somebody can just change their behavior tomorrow it'll be ideas so you have with this program then they have the disease management programs about how do you self care for that and then prescription assistant. Medicare weight loss and then obviously the bedroom regime so the vendor options are very prouded I like I actually have a slide with a lot of rendered names as well which I don't have here but these vendor as the digital app renders so basically starts with an app on your phone and then they're constantly kind of bumping information that you and may need many many different directions. They don't work because smartphones have done wonderful things for health care honestly are everybody has smartphone at the disposal of the even if some somebody might might argue all our membership doesn't have smartphones that's not true because when i'm looking at the data from the national carriers the advertising center mobile. They will what they will tell you ninety eight percent off the united states population that includes. Adult population that inclusive in the retirees has smartphones so there are many many advantages of these digital terror periodics as they call it what is basically smartphone or app induced or of a sort of app. Beast product that reaches out to your membership. And then there are top point solutions in the diabetes and weight loss space i've just listed them here and not going to go through them one by one but if need be and that would be our eventual next step is we we can invoite. Top three of them to come to a population and the way they were better with one I would kind of point out here is there is a third one from the top in the weight last week stressful three they're all can so based organization that is getting a lot of traction in the year in the week lost beat still so i'm like that might be an easy one for us to have in bringing talk to you guys eventually so this steps what stuff will approach what they do is they do adjust the teddoby based on where the member is and then going through those three stuffs I talked about the direct nutrition exercise and then the drug and the surgery they will walk the member through that journey and then there is a constant messaging that goes to the member through the app. And that's kind of pretty much what I wanted to cover today I don't I know I didn't give any any time for a which I can technology because the following slides I want me have they will be seen and I really statistics you don't need to hear more because I just talked a lot about that but visa from the nationally reliable data from the cdc about how the whole bees and the diabetes cost you more and hands it's imperative that we do something about that population so that's what the rest of the slight side is really talking about the cost the area the provision index but I think I would stop here and then just take some current aids if you have any in this next series of discussion that we cover nutrition and will be cds the reason for a day to population. Okay she did my you have a question. The. Just a couple examples of make sure interpreting the slides correctly soon we try to engage through nutrition I guess suggestions or whatever it may be and that's not really that successful if you're going to look at the page maybe some lifestyle change regards exercise and then that's not typically that successful and then you get to their medications out there that people are taking in them assuming that were we're seeing some I mean I don't know if you call it reburst or not but I look at some of the numbers in your letter slides and it's pretty robust as far as the cost changes that are growing and then you get into someone you know severe and they do in the lab band or whatever you know the surgery is there then it diment parallels pretty much with the changes that are happening with the medical work where I guess it's an increase because that person was in a much. Different place worse place to begin with. Yeah and so you know with the way that we are right out at what I don't know is affordability you know for someone that was participating that and I think we have some doctors that are coming i'm not sure but about like to hear about results in as far as other side effects as I don't know what goes into that calculation but it's one and can make sure i'm understand what your seeing some pretty promising results even off just a medical. Absolute the the surgery so yeah absolutely so anytime some really successfully losers weight whether it is because of the drug the salary or simply because the adopted that held the lifestyle doesn't matter what caused them to lose the weight but if they lose the way we are seeing substantial benefits of that into their own health as well as into your plan costs so that's definitely a given okay yeah it's so i'd love to pursue that like so we get some expert turn a little bit their company a little bit more about that in one of things that that are sold on there was is the disadvantage population as a higher percentage of ABC kind of branches up the kind of the worst I guess you're financial position. In one of things we've talked about is the snap program here in the state there's some federal matching I think that you can do with healthy foods and that sort of you know those types of programs I think we just recently approved in peer a program essentially to encourage healthy eating and that sort of thing is is that something we should be pushing our. Folks department with you know foot in the smart program on encouraging healthy foods because they're utilizing snap program as a disadvantaged population in their own some type of insurance then it would make sense that we would try to mesh those. Two interviews together and we can definitely make use of the snap program even if we have a third party coming in and driving the program we can make that and as an indignant part of the third party program as well i'm pretty sure the vendors are used to that I haven't asked their specific question but that's a good one we can ask the renders where coming in do you have any experience of working with the separate better to help you that may be missing right now and then on the the fidness I just want thing that we've not talked a whole lot about you encouraging memberships across be shield through the credits done a lot of advertising lately on social media about joining a good clubs in that sort of thing and what that means to me the only the only concern that I have is is one thing to join to club it's another one our unit to actually participate in go but better way at some point i'd like to over further discussion about what that looks like something alright thank you sounds good thank you one thing i've learned through the years of a basics of losing weight is it you cannot exercise a poor date and so it really goes back to what we theater kids in ourselves but you you can have a good exercise problem but if you have a poor date it's just senator boyd. Thank you mister thank you for this presentation it's very insightful I appreciate it so just a couple questions that I wanted to ask so like we spent a lot of time in our less legislative session on legislation for a physician gold cards so that they didn't have to do the prior authorization process so i'm thinking back to the medical nutrition therapy and a mother job on the pharmacist if he didn't know that so i'm the mads have a you know and make thinking here too I mean the medications are expensive in they don't you don't quit using them and my right like there's not a fan out I use them for twelve months and then i'm done and then it's twelve months in and behind unless you can somehow modify that behavior up front so I don't know that I have a question exactly for you but what i'm asking you to think about and if you have an answer that'd be great is. We don't want barrier I don't proceed we want significant barriers to obtaining medical nutrition therapy we don't want barriers to preventing exercise we want to make those as easy low hanging fruit as possible but at the same token we don't want to just. Pay for things that people aren't really using and taking seriously and so that's where i'd like to see some focus is how can we implement minutes or that there is barrier minimal but we're catching things on the back in and going maybe it's not right for this person I like your question because. And we have thought about that a lot so some of the vendors that I have worked with in that space who actually administered these programs what they do is actually work with the betin on the behavioral change aspect as well and we can make it such that you do get the drug two if you provided your engaged in the program and you're working with the health coach and the healthcare is trained to sort of ween the patient off the drug eventually and just continue that lifestyle and one one of this render that you it was trashed who sure as the results in eighteen months they were able to win out twenty percent of the population that was in role in the program and they were successfully losing red and then they kind of wind them off the drug because the drugs have side effects these