Public Health, Welfare and Labor - House and Senate

course are organizations just directly across the street somewhere nearby. There is a couple of recent publications that were updated during the pandemic out of a national group that's called the pharmacy workforce center and from a demand purpose someone talk a little bit about specific in Arkansas and then some national trends and how that impacts Arkansas but certainly in recent months some of this is driven by pharmacists either leaving the profession some of it is new services that are offered or an aging population services both during the pandemic in after but there is an increasing demand for pharmacist position so when you look at this the south part of the country there's about a nine point five percent increase in jobs that are posted in Arkansas in compared to rest of the states in the south region which includes states like Missouri Arkansas Louisiana Kansas Oklahoma and Texas Arkansas actually has one of the higher job postings so when you see four hundred forty seven postings that's about ten percent of the licensed pharmacist positions that work in the state of Arkansas in all those different sectors that I talked about or sets a significant number same thing for pharmacy technicians we appreciate the the collaboration with the legislature within the profession recently where we've expanded the number of pharmacy technicians that can work under a pharmacist supervision in recent sessions we've also added some new responsibilities that are allowed last session with regards to assisting pharmacists with vaccine administration which has been a good thing for collaboration patient care but there is a a big increase in demand similar to what we saw with pharmacists and just for perspective there's also about forty five hundred licensed pharmacy technician so just a little bit. Barely above like a one one ratio of a licensed pharmacist working in the state and there are about twenty percent of those positions are posted right now in terms of of pharmacies trying to hire pharmacy technicians a lot of what's I think why there's probably more demand for pharmacy technicians there's been a lot of turnover meaning inflation rising salary expectations work from home positions which isn't possible in a for for most of the duties that are done healthcare in a community pharmacy or in a hospital pharmacy most of that has to be done in person but you're competing with those other jobs that demand that are becoming more available for those types of positions just for perspective the pharmacist is a a six or eight year degree Dr degree in pharmacy technician is a high school degree with some background check and also being supervised by a pharmacist so in terms of education. We have also at the national level Senate not just in Arkansas but all over the country issues and some of our chain pharmacies in particular I'll talk about independence and just a minute but is you and I've talked Mr chairman that you we've seen Walgreens we've seen Walmart we seen CVS particularly in Arkansas it's been Walgreens where they've reduced store hours they've had unexpected closures when you talk to Walgreens leadership about that just relationship with them some of that's driven by labor issues the pandemic and competing with other sectors and and I would say that is true. They're also and and this just a slide on some of the complaints that the Arkansas state board of pharmacy has had about some of these issues where patients or prescribers were expecting a prescription to be filled or picked up and then they were unable to because the store has unexpectedly closed in talking to Walgreens I think about seventy five percent of their locations at some change in store hours over the last year and in some cases they were able to take employees that might be in a store that had a bigger amount of staff and move them to another location so that they could continue to operate at the required forty hours a week That is required of any licensed retail pharmacy. some of these national issues I'm a show of a workplace workplace survey here in a minute from a national survey was released last year about a year and a half ago but some of these national trends in the stresses I think you've contributed to making it more difficult for our colleges of pharmacy we have to in Arkansas one in Little Rock and wanted Harding when I graduated from pharmacy school it was about you know three to one I'm not gonna say how long ago that was but you know three or four one applicants to one person admitted in recent years it's been more and more difficult to attract talent to attract students to apply for pharmacy school and we're we're about ten years ago UAMS have a class size of about one twenty in Harding opened Searcy had a class size of sixty this year's numbers are about a little bit a little bit less than half of where our peak numbers of students were a decade ago just for perspective and I believe some of the stressors that we're talking about just manner contributing to that so here's the survey I was talking about that was published in may of last year by the American Bar Association and national months of state pharmacy associations we're talking about some of the good and bad and some of the things in the study that I'm highlighting were some of the more concerning things that we might be able to think about and policies that we introducer consider around the pharmacy sector but they found a lot of things that I see on social media but it's interesting to you know what from colleagues anecdotally but at least and then the numbers of pharmacists they surveyed in all settings they did say that there were stress issues there were concerns of cultures of patient safety and and pharmacists in certain positions they were breaking point and I know many of you have heard this is and other presentations about conditions in physician offices and conditions in hospitals I just want to say. There's some consistency in the pharmacy sector as well there were about seven thousand respondents across seventeen practice settings in about half of them were in chain pharmacies another thirteen percent and supermarket pharmacies in in a much lower amounts of independent pharmacists responded to the survey but still interesting one thing that jumped out that are included on the slide was it was the first time we had seen in a survey like this in a workplace survey and I don't know how much of this is you know because of the staffing issues and how much of it is pandemic but it was for the first time I had seen where there were complaints by both pharmacists and pharmacy technicians and I work for survey of a bullying or mistreatment by patients consumers I mean let's face it there been some stressful times in recent years one thing that stood out to me to is that three in four respondents in this recent survey and this is a national survey want clarified not Arkansas specific but national survey that seventy five percent felt like they didn't have sufficient time allocated to safely perform patient care clinical duties so only one in four felt like they had that familiar with probably what you might hear from our colleagues in other practice settings I'm not gonna go through all these complaints but just for the record I do have some examples of comments that were made by the pharmacist that felt like they didn't have sufficient time you know for clinical activities and patient cares but it you know kind of the. The theme that you see over and over is not having enough staff not having enough support not having having too many tasks for the the work force to to conduct this task was a of a theme that we saw over and over I talk about social media minute ago for those of us in the pharmacy world we've all heard of the hashtag pizza is not working and it was started by a pharmacist in Oklahoma who quit her job because she was at the breaking point in a chain pharmacy environment where she didn't feel like she had sufficient resources and they had said here some pizza you know everything's gonna be alright kind of thing and she said that's just not cutting it anymore real changes got to occur and it's taken off in the documentary films being put together on this and experts in the field around the country have been interviewed about that I did want to point out that from an independent pharmacy point of you in this state has been one of the most progressive in the country at reforming the payment models around the interactions between pharmacy benefit managers and And and the pharmacies in the retail sector and at least in this survey nationally the independent pharmacies had the lowest average score meaning they were that the happiest in the work environment also hospitals in academia positions were in the middle and chain pharmacies tended