ALC-Hospital and Medicaid Study Subcommittee

The first item is the item city of Mars modernize in hospital inpatient payment system of I'd like to ask if Matthew Ferrara who is with three PM if he would come forward and state his name and make a presentation. Which. Good afternoon my name is Matthew for our I work with three M. health information systems thank you Senator Ingram and center Ladyman and members of the subcommittee for having me and allowing me to share a little information with you today. Great well we're glad to have you with us and for those committee members this is just sort of make an extension of the health study that was done a few years ago that this was one of the recommendations if we study and and and DHS took a look at and so it's a shorter time to update that we appreciate you being with us and of please proceed okay I before I get into the dive in the power point which I'll go over it a fairly high level just wanted to re introduce any members of the subcommittee that might not be familiar with three M. three M. is a big conglomerate manufacturing and all sorts of industries but they have a Division within three AM that's called health information systems and that division their sole purpose is really creating software to help state agencies health insurance companies hospitals and other provider types in the healthcare sphere understand information and understand where there's opportunities for improvement where there's opportunities for efficiencies and so they take this vast amount of healthcare data that's very complex consisting of thousands of diagnoses tens of thousands of diagnoses tens of thousands of procedure codes in groups them into meaningful groups so the entities can understand whether PF payor or provider and it It allows condensing that information into understandable meaningful groups. Are just a little bit about myself I work for health and for health information systems for about a year and a half prior to that he worked for the Texas Medicaid program for about twenty one years until my retirement in twenty nineteen about two thirds of my career I worked in behavioral health services which is a mental health and substance use disorder services program administration setting up programs running programs the last third of my career I was the director of quality oversight worked overseeing hospitals and health plans in terms of quality so we had some six hundred hospitals in the state of Texas we oversaw and we had about eighteen health plan so was a big Medicaid program and that's the area where it exposed me to using three M. tools to understand where we had opportunities to improve. So well done I read into the powerpoint. So for those that aren't familiar what is the diagnosis related group it's basically a classification scheme that takes up an inpatient stay in groups into a meaningful categorization based on the clinical presentation of an individual. It defines the product of a hospital and takes this inpatient stay which is consistent procedures and diagnosis and puts it into clinical senate Senate clinically similar groups and with those clinically similar groups it would be the categorize in such a way that similar hospital resources are required to. treat the individuals in those groups it's a categorical approach it condenses this information down into a category there are about three hundred twenty six DRG switches the diagnosis related groups each has four severity of illnesses the I think the advantages and the features that I think are most noteworthy about a DRG it's a categorical model it puts them into a clinical category but there's a fixed payment that rewards a fission see for hospital but there's also increased payments for individuals who have long like to stay or or high high cost and so it protects all access in that way. they've been around for a long time the Medicare DRG is for about three five years and the APR DRG is about twenty five years both DRG categorization systems are maintained by three AM so they have a team of clinical folks and coating folks that keep up with the of all the changes in healthcare and maintain the so that they're always current the APR DRG is which is a three AM proprietary product are most suitable for the Medicaid population in that they have the most clinical categories for pediatric populations and newborns which is a big part of the Medicaid program. They've been a success in that they allow for transparency and good communication between state agencies and hospitals and within hospitals as well and so like I said there I categorical approach to have a fixed payment that rewards efficiency SO if you can treating individual more efficiently you can benefit from the C. the DRG payment but it does have out wire payments for individuals with long lengths of stay or sicker patients they have a very costly state there the advantages that are available based on claims data so you don't have external data sources so everyone would hospital submits a bill and it uses that information on the bill in order to categorize each individual in the been around a long time I'll show you a slide that the states have all the states that have moved to the R. G.'s once they move they don't back they continue moving forward. Here's a map of the different states have adopted the Archies the bright red or the three AM APR the IG's. the I guess purple color are the Medicare DRG these both the R. G.'s are very similar and construct they're just designed for different populations. Then there's this pink one this is tri care this is the department of defense DRG that is also maintained by three AM again conceptualization or G. and that's a categorical approach that puts a person into a distinct had or or or hospital stay into a distinct had a gory. You can see the white spaces those of the states that continue to pay per diem or cost base. this is the sort of the I think one of the the things that is not worthy about a DRG payment courses DMR costs based I'm not saying this happens is there is an incentive for this to happen