Insurance & Commerce - Senate

Okay moving right along we have a. The Senator Hammer is not here yet. Senator Wallace in here senator urban. As an over that pass over SP one forty two. Okay. Senator pens overpass over years. Okay passing over a SP one fifty one. Passing over SP one seventy eight and I want to Senator Hammer. Passing over S. B. one eighty three as well second row. Centroid. S. B. one ninety two. Centroid you're recognized to present your bill. Mister chair the senators this this bill hi from my and my mind is a fairly simple bill I'm happy to explain as much as I need to but this goes to the stepped therapy legislation that was passed and it adds one of thing to it under section eighty so on section two. H. there's the this a patient to try a generic equivalent. Interchangeable biological product and then it adds up for biosimilar medical products so what biosimilars are are FDA approved medications that are. It's very close to the originator product so you might have Lantis insulin and you might have about similar and the reason they're called biosimilars is because they're made through a biological process so these are larger molecules that might have a slight structural difference but are not anticipated to have any therapeutic difference and so what this would do is it would allow an insurance company to say Hey we like this biosimilar over the originator product or another biosimilar. the I suspect she received several letters of support from industry and elsewhere like I have been on this bill so that said I really think I should just try to answer questions. You senator Johnson. Thank you Mr chairman centreboard without getting deep in the weeds with fact that you and represent acre on this bill I sent to pharmacists know what they're talking about but I just I want to just for my own information. Ask you to clarify. The difference between a generic files interchangeable biologic or biosimilar is it just they they I know a generic is the exact same drug like a private label or a clone or whatever you wanna call it see it is exactly the same. But I put is biosimilar it does exactly the same but it structurally and she said molecularly that's or slightly different okay so you're you're exactly right on a brand generic those are small molecules and it's an identical product there's there's not a difference the the active chemical and the babies are the exact same and there are thresholds by which it it has to produce similar levels in the blood to to qualify for that and that is and then of an interchangeable biological product is really a biosimilar that is gone one slight step further and gone through and said this really is the exact same thing despite potential molecular differences okay so a biosimilar is an FDA approved product that is gone through all of the rigorous trials in and all the things and said this is a safe and effective thing it has the same dose as whatever else there could be. And this could be true with the originator product you're using bacteria you're using a biological life form to produce these and because of that since it's not done in a chemistry lab there can be small variations but that said they're expected you know I would expect them as a pharmacist to have an identical process like if I had Lantus insulin and then the bio similar Lantis insulin for all practical intents and purposes I would expect the same therapeutic outcome now yes yeah so again there has to be you know just because there are what this does is it allows the insurance company to say Hey we like this one over that one right it doesn't force a change it doesn't do anything you know the healthcare provider still ultimately decides which one the patient receives. Okay but what this does is it really introduces competition there's forty biosimilars there's only three interchangeable biological products and these are drugs that are in the hundreds and thousands of dollars and if you can come down on that proselytism the healthcare system a lot of money so I really think that the competition is a reason I'm coming at this and I think it's a good thing. Okay thank you senator thank you Mr I wanted expenditure that on that date if you would just just talk about the economic side of it is is cheaper on the insurance company and more profitable for the pharmacy what is the purpose of this. I don't think that the the pharmacist. I would have given a disclosure five felt like that pharmacy we're going to make more or less money I don't think this has anything to do with the pharmacy in fact I could say well the pharmacy might have to have more product in stock or something but I don't think any of that really matters for practical intents and purposes what this does is if this drug is basically the same as this drug. It allows competition in the market place so biosimilars are exactly what they are they're biologically produced that are similar in nature so again you would expect a similar thing so again This Is goes back to the stepped therapy and it allows an insurance company to say I want this biosimilar on formula airy rather than this file similar where is current law would limit it to just brand generic or just interchangeable biological products thank you they're doing. It's again just kind of walk me through the process is going to make a decision on if the biosimilars used for a minute so what exactly are we