Public Health, Welfare and Labor- House & Senate

Ladies and gentlemen we're going to start our meeting if you would take your seat. All right the chair sees a quorum. I have just the. A few things to say if you look at your agenda item any. We're going to Mr price's going to hand that some information on item any we ask that you review it and then in August we're going to have someone here to discuss it. And the I think it be very beneficial this is about an update on pharmacist association requests for funding from the American rescue plan it's very important. And he's coming to my you're destiny give you the information. I need a motion to approve the may thirty first and June first a minute's motion to have a second aren't all those in favor say aye. All those against all right motion passes thank you. Now a. Adam D. we have the. The Arkansas Medicaid formula requirements the. With John Benson please come up and we'll get started John and anyone else you want to bring with. In please introduce yourself for the records. Good morning John Vincent CEO the Arkansas pharmacists Education thanks for having us manager Mr there was a committee. Callow Max pharmacist independent pharmacy owner in the northeast Arkansas area. Brandon Cooper pharmacist independent pharmacy owner from Jones for all also served as strategic advisor for the Arkansas pharmacists association all right thank you for being here thank you then send you're recognized to start your topic. Thank you very much members the committee were here today to talk about an issue with pricing for prescription drugs and that are covered through the Arkansas Medicaid program and course they're also three actually four passes as well or the provider led care organizations that follow the same formula airy and cover the same policy on these drugs and over the last twenty years there have been an increasing number of prescription drugs that are required to be brand name to be stocked by pharmacies when there is a let much less expensive generic on the market at least for the purchase price to the pharmacy we want to tell you a little bit more about that you also have a handout I think in front of you that Mr price provided that goes through I believe the some of the specific drugs there many more than what is on this chart in the chart has some green and if it's printing color I'm not sure if it's color black and white but its says Brandon generic at the top and then it has tried web tool oxcarbazepine Lamictal and motor gene and several different strengths of those products and just to be clear there are some other drugs like inhalers for kids flow vent for tickets on which are not on this chart what are some others like some of the medicines for children with attention deficit disorder my concert at and some other products we don't want to go through all of them we just have a few examples of the most recent ones that are causing some issues I do I do want to say like with DHS with working with Medicaid and their staff I know they're going to present a minute we do have a very collaborative working relationship with them we've met about this recently but we've received a lot of phone calls to our office and his the pharmacist that are here with me today about the the challenges of stocking some of these brand name drugs that are. Fifteen hundred dollars or sixteen hundred dollars the stock of all of the hundred and you may only have a prescription for thirty for example so you may be stuck with seventy pills at about a thousand dollars that you can't be reimbursed for and that's why we'll make to intro trileptal OR on the list because they happen to be quantity sizes that are much bigger than a single package. I'm not turned over to you Kyle Lomax from northeast Arkansas who gives more specifics. so that Saturday afternoon my last prescription that I feel was four AM. Brand name concerning a that medication cost around seventeen hundred dollars to purchase and The generic equivalent cost about mmhm about a hundred and seventy so we're talking about a dollar a tablet verses seventeen so for that medication is specifically hard for me to move it Over to another patient because the Medicaid program the most some other pairs only pay for the generic version so for that single patient that medication is going to spur of most likely set there in and go out of date if that patient changes during which is quite common in that particular medication another one that I think that's really race and as low make dole a calendar related cost is about six cents a tablet to purchase that and the brand name cost is about seventeen so you can see that I can purchase a hundred of the generic version and it sat on the shelf and if it happens to go out of date it will be a huge loss but the brand name definitely puts more financial burden the space in a lower volume pharmacy that we we can't move that product to another patient. And just to clarify the reason they have these policies and I know when DHS staff members come up and explain they they negotiate either for a state supported brand or for through your preferred drug list they're able to get rebates from the manufacturers that mean that that the overall you know what they report to us it's proprietary we don't know the details but we just trusting that whenever they the the total amount they pay would end up after rebates being less than what the generic would be if they were by the generic if that makes sense but for the average mom and pop pharmacy even the chain pharmacies we don't ever see any of that rebate and we're not able to purchase at those low prices so our members are having to pay the full amount which in this case with limited which is a medicine used to treat either seizures or for patients that might have mental health issues like bi polar disease we would have to do our members would have to pay the full price in order to stop those or anyone explain what Nate Act is and have anything you want to add to that. Sure I thank what you'll see on your chart instead of actually showing like invoice cost from various pharmacies Medicaid uses night at pricing which is that an actual more true representative of what it costs across the board so you'll see the night at price there is actually posted on a website and you I think I've included that on the hand out as well and for each drug what they do is do surveys fairly regularly announced pharmacies where they be independent chain you know your large big box store so it represents more of the true cost when you average it out across the board so that's actually a more representative costs that we have here's the night at crossing and that's actually what the reimbursement is based on four Arkansas Medicaid so you'll receive the night Act pricing plus the dispensing fee and so you can see there's there's quite a wide variance there if you're receiving the same dispensing fee as well you know whether you're dispensing something that cost thousands of dollars rather than single dollars and so one other issue I wanted to raise was if if all insurance plans were as easy to work with with Medicaid would be in great shape because like John mention we have a really good relationship with those folks were able column we can get a hold of someone to remedy a lot of issues but what I ran into recently with with a child on a Friday afternoon was with one of these medications the trileptal suspension they are actually covered one of this past plans so in other words Medicaid you know the state then contracts with these other entities so you have to deal with another PBM insurance plan instead of Medicaid well it's it's almost impossible to get a hold of someone to help with any issue there so it if it were Medicaid we actually reached out to Medicaid to try to get their their help try to get the generic cover because the child is going to have to do with and we called all over town to try to locate the brand name we could not do that and not try to get on this medication so they would have to go until Monday and it took absolutely all day. Get a hold with the help of Medicaid finally we were able to get a hold of someone at one of these past plans to get that covered for this child so you throw a whole new wrinkle into the equation as well when you're dealing not only with Medicaid within these various pass entities but like John mentioned Three my role working with the association as well I received countless calls from throughout the state from pharmacists who are working there like you know we can understand inhaler or unity of use products for using one thing but when you're dealing with bottles of a hundred tablets in these medications state the doctors will change the strengthening doses around so often enter gonna be stuck with a lot of this thousand dollar the thousand dollar products stuck on your shelf they're simply going to be there unless you know you can find someone else to buy it from you but sometimes that's