but a DRG attends to incentivize value and has more transparency associated with what's being purchased in this in the. In in the. Because that is bundled it and has a fixed payment it incentivizes that value. per diem tends to I'm not saying it happens all the time but it tends to incentivize volume more days equal more payment and so the and I basis and it's it's a little less transparent in that you're really not knowing what the stay was for because there are different diagnoses that are coated on an individual I think there's a transparency aspect and in sanitization of value aspect that DRG is bring to the table. The basic building blocks of the R. G. as you develop a hospital base rate which estate embarks on going to the R. Jeez they take all the hospital inpatient claims data and they come up with an average of state cost per se in this example is ten thousand dollars if you use an example of an A. P. R. D. R. G. one thirty nine which is an ammonia severity level three it has a weight associated with a weight is simply a relative resource use of the Haas of the DRG and so each DRG has an attached weight associated with it this one is point six five five what that means is a little less costly than the average stay in terms of their resource intensity. Are you can do policy adjusters with a PR ideologies and you can to sort of Juster is which are different kinds of hospitals and so what it allows you to do is adjust if you do an APR DG conversion and you model the simulations and you see winners and losers you can do adjusters in order to bring the losers up it's a budget neutral process and so if you do that kind of adjustment the others will be taken down but there are all sorts of little adjusters that you can do in order to try to mitigate any impacts negative impacts to hospitals but in this case is a very simple mathematical formula the base rate times the wait times apology adjuster times the peer group adjuster equals the payment. And then if the individuals to stay longer than the thresholds identified for each DRG there's an out liar payment associated with it so it's a very transparent and and simple process but effective. previous efforts in Arkansas you're probably familiar with that we have the Stevens group this is all based on my research on the historical information because I was not here at the time but the research the Stevens group had a recommendation to create a task force to move to a DRG system that task force recommended what was moving twenty RG System Act five seventeen had that language and I won't go through it to in the interest of time but it really directed the department to the extent feasible moved to a DRG system into all these things associated with the legislation but in the legislation directed the department to do this Department chose Navigant which is now a a company called act guide house to do this study. In the study had for some key points in it how supplemental payments would be handled whether be transition finding whether the hospitals that will be exempt from the RGA's because some states that moved to the R. G.'s exempt hospitals for the reasons not to impact negatively those hospitals. And the estimated impacts of conversion for for all the hospitals involved. The impacts of the study Again it's a budget neutral process so that there's the intent of the Archies is not to take money from the system but rather take the pie which is the whole funding and re distributed in war rational ways based on the case mix for the clinical presentation of the individual so there was three pre and post simulations that show the impacts each hospital's overall inpatient payments and the impacts each hospitals payment to cost ratio. And it you know it all simulations produce winners and losers one of the simulations which was simulation three incorporated supplemental payments into the simulation is mitigated the adverse impacts to many hospitals overall reimbursement but it still created winners and losers based on the overall payments and I know if there that fifty seven hospitals experienced a negative impact fifty six hospitals experienced a positive impact and that's kind of what you expect the bank into those impacts varied some act impacts namely the children's hospital Arkansas children's hospital is a big impact. eighty seven percent of the hospital's experience to pay the cost ratio greater than a hundred percent that was post simulation or post APR DRG thirteen percent of the hospital's experience to pay the cost ratio less than a hundred percent. it's important I I think this is an accurate statement but it didn't exist explore the full range of policy adjusters that you could do in order to mitigate the the bigger impacts to some of the bigger hospitals but there are numerous policy adjusters that could be done there's some states that do many many simulations in order to get it right and mitigate that impact I think there were three simulations done here. But in summary that the state Medicaid programs all across the country they're really trying to develop programs to drive quality and effective and efficient care and not just with hospitals but with outpatient providers through their health plans is really this movement towards value based care and that's paying for value in much of what's being done in the value based care activity is really designed to keep people out of hospitals which had a recognized in every I think you're recognized is that hospitals are such a key part of our safety net system in our healthcare system but they're expensive and so keeping hospitals out of the value based pay characterization I think is it's in it's inequitable all parties I think need to be on value based care if you believe that value based care will produce a more efficient and more accountable healthcare. APR DRG and if they did enable this call may improve the transparency and fairness similar pay for similar care and I think that's important there's fixed payments based on patient diagnosis and acuity it promotes efficiency there's protections for high