doing here man we're not injecting ourselves with the doctor and the patient or allowing someone to make a change or. Do they have the ability to already prescribed biosimilars yes and so what is this a cop what would we composition exactly I guess that's where I'm confused okay. So you have to go back to the it took me a little bit to figure out what this was done I had to go back to the stepped therapy and understand exactly where this fits into stepped therapy okay if you follow it all the way down there's a clause in the concerning the application of of exceptions of step therapy protocols right now the only exceptions are for generic equivalents for interchangeable biological the physician and the nurse practitioner or physician assistant they're always in control because they can always write do not substitute or do not therapeutically interchange so if it's important to the prescriber they have full control of the point of writing a prescription to say in this patient I do not want this to happen okay and then if they write that and then the insurance company says we preferred of this product then with that would signal the pharmacy to do is say Hey patient or a provider insurance don't cover this is to me a few thousand dollars what do you want to do and then the physician can go through a PA process or say well what in that important to me so I'm I'm just going to go with the one that they prefer but. In Arkansas the prescriber always has that control when he or she writes the prescription but if they submitted the. But they have to say specifically that you know do not change whatever it is in a minute and then if they prescribe something they have to say specifically not is that become the norm now that everybody understands that that's the way that needs to happen or do we have prescriptions that are written or maybe they for a minute and you know forget today because it's busy or whatever check the box whatever they're doing anymore that it so it that substitution are allowed so let me clarify there's no more check the box like that's out that's not been lost for a long time there on that a lot of prescriptions have that but it's not been the law in Arkansas to allow a check the box since I've been a pharmacist over okay now over twenty years ago but they can ride do not substitute do not therapeutic interchange these are ones where I don't think that there's going to be an issue I would be sitting here if I thought they were these are drugs that I expect that the vast number of physicians are going to think you're going to work ninety nine plus percent of the time either way and if they have a specific patient where they have a specific concern the physician is always in control or the nurse practitioner PA who members always in control of the site I don't want this this product but they're always in control so long as they say they don't want to be served right but if they don't say they don't want to be substituted and that's when the control for the position goes away so what would happen in that situation is to two pathways okay so pathway number one because you said do you think this is well instituted in Arkansas or something like that I'd say the answer is I don't think most people understand this are I would say most pharmacists I don't think I understand this back be wrong but I don't so pathway number one is you go to fill the prescription and it says well we don't want Lantis we want whatever the bio similar to Lantus and so the pharmacist at that point in time pathway one would send a fax to the physician and say Hey insurance doesn't want. To cover this you know this is the one I want and most likely the physician in this case I would suspect would say okay let's give them what they want because it the. It's gonna save that patient a lot of money and I don't really care. Pathway to is in the last General Assembly would pass legislation that allowed for therapeutic substitution okay so. The pharmacist could then therapeutically substitute and then notify the prescriber that it happened. So that's Arkansas law right now so that could that could happen regardless. In order to stay in that. Number two. Synereo an amendment requests is everywhere is liability let's say we make a substitution and and it doesn't it's the one percent that doesn't go well. Who is liable for that is that the physician because that in right do not substitute is that the man is just health care and we all move on and it's tragic incident that one percent save money I that's what I don't know so what what I would say to you is first of all with this list of forty drugs. And the whole concept that I'm bringing here before you I really don't think that's ever going to happen but if it did what I would say to you is if the pharmacist were. Working in his or her capacity a pharmacist and doing something then they is he or she would need to dot every I and cross every T. to make sure it were done within the manner of the law. And if not then he or she would be. Audible to the patient and to the board of pharmacy. What I would say is the physician did his or her job when she wrote here she wrote the prescription. And that so I don't think that there would be liability on his or her and I mean that's I do I just I'm not an attorney I'm not gonna play one but I don't know when the the practical world how that would play out to be an issue. The