drugs are too new we don't even know half of their side effects long term side effects yet so that's the member's advantage in like not continuing that life long and then win them off so the health coaching does work toward weaning the patient off the drug and maintaining the latest style and then kind of doing that behavioral health concerning so that they think differently about food. There is such a thing by the way you think about food differently when you are when you are into any kind of dietary program and that's what we need to learn about healthy behavior so yes we can definitely make that as an indignal part of the program as well. Thank you I appreciate that and appreciate your response especially the part about long term we don't know what's going to happen in surgery on some level and probably know more about that then the other thing is I can't remember the exact term with the the underserved area there's some kind of balance between when we're talking about health care there's you have a payer who's involved you have a provider who's involved and certainly last but not definitely not last but in there is the patient impatient choice and so. What kind of relationship is there between having providers and unserved underserved areas vs night so like at some point if we put so much emphasis over on this other part of the try to hear that we're losing providers like where is there just some reason providers they're just not going to show up and underserved areas or they don't matter anymore and so any insight on that would be appreciated thank you yeah and I think a good question I don't have a full answer to that about the actual relationship between under several areas and having more providers however there some of the virtually care and the telemetricing access for understood population to the right providers has done good things for the understand population so if we can promote the use of telemedicine and virtually care. I would understand people are also now able to take advantage of the best in plastic air so that's all I can think about is from wording. Some of the telemetrics and options for areas where there are no providers because a lot of this dietary advice and nutrition advice can be very effectively be given by the digital health coach order or a video coach or something like that. Thank you. Share it love thank you mister i've just adam few questions. You discuss buriatric surgery. And so. What my question is. With the buriatric surgery are are you are doing pre imposed as far as gathering information about the car savings cause I know the situation car savings in the i'm just trying to see how you qualify there in can you discuss that with. That the cost savings was to the health plan so yet took in the medical and pharmaceutical entire expenditure on that person. From please surgery to post surgery. Okay so that is that is how you all are yeah it was pretty inposted pre password and when I was that all data from twenty nineteen hook no no what was the cost savings on the I have a number here. Here. So the twelve pm pm and the right side you can see in the barchard. The medical rx so in terms of a poor member per month. It was about fifty dollars for medical learn about. Forty seven dollars for x. PP m. Okay are just adjusting to get an information I just want to better understand that yeah this is like I said we weren't unable to applicate that for last year because there were somehow a very small number of people undergoing better exception we kind of think something is wrong with the data considering what I don't think I have any other questions mister chair thank you not sharing any other questions thank you very much for your time your press thank you. The. Okay you shouldn't rise thank you mister chair if committee members will listen to me just minute i'm going to have a motion there is emotion it was made to refer the vote on that and b wine the legislative council before public test money was taken on this item. I have report referral of this adam to legislative council my policy overlages lady council no public testimony is allowed. Therefore it is if it is important for the committee to hear public testimony. I moved that we expand the vote by which adam b one was hard for consideration in a legislative council for the purpose of hearing public testimony and discussion today. I'd open up a chair if we have a discussion on it we will have discussion on this. Thank you it's really just about the order of things I would like us to move through the port I think most of us here on a timeline you know wouldn't part of the motion minute ago that that put us in the having to make this position but I would like to move that discussion to the end of the agenda today in other business. Yeah and if that's agreeable the minute I just wanted to hear that if there's any discussion on there. The. And van who. Order. The. II think send dismantled request as I was a great request I need a reason to rise instead of writing speak to this made emotion at this point so we catch committee members in their seat but moved it to the end agenda is proper because where we are in the middle of this discussion at the moment so I would second senators means request. The. Ok that the motion is to expine to vote so I have emotion and second is your discussion on the expense when vote if not all in favor so i'll apple most curious okay said it is being you'd like to take out again. I think back many rule is probably going to work out that way anyway we've already been we've essentially already disposed with it so I think it automatically becomes over business anyway so I just didn't want to be this perception that were immediately gonna fix right back up and start this discussion again i'd like this to get through this obviously to discuss your mile everybody will bring to that I don't think. Just moved to item e on the agenda the discussion owner will be sitting. Uh doctor clark and in charity please come to the table. You have one michael if you would turn the other one on in when micro now please introduce yourself for the record and you're recognized make your presentation. Yeah. I think i'm supposed to share this zone right. I'm doctors is out of chatter just absolutely and this is an inch attorney i'm a physician in russell the arkansas obstitution kind of colleges have moved to an working on a board certification nob city medicine as well have treated patience and they upstate tricks realm for fourteen years and err ob city medicine for the last five and i'm a michael clerk and i'm a position in jones borrow arkansas and board it in and got a college also i'm bored again because the medicine i'm also a fellow the obesity medicine association or omay so omay is a association of five thousand plus positions that are bored again or basically medicine interest that nobody city medicine in oma is actually the leading body in the country that trains positions and evidence base obviously medicine and develops evidence based our thems for the treatment of obesity and i'm trying to get my power point out. Hear me okay okay. I might need a tea up here. It's just not part of. I can you say it okay perfect. Okay so if I can get the store so i'm trying to go through. The previous speaker did an amazing job talking about obesity and its relationship to other diseases and I don't want to cover all that again I want to spend ten minutes maybe talking about obesity as a disease itself. And how to facts that affects healthcare spending and then talk about some newer things that have happened in the last few years to the last few weeks as far as you know thoughts on treating obesity as a disease. So again the arch american medical association has designated obviously as a complex chronic disease with the high relapse rate that happened in two thousand and thirteen and I think that spurred a lot of attention toward obesity and effective treatment. It's associated actually with two hundred and thirty six different disease processes in thirteen different types of cancer. So if you look at any health care plants since obesity typically is a room cause the diseases were treating. Are especially diabetes hypertension and courtyard escalate disease it ends up being the root caused a lot of healthcare spending and it's also noteworthy that obesity itself is a leading cars of employee absent tism and disability claims. So currently seventy percent of our cans and suffer from overweight and obesity I think the number for obesity and arkansas right now is forty six and the thing is these numbers aren't going to anywhere but up until we develop you know evidence based effective treatments for this. Um they're exist a significant bites against patience with the overwritten of the city no you see the people on the scooter at walmart and it's easy to kind of sniff your nose adamant to say oh well they just eat too much or whatever you know they're they just it's a character flaw and it's absolutely not the case okay so when we store excess way in our body as fat to shoot or at a post tissue it actually is not sitting there as a dormant single energy to be used later on is actually a very hormonally active