Public Health, Welfare and Labor- House & Senate

Members of the committee we are getting ready to start the chair sees a quorum. A I have a few little noun Smith's first I want to welcome everyone to the public health a public health committee meeting today and we do have a long agenda so we would ask that the committee be aware of that and if we have legislators that are here that are not on the committee that would like to ask a question we ask that they would wait until all the committee members have had a chance to ask that question or ask a question and then ladies and gentleman we are not taking any action today we are just getting the most current updated information on COVID and on the of variance and so we would ask that to you understand and we will not take any comments from the audience of we again we're on a limited time schedule and the we appreciate your understanding and with that being said. Yes a my co chair would like to make a comment. Thank you senator of I just want to thank the agencies for being here this morning some of monster very short notice so I appreciate so very much coming today and also isn't Bledsoe said we're very limited on time education as a meeting in here so that's a hard stop for us so we're very limited so we appreciate everybody working with us on that all right the other thing I'd like to mention is the next meeting is a. OWN March 7 but that would depend on when the fiscal session which starts February 14 when that actually ends so be attuned to the calendar and keep watch because that could change right with all of that said we would like to start our meeting with the the. The approval of the minutes do I have a motion have a motion second all those in favor say aye all those opposed thank you meeting the minutes are adopted and now we're going on down to D. and to to speak with us today we will have from the Arkansas department of health Dr Romero who secretary of health Dr Delahaye who is the chief medical officer of the Arkansas department of health.to Qatari who is the outbreak response physician and Mr Adams who is the deputy director of administration and operations if you would please come forward and introduce yourselves for the record. Good morning because they were male secretary of health. Good morning Jennifer Delahaye chief medical officer for the Arkansas department of health. Good morning I thank god Hannity infectious disease physician outbreak response all right and done it done Adams could not be with us this morning okay thank you all right we SO appreciate you being here and we're having this meeting today to discuss the effectiveness of the vaccine based on the most credible and scientific information available and since we're love story we feel like the people of Arkansas or listening and that to of they have a vested interest in knowing what. We're going through what we might be going through and as a matter of fact one of the reasons I wanted all of you to come today was because I was in a small business about 3 weeks ago and the owner of that business was concerned that people weren't coming in and that may be because of the McCollum variant that the people were becoming frightened and that possibly this was going to have a fit affect especially on small businesses in the now we're hearing reports that the the numbers affected by Omicron or diminishing and the numbers of House hospitalizations and deaths or fewer. So what we see today is the confirmation of these recent reports and to Dr Romero would you like to start the discussion thank you very much chairs Bledsoe and Ladyman and representatives and senators I'm yes at so we have a thank you for having us here today And we I want. Make my comments long just to inform you that we have provided hand out for you a summarizing vaccination status are hereby age in the state as well as vaccination status of cases hospitalizations and deaths since December of 2021 available therapeutic options a map showing distribution sites of these therapeutic and preventive options as well as the latest data on our receipt of monoclonal antibodies both of. Post explosion pre exposure and antiviral agents for your review and for questions so I will entertain any questions that you all have at this time all right let me ask you this. Would any of you like to start off by discussing the effectiveness of the COVID vaccine or any. In any other aspect before we get into questions I certainly would so um COVID vaccines have been proven to be highly effective in the prevention of severe illness and death in the United states around the world if you look at our handout our second handout you'll see that those deaths that we're seeing in our state hospitalizations they are made up of primarily and all by individuals that have not been vaccinated or have not received a complete immunizing series or booster doses we know that the the novel of the newest variant of the on the crime variant requires a booster dose in order to have optimum immunity against and as you can see those individuals that have been boosted it form very very small percentage of the total number of individuals that have been hospitalized or had us here in our state of the vaccines have been shown to be highly very safe throughout the United States and they're being monitored by a day and reports are being issued to the CDC about adverse events we have of 4 to 5 very robust systems to capture adverse events and they have been effective in identifying these events very rapidly these events that are brought before it the CDC adjudicated with the ACIP recommendations issued within a matter of days to weeks so the the vaccines are effective they're available throughout the United States throughout our state and we have no shortage at this time uh vaccines. All right the is there anything else either one of the other 2 speakers would like to say before we get into questions. Okay all right all right of Senator Hammer you are recognized for a question thank you measure Dr Mary let me ask you when it comes to the adverse effects of either the vaccine itself for the poster. Who is it that determines and you hit out of state government which expand a little further who is it that determines that whether or not it was an adverse affect or not explain that process which please yes so every citizen in the United States physicians nurses any healthcare provider can report and what they believe to be an adverse event I to the CDC through a system called bears and the CDC collects this data analyzes it and then determines whether the signal is significant enough to warrant further investigation and based on that then the investigation is undertaken and and decision is made regarding the significance of that Baxi of that the vaccine a side effect. And does the health department itself and have any role in that or is it all direct between the whoever's reporting that a nurse a doctor and do the patients have an opportunity to participate in that process result filtered through the doctors or the medical provider no the the the the patient can directly report this to the CDC and then the CDC can reach back out to the individuals or the hospital with the individual's been hospitalized to obtain their medical records in order for the review the. Okay and where would we fight it that's not anything issued handed out today is that the number adverse reports for Arkansas I don't have the numbers your doctor delay you have the number of of total adverse for the defense. So. For Arkansas we've had a total of. 473 a serious adverse events and that and 3777 non serious adverse events all this after vaccination are received of also are required to be reported even though at this point none have been associated with the vaccine and those are 95 so we have a total of 4345 at reports and bears for Arkansas. And I just like to get all you get with health line read like to get more information about those reports and what those adverse affects or so sure I'm happy to do that thank you thank manager Margo barbecue for one more question thank you all right representative Ferguson you're recognized for a question. Thank you madam chair I guess I have a question about the treatment is the distribution in any way related to the case load of Kobe cases because when I look at a map I don't see a single location from West Memphis secret and county that has access to the romance. So we receive an amount of of antiviral from the federal government that is determined in part by the number of disease by the mental disease we have a number of of individuals in the state that have there are a number of individuals in the state distribution is determined in part by the sites available to distribute the vaccine and I'm gonna turn it doctor because sorry and have them comment more about that because he has a finger on the pulse of that. Thank you doctor metal so a yes thank you are could act that it does depend upon the active caseload and what we try to do is divided based on active case load per and housing population and try to make sure that all the 5 public health regions are you presented IT quickly I'll close that is being a shortage of Orlando vitamins through chat and that is that is one of close and that is why you see certain counties nanti presenter just because we don't have enough does is to go around. So in the map I'm looking at is accurate there are none available in print and county is that. This map was made I think Thursday of last week and things almost injured 90 basis so I know that there was some allegations made on Friday so I council shall see that either that county's representative or not this morning so so how are physicians being notified of where the Mets are available and if they're limited to the specific NIH usage are. A lot of. Book from my the the the EDH has gone into physician outreach the ward weeklies on because Board website as well as that physician groups what interested I've done that allows for the Arkansas medical society and we try to inform physicians and keep them updated on various sites are because that's changing almost on a daily basis we have a website of which has a link to all the maps as well as bad product but most likely be found. I have a question about the monoclonal antibodies teaching come back to me right. Co chair Ladyman you're recognized for a question thank you manager of your doctor at one reasons I wanted to get this on the agenda was to just talk about the treatments that are out there and not not really the medical community but that's a very good question that represented Ferguson asked because I was one about the same thing but but when I talk to people I even talked to a couple of reporters the information newspapers and they weren't aware that there was treatment even available so what I wanted to do was just get this information out so people know that we are making progress and there are treatments available and I just found out this morning one that I didn't even know about so in your handout the COVID 19 treatment options. Could you just go over I mean you've got 3 different categories there could you kind of summarize that just so people understand that Hey these are out there and I know they're all prescription but just so they know that the options at their doctor might have yes thank you very much representative Lehman so we have made efforts to communicate to the general public even in our of press conferences with the governor I and he have of repetitively talked about these agents and this is a this a handout which you have it was actually shown at one of the press conferences and as been updated so we we can divide these these therapeutics into monoclonal antibodies and into anti viral so moving from the left of the hand out to the right we start with the of approved a monoclonal antibody that is available currently to effectively treat a COVID variant in our community and that is so troll the map and that is started once a diagnosis is established and if the individual has a criteria for a treatment of the disease and is given through an infusion so that is so trove amount are there are oral antiviral agents available to us and at this time within the state that we have a larger supply of antiviral agents and we do of yeah I these therapeutics such as monoclonal antibodies and so there are 2 currently you a approved medications one is called mon you pair of year and the other one is called packs loaded and depending on how much granular you wish we can return I can talk about them and how they work these are started once an individual has been diagnosed and there's a finite window within which you need to begin them for them to be effective. But they do prevent deaths and hospitalization and then we have what we are called pre exposure monoclonal antibodies and this is every shield and this is a monoclonal antibody that is infused in used primarily for high risk individuals that have immuno suppressive conditions and most likely these individuals did not respond appropriately to their and about their anti us or their vaccine and so this is it and added insurance policy so that they do not become sick this has to be administered before a contact with the virus it protects the individual for approximately 6 months after having the infusion. One follow up please a. Dr Merrill 1 question I saw on the it was a either a national web pager on Newton it was nationally okay wasn't state of but they talked about the monoclonal antibodies not being as affected with the Omicron variant but we're we're still using that for the home come very and and still is effective yes thank you for that for that clarifying question so so we have a number of other monoclonal antibodies available to us in this country many of those several of those removed at this time by the FDA because they are not effective against the Omicron variant they are effective against predecessor variants the Delta variant and the parents before that the beta of the current the current variant that is circulating in greater than 9995 percent 97 percent in our country is the only crime variant this is the only monoclonal antibody that has efficacy against. Thank you for. All right the. A representative Payton your next. I thank you madam chair and almost canceled my call there because he just answered 80 percent of my question on the monoclonal antibodies I was curious why this list of treatments is so short in each category also you answer that but from personal experience of. I know several people that were prescribed as if their masks and why is it not on the list is this my scent can be prescribed but at the discretion of the physician it is an individual choice that it should be made with the patient but it has not been shown to be effective as an anti viral agent for this particular for this act a fork for coping for a sars CoV 2. Okay so is it may be because they prescribe for secondary infection it is possible Sir but without knowing this but the particulars about the case I can't comment about that okay thank you madam chair all right thank you C.. Representative Bentley you're recognized for a question. I thank you chairman thank you all for being here today and as well so my questions of already been answered can you first on the distribution of the overall and of ours can you tell me why we so much for going to Walmart I'm just curious about the distribution here as I'm looking at here can explain that to me 31 a current. Can you excuse me would you pull your microphone up to your. I'm not hearing you quite as well as that thank you thank you representative the reason level mark was chosen initially was because these products that release just before Christmas and leave the door there to be there only able to die after the fact G. day partner to start off distribution we actually have increased distribution to include a lot of community pharmacies and that keeps on getting added on a weekly basis soul V. have died out that CBS and that to the community pharmacy network and they get distribution is that. Okay thank you for that and for all