ALC-Employee Benefits Division Oversight Subcommittee

Meeting will come to order thank you everyone for being present today we don't have any particular comments this morning other than to handle the business I do want to recognize if he's in the room was represented Wardlaw back in here yet. C. stepped out. Okay I want well I'll just go ahead and make this recognition he's out of my line of sight but sitting next to Jerry but I believe trooper Trey Moore is here and there's representative Wardlaw will recognize him since the this is the points of his. Thank you Mr I just wanted to introduce one of our finest and now you come today because he's trying to better his education and get a master's degree and his assignment was you had to watch us today I told him yesterday would have been the better day to come watch as but he's here today so if you guys would help me welcome auditor for more to the committee today. Thank you Mr thank you Sir members would entertain a motion to suspend the subcommittee rules to take up the agenda items that we have today I have a motion and a second old favor say aye. All opposed no thank you very much with that I'd like to ask J. bleed if you would please come to the table. And we've got to items here approvals actions of the state board of finance I do have a third item that without objection we're going to recognize that which is the employee assistance program if you would mind taking that up at the end Jake this is something I believe of the members aware of so with that I'd like to recognize you related to item number one proposed berry aptrix surgery policy thank you senator good morning before I begin a if I could I'd like to recognize we have two representatives from United healthcare here today John Thompson and Jeff Rense he or leading the implementation of our Medicare advantage plan they are great to work with we have had I want to say fifty meetings around the state and we will be doing another eighty three here coming up of before the the period of time so we are working hard to get out I was actually just in federal yesterday to talk to members about the Medicare advantage plan we continue to have lots of good feedback and questions and so for the implementation that program has been really effective. On the first item of the agenda is the bariatric surgery program if you recall back in the spring or the early spring we adopted ACT one oh nine which mandated that EBT begin coverage for bariatric surgery that act included some limitations such as the BMI as well as a surgical solutions which could be required but there were some additional parts that needed to be filled in so that we can have a more comprehensive coverage policy as part of that we have worked with different providers we looked at these you might recall the pilot program that we had in place and we look at the recommendations of the legislative consultant to Segal group to trying to determine the best possible policy that we could come up with going forward what we came up with is what's before you today I'd like to draw your attention to a few different aspects of the policy and again this will become effective January one of the the coming calendar year so it's brought to you before it's brought before you today so that we can get a public policy out for members in advance of open enrollment which starts in October the idea being that if our members feel like this is the secretary did like to pursue that might affect their decision making as far as our insurance to enroll in. So the first thing I'd like to draw your attention to and there's there's a policy that you all can read on your own but we would be limiting coverage of this two in the employees of the state public schools who have at least five years experience so the ideas were really wanting to limit this to our longer term employees to people who put time in with the system who hopefully paid into the system and will stay on with the system after the surgery we want to avoid people getting a state job or getting that gig so they can get the surgery and then leaving state work. We are not extending benefits at this time to dependence so this would just be for active state employees this is a starting place I understand that there are probably likely to be a lot of spouses and children out there that would like to benefit from the surgery but one of our questions and one of the big variables that we're trying to manage is this your volume of demand that we are going to have that I know there's a lot of interest in it there's going to be a lot of folks who think this is a good benefit for them we want to make it available to them but we also want to mitigate the fiscal impact on the plan up front. Finally the big question that we had to answer and all of this was how can we make sure that our members are really put in the best place to succeed I think that this is a server that a lot of us are familiar with and a lot of us are aware of of circumstances under which it's been very successful and where it has not been very successful and so in working with health advantage are our of the third party administrator in looking at the literature looking at the pilot program and what worked and what didn't work as well as a consultant's recommendations we came up with the idea of making sure that we only cover surgeries performed at accredited institutions in the accreditations there it's kind of a mouthful but the metabolic and bariatric surgery accreditation and quality improvement program. Is a limited group of specialty surgery centers and surgeons here in the state I believe we might have one on zoom if I'm not your doctor Bledsoe was able to join us I was advised that he was planning to do so Bills this is doctor Bledsoe we sponsor as he logged in I I sent him the link. the idea being here that these are folks who are there is no board certification for bariatric surgery this is as close as we could determine or we could find it's a very high degree of accreditation it's something that we wanted the members to really focus on and it's something that places an emphasis on positive outcomes. If you remember from the pilot project we had a very rigorous medical management program before hand nurses were calling members members had make sure that they were checking the boxes they had to do this they have to do that a lot of members did not succeed in that in talking to the providers they were pretty critical that process and saying you know what that was just bureaucracy that didn't necessarily achieve the purpose we saw similar recommendations in the sequel report and so one of the things we wanted to do in developing this process is basically say to the doctors okay you're the experts. At least initially we want you to really be able to pick and choose those individuals that you think are going to be in the best place to succeed so we're really I think placing some faith in emphasis in the doctors to really make qualified decisions on who is best for the surgery. one other comment I make is that we are not covering pharmaceutical solutions for weight loss through this we read ACT one oh nine to be limited only to surgery it's not to say we won't cover secretary of pharmaceuticals in the future in fact we're scheduling discussions on that subject in the future we've had requests from manufacturers to talk about that but under this policy we will only be covering surgery. Right may I have some members in the queue first representative Wardlaw. Thank you Mr. Jake as I read through this is you are going through it at the very end you've got a few ask Ridge points there and. Is a co coverage will be limited to surgeons performed at a surgery center which is accredited through the metabolic and bariatric surgery accreditation and quality improvement program how many of those who we have in the State of Arkansas that are created through this program we had seven when I last look and I know that we are going to be adding more of we have accredited programs here in central Arkansas up in Northwest Arkansas and we know that insulin County of course those silly Memorial and the encore facility are working on that accreditation if they don't have it now okay at my point in asking that was just access and what that access look like your county state is there is there no credited bodies in south Arkansas that can perform the surgery not that I'm aware of right now and one of the things we did when we made this accreditations we reach out to all the members we could find all the doctors who had that accreditation to say Hey this is coming here's what you can do before hand of they all expressed a lot of confidence to be able to manage the demand because my expectation is of their stock Bledsoe my expectation is there will be a lot of interest in this Mister I do have a second question on another subject Sir she. And and and maybe more of us statements last question I'll do you agree at the end I'm really really happy to see of which and I and I don't matter Jake but I I'm really happy to see these qualifications I'm really pleased to see the five year participation role because we will achieve the savings the only way to achieve the savings from putting someone through this