organ and the body in it of itself and it disrupts normal better ballic and hormonal pathways in our bodies so that losing weight is actually hard to do when she get there and then the fatition are body too releases warmounts that kind of keep us from losing white effectively so to to. Lose weight effectively we need to kind of address all those metabolic in a motor pathways to see the best results that we can. Yeah. So what is evident space obesity medicine look like well there are four pillars we say so one is nutritional changes and what I teach my patience is not you know do tito diet or things like that we learn to eat a balance diet in a while the way people eat as driven by the way they were taught his kids you may finish my plate for a left cable and then a lot of it is driven by advertising. So they're need what we need to do this make a reasonable you know step by changes in their eating that makes sense in real life and real time and that can carry forward as a new normal and it's actually pretty easy to do cry we have to do some behavior modification we all have behaviors that don't necessarily help our waste line. For instance we stress it a we eat one more board or you know we eat when we're sad there are bingeting disorders you know actual psychological disorders that are associated with overwhelming obesity also so we have to do some behavior modification and in general it's actually pretty easy if we could just teach patience to be more mindful with what they do with it. A physical activity is support of the big picture but when my patient start with me I tell them we are going to work on a physical activity plan slash exercise if you want to go to the gm but it's going to be a bigger portion of you maintaining your new weight later on then it is at producing weight loss to really lose significant weight with exercise you have to put in about three hours of intense courtio a day so it's obviously not going to get us where we want to be. But it is a part of the big picture and you know I see a lot of folks that are not going to exercise are not going to go to the gym that's fine we get him to walk we start with walking five minutes a couple days weekend fell from there. Any of these city medications and buriatric surgeries I think are really important tools. Um if you look at just eat less and exercise more it really didn't work and we've been trying that for the last fifty years so um doing lifestyle changes alone exercising a little bit more produces about five percent weight loss but it's not very durable if we look at any obesity medications in conjunction with those four pillars I just talked about. Some of these new medications are showing seven to twenty plus percent initial body waiting a year. That significant weight loss and especially these newer medications that people are getting buzzy about zap bound which is a new weight loss version of major o w the weight lose version of exempting is they work. On a. Metabolic way to correct a lot of this stuff that's not going right inside the person's body that suffered from city that's why they're so effective and I think that's why they're going to be a really important tool to fight this epidemic that we're facing. Additionally I was just at the oma's annual conference and zapan is is again they are. Weight loss version of major diabetes medicine and it showing over twenty percent weight asked first year. There is a new driver called cargo semi that schedule for release in two thousand twenty five I believe it's a nobody nor guess product that showing twenty five to thirty five percent weight last in a year. That's crazy that's what we get with buriatric surgery without doing surgery on somebody so it will want to step in the pipeline. Let's see so a couple things I want to talk to you about that it happened recently that I think they would stated in twenty two the year ninety six office of professional management mandated that the federal employee health plan cover comprehensive obviously care including medications and interestingly in that letter they stated that all public and private carriers should reveat their plans and also comply. Well that obviously hasn't happened but there is. Basically a mandate federal level that we need to take the seriously and include these treatment options so the first of this year the federal employee health benefits plan covered medications and care. Actually two weeks ago after I presented to the organs all medical society they are adopted a clinical position statement stating that all or cans should be have access to evidence base obesity care including medications. And then lastly I want to talk about act one oh nine or your familiar with that from last year. So it was the original bill that was passed. To cover diagnosis and treatment of more bidder basically ie over forty for state employees and guy so in the. Bill itself the act itself it states that all state employees should have access to comprehensive obesity care and medication answer. So the final. And that was passed and actually in the spring two thousand twenty two. E newsletter for state employees it stated that that there would be access to medications and then also access to comprehensive b c care now after the bill's past and the I guess the the people that actually turn that legislation in two law they opted to only include buriatric surgery which I think is really unfortunate because medications or cover based on that legislation and the angel affairs is a harvard professor in the current president omay and she has pin the letter to stay employee benefits corrector mr wallace to consider that in moving forward when these issues come up for a debate. So I think that it for me do you have any questions specific to what I present. The. You have a presentation I do you have going to do that. Okay so before I get into the sides I want to address a few things like doctor mcclerk and state there. It has been some great information that was presented before we came here what we really want to do is move away from talking about in in the steps that were presented to you you know move away from talking about diet and exercises data clerk and just said we see with lifestyle changes maybe a five percent difference so you have those are those are the steps that we can take and for patients that are closer to their goal away or closer to a healthy that that is absolutely one hundred percent what we need to do but we get further and further away and again as after maclicken sad when we get to a point where we have more out of this issue we have more fat we can eye lose way the way that somebody that is five or ten pounds over a week can it's just physiologically not possible so we need to really move away from talking about just die exercise and move into these next steps which are first medications and then buriatric surgery last sale again in the interpretation of that legislation to move only to surgery I think it is agree is unfortunate the other thing is medication these medications are not new other big from never northeast which is some gluties and now rebranded as we go for fifty approved four week last has been around since two thousand and twelve that means it was on the market in two thousand twelve at me the data is coming from before that because of course they did trials there is a select child that just came out on saturday that that shows all cars mortality not for diabetic patients for patients that do not have day beaters that take the medication there is a nineteen percent reduction in all cause mortality of course party of escalator disease is the number one killer for people in the age groups that were talking about and our patient population so if we can reduce mortality by nineteen percent by taking a medication that is not only shown to be save but is going to reduce our cholesterol it's going to reduce our party of escalate res. It's going to reduce our way and our diabetes and then all of the other commercials that come with that so these medications I cannot stress and have are not new yes there are some newer medications coming down the pike we have a trash advertised from **** that is now rebranded as that bound for obesity and we have cagre some and some other medications that are coming out yes those are near medications but if we talk about semiclear tag which is the first medication to hit out and then before that victor or lyrically tied which is rebranded for six sender as a daily indiction these are older medications that we know to be safe. Certainly move into this really quickly. So you know what about surgery surgery is absolutely something that we need an article barratric surgery is useful for some but it does have risks of complications if you noted in and similar slides you know there was overall risk in. In medication prescription cost however if you saw there was increased impatient admission and there was increased urgent care visits and i'm i'm sure you know the hospital matches me in a hospital but doctors visits so you know we have patience that are diabetic and their obvious we know that baratric surgery or any type of weight loss is going to reduce day abides but diabetics here