Public Health, Welfare and Labor Committee- House

Thank you the members for let's turn into a marathon Committee meeting so I thank all of you for coming back I know several of my colleagues had to had to leave during the intermission but just wanna make a few remarks in opposition to house bill thirteen eleven as an independently owned retail community pharmacist and owner I have witnessed first hand just what the effects of hospitals competing directly with retail pharmacies can do to our businesses our livelihoods our neighborhoods communities and what it can mean for the patients that we serve and at the end of the day lack representative Johnson mentioned this is ultimately about the patients and taking care of their needs. So first of all in twenty fifteen our pharmacy started working with representatives from a local nonprofit hospital in Jones for all to assist them with their transitions of care during these meetings many of my retail pharmacy colleagues joined with me in offering help and assistance to the local hospital to try and remedy the situations that they were having with readmissions and transitions of care during those meetings several problems were realized in solutions were given on how to implement a program to use the existing community pharmacies with the hospital pharmacists and hospital administration. Likewise we offer to change our work flow and offer extended hours to assist the local hospital to serve our mutual patients part of the issues we found were internal communication problems with the hospital its employees departments and clinics we offer solutions to these communications problems as well as providing examples of how the same transitions of care and meds to beds programs have worked in other communities in Arkansas as well as programs that have worked in other states to great success thus these programs would be mutually beneficial to the retail pharmacy world and the hospital pharmacy world. Now flash forward almost ten years later in here we are still unable to partner with the hospital in hopes of bridging the gap that they found with their readmissions and transitions of care and piecing things together as we realized problems upon discharge from a local hospital as they arrived at our pharmacy counters. Now the share one example that happened this past Friday I received a call from a care coordinator from the same local nonprofit hospital to try to have us run a few claims to try to figure out the best course of action and the lowest cost medication that the patient could receive upon discharge after running a few tests claims the case coordinator and I spent probably thirty minutes trying to figure out we determined that the best course of action would be to try them on a look less instead of the real title is as there would only be a ten dollar copay for the patient so she replied that they would be sending that prescription later that afternoon and so we waited around till about four o'clock that afternoon and the provider from the hospital sent over a prescription for Sorel toe the total opposite of what we had spent. The minutes working together to try to remedy now this would have ended up costing the patient hundred twenty five dollars that I give this example to say that there needs to be a system of checks and balances in the situation and if the hospital can't communicate effectively amongst their own departments and how can we trust that they'll provide better care through operating their own retail community pharmacy. Now through my role with the Arkansas pharmacists association I've heard similar versions of this same story from around the state and especially as I've worked with a team of pharmacists who are part of the C. P. ESN group or the community pharmacy enhanced services network which was designed to assist patients with the ultimate in patient care they we provide partnerships with payers employers clinics hospital groups even manufacturers to try to to provide the same services that hospitals and hospital pharmacists in fact work in tandem with them to try to provide better retail pharmacy services. Now we try to partner in twenty seventeen twenty eighteen with a local nonprofit hospital through their pace organization now pace is a program that provides comprehensive medical and social services to certain frail elderly participants that still are living in the community in other words they would be eligible to be placed in a long term care facility but they are still able to remain mobile now these are high touch complex patients who need personalized care. Well the local pharmacies in Jon's friend been serving many of these patients through this pace program prior to twenty eighteen however these patients were then asked to receive all of their medications by mail order instead of partnering with the community local community pharmacy and allowing us to deliver that same face to face care that these patients had been accustomed to they were now forced or see their prescriptions through the mail and problems continue to in situ to this day we are not allowed to fill prescriptions for those patients as this what we have to look forward to if hospitals are given the luxury of having these retail pharmacy permits to again lose business only to have the local hospital fill all medications in House require patients to receive them from a centralized location likewise the same hospital now incentivizes all their employees to use their hospital and pharmacy there by taking away even more of our long long term patients and clients now we heard mention that patients were unable to procure their medications upon discharge outside of normal business hours you've heard that argument made. First of all through this pace program and you've heard many of my other colleagues already testified to that we are available after hours if there was a medication to be found our pharmacy where that I've worked at since high school with was the one in the community known to have that hard to find medication in fact we used to stop many hard to find medications injectable specialty meds and then starting about ten to fifteen years ago we stopped getting calls for those products as well as many of the other local pharmacies in our area suddenly when some larger chain stores and this of course is no thanks in part to the PBMs and and the insurance middle man because we didn't receive as many prescriptions from the ER or the walk in clinics are any of these harder to find items were sent to us by prescription we simply stock stocking stop stocking them. So in or in order to since we didn't have any demand or that are hours were cut or we had to cut hours decide not to stop those medications we were told by the hospitals or clinics that their prescriptions were being sent to other pharmacies. So in fact many of the problems you've heard about as examples given here today by the hospital pharmacist or proponents of H. B. thirteen eleven. I feel are self inflicted if they are truly having issues with patients not being able to find these prescriptions are finding pharmacies with shorter business hours let me do speak from experience is partly due to the at their own activities in the past. H. B. thirteen eleven is not going to solve this in fact hospitals competing it with us would only make it worse the fact is when I gave many of these examples it is that we want to partner with them we are ready to partner with these hospitals we remain committed to partnering with them in the future we simply must be given the chance to partner with them and take care and remedy many of these problems that they're having especially with the three forty B. program if we are given those contracts and asked to participate then we will so at the end of the day is this about patient care or are we. To believe the points that were given earlier that this is about access and three forty B.. Program medications using the guys that patients are being under served or not able to get their medications is simply a red herring as to what the real reasons are for these hospitals wanting to obtain retail pharmacy permits if we thought PBMs an insurance middlemen were batted imposing unlabeled playing field in the pharmacy world and I can only imagine what having local hospitals with their three forty B. preferential pricing being vertically integrated or of being able to have providers steer the patients that they already do in many instances to their own hospital pharmacies and having a captive audience can do. Not to mention the vast amounts of property that they own in my own community property that they paid no property taxes on this vertical integration of health care must end. And hospitals to be it will be allowed them to be the judge jury and executioner for retail pharmacists so let me stress enclosing many members of this committee may have heard from hospital pharmacist contacting them telling them that there is no need for retail pharmacists to worry promising that we are overreacting stating that we will only use these contracts for the greater good or to stop re admissions are only one time for transitions of care let me remind you these hospital pharmacists have no skin in the game this is not something a majority of hospital pharmacists would need or desire in our own communities from their own free will is coming instead from above them it is the hospital it is the it ministrations in the CEOs and those that are above them that ultimately will that will decide how and where these pharmacy permits are utilized it is much more than transitions of care and re admissions or patients not being able to get a prescription filled at three AM in fact the nonprofit hospitals who already have retail pharmacy permits aren't even open that late I looked up the ones that currently do have retail pharmacy permits and they're open shorter hours than we are and not on the weekends for many of them. So the real reason is about market share creating an unlevel playing field to compete with retail pharmacies and maximizing profits from the use of three forty B. program and that is not a reason to allow them to compete with already established retail pharmacies of Arkansas giving hospitals or retail pharmacy gives the administration carte Blanche to compete directly with their own locally owned and independent operated pharmacies those who are willing to work with them to remedy the problems that they have mentioned here today so again I ask that you oppose and vote no on house bill thirteen eleven I thank you for your time. Thank you are there any questions from the committee. Represent Bentley. Just one quick question thank you chairman this real quickly and I know we are very short on time and tell me real briefly what market shares of change for you in the past four five years and with a lot of mail order things and different things that are going on second tells how things of her you financial the passed for five years and I think this will for the detriment you if you do that quickly forced out of prison well I think I mention part of them is You know when when chain pharmacies and those preferred pharmacies moved into our area then a lot of times we are from the PBMs Force the patients to have to use those pharmacies are to use the mail order facilities and and I fear that may be the same thing that that comes with hospitals having their their own pharmacy permits I can tell you reimbursements continued to to decline One thing that we would like to be able to offer is to offer the specialty meds and help the patients with that but we are simply blocked out of a lot of those networks so one thing we have been able to partner with a few of our local hospitals three three forty B. programs and that has helped because that way were both able to mutually benefit from that but I can tell you the market share continues to dwindle if you talk about the Medicare part D. world and and a lot of these preferred networks is is they continue to try to shift prescriptions and and it's our own tax dollars and tax base from out of this state to the other states. President for K. Ferguson. Thank you Mr chair a quick question three forty B. program with pharmacists pardoning with hospitals does that translate into lower our pharmacy benefits for patients. Now I would say it it benefits the patient along with the because that way they're able to use the the pharmacy and the pharmacist there that they're already established with they still have the same copay on their medications that they're able to access that through our pharmacy instead of having to go you know utilize some other pharmacy somewhere else but it in regards to the three forty B. program it only helps to create access if we are partnering together with our local hospitals. Quick follow. Just wanna follow Mr you're recognized so. If it's a prescription. That an insurance company doesn't cover. But yet another three forty B. program hospital gets a big break on that