programs if they stay a member down the road and really happy to see the qualifications I think you guys put a lot of work into this and just want to say I appreciate it. Thank Mr. Right thank you this time Jake would you like to for me to recognized Dr Bledsoe. Yes Sir please all right Dr Bledsoe can you here Sir. Yes Sir I'm so sorry about that. Polities that's okay I don't know staff could help us with a little extra volume for you or if you might could speak a little louder into the microphone doc Bledsoe but we appreciate you for your parents by zoom and we've just covered the issue related to bariatric surgery and I guess I would say do you have some comments about the the new policy that is being implemented. yes thank you Mr chairman thank you so much for invitational E. here here here in Tampa speaking a little louder I keep I'm I can hear you so I don't have any complaints great thank you Sir so I think it's a policy that Director believe NET has put together is very very good admissions to director believes that your concern that I have is that if the you some in some areas it's a little bit vague which and my mind is a clinician makes me think that what this I mentioned one way or another specifically that you could end up with a number of peer to peer reviews where they get the nine we have to go back and look at it but overall I think that it is a very good policies certainly as good starting point I think that's something that we're complete is really trying to accentuate is that this is a good starting point I agree with him on that point it is a good starting point I'm very happy to see that the state's making motions in this direction it doesn't help the teacher state of Arkansas. If I could add to that the doctor Bledsoe his colleagues pointed out through their day to day experience there are going to be a lot of very difficult decisions that we're going to have to make so for example what do you do with somebody who had allowed band that needs to be removed what do you do is the surgery was performed by somebody who was not accredited wasn't qualified but there that for whatever reason something happened and now the plan is paying significant health care costs do we go ahead and cover the revision there's going to be a lot of very difficult situations and in fact we've got meeting set up internally with health advantage and others to make sure that we can hopefully get as clear policy as possible so I really appreciate him pointing that out. I do have a question related to the especially when you mention it to the decision's been made not to do anything pharmaceutical. generally if the commonly people think that pharmaceutical approaches whether using medications to to address an issue is usually cheaper than surgery so could you a mental give us some insight as to why that that particular decision would be made because most people if they can address the situation without a surgical procedure is usually preferable absolutely no we cover a variety of weight loss treatments sleep studies psychiatric a lot of the pieces that are built around if not the surgery itself up in looking at the pharmaceutical options we've actually through our relationship with you I am as I asked R. E. B. are exposed to look at it and to tell me okay we'll go V. then pick the drugs that are out there being used today what is the literature say and we will be presenting those findings here at a future advisory commission meeting I will tell you though those drugs are very expensive and they can be at least and they tend to not necessarily be as effective as you might that. So be we have some tough decisions ahead of us as far as that goes. And and then I and I want to make clear to you and I appreciate you highlighting the fact that you're saying that for a family of were one of the one of the spouses of is a member of the planned their state employee you're saying that their spouse may not be employee would not have coverage under this policy right now and I do wanna emphasize this is a starting point but this is really targeting our employees is a benefit for them I have mixed feelings about that because I think that if you're living together with your spouse the two of you are sharing a lot of ways lifestyle and if we want to put our members in the best place to succeed and we certainly do that and not extending coverage to the spouse may undermine that. But at this point one of the things we're trying to manage is how much demand is out there one of the points that I emphasize with our board of finance and with the advisory commissioners is that we can revise this policy in the future if we feel like there is sufficient evidence to show that a spouse extension or dependant extension is is warranted so for and against just stating this because obviously it is and as it is a tough issue but when you have someone is faced with a diagnosis from a doctor that says you're either going to get your waiter to control you're going to die. What are your options. If bariatric surgery is one of those recommendations it in the current policy you're saying that spouse doesn't have an option to have any coverage not that we would pay for no out of pocket and there are like I said a lot of other options nonsurgical for weight loss. D. and again just being thorough it do you have any benchmark around the country where you have a plan that is severing the compact the opportunity for a spouse to have coverage when a paying member is a participant in the plan is paying for spouse you know for for the family coverage my review of what the other plans did was it was pretty typical to limit coverage to only the active members to the extent they do covered and not to limited to spouses or dependents but we can certainly get back with you on the. Thank you for for insurance questions I do have Senator Rice and three others in the Q. centre crash you're recognized thank you Mr. J. could just and I do have my hearing aids in but I want to make sure of what I heard I heard you say active this is active and retired state or public school employees so the retirees the post sixty five retirees of would be covered under Medicare Medicare has a very attractive procedure in the United man and a plan would as well this policy only goes up to age sixty five the twenty twenty sixty five great and I'm here. Committee echo my. Cheers thanks up for you and and AB de for work in the ballots that we have as far between financial and in the benefit I know and and you sit there and tell me things I hadn't thought of that you don't have to act on a future but I appreciate all the effort on that because it's it's a big day of it in in good question from the chair about the the spouse and I'm sure United can come up with a a right they would do the spouse far but we're we're working and we work towards the best affordable policy with the most benefits and appreciate you working on thank you. And and thank you Sir and if I might add obviously this policy was put into place because Act one of mine was put out there this does not preclude us and I'd really like to explore us looking at a targeted policy that looks at people if you think about folks who are in their forties or fifties have been with the state for twenty years and with the public school for twenty thirty years we know that they're going to retire on our insurance and we know that they are going to be with us for the long haul. If we can show the data that they are saving the plan money that the surgery is not only helping them and helping to plan to what extent do we need to create a pilot or project where we offer them a credit or or offer them a benefit for for doing this if they meet certain requirements. So we can certainly expand on this policy I guess thank you senator urban. Thank you Mr chair of follow up with representative board laws questions about northeast Arkansas north central Arkansas. Do you have we get to a list of all the currently accredited institutions of the great and that's that's out there on their website now but I know that and my expectation is that with the this policy put into place will have more providers begin to look at it okay absent this requirement we would and either have to have some kind of a medical management policy which we wanted to avoid. and again there's no board certification so it would be open to pretty much anyone as I understand it with the a basic open a surgical background we really wanted to limit this to the specialists nine stands I'm just thinking of access you know for your employees and your public school employees in your state employees I'm just thinking of an access issue and you've got some great you know healthcare facilities in north central Arkansas and northeast Arkansas particularly engines for all and so I just wanted to I think that would be an important thing to look at as well as some Arkansas M. and at second question I appreciate the the questions by the chairman I think that's probably something to look at as far as just you know if you're paying the same amount for a plan then you would expect that you would be receiving the same benefits so and I appreciate you looking through that and kind of developing that I want to follow up on