he'll poorly so we're gonna take somebody that has elevated blood sugars we're going to do an invasive surgery on them and then we're going to expect them to heal when they haven't last the way you know once they get their a one c down to a healthy level absolutely we can do surgery on them and they're going to heal well so not only the poor healing but the complications that come from that and then these patients have come our abilities they have sleep apnear they have high class draw they can their own increased risk of quality meaning they can throw a blood cloth they can get a they can get a pulmonary ambulance these are live threatening things that can happen that are complications of surgery the other thing is some of this is not physiologic depending on what type of beratric surgery we do we may be bypassing complete systems and our body and so it's not physiologic if we but I passed the small ball in or weren't we're gonna have my observation issues we're not going to get vitamins a new trans that we normally do and then again talking about you know downtime so when we have a surgery of course we're gonna take time off of work and then we have to recover and everybody recover is at different rates some people may come back to work in a week some people may have to take a year off and I have seen that impatience where they have so many complications that they they have to take off now that's not the norm but I think we have to take all these things into consideration so as I tell my patience even in gangology surgery is the last step once we get to that point where we've tried everything we've exhausted all medical options and that's how insurance works as far as prior authorization we have to show that we have tried other medicines first before removed a surgery so why are we jumping straight to surgery in this situation. So we have a few different classes of medications that are available we have still to two medicines the glp one medicines are the ones that we've really seen the most and have the most experienced with and then we have a new gip category that has come out. So let's talk about actual practice i've been treating obviously is my entire courier but it really is just very specifically targeting that for the last five so I have two practices and there's two providers currently I have myself and I have a APR and that works with me so at my early due on practice alone and just to one of them we have we have seen thirty one hundred and nine weight loss of visits in the last twenty three months one patient out of all of those has had pancreates and we're talking about somewhere between six hundred and seven hundred patients and these visits so one patient has had pancretitis was hospitalized and recovered the most common side effects that we see are nausean constipation both of which are alleviated by a couple of things one is over the counter supplements there is a very small number that require an anti nausea medication and that's prescribed and then the other is really again we get back to this proper counseling when a give patient a medication of any sort you want to do some lifestyle modification with it so you know if you go all day long and you don't eat you're gonna feel nauseated if you continue to night you. You're gonna start to vomit when you finally do eat something so what we do is really talk to patience about making sure that they're having healthy habits on their eating a regular at a regular interval and that they're not just eating what we call naked carbohydrates so if I have reached for something that just has sugar and i'm taking on his medications i'm gonna get nauseated that's part of how the medication works it's teaching us how to had a change our lifestyle and that's why it's at such a great tour. We have seen no severe adverse reactions in all of these patients and this is just one of my two practices. So let's talk about actual people this is a patient location is a forty six year old female she had more bit city when she came to us hypertension how both I read is high cluster all as mostly back near and joint pain she started with us in june of twenty she was two hundred and sixty pounds of the bmi of forty three point three she started on six sender she was also taking the center pro central lipitor advert and i'll be all in hailer's daily she was on c pap for a bad time there for sleep and she was on hydrocodon as needed for joint pain. A year later she was two hundred and thirty eight point two pounds her bmi was thirty nine point six and this was from doing daily lirical retired. We switched her at this point to some of the tired and we try traded her absolutely to the top does of two point four milligrams at that point after a year of lyrically tied she had reduced her decide of central aid and was still using cpat but did not need to use hydrocode on any longer for her joint paint she lost enough weight that are her joints didn't hurt as badly. So a year after that six twenty of twenty two she came back in she was one hundred and seventy five pounds with a bmi of twenty nine point two she reduced her bmi by ten points. She was on weekly some of the tired maintenance she was taking the two point four milligram she got off of her led pressure medicine she got off of her as no medications and was only taking out pran she had dropped down to only a hundred micrograms of central aid and was no longer requiring c pap or pay medication. We saw her a year later she was on maintenance so she was still on a maintenance message but she still continued to lose wait she was one hundred and fifty eight point eight pounds with a bmi of twenty six point four and went down to a maintenance does of just one milligram of summaries had were seen her every three months we saw her again back in september she's maintained or wages and gained you know one and a half pounds she's a hundred and sixty pounds and I have twenty six point seven so this woman went from two hundred and sixty pounds to hundred and sixty pounds and three years. The. Another patient of my own g sixty two year old female with more bitter be citiesly about near type two day bd's hyper collector alert me I have with iratism anxiety and depression and had a history of drug abuse. She he started the summer blue tied weekly how to him ago when a one c of seven point eight her average which is equivalent to an average blood trigger of two hundred she had been recommended see part but didn't feel comfortable with it so she wasn't using it and she was previously forming which was not well tolerated because she had a dominant pain in diarrhea with it she was also on classroom medicine and I read medicine on a anti depressive medication and tanks id medicine two to three times a day scheduled and she was a method on patient. A lump I guess four months later she was at two hundred and forty three point eight with AB m I of forty one point eight we transitioned her at this point to his advertisement she's typed to diabetic so she used it for that and. In february of twenty twenty three so a year after first starting with us she was a hundred ninety two pounds at the bmy of thirty three we continued her week later his advertised and she had dropped several of her medicines she's taking a hundred and twenty five micrograms of leave with iraq's and still taking her anti depression using a antance item medicine just as needed and of course still clean and on her method own program and we just saw her again back in september she is eighty two pounds at the bma thirty one point two her insurance is no longer covering the transaction even though she's a type to diabetic and so we transitioned her back to the summer glue tied and she is doing well with that. Another patient s eight forty four old female that was more billion and had pre day of ideas but was not on medication for it she started out in december of twenty one at two hundred and forty four pounds with a forty two point six we started her at that point because she didn't have coverage on medications and there wasn't a good availability at that point so we started her on fenture mean thirty seven and a half milligrams daily she had previously lost seventy pounds with that and fears back but then had gained it all back and then some when she discontinued it so three months later she came in and she had last about fifteen pounds she was two hundred and twenty nine pounds with a bmy of thirty nine point nine but she had discontinued it because we don't really recommend staying on these medications long term for more than three to six months so we recommended some lifestyle modification and to return to us and to continue with her life's a medication excuse me and to come back to us in six months when she came back in september she had gained almost all of her weight back and we started weekly transappetite at that point. She enjoy of twenty twenty three was sixty pounds with a twenty seven point nine also lost coverage features advertised and she started on weekly summer blue tide so as of a month ago sees me as of a few days ago she was a hundred and forty five pounds of the beginning of twenty five point three so another patient that's last a