Public Health, Welfare and Labor Committee- House and Senate

All right everybody will take their seats want to welcome everybody this afternoon to the public health welfare labor committees and happy to be a joint committee meetings and my co chair is on his way he had a work issue that popped up so representative Johnson and it will be on his way and just a couple of of notes and public health committee we will be meeting monthly and as you know any rule that as affecting a public health has to go through this committee first before it goes to the Legislative Council rules subcommittee meeting and we did not have any and may so we didn't have a meeting and may but coming up most likely we will have monthly meetings beginning this month and moving on also representative Johnson and I have discussed we are going to be planning meetings around the state of Arkansas and to visit really all the areas of our state so that we can really get a on the ground assessment of what's going on with healthcare in lots of our corners I am very passionate about that and I hope that you as members will help us as chairs inform us and help us coordinate those meetings because we want to come to as many areas as we possibly can and we want those to meetings to be good information and I'm informative of as for us as policy makers as to what we can do for those different areas of the state to help with their health care situation and. And so that would be on the look out for that and coming up this later this summer and this fall and so we may have more than once a month meetings M. and then also just as as issues come up we may call meetings but generally will try to deferred to Legislative Council and we'll try to have those meetings during Legislative Council me at week as well and with that I think those are my only comments we will have subcommittees I haven't gotten to the Senate set assignments of the subcommittees just yet but we will send those out this week will get with them and we'll send those out this week other than that I think we're good happy to be back during the interim and talk a lot of issues that we have ahead of us and with that I will need a motion to authorize the chairs reprieve are special expenses incurred by the committee motion and a second all those in favor say aye and oppose ayes have it motion passes next item seat we have adoption of our minutes I need a motion to adopt the draft minutes of the December twelfth meeting motion made and second all those in favor say aye opposed ayes have it the minutes are adopted okay item D. and we're going to add it is really an honor at true honor to enter days the snacks person I'm so excited that our governor Sarah Huckabee Sanders appointed Dr K. Chandler as Arkansas's Surgeon General and if you will come up Dr Chandler we would like to hear from you and introduce yourself and tell us a little bit about who you are what you're working on but I can't tell you how excited I was when this appointment was made you are truly a champion for and women and for. At Madison and you've just done so much for your areas of the state and it's just a great pleasure to see you in this role without your it you're recognized. Just turn up push that button. There you get. Okay okay all right well thank you so much that Irvin for your having for your welcoming I certainly appreciate that and thank you committee members for having me today and thank you for all the work that you do for our state yes I'm so excited to be here and excited to be appointed as Surgeon General and I'll be honest and I just say it's a tree that wasn't really something I was seeking or on my radar but I am truly truly humbled as well as honored to have been appointed as Surgeon General and I'm really have some exciting things that I'm you know really side to work on and that that to look at that myself I'm she said a mechanic I'm was OBGYN deliver lots of babies and and then enjoy that for years but now I'm just doing out of college and I've been a cornerstone player for when for twenty six years and Adam and of all the Arkansas medical society as a board trustee and just a lot of different organizations and healthcare but one of the things I'm super passionate about and it's really been probably for the last twenty years is just preventive health and wellness and I'm real excited because that is something that also the governor's very interested interested in too because we really I think is is as a whole have been kind of reactive you know we wait till somebody's got a disease or got a diagnosis and then we fix we treat them I'm and I know that we have for years we do preventative screenings preventive wellness I think we can do more add to increase you know just wellness in our state so released out about that and we've also been talking and really looking at the issue of maternal mortality in our state which has been is not it is it's increasing but it's not that is not been there I think will become a lot more aware it is a problem nationally Arkansas has been right higher in the numbers as far as wore a percentage wise maternal tally which were very is very saddening and but we have the opportunity to make a difference and. So I've been meeting with the measurement how to committee members that Dr greenfield and health department of the governor's staff and we are just gathering a lot of information to see where the issues are we know a lot we need to know more and and we get an update on great work as far as you know looking at these these All the cases in determining what underlying causes or with the things that we can make a difference and there's things are already in process but I want to continue along with that and then also take another look and that continued to investigate that but those are the main things right now just try to really fact find and get to know people and meet with people to kind of just get my parents first. Thank you so much and represent Johnson just came and someone recognized him for comments and then you want to say anything just policies for being late an expected and can be controlled and and Dr chan or thank you for being here is good to see you thank you thank you so much and one thing I will say I really I have also been looking at obviously there's been a raise awareness which I appreciate very much with maternal mortality in those issues and complications post pregnancy and post delivery and but you know one thing that I would be excited about is really making sure with you and the leadership of Arkansas Surgeon General that you can take a lead you know on any kind of a policy discussions as we move forward I think that's going to be critical to us really making an improvement on that you know statistic of that increase a percentage but for me I just wanted to say this also it's important I think that we have an education campaign around women's health and young women you're not healthy before you get you're going to have a complicated pregnancy and I've been talking to so many people and they said we don't win once that are who was it that told you when you're supposed to go to the gynecologist for your mother you know there's no real campaign about it there's no and coordinated efforts at to really raise awareness about your own bodies and your your health and when you need to be seeking out of college school care and things like that so I think there's a good starting point and just again preventive health an intervention with you know people that don't have moms that are telling them when to go and what to do and how how did they learn about that and so that's where it really starts for me absolutely we have to start healthy we got it got a bill that foundation first right and is pregnancy possible yeah so looking forward to working with you on that are you open to any questions. Okay are there any questions for Dr Chandler AZ senator love you're recognized. Thank you mention thank you doctor channel for being here and you know sticking with the the the theme of maternal mortality I it's disproportionately impacting African American women in so doing this campaign or the campaign that US Senator Irvin mention of. What what is the one or two things in you may not want to discuss the number of just thinking about what is the one of two things that that the African American. Community can do in regards to actually lower the rates of of of mortality maternal mortality in our community because that I mean we really isolate the numbers you you look can you see that so it definitely Sturch yeah I speak to that yes and yeah we see that I think it's nineteen percent of births are to African American women that thirty eight percent of the death and that's in two thousand eighteen two thousand nineteen and so when you look at what the causes are in the African population it is more cardio vascular hypertension and other cardiovascular and issues that are the number one and it's really more pregnancy related there Springs related pregnancy associate this is definitely pregnancy related and I really do want to look into that further back before I even take this appointment I had attended a lecture about that just black maternal mortality of black women's health and and I think that some of that I'll be honest I think so that could go back to the mistrust of the medical community in general in general I think possibly I mean is a lot of women feel like they're not in this could be any any rights that you may not listen to well and sometimes I feel like there's a hesitation to go that's part of I think what we need to be working on I also think it's same kind of thing that has entered with a and is is just underlying health we have to start talking about and I have people that I really want to that are interested in like preventive health to in particular by community I want to visit with us I what what what your message be how can we have we do this. Thank you well I hope that you know when we when we begin to to really drill down I mean the focus can to Committee on and not only have so not only black women but I'm just saying what we're going to we're going to get control of the numbers then we really have to have the emphasis on that so definitely so something I'm very interested in all right thank you not thank you senator yes thank you and and we will have a fuller discussion about this in July as well just just FYI so this little teaser. Thanks. Senator Solomon. Thank you I'm back here in about so as we talk about needs of various population what those are if you decide where to focus our resources because resources are limited as you decide where to focus those resources three base those resources on your particular characteristics of a population are we based on one with the need of the person is can you speak to the. Yes I am well I think it's kind of someone of both but I also think that what I think there is a trend that we're seeing is more how can we be better stewards of our resources and making sure that you know we talk about evidence based medicine for sure but you know the C. keeping patients out of the E. R. do you know having we're close relationship as far as like contacting patients after they've been to the hospital to make sure they get back in and some of those issues I think our way I really see some promise in some of the ways that some of the changes that we're seeing a primary care I think it'll come back to the other specialties to but it's more about hi if the patient home kind of Senator things like that where hi you have a you have resources that we're going to say okay how can we best utilize and another doesn't your question completely but but I definitely think it it time is something that we can do with our resources and don't have to always spend more. Thank you thank you manager thank you one last one is represented and that you're recognized. Thank you chair I had I had a question more of a common at a question I am I was just wondering if in the future we can discuss fibroids you you're in fibroids and how we can better educate women about that because I personally had and had a hysterectomy so I just was hoping in the future we can have that conversation thank you. Thank you represented in it And. Appreciate you much okay any other thank you so much for and very glad that you're in this position and looks really really look forward to working with you thank you so much thanks for coming okay. I am eight we're going to have I have Secretary of them will come up and we're gonna have an update and timeline of the Arkansans for the hospitals this was discussed at the Friday Legislative Council meeting and I'd visited with sexually Putnam and the team at DHS about having a discussion here about obviously public health has we're not taking any action this is just really for discussion only that peer subcommittee are the ones that will be the voting members on any of these requests that come before them for our funds for our hospitals and members the a full reports was emailed that correct G. email before the full report was emailed to you it's over two hundred pages that lists all the hospitals that the consultants like that that participated so just a little bit of background I'll share is that you had twenty six hospitals that were deemed eligible for these are but funds these are federal funds from the American rescue plan act those twenty of the twenty six that I wear eligible only eighteen decided to participate in making requests and so does eighteen then at the state of Arkansas we hired a consultant through Legislative Council to provide and a study as an assessments in the study of of their situations are financial situations to give us an advisement of how to proceed with the disbursement of the funds and I believe the funds were at initially approved by legislative counsel of sixty five million or more okay I'll let you all talk about that but anyway so and there was kind of one big lump sum of of money that was approved that would be disbursed amongst the qualified hospitals and with that I'll let all of you introduce yourselves for the record and proceed. Thank you for asking us to be here Kristi Putnam secretary department can answer Mrs. Janet man DHS. Andy Babbitt DFA. madam chair and committee members thank you for the