to have the worst responses in that states that was an interesting finding to me there was a recent article around this story that was called how pharmacy work stop being so great that was published in August in The New York Times and they had a couple of interesting quotes that talk about doctor level degree the amount of time in training average student loan debt hundred fifty thousand to a thousand dollars for student coming out of pharmacy school today and during the and during inflation or during pandemic one question occurred many jobs wages increased I don't want to say equal to or greater than inflation but wage increases happen we're seeing that with pharmacy technicians even within our own field I know doctor acre represent Baker set up there around the state I've heard from a number pharmacy owners and also chains where pharmacy technicians hours of in some cases doubled what they work prior to the pandemic but for pharmacists compared to inflation their salary according to this you know the data in the study fell about five percent just give the perspective of not being able to keep up. some of the large chain pharmacies that I talk about a minute ago they have made some changes by offering breaks larger salaries bonuses some of them are even able to recruit a little better because of that others because relationships are able to recruit to the work force but so a lot of movement on that And then wanted to show you that from an independent pharmacy perspective that the national community pharmacists association did report that even though the working conditions are you know we're best in that particular sector pharmacy that the independent pharmacies are also having a difficult time sixty eight percent reporting and white two thousand twenty one. issues with filling positions and almost ninety percent with technicians interestingly about thirty percent felt good about their finances and forty per two percent felt poor about their finances and their you know are there different things this is a national study in Arkansas I like to think because the good work and policy we've moved forward that many states around the country are continuing to emulator to to also implement that should continue to get better but it's still not perfect and we've got work to do cash flow wise just from talking to our board a typical independent pharmacy ranges from somewhere as little as fourteen days to as long as a forty five day cash flow on hand to pay bills and pay salary so any kind of delays in payment I know we had an issue recently with even doctors may have heard of the drug um Gero error the drug was emphatic that are used for either weight loss or diabetes treatment depending on the drug in the patient there were some even doctors are coupons where payment was being delayed by a PBM or our claims processors not just thirty days are not seven days but as long as four months you know ninety days to hundred twenty days so you know do we need legislation to address that as the private sector work that out not here today to to necessarily say what the right policy is but opportunities to fix those issues for our pharmacies to succeed and we have had an increase in pharmacy desert's everyone of the members of of the of public health asked me to include this there been national stories I know doctor Cassie is actually here in the room today one of our members he has pharmacy in rose city and he's the only pharmacy and over in a pretty even though is in an urban area it's a really under served area and so anything we can do to promote encourage. pharmacies to to stay open and provide services where there need needed to prevent pharmacy deserts like we're seeing in many areas of the country we would appreciate working with you to solve those issues number of retail locations I get asked this question a lot so two thousand for about almost twenty years ago about seven thirty nine it peaked in two thousand sixteen and over the last eight five to ten years it is declined to where we have about seven hundred six sixty four retail permits in Arkansas now interestingly where is it used to be the vast majority of those were all service like meeting they provide a controlled substance prescriptions antibiotics maintenance meds the whole gamut of services vaccines some of the retail permits today in recent years have been more limited meaning they provide maybe specially only earn fusion services as opposed to what you think it was a typical retail pharmacy so that we don't have a separate category for those limited services they fall into the same bucket I also think it's interesting that while prescription volume has quadrupled in the last twenty years the number retail pharmacies has not quadrupled you know like they've not increased based on what you think a need would be based on an aging population number of prescriptions and at the same time out of state mail order pharmacy permits which are on most of the time owned by insurance companies and PBMs have more than tripled you know in the same time frame so big. Growth in that I'm not saying it's all bad but there are certainly some concerns if patients are being forced by a plan designed to pharmacy they don't want to use and dollars are leaving the state jobs in or leaving the stated be nice if we could keep those in the state you know and and treat patients where they are rather than force somebody to a pharmacy based on finances rather than what's good for their actual outcomes and patient care so just want to show that so we do have concerns about vertical integration finally we're getting past you know well past the peak of the pandemic but that certainly added a lot of stress to the to the work force in a lot of those comments I talked about earlier while I think the independent pharmacies had a better working environment versus chains I don't think it's because it is stressful and an independent pharmacy I just think that the pharmacists have more control over their work flow as licensed healthcare professionals they have more decision making about what their work flow looks like staffing verses in a corporate setting they have less control over those things and that's more stressful so we still do have even though we've made a lot of improvement we still do see it he's in contracts out there I know there's a Senate bill right now on TV and reformed to to increase enforcement of previous pharmacy benefit manager legislation Senate bill ninety four that senator Hammer and representative Baker or running we'll see how that goes doesn't have new regulations is just better enforcement of existing regulations but we're still seeing it and for those of you who may be due or and don't know the history to the legislature we have the particularly from two thousand eighteen for there's period of time where there about five hundred pharmacists that fill this room because pharmacists were being offered take it or leave it contracts there is data that pharmacies owned by insurance companies were actually paying them. Selves in their contracts much higher rates than their competition that has been outlawed in Arkansas but it has not been outlawed in other states so that contributes to some of the issues were having around the country on work force and the ability to attract young professionals to our profession so appreciate this state for being a pioneer but it still has an effect until it's fixed all across the country we did through a series of lawsuits our state was able to uphold those laws all the way to the US Supreme Court back in twenty twenty so one upon legislature leadership and Currently ten governor and former Attorney General Leslie Rutledge for working on that but even recently tricare which services are military and some of our veterans and retired military issued a new narrow network contract where most pharmacies in Arkansas used to be able to service our tricare beneficiaries in the new rates and the take it or leave it terms meant that sixty percent so of those seven hundred fifty pharmacies I talked about earlier sixty percent are not in network in twenty twenty three so it forces the the veterans to either use mail order pharmacy owned by the insurance company so express scripts is mail order pharmacy in another state or to go to a military base or in some cases drive two or three hours from where they live in a place like Helena to find a pharmacy that is actually a network for military and just from a state legislative point of view the tricare program is a federal program and we can't regulate it at the state level it's it's controlled and preempted from state law controlled federally but I just use that as an example of of how it affects workforce and our ability to service our patients and in rural Arkansas we did have we had a few pharmacies close recently fry the most