number of. Thank you chairman Senator Dismang hate most of my questions but so the one the one component we had talked about it the end user which is the patient. So how does. You have something I was about to answer that but finish your question well I was going to act hi this is at the end of the day affect. For what in public even do the patient have in the choice of what happens in this situation this is merry all in terms of what the because it going as it addresses so let's go down pathway to okay so pathway to that we describe where the pharmacist was gonna making it therapeutic interchange that is perfectly legal in the state of Arkansas then the patient has to be informed and agree to that so the patient has to be consented it can't be more money for the patient it would you wouldn't be nobody would therapeutically substitute in the right mind if it were a constipation more money so if you went down pathway to then you you've got to have a conversation with the patient and make sure the patient knows this is what the doctor prescribed and this is what the insurance company wants do you have any concerns if not we're gonna we're gonna go through this process thank you so that halfway one. You might just facts the doctor to the patient might not be there so you might just facts the doctor and or the nurse practitioner and say Hey this with the insurance company said and I might sit back and say we'll change it to that or their radically they could say. You know don't change it but again this is a. These are drugs that are safe and effective and expected to have the same or very similar outcomes to the originator product in this with this being relatively new I guess to the industry or this letter that came from San does talk about two thousand fifteen as you have folk medicine bow submission to the U. S. in two thousand fifteen I guess my question would be. what is there another side to this bill you know is there some again ours about this you know what's what's the other side of this or this is all good from your perspective I think that it comes back to competition and these drugs are extremely expensive if you want to seize drugs continue to go up in price then you don't want to go down this path if you want to see competition in the market place and see. We'll prices plak tow force and or start to come down this is a path we want to go down this is good for the citizens of Arkansas and the people paying for the prescriptions of Arkansas because it allows for competition that it the current law limits thank you. Thank you as at and I appreciate your comments questions and I'm not sure how you can answer this but. My my concern with therapeutic substitution is it's not always about money or saving money for the patient and the doctor the prescribers the only one that actually has the full history and physical and chart on that patient knowing what other medications that they may be online or issues that they may have to where you know they they don't want it to be substituted and it's not about money it's based on the help that patient the history of that patient the medication history of the patient emotional you know the emotional history of that patient because we know that you know there are some medications that really have side effects that are stressors for folks that are dealing with emotional and social traumas and and events like that so. I mean. So it so I I suppose my question to you is where where. Is there any concern with the interaction of a tip I products like this with other medications that the pharmacist may not be familiar with another and the insurance company may not also be familiar with but that information resides in the physician's medical chart with the history of the patient. Senator thank you for that question the answer is I would not expect that these medications are virtually identical medications that's why they're called biosimilars I would not expect a drug drug interaction to occur with one of these medications that wouldn't occur with the originate product I wouldn't you know it would the would not expect there to be some kind of allergy issue and the pharmacy should be asking for allergy issues now in case there was some random thing you know that yeah that I wouldn't expect so I just don't see in the case of biosimilars this is an issue I mean these are. I mean like the generic names are the same it's like Lantus is insulin glargine the biosimilar is insulin glargine I mean there's really no. Difference but at the end of the day if you want competition which we as a Republican I believe competition will lower costs and have better outcomes in the long run then this is a good thing it is a small thing we as a state legislature can do to do that. Thank you. Senate is nine. In an independent honest this is one thing that always struggle with and be in on the original bill that we're kind of piggybacking off of what this one is we've put the burden on the physician to specifically right out that it cannot be substituted. Instead of. The opposite that it could be substituted. And that's my concern in general is that you know we we put the burden on the physician and we allow a pharmacist or an insurance company in this case to make the decision related to the health care so those would profit incentive. Have the ability to make the decision. I'm just curious. I don't know if you don't