opportunity to be here we did we did just want to provide an overview a brief overview of the process that was followed I do want to provide a copy of that about half of that occurred before we arrived on scene so we've got anybody here from D. F. A. as well to answer any questions that have to come after the summary but just to give you all of a brief timeline and want to make sure that we communicate what we share with the hospitals when and give you chance to ask questions said this began as the chair noted back in September of twenty twenty two during the September LC meeting legislative members expressed their desire for an evaluation of the hospitals before dispersing any additional funds of the from the arpa funds into secret meetings with leadership there was a concern expressed about financial health of rural hospitals but leadership also expressed a desire for a method to determine the viability of rural hospitals to address both of these concerns the FNA staff researched various consulting firms that could conduct this type of analysis the research healthcare consultants identified the top fifty in the United States the listing was reviewed for a healthy couple it would be to the states need to ascertain financial viability of the hospitals. Do you have any staff eliminated several firms due to previous concerns and and in addition also limited firms that did not appear to it to be focused on the state's need for assessing the rural hospitals they did identified three firms that appear to possess knowledge skills experience sufficient to evaluate the rural hospitals financial situations. that was all in September till November in November do you have any selected Alvarez Alvarez and Marsal and initiated a special procurement the contract for over is Marcel was signed reviewed and signed in December by a LC funding for the contract came from restricted reserve funds and it was all approved in the same month December twenty twenty two in January of twenty twenty three notification was sent to all twenty six qualifying hospitals of this opportunity to participate in the a and M. review in February of twenty twenty three Alverson or sol have on the ground to begin on site evaluations with the hospitals. those continued in February and throughout March I do want to note that in March and I'll let independently handy handle any questions about this but there was an adjustment made to the actual application of the hospitals could use to apply to participate we did have one late addition that was Eureka Springs that decided to opt in a service as a result of that change but then they were completed in the month of March and by April all the evaluations were completed discussions continue between over a somersault department Human Services and the FNA to determine the format of the final report we then got the draft reports in may and shared portions of those reports with the hospitals who were receiving them and then as you will know in June we released the full report last Friday so that is the the overview but there was communication sent and there was a second communication sent to all twenty six hospitals that they qualified to participate in this process. Thank you do y'all have any other comments Mr Perot what was the the initial amount that was approved the member. Yes the initial amount was sixty million okay of which Ouachita received approximately six million okay all right thank you okay we have questions representive Ladyman you're recognized thank you manager. Of well. The reason I raise questions in council the other day you don't we were asked members of council to vote on one hospital and I had not seen report maybe other people had but but I guess my my concern was or my question do we have enough money. To Fund. What was recommended for all of these eighteen hospitals I mean is it does the sixty million. Cover all the request from these eighteen hospitals or what was their total request Zimm I know that. I have it hold on one moment. The my reason for asking a question if we're going to have to limit how much money we give of how how how are these hospitals ranked who ranked on you know what's the ranking. And I I did not see the report will just now but I'm lose mail that back maybe I just missed it but I didn't get it before the meeting and all that to be secretary man talk about some specifics and an anti about as well about the funding. The the allocation methodology for funding but the requests that were submitted initially were part of the original application process those were documented but you know it I don't know that the hospitals expected to receive you know exactly what they requested but they were they were just requesting funds according to what they assess their needs to be that was the reason for the needs assessment of the financial assessment of their status. Thank you yes seven nine of the hospitals requested if you're a specific dollar amount that ranged from one point five million up to ten million dollars most of the hospitals through the assessment did not request a specific dollar amount and when Alvarez and Marsal worked through their assessments in on the report they did a break even analysis and they did some other metrics that are in the report that eight a specific funding calendar recommendation was not made by a president Russell. So follow the. How did we determine you know which was the first hospital I mean was it because they they did their work and they got it in and who's gonna be number two I mean how do we determine that. But how we how we give one hospital money and maybe another one gets nothing we because we run out of money has that determined so I was not here for what to top that my understanding is it was needs based when they approached you all in September the payment that was discussed and approved last week for three memorial came out of the need they contacted us during the assessment worked with the FNA Alvarez and Marsal and and D. A. DHS because of where they knew things were headed and they have the potential of a merger so we have communicated with the hospitals as they have communicated with us we are trying to finalize some details of how to approach it extending the rest of that money out with different tracks for transformational change or strategic change one of the things that we operated under with looking at how to fund the different hospitals and making sure that hospitals had access to the archive Fund was looking at in a way to equitably distribute equitably being objective by some of the metrics used in the report so there is a proposed funding formula I believe you are given a copy last week I'm more than happy to get you another copy Sir where we looked at several different formulas and then we looked at what was requested and then we looked at we'll what would be the best case scenario and we tried to spread the money for the lack of a better description and said now those funding requests are coming in we're trying to schedule those meetings with the hospitals and then trying to finalize the details for that transformational track or the strategic reform tracks so that we can continue to work with the hospitals and fund them and find them in increments as they make changes in produce results that they come before the committee so that they can continue to be funded. So I don't have one these hospitals in my district I'm I'm just concerned statewide but so I do have a hospital and I'm concerned about working until them to be able to get on the list and move up the rankings what or they needed and I think we are open to meeting with all of the hospitals I don't know that there's a ranking at its not first come first serve let me just say until we run out of money limit but that. Okay it and so we are trying to schedule those meetings in the next couple of weeks and trying to get those details out so that we have enough time in between ALC in council meetings to meet with them obtain what they would like to do and work through that transformational of that strategic reform so that everything is ready to be presented for you all to consider and the jury was a needs based due to the merger. Thank you. So I appreciate the line of questioning from representative Ladyman and I share your concern representative Ladyman and I think for me it's really about us as a state trying to say four going to. That money towards. These hospitals we want to make sure we're not just throwing our money to a hospital that's going to close our doors and four months and that's an issue in a problem and so and I I think that's a good. We want to be as wise as we can with these dollars and make sure that we're helping them and so I appreciate the fact that we as a state hired a consultant to come in where is a lot of these hospitals may not have the funds to even hire consultants to do what we've done for them to be a Frank with you and and so I think there's been some really but good best practices I have been learns through this process with your different levels of different hospitals and there's a value to that that we've put into this and I think that's been recognized by by many of them the other thing is is that even if they requested a certain amount the maximum they could request I think was ten million or I could have been less but but you know if you're gonna have if you can this is the maximum you're gonna request and why when you request a maximum it doesn't mean that they're going to go under if they don't receive the maximum but that you know some of those were were made those requests and so the consultants looked out you know this pot of money and then figured out okay these are the recommendations we would make and these are the types of things that you could help them with that would really get them back to you a financial help the state is not at it and then we have the our professions and this really is a primary purpose for them and I support that I think are legislature would support that so and yeah I can comment on that I'll start and let your followers and yes some of the hospitals did request ten million dollars back in September of twenty two which I do believe was the ceiling when we tried to approach a proposed funding formula objectively and and knowing that there were a lot of hospitals on the list and we we considered it finite funds of the arpa funding we did propose a cap of five million dollars to each hospital said that the the money could be allocated to all hospitals that. Is a proposed funding formula that we we presented that is can be modified but that was one of the ideas that we present right so so so trying to be judicious and trying to help all of them is the approach that you all have been taking right from my understanding and also to use the approach to dance point about making sure that we are considering both the financial viability and when with their current status is financially but also with they are there. Willingness to be transformative and to think strategically about how their sustainability plan will carry them to their next phase of development. I just had a question for clarification so the the distribution of the rest of the money that's propose these other hospitals that gonna come what's the timeline for that how do we anticipate the timeline for that rolling out is that can become available simultaneously is that asking decisions are met as these as the different transformative strategic plans are presented what's what's the time when we can expect for the to the facilities. What our plan is Is to extend our contract without president Mar sol host you live so they can help us monitor these hospitals we anticipate coming back in September working with the eighteen hospitals or. Some number less that chooses to continue down this path with either the transformative reform or the strategic reform and then have Alvarez Marsal help us monitor those help us guide ultimately the initial distribution we get the plan and then subsequent distributions as they meet certain benchmarks in just some clear the difference between the transformative and strategic strategic is just it may be this is how we've been doing business we anticipate things to be better because of these different changes in our work environment versus strategic purchase versus transformative which is we're going to change completely what we're doing is that I'm can you give us a little more information on transformers a strategic sure I'll start senate finish me mmhm okay I'll give it is the account I'm give this world so a strategic change would be where the hospital identify certain benchmarks whether it be patient volumes kind of hard to deal with because we've seen declining patient volumes however it could be Cost per patient for labor overall staffing a new surgical. like orthopedics or something that they bring in their densify the benchmarks and then we're going to offer is more saw we monitor those so that would be more of a strategic where they're they're really looking at the current operations and determining what is really a loss what they maybe bill bring online that may be a positive forum and then we'll monitoring over the next twelve to eighteen months to make sure they're cheating certain benchmarks such strategic transformative is what you said it'll be transforming from a non critical access to potentially critical access or rule emergency hospital it could be a merger with a larger system or it could be a group of rural hospitals forming something like a procurement cooperative to help them reduce their overall calls for supplies things like that so and all that Janet hit what I missed. And I think it's easily stated for strategic it's ever either revenue enhancement or cost reduction something that's done internally at the facility to help them sustain their long term state's financial sustainability and transformational would be changing their entire environment is it a merger is it achieve some form of transfer agreement is it something that's going to change how they practice with the potential external partner think that's helpful so is something hearing correctly strategic it sounds pretty concrete I mean transporter sounds pretty concrete there's some pretty clear past strategic there's a little