particular medicine. Correct. So I'm saying if the pharmacy is partnering with the hospital. Can that patient get the same cash break if the insurance company doesn't pay for the medication like insulin or prescription like Jordanians for instance yes they certainly can and that's what some of the the hospital or entities that utilize the three forty B. program provide cash cards to patients so that way they just take those to the pharmacy and then were able to use that to process the prescription so if it weren't covered on their insurance they could then use utilize that card to cover that medication or thank you thank you Mr. It better are there any other questions from committee. Senator thank you for your testimony thank you. next up to speak for the bill is stand CarMax. Don't say Mr Carmack so now I will call. Melanie Burnett. To speak up for the bill. Please identify yourself for the record. Yes I am Melanie Burnett I am the director of pharmacy at St Bernards Medical Center in Jonesborough and it's ironic that I'm following and are one of our colleagues in the area and because it's interesting I'm I'm really glad to get to be here today this is not something I've ever done before so I appreciate you guys bearing with me as I share my experience at St Bernard's in that in that and area practice so I've been there about twelve years and as my colleague mentioned over here and. We have tried many many times over and over on to improve our transition of care at the hospital and unfortunately we have not made a lot of ground in that area and I think it's important what he highlighted there is and probably much more complicated Dan and ed then I can't even put into words here today but as you know we are caring for the sickest of the sick any cute medical setting there are things that change day to day hour to hour in relation to our patients and so that communication that needs to occur at the transition of care out of the hospital is sometimes up until the very last minute and some of that has impacted our ability to work with our community partners and we really feel like it's important engages community partners and we have not had the ability to provide medications to patients at discharge and you know since I've been in practice and so we've we incorporated a lot of efforts and with our community partners to try and find a way to get meds to the bedside and to improve transitions of care clearly and is aye and Mister Cooper stated to no avail so you know that's why we're here to support this bill I think if the hospital transition is and very complex and and for patients in our communities and we are not serving them and to the best of our ability in the way that current state is and it's really important I want to highlight that access to medications that has come up as a phrase over and over again but what I see in our practice is patients that and affordability is important there's no doubt we have a lot of underserved populations in our in our state however and that transition of care patients are are running out of the hospital and we have to care for them in that moment and when we try to coordinate efforts and in past years. with independent pharmacies some of the barriers ever related to that timing right maybe they were open they did they have enough time to prepare this medications run the insurance claims center runner over with with the medications and counsel the patient there's just a lot of barriers related to to getting that add logistically ADD to work and it's a twenty four seven need there's physical distance issues honestly also obviously technology in resource deficits that wanted to play there so I appreciate and I guess The comments related to the failures because I think that's why we're here today is because that is a very complex situation. And so and as I mentioned before the care plan for these patients to does not come into full effect until that final day of discharge and so and we are all scrambling you were preparing every day but in that last minute you've got to treat you've got and specialist you have primary care physicians excuse me hospital as they get to this point and specialists that are collaborating to come up with a plan of care I think the eloquence example that was brought up earlier highlights why we are asking for the ability to care for these patients at that transition because we may have had a great care plan identified and it's not executed because we are having communication issues that patient was an. Thankfully a part of a an attempt to communicate with a community pharmacy and not all of our patients have that and luxury at this at this time and so those orders that are anticipated to be carried out Without that coordination with a dispensation of the medication and final and counseling effort and can often times be confused and so I think that's a really great example and I'm glad he brought that at and. I think that's when they're it so the twenty four hour retail services I know it's been brought up several times we are really fortunate in the northeast Arkansas area that we have had and some semblance most of the time of twenty four hour access to medications and however recently and the one and pharmacy in our area it happens to be changed on independent pharmacy that's open twenty four seven did cease to have operating hours overnight M. R. hospital is not prepared for that and we do have the ability at that point in time because there's not twenty four access to medications for our patients that are just charging and to dispense it forty eight hours supplier it and limited supply and you know at that point in time we were handwriting prescriptions and we were and you know often times I probably can't quantify and nor do I want to know how many times are nurses were dispensing medications without proper oversight to our patients out of automated dispensing cabinets and we were obviously not able to recoup any medication costs but that's something that we deal with often in the hospital and we are a three forty be eligible hospital we have a hundred and fifty six contract pharmacies and we are very involved with and three forty B. and partnering with our community pharmacies through contract pharmacy and we have no need to cease any of those relationships that is that is beneficial as Mister Cooper mention to our patients and that is really what we're here to focus on and so you know regardless of the stated this particular bill and we will continue to provide and and have relationships through contract pharmacy what we're really focused on here is the patient I can't count how many failures we have with patients as they transition out of the hospital due to communication issues and the inability that we have to have that final point of contact with the patient before they leave. M. as many patients and don't go to the pharmacy and after they leave us many patients may go to the pharmacy to have some kind of roadblock and whether it's coverage of through their insurance or the pharmacy is not open And and you know many patients and just also for the bility is an issue so. We don't want repair we don't want repeat customers we discharge at fifty to sixty patients a day that's twenty one thousand discharges a year we don't need the volume every peak business from our from our community partners we we we need them the health care system requires that we have that that retail partnership and because we need to focus on our patients as their being discharged from the hospital that's really our primary focus and. The other thing I would mention is that you know post pandemic we are very busy I don't I don't I don't know I can only speak to the volume in our facility but every day most days we walk into and fifteen patients holding an E. are awaiting in an inpatient bed That is not ideal for any patient specially icy level or step down level to be waiting in the ER for the proper level of care and they're waiting there because our beds are full and we have throughput issues we because our volumes are up we we still experience read missions we we have if anyone would be interested we have less of it and occurrences or we've got patients that are returning to us because of our failure to to treat them and help them and attain their medications when they when they leave us so we would like we feel like we're we're at our hands tied behind our back at that discharge and so I think that's where this bill helps us and. I think that by not allowing hospital pharmacy to provide a better little level of care transitions of care for these patients we are ultimately hurting other patients and they're having to be turned away or held in the ER because we are all it our business is not in keeping our beds full and and we're here to try to help people treat people and and get them home safely to where they don't come back to see as as you all know we're penalized for that so and this is all in an effort I know It was mentioned earlier that these these at. This bill or what would happen with a slice in would would come above that the manager coming from above them as in you know me as in a hospital pharmacists that are administrators are dictating kind of what happens and you know the need for this bill and I can tell of to emphatically that is not true as a practicing pharmacist and a person that has been in the hospital for twelve years I have seen this healthcare system fail patients repeatedly and we have kind of come to a point where I feel it in the in my facilities specifically we have exhausted. As many resources as we can to try to make that transition more favorable to our patients and this is really more about them than anything and so I guess with that I'll take any questions that you have. Any questions from committee. President Bill Clinton you're recognized. That thank you Mr chairman I'm just this is more curiosity and in two thousand three the three forty B. was expanded to rule or nerve and hot a rule and summer urban hospitals in the courses expanded in two thousand ten with the affordable Care Act. You can you can help walk me through why is it taking till two thousand twenty three for this push likewise why am we why am within hospitals push the sooner I'm just kind of curious on that because you're talking these issues we have but if the expansion to like your facility with having two thousand ten why we wait thirteen years and now here about this so just specifically here about the need for retail permits. And well I think it's because and. There was a law that was preventing this from happening right so we were trying to circumvent every Avenue we could take to take care of patients you know we're we're very three forty B. and have a hospital like I said we have better fifty six contract pharmacy so three forty B. really has very little to do with this for us and for us this is really more about taking care of patients in and I know that. I hope I can convey to you that the N.. You know. The series is seriousness of that statement because it is really frustrating to put all of your efforts into you know a plan and to coordinate you know a mess of a program and then we repeatedly have failures and you know we've done that probably three times and and and you know some of it may be an internal issue but I think that just goes to show the complexity of the process in the need for some more support to be able to take that extra step to take care of those patients so I think it's really just kind of like a last ditch effort you know we're kind of to that point where we don't have any other options if I could add something to that too you know while hospitals of always been concerned about readmission rates that is not a statistic that was initially tractor or used as a penalty back to hospitals until more recent times so now that Medicare is looking at re admission rates as as a measure I think that's been a lot more emphasis on hospitals trying to find solutions to how do we keep patients out of the hospital once they're discharged here that's the that's the business spots behind things like the Committee paramedic movements going to check on patients make sure they got the prescriptions filled make sure they got the ball performance they needed at this mess to beds program is that the idea behind that is to try to reduce readmissions and there's been an increased emphasis on that the past few years I think that's part of the reason we're seeing this person now. Yes thank you. Am I can add one more thing and I'm sorry and I did also want to address the issue it was brought up earlier about and you know brand drugs brand name drugs and and again I just wanna focus that this is not about the money four four at the three forty part B. program I think we are incidently in a part of that program are eligible to provide three forty drugs but that's not why we're here and you know three four three forty drug prices for both generics and for brand drugs and so it's