the prior authorization issue that Dr Bledsoe brought up because I think that's really important to make sure that you have a peer to peer review of these if you're looking at requiring specialist to perform these types of procedures and the necessary in the need for them then I would hope and expect that you would have a specialist peer review on any prior authorization through whoever is going to be a you know doing those for you yeah I think that's a great comment and the PA criteria and how that process works is something we've actually had a meeting scheduled with AJ health advantage to to work over the idea of using this accreditation actually came from their medical director who's been a big supporter of the surgery over the years so minor my expectation is that that will be able to that that that peer review will be of a higher order right but because there's if the if there's not that same love. Full that is speaking about the patient and the procedure that a lot of times you know it gets denied and it puts those positions in a a really hard situation when they're trying to advocate for their patients and trying to do what they believe it's the right thing to do and you know the person that's authorizing this or not authorizing it may not be at that same level of expertise and clearly doesn't have access to that patient in the situation at hand so I'm concerned and I hope you really dig into that and follow the lead of doctor Bledsoe if you can on that that would be great and then my last and question is I think it's important are you working in any type of a requirement for after care of a surgery for these types of individuals because I think you know that's an important piece of follow up and once they do this secretary and they undertake the surgery which is traumatic on their bodies you know there is a long period I would think of kind of managing that patient to help them maintain what was achieved by the secretary and and so when you're looking at this policy I would I would encourage you to work with the specialist and the physicians that not just perform the surgeries that also follow up and manage those patients for a period of time because if we authorize the surgery but then do not authorize any type of after care or therapy or whatever you know that is required to maintain what was achieved then it's it's lost it's lost it so I think that really needs to be explored in your policy as well the doctor Bledsoe could you talk a little bit about your how you manage for. X. after the surgery yes and I progress recognized. That's a really really good point senator thank you so much for that so you know course every program is different and in our program we do encourage lifelong follow up and the the first year after surgery we think is more critical because that's when the majority of the changes are taking place in a paid and with the weight loss and so we'll see them five or six times in the first year twice in the second year and then we do recommended ACS once a year of ever up there after we check vitamin lands or checking with the laws and things as well you know it's it's much easier intervene when it's a little problem or little weight gaining versus if it's a big problem or a big weight gain so we always try to catch things when when they're little so they can be addressed more effectively you know there's all sorts of things that can happen to patients and so that's one of the reasons we also recommend a comprehensive center not just that I just wanted animals and it you know we have psychologists to work for us we have exercised is the odds we have night visions and all of them work for us and some of the patient goes through something traumatic like they get the horse well that can contribute to weight gain so we have this is a psychologist if they have an injury or some sort well they have to work their exercise around this new injury and so let's I happen to see the exercise physiologist and the forgotten how to eat properly or their legs inside was go back and see the night vision so I would I would also encourage the follow up to be a very pronounced in whatever package that we're doing so that's a that's an excellent on and just opinion back on one of the questions it was already out there there is one comprehensive center that's in Jonesborough there are none that are in north central like a home or anything like that so there's one in Jonesborough that that I am aware of okay thank you and and just a follow up I think it's also important if they're traveling that that comprehensive program and follow at the manage with their primary care physicians as well because they're gonna be also part of the team. You know to help keep that patient going in the right direction so I just appreciate that in because these types of cases really do require kind of a big team approach yeah thanks it and if I can take you back on that one last comment one of things we're looking at and we've got to help the healthcare economist that HA has been digging into this we pushed him pretty hard on it looking at the cost both before and after the surgery and certainly one of the big cost drivers after the surgeries that psychiatric care is the kind of depression anxiety and making sure that we manage that we cover of solutions for that is certainly going to be important for the outcomes we have two more questions Senator Hammer you're recognized. Thank you share Jake to you and everyone else's question this was originally a pilot program that had a three hundred cap on it and. When we went through this process that we're now removing the cap that you go back historically and look at the number of requests for surgeries about the three hundred during the time it was a pilot program we look at the success rate generally speaking we did not look at how many kind of we had in total courses you remember under the old program there was this kind of window and the first three hundred get in and if you didn't get in and I was like the January one or whatever and we didn't look at that necessarily my inclination on this and you'll notice there is no cap so they will need to monitor it and that just makes me a little anxious the micronation on this was to really say to the providers who are specialists in this field take this forward and let's see what happens and if this is as effective as surgery is as we're told and if there is a cost savings on it for everybody as I'm told then let's go ahead and make sure that folks who are interested in it and who would benefit from it can get access to it without a cap in of that look back of the three hundred their plight because they I mean I think open about like mid nineteen by twelve thirty it was gone yeah and and did you did you have to look at of those three hundred that works sept nine though they had to go through an approval process how many of those three hundred were spouses or were actual employees give us to gauge as to what percentage of the three hundred maybe were spouses were not covered under the pilot program or family member I mean anybody anybody else that was on the planet was just active members regs active members raises okay all right and then the second thing is who who is at the controls the certification of the centers that is handled by the American society through the American college of surgeons in American society for metabolic and bariatric surgery. Okay so could we maybe get of idea or maybe doctor Bledsoe could speak to that Sir can we get an idea which hospitals are looking at being survive may may not fully certified but are looking at or is there any way to get that I don't know how we can get that we can certainly give you who is currently accredited but we would have to get with American college of surgeons to see if they had any contact or any interest in it and I don't know honestly. A my expectation is the process of obtaining that accreditations fairly rigorous and you have to show that you've got the resources in the background in place I can tell you that the folks that are employed like Dr Bledsoe and his colleagues have a fair and a significant amount of specialized training on this is not something you can just pick up okay thank you Mr all right senator Bledsoe. Thank you Mr chairman of Mr bleed as I understand it one of the interesting things that happen because of very at trick surgery is that diabetes type two is heard in somewhere around seventy to eighty percent of the cases did you factor in the cost savings because in a diabetic type two is an expensive very expensive and that's actually something that we're working with the healthcare economist Dr Novotny in fact Octavia young in Arkansas who is with the B. R. acts look at the pre and post surgical analysis as well and so if you look at the cost of the the pharmaceuticals that people are taking before and after surgery. Insulin and insulin dependent diabetics in particular the ones we're looking at basically disappears so any the program is very successful in eliminating one is one of the more high cost drugs that we pay we have to weigh that against the increasing use of other drugs like the anti depressants some of the other kind of phenomenon that you see cropping up in the