mind is kind of rehash the history of why we did it that way a fax machine in all of these things that we do were so weird to me because of our we don't use fax machines but what what what is what why why is it the reverse why don't we just say I if it says. You know that you can substitute being great but instead we're saying unless you specifically right on we have the latitude makes these adjustments so Senator that excellent question and what I'm gonna say is its efficiency as you know and health care there's an upward expectation of productivity and the downward ratcheting of margin and when those to collide it's both challenging for a busy doctor's office and a busy pharmacy to do this is a small thing that can be done that. All that will help lower cost and probably make for a more efficient physician office at a more efficient pharmacy if I really thought that the average physician and I'm Arkansas really cared about this probably would be here at the end of the table I'm not going to tell you that. Somebody somewhere might go ahead with the here they are taking power away again but these are trump products that are so similar I don't think that the average practicing person really cares this is just a way to introduce more competition into the market place. It's really that simple I mean from my perspective I realize there's other people on the committee but from my perspective this you know this is. That so but to answer that let me go back to what your real question was that's. A whole nother section a law that we didn't pass in here that really has nothing to do with this other than therapeutic interchange is a legal thing that that Lee Johnson your representative Johnson had a bill and it was included in the bill it was a compromise bill and you know to my knowledge there's not been any real problem with that since we passed it. You know last time I may be therapeutically interchanged handful of items because sometimes I'm I mean it just. You go through in and sometimes that's a good fit sometimes is not I make. Any other questions. Seeing none is anyone here to speak for against the bill. No one signed up would you like to close. I would like to close thank you Mr chair project thank you all for entertaining this a bill today this bill is a good way to introduce competition into the market place create efficiencies that are not necessarily there and I think with the price of drugs going up competition is it more important than ever especially drugs that cost hundreds to thousands of dollars and so with that I'd make a motion do pass and hope someone give me a second I don't have a motion to pass I have a second senator Penzo all in favor say aye. All opposing sign. Thank you senator your bill has passed. Senator Hammer. Yes. Okay. Senator Hammer you do have an amendment for this bill correct. Yes Sir I do have an amendment so. Committee will be presenting them in a first. Mr chairman yes which chairs permission like to have a booth ran with the insurance commissioner's office ships I mean he's going to help present the bill to expedite the process and make sure there's clarity and understand what the bill does with chairs permission permission granted than yours B. a little less controversial than the last one is that correct. We'll see. That's my intent. All right you may proceed Sir thank you my name is B. three I'm general counsel Ridge Mr chairman do you want us to adopt the amendment first yes Sir yeah do you want explanation are or how would you like to let you let you present. All right this is the thread general counsel of the Arkansas insurance department let me explain to the members of the amendment the original bill before the the proposed amendment came through proposed that the insurance department find PBMs ten thousand dollars per violation of the people in licensure act in in addition it also provide unlimited power of the commission to enforce this subchapter and some of the PBMs including the lobbying organization for the PBMs had some concerns about the fine amounts being too high in about the powers being given to the Commissioner too broad so we met with the PVM association last week over their concerns over the bill if the insurance department agreed to reduce the penalty amounts as proposed originally from ten thousand dollars to five it agreed to remove the unlimited power provision of the Commissioner that's essentially what this amendment dies and it's result of negotiation and discussion with PCMA the PBMs I'll be glad to answer any questions. I understand this amendment maybe the appropriate time would be left without that but. So let me ask you this is the Insurance Commissioner I see your role request this but are you allowed to do all that so that if you ever wanted to go go in and look at it with that be available to your desist totally limit you from having any power whatsoever we have audit power Senator Hickey we have examination powers this is just additional monetary penalty violation so we already have statutory powers to do exactly what you said thank you. Centroid. Thank you the strength that I just a little surprised there's a reduction in the fine these are you know companies that are going to be in the top ten. Most let me let office let me explain that the fine does it have a cap either so the current the current finds are capped at fifty thousand dollars for intentional