more flexibility within that is how they qualify is it transfer teaching is more about accountability and and providing a clear pathway to financial stability through an accountability processes that person that is the intent that helps me thank you very much. And this follow up what I don't I want to see is us delay and then it more emergencies pop up so I hope that to me September sounds kind of far off particularly since we've already gone down the path of opening the store with the jury. So I would appreciate if that can be set up to be honest with you because out let's get this money out the door like I just I'm I think we've they've waited all quite awhile and so for me I just think it would be more prudent just to try to speed that process up a little bit because if not we will then you know finds where. Emergencies arise and so at which I just think that would be get to avoid that and and those other hospitals will be under the same monitoring is not correct that have already received funding from us will they still will they be under the extended contract with Alvarez and century memorials does fit under transformational change because their margins say we and they really kind of have created that pathway in our in our thinking so they will be monitored and. And then we will move forward with the other seventeen okay Washita would not. I don't have a clear answer we okay not really okay well I I think my vote would be that they would but that's not that okay I'm gonna move on to more questions let's see we have senator king. Thank you madam chair so I guess on up with what represent Ladyman said and maybe I didn't catch it Sir is there any way to just get a simple spreadsheet of how much the sixty million and to know and get updates on allocations or what you're going to propose we know ahead of time a little bit this. May just get a simple spreadsheet where we're at what's been committed so far ready said fifteen million for one back for law and in this last application is that the only to yes Sir it was six million and and it was not an even number for Ouachita it was four point nine for juries and we we can. Subtract that ensure what's left I think when the hospitals choose the path that they would like to go down being transformational or strategic or if a hospital chooses not to participate any further that will change the proposed funding formula so what while we can show you the balance I don't know that it would be accurate to display the current funding opportunity until all the hospitals have responded on how they would like to participate but as soon as we have that in July or August as the chairman indicated any earlier would be more than happy to to supply that so you don't see anymore allocations going out the next couple months it's just going to be meetings lark. With the hot I mean I think a contact that meeting so we're going to meet with a hospital consultants all these people and there's there's no allocations that you see for the next couple months is that correct. I don't believe so because I think what we wanted to do was present the entire spreadsheet drew was in need of a timing need with a merger and I think we would like to present and meet with the hospital's president which pathway they've chosen then present their documents so that it can be decided all at one time on the future of the funding yeah okay that inferno up there with saying is is kind of this language or trying to talk about that basically for them to get funding is conditional with what this consultant says I mean I kind of issue with that I mean without passes three of and I'm not saying in this case but past histories consultants a came in and what was a total waste of money they totally. Misled us on what things would cost later on so I mean I kind of issue with that because the passes three of spend so many as many millions with these consultants are wrong so and I'm not saying this is the wrong situation just saying a kind of issue with. You know the reason you're gonna get the funding is conditional with what we say you know I'm saying I mean a kind of a problem with that I hope there's some room to to look at situations after the dialogue to say Hey this is a little bit different that's the only thing I ask. You senator king I understand where you're coming from the intent with having the consultants continue to work with hospitals and monitor is we understand that a hospital say you Rica has a unique service line in a unique constituency as opposed to say drew Memorial these south Arkansas indivisible part of the meetings that we're gonna have with hospitals is for them to self identify which path they want to go down and then also self identify the benchmarks and the metrics where they believe they can see sustainable increases or improvements whether be from a revenue or expense side and then Alvarez more saw will help us monitor that the intent was never to have a one size fits all approach to all the hospitals where the consultants pig exactly hello a hospital is to improve those that come here that's that's that's all I ask community see this question your answers what I'm concerned about so I appreciate that you give your risk is perfect example I mean it's a small town you know we're close to Bentonville you know in that health care system but yet we're to restrain or the returners town which is different from a lot of cities so I just like I said I just create the fact that you weren't willing to listen talk these people it's just not coming in this is what they say in this conditionally you know you're gonna have to do what we say before we get the money that's one thing I ask. Thank you senator love. Thank you ma'am share of the my first question was Reversing Medicaid. in how Medicaid how Medicaid played a role in I guess the formula to ensure that you all have been in looking at the hospital viability. Because. Arm listen to your comment about patient volume and it's kinda hard to pick patient volume but we're looking at the decrease roles of persons on Medicaid so how did that play a role in determining kind of how consultants look at the hospital as far as the viability of it and the percentage of revenue then the hospital earns off of Medicaid dollars. Do you I mean do you understand my question. I believe so let me see if I can M. in certain obviously follow up questions. Medicaid would when the assessment was done hospital by hospital that over as a morsel they looked at all of their payor mix commercial Medicare and Medicaid they looked at a six month time period I believe that ended on twelve thirty one of twenty two then they also went back and requested the past couple years of information which did include pre COVID and covid details and then there were extensive interviews and work done without reserve Marshall and the individual hospitals over how they had seen their revenue mix change in and most of the the details that we heard that came out of those discussions and assessment was that revenues were down for commercial Medicare and Medicaid so. We did listen for that I was not part of the assessment I've only seen that the draft report and works with Alvarez and Marsal after they did their assessment. Sorry Arkansas are you saying that that was one of the factors that were that is taken into account when you begin to judge about the hospital viability. It was one factor they looked at several things they looked at an income break even analysis they looked at net patient revenue to labor cost and That they looked at a whole list I'm I'm sorry I'm I'm kind of drawing a blank but I can get you some of the key metrics okay. But it was it was cash on hand it was a R. it was it was several different scenes that that was what they looked at in the assessment when we proposed the funding formula we took pieces out of that report that Alvarez and Marsal had done objectively across the board by looking at cash on hand or looking at they were critical access hospital or not because they're paid differently or looking at their financial condition so that is kinda looked at all the way around okay fully so so. Out of the eighteen hospitals that did apply. No the consultant I mean. You say strategic U. SEC transformative. Is everybody on a plan of strategic or our or our transformative or. That is going to be the hospital's decision and that's the feedback we don't have it yet said the hospital the individual hospital will have to choose which path they would like to take and create their plan and we will help you out as a muscle may offer technical assistance or assistance to them that that will be an individual hospital decision so that hospital can choose to do nothing and receive money no Sir no okay what we're proposing is that the hospitals have to take a path forward for long term sustainability so that we can see where they're headed and how they're using the money be it transformative or strategic okay but they're not proposing funding without any accountability okay but there's no there's no hospital that the that was out of the eighteen it was graded of the consultancy said Hey this hospital is critically in trouble. You know it was there any hospitals like that I don't know that I can say that our president more salt did identify at hospitals that had critical I mean I don't I don't I don't I don't want you to name. I think in different different areas of concern were noted by Alvarez and Marsal so I don't think they made they made some recommendations that they should consider conversion to a role emergency hospital for one hospital or they made another recommendation I would have to go back and look I don't know that I can give you the specifics but they did identify some critical issues for the hospitals between revenues expenses are property in plants I I mean I just. So so manager this is what I'm gonna say aye aye stopped on the question because I I think it's becoming uncomfortable but I'm going to this is what I'm on the same because I truly believe in the concept of having rural hospitals I do truly know that we are know for a fact that when people have to travel long distances to get health care that the outcomes are worse. Out for. I do believe that. We should not throw good money after bad in this just this is something that I this just kind I'm stuck on because I want to make sure that we are providing a lifeline to hospitals. But not if they're going to close our doors in this this and this this will kind of where I'm stuck hello and thank you Senator love for articulating that so well because I think that's where we all are and I think that's why this is a difficult conversation but often also a difficult task at hand for our that we fit on to the Department am by the FNA and Department of Human Services because it is important but you can identify these passport just to be to create sustainability and that's that's the whole goal here is to how do we identify password of sustainability to keep as many of our rural hospitals intact and in place to provide critical access for patients we've discussed even what does not look like from the Arkansas Economic Development standpoints because without those cornerstones of those local economies if they are taken out then that whole area and region can just cater and we need to make sure that we are cognizant of that particularly with all of the Arkansas Economic Development Commission money we've put into an area that was the conversation around Camden Arkansas to be Frank the Camden hospital it is a declining population but we have invested a ton of money both state and federal into the defense industry down there in Camden and so we have and it's important you've got some critical work going on it's like the steel mill and bobble no that's dangerous work that's happening and we've got to make sure that we have a healthcare point access for that to support that area not industry I think Senator king made a great point of Eureka Springs mountain views in that same boat we're tourist towns it's going to look differently and your patient mix is going to be to. Reference Mountain Home has a lot of retirees so they're heavy in Medicare as part of their payment mix is always going to be having Medicare and tricare which is we have a lot of veterans there but that's a different payor mix and stuff Arkansas which might be more Medicaid's revenue so it's very it is it's not a one size fits all it really is that you've got to look at every hospital has a look at their patient base their population then what they're payor mix is and how then you combine that payor mix with you know trying to keep your your overhead down and and those types of factors if you're a critical access hospital or not that also plays into your level of reimbursement and then representative Johnson's bill on rule emergency hospitals that I co sponsored with him is another path for that's been opened up by the federal government that gives you different options so that's why it was critical I think to have this consultant come in and just to provide that level of expertise with all these different dynamics at play for each one of those particular hospitals and to help us identify as a state where we need to really put our resources that's going to make the biggest bang for our Buck to be honest and so I appreciate the line of questioning because I think that's why we need to have this one for discussion here in this public health committee meeting and I take it upon all of you all to help inform your colleagues that are not here today or on this meeting at this meeting that may have a hospital in their area you've got to help inform and educate your colleagues as to this process the other thing is the metrics and the report. That they're referring to was presented last Monday at peers subcommittee of Legislative Council of asna steel if she will also send that report out that outlines the measures that was presented by Alvarez and Marcel and that that that they used in order to create their recommendations so miss at still also send that out to to the membership as well. At. All right senator Hammer you're recognized for a question and members if you're not a member of the committee we are what we will allow you to ask questions I like that because I think that's