Joint Performance Review (JPR)

Members if you would take your seat we're going to call this meeting to order. Chairs is a quorum we're going to begin with item C. on the agenda consideration of a motion to approve the mate ten twenty twenty two. Meeting minutes that should be in your packet I want to take a minute to review that. All right to see a motion Senator Flippo. Second representative Cavenaugh all in favor say aye. All opposed as habit motion carries. Next up we'll move right into the agenda which is a discussion of the provider led. Arkansas shared savings entity or pass programs for behavioral and mental health. my understanding is that there have been some issues with our community mental health centers and the reimbursement rates for mental and behavioral health services that they provide and we have several groups here on the agenda today we look forward to hearing from all of them. the Arkansas health care alliance we have members of the Arkansas healthcare alliance here Arkansas department of Human Services and then. Several the passes I will be making a presentation as well as my understanding so what I'd like to do is begin with the Arkansas health care alliance. Is. So reporter for the record Reggie Gazaway that's actually inaccurate we're actually not that of alliance we're actually behavior health council of Arkansas okay mixed up so they are little different entity but for the record thank you very much we appreciate that if you would identify yourself for the record who you're here representing and then you'll be recognized to present your presentation sure so I'm Brad Holloway and the CEO of archery communities we're also member of the Arkansas behavior health council and delivery fell Senators herself as well. Hi I'm re thousand over we are I'm here representing mid south health systems an affiliate of Arissa Health and I'm also a member of the Arkansas Health council. And so if I can so what we can and I'm going to go first and describe a little bit about what they're pretty communities are just for the record I know I think you've got a document in your packet and I will of I will read to you but but I did want to find a little bit about what therapeutic communities are in that model of care has been a lot of it talked about a lot of this you know the the long time coming of where we are going to be committees are sold and also just for the record there's only two providers of behavioral health therapeutic communities right now in the state the birch tree communities and mid south health systems and and Ruth also gonna talk a little bit more about our program and I'll tell you a little bit about what what we do and Burch as well so there P. committees is basically the we're reimbursed or permit per diem basis in there either there's two levels of therapeutic communities there's a level one and level to the level one therapeutic communities are are the locks secure facilities which the majority of mid south of members are level ones the majority of birch trees on the other hand are level two so what that means is we have a bursary does have one level one unit which is a sixteen bit lock secure facility and then as they stabilize most of those most of those members we call our clients members they come out of the state hospital many of them on an ACT nine eleven conditional release right from the state hospital on of after making been acquitted for reasonable disease or defect not all of them but but many of them and then. We get referred the go the lock unit in our program we have about Well we have about three hundred twenty or so members that live in homes group homes full therapeutic group group homes that's level two it's unlocked facilities but supervised okay so that's kind of the difference and so that's the the next step in the continuum of care the law locks secure unit level one which comes with a little higher rate we're talking about rates and then the therapeutic communities level to progress of into a Groupon supervised group homes and start working with those members to help them get out into the community so as you can see here again I'm of the level to we're we're the lower level of care and we emphasize integration into the community so that's what we're trying to do is to help them get gain more independence but we currently have well at the time this was written three hundred twelve T. C. so I know we talk about acronyms that means therapeutic communities are referred to Tesei of therapeutic uses Stacey we have three hundred twelve T. C. members at twelve locations in eight cities across the state we currently have a hundred six of a court order we have eighty one under that nine eleven conditional release order sixteen a hundred ninety to a court order and one on a forty five day court order in an eight on ACT three ten release orders so that's a little bit about what they're paid communities do and then as as they finish F. as they progress through the level to then we will refer possibly out to the community mental health center or if they gained independence and live in their own apartment and be able to manage from their cell. A few key points to consider no waiver on this but just for the record the last adjustment for behavioral providers was in two thousand eighteen which was a decrease I know you've all heard that the Medicaid provider report rate review port that was done over a year ago shows that human development centers in the Arkansas State Hospital both offer somewhat comical levels of care at daily rates forty nine percent to sixty four percent higher than therapeutic community rates the current rate for for providing services actions about seven hundred dollars a day I heard doctor Jones earlier today mentioned that to acute inpatient psychiatric care same vessels about eight hundred dollars a day DD program somewhere around four fifty to five hundred dollars a day that's developmental disabilities ET and then the therapeutic community rates which actually can be more costly than providing the other goals other services are only a hundred seventy five dollars a day. Of course the cost of providing these T. C. services of doubled in the last year since the study was done so likely that percentage of quoted before would be likely higher of course with all everything we all know about gas prices food prices labor costs so DHS recommended that the T. C. rate be increased after the Milliman study came out to be increased to five hundred dollars a day for level one and three hundred fifty eight dollars per level two which is still below what some of the other comparable providers are although we can live with that now we talk just a minute about an hour into this real quickly so the value of therapeutic communities and kind of what what it's all about so you know the DS officials I should move it happened many years ago back in Kitty administration out of the the institutionalized care into the community mental health centers what was a great thing and the the therapeutic committees of programs. Right now are really the only relief that the Arkansas State Hospital has for referrals some of the overcrowding that you've all probably heard about for seriously mentally ill adults so eighteen percent of birch streamers are either employed at least part time or in the community which is where we're proud of that we work with these members after the from level two to get that part time job and so full time jobs and to gain independence within the last four years since I've been Burch we have transition a total of a hundred and eighty nine members from the T. C. level of care which is that per diem rate to the lower rehab level of care which is quite less costly because it's much less services okay and then Burch currently has thirty six now tiered at a level three which would qualify for T. C. services but we transition those out into rehab services that results in significant savings to our friends at the passes so The cost value alone is if they're paid communities is is tremendous let me point out one more thing about calls that I think is significant so there was a peer reviewed study done of set of the sept seventy eight new members admitted to Burch between July one two thousand eighteen in June thirtieth two thousand nineteen and what the study documented was number one the impact of birth of a birch tree on reducing the number of acute psychiatric hospitalizations which are quite costly so the research showed an eighty seven point three percent decrease in the number of psychiatric hospitalization days of members one year prior to bark Commission and when your post we took the seventy eight members look at how many psychiatric hospitalization days they had one year prior to admission to March and then they'll same seventy eight members one year post Burch and the numbers reduced from sixty seven average sixty seven point four six days in the hospital one year prior to Burch and only eight point five days of psychiatric hospitalization when you're close Burch if you look at that in dollars of the cost of providing inpatient psychiatric care to seventy eight members the one your Prada Burch was approximately three million eight hundred seventy eight thousand dollars the cost of the in patient care for the seventy eight members the same seventy eight members one year post Burch was for ninety one thousand dollars which again is so thirty communities work I don't think anyone none of our friends at at DHS or the passes or anyone are you or have disagreed they're pretty communities don't work we know that they are you know that they do work and and we need more of all right we need more service and we need more places as we've heard this morning for two for members to go Now real quickly in a letter thousand talk about her program little bit about the timeline of changes in some of this when this was written there's been some developments since then saw kind of touch on that just a second but so. Back in two thousand nineteen the T. C. providers that would be awesome itself NDH yes we begin discussions regarding changes to the tasting menu so both to see providers DHS we all agreed that a lot of things need to be changed the frequency of service is of the region ritual certification manual and there's a lot of meetings in between us a long time ago it seems so they're just begin writing you propose to see certification manual with would make some adjustments with lower number of frequencies because it that some had six you know different hours of of treatment how much he had to have and all of us agreed we kinda table agreed that the new certification manual should be adopted now before the T. C. manual could be promulgated like everything that affected everything else COVID hit right and they created the the credit a public health emergency because the public health emergency by executive order the rules are scheduled to be promulgated in you manual including the reduced members some of the changes were put into place until the P. H. A. in and that's still in place so we're still kind of in limbo from this long ago The New manual still was a run so then the report here shows a couple of things about the solutions are offered you know how we resolve the gap between the end of the the public health emergency in promulgation and we know how what we do about that because once the public health emergency and then we have no we don't have the promulgated manual so birch street and again I'll let thousand speak for yourself but but we both programs continue to operate under the rules of the public health emergency while we're waiting promulgation of the new T. C. manual and the PhD as you all know is extended several times that's still where we are so in two thousand twenty so DHS announced plans promulgation of finalization of the new home community based services manual other so. Number of two thousand twenty one so that UTC manual was to be promulgated at the same time and then we're the concerned continue to be that there would be a gap of all parties agreed that the U. standard or preferred but the uncertainty of how long the PhD would last was was because of some problem so then the next thing that happened community support system providers you here that that that is C. S. S. P. that's a that's a a model of care so while we continue to provide services during the PhD and wait promulgation of the new manual DHS of approach to both of the providers of therapy communities to become CSS P. providers and I will go on all the detail about what all that is but basically CSS pee is a developmental disability top model and we're encouraged to adopt this primarily to allow delivery of services to all hopefully some the newly diagnosed clients as well as the difficult place so we we ask again us and itself assisted DHS in drafting the CSSD manual we work really closely together in drafting put again behavioral health therapeutic community stuff that we wanted in the manual and that was real opened really good discovery we got it kinda where we wanted it and and then in the fall of two thousand twenty one back in October. we both the tasty providers agreed to do this we're greedy because CSS P. providers that adopt these do standards in exchange for doing that we were we were told that our rates would be increased that was in October of last year and some other changes in the menu like reduced minimums for day services and so on so forth but the race was the big thing well by January one we were to have the right to place well that didn't happen and I don't really know all the reasons of how the can got kicked down the road so long but then continued ongoing meetings with the chess about rates we still kind of in limbo as to when it would become effective so we solicited help from our legislators and some a lot of other people and started asking about this and as you all know representative Paul and other legislators formerly the caucus the mental health office addressing ongoing issues with DHS and behavior health services delivery so and then just a timeline I'm almost done