cost and high length of stay incentives for volume or removed but you have to watch for under provision of services because of that tax payment. in Texas for example they pay a PR DRG we also had a quality program set up for looking at our hospital quality care to make sure that individuals will getting the quality care so inpatient stay complications were another metric that we looked at and also readmissions and we had payment adjustments associated for hospitals with low quality so we're we're trying to do in Texas when I was there is a efficiently but monitor for quality. Another important piece of this is that supplemental payments can be incorporated by just simply adjusting the base rate so it be provides for uniform payment system both for the the base payments also supplemental payments. And there's just a list of different three AM tools that are designed for different environments. I'd be happy to take any questions. Senator Hammer you're recognized. Thank you thank you Mr I'm just curious if you noticed any distinction between hospitals as far as far as like the private ones purchases maybe you know public ones are just the structure of how hospitals are arranged into businesses or any anything we need to know about this verses way hospitals are structured well I think the impacts you know sometimes are seen as a critical access hospitals and children's hospitals but again those policy adjusters if you should choose to utilize those can mitigate those impacts within some states keep certain hospital types out of the APR DRG structure I just a lesson those impacts are thanks. Other questions. Of regarding how do you. Okay just one second from the chair of a question your of. Reimbursement rates that you talked about to come up with your peer group of what that is is that nationally is that regionally or is that within the borders state. Usually your base rate that you come up with it's defined by your state data so it's within the state and using your state claims data to come up with that then you can do those policy adjusters as a mention for different types of hospitals depending on what you want to do and what you're trying to achieve and whether the you know how much you're trying to mitigate the impacts those policy jesters become very important. Represent read when you're recognized. Thank you Mr chair I apologize of these questions are so obvious that I'm just missing it but what's the impact to the cost to the patient the quality of care to the patient and why. Have we not already done this transition if it's going to be beneficial to the State. Well the impacts the cost of the patient Medicaid program so patient costs are not sort of in the Medicaid program it's a I said no cost to that to the patient itself what about tricare. Somebody was on tricare Medicaid military retiree I'm not so familiar with that I'm mostly familiar with within the Medicaid program itself but hospital costs are not worn by the patient. The last question was why why are we now waited this long to make the transition this would just get around to it or what it's an adjustment is a change in changes often are it is a change in the House there individual hospitals are paid and that creates anxiety but is a change and I I just think change is difficult right thank you thank you Mr. I have Senator sample but I don't see who's in sample Senator Irvin. So am. As when we talk about you know. Value based in bundled payments and rewards efficiency and all these types of things those are defined by who. You your company the policy that's created behind that because that's a moving target depending on how much money we want to keep from you or how much we want to give you is basically what I'm hearing you say because you're not a lesson the impact when you have rural hospitals on the verge of closing and and our. Trying to provide critical access care points for rule our Kansans you're talking about winners and losers and lessening the impact not sure if that gives me any comfort coming from rule Arkansas. Well your first question about value based care who defines what's value that's really the purchaser and in this case is the taxpayer in the state agency I think all Medicaid agencies are looking to get the best value out of the Medicaid program this is one component of that and one type of service in terms of impacts the hospitals and negative impacts on. When the modeling is done if you do a simulation and you see those impacts in my mind that's where those policy adjusters can be utilized one state I recall did dozens of simulations in order to figure out what was the right combination of adjusters but in the end if there if the you know the agency and the legislature of that agency should determine that this impact is untenable those individual hospitals those hospital times can be kept out of the the payment structure and be maintained on their current and structure but the real definition of value is defined I. think by the the Legislative appropriators and the agency well I thank you I mean the value of my health care is is really up to my doctor I mean I I trust my doctor and I trusted the doctors and the physicians you know need a guide to health care and what we're getting away from is the ability for physicians and doctors and health care providers to actually provide health care that they went to school for and that they know how to deliver and so you know what I see is we are using all of these schemes because I think you said at the classifications game or using the schemes to create these quote unquote efficiency so that companies like yours can come in and to a management scenario I make money off of that. Tell me where I'm wrong because that's what I see with managed care companies before. Well first I think the term scheme does have a negative connotation. Yes is that what I think is always in the system which is really the technical definition of a scheme but really all this is really designed to is is just to Medicaid is always under budget conscious in every state this is really about how to allocate