Public Health, Welfare and Labor Committee- House

Little bit. President of a being here that we've got a full day this morning I'm sure they'll be more members filtered in as we go without objection members will take a few things out orders are going to if we're gonna hear a resume berries bill first before we hear representative fights bill house bill twelve thirty four person may bear you here. So you're ready present house bill eleven oh three. Do you have something to pass out to understand given amendment as well I do have an amendment if we could adopt that first sure sure you're you're recognized presenter moment. UP members will get a little bit more into the bill in just a second with our our presentation but the original bill of was for universal home visiting I narrowed it down during the session to include ten counties and this amendment actually narrows it down even more to the very smallest pilot program we can possibly do on. This type of universal home visiting program so this is the smallest of fiscal impact. That we can have and I appreciate a vote to. adopt this amendment so we can talk about a member's any questions on the amendment get a motion dot the amendment any discussion all those in favor say aye. Opposed your minutes been adopted amount may now present hospital level three as amended thank you members I I have two people with me and I want them to introduce themselves before I begin speaking of that's okay. If you can just introduce yourself for committee. Hello my name is tire Greenwood and I'm the director of the Arkansas home visiting network and I'm here today at the request of representative Mayberry to talk a little bit about home visiting. Alice is down on the Director women services at the Medical Center south Arkansas and we have implemented a universal home visiting program there and have been doing that for the past two and a half three years. You're recognized thank you members. When I had my first baby that was back in nineteen ninety nine we were about two weeks out of being out of the hospital my daughter Ellie is about two weeks old it's two o'clock two o'clock three o'clock in the morning and my husband and I are sitting in the bed with our daughter screaming her head off. And we looked at each other and we said what on earth did we just do. She was constantly crying she was very colicky baby and as much as I love being a mom I was sleep deprived and we looked at each other and went. How do people do this people offer sentries have had babies and they seem to make it look so easy but boy this is not easy. And what we said I'm halfway intelligent I resource full why can't I do this why is this such a struggle. And that's what this bill is all about it's trying to reach out to the people we might not necessarily see as the most at risk. When it when we're talking about having a baby and the the care afterwards if you look at the handout that I passed to you you can see that the program that I'm suggesting which would bring a nurse into the home about two weeks maybe up to thirty days after delivery of a baby to check on mom and to check on baby and I want to point out the evidence that's in their fifty percent reduction and emergency room visits and hospital overnight stays in the first year of life this is evidence based models thirty percent reduction in maternal reported post partum anxiety depressions a thirty percent reduction in post partum depression forty four percent reduction in child protective services investigations for suspected abuse and neglect through age to an increase in the completion of maternal six week postpartum health checks. We are not doing enough to prevent problems we spend all this time and money and energy at the other end of the problem when things have gotten so bad that we say how do we fix this. And this is the solution that cost a tiny fraction of what it's going to cost to fix that emergency if we can prevent the problem from happening in the first place I'm gonna let our our to explain a little bit more about our our current home visiting programs that we have in the state we do have quite a few so. But tired Sturch. Hello yes and the Arkansas home visiting network we provide training and technical support for over sixty of local community agencies that implement home visiting across the state we have eight models and. And we have collectively been involved in home visiting for over thirty years in Arkansas. About three years ago the we decided to implement a universal home visiting model pilot in Union County and that pilot is going extremely well including being accredited almost straight out of the gate which is a pretty phenomenal achievement so Miller Allison and discuss some details about that pilot. we serve family connects back in two thousand nineteen what we do we have a nurse go into the home and we do and are an assessment on mom and baby we include postpartum depression scales domestic violence and kind of go from there we it's kind of a light touch we go over a lot of the things in the home we go over safety in the home there's a lot of safety issues gun issues that we go over and then we talk about baby a lot of the moms don't have PCPs so we set them up with the PCP that's a big deal in south Arkansas and we have a lot that do not have an at fault of one for their infant we see a lot of postpartum depression which we used to not get referrals for we had no idea it was so under served so that's a big huge win for us as well It has reduced a lot we talk about the period of purple crying which decreases your Senate but death shaken baby syndrome which decreases your ER visits. I you can be sure any specific you were telling me about a family yes okay so we have a lot of it you would think that you see a lot of under served less as economic but we have a lot of families who don't fit that typical mold they're just going through situational crisis at the time has been doesn't normally work shift work but now he's having a work shift work it's our second baby mom doesn't know what to do she doesn't know where to turn there's a stick my sometimes post partum depression so this gives them a it's okay that is normal we just need to get some help we have resources available we do a lot of referrals term mental health facility there so that's really a big huge deal I mean we know about the moms that really need it but also the moms that you wouldn't think would need it moms that can be in this room I suffer postpartum depression when I first out I'm a nurse and then you think that you would narrow that you don't because you're in the thick of it you have no idea until you're there so. I think we are talking about a lot of overachieving moms and they would not be the ones that you would consider as needing needing help in most of the other home visiting programs are targeting what someone else is deemed as high risk and my point is is that when you go through a pregnancy your hormones change drastically your body changes and then you're sleep deprived and you have a child in the house you have other family issues that might be going on and if we spend a little bit of time fixing the problem getting not hopefully preventing a problem. So much of what we're dealing with here at the capitol every day is fixing that emergency if we keep the family together and we start at the very very beginning at the birth of that baby. We might see less crime we will see less child abuse we will see less of divorce and all the problems that go along with that we will see less poverty and this is a solution and I'm asking for a very small Sturch twenty five hundred families would be affected by this pilot program so we can see how it's going it's a very small cost to the state for every dollar put into this program this state will save three dollars on down the road I also would like to say that this program is probably even more impactful because of what took place in June as you all know we no longer allow abortions in the state of Arkansas so imagine we will have more births and we will have more moms who will bring a baby into the world that they did not necessarily want to bring into the world and that's what I'm trying to address be happy to take questions. Was there any questions represent Bentley recognized for a question. Thank you representative Mayberry K. first of a number of questions to stop me when I need to stop so I can get some more details on Union County the current model how often do you guys go to see the mom wanted to start it was a little more details on that it stars three weeks pardon three weeks postpartum visits do we do we typically do ten a week whenever the patient comes in and delivers at the medical centre south Arkansas I have one of our home visitors go sign them up one there in the hospital so they see a familiar face and kind of develop a reporting in we go out three weeks we do our home visit if there is a need for a referral or say we have a like you know like Tatian consultant we need help breast feeding we can also do that weight checks it's kind of just a light touch we can do up to five home visits after that but we typically just due to maybe just one ninety three it just depends on the patient on the family okay follow UP chairman that's okay so we recently instated Arkansas homes mom when I know that we're doing so home business with that we haven't started yet so can you say is that going to go with this is it gonna be complementary or with women maybe mark what's my best plan how within this or any we certainly can have DHS come out we in the bill I've talked to DHS the department of health have been working on this over a year I promise you those departments know about this bill. And know everything that Senate we've had many many conversations this kind of also came out of the the fact that New Jersey and Oregon were the first states to have this program universal state wide they are actually providing it statewide and that's what my original goal was right now we're just talking about a small amount but specifically your your question representative Bentley those who have Medicaid if they are already enrolled in another type of home visiting program which tyrant spoke about there are others they would not Be offered this program we don't want to duplicate services if they're already in another home visiting program and I do want to point out that this is voluntary if there is no one has to do this that mom will be asked do you want someone to come into your home and if they say no they don't have to it's a voluntary program. I need to stop assuming some questions a compatible K.. Represent waters. In the end. It's working now yes Sir thank you Mr thank you representative Mayberry for bring this bill I I guess I would have to questions I can ask for a follow up recognized asked them both and at this time either way I guess what is the need for this to be in home if it's already optional at the doctor's office so currently these mothers can take their babies they can receive this care in the clinic correct. I'm gonna let you to answer those questions more professional. Not. Now we see a post partum And that or say that service anywhere except with us for the only to do the home visiting yes they go to their position is that what you're asking that's what I'm asking the services available inside the clinic correct no now when you go see your doctor post partum they either take out your staples and say carry on good job are they do pass me or six weeks out your post partum depression sets in way before six weeks at your main need is within those first few weeks is when you're going to need to be screened for postpartum depression. With your baby needs a B. C. B. C. pediatrician within three days most of ours And you County don't see until seven we do follow up calls before we do that is it so no they're not giving our service in any clinic. So there is no where other than home where they can receive the service. Not this type of service now okay The rose recognized. Thank you for testimony and represent Mayberry thank you for presenting this bill I just had a question about the the. The voluntary nature of the program first of all I remember coming home with a newborn baby like the nurses here's your baby and I'm thinking you guys come home with us like how we gonna do this never done this before you know so I hate to certainly understand the need the question I have is should somebody enter I don't program or whatever you. Define this they opt in for these visits. Can they say no at any point and stop and if they say no. Do you through the program have the ability to override that know and be like yeah well no actually we feel like we still need to come in so we're going to is is there can you can you answer that. Now it's completely voluntary at the point that the parent wants to sever the relationship the relationship was severed. What happens should somebody say okay we don't think we want any more visits and the nurses or lactation specialists or whatever is still very strongly that they do still need help with I know this is the where does it go from there. Do I I'd actually like you to talk about because we have someone else talk about it annexed stimulation at an extenuating of this program that you're starting in Union County as well. Sorry sometimes patients are very reluctant just because we do have a lot of DHS cases in our county and I think that that's what we're doing we're committed there by the way what you develop a rapport you explain to them the program they're a lot more it eighties free coming into their home we have not yet had anyone have the