prior to the prior to this may sixteenth caucus meeting a meeting was held just with us DHS and legislators to discuss the information implementation of the rights where are they where are we with this and then our friend a list was bit minute DHS we met with her and some others on may nineteenth the two providers and we were told at that time that the proposal for the new rates would be submitted to CMS by the end of the day Friday so we were encouraged and then I think actually June ninth of the is the official date I believe DHS for it but I think that's the right date that the request to CMS was was made by DHS and all now it we did it was submitted under the PhD emergency which is only temporary so one concerning again was okay so now this rate increase everyone agrees we should we need. Read it's it's set off to CMS to for approval but we it will only be temporary until a public health emergency ends so we were concerned about a gap within their some clarification from DHS we've had some great meeting great meeting on Friday so again since this was written so low resolutions have been made to this let me say that so they have a DHS has assured us that there is work as we speak is ready to go for promulgation of the new apartment at rates and hopefully that will happen before the PHG Ian's which so would create would not create that gap so again a lot of great discussions we had just this past Friday with DHS a lot of lot of uh no one other thing we were encouraged by DHS at that time to negotiate with the four passes about rate increases until there promulgated that the passes have the ability to pay us a different right if we negotiate that so we did do that and again I'll just speak for Burch on this one so the ghost yes with the passes there's four passes as most of you probably know all one of the passes in our negotiations but we had to extremes well the passes was all in well I forgot to mention DHS lives with recommended that the rates be approved and also that they retro back October first that is really significant and so the response from the Goshen Asians with the four passes for us one always a hundred percent on this end is going to pay the full right beginning July one and rector all way back October first that's also the other one of the passes with the other end of the spectrum we haven't heard from yet I think some of those represented here today about where they are and then the other two passes or somewhere in between offering to looking it still kind of talking about. Returning back or some blended some right step up rate or whatever so that's kind of where we are with the time line and then I recommendations which again keys resolution which I thank all one of these is probably conflicts after our meeting Friday that we had asked when the time when this was written that the Medicaid rates be published for five hundred dollars for level one three fifty eight for level to retro back to April one they did even better that better than that so thank you for that we certainly appreciate it Elizabeth noted it and mark white that you know it was their view that they need to go all the way back to October one instead of April one which would help us board that's when we were gust also started anyway so that that's what the recommendation was and then our second thing was as we mention to eliminate any gaps between a public health emergency you know when it ends in one before the new rates get promulgated now we're also been assured that likely that won't happen because as as the newspaper reported that typically they they're notified sixty days in advance before the emergency ends and I have been notified yet it's their estimation it likely will be extended which would take care of that gap if there was one if it is extended again if not we'll see how fast you can move to the promulgation process so that's one of the big gas that we were looking for and then there is there is one issue that we're we're still negotiate with the passes with reclamation some headway and that is that the weather not the passes will be allowed to pay less than the the published Medicaid rates but we I think we're I think we're going to get there to be able to negotiate it sounds like it as recently as thirty minutes ago in the hall about of course of the past as may be with that so and then the last thing was commitment from DHS to have communication transferred to with he's actually providers about any changes we were a little bit concerned that well we just want to make sure. that indisputable gated manual that we haven't seen yet there may be things in it that we can note changing service definitions and may even be more costly but they assured us that that's not the case that there's no no surprises in that other than the new permit rates so I know that was a lot the real fast but that's where we are but again I feel good about some of the resolutions that have been made some some key conversations since then and we're kind of we're Goshen with the passes so. Two thousand. Yes so bread did a great job of talk a little bit about not only what the T. C. program entails but also kind of the time lines and and what is transpired I will just briefly give you some specifics about the mental health systems or a health program so as Brett explained T. C. as this is a transitional program is designed to get clients to their highest level of functioning toward the end of transitioning them into living in the community and and the only so some of the type of goals we work on within the program or learning to improve basic independent living skills learning and practicing better ways to interact and communicate with others developing improve time management work habits and skills developing effective support systems increasing motivation to engage in healthy recreational activity prevent and or decrease psychiatric hospitalizations decreased self destructive behavior improve self esteem and image maintain optimal mental emotional and physical health improve ability to maintain independent living and increased autonomy through the successful completion of a multi faceted transitional living process so those are the type of things we're doing every day and therapeutic communities to earn that per diem rate as Brad explained there are two levels within the program level one is a secure unit while level two is not secured and you can think of it more in like a group home format. At mid south we operate seventy level one beds in Jonesborough and Corning we operate for the level two bids in Jonesborough and Helena for a total population of a hundred and ten bets. You'll see based on those ratios that mid south the specifically geared toward that level one population and there's a good historical reason for that mid south what is now called therapeutic communities that program developed shortly after a two thousand and two federal case that was about a civil rights case about access to the state hospital in Arkansas and so the state hospital needed a way to transition what we call nine eleven clients outside of the state hospital but yet maintain safety in the community and that is how we created what we're now referring to as a level one T. C. bed and so those nine eleven clients as Brad said they have committed a felony sometimes a violent felony and been found that quitted of that criminal charge based on what the law because their mental defect and so those clients are typically court ordered into our level one facility and we transition about twenty six of those clients per year. So what those levels look like is are anticipated that expectations for clients is that they transition through level one between six and eighteen months and they transition through level two in about twelve and eighteen months that's if everything goes well when we are looking at a transition to the to the community a hundred percent of our clients or referred to some combination outpatient rehabilitation day services or access services which be assertive community treatment of that hundred percent seventy percent of them remain compliant throughout their transition to independent community living since twenty twenty one eighty two percent have been compliant and cents twenty nineteen sixty eight percent of those who've transitioned have been able to successfully maintain their life in that less restrictive environment. Since June of twenty one. Of those over a hundred residents we serve we've only had to render twenty four crisis services. Which is quite impressive when you considering that these are being transitioned from the Arkansas State Hospital the highest level of care we have within the state. Some other things that we provide for them with physical health also we help coordinate their physical health with their with their PCPs and if they're hospitalized we provide a one on one staff to client ratio with them for the length of time that they are in the hospital. What if these clients look like how was the house state of Arkansas I hate paying for this when we are not under a public health emergency about seventy percent of our clients or in a pass in about twenty five percent are paid for through Medicaid spend down because we're currently under a public health emergency right now about ninety eight percent of our clients are paid for with Medicaid some combination Medicaid or pass funds so. The we consider level one therapeutic community service that we provide to be integral to the success of the Arkansas State Hospital so that we do not have access to care issues similar to what we face back in two thousand two in the Terry vehicle case it's about systems is probably been providing those services since that time and look forward to continuing to working with the state to do that in the future. All right thank you for those presentations I would open it up to members questions at this time Senator Dismang you're recognized. Thank you Mr chairman in in maybe just a little bit explanation were headed may help minute and may leave if the question but what we looking for them today many are you asking legislators get involved with the negotiations with the organization in the passes or I mean that I think you already have them involved between the negotiations between DHS in your organization the goal are pretty clear about that but I mean you're not asking legislature to intervene in the. What was supposed to be a. Coming up I guess say no non governmental entity you know trying to negotiate rates with you all know that was kind of the point of the passes was to get us out of the picture so begins going to restate what we're looking for today I appreciate the review the services that you provide. So thank you Senator Rice that's a that's a great question we are not looking for you know the state to intervene in individual contract negotiations between individual providers and the passes what we set out in conversations that we've been having a blast several months was that we needed the Medicaid right the traditional Medicaid rate for the service to be increased when that happens when the individual Medicaid rate the state as one to pay is increased then that allows passes to want to and need to come to the table to to look and see and really provides the foundation that was being paid today is an adequate that that is now happening and so we've recently had a lot of momentum in that regard and so we've had a significant amount of right of progress since I think this meeting was called. You senator does make you question your your right mind thank you and what you have asked members to get involved in those negotiations those what you're selling me with the passes directly we're working with passes directly S. okay but not not through legislators is being admitted into okay but. Representative Cavenaugh you're recognized. Thank you Mr chair and I'm over here I just wanna make sure that I really have two quick questions just wanna make sure that. I understand where we're at because I've spoken with DHS basically your concerns of all been made except for two things you would like to have the language back in the contract that says that they have to pay at least Medicaid right and they begin the passes. The other concern is that because we're under that emergency health order that when that goes away then the right goes away but DHS has already begun the process to make that a. Plate so that the right can then become permanent or new right schedule since a permit but under the new right schedule so. Really. Those are your two concerns that you have in my understanding from DHS is they are willing to look at the contract issue that if they feel they can get that language back and they'll they'll do their best to do that and that they have already started that right. Yes yes it for Markham or sessions on Friday with the H. is we've been assured that that that promulgation process is is taking place as well the permit promulgation right yes and that will actually they have recommended that you be reimbursed retroactive to October twenty twenty one yes ma'am okay thank you. Representative authorizing as. Thank you Mr chair thank you alluded to one of the passes as agreed but the other three haven't I know that our stuff doesn't say who is white but what is hindering the others from committing do we know have they said or if you just not sit down in the negotiations. We've had conversations with all four passes and we've got one who's put in writing a commitment to retro The New right back to October first we've as of today had a verbal commitment from another pass to to look at going retroactive we have one pass to requested a good bit of data which we both submitted our data so that they can then make a decision and then we've got one is recommended some sort of a stair step blended rate to get. Okay thank you. I'm gonna ask a couple questions and kind of chime in here You know sounds like what I've heard you guys testify to is that there was a meeting Friday and that the vast majority of these issues were resolved is that accurate. Yes okay. And I'm