impossible and in the smaller communities and so I think that's one of the issues they had and I actually received reports from a lot of the pharmacies in the smaller communities where they were like we we just can't afford to do this we would rather just give the product away so in other words they were just giving them the generic product and in that case it helped no one rebate lies because they were giving away so they were not going to stock that brand name and lose you know all the dollars to keeping that in stock and I actually just gave on the tablets to get him through so I think that's that's another area that this presents quite a problem for specially in some of the smaller communities it's also often that the wholesalers just won't have it because there's no other plan that they deliver to that uses these brand name products it would be a rare situation where a patient might have an allergy to something in a generic bill which is not very often but occasionally that happens but will will frequently have wholesaler out of stock so if it does happen on a Friday afternoon and it's not during normal business hours then what do you do you know do you loan them a few the year like you said dispense it for free there's not a good way to reach these call centers to get these prior authorizations approved on nights and weekends so in your business hours. And that's it what else any questions from committee members also mention this is well you know when you're talking about three back dollars which we understand that you know are state employee plans to use that as well state employees their insurance plan and when they use these formulae very committees you know that decide first of all the way that one works is you know they decide which is the most effective product which one are we going to receive the most efficacy from if we use this product and then after all those things or you know all in line then they'll say okay with and if if we farm this off to try to you know get rebates back from the drug companies in which one's more cost effective but I think in this case if you can see from you know sixteen hundred dollars for a hundred of the brand name versus six dollars unless you're receiving a ninety nine percent rebate it's just it's kind of hard for us out and in the world to kind of grass that exactly how that rebate system works in other words Tucker the Jews to be worth the squeeze and I know they're gonna come up and explain but our members don't understand can't you know something cost thirty cents or six dollars how you could possibly get enough back in savings to make it worth it you know like on these most recent examples. Some of the ADHD meds may have been three hundred versus a hundred fifty dollars and so you could see pretty quickly if you had a seventy five percent rebate in my lower the price fifty or a hundred dollars but not limited to it's hard to understand for all right thank you we have a couple questions of representative Bentley. Thank you chairman thank you all for being here so can you just are you bring something for us to do today or is this just make us aware of the situation I'm sorry did I miss something beginning but exactly what you want from this body to do so just to clarify I know senator Wallace had gotten some calls from pharmacist up in northeast Arkansas and did your ask first to bring these for the yeah so I got a call ask him you know to report to the committee on what the issue is we didn't have a specific **** but you want to comment Senator walls. Well we do that welcome I think it needs to be in form of the question so. And then also ladies and gentleman of the committee we're going to have DHS come up next and so you if you have questions for these three gentlemen let's ask them now but if you would. All right and I can answer that represent Bentley if I could Senator so are like our wish would be in our in an ideal world there would not be any brand name medicines that are required when in low cost generic is available we understand there could be fiscal implications for that bill Act none of the other plans to do that so it makes it hard with Medicaid and the second best thing would be to work with the H. S. to make you know point of sale and it's available you know when or though when you do get a prior authorization for them to last longer those are the kind of asked we would have the chance that they could do that but we understand there's fiscal impacts on both sides. I have a quick follow up chairman as a real brief and this really does not have to do what we have what we're talking about today but I think it's very important for our constituents to hear from you after hearing the news and other things that pharmacists are not prescribing of emergency contraceptives or that contraceptives are being hard to find and if you also follow up with that on the legislation that we passed to allow pharmacists to dispense or contraceptives because so much in the news can you ask this gives a brief summary of that Mr I think we're on I think maybe that might be. A. It It is not the Senate but since it's very much in the news right now I think our constituents like to hear from handle that your available at and process this weight into the end and then I'll go back to the okay thank you all right of. Senator Wallace you're recognized for a question. Thank you manager. Do we know What's being done in the states around this Missouri Tennessee. In terms of what other state so Sir I don't I can't answer on specific states around us when prepared for that but I do know I do know it's common around the country for state Medicaid programs to require brand name drugs when their generics available if there are significant discounts or rebates that the state can get I know there have been there's. Debates about whether that's good policy or not and how that affects a patients bill ability to access the medicine depending on what drug it is and yet and so it's always a constant battle in figuring out what makes sense financially when it doesn't disrupt access follow up and yes so if you have one ask date one you're if you had one shot at getting something fixed on this what would be your your top party I think that if there if it's a. A bottle of you know like words not a single use product it would be ideal E. not required so if you have to like from a flow of an inhaler words a single unit of use any stock a single inhaler and then you dispense it and there's none there's not a thousand dollars of drug that you can't use left on the shelf that would be a good place to start and then. Obviously I can mention a minute ago and easier way to get a prior authorization approved when a manufacturer when the products not available so you don't have to turn away the patient without medicine. Thank you Sir. All right of. Representative class. Thank you madam chair. Excuse me John you mentioned that there were the rare possibility of an allergy you know with the generic or whatever could could just kind of give us a primer and educate us on the chemical composition of a brand purses a generic sure go head count so the FDA there's a book called Orange Book and in that they'll have the Brandon and the genetic equivalent so my of earlier I talked about considered a early on after that product came off Patton there were a few generics that were not therapeutically equivalent as you get on later into life the twenty eighteen you start seeing generic A. B. what is therapeutically equivalent brand artifacts come on the market multi source and you start seeing the price come down because you have multiple manufacturers manufacturing a genetically equivalent product in that system and most of the cases on where there's a brand on the generic formally having brand formally for Arkansas Medicaid its multi source and what we're seeing in the market is we're saying a deflation and prices for generics but at the same time we're saying in inflation and brand name prices which is market driven and but you know in smaller town pharmacies which I'm a part of a you know if you that one of those drugs is branded could represent anywhere from two to five percent of your total inventory in one setting and and for one patient and that's a it can be a struggle in this when it's then margin so um Orange Book and that's therapeutically equivalent. Thank you didn't mention that you know that's not directly. You know I'm access the patient but the more brand names of pharmacy has to stock the less they're able to purchase from their wholesalers like in other words the wholesalers what you do use generics the state employee program once the use generics and most employer in insurance plans what you used in there so the more generic she by the bigger discounts and better you can purchase your drugs the more brands you have to stock and by the west of the discount the wholesalers will give our pharmacies on by making those purchases because it's expensive