of you here have you have you doctor treated any COVID patients at all yourself. In a hospital yes ma'am okay I guess that is I think it's very important we hear as well say for the record that I have asked for physicians that are actively treating publication successfully 7 covered patients successfully across the state across the nation to be here so we can hear their great reports on some a numerous medications that you sent include a host of therapeutics that they use and I hoped we could hear from them to them just kind of disappointed that we don't have a stations that are actively treating cases here today because there is I can set a host of therapeutics I've been reading reports reports reports after host medications including ivermectin huge report I just heard at today so can you tell me any other therapeutics in one quick question out of going to queue after this chairman but I don't see him disappear listed on here and I know that some patients are still receiving even though the who said it's not effective so can you give us your comments on that Dr accretion. So the the address fidgety presented on head of the ones that you're easy way and the check distributed through the US government so damn does of it as a fully approved drug and it's not distributed through the US government 88 as normal in that distribution but just by a and best of it and other drugs in our district has. I'll go back thank you chairman thank you all right of center so Sullivan you're next thank you madam chair yeah I'm back over here so you look at the history of vaccinations through the course of the pandemic I've looked at a lot of research today in their vaccination rates vary from state to state yes the the how significant the. OR covert is stays about the same everybody's got that are lot of people have so and there's also been some recent studies and backs them studies historical studies on the effectiveness of the lockdowns could you speak about the effectiveness of the lockdowns that we went through. Yes so the issue of the lockdown in in in our state or in it in the nation overall I'm just wanna make sure I understand the question. Well how effective with the studies are saying that the lockdowns were not very effective. Some studies going back to 2020 saying that and most recently you know they had it's not just the John Hopkins study but other studies that said the lockdown for really not very effective so could you comment on those studies so in those studies that show that markdowns that were effective they were prolonged and and universal throughout the throughout the the Society or this country that was being used shorter lockdown were not effective your correct and that is because the individual in that society expose themselves over and over again so in general short period lockdowns were not impacted so what so where the effect with a lock downs that we had in Arkansas did they achieve the and the intended purpose or we affected I think they slowed the the the spread initially but in the long run as you can see we continue to have widespread disease an infection to route the the the pandemic and really the the virus that was dealt with initially has different characteristics of what we're dealing with today. So is that a yes Sir no I I I believe I answered and said no it was not fairly effective for preventing the the the the path of the defendant also and I'd like to request some information if you could on your on the vaccination status by cases hospitalization death do you have that same information with comorbidities. I'm sorry that do with the individuals having co mortgage mortgages sort of the people that were vaccinated versus unvaccinated and the comorbidities of each population I'm not sure we can we can see if the if our epidemiologists can call that information that you think are comorbidities significant and the rates of cases hospitalizations and deaths Committee certainly are a cause for the increased risk of hospitalization and death but we also know that individuals who are healthy can succumb to severe disease and die hence the need for that data so if you could get that format appreciate it thank you thank you madam chair all right the representative Dotson you're recognized for a question. Thank you madam chair or to right. So looking at your your hand out here it it appears to me that we've been having quite a few people get booster shots and then I'm just curious what is the percentage of folks. Of the shots they're going out right now that are boosters verses initial vaccinations yes so roughly 5050 percent 45 to 50 percent of the total amount administered each day are in the form of booster shots so. But only about half for our. Initially coming out and saying Hey I'm I'm ready to get the vaccine initially no it's actually less than that Sir I'm so it's up to 30 percent or less receiving a primary shot okay so they'll so we we can we look at this data from individuals that are receiving the primary immunization the first dose we also break it down as to who has received the first and second so who's receiving the second does and then boosters so roughly that is 50 percent are getting boosted okay a quarter to a third 2 with 30 percent are getting getting the first dose and the remainder getting the Secondus gotcha so. The vast majority of people are that that have gotten vaccinated or going to get vaccinated largely they've they've already been vaccinated we're we're now focused on a much smaller group of folks that that is out there and. For whatever reason decided not to to this point how much I mean we're we're looking at all these my client of bodies Orlando virus and other treatment options that are are designed to help the vast majority of the folks hopefully that that for whatever reason haven't gotten vaccinated because that's the ones that are at higher higher risk of serious disease and hospitalizations and all that. But for whatever reason that's the group that's not getting vaccinated and so. What percentage of your ad budget are you putting toward trying to encourage or let those folks know that there are treatments available to come in early because it seems to me as if the longer those folks wait Senate homeowner stubborn the higher their percentage chance of going to the hospital and having a severe consequences if we can treat them earlier. It's more likely that they won't have dizzy heights hi disease and death rates in that population that are for whatever reason I made the decision not to be vaccinated are you making that shift in your ad budget to try to get outreach to those folks to come in. So so thank you Sir for that for the question I I didn't come prepared to talk about that but we can get you the those numbers but I'd also like to point out to everyone that the number of fear reputed doses we have in the state is extremely limited and so that to put your faith in therapy instead of a vaccine is is if I can say ill ill placed a because there is not enough to go around I'm and you do not always get the therapy even if you're positive because there are a number of risk factors that go into deciding who should receive the the medication so the best form of prevention of of of hospitalization and death is the vaccine not to wait for the therapeutic. Thank you all right to anything you senator. I mean have you finished representative thank you yeah our. Okay a representative Gonzales you're recognized. Thank you madam chair I want to ask about the the monoclonal antibodies so you have one listed here that's an approved you a treatment it is it necessary to get you a approval before using these presence. Medications are used off label all the time that they show effectiveness for treating any type of illness or disease whatever I'm sure you sure you'll use a like that as well so do you have to have that you a to use these other. Monoclonius to treat COVID so so it just clarification. That issue is also monoclonal antibody so there to listed on this okay okay so these these agents are released to the general public through an easy way by the FDA right and they're indicated for the uses okay that are listed in these categories indeed physicians your are correct are allowed to use drugs off label but the at U. A. for the use of the other monoclonal antibodies has been rescinded at this time. That's what I'm asking was that even necessary to have that you a to to use those Monoclonius to treat COVID or the other the other variants of covid and it and is it necessary now the the positions have to stop using those monoclonal bills because that you A. was removed. Well certainly that they're not available because because there is no you a indication yes so so the use of the at the the monoclonal that is not indicated for this is is not corrected on many levels levels it is inappropriate to use an ineffective therapy for the treatment of a disease so let me let me okay as an analogy analogy I mean you wouldn't use an antibiotic to which the factory were treating was resistant that's analogous to the situation it engenders false hope in the patient because the patient thinks that you're giving them the best therapy that's unethical further the charge for this if it is Medicaid of reimbursed is fraught because you're not using an appropriate therapy okay but you said yourself that they were they wore affect of on the previous variants but they're not effective on on on the cross are we saying now that only from variant is the only very and out there we've defeated the others they're they're completely wiped out and gone no Sir about what we are saying is that greater than 9798 percent probably higher than that in this state isolates are of the metron variants as a matter of fact the last report I had from our sequencing laboratory at the health department was that they were all on the fronts of their they were all the on the con variant okay so it is far for it's a minuscule amount of of of black very virus that's out there that is not on the crime and therefore use of any of the other agents would not be effective at this time. So how do we know that for certain we've got people out there doing home test of those home tests that they're correct taken internally and that did they distinguish between the Omicron very until the very end or. The original whatever it was called only remember what wasn't yet yes Sir it at I I understand your question no Sir they're not designed to determine the the the variant type of the gene the type of the virus but we know what the genotype is from sequencing both locally from our test through inference and from national debt. We're in the merger of. All right. All right the. Representative Davis you're recognized for a question. The doctor my question I'm. Carried along with representative Gonzalez I'm over on the monoclonal antibody ma'am. So. My brother in Florida he was 82 he had code you got monoclonal my wife got the monoclonal. My testimony as I felt like it really helped both of these individuals. And I appreciate everything you're doing or you're at. But as I look at this map it's Caroline representative for use in as little concerning that appear in my district it's I don't see a red.and so my question is about the supply demand were we at on are we gain in on that are we losing on it from the beginning. So thanks any forgive me for interrupting you Sir I'm so thank you for for for for those those comments about the effectiveness of these monoclonal antibodies it's clear that they do work and they they are terapeuta read mentality I'm so we have been somewhat but but there it's really an issue of supply and demand we don't have enough for this country and unfortunately you know we're at 3000000 person state correct when you complete when you're when you're when you're competing against California Texas New York with populations are much greater than ours they're gonna suck everything in and we're going to be left with a smaller amount even though they're they're it's it's it's equitably distributed throughout the United States so yes Sir we're trying to get more we're doing everything we can but it's a supply and demand issue. Follow yes. So. But specifically from the beginning on your and what you're saying in. Do you feel like it's more of a man now or let and I think that there was more of a demand recently and that is because of the Omicron search we saw more cases more individuals infected and although you can say it was a mile door disease individually societally it was a major blow to the system more people required therapy. Thank you all right. Representative Gary I'm sorry read it representative gray. Service representative wing. Thank you madam chair I'm looking at the page 2 of your hand out and I see this is vaccination status of the hospitalizations deaths and case load and I see it's dated from December 1 of last year on so I'm I'm assuming this is predominantly the Omicron variant that were that we're talking about here do we have any data on the status of those who have previously had the disease and what they're hospitalization rate their death rate is 6 after for this same time period I'm so I'd these are individuals that that had the disease and where vaccination or not facts and may or may not okay both categories I'd be curious yeah so so I can't give you that data specifically I I think nationally that's being looked at but at this time I don't have it that it in front of me and I don't know that we're actually trying to call that out at this time but we can I can ask and certainly follow up okay and that might be something that perhaps we could track moving for because obviously with about 800000 are cancers that we know of I've already had the disease and whether or not they were vaccinated I that was those would be good data points for us to see truly when do we round the corner on this so yeah I appreciate that and I appreciate the question if I may have just one more comment we know that that that individuals that have received in that have been infected previously have some level of immunity. But we don't believe that that immunity is enough to protect you fully against Omaha and so even if you have been impacted previously it's recommended that you receive a dose of animal of a and a vote of the vaccine so that your level of antibodies will be boosted to a level that you're protected against it so it's better to get those or be fully vaccinated after having received after having had infection that's the best protection you can have. All right thank you representative Boyd. Thank you madam chair I wanna go back to the emergency use authorization I'm just gonna ask questions to to try to help create some clarity so when we're talking so we're talking about emergency use authorization. Who actually owns the medication. Well the the the it depends on who and who owns a patent but but it it it's owned by the company that produces the medication right right but when it goes out to the hospital or the pharmacy at that moment in time the company on that are the government owns it who really owns it I mean. But I'm not sure I understand your question referred that it ignored that the use of that of that drug then I'm is is transferred to the institution where the weather is is that the question we've got what you're asking it is the institution that that holds that drugs then that that dispenses it right so now well that institution that let me just say the institution that really on it right so the so in under an emergency use authorization the institution has had this sign in black and white have a an agreement with the government about when and how that drug would be dispensed with there's a hospital pharmacy or anybody else right that's great so how might how is that different than say another or treatment that that the pharmacy or the hospital actually owns I mean when we're talking about an emergency use authorization. You can't just go off label I mean you there's a different set of criteria is what I'm wanting you to explain a little bit more fully so everybody in the audience understands