recent one that was a big losses and holiday island which is a retirement community and that was a big deal you know to lose access for retired population in that community up in northwest Arkansas. With that I will yield to next presenter and entertaining questions or comments from members thank you Mr. Thank yes good presentation a representative Graham like you're recognized for a question. I'm sure I and I guess I didn't realize how big the issue was is a little bit migrants thank you for being here and teach us a lot of that so I guess I guess I just going to getting more pharmacists in the state you know you I was looking at those numbers and it if you say like ten years ago all the classes are full you know so are we not even getting applicants for the open spots that just not meet meet the stuff that's actor we're not getting enough qualified applicants for the spots. And ten years ago were fighting over spot yes so so I mean what what's happened in the last ten years with a high school and college students where pharmacies just like. Not interested anymore I think when they come shadow and they see how stressful it is and I'm not saying that pharmacists are being success there are plenty of pharmacists that are successful and fulfilled I've been successful in the field in my career various places I know we have a member of the room and I was if the price say that Randy you know has a thriving business and is able to expand his businesses but I do think there's a significant amount of stress and all of health care where you're not able and if you're provide services to patients you're not able to remote work remotely like a lot of jobs offer today in student New World environment and it is The reimbursement model I don't think is kept up you know from where it was years ago when I graduated from pharmacy school it was common to see a professional dispensing fee is part of the reimbursement methodology of anywhere from four dollars and fifty cents to eight hours a prescription for example in recent years we've seen those dispensing fees disappear from four to eight hours a script to literally zero dollars per prescription filled by pharmacy benefit managers and insurance companies and you may be thinking what the world was the pharmacist signed that contract if it doesn't provide adequate payment for services and I'd be asking the same thing but we've got a situation where when you own a small business and stuck are it's difficult to negotiate a fair contract with somebody who manages literally hundreds of millions of lives and prescriptions and so we've we've passed legislation it's made it better but our legislation is not perfect and there still loopholes in issues to solve if we're going to get it back to driving again to be you know if not a stressful adequate payment model to have time to provide the services. And and pizza hasn't worked apparently that's exactly correct hashtag pieces not work that's wild. Thank you for the question. That represented acre. Thank you Mr chair and I don't know if I would qualify my career is thriving is that it can get this is a second job to a year but to further expand on a represent Graham looks question you know back when I was a platform to school we would have upwards of four hundred applicants and now we have. There was off of eighty yeah there were ninety three and tires high school student I mean college students who were eligible to apply who were from Arkansas who applied this year and moving to a separate line of questioning and do you have any idea of the number of claims that pharmacists are sending to the insurance commissioner that have four PM so violated laws while these laws have been enacted what what is their volume of transgressions having had these laws on the books for north of six years now so what rough numbers I believe there were about ninety thousand claims last year in about twelve thousand or so were. You know validated is enforceable in Arkansas there were another thirty thousand that from a technicality or a loophole they couldn't enforce it which is why Senate bill ninety four was drafted to make it better and forced the other half of those claims are either tri care that I talked about a minute ago which the state can't enforce because the federal program or Medicare for retired population which the state also. Not enforced because the Federal preemptions in a big govern at the federal level. So that's answer thanks for the question. Appreciate you taking time to be here today that's a lot of good information to process and make sure we get your slides out on the committee members thank you John you're welcome thank you the. Ballinger Danielle here I did not mean to skip over all his slides popped up at the in front of me and I saw his name I didn't even look at the agenda. She just come to the table identify yourselves for the committee. Good afternoon by Ryle presidency of Arkansas hospital association. I'm Jerry and tread on the executive vice president of the Arkansas hospital association thanks for having us today thank you for being here you're recognized to present your presentation. Thank you Mr chairman as we sell records represent the Arkansas hospital association over a hundred member hospitals across the great state of Arkansas proud to represent them. Also want to start out by saying thank you for the rule emergency hospital legislation of you did a great job of passing that through the process and we appreciate that we will recognize that other federal government offer that designation and we need to state legislation to have that designation here as an option for hospitals and we think a handful hospitals will take advantage of this and it will be a lifeline to those hospitals in those communities they will have to to give up the in patient services that they provide but certainly providing outpatient and emergency department could be a lifeline for some of those hospitals and small communities to survive so thank you for that piece of legislation. And talking about a hospital finances over the last year certainly through the pandemic we saw increased expenses but those certainly begin to catch up with hospitals over the last year we saw labor costs increased by over thirty percent supplies and pharmaceuticals twenty to thirty percent and I think we could all say yes that happened all of this pricetag certainly reflects that but we're not able to increase the costs to prices and pass those along to the consumer hospitals are paid by Medicare Medicaid and commercial insurance so two out of three of those are government revenue sources so those don't really increase to match expenses commercial insurance those are privately negotiated rates and we've we've heard to some some insurers are increasing a little bit but certainly not enough so when we look at payment reform for hospitals we look at all three of those buckets because it's going to take all three to keep up with the expense increases that we've seen over the last year in which we certainly think those are going to continue in particularly labor. So when we look at Medicare obviously Congress and CMS dictate those rates we're one of the lowest paid states in the nation as far as Medicare rates so it's blow because for a lot of hospitals right it even does it keep up with the cost inflation no there's adjustments each year but not enough to to keep up with the inflation. On Medicaid the Medicaid rates for hospitals have been changed in a very long time outpatient rates last changed there was in nineteen ninety to nineteen ninety two and that was a decrease in outpatient rates inflation rates haven't been increased since two thousand and seven so there's certainly some work to be done there on Medicaid rates the Medicaid division recently completed December thirty first a rate review for hospitals and certainly indicated which just giving you those numbers right there those years of increase and decrease so that help is needed for hospitals not only just because of the expense is going up certainly we need to we need to have that word it is reviewed and looked at to be increased every year is critically for outpatient will never catch up with those rates but we need to look at it every year so that it can be adjusted because as we say in in expenses have increased over that thirty year period. So if there's if things remain the same for hospitals there are hard decisions to make for hospitals. Obviously expenses are more than revenues so changes have to be made so what we're hearing out there is certainly the cutting of cost that are going on in communities we know that of labor cost or big driver here so they are reducing the number of bets that they're staffing right now so you don't see that you won't see a press release you won't see any kind of documentation but hospital or just not staff