hundred pounds and really she started on medications september of twenty two and within a year is a hundred pounds down. Yeah. And then finally ta it is a forty eight year old female with morbido city sleep apnear hyperclusterely mia and insulin resistance she started out in may of twenty one with a weight of two hundred ninety three pounds and I have fifty seven point two she was started on daily sec center earlier a gluten and she previously been on three time the daily method she was on sea paper she's on clustering medicine. Three months later she was two hundred and forty one pounds so she's last fifty two pounds and reduced her by ten point to forty seven. She was started on weekly summer lou time and at that point was still on her classroom medicine and her seapap. In june of twenty two she was a hundred and sixty nine pounds at the bma of thirty three shes a patient background works for the schools and had a message for health no longer being covered on her similar time was no longer covered and she was no longer i'm classroom medicine or AC pap we saw her back through scanning six months later and she had gained some weight back at a hundred and ninety pounds with a bmi of thirty seven point one we started her on fenture mean and resume term format tid. So unfortunately this patient is an example who had lost a hundred pounds at last seasoning hundred and thirty pounds and then had gained some back and is struggling at this point to maintain her weight last. The. So what I want to leave you with is we need to do better we need to provide better better benefits for our patience and employees this is not a laziness or a lifestyle problem yes it starts there but once we get to a point of a city or more but obesity where were passed that point we really need something else in our toolbox so this is an issue of an underlying metabolic disease and instant resistance that's causing obesity which is a disease prosects in itself if a patient has high blood pressures or has high cluster all we try lifestyle modification for a 3-6 months we treat the failure though when they do not have a successful outcome after three to six months we immediately placed them on medications for cluster all our highway pressure we don't let them set it and get all these commercialies that come with those things so why are we withholding medication that we know works and that we know is safe why are we making people who have struggled with her be city for their entire lives jumped through hoops to get care that they deserv. Would be happy to take any questions if they're. Not we'll thank you for the presentation the slides are not also have to agree a minute. Unfortunately i've been here long enough to be the first rental at band week decided that it wasn't worth it because all the negative outcomes that were happening and then we've flipped that policy as you can mention before it sold again and I understand where you're going in it and kind of disappointed that these aren't also available when I appreciate you can aligning out at least some examples of what happens and so just for me a couple of questions in the next leading into guidance I think but at the you know the first is on the ups and doubts I mean when when you're putting someone on medication visitor for everything I mean is that I mean already you have patience that essentially can take it the utilized integrated new laugh and they're able to rely on that you know what they've. That their needs you know position I guess is you know health wise to move forward what you're on the medication on the medication have an outcome so make sense I think this is where we come to we don't know so what I tell my patience is if you have a struggle with observing your whole life this is going to be a whole life thing we're gonna have to keep you on some sort of maintenance whether that means we're going to drop you down to a very very low desage and maybe even space out messages which i've done with patients I think we're at the point now after doing this you know these medicines have been available and approved for weight loss really only for the last couple of years so i've had patience that have been successful we put them on a maintenance and then we march them you know we don't just let them out into the world and say okay just stay on this for the rest your life so i've had patience to do both i've had patience that have really adopted the lifestyle and there you know as our democrat and stated you know once you get there it's it's a maintenance thing so yes we can maintain and that's where the gym memberships and the the dietary programs are really going to be helpful you know I think that the jury is out as to whether this is something that most people are going to have to stay on or or night but I think what we know is that long term if we let people continue to be obselling term ramifications of that and cost are going to be much higher than allowing a patient to stay on this medication for maintenance I approach my patience sort of similar away I tell them at their first visit when they can see me I want I need to see at least three years so yeah I want to see them for active weight loss a medication or no medication but I want to see him for at least two years after they get to go away because leading theory as there's this place in our brain that tells our body what are we should be. It's in hype the and it takes somewhere between a year to two years before the body kind of resets in the new stack I know that personally okay and so my. My roommate is like I typically keep my patience on medication for two more years and the thing is if they keep that weight off their body resets and they stick their pretty effectively but it also is two years of creating this new normal with food and behavior modification and stuff like that and so my goal is to get them off a medication eventually after two years and see how they get note if we need to restart it then we're going to restart it now that makes sense and then as far as so in in cost just from what you see let's should say someone gets a laptop and it's obviously pretty expensive surgery but I understand that these products are pretty expensive expensive too and what are we looking at cost wise for someone to go through let's say years where the treatment I guess it fludge weights based on the need but legitimate average person is going to spend out of people looking at the combination of drugs that are new or cuse me and contrary those are tipling four hundred dollars a month out of pocket and they're not very effective so with the new gop one or ays will go the transaction as partially that you know you're looking at about fourteen hundred dollars a month out of pocket. If they just pay cash but here's kind of the canada. So if you have a diagnosis of diabetes you can get the diabetes version of what government. Example for twenty five dollar copay. So there's there's something going on with buying the products or something where we're not getting contracted decent prices for the weight os versions again it's a stick my thing I think whereas for diabetes over there have diabetes we got to give get them their drugs you know so there's something going on there where there's a huge discrepancy in what people are paying for if they have died beatees vs well they're just up away. So that needs investigating imagine there's the only other thing is when we re random medication even though it's not a new medication per se we rebrand it there's a new patent there's of course cost of research and development so anytime in a new drug comes out it's going to be expensive what we see classically it is after a couple of years as there's more adaptation earned some of the r indeed is is recouped by the company the price comes down and so I think that's something that right now they were pretty costly but I think we've seen with lots of other every other medication they start out costly and then over time as they are utilized we can bring the costs down in suggested a sidewalk for I mean I would like to kind of know what we're spending may not copays anything else what are we spending on a surgery and what are we spent when where I guess we're not spending anything what the cost would be to treat someone you know on you just on average from these products that may be hit the same level of. Obesity and in my last question is is on kids you know so I think that's one of the biggest problems that we have basically children what that's leading into later in life the you've mentioned it a little bit there's it's very it's even harder in order to design the to reset our body to a new body weight we find that difficult that when people leave in them with their not participating I mean they can't get past the up. Is this something that's available for we wouldn't what four children is it something we should be looking at for children you know so as far as medications met for men which is a commonly prescribed drug for pre diabetes or insight resistance it's approved out at age aid I think in children and for the gov. Don't know about zepbound yet but it's approved to age twelve okay and I don't know if you all are familiar