it's not you're not you're comparing apples to oranges in that case so so so a drug that is or a vaccine that it that is authorized by FDA okay is approved for use widely throughout the United States as per the it's indication I'm and there can be what we call off label use for that vaccine at the discretion of the physician and the patient and and that last part has always be borne in mind and the patient the patient me when it is an easy way okay then the the the the the the the recommendations for use of that of that product I'm are much narrower and a fit within a certain guidelines and that's currently where the most of these agents currently live that is they are you a approved under this condition and that you A. may be withdrawn and has been withdrawn in the past so for example Hydroxychloroquine I. drugih Clark one had an easy way to begin with that was withdrawn by the FDA as it has been with this case with the nonsense so trouble may have monoclonal antibodies. Are you finished representative. All right. All right of a I'm looking at the list of if you are sitting in a someone else's seat you may get called by that person's name but that's okay but I I do see a representative Penzo you've not had a question so you're recognized. Thank you. I have a question about the current vaccine that were ministering in the state is that was that baxeen based on the wild type or is it been updated to. Yeah so so currently in in in our state there are 3 vaccines that can be used of the 2 most frequently used are of the vaccine from Fizer beyond tech and from the during I'm all of those vaccines were based on the original the original a stranger I salute of COVID 19 or sars CoV 2 they still retain some degree of immunity against the the current variants and is we have now if we as we have now learned that you know of a booster dose is required with these vaccines in order to get the maximum benefit against these this very okay so the monoclonal antibodies. OR based on the the previous versions that were that have lost authorization were based on that same while tight so we're being told that the monoclonal certificate but the vaccine is and it's based on this create an insane antibodies so I mean that can you just explain that a little more detail yes Sir I I can't so I'm when when you are immunized with the vaccine your body develops a of a of a bunch okay I mean many many different antibodies to different parts of that protein right I'm and so because of that you can attack that virus prevent that virus from hurting you by attacking it at different sites a monoclonal antibody is is is is exactly that mano one that is one single type of animal so instead of developing 10 antibodies like you would being vaccinated you have one out of one and if that antibodies attach is to a specific site on the virus so in my pen for example if the original monoclonal antibody if the original virus a strain before the one we have now the monoclonal antibody attached here right but now with the current version of this virus is different and it can't attach then you have no effect from that Michael Leinbach and that's what has happened so the monoclonal antibody that was developed initially for those particular viruses didn't attack doesn't attach now the so trove announcmenet happens to attach at a different site even though this site has been modified it's still a taxes here and that's why it works okay so so natural immunity would create even more diverse. Antibody profile then the vaccine in the vaccine produces a better profile than one club with an accurate statement in theory it should okay thank you. All right thank you. All right the. Senator Hammer you're recognized for a question. Thank you madam chair back to the issue of the cases that were reported as serious and non serious percentage wise how does that align with regards to experiences in other states is that are we within the rankings are we within how it's being received or experienced in other states. Yes. Yes Sir the experience of Arkansas is not very different from other states okay and then when it comes to reporting of deaths do you distinguish the difference between COVID test with COVID. From daesh will. A as a result of code or those distinguish differently. So if a if COVID is listed. On the death certificate it is counted as a COVID death with whether it's diagnosed as with or from it there's no difference is that the current the current guideline for listing of a COVID death is that if it is listed on the death certificate it should be counted as a yes as a covert S. father. Even it can be re educated that if it wasn't on the the the death certificate and it initially it can be added afterwards right then the last thing is there's an attorney general's opinion came out on December 17 and you brought up the word guidelines and according to the attorney general's opinion it states that the guidelines that you issue from the department of health do not carry the same weight of law as those that are promulgated through the rule making process with the basis on the basis that tourney general's opinion the guidelines that the department has imposed upon educational institutions and others moving forward are you going to be a little bit more cautious about using guidelines as treated with the same weight of law based on that street General's pinyin or if you've been privileged to that attorney general's opinion to review it I'm not reviewed it and I would defer to our general counsel for advice on this we'll take it up with him or her thank you. Thank you a representative Bentley you're recognized for a question. Thank you chairman it appears to me that we are taking all our directions from public health officials in DC and not working directly with our local physicians who are doing a host of different therapeutics and the way that they're working and communicating am I correct on that because I I guess I see a real disconnect of our local physicians and the directors at their get away working together with our local business to make sure we're hearing back from them and getting feedback from them what's working from them making our directors on that are we getting all of our direction from DC can I have a clarification on. Well our guidelines are based on recommendations from the centers for disease control and for the FDA we certainly listen to what physicians tell us that wish to tell us and we factor them into our ultimate decision of what to do our recommendations for the state. A one quick follow up Cherokee time with the current was our current death rate per 0 cases in Arkansas. I don't have that current number I have to go back and look at it may have changed a as a result if you if I it to answer your question so if you look at our it indirectly if you look at our death rate over the last week we have hovered between 20 and 30 deaths a day and these are not delayed deaths we are seeing right now the delayed consequences of our infection and unfortunately we will pass a grim milestone in the next several days possibly in 3 days we will we will top 10000 deaths 10000 deaths in this state to the cove. And when we have appropriate vaccines to prevent. Again so you can give me a break a death rate per 0 even like last month or 2 months ago just yours I think it was for forgive me forgive me go ahead I just care shall we have one from a minute doctor bill and give us a member from 3 or 4 months what is our percentage of deaths per 0 cases I think it's best if we give you an exact number rather than us guess as to what it was or wasn't it rely on memory let's let's have that data provided to you directly did you get back to that thank you very much all right thank you. Right a representative Ferguson you're recognized for a question thank thank you madam chair at trying to feel better about this allocation of medicine I was looking back through the list I don't see if you 8 cities on here and they're probably the largest primary care provider in my county did they get a separate allocation because their federal and how does that and that's probably their trading the most low income people I would think had is there if they do get a separate allocation had is that compared with the allocation the state's providing is that taking into consideration doctor if I can answer that question more that's a great question if committees do will get a separate allegation directly from the federal government but they have not toward us walked that allegation is. So it's not a consideration in which the you send money to the county or not if not been given that it session 96 send me it's a and just a quick note should I get a fourth shot when it your question is a good one so at this time we have not seen the need to do that in this country I know that that reports from Israel are suggesting a 4 shot but we know that it leased from our data 3 shot regimen is probably it is insufficient to prove to to prevent severe serious illness and death let me also make a comment about that remember that this is a new vaccine or and that has been that we're learning how to use it right more than likely this will turn out to be a 3 dose vaccine that is that we need to receive 3 doses in order to become immune and we have vaccines like that we have the anti cancer vaccine that requires 3 doses we know that there are other does it other vaccines require multiple doses I think in the future we will see a re a redefining of how best to use this vaccine and whether we'll need that administers or not will be determined as we go forward. All right thank you all right representative Payton unit the last member of the committee on the. On the list and then we're going to go without Senator Clark it's not. Thank you senator yes the doctor Maryland you mentioned a couple times that. We have limited availability of these medications that we use for for treatment a. So. On the monoclonal antibodies you have a. Described as set of conditions that have to be met before they qualify for the monoclonal antibodies. Is the fact that they are vaccinated or unvaccinated part of that consideration we have a different prescribed a treatment for people that are vaccinated versus people that are on vaccinated or do we have a different priority on using these limited treatments based on whether somebody is vaccinated or not vaccinated. It's not just in the the having been vaccinated or not and there was there are other things other things so a healthy individual that it had been vaccinated I would probably be lower on the prioritization schedule okay so it doesn't have to be just the the status of vaccination you can be vaccinated but have multiple variables obesity hypertension age ethnicity and those things would would would place you at risk for for adverse outcome similarly somebody who has no backs and no vaccination but has risk factors would get it because of the vaccination status is part of the. Criteria that that is correct does it positively or negatively increase your chances. It is for the monoclonal antibodies I mean if it's part of the question is it a positive or negative it is just one of the factors that you take into consideration. It doesn't mean that you it's a series of checks is a determination but made by the physicians as to the risk of the individual okay. Well I thought we were telling the physicians how to. Use these criteria to reach the bottom line so do we tell them to consider the vaccination status as a positive or negative. Certainly an individual who has not been vaccinated is a greater risk for death and for severe disease and someone who is in vaccinated but it's not the only criteria that you would use. So in most cases you think that the non vaccinated with moved higher on the on the priority list I I I don't know it depends on what the risk factors are the of the individuals that are on that list okay thank you thank you madam chair thank you I do see a representative Gonzales so just take a few minutes a representative because we've been at this for almost an hour and we've got a long intend. Thank you madam chair up so I wanted to clear something up on the monoclonal antibodies to so the the the previous Monoclonius that were used to treat COVID where they've fully FDA approved drugs before the USA or or. Dinner so what I'm saying what were they. So they were developed during the covid I pandemic they are you a approved okay so so they do not have full FDA approval for any treatment at all no cancer treatment so nothing like that there is a they were only created for the for this yes okay all right another another question the the vaccine itself is it still under UA authorization or. What's the status on so I know and the Fizer beyond tech and and thank you directions are are approved it also depends on age right so so for the very young for children there you As for adults they are not so that they go through the same clinical trials and scrutiny that any other FDA approved medication last 30 years has gone through same time frame and everything no they did not go to the same time frame this was an accelerated The New the accelerated development process however. The vaccines have been asked route night if not more than they have any other vaccine previous to this time okay one last question my interview so previously vaccines created munity to the disease of the CDC has now said that this vaccine does not create immunity you can still contract the disease you can still spread the disease so why are we why are we still call this a vaccine and not considering it an early treatment just like these monoclonal bills that are are listed here well it these are active what we call active immunization they cause the body to create antibodies now let me go back and and and just clarifies previous vaccines don't prevent infection you can still become infected and you can still shed the virus depending on what the and what the viruses so these faxes this vaccine these vaccines today act no differently than any of the previous vaccines and so these are what we call active immunization as we give something to the host to the individual to make antibodies monoclonal antibodies are immunizations also but that's called passive immunization where you are giving them the antibodies that are already for and we've use passive immunization for decades to treat diseases such as tetanus okay diphtheria and in in in early medicine it was used actually as a way of treating certain bacterial disease so it's it's a it's a it's a it's a a technique that has been used for for a long long time. Let me add to that. If not I might add to that when a person receives a vaccine it trains their immune system to recognize the organism. By introducing it to a protein or the organism usually that's enough to prevent infection but it's not always enough to prevent infection it's gives the body though I had to start so if a person does get infected it limits the severity of the disease because the immune system has already gone through the steps needed to learn to recognize the organism so it gets a head start so but the current vaccines are just like any other vaccines in terms of that kind of community it creates antibodies but it also trained certain white cells and terms of how to fight the illness also so it's it creates actually a very complex immune response which is very beneficial in most cases if a person's ability to respond to the vaccine it's there. Right thank you so much all right the Senator Clark you're recognized for the last question thank you manager. Of the sector Romero the one the problems that you're up against and okay. I wouldn't want to be in your shoes of is during the pandemic both government and Madison of. Or medical establishment have lost a lot of credibility right or wrong. Of. And for the most part those who are not taking the vaccine I believe that there's more harm caused by the vaccine then what is being told. Whether you again whether that's true or not that's what they believe. And the I'm looking at a chart of moved from department of defense numbers that shows