gonna and I appreciate that I wish someone would let me know because we have a committee full legislators here that may not and and witnesses who may not have had to have shown up if we if I had known that most of these issues were resolved Friday however I guess is this does give us an opportunity to get this out here in the public and my understanding is that this is a condition that has existed a long time that is just now being remedied can you talk a little bit about. What what it's been like to try to operate under the not my understanding of it was the reimbursement rate currently is a hundred and eighty dollars approximately up. You just second while other providers to provide similar services not the exact same as therapeutic communities to similar are reimbursed somewhere around five hundred dollars so can you can you give the committee some perspective as to what it's been like to try to operate a business to operate these therapeutic communities on that kind of reimbursement rate. Yes certainly it's been difficult to say the least especially within the last year you know when we started trying to trying to do budgets for July one this upcoming fiscal year you know I I don't I don't mind telling you we were we were scratching and looking in every way possible obviously yeah we we have like over a hundred vehicles emerging transport a lot of members to work and other places is to program centers food costs is extremely of course as we know food costs have gone up what double at least gas prices work force where you talked about that so workforces or in what we've had to pay our staff to keep them and that's a whole nother agenda but so the cost of of labor food and gas alone has Just there's just no way to make the ends meet coming up with this fiscal year without this rate increase to even keep what we've got let alone doing expansion already could ongoing services so it's been it's been quite challenging but feel a lot better now or maybe it. Mister read anything you wanna add to that. I just like to add that the current rate is one seventy five for level two and two hundred fifty a day for for level one and so the new rates that have been suggested which is level one five hundred and level two three fifty eight were studied and approved by the Milliman so the state has has done the work to really really study what. What that service is worth in the market and verified through Millman. Can I have one last question in this relates to what Senator Dismang asked you know I I don't think it's appropriate numbers given my opinion here I really don't think it's appropriate for the legislature this committee to intervene in negotiations between a private pass and your businesses which are also private businesses I don't think that that would be appropriate but it is my understanding that the whole purpose of the provider led or the passes is that they are provider led you guys are providers the providers are supposed on or in my understanding fifty one percent stake in the passes and so are you know from birch trees perspective from mid south perspective are you guys participants in the passes you have a seat at the table when their meetings how is that process work. That's a great question thank you so both Burch in mid south are investors in one of the passes so we do have a seat at the table for those those meetings for one of the pass one out of four. Okay thank you. Senator Irvin you're recognized. Thank you however here just and this could be it more of a question for DHS but in reading this report on it talks about once the public health emergency and Sir will be a gap unless the new rates are permanently promulgated. Are you advocating at I am concerned because we have seen levels of spending through the public health emergency that we as a state absolutely could never sustain yes we've had entities ask for that level of support financially from us at as the state governments and quite frankly you know there's no way we could ever means that level of sense that we've seen through the public health emergency from the Federal influx of money. So perhaps this is a question for DHS because. Precedence matters and it's really something that I would be concerned about that if we did this in one area where there be them pressure to do that across the spectrum of Medicaid providers in all areas of health care and pressure across the board in all areas of government. Where were there's just no way we could ever sustain that level of spending utilizing general revenue or even our portion of general revenue as in the reimbursement from the ETC by. So I'd like. Your response number have CHS you should take note of that. Yes I think you raise awice point I would simply say that all of these conversations began well in advance of the public health emergency and there was an acknowledgement that these rates were too low for this service before the public health emergency began and and the you know all the different levels of code funding came into the states so while I think of it just delayed this conversation it was it's not a code related conversation it was a problem prior to that in and your where and this is my last question Mister chair thank you for the latitude but. There's there are those discrepancies and funding levels amongst Medicaid providers for example the same service as provided by a hospital based clinic or a private based family practice clinic is paid at a lower reimbursement rate than a federally qualified health center Medicaid rate I personally don't think that that's correct I don't like that policy concerned direct competition thank you that does exist in other areas of Medicaid are you aware of that. Yes we're well aware because the same service that can be provided in a behavioral health agency is paid less than at that same service were rendered in the PCP office so we're acutely aware that is yes thank you. Senator Hammer you're recognized. Thank you Mr I just wanna make sure and everything that you said your presentation while ago the waiver that is being presented to CMS that is currently being offered temporarily because the public health emergency do you know that that is actually been submitted to CMS for final approval and did you say that a while ago and I just missed it yes we were told by DHS that that had indeed been submitted we were told that Friday in a meeting. And I will take it all the head nods from DHS staff back there so is it permissible for us to get a copy of that if it's not if it's short of a Sears encyclopedia. Okay like if you don't mind Mr everyone direct that or I'll get it off line thank you. Thank you senator Hammer will ask staff they can try to get a copy of that for the committee. Representative Johnson you're recognized. There again I was determined not to push the button I knew that was the wrong thing to do. I so you you talked about thirty community level one level two services I think as long as we're looking at these rates I think I think a question that I have would be does there need to be a third tier of services you know we talk about the gap between level one level two services is relatively close in the drop off from level two to just during the community is there an opportunity to create a third two year and if so where's the timing for that isn't something that you see in that there the manual CCSP manual where would that be created how would that work. I also appreciate that question because you're exactly on target so and I've been saying this for a couple years now and and talking and and our friends at the yes Sir I think or where to there is a therapeutic communities level to as we've talked about in the supervisor Paul there's a he and our goal is to try to to help them to to get into to to move out in the community in independence but that step between supervised group home level to and yes see you later here you you know go get you Department and start you know that that gap is is is really really big and so I've said for a long time they're they're likely whatever you call it a level three of some type of transitional care and maybe a semi supervised system to help because we're kind of doing that now but we're doing it under T. C. level to like they're ready to kind of do part time job to kind of go out and do things but it's either T. C. either follow the rigs of THC level to the group home setting or be out and outpatient communal house and there's no that so that is a big great big gap exactly so your point. You're recognized for follow up. It's been awhile since I've been out here president John give me the latitude so it would be fair to say that if that were if there if there was an opportunity for that care is this is sort of an if you build it they will come kind of situation if we created a tier three rate or level three rate would that create more opportunities for these kind of supervising bridging roles in and if so I mean I would think that that would help reduce recidivism to some degree by not putting these people in the community to early is that a fair assumption yes I think I think that's exactly right and in by moving them into a level three transitional level of care which would understandably be a lower rate than two right everyone is tired too then the third level when we get those folks moved into that transitional level care which would be you know would cost a little less and then and then get them on our community would seem to make sense to me thank you thank you Mr. Representative Lowery you're recognized. Thank you thank you Mr chair just trying to get a better handle on this process especially of considering that the services that you provide more than just public health services mental health there also in part public safety concerns correct that's correct so so that really excel rates the need for the state to become involved in making sure that you're compensated correctly I would assume cents and I and I know the clients that come to T. C. one that they have been found not guilty because of mental defect right mental disease. Correct but as you've stated of many of them are there because they had been arrested under felony sometimes violent assaults so there isn't an extra level of scrutiny or protection that we have to have to not only protect them but also protect the general public. Has has some of your xcelerated cost the that you've seen has that under the T. C. one those to secure facilities so do you have staff in those that are akin to a probation officer or a law enforcement officer because I know we've experienced difficulties of filling community corrections positions corrections positions is that something else that is also accelerated the cost of of running these facilities. Yes Sir I don't know if I can draw a parallel between like probation officer but I tell you they are trained in what we call the escalation techniques which sometimes might include a physical hold if that's absolutely necessary and so the program we use is called tact and everyone who works within these level one facilities is trained in not only in those measures of the escalation but also the physical holds aspect just to safely keep clients from hurting themselves or others but as secure facilities there's also responsibility to make sure that the clients do not leave the premises that is correct we we do assume that responsibility and have extensive dialogue with the communities in which those those those services reside we have regular conversations with law enforcement with other stakeholders within the community to ensure that the community feels like we're upholding our into the deal with public safety right you mentioned will one of the areas where there's been an increase in expenses has been transportation costs what what are the transportation cost in a secure facility. Well not so much I was talking about so level two rebels program is primarily level one we have one level one program with only sixty minutes our other three hundred members are and supervised group homes that do that we do transport them from the group home to the program center every day we transport them for for outings to go to Walmart to take them to their job take from you know we're we're all over the place with with transports that's for the supervisor group home not the loft unit okay it'll last question on this conversation about whether there's a need for a third category I've seen by your answer that you're saying that the T. C. T. T. C. two facilities have taken on some of the follow up Pretty much all of it I mean all of it so we either got you know you've got some people in the T. C. to to be quite honest in the T. C. level to level care they probably don't need that high level of care but put them out on the street is too big of a gap to just to say go you know I'm saying so that from a fiscal standpoint you know alone a lower rate for that transitional level police law I mentioned in my report some thirty something members we have right now thirty eight or so are kind of in that kind of transition about ready to maybe referral out but they're still in the T. C. level two because if they're not they're they're out on their own so there is that gap okay all right thank you thank you Mr chair. Representative Cavenaugh you're recognized thank you Mr chair and for the record can you just tell us how many level one to have a how many level to use you have both of you my mind's easy we have sixty level ones because we have one sixteen bed unit and then level twos I have three hundred and twelve I think is real close. Thank you to my numbers are in that report. In mid south we have seventy level one Betts those are split between Jonesborough in Corning we have forty level to put bed split between Jonesborough and Helen okay thank you. I have a couple questions related just to therapeutic communities that may be helpful for the committee. And for my own understanding and I have what I think is not idea about therapeutic communities and how there's decides to work are supposed to work. But maybe you guys can enlighten us a certainly not