with that doctor daniel mac. He's a interconnector she is head of an economic article children's hospital and spearheads there pediatric weight management clinic so if you have questions along those lines he would be the perfect person to speak with it again appreciate presentation and I would like that i'd like some additional discussion with I think else kind of started the discussion with. You take medication this is the reduction at the cost this is it you know I would like to play that up is what I think what we're struggling with is had a we. How do we manage the cost the new cost of you would be able to implement this program and you know and then what's the payoff period you mean cause it it looks like transport show there's a payoff period but there's going to be an upfront class to be able to to kick it off so thank you in two coming up to so in canada they have one payer system and for a long time they negotiated the country health plan negotiate with nobody nor desk and then mark two. Give. Yeah. Ozemperiod were govi. For four hundred dollars cash pay. Here it's fourteen hundred dollar so you know there's some negotiating room there there was another point I was going to make also. Um. I think about it sorry. But thank you. Any other questions finished double field thank you for chairman oh a lot of my questions go along with it centre just mind but you're on a fish did a number of the clinics in northwest arkansas western art on central arkansas it seemed like you can't even get a. Surgery at manners sort of hernia sir anymore. And some of these clinics all they do is surgery they have become would you agree that some of these are clinics the surgeries become so lucrative. If they've all switched to this. Because I called dozens of doctors and they said all we do is bare attribute surgery right and it's a cash pay you know it's a very lucrative business correct and the thing though too about surgery and speaking to act on a nine also where they just kind of skip the queue and went straight to surgery is we kind of want to use that as a method of last resort when they don't respond to anything else in you know study show only two to three percent of patience that are eligible for buriatric surgery actually get it done it's very expensive lots of outsides to and in my practice I see probably five percent of my population have failed mariatric surgery and now they're here you have seen me to figure out what to do next. So you can always figure out how to eat around a barrier you know weight osperiod it's tragic when you see those patients yet to add to that i've seen a lot of patience that have had bearatric surgery and they got to a certain point and then got stuck they couldn't get the rest of the way there and then that's where we bring medications then the other thing to speak to your point of there being more bad trick surgery. There's more abicity to so we're seeing more and more patience and we're seeing patience going out of the country to pay cash for a procedure because of the car asked so if if insurance isn't covering it there choosing to go to mexico to have been trick surgery and we see a lot of that happening so population is leaving the country and going and getting a cash pay service somewhere else I have to do notes of people who went to mexico the drug to go the centric that you were talking about in the new drug that had a twenty two percent success have thought drug been around long enough to know any any salafix. From taking them over a long period of time yeah so they have two thousand and twelve is when them back hit the market and so the the research has been since before that and then as I stated this past weekend there was a select trial that came out there was actually funded by november northeast to look at some of the tired which is the active ingredient and both of these ambition will go it's the same drag just a different dessages and that it's very safe so it actually we see that reduction of all cause mortality they take in the medication in in the entire population so they had they had many many page it was in. I think seventeen thousand patients in that study that they looked at seventeen thousand patients over the course of of all these years and and there's a nineteen product percent reduction and ask all cars mortality some of these drugs were manufactured manufactured for other things and yet I found out that they were waiting work well in weight lost production because they they interviewed with the just a process and curb the diameter people desired to eat so so these kind of medications work on the right different levels sir they helped to modulate blood sugars insulin levels. High and slow levels and high bloodshitters just put you in weight storage mode again so you work on the gut to to decrease the amount or to increase the amount of time food stays in the stomach so you feel fall or longer and then the most important thing I think they do is they hit these nerves in our brain that tell us that we're hungry. And turn off. So they work on multiple levels and that's why I think they're so important from a medical example as a way to deal with this really complicated problem now I just remember works convention earlier the other senator was asking about you go the cost of theirs but I think we really need to kind of flip the script on that and say you know look at what the cost of not doing this is it's only going to get worse people are only going to get sicker and so we we need to take the seriously. Thank you and in the cost of the latest drug and the success rate what is the cost of it so will go the in my area out of pocket is about fourteen hundred dollars a month. In a man the zound is isolated for release I think the first week of december so it just got clear this past week and I have a feeling it's going to be a long those line will be on power with it. He know here's the deal to if I have a federal employee patient guess what they're on will go because it's covered I won't work some of these drugs developed for diabetes so actually they both were developed major no zimpic or developed as diabetic medications and just with studies and years over time. It just produced this dramatic significant weight loss and so they remarked it them solely as weight as or anti obviously medications. Will it it seems to me the pharmacies would realize that treating people with his way after I would be much more cost efficient than treating them for years for dob data. You were there you would think you would like to make sure. Representative all you recognized. The he was chair I think serious dolf building service may have hit on a lot of the keys that that i'm going to tap on but I think one of the real request here needs to be that maybe next month on the agenda with permission of the chairs ebd percent of those cost measures and comparison to surgery versus the medication or one thing I want to talk about is a couple weeks ago we had a public health meeting in northwest arkansas miss watton testified the committee that one of the ways to manage health care are to be a proactive measure instead of reactive measure and one thing we're doing today with our interest companies as were were reacting to an issue all the time but we're never actually looking at those patients are checking on beforehand in catch and things that earlier stage and one thing you can see with obesity as if you treat obviously as a management and is as doc said while ago a three year plan and you look at it on it on a monthly and daily basis and you make these patient start behaving different but but bringing it to their attention you get a better management on the long term illnesses of these patience and such as diabetes pre dobbies and and so heart disease in so on so at a kind of like you guys are coming a little bit on that and how you would see the the payers change to where they would pay for more a proactive maintenance than a reactive and how that could fit in. Well I think there's definitely a need to treat overweight before it becomes obviously a lot of these medications aren't really approved for bmiss you know about. Well I guess they will get folks twenty with twenty seven you know if they have some other coexisting you know problem white diabetes attention so I think there needs to be couple things more education of physicians in the state on how to actually treat this disease because even my colleagues and jones works like they don't need a medicine just tell them to eat less near all these way it just does not work okay but we do need to be proactive starting to address you know increasing way especially in pediatric population to connect niper than the bad development or eating habits behaviors things like that so there is a place for that. Taking you back off that I think the other thing is that the more that we see patient so when when they see results and there seem that they can they have a physician that's listening to a provider that's listening to them where they have in the past you know i've had patience after they've had a baby they complain about weight last to some of my colleague is me wait gain to my colleagues and you know it's it's a