those dollars and I don't believe that DRG system takes away from the decision making of the hospital when you're kicking the patient out of the hospital because you're fixed payment requires that their stay is only for three days and they may need to come back but then you're gonna demand if they go back because we admissions you just that is going to count against them and so yes it does tie the hands of the physicians when they're trying to take care of their patients absolutely it does because when they try to admit their patients and they're trying to give them care in the hospital and provide them with the level of care that they themselves are under a moral and ethical code to provide and your policy says you better kick him out are you gonna lose money then it does affect the quality of health care for that patient it is going to end up having a readmission for that patient I guarantee you because I see it time and time and time again so that is the concern with all of this because you don't have people at the local level making those decisions with the patients and I understand Medicaid of understand savings I understand all of that and how it's incredibly important but what I'm saying to you is with the there's got to be you know when you say value to whom and then you're making money off of this for sure or you wouldn't be here. So I'm trying to understand you know. What it is that we're doing here. On the first point about kicking people out it really just provides a fixed payment that we would sufficiency if treatment can be done sooner that hospital benefits from it but the online payment policies are another integral part of that those are developed by the state when the design and DRG system that can provide additional payments for longer lengths of stay if they are needed. And the reason that we're here is first because the Stevens group recommended this I think were you part of the health task force Senator yeah in we DHS look at this man that's the very reason here because of that was what was recommended in a review it and obviously of of. To find out what the it with. Thirty eight states I guess of or more there's only seven that are still on cost basis per diem if I if I've got my numbers right representative of that. Mr. My question is somewhat related to the senator's question. It's about rule hospitals and as a group I understand that there can be adjustments factors made I guess and in that in we can also could exclude them out of this if we want to five if I understand your my question is is from historical standpoint have you seen that rule hospitals are the ones that require additional factors as far as you know just payments or indoor are moved out of this versus the non rural hospitals. my personal experience in Texas is that the rural hospitals had a much higher base rate and so there was a specific base rate for rural hospitals that was higher than a just and the General Hospital children's hospitals also had a higher base rates so with that really was the result of these policy adjusters that increase the base rate for those hospitals but they were subsumed under the DRG system but they can be kept out I can get you a list of the each state's decision making in that regard if that would be helpful for you in terms of hospitals that were under the DRG payment and those that were kept out. I think that would indicate Going back to the center that would indicate that there was an issue there with that if we knew if it shall not that those are the ones that are priming or being excluded from the DRG saw now that be great if you have that. Senator Hammer. Thank you Mr I'm I'm curious about two things one do you know what the patient outcomes are driven by data in the states have implemented the DRG since they were in were originally put in place to see if the needle actually moved as far as health outcomes to the overall population. It would be difficult I can tell you the ones that are looking at readmissions and things that are sort of could be indicators of poor quality of care if they were doing that pre and post that would be sort of the the ideal and if there were states that did that and we're measuring that pre and post we can see if we get that data for. Thank you would be critical to the discussion to see if they there were changes in outcome as far as improving health quality of the states were to your cheese were implemented bills would which benchmark prior to which benchmark after and how much after does that go out I think that would be critical no and the number two by the same token do you know how many rule hospitals have closed in the states where DRG has been implemented to see if in fact having a G. R. G. did close down rural hospitals. Or had a contributing factor. To the role hospitals being closed. I don't have that at the ready but I could do some research. And. In the third the third question would be the if you are a role hospital. I'm sure I understand what you said well go is our different base rate based on where you are located and other factors that might for example your your big hospital set and will rock verses a roll hospital sitting out out somewhere and I'll tell you know Bittner beyond that out the rural area is our different base rate that's assigned to and factoring in that that there is a difference where were you located. Our each state does it differently those are state decisions in terms of those policy jesters but I could do some research for you but that's really a state decision in Texas I can tell you that the base rate was with higher. For the role for the thank you all and for the children's hospitals I'm sorry for the world and for the children's hospitals okay our state thank you. Other questions. Represent. You're recognized thank you Mr chairman of these states that have implemented this program how long have they had the program I mean that and all of the state's been for a long time did you have a few what what's the history behind that the oldest one that well I I can say that there are many states that have been you