in the same amount of minutes as they did a year ago because they cannot afford to keep up with the cost. We're also going to see of services service lines reviewed such as we've heard a few instances of rule health clinics being closed across the state as I just can't afford to keep those rule health clinics operational they're losing money and some of those communities. And then also we've got. Labor and delivery across our state we have less than forty hospitals that deliver babies at this point in Arkansas it's a concern that cost the smallest hospitals that are still doing this type of service will look at it and say that's that's somewhere we're we're we're losing money it's it's a big drain on the budget we have to make a change here and they'll make a change there will have less than less than we have now so when you think about that delivering a baby driving driving across a county or to counties to get to the proper hospital that is certainly a concern for all of us so I know I've certainly cover that quickly but happy to answer any questions and I know Jody and wants to fill in the gaps there and and talk about workforce issues for us. Members do you have any questions from Israel. C. nine grand jury and thank you okay thanks again for having us here and most of you know that in January of this year that Arkansas hospital association and serve at that AHA services incorporated if you will at sort of a subsidiary of the Arkansas hospital association commissioned a study by a group called global data to look at a wide variety of types of health care workers inside our hospitals and we it said what we thought it would which is we don't have enough of any particular type of healthcare provider that was studied and representive Schultz I see you there we add they asked about EMTs and but didn't get good data on paramedics but they told us that for sure there is a shortage in that particular area they told us we were short by more than nine thousand nurses and no end in sight to how we can create more of those we talked a lot about respiratory therapist all of these things were bad it prior to our reaction and response to the a COVID nineteen pandemic but they were exacerbated when the supply and demand issues of those very critical health care and professionals we couldn't get and we were in a bidding war with other states to get them you all have heard us talk before especially when we were having discussions about COVID about how the travel nursing industry really and increased the cost and the prices especially for travel nurses that we so desperately needed and I know my boss vote rile already told you all that are rate limiting factor for how many patients we can service definitely capacity issue which has everything to do with how many beds we can appropriately staff I saw today senator Hammer filed a number of bills for which we will be support if one is to help with the clinical identification of space. Is that hospitals might have available for clinical rotations through sort of a an online portal per se one of the largest things that the global data consultants at talk to us about and then put in the report is that we need better data collection for licensing boards and we need to know why folks are not staying in hospitals or nursing homes or other health care organizations and entities where they going what are they doing if their license and and we can't keep them we recognize fully the demands that we placed on our healthcare heroes inside our hospitals from dietary janitors nurses physicians everybody in between and have done our very best to maintain the work force and the work tool that we have and but we certainly had a difficult time doing that especially as costs continue to escalate and we have more than forty three thousand employees inside our hospitals and who do I know at incredible job every day and trying to hold what we have it has been very difficult especially as financial constraints continue to two of the push down on us so we're looking forward to work very collaborative Lee with other association to represent the healthcare heroes who work inside of our hospitals and I know that some of the measures that senator Hammer and representative Bentley fall today are supported by the nurses association and others we are grateful to see them because everyone knows that we want to be able to increase the numbers of health care professionals that we have inside of our hospitals and we have to do it in a way that efficient and we need the boards who are also licensing these professionals to do so in a manner that's quick and efficient so that we can get folks that experience that they need quite quickly and we stand ready to do our part there I'm happy to answer any questions too about workforce I'm also happy to get you all the global data report. It came about because we felt like and many many groups were all coming together trying to identify appropriately numbers of licensed folks and we can get those numbers and global data fully recognizes that it falls short of knowing where those folks go over time it did do a good job of projecting out over time how many folks in the health care professions that hospitals might need moving forward and but we know we're going to have to do a better job at data collection both inside our hospitals when folks leave and also at the board level when folks are licensed or they decide to retire. Resent Pilkington you're recognized for a question thank you thank you Jody and thank you both for being here today also is to I I know we're rate review I'm glad to see they were finally doing that I once had an Arizona hospital minister once tell me if they had to do with the rates that we dealt with there's no way there to be a single hospital opened in Arizona so I know we do a lot with very little one of the things I was curious about thinking about this and think about the hospitals you know obviously there's some they're doing better than others and one of the things that I keep on going back to is I know what the reasoning of the sense as we saw their areas of growth and areas of decline in Arkansas and I know course this emergency hospital designation obviously kind help thank you can explain a little more about for the areas that are losing population I mean obviously it's hard to recruit in near like that because you can walk us through like what what is a game plan to can help us to sell these remain open because there it's just the normal rumors and rate not having of Fleiss professionals there but they they also the other party where it's you know community that's in decline and and so how do we how we can work through that he can help explain that. Sure I'll go first and then you can add in so the rule emergency hospital designation was created by the federal government mostly as a Medicare designation so Arkansas of course is not the only state that's losing population in our rural areas with folks moving into more populated popularized areas so what the rule emergency hospital designation would do is basically require a community to give up in patient beds now you must have a a pretty not to use a consultant word but a robust transfer agreement system in place with level one and level two trauma centers and that will help with the transfer of patients who come through you're basically emergency department or outpatient services only departments the Medicare designation and is a really good thing for some of the small hospitals in exchange for giving up your inpatient beds you get a monthly stipend from the federal government in the Medicare space and you also get enhanced reimbursements for those outpatient services at about a hundred and five percent of what the rest of the hospitals would get what we call prospective payment system hospitals would get in the bill that a representative Johnson and Senator Irving filed on behalf of hospitals who want to make this last interchange that bill also requires commercial payers to pay the hospitals that change their designation and at whatever they would normally be paying a critical access hospital and the reason we picked critical access hospitals as the designation is because the federal government is basically using the regulations for critical access hospitals and outpatient settings as the defacto regulations for the role emergency hospital so the reporting requirements are the same the quality indicators are the same the Medicare conditions for participation are the same so it made sense that your reimbursement would act as if it were a critical access hospital in the spaces the same is true for the Medicaid program written in that. Bill we only have a handful of hospitals I think six or less that are not critical access hospitals who could meet this determination I have to be in communities with less than fifty