for the wholesalers to purchase and stock and deliver these brand name drugs as well especially when ninety nine percent of the market is generics for oracle nickel for example. So it hurts my help the state but it hurts the rest the supply chain when trying to say and I think that's why they're sometimes out of it and don't have it because it's expensive for them follow up yes. So what I'd like to drill down to is the actual chemical composition the the brand verses the generic so in some cases the branded generics have exactly the same chemical composition meaning the same like even the the brand name manufacturer will actually manufacture the generic version to market separately if it's a different company and not the same company in some cases it may be exactly the same chemical composition in some cases there may be something in the bind that binds the bill together that might be a different ingredient than what the brand name has in it And so if that bonding agent in the in the chemical somebody's allergic to that for example they might have a reaction to that bill where the brand name doesn't have that binding agent but the active ingredient that actually causes the therapeutic effect is exactly the same between brand and generic in terms of absorption there could be slight differences but it's. Very small negligent considered negligible in terms of therapeutic effect and how fast it might be absorbing that kind of goes back to what did they use to bind it together and how fast is it dissolved in the stomach if that makes sense but the active ingredients exactly the same between a brand engineer thank you thank you all right of representative peer. Thank you madam chair of is there a difference between the name brand and generic for the shelf life. As far as expert expiration date. I think that said manufacturing levels. Manufacture sets that based on the date it was manufactured so. Most of ours we see about eighteen months to two years shelf life on on most of products but there shouldn't be. There should be that much difference as far as the between the brand and generic manufacturers decide to okay all right thank you all right of representative Payton. Thank you madam chair so based on the work of this body a couple years ago regarding the insulin rebates and and how these rebate programs work the Arkansas Attorney General has entered suit under the Arkansas unfair trade practices act and it seems that these rebates also would violate antitrust laws and border on collusion of it's quite possible that in the coming months we'll see a resolution in that case do you see any of these. A very similar situation sounds like to me use do you see any need that they should be include these companies and and these products should be included in that litigation. Thanks for the question represent Payton I do I am aware of that lawsuit and I know the Federal Trade Commission is also looking at this right now and threatening legal action in terms of the private market you know in terms of the private PBMs in the private industry I have not heard that they've looked into it with Medicaid yet and I know you asked do I think they should I'd like to. But I'd love to hear their presentation on how this works and and why they pursue these in other up next and and the so I guess my real question is Arkansas. Code which I can't quote this chapter verse of actually addresses rebates as an unfair trade practice when they're on Arnd rebates. And the idea is that the manufacturer and the middle man Wetherby PBMs or whoever use rebates to capture market and fix prices in a way that becomes an unfair unfair trade practice I hate to find out that DHS or Medicare Medicaid the state Arkansas is participating in a rebate scheme. That borders on unfair trade practices. Which seems to be affecting our suppliers at the retail level so if if any of this seems very similar to what has been happening in the insulin market I'd like to get a list of those the complete list of those drugs in manufactures but I'd hate to think that Medicare and Medicaid in Arkansas DHS will be participating in unfair trade practices thank you thanks. All right a representative when you're recognized for a question. Thank you madam chair I wanted to go back to the generics is their own a list where the consumer can see which generics are identical and if there are differences between the generics and the name brand what those differences may be just for each individual drugs so that they can now because that can be quite concise confusing for a lot of the consumers. FDA purchase of Publicis online resource call the Orange Book and that's where all the professional pharmacist and look and and see where the equivalency ratings are it's it's online and you can access at any time okay so that any consumer can go look at the Orange Book and that'll tell exactly here's the name drug and here's the generic this is identical or it might be different but it might be like I said the binding agent or whatever right there's a yeah I think it's when you do the search it'll tell you the manufacture and if it's a B. rated which they would say consider therapeutically equivalent okay great thank you very much. All right of we're going to have will let represented Bentley ask questions that you wanted to ask about the birth control okay women all right of this let me go to chairman Ladyman and then we'll go back to a representative Bentley you're recognized. Okay questions about the process and maybe the ages when they come up this might be for them but but I'd like to get your opinion soul. Who makes the decision that we have to use the brand name I think somebody mentioned the Committee awhile ago I mean that's that's Medicaid I understand but who does that is that state by state. Do you understand my question. I do understand the question and I would defer to DHS because they'll be able to explain exactly how that works okay and it does it does very state to state yes but they'll be able to answer better. Okay. Follow up for me. Of on the rebates So unless the pharmacist here you don't see anything about the rebate how do you know. The cost of this I mean the you paid for this drug when you get it or as at work what our pharmacies notice what the wholesalers charge the pharmacies so they see that on their invoice they can see it in their ordering system what it's going to cost and then they pay whatever that process that the hosts seller offers they can work to secondary wholesalers and other wholesalers to try to find a better price and they often do you to always try to get the best price in the better price they purchase at the lower that an eight ACT value is because it's a reflection of the true average purchase price approximately all the pharmacies averaged out done by national accounting firm but the rebate side and whether or not they get a fifty percent or seventy five percent or ninety nine percent and whether or not it's better for the state or not none of that is visible to us we just trusting that that's really the best thing for the state financial aid because that you know it's the decision by making there's very smart people set out in the audience they're gonna come up president mental but it it's not true you know it's not clear or transparent to us or to the consumer that that really is a cost savings for the state. So when you order the mental you pay sixteen hundred twenty dollars. That at like I mentioned before the nasdaq is kind of an island pharmacies may be paying a little more than that some might pay Hey that the dollars yes we pay that when we purchased the bottle yes so does the rebate come back to you then. Now if you're speaking of the Medicaid rebates and that goes back. So for example one will make door hundred milligrams I'm just picking on our spot of a hundred if if the pharmacy really pays one thousand six hundred twenty dollars and fifty third or thirty fifty one cents little less or a little more within five dollars either side and then they might dispenser thirty count or sixty count so they're not even dispensing the full amount and then they may be reimbursed and I'm just pulling on a number to be easy here thousand dollars plus a ten dollar dispensing fee so are they really are reimbursed. The close to what they paid for it plus the dispensing fee for Medicaid but then they may have another five hundred dollars sitting there that never gets used if that patients those changes or there's no other patient on. If they happen to have a lot of patience on it it's not as big a deal as it moves and it turns over but still you're having to purchase a brand name drug costs thousands you know sixteen hundred dollars versus ten dollars the stock it so. I just wanna make sure that the issue here is just the eminent or the cost that you Kerry and then if you have to dispose of that because it's outdated correct then that's the cost of your bottom line is that correct so I mean this