know fifteen years or more they've been under G. R. G. system new ones are coming online in the last ten years you know the couple states a year one stating here comes online so I can get you sort of what that looks like over time but there are many states that have been that doing this for more than a decade. Senator when you're recognized. Thank you Mr chair one quick question I know in Texas you know this has dramatically impacted your secretary head and because they are not making enough money to do surgeries within the hospitals so physician groups and independent health care associations are actually creating their own surgery centers ambulatory surgery centers or whatever to big because they they can't afford because the payment is so low that they can't afford to treat Medicaid patients at those facilities anymore even at hospitals so it's really dramatically impacted the shift away from hospitals for particular surgeries like orthopedics into literally office buildings whether setting up surgery centers. And I know that particularly in the Dallas area so as I have you I would like more information if you've seen that Germans because that that that becomes problematic in my opinion for your Medicaid patients that they would that it would restrict their access of care to those hospitals or surgical facilities that in our state of the art facility. One thing I can tell you about Texas is that they have a Really really sizable the call directed payment program and that is where local inter governmental funds are transferred to the state so these are local dollars transferred this state to form the general revenue match and then the federal match comes in a push down the state and they are Taking their rates at the average commercial rate for that directed payment program so they're they're funding has increased dramatically because of those directed payments and which are all financed through local dollars right and that sometimes obviously the commercial rates sometimes also hinges a lot of times on Medicaid rates as well as Medicare rates so that's becoming more or when that we're we're seeing not March down because of this isn't just something that's in Medicaid it's also being worked into your commercial plans as well and that is becoming problematic as well so you know the more cuts across the board when it comes to reductions in Medicare funding or Medicaid spending and commercial you know you're gonna it there's there's got to be a balance there for anybody to create an overhead situation that they can meet their overhead and stay in business you've got to have a mixture of all the different payment types and when you start to mess with one it's gonna start adjusting and fix on on another one of those payments so it's going to put more pressure on those but as we see a lot of this move into the commercial based payments. From insurance companies doing the US it has more pressure on your Medicaid programs. So it's just you know you have to look at it in its entirety for these hospitals thank you know that was a strategy I think it was a pretty clever strategy in order to. Maximize the reimbursement to hospitals whether or not it meets their full cost not quite sure but it has significantly boosted the hospital's rates. Thank you. Senator Hammer. The representative three AM correct yes how many other companies or how many other entity how many other entities have Have interest in this besides three AM are you the only one. Well we develop the software and so we have an interest and our interest really is developing. Sort of or helping to support efficient health care but not I'm not aware of other entities. Okay in taking on center ridge question under I know when it comes to the Medicaid population sometimes they have trouble finding PCPs I know none would like to thank everybody gets accessed one but not everybody does depend where you live sometimes I have trouble finding one just because of your limited access I would does not create or help educate me as to how this would not create a disparity between somebody that has say a private insurance company work for firm that you're recognized card versus some its Medicaid patients so that Medicaid patients would would get less treatment or poor treatment than somebody that has a gold insurance card. Well this is you know the DRG system is not intended to solve all of Medicaid financing problems it's about hospital payment I know that is disparities in and Medicaid payments verses a commercial payments in many areas this isn't designed to solve those but it's designed to take a cost category Medicaid that's pretty. Pretty significant and tried to rationalize that payment based on the individuals and the presentation to the to the hospitals but is not designed to solve All Things Medicaid financing okay thank you thank you Mr. Other questions. I think it's important notice that what we're talking about here I think most of us understand is three AM is not a managed care company what we're talking about is the software yes for read reimbursement I think that's something that needs to be very clear because I I. I think that that that can be confusing I mean this state already owns would own the software correct their license for the software already yeah they've they've already got it so what we're just talking about is implemented a program that the DRG is makes up that program up if there's no further questions I don't I hate to put on the spot out here but Jody and treat it is from the Arkansas hospitalization ation is we know if Jody and is one of of a very quiet opinions about things of the would you come forward and just sort of walk us through have a hospital association use the DRG and the positives and negatives I. Read on. Man manual or messing up my stop right and I'm thirty entered on the executive vice president of the Arkansas hospital association and appreciate the opportunity to visit with you today and I think from a higher perspective Arkansas is in a unique position because the Medicaid program itself pays hospitals abysmally low and