service and then not wanted anymore it's very supportive it's a very supportive role and that's what we're here to do we're here to support the mom the baby the family whoever's in the home and help them because also we've helped other people in the home that's part of it we can also send them to different referrals within the community so I have not read across that yet but if they say no then they say no we try to give as much education as we can but they make the informed decision last fall of Mister. You're recognized. In the event that you observe of the use of any kind or the nurse what's the process there how do you how do you have you go through that. We do have a story to call our local DHS in reported cases Arkansas sheriff's office and any other mechanism that you guys would go through DHS. That's all thank you president Bentley recognized for another question. so who is going to implement the program is going to be through DHS or what is it going to be through the hospital or doctor's office so who's gonna implement the and where the twenty five hundred going to be selected from we would ask the department of health five I've tried to write it is loosely as possible to ask the department of health to put all those details together and we wouldn't see this program take place until twenty twenty five February twenty twenty five I specifically put it a little bit into a legislative session just in case there was an issue that we need to fix before the the roll out of it so it would be February first of twenty twenty five Jamek we have more work come up with a really want to hear from DHS on there yeah absolutely yes Mr white in the room. The lawyers here he's out of what we waited to represent rich and you have a question. Thank you Mr thanks for this bill appreciated sounds like a good intent I just have a financial questions associated with the the fiscal impact it says sentence about two point four million impact and you stated and we've got the handout that says it has a of one to three return I'm assuming that's not included in the fiscal impact. So the. The reason why I filed this bill back in January it took a long time to get the report back and how it would affect. Because we are requiring private insurance to cover this and so our employee health insurance had to do a fiscal impact on it and you can see that in in the bill it's negligible it's is very small amount of anything DHS had to see how it would affect Medicaid I think it was a half a million dollars but that was also ten counties and this is even smaller than that so that would be maximum again we're not hitting all of the Medicaid patients because we're already taking care of that through other home visiting programs this is really geared towards probably women who have private health insurance and would not have fallen into other high risk categories. Just just to be clear this is not the the two point four that's on the fiscal is not for the twenty five hundred you reduce that amount and this is it be substantially less than that yes so I mean we can well at and feel free we can ask the department of health to come up here if. That is in the room somewhere. Per share is before we get down that road to follow trying to keep things in order I never represented Bentley had a question I think miss manner you ready come to the table what will will allow you to kind of have a first met to make some room and And represent Bentley had a question for DHS and then we'll proceed. Good morning Janet man DHS thank you chairman I've asked so I know that we recently implemented Arkansas home and that when we do is in home business with that as well so I just want to how this is going to integrate with that will integrate with that who is going to be doing the visits and anyway just let more details on this and so and by how the twenty five hundred will be determined who will get the. We're working through some of those details in meeting with a representative may very we shared the chart of all the home visiting that's currently going on in the state in addition to the our home in indicated that it could not be duplicative so if this bill were to be implemented it would lay on top of that so we've been trying to do different fiscal impacts at the time I actually was outside texting with the finance staff to try to update the fiscal impact or get a number for you and I don't have that at this time that our intent would be to take what is currently being offered and integrate it with this option if it were passed by the legislature and then not have not have duplicative services. And that's all I really know at this time. Richey Richmond you have a question that I think the professor can come to the table answer thank you miss me thank you. Matt Gilmore partner health. I didn't have your question I'm sorry. That's okay I don't remember it really. So so we were talking briefly just about the financial impact associated with this particular bill and trying to understand with the reduction to twenty five hundred individuals being on that what and associated with the one to three return ratio was that figured into the financial impact. So originally you know there's there's been several renditions of this bill I think with the amendment that she has presented this morning it's going to be dependent on where we start that model or how we do that there are multiple programs in the state now As you've heard that kind of do some of these different things. So I think if this was the past we would start that in a county is not being certain areas not being served so I don't have a good number for what that would be at this point but I guess. Yeah I think we're trying to reprimand or how would work with the current programs what it would cost and then not be duplicated at the same time so I don't really have a good number on that twenty five hundred in a way that would be in that sort of thing. Review shall she had a question. Thank you Sir this is just to a point of clarification on representive road question on abuse. Earlier it was stated that you have the authority to report if you would in fact be mandatory. Are mandatory reporters correct okay yes Sir thank you. Members we have several people signed up to speak for this bill their travel to speak for the bill if if we are to the Chris will take and if not I was gonna have a representative go ahead. Thank you Mr my last question is for the department of health also so this pilot program you said it's going to cost projected around a half a million dollars is that the way I understand it well the again there's a few different things that was what DHS was estimating that it would cost to Medicaid there is for this program it's about a million dollars for licensing training and all that for that twenty two hundred dollar amount so again it's a very small amount I do recognize that I have changed it today making a smaller number and I did speak with representative Johnson I would I have people here to speak today and I'd like for you to hear it and I don't mind holding it until we can have even more discussion on an exact cost so I don't want to spend too much time on an exact cost because I have changed it and let them work that out but I do have families here who really want to share their story and I would appreciate the opportunity to let them share and we can come back at a later time I know your agenda is also really full today to are you thank you president first general question before you start here inside Russian for Janet mean that that's a pressure. Thank you I am just trying to figure out how this might coordinate with I know that she's been talking to you all but for some time for six months or a year of explained to me in our homes and I I don't have the bill in front of me but the people who can participate in our home to your post part of nurse visiting programs how does that language rate that they have to be a certified or recognized home visiting program and I guess what if this bill passes why could these programs not be recognized as one of those entities. Yes ma'am my understanding of the reading in our home is it has to be an evidence based home visiting program and I think one of the differences between what is proposed here today and that is the language around a nurse we have evidence based programs that use different types of clinicians are different levels and my understanding is in today's proposed language it would be a nurse and so that would be one difference in the in and what was the second part of your question but yeah I'm just trying to figure out why these programs would not qualify under the existing our homes a model at. I mean I you know I have and that's the real question is yelling I'm just trying to think that through because I mean I've had some real concerns about that really ability to stand up these are homes you know we've we've had some real roadblocks in that so it would seem to me the more people that are allowed to qualify and participate in this home visiting model the better but so I guess I'm just trying to understand why you don't think they would be recognized in their existing model I think it was two things is this just the prescription of a nurse versus an evidence based practice would be something we would have to reconcile and then when I reconcile the program pace I think I would have to reckon reconcile the financial piece I think what we've proposed in our home in evidence based home visiting and what we currently have in the states with different programs have different price points because of of different types of clinicians I don't have a definitive answer we could definitely look at it I just know those would on the program side evidence base versus nurse and then on the finance side it would be reconciling the differences so you're saying in our home modeled those evidence based practices are not necessarily nurses that do the home visiting we have at I don't know specifically because that because we are looking at it but I know in some of our other evidence based programs that we have through the state there are different types and different levels of clinicians used and so one of the things that we had discussed with the representative Mayberry was change using different language besides a nurse at a thank you consider that I I feel strongly that a nurse is an important part of this and the difference I think in some of the other home visiting models which I think are wonderful there are families that need a lot more help for a longer period of time and that's what those other evidence based models are some of them to three you know for I think maybe for five years is that correct this is a. When we first started looking at this what I wanted was a big umbrella. So that no mom is left out so that we are we're catching everybody and that is lower cost and that is more direct and so that's why I personally really like this model because it did use a nurse who can pick up on a lot more than a community health worker can pick up and if there is a problem that needs more attention there are other programs that then you can help this mom get into if they need more help but if we get there in the beginning with one or two or three visits we might have just prevented a whole bunch of other problems that could have happened and that's why this program is important. No I mean I think everybody agrees the importance of the program is just had to make it coordinate with the our homes and all the it is it doesn't LPN qualified to do this under your bill or to have to be in foreign. Our model has to orient I have to registered nurses that are home visits it but is that what the bill is that it is in foreign. Or just nurse. And and it's an evidence based model but it does say a nurse and a console him and says I'm sorry minute so how many programs in the state besides your program would qualified to participate and any other programs are have this model that they have. There is no weather model like this so we're just doing this for one person this bill for one person well I wanted statewide universal I had to narrow it down to ten counties now I'm I'm doing a model of twenty five hundred for a pilot program to get started but I guess I'm saying her agency is the only one that would qualify under this bill. I understand the question. I don't understand the question. The the model our agency is not as any other agency in the state have that model is my question. No no but there's nothing that would prohibit any agency from adopting or implementing this model it's not a okay okay I'm sorry for it and we can move on with me to talk about we we do have several people Senate did travel to speak for this bill so C.. We have so. Actually Thomas. Here. State your name for the committee. Hi good morning my name is actually Thomas I'm here in support of this bill Julie I just want to share a little bit of my story. Okay I'm thirty nine I have been wife's to an incredible man for the last eighteen years I have three beautiful children twelve year old son and twin six real girls I've also been a nurse a practicing nurse for the last fourteen years mainly focusing my career and women's health coverage in labor and delivery the NYC you and also some on postpartum and in and local Bijan clinic here in Little Rock. I am educated I'm in a safe loving supportive in financially stable relationship I have incredibly supportive family and friends on paper I check very few boxes for someone at risk for significant postpartum mental health episode but in late April of two twenty seventeen I experienced exactly that five weeks prior delivered