the total number a couple charge actually told number of acute myocardial infarct reports by your total number of acute my card is reports by your whole number of pulmonary embolism reports by your. And they're showing of the first chart of 343 percent increase of myocardial infarct enforced by your in 2021 partial not the whole year over 2020 of 84 percent increase of the acute my card is. And 260 percent increase of the pulmonary embolisms have you seen that of the and do you. Is that correct incorrect. Because these type of things again because people because I know people who got this. Of boxing originally lots of people who are getting boosters and and I know that you feel like that definitely looking at the statistics. That that's something they certainly ought to be doing. So can you. But the. What should we looking at these reports what should we be thinking what is the answer. Yes thank you thank you senator and no I have not seen the department of defense numbers and and and I don't know if they represent the general population or they represent the military population so excuse it will it is military yeah so so I I'm sorry I don't have I'm not privy to that information and haven't looked and I'm but I can but if I can answer that question I'm with with the following so. Myocarditis occurs 15 times more commonly. After COVID or during co infection than it does with the back with without having with with individuals that have been hospitalized with other conditions my addresses one of the things I studied before I came into this position my background in in basic research is myocarditis due to viruses. I can tell you today that COVID is the number one cause of myocarditis in the United States it strips that outstrips the previous causes known as adenovirus and coxsackie virus by many fold so we know that myocarditis occurs with COVID the incidence of myocarditis for example I think this is what you're getting at is exactly what people need to ask what is the risk of getting my occurred as from the vaccine and the risk of getting it naturally so the risk of getting myocarditis from the vaccine is on the order of 0.3 to 5 individuals per 0 overall it may be more free it is more frequent in the very young group but even then even then the risk is much less than getting natural infection and if you want to put in in a common terms in these online this is my my analogy but I'm it. You're more likely to be hit by lightning. Then to get my car dies from the vaccine. Can. Thank you so very much follow up all right just quickly please thank you madam chair. Of and I thank you for that answer Mr secretary and and I've heard that answer but the. The. From 2019 to 2020 there's only a slight increase but a great increase from 24021 but on the. Credibility. The New York is one of a couple state to start separating their numbers from those hospitalized with COVID. Verses for Coleman in the last number I saw from them was that 51 percent of those that were hospitalized was with COVID not for cope with over half. The and I think that it would not be hard to translate that into the numbers of who died. And they did that because only across. Was so much less. Deadly. Then the the other variants more contagious less deadly of because we know that from the beginning not everybody who died. Died from covid as you pointed out but if it if it they had it it's on the death certificate. If we take the numbers you talked about the the number of deaths are coming through and we're going to hit this number of 10000. If we take this at face value. Then. These numbers are coming through then I'll then as a man of science and only problem is the most deadly. According to the numbers as a not. So on a societal business yes it is the most deadly because more people became infected more people progressed to being hospitalized and there were more deaths associated with it because simply you infected a larger number now. I I agree with with the I haven't seen the report from from New York City I can tell you that a single snapshot in our state indicates that on one day during the peak of the Omaha during near the peak of the on the crime search about 25 to 30 percent of all hospitalizations were as you said individuals who got admitted for one problem and were found to have covered. But that number is probably lower today than it was then because we're seeing less cases in the in the community which means we're probably seeing less transmission and does not apply because not apply to the predecessor variants that existed because the different these are different viruses so correct during this particular search there were a lot of individuals admitted with co infections if you will that is the founders infection at the time they were admitted for something else but this does not hold true going forward and did not and does not hold true previous so what are you service on the crown was the most deadly. If you look at the number of deaths this is the one this is it we're seeing more tests at this time that we have in the past I'm going to interrupt him thank you ma'am all right thank you so much in the Secretary Romero Dr Dylan hay and taught to Qatari we thank you so much for being here I think this is been an excellent presentation not only for the community but for those who are watching the live streaming of this and for those who are interested you can go to our clinic.state.A. R..U. S. and then go to Mundy's agenda February 7 meeting of public health at 10:00 click on that and you can have the whole thing and in fact I intend to do that myself but thank you so very much we appreciate your time and it was so I think very informative and very good for our people thank you. All right leaders thank you all right ladies and gentleman we are going on to item easy and we will have Mr John Vinson and Mister Health Forrester to the table please and we're discussing treatments of COVID 19 prescription treatments for COVID 19 and the availability of these treatments throughout the state. If you would introduce yourself and who you're here representing. How will foster I'm the director of the Arkansas drug information center you M. S.. This is John if he has. The persistence. Good morning John Jenson pharmacist and CEO of the Arkansas pharmacists association thanks for having us well thank you all for being here depreciation coming I think maybe most of the questions have already been asked so that we may not get as many questions for you guys which you've got a different perspective on this you're kind of the receiver on these treatments I'll ask the first question and I was going to ask the doctor Meryl this but maybe you guys can answer it the maps that they handed out for the antibodies the 2 antibodies that are currently effective against the Omicron. And on these maps we've had a 23 people ask about the availability and they're only available in certain areas not very available but when I look at this map it looks like it's only available at hospitals do you know if that's the case and 1 northeast Arkansas was only like 3 hospital shown that has that so yes chairman Ladyman for the most part Citro overpass which is an I'll be in fusion monoclonal antibody that a treatment that is 1 that is still expected to be effective against Omicron is in very short supply and because it's an IV infusion and they're such a limited amount it's primarily in hospitals there is 1 a community pharmacy that has a physician medical director and has our ends on staff that has had a few doses of central map down severe County and the queen but the vast majority of the very tiny supply is in hospitals there is another monoclonal antibody that is not a treatment called Evie shelled which is a prevention for patients to at contracted caissons to the vaccine or maybe they have chemotherapy in cancer and vaccines not expected to work that particular monoclonal antibody to prevent infection not to treat but every shell is mostly also available in health systems but there are a handful of pharmacies that also have that. Do you all have any input or advice on is this supply going to grow the I mean do you have any information on speeding up the supply of these treatments great question first of all just for perspective if I could for just a second on the the previous mark on those that were available that are not expected to be effective right now the region code was a subcutaneous injection that pharmacist actually have the ability to either work collaboratively with the physician and and receive a prescription actually prescribe it because it's and passive immunization back between September and December the supply had grown with that one when it was effective against the Delta variant of COVID 19 and community pharmacies and their pharmacists actually treated over 10000 patients just to give you perspective in over 100 different locations and saved a lot of lives you know just based on number needed to treat you know of a statistical term we use in health care that you saved over 250 lives or prevent hospitalization so very proud of the work our pharmacist added there in partnership with the department of health to provide that great access but I agree with you that moving forward there's a a big issue with not enough supply of any other effective treatments that exist right now and we're not expecting that supply to grow significantly until months down the road so it's a you know it's it's it's concern of the virus mutating faster than supply catches up to treat. Thank you for that the journal have any opening comments that you wanted to make or do you just want to take questions I just just real quickly wanted to say that initially Dr Keith already talked about partnering with Walmart Walmart's open 7 days a week they were prepared for these new oral antivirals with their there's a new complicated online tracking system that the doses have to be received in that day reported the independent pharmacies quickly came on board as well and that second cycle and weak to early January and they're about 100 pharmacies now around the state of between 110 plus some FQHCs which I don't have a good track either I agree with you that those numbers ought to be reported in and out of the reported on the online website so prescribers and patients know where to access them but out of that 100 or so about 70 of those or independent pharmacies in bout 30 year Walmart knows or just rough numbers in in about 2 thirds of the counties. Yeah and and again I this is a national thing assault on national webpage of the Walmart connection there that was a national decision wasn't there were about 19 or so states that I wouldn't say it's a national they are federal retail pharmacy partner because of the timing of it happen and around Christmas their systems being ready as well as one thing we haven't talked about a lot today is these therapies are only effective if started early I know representative bill if heard lot of your testimony about if the state if these therapies are started early they're not effective and that's got to be within the first 5 days of onset symptoms and a lot of patients are now self testing with home test we've got to get a better message out that if you test positive you know to seek treatment and see your physician early in order to potentially be a candidate for these new therapies. Yeah I know the price of it is is effective my son and that he got the next day after he was positive and it was very effective so if you already for questions could up can I say 1 other thing to this too the Committee pharmacies around the state that are providing therapy they're providing the therapy on a good faith that it is something that is beneficial to society and the compensation or the business model for paying the pharmacist for their time and effort it takes about 3045 minutes a patient per prescription of communication with physicians and nurse practitioners they're very complicated meaning they have a lot of drug interactions and they have a lot of counseling that's needed in a lot of manual online reporting there is an issue that I'm concerned about with the insurance companies in the pharmacy benefit managers are not required to pay for the the dispensing and in many cases they're doing exactly that they're paid 0 or less than $1 for the services in time that the pharmacists are providing for these therapies we do have over 100 which is good news but when the supplies do catch up representive Ladyman their 750 pharmacies around the state I suspect there will be some because I've already heard and until there's a business model that supports this I'm not gonna be able to provide the service so I am concerned about that and I want to point that out to the. The Committee. Be happy to take questions all right. Representative Bentley you're recognized for a question. Thank you chairman just a follow up with that you just said can you hear me OK yes ma'am why do we not have a business model for that can you can help us understand those don't services so back to I think representative Boyd was talking earlier about who these products belong to because their emergency use authorization products and they've been purchased by the federal government and all of them and I'm not talking about how drug to Cork winner ivermectin which you're fully FDA approved products but these newer products that just got emergency use authorizations that don't have a a fully FDA approved indication there still owned by the government and the government up until this point has set what they think it should be a benchmark of what the payment should be so for region code for band will move you may have and at this if you may have for every shield for central the Mavin others federal government put forth like a benchmark of what the pricing should be for whatever reason with the oral antivirals. What we further National Association is there's an interface an interference clause and not an attorney but a non interference clause in pricing for Medicare part D. is and D. as in dog in the Medicare program and the federal government has been hesitant to put forth what should be the payment for these oral antiviral Senate dispensing fee and they've left it optional rather than mandatory the federal government and the private insurance market has responded and the Medicare market has responded with exactly that because it's optional we don't have to pay for it in many cases they are in fairness Arkansas Blue Cross blue shield and CVS in Arkansas did step up and did select a dispensing fee of of $10 which is I thank not enough for that amount of time that it takes but it is better than 0 or better than less than $1 that some of our members have seen from other planned so there are some plans that have the uninsured program is represent is just a few days ago set up a $12 fee I know our state employees program has a proposal that they're looking at tomorrow if of increasing the amount they pay that they pay but it is optional representative Bentley. Thank you one quick follow up chairman of this okay. I know that you've just mentioned I've imagined Hydroxychloroquine is is a certain rights which I know physicians across the state are seeing great results on so what is our supply of those and available for our constituents at this point so hydroxy Cork one is that there My center are there's plenty of it available in some cases ivermectin is hard to secure or hard to secure it at at a fair price point because it's there's been a 24 fold increase in the amount of prescriptions normally rarely used for unusual infections in there and over the last year there's been a big increase in demand and it is more difficult to secure or procure and when you do you often can't procure at a price that's less than what your what an insurance company would pay for it so it's that one out of the 3 is the most difficult for care I just want to say thank you so much for committee pharmacist what they've done to this pandemic you guys have done an excellent job so thank you thank you. All right to a representative Ferguson