what we're supposed to be here about that just be respectful I would ask and and so that everybody can get the questions and Senator Hammer you're recognized thank you madam chair I'm going to check on to representative Johnson's discussion about transformation versus the other term that was used the the the areas of like looking up like looking to open more our slots be little more creative as far as the use of our spots and things like turnover rate based on employee if valuations whenever they leave position on versus traditional hospitals first you know like a S. heart hospital on core verses like a Saint Vincent Baptist UAMS setting up management styles are all those things considered by the consultant when making a determination recommendation as to whether or not a hospital's worthy of the money we're going to be offering. Okay let me let me make sure it. We're talking about the same thing for this for the consultants what they looked at was non system. Hospitals that were non critical access in communities of fifty thousand or less or critical access hospitals in the state. However to your point in the mix of rule hospitals that they did look at they did meet with us of various people at the hospitals typically the CEO CFO they did go back is miss man said and look at it several years prior so they did get a feel for how the hospital's management style was they also saw the declining patient senses at times they look did various factors including their accounts receivable how quickly they're they're collecting that so they factor all that in into this report this is a question. Okay and then you made a comment while ago that once a hospital's my the question was that a hospital may choose not to participate in this or they may choose to go down the trans formative router they may choose to go down the other route once the hospital starts down that route given the limitation of the time's gonna take to get the money out if they start down a road in St Luke's way meant we should went the other way of what's the reverse engine policy as far as and be able to divert and want to go a different direction or because it is time sensitive as far as money get now I will mail it Janet correct me if I would say that we're looking for accountability if they start down a strategic reform pass. Which has metrics that they're going to have to meet benchmark metrics that they choose they're gonna have to meet and they see the transformative merger or something like that. Would be better for them than I believe we're going to allow them to do that and we'll let them cross over here again the whole point is accountability and sustainability for the taxpayers and for the local communities okay and then last question be the consultant. Has free unlimited access and rain to get any information that they need in order to bring a recommendation to this committee or A. L. C. that includes turnover rates anything and everything or they limited a day having limitations as far as what they can ask for. Do we have not placed any limits on them and I would I believe they would bring to our attention of a hospital tried to limit their their access to their ability and So I think to your point no there's no limitation from the state side of the coin the can contract that we have a DNA with Alvarez Marsal on what information they can have access to. I just respectfully made this request if they ask for something they're denied it that that be noted in the report because to me that's critical for us to know because that to me would indicate that there's an area that is there's not a willingness to share information I mean I've asked for turnover rates on hospitals before and been denied it because I think you for rugby funding hospitals that have potentially poor management styles whether they partner with another one or not and then they're going to ask for money of I don't think I think it's time to be very transparent appreciated and I will I will make note of that have them draw that to our attention thank you ma'am chair for the latitude. Yes thank you M. represent of rye. Yes ma'am thank you Mr lady let me ask you this shall I'm sure there shall have went through this but Senator love was kindly hit an owner not want to come back with you just a little bit have you looked at say two five two thousand fifteen through two thousand nineteen and then look at two thousand twenty through twenty two and saw the differences within those years and there's probably an overload because of covid and that would come to have something to do with the amount of money that there were questions yes in in assessing the financial condition of the hospitals they did use pre COVID information on the in the financial records as well as during the pandemic the records with the record showed there for hospital incomes and then the most recent six months and all general correct correct me if I'm wrong. They did they did look at pre K. of it but I can't guarantee that they want to twenty fifteen I just wanted to clarify to clarify I think they looked at twenty nineteen and potentially twenty eighteen I would need to verify that they did they did try to look at pre code data. I mean just just a. Cap off that point you have to look at pre covert data because COVID was an incredible complete destruction right so many times your impatience care is not where you're going to make your money it's going to be your elective surgeries your elective procedures your lab work your draw all that other stuff that didn't have her for a good length of time and so recovering from that they are still in recovery mode and I think will and represent lighting that we have one more question and then I'm gonna go to represent lay members but I think that's important for us to understand that when you shut down or the beat you know elective surgeries when you shut down elective procedures when you shut down a lap and you can't draw lines you when you shut down a hospital effectively and the only thing that you're focusing on is one item it's like the only thing you're selling at the grocery store is milk okay that's it and that's the profit margin you're going to live on and you don't have any other product to be able to sell I mean I'm trying to that's very very basic but I think you we have to understand that right and and that's the only thing that you can sell during that time period and that's the only profit margin you're living with during that time period so you there's gonna be a recovery period because you've lost all that time and all that income and now you're seeing patients you know with even more complicated issues because they delay their care because of it so they're just there is just a. There's just an after effects that worst we're still coping and dealing with last question representative Dick and then we need to move on to the next topic. Thank you madam chair I appreciate you let me ask a question about one thank you all for your hard work on this and I do appreciate the desire for accountability we're work with people at the people's money and that's whose money it is we have to do our due diligence with that I want to kind of follow back up with what the chair's asked as far as the time line on this for these hospitals I know you mentioned several you know they started this process in September twenty twenty two and your if I understood correctly you're thinking that we're not gonna you're not gonna begin that process with the funding with them most until September of this twenty twenty three is is that accurate I understand that correctly and because many hospitals I think they're in here because of an emergency and every month that goes by every day that goes by is is more challenging for them so the delay concerns me a little bit actually this was a quite a bit so could you give a little more clarity on what you're looking at is them getting an answer especially the ones that started out in September twenty twenty two that have been delayed. So. Thank you the plan I mentioned was to use for the hospitals in September twenty three. I had to work backwards are actually forwards from the contracts we're going to extend the contract but I cannot do that until a L. C. in July. And then we'll have to meet with the hospitals which were already doing so hopefully it'll speed it up a little bit but we've got to get them to self identify which path they will be on which track and then once we do that then we can re engage Alvarez and Marsal all to help us monitor through the process so yes I did lay out September it could be earlier since we're going to head meeting with many of the hospitals now just keep in mind that as we move through this Those hospitals that are on our list again going back to Janet said some of them may fluctuate an amount not in and out let me rephrase that they may not choose to participate to actually request funds that made transition and and shorten our time frame for some of this also. Thank you okay a representative Ladyman do you have a. Thank you manager I don't have a question for you all but I I would like to request someone from hospital association to come up. This is just to I'd kinda like to know if there's any feedback from hospitals. If you'll just state your name for the record and then we can. This. Per se being here. Good afternoon I'm Jody enter at the executive vice president of the Arkansas hospital association. Thank you Mr per come up and I I don't wanna put you on the spot I just read the report myself so that I know you haven't seen it but but I'm just interested in the hospitals is there any feedback because the process is been going on for a long time so what are you hearing or are you hearing anything if you're not and that's I'm fine with that but what what's their feel for this and do they think the process is working whether they think about the process how's it going. So I think hospitals have been pretty resilient through COVID and trying to take care of patients and do all kinds of things so we're sort of use to the rules of the game changing a little bit especially in this space and we're very respectful of the process we like to be rule followers and when I talked with these ladies at the Department of Human Services they know that a hospital's recognized Medicaid is about a third of our issue right uh we also have Medicare that's about a third of our issue and and don't get me started on commercial payers of because that's the other third of what hospitals have going on right now so we're looking for any mechanism that can get us a bridge to be able to figure out how to get adequate reimbursement when the cost of labor the cost of drugs the cost of supplies and of course just the cost of operations have increased just like many other businesses costs have increased throughout COVID and in our response to it so for many hospitals this is a bridge to be able to move from one area of success to another I know I've told you all many times when I've testified before you hospitals very very quietly reduce services we don't put it in the newspaper that we're having to close a rule clinic or we don't put it in the newspaper that Hey we know you're used to us being able to staff fifteen inpatient beds but this week we don't have the right personnel to be able to do that so we're only gonna have eight beds available which frankly you all know hospitals are in network sort of the backbone of the healthcare system so when one hospital reduces its ability to take care of patients not that those patients are still sick they're transfer to a nother location and I think that's where you're seeing the push and pull here I think I don't wanna put words in the Department of Human Services mouth but I I represent almost all the hospitals in the state I do think the Department of Human Services was trying to focus on the non system hospitals to make sure that it helped everybody in a way to where even the transfer agreements and those kinds of things could be to serve the citizens. Of Arkansas better our hospitals I have been very proud of them they've collaborative we worked very very well together throughout COVID and beyond and they're helping each other accepting patients a little bit more readily but everyone recognizes that labor costs are not going down and if labor costs don't go down and supply costs don't go down and. All of the other things that are going there without a requisite increase in reimbursement you're going to keep hearing from hospitals that this is at fever pitch we're not making it up it's not a finding games kind of show we have to be able to be reimbursed the actual cost of care that we're providing to patients as their sicker and sicker and so that's sort of where we're standing I have heard from a few of our hospitals and they're having meetings with you all as their elected officials in their own communities which is a good thing And we appreciate it when you all are super duper interested in our hospitals and they like it when you come and visit with them and want to know about them in many cases there the economic engine in your community so it's good for you all to have an open dialogue there and senator Hammer to your point I don't think you're gonna find hospitals kind of hiding the ball here they're at a desperate need and want people to have information so that and we can all sort of collaborative collaborative we work on this and move the ball forward so that we can improve patient care so to your point we stand ready at the Arkansas hospital association to help in any way we can weather that to help get resources to hospitals who may be eligible for these dollars or frankly to look under any other rock where their dollars and resources available to hospitals that don't have them right now so that they can stay viable partners in your communities and take care your patients and we don't need anymore service lines closed it doesn't make sense and we need more emphasis on outpatient care that's what people want so we're we're working collaboratively with government officials hopefully with commercial payers and others to really try to provide the services that patients need throughout Arkansas. Thank you thank you thank you for your comments I apologize for bringing up like that but I'm