is a big problem I have two pharmacists in my district who told me they give out the generic free. And that's less cost to the. So I mean it it's a big issue. Thank you for all right there are no other questions of but the representative Bentley if you would like to ask you questions now about the thank you chairman is because it's been in the news so much because of recent rulings from wrote on roe versus Wade and heard that some pharmacists are not dispensing contraceptives of emergency contraceptives are and have can you just spell that are for her that it all just because of the news and the other thing is if you're update where we are on the legislation we passed to allow you guys to dispense contraceptives update those things quickly for our constituents I appreciate. The emergency contraception or plan B. which is hormonal contraception over the counter and it there's several plan B. as one brand name there's several like ten or eleven other generic names for that but it's leave owner jester L.. initially the media incorrectly put out statements I want to name who it is but I mean there was misinformation in both Missouri and Arkansas on whether or not that was legal in fact the media said it was illegal it is our understanding that it is not illegal because it's contraception in the state law that was passed in twenty nineteen allows an exception for contraception so we're we are educating our members that it is legal in the state of course talk to your own attorney but our understanding is that it's legal I know that the state has been working on some language around that is to share with the status Medical Society and farms Association some others I have not seen anything yet that we can distribute but we'd love to have an official position on from the state it has been in some cases temporarily out of stock from wholesalers but that's been not very often are you able to are you hearing about anything Northeast Arkansas that people are able to get it I've not had any body say there's been a supply chain issue an opera that's been rare but I have heard a couple of times for that was an issue but my understanding is our members are providing and or or its available out in community pharmacies. All right question. All right ladies and gentleman we are going on with the. This is the second part of the program Mr white and Elizabeth Pittman if you would come to the table please. Once. Please recognize yourself. Thank manager more quite warm Human Services Elizabeth and Division of Medical Services you're recognized. Let me again. I'm I don't wanna repeat what Mr Benson and that their gentleman said they they were very accurate and they were correct we do have a very good working relationship with them we have actually spoke on this issue several times and it just give you a brief overview of the process and to your question representative Ladyman and we do have a drug review committee that establishes R. ET AL are preferred drug list is made up of state pharmacists and physicians does have a DHS representative on it as well where there I'm in our Magellan contractor is there as well but these pharmacists and physicians actually review each class of medication and this Lamictal is in what we call the anti convulsant class which I am not a pharmacist or doctor so I won't get too detailed on that and but they review that class for and they look at the drugs for efficacy the clinical appropriateness of the drugs and make recommendations to last and said they don't just use one drug in a class that use multiple if that's appropriate and they make those recommendations to us and then we as authors and we then look at prices that the DRC Drug review committee does not look at price and all that first level of review is not considering that that's really considering clinical efficacy because of the proprietary rules by the federal government we can't really share any of the actual pricing information with that T. R. C. so they don't get the rebate offers or anything like that that's something that we look at internally and we do not generally overturn their recommendations but if their recommendation is to choose the drugs within the class based on what's most cost cost effective for the state then that's what we do and so that's sort of how the process works it's a very brief overview if you have more detailed questions that you have someone here from the pharmacy program he can help answer those and. Could you pull your microphone is sure I'm sorry I have a very softly just tell me to speak up and so that's how the overview of the process works in this particular instance we do receive I have a fairly significant federal rebate and I'm Mr Vincent's plan that very well so the the pharmacist buys it at their **** so cost and we reimburse them at that average or nat Act costs that and they went through we don't we claim the federal rebate every quarter when we report to CMS what are drugs and you expenditures where and they give us that money back so that's how this state realizes that sex is that it's a return from the federal government based on those rebate agreements that we insurance you on a quarterly basis and it goes back into the Medicaid caps so that's how the rebate process works so and they also went through that there's several different types of rebates but once you factor in all of those rebates if we actually used the name brands of this class in every case which I'll go through how we don't actually require that here in a minute but we would actually look at just for this class about a million dollars in savings here so that's what the federal rebate is getting us. Now that being said we do realize that there are some reasons that you don't want to use that name brands clinically there can be some clinical reasons I'm like they describe that some allergies may exist or some other factors but there can also be Sam I'm stalking issue some market issues and we if you can't find the truck or if it's very unrealistic to stock it on your shelves we do allow for a pharmacist to call and get a prior authorization. Generally that process is pretty easy and we have a voice response system is it is only open Monday through Friday eight to four thirty but we usually can. Issue a prior authorization within a couple of minutes if you have any problems with that during that time and you have any issues getting that we ask that you ask you escalate that to our program because that is actually run through Magellan Arvinder that's who runs the call center so for any reason you have any issues with Magellan in the prior authorization process please escalate that to my staff and they can help work without. We are looking at right now we do refills on it the every thirty day basis so prior authorization every thirty days we are looking at whether or not that's realistic in this case and and we do allow for some longer prior authorizations happy to talk to Mr Vincent about how to work that out you can even go up to a year I mean I just spoke with missing awful about that so I did get that confirmed. Please and how pharmacists are having problems reach out to us so that we can work with them through that process and so that way we can take into consideration low volume pharmacies like a lot of independent pharmacies that are here testifying today maybe do not have a lot of clients use Lamictal so they cant a stock a hundred dollars Hendren pill bottle and they may only prescribe thirty or sixty and so they they end up throwing some away that's not appropriate and we do want to offer those pharmacist PA's versus your chain pharmacies a Walmart your targets where they can they can stock and supply that and name brand and we can realize that savings so we do want to work with the independent pharmacy so that they're able to get those prior authorizations I miss new awful I think was working with Mr Bentsen on helping issue a statement on this issue to all of his members so that they understand our process and how to take advantage of it and how to escalated if having problems. I'm happy to take any questions the minister of August at one additional piece of just be very clear although we as a state we do have authority to pursue agreements may factors around rebates most the re measurement she by the federal government in fact that's what typically triggers Medicaid coverage of the drug is when CMS to go she adds that rebate with that manufacture and they make that available to the state's social be clear about that this is a very an area where it's very. The federal government very heavily involved and we receive the benefit of of that but also sometimes the headaches manage well all right go ahead well I'm just gonna say to add to that if we do have a state preferred brands and we do have to report that to CMS so if we enter into our own rebate we report that to CMS as well and that's required. Terminaling so just to be clear I think what I heard you say. In layman's