not an exclusivity from our perspective that we would be dispensing brand name only drugs to these patients that generics are also eligible for the program and it a lot of times in the contract terms the real the reason why those are those excluded by the contract and that is to benefit the retail pharmacy because then they get less rebates back when they're not purchasing engineer drugs that we really most of those contracts with the retail pharmacies are brand exclusive and for their benefit and not for anybody else's. Represent Johnson Jensen I have a question if I think I'm allowed to ask questions I guess you said you contract with a hundred fifty six pharmacies help me understand what that means that mean you're contracting with hundred six individual different pharmacies to share the dispensing of three forty medications Care Act okay have a follow up so is that common place and is there any limitation or move to limit how many contract pharmacies you could have in that program. No there's not and and and just the and compliance is a big piece of that and so we have you know invest a lot of resources and into ensuring that we're compliant with the regulations and so it's really have as much as you can handle and so and that's been a really positive thing for organization or patients and obviously some of our and community partners so. Of the representative wrote question thank Mr. Does the hospital financially benefit through those three forty B. arrangements I would say I mean ES and no but I will tell you and charity care is a huge part of the purpose of that program and and I would say that you know we're able to sustain a and I health system in the northeast Arkansas a region that's able to care for patients expand care provide extra services so from a financial benefit and I regard absolutely yes and we have a very high proportion of indigent patients that code or hospital and were able to care for all of them as a result and I don't know I can't speak to that specifically I am an administrator have to comment on that but I would say there's very good reason that program is a very good reason why we're still operating today in the way that we are. Follow Mr you're recognized thank you just final thoughts should this bill pass would your hospital have more of those three forty arrangements rather be more prescriptions that would qualify for those. Absolutely I mean yeah we would re we have no intention and like I said earlier reducing any of those relationships and like I said they are. Valuable relationships to us and also for our patients and so and no no intent on reducing any of that M. and no intent on and I'm not pursuing others and like I said we're looking for those bills and right out of the out of the hospital and because we want people to be. And taking care of. Any other questions from committee. C. and not our business art represent K. Ferguson. A follow up question thank you Mr chair but to. What representative road asco under the three forty B. program. If your pharmacy hospital pharmacy solely brand drugs and brand drugs. Of the three hundred dollars you guys get a little bit less expensive right. Yes Sir so. So would you all sale that at the retail price who would it be at a different price yeah I think that's a great question so you know as any retail pharmacy would do we would bill the insurance right and we're going to cut we're going to dispense the drug this were that is preferred by the insurance company we're going to bill as per you know any other committee pharmacy would and so you know whether they get the medication from us or from you know the kind of the arts it would be the same but if they had to pay the cash price in the insurance company did coverage. How would. You build and it was cash in there is no insurance we we probably bill for the I don't really know I guess I can't really answer that question and without discussing okay with them yes but I don't I mean there's really no intent to profit I guess is the point and there's there's no intent to profit but you don't know how I would be. I do not know that that's not it's you know that's under discussion that I don't believe in violence yeah thank you thank you Mr mmhm. That. Similar questions we thank you for your testimony. All right next up to speak for the bill is the mystery and tricks. Good afternoon I'm Jody enter at the executive vice president of the Arkansas hospital association I know this is been a long day thank you all very much for at continuing to hang out with us and let me start by answering the questions that I've heard and then you can pummel me anyway you want to about the three forty B. program so I just to clear up a few things and that program started in nineteen ninety two you all remember in a representative Pilkington is exactly right about how hospitals came into the program one of the reasons hospitals were selected to be covered entities is the federal government recognized that hospitals were really starting to hemorrhage cash back in those days and so they were looking for a way to fluff up or build that the hospitals without causing costing state for federal tax dollars so what they did is require those pharmaceutical manufacturers to offer drugs that pretty heavy discounts to hospitals and so when that happened it means when we buy the drug and then bill the insurance the difference there goes back into the three forty B. program for us to use for community benefit to answer your questions represented Ferguson we absolutely on a cash basis those hospitals could give that drug to the patient at no cost if there's enough three forty B. savings from that program today and make sure that that patient had access to that medication giving reduced prices of drugs to patients is a part of the three forty B. program and a very important part but it is not the only part that three forty B. program benefits not only individual patients but also communities at large many of our hospitals are now telling me that the three forty B. program savings and it's not a profit center trust me up but the savings are used to bolster labor and delivery departments I will remind you all we have less than forty hospitals that continue to deliver babies in Arkansas if we don't have the savings of the three forty B. program to help. Bowstreet those programs things like labor and delivery go away especially in our rural communities and that's one example we we buy equipment we help improve patient care by making sure we have enough nurses and doctors on each shift those types of things are all used with three forty B. savings specifically to talk to you representive Pilkington about what's changed in the last few years why do we need to retail pharmacy permit now more than we have before to cover the three forty B. program the long and short answer of this and I think the pharmacist association I would agree is the pharmaceutical manufacturers are not playing nicely we've had more and more pharmaceutical manufacturers tell us that they will not allow a contracted pharmacy to fill a three forty B. prescription on behalf of a covered entity in certain circumstances when that happens the really expensive drugs the chemotherapy drugs and other things are then limited access because if we have a contract pharmacy that's able and willing to stock that particular drug and they also have to have it easily available readily available at cetera as the pharmaceutical manufacturers are squeezing us on who can dispense those medications on our behalf it becomes more and more imperative that we also can do it in case there is no contract pharmacy who's got that drug in in house ready to go ready to dispense it is very important representative road and the cancer situation not only for the infusions that run through but also for the anti nausea medications that folks really need upon discharge so if there's not a contract pharmacy available who has been able to stock it of no fault of their own when they want to just because the pharmaceutical manufacturer is limiting the supply to that contract pharmacy that hospitals need to be able to step in and bridge that gap to cover that a access to care and you all talked a lot about access to care there's access into bass one is the physical access can you get there can you. You get there in a place to where it has the thing that you need at the time and then the second thing is affordability the three forty B. program does offer affordability to patients who have no resources whatsoever by using some of those savings and that are developed from billing insurance at its regular rate and and taking what we've had to pay for them at a reduced rate taking those savings in the middle in an office setting that expense I suppose the last thing I'll tell you is we talk about communication errors and and things like that that can happen currently our hospitals that do not have retail pharmacy permits they don't always know which drugs they ought to dispense whether it's a two day cycle or thirty day cycle because without a retail pharmacy permit hospitals are unable to make the investment in the software for retail pharmacy where you could actually run a patient's insurance through know what that patient could afford and dispense the appropriate medication to them for their two day cycle if that's what you have for their thirty day cycle it's very imperative that hospitals have the skills the technology and the resources to be able to help that patients upon discharge at time of need to know what that patient can afford what their insurance PBM will allow them to have and then hopefully we've got that medication in stock and if we don't we absolutely will keep those relationships with the contract pharmacies every hospital of talk to who's doing that three forty B. program now which is about fifty five zero in Arkansas and those hospitals rely heavily on their contract pharmacies and there in incredibly appreciative of all they provide it is a partnership between hospitals and contract pharmacist some of the problems that we're having now not having a retail pharmacy permit is not the fault of the pharmacist it's the fault of the pharmaceutical manufacturers for not playing fair and really limiting how we can dispense drugs to patients that really have to have them and with that I know I talked pretty quickly. I think I answered everyone's questions representative Richardson you had one about where the savings comes from it really is the pharmaceutical manufacturers who by the way hate to do it but they have to give us discounted prices on those trucks that's with the savings comes from No state tax dollars no federal tax dollars included happy to answer questions. We have any questions from committee. Represent road. This part of my navigation of this bill because of this representative Johnson said. Most of us if not all of us have heard a lot from both sides of this bill and so I'm interested you provide a lot of great answers thank you for that I'm interested if you know of any independent pharmacies that are in favor of this bill I do not. Follow up. Thank you for the direct answer why do you believe that is the case. I think there is a real fear and I say real in the this thing that happens when someone else gets in a market that you've really worked very hard to build up I cannot emphasize enough that independent pharmacists throughout Arkansas have been the best partners of recent and especially for some of the public health things that hospitals also try to reach out and do together collaboratively so that what we don't want is to instill that fear one of the reasons to not come at you all with a bill that's a full repeal is we wanted it really slow process and progress into the market with if you've got less than a thousand police after hospital you're probably pretty small your critical access hospital rule referral center that kind of thing so if we only had one permit there if it caused problems we can see it without opening Pandora's box by asking for a full repeal where hospitals could open pharmacies any anywhere they wanted to I also think there's a lot of confusion about what hospitals do with their inpatient pharmacy drugs and how they by those with their group purchasing or organ arrangements and you may want to ask me about this offline because it gets really complicated really quickly and but I think there is a fear that hospitals will have their outpatient retail pharmacy permit set up in a way to where we get these dramatically lower prices on drugs and then directly compete with those independent pharmacist. For inpatient drugs we get reduced rates right and in some hospitals were able to use our self insured plans to fulfill those impact we use that inpatient drugs and pretend if you will that their outpatient drugs to fulfill the requirements that are employees need I think there is that fear that mixes in with what hospitals can do with how they actually purchased the drugs