my twins at thirty five weeks and we went home five days later the first my home I knew something was very wrong but I brushed it to the side as hormones I have to premature newborns it's overwhelming allocated just said I'm just in survival mode right now and that's just what I kept telling myself for very for a very long time every day I really just fought to kind of drown out feelings in my mind that were just fighting for air as the weeks went on things only got more intense I had very intrusive thoughts about harming myself just disappearing from life and actually even. Having my own children I would have very distinct imagery in my mind of the dropping my baby's down the stairs of my home all the while thinking to myself that if something happened to them I wouldn't be sad. It was like feeling nothing and everything all at once I knew all of this was far from normal but the guilt fear and shame over these feelings kept me silent but finally a five weeks postpartum I was no longer able to contain it one morning shortly after my husband left for work I knew that I was no longer safe I experience what I now know is postpartum psychosis over the next several days well my children with grandparents my husband and I stayed isolated our home or trying to navigate me safely through what was happening all the while I never made a call for help to a professional I just couldn't do it. I am so very lucky to still be here today to share this experience looking back now I see how close I came to ending everything not only my own life that my baby's life as well it's hard to even say the words now but I know how incredibly necessary it is to convey the severity of my experience and collaborate with others to bring awareness and formulate plans to help moms across the state in fall twenty eighteen I was approached by local news anchor to share my story on TV and an effort to continue to shine a light on pose for an impression anxiety as this person also had a very harrowing experience the response that story was overwhelming and very supportive it led to a start of a series on the channel and went on to gain national recognition even winning a daytime Emmy the bill before you today as a step in the right direction for postpartum mental health support had I had access to someone coming to my home I truly feel that what happened to me would have been avoided it would have eliminated the need for me to initiate that initial contact which is why I could never do a trained professional would have been face to face with me and I have no doubt would have picked up on even nonverbal cues that I was struggling in a major way and help me obtain a health treatment that I so desperately needed well my experience was very extreme I can tell you that I come in contact frequently with women from all walks of life who've experienced postpartum depression and anxiety and some degree but the vast majority have suffered in silence and I'm hopeful that one day we can put into that and I would just with thank you for your consideration of this bill thank you thank you so much for your testimony. Morgan ins. If you state your name for the committee in here with and my name is Morgan ends and and I nurse also like actually I work in and labor and delivery postpartum a nursery so I am very well educated in. To but I just had my daughter seven months ago and in August and she's my first born and so I signed up through our hospital to do the family connects and they came and visited me three weeks after I had her and I thought it was so helpful that they came to the home because if you have ever traveled with the newborn it's a lot of stress it just adds to that so that they were able to actually come in and sit in my home I don't have to stress about getting her in the car seat making sure she was fed they just came and sat with me and kind of talked with me and. Being educated and having all that you know education in the hospital whenever you go home it's kind of just like an in one ear and out the other when you go home you really don't know what to do these babies and you're like wow what did I just do as so it just have been a nurse there and looking over Collins and saying that she was good she was healthy and that really just took that way and anxiety off of me and I was breast feeding her at that time and what I thought was so beneficial was that they had all this equipment to like measure her make sure she was gaining weight and she did gain weight and you know that just really reassured me and making me that confidence and that support as a mom and I you know it's benefited me and I really do think that it benefits a lot of our families in our community I don't have a lot of the other issues that some of our family space but I do have anxiety depression of struggle with all that and but I do know that you know there are some families who struggle with domestic violence or just not safe environments and so somebody coming into that home and seven and then kind of gotten somebody through that you know I just I can't say enough how beneficial that would be for our state. Thank you thank you so much for testimony Kathy going here Kathy you're recognized come to the table at this. Katie Klann I'm from elder radio I am a registered nurse and labor and delivery however I have recently taken on the role to manage HFA which is healthy families America which is a spin off of our local family connects program so basically family connecting a light touch you have an are in that comes into the home check the baby three weeks makes referrals as needed HFA is there to step in and actually follow the baby up to five years of age if needed also it something special age of phase it literally can follow the mom prenatally so we're also making sure they're getting prenatal care and following them as needed The I'm very passion about this program I think it's not this isn't family connects but there isn't an end at family connects we pick up right where they left off so it's not just going to stop there family connects or these home visiting programs really have the potential to change Statistics in the State of there's such a need to a lot of people don't talk about they think that you know if your lower socio economic status or you have other kids in the H. S. or that kind of thing that you know the that's automatic check to the box but there's people like me and you sitting in this room that have been I have experienced postpartum depression of experience you know as maybe not A long term thing but just a situational crisis and we had a family that the mom came to give birth and actually passed away from covid and so then now you have a new dad with a brand new baby and also grieving the loss of the wife and mom So I I think to me this is a no brainer but I work in the field I see it every day we are real health care and the right to this really has changed our community it's change the lower socioeconomic. groups of people but it's also changed the normal people that you don't assume would have these issues. Thank you so much that testimony represent Mayberry thank you for presenting this bill today and give us as I did it does seem like you've given some things to think about and with the amendment it does seem like it changes the fiscal impacts and that's been an important part of our committee here's looking at fiscal impact and trying to be responsible would you be willing to put the bill down today let us take a look at it maybe later after there's a little more discussion on the fiscal impact I will I be happy to hear from committee members continue discussion I appreciate you allowing us to. You're from these moms actually a friend of mine goes to church with me. It's and You wouldn't pick. A lot of people. These problems. And those who are the ones that I'm trying to reach out to I'm tired of hearing someone's at risk because they're poor. All moms are at risk. All families are at risk and that's what I'm trying to address thank. Thank you so much and thanks everyone the travel today to give us that testimony thank you. Resent five. You're recognized incoming president House Bill twelve thirty four. You're recognized to present your bill okay you Mr chairman committee if you don't mind I'd like to call up to the table Bailey Taylor and Michael Gruppe absolutely. Introduces. A retailer associate environment administrator for department of energy and environment. Mike over paid a primary environment thank you you're recognized yes I'm representing Lanny Fite District eighty three we like to refer to this bill is one two three four we there was these is bill I've ever had to remember the number of. let me get started I'm notices that there's a lot of freshmen here that may not know the history of the tire district and so I've asked Bailey if she would do it just full oversight on it for years so you all might understand a little bit of what we are changing here. So we have several tire districts in the state of Arkansas they operate under the solid waste management districts and tire dealers in the state each time they put a new tire on a vehicle on the A. remit three dollars per tire to the FNA they get to keep five percent for their for their troubles of the the administrative costs then D. F. and a processes that and gives D. E. Q. that money we approved business plans for each tire district and they come up with their tire rate that that rate is what it costs them to dispose of the tires that they collect of the current bill requires them to have a trailer collection trailer in each county that they have to man and and paid to keep up then they dispose of their tires in several different ways Arkansas is you know has different resources across the state so each district kinda something different there for their time our rate is a little bit different once we approve those rates then they submit quarterly reports on how many tires that they disposed of that quarter we pay them number of tires disposed times their tirade they get that money reimbursed to them it is a reimbursement program any money we have left over we can use for abatement we we haven't had the money left over for abatement actually the third quarter of last year we did not. Get enough revenue from the tire sales in order to pay the full amount of their reimbursement requests the law contemplates this scenario and so we did the pro rata at that time and gave them sixty three percent of what they had requested for their reimbursement and then at that time L. C. we went to L. C. and they gave us some money in order to fully reimburse the program. Okay. Let me and let me tell you a little bit about what the bill does what the bill does we're gonna privatize it the tire which tire industry in the state of Arkansas. the tire generator is responsible for the disposable for the disposal of the waste tires. and working with the power of the tire processor in setting a price for disposal okay the to let me read what a tire generator who they could be in the state of Arkansas a municipality and council a state agency a federal agency a school district a political subdivision the state a person who an ordinary course of business buys tires on the ball for the use of commercial vehicles I tire retailer and that's the main one we're talking about a general merchandising store that also sells tires in internet tire company that sells tires in Arkansas and a tire importer or used tires what we're talking about. What they do the tire generator may hall is on tires if he lives to the processor but if the lex not the whole is hires owner he can get a certified a DQ certified holler and I'll explain a little bit about that a little later. let me give an example of how the system would work we're going on free enterprise. Okay take precedence here in central Arkansas Davis robber is a processor of tires a tire dealer would negotiate with Davis Robert for the price of the disposal of the tire the dealer would calculate the cost of getting the tired today was robber. That plain and simple they would be working with the tire dealer working in conjunction with the who's ever going to process some dispose of the tires and if they have to have a holler if they'd want to haul it themselves then they would have to Get a D. EQ a certified hauler. You today if some of these tire districts water to keep working as they are. they can't work exactly how they are but the here that I give you an example Craighead county solid waste district collects tires in all the county they bring them to their local landfill they're picked up by a certified collector and taken to a processor if they elect to keep this process in place the tire generator the tire collector in the processor will negotiate their prices among them but the tire generator can select anybody they won't they're not bound by anything under this bill they can select who they want this is private enterprises what we're talking about. As cost let your way and that's what happened to those in this last couple years inflation hit us the tire generator the tire collector the tire processor can all just surprised in the pre market we didn't have that now and that's what threw us in the tail spin in this last recession. hello let me tell you the state's responsibility under this bill. They're going to set up an environmental fun it'll be called the environmental abatement fund one dollar charge will be on the wholesaler who selling the tires to the retailer for each tire which will fund this fund. The Division of the firemen quality shall have an annual report given to peer it A. L. C. once a year on how they spent the