data we're still digging on that we're still looking at that I'm very hopeful that there will be a cost savings for the plan but also that this is ultimately going to be just a better plan for the individual all right in a doctor Bledsoe was not correct about seventy to eighty percent of the diabetic type two employees would be cured or do you have any. Statistics on that may be a. Described in. Now you're you're also correct thank you for the question in a gastric bypass of course depends on which shall you you reading what one I quoted eighty three percent of the time we can cure diabetes firstly is that sixty six percent of the time I've all comers of course and so in one of the things that have made clear DVD is that early intervention is better than late intervention and so if you have somebody that was just diagnosed there on one hill that form and it's almost a hundred percent here but if you wait until they're on an insulin pump in it and it I'd ask for twenty five years well the rate is much lower it might be as low as thirty to thirty forty fifty percent and so one of the things I always try to accentuate is this is a progressive disease the treatments are just controlling controlling symptoms and controlling the butchers not exceeding the underlying issue so it typically grades over time and so if you don't earlier versus later that's a big big deal the other thing is that oftentimes like most of the time if you're is immediate meaning that the cure for the eighties is weight loss independence meaning they can go into the operating room a diabetic and leave the operating room not a diabetic in the home of one of their medication so it doesn't take long for this effect to the bill to go into effect it's oftentimes an immediate response and that is one of the big drivers for something that the single group noted which was that the secretary will often times pay for itself within two to four years and that is also well in in the literature as well where the the costs are recouped over about a two to four year period of time for a a laparoscopic surgery thank you for the question thank you it members this is related to have a member of this actually watching the this today and this is Senator I assume there what year would be a live stream today. Phil Sir are we being live streamed today okay well I want to make sure that I'm correct on that but they did send a message and from a member I thank you may this may relate to the question was already asked related to additional opportunities but the question's been asked is the plan going to cover an injection drug called it's spelled W. E. G. O. V. why would go B. as the drug okay and at this point we do not cover it but that's a decision that we will be presenting it to the advisory commissions we've actually gather data on it our way and we'll be making a recommendation at that time but that will be something that we will be inviting representatives of manufacture in to come and Senate president their perspective on it as well as the perspective of our folks are consultants at UAMS on hold on behalf of my co chair representative first and would you please follow up with her on that particular issue what I've been advised is that uh most patients have about a twenty percent weight loss just from the injections so and it is related to senator Bledsoe suspicion of diabetes so if you please follow up with a co chair on that I appreciate that members is there any other questions on this particular issue before moved for. I see representative Wardlaw there. Thank you Mr Knecht there was a follow up question to some meds and and I think it leads into what you were just discussing Mister chair it came to my attention last week that we weren't going to cover the medications for certain bariatric Applications can you kind of give us an update on that Jake or where that was that and I believe and and I'm saying that because in passing someone said that to me last week and I just wanna make sure that so yeah it was so first of all my reading of act one or nine is it's limited to surgery I agree so in looking at the pharmaceutical applications yes there is indication that these drugs will lead to some weight loss the challenge we've got is that the drugs are significantly expensive and if it's not a one injection thing it would be perhaps an ongoing obligation. We have to balance that against the cost of the plan and the efficacy of the the drug as well as other alternative options that are out there that we or cover and so that's kind of the balancing act that we have to play so twenty percent weight loss sounds effective on average but if it costs sixteen to twenty thousand dollars a year for the entirety of the person's life I'm not sure that's necessarily a feasible option. When you compared to for example diet and exercise of other of pharmaceuticals we might cover or the surgery itself. Okay members any other questions on this issue. Saying none and we will proceed on to the formular recommendations report and I would appreciate you Dr Bledsoe for being with us and I don't think there's any further questions we do appreciate your time thank you doctor. You are solely so the formula recommendation report as you are aware the you B. R. acts over at UAMS has a committee that helps us make decisions on which drugs we cover and on the conditions under which we cover them there are always new drugs coming on the market there are always new studies new evidence on existing drugs so we have a regular process where the E. R. X. P. anti Committee looks over it the X. in the pharmacy and therapeutics committee looks over and makes a recommendation the recommendations have been presented to you all today included in them is an alleged here on the front which gives a recommend a kind of a code for why a drug would be excluded which is to say why we would not cover a specific drug in addition to that there's a medication costs for some of the drugs as well as a projection on how many people are currently on that drug on the plan. On the there are no major kind of the the stories here I would know that some of the specialty drugs that we are covering are very expensive but we believe that the the efficacy of it demeaning the effectiveness of the drug supports our inclusion on. Okay. Evers you have any questions on this item. I don't have anybody in the queue of. Members if there are no questions on this specifically do you have any my I'm asking I got one so I don't see who the name is but recognized C. twenty seven representative Springer. A good morning thank you Mr chair my question is just a general question not about this I just wanted to inquire of maybe our legislative representatives of representative to warble I have had some questions from constituents and I just want to inquire of him his opinion about been told okay if this is general not related topic we hold a little later on that yes that's what I was saying yes thank you represent Springer members any questions related directly to the formular out of. Senator Hammer. Sergej can maybe answer within the sheet notice cedar didn't find it one the the medication costs could you talk about the column a little bit deeper. Sure so that's the cost and I think there is a Asterix somewhere on here it's one year for yes so that's the cost that would be up for providing treatment for one year all eight and so average wholesale prices a W. P. and it's one of those acronyms that the pharmacists and the PBMs through around it is a number that's calculated by the industry we reimburse to providers to pharmacies on a number that's eighty P. minus say fifteen or twenty percent that's the amount that we negotiate with them so that's the cost that it would provide for one year it's really included here to give you a some kind of shot from now on. Wow how much this drug would cost the planned these aren't necessarily medications that would take a year dates some might only take. A little bit or a lot it's really kind of hard to gauge demand going forward on some of these trucks but it's really just added there to help you all get a sense of how much money we're talking about and and do rebates plan to those numbers that are on here at all or is that not a related topic at all no no these do not include any negotiated rates with manufacturers but that's a great point so it could come in less than what's on the sheet yes Sir and that money goes back into the yes to the plan right to yes so all you've done is just added these to the menu as far as drugs are available to PCPs to utilize for whatever treatment there sure and so for example on that middle call on recommendation says we would either excluded or coverage cover with a prior authorization coverage with this coverage. What about a list of drugs that you drop off and do any of these take place of some others are set on here somewhere it is on here so if you go to the back I believe second review of drugs is the drug and there's this. A number of pages where we're looking at drugs because some new data has come along so we are either changing an existing drug to say we can also use that for this new condition or we're saying we're gonna retire it so for example on that first page. Members