that they'll be dispensing through a retail pharmacy permit which is outpatient related verses the inpatient pharmacy group purchasing arrangements. And I'm sorry to be so complicated it's not an easy issue. represent Pilkington you're recognized for a question thank you chairman that thank you Judy and Testimony I'm sure you're aware of some of the issues that are going on federally with the three forty B. program center Cassidy Senate he wants to review and potentially get away the entire program especially on the heels of the New York times piece about the fraud that's going on in Virginia with the three forty B. program. Can you kind of just as it is how we make sure that doesn't happen here in Arkansas it is kind of what I'm saying because it's is given a black eye to the program and what I've heard from some people as well as we're really scared that if the hospitals get into this game we're going to see a similar situation in which they're using their indigent hospitals to prop up and build centers either places that could you address that concern share and and obviously that New York times article wasn't favorable for any of us that participate in that three forty B. program and I and and work that three I can say that providers in Arkansas are honorable and they do right with it I can also say that because of articles like happened in that New York times and other places you know this as well as anyone I know your employer also has three forty be issued like you court cooperate with the program and do those kinds of things the amount of scrutiny that we're getting from the federal government has done nothing but increase so her set is definitely coming down upon folks wanting audits to be more and more difficult and more more thorough I think one of the reasons it's not always super easy for a hospital or a federally qualified health center to contract with an independent pharmacy for the three forty B. program is all the additional scrutiny and the record keeping and sometimes just the busy work to make the federal government feel like they're making us do our jobs and I feel like the three forty B. program is one of the most audited programs there is and we have to be very narrow in how we and use those savings we can use them for lots of different things for community benefit but we have to be very narrow and how we can use the savings to make sure that we're not overstepping our bounds nobody wants a black eye. represent Gonzales you're recognized Mr so you said you think there's some confusion in the in house pharmacy verses a retail pharmacy permit so are you telling me that there is no one there is no price advantage if we if this bill passes and you the hospitals have the retail pharmacy permits there's no price advantage for them buying drugs. no Sir there it does three forty B. program is absolutely a price advantage for us to buy outpatient drugs at the reduced price and then to use those savings back for people who need drugs and for the hospital to provide needed services the community would otherwise have there absolutely is an advantage in us using utilizing the three forty B. program to purchase those trucks what I'm saying is not every drug and outpatient retail pharmacy permit can purchase is a three forty the drug at the three forty B. price there are other things that have to happen in the retail pharmacy permit space that are a level playing field. But there is a definite advantage for hospitals over a retail pharmacy for that three forty B. program ability to buy drugs unapologetically absolutely yes okay. Follows. So hospitals aren't known for providing cheap drugs when I can look into bills from from the hospital and you know Donald cost me an astronomical amount so how can we be sure that these prices are gonna be passed along to the consumer and they're not gonna get charged like they are for inpatient you're absolutely right just because care is expensive doesn't mean they're large margins in it I can assure you of that and you're correct an and I think that's why this bill is super important because at three forty B. drug program actually let says sort of for the first time be able to buy drugs at a reduced rate to then pass on those savings to the patient if the patient's uninsured or underinsured and to provide those community benefits I'm not saying your hospital bill go down because those inpatient drug prices are what they are but for outpatient services were certainly hoping that more patients have access to care and believe it or not we actually hope we see less patient in the emergency department for routine care because they're actually taking their drugs when they need to and it hearing appropriately one so we don't get penalized which is all fine and good but ultimately at the end of the day it's because we want patients to be healthy and thriving in their communities. next up is representative will reach you're recognized for a question thank you Mr duty in we heard earlier that of the for profit hospitals that have the ability to have a retail pharmacy none of them do why do you think they choose not to participate. I think a lot of decision making is had when hospitals are trying to determine how they want to be incorporated whether they want to be a for profit hospital and have those standards are not for profit hospital for whatever reason and I do think there are for profit hospitals that will look into how they can handle their own self insured and opportunities in that space I also think for profit hospitals and I will be quite honest I wish they could take advantage of the three forty B. program and that three forty B. hospitals I think one of the reasons the federal government selected then is because there's about a almost a thirty percent higher cost for three forty B. hospitals then for the rest of the hospitals and I'm not necessarily singling it out for profit saying that you know Hey they do things a little bit better but I can tell you that the uncompensated care and the under compensated care is part of the calculation in the formula that helps determine what at three forty B. hospital is and and how it can participate and it's not an easy process to become a three forty process it's it's not as simple as I meet these qualifications alternate into hers and they'll say yes right you have to prove that you're a disproportionate share hospital you have to prove what you're patient mixes you have to prove what whether you're rural or urban it's not an easy process so I think that the for profit hospitals are doing an excellent job at serving the patients who come to see them I think sometimes and it's important to note that the programs designed to help bolster up hospitals at the federal government sort of Hicks as the ones that need that bolstering I'm not saying that are for profit hospitals in Arkansas are hurting right now they are every hospital in Arkansas pretty much is hurting right now especially after COVID and increased prices of personnel and not having an end. Crease commensurate increase in reimbursement from commercial payers and other things that all occurring and but I do think the people who go to three forty be eligible hospitals have their less a fluent and as a population and therefore have costs that they cannot. Cover follows. Recognized so simplistically put it's not cost effective for for profit hospitals I would think that's correct for profit hospitals are excellent at determining and what they need to do to take care of their community and yet still to be profitable. Okay next up is representative Deborah first. Thank you Mr chairman I think I'm trying to understand this because I'm I'm I'm not in the farming of pharmacists so the hospital if they have a three forty B. program then they use that savings to shore up other programs to help treat patients because thank is typically these would be somewhat indigent patients that are three forty B. drugs so if you're if the hospital is doing it in cooperation with the community pharmacists what happens to those savings to the hospital get all those that get to still use those Sir that that's a great question so hospitals and community pharmacists have again excellent partnerships we would not ask for nor do we expect a community pharmacists to dispense those drugs without a dispensing fee so most of the time when hospitals are the covered entity for the three forty B. program right an independent pharmacist or the whomever we're contracting with this dispensing those drugs on our behalf we absolutely pay them to do that and and that's important and they share in in that work and they deserve it because they're dispensing drugs on our behalf to patients who need them. So but the rest of the savings the pharmacist would paid back to you right hand lane each contract is different on how those shared savings programs work but I guess if the hospital had their own pharmacy doing the three forty bay then they would capture all of those savings to help pay for services in the hospital that are uncompensated or fully compensated is that that's right that's right and hospitals alike to be good partners with community pharmacist and that we do have for grandfathered in I think you all know this for grandfathered in retail pharmacy permit some at do three forty be more robustly than other summer just kind of get started in the program and one of the things that I've heard at least from one in particular is when the independent pharmacists can't get the really expensive drug and I keep using cancer at as an example but when it when independent pharmacists can't get that really expensive drugs the hospital can through its retail pharmacy permit and so that's patients don't go it don't have to go without access to that. All right of reserve road you're recognized thank you Mr chairman. Regarding the. three forty B. arrangements and that the process correct me on the language if if need be but of the retail savings or earnings whatever the differences have you wanted term that. would you agree or do you anticipate that patient savings would utilize or represent the majority of that I think that's going to depend on the patient payor mix and I'm not trying to be cool way with my answer and patients who are insured are going to feel the same right they're not gonna be treated any differently whether you have a retail pharmacy permit within a hospital or somewhere else I think access for patients who have no ability to pay will be increased I'm not sure about the majority statement because it will truly depend on the patient mix for that particular hospital it's very possible that a patient makes for that hospital has and let's say. Thirty percent of its insured population is covered right and but fifteen percent who come and have no coverage whatsoever and so we can offer a rebate cards or do other things in that space to make sure patients have that access if the case is that sixty percent of the patients in that community are insured and there's more savings there that hospital can absolutely do more robust things in the community like labor and delivery right like buying equipment like having more more people there to serve the patients I can say unequivocally unequivocal plea that a hundred percent of the three forty B. savings goes to patient benefit. Follow up. Is it thank you and I think thank you mostly interested just seventy said the one hundred percent but my next question was to if it doesn't go to patients savings where do the funds end up going and its community benefit it's binding equipment doing things that are not one on one it doesn't help representative road particularly you but it helps the community overall because you have a service line in that hospital or in that community you wouldn't otherwise have. Thank you. representative Graham what you're recognized for a question. Thank you chairman So I've heard readmission and how these retail pharmacies will help lower readmission rates they are currently reads some grandfathered in retail pharmacies do they have lower readmission rates than. Others if so how much that's a great question and I don't know the answer but I promise I'll get it back to you the for grandfathered in hospitals are and hospitals that. See a lot of patients who need a lot of care UAMS Arkansas children's hospital Jefferson regional and Baptist Little Rock or the four grandfathered in permits so and again it depends on their patient mix in their severity because you can't just look at regular real rates well you can look at rates but you can't look at regular old numbers of so if you don't mind I'll come back with you to you with that answer. Yeah I I understand and and obviously that would be the date was seems to be difficult to grab but I would I would figure that there are individuals that don't fall under that high intense care who go I mean that just seems like it could be a powerful piece of information for us yes. Thank you for making me feel unprepared. represent