you're recognized for a question. Thank you madam chair it yet a little bit to representative Bentley's question I I've talked to people so that they had the monoclonal saying they were completely free and then others got a big bill can you kind of address that disparity I'm so payment models yes so sure so for the monoclonal antibodies it least in community pharmacies I'm not as familiar with the billing process within a physician's office or in a Health System of what their policies may be but in theory the administration fee should always be paid for by an insurance company or by the uninsured program through her said HRSA if there do not have a credible coverage there are situations though where health plans particularly in the commercial space have you have you heard of surprise medical billing where they won't cover an out of network provider and so you'll submit a bill and then they will not cover it so in those situations you might see a patient receive a bill for the administration fee if that happens that it's an unusual situation if if you know about it happened in the love to help check into it to figure out what the issue was on that specific case but most the time it's covered by Medicaid Medicare or commercial insurance with patient. Question yes at the at the end the shield is it. Is it the wave of the future of it are we just not giving it to everyone because there's not enough supply I mean is that is that where we're headed so would language yeah good quick good question so if the shield. Probably does have activity against Omicron meaning it's probably effective but they have not since they have not sought FDA approval as a treatment just yet like they haven't submitted data they haven't completed trials and got approval it is approved for prevention of in a patient who's unvaccinated because of a contractor cation to the vaccine or they have an autoimmune disease or cancer treatment and and the vaccines not expected to be effective so trover map which is the other product that right now believed to have activity can stomach on they are seeking an intramuscular injection indication meaning it would be easier if they can ramp up the supply to to reach more centers you know with greater access beyond just the IV infusion hospitals and region code of the one that's ineffective against Omicron is X. you know they're expected to work on clinical data to get an approval you know against the new variants but time will tell whether that happens or not. To reformulate. Thank you a representative that Davis. Thank you madam chair. Thank you adductor rensen doctor foster for being here today. We're all students together. Thank you for what you're doing for the people of Arkansas as pharmacist. I want to tell you that. I'm still in the pharmacy a lot. And. My question is let's say I get this a lot. I'm at home I got a home test a test I'm positive. Well my next thing I'm going to do is run down the doctor Davis at the pharmacy and I'm get the question every day for these new drugs like packs loaded and others they're gonna ask me. Do you have. A lot of times I have to say I don't have and I know so we're cannot go. Website to get the answer because the next question is always invariably. Where do I get help. So Dr Davis good question thank you very much for that the best place to find where they are I'll give you. I'm not gonna be able to just quote this address but if you use your favorite search engine and you put Arkansas department of health. COVID 19 therapeutics. They have a map and they have a searchable field at the bottom of that web page on healthy.gov website for therapeutics in Arkansas and you can actually see you know there's. 19 pages or so of the hundred 50 sites and it shows you exactly what is it perfect no there maybe 5 or 10 off that aren't on there because information updates every day and doctor Cathars teams always updating it as more sites are added in addition there is a link on that web page that takes you to the federal map where you can see the location everywhere in the United States Mr price we can share this afterwards and yeah sure Mr chairman with the committee members but for the whole country and then you can drill down to Tennessee you know if you're over in West Memphis or Arkansas for the rest of the state and see exact and you can actually search by product now that's 20 4:48 hours behind meeting you know the date is supposed to be updated once a day to get an accurate inventory and if they're behind it may be not perfect but it's the best tool we have and then the last thing would be Walmart also has their own real time tracker on their own website for the doses at their locations around in Arkansas around the country. Thank you ma'am thank you all right Senator Hammer you're recognized for a question thank you ma'am churches were quickly on the business model you talked about that's not develop is that related to all the drugs are available for treatment or is that 1 particular drug among all that you're talking about so with the drugs prior to December you know not the new ones but prior to December twenty twenty one like region Covin others we still have issues where a pharmacy would be administering that and they would be out of network in the insurance company wouldn't recognize him or pay for it so we do have that issue but 9095 percent of the time that's we've got a model that will pay for. In addition to that the new drugs packs loaded and mold appears here the father product packs loaded and moment here fear by Merck. That those are the 2 that I'm talking about where often the dispensing fees paid to the pharmacy are anywhere from 0 to the dollar with several players the largest one you may have heard of humana I believe it's $2 prime therapeutics nationally as a calendar which is a fill it fill it with BlueCross BlueShield nationally I know Arkansas uses CVS and state for most of their commercial space but just to give you a flavor and there are others that are paying. Even less than that senator Hammer at as low as 0 okay on the dispensing fee all right and on the map that was given out by the health department while ago it kind of shows with regards to some of the drugs that are available what I would refer to as desert as far as pockets of the state and that was hit on a while ago I know that some of the issue is the cost to the pharmacy to get you know the the thanks necessary stood up of flattery IV treatment so even if we did have a supply company in the state they're still to prohibit. Still part of what prohibits accessibility is going to be the cost to stand those things up Maratha wrong on that I totally agree with that the staffing in pharmacies No representative Davis is very well aware that a lot of pharmacy civil lost help just like all industries especially both pharmacists and pharmacy technicians and then there definitely barriers to start up costs for the infusions I know we've had a rescue plan proposal that's been out there for a while that you know has it gone through the process been approved yet but that would be a big help you know to help. Jumpstart some of these things is the business models take time to. To be fully implemented and that's part of the point is if the medicine does make it down into the state but we don't have the outlets the pharmacies. A team player to help get it administered it it's not going to help solve the problem of one last question I didn't get a chance S. health or Malaysia are you guys treat and see many patients come in the pharmacies for flu we don't hear nothing about flu anymore I'm just curious are you seeing many come through the pharmacies treating for fuller thank you after. I don't have the numbers to answer that like the exact numbers but we do have a few but it's not very many. All right thank you. A co chair Ladyman. The foster I just like to get your perspective on how you A. M. S. is is is getting these these drugs and you know how many of Marley you putting out maybe in your position don't have those numbers but I mean are you giving a lot of the antibodies are you giving a lot of the antiviral drugs out can you just give us your perspective from you M. S. well to be perfectly honest I'm not part of the pharmacy 8 U. M. S. so I'm not I don't have information on any of those numbers and John actually asked me here today if there was toxicity questions would I be willing to do those as the director of the poison center for the state. Thank you sorry. Thank you all right of seeing no other questions. We thank you for being here and you were very important part of this program today and we are grateful for your being here thank you so much thank you madam chair members Committee all right ladies and gentleman going on down to the next item which is itself overview of the current status of emergency medical services around the state so we have. Amended warrant Jamie Pafford Gresham can Kelly if you please come to the table. Introduce yourself for the record. Good morning Amanda warranty then the CEO of Columbia County ambulance service in magnolia Arkansas and the president of the Arkansas ambulance association. Hello I'm Jamie Pafford Gresham the president and CEO of Pafford medical services here in Arkansas I am a long time board member of the Arkansas ambulance association as well as I currently serve as the American ambulance association secretary and serve on their government affairs committee. Good morning my name is Ken Kelly I'm the president and CEO of from an ambulance and also for the Arkansas times sociais Haitian Services secretary treasurer and the chairman of the government affairs committee I'm so glad that you're here today and Mr Kelly if you don't mind my to start with the yes ma'am thank you madam chair Mr chairman members of the committee I certainly I am honored to be here and I know you had a long morning and will be as brief as possible but we do have a matter that touches every our cans and in fact is a matter that is potentially life threatening and we feel it's important update the committee also very important issues today like no time and are more than 50 year history of serving the citizens of Arkansas with the fact even high quality EMS systems have we been the rescuers asking for rescue but we are exactly in that position today we need your help before we share some critical facts and data let me first say that we are honored to represent the 196 ambulance services and more than 7900 license EMS professionals both men and women they've been standing strong on the front lines throughout this pandemic. Many of our professionals have seen things that was thought to be once in a career events they now face those on a daily basis they are tired they are wary and they have done much of this without relief and to say that these challenges are you need to Arkansas would be a disservice to our industry as you saw we provided some information prior to this meeting from our neighbors in Mississippi they're facing very similar crises and you see on the headlines every day and through social media all the events that are taking place around the country some states have very big been unique in addressing their challenges summer taking very bold steps to solve systemic problems but here in Arkansas we find that we're getting little traction to address some of the serious concerns so today I'd like to share with you just some information on some key metrics and then offer some possibly some of our solutions. And service is a vital component of public health and safety and the system is in crisis that is a fair statement across Arkansas in every community and every county citizens are benefiting from today a robust system of pre hospital health care over 98 percent of our state or protected by advanced life support providers to bridge all aspects of health care everything from handling emergencies to the livery or critical care services as well as general ambulance transportation for many of our rule and medically underserved communities we act as a gateway to definitive care and especially in those communities on nights and weekends we are often the only access to critical care. More than just a ride to the hospital or services bring rolling emergency rooms to decide whether it's in a bustling downtown business district or a rule delta farm house or down an embankment along one of our scenic highways EMS has always been there to answer the call but this may not be the case in the very near future and what services are struggling to maintain vital coverage some have already reduced coverage in their communities and others say they plan to do so in the very near future. To gain some insights into this we got a first look at some key metrics that are pertinent to our industry and these are data points that we have been gathering over the last 2 years since the beginning of the pandemic but some of them go back even further than that. Since the beginning of the pandemic Arkansas's animals providers of touch more than 1000000 lives EMS systems have been riding a roller coaster of challenges when it comes to response in the early days of the pandemic we were shocked actually to see a decline in the number of responses this marked downturn resulting in significant loss of revenues of which many of our providers are still struggling to recover today. As you'll see in this chart as as the pandemic has progressed on we have seen actually an increase in responses but we still face challenges in the loss of revenue and that now we're often treating patients in place not transporting the hospitals but that is done so it and uncompensated care cost there is 0 reimbursement so if you can imagine now the 1000000 lives that we have touched 300000 of them have come at a high cost of delivery with 0 reimbursement. On average at the beginning of the pandemic providers of seem to 24 percent increase in responses and almost a 30 percent increase and treat no transport. With these because there are several different things that are driving factors that are really burning or ambulance services and many of those come in the form of increased response calls for things such as fuel personal protective equipment decontamination supplies all the while again with no reimbursement. As we work to measure the financial impact there are few figures that we like to consider the average supply cost per response is approximately 7 percent. RCV $27 up approximately 120 percent decontamination calls for transport now exceed $18 on every call and that is almost 86 percent increase lost revenues for the treatment in place had been calculating the quite it to approximately $456 per call and then the critical supplies and medications that are necessary to treat particularly covid but other things such as heart attack stroke and sepsis are up more than 1200 percent many of those items are still rationed or they're in no supply. These numbers continue to rise and they are staggering in affecting our ambulance services every day. While most of these have a direct correlation of the pandemic there are a few things on this list that are not to pandemic related there the more systemic problems it is important to note that ambulance services have not been properly prioritized and we have received less than 2 percent of any relief funding not from FEMA not from the federal government not through cares Act north to Arbil or commercial insurance payers. Such are the challenges of both response and non transport but they're still one other element to this crisis that we must bring to your attention today. The scope of our work relies on a rapid turnaround of ambulance resources the unpredictability of the next 911 call the next heart attack the next child having an asthma attack requires that we remain constant state of readiness that we have the ability to respond quickly you've most likely seen the recent news reports talking about ambulance delays or what is now quickly turned in the industry on the wall time. This occurs when a bill is facilities when name is Robert facilities but they cannot transition the care from