violations in ten thousand dollars for unintentional so this proposal actually exposes the PBMs to is unlimited fine of liability without a cap so that's and I agree with you that those are multi billion dollar industries it might not or likely be deterred from a small amount but we don't have a cap now. Thank you that explains it. Okay you senator Murdock. So I'm I'm trying to get it to where we are with this historically I know that we've had some ongoing conversations issues if from bank of a better word Senator Hammer and we work together on some of this over the last few sessions terms so as I look at some of these things the controls that we wanted a ID to have as a result of the relationships to make sure that we have the safeguards in place to protect all involved so. As I look at some of the language of the amendment out So down in the second part which talks about the The powers of the insurance commissioner it be is is not subject to the freedom of information act so. Proprietary confidential under so we're protecting the information but the Commissioner still can get whatever they need to make it you can still get what you need to make decisions Okay you asked the question about the fine amount okay so just wanna make sure that we still have the safeguards in place that we work so hard for because of the myriad of problems that we did have at one time senator I would address that includes can back me up on it or creek community to one and that is I do not think we're weakening the process any at all I think we're taking the next step in a reactionary way because of the activity of the PBMs and this is just one more tool in the toolbox or a bigger hammer in the toolbox or bigger driver if you don't like hammers you know that can that can be used in order to help bring them accountable thank you the yeah right to address the confidential proprietary language that you up he per drop balls on just that does not mean that we can't see the the data at the insurance department I think the problem is is that we we acquire the rebate data in the financial information from the PBMs it is competitive information that would advantage competitors if they were to see it so we can see it. Okay any other questions on the amendment. the Amendment only. Senator. If you could just read three line Page four I'm I'm confused on the amendment and what it does on page four line one delete and delete services and substitute services. I'm. You'll have to help me with this I think that's just a topographical changes has really no no Marable impact on any of the I think to be a purposes fixing that right but there's two. Services is a word that appears twice and line one and so which one is it. Page four. Page four line one out. You have services appears twice so I'm just making sure that your amendment is correct because as if it's. I don't understand the purpose of having this in the amendment because. If it's the second one it doesn't change anything if it's the first one I think she's just making our our grammatical change to to make the Senate Senate three better are honestly. Okay Fite track with me light page four line one and says in goods and services common. Period period this was include yeah I don't know so it's not correct. I think you're right I see what you're saying I'm sorry. Senate is nine. It just kind of a suggestion and maybe not just on this bill but other bills because we're we're we are the session there's no concern that you know you we cannot we can adopt a minimum floor having gross it back to committee and everybody could read the bill as written instead of trying to do the the piecemeal you know you can hereby stencils lining out and try to write in what's happening so just as a recommendation is that we have to do that today but for to. Hey if you've got a an amendment you've got it for a week go ahead and dropped on the floor and we can see the full billing here not have to try to figure out if there's been an issue is that the worst thing that I think Senator Hammer is going to want is to realize that we've adopted an amendment in this room had engrossed realize it's wrong after dropping them on the floor again Senate back here to have a voted against going back to the floor yeah just as a. But you're amendment. Yeah you see what I'm saying I do I do yeah that would do not come from the insurance department so I understand. I don't want to adopt your amendment when that I'm going to make it right. Wonky and weird yes we will work and I think if. Mr chairman may make recommendations yes Sir. Will be available to answer any questions about the bill this time if you'd like to shorten process next time let me pull back a get the amendment of the school ahead of members on engrossed in and and bring about that way but if the chair wants to exercise will be glad to answer any questions no member's clarity receipt or something else and then I'll go about handling it that way that's the that okay. Five so Mr were available for any other questions about the bill members may want to ask Howard your direction and just make sure when I stand when I when voting today easily amended that have any questions on the content of the bill Senator Hickey. Okay okay Centerton. Yes thank you I appreciate that I think that's a good idea but I do want to make sure that when we do eliminates that you may examine the books and records of