interested in boots on the ground what comes back from that I think most people once committee are so thank you very much. Thank you representative Ladyman thank you Mr at per se that and I will also say am I really do appreciate the meetings that are happening with their local of elected officials but and some of those systems do affect regions so I'd just. Be mindful that even if there and not unlike that officials right there with in the location of where the hospital is it does have a regional a fact so you might want to make sure those other regional representatives and legislators are are and forms so I appreciate that thank you all so much moving on to the next topic we can just stay at the table. And. And. And my apologies we we are sending that report out it is a lengthy report but it will be in your inbox The next item on the agenda and is a discussion of the Medicaid redetermination process and you do have a hand out and I'll let these ladies identify themselves for the record and and move forward as they're coming up I do want to say as as a matter of history I've been incredibly frustrated at some of the reporting around Arkansas and this issue and let me just be very very specific it is a necessary function of government to always re determine eligibility of Medicaid this is not a new thing it happens. I all the time. In different areas of Medicaid and these programs because it is directed by the federal government under CMS for that to occur so there is nothing new here and secondly the state of Arkansas has been criticized for being efficient. That's unbelievable to me but I am so glad that we are being criticized as being efficient in government because we're not here to waste taxpayers dollars we're not here to abuse taxpayer's dollars either and so the criticism that we're being efficient I will welcome every day of the week so kudos to you all for being efficient with taxpayers money in REDETERMINED eligibility for Medicaid to me that's a compliment and that's a job well done and I'm really tired of the spends and the the reporting that as that is is completely leaves out so many of the facts and as a matter of history I think it's important to understand that this legislature also directed a re determination of eligibility under previous of secretary of DHS and so miss Franklin I think can speak to that because we've already been through this once already so to speak and and I was noticing that the state of Ohio Idaho I'm sorry the state of Idaho was continuously monitoring eligibility through the pandemic so that when this day came they were ready to go to clean up the roles so that we can refocus the program into the areas of need where it truly needs does folks really need the resources so kudos to the state of Idaho I think that was a job well done as well to continuously monitor that eligibility and that so with that I just wanted to make those comments before we started this section if you'll just introduce yourselves for the record then you're recognized for state. Kristi Putnam secretary DHS. Janet man Medicaid director. Mary Franklin director of the division of county operations. Amy Webber director of the Medicaid control. Okay. Thank you for this opportunity to present what were what everyone has been working on for a very long time and so everyone I think is familiar I'm going to start and then Mary and Amy will chime in and they've they've done a lot of hard work over the past fifteen to eighteen months instead I'd like them to be able to give the the details but on the first slide you know this all started and passed in March of twenty where we had to have continuous eligibility for everyone on the Medicaid rolls that Arkansas continue processing renewals and determining people in eligible but we did not in their coverage so we spent the time working on all of that knowing that one day it it would end so that we can be prepared then in December of twenty two president Biden signed the consolidated appropriations act ending the continues eligibility condition for Medicaid and requiring the state to return to normal operations as of April first. Then ACT seven eighty of twenty twenty one was triggered by the signing of that bill that the in state law requires DHS to complete within six months redetermination of eligibility for anyone whose case had not been reviewed in the last twelve months so a few details and then will move to the next slide. But over the course of the pandemic we had six hundred forty six thousand beneficiaries considered extended so that meant that we kept working those cases and as we continued our work we transitioned two hundred forty seven thousand of those extended beneficiaries back to regular coverage because their circumstances have changed and they were again eligible. So. That should just shows the ongoing work. John. You know talk about this one. Sure. So at S. peak over four hundred twenty thousand enrollees room remained covered by Medicaid but we had at some point determined that they were in eligible but due to the continuous enrollment condition we kept their coverage open And that this act you know that was about a twenty five percent growth in the Medicaid enrollments. Of so over the last fifteen months we've really kind of focused our efforts on three big areas and the first is making sure beneficiaries knew what was happening and they knew that they needed to update their addresses and they knew that what they were we would be reaching out to them and the next we focused on our providers and our stakeholders and making sure everyone they knew what was happening but to that they were ready to step up and be partners with us at the table as we went through this because we know that DHS can communicate with our beneficiaries but they trust their doctors they trust their pharmacist those are the people they have real connections with and so we wanted those people to be saying the same things that we were and reminding them about what they needed to do and then last we focused on ensuring that our case workers and our agency or ready to handle this this is I say this all the time but this is a historic effort we've never REDETERMINED eligibility for this many people at one time so it is a huge and unprecedented effort and so we knew that we needed to get ready for that it's all just talk a little bit about the the beneficiary work so we began in the spring of twenty twenty two and launched an address update hotline and I'm really proud of this effort what we did was did outbound calls to everybody who had been extended so those four hundred plus thousand people who are still extended on April one we have tried to call every single one of them and what we wanted to do was confirm their address or update their address so that we can reach them with our renewal letters and so during that process we updated our confirmed addresses for a hundred and seventy thousand. Beneficiaries and we also implemented some new strategies that the federal government allowed us to do where we get except verified addresses or managed care plans the passes the qualified health plans to serve our home again those people are working with those beneficiaries on a regular basis they might have a better address last and then we also were able to access the national change of address database so we've done a great deal of paid advertising as well end of organic what I call it organic the outreach and media outreach where wasn't paid but it was through social tapped into a lot of ways that we have not done outreach before I including there's a lot of a primary care physicians who have of TV's in their lobbies and stuff and we targeted Medicaid providers all across the state with those so we knew that's where the the patients would be and that they could see that we've done some other digital campaigns and then for the first time we started sending text and emails and then putting alert on the citizen portal when the renewal letters went out and we have not done that previously and we are currently in the process of adding texts and emails for reminder letters as well and then lastly for beneficiaries we took a whole of the agency approach saw one DHS approach where it was not just Mary's team worrying about eligibility it was all of the programs so for example the Division of aging and behavioral health services well may administer the our choices program and so but they don't do eligibility so those. Nurses who work with those clients actually took packets out to their clients when they met them in person and said here is your renewal packet let me help you fill it out so we did a lot of different strategies like that to try to connect with people in different ways I'm married you want to talk a little bit about how you handle them the manage the workload. Sure well. As everyone is mission we have been working on this for a long time part part of what we have done is kept doing our work throughout the pandemic to to get to the point where we didn't have to renew everyone within twelve months only the only the clients who have been extended but one of the things we did to get ready for this was we we had some contracted search support on board and we staff that surge support team up in preparation for this unwind that are we are working on over six months from starting in April so we have two different contracted teams that are helping us they were already here and already helping us with eligibility and so we just. We just extended what they were doing and added to the team so that they could be here to help us with Medicaid eligibility through the online. And then I'll just said lastly so on the provider and stakeholder peas so we began talking to providers and stakeholders all across the state and and summer of last year at least maybe earlier than that and we have been sending weekly list to primary care physicians that passes the dental managed care group and the net transportation groups of clients who are at risk of losing coverage we've been doing that for about a year and we did change of how we did that a little bit but really we wanted to equip our stakeholders and providers with social media emails text choirs all of those things they needed to help reach out to their patients and clients and we do have an ongoing a weekly call with all that's open all Medicaid providers in the state as well as their associations we've been doing that since we started the unwinding and we also did some grant funding for community based organizations all across the state to help us with outreach and in some cases they're also helping a beneficiaries walk through the renewal process and then lastly we work really closely with our state agency partners the department of education community corrections DWS at of yes it education so all of them to help message to their specific populations and they've been great partners. Leding we had to determine what we were gonna do every month what was going to be our case load so we prioritized the reader terminations with the extended population that we had already seen that would potentially not be eligible so this chart just shows you how starting in February we began sending notices and we are going to be doing that through January but the bulk of the work is from February through September mainly you see July where it drops off on the number of notices so we will then be working with them by giving them ninety hundred twenty day notices and different reminders of their cases coming due so we just wanted to go to see the the workload as we designed it. Let me let you talk about your out of. So what you see on this slide is how we go about conducting the renewal process for our match I categories and my jaw it stands for modified adjusted gross income that's the methodology that the federal government has set for how we determine eligibility for the certain categories and here in Arkansas you know those categories is our home or our kids A. M. B. the pregnant women category the new board and some former foster care so we often call those are regular Medicaid category so regular Medicaid we initiate those renewals about ninety days ahead of time before the renewals actually do we first attempt to use our data sources to see if we're able to complete those renewals without having to ask for clients for more information and if we are able to do that we let them know they've been renewed and I ask them to let us know if anything's changed within ten days for those that we are not able to renew during that ex parte process we we generate a pre populated renewal package for them and pre populated means we put on that package. What we know about the client what their income is whatever we know about them from the system goes on that packet for their convenience so they just have to tell us what's changed or added what's new in we send those packets out about ninety days ahead of time and we also if we have an email address or mobile phone number we send them an email and a text alert as well to let them know that packet is been sent to be watching for to complete their renewal. We also since we have a citizen portal for our clients that choose to do their business that way with DHS there will be an alert in their account when they log in it tells them that the renewals to you and they can actually complete that renewal online as well and then after we mail those packets out in about forty five days we send a reminder notice and an enhancement we're gonna be making starting with the renewals that go out next month will also be sending that email and Textron with that reminder paper notice that goes out as well and then we send a closure notice before we actually close. Before the packet is do we let them know the case will close and then we still accept packets whenever they are turned in. And the next group this is our long term services and supports categories this would be our nursing facility or assisted living facility or our home and community based waivers those does eligibility categories we start them even earlier about a hundred and twenty days in advance we send those pre populated packets and we do the same email text of alerts to let them know that they're going out we also a post that renewal information on their online account and then