the EMS team to the hospital staff. These delays in transfer also served to drive up the cost of ambulance service providers cannot respond to other calls. In rural communities they may not have the opportunity to staff extra units to cover for the next called it may come in any additional overtime hours to cover those that are sitting on the wall are staggering while hospitals to receive millions of dollars to fund critical staffing an increase bed capacity ambulance services have received nothing and we're providing the volunteer labor. All ambulance services especially a rule providers that often transport great distances from their home service areas are the greatest risk holding an ambulance outside of the service area jeopardizes not only response time but it also shifts the burden to their neighbor which may have provide back up or back feel services in fact Mr chairman one of the leading discussions that brought us here today was the issue that occurred in your own district of which my company has had to respond several times for this very situation rarely does a week go by that Jamie and Amanda not through the association do not receive calls or reports of people activating EMS but not waiting on the ambulance to arrive driving themselves to the hospital unsure if an ambulance will show up. These critical issues have been closely tied to the pandemic but some of them as I mentioned are systemic our greatest concerns today in addressing the EMS crisis include our work force our ability to recruit train and retain employees the sustainability funding that'll help ambulance services retain that critical staffing and the recognition of treatment and no transport and the establishment of payments to offset some of those lost revenues. We have a couple of the other other key metrics that would like to share with you just briefly and then we'll be wrapped up for any comments. Skip I had a couple slides here just for the sake of time. Are you Miss workforce is also in a very significant state of crisis more importantly this the lack of any EMS work force over the past 5 years the number of active participating licensed professionals has declined as I stated in my opening from nearly 8000 to an effective number of only about 3000 or about 42 percent of an active work force while the health department reports is number is a constant an increasing number every year the true number of active pre hospital providers is declining. If one compares the total number of licensed professionals those who work in the streets you will see that this 42 percent is not effective in maintaining adequate coverage the remainder of the licensed do not work in our setting they may work in nontraditional roles or they may be just barely holding a license. Due to low participation numbers ambulance services had to absorb a tremendous amount of overtime costs to feel necessary unit hours. In our early discussions with the animals providers an average overtime of 10 percent was not uncommon due to the type of work patterns that we work 2448 hour shifts 4890 6:00 hours you have this was common in our industry however today the employees are reporting that the employees are working 88 to more than 120 hours per week just to fill the necessary vacancies. Adding to this workforce issue is a problem with our EMS Education pipeline over the last 2 years we have looked what has been a trend over more than 2 years at the production of EMTs and paramedics in our state. As you will see in this graphic here only about 34 percent of our available education seats in our training programs are filled this is both true for EMTs and paramedics. Paramedics have taken the greatest toll or education system in that they have had the inability to maintain clinical affiliations to complete their training the high cost of the training and the length of the training has been stumbling blocks for recruiting new paramedics. Coupled with low wages as compared to other healthcare professions many of which have been incentivized to retain staff are EMS workforce seems to have hit the wall. And just a few weeks over half of the M. S. workforce in Arkansas is scheduled to re license we say that in that response and your period we will probably lose 200 paramedics and a large number of EMTs committee through attrition something retirement but mostly through just the fact that they see no end in sight to the dilemma they faced everyday this number also does not account for number paramedics who may remain license but are now taking positions outside of the pre hospital environment committee ever taken positions within a hospital systems or through lucrative travel contracts which is further decline in the number of available workers within our industry. In conclusion you will say that the ambulance industry is in crisis over the last 2 years and even before we work to find solutions during the pandemic the response in the annual sinister has delivered no less than 4 well crafted proposals that would address many of these issues in the first few weeks of the pandemic we developed vetted and ambulance alliance plans to address hospital surgeons this plan would have assisted in the movement of patients both in and out of our hospitals the plan has never been implemented and now today we face delays. In the early days we also were facing the skyrocketing cost in critical staffing our industry proposed a 2 phase proposal that would have use cares Act funding for critical staffing in a bill sustainability much like the bed availability in critical staffing proposals proposed by our hospital systems the only response to this plan was 8 weeks of payments to our feel providers ambulance services receive nothing. And it is important to note that on those payments are EMS professionals receive half of what other sectors of health care received for the same scope of work over the same time.. period This past June we shifted gears yet again and made another proposal looking this time to the American rescue plan act this plan was also crafted to address critical staffing and sustainability of our ambulance services it was our understanding that as of late September that the plan had been reviewed by the health department DHS the FNA and the external consultants and was shown to be a viable program in December we met with Dr Romero and his leadership team in the hopes that we could clear any hurdles under the Arkansas proposal and just last month we met with governor Hutchinson to also shared many of these facts and information about our industry. What you may ask why has not been more widely reported the ambulance industry has been very careful not to raise public alarm in fact it's pretty much ingrained what we're taught to do we're taught to handle emergencies were taught to adapt to overcome to improvise but today we must to sound that alarm because we are in fact in crisis and we must have some help you can no longer sit back and continue in the current state we are sounding this alarm today hoping that you would help us send a strong message that are ambulance services do need assistance the citizens of Arkansas are counting on us and certainly as an industry we are looking to you for your leadership and guidance Mr chairman madam chair thank you for letting us present this information we wanted to share this from our art and we are available to answer any questions that you may have thank you very much all right thank you appreciate that the information I do want to tell you that I did go to the link and read the Mississippi of status and I'm I'm appalled and it looks to me like Arkansas is in the same boat but what I guess there's misconceptions out there let me ask you this and yes Sir no it's fine all right for those intelligences that are attached to hospitals the hospitals or supporting them is that correct that is our understanding we have approximately 20 percent of the services that are provided in the state are licensed under hospitals and those would certainly be using any finding that they may receive those channels that is correct but better than 80 percent of our ambulance services are either government third service or private industry all right now the other question I have is I was under the impression and I'm thinking it's a false impression now that a lot of the counties were helping supplement the cost of any bill it says in their in their counties that is an incorrect is that right. There are few I'm let Jamie address okay if you don't mind she's she's more in tune with 5 the discussions around some of the county local option can. So I think a majority of people do not realize about 60 percent of the ambulance providers across the state are private providers and like myself and hope and Nashville Howard in Hempstead County is in Lee and Phillips counties I have contracts in those counties and Leigh Ann Phillips basically pay a very small subsidy of under $40000 a year just as a placeholder for me as a provider and then in the other counties that I mentioned they do not pay a subsidy so it to each county its own and we are we have seen this over the years that more providers or having to ask for assistance but we know we're going to a dry well and there is not funding to get that from our local areas they just don't have it to give and since we're a fee for service operation across the state for most all of the providers this is why the treatment in place comes in so volatile to our system is because if you think about the ambulance industry touching 1000000 lives 1000000 Arkansans in the past year with that being said 30 percent 300000 of them did not go to the hospital and we did not turn a wheel to receive their proper reimbursement for that transport so what coming from arpa standpoint and things like that the the money that goes back to the county providers have been on hold to ask for any assistance in that because we really thought that from a state level that we were going to be able to take care of this for all 75 counties you guys brought up some great points the walk as before us just the fact you know we're a representative Ferguson and as well as representative Davis talking about the Little Red.and did their community get the vaccine and did their community get that for an ambulance provider we are in all 75 counties in this state and our providers do not shut down there 247365 and so that's why looking to find the money whether it be from whatever pot is so so important at this point in time. All right of. I'm sure that. The 3 of you have. Ugh going to great lengths to find money but let me just ask you this. Allen I have a server rule districts and for the I don't know what it I can't remember what it's called it's been and maybe they're not doing it anymore but that was a flight service and you bought insurance for that there isn't anything I mean I realize that the ambulance is to me anyway an essential service I can't imagine a an area without an ambulance and the and by the way I've heard great things about your ambulance so if you selling insurance I would like to buy yours but anyway of I I just I know you've looked in every place but to. What you're really doing today is saying to the state we need help we tried everything else and and we can't find a place to help us do the job that we were called to do is that right that's correct and and we've looked like you said we've we've started Freeman I mean this was a global pandemic declared a disaster a public health emergency that's the first place you go to and we know we houses along the way you look to fame for relief if you farm gets flooded you look to FEMA for relief we like to think about and and and got nothing and then of course there's acts was was not enough money we know that but we look there and we look to Arkansas and as we go throughout this process it's I guess this just on our part we're not looking for money to fix a quick fix we're looking for sustainability you could you could throw money at my supply costs today and I could pay some bills to medical supply vendors and cover costs of chemicals and decontamination and mask but that's not gonna help me have a work force a year from now we've got some real systemic issues with work force that this money would go to provide a long term fix not only for COVID but for other systems of care that Arkansas has put so much money in our trauma system are stroke System or heart of Texas them we have got to protect those systems as much as we do respond to the pandemic on I'd like to point out that representative Westerman was a huge help conversely Weston was a huge help in making sure that a treatment in place a piece of legislation was passed last year and unfortunately once it got to us CMS it was watered down and the providers especially rule providers were not able to tap into that resource that we thought would be out there for us and this is something that over the years we've always talked about doing a treat a version of treatment in place we're keeping people out of the hospital they don't want to go it's not our fault it's not the hospital's fault they're just afraid they're going to catch COVID and they don't want to go any further. I just want you to come check on them make sure my brother was vote to set you know what all of these kinds of things that are that they probably don't need to be in the hospital but we are the ones caring for them and at that moment in time there should be some type of reimbursement for the provider and congressman Westerman did step up and try to make that happen for us so on his behalf but it just it was one of those things every time Washington sends down money is kind of like the drugs at their standing now we seem to miss it we can't seem to catch it just trickles on beside all of us and we're not able to capture those funds that are needed to properly run our services all right I appreciate that we're gonna go through this list but I was just notified that education needs in here at 1:00 and we've got several of the things on the agenda so of representative Ferguson you're recognized for a question. Thank you madam chair of I'm this ambulance alliance plan of 2020 is that available somewhere I was sort of looking on your website and couldn't find it we if we can provide a copy to you certainly if it was a a proposal that was vetted through FEMA in the early days it is a by contract that allows for the the contract up to 25 initial ambulances that can go anywhere in the state you know many of the local providers have contract or franchise is that the affords them the service area the ambulance alliance plan would have. Broken down some of the barriers across those service lines and we can move ambulances to districts that were having an overflow research and it would provide funding for the providers in those areas as well so we can get you a copy of that plan has not published on anyway all right send it to Mr price and he can distributed to the committee yeah he had I guess but the plan doesn't really address what what they call in public health upstream problems of it what's the analogy where you're staying on the banks of my files of the river and you see him drowning you pull out the pull them out another one comes and you pull about the political at Sally you say let's go upstream and see why these people are drowning by the end of the line plan was designed specifically to handle the surge facility right on the facilities and reduce that wall time it was a very targeted specific proposal did not provide a lot of upstream fund but and I think I hear what you're saying in terms of the not getting paid when they're not transport to the hospital how are those decisions made is that made on the phone with a physician in the emergency medicine department or is it strictly made by the a paramedic commit who decides they don't need to go to the hospital actually the patient decides the patient has the right to refuse the service so in many cases we respond within 2 minutes according to state statute we have to respond to an emergency request an ambulance is rolling we send