terms here up so. This Lamictal situation. So a druggist or pharmacist can actually request to use the generic and you all can improve that on an individual basis yes Sir. Okay. One of the questions when you talk about the rebates. These are not approved individually but they're approved by groups said the rebate is entered into with the manufacturer of the drug so we enter into an. I can't think of the name of the drug manufacturer but the maker of Lamictal is you are entering into that rebate and. And they're the one and then we claim that rebate the federal government enters into some of what I'm talking about is the process that you talked about would you get approval to use the generic or the name brand yes Sir that's not on individual drug basis in other words your rebate is based on the volume of drugs that are closed in the family or whatever I think I understand so if I don't please let me know second clarifies that we look at a class of drugs when we're deciding what to be paid on the PDL and what not to do so for example ADHD and the medication that is used to treat ADHD and in for that example specifically their short acting and long acting in our physician representative was very adamant that we had to have a long acting agent on or PDL so we have both short acting and long acting agents regardless of price right we had to have both of those on even if one's cheaper than the other so we choose based on that what types of drugs to put on or PDL if if everything's equivalent within that class of drugs then we look at how much rebate or how much money it's going to cost the state to use which struck. M. and that is done on a drug by drug basis not but when we look at what to cover its time as a group okay. Thank you. A representative Payton you're recognized for a question. Thank you madam chair. So when you submit a budget. Word of these rebates where's this income show up in your budget I mean does it come in Under unexpected nonregulated or do you projected in your budget because I don't remember ever seeing that line in the budget it's not a separate line in the budget we do projected when we do our pharmacy projections we do consider I'm so we know how much money we're gonna have to pay out we do consider in our total budget how much money we're going to get back in rebates so I guess from what kind oversight is on what's coming in what's expected whether or not we get what we expect and then what oversight on this I mean when you spend that money is it under the normal appropriation process yes Sir it is I'm in CMS governs our rebate agreements and and all of that pretty pretty tightly as Mister white explained. Okay if I have a follow Madam. I guess. How do you how do you find out how your rebate percentages comparative to say insurance companies because I know in the insulin thing that I became very familiar with you know Walmart was able to negotiate an eighty five percent rebate and our state plans were only getting sixty percent so how do you know if you're if you're doing a good job on the go she those rebates. So I don't know much about the insulin lawsuit because we're not covered by the insurance regulations or actually not a part of that lawsuit so I can't speak to that very well I am I do know missing hopeful was telling me while we were in the audience that we we get some insulin products for basically no no money so we're paying nothing sweet fairly significant rebates on insulin products I think we're doing fairly well comparatively I don't know exactly and we may be able to find out but I can't tell you right now I would imagine that a person Payton. We we made a lot of visibility into what rebates being paid to the insurance companies since the these rebates on the Medicaid side or primarily to go she added at the federal level but with that said we did do a rule change that came through all few months back it does allow us to partner with other states so if one of the state's finds out that there is an opportunity to their pursuit then we can go as a group of states and get better value okay thank you madam chair. Thank you senator Wallace you're recognized for a question. Thank you madam chair. Misstatement first of all thank you you always been into my talk or work with you been great to work with so thank you for that recognized for that. Now I'm looking exhibit D. and if. I understand what you're saying. Is on every drug in on the sheet that if. Our pharmacist would call for a prior authorization then we can use a generic yes Sir okay manager if I could I'd like to get the perhaps Mr jin Bentsen two comment on that and and I want to hear their their comments on how difficult that is from the user's point of view. All right Mister Vincent if you'd come back to the table please. And then I have a follow up after that all right thank you S. a please identify yourself again for the record John Vincent CEO of the Arkansas pharmacists association thank recognized thank you madam chair The ticket the prior authorizations if it is with Medicaid and through Magellan and during business hours it's pretty easy to do especially if they're allowing more than the thirty day and you're allowed to you know six months a year it is still pretty difficult right now with the passes you know the four passes it's more difficult because they they all have their own PBM in their own process it's more challenging something went to work on with the passes to make it more streamlined. But if it's on a weekend or after hours and it's very difficult if there's not a point of sale over Rider ability you know in place then it's difficult after hours it is sitting at your question of senator well it did branch of another one for me all right go ahead so it sounds like our Issue is not so much with Medicaid this is with the past program. It's a little bit of both I mean it's during business hours with the passes there's an issue and certainly. After hours it is hard like in the example bring and share with trileptal where the brand name seizure medicines not available from the manufacturer it's a Friday afternoon do you know do you on good faith dispense it for free because that patient certainly doesn't have a hundred dollars out of pocket to spend they just don't and so that you know without having to a point of sale over rider some ability to do that at six o'clock on Friday or eight o'clock in the morning on a Saturday and it's not easy with Medicaid either just to be clear it's better with Medicaid but in certain instances it's difficult especially after hours. In manager I'm I'm just wanna there's anybody here from in the past programs that could recess. I don't see anyone but we will be needing in August on August the eighth at ten o'clock and that we could have maybe someone I would appreciate it all right and it did provide us some great email addresses and phone numbers and I a way to hopefully streamline that that we didn't have before that's going to help improve on that from DHS if the new awful director pharmacy so we're continue to work on it Senator. Thank you Sir thank you all right thank you. All right the representative Bentley. Thank you chairman just real quickly can you just give an average of what you get monthly and rebates on CMS and. We we claim rebates quarterly and I don't have that number of an act we can we can get you an average. Thank. For. All right ladies and gentleman I see no other questions we thank you for being here and for the discussion and again we will be discussing item any in our next public health meeting. All right we're going to add an elf in of Mister price has a hand down in marketing of Mr white and misstatement sitting where they are. Delay your leaving. Thank you madam chair again more quite a DHS we've got a a handout has more information for you but will give just a brief walkthrough and we're us talk about the status of reviews for psychiatric psychiatric residential treatment facilities or P. RTS was just a little background which I'm sure that most all of you know we've been engaged in the process of last couple years of reviewing all Medicaid provider rates that's in the governor direct budget to order back in twenty nineteen since then we've been working through so that each for each for the ninety five provider tops we look at their rates if it needs to be met updated it and make corresponding updates for those rates we're in the last round of getting everything finalized we tend to have all those reviews completed through the end of this year we've been looking at all of the behavioral health entities tried look them together so that we come up for the race that are consistent across that paper all system and so would working through that I'll let a misstatement talking more detail about what we are on the RTS I specifically thank you I'm so we actually had our first kick off work group with all providers stakeholders last Wednesday June twenty nine eight I we presented at a lot of the sites