thousand people have less than fifty license fifty beds or less licensed beds now at so in a community like that you're going to have to be very transparent that you're giving up your inpatient beds and you all know from an economic development standpoint business is really like to locate where there's a hospital where there's a hospital with emergency department services and inpatient beds for their employees for accidents for those kinds of things so I community is not only going to be making a financial decision about whether it can remain it's hospital can remain open with the new designation even with Medicare given you have a monthly stipend but they'll also have to make it a healthcare assessment of whether that community can survive without those inpatient beds and and that's a difficult decision I think most of you know this but we have more than twenty hospitals that still have some kind of extra tax on them put on by the community whether it's a sales tax or millage or something like that to really try to supplement and augment and keeping those hospitals open from an economic development perspective anyway so anytime a community is making an assessment for healthcare and many of you in the healthcare industry know this already it's not just a financial decision it also what do you need in that community to meet the needs of your population as socio economic status and healthcare status continues to be fairly stagnant in our state it's important that we have the health care access to everyone regardless of where the hospital is located we think that that rural emergency hospital designation is a good stop gap to at least keep those emergency medical services but we don't think it's the savior for all communities. The other questions from the committee. Receive acre you're recognized for a question. Thank you thank you both for your presentation use mentioned that there were several challenges or several different buckets I know that when I'm categorizing hospitals that seem to be two different buckets nonprofit and for profit are these buckets universally a challenges universally applied or universally stressed in those two areas and if there's any variations what are those. So in Arkansas the disparity between not for profit hospitals and for profit hospitals is not nearly as wide as it is and some states that are populated more heavily for example some of our most struggling hospitals especially at on the border state is it's a for profit corporation that owns it but the amount of uncompensated care that particular hospital does as a for profit hospital is it rivals some of our not for profit hospitals hospitals have made decisions based on being able to stay open over time on how they should be incorporated so are not for profit hospitals definitely make that decision and many of our for profit hospitals began as not for profit hospitals and when a pay roll and lines of service and other things can be met the only way out was to allow a for profit company to purchase it and run it under a management agreement. Senator Solomon you're recognized for thank you over here you are welcome so I know right now there's been concern about our rural hospitals and their pharmacies there's been a lot of talk about letting them be more competitive in the rules there areas would also be true then that hospitals who currently are non profits in an urban area where there are plenty more pharmacies and better access would also be true that they need to lose their nonprofit status as far as our pharmacies are concerned and if not why. I certainly don't think so and there are four hospitals that have a grandfathered in retail pharmacy permit right now and they're grandfathered in by the state statute something about day in March prior to nineteen seventy five if you currently had a retail pharmacy permit then then you could keep it and that the not for profit status is a decision that each hospital has to make on how it's going to organize itself from the beginning we don't only have for profit or not for profit hospitals in the state we also have governmentally owned hospitals and creative ways to try to to incorporate I think making them lose either their permit or they're not for profit status just because they have a pharmacy and seems and Justin unfair because those hospitals are doing their very best to solve the problems of filling prescriptions for and sometimes their employees but definitely patients on their way out the door and other programs I think you all know this all all just it on the head that the three forty B. program is super super important to hospitals it was created at the federal level that allows only not for profit hospitals with certain disproportionate share number so in other words and a large number of Medicare or Medicaid patients and the patient mix so not every not for profit hospital can participate in the three forty B. program it was designed for federally qualified health centers to be able to have their own of retail pharmacy permit to be able to offer drugs that reduce costs to pay to poor patients and they're able to I'm sorry but my question is more specific I'm getting no I do not think that our hospitals should lose their not for profit status even if they have a retail pharmacy department okay so we have four hospitals two of them are receiving tax dollars. State tax dollars or county tax dollars to or not. So there those two are operating competitively in urban areas against private businesses that are for profit so it seems like it creates an unlevel playing field fark hospitals who are receiving state funding and county funding that be in competition with our small businesses that's that's the point to me can you speak to that share and it goes back to that that three forty B. program and the one of the largest reasons that those not for profit hospitals like their retail pharmacy permit isn't for folks to be able to walk in off the street park in a hotel or hotel in a hospital parking lot walk into the building and and get a prescription filled it's that there's this opportunity with at three forty B. program specifically designed for hospitals and federally qualified health centers to offset some of their expenses of of drugs no taxpayer dollars involved the pharmaceutical manufacturers have to offer those reduced prices and so it we do not believe that we're unfairly working against independent retail pharmacies in fact independent retail pharmacies are an incredible resource for hospitals and great partners in the three forty B. program and they will continue to be whether a hospital has a retail pharmacy permit or not it is not that hospitals intent to compete with an independent retail pharmacy and most hospitals who would be interested in holding a retail pharmacy permit would do so to take advantage of the federally given savings of a covered entity through the three forty B. program Mister I apologize right one more follow up. If so. I'm not sure I follow everything you're saying I'm trying to may we can we need to talk off line but it sure appears to me that were if the rule hospitals are surviving maybe not. As much as a there's a better economic environment for them but it seems like we've created an unlevel playing field with rule in urban and they were offering offering urban hospitals who have a commercial pharmacy an unlevel playing field by giving them not only state and county tax dollars but also allowing them to operate as a nonprofit against our small businesses who are struggling to we'll get together offline and talk about this thank you Mr and I can make one more point to that to that for profit hospitals right now if they wanted to own and operate pharmacies there's no prohibition against them to do so it just so happens that none of the for profit hospitals have wanted to open a for profit pharmacy in this state at this time. President Pilkington you had a question for you get your lot again. Sorry this is kinda on the total opposite side of pharmacy so But one of the things that that I've found really concerning was we've seen and you mention this your presentation We've seen a lot of the home of the lesser. Birthing hospitals I know we've got a certain amount we've lost a few and I CH I sat there is down a few years ago and to me it's really concerning. Because obviously I think the farther way we have women from hospitals when it's time to give birth getting there in time it is is important and so obviously I think our Medicaid reimbursement needs increase on that But I'm curious because I mean is there but nothing from the insurance company should you know saying okay there end up paying more because High Respers obviously cost health care plans way more than normal bars. Yes our current president rate is not allowing them to keep their their areas open and so it