bill. As a mobile. We're we're retiring a prior authorization criteria there because and may Gates yours this is a drug as provided medically speaking so there's already a coverage criteria that health advantage applies therefore we don't need one also I point out the nobody's impacted by it. or retiring prior authorizations that's okay when you talk about prior authorization they no longer have to come to the doctor can write it it's going to be covered without having to go through hell to get a pharmacist or the doctor would not have to call and confirm hate this the these are the circumstances under which coverage is appropriate all right let's question some of these are pretty high dollar drugs When we do the cost analysis on the pharmaceutical side of things is it factored in the drugs are being dropped off drugs that are being added OR is there any even predictable way because you don't really know who's going to use these are not such kind well of a retrospective the first thing I think that we do is look do we have a drug that does the same thing so I knew trouble come on the market and it will treat something the first thing we're going to look at is okay what we cover that treats whatever that is a lot of times we specialty drugs there is no other alternative I think I can say that and so I don't like the idea just to be perfectly blunt of paying this much money. But is this is the only option in our members need it and we have to I think we have an obligation for that first decision that we look at is what else is out there and how effective is it so very often what we'll do is we'll see a brand name drug that comes along it's very expensive well there's a generic out there that does the exact same thing for less so we'll come junior got it thank you thank you sure. All right members should know others I'm I'm just you have to take a look at these numbers shall review take a look through these pages some of these drugs hundred thousand dollars a year three hundred thousand dollars a year it's cetera is just astronomical so we appreciate the work the DVR access for the state of Arkansas on this and I appreciate the comment that you made which is at the end of the day for caring for members and so there are times when costs are not avoidable if may if the treatment is going to be maintained so I appreciate the effort made to at least come up with alternatives that are gonna be sufficient because I would hate to know that anybody's life was adversely impacted just because the plan wouldn't cover medication a doctor recommends and these are it if I can add on that these are really really hard decisions they're not fun to make but these are decisions that because of how we structure our relationship with our existing BBM that we can make some and if it's an unusual feature of how we handle our pharmacy coverage in Arkansas that we can sit in a public meeting and have these kinds of discussions normally these decisions are made by PBM outside of the state and without a whole lot of input from us. Thank you members don't see other questions on this item as mentioned earlier without objection we approved taking up another agenda item employee assistance program and filled members have a copy of this you can they have a copy of this. Which if you would have staff at least get them a copy of that and I want to recognize Director believed to speak about this this actually was provided just prior to the to the meeting so we'll get this passed out to members if you would go ahead and address this yeah this was prevent presented to our last month's meeting and held over till today the employee assistance program or E. A. P. is somewhat unusual program it's a program that's not required under law for EVD salty on the front and I didn't want to do it but in talking to our employers and both at school districts as well as our state agencies there we realize there's a need for it eight of counseling program it's a program that provides assistance for employees on a variety of different levels to help them through stress to help them deal in a stress be working in a stressful environment help with family problems give them financial assistance financial guidance at times it's really a support program for our members who if they don't have that support as an employer we rarely have another option so for example if I think about someone one of my employees who is struggling in their personal life when we come to work or when they come to work our expectation is they will suddenly not have those problems and they'll be able to be a professional and sit at their desk and work hard but we also understand that's not realistic so if that person's personal life suddenly interrupts the Office interrupts their ability to their job as an employer the only option I really have is to discipline them which probably is not going to help and so in those circumstances it's helpful to have a number that we can say you need to call this number and you need to get counseling for your problems as an alternative to some kind of discipline if you think about teachers. Teaching in the classroom people working in correctional institutions or human development centers you can imagine those are very high stress environments so this is a program that we have sought to extend out right now we're paying a dollar thirty three so it's a little more than a million dollars a year Ross the plan. Our current program is pretty basic but our understanding is there's a lot of potential out there there's a lot of different options so the R. F. P. that we would like to put out on the street really says to the industry the employee assistance programs that are out there tell us what you think we need and we don't want to spend a lot of money trust me but I also do believe in there's a lot of studies that show the benefit that the stated reason having it could very will outweigh the costs so that's generally speaking what EAP is I'm sorry that's a little ambiguous but it's a program that EQT's always provided it is something that we would like to continue to provide. Okay. Members you have any questions on this particular issue I'm looking at I don't have the name popping up here senator Bledsoe but I'm going to push this and hopefully hopefully that you all right thank you When you're asking them what they need they say I need drug counseling is that an option I believe so now. there is a lot of substance abuse counseling that's out there one of the things that we're working on is of course we cover a lot of that through our medical policy to so there's a line there where this is going to cover the stuff on the front end obviously if somebody shows up in emergency room going to some kind of withdrawal or some kind of substance abuse issue will cover that on the medical side this is more on the front end so that we can if for example we have somebody coming in and they're a great employee they're a good human being we want to keep them but we think Hey you you might have a substance abuse issue this is an option for us. All right in a scene that. When employees take advantage of this opportunity to get counseling that it that it's okay in other words there are places where it might not be good to do that through the work the work placement yes so our current it's all confidential it's anonymous and it's an opportunity for them to get some support and some benefit but you know very often if it's something where we still have an office to run right and if they have an issue that they can't get under control then we and and the EAP or the counseling does not succeed then we might have to take further steps thank you. All right thank Senator Bledsoe members for some reason the machine is not put posting your name your number up right now we have somebody live and is ready to speak to is that senator Senator Irvin you're recognized then we'll go to senator Hammer thank you Mr chair and so we currently have this so what's the utilization of it it's less than four percent three percent icy okay but then on the back page you're saying that. It so the utilization across all the A. P. programs nationally is very very low okay during COVID spiked as you can imagine a lot of the benefit of and one of the things that were right now we're paying for people to have an option that they're not using and when we put the R. F. P. at what would really like to do is to price and not based on whether or not you not based on on how many people could call but how many people do actually actualize the former. I want to kind of compare those two options right obviously we don't like paying for something we don't use but I've heard from a lot of employers bosses who say I really like having the ability to do that it gives me an option other than just firing some yeah I think I think that was my main question is the structure of how you do your R. F. P. and what you're looking for I'd much rather pay for a service that's being utilized verses you know paying for something that may or may not be utilized and then I think I see value in it I appreciate the conversation about it and see value in it I think you know you might also consider in your RFP process how they're going to actually make members and