that you have here today to that work group and within that slide deck you see the timeline for completing that so we are working with a vendor and milling and he was actuary and they've brought in some experts in the behavioral health and space to help us with this and we are working with stakeholder groups so we're looking at each of those provider types that Mister white just went three for behavioral health services being actively involved for P. RTS this means all thirteen purity athletes thirteen will will be involved so each one of those And Pierre TF providers will be involved in this we will conduct all the stakeholder waiver webinars and three the next month's. Through July twenty twenty two like I said we kicked off last week and will complete those groups this next month we've gotten cost surveys that we had sent out previously we group those together we're going to look through those and and then we'll work to develop the comparison rate sections and draft rates through the month of September and then in October and November will work without stakeholder grant group again to finalize that draft report and recommendations. So that is the process that we're going through and happy to answer any questions all right thank you any questions from the committee all right to a representative for a Bentley. Thank you thank you chairman I can look at making making this retroactive to the beginning of the fiscal year census come take a little while sounds like here for this rate review. We can look at Roger active options and based on what the rate is so we'll need to see what actuaries say about it we have some options I don't know if all the way back to the fiscal year will be possible based on what they provide and based on what CMS will allow there's also some requirements around notice you have to give the notice prior to the date that the rates effective in most mechanisms was the last so we may have some limitations there but we can definitely look at what options are available to retract that are appropriate for retroactive rates if I was that we we have a couple situations in the past for we have gone back farther we've been able to use some flexibility is that CMS made available for and as a result the pandemic those are starting to come to a close that is narrowing our options for retroactive payments by the just as I was having some other instances will be clear that that's that's not who we may not have going forward and to follow up on that when we have done that we've had some form I've actuarial study saying it's appropriate to resume that ring back for example the therapeutic community ones with we just add that the actuaries have actually sent back in October of last year that was appropriate so we were able to carry it that far CMS does actually look at the appropriateness of the rate that you're that you're asking for as well as what they allow so we will look at pieces but if if retroactivity is appropriate we will pursue that. Someone just real brief follow up chairman yes I do we have a we have to have a number that you're looking at all right now as far as increase just real brief if you're looking at a number at this point do we have anything we don't have a specific number in mind we are looking at a per diem and and I believe that's assuming your slide deck and continuing to pay on a per diem basis so we're looking at the cost and we're also looking at something called comparison rates which are often used in managed care programs because the security of services are primarily past services the comparison rates allow for quality and effectiveness of the service as well It acuity of the member to be considered inciting as rates by the managed care entity so basically met Medicaid comes in and says this is that a good negotiating starting point for the rate and the passes can you stop from there okay thank you chairmanship. All right of Senator Solomon you're recognized for a question thank you madam chair yeah we're this awhile back we're gonna take something into consideration in response to people so when we talk about being your retroactive payments I'm not real comfortable with all we're gonna take it into consideration you think it's deserved or not this or. I mean act. I want to say whether it's deserved or not deserved will look at all of the information provided another yeah we're gonna take into consideration is what I'm hearing you say I think you know the cost of these folks with their they're upset they're they're paying these costs right now and I thank you for being my consideration that they deserve some sort of reconsideration for those past current service so that your opinion is my opinion it sounds from the. The time line that you gave by these monthly updates would be appropriate to say by our meeting in December that you'll have finalized this and if not why not. If not we've gotten of the timeline because that is the plan is to have a final report by December okay so you'll meet as frequently as you need me yes in order to to hammer this out by December our December meeting okay thank you madam chair thank you thank you any other questions from the committee all right seeing none thank you so much thank you all right ladies and gentleman going down the intended to identity of Michael McAllister and Daniel Pilkington would you please come to the table. And if you would introduce yourselves for the record. Good morning I'm Michael McAllister I'm the managing attorney at the department of energy and environment. Good morning my name is Daniel Pilkington attorney at the Arkansas department of energy environment division of environmental quality thank you you're recognized thank you we're here this morning for review of a pollution control and ecology Commission rule twenty seven this is an update to that rule it has been through the rule making process with the commission they initiated the rulemaking and went public notice and comment This rule is to this changes to update the rule to reflect some changes from previous legislative sessions about the authority of environmental officers and also for waste water operator licensing issues and that's been through the process and will go after review here to A. L. C. before the end of the month for final approval and we're here for that review. Just to clarify the changes were for the environment officer program in the solid waste licensing changes all right Sir wastewater. Sorry I misspoke and solid waste licensed operator all right a representative payee you're recognized for a question thank you madam chair so it seems that the environmental officers being give them. Policing authorities to issue citations how much of that authority to they already have. To issue citations or or does this include entering premises and. Investigation what is. Previously before the changes that were made that are addressed here they had authority to cite people for violations of environmental laws that was very specifically defined this change actually addresses an expansion of what they can cite people for from a compliance standpoint it includes things like open burning in things that were not previously in the definition so they have expanded role in what they can do from an enforcement standpoint however they have not been given any rights or authorities to go beyond what they can do as an officer they're not an actual law enforcement officers are not allowed to carry a firearm they're allowed to do certain things through a warrant process that we have but they're not really expanded upon that further. So if I may what all. Is the comes under the definition of open burning. The most the time the reason why the program was originally created was to deal with open dumps for instance if you see a big pile of solid waste that is illegally disposed what they're supposed to do is to try to make sure that the citation course that process that those illegal dumps a remediated and cleaned up. Okay. All of go back and ask you if I get another question thank you madam chair thank you. I talked a representative Dotson. Thank you madam chair so where these rules results of the the act that were passed to require the expansion of their citation authority. Yes part of the changes dealt with the expansion of the environment officers authority to issue citations yes and that was part of the legislation is passed that's correct yes thank you. Any other questions. All right seeing none without objection this rule stands its review thank you for being here. Ladies and gentleman going on. We have a item H. in will have Mister white and Melissa whether. That will have you back a. If you would identify yourself for the record again and this will continue as well please thank you. Thank measure more quite warm Human Services. Hi good morning Melissa whether ten director for development disabilities services you're recognized thank you. So today I'm an. Here to explain what we're trying to do on transportation