money. Of let me tell you what a let me to find a wholesaler a wholesaler means and I'm going through these again is a person who sells tires to a municipality in a county a state agency federal agencies school district a political subdivision the state a person who in the ordinary course of business buys tires in the box and use for commercial vehicles a tire retailer of general merchandise store that also sells tires and internet tire company that sells tires in Arkansas. And a tire importers are used tires. monies collected for this use we'll go for administrative costs and abatement right now we have twenty seven of major Sites that need to be abated tire sites in the state of Arkansas many were created by the tire districts themselves and they do not have the money in which to debate. also there at the permits not tire generator he will have to help be permitted the tire collector permitted and haulers will be inspected their trucks with a ten thousand dollar bond. Of. And they'll also eighty two will also enforce all these rules they'll do what they should have been doing the whole time is have oversight over the program itself. Also there is a fine of a hundred dollars per tire for dumping tires. Does your call dumping tires You can go in you can have these tires disposed of and into a processing facility and show proof of that and then an inspection by the eighty two to verify the clean up in the fee will be that one hundred dollar per tire will be waived. I think I'm close to the end I'll be willing to take questions now. The person you're recognized for a question. Thank you Mr chairman. And thank you that you know as a former county judge I've. Gone through this program with you for ten years and I have tremendous respect for what you've done to help develop the program at I was surprised when I got a text from one of my County judges any city opposes the bill because he thinks it will increase the. All of the leader of the tire later throughout the state and he said to please wait that that senator Payton has a bill that he likes better I do you have where to the county judges association ball on this and can you explain to me yeah let me give you a little overview I filed this bill over two months ago and was ready to run it and senator Biden told me that he was going to do a bill that kept the districts in place in. You know. And the. And so we're getting close to the end. The but the bill hasn't been filed yet I've read the bill I don't think it's in its complete yet but there's tax increases in the bill and anyway and we can't wait much longer we the we privatize it are we. It is a precedence for this in other states have they privatize their yes ma'am hello let me say this what once we filed this bill She's the Bill. Very familiar with this tire bill the situation that we currently have been dealing with and You know I wanna. The. Commend representative fight for his intent. But seventy five county judges it's rare that you could get them to agree on anything this past nine hundred dollar bills. but seventy five county judges adamantly unanimously opposed the privatization bill. There's concerns in it that We will wind up with more tires. Senator thanks bill does not have enough teeth in it in in our opinion to regulate. Of the fees so for instance. No you privatize this and a private company a negotiates the of fees they're the ones is going to set the fee on to just get rid of the disposed the tire for instance of farm type could possibly cost you a hundred Bucks. to get rid of it and when that happens. when that happens. They're gonna wind up in the ditches or you know down south the skater tires for instance they're they're gonna wind up on some back road. being disposed to. Sh. You know Sentifi I mean it keep going center but the representative Fite mention cricket council. A good county sends their tires out of state to Mississippi. There there is an alternative bill in its just come as of late because we have met two three times a week. FOR several liars with the county judge executive committee to You know to determine because we are aware of the problem. The alternative bill five oh wonder senator Payton filed just recently came. And it Talks about four different districts. And if the. If it is working currently. They're they're allowed to keep doing that. And it's going to generate more money because there's going to be a fee on all tires. even new cars so if you've got five. Five tires on a new car any charge another three Bucks for that I don't think anybody is going to not buy a car that cost eighty thousand dollars for a fifteen dollar fee. So Mr what more would you like to. Show more you're recognized speaking as well thank you Mr chairman mark Whitmore Association Arkansas counties of as to Darwin said the county judge associations met numerous times with senator Payton and represented five course we respect representative fight in his position. What the county judges determine is Arkansas has three tire processors currently. If you're within fifty miles of a processor there's a comedy the feasibility to it if you're within a hundred miles of the border Clark's full terms these tires into mulch. There's a distance at which if you let this be privatized don't fool yourself. Fees will go up there's a uniform fee of three dollars to six years drivers three dollars on small tires is one account established it used to be five dollars large tires. Unfortunately six years ago when the legislation flatten that the three dollars per tire and what senator Payton addresses is would you buy a new vehicle there's five tires you know the four tires on the vehicle despairs those tires are going in and being process without having paid the fee so it's really a fairness issue center Payton Senate bill five one captures those fees what I'm where we come during disagreement is. I remember fifteen years ago talking about tires there's back Randy Thurman was a young lobbyist that's why I look at it and investments Nucor maybe one begin at seven hundred fifty thousand tires would be wonderful that be great hadn't happened Jett. And you might wanna know their we have over two million plus tires in Arkansas. Assess currently with the three dollar fee there's about eight million dollars in revenue. So you do the math. If you live in south Arkansas is it going to be feasible. To take a car tire all right of Nucor what kind of fees would your constituent pay to have a tire called the Mississippi County. So don't fool yourself that there will be increased fees what what the alternative is is to set a cap on large tires. And have them pay the freight because it costs more than three dollars to process large tires under this bill privatization as determined says large tires after large tires but cost eighty or a hundred dollars misstates eighty. We'll under by Matt that's a lot higher than thirty dollars. This this bill house bill twelve thirty four definitely will cause an increase to the consumer. It's that simple. And like the German says you don't get certified county judges to agree on. Every on something and they all oppose this bill and they work in the tire business and they get stuck with the tires ditches they're the ones who have to clean it up clean up the legal docs it just to be clear about it. The last few years eighty Q. has done little or no tire by. This bill would provide one dollar for every tire sold at wholesale millions of dollars Mr trust in the state to have a tire basement and I'm telling you there hadn't been much going on the last three years and tire by. That's that's basically our position. Members of the questions for judge or when Mr what more. Representive Ferguson you're recognized for a question. I don't really have a question I have a request I guess of the chair I think all of us maybe are confused because they understand patients bill is just a shell bill right now it's best it's under review is supposed to be filled out today. Is there some way to wait and let bill or do some side by side comparison because I do think we're making a decision about how the tire programs going to go forward without fully understanding both of our options I think it's hard to make that decision I certainly think you set up to the sponsor side whether he wants to close for his bill or or pull the bill down at some point to let that comparison happened I think today we have the sponsor The sponsor present the bill and we have certainly want to hear the testimony either way so we have some at least one of the person signed up to speak for her before you get up I think we do have questions represent Rocha question. Yes it was kind of in line with what I represented Ferguson had just said I think I heard everyone of you by the way thank you for your testimony today the card one of you say for months you guys have been working back and forth to develop. This bill did I understand that I understand it correctly. And so that was kind of my question is after months of negotiating and work at this point the session for just have been filed as a shall we just curious why there hadn't been more produced on that bill will just be plain simple batted bill are in review. Senator Pitsch provided us a document to whoop two Fridays ago that we provide the bill or on Friday and we didn't get that draft back to last Thursday we provided more we met again last Friday for Senator Pitsch in this state in just the last few months has been over the last few years actually we provided that information after the Friday meeting with a lot of people vacation we had a meeting Senator Payton he was up here for five or six hours. Villar's reviewed it they got a second review he could have filed this bill but because he wants to run it he wants to have the amendment be the bill and I'm certain once they get the amendment back to provide return filed a member let him speak to that but this bill order V. dismayed by that. President will be recognized thank you Mr a judge I understand your position on it does the private privatization of this take the judges out of the equation I mean no longer be responsible for to we still be responsible for the tire program even though it's a private now venture. Well at the end of the day if you wanna with tires in your date it's it's County judges profitability so that's why that's why probably our number one concern and and I would I would add this and. And in defense of represented by in most cases I don't think there's anybody in a room that wouldn't agree that privatization works a lot better than government. But in this particular case it won't. And We're we're gonna be left holding the bag. If I can may add to that I'm so happy since cities under law responsible for the collection disposal of solid waste tires for a major part of solid waste. We had tire dumps decades ago will have tired of the future. What's unfortunate is that the state of crisis situation where people that are further away from a tire processor. They're fee doubles or triples or whatever it does and there's more tires those counties that are further away from process some location will have those tire dump illegal tire dumps also of I think there to me into the bill once a contract is signed there's some enforcement capacity and your trust in the the state a DQ to do all that enforcement and there has been some issues in the past years of the administration of the program so we're going to be handling the burden would have little control over the. Situation program. Members of the other questions represent Richardson you're recognized. thanks so much for testimony thank you Mr so my question really revolves around something that and I can't remember which if you actually brought this up he said the biggest concern or one of the biggest concerns that you have with this current bill is that it doesn't have any teeth associated with the tire dumping is that something that the bill represented by could fix and you be in support of actually privatize in this this process let me comment on that the Bill has a assertion of there being a hundred dollars a tire. That presumes you catch the human being dumped on the tires. So it's kind of back in loaded situation and we're having trouble catching murderers and other criminals but the idea of catching somebody dumping a tired imposed hundred dollar fee on is a very right now we have we went to one a tired office that copy plant but there's half million tires. And so we don't been trust the idea that. Have an opinion on a piece of paper is actually going to result of revenue stop tired. Follows reckons followed I appreciate the comment my and my concern would be that that's the same with any finances with any situation right I mean we we avoid doing certain things because we're concerned we might get a speeding ticket in and up that having to have the cost associated with that so that I appreciate the comments so my question would be still around that is that something that you would consider I guess what I'm sort of suggesting is that this is a backloaded bill in the sense that if it's true proposition cars and if it's true that the fees go up to the consumer seventy five county judges are very feel for a concern there to be a lot more tires to. The solution would not be to pass this bill and just hope we catch people dumping tires and possibly fail I think that's not the bad number four six searching for to try to clean up the mess Act retarded and corrected the criminal justice system business solution here is to prevent the circulation. Members of the other questions. Given a commentator yes Sir Mr chairman I would just like to express that