aware of it the availability of it if they have a plan to try to make employers aware of it so that they can share that with their employees and and then to make sure that they also understand if they utilize it is confidential and that these are the benefits you know that senator Bledsoe asked about as well so that might be something that you can consider is kind of a certainly a committee marketing communications plan or something that could be worked into that you know that it can be effective I think that's a great idea yeah absolutely thank you for the question. Thank you senator senator Hammer you're recognized. Thank you Mr on the back of the page it says our reliance on actuary has increased these costs about nine hundred sixty thousand across twelve month period what exactly is it that we're depended on the actuary that has driven up the cost of trying to get my mind around how that works so that was the information that was presented at Nailsea last month there were two items on their one was for the eight PM one was for the actuary I think you might be reading the actuary the request to approve an actual or are at P.. the actuary the utilization has increased because the there's been a whole lot of change ATV the last two years and the contract they were using them on really envision them having a pretty set basic amount of work as the EVD existed under consult the its old form over the last year and a half though two years you're where we've had a lot of changes we've relied heavily on our actuaries to not only confirm the numbers but also give us some consulting and help us figure out what we're doing it all the changes that we did for example on the ratemaking structure came through of and working closely with our actuaries so that's what those costs when a. And I'm sorry for the confusion but I've we're talking about a line in my mistaken or were you talking about a a number where people can call you know to to get assistance right the AP is separate from the actuary asserted okay we'll talk about two different subjects on yes on the sheet of paper that's okay all right the All right let's go for the eighty litigation been pretty flat since the COVID pandemic. Okay and. All right thank you. Okay representative ray. Thank you Mr chairman I want to go back to senator Irvine's question the line of questioning about the EAP I I agree with what she said it seems like something that would have tremendous value especially in light of what everybody's been through with the last two years of the pandemic and the stress and all of those pandemic induced things that we read about in the news I guess my question is what are we what are we doing to make. employees aware that this exist I started working for the state in twenty seventeen in this meeting today is the first time I've ever. Heard about the AP and I feel like I'd try to read the emails that I get about employee benefits but maybe maybe maybe I'm not as good at reading those emails I think what what are I've never heard of this well how are we making employees aware so most of our communication on this and other things will go through H. I. R. city the HR office where you're employed that's not to say Members that I don't think they're probably aware of or utilizing as effectively as they could HSA is come to mind but of it in our defense and this is Both bundled so to speak with our third party administrator contract sorry Justin contract is really a contract the HA health advantage had in which we then contracted with them I don't like that arrangement in one of the reasons that we brought this R. P. to use so that we could have a direct contractual relation ship with our EAP provider we could have a direct hand in developing those programs those benefits and then we could also have a direct hand in requiring a certain amount of communication and outreach. Okay thank you at I just think I think that's gonna be a point of emphasis because that may be one of the reason the the adoption levels been so flat is certain folks just don't know about it and it under the reimbursement structure there's not a lot of reason for the vendor to make sure that people know about it okay thank you. Representative very I think it's a great question I will take it opportunity here Director believe and and really the members are going to be continuing on here to raise an issue to your attention I think part of it representative ray is there still a terrible amount of stigma as much as we like to say that there's not a for employees even to articulate that they really need some help in and that's been going on I actually of and talk with some other members of the state and the department of health in the past few weeks a very difficult to talk about because this is not my own family personally. But we have a terrible crisis. In the state with not having bids for people that need help be on something like the AP. to the point that I feel it's really unconscionable. And I know what the situation. where a person is going through a terrible situation. They needed help they need a long term health. And is much is our legislature. Has put money into crisis stabilization centers. That that lady. Lay in a jail cell. For days. Needing help. And as much as the people that I would call upon that we're trying to get her help. Excuse me. I agree senator and much is all finish as much as the people try to get her help director Billy. We simply. Have no help. And I and I had talked to the independent providers in they told me we simply don't have that is that a cell the in the third what's happening for the members that are listening to me is you've got people in your communities they're not criminals. They don't need to be House with criminals in the only option for them to have a place where a guardian. Get them placed without their consent is the state hospital and with all due respect for all the work that is done there what I'm being told by these providers these people do not need to be house with criminally insane patients. It would not it would be worse for them. And so. I waited for my comments at it know that it would evoke emotion and self. But for all of the effort that we've made. I'm being told by sheriff's they don't have a place to take these people they want to be in the hospital. But the only options there laying in this in a jail cell. And this is wrong I talked to one sure if there is a person there there's been there a year. In a jail. In and I'm just telling you I know we're so many needs in this state. And so appreciate it for all that we've been doing we have these resources that are available right now. I just wish somebody would become a champion if I have one regret I've been supportive of mental health issues since I've been here but if I have one regret it's that. I didn't even do enough because I was not aware of the death of the need. And and I would ask if somebody decided to be a champion for this because when you see the term will that it's causing people and even may I'm I'm touched by even relaying the story because we were simply unable to help in the situation that person by the way that person is now in another state because our state does not have the proper treatment for these people and it's wrong. Its role is so all I wanted to bring it up to say this may be my last opportunity to get a chance to say it would be wonderful for EBD. Representing one of the largest contingents of employees in the state if not the largest. And for the legislature to decide to bring a voice to to the mental health providers please listen to them it's not just about them trying to have a new facility. They don't have the facilities and we have made it high enough for priority but when you deal with the family is going through one of the situations it just rips your heart out the fact that they need help but there's no place here that says they can take care of them and so I just want to lend my voice to what the others have said that this program is helpful in and if we should be stigmatize it to the point that people feel like they can actually ask for some assistance and I am sorry that I got somewhat emotional with this but but it is. It's very disturbing that our state is not able to serve these residents and they're being forced to go out I literally in this process know that they were the family was asked thirty thousand dollars a month just to get that family member help in another facility in we've got to do better but this so I appreciate your indulgence on a very personal reflection on what's happening in this space and the Director bleed I appreciate you bringing your voice to this in the future to try to help us find a way to come up with this see some of the questions now it's come up senator Hammer you refers to Q.. Thank you Mr the process somebody needs to talk to somebody so they call the number and they're gonna be connected with somebody with the company called new directions is that correct well that's our current vendor yes all right and once they receive the call what do they do with that or they're counseling firm or they referral service or their referral service and they are supposed to have a network here in the State of providers that do you will then