for our adult day treatment facilities and are and early intervention day treatment facilities we have two types of transportation that run children and adults to and from these clinics every day thank M. providers can choose whether or not to use contracts we have in place with brokers or they can own and operate their own fans and be reimbursed for and for that and transportation costs to them. For many many years for as long as I've been in this position the transportation if you owned an operator owned vehicles was based on a methodology called loaded mile which meant when someone loaded the van the very first person to get on we consider the van to be loaded and at that point no matter how many miles you drove or how many people you picked up you were paid based on that loaded person and so in nineteen and twenty nineteen they were paid a dollar eighty a loaded a mile and we would then immediately adjusted up to two dollars and nine cents back at that time in an effort to give them some financial relief but we wanted to go forward with a more and comprehensive rate review which we have now done and we are and changing the methodology in which they are paid to more closely resemble the other ways we pay transportation which is on a per person per mile basis that's what the contracts for the brokers are paid for doing this service to and from these clinics so we want to mimic that so we are here today we had to change the methodology in the State Plant pages and then we also had to change the and the language in the manuals for these types of clinics and it is a substantial increases you'll see bait changing it from a loaded mile to a per person per mile and it's about a seventy five percent increase to their transportation cost and the providers we've had and conversations with their extremely satisfied and feel like that they are now able to not lose money on their transportation when they take their children bills to and from these clinics I think some of them are here today in support in addition to that we did go in and make several just I'm grammatical and add it simply. Applications while we had the manuals open and so those were also and in this package that was brought and before you today and I'm happy to answer any questions or any questions from the committee. All right seeing none without objection we will. Thank you. The stand this rule stands as of the. All right next we have a. I we have but not only Mr white we have a misstatement again. Just identify yourself for the record then we will let you get started Elizabeth and Division of Medical Services okay at we're here today to present the role at dates to the cost reporting manual for skilled nursing facilities and as you can see from the summary quite a few changes were made a lot of those are clarifying changes and we worked with the and Arkansas health care alliance I believe at that group to and do these changes and if you can tell from the comments they are all they're in agreement with them we are also about to start a second round and to go through some other things that they did not feel were as crucial to get done within this time frame that are important and so we'll be working on and around to some of the major changes that we did agree on with that association and implements for an August first start date and include a change to how we do the permit values so we now have three definitions of the types of residence rooms and we've increased the provide value to incentivize and private or semi private rooms if you have the old community style room the permit value did not increase and so we are trying to incentivize really have private and semi private rooms in light of the pandemic and the health concerns that were raised by that we change the filing timelines and extended it out so that facilities have longer to file their cost reports at the end of every year. We changed from re basing every three years to re basing annually at we also adjusted the minor equipment at maximum allowed it had been five hundred for twenty years and we've taken not to twenty five hundred and we're going to look at that and see if it needs to increase further over the next year. We have decreased the minimum occupancy rate was was actually something we did I believe through. We had done it earlier through an arpa proposal or cure I can't remember I'm but we have done it earlier we're putting that in place permanently at sixty five percent with an increase every five every year by five percent until we get back up to seventy five it was in the eighties before so this is an overall drop but we do want to get it back up to where it needs to be but we realize that due to pandemic there have been some market issues and we adjusted that down. And with C. we've also to. Allow them to including medication assisted salaries as direct care workers so these are some of the major changes that we've done it within that manual as you can tell there's quite a few other things to make sure those things were effectuated and to clarify some of the older language and happy to answer any questions all right ladies and gentleman do you have any questions. So a lot of these were due to things that were not during the pandemic like dropping the representative occupancy and some of those place yes Sir a lot of these a lot of these were done because we just have not updated as cost manual in twenty years and it really needed to be updated to align with current market practices some of them were to reflect things we did learn during the pandemic so the minimum occupancy for example nursing homes have just not had as many residents coming in and have not been able to meet those minimum minimum occupancy thresholds so we wanted to drop out for the pandemic but we all realize that it needed to come back up so we're going to gradually raise it back I'm asking. Thank you for representative Bentley you're recognized for a question. Thank you chairman just on equipment line we're going from three hundred to twenty five hundred dollars so we can do another review on that I know some of my constituents have a tough time in the twenty five hundred to pay for option agreement and various other things so when we expect to look at that again I know you said we're starting that. Now I think it's already started the second round of look and in I believe medical care goes up to five thousand but we really couldn't get a good estimate of what that would look like for providers just because of how this works so we all agreed to meet at twenty five hundred for a short period of time kind of see how that played out and then we're going to look at whether or not that is actually an off okay in one of the following week share this I had a a constituent coming this week whose it was entered at twenty eight was in the nursing home and that was quite a few years ago was receiving forty dollars a month after all that you know their Medicaid takes all their money to pay for the for the bed in a nursing home and so that was twenty years ago they were getting forty dollars a month to have expenses whatever they wanna get their hair done whatever the forty so now it's still twenty years later still forty dollars a month so as we look at for them was I know you know just to get a haircut twenty years ago so the more expensive now than it was then so and I don't and I don't know how the funding works on that so right let's take this opportunity to ask if that's okay I will also go back and double check that my memory is that it's that personal allowance amount is set by federal law but I will all confirm that election of sure if there is an option there for us with that okay thank you thank you chairman for the lenient separation. All right any other questions seeing none without objection this will stances repeat thank you very much thank you alright ladies and gentleman going on down to J. we have met Gilmore and Charles Carter if you come to the table please. Do we need to teach yourself for the record. Thank you madam chair Matt Gilmour Mr couldn't be here today all right you are recognized thank you committee these are the rules for the board of examiners and speech language pathology and audiology most of the changes are due to legislation there was changes around ACT seven twenty five and twenty twenty one regarding the fee waivers for eligible individuals there was changes around ACT one thirty five regarding the new education requirements there was also acts seven forty eight and eight twenty nine to telemedicine some changes were made there also made some changes around the assistance and some flexibility for them as far as their licensure process but I have to take any questions we had we got some comments we address those we have a question that I can all right committee do you have any questions. All right seeing none without objection this rule stances Review thank you. All right K.. We have holiday in Chuck Thompson. Good morning members