Richardson you're recognized for a question. Thank you Mr just for my own benefit still navigating some of this stuff to all of these hospitals already have an in house twenty four hour. Seven days a week pharmacist. Already there you mean from an inpatient perspective well I mean you work without an inpatient outpatient there's always I mean there's a lot of different pieces here but and I'm assuming that if there is a pharmacist on board twenty four seven whether that's inpatient outpatient whatever patient that they could service both sides whether be retail or not and maybe you can correct me on that one I'm just curious how many hospitals have twenty four seven pharmacies so most of them have at least twenty four seven on call pharmacist there are some of our smallest rural hospitals who may not have twenty four seven person in the building but they have the ability to get all those drugs there in the pharmacist in the room who are my health system pharmacists experts can correct me if I'm wrong there and but for inpatient use an emergency department use absolutely there's a pharmacist there for patients to come in when patients come in this bill is pretty separate and that it's really an outpatient retail pharmacy permit that folks are looking for. VOL. You're recognized. This is so it if this bill passes they hospitals will not be able to leverage the current staff that they have all they will have to have the staff it depends and sometimes they'll be able to leverage the current staff that they have and for probably the larger facilities they may need someone else to run their outpatient side of things apologies for not understand it was a personal question. All right seeing no other questions thank you for your testimony. Of the last person signed up to speak for the bill. It's the most beautiful name I've seen. And I know I'm going to butcher it. At Senate better myself. So my name is agents on I'm a pharmacist at Baptist hospital Little Rock or so in Arkansas licensed pharmacist member of a PH a H. P. L. houses the pharmacist sector so I am really here to tell you about the patients we're able to help because I am unfortunately from hospital that has retail pharmacy so. We I just wanna tell you three quick stories that we have had in last a couple of months. So first one I want to tell you is a patient who came it was of a new board a mother with a newborn who came into our E. R. because she had mastitis and see it was Saturday night and see cannot bind the pharmacy that's open and I heard from our you know our community partners that there are whole programs they can contact you but they couldn't find anybody to fill her in about experiments that is then she said she had to the closest one that she bond was out in Searcy I believe and she didn't have to drive to search with a newborn with mess that is so she came into the yard to get the medications so that within your visit and that was what I want to get if they could have babies at home too but step we were able to help the pace and and get the antibiotics and so to go home so I think that. Having the ability to help the patient what's very helpful for that patient and I wish we didn't have to have an ER visit to you know for the patient to be helped another one I want to tell you is about a patient who had a heart condition and supposed to be taking a blood thinner but he thought he didn't have prescription coverage so he came in with a blood clot so we treated the patient but at this tardes we work together pharmacists and physicians we work together to come up with a resume and that patient could afford because we were under the assumption that picks and couldn't afford any medications and Payton wanted a medication to be filled at our on site pharmacy to be delivered to the bedside so they work together sent the script but then our retail pharmacy figured out that the patient did have praise for prescription coverage patient in real life stack so but the pharmacy was going to help that patient no matter what even if they didn't have the prescription coverage that we're going to help the patient to fill the medication and I have that in hand because they didn't want the patient to leave with treating Claude ample also heart condition and have to come back because we've seen studies that show that when patients leave the hospital with their medications they're less and less less likely to be readmitted. So out. Helping that patient and I think also made us realize you know we were able to bill for those medications so that we were reimbursed for that medication so now we can help the next patient who truly didn't have insurance and they could walk out as well with their medications and we do have an internal study that we did because it is costly to run an operation pharmacies not just free operation because it costs labor costs software because technology all those things do cost we did internal data where patients utilized are met to that service do they have that are they are less likely to be admitted and our own data so that they were less likely to be admitted so I can't tell you exactly how it compares to all the other hospitals because this is a patient will they have to ask us to participate in this program they don't we don't just bring them medications and it's their choice and when they chose to participate they were less likely to be admitted and based on our internal data of the last story I want to tell you is about a we had we have to transplanted patients who are on anti rejection medications and they were on the part of a manufacturer patient assistance program and that program appearing ended January of this year because many factors can just do that Monday one to pull the assistance programs and they did not have an ample time to switch the rejection medication get on different medications different things different reason stayed not could the for their co pays so they asked us to help the patient and as we all know that we can't just wait the copay because that's the the contract and so our hospitals able to provide medications at no cost to the patient because we don't want the patient to go through rejection and that's wasted healthcare dollars and that's wasted quality of life and that's another or somebody else could gotten so all we have two of those patients just last week and I think there might be more so those are the things we were able to do because we did have retail license that we're able to provide those medications at no cost to those patients. So that's all the stories that I wanted to share. Thank you ma'am do you have any questions from committee. Seeing none we thank you very much for testimony. Of represent Johnson. You're recognized close for your bill Sir. Thank you Mr chairman and committee I'm glad that we ended with that testimony because I want to thank for review and comment about who's testified today we've had independent pharmacists who run their own pharmacies we've had employees of hospitals we had pharmacists who employees of hospitals come and testify what you heard here deandre stories about patients stories about the difference it is made impatiens laws with having a retail pharmacy permitted some of these not for profit hospitals are grandfathered in this is about giving that opportunity to other hospitals in the state leveling the playing field between hospitals in the state in making us in line with every other state in the union again we're the only state with the complete prohibition on not for profit hospitals have in retail pharmacy that makes us stand out in a way that I think is telling in something that we need to try to correct and so with that I'll close my bill appreciate a good vote to make a motion to pass. I have a motion do pass is there any discussion on the motion. Sam none all those in favor say aye. Is no. Say the nose having said that pretty line. Thank you for this and all that testimony percent the time we are going to try to meet till about five o'clock we have a lot of business take care of my preference would be to meet this afternoon as long as we can and hopefully want to meet on Thursday afternoon because we have a lot of bills to try to get to representation fair to run. House bill ten eleven. Okay you're recognized. this is very similar to a bill that we passed earlier about depression screenings for postpartum women this is a different screens for pregnant women so before I have the baby no direct impact to general revenue no impact any of our funds as well sequel report came back as zero so non controversial no opposition to it yes this is also a time were able to screen for depression and these women to try to have better outcomes and with that And then the questions representative. Seeing none representative closure I'm closing the commission do pass mostly passing discussion on the motion. All those of favour say aye. Posed. Graduation patch bill we got my phone on the back with the charger swell resented Vaught are you here. Recognized president house bill fifteen seventy four. Absolutely she's come to the table in addition so. Thank you Mr chair. DM Vaught District eighty seven. You're recognized yes introduced and I'm in a strong and executive director of the Arkansas chapter of the American initiative and yes Sir okay. The text. Are you a second you're recognized thank you Sir as many of you all know this past year we've done a mental health working group in that working group we had a bunch of sections that were broken down a I actually was over the The children part of it. Prevention early intervention prevention early invention that's correct thank you look I'm sorry I lost my spot and and the reason that I think. Finding children sooner rather than later he might have developmental issues in which they need to Get help with or if it's something mentally that they need to get to help with that five the sooner we can help those children the better off they'll be I think we could actually have a lot of kids learn how to cope much sooner with issues that they have going on in their life if we started so inner our group came out with a lot of great ideas with several different topics you know around screening for behavioral health and support families with young children during the important early brain development that happens from the age of birth to three years of age I'm excited to share of a bill that helps with both of these issues and it's proven to save money for Medicare program it's at this bill would support primary care clinics who take the extra step of implementing programs like healthy steps that goes beyond basic care and if you want to kind of see what healthy step says that's the handout that we handed out to you all just so you know. healthy steps is one example of this kind of program already operating here in Arkansas healthy steps in bads an Exter staff person I healthy step specialist in a primary care clinic the specialist is in early childhood development expert who have screen off families with infants and toddlers for needs lack of child development maternal depression and food insecurity the specialist provides short interventions for the family and works to connect families in need of two existing community programs and have hot to have positive outcomes the specialist make sure families don't fall through the cracks which is so important when you're talking about people especially out rule Arkansas this bill would provide a framework to build a substantial and sustained a sustainable pathway to healthy steps programs like it in a partnership with Arkansas Medicaid we currently have seven healthy step practices already in Arkansas and and a concert a little bit more about the information and how this has impacted this program has impacted the state of Arkansas. Thank you representative Vaught and I just want to give represent representative I sat out she has been sent to a champion for that the idea and the concept of prevention and early intervention and we do have to start early and really work comprehensively to support the needs of kids and families in our state in thank you Mr chair thank you for committee for the opportunity to be here so I mentioned I'm the executive director of the Arkansas chapter of the American academy of pediatrics and we represent about four hundred and fifty pediatricians here in the state of Arkansas I'm also lead partner with excel by eight which is a local organization that works to improve health and education outcomes for kids prenatal to age eight in Arkansas and so we're really excited to get to work with a representative of all right to hell and and with DHS Medicaid to help develop a framework to support families with infants and toddlers in any way through primary care clinics in Arkansas is that this bill outlines a general structure and timeline to support the optional cost savings more as an optional model for practices but they can put this new team based modeling into care in their