everyone that sent in to this table. Your county judge opposes this. Some thank you Sir appreciate your time thank you appreciate the testimony we do have some of Senate speak against the bill Mr power here. You're recognized kind of the content of that letter you sent to us here with. Thank you fill a Powell with Arkansas farm bureau federation. You're recognized thank you Mr chairman committee for allowing me to speak here today a represent Arkansas farm bureau and we represent over a hundred eighty thousand members across the state many of which are farmers and ranchers and our our biggest concern with this bill is the unknown cost associated with the tires especially with the extra large tires that are farmers and ranchers use on their tractors and other equipment and so we put the number of a hundred dollars being thrown around you know for those of you that have tried to is you can have five six tires on the tractors of the because adequate quickly so that we here to say that to express our concern about the unknown cost at this program and that the current tire recycling program allows all farmers to manage those costs as you know in the last couple of years we've seen a huge increase in input costs up beat for allies and feel of all going up so farmers and ranchers a struggling every day to try to manage those cost and we're concerned that this might be another cost added to their operation so thank you for your time today and and I'll be happy to answer any questions. There is there any questions for Mr pal. Senate rich mistress or representation you're recognized. Thank you Mr just really quickly how much just give me a round number I have no idea never replaced a tractor tire so on a large combine something like that how much just want us to secure question I received so I've heard I I don't own one of those laws because I don't this message yeah medium type we're talking five hundred to a thousand dollars two thousand dollars depending on the type number talking thousands thousands of dollars thank you. There's the other questions Mr pal. C. nine thank you for your testimony. There is a felony ready to come closer to. Mr chairman As I say my bill came out in late January and I've been waiting for Senate Republicans bill be complete it was filed as a shell bill I say yesterday I am I would assume that was yesterday. I would be willing to pull my bill down and come back next week senator Payton run his bill in advance of mine in his passes I'll put mine down. There is there any questions represent a fight on that issue. Thank you represent value of the compact presented in town thank you. Members I have to stand up and use the restroom. And I'm gonna say we've been Senator little over now I have a feeling gonna be here for at least another hour we're gonna take like a three minute recess without objection just long enough for people stretch their legs and will call back in order says I get out of the restaurant. We're going to start the process to get it back to their seats. To seize a quorum calls meeting to order. I have no bill today outside. We're calling this meeting back to order I'm gonna give it a few more minutes for members to wander back to their seats wherever they might be outside if anyone sees any member outside they can grab on. Yeah go hunting down former Wardlaw. So as members return to their seats I'll be turning the committee meeting back over to represent a Miller as I come to the table to present House Bill thirteen eleven you see me talking really slow. Seeing none of the members come in the and so I'm gonna head down to the table and will. And I'll walk really slow as well. Maybe members may be leaving on purpose will say. If you have. Representative Johnson. You're recognized. Thank you Mr chairman. Try to get the story this my current all it down members. I see a couple more wonder again I want to start by apologizing. for not coming to the table with negotiated language you know anyone in this room who knows me knows that I like to solve problems I like to take people that are on two different sides of an issue in trying to bring them together and find some middle ground that we can work from and I want to assure you that every effort was made to try to find some sort of compromise language I want to say to my friends at the pharmacy association. And the hospital association thank you for your hard work and there was a lot of time spent in the Goshen ations and as you can see this is just a difficult issue and sometimes when you have a difficult issue that is hard to find compromise language and that's why that's the case in this since you're going to hear from the hospitals are gonna hear from pharmacist you're gonna from pharmacists on both sides of this issue and I think you'll understand why it's challenging and when we have a challenging issue would bring it to committee we talk about it that's how the system works as the chair of this committee I feel like it's important that I maintain some distance at times I don't want to ever be perceived to be leveraging a any influences chair of remembers you'll know that I didn't I don't think I recess was including one this committee to try to address this issue clearly be in part of that is because I didn't want to set a precedence of looking like I was leaning on anyone on this issue this is an important issue it's an issue that we're gonna have to discuss and have to face is a committee that's the state and my hope is that everyone in the committee will keep a clear head in an open had as they listen to the people testify back and forth I also is pretty confident that you be lobbied by people on both sides the issue as I'm sure you have heard from other folks about this issue I'm sure you have some information as we go into these proceedings to talk about this Yeah. The other is I wanted to wait latest because I do want you to understand that as a group of healthcare providers we see eye to eye on ninety nine percent of these issues the pharmacists and hospitals have proven themselves to be friends over the years we've worked good together we will get to this issue today will continue to work well together on issues in the future so however this turns out today I want to understand you know we we will continue to be as we are before and after good colleagues and friends together working together I do what you know to the this is an issue. That is going to come up if it doesn't get settled today it'll keep coming up and I the part of the reason why is because we are one of only two states that any kind of prohibition on not for profit hospitals have been retail pharmacy permits so in we're the only state to have a complete prohibition on that someone said again we're the only state in the United States have a prohibition on not for profit hospitals have an retail pharmacy porn at that position in a very unique position it's been that way for fifty years in this state in this is going to continue to be is at topic of discussion whether this gets settled today or not the other thing I want to mention is the language that you do have before you and I'm to get to present the bill it is some compromise language as a compromise in the sense that is not the bill the hospital association started with I don't want to misrepresent this is something that the pharmacists agreed to that not budget so that you understand the bill itself it does limit not for profit hospitals under a thousand employees to one single retail pharmacy permanent it also limits hospitals with more than a thousand employees to three retail pharmacy permits and it makes it specific that they have to be on their campus would define campus so this is not a situation where retail pharmacies to go across our adopt profit Austin could go across town in open up forms across town it would have to be on their campus there are two things pressing this issue primarily one is access to medications and one has to do with them to call the three forty B. program which you're gonna hear quite a bit about I think today from the from the medication access point of view I think all of us know that there are many places in the state where there exists pharmacy deserts with there are no pharmacies available in some of those places the hospital may be the only place to access pharmacies the other thing is there are not many twenty four hour pharmacies available in the state anymore we're. I practice in Fort Smith there are no twenty four hour pharmacies and so in order for patients to get medications upon discharge it's important that they have access to a pharmacy in this bill would allow the not for profit hospitals in my community that the places in the state to provide medications upon discharge for outpatients inpatients admitted to the hospital in B. and reimbursed for that service which is an important new wants that you can hear more testimony about later the three forty B. program and I'm I'm not gonna spend a lot of time talking about it because there are a lot of people I know signed up to talk and what you hear from the other people that are here both warn against the bill but the two forty B. program is a program that was designed to try to offset costs for hospitals and clinics that have an an an an exceptional burden of uninsured patients in minimally insured patients that are taking care of so to be a qualifying entity to come to participate in this program you have to have proven that you're taking care of a disproportionate number of uninsured patients compared to other not for profit hospitals and clinics in the country if you qualify the design of the programs to try to offset the costs that you incur by having to take care of these uninsured patients so for me in the emergency department I think many of your where if you shop an emergency apartment I cannot ask for any insurance information or any money until we've completed a medical screenings and that's our obligation that's a law it's so we incur costs every day as a hospital taking care of uninsured people because of medical screening exam includes more than just me talking to you as a patient includes doing cat scans and lab work an EKG ease another test the cost money for me to decide are you having a stroke or having a heart attack and so the three forty B. plan initially was designed to try to help these clinics and hospitals that are in. During these cost recoup some of that money back to them to help try to continue service population So the program is set up to allow not for profit hospitals to buy drugs on the Medicaid approved let listed at a discounted rate currently for hospitals that are qualified entities in the State of Arkansas to qualify and participate in that program they have to contract with the pharmacy because they cannot themselves. Dispenses medications because of the they can't have a retail pharmacy permit so that is also an important part of this issue that you're gonna hear some about I'm gonna stop my testimony there because again I know we have a lot of people signed up to speak for against this bill I'd be happy to try to answer any any questions from committee members before your testimony. Okay of. We do have we do have one question I have a member's. Of. We do have a lot of people signed up to speak about this bill I'm last are members of we're going to question in one follow up. And if you've got other questions will be happy to put you back in the queue and. Also for members could keep let's try to avoid asking repetitive questions and anyway that'll help us flow right along that being said representive Wardlaw you have a question you're recognized thank you Mr out I'll do my best not to get repetitive. It's on first I should be okay you made a comment just then and and Mr this part two part question you made a comment that you wanted to be sure to recruit some of that cost. But if I read this bill right and I understand it right. You're recouping the cost from our neighborhood pharmacies no that's it and when that and to me. Majorana man and I know you chair and I don't want to return home only member you did you say you want to do that but I I know you So. I mean explain to me. Where that cost is coming from because as a healthcare provider if I'm bill in that wheelchair and then you're all as a hospital bill that will adjourn now I'm not going to build a wheelchair anymore same way pharmacists bill in that town or three or whatever it is they're not in the bill that Tylenol three anymore so you're definitely moving that money from one entity in my town to another entity and your excuses to recoup that cost or make money over here if we save a hospital we save a hospital we don't to kill our pharmacists to do it so can explain that sure yeah and what a specifically referring to is not this bill but the three forty B. program I think people need to understand what the three forty B. program is intended for because that's a part of why the not for profit hospitals and retail pharmacy permit I'm not saying that we're recouping costs at the expense of retail pharmacists in the community what I'm saying is that three forty B. program was intended for not for profit hospitals to try to recoup some of the costs they incur by taking care of uninsured patients so again it is not have doesn't have to do this bill specifically ask you at three forty. Recognized for five. So glad you said it that way. So. You just made my analogy exactly right because what you just said was. You're going to sell on that on all three at the hospital because of three forty B.. And so you're taking it away from the pharmacists because the farms is not gonna feel that