seems like where being a penny wise pound foolish here could you talk that at all I mean is that maybe I'm wrong on this but just the way I see it seems like we're shooting ourselves in the foot and we've got three thousand new birth we're expecting this year of an increase and it just seems like no one's really. Trying to help out our hospitals in that regard. But maybe I'm wrong so could you talk to that a little bit more you're absolutely correct about the reimbursement rate for for labor and delivery I will also tell you one of the reasons that labor and delivery is expensive is you you can't have just one physician and community who delivers babies you'll burn them out and and you need a helpful hand this if you have multiple people giving birth at the same time right at so labor and delivery is especially hard because of the reimbursement rate the other piece of it that deals with the overall health care system is that prenatal care needs to be valued even higher than it is today also and if you really increase the amount of prenatal care in the locations where people can receive prenatal care it really helps off off set if you will the burden of operating a full labor and delivery service and when we can get people transported from one place to another but your point is made perfectly that when you continue to reimburse births as low as they are it's hard to recruit and retain the healthcare heroes who deliver those babies inside our hospitals especially at the rate and the number of which you need them in order not to burn them out and to make sure that the carrier delivering is the highest quality and most efficient. Any other questions from the committee. A question Irvin. At one of the I appreciate the comments by representative Pilkington you know that's something that living in rural Arkansas people don't really quite understand. You know how. Honestly terrifying it is. For a woman who lives in rural Arkansas particularly down you know a dirt road that may be miles and miles away. And there in you know I mean I can just give you. You know what Springs Arkansas or fox Arkansas is a great example see you live in fox Arkansas on you live down in. You live down in. In an area that's just incredibly rule in remote and so where you gonna deliver your baby so your choices the closest would be from fox Arkansas which is treacherous at best down a dirt road meadow creek. And you have to deliver your baby in Batesville so that's going to be at least a two hour drive from where you live or you're going to love your baby in Conway which is again probably another two hour drive. Or Harrison which is probably another two hour drive. So and if you're poor you do you don't have the capability of going and spending the night in a hotel the night before or having your baby induced you don't have those opportunities and so these it is a real situation that we do nothing about households and it drives me crazy because this is why I was a tort reform proponents because these hospitals should be critical access hospitals but it should be a critical access hospital for everyone. Not just for men. Not not just for children for women who are expecting babies and I critical excess hospital it's not fun when your husband has delivered you know in residency he's delivered a bunch of babies delivered my babies but you know for sure of to have to come to his house and knock on the front door in the middle of the night say I need you to go to the hospital because we have an emergency situation of a woman who just couldn't make it to Batesville. Or to ride in the back of the ambulance. On the way to Batesville in case she delivers on the road between Mountain View in Batesville which is curvy and treacherous and really dark and so I mean it these are real things that happened in the State of Arkansas that we do nothing about and so you know I just I wanted to follow up on those questions because it's my soapbox and I think we as a state just have to. Do better for the people that were supposed to be representing and serving and if we're not then we got a re calibrates. it my question. I do have a question my question I think when it comes to workforce and I've talked about this. And I apologize I was actually somewhere else talking about workforce needs and issues and long term care but my question is I think it's so important for us to not just focus on certain areas but really the entire spectrum of healthcare you know when you go through something with a loved one personally and you know as exasperated I think by covid but I mean the people that were working so hard during that were your palate of care nurses and doctors there's a huge need for people and palette of Kerr that are helping people trying to. Transition from this life to the next life and dealing with families and social case workers that are employed by hospitals in the hard work that they have to do to get somebody from the hospital bed to the help rehabilitation center find a position for them make sure all the funding mechanisms are in place that is a healthcare worker that needs to be in this work force discussion people that are wounded care specialist my words there is such a need because you have advancements in technology you need wound care specialist and you need them not just in hospital settings but you need to amend rehabilitation centers you need to amend long term care settings if you have those people guess what people recover and then they're able to walk out of those facilities I mean. Respiratory therapist that's a huge needs we're struggling because people are having more more COPD and all those different respiratory issues so I think it's so important for us to really speak about everybody in this entire spectrum when it comes to our work force and I hope that the members of this committee I'm jointly will really engage on these issues when it comes to our any discussions as it relates to our phone money and how our money can be utilized and. For me it's not about just propping up an institution it's about making sure the money follows the the person and we invest in that person and make sure they're on the right career pathway with the dollars so that they can graduate and be ready to go right step right into your doors verses building a big building you know for a program that may or may not exist or that may not be good at graduating people that you know are ready day one for the work force so I hope that you folks that are here were really engaged on that issue so you can add to the questions that really what the question if you hike but those are my comments that's so we agree. No I appreciate centers on up and injected some life into the Committee to comments pre said that the president just time in your presentation as we we all are listing we know it's important we're glad you're here today we have a. Susan C. March is here with the nurses association thank you. Anyone that wants to come to the table the nurses station. You can just have a seat at the table entity shall for the committee appreciate you being here today. They're getting copies of our workforce reports for you. So I'm Margaret Love I am the current president of the Arkansas nurses association and this is. Hi Neil Reeves I'm the health policy chair for the Arkansas nurses association you're recognized president Kennedy and the Arkansas nurses association is has about fifteen hundred members across the state in five regions and I personally am a hospice and palliative care nurse for seventeen years so I do understand and I still do practice and I am also a nurse educator just to make those things clear but we have a workforce report here instead of going through the entire work force report I'm just going to read a little summation of some of the data in here as well as national data that we have from nurses and just in general what's going on in the work force and then you're free to answer questions ask questions okay so the easy are I quality research safety institute reports on the top ten hazards that threaten patient safety every year they identify nurse staffing shortage as the number one threat to patient safety in twenty twenty two shortage of all health care professionals amount to a crisis but the issues of the nursing shortage has the most immediate impact on the quality and safety of the healthcare workforce as it relates to nurses because we are the largest number of health care workers in the system nurses are employed in all sectors of healthcare including the private sectors and in twenty twenty two several sources sources found that Arkansas had about twenty seven thousand three hundred and twenty or twenty seven thousand or so active employed Armenians however more nurses are licensed in that there's a. There's several reasons for the variation in that number it has could be due