practices many programs are already having a significant impact on families with young kids here in Arkansas. Amendment that was made to the bill insures that the bill comes at the opportunity to work with Medicaid on the administrative side to make sure any investment in this program is budget neutral and to work with existing programs like the patient center medical home to do that and the supplemental rate of payment approach in the bill is really narrow in very specific to the clinics who gone the extra mile to implement this program under achieving very specific quality outcomes and achieving cost savings in this work and to make sure that the program can be available even in rural and underserved areas where there might not be licensed professionals available you can train like community health workers or other types of early childhood development specialists to do this work and so healthy said healthy steps like representative Vaught said I really transforms the way pediatric clinics care for families with young kids you might not notice that the that pediatrics and primary care is one of the only systems that serves almost every child before they enter school and the kids have about it more than a dozen well child visits before they turn for and so those frequent visits allow the team of pediatricians nurses in early childhood development experts to really intervene early and check in often when those problems become apparent which saves money and helps to really support child development is critical early years so I'll just wrap up with a couple stats about what's happening so far in Arkansas since the first healthy steps clinic in Arkansas launched in March of twenty twenty two so just about just every year ago healthy sepsis served over ten thousand infants and toddlers in our state from in communities from Rogers to hot springs to Jonesborough here in Little Rock and they are helping the seven primary clinic primary care clinics transform the way they care for infants and toddlers and some of the top needs that they have found there's a ton of data collection that goes along with this they're helping address food insecurity early intervention for a child's physical and behavioral development maternal depression access to affordable child care and quality childcare and more in this all impacts entire families we are really excited about. All what we're seeing with this and as you all know when when these issues are not addressed when we have unmet needs and physical health and other things family needs mate ria really derail a child's ability to enter school healthy and ready to learn but it also costs more to the state and to those families. input from our members our pediatrician members had really who implemented this program says they they just really feel like they couldn't go back to the way they were doing care before they can more comprehensively addressed the comp complex needs that many families have it lets them dig deep on issues like baby sleep concerns managing tantrums transportation parental substance use or even one time task like helping a family sign up for weeks so they can have healthy and affordable food for their child. and then like dolls like the representative Vaught said don't have handouts to talk a little bit about the way practice might have handled this before and then what that extra capacity that comes into the clinic helps to bring and to help health care givers problem solve the mood moved toward financial success and system instability so I'm like we mentioned all wrapped up with this covering the cost of healthy step saves money with and Medicaid program within one year every dollar invested brings two dollars and sixty three cents back to the but back to the Medicaid program and as in other states and this model is being looked at in many other states as well in a statewide since sept we are really appreciative to you for like hearing this and thanks for your time today I'm happy to take any questions thank you are there any questions from committee the first recognized for a question. Thank you Mr chairman who is this primarily a part of children's hospital program now healthy steps this administering healthy steps it's actually mostly community based practices we have practices in Rogers and Springdale in Fort Smith and then we have a couple in Little Rock one in Jonesborough and one in hot springs and so those are for the most part those are community based practices in a nightly and they're not children's hospital a couple of them are affiliated with Arkansas children's so we we have in our of P. to fund and administration of this healthy steps program trying to figure out where we go from here right now it is grant funded of Walmart foundation and the blue and you foundation both invested and and this program to help do a demonstration project for several years and you know ideally we will if we build this supplemental rate into the reimbursement that practices already already getting for well child visits they will be able to sustain that program and looking at private insurance as well as because it is a universal program that supports every kid and family with an infant or toddler that comes to that practice that helpful it may ask for it and at the reading the bill the physician has to already be enrolled in the patient center medical home is that is that correct that's correct on the Medicaid side we've just just to kind of keep it within a program that's already looking at quality already you know and already is looking at different types of payments that was something that DHS had requested when we were happy to do that I'm sorry but maybe Pilkington content with this has this going to coordinate with the passes. you know they're honestly not a ton of family of individuals under the age of four is this really focuses on families with kids under four and I think there are very few people under the age of four in the passes to my understanding. Okay. Represent Pilkington you're right. Sorry if I answered on your bed presented looking to. The questions from committee. Seeing no other questions. Facilitating. However yes may speak for sorry since his per here doctor Burke. Yes I did not mean to leave you out you've waited patiently is given the opportunity to speak thank you doctor. Hi good afternoon my name is Dr Natalie burn the general pediatrician here in private practice in little rock and I just wanted to share a little bit about my experience with the healthy steps program I've had the opportunity to implement this program in the last year in my practice and it's really been transformative so as pediatricians we do know that family needs things like food insecurity transportation difficulty parental mental health substance abuse issues like that really have a huge impact on our families M. prior to having a healthy step specialists in our clinic we might be able to screen for some of these things but we really didn't have a good network for referrals and we really didn't have a great way to follow up with families even if we did make referral so we were really often left feeling helpless and unable to address a lot of our families most pressing needs of now that there's a healthy step specialist which is what we call this the member and our clinic now that we have that in our clinic and they can address these needs with families at well child visit sick visits and in between visits so there really vital to connecting families to developmental and behavioral services so for example if I have a kid that comes in my clinic and I think gosh this kid M. is having some developmental delays I'd think this child might have autism I'm going to place a referral for intervention I'm going to replace a referral for evaluation I won't really know if that family followed up on that referral until I see the child at the next check out that could be six months from now as we know in this under age for Group six months is a long time to miss out on any type of intervention or help that these children could be getting with the healthy step specialist we're going to follow up with those families within a matter of weeks if they didn't get to the evaluation if they didn't hear from you know say it was consortium we're gonna find out why families phone numbers change often unfortunately you know another thing is you know maybe they couldn't get to that appointment so what barriers are they that we can help with. the healthy step specialist actually will come into the patient rooms and meet with the family and talk to them about what their concerns are and what they can do at home just a specific example that I've had come up a lot my clinic is my foster families so I've had specifically about a year ago a patient come in and he had recently been placed in DHS custody he was about seven months old the reason he was placed in DHS custody he was in a car accident with his mother his mother did not survive the accident I'd seen the patient for a new one visit and then he was lost to follow up he didn't come in for two months four months six months visits he missed some specialty appointments including cardiology and really there was a lot of catching up to do for the grandmother that he was placed in the custody of she herself was disabled and hard of hearing so you can imagine she was pretty overwhelmed by his needs and the needs of his two older siblings so are healthy step specialist really came in and came alongside her and helped connect to specialist she helped within rolling and child care she helped with we can roll that she helped with communication with the DHS case workers getting the two older children and behavioral therapy and also trauma informed therapy these are all things that she came in and this help this family with over the last year so this is an example of a family that would probably use the services over the whole three year period however sometimes you might have services that are only needed for a shorter period she follows are healthy steps specialist meets with mothers who feel their maternal depression screenings and make sure that they're getting plugged in with behavioral health services they also connects you know with local resources in the community so now we have a pack and play which is like a portable crib for those of you that don't have kids and we have taken place in our clinic that we can give to families that don't have a safe place for their children to sleep we have resources even some materials for breast feeding to help families established breast feeding and connecting them to wait counselors for breast feeding sometimes all family needs is one visit hello. How do I sign up for which how do I sign up for our kids other times they need a lot of different services over time but all of these connections are important to improving the well being of my patients after being a part of a healthy steps practice for a year I really don't think there's ever away. That we could go back I mean it would just be a total disservice to our patients and their families if we went back to the old way of doing things I really think that this program without a doubt is improve quality of care quality of life for my patients and families and I think creating a sustainable programs in Arkansas would really be transformative for pediatric practices and also the families we serve thank you. The questions thank you for your testimony thanks review body ready close your bill. Thank you Mr chair and committee again This Is. Something that everybody could have in their tool belt to help with more than just one issue that might be going on in a family maybe the family does need wit but maybe they also like she testified about need behavioral health or maybe they need developmental help and this program helps do that so I with that I would appreciate a good vote. There's too many motion to passing discussion on the motion. All those in favor say aye. Opposed Gretchen gradually she passed bill. He. Without objection roulette Senator Dismang presented Senate bill. Three of six and then we'll get back to the order of the agenda Senator Dismang you're recognized thank you Mr chairman committee members for allowing me to go in percent we do have an amendment The representative has if we can go ahead and get that signed out. In doing present the amendment to solicit which shows you what you know essentially this is an agreement that was reached between the executive branch and second floor and us the sponsors at as far as amendment four of the bill thank you still creates plenty of opportunity for Kansans to better their situation and and hopefully help pull themselves up and out of poverty so just quickly the original bill stated that essentially you would be able to have assets that would not exceed six thousand dollars I'll talk about that a little bit later when acts presenting the bill this is been changed essentially say that you could that they will request a waiver