prescription because your fill it at the hospital now the pharmacist can't participate in the three forty B. program I'm not taking anything out I'm not or not this week we can leave three forty three three forty B. off of the table you're filling the prescription that was being filled outside of the hospital true or false. It depends on the medications your doctor House no it's not because it does depend on the medication there some medications that hospitals locally can fill that pharmacist may not carry a minute be willing to carry the start of the specially medications and drugs the local pharmacists don't Kerry's I don't know that is necessarily the company passed that bill two weeks ago for complicated mess right the bill we passed if you're referring to representatives Bentley and senator Boris bill that bill did not have a a cabbie out for allowing hospitals to bill from that formula airy so well they could dispense those medications they would have to do it for free. Get of next that represent road you're recognized for a question yes thank you Mr. I think you said the beginning that you imagine that most of the representatives on the committee been lobbied on this issue and for me anyway that's accurate I've heard from several individuals and I hope it wasn't disingenuous but did mention specifically to me the importance of an oncology component to this bill and I assume you didn't get into that because you know there's several is going to speak but what I got to the table somebody who I know and trust could you could you dive into that a little bit for me yeah and I think that gets back to the I do the specially drugs or certain drugs that are very specific to certain types of disease states that we treat they're very expensive drugs and they're not traditionally stocked by retail pharmacists locally and so long currently under current state not for profit hospitals can contract with a local pharmacy to dispense their three forty B. qualifying medications if the sponsor doesn't stock that medication in the patient's gonna have to get that from a mail order pharmacy somewhere in that means delaying care so what that means is that rather than picking at this chemotherapy drugs that you may need at your hospital you're gonna have to wait until that sent to you to a larger pharmacy that stocks that medication. All right of return will bridge you're recognized for a question thank you Mr president Justin you talked about when you're presenting this the need for the retail pharmacy was because there are no twenty four hour pharmacies are that's the one of the needs why what is a hospital need to retail license and how to solve that problem so currently if you if you have an inpatient pharmacy and out into into the credit of representative Bentley and Senator boys bill that it before that bill we can act as I understand it in inpatient pharmacy could not dispense your significant supply medications to go home with that bill does open the door for that the difficulty is because it's an inpatient formula airy there's no billing mechanism for the hospital to bill and collect a dispensing fee for that medication when they send patients home for it so well now under that new act they could it has opened the door for them to dispense medications from the in patient for me Larry there is no way for them to bill for that as well understand so they can provide the thirty days with the bill we passed but you're saying they can't be Rick thank you for giving me the correct in and so for some of those things I think you if this bill doesn't pass I'm sure there's some hospitals that will do the math and say Hey you know it's worth it for us to give away the medication for free to try to prevent a readmission but my question to you would be your why why should anyone in any business model be required to make this difficult choice of giving somebody a service for free. Verses with reverses recouping some of their cost. Thank you. represent Pilkington you're recognized for a question. Thank you. Representative Bentley you're recognized for a question. Thank you chairman of so quick question can we. Could we not a neighbor this before today I'm just trying to think this author. Is there not a way for them to apply or could we compromise a bill where the you just allowing them to to Get money on the on the medications they go home and not open up retail pharmacy people come through all the time with that not be a compromise to allow you guys to set up to be able to bill for that medication going home but not allow you to open up a retail store people come through to get more medications to you know to feel again the second time and I making any sense to you that you may get system represent Bentley and and certainly that would improve the bill that passed into an act if we could pass some sort of bill that came back and allowed hospitals to a credibility mechanism to bill as they dispensed either impatient for military but that doesn't solve the larger problem at this three forty B. program so again a big part of the problem with not for profit hospitals not having a retail pharmacy is they're not they're not able to extend the benefits of the three forty B. program fully to the patients that are intended to benefit and it allowing them to have a retail pharmacy permit would solve that problem your compromise would not solve that particular problem. President Wardlaw. Back up. He's out looking for issue. A representative Alan your next for questions I am sorry for being late in terms of three for the B. programs. If I if a hospital. Does not have a phone. Am I correct that they can't. I have a three for the B. program the. That I that I know they could have ones to contract with the with the retail pharmacy in the way that works is you know the the hospital is the qualifying entity would purchase the medication at the discounted price and then work out an agreement with a local retail pharmacy to dispense the medication and then that money whatever recruit to be split between the pharmacy and the not for profit hospital. representative Richardson you're recognized for a question. Thank you Mr my question really revolves around that the three forty B. because I have no idea what that really S. but my question is should associate with funding associated with that is that a Medicaid reimbursement work where those dollars coming from to help those this is so it's a it took me a long time to come to the understanding that I have now and I'm looking over there my friend John Jensen he's laughing because I've asked a thousand questions about it and I still don't have the complete full grasp my understanding is this federal program in that what it does is it allows qualifying entities which or entities as we said before have a disproportionate amount of uninsured patients are taking care of it and they they can only be called me entities can only be not for profit hospitals or clinics those entities if they qualify are able to purchase drugs that are on the Medicaid approval is for each state at the lowest cost sold by the manufacturer so they get to purchase them at a discounted rate how they recruit cost is then they then are able to sell those drugs back to insured patients at a higher rate than the paid and so they make a profit off the drugs that are sold. And I'm I'm looking to get a little not that that not be halfway correct I'm sure there are others will come to testify stronger to that. Are there any other questions from committee. Senate represent Johnson you it was I just if I can say one other thing before we start with testimony I thank you I think you heard in and I've certainly heard a lot about what's best for the pharmacists. And what's best for the hospitals I would encourage you as you listen to this testimony. To to not think about what's best for the pharmacy the shore the hospitals but what's best for the patience of Arkansas is at the end of the day this isn't the first time we had a territorial dispute in this committee or for this legislative body those are things that we do with regularly in this committee and that's what this is the end of the day this is about territory in what we've traditionally done with the territory was physicians or nurse practitioners pharmacists or physicians athletic trainers or physical therapist or whoever would have in this dispute over traditionally we make the right decision not based on the special interests of either group but on what we think is right for the patients and the people of Arkansas so that I would just say as you listen to this testimony I would you encourage you to listen with that thought in mind and then also say this is not a vindictive occurred you know this is a place where I think you can you can vote your conscience you know I I can tell you that I'm sure you've heard from hospital CEOs and pharmacists again we're gonna work together after this either way so as you listen this testimony I'd ask you to keep an open mind to keep those thoughts in mind and I'll get off the mark and that people start talking. Okay first up to signed up to speak against the bill is Mr John Vincent. Thank you Mr. A John Vincent CEO executive vice president of the Arkansas pharmacists association and a pharmacist license pharmacist in the state of Arkansas our organization has approximately two thousand members pharmacists pharmacy technicians and student pharmacists from various practice settings around the state we do have members from all practice settings meaning nursing homes hospitals independent pharmacies chain pharmacies and. We have academies in our board I just wanna make sure because we have members in the room today that are members of our association you may hear from that have different viewpoints is represented Johnson. Alluded to our organization the Arkansas farm association is opposed to HB thirteen eleven and we do appreciate the the work that went into this to to work on it it's a very complicated issue I wish I had my white board that we could draw out all the complicated areas of House three forty B. works I know you'll probably hear some more about that from other testimonies in just a minute so on the surface it's a may seem complicated but from our perspective It's simple. Our community pharmacists in many of the cities I know it hurt her from representative we Johnson and to go about hospitals may be in areas that have pharmacy deserts one of the unique things about Arkansas and our fifty years of precedence of this law being on on the books is it has encouraged entrepreneurs and small businesses to open in areas where you otherwise would have a pharmacy to his or see you may look around the country and find places there's many that don't have pharmacies if you look in the state in the Brzeska for example more than half the counties don't have a community pharmacy in this state all seventy five counties do and I have the list of the FMC puts on the website of every hospital in Arkansas some for profit some not for profit in every single community in this state there is a local retail pharmacy the vast majority of these men independent pharmacies in rural areas where you don't find some of the larger chain so I do think our law has worked there are still opportunities I know some of you on the Committee or more familiar with three forty B. than others but there are opportunities to contract with these pharmacies most of the hospitals do a few of them do not so I would encourage you to ask why not because they can take advantage of the contract relationship to maximize with difficult work force issues a fragile healthcare eco system they can work together to solve problems to to take care of patients to make sure that revenue that he talked about a minute ago does go to the entity the when that revenue is intended to go to them to help them for uncompensated care but at the same time not directly competing and and making it impossible for the some pharmacies in some areas to to continue to provide services like to have some of them for more than a hundred years so that's on the surface why it's simple that we want to continue to work with. Hospitals from the association point of view instead of in competition with each other special in some the fragile areas we do have several pharmacy owners in the room three of whom are going to speak and then give a little bit different testimony from what I gave in any of us will be happy to answer any questions that you may have with that I'll take questions. We have a question for committee. represent road you're recognized thank you Mr chairman thank you for testimony Mister Benson I just had a quick question about this navigating kind of how I'm understanding everything here you have independent pharmacies in counties where there are for profit hospitals who have pharmacies is that right there are about the way I understand it on this list thirty to forty percent of the hospitals eighty nine hundred depending on how you define it our for profit the other sixty to seventy percent are not for profit so the for profit hospitals like heart hospital in north west in Bentonville St Mary's in Russellville Salim memorial in Benton and hot springs national park just a few examples of for profit hospitals in case you're not familiar with the difference those today and and for the last fifty years can own a retail pharmacy permit they're not eligible for the three forty B. program because their for profit they don't have a disproportionate share number of uninsured patients and nonprofit setting so they don't have access to the three forty B. pricing differences those pharmacies representative