a PBM as necessary to determine. So you're gonna be limited to what subscribed in this bill under those lines you know sixteen through twenty three on page three and then thirty one and and down. Another words I want to make sure you have the available available flexibility that you need. And and if it's a described in the legislation is that going to be an issue or problem no because because you might want to look at something that's not listed here well or that might not be necessary for you to do a full audit so so the provision that you're looking at is pertaining to the rebates and how they are acquired by the PBMs it relates to the insurance commissioner's power to review the particular rebate information and spread pricing practices The Insurance Commissioner Senator Irvin already has separate statutory powers to examine the books and records of the PBMs outside of that this is not going to limit our powers or limit us in a way where it might hurt the Department in my opinion okay okay. And so we don't need to okay as long as that other statute then. At okay. Thank you. The any other questions. Seeing none is there anyone here to speak for or against the bill. No no. C. signalman here center did you have something to. Yeah but. Back on the does does. So. That in no way limits us since we're just going to say that we may request the following information within this bill I do not think it does Senator Hickey at all you should you should just as a question then do we even need that I mean tell you why that is in there if the if you want to background because we've not really had discuss why we're amending that the the current law the people in licensure act requires the commission to collect spread pricing data and rebate data technologically and keep it at the department we don't have the staff to actually technologically or quarrel that claims information so what we decided to do was remove that particular requirements and just gives the Commissioner powers to audit the PBMs for that information should he or she wants to do so that's what we're doing in in that proposal language okay. And I think that makes sense to me it should as an abundance of caution if you don't think so it's fine by me should we should we put in there that you know that you all retainer auditability or something like that I mean or is it that's not a bad idea it's not I mean since we're going to have an amendment anyway this will have an amendment anyway and let staff see some issue that way or yes Centerton actually that's what I was going to suggest to you is that perhaps just reference back I know put in this in reference fact that you you maintain that power under that code and just referencing it here I think this would be a good idea you would never it wouldn't hurt thanks. Thank any other questions. Seeing none we have one signed up to speak. State chamber against. Remember the members were not voting now we're going to hear the testimony and we will vote whenever the amendment is correct senator our way so we get a chance to review the amended bill and get a good legal our concerns about arrests of. From nineteen twenty to now I've been able to direct government a lawyer to give you a description so we'll do that I'll get backs Hammer if we still have problems thank you thank you. Okay Senator Hammer you're gonna pull pull the bill down and have a corrected then ran back will vote on yes Sir what I'll do is I'll pull down I appreciate the things that you pointed out today and up I'll do a member's own sort of being engrossed in the bill before comes back here and then anybody wants you can see it as it is as it is drafted okay thank you thank you members project. Senator Wallace. Senator Wallace is here for H. B. ten forty two. Good morning Mr chairman center Dave Wallace nineteen. Go ahead senator Wallace. Your bill thank you Sir members of very simple bill there's no fiscal impact. The process is already being done. there's no known opposition. What this does is it just enhances the prostrate cancer screening ended of. Simply means a current law to make sure that it meets the current national comprehensive cancer network guidelines of this improvement is already saving lives. And with that Sir I stand by for questions. Any questions for Senator Wallace. Senate did my what we doing again to make sure I understand I mean I see removing the effective date out. To be able to add that I guess would catch is this new language is that that's that's what it's doing is it's just make sure that if it were me in this law to make sure that it makes a current of. Network guidelines that they put out. Which is if people or that our. Follows are have the option to do this thank you okay. Senator Hickey just just want the Senator Wallace. By putting in this additional language in here I mean is this required for people to getting temporary embarrassment or anything is or any call somewhere that. This is going to create that you part of. None that I know of but I I will I'll find that answer for you and and I get an answer back to you I was told there's no fiscal impact at all. To the state I mean the only thing I guess with the state would be if it was under our. Something to do with our Medicaid program or something like that it tied back to it. again I'm I will be filed the bill today but just if if we can just make a hundred percent sure that before we