an expert but. When I was a prosecutor. We used to send people to the state hospital. My feeling and understanding is the state hospital really doesn't keep anyone anymore. And is that kind of the purpose of the therapeutic communities is kind of take the place of what the state hospital the function that the state hospital used to have which is to keep people who have been found to be either unfit to proceed or not guilty by reason of mental disease or defect I mean these are dangerous people and a lot instances people who've committed sometimes very violent crimes again their suffering from some mental disease or defect so they can't be found guilty because they're criminally insane you may say that's probably not a correct term anymore but they have a mental disease or defect. Instead of sending them to the state hospital now they come to live in one of your therapeutic communities whether that's a level one which is like a lock down type facility or level two which is supervised group home is that an accurate description of what the therapeutic community is. Yeah that that's that's partially adequate I would I would say that this that typically our clientele goes to the state hospital first and a stabilized by the psychiatrist at the state hospital and then after that stop at the state hospital transitions to therapeutic communities but because the majority of cases in the state hospital now or forensics related I think we do serve as a key component is that has that out file to once that patient is stabilized at the state hospital then transition them to our program. And if obviously if it weren't for these two programs which are the only two that serve that that do this for the state hospital to help take care of some of those some of those people did you know before they go I mean You know it's either back in the legal system and back in the psychiatric hospitalization here in. Prison or jail. Yeah okay thank you for that looks like representative Springer you're recognized. Good afternoon thank you Mr I just would like to follow up on the stitchers comments regarding the need for this committee's involvement. Today in. Have either of you. Of such taken the opportunity to reach out to the other three passes that you say you've not had contact with. Yes we've met with all four passes okay okay so this is a matter of you following up with them you said that you had made some discussed had some discussion with one and you all have some type of agreement and then you not it agreement with the other three so that's something that you can have meetings with the work out with them as well yes really good place we we we've had full resolution with one we've had contact with all Fortner to go she Asians thank you thank you Mr. Senator Beckham you're recognized. Thank you chair of. Which. Which pass reinvested the. So we're pass real invested with bursaries invest with some at some. Is that one of the passes that offered resolution. Party partial we're working on that yes or no from this initial report you name for passes all four passes two of them had no resolution two of them had partial resolutions since then since the late forward written yes Sir prior to the report read in the the past that you're invested and whatnot great an increase. Not a fully increase there were some there were some to go she Asians for partial ended in stair step a little bit okay and your part of the agreement is to be retroactively paid till of. The October of last year from the request is how much federal money did. You're too facilities receive. I would have to research that I'm not positive I can find out for you. Reporter yes I'd like to know that so we're looking at retroactively increasing rates. We can see how much additional funding was. The facility so to make sure that we're not just burning taxpayer money then. Last question I have is specifically who would come to the table to negotiate with you until this meeting was on the books. the one pass that we haven't had eighty offered to go she ation from is CareSource the newest pass there but they they weren't involved back away back in October and was there for when you pass you senator expected retroactively pay when there were and all member they were involved back then okay and that's the reason for this meeting is because care source would not. Come to an agreement with you. The the reason for this meeting yes now for. But not the reason there is for this meeting is not because care wouldn't come to the table no Sir. We're still where we were working on the go stations with an act we have met with them I know that miss South and meet with them as well. We just wrote System only today it's been discussed the last Friday most of the issues you had were resolved. Yes with DHS so we started the conversation with DHS because we were requesting that the traditional Medicaid rate be approved first none of the passes wanted to negotiate until such time as the actual Medicaid rate set. The the refers a question we got was probably fifty legislators in this room for this meeting. I am trying to figure out who would not come to the table and sit down discuss with with you. That will make this meeting that happened today. What's. Specifically who is the one can what they I think the H. S.. I think had we been able to have that Friday meeting even a week earlier we would have had time to say we might not need to speak but it was just Friday that we got this resolution. Recommend you have more questions or you're welcome mass. Okay. Okay at the other have a couple of follow ups on that so this meeting has been scheduled for a while and you guys have been in negotiations or you guys have had conversations with DHS for some time is that correct and in fact DHS has promised you it sounded like to me based on your testimony on a couple of occasions that they were going to increase your rates is that correct. Yes and of despite those promises those rate increases never materialized is that right correct and so we put and we're not talking about the passes here because the passes would cut a negotiation to the passage would come later unless you get a Medicaid increase the passes at that point really don't have any reason to have those discussions if and so you've been waiting on Medicaid to fulfill their promises they didn't do that and so we called this meeting and then Friday my understanding is that they they came to the table and you guys met and they are resolved a lot of things used and I think the ultimate question would be do you think that would have happened absent this meeting being called and put on the calendar. All I can say that hasn't happened in eight months okay. That I don't expect you to be able to do that I'm asking you to speculate there but but I think the point is made. All right any other questions. Because we have DHS next so. Mr. Okay Senator Gilmore you're recognized. Well and and and maybe this is a more appropriate for DHS but I will ask this anyway who who DHS is and your point of contact. In almost all the meat market Y. eight and lived with Pitman Tristan. Primarily those those three often been talking with a lot over the. Course of all this okay and miss Pittman who signed this letter sent out Friday I guess following the meeting but you guys have I don't know I don't know when we received this letter Today okay. Thank you urgency there okay thank you I guess I'll hold questions for DHS. Senator Hammer you're recognized thank you I'm just here shall were in a meeting this morning and there's comment made about all the hospitals being full and about them not being able to take patients because they were full do you know if those patients that are in all the hospitals whose beds are full do you know what they meet your tier one tier two criteria and I know there may be some medical issues as to why they're there but the impression I got this point was there's just nowhere for those patients going I'm I'm just curious or they cheer one tier two level patients or do you know most all of those Senator Hammer and they're very unlikely if they would be a tier one if they're if they're in need of acute psychiatric hospitalization and yes or at least at least at mid south we do accept referrals from acute psychiatric hospitals into our whether they need level one or level two care not a hundred percent of our members coming in from the state hospital most of them do on a level one but folks are to cute hot we have referrals all the time from the different acute psych including site visit the doctor John was talking about we take members there all the time so they make referrals we interview those and then if we if they fit the needs and meet the criteria for level two or level three whatever then we will accept those. And Andrea follows Mr requirement I read the reason I'm asking that is because on that's what I'm saying about the cost of what it takes to keep somebody at the state hospital and then based on the conversation this morning and the rates that you just quoted a while ago and we're keeping them in the hospitals at what day rate and is it time to take a look at because if you had greater capacity and you could take more at a less cost per day rate than what we're paying at the state hospital and these other hospitals around the state why would we not want to do that that's a great question and I agree a hundred percent we look forward if we can get all this done we look forward to expanding and offering more bids for some early for some of those acute hospitals and we can do that. Our thank you thank Mr. Okay thank you Dr Holloway and missed over we appreciate you being here today. And for your testimony if you guys would like to remain in tendance it's possible that there may be questions. as we go forward. At this time as the DHS. Make your way to the table. You're recognized. Thank you Mr chairman mark why DHS Elizabeth and Division of Medical Services. Mr I think what might be helpful is if I can just touch on a few points just comics explanatory points that it was bit more talking more detail around the rate setting around and therapeutic communities and we'll see if we can. but clear any confusion answer we have to answer all questions after that on the explanatory piece a which after my myself not everyone's on public health I know some members understand passed more than others so we used a quick explanation of house just in case there any members who are not familiar with the concept so Pastora stands for a provider look at Arkansas shared savings entity this is the managed care model that the state set up a few years ago to take care of our individuals with the most significant I'll be able health needs and also those individuals with developmental is disabilities and of course I as as managed care that means the pass is responsible for all the care for those individuals so it's not just those specialized B. H. or duty services they'd take care of all of the medical needs for those individuals in the state in turn pays the passes will call capitated rate essentially the move up up a certain amount each month to provide all the care for each of those beneficiaries. Excuse. And so and that does make within the passes and turned they have agreements with the individual riders to provide those services and to pay those rates and so those rates are negotiated between the providers the passes those contracts are between the providers in the passes and we're centers was discussed earlier the passes themselves each pass must be controlled at least fifty one percent by Arkansas providers so it's just a quick overview of the past system the other two things one dimension one is just wanna make sure that you keep in mind that these discussions around the therapeutic community rates this is the context of the rate review process that we've been engaged in for the last couple of years the governor entered executive order which directed DHS to review the rates for all Medicaid providers because many rates and not been looked at in many years and so we've been working through that and therapeutic uses a piece of that we have a very intensive ever going on right now around behavioral health as a whole because we want to do the right sitting there in a way that is consistent across the various pieces of the paper health system and that's on so we saw the letter we sent out Friday to stakeholders that's part of that effort is to bring those other stakeholders or as we have a right now for TC's we want to get to the other rates for those other providers in a similar process and in a way that is consistent and that complements the work being done and therapeutic communities and the other settings. Of the last thing I want to touch on was again relationship to the state hospital there is certainly a connection there and the the therapy committees do accept individuals who are coming to the state hospital they set other individuals as well and that's one thing we want to we want to see more therapeutic communities operate in the state because we know there is a need out there it's not just folks who've been an ash is also other folks who have those real significant need for they need a setting like a therapeutic community and it's it's helpful to think for behavioral settings thank them in a pyramid not the very top we have the most restrictive settings and that would be you know inpatient settings like the Arkansas State Hospital like a hospital inpatient psychiatric unit that's where individuals with the most severe needs who need the most amount of care our house that as you move down from there you have gradually less restrictive settings that can be appropriate depending on the needs of that individual and that's one thing we're going to do is expand the amount of less restrictive settings in the middle that pyramid things like therapeutic communities and because of that they're permittee it is considered a home committee based service that does mean that it has some extra rules that attached to it yet and other H. C. B. S. services around what kind of settings those we