road that are for profit that have pharmacies and a committee like Russellville and Benton and hot springs those hospitals today do not own retail pharmacy permits and what they tell me and I've heard from some members from some of those hospitals that have called me text to me they're not here today to to share this but they've shared with me an authorized me to say they're against this bill and the reason they're against it is because they would rather work with the existing pharmacies that are there they provide good service for the patients and around near the hospital in margins are thin it's a tough industry there's lots of issues and retail pharmacy that I think we still have yet to to solve that we need to continue to work on to make that industry stronger. Mr chairman I clarify and then ask a follow up you're recognized for follow up. So just to clarify I was trying to to find out for their or their pharmacies in any of these. For profit hospitals in Arkansas no Sir they're not they're not they do not own retail pharmacy there's none of those and they have hospital permits to provide inpatient pharmacy services but for outpatient retail none of the for profit hospitals currently even though they're allowed to by state law none of them have one and they don't provide services okay thank you thanks. represent Bentley you're recognized for a question thank you chairman thank you Mr Benson for being here so I want to just clarifies I was a director of nursing when I got a nursing school my first job if I remember right or nursing home contract with a local pharmacy to fill the prescriptions there for our patients that were there in the in the nursing home so a hospital could do that with the local pharmacy now and recoup these three forty B. funds is that they can there yes and I'm not gonna lie there it's. There are challenges whether the hospital owns their own pharmacy or whether they contract to work three but I'm confident the vast majority of the issues and challenges you're gonna hear about today can be solved with the communication collaboration and contracts like you describe okay follow up on that. So referring back to the bill that we passed recently Senator board and I to allow them to send home thirty day prescriptions that could be included in that as well to allow them to be able to get some funding for the medication they're sent home for the thirty days our organization is committed to working on any method to provide reimbursement for services provided by hospital independent pharmacy chain pharmacy any of the practice settings were there pharmacist yes we would work to help make that happen what clarification about there for me where it is true that inpatient pharmacies have a limited formulary for inpatient use however those who provide outpatient prescriptions for their own employees have a much broader FOR me wearing them what they might use for inpatient use in that bill allows them to expand their form muelleri and use whatever drugs they want to order to provide for whatever patients they want to provide services to a and that thirty one day after this charge scenario that we talked about a minute ago so it is possible into sixty five your bill did for the first time in history put in statute that this would imply for their own employees as well. Of next if the region version get represent K. Ferguson you're recognized for a question thank you Mr chair and this question may be the better as it maybe by a hospital the hospital association but I want to ask you do you have kind of a little bit for me with three forty B. program a call a friend of mine last and Washington DC to get some clarification on something but let me ask you this now how does the program help patients three forty B.. That's a great question so three forty B. program is set up for either nonprofit clinics that pertain that are eligible like federally qualified health centers or rural health centers or nonprofit hospitals that see it a higher number of uninsured patients or under insured patients. Two ways they could potentially benefit directly to the patient one is the entity that gets the savings and by the way there is a question asked where does the savings come from or where does the discount come from the discount under the federal program comes from the manufacturer so the pharmaceutical manufacturers and they in order to agree to. Their drugs to be covered in state Medicaid programs they agree that entities are eligible for three forty B. that a bottle of insulin for example that might normally cost four hundred dollars for a pharmacy to buy a three forty B. entity could by that same bottle of insulin for a nickel literally ninety nine percent off the price in some cases it maybe fifty or sixty percent off like a twenty five thousand dollar cancer drug might be five thousand dollars not a nickel but it's still an between fifty to ninety nine percent depending on the drug and there's super complicated to explain why those for how those prices are determined but it comes from manufactures into to answer your question they can either be done through the facility adding more resources adding MRI's hiring more doctors those kind of things clinics building facilities or in some cases cash savings cards or discounts on copays are offered to patients and what we would like to see is any time that program is offered that the pharmacies that participate in that program they all have equal access to provide those same advantages to patients no matter which pharmacy it is so that it's not abused in a way that steer patients or incentivize them to leave their pharmacy of choice represent person one final question and I'll go back in the queue if I have to the the the reason why I ask that question. My. Former wife who's going to be with the lord had a very bad case of diabetes some point in time there was some medication not covered. About insurance we had to pay a high cost right now under that three forty B. program. The hospitals could scale. Of this when they passed that discount on to the patient but my question is sometimes when the insurance company says we are not going to pay for this that Betty medication. I'm assuming that the hospital can sell that medication at a discount for cash price. To the patient yes they can but also through the cash savings cards this is complicated why I need to what board but there's a three forty B. consultant near our state who works with a lot of the hospitals and federal qualified health centers and other others explain this but it is it is possible not just for the hospital to do that or the clinic to do that it is possible to set that program up or any contract pharmacy that contracts with the three forty B. entity at the direction of the entity could do that same service that you're describing so we have a pharmacist here from ticket for example today and if that hospital and pick it chooses the set that program up to pass those savings to the patients who are eligible the not just the hospital but any contract pharmacy that works with the hospital could offer that same benefit to patients thank you Mr chair I'll say one questions for hospital association. Thank you. Okay Next up is. Representative Richard members I would remind you all we're still on our Our first. This. We got a long list of thank you Mr chairman of the really quick hopefully I'm still confused by the whole three forty like most people are but I come back around to the for profit hospitals not taking advantage of retail pharmacy permit is that associated with the lack of reimbursement from the three forty or. My understanding from talking to a hospital pharmacist who working for profit hospitals their existing pharmacies that already provide the services needed in their community and there's the the Committee pharmacy market in terms of reimbursement the lack of dispensing fees the R. fees and Medicare which are callbacks under federal program the eroding of payment models in community pharmacy there's not enough profit for the Jews to be worth the squeeze so they just don't do it they let the existing pharmacies fill that space and partner with them and they don't open pharmacies. But I would think if there was a patient care needs back to that they would do that I mean I would think so but in those particular communities there hasn't been a need. Okay representative rose you're recognized for a question is it thank you. Representative Ferguson kind and triggered a memory for me a couple years ago. my wife was going through chemotherapy and had to receive the day after a new last to injection and the cost on that it's a white blood cells you know thing whatever was just shy of twenty thousand dollars and should get that after each chemo treatment and after about the third one we started getting the bills and insurance company and they're like Hey this is too expensive we're not going to pay it you had three of these tough luck kind of thing and pharmacy can do anything they couldn't discount it tried numerous things fortunately the hospital was able to do some negotiating on our behalf and made it much more affordable and so what representative Ferguson just made me think about as well as is there any way that the way things currently stand that these types of drugs diabetes diabetic medication insulin commit there be new last of those types of things where it's not going to break the back of the consumer like can that happen now and why is it happening now. Great question thank you for that question two things that could happen I know Hey agents son the Director Baptist is in the room Michael shepherd my good friend in Fort Smith director of pharmacy at Baptist if if Baptist is three forty but it three forty be eligible they can answer this And tell you this in Fort Smith community but if they are they could contract with the pharmacies in Van Buren Arkansas it's my hometown to information here and for those of you don't know. They could do that today and contract with them what keeps most local pharmacies from stocking the drugs that you just described is the insurance companies and PBMs own competing pharmacies those are more profitable drugs and they set up plan designs that force patients to use mail order pharmacies outside this state so one policy change if you want patients to have access to the lowest cost drugs we need to put a stop to that and bring those drugs in patients back into our communities where they want to access those drugs at the best price possible that is a problem that is some I talked to representative Johnson about I know that's not part of this bill but we talked about that in some other versions about that issue and why that's important to partner with this to ensure that both hospitals and local pharmacies have access to those drugs at the lowest cost. Okay seeing no other questions from committee respectfully appreciate your testimony thank you for having me are very much appreciated thank you next up to speak for the bill of Is Derren Caldwell. Thank you Mr chairman committee thank you for having me today my name's Darren Caldwell I'm an administrator with mercy health with me is Michael things he's the Director pharmacy AT Fort Smith mercy we're thrilled to discuss this matter because it's near and dear to my heart I'm speaking on behalf of fifty five hundred and eighty three co workers and physicians that are also members of the mercy team but most importantly I'm speaking on behalf of the patients that we serve. It's important that we take the opportunity to pass this bill thirteen eleven because it will give the opportunity for hospitals to benefit not only the patients but for themselves it there's been comments made earlier as to that alluded to me that we might be saying what I would do a better job of managing when the patient is discharged or what kind of case management could we be doing to help benefit this today I'm going to tell you that twenty seven percent of the patients that present to my emergency department come between eight PM and eight AM so those patients cannot be managed of that one in seven or of a vulnerable population of kids and seniors. Arkansas is a month we all know the least healthy group of states in the United States and any time that the hospital can have an opportunity to assist in filling the gap where these patients could potentially get medicines that will affect them negatively and we can take care of that at the time of discharge it obviously will be in their best interest another comment was made what we're trying to take business away from the local pharmacies the fact is many local pharmacies are getting this business I'm familiar with administrator in Virginia. She started a pharmacy in she said quite frankly the reason they did it was to decrease the number of readmissions that they had because the patients were given a script and they chose not to fill it and then they would come back and instead of being having their chronic condition managed it was they were coming back to the V. and having to be readmitted so this is another. This gap to where we can assist and make sure Hey I'm a huge community pharmacy thing I mean I am a born and bred lifelong State of Arkansas citizen. I only knew community pharmacies growing up in Arkansas that's the only thing I knew and so I think that they play a vital role in the continuum of care with these patients but we're talking about filling a gap that they are not currently feeling. If we don't take the opportunity. To see when patients are in need and then they are not being taken care of we are turning our back I can't speak I have worked for city