be routed to so you'll call that number and you would get an appointment with somebody to speak to them one of the concerns is that our current policy for example is does not clearly envision virtual or online meetings so as a result in the in person meeting obviously you can imagine the benefit of meeting someone in person might be better but that puts a bottleneck on the process because that means you have to wait for somebody local US time there's a very. I found to my own experience a pretty limited network and I live in here in Little Rock I can only imagine so one of the things that we want to do nationally is really open it up and allow for virtual meetings as well so that people because if you need that help you need it now you don't need to wait two or three weeks or months. Well I'm second meetings to represent Vaught had over there about the limitations of access to healthy season you know licensed social workers like Senator and. So new to so how much we pay new directions and what's percentage of usage that they're getting for handling those calls we pay them a dollar thirty three per member per month and ninety six thousand police ninety six thousand across state public schools that equals a little more that's a one point three million that split between a S. C. in the PSC plan and they get paid that would regrow should never cross that they get you want to change it to it's gonna be on a per call basis so utilization basis if if we can make that an affordable option what might what I've heard from talking to other providers who have looked at this is you might say I might pay one point three million dollars to have on our current process or we might have utilization base where every time someone picks up the phone it costs twenty thousand dollars and you end up spending one point three million so we have to we have to really figure out how we can make this work okay it's not though in my perspective a huge cost driver if you certainly compared to some of the specially right drugs we just looked at sure and and and the question I guess I would have is once they get referred to that counseling firm then. The the ability of our plan to pay for for the need and just refresh my memory within our health plans. What are limitations because we identify unemployed that needs help they get sent out to somebody and and then our health plan will actually pick up the cost of those mental health services I just can't remember this moment if they get referred to the a a. If they get referred to a provider. The people so under current contract you can have three of the visits with the counselor under EAP per incident so if you are going to divorce that's three if another incident happens in your life that's three more BiondVax then you would have to either pay for out of pocket we'll find some other alternative that's the maximum amount that we cover I'm sorry if the and that to me is something we need to look at because that could be a problem because it's like we know you got a problem we're just going to get you started right direction if we're not gonna take all the way and I know that's that's something's got to be looked at the cost of employee but I really think that's a drill down issue because we can identify the got a problem requirement hand somebody if they can afford to keep going the problem just career curry I agree okay and I'd like a list of who all new directions refers people to I'd like to know who it is that they're referring people to what entities that they're actually sending these folks to please the network providers. Well like you know who their network providers are then okay Mr can at one point of personal privilege just requests or I wanna make it very clear because of a follow up comment my questions about the cost of the drugs while go is not to call into question the people need it because to the bottom line if somebody's got whatever this drug is going to take care of getting healthy they need to get it will work out everything else I just want clarification my questions about the cost was strictly just informational purposes not call into question that we don't that we need to provide services to our employees that need whatever drug they need to get healthy and live a good life thank you. Get two more questions representative right recognized. Thank you Mr chairman Mr chairman this question that I have is actually related to the situation that you're speaking about are these folks Services substance abuse or is it mental abuse I mean abusive but of substance abuse or mental health issues mental health. And we don't have any for for those folks to go we we have they will tell you they don't have beds available for them in a facility where they have to be placed there outside of their own will on an involuntary basis. So thank you and presheaf your interest and hopefully the legislature will take it up in the future. representive all thank you a. Sir I appreciate you recognizing me even though I'm not on this committee just for your information we there's about a hundred and fifty of us has been working on this issue for about the last six months so with that I'm surprised that a B. D. probably hasn't already reached out to us because we have a big meeting once a month it's been great to have them at the table explaining to us what they provide when every other entity in the state of Arkansas has been at the table explaining to us what they can provide for their employees or their clients when it comes to mental and behavioral health so J. maybe we need to have a. Offline discussion but one of my questions is why three visits when Medicaid pays for twelve. So the original contract was four dollars thirty five four three visits and things calendar twenty five an increase to one thirty five when we were looking at the renewal last year they wanted to increase that amount dramatically to I thank north of three dollars PM PM the utilization what Justin's justifying my mind the additional cost. Okay so if you're gonna do it her if I understand correctly you're going to do it per person now on a need basis did I get that right we're going to ask providers to give us their their proposal and within that proposal we're going to ask for pricing to be like it is today on a PM PM basis or on a utilization basis which is to say we only pay when somebody calls okay and so are they getting screenings to see what their actual light when we talk about screenings with then our mental health group I mean are the clients go through a screening process that helps them know which what they need I. see to head shaking back there so they are going through a screening process so after three visits are you recommending them to go somewhere else because three visits is just. The service sure and we would certainly rely on the Council or the professional they're they're seeing in with their judgment would be for that individual but I would ask the to keep in mind that this is really a benefit we're providing to employers as far as managing their staff that was the intent of the program from the get go I don't think it was ever intended or or really could be a strong source of mental health benefits or support we of course cover that through the mental health parity and federal laws okay but the EAP program is really meant to be an option for employers who are trying to manage their employees and put them in a position to succeed okay thank you. Thank you the representative vote I'd love to to follow up with you as well and this issue again I'm glad to hear that you're having these meetings and I'm hopeful that you all will be able to raise this to the attention of the incoming governor because it really needs to be addressed I was unaware that we just have lack of capacity to help these people and it's forcing Arkansas residents to go out and seek the services in places exorbitantly high for them so Director bleed you've you've been very good today I don't see any other questions in the queue is there anything else further representative Springer you had one question if we could address that to think represent Wardlaw you have a question for. Springer. Thank you Mr chair of representative Wardlaw as the representative from this body with the B. D. I've had several phone calls from his constituents in my area concerned about and these are retired teachers say was concerned about I guess there were two questions the benefits in general up to good to be true and and then I would like your opinion on that if you want to or since we have persons here to address that that that they may do so so I can report back to them and then is it your recommendation that they attend these meetings and when I asked them about whether or not the intended meetings they indicated that they had not received notice of such meetings so if I can get those questions answered general law you're recognized of course the meetings are all publicly posted shall represent Wardlaw Mr I would I would ask that we invite John Thompson and Jeff to the table to join Jake I think this is actually a good discussion. You're with your permission yes of course thank you thank you. Can I address the representative yes gentlemen if you would please please state