offered in what kind of restrictions are available in the settings but even though it is it is in a central location but CMS still considers that a home community based service. And with with and and in terms of the placement for individuals out of state hospital we do have individuals that know they reach that status status they've been evaluated it's been determined that medically they could be in a less restrictive environment without creating any excessive risk for themselves for the community and that's type of individual that we can place in the therapeutic community or a group home or some other setting where they could be a place that is less restrictive the state hospital the still receive the care and the treatment that they need to continue their progress towards recovery with that let me stop internus Pittman and she's going to talk about some more specifics around the to therapeutic community rights. And sure enough I may first expand a little bit on what and Mister white sat on a couple lot of time but when we switched from R. S. PMI to be H. S. and so I do not remember what R. S. PMI stands for but rehabilitative services for people with mental illness I believe and we take we take it over to outpatient behavioral health services and back in twenty seventeen twenty eighteen when we did that the vision for that was a continuum of behavioral health care that went all the way from the tier one services of individual counseling to inpatient psych so we're looking at this full continue I'm and that's what we're here to talk about today therapeutic communities being a part of that so inpatient psychiatric services would include the State Hospital they would include those inpatient psychiatric units at critical critical or acute care hospitals that and Mr white was referring to then you go down to a residential home and community based services program like your therapeutic communities that is a lower level of care for for clients that no longer need that that high acute setting of an inpatient psych and you have level one and level two within that and so you have your level one which is providing your more intense services those that need still need that security unit level to that is providing that group home type setting we didn't envision it moving down home and community based services in the community and we do actually have all of the services available to be paid for now and I'm sorry I have a quiet voice you just told me to speak at and we we do have a lot of these already ready to be paid for but we do need additional providers and we need to expand that service array so we have transitional housing we're working on some other and package services assertive community treatment which missed over referred to you is one of those that is a package of services for individuals that don't necessarily need that group home setting anymore but they still need more care than just we're putting them in an apartment and they're going to go to therapy services so we're looking at that. As building out that home and community based service outside of the facility and then you go down to counseling services so with that said I think that brings us to where we are today which is working on the rate setting I'm an you Mr hall and Mr ever talked a lot about this error college eyes for any repeated information last night June second is actually the date that we submitted the disaster spot to CMS so and it was ten seconds and had to go through some internal processes a lot of people are out soon fortunately it was June second we submitted at we are asking for a retroactive effective date of October first twenty twenty one we are able to do that because we are using a disaster spa authority if we had used a regular spot the already that would last beyond the public health emergency I would not be able to retro actively go back to October first we did feel that COVID did impact I knew Mr president a lot of this wasn't due to covid but COVID has exacerbated the problem it's exacerbated the number of people with mental illness that the heightens and. Symptomatology that they're having in needs that they're having it's exacerbated workforce shortages and things of that nature and so we felt that due to that public health emergency and due to the fact that Milliman had written a state letter about September seventeenth at telling us that those rates were appropriate October first was a good day to return back to so we use that authority to do that we are right now I worked on the draft this morning going through internal approvals on the nineteen fifty nine I'm one of those approval so I had to make some comments and and submit my approval so we are going through that right now our goal is to get that out I can't remember what I said I think mid July as what I said yesterday and that is still the goal course we have internal proper approvals and then the governor's office officer has to approve we're gonna make every effort to get it back out for public comment by that date. And that is already will and and they said all of this so again we do anticipate DHHS federally health and Human Services will give sixty days notice at the end of the public health emergency they have committed to that they have not given a sixty days notice for the July fifteenth date so and and CMS and everyone is acting as if we will get a continuance so we are not anticipating the public health emergency ending July fifteenth and we are looking out at least a fall in date and so we feel like we have enough time if for some reason we're up against the end of the public health emergency there are some other things we can do we can come back here and ask for emergency rules already we can there is a way to extend to public health and disaster spot that you put in place during COVID for its temporary amount of time as long as you don't make any significant changes to it you can extend not so we can do that as well so we're looking at all of those options but our main goal is to get that permanent rule in place before the end of the public health emergency that's what we would like to see so that we don't have a gap in the rates. And with that you will also and. Seasoned references to CSS pee they made a reference to that community services support provider type as well that vision of that provider type was for the past population we serve both high needs behavioral health and high needs developmental disabilities clients a lot of those clients actually fall into both of those categories the primarily serve three one bucket or the other but they really have the developmental disability answer behavioral health diagnosis and historically because of how Medicaid pays for services we have not been able to treat holistically those individuals so we were hoping through the CSS peak community services support provider we could. Move forward towards crossing those pockets and have a provider type that could serve the full array of clients so they they get that CSS pee and underneath that are all of those different services so you can become a CSS pee here provides therapeutic communities and developmental disability support of living so you can provide services for the whole person it's not meant to be a DD or A. B. H. specific provider but it's really minutes across across but that spaces so you'll see that referenced in the nineteen fifty nine that we're putting forward to allow for those providers to be either opiates As which they've always been or to be this new CSS peach trying to move us in that direction you'll also see in there the addition of that assertive community treatment service that I also that I just spoke about so we really are trying to move all of these things forward I Mark also reference the rate reviews we had done an initial and at cost survey for BHS services and we took a look at it we took a look at the methodologies are all very old sure the providers could vouch for me on this one we're talking about cost methodologies and pricing methodologies that really have not had been examined in twenty years and so we did not feel like just doing the same old process for that was going to be really effective or appropriate and so we're doing what I sent out on Friday which is a more in depth process I we're we're actually going to engage stakeholder workgroups to take a closer look at these services how they're provided and make sure that our methodologies are really matching what the service is and that we're paying for the appropriate service for the appropriate individual. And. I thank. I'm sure I've missed some stuff but I will let you ask me some questions to fill in the gaps and thank you so much. Thank you very much. Senator Gilmore you're recognized. Thank you Mr thank you guys for being here Sir going back to my line of questioning of this letter and and how it came about it I mean I just say that seems very coincidental that were here and there's been a lot of negotiations and most everyone in this room is where those negotiations think you want to go maybe instead of eight months worth of negotiations so is it fair to say that with this meeting pending you sped that process up. I would say we we been speed up the process for that letter by weight emphasize that letter that letter is not tied to whether we increase the rates for therapeutic communities because that that has been on an independent track is already moving forward that letter is really about these other provider tops like the others of payroll services in getting the rate straight for them actually got a good good system in place for those other provider types just like to say that you've tried to push it even faster these last few weeks yes we're trying to push because of course we know the providers needed another slaughter discussion around it but also we were aiming to finish all this by the end of the year and so we know that time start run short okay then the only reason I ask kind of the time line here because there's been other things shifting a little bit off this topic but similar topic there's been other things that have happened in the past and rules that were recommended and things are recommended even by the attorney general's office as relates to passes that you know I just wanna make sure that are being implemented so we're what's the status on some of the recommendations as relates to things up in the news with passes sure that's an excellent question we are currently working on an update to the passing green met with and negotiating with the passes on not for several months now at that date does include the the majority of the attorney general's recommendations they had written as a letter telling us what they would like us to add we've responded to that letter telling them and I believe we adopted the majority of the recommendations and the ones that we do not feel we could adopt we responded back and explained why I believe they were okay with that that response and we've reached a place with that and we're now working on corporate not into the agreement and I would add that there is still at least one on one matter that that the turtles offices working on understand or some discussions going on around that and we're awaiting the conclusion of that is certainly wants that is included we'll see if they have any additional recommendations and take those account as well okay because I think. K. once before a request I think it may have been a public health meeting just to see kind of what the plan going for forward was for all the the additional requirements to help mitigate circumstances that happened the past I don't I don't know if I ever receive that and if I missed it I apologize but you make sure that the committee Mister chair could we we have those sent out to the committee. Re referred to the letter dated Friday no I'm I'm referring to other matters with the AG's of recommendations for passes and some of the new requirements for DHS certainly yeah we have to look at that I will get you evidence of emergency center will gets a list of what they what they recommended SMC actually take on that with that that that would suffice thank you with that too. Representative Cavenaugh you're recognized. Thank you Mr chair I'm over here come in the mail so I just want to ask real quickly so we hear about some of the negotiation between the passes in the providers to make the therapeutic communities go back retroactive to October. If a therapeutic. If I pass wants to do that. And they have to pay additional medical expenses because that's what this is is there a way that they can get reimbursed for those additional expenses that they're having to pay because I choose to go back retroactive. C. understand my question yes ma'am I do understand your question so when we change our rate I believe I understand if I don't please let me know it when we change our rate for any service provided under the past we actually letter actuaries no I'm in they take a look at that when they looked at the therapeutic community rate increase back in September they they stated that it could be absorbed within the rates that we were currently paying the past so we do that I mean if that actuary says no we think an adjustment is needed here they will go in and do a retroactive adjustments to the rates which we can then implement if they don't then we allow the risk corridor to plan out so we have a medical loss ratio of eighty five percent within the past which means eighty five percent of the dollars have to be spent on services there's a certain percentage either way and if they don't hit those targets than the passes paid as back money that goes either way if they do have that those targets and exceed those targets meaning they far exceed that medical loss ratio we would actually then pay them more money because they spend spent out more and services than what we had to actually required so we would play out that way if for some reason actuaries are incorrect in their assumptions okay that was just one of my questions is if if you're saying that we can make this retro if there is