about sixty days are we send a reminder for those we haven't gotten the packet back yet and then we also send a closure Before the case actually closed and we have been doing and this was mentioned by aiming we actually are sending weekly files to these providers with updated information so they know if someone hasn't turned in their packet yet so they can do some targeted our reach we also. Our beneficiary relations contractors also making outbound phone calls to remind people who haven't turned in their packets as well. On the screen and yeah thank you as noted earlier by the by chairman Arvind CMS has expressed publicly some concerns about our unwinding and our procedural terminations specifically how high the rate has been for our procedure terminations so Arkansas was not surprised by this because we have several factors we have record low unemployment I believe for the third month in a row in as in significantly lower than when the pandemic began in March of twenty twenty the unemployment rate was four point nine percent in April of twenty three it was two point eight. So also Arkansas we have increased our minimum wage twice during the pandemic it is now eleven dollars an hour. And Senate and also historically during normal business operations DHS dissing rolled twenty to thirty thousand beneficiaries every month. Prior to the pandemic so we suspect that people know they are no longer eligible we are taking additional efforts to reach them and to ensure if they're covered that they remain covered and we're also taking phone calls and emails and tax we may not get this perfect we may take someone off in error and we are working to correct that when it occurs that I just wanted to note some of these concerns and some of the reasons we feel that they date the results are not surprising. So eligibility outcomes so far so in April and may we have done a number of renewals of a hundred and one thousand beneficiaries and then coverage ended in that month. In those months totaling approximately a hundred and forty thousand plus I can't do math. Publicly anymore so it is an extended categories and the regular category regular would be regular Medicaid they were to they were eligible it was time for the renewal the extended population that we've been trying to pay special attention to at the beginning of the unwinding because we felt that they were not going to be eligible but if circumstances change we we keep keep them on the rolls this is public information we do report this monthly to CMS on a very prescribe forms and. And then also that this slide shows by the county's I believe this was requested as additional report after we began unwinding in may so we will start doing this every month said that people can see where the the beneficiaries currently reside in. And then the remaining work to be done we will continue to process the extended renewals through September and will anticipate finishing those by the by the end of the month we will continue our regular renewals as normal course of business as we do every month and then the I mentioned that we have to submit the monthly reports and then at the end of the six months we also have a requirement we will send you all a report on all of our and winding efforts to date and save at I think. At am I briefly touched on this but if people do lose coverage in record failed to turn in the information we will get them and stated as quickly as possible with the information that's needed and we do have it period of thirty to ninety day retroactive eligibility to help the beneficiary if they have some coverage issues and so and then if they're over the income we are transferring them to the market place and we're trying to get better better tracking of when they go to the market place are they on not Medicaid or a different market place Plan but also employees sponsored we don't have a really good line of sight to where they go once they leave Medicaid we're trying to find different ways to track it. That's all thank you I appreciate that very much and and I I think it's just important to get the facts out there and just really appreciate the work that all of you all are doing in your entire teams and you've done this before you know what you're doing and we're grateful to you and the also if I mean the point that you made is absolutely correct that if somebody needs something they there's no hospital can turn away Medicaid patients they show up in the ER and they don't have coverage that hospital wants to get paid they're going to work with them to make sure that they're enrolled and you do have a retroactive correct policy so I think it's thirty days is that correct now you can be up to ninety it can be I'm not a great day meant a different category okay one question so there's just a lot of. Junk out there that's just not factual and so unfortunately KTV and KTHV M. that reported and accurately or not here today to report accurately but You know if they want accurate they should show up to meetings information one question do you have we know also you can look at your claims usage is that correct you can see who's using the program and not correct and then but those that were I guess frozen on the rolls we did have to continue to pay like premiums correct under the expansion program so yes is that correct do we have a dollar amount of what that was not yet we had we have begun the analysis as beneficiaries have been dissing rolled and looking backwards at their actual claim history and then also looking at our forecast so it were also at the end of the year say I'm trying we're trying to pay bills and do some analysis and the reason I ask that question is because moving forward I think it's important in return you know when any increases at record or classes or is made we have to understand what that cost was and and calculate that and consider that with any request an increase that might be made. And so anyway that's just something to. That that was on my mind representive road you're recognized for a question. Yes thank you madam chair. I have a couple questions back in. Late January I think some of you came and spoke to them the house public health committee and we talked about. E. R. messaging kind of getting the word out which you do you touched on I was just curious if if you could answer a couple questions pertaining to kind of the the efforts that were done there we talked back in January about the budget just on some of the I don't know if their PSAs or their commercials or what you would title them and I think somebody had mentioned around seventy five thousand dollars have been committed to or or or so on some public messaging do you know what you guys ended up spending to get that word out weather was I saw on your your notes you you reference digital social media advertising that was something that I thought would be pretty important to get the message out and I know you guys working on it but I never did can hear what your final. Assess was on that. Gavin Lesnick is gonna come up he's our chief of communications. Thank you for the question Gavin Lesnick with the H. S. so I have a breakdown of our total spending that actually includes prior to January that goes all the way back to the update phase but we spent almost a hundred sixty thousand dollars on various paid advertising. The reason I ask is I'm sure as many other representatives we've got folks who are reaching out saying Hey I've been distant rolled maybe it's an accident and there maybe it's because they no longer qualify which I'm all for people who no longer qualify no longer qualify but my my big concern was I think we're talking then was appointed five or thousand people not being qualified anymore how did we let those people know is there still an effort even though as the chair chair a said just a moment ago that it's being incorrectly reported by the news media is there any effort still to get correct information out to the public for as you're mentioning the descent Roman for the on one and that's going to continue absolutely that's a of the tremendous focus of our whole team so we are continuing with paid advertising right now we have a digital campaign that focuses on social ads across the state as well as on some streaming services they're free targeting people of lower income but really the paid side is just one aspect of this everything else that the my colleagues here mentioned I continue to be a big focus as well that includes the community based organizations that are doing outreach and most of the counties across the state DHS's using its platforms including our social accounts news releases interviews with media work with our partners both state agencies as well as hospitals doctors I really everybody that we can think of who connects with our beneficiaries we're trying to use that to get the word out because certainly we share that goal we want people to be aware of this process. Madam chair to pre follow. The first of those was one of my main concerns the people who have no contact info whether it's their phone their address whatever might have been everyone of you mentioned the the hotline the ad address update hotline and that I think it was a ridge you said a hundred and seventy thousand roughly had been updated of those that had been updated how many of those were on wind unwound OR dissing rolled. And I'll take just a ballpark on and only the exact number I don't think we have that they did. We do not have that data we know how many have been distant rolled and how many work in the extended group but don't know how many of those were people that we had reached a verifier of date their address and my final question or go ahead did you what I also wanted to add that we do have a requirement we do monitor are returned to mail in our return mail has been very low less than five thousand pieces and in the two months that we've reported that in the I. appropriations act that was signed in December of twenty one we was an added requirement by CMS or are by Congress that returned to mail was not the sole reason to descend role someone we have to take the extra step and a different modality so in addition if they do have returned to mail we are trying to reach them through email text or phone to make sure before we descend roll them. thank you I'm I'm the the five thousand or less than five thousand to be pretty encouraging actually it's you you're not getting a larger percentage back we have seen larger percentages in the past right as I do think that is a direct result of that campaign of to update those addresses and have added adequate information for mailing the last thing Alaskan thank you madam chair for indulging me you too all you have reference the outreach methods that were used so thank you for kind of covering you know such a wide spectrum of trying to notify people could you touch on what methods they go outside the standard you know multi media messaging which methods have been the most successful in which ones have been seized but he's been really successful in reaching people for unwinding purposes. We have not done an analysis yet of the different outreach efforts but I will say that. Tapping into our providers and our partners has been critically important because we do know that like for example the passes will they all have care coordinators and so those care coordinators they've been getting a list of their clients and they are going down that list one by one and they can see this person is getting desyrel because they didn't send in their their renewal package or this person didn't tell so security their new address and so they're working individually to get in touch with those people and make sure that they take the steps necessary and I think that's important and one of the things that we've learned and I think this is true of most programs is you have to get people multiple ways multiple times for them to kind of accept the message and take action and so I think it's taking all of those pieces to try to make it happen. Thank you thank you manager thank you I think I might have heard something on Pandora I think there was an ad on Pandora the other day last week a representative Springer you're recognized for a question. Good afternoon thank you madam chair I have several if that's okay well look we have I'm just let's go and also try to make Womack I'm the reason the people to a party in the back of her okay I so I can hear the laughter back there. Read the reason why I say that is because I'm trying to understand that I can go ahead that's good news so on page five of the handout the unwinding is that total number is that the number of cases of number of persons that were contacted I'm trying to understand is that what that means between up to date to this date. Yes that was the number of cases by month at the renewal was sent okay all right so then okay thank you so then I guess my question isn't it first of all let me just thank you all I have some questions when this initially took place and you all provided information to me about that thank you for providing that information however I guess the big question I have for you regarding this whole process is who is doing the work in processing these renewals and determine the eligibility who are the persons that are doing that not here to talk about you mentioned contractors are the actual persons that work in the offices of doing this work so our team in division of county operations our our state employees to determine eligibility and Division of County operations are working hard on this we have an amazing team and they work extremely hard and they care very much about what they're doing to do it right we also have some additional support through contractors who were also helping with this eligibility process so can you tell me how many the common employees goals that you have within that because I'm trying to get numbers for them to look at almost seven hundred thousand individuals I mean that that seems to me to feel pretty still work load so I'm trying to understand so please help me understand because I'm on children and families of committee and I heard de you all talk about the number of workers within your departments all the working of the they complain about work and and the pay and then you