I will I will center thank you and. Senator Johnson. Thank you Mr chairman and senator Wallace because this is monitored by my friend representative Allen who is suffered with prostate cancer and is winning and we continue to pray for his good health I'm almost knee jerk yes I'm for this I just want to to say that the asked the question is that. This is Prost Bective one it says if additional clinical recommendations are recognized so it's like if. We discover scientists discover something more helpful this gives the Commissioner the authority to just sort to add that to. What is already there is far as better screening maybe maybe more economical screen causing a lot of things that you know we know about well I don't talk too much but the way they used to check you for for prostate cancer versus the PSA test is this sort of to give that discretion to the Commissioner to if if the newest equivalent of PSA test comes a law he could put that in by rules that that's my understanding is as hopefully as improvements to come along the commissioner will have the flexibility okay all right thank you senator thank you Mr. Seeing no one signed up to speak for against the bill. What's will committee. A do pass in the second centreboard. All in favor say aye opposed same sign Senator Wallace H. B. ten forty two has passed thank you Mr chairman. Seeing no one else here run a bill I think Senator Johnson had something he wanted to to cover for all of us or announcmenet senator Johnson. Thank you Mr chairman and I'm honored to be able to do this some of you may have had the opportunity to meet with Mr Tom Considine of in court when he. I was visiting a couple weeks ago for those of you that don't know in call is the National Council of insurance legislators. It is a non partisan or maybe just like bipartisan group of legislators course we know the importance of state regulation because insurance is one of the few industries that is almost exclusively regulated at the state level we're honored that a representative Deborah Ferguson is the current president Senator Jason Rapert is that is a past president of in call. Those of us to go to legislative meetings around the country we can be a little critical of how they run the the meetings even good meetings can get a little tedious in call is probably the most efficient organization as far as presenting a lot of information in a well organized manner in a relatively short period of time so I wanted to call everyone's attention to how they help us the national model bill they they thank take model bills one state develop something that works very well the proliferate that as a model bill for other states as a matter of fact the PBM legislation that Arkansas passed Senator call will sponsor but this one issue member went all the way to the US Supreme Court and then Attorney General Rutledge appealed it and we won unanimous decision in favor of holding the law so I just wanna talk about this is a good organization only encourage all of you to be involved in it they don't overwhelm me if information but they give you a great way to understand it and keep you informed about it in call was national meetings this year our March ninth to twelfth in San Diego July nineteenth to twenty second in Minneapolis Minnesota in November fifteenth nineteen in Columbus Ohio and I'm sure that's chair the staff can give you additional information if you for instance this was actually the first legislative meeting out of state of any kind that I tended and they they kind of set the current five enjoyed a lot of our our meetings where we meet with legislation of the states and learn things I have to say that the in call is right there at the top of the what a good job they do so thank you Mr chairman and and I guess we can let anyone that was no more about it talk to you okay thank you for the one that in representing that please. It with either myself or staff and we're going back up on one thing Senator Hammer has one more. Okay this is a regarding Senate bill one seventy eight the we put an amendment which added representative ought to that last time and then after the meeting or during the course of meeting Senator Irvin asked to be added to it but just about five minutes ago had the of medical Arkansas medical society come to me with a proposed amendment to go on it which I'm agreeable to so what I'd like to ask Mister chair is that the committee would expand it the committee would expunge the vote by which the amendment passed last time which was just simply adding representative ought to then what I'll do is I'll take this all in grocery run it members own at Senator Irvin and this proposed recommendations been brought forward this morning to me and I will send it back in here as a clean bill with this amendment and so when the committee looks at it next week then it'll be it'll be totally engrossed shall have servants name on it you'll have these recommended additions in it and to be a cleaner way to look at it but if I can get that expunged then I could do all that a one time adding her and the other one. Most by Senator Irvin. To expunge the amendment that passed second Senator Johnson all in favor say aye opposed same sign it has been a sponsor thank you Sir thank you and committee members. President everyone's time create you coming and we're going to adjourn before someone has something else. We got pictures.