man chair Charles Thompson Arkansas department of health Mr Gilmore's up here assisting we can I miss day if we go into substantive matters in and to the health safety issues but really what you all have before you is really a two issues when it comes to and effectuated the intent of the legislature. And if so if you have before you is the update to the rules regarding home health these Promulgation was done pursuant to comply for compliance with ACT seven six one ACT eight seventeen ACT seven six one as we reviewed it does actually I'm so and I apologize that was some old reference because we as we reviewed ax ax seven six one we actually already comply with that with home health all whom health agency individuals that are have direct care workers are are have background checks that we do need to do actually any substantive changes or any changes at all to to the to the rules the other role the US regarding ACT eight seventeen which we had quite a bit and put in public comment on ACT eight seventeen Regards the expansion of home health agencies when they already have a permit approval and so as we went through the public comment period and looked at the act it got everybody's input and also reviewed the the videos of presentation to committee as well as presentation on the floor of both chambers the department of health determine that we believe the intent of ACT eight seventeen is to allow those that already have a permit of approval home health agencies to expand without further permit approvals necessary as long as they have a a office within one hundred miles of of the service area so this means that if you have a a principal or a branch office and then you put another one hundred miles from that you could still go ahead and provide services and expand expand your service area that way I would be happy to take any questions you have the public comment report and before you and I would be happy discuss anything you have questions on. All right thank you so much of members do you have any questions. All right seeing none without objection this rule stances with the. All right next we have J. and I'll call on the day Kerr Gardner in Chet Thompson if you would just stay. Thank you madam chair and I'll if with your permission I'll call curtain call up is necessary there's not really this is the rules update regarding hospice the only changes are one well only the changes are to get them and uniformity with the rules for hospitals and rules for critical access hospitals first to regulate this control used to be that everybody had up to preclude the status employees you don't have to have that anymore when it comes to hospitals critical access hospitals reside in hospice to that list the last ones to not require you don't not required to have the regulars is that's just make sure that you have a policy to ensure that your tuberculosis control or any any regular says policies are accordance with CDC guidelines the other is adding the language regarding ACT three eleven which is no patient with the lone Act this is to ensure that the language in here coincides with what was already in the rules regarding hospitals in the rules regarding critical access hospitals Zacks three eleven the exact language from what was passed by this body by let's by the General Assembly and added into the rules this was already added into it like I said to hospitals ians glass access hospitals which you all have already reviewed last last committee last committee meeting we have to take any questions. All right any questions from the committee. Seeing none without objection this will stances with the. Going on down. Add an EM. A Kelly Kersee. And Mr Thompson again thank you madam journal column is curse if we need to get into the specifics of massage therapy technique you're recognized thank you ma'am this is an update to size therapy rules this is done in compliance all of these are done in compliance with Act of the General Assembly for twenty twenty one this includes the majority are occupational licensure items such as fee waiver Senator Gilmore city waiver acts one thirty five I'm also updating automatic like Senator language for uniformed servicemembers pursuant the the applicable acts and also the earn and learn act now the only learn act was the one where we receive the most the most comments on and it was we have some robust discussions in public comment excuse me or me. As well as the massage therapy technical monitoring committee meetings as we review that and we have and because of that we've gone had added some ad hoc committees to further explore the issues that were brought up in public comment however we are moving forward with the rules themselves so to ensure that we can effectuate and implement the acts that were passed by the General Assembly when it comes to earn and learn the question the main question was your learning provides that you can require tests for those individuals that are receiving their licensure through apprenticeship this is eight and this is consistent with what is required of those occur the massage therapy schools so we wanted to so the so we have required that the R. three tests that have been required at least a decade under the rules for individuals to be passed before they become licensed massage therapists and we make sure that that those tests the the option was required of those that receive their licensure through apprenticeship now all again all that being said we're moving forward because the act the to learn act allows us to do that however we have started adhoc committees we've already had our first meeting last week when have meetings all through the summer to study the issue whether we want to go ahead and change the role in the future this was done as a result of the public comment and individuals in the sauce therapy with interests and not interest in this item on that how committees have members from schools massage therapy massage therapy spa owners massage therapy licensed massage their persons and socks therapist instructors so we're going to move forward with that you all may see us try to update these rules based on their A based on their recommendations in the future in the fall but right now we would ask for a the go ahead to move forward with the rules as written I'll be happy to take any questions all right ladies and gentleman any questions sing none without objection this rule stances repeat thank you madam chair thank you members thank you right going on down the agenda items in. And I have on my list daisy DA pale in Craig Smith. Thank you madam chair cracks Mr public health attorney called daisy dimple if we have any questions but we're here to With the pros rules governing the advisory board for interpreters between hearing individuals and individuals who are deaf deaf blind hard of hearing for will have The changes are reflecting the changes for the deadline for renewal and make sure that someone to to process and licensees can know when they need to get their licenses renewed when light is applied and when they will have to submit a new application as well as implement ACT one thirty five the end of dating the licensure for on my questions or for military individuals as well as include ACT seven twenty five for the fee waiver program and you have any questions all right any questions from the committee. Seeing none without objection this rule stances Review thank you for being here. All right don Adams Lars to. Thank you madam chair members of the committee on Larson I'm general counsel for the department of health and I have with me at John Adams he said is currently serving as the deputy director for administration interim chief of staff and he also happens to be a registered sanitary answer he's here to answer any questions that you may have any technical questions thank you you're recognized. Thank you. We're here to present the rule at pertaining to the State Board of sanitary and we made a miscellaneous corrections two references and descriptions and we're also implementing acts one thirty five and seven twenty five of twenty twenty one we did have a public comment period there were no public comments and we're here to answer any questions that you may have thank you any questions from the committee seeing none with the objections of this rule stances repeat. Thank you and then the next one I believe Laurie you're on that one P. yes on IP we have the rules pertaining to water operator licensing we have had a public comment period and there were no public comments we are implementing the axe one thirty five seven twenty five an ACT eight eleven of twenty twenty one and I have with the lance Jones the chief of engineering here to answer any questions if you have any questions from the committee. I am seeing none of this rule stands as reviewed and we thank you for being here. Alright ladies and gentleman do you have any new business to come before the committee all right seeing none in. We are turned.