to retire nurses who have kept their licenses APR ends who are also hold two licences or to. And then there also people who have exited the worst workforce but also still continue to hold on to their nursing license the demand for nurses continues to grow as the nursing shortage across the country increase increases if you will by an aging population in the pandemic and twenty twenty one the national are in turnover rate was twenty seven point one percent with the seventeen percent vacancy rate while turn over in Arkansas was not quantified it was stated that ninety percent of acute care facilities reported the demand exceeded the supply of both new and experienced RN's. The lack of educators burnout an aging workforce are among the factors contributing to the national data as far as nursing shortage goes the number of employed nurses in Arkansas compared to other populations creates a deficit I think got the hospital association said around nine thousand nurse shortage right at this time long term employment projections suggest that the demand for nursing faculty will increase due to growth and the replacement for expected retired nurses. Despite the increased number of newly light not licensed nurses last year there was a net loss of actively licensed nurses in Arkansas in twenty twenty one the state of nursing workforce in Arkansas reported a decline in applications resulting in unfilled seats in some nursing programs nurse faculty salaries on average are well below the average salaries of other professional faculty. another key point to from this report is Arkansas has thirty nine percent of the nurses are less than forty years old only thirty nine percent an increased amount of course from a four percent from twenty thirteen but a decline in the number of nurses aged forty to fifty nine occurred during that same time period. The number of younger nurses in Arkansas may reflect the influx of new nurses graduating from nursing education programs in contrast younger R. Ian's that's under the age of thirty five have less the national work force at a higher rate than older nurses again are younger nurses are leaving the work force within two to three years. The loss of younger nurses in the workforce reduces the potential years of employment as an are in traditionally nurses have worked from their entire lives in nursing the entirety of their careers ultimately this widely experienced complexity out for fewer X. for fewer experience RN's so already and experienced is diminished and the call that the calls for safety concerns in our hospitals. In years past the supply of licensed LPN nurses with adequate to meet demand however many organizations have identified LPNs as a key component in addressing staffing shortages and fueling increased demand without increased supply is not going to work they're still going to need a growth in LPN of some nurses as well. Eighty six percent of our ends in Arkansas are white in collocation females which has been the traditional pipeline for nurses the supply has slowed as as more career options are open for all knows all women the pipeline should expand to increase the recruitment of men and minorities. Nurse practitioners and see our days have grown rapidly in our state nationally and within the state there's more data on that here I feel like that's a price for a bright spot nursing right now in Arkansas. The impact of the nursing shortage on nurses is a psychological distress so we have COVID related PTSD anxiety depression increased burnout increase illness related absences and then they're leaving the profession. On organizations increased staff turnover directly related to patient safety loss of inexperience nurses to to lead and mentor new nurses we have reduced quality of care services decreased efficiency increase human errors and accidents and the work and the work load increases for nurses more fatigue and air and the likelihood of patient or outcomes. So workplace workplace workforce violence is a key factor in this as well nurses are at increased risk compared to most professionals before the pendant pandemic even happen in terms of workplace violence and now this incidence is higher. Balance in the healthcare setting plays a role in nursing shortage the ever present threat of emotional physical abuse and and adding to already stressful environments job satisfaction work efforts are affected negatively as the physical and emotional insults take a toll on the well being of healthcare professionals physically. Emergency departments and psychiatric aids techs nurses and physicians all at high rates of their patient population affected by workplace violence again healthcare workers and social service workers in general are at higher risk. increase there is increased rates of suicide amongst healthcare workers at this time. So in in nursing education the shortage of nursing faculty is the primary driver of the large and the larger nursing shortage the law faculty wages is is one of many factors working against attracting nurses to the role as of educator. Nurses in general what I get from them feel unsupported and at a recent survey by the American nurses foundation of twelve thousand five hundred nurses nationwide supports the need for sustainable solutions to support the nursing profession in addressing the issues facing the work force working to improve nursing satisfaction directly impacts the quality and safety of care delivered. So some things to kind of help expand the pipeline for nursing that with Arkansas nurses association of support would be that first and foremost anything that's going to increase the awareness of the an image of nursing and resources to support IT staffing training and education allowing nursing nurses input on staffing assignments improve care delivered to patients in states with staffing committees in his recommendations from the staffing committee or followed we see that nurses are eighteen percent less likely to report caring for larger number of patients and we also see that at the representative at. Experience less moral distress in their day and as many as eleven percent are less likely to leave the profession over the next year where this is considered and as you heard Margaret say that nurse educator pay is a huge concern on average the bedside nurse makes two to three thousand dollars more than the average nurse educator right here in Arkansas so you can see that is it's hard to retain and attract faculty to develop the workforce for the future in these positions many times require graduate level degrees similarly with our school nurses we support that increase the pace you look at the workload that there under in some instances there one nurse may be cover and seven eight hundred kids over multiple campuses so it's very hard to address the needs of those kids in that manner and the grossly underpaid for the work that they do and the other thing when we talk about workforce violence obviously we support anything that's going to reinforce the. Awareness of workplace violence in the statues that are on the books so that our our health care professionals in general feel supported as a to do their care in the health care environments they're in on a day to day basis so we support the The opportunity to get that word out there to our communities and impose signage within our facilities to show that we do support our health care workers and that any violations of the current statues will be pursued. Members of the questions for. Rose you're recognized. Yes thank you so much your testimony you highlighted great number things it certainly piqued my interest my younger sister is a as a nurse and so I had asked her a couple of questions as well just to kind of get her feel of co workers and individuals that she graduated with but one of the things that you said I can't remember if you said it was younger nurses were leaving the work force in the two three year window or the three to four year window was it two to three or three to four. The day that I have sixteen said two to three years what I was curious was was what was the source because I would like to study that further so a lot of that again This is talking about the younger population of our nurses so under thirty five years of age and this is relatively new or information about this particular population leaving the workforce initially when COVID started we all thought it was those who were pushing toward the edge and so the data out there is suggesting burn out burn out being the number one reason there study that the survey that was recently done by the a and a this year will publish this year than last year it kind of goes over the fact that most most nursing feel like they have anxiety as well as stress and depression thirty three percent and then these numbers were higher in that younger population that