it's not the Medicaid programs fall it's at the how the state funding works so if you make your hi this same size under DRG methodology what wind up happening is our rural hospitals that don't have the same kind of specialty physicians lose dollars and then you enhance the payments for mostly in your urban hospital systems so if you're past stays the same size the hospital association would have a hard time with the Archies just because we need all boats to rise if the Medicaid program has the opportunity to report to raise all boats to where you don't have the stuff of if you didn't see the paper on Monday you probably missed riles editorial really talking about the financial distress that hospitals are in right now so if you're not careful and you don't add money to this system you really create winners and losers and is in a situation to where you're rural community hospitals lose footing and that is not what you want to happen if you have the opportunity to raise the boats raise the prices for everyone the DRG system in and of itself isn't the threat it's the amount of money going to each of the hospitals were providing care to patients that becomes the most important piece of the puzzle I will remind you all and most of you probably know this the last time there was a rate change on outpatient Medicaid was in nineteen ninety two and it was a decrease. And on in patients which is what the DRG system would be used for now the last time there was a change was in either two thousand and six or two thousand and seven and we got a per diem rate of six seventy five that was increased to eight hundred and fifty dollars. So Medicaid pays for open heart surgery eight hundred fifty dollars a day Medicaid pays for a tonsillectomy eight hundred fifty dollars a day there are some hospitals paid very differently UAMS obviously because it's a graduate medical education you need them paid differently so that you get good quality care and good quality education for the physicians and nurses and allied professionals who are graduating from those institutions obviously Arkansas children's hospital for the same thing when you need specialty physicians and specialty care that's expenses and just because things are expensive doesn't mean there are a lot of margins in it especially in the hospital world critical access hospitals are also paid differently by Medicare which is helpful and why some states did choose to eliminate critical access hospitals from there the R. T. methodology I will tell you that right now in Arkansas it is not just the critical access hospitals who are in major financial distress in fact the small rural hospitals of eighty beds in less are in major trouble so trying to implement a DRG program right now is very scary for hospitals and less of course you're going to infuse the system especially the Medicaid system with massive amounts of dollars that can help reimbursement overall that in addition to the supply costs that hospitals are experiencing that are through the roof pharmaceutical cost that are excessive a higher than ever obviously inflation and then the cost of personnel which frankly a person on our hospitals are what make them so great so we want to be able to continue to provide the right kind of care at the bedside and it is also worth noting for value based purchase a ideas most of our physicians nurses allied professionals dietitians at cetera at the bedside have no idea the pair of the patient value. You is a different schematic that works with systems in place in hospitals to improve everyone's care not based on pay but based on the quality of care we can provide to you to the patients I know that's a lot of information I'm obviously willing to answer any questions as the chairman so politely alluded to I'm not shy about opinions the DRG system in and of itself is not a bad thing necessarily it's the pricing for the hospital care that can be re distributed to make the DRG system not ideal in a state like Arkansas which generally under finds hospitals for taking care of Medicaid patients. Would it be fair to say that the Medicaid expansion Arkansas Works whatever has been the the the lifeboat that our rural hospitals have relied on but now it's sort are called up I know that we have so many surrounding southern states that so many rural hospitals have closed because they did not have a Medicaid expansion but now ten years down the road we've sort of reached another crossroads of of it would that be comment on that. Sir and have you all not created the Arkansas private option that's now morphed into our it was Arkansas Works and now Arkansas home to our rural hospitals would be in even more distressed than they are now and you all know what the global pandemic has done to all health care providers but especially hospitals as the prices for things have exponentially increased when Medicare payments have not Medicaid payments have not and for the most part commercial payers have not increased their reimbursement either so when all of those things happened at once we don't get to set our prices differently and expect to get paid for them we're reimburse what the government and what commercial payers tell us we're going to be reimbursed to do so Senator Ingram you're exactly correct pre pandemic Arkansas was in a lovely position because we had Medicaid expansion and you all did it on and really the back of qualified health plans which really helped to spread the risk across commercial insurance companies who were willing to take on and that expanded population in a way that gave higher reimbursement than those traditional Medicaid rates so you're absolutely correct in that statement. Any questions for. Mr. If not as always thank you so much for enlightening us. UP next up we have of from DHS thank you for testifying of Matthew of Elizabeth Pittman. I don't see Clark here today you're the lone ranger you left. Into the left your when when they're of would you introduce yourself please sure Melissa fitment on the director for the Division of Medical Services. Of Louis with would you maybe