an ability that if they decide to go back and make retro they don't have it built into their budget and is there a way that they can recoup you're saying if it goes over that corridor then there's a way that they can recoup that money gets man that recorder does go both ways so when they don't hit it they pay us and if they exceed at wheat and wheat and pay them okay from real quick follow up is how did we arrive at the number of passes that we have. Okay so when we started the past program as you know we did not do a procurement traditional procurement because we set it up to allow any past that meets the requirements to enroll as a Medicaid provider that was brought before this body and approved to allow us to do that so there's no limit on the number of passes we can have as long as they meet the requirements to become a pass in Cerro and right now that's for individual companies that have met those requirements have been enrolled as passes and not to we have allowed to enroll what happens if the past is enrolled and then they go default what happens then just saying because it can happen yes ma'am and yes ma'am we have built into our agreements and transition requirements we would then step and we have the ability to step in as an agency or to put in other people to monitor that pass we within transition as beneficiaries to the remaining passes working with the passes that are still remaining to make sure that they had the staffing and the ability to handle those so it would be done over a time period and we looked at you know how that would look a little bit last year as an as we just discussed and and so we are aware of how to do that we would then step in and sort of and step out that plan work with the other passes to allow them time to staff up there there care coordinators there utilization management or doctors that do peer review and once I was ready we would go in and then transition as beneficiaries but we do have the ability under agreement to put in staff on the now defunct pass and to help them maintain and continue operations while we're going to that transition they we have a fund of the state money that pays for that day fund December to what we might we take over at a nursing home facility. I mean I'm just wondering if it's going to cost the state if we have a different one that goes out does that cost the state eighty dollars if we're going to be managing it for a short time. I don't believe so because I think we have that if I understand approved procedures we have in place we can make that transition over it was transitioned right one past pain the other pass the trouble is just the the logistics the mechanics of that okay but that's. With the protections built into the system or the solvency requirements which Arkansas insurance department regulates and but we do have solvency requirements for each one of the passes to ensure that they can continue to provide some level of service even if they do happen to go out of business okay thank you. Okay I have a question about the agreements that DHS has with the passes so it's my understanding that DHS has agreements with the passes. then the providers. Negotiate a I take it within the past because there's an insurance company component the passes the provider component the past the provider of the passes the majority fifty one percent insurance component the passes forty nine percent and then they have agreements with you guys is that accurate. It is yes. And so part of what we've been talking about here the purpose is the reimbursement rates for therapeutic communities. And my understanding is is that I guess that the meeting Friday you guys agreed that there would be an increase in the reimbursement rate for therapeutic communities is that correct also we agreed earlier a question the June second letter to CMS that was to request and bill to implement that increased rate there was some confusion about what we have done what we were going to be doing is that's far with that's why we have the Friday meeting was to clear the confusion make sure that everyone's on the same page to understand exactly what what steps we have taken and what steps would be taken well and you know we could I could go into that part of the really the complaint I think part of the reason this meeting was called is it's my understanding we're talk about therapeutic community rights is in twenty eighteen there was an alleged increase which in fact is my understanding resulted in a decrease for therapeutic communities is that correct. So I will carry out this week I was not here in twenty eighteen my understanding is there was a rate study done in twenty eighteen and several of the services did decrease I can't remember where therapeutic use wasn't okay it's in some of that also there was a kind of less frequent meetings recommended and other things that would result in less money being paid to the therapeutic communities. The end that happen in twenty nineteen to open twenty twenty is that correct dedication getting is no and that in the an early indication was that the rates for therapeutic communities at least did not decrease okay. So twenty twenty. and I'm just reading this information been provided DHS announced plans on promulgation and finalization. Of a new manual is that regarding therapeutic communities are you familiar with that so there was yes are there there was a lot of discussion back and forth around changes that we need to the manual and and co would help illustrate some of that because we the providers and ask for some flexibilities with the providing those flexibilities as a result of the pandemic and as we saw how that played out we saw that made sense for a number those things to be in place permanently and so the way we accomplish that was through that CSS B. mantle I was referenced earlier we sent the new provider top because we wanted to bring those two worlds together as the providers concert either side of your No individual department may have health issues or individuals with mental disabilities and also create more consistency across both sides of that equation that a question across our programs and so and that was the end result of how we address that is that the existing there be therapeutic communities they agreed they would become a CSS B. providers worked out the details but that in that manual and then probably that made right and that would be in the fall of twenty twenty one I believe that's correct and it was my understanding that based on them agreeing to become certified that they were promised that they would there would be an increase in the rates and in a once again we're talking about the fall of twenty twenty one. And it's June twenty twenty two in the rights of not been increased right. Yes all the efforts that we did because we did do that read study back in October twenty one that brought us that new rate back I think the key issues been just again trying to do something that is or not doing just therapeutic communities not selection trying to address the role sister across the board I think that has been the largest source of delay is trying to bring all those different pieces together and unfortunately this therapy communities got that delayed the implementation there right okay so that brings me back to what I originally wanted to ask about which is with these agreements. My understanding is that in the new agreement that DHS is working on I'm not sure they've been finalized with the passes. There is not a requirement that the passes paid the base Medicaid rate to the therapeutic communities so even if you agree to increase the Medicaid rate for the therapeutic communities if there's no requirement that the passes pay at least the base rate to the therapeutic communities this could all be for naught is that correct where where are we on so the the lane when we start of the past system we did include a requirement that has had to pay at least Medicaid rates and then that requirement would away about two years ago a year later your sewing twenty twenty four twenty twenty so that was pulled out since that time and because we wanted to give the passes the freedom to set their own rates whether that's above or below Medicaid rates because at the end of the day the past responsibility as they have to maintain a network that is adequate to provide services to all their members and that means they have to pay enough to make sure they have that can that works the same as new as is insurances those interest counties have that network adequacy requirements they have to have enough providers and if they say we're going to pay you you know two cents then there are other providers they can't meet their obligations. Now with that said we know we have heard the concerns about that language and we are going to talk with the passes about adding some language back in there's nuances there I think we have to work through we're looking at that but with that said at the end of the day as of right now all the passes are paying at or above Medicaid rates for their in network providers okay well I think we would all agree that the therapeutic communities provide a vital and essential service for our state Cnidus and a decrease because from what it would be to keep these folks and state hospital and the state hospital doesn't keep anyone anymore and so these therapeutic communities a stepped up to fill that role and a decrease cost again from one of the if that they're in the state hospital so certainly I hope that. The bill would receive at least the base Medicaid right but instead I'm not a part of that negotiation necessarily representative Vaught your record. I'm tired only. Sure. Senate Johnson you're recognized less off the counter. A my question is if the state hospital wanted stand better the role it plays in in the role and how that test with their P. community so I guess my specific question is as I understand it the population that comes into the state hospital or coming on the ACT nine eleven that did are those people ever directly going into level one care court ordered or the or is that only coming straight to that does that question make sense so eighty because sometimes I was under the impression that that the they're pretty communities or serving as a pop off valve for the state hospital taking people that record ordered and bypassing the State Hospital that's not what happens is it. I'll I'll it miss miss Gander especially is our expert on yeah I'd like to better understand how that there P. communities does tell to help offload the state hospital that burden because that that I could use some clarification on that front and I will add the District Court. Hi it really any placement in one or another is gonna be a little pop off valve because because the hospital stays full to the extent that someone is ready to go into a less restrictive environment and we can get them that less restrictive environment yeah it the releases that pressure enables us to move somebody else in who is waiting for a position at all at Miskin answers to the questions. Thank you Patricia and deputy director division of aging it don't matter of services. And the state hospital. The large portion of adults who are in the Arkansas State Hospital at this point are they are on some type of order forensic order we have very few there under civil commitment anymore the majority of them are under forensic orders and the process for that forensic course there's at three twenty seven fitness evaluation three twenty eight responsibility evaluation. And then individuals who are found on restore herbal or who are deemed to be a safety issue as you say are often ordered into the state hospital certainly we have worked with our partners the community mental health centers but three thousand and and Brad to try to divert individuals from the state hospital in the therapeutic communities they are full as as is the state hospital. But we certainly want to divert individuals from going to the state hospital into therapeutic communities that that's appropriate however the majority of individuals are going through the Arkansas State Hospital and either going through the restoration process were becoming stable state hospital and then being referred out to the state hospital either into therapeutic communities they can become nine elevens that that is certainly true individuals who are not restored or cannot be restored cannot become a nine eleven so that's an entirely different population of individuals but the nine elevens do you often leave the state hospital especially if there is a safety risk and go into therapeutic communities and hopefully hopefully I answered your question but if not. Ninety I'm sorry it's my fault I'm to come work yeah that does answer my question that it did it opens up more questions but all I I can **** off line because that just creates more things I don't understand about that we can take time away from this committee tomorrow night thank you. Representative ought you're recognized thank you Mr chair so miss Elizabeth not to contradict what you said but I think you stated something incorrectly. The rate decrease was not it was done through the help task force and my not right miss Paula. I think the rate I think if I remember correctly and everything I've been sitting in the decrease came from the health task force when that was going on due to other states charging their rights were way less than ours and ours were like three times higher than most states that we connect to a no problem I can tell me that I'm wrong but I think that's what I remember and several of our committee may have probably right like I said I wasn't here I just want to leave I don't want to be on record being wrong that. Paulison I'm with department Human Services and I work with Russian division of aging adult behavioral health services as well as the list but with division medical services and so I was here at the time and so while we were doing the healthcare task force we did a whole behavioral health transformation you're exactly right during that time we did two things