the advanced life support ambulance state permit gets there makes the assessment provides information we think this you know you this is a treatable condition but the person just refuses to go then we have to sign a release and and leave the patient yeah I have most of those are not through telemedicine certainly saves money if you don't admitted to the hospital in at do you have a plan to address this of health care you know employer employer problem of paramedics been and it's all across all this. Funds I mean as as you say it is not just an EMT or paramedic problem because when you get to the hospital and you have all this wall time to. Sit there because you don't have nurses I mean we have a health care of the problem coming like a tsunami with all of that across all disciplines of health care do you all have a plan for that have you address that with education or we had this we don't have a specific plan we have a lot of industry ideas and and we we're willing to set the table and that those out most of those are models like I said other states that have dressed this very issue has taken some very bold steps to have a you know opportunity training grants for workforce development directed to the service that not only provides the education of the new paramedic but it helps offset the cost of wall that medic is in school for somebody to fill that position to pay like I said these overtime costs and and so we have an education plan to provide some grants for training we have some possibly some rule changes that could take place in the earn while you learn model so that and the M. T. that's been with the service for a number of years could have some accelerated training and that's one thing that we have not done for EMS like we've done for other professions we've not changed our education our licensure model one iota we're we have accelerated some of the licensure plans for other professions so we have to earn and learn models that we'd be happy to put on the table and then long term we have to just look up at and how we're or certifying and licensing are individuals we may have to make some changes in our license or Act to to make accommodate some of these new workforce shortages in it in terms I know Medicare Medicaid or the payor spoke in terms of these non transported patients do we as a state have any medicated 30 to pay you for those not transported patients without federal approval you do you have the opportunity to activate codes that are not activated today for this very to identify and target this very thing and of course they would go through the regular medical review process and then they're also waivers waivers that can be requested through DHS from the fed. Our government to to target a treat release program and we talked about that early on in the pandemic with the ability to transport alternate destinations we got some emergency rule suspensions for a short period of time but because the health department failed to enact a statewide protocol that's the joy of our providers were unable to take advantage of even that and then of course those of sense expired have you met with secretary Gillespie and talked about reimbursement from Medicaid of creating a a code for that has it been a discussion that was in our that was in our proposal to treat and treat in place and and I've seen was that is part of our polls thank you. But you have not personally met with senator I'm a with the Secretary Gillespie now your last 2 years that we requested we meeting before this meeting last week and that because due to some of the weather I think we have some scheduled delays but that is the only senior leadership group that we have not met with specifically all right thank you all right to and again looking at the clock in the knowing the number of items still on the agenda Senator Hammer you're recognized for a question. First of all like to ask if you'd send I didn't see it on our agenda I'd like to see your deck pages send if you don't mind if we get it in the notes that you read from if you don't mind just we can absorb that if you'd send that if the chair would allow and we send it out yes on the treatment in place you said that's because the patient refused refuses what percentage so. Are treated to a patient refusal verses direction that you received from a higher level medical provider that is giving you instruction to treat a patient there so you don't have to transport. Not sure what the percentages and can make an answer this but one of the things we need to realize is that all of us have been placed on diversion to a different facility or don't bring a patient here currently at this time and then that also helps the paramedic make its decision on what they need to do with that patient that how critical they are they need to call back and check on later you know what process needs to take place to take care of that patient and keep them out of that facility or prevent a provider let me from driving you know another hour to find a facility if it maybe even further than that for the patient to go to so can you happen to know we the number is is not probably is not off the top of my head but I would say just knowing the systems and how the medical control operates most of our payment service around the state operating what is called offline medical control in other words the paramedic has their clinical guidelines that they follow but they don't communicate directly with the physician about the only active physician interaction that medics have is to a trauma system through the 2 routing trauma patients where they receive directions of whether to bring a patient to one facility versus the other but for general medical and in cases such as this it is at the discretion of the permitted to do the assessment to provide the information to the patient and I would say that in better than 90 percent of the cases the patient and or the family or caregivers are making that determination not direction of a physician our I'd like to get copy of y'all's proposals if you don't mind and Jamie welcome sling county by the way thank you Sir all right of a representative when you're recognized for a question. Thank you madam chair thank you guys for your presentation we're also really appreciate what you're doing for our state just a real quick question with regards to everything that you've listed which is of a multitude of things that's created this kind of downward spiral from a lot of different directions you know you mentioned the staffing issue I know that we had talked in the past about if we graduated 100 percent of our students from the course it was still wasn't enough to fill the vacancies that are being created each year is this proposal that's the the June twenty twenty one is does that answer does that address all of these issues to your satisfaction. That that that component of our proposal we think is absolutely critical it It allows us to put people into the pipeline in you're exactly correct and I I glossed over that point in my comments but if we graduated every paramedic today that's in school we would produce approximately 130 paramedics in the state of Arkansas March 31 we will create a vacancy of more than 200 and that cycle has been going on since 2017 I was paramedic education program director for 25 years to 1 of our community college systems and this this trend started back in about 2017 and its continued so you're exactly correct but we do think a portion of that proposal will address the long term systemic problems of workforce but you have to realize that the paramedic is now everyone is figured out they are the Swiss army knife of health care professionals they can do just about anything and we as a bill is providers can't pay them what they're worth and we don't have any other way to get those funds to bring up their Hey to the level that it deserves to be and that's what probably hurts us the most is because there's some of the hardest working men and women in the ditches today but yet we can't properly pay them with the system that is set up currently so even if you did 100 percent of those. Attics that those classes they would probably look for other avenues of work as well. What is the average paramedic salary. For the private sector industry in Arkansas they are about probably about $14 an hour I would say on average for paramedic and about the $11 minimum wage free anti okay so we we've got a lot of a lot of issues that a lot of issues and just so you know right now we're having to pay upwards of 18 to $22 an hour during the pandemic that we have no way to receive additional benefit but although we're calculating it we're counting it that this is basically a COVID stipend to help the the communities to keep up with that number in whole in hopes that someone allow us to turn it in whether it's fame of the state or someone at some point in time to say we provided this service I think the one thing everyone misses is the cost of reading this for the EMS system across Arkansas and the United States no one realizes that whether we roll will or not there is still a cost to be had in every community so that just to summarize all this so all of these issues from staffing to the to the on the walls issues business model and everything if we were to address what your proposal is from June of 21 that would that would encapsulate these issues. It would be offsets to the cost of the pandemic and the response that we're facing today I would also address the more long term issue of a valid work force that's correct and I just wanna make sure if we can get a copy of that as well yes we'd like to have a consulate thank you. All right of representative Dodson your next 4 questions but let me interject this we were going to add UAMS and have an explanation of their exemption policy for vaccines but we we know we're not going to have time so if any of you who are interested would like to go to UAMS and ask about that you can do that individually and if there's more interest we'll we could have a meeting later this week on that particular issue if you just talk to. We will give you all the copies of the policies you can look those over all right of going to the next question of of representative Payton you're recognized for the last question. Madam chair. I didn't get to ask a question oh I'm sorry thank you madam chair so. I may have missed it and I apologize if I did but what is the reason why you're not reimbursed when you roll as a fee for service without actually taking somebody to the hospital what why can't you direct bill them for the services of rolling out there helping save their life and stabilize them at that point in time. Well there there's nothing says you can't send a bill that's for sure better than 65 percent of all of our reimbursement any fee for service ambulance service whether it's you know fire department hospital or or whatever still in fee for service we are capitated and reimbursement for Medicare and Medicaid by national fee schedules and those rules promulgated by CMS say that there is no reimbursement unless a transport to a destination so you have to transport to a hospital of commercial insurers typically follows the same similar rules and do not allow for any charges that are not deemed under those fee schedules to be appropriate and then the only small back to the remains as those that truly or have no coverage or private pay and to send them a bill there they're just not going to pay it so federal Medicaid and Medicare that's right wills that's correct major players dictate that it is a transportation fee associated with the transport not a delivery of a service okay thank you thank you. All right of. Okay representative Payton in the last question madam chair this I'll be quick because most of my questions was same thing jim just ask of so. If if you're contracts with counties or something like that. You've mentioned you have those contract who's negotiating your compensation and if you have contracts with insurance companies I mean who negotiate that compensation but. What you just said CMS at the federal level setting rules insurance companies are picking up on that. So it seems to me like the only people that can fix this problem is CMS if if all of your contracts are going to be based off of the CMS rules. Then I don't see how we at the state level are going to change that so if you could maybe help me out I'd appreciate it. This is it really well that would be the last one that okay no earlier soapbox now sorry no I'm not I'm respectful of your time but part of that deal is it's been 2 years and this is the first time using the ambulance industry in front of you nobody we are a blip on the radar of what goes on whether it be CMS the health department this date or whatever we're very good about taking care of our own and and managing emergencies the problem with this situation is is 23 months in the making and this is not a normal emergency CMS had its guidelines for 50 years and and we're currently going through a whole cost of a study for the implants industry we do not do cost reporting but we will on a go forward due to new legislation and we're excited about that because I want to show you what my costs are and I want to be able to prove the point that ruling bills providers are not properly reimbursed and that there's a staggering difference and what needs to be done for them so there's part blame on CMS but us as our Kansans we need to make sure that whether it's for our own citizens or people who come to visit our state that we have a very robust EMS system a trauma system and a healthcare system that will take care of our people and that's what our focus should be on so I think with you knows as mystical less be and others I believe you treatment in place could be push forward to make sure that there's a savings on the back end but patients are being taken care of on the front in their solutions if we can get across the table and talk to people and then be open minded and realize that the ambulance industry has some solutions we don't come with their hand out without being able to work at the same time we're not asking for anything for free we're willing to do our portion of the work to take care of our Arkansans. All right thank you. Ballinger. It's not really a I'm is a little bit of a follow up I mean number one I think you're exactly right it needs to happen but as somebody who is self pay my medical bills on my life if an ambulance could if I called an ambulance and they showed up. They need to send me a bill I'm a pale and I don't know what percentage of that money your leave and set out there maybe it's 10 percent maybe just wanting but I highly recommend that you start billing people we do is we do there is such a a disparity and uncompensated care in our state and and and the different regions in which we serve in the money is not there you can send a bill all you want but if it if it can't pull blood out of a turnip and that's really what it ends up being the most of these cases you know 65 nearly 70 percent of what many of us do is related to Medicare and Medicaid and the state from an ambulance provider standpoint and the other 15 plus percent if you're lucky would be an insurance. Thank you thank you madam chair all right thank you someone asked me to ask the last question so of have you considered asking DHS for a waiver from CMS. Yes ma'am that's good I didn't mean to have a good plan. So have you had well have you ever we we've talked about waivers for behavioral health services we talk about waivers for treating place we talked about waivers for community paramedicine and yell. Yes from from sickness to CMS thank you so much we appreciate you being here thank you very much thank you stay safe and the announcmenet will be there and this is all right thank you all right ladies and gentleman we're gone switch of we will go to item of age and then go back to Adam G. as you look at the clock we we're running out of time as you can see so let's do a item age first and that is the report on the current status of the N. power health care