don't have people there often times so I'm just trying to understand as to whether or not this particular task that was given to them is the basis for how they're feeling so I'm that please if you can kind of speak to that and tell me what is taking place here because to look at over me almost a million cases in addition to your other work that you have to do to me that's kind of. Unreal it's a it is a herculean effort you you are correct it is a lot of work and it's unprecedented to have go for that period of time and maintain eligibility for people we had determine an eligible and then work to get them renewed and make sure that. Well who were receiving the coverage are eligible we have around eight hundred plus case workers we also have over three hundred clerical support staff we have supervisors county administrators and so we have our our whole team we also have contractors who help us with call center support to help answer the questions of better coming in and as well as our contracted search teams are one of those teams has close to two hundred employees and we are surging them up a little bit to help us with the volume they're going to be sending troops fifty four additional people through training and the the other one is has about a hundred and eighty and we are going to ask them the staff up some additional employees as well just just to have us have some additional people on board and of course we are also hiring vacancies as quickly as we can and we'll send our own staff through training to help us you know as quickly as we can so have you done a breakdown as to how approximately how many of cases that the individual those eight hundred per person of handle over this period of time. Cases per month. Yes. To have some information. It's all also and I'll I'll say this is well you have a county office every county every County and some of the county's help the other counties it's a it's like a network and so a lot of times I know in my past my Stone County office will be assisting another county where there's more cases third there happen to deal with right yet yes in in if I add to that what he's looking for stats that includes the eight hundred case workers that are in central office that primarily in the county offices working those cases but one of the other things that we have heard and seen with this is the phone calls phone calls are coming from because it's taking longer to get answered so we've been in the process of rolling out universal calling and we're rolling it out by region so we've rolled out to regions I think we have forty guys but that will help where if the phone rings and someone is on hold it will route to who is open yeah and then we'll have a few pockets for that one exactly work immediately but we're working with the I. S. and eighteen T. to work through those details that's what we do at county offices help county offices right get the work done yes ma'am my last question is ma'am so what kind of reward or incentive of payment that you all excited you all considering the type of incentive for the work all the work that these persons have done over this period of time the what has it been a McConnell recommendation for them to receive similar to what was approved requested of before the Legislative Council of of last week do you think that they are deserving of anything for this extra work that they've done. So I our as I said we have an amazing team they work very hard and they're very dedicated I can tell you that during the pandemic as we launched the new eligibility system and our state we were moving to this universal case load instead of working just by county where where clients live but everybody we you know. We are one DHS and we are one team now and our clients do not have one case worker anymore they have the whole team it's all of us in it together working together but they had new things to learn they had a new system to learn some of them maybe we specialize in Medicaid but didn't know the other program so we we were able to get a labor market rate in place for the case workers in particular once they learn the system were proficient or certified in all the training across the programs they could get up to a ten percent raise so thank you sounds like you're making the point that I'm making that there is a need for something some type of Senate based upon what you said so thank you very much for and we're looking at multiple ways to address that you know we are as a as an agency were reviewing our current positions looking at how can we upgrade working make changes that are within our purview to make to support the efforts and you know really reinforce the work that's being done by fewer staff so and I think that would assist with your committee of the rail that we we've talked about in my of the committee that have come before me having this type of discussion about the work loads and that sort of thing so maybe the incentive to encourage them to go for the work that they've already done thank you. Thank you representive and that we have two more and then we're done with this topic senator Hammer and representative Ladyman senator Hammer you're recognized for a question thank you major refresh my memory but in the process this was a blanket policy where everybody even if they had long term disabilities and they were provider groups like Civitan some of those organizations did they also have to recall five. So it's a Medicaid requirement that we have to re determine eligibility annually so that that requirement has been in place for many many years but and during the pandemic we continue to do that work to the extent that we could and sometimes we determined they were no longer eligible but we continue their coverage or maybe they didn't return the paperwork so as you know during normal processing that would have caused the case to be closed we kept those cases open and now that we are returned to normal operations part of doing that is doing these rated terminations both on the extended group that would that may or may not be eligible now but we determine their bills ineligible at some point during the pandemic but also the regular renewals that are due every month so this regular annual renewals happen and then we just do that every month based on when they're due. And the hundred sixty thousand was referenced while go for advertising that did not include the cost of like to direct mail pieces I mean it was. There were the direct mail pieces in addition to that so I mean it was a well blanketed effort to make everybody aware of it because our testimony about the direct mail pieces of which only five thousand which is pretty I mean historical that low return rate is that correct related to the the cases that have been up for renewable yes okay and then last question is is have you and maybe this is in reference to what was mentioned while ago at what point would you have the assessment as far as the financial impact on your budget with the reduction of the number of cases and the direct impact on the Medicaid trust fund. I'll get you a date we're working on it. Or a manager I'm a member's committee but you think you could ask them when they get stuck back to this committee and yes of think that be a good discussion to have if you don't mind we will we'll we'll be talking all about medications since the last one final one yes go right ahead if the Ladyman if you'll just hold for me you're about to hit the end of the year where you're going to have your you know your your counts rollover how are you gonna separate or are you able to separate what you're gonna be able to roll over into the medic you know into the Medicaid trust fund from your various accounts of being that you're fiscal years about to end so that long term in the future we won't have that expectation of an inflated number that one into a person's normal day to day your to your operations. The finance office has begun tracking potential suite we won't we will not begin our actual sweet procedures until four thirty on June thirtieth because everyone has up until that time to pay their bills handle their business for their respective divisions and then and I will deferred financing case they get this wrong it finance will begin their work at four thirty on the sweet they will work with internally DHS and with D. F. and I. T. to finalize that sweep from NYC for next week. K. R. thank you thank you all right represent Ladyman Love. Thank you manager and I am a member of this committee I'd like to see those numbers that was my question Senator hammer ask questions but the finances because we know some people are going from ten percent to thirty percent our state pay and we we don't know what that's going to take out to be so I'm interested in seeing where we're at today your best guess because I know it's going to be a gas right. but let me add one other thing in this is a statement more the question but Senator Irvin talked about some publicity nationally and locally about how many people we've taken off the rolls and I think there's a national campaign the with the article I read started out with how many people nationally was taken off and then they throw in a few states like us Mississippi a couple others had taken off a lot of people my opinion is believed because we're taking off more people because of the work that you all did and by the way excellent work I think early on by keeping track of how many people might go all so if you're prepared and you have the information and you can remove those people that need to be removed a lot quicker so I believe that's why our numbers might be able to hire some other states and I think that's a good thing because you did pre work. And I know how much work you all did you been working a long time and you've done a really good job on that so I wouldn't be bothered too much by somebody not knowing the facts and saying that were taken off too many people but in that I just thank you all done in a good job would you agree. You don't have thank you they have done a very good job I was I will yes the team has done an excellent job. Thank you representative Ladyman I one hundred percent agree with your comments and that's why it was important for us to have this discussion today because I wanted to set the record straight because Medicaid requires an annual re eligibility determination at that's been the policy federally for ever and so you know that work didn't stop or that we just had to have a freeze we can remove them but that you're one hundred percent correct I guess that's why I was so frustrated by some of these very very slanted national stories and and even local stories so with that I'm I do have other questions but I'm going to move on because we're we're going to move to the next and item of it as the discussion if you do have additional questions I would just add an invite you to get with DHS and the folks at the table thank you so much again for your work I think represent Ladyman said it very well and I appreciate the on going efforts they are making and we will talk numbers later and. At I. N. G. Matt Gilmore if you can come for a review of the tobacco settlement commission quarterly reports and as he is coming forward we do have a number of interim studies under item H. I will consider a motion to bundle those and and and adopt those. Some moved and seconds All those in favor say aye. And oppose ayes have it as Adam age then will be dealt with those those ISPs are going to be adopted will assign this to the various subcommittees okay with that Mr Gilmore you're recognized. Matt Gilmore department health thank you madam chair I know we've been here for a while I'll keep this as brief as possible I'll go over the report in front of you. An impasse committee meetings golf asked home for me to bring one of our programs with this I brought Mr gray with me she manages our tobacco program the department health and one let her give a few comments about her program into the things she's been involved in so I'll do this very quickly on my part and I'll turn it over to her that's okay. So you have before you the July to September a quarterly report for the tobacco settlement commission of twenty twenty two this is similar to what you see in the past you also have an infographic there the staff as provided in color of the first few pages I think it's pages. Of four and five of the report it just provide some numbers across different programs I like to look back at the year before this and these numbers are different from year to year quarter quarter for for sure but. Think back to your before this we were in the middle of COVID and some of these numbers were inflated due to different issues they were experiencing them at the time for example that education numbers these numbers are higher than they were a year before I think a lot as to do with just the nature of what was going on back then and there's more opportunities now for the programs to meet with folks get out there and provide more education to the to the US populations they serve. If you look at the number of services provided in there several bubbles there these numbers are kind of make some up some are down again a year before I think the programs were heavily involved in things around COVID was screenings with a testing immunizations things like that so those numbers you know might have been hired them they're more data norm more normal level now I believe if you look at the Medicaid expansion numbers on the far left in the bottom there towards the service front page of the infographic that handed out those numbers are down I think you can speak to what we just heard about was with DHS and then evaluating and making sure that people are getting the services they need but also doing the redetermination is but at the same time I think there were some things here and COVID that were up more flexible some of the eligibility requirements. If you turn the page the next page the handout we gave you you got the research section this numbers more stable across these different categories of particular on the projects and the publications and some of the presentations they do against more stable this happens year round across the programs on their and their partners across state with educational institutions but