we set the rates we had a rate setting activity which was as it was that state survey sticking person survey for counseling services and those are just the services provided like outpatient individual counseling group counseling for those services that existed that we kept in the system and then we did a whole new were right of services branding services that had never existed before and those services included all of our home and community based services and therapeutic communities so there was no therapy keep a community right prior to that time so that was in a I knew we separate and then the rate changes came to those counseling services thank you add one I didn't want there to be some type of confusion for any of us that's heard something differently thank you. The representative right you're recognized. Thank you Mr chairman you know mark we heard at one point here that day the fares were not going to increase their rate okay now if that's the case. If there's gonna be an added cost a county explain this force what would the increase they aren't four is is actually going to take us for this transformation as far as Arkansas dollars can you give us an sure I can touch on that so that's what we are expecting CMS to up well everything we don't know of any reason that CMS within not this requested increase and so I think we're expecting the approval if it does it'll come in at the hence match rate that CMS is currently paying because the public health emergency that is going to be going away and so when the public health emerging spires whether it's this fall or the start of next year then we going down from its about seventy eight percent now believe roughly down to about seventy percent or so In our regular matches he's very close or regular match rate is around seventy one percent by getting about six point five percent increase to somewhere around seventy seven percent right. Can you give us a projection mark of how much more this is going to cost the state of Arkansas I'm sorry for the for these their community. I don't have it with me we can get you that we did school impact we did that the spot so we can get you that information look at that for. Senator reckon you're recognized. Thank you Jeff. back in the fall of last year I was in a public health meeting we're discussing CSS peas. That ended in I'm sure you're also several times since then but there's something online to CSS peas we're going to start doing to see work and be reimbursed for that and vice versa is that correct. Yes therapeutic news that is one of the services that a CSS provider cannot. So are there any CSS fees being paid for therapeutic. Community work today. Right now it would be that these to occur today and we both burst out no other one no one else has been paid for December. I'm sorry we do have we do have some others I'm sorry of yes we got to harbor house which runs a little wanted to Methodist has level one and two a lot of strategies has little to only and recovery health systems little to only all right a great memory there. So we do have several providers that are offering therapy okay so the. Back in the fall when the public health committee was meeting was taking place the idea behind it was CSS please consider going to seize to seize we'll be certified CISSP so they could be paid for either services are providing the services but what it sounds like happened is CSS peas were able to move forward TC's or not ever paid their increase and they've been working on it for eight months is that correct the the T. C. rate is consistent on both sides of that equation what would you expanded the number of people who can do IT zero converse eighty six it's will with the the flexibility isn't that we put in place those put in place on the CSS B. side and so that's a so yes if it's if it's easy provider want to take advantage of those they were switched the CSS P. side. But am I wrong the part of that agreement with the TC's to. Yes not oppose that was at the rate was going to increase okay no that's not trade but that was kind of the story was told of those that is an actor there is also that was part of the conversation I don't wanna say those actually part of the of the trade because I think my memories they were two separate conversations but they were. They're certainly topped with those two conversations the very least. So fall last year just to summarize their CSS peas in TC's were paid separately for two different types of work. Before the meeting before before that season seasons we did not exist before that okay so you know we create a new provider type right that allowed people to refer organizations providers to receive compensation for T. C. work without actually being TC's well without going under the old mail is right that there was a given that new manual which is I think to their advantage and it offers more flexibility as and as gives them more opportunities and the reason why the project using communities at the time did not oppose that or speak against that is the part of that was an increase daily rate. I think it well lease the main conversation at the time was around they were wanting those increased flexibilities and so am I so this all seasons B. as the way to get those increased flexibilities. All right am of respect and the actuaries The passes. Cozart the daily rate. Yes good day rate given a small number of individuals in it and the way that they decide so the rate looks at how much those individuals costs at the look at the mix of everybody inside of the past and how much they cost at because of how it was that yes the rate is broad enough at this point and according to them to absorb that but like I said they also build an adverse court order so if the assumptions are wrong that they make when they make those determinations the recorder will play out and if the passes and that in fact spending more money on that population or those that build population than what we anticipate that we actually treat them more. So that would be very minimal if any increased cost of the state. You for increasing the daily rate to these TC's that is what we. Thank you. Senator Gilmore you're recognized. So I may just show my ignorance here but I just I need to ask how many the help I think the couple hospitals that provide I guess more acute care for these type of individuals how many of those are there in the state. So I'm Trish may also want to add to what I'm about to say make sure I don't see anything wrong again I bet my understanding is for adults there are there freestanding inpatient psych units for adults no there we pay we pay for those services through acute care hospitals Senate president and since the gentleman that testified this morning and those type of plays yes the savings was so what is the rate for that is that it's our hospital inpatient rate which is up to eight hundred and fifty dollars a day up to okay okay. Thank you. Seeing no further questions we appreciate you being here today and offer testimony. Thank you. Looks like next we have the passes Arkansas total care CareSource empower. In summit. We have looks like representatives from each of those passes who are here with us today I think the easiest thing to do would be to ask all of you to come to the table is probably not a chairs there but if we could maybe get staff to add some additional chairs. I think that would be easier and more efficient than having you guys come one at a time. Thank you. Okay. Turn. Okay appreciate everybody being here today you guys are probably gonna have to share the Mike. A little bit but when it's appropriate and there are there questions if you would mind to share your Mike. With their neighbor I don't know who we who we have where but I'll just say let's start on my ride the jury would introduce yourselves and who you're here representing and then if you have presentations that you would you like to make you be recognized to do that. Thank you very much Brian Meldrum I'm the senior vice president for planning product with Arkansas total care. Jack Hopkins Arkansas total care. I'm Jason Miller on the plan president for summit community care. Good afternoon my name is Mitch Morris I'm CEO with empower healthcare solutions. Good afternoon any candle interim CFO for CareSource pass. Good afternoon I'm the chief financial officer for the market for cures was passed right Preston. Okay so you guys have heard the discussion that we've had thus far I'm not sure if you have a presentations that you prepared to make today but regardless if you have comments or presentation if you'd like to make about the issues that have been addressed so far I will start to my right I think it's total care if you guys would like to. Address some of the issues offer some remarks you you're recognized to do so thank you very much so I think I want to just comment on the T. C. rates and how we approach this Our contracts exist with these entities today and in our contracts is a reference to the Medicaid fee schedule as the basis for our reimbursement today and we are sort of structured so that we take our lead from changes that Medicaid might make to the the schedule for the for service Medicaid once those rates are set and then we have a opportunity in our contract to implement those rates within so many days just operationalize the the rate in the system so that's our normal process and we do all of that on a go forward basis we do not retro rates and really the reason for that is because we've already process those claims there's a specific cost to going back in managing those claims and pay an extra amounts and we just don't really operator check but that way we operate on a go forward basis so that's that's how we look at these rates we have made an offer to all of the providers who are providing services to our members today for therapeutic communities and I'll go head raised my hand we're we're the ones that are offering the separate so from our perspective we were looking at a separate that would occur in the contract and then a rate that would to move them all the way up to a hundred percent the Medicaid rate and the next step so that was our plan that's what's been offered for a July first implementation if they're agreeable. Again Jason Miller assignment somewhat similar to Brian I think retro is hard it is challenging because you're going back out what we are agreeing to to do a retro but we also did I request to do a potential increase effective July one and then agree to retro if the state if the that gets approved because keep in mind even though the state publicist see Mister has to prove methodology right and asked us to go through so we were we wanted to err on the side of caution to make sure that things were going to be published in the rates were going to be what they would be in that we would agree to to adjust accordingly so we're working to do that we have been talking with them with them there it's just until you sort of know things land I think someone brought up for about the the difference in time and what one of the issues that about the Medicaid base rates and it is true that passes have the ability to negotiate but when I write studies done by the state and the rates are published whether they're of this in the schedule of the route it that's one pass and then we come in and have to come in on the back end of that so it's a little different than saying Hey I'm a provider I'd like to have your in I'd like to have an increase let's talk versus a set of rates that were out we have become so we've been coming to back back into those to make sure we do that so again completely agree with Brad three thousand we talk all the time we know there's or a need for three B. committees rates to increase we probably wouldn't have doubled the rate and enterprise fully probably with a phased into that a little differently but they were increased a hundred percent and all at once so we would and we probably would have looked at a phase in rate over time but we are we're trying to just so no presentation but just to comment. Right. I miss Morrison how are healthcare solutions so totally agree with the the prior comments on my colleagues have made and and some of the considerations that we take into when when we look at rate adjustments I despite those those those considerations which are very true and and fair considerations and concerns that times are provider ownership group made the decision last week to go ahead and align with the anticipated rate increase in advance of those being formalising finalized and I think nobody ever everybody would agree with this I mean it's just recognition of the importance of those services and and care that's provided through those providers to our members we decide to go ahead and and and kind of make that move in advance knowing there's a little bit of risk involved is my interest because we do as the as you heard for DHS college we do anticipate that that will be formed formalized and final here within the coming weeks but it's also based on what we hope to see in another provider to see this to is just more collaboration from higher pay your side to the provider side because we are aligned in our primary mission being to care of these numbers any Medicaid beneficiaries and these are very challenging members very challenging clinical cases in and complexities that come into play the challenge a provider certainly the challenge us as a pair and and health plan as well and so it's just we kind of made that decisions from that Winston from from the from the care lands and that we in in recognition of the value and the need to be able to make sure that our members can can get the services I think we'll. Good afternoon any kind of care source pass just to give you a little bit of a different perspective because I think the care source pass it's in a different position than than my peers. We went live January first of twenty twenty two so we've only been in operation for less than six months at this point we negotiated contracts with these providers in the fall of twenty twenty one so we've been actively