solution as an Arkansas pass so if the people connected with that would come up. We will get started. And if you would introduce yourself for the record. Thank you manager Marc white armed services. Thank you madam chair dawn Staley permanent services. Good work good afternoon Elizabeth Pittman Division of Medical Services. Sarah linum Department of Human Services thank you so much for being here and you are recognized thank you madam chair or not I know you got a big crowd up here but recognizing the time let me give you just a very quick overview back in our budget hearings their number questions related to the passes to them in related to empower in particular are not the time by Senator Dismang had asked the the substantive committee hold a hearing just so to give you all operate ask this for questions and so that's the reason that the chairs added this today's agenda we repaired a power point for you and I believe you have that front of you gives an overview of where things are one to get a little broader skip some context of where things stand with the pass system I including the power and use an update on that and mentor so that we can walk through the park will be locked in a given time if you like go straight to questions we're certainly open to that all all look to see if there's any in the particular folks want to bring out. So I will will be happy to fall the committee's direction there talks walk through it or just hold for questions. I think that it because of the time of we're gonna go straight to questions all right to a representative Ladyman you have a question well I just want to say one reasons we want to do this I like a lot of others on the committee got questions about what the status of empower you know. Are they still effective do what number of clients are they serving how many did they give up Mr future plan and I'll just start out with. Are they how many of their clients that they give to other folks and how many do they have now and kind of what what is their operating condition or they operating at present capacity can just kind of give me the health of that company. Yes Sir. And if I may right now they currently have 20063 members that as of January 31 of this year during the time that they were suspended and cannot get any new members at people were allowed to transition out of in power for cost so because they were sanctions they were allowed to say I don't want to be part of it power anymore we had 145 members transition during that time period for costs. 7 we also have another I believe close to 600 DCFS has decided to go to 2 passes so they're moving there are no 3 passes I'm sorry 3 passes so they're meeting their members out of an power into other passes and that's about 600 members so that's what they've lost during that time I'll be effective in March 1 they have completed a readiness review for us which what we do with readiness review is just make sure they can complete what we call core operations they can keep playing claims they can keep providing care coordination of somebody goes to the pharmacy the prescription will be filled it won't be sent away they can on issue prior authorization so that providers can get paid for services so we went through starting and I believe late summer early fall within power to do that reading this review they have completed that as of January 31 they had actually checked all the boxes we were still monitoring so we have lifted that suspension effective today so they can start receiving you members today. Thank you for that and as far as I know you may not be able to talk about this the the legal question might prevent you from answering some of these questions are this question but the situation with repayment of issues that came up. Has the state been made whole or is that have they corrected the issue. It can you answer that. Certainly so as part of the settlement agreement and I do want to clarify that so agreement was with the Medicaid fraud control unit with the train General's office so specifics regarding that we can certainly speak to generalities but would referred specific questions to them but as part of that they actually determine that the amount of repayment was just over $30000000000 of which 75 percent of that was to be repaid to the state and that was repaid as of December. Thank you all right I have a question a. You mention to. In the reading this review and I just wondered why they failed this review and are you sure that they can meet a the standard snail. So they never actually failed to review the aged they were conditionally passed I believe is the terminology that was used by the external vendor I believe and and what he had said what he actually said in that report is while there were concerns which we can walk through if you would like he did believe that given the number of members that they served in the amount of services those members received it was in the best interest to continue to work with them to see if they can complete that ratings review successfully over the next several lines which is what we did after December thirty first twenty twenty one will. Conditionally. Past what you said that doesn't sound too good so we're going to expect all of you to keep an eye on them and make sure that the they are doing the right thing I understand the problem with all the people that are part of that pass up but. The date in my opinion. A conditionally is is not a good word we understand and they they have officially passed of it as of January 31 it is no longer conditional okay I during the time that it was considered conditional on we met with them very frequently in fact at 1.we were having daily meetings to review every payment they were making that wasn't to a provider okay and and we continue even though they have now passed reading this review to do what we call enhanced monitoring so they will submit additional reports to us for the next believe 6 months and we will have more frequent meetings okay enhanced monitor yes okay thank you very much if I may just to just add to that that is that it's a typical process that we do both in the case of once a pass has completed readiness review whether that's an existing pass or do pass because we're actually conducting that same type of monitoring with Kerr source which is a new is passed that was also added to the program all right thank you for any of the seat we have some questions Senator Hammer you're recognized for a question thanks measure just maybe 2 points one the other 3 passes or crime file because I think a lot of latitude and you should have cut him off long time ago and for whatever reason so address that because that's the buzz I mean. Address that please. So the first of what I want to just like to comment the comment that is made with regard to Kerr source we have been working with all the passes I know it there may be some you know there's been a lot interest with regard to the powers that you ation but we continue to have that same type of level of oversight monitoring with all the classes I think one thing that's important you know as we look back at the events have transpired has been looking at the focus on the beneficiary and then the taxpayer dollars and so as these investigations started come to light and we were notified by the train Jones office of what was happening at that point you know we had to think about what was in the best interest of both the beneficiary in the taxpayer and from that perspective we work within power we work with the other passes to then figure out what's the best way to ensure that critically for these very fragile clients how can we ensure they continue to research receive services and what's the best way to do that as as the Trejos Office was going through this transition so we certainly understand there's been a lot of interest in this and you know we want to continue to do we can to support the passes but also primarily the beneficiaries as we work through these transitions did you ever consider just cutting I'm awful altogether and letting the 20000 be distributed among the other 3 because if you didn't consider that that doesn't say a lot about the other 3 passes ability to be able to absorb 20000. And are we set up for failure down the road because it seems to me like you would have been able to say you know what doors are closed and will start transitioning these 20000 out to the other 3 passes certainly so any time that we have a suspension within the Medicaid program you know I think about whether it's been a physician or like an eccentric inventor colleges provider their situations we have to look at basically with regard to access and certainly in this case that was no exception when things we had to look at was with the number of clients that empower was serving at the time were there other options in this case other passes they could help it care for those clients if we were to do a total suspension and so we reached out to to the passes and asked them and said what is your current capacity and then what would your capacity look like in the future and so as part of those discussions and talking with the Medicaid inspector general's office as well as with the attorney general's office felt like that in the short term it was early in the best interests of the clients to to keep in power from receiving any new clients but allow them to keep taking care of their existing clients up until the point to the investigations have been concluded or until at such point we need to look at doing and overall transition but that definitely was part of the decision making an assessment that went into that process we continue to work with those passes since that time to understand as they continue particularly for newer passes in the program if they can increase their capacity what that looks like as we all know that situations you know can change very quickly but that was something that went into our evaluation assessment process in making that determination and the last question is this what's the difference between pushing the envelope and fraud when it does one is it's no longer pushing the envelope because you're talking $38000000 I mean there's some big numbers in this report what's the difference between pushing the envelope and then it breaks over going to the fraud area was anybody convicted of anything was any discussion about. Turning this over to the prosecuting attorney because of fraudulent activities what was the discussion around that. In those questions are really gonna be best addressed by the attorney general's office since they're the ones that conducted the investigation they would they would be best position to fill the speak to some of those some of those questions directly and I'll just add that the Chargers loss they do have that prosecutorial prosecutorial authority and so that ultimately when a prosecutorial decision they would have made based on the information I thank you. All right representative Ferguson you're recognized for a question. Thank you madam chair of ad no part of the problem was there equity partner bacon it in because they S. Blue Cross bought them so who is their new equity partner. Then you equity partner is tribes and it's an investment company and then they replace the beacon functions with 2 sub contractors that they already had Evolent and. Sure sure. Surender Sherman church I can't remember the name of it in these documents those are confined. Okay and I guess what's the ration is there is there can be a maximum number of passes we allow I mean it seems like we're sort of deluding the possibility of a company being successful by. Continuing to expand the number of passes so at this time there is not a maximum number and anyone that any company that meets the requirements and enrolls with ice through the provider enrollment process can become a pass it of course the market would have to support them in doing I but that is that is how it works right and I'm sorry just have another question I have from time to time patients call and want to change passes what is that process had that they do that so there's 2 ways you can change a pass everyone can change passes during open enrollment which occurs at the last half of the year the just for any reason or no reason at all they can just contact our number and we'll get it for you and change passes during that time period they can also change for calls at any point during the year and there's there's a list of reasons that are for costs including a passes incurred under sanctions or the provider that they see is no longer in that passes network if the past is not provide a service that they need those are some for cost reasons and they can call that same number in change for cost. Okay do you happen to know the number of I will get it for okay thank you all right our last questions Senator Solomon you're recognized for a question. Okay. Okay here we go. And the I believe both of this started when anthem violated the anti trust act I thank you that was a $600000000 settlement is that correct. So for us is actually started when legislation was passed during this last session that there directed that that empower we need to find new partner so that that's really when kind of our involvement again junction well as make a comment and that the anti trust was a $600000000 settlement with their any our quality of care issues with with the empower thank you already answered it but just want to get a real quick snapshot that they have problems with care. There were not significant quality of care issues raised during the readiness review noted had mentioned several times that that that was one of the chief reason for working with them and my past experience with you all as you do a good job working with people to make sure the quality of care stays there is your primary focus. Senate people can be rescued impact at various levels individual companies are large groups the last comment I'll make is your 30 $8000000 sounds like it is a lot of money but they had how many clients 20000 yes Sir so based upon that I mean it's not a huge settlement doesn't appear 11 compares that to the number of clients they have when that's not about $2000 per client. As an accounting error our our practice I guess one would say if I may add to the quality of care monitoring we did have our own internal I have call center to take calls during that last part of December and we asked some I am in power to as well we do not really receiving quality care issues that emerge bridge again in the business of we had a $2000 error per client that we make those when you find them you correct so I appreciate it thank you madam chairman thank you all right seeing no other questions we thank you very much and we are going back to G. very quickly. First. J.. Do this quickly all right unless you want. Are they if the stone would come forward. And. It of both of you in a dental for yourself for the record please. Thank you Mr Clark white forming in services. I am less the weather 10 I got married over the summer and I'm trying to listen hard whether 10 whether 10 yes. All right you you're recognized all right. Thank you at the minute first mission this is us somewhere constellations the previous autumn there were some questions during a budget hearing and so this is to follow up to that all right that alternate with ms weather thank you I'll be very sort Senator Bledsoe as a 9 year and. Trying to wrap this up so like Clark said I was asking questions during that budget hearings and there was and as suggestion made that we come forward to answer questions here actually got to go before and Children and Youth about a week point 7 weeks ago and did them a 3 hour presentation with the bureau on this as well if anybody wants that kind of detail but I am the reason it came up as an many of you also governor Hutchinson's press conference on December 14 where he announced that and we had come up with a plan to and reduce the wait list for the community and employment supports waiver which is the large DDS waiver and as it stood on December 1 of 2021 and on that date