your name and your position for the record. Thank you Hey good morning everybody I'm John Thompson with United health care retiree solutions amid the national practice leader for United healthcare. Yeah. Your. Chevrons the vice president hi management with United healthcare. Alright. And represent Wardlaw Percy. President Springer yesterday I'm I'm that with these two gentleman that had a number of members are invited a number members to go buy me yes there was a very intense day so I don't know how many members got by and met with these two gentleman but that was sort of the the the subject yesterday was how to address those members in your district on how to understand the difference between M. A. D. plan and a Medicare and a part D. plan with the net with a secondary plan through employee benefits John's been very very open and very easy to communicate with and very likely to call your constituents himself of so one thing that we told him yesterday that we were here and as some of the members that came in was providers are very reluctant so he told us yesterday and hopefully he'll tell the committee today that they're going to a whole lot of provider education over the next few months to try to help with provider guidance because when folks get nervous about the health insurance to go to their doctor and their doctors reluctant to persons probably going to be reluctant as well also represent Springer I'll turn this over to you to question John and you're welcome to get any information. Well I I guess that's my question that and thank you representative Wardlaw you hit the nail on the head with respect to what their concerns are they will have some new doctors that they go to win and may I have for years and that is the question as to whether or not they're providers will continue to provide the services that are necessary for them to have quality of life. Upon entering the transfer your first question too good to be true yes please and I wish I had a visual but imagine an iceberg. And you only see the very tip of the iceberg so the key is a lot of retirees are saying I'm gonna lose my Medicare. A Medicare advantage plan is a Medicare plan and eighty percent of the finding of a Medicare advantage plan comes from Medicare so that's a key where retirees say I'm gonna lose my Medicare under Medicare advantage plan the plan the group custom plan that we're offering for a R. benefits is a custom group plan the funding comes from the government the federal government CMS and the I use the iceberg analogy because people say well this plan it it doesn't cost enough so must not cover anything that's what we like to try to explain is the funding is coming from Medicare the rest of the funding is coming from the state based and I use the state as a term I think we all understand and the rest of it and then you are paying your portion so there is tremendous funding in the iceberg analogy of it's not too good to be true because it does cost more than that premium that you're saying so that's what I wanted just any further questions on that before I talk about the provider issue can can I just jump in really quickly so the providers in these are public school employees I'm assuming so they're looking at that eight dollars and fifty three cents a month and they're saying No Way right and I understand that. What I see when I just spoke to some retires yesterday about this that eight dollars and fifty three percent fifty three cents is ten percent of the monthly cost the state is going to K. the other ninety percent so ninety percent of these costs are not being paid by the retiree for covering them at the state okay we're going to combine that's that's eighty five dollars a month we're going to combine that with the amount that the federal government is going to pay United to cover that individual so I think the iceberg analogy is a good one and that what they're seeing is only a a small sliver of the total cost that they're getting from this benefit. Thank you. With regards to the providers so again this is a national plan so the plan is available in all counties in Arkansas in the plan travels with the retiree nationally so the key is the benefits of the same in an out of network so the key is it's the providers they can go to an in network provider and they can also go in this is this is confusing so they can also go to an out of network provider at the end network level of benefits so it's really not in an out of network it's really the Medicare network so for provider accepts Medicare they're going to accept this plan the key is for out of network providers. We pay them. A hundred percent yes that yep one hundred percent okay yes and that's the key so the provider acceptance under this and this is not a new solution for United healthcare so we have twenty other states that have adopted the solution through United healthcare ninety nine percent ninety nine point nine percent provider access committee you're going to set the sort of retiree asked says can I still see my doctor yes can I still go to the same hospital that I want to utilize yes how are my drugs covered we encourage a retiree to really do check to the specially the teachers which we understand or been on these individual party plans where we want them to check to see how their drugs will be covered in the United plan we've had a lot of teachers that have said wow I'm gonna save a lot of money my drugs covered I have no deductible it's going to be a better benefit for me but they need to make that comparison now we also are doing a lot of provider education meeting we're reaching out to the currently hospitals doctors positions that we know are currently being utilized for by retirees to make sure they accept the United healthcare group Medicare advantage plan the one last thing I will at sorry and I will be quiet is that this is a group Medicare advantage plan this is not the Joe Namath plan you see on TV I know we've all seen those advertisements this is a custom group planned so if a retiree goes and asks there ask the provider do accept Medicare advantage the question was should be do you accept a group Medicare advantage plan that is specifically designed for a R. benefits and they will typically get a different answer. And then if I could add on that what I like to say to folks is that there's a doctor out there that doesn't take the plan please let me know who that is because I want to call them and find out why okay and in response the chairman's comment about this out there available I was on the understanding that people would receive notice from you all they were they were mailed they received it if we have their address they got a letter from us laying out exactly where all those meetings are going to be held okay so for sure they they should have received letters yes you and it'll if for whatever reason they get it they can contact us and we will mail them a little all right I'll direct them to you thank you so much Mr Johnson unless this question because it's one that that that comes up that person that is that retiree right in their Medicare eligible but they also were retiree When they when they have this plan are they completely excuse me completely off of Medicare and and now I have the Medicare advantage its replacement for that could you address that just a little bit. Bye thank you I'm I'm you can hear me yes so thank you for a Medicare advantage plan they have all the rights and privileges of Medicare they are still on Medicare but United healthcare is now processing the claims so the key is all the rights and privileges of Medicare this is a Medicare plan it's it is a Medicare advantage plan funded by Medicare so yes they still have all the rights and privileges of Medicare they have everything that was covered under Medicare part a and part B. plus they have additional benefits from United healthcare so they're still part of Medicare a lot of a lot of retiree said I don't want to lose my Medicare you're not losing your Medicare. Change in does that also apply for situation where somebody's getting to end of life and I've seen that be a stumbling block for some they say well you switched plans Medicare would pay for expert you have this replacement plan and it doesn't cover that by law we have to cover what Medicare we have to cover what Medicare covers okay so there will be no exceptions to that okay and the one thing to point out to is this is United healthcare is providing this plan I said it's a custom group plan but it's the A. R. benefits plan so that's a key point point when I was going to say and and one of the conversations we've had is how strong this benefit is of all the twenty states that they covered this is probably the strongest richest plan that they've seen for state and public school retirees but when we put this bit out and when we solicited everybody's input on it what we said is here's what we currently cover that's the floor right so the if we currently cover those sorts of end of life issues we will continue to cover those sorts of analyzation okay where will I don't see anyone else in the queue with nothing else members thank you for your participation day thanks many good meeting thank you director thank you as well we're Jr.