you're referring to first of all and you maybe didn't mean it this way because you reference the under thirty five my younger sister falls in that category because I'm young as well as to but I follow I was just curious what the source specifically was so it be our a and the a in a American nurses association just published this survey these the issue outside the nurse's foundation are the Americans that nurses foundation published a report okay follow up Mr Mr Was that the same source that mentions that the decreased care as well you mentioned that that with the eighty six you went through several is trying to write notes and there's a lot of great stuff there. Most of the Arkansas data is in here is in this book is so as an executive summary as well as there's a breakdown of more details about some of those but some of the national data is what's not okay is that something we can get electronically because we can send the members sure so if you give that to myself for Senator ever Kate even better yes we'll make sure we get that straight all the members of the committee so they can have access to that okay I have one final question before you ask your question I have to run to another meeting my apologies so I'm gonna let you get back right just keep your Mike on but I just wanna say thank you so much for the presentation or so organized everybody that presented and I was actually watching the pharmacy presentation I was I was driving back over here and important for us we're gonna start a binder of all of the information that the hospital association that you all are doing and. Making sure that we have all of that accessible for members both in print form and an email form but you know I I think it's so important we focus on also we movement of these people and and then what kind of exasperated you know where the shortage is there may not be a shortage here but there may be a shortage of our nurses or absent you know and so I think that's really important but that is important thank I'm even from region to region around the state yes you're going to find some variation yes I love to presentations thank you. The the follow up that I had you mentioned again like I said everything you said was very intriguing to me especially the sister is a nurse but you mentioned increased rates of suicide do you have that statistic right in front of you by chance I know we're gonna get that book but if you had that no I don't have it in front of me but it nationally what's known as both for physicians and nurses in general even before the pandemic and all this happened suicides rapes for healthcare workers were hired and now it's it's higher so I will look for all this or I will get you the resource for that one as well with that thank you so when you when you a lot of language that you said with regards to burn out and several other things I message my sister she almost said the same things back without me Leding I just said questions to the nursing industry and her colleagues and you know for students to graduate with some thank you for sharing that yeah and I I do want to let everyone know that you know we're having our nurses day at the capitol on the twenty third and we have about at least four hundred and fifty people coming nurses and nursing students and coming with us I mean this is really something that you want to get a nursing past about talk about the shortage so I appreciate anything you all can do to help us navigate this because many of us love nursing and even the state the survey suggests that nurses love what they do it's just the environment has to change in which they do it thank you. Reserve grand what you're recognized thank you so much and thank you for being here today you know I I I I did think think when things and I'm a school teacher and and it seems like any any industry that has something to do with serving other people is experiencing burn burn out just absolute to Max so just I I definitely feel your pain I do have a question about like capacity in a retirement prison pipeline and stuff like that and we had our pharmacist coming earlier and talk about how they can get people said the classes is an issue in our nursing programs. Well I think this is a relatively new issue based on the data I mean in Arkansas we have done really well in terms of our higher education in nursing in terms of the bachelor programs are in programs you know feeling their seats up until twenty twenty one this was the first time and noted decline was document in terms of not filling all the seats in the state and then also during covid they were high interest rates for nursing students I think it was somewhere around thirty percent or more so I'm just pretty sure all that is you know the perfect storm and and your point like I've I've heard I've heard some of that as well especially with our faculty issues I've I've its name just to pay but it just finding anyone to do some of these jobs in the first place so in fact he's going to be one of the issues that are really going to drive home if we're able to keep nursing really calling because they are the infrastructure that we know and have for our part for educating our nurses in general so especially we need to we need to figure out a way to fix that and I guess this is a general question I mean do you think it's necessary for the graduate degree to teach those nursing classes a collegiate level I think that there are some level of graduate degree nurses that are needed depending on what the task is right or. I don't think it's a one size fits all depending on what the if what kind of programming do this kind of program state but that's my opinion that doesn't give any weight to what the state board requires things that would. Thank you for ballot for being here today I it's a it's a great presentation I mean this is an issue that's going to demand our attention as time goes by are there any more questions for anyone in the committee I see a question represented Clinton waited patiently please ask your question thank you and thank you for letting me kind of jumping committee meeting here so I do have a couple of questions I am very curious about this can you tell me first how it compares to other states are is Arkansas seeing the same attrition and the same lack of the other states on average or do we have a outsized. Portion are you talking about on staffing shortages are each about nurse educators on staffing on staffing I think I don't really know all the data for all the other states I don't think Arkansas is the worst by any means just from reading things but I don't have exact numbers on where we are in that casket okay so then are you seeing anything that is specifically being done in order to help retain nurses here or something that should be done to help retainers both I mean I do believe that organizations this is become a become keenly aware and more sensitive to nurses and have tried to do certain things some organizations but not all places that nurses work had the same capacity to expand and to address some of these organizational wide but it what any of it impacts all nurses and all of our communities as well so it's not something we can isolate and I think that we need legislation to help with some portions of it I do believe there's more that we can do from the standpoint of of a quality and and and and just quality improvement in terms of organizations but I do believe it is necessary for us to have some guard rails more push to have nurses hard work wish to have nurses incorporated in healthcare from the standpoint of not just being the The healthcare provider with no opinion okay and you find things like I know if you if you I'm sorry ninety five thank you thank you chairman do you find things like if I work in a rural area for three years I get my tuition reimbursed right we have some of those programs in place to find those to be helpful and retaining nurses or do you find those to be nice but it doesn't really move the needle I don't know if I have any data on that particular that feel I don't I do know that that we do get students in schools that participate in those programs I would like to say I think I'm not sure that this is address in here but we got were not aware that many of our students come from out of state I don't know how much of that legislators are even aware of so in talking or thinking about those nursing nursing students who do graduate many of them will not stay anyway because they were just here for their education for some reason and some of them to stay but I do think there's also a a concern in terms of Nursing just in general thank you I appreciate that thank you this great conversation anymore questions. Seeing that again thank you for your presentation thank you for your patience this law Tuesday afternoon is get informations meetings adjourned.