give us a little background on what all we've heard here today and sure as much as I can and I will go ahead and carry out with I was also not here the study was commissioned to I'm back and I believe twenty seventeen so I've had to do a little research to get ready for today so bear with me on that but before I do that I do want to let you know what we are currently doing because I think Mr testified as to how long it's been since we've looked at hospital rates I mean it has been awhile so we are currently actually working on a hospital rate study we are working with our vendor I'm it's Amendment Milliman has hired and some policy experts who I think one of them actually helps with this and study back in twenty seventeen so they're coming in and they are looking at a bunch of different payment models including DRG is on a high level so that we can do a comparison of how we're paying and how other states are paying and then we're also doing a state by state comparison who we've chosen ten states I would choose the states we always use for these rate studies which would be region six states but we also looked at other states that are similar to Arkansas population as well as the other states that are paying on a per diem so we're trying to look at a variety so that would include states that are using the A. P. R. and D. R. G. methodology that Mister Ferreira testified about states that are using the other major DRG methodology which would be that Medicare one that he talked about as well as states that are paying on a per diem so we're looking at all of that And looking at hospital cost in those states compared to hospital cost here they're trying to get kind of a full picture of where Arkansas sitting so that we know how we are paying hospitals and what we need to change and so just so you know that's where we are with that we have talked to the hospital association about that and I district here so she can testify as well but when we presented that to them they seem happy with that plan and that approach to act kind of taking a well rounded look at Howard Payne hospitals right now and with the understanding that we are in the middle of a public health emergency and whatever we decide to do if it's an overhaul of how we pay we would def. Really want to go at a relatively slow pace we wouldn't want to change quickly how hospitals are being paid when they're under financial distress and that being said yes the department did commission this report and back in twenty seventeen that Mister Ferreira testified about I think he was pretty accurate in his analysis of that my understanding is that it was decided not to move forward on that because of what I'm district had sad which is there is a an amount of pie that we have in Medicaid right and right now a lot of that through how we currently pay is funded through an what we call access payments with your taxes to the hospitals where we're able to then take that money and draw down more federal dollars and then we also use inter governmental transfers with those hospitals that are because I governmental or UAMS for example I'm into all of that is the planning stage general revenue for us right now and so we if we did move to this model we'd also have to look at how do we take that revenue that's currently been being generated and buy things that are not as G. R. and find other revenue sources and so because of those factors because of the factors that mistrust testified about that pediatric hospitals in rural hospitals seem to be the ones most affected it appears it was decided not to go forward with that twenty seventeen again I was not here so that's just my understanding of what what had happened at that time and I'm happy to take any questions about what we're doing and and happy to take any questions about what happened in twenty seventeen back and find the answers for. Senator Hammer. I know you've had a lot of great reviews going on when you suspect this one to be out yes so by the time line that we've put together as a report draft will be out on the thirty first of October with the final draft and Novembro fourteen so by the end of the year we should be able to finalize its about time going to budget hearings or will be either in the traffic will be in the middle of that are right rusted one side or the other of it so we should be pretty close to the end of March thank you. Other questions. Represent Ladyman you're recognized. Mr maybe you can answer this was but the but at that just get this question the Federal Emergency is still in effect yes so if if that ended I mean I don't with that affect us making a decision now or or would be better not to do something now to wait and see what happens they understand my question are you asking about the money aspects of will to the public health emergency or we we we haven't been able to take people off Medicaid correct because the Federal Emergency and other things that we can't do because it's still in effect so it you know it if that ended would we be but in a better position to evaluate make a better decision I think we will have a few more things and and. I'm getting my crystal ball out here soon bear with me but I'm I do think we would know a little bit more about exactly who would be on the Medicaid rolls without population would look like will also know right now we're getting and hence federal match rate because of that the public health emergency in because we're keeping people on the rolls and that's actually a substantial amount of money that we've been able to to put aside and we would also know exactly a better picture of how quickly that many would would be spent down and and so we would understand our financial situation as well as you know how many people and how many lives we have to cover at the end of the public health emergency a little bit better than I can tell you right now what that's gonna look like. Other questions. If not misstatement thank you so much for of coming before us today. Of is there any other business that should be brought before this committee. If not we stand adjourned.