well you need to eat less than exercise and continue breast feeding and do the things you need to do. The hard part is that patience not going to come back to that position then or a trust that physician so then you have these patients that are out getting sicker and we talked about kind of underserved populations you know the cost of care is going to end up being much much higher because we're blowing patients are not treating them for what their concerns are people want to lose way that's not that they they want to be obvious they don't want to live that way they don't want to have all the commercials that come with it but they feel like providers are not listening to them and not hearing them and then when they do find somebody that listened to them and hear them their insurance won't cover it so you know all these things kind of go hand in hand but what i've seen with my patience is. By educating them by helping them they take an invest in their health more and that's going to end up costing everybody less because they they care more about their health and they're going to want to come in and there want to take care of themselves so you know we talk about the cast right now and maybe for the next year to three years of treating somebody but then what are we saving for the next third of fifty years of their live. Well and reading the studies that you are gave a committee leaves the last one the example here is showed that the insurance no longer covered the the drug on on miserable health plan and therefore they are gained twenty one pounds so if you don't maintain these practices and you don't maintain the behaviours the cost is gonna go right back up and it seems like at some point the interest company starts seeing that if they're truly year savings into lowering these weights and maintaining these issues so I think that's why it's important next month that ebd look at the car savings and I know it's hard to look at overall and hard to project but we need to be able to see that as a committee in order to inact different practices because right now bureaucratic surgery is basically the only practice that it has been an acted on and that's not a a true solution so I appreciate you guys come today and appreciate your destinies to add one more thing to that with that patient specifically she had her clush a whole life tried to lose way she was so excited and so happy at the point that she got into she was exercising an eating healthy and to be honest they're there was a bit of depression there when all of a sudden it was cut off you know she'd been taking this medication and then i'll sudden it's like okay now i'm back to where I started and so the repart of that as mentality you know it's it's a discouraging when you finally find the thing that worked here you know in your forties you've finally found something that works for you and then it's taken away you know there's there's a mental component there as well I understand thank you. Certain board you recognized. Thank you sir. Thank you for your presentation appreciate it appreciate representative would last comments to about hearing from ebd and so I wanted to cannot make a comment and then get your your feedback on that and then i've got one other statistical thing that's kind of related to the question that I wanted to throw out here while you're here today because you might not be here later on. So II guess is I hear this any time in medicine when we start hearing about cash businesses on the sides when we start hearing about things that this is a miracle cure this is. It cannot takes me back to the ultion epidemic and I start going maybe we should have asked some different questions before we believe that pain was the fifth battle sign and before we believe that everybody who was told here she had you know you're committing malpractice if you were not giving prescribing opinions because someone tells you that here she had paint right and so I don't want to compare this to that but at the same token **** or think this is no there's new technology it's suddenly here it's not going to be the last time we have new top technology for a condition that is challenging to tree so given the perspective I just shared with you how would you respond to that. Let me start so everybody's looking for the new shiny thing to dark after right some you don't have take responsibility for anything you do you just didn't decide he lose way and I think we're you're seeing that mostly or these med sparse there. Promulgating all over the say and what they're getting is what they call generic will go be or generic exemption sir couple things about that they don't really do an intake on the patients are not ruined monitoring the patients they just come in and give you the shot and said tell them and they don't get any kind of behavior modification or you know nutritional cancelling or anything like that it's like take the shot in your gun was waiting at it so a couple problems with that those compounded shots will source out of china and they don't have any quality. Information about the compound are using their frowned upon by the fda they actually can't compound those and state arkansas amen pretty constant contact with mister curtailey the director of the state board of pharmacy and they haven't come out with a blanket statement saying don't use that you know and because of the ftate hasn't said that but it's problematic on a lot of read on a lot of skills and I think that's probably what you're seeing driving this you know but it's not really will go be or it's not really major and so we got to be cautious if I had my drivers out showed over one of those clinic down because it's not safe medical practice guy but that's where you're seeing it all over facebook and it's like you don't have to do anything but take these shots and you're going to lose way but guess what happens when you could take in the shots. You have an address that were causes in there you know disease and their decision regain everything. So thank you for highlighting too harkanson's at large that there are concerns with these compounded medications i'm not going to issue a legal opinion as you didn't issue a legal opinion but be be cautious right and so thank you for for that response the next thing is again kind of statistical just as add on that one thing which is you know these places that are dispensing compounded medication are capitalizing on a cash service in order to sit there their capitalising on the the fat that you discussed that like this is the the shiny thing that it works and then you know patience I think inherently they go first to reputable provider and they try to get it the right way and then when it's not covered. They give up for a short time and then you see as you're driving on the interstate you know get these shots lose ways and they're turning into the parking lot to to go into that and and says some of these providers are capitalizing on that rather than in a trying to really treat the patient and tree obesity so II think we have to can have separate motivations there are because of course in any business that in anything there is going to be different motivators and so looking at it from health perspective of trying to treat you know with the epidemic you know it was. It was positioned that we're trying to treat the first vital sign and try to do the right thing and then you had these people come up and go you know what I can open a pain management clinic and I can sell oxygen down for a cash price patience come in to see me and then it went from being a i'm trying to be do not harm and be a good provider to i'm just trying to make money so I think it's I think that's a good correlation to me because I think we're seeing the same type of thing happening here I appreciate both of you acknowledging the importance of the patient in this first in that the provider is is important in this as well a good well trained provider the next one is more of a a statistical financial question and again if there's a presentation you might not be here to answer this I want to ask you today so it's my understanding that number needed to treat for patience with obesity and established car investigator disease for thirty six months you have to treat him your sixty seven patients for thirty six months to prevent one of the composite in ten points. How much money would we have to spend in one of it with one of these medications in order to prevent one of those composition points. So II think this really variable because you know we always talk about ideal body weights with our patience that's not necessarily in a beat perfect percentage body. But still is a show that if you lose his lives five ten percent especially of your initial bodyway you've already added eight years to your life you will normalize blood sugars usually normalize what pressures and so you know if the goal is to lose ten percent of your national by way we can get their pretty bad quickly okay. But again as far as you know what it's going to cost medication wise it's going to be depend on which medication is using and you know how many visits it takes to get them there plus two on the back in the main