you know negotiate or we were actively negotiating those contracts at the same time these discussions were happening around rates for us our contracts are set up a little bit differently said do we do allow for automatic adjustment of rates based on Medicaid fee schedules retroactive date back to the date that the Medicaid fee schedule was amended serve in this particular instance once this disaster spot is approved we will automatically adjust rates ninety Cup coincides with the Medicaid fee schedule retroactive back to the effective date or the date of go live which for us is January first of two thousand twenty two so that will be taken care of we are one of the passes that has been actively negotiating those rates outside of the disasters file trying for us it's a little bit more challenging because again we only have. Six months and market less than six months a market which means we have even less in the way of claims experience or utilization experience which means it is more difficult more challenging for us to set an actuarially sound rates on our side to acted to inform those discussions so that I think is is a summary of our care sources that today and and how we're approaching this renegotiation. All right thank you so much I will now move to questions representative Cavenaugh you're recognized thank you Mr chair. I have a set of questions I had asked all the passes to provide me with some financial statements earlier on and I've got those and I have questions based on that information and it'll be the same questions for each one of the passes and if you don't have the information if you could please give it to staff and they can give it out so I'll just go real quick through the questions my questions is do any board members get paid either a salary or per diem for standing on your board. And then are contracts between board member providers same as non board member providers. And our contracts difference between nineteen agency providers and independent practitioner providers. And if so what's the justification so if you've got an agency that's a provider but you got a standalone sole practitioner. So what's the difference. we hear a lot about the passes made this much money in dollars what I'm really county interested in is in the the money that you major profit what is that a percentage because the percentages of better tale for me of what it is if you can tell me like is it one percent to three percent you know whatever whatever it might be And on the financial statements that were provided there is a category called general administrative expenses. If you can provide me what is made up in that category. And how much goes to each one of those in that category. And. What is the percentage of salaries and benefits paid as it compares to your income. And just finally on an Arkansas total care. on your twenty twenty one financial statement that you provided it didn't provide me with the assets and liability or the income and expenses. In the report you gave me it did not provide that if you can get that to me. And on summit if you could on your financial report it does not less to your directors are if you can give me a list of your directors and what position they might feel and also when you're twenty twenty one info it does not have the asset and liability in income expenses and I did not get your March twenty twenty two information and I can get that also. That's my questions thank you. It ended procedurally I guess I have a question at this point representative Cavenaugh are you wanting some answers to some of those questions now that can be answered or do you want all that provided to you later. And we can take a one by one what we can do it however you want I wanna make sure if you've got questions you get unanswered if you don't wanna answer right now and you want me answered later we can take that up you know set off line but that's totally up to you. If they have the answers really quickly they could give them if not then they can provide a I don't want to just drag it all out all afternoon but if some of this information can be provided now would be great but I know some of you might not have some of this because it's a little detailed. Yes Arkansas okay we'll answer the the financial disclosures I don't have that right from the right this minute however are or board members are not paid extra salary for C. R. board they are made up of members of our ownership structure and then all that Bryant's of the contract questions. Yes so the but I think your first question about contracts is is it equal for board members and non board members yes Sir as providers and the answer is yes those are stand we have standard templates we're operating under any willing provider provisions under the regulation that the insurance department and provides and we operate other lines of business under that same regulation so we really operate you know across the board in terms of our contract provide to providers their consistent the language is consistent the rate exhibits are consistent and the answer for your second question about independent versus agency a licensed independent person would get the same contract offer that an agency gets the only distinction would be is if there's a distinction in the fee schedule that comes from Medicaid. Hi this is Jason with summit base the same answer board members are not paid all contracts are built on a template that is universal for all of our providers again the Browns point there could be nuances that based on negotiations or something with a particular provider for something specific but overall we do not certainly do not paid I do not have different contracts for investors or board members versus for the day our providers and I have to wear two hats right there board member sometimes and they are providers but they are providers and so they do that so that there's no difference there and same for independent practitioner so they're all providing the same primarily because they are providing the same service on the medic right so it's it's no different. Hey this is Mitch within power I believe I can say that to these but I want to be sure so I'd prefer to provide all of these in response in writing thank. same for forecasters Paso none of our members get a salary but the remainder of the questions I just like to confirm and get you in writing thank you. Yes yes you guys would mind you can provide those the. Doubt for for this committee we would appreciate it centre back Americanized. This is for all of your yes individually. Meeteetse members each of you have and how many members total do you have. So for care source I can speak to that we have about somewhere between fourteen hundred and fifteen hundred members in total today and we have seven T. C. members. The. Yeah. For Arkansas okay roughly a hundred. Hendren to see members yes Sir washable number. Yeah sixteen sixteen sixteen thousand okay. Should come with a number I think I probably have the most to see members but about seventeen thousand eight hundred members total I'm I'm not positive on the number but I will get that to you but we do have a fairly significant number they're pretty committees. Yep FOR in power right at around twenty thousand total members have to follow up on the on the T. C. specifically. And just follow up on last on the question no board members are paid any differently than any other number at all. No. Different type of billing or anything that they can do that so the scope of any other man. Your term of the provider yes Sir so it is possible that a provider as a provider CEO could have negotiated a different contract right but is not because they would be a board member because that happens is in San in any provider can't do that with this or are contract at times contract things I can't defend of say that is that the same one you ask for a pay raise for a service and I happen to be a board member number member or that could happen but it's not because our sense yes and I think that was so you're going question under the other question was the when a covered money was going through the passes in the H. us during board members receive large sums of money from. From the passes for a related expenses we did add some that we do not do code related expense amounts we did do a value based program where we were allowed for providers to do quality based work and incentivize for work but it was not code specific could you give an example quality base for meeting certain metrics around appointment times I have to get to the list but there were things I had to do in terms of the clinics and and doing certain deliverables to help the members get in getting members in for their appointments during cope with those kind of things that they met those metrics thank you receive value base very base is a common practice and managed care where you actually pay folks for quality efforts and quality hours we did we did that we we didn't we didn't give COVID up thank. The help I can give you the the actual program if you'd like it was given to the degree. Sure that does some of the. Okay. COVID related I just wasn't here and I can have that to list the following questions yes. When. We have yeah we have been in operation or yep FOR total care there there wasn't any covered relief funds we allowed all of the waivers and exceptions to services that DHS allowed us to pass through so if you could deliver a service telephonically during Kobe you're allowed to do that and then you can get paid like brewing in person so that's the way we helped facilitate access to care contract wise no provider who is a owner of the of the pass as any different distinct difference that contract for compensation. Thank you. I do have a question and that I should know the answer to this I'm sure but for each of the passes my understanding with the provider led model is that the providers are essentially teamed up with an insurance company who is the insurance company involved in each of the passes so total care I'm guessing seventeen that is correct okay CareSource. As care source okay. Simon is is anthem. For and how we are no longer partnered with a large insurance company we do have a vendor relationship that processes are claims that she's provider payments a lot of that back in administrative functions. Okay. and then the specifically we talked about two of the the two entities that were here testifying today birch tree communities and mid south health systems were risa Health are they I'm trying to understand the dynamic of it all they're provide those their providers as my understanding. But then. They may also have a seat on the board of one of the passes. DO this birch tree have a seat on the board of any of that these passes. In the past yes which one seven summit Committee care. Birch tree on the board of any other. Okay and then. mid south health systems or risk a health or they are on the board of any of the passes yes also on the board or something okay any of the others. And my understanding is that those are the two main entities that provide therapeutic communities in Arkansas I I know do you just mentioned some others but my understanding is that they don't maybe operate that those types of facilities in Arkansas they may have the capacity to do that let me do it other states but they don't do it Arkansas. And maybe DHS can answer that but that was my understanding. You are used reserved you're speaking of a thirty committees programs for these folks. I guess my what I'm saying is. The two providers that we've heard from today birch tree and. Midsouth slash or is that they offer therapeutic communities within Arkansas and are they that they operate these facilities within Arkansas there may be other companies that provide the same type of service. But are those other companies operating in Arkansas there are other companies providing this they're just not here today okay we'll get in and I think the distinction is that the other folks that are involved in providing therapy communities are are generally focused on the TV side. Where is these folks are are the main players on behavioral health side right right and I'm speaking specifically about behavioral health not DD right and and regardless of whether located they have to be in Arkansas Medicaid provider rates approved in can contact with so is there any are there other any other entities other than these two that are providing therapeutic communities for behavioral health in Arkansas. Mark if you'd like to come address that. Thank you Sir Clark what DHS does gonna say that the other there be committees I believe there are some that do be at B. H. working actually can do we here all for the key distinction for the mid south and four burst three is those are the two that take individuals out of the Arkansas State Hospital right and that's what differentiates them from the sea of the others okay thank you I appreciate that that. Those are all my questions Senator Beckham you're recognized yeah I Mark if you. A question of it's going to be for an hour for DHS. During the. The Germans a lot of questions there is asking who does who's your insurance company partner and power so they don't have one. Wasn't part of the laws to establish passes requiring that. It does not require them to have an insurance company as a partner they do have to be licensed by the insurance department and so they have to meet certain reserve and other requirements that typically an insurance company is the best position to fill it but in power has those arrangements in place they can fit those requirements on their own Legislative intertitles firm private investment firm or. I'm so we have six board seats one of those is filled by a capital partner and the other five were filled by Arkansas based provider organizations. Okay. Thank you. Okay sitting no further questions we appreciate all of you being here today thank you so much for answering our questions and. Offering your remarks do I see a motion to adjourn. Motion it's center back on second representative Godfrey this meeting is adjourned.