council and not for profit hospitals I've never worked for a for profit entity and I can't speak to the reason why they would not want to take care of patients that they know or in the gap situation that's not being taken care of but I can tell you that I have worked in or representative small hospitals for third over thirty years and I recognize that in the communities that we serve that there are many people who are incapable of making a trip. Transportations the worst thing we have to deal with and health care are quite honestly it's been all get to the number of them get to us and so if we don't take care of it at the time that they are leaving we're potentially missing out on an opportunity to help them the other comment that was made is that a brassica. Half of the state didn't have of pharmacies I think if you look at the census half of the state of Alaska that neither there's no one there so we would obviously want to community pharmacies to be available to take care people in populated areas so. That is the comments that I have I really appreciate your time and I'll be glad to take any questions. Are there any questions from committee representative Bentley. Thank you chairman can you tell me why you've not reached out to a local pharmacist independent pharmacists and try to work at three forty B. contract with them like the nursing home yes then yes thank you representative we have tried to reach out to local. In the pharmacies in the past I have the opportunity working another location I'm I'm aware of the fact that some local pharmacist feeling comfortable being a part of three forty B. plan they think there's either administrative responsibilities that they're not comfortable with or that there's a risk of expense that they don't want to take so it's not that the hospitals and reached out in the past it in many cases these pharmacy didn't want to participate. Okay one quick follow up you're recognized of this to the for the pharmacists with the there I'm very concerned about our our nation going to socialized medicine I see that we're really almost to that point now we have so many people Medicare Medicaid were at that point so during the pandemic did you of filling prescriptions for any alternate treatments to COVID like ivermectin Hydroxychloroquine in the hospital. Thank you for the question representative of my name is Michael things are can you introduce yourself yes you may start at Mr chairman or Michael times on the Director pharmacy for mercy Fort Smith. And to follow up with your question representative during the pandemic did we dispense any alternative medication such as ivermectin and the answer is no we we we did not go down that path and all up I'll keep my comment short as far as the the matter of this bill but I look around the room and I see a lot of people that I've practiced with over twenty plus years in the state of Arkansas and have a lot of respect for people on both sides of this issue what what representative Johnson has as proposed is really creating more access to health care for cancer and so I'm happy to take any other questions. Relevant questions from committee. Sam Nunn we thank you German for testimony thanks. Of next up to speak. I guess the bill. Is. Misbranding Sanders. Represent road like to make a motion. What's your motion limit testimony time to five minutes or less not including questions answered. Per person or per side per individual. Handful. I don't know let's let this ride for another little bit and we'll see thank you. You're recognized ma'am. Thank you my name is Bernie Sanders I am co owner of the pharmacy at Wellington here in Little Rock and I'm here today just to against this bill to say that the current structure with community pharmacies there are things in place for patients to have access to medication many of the community pharmacists you see sitting behind me offer twenty four seven after our service if someone is discharged from the hospital and is in need of urgent medication it's a phone call away we're there to provide that service and. Assuming that there's a need for the patient we can get there and meet them after hours that's something that most community pharmacies in Arkansas currently dealing offer for patients. By a. Establishing hospital pharmacies retail falls possible pharmacies and some of these more rural locations actually may end up limiting patient care limiting each patient choice. Bikel these pharmacies closing it allows for the dollars to be stirred back into the hospital in may for some of the smaller pharmacies to close so the concern is if we're here for patients. Partnerships between current hospitals and community pharmacies can allow that to happen for patients. Thank you ma'am are there any questions from committee represent Gonzales. Thank you Sir have you had a hospital's reach out to you to the contract with the on three forty. Yes Sir we are contracted currently with Baptist hospital to provide three forty B. services for patients thank you. Any other questions from committee. Sam Nunn thank you ma'am for testimony thank you. All right next up to speak for the bill is Mr Kevin Roberson. You just identify yourself for the record. Name is Kevin Roberts and. I'm the current president of the Arkansas association of health system pharmacists to have with me today amber pal is the future president of the Arkansas association health system pharmacists and in agents on Tuesday a past president and also Director forms it beds hospital I'd like to read a prepared statement from a. You're recognized with. I'm a pharmacist for of twenty seven years with most of those in a hot as a hospital pharmacist. I am currently the president of the H. P. which is the largest of the three academies of the Arkansas pharmacists association with approximately two hundred seventy members our board of directors is asking your for your support for house bill thirteen eleven. I would like to provide an eggs a personal example have the current statute inhibiting nonprofit hospitals from attaining a retail permitting packs or cans my mother who lives in Tate who lived in Texas in Arkansas at the time was receiving oncology therapy at Texas oncology in Dallas for metastatic ocular melanoma. After particularly exhausting course radiation therapy and driving home three hours the intervention radiologist had phoned in a prescription for medication that I as a pharmacist new is going to be particularly difficult to attain due to the nature of a shortage and the narrow scope the potential patients it would impact. Per common pharmacy of used to not stop the product and they were not eager to purchase it due to its limited usage. There far call the prescriber in hopes of having it changed to something more readily available that request was denied. Because I patient my parents lived in a border city I knew there was hope. St Michael's hospital in Texarkana Texas had a retail permit. Because it is a drug commonly used in Stockton hospital St Michael's had in stock. Mothers pharmacy was glad to transfer the prescription of my mom's needs were met and timely manner I remember saying at the time god bless Texas. If my parents had lived in hope the nearest city with a hospital on the Arkansas side of the border. And set a senior Senate Senate bill two sixty five now ACT two thirty three existed this it would not have helped her as she was not discharged from widely and she was not seen via the widely E. D.. Also Senate bill two sixty five does not allow hospitals to fill prescriptions written at a non associate AD or any urgent care clinic. House bill thirteen eleven fulfills the prac practical needs that Senate bill two sixty five live short and made me believe that every hospital will be able to spend two thirty one day supply of necessary medication for patient go home they can't. Passing house bill thirteen eleven give nonprofit hospitals that currently don't have a retail permit the ability to provide that care. Again H. P. request your support for for house bill thirteen eleven to better serve patients of Arkansas by expanding a six accessibility of medications. I'll be glad to entertain any questions you have. Thank you Sir are there any questions from committee. Sam number thank you for your testimony. next up to speak against the bill. Is Mr stay bright. Please identify yourself for the record. good good morning thank you Mr chairman and members my name is Steve Bryant the pharmacist from Basil Right can you turn your a microphone on thank. Is this where no. Okay. All right maybe I move up a little bit okay is this better. Okay My name is stable right the pharmacist from Bates full. I own and early partners in seven different pharmacies home health agency or hospice we employee. proximally two hundred employees in the State of Arkansas and we administer an arrest the qualified health care plan also I have served on the board of directors of White River. Health system and hospital in base for Arkansas for for ten years now. So I have a pretty unique perspective into. Hospitals versa and retail pharmacy relationships what's been said about patient care prescriptions go unfilled unfilled to shorten pharmacy hours of. I'd just like to reiterate what doctor Sanders said we come out we get calls at night we get calls from hospitals in Little Rock we were sending a patient home Do you have this medication can you wait for this patient or whatever but we we serve the needs of the patient and if it's after hours it's after hours is that that is never an issue. And But to address the situation Dr Robinson referred to it's. If you know when you send the patient. For a from another state home. And if you really need good discharge planning you need to plan that situation to deal with that patients needs. Our plan for it before they ever leave Just send in the prescription somewhere and tell them to go home and good luck go pick it up is really not a good solution so one thing we do at and I have worked with our local hospital is to improve. Yes charge be put more proactive in discharges and that provides or promotes better patient care and prevents readmissions. So those situations can all be resolved with better communication and and the hospitals working together. they say three forty B. will take care of this problem. Of. A lot of actually three forty B. pharmacies are open even is there only maintain ours that we maintain. In different states but they have limited hours. And. But the thing about three forty B. of you know the address what Representing Ferguson was talking about that copays the. And in such a hospital gets a discounted price that they can pass that on really if you have insurance they they don't pass that on you pay a copay just like you do. Is if they didn't have three forty B. that part of the equation is is the same it doesn't doesn't change just because. You know like for example a thirty day supply of Nexium the wholesale price on that cost is about two hundred sixty two dollars but a three forty billion eighty pays thirty cents for that penny capsule unbelievable. That is billed to the insurance the copay is the same to the patient regardless of whether that's three forty B. entity or not so all the money goes to the three forty billion a to a. Doesn't help the patient. Getting that prescription on that prescription copay. Yeah and and the thing about. If. What we want we all. Contract with. Hospitals that qualify for three forty B. of participation. it appears it MRCY has not done that they have various reasons why they say we won't do that but. I can tell you that our group of pharmacies if we were asked by mercy we would participate we'd be glad to. And they would get the benefits and. And the we would have a good working relationship and I've never would be a problem with that But we we would need to be offered a contract and and and would be glad to do so. One thing about. They are mentioned on the we have a really good health care plan with our organization that we oversee in its original plan and its self funded but more important self directed. And We. One thing back to the you know when when you have a three forty B. contract the the read with retail pharmacies. We feel the prescriptions based on what is best for the patient. If you have a three forty B. entity that's owned by the hospital. And if you've got this vertical integration thing going on then there's really of the motive is to. To dispense the brand name medications which is what. It is what the three forty B. programs about it's not about generics. So. What we do as retail partners the and when it those medications are available generically we dispense those medications generically because that's the best thing for the patient best thing for the healthcare plan. And. And. It's it's just it just saves the system money. That's a. Of service excuse yes I hate to interrupt you we are we've got some members that have some impending appointments Real quick we have any questions right now all the stuff is fresh Armand of for current witness are there any questions from committee. Okay saying none of excuse me representative sauce you're recognized by Mr so you do you do not have any three four B. contracts with not for profit hospitals now a yes we do you do okay yes the but you don't with the mercy system so they they just thank you say they have amassed I have asked but if they did we would participate okay thank you yes okay. Okay thank you it's are again I apologize of the Freeman ranch of. Committee I think we're going to of. The Journal recess will go session will come back after session pick up where we left off oh happy day.