inside of this too but but on some level we're looking at a pharmaconomic model where we're going to best with this intervention here in order to attain this outcome and then we have to apply that to the real world right that's it's not a clear cut scientific answer right correct they're a lot of variables in a model like that. Thank you but I i'd be happy to to discuss that further at some point you know if you need input from the clinical side of the way I would definitely appreciate input and II from the clinical side and appreciate you being here today for my perspectives thank you has all of our contact information that you need to get thank you. Again. Committee members have any other questions. In that well thank you very much the day we're coming providing that testimony thank you we appreciate you get as a chance to speak again next on the gender is united healthcare group and see that they are still here. You would come to the table recognize yourself and you'll be recognized. Yeah. This. John care me i'm sorry yeah i'm john thompson national vice president with united health care where we specialize in retiree solutions providing the group medicare advantage plan for the state I good morning differency on the vice president of client management I appreciate your time this morning and I know that we had provided some detail on the medicare advantage plan and I hope this morning was to provide an update on the enrollment statistics and are open enrollment which will lead us into twenty twenty four. Good afternoon and everyone my name is joe larson strategic cone executive with the united health care I lead the team that supports the are benefits you know to health care group medicare advantage plan and work closely with the director wallace in his team to ensure that it's running smoothly. Are you guys recognized. All right thank you and there's jeff mentioned we did hand out some information all slides about the plan but we did want to focus on the twenty twenty four retiree open enrollment updates are regarding and roman itself as of. The november thirteenth where of approximately sixteen thousand four hundred of your retirees enrolled in the plan consisting about. Excuse me about nine hundred state employees and seven thousand four hundred retired public school employees we also held information or sessions in the months of september and october this year we had thirty three n person meetings across the entire state. And we also held three virtual and telephonic meetings as well we're glad to speak to about almost nine hundred of your retirees at those meetings in the goal of those meetings are really to educate folks about the benefits the programs the features the enhancements of the plan that we put in place for twenty twenty four along with discussing the enrollment process through ebd and certainly answer any in all questions folks had at those meetings I do want to call out as well it was really we're fortunate to have direct wallets in his team attend those meetings as well so there was a really great benefit for people. I'm and with the air benefits retired you open a roman period happening now through the end of november we continue to educate an answer folks questions through our call center we actually have two united healthcare employees that sit in the ebd office as well if people want to walk in and ask questions that's another way for people to learn more as they make their decision for coverage for twenty twenty four this month. And thank you mister chairman i'm glad to answer any other questions people have. Set the board to recognize. Thank mr thank you for being here today I just got a new might just say how I can't talk about that run out of the day but what right here i'm gonna ask you because you're in front of me so I represent for smith there's some challenges with baptist in united health care coming to agreements do you have any perspective you can lay out here publicly while you're here the table yeah thank you I appreciate the question II might be a little limited in my answer to that however what I can say is that we are in very good faith negotiations with baptists and several other provider groups across the as well as nationally all insurance carriers will you know continuously be in negotiations with providers we always approach those like I said from a very good faith perspective the benefit that I feel that we have from a medicare advantage perspective is the way that the product works with regard to the fact that we call it a passive ppo where there's a non differential benefit so a member pays the same cautious in network provider or a contracted provider that that member would pay for an out of network or non contracted provider. The the benefit to us is that the provider if they are out of network still has the option to bill united health care and see that number so what we are learning from the baptist negotiations is that they have at this point time agreed to continue to see the state of arkansas retirees if in fact we are not able to come to a contractual agreement. In the other questions. Seeing nine gentlemen thank you very much for your update today thank you so much thank you sorry that had to hang around to. Right I think you need to come back up here. As you recall earlier we had a motion to delay and then we had that most expansed and so we're back on. Item be one. And part of the reason for that was because possible public testimony. So director do you have somebody from the public that the you need to come up or want to come up I do not but i'm here to answer any other additional questions after members have had another opportunity to read everything that was included. Do we have any questions yes represent more lot thank you mister great without multiple meetings over this amendment to this contract and one of the things that kept burnt kept getting brought up was leowners or was legal what was against arkansas law what was breaking any of the pbm also can you go through with me on this amendment are walked me through the contract as a whole was there anything in there that did not follow the arkansas code. As we work through this amendment and followed up on those questions around the legalities nothing came to light that would have voided or made this contract illegal in full disclosure there was a programming issue that occurred the first two weeks of this rollout which caused some pricing to be incorrect that was corrected within seventeen days of the initiation of this contract and up to this point I have not been informed of any other issues if there were pricing discrepancies or any of those things that came along they have been sent to navigators and navigations worked with them and to my knowledge has corrected all of them that have been brought to their attention miss chair crab just a little bit lead away for second you may I hope all the other state agencies are watching. The man just told you they had a problem they addressed it and they fixed it it's important that when the state agents come to our committee is that they were mit when they have a problem they will admit to us that they fix it how they fix it so we can be better serving to the constituents of the state so great I want to tell you i'll appreciate that not really appreciate your honesty and bring an added so thank you. Senator boyd you recognized. Try again. Thank you mister chair thank you and and just fraud forth and a reiterate what represent a board like about state agencies and the way you've worked to address that II appreciate that just the only question I had was on page four I wanted to just double check and get a little bit of reassurance on this if you go to page for the actual contract up page for the packet and and I do appreciate you staff getting as a copy of this so that we could see before we voted so thank you to the staff for that under rebate submissions it just says agrees that consistent with hip and average will submit members protected health information for pharmaceutical manufacturers in exchange for rebates I just want to make sure that you feel comfortable with that language and you feel comfortable that patient information health information is protected and we're not inappropriately or illegally sharing data I mean because we're intering into contract it says we're going to do this so presentively where are so I just want some reassurance that you're good with it yes i'm good with it I have full faith in confidence that both navigates and us will be able to do that in a way that does protect our members private information and yet could ports with the systems in needed in order to get those rebate so I do have confidence that we will be able to do that but in full disclosure if there is an issue that arises you will hear from me about it and we will fix it and make sure that it does not happen again. And I appreciate that response right there thank you mister wallace there's committee have any other questions. Recognized promotion. We have emotional review second or is there any discussion. The. All those in favor say i. In the opposed. This. Motion as passed. Members are any other business. Saying none we are journal.