that two thousand and it is by the way for everyone in this room currently two thousand two hundred fifty dollars would be stilled asset limit for those coming on the program for household however there would be a temporary waiver for that family so that they could exceed that threshold over the course of the year so they could accumulate savings and again hopefully create some opportunities for Arkansas families to get out of poverty so that that that limit of what they can accumulate cannot exceed more than five thousand five hundred dollars which is essentially double what the federal amount is again even though we have not adopted rule or still two thousand twenty two dollars here currently so with that that's the presentation of the amendment. Members are there any questions on the amendment. C. nine a motion to pass all those in favor say aye. Posed graduations pass amendment you may proceed to present the bill as amended all right that thank you Mr chairman members just real quick I'm gonna talk a little bit about this issue because I think it's important for you to have full perspective of of what we're talking about when we talk about snap number one there are very already very stringent work requirements for folks to be able to stay on snap in again once they exceed those thresholds they're no longer participant and those are very stringent and if you're not working or not meeting the requirement to be in school and at on the Senate I passed out the what you look at online it would make a little more sense but you would also have to register to work so again it is already very stringent that we're insuring that these people are trying to find jobs and fill positions there's some exceptions for the elderly and discipline those other disabled as you would expect and there is a different different asset limitation for those individuals but when we talk about assets lots of people like to say that that savings that is in fact not what we're talking about it is the asset value in that household there are certain items that are eliminated from that so your home doesn't count we're asset value your first vehicle in your home doesn't count your asset value but your second one does and that second one must be used to take you know for someone to go to and from school or to go to and from work and it cannot be worth more than four thousand six hundred and fifty dollars okay none of us can buy a vehicle for four thousand six hundred fifty dollars so if you buy ten thousand dollar vehicle to send your kid a living believing your senior could you see a to have safe represent transportation back and forth you are above the asset limit so you're above your that ten thousand above the four hundred sixty or four thousand six hundred dollars and it reduces what you're able to have in savings that two thousand two hundred fifty dollars so again you would eliminate yourself from the program buying that vehicle for your child to be able to go to school at UCLA I don't think that was ever in our tent I think there are lots of issues with the program the way that set. Up right now we have an amendment in place I don't think it's perfect but I do think we should have a bigger discussion about what we do moving forward we should not discourage people from savings I think it was a study that was done in two thousand thirteen by the heritage foundation one of the number one things that you can do to ensure that people are moving themselves out of poverty is allow them to save and creating a program that that encourages a spend down in a family that in that discourages savings is a problem one that encourages high interest rate loans to be able to buy vehicles because again you're not even able to save enough to buy the four thousand six hundred fifty dollar vehicle under the program essentially you are required to borrow to buy a vehicle at a high interest note typically because folks in lower income levels have up higher or lower credit scores and and higher interest rates but with that again we think we have an agreement on the bill I'll stop I'll stop there and we have to take any questions. Members of the questions for Senate is going to be Bentley you're recognized. Sir just means so what is the federal level right now for asset limit the federal levels two thousand seven fifty dollars but we have not adopted the rule that would move that to that two thousand seven fifty dollars so we are at two thousand two hundred and fifty dollars. And I'm quick follow up some I'm sorry this is late in the day and I'm trying to grasp all this entrances and also We're going to allow a family to have five thousand dollars for a one year because I know we really have to reapply friend is able bodies are not talking about those are disabled or elderly this bill working and have a job have to reapply every in Arkansas over six months correct you're right and they would be able to to have that higher accumulation for a one year period and they're only allowed to do that one out of every five years before they would be able to get back into the program. Okay that's all for now thank you. The questions from committee representative road you're recognized thanks thank you Mr Educate me a little bit Senator with the asset limitation what happens a one of these families it's an income tax return and it's five thousand dollars are they immediately disqualified from qualifying for these benefits I think what you saw was them all spin down very quickly so that they maintain their qualification inside it again I think it's a. I don't know how to spot check works with BHS now the utilize the program but I think meant the reports that I got back from individuals was that was a pretty quick Smith down honestly there's been a lot of it at the grocery store and that was for DFA when we're talking about collections and what we should expect on the state level for those refunds coming in or those credits that were coming in honestly the state didn't collect a lot of that because it foods exempt and they were spending on food and grocery stores will tell you they were spending that money on food follow Mr you're recognized the reason I asked so I have a small car dealership and up until. Twenty twenty and everything that's come along with COVID I was more or less specialize in selling vehicles under four thousand dollars cash out in finance didn't didn't do any high interest of we still do pretty regularly sell vehicles now for under forty nine ninety nine that's my sales managers in me some information on some of our most recent sales you said none of us can buy a vehicle for forty six hundred dollars that may have been a little tongue in cheek but also as a that I sell vehicles for under that pretty regularly their their quality their mechanically sound they may not be perfect they may not be a Mercedes Benz that came out a year or two ago but they are good transportation I work with people in my church for number of years to trying to be fiscally responsible and so for me. I just want to maybe argue that point slightly if you can receive your income tax return because everybody in the auto industry knows that that's peak time for selling cars whether it's a down payment or purchase of the vehicle if you're able to receive your income tax law people save that are utilize that to buy a vehicle there are vehicles not tons but there are vehicles for under five thousand dollars that are mechanically sound so I would simply say from my perspective I believe that you can utilize those funds you can purchase a vehicle Would you agree that I'm correct in that senator Payton would disagree and that and so that's to that was my reference point actually he said the cheapest car that you can purchase that would be semi reliable you might find one for five but don't expect to find one for five minutes if you knew or you're looking into what you're doing and again I'm not I mean I'm not in the used car business I'm I'm just gonna tell you when I was out looking for vehicles for my sixteen year old and find something arrival at his he drives in nineteen ninety seven vehicle it's it's difficult to find one in that price range and again that we are about that if you'd like I don't think it has any impact what we're talking about now but if you'd like to we can I don't argue the point but I will say that I am correct senator Payton is not here and I would challenge amend that because I work with other dealerships in my community that we focus on providing for bill automobiles so I'd be glad to have that conversation but since it's being said that I'm incorrect I wanna say that I'm I disagree with that I guess I appreciate your position as well and the threshold is very close I agree to that okay. Representative Richardson you're recognized. Thank you Mr so my my question really revolves around perspective and data points associated with savings you you stipulated that that's the primary driver here is that we're trying to get these individuals to save more so that they will draw themselves or pull themselves help themselves out of poverty what data supports. that's providing them a long term food stamps or snap program will actually incentivize them to save more no I don't think that's the argument I think the argument is if we have a program that dis incentivize savings then that's the problem committee you can pull up your phone right now statement just Google poverty and savings and is going to be article after article after article about how critical it is for safety nets to be built for those in poverty because that is actually one of the major steps of of pushing pushing them out and so that I don't think I'm I'm not trying to correlate an argument that people should just you know perpetually be able to save and be on food stamps I'm saying they should be able to save a reasonable amount to be able to have a backstop for their family because that again I think it just helps them prepare for whatever it may be it may be the first and last month's rent a better accommodations or a rental property or or many many different things which is hard to achieve with a you know a limit of two thousand ten fifty dollars and then also taking off whatever else you may have an assets that would you know take away from that. Follows recognized for follow up it's so you the point is. The current program as you see it reduces the likelihood would say it absolutely yes but you don't have any evidence that would suggest that increasing that asset limit would. Incentivize them in anyway so I I guess I'm trying to follow in the way the disincentive to safe I think that that's that's the point I would be are you in completely different we we having a very different conversation if there were no work requirements in place in this program so I talk to some national folks that that deal in this very conservative by the way they would tell you that is what matters the work requirement is what matters and if those are in place and those are working which by the way got into the bill on the other end that to help tidy up some of that then that's what matters not not these asset limits and that's why you see I think it's forty two other states are above this federal amount I mean in a vast number of states have no asset limit whatsoever non advocating for that I do think there should be a spin down that would be required before someone going to the program and again we're not. Even really on the bill even at this point the way that it's been re written but I don't think we should create an incentive for people to spend everything that they have so that they may maintain benefits so Milton Friedman would go on in and talk about going to you know listen what he says it wasn't really the programs that he was arguing against he was with the programs created and the behaviors they created and I think in this particular program we are creating a behavior that fosters high interest rate loans that fostered that dis incentivize savings and those are to the primary issues that people find themselves in the cycle of poverty. You the questions risorse you're recognized for a question Mr do you do we know how many people almost that benefit now or are at that Max that I'm. I do not. So if we don't know how many or are taking advantage of that much then what's the what's the point and and raising it. Above that it and we're not at this point all we're doing is that on them if they come into the program thank and they qualify and all we're doing is saying Hey if you're doing everything you can improve your situation we respect that and we want to encourage that and we're going to let it is safe to do that that that's all that this the way that is amended right now and it again. Do I think a lot of people are going to take advantage what we're doing no because number one I think the average individual or family household on food snap on this only on for six to nine months so it's not even I mean we have a I think a very gross