I do think that it's if they're good solid numbers in there more normal for what you should see for the quarter. And then at the bottom of that page you have economic impact and these are numbers that they report a quarterly and annually all these are good solid numbers we see growth from quarter to quarter I think these numbers are they're higher but I think some that has to do with some the funding and in the state and across the nation in that they've utilized with contracts grants donations and that sort of thing. So that was pretty quick but I do wanna say sometime from it's great to talk about the back program and if the department of health and let her talk about the project using HM. I'm joy grant I'm with the Arkansas department of health and the branch chief for the tobacco prevention and cessation programs and I was just going to give you just a very brief overview of a few of the things that we have going and then I'm ready to take questions if you have any and one of the big things that we're working on right now is prevention of course we know vaping is an issue all across the country and especially you know in the southern states in Arkansas is no different so we've been going into the schools now especially that we've been able to actually physically go into the schools and in this last school year we did a hundred and eighteen we've visited a hundred and eighteen schools and four hundred and forty two presentations that were affecting prevention and so that we had seventeen thousand seven hundred and seven attendees across the schools just for those presentations and those really focused on the health impact of vaping we focus on making good choices we show them not just the health impact but also if they get money if they have an allowance if they're working all the money that they're spending on these rates what can what else could they be spending it on so we're really trying to show them sort of some immediate impact along with health impact because they do need to know what they're doing to their bodies as much as we can educate them on that we also have project prevent which is a program that we fund through Arkansas children's and it is an extracurricular program we currently have ninety two chapters around the state in fifty counties and it is a program where you can gauge and health promotion and health activities around their school and they also go out in the community they do community events anywhere they can get out there and promote you know vaping prevention smoking prevention general health initiatives they give speeches to their local city council their local quorum court and encouraging a local thought leaders on developing programs that help with you know general health and nicotine and tobacco prevention as well so we had that going they also do have some really big programs that they do annually were they create their own commercials they create their own sort of stories and scripts and things that have big you know competitive events every year rather schools compete for all around. The state to win prizes for creating their own commercials that are providing you know anti vaping anti tobacco and just general health so the kids really like it it's very engaging and we allow them to sort of lead it so that they can take some ownership for these health programs and then a program that we launched last year in August is the corals reef program it's a vaping cartoon program that was created by the Arkansas department of health I'm one of the writers and creators of it it's the only thing like it in the nation and it targets children ages five six and seven because we were getting constant phone calls from preschool teachers in kindergarten teachers saying they're bringing the state to show and tell they know how to use them they're putting them in their mouths are popping open and we look for years and we try to find something that targets children younger than twelve and the average age of initiation Arkansas based on CDC data is thirteen for nicotine use so we wait till they're twelve or thirteen to start talking about prevention we've gone too long so we created a program that's funny and engaging but also very educational and it's aimed at five six and seven year olds episode one is out we've presented in eighty nine schools to thirteen thousand three hundred and thirty two children and the response has been overwhelming we've created auxiliary materials coloring books and activity books that also show them the dangers of vaping and all that kind of good stuff so they can really say there's like a multi layered approach to teaching them about the dangers on the harms and the you know helping them with their physical safety so we've I can't even describe how many teachers have called me emailed me the other begging for episode two they're so excited that someone finally doing something and we're again we're the only state in the nation that has anything like it because everyone else is still waiting till twelve and thirteen so we're hoping in a few years we can see a difference in initiation rites in use in Arkansas and then for cessation we are still or fifth year of operating the Arkansas which is the only state operated put one in the nation and we have really good success rates with it as compared to when we were using a private vendor so we have enrolled just now a little over fourteen thousand user. There's into Arkansas over the last five years so we're excited about that. To. Thank you so much okay one thing that you might put on your list is I don't know if you can target some outreach to your community centers and and perhaps even senior citizen centers back I drive by community center the other day for children and they had. Buckets with sand in them for smokers to put their cigarette packs and and it's right in front of this community center on a sidewalk and not just encourages smokers to sit there and smoke and so. That's very disheartening to me out out in front of a children's community center but if if there's some sort of outrage and to community centers I think particularly those that deal with our use At I think that would be something added and then have a quick question as far as where the money is directed is that I direction from the commission is that statutory. The the settlement money could you just give me an update about that sure so there's seven programs are funded through the coming through the commission but it's set forth in the initiated act from two thousand and so it's and then it's distributed that way the commission doesn't really determine its moral watchdog it's more of a monitor make sure the indicators are being met as far as the funding it says statute for the initiated act okay initiated legislative yes ma'am not a constitutional it was it was a mission statement of people by the people as assets it's in the constitution okay construction okay I'm just curious about that thank you a person of. Johnson I hear some. Some possible centipede and from our staff. Because I have the same question I was looking at the same thing I've had that question before trying to understand what are you what it in and I can set my own that I think it's I think it's worth asking the question of where these funds you know what we allowed to use these funds for what's the flexibility within the initiated act is constitutional their ways to change that within the legislative session although we're loath to do that is the General Assembly you know it's been twenty three years since that act was initiated and I think a lot of things have changed in that time frame and I think it's you know it's worth considering asking so yeah this bill you when I get the great and let's see how they how they for a it's my understanding they were set for the announcmenet change from year to year and on the the Dollars of coming state but I'll I'll for staff. Good afternoon everyone just give those bare of Legislative Research Mr Gilmore Friday it's initiated measure but not a constitutional initiated measure it has been changed in past years there legislation it is not in the Arkansas constitution it is and the title nineteen of the Arkansas okay so I think I understand since initiated act in the sense that it's a piece of legislation those passes a bill by the people there's a pathway for that right to put the you in so that's yeah I as opposed to buying your health person so I'm not going to get into that but it's an initiated measure not a constitutional amendment there's a difference so to amend that it would take just a regular majority no to search that because it's an initiated measure but not three force that it takes to change the that's what appropriation that's different okay. This I mean this good conversation I mean at your for whatever it's worth I think it's a lot of money were back settlement it's it's there it's I'm sure it's being used well I love it so we're doing to try to prevent vacant tobacco cessation but have some clarification on that at some points worthwhile and I don't mind you can chase that honor of some after the meeting well it has been changed in past years representative may very changed it for medicated couple years ago couple sessions ago I want to say governor Hutchinson changed it for regarding the funds. And but it's mostly percentages matters more about the percentages than I do. Yeah I think there was some money moved twenty seventeen Medicaid has some extra funds it wasn't being used in a move that around to provide slots for the wait list which they had to change the initiated measure in order to do that okay that makes sense yes. Thank you yeah that's good thank you appreciate that representative grammar. Thank you for being here today just just talking about the. Having an issue this tobacco on the basis of this in our schools a middle school teacher and and I appreciate everything you're doing because it is an issue is a huge issue I'm I have I have to constantly check bathrooms in between periods for kids because they're trying to bait it's an Arkansas high schools it at like and if you're on the ground and you see it every day like I am a chunk of kids in every class or hiding one and and it it's just a huge issue so thank you for you do. That that just appreciate. Thank you representive Ladyman thank manager I'll be quick try to be. This firm is gray you know in in Jonesborough where I live. There's like to tobacco stores and six vaping store I mean Beiping is just kind of take over taking over so the question is is vaping a bigger problem than tobacco now as it passed the back when being in the as far as usage goes so in terms of usage for use yes it's youth are vastly vaping right now more than they are smoking but what we know is that you are seven times more likely to become what we call a dual user which is they're eventually going to start smoking cigarettes all right now they're fifteen sixteen Beiping school they like it it's got easy access it's tutti frutti and they can hide it eventually they're gonna get older they're not gonna have pocket money probably as much as I know no the older we get it seems like those pockets and a little more and they're gonna go to cigarettes which are a little bit cheaper and easier to get so I tell people all the time when I presented webinars today's papers are going to be tomorrow smokers and they're going to put that smoking burden on us right now so smoking is still a much bigger issue for adults vaping just really has not caught on with adults nearly as much but it is a much bigger issue with use and I think looking forward we can definitely be concerned that those kids are vaping right now going to become smokers and then also the the long illness and infections that that happened from vaping it happens very quickly whereas a lot of times the smokers not necessarily see the impacts for several years you for saying it immediately so that's something that we're really trying to express to them is the immediacy and you know teachers like Hammer the reason we even created a whole new program we were just getting such an overwhelming you know series of questions and and need for help and we just decided if nothing exists we're just going to make it because we can't keep sitting here waiting on someone to make it for us so I appreciate teachers like him in their feedback because they're the reason we got started doing these things anyway. That's great thank you so much representative Pilkington last question. Thank you chairwoman So talking about what some of these funds can and cannot be used for I know in the past in another state some of the tobacco settlement funds have been used to expand access. For new clinics and areas I was curious if you could that money be can this money be used every route it for non emergent transportation. I think it can be used for anything. It's broad term but I need to yes we health related I think was the way it was written it can be moved around I don't see why I couldn't but I will defer to this body as to how that would work but I mean I think that is a possibility So does not have I guess just so there's nothing in the act would prevent the use of those funds to go toward programs like that. I'd be. Not that I'm aware of representative I think I think there is some flexibility in how it's used but again it's appropriate by this body so I think I have to go back through you know. Y'all's decision making to do that okay thanks. Thank you so much really appreciate what you're doing thank you continue hope it's so sad to me that their preschoolers that are vaping you know accident. Whatever thanks being exposed to it so I I agree and I appreciate the work that you're doing there on that and that thank you for the questions thank you for the presentation all right members and be on the lookout. The report will stand as refute and members look on the at look out for the the future meetings coming up and anything else that comes up represents for years you have a question. An. Well can is it for the committee. Yes I know that you're recognized said representive Springer that's who I have down representive and it had made a question earlier so. Okay we'll. Well I would disagree that I said that but I I appreciate it thank you with that were adjourned.