misunderstanding this program and I look for to have a conversation about that more in the future. But but at this point all we're doing is saying you're gonna come on the program the qualifications that exist today and when you do we're going to allow and reward you to save if that's what you choose to do. The the the questions from committee. This review Miller you're recognized for a question. Thank you Mr chair of the center so it just. I'm trying to make sure I'm clear on this amendment. This state is changes nothing whatsoever with the asset limit other than. Basically and I'm paraphrasing. You're saying that DHS or whoever will go to work go to bat for the individual if they're meeting the work requirements and keeping your nose clean and doing whatever it to get a A waiver for an extension. All this has to be approved by the federal government so that the state will have to seek a broad based waiver from the feds to allow this type of program which does not exist in any other state so there's no even guarantee after the passage of this bill that we're talking about doing is going to be granted but it would allow them to request a waiver that essentially says when someone gets in our program we're going to allow them to save up to five thousand five hundred or five hundred dollars. Before they would lose the benefits and they can do that over of course of the year and they can only do that once every five years. I got you so is that what this amendment is there any Is there any asset limit for that let's say that this does happen federal government okay is it you're going to have you know. Let us say Josh Miller we're does real good and I go to work and I'm a good boy and and and and your let me keep my food stamps and then of at the end of the deal. So okay we're going to we're gonna give you waiver how I mean how long how many chances do you get if you get one year every five years it would if you were to have to cycle back in the program I mean you it's it's the only to do this once every five years so essentially you're saying you're going to get to save up to five thousand and that's not even with the amounts going to be by the time you take your the deductions but you're going to be able to accumulate a hassle of asset value of five thousand five hundred dollars it paid one of things to keep in mind because. I'm not concerned about the single guy that's twenty three that loses its job goes implies for food stamps but guess what he has the exact same asset limit as the family of four the single mom with three kids that's not right I'm not asking to change that but that's the current construct that we have right now. So. Anyone with that I'll be happy to take any other questions are there any other any other questions from committee to stop. All right C. N. nine. we have one. Person signed up to speak against the bill. neck cord. Please identify yourself for the record. Thank you Mr chair new cordon with opportunity Arkansas action. You're recognized forgive them just gonna pull up my notes here had to rewrite my testimony after the amendment Thank you members of the committee and Mister chair for the chance to to speak to you today I'll keep my commentary briefs I know many of you already heard from me about this issue but I did want to speak just briefly to the amended version of the bill for those who don't know me my name is the court and and I I represent opportunity Arkansas action as I said before that actually works for a national think tank and served as research director specializing in welfare policy including food stamps so I've testified on these issues. In states across the country engage significantly during the last congressional debate on the farm bill and even worked closely with the trump White House as they work to reform food stamps during the trump administration and my current organization opportunity Arkansas Works to simplify government and sol generational problems for the next generation and so a big part of that focus is reducing government dependency which I think is a generational problem here in Arkansas and while I do sincerely appreciate the work that's gone into the amendment and I think it is safe significantly better than the original version of this bill that was proposed I do think it still moves us in the wrong direction as a state I think it moves us towards more government dependency it also introduces more and unnecessary complexity into the program and so I'll just briefly touch on for things and then I'll wrap up first I would say that I think any expansion of the food stamps program is wrong for Arkansas I think even with this amendment should the waiver be approved which is in question the result would still be an expansion of food stamp benefits albeit for a smaller number of people the second thing is that that I've seen there is still no fiscal note on this bill and there will be some state associated costs with this as well as certainly federal taxpayer costs which I think we should all care about be concerned about thirdly I would say that the waiver outlined in the bill is. Unprecedented it's of questionable legality I would say to my knowledge having worked on food stamps in numerous states across the country there's there's never been a waiver like this that's been that's been done or granted so I think we we don't frankly know whether or not this would even be approved. and then finally I would say you know this revised program of letting people hit the asset limit and then giving them a year and then maybe letting them come back later the the implementation and the complexity of that I think would be frankly difficult to administer for for the state and for DHS and then the tracking of monthly assets that would have to happen in the provisional yearly period I think would be would be complex so while I agree with the stated goal certainly of wanting to help people climb their way out of poverty and save money and transition out of welfare dependency as quickly as possible even with the amendment I fear this bill falls short of that goal I think it would extend it would extend the length of time some individuals could stay on the program NO worried that it would open up the door to future expansions of food stamps in the in the future so too because I would just say I think the best way to help people that are on the food stamp program transition from dependency to independence is to keep the the asset limit low and and keep it in place where it stands that gives certainty to people that are in the program to taxpayers and to the state agency that has to administer the program thankfully current law which this law would at least partially change provides that clarity and that and that certainty so again I appreciate the work that was done to address many of the problems that were in the Senate approved version of this bill but I still feel that the best way forward for Arkansas would be to leave our current asset limit in place as it stands thank you. Thank you are there any questions from committee. Represent Gonzales you're recognized thermistor you stated that the you're not aware of any other waivers similar to this the sponsored stated that other states have a higher limit did they have to get a a waiver to get those limits so they do use that they do use the same broad based categorical eligibility waiver but this idea of tacking this on for like an extra year of benefits just temporarily for some people to my knowledge that has not been that has not been tried okay thank you. Like to hear from DHS at some point whatever's appropriate. Of. Mr why come on up. Please identify yourself. Thank Mister Clark what form Human Services. So I just like to know if the employee implementation of this would look like on from DHS standpoint as far how do you how do you track these asset limits and then track of somebody has been on the program or all for five years and can get back on what was second look like real. Sure we we have a was a relatively new in red eligibility system that manages the stat program this is not too dissimilar from the things we already have to trek around snap snap is I'll tell you is one of the most complex regulatory schemes ever designed and so USDA is not known for making things easy just to be just for you for a blunt about it so with that said this is not very dissimilar from what we already have to track because like with work requires for example there certain requirements have been met and if you don't meet in one month then you had me for the next thirty six months or otherwise you potentially lose your benefits so that's that's that's that's only we are equipped to handle and track. AS in bail seven questions for DHS. Represent water just so you're on the list if you have questions dates okay. Anybody else all right thank you Sir You are recognized to close your bill. So I kind of want to tell you all what this really how this is really affecting people in your area in your district. A lady nearer my district was trying to save up enough money to go to be a nurse which is what we all want people to do right get a job I would think all of it by this table would want that she saved up the money so she could pay for her rent because she knew she was not going to be able to pay rent for four months because she wasn't gonna have a job she was going to be doing school her clinicals. She did not because she had saved up she was hurt by this because when she saved up she had too much money to try to pay for her of her rent and therefore she couldn't receive any of her snap benefits at the same time we'll talk we're not talking about people who are just sitting around on their Tisch's trying not to to work to get snapper talking about real people who are truly trying to save money to better their families that's what this that's what we're talking about we're not talking about a dead beat is not working we're talking about real people who need help this is not a handout it's a hand up. It in just to do not not labor too much more but I mean one thing that we talk about the complex of the system one thing I would challenge each one of you to do because I had a because my name was in the paper so shared with this is a man's been trying to figure out how to fill out his snap benefits he was seven years old. He called and said. We talked about this is so I pulled up first time I've ever seen it. I feel that some this complicated tax returns that you can fill out. And I couldn't fill out that form because there's not enough information to even define what they're asking for different places in that form. I mean it is a complex system and lots of people just get deterred but you know it it's hard to follow it's hard to process it's hard to be a part of but but with that I just say that. The committee was stated that. This means Arkansas in the right direction a wrong direction I'm sorry. What I would say is it news families in the right direction again we're not concerned necessarily about the single guy that's at home you know it in a two thousand two hundred fifty dollar cap on his assets but I am quite concerned about that family of four I'm quite concerned about that family for that's a single mom that's got a sixteen year old kid the trying to buy a car for to drive back and for the high school every day. And I think we should do everything that we can to help those people lift themselves up out of poverty I think we should create opportunities in Arkansas for those individuals those families in those households to better themselves and if we see road blocks in our programs. And I don't think anyone of this with our common sense would see anything else this is being a roadblock we should remove them. And with that I'd appreciate a good vote and thanks for your time this afternoon. You're recognized the strap motion watch motion. Two. As amended. All right we have a motion. And Committee I think we need to discuss this motion. For a little bit so. If you have a point of discussion Richmond. You want to discussion. You're recognized. This being the chair. I had a request to the chair. You can we take a five minute recess to wait for members that are in a medical emergency at the moment to get in here as a. And absolutely will recess for five minutes members I would suggest that we just a. Stay in this room and allow them to do what they need to do out there and then we'll get it back up thank you Mr thank you. I don't know if you do that. Yeah. We will call this meeting back to order. Per share based patients be kind of a crazy into the Long crazy day already forget all the members back to the table. Trying to reorient myself to where we were my apologies again for having to step out as I understand it we have a motion on the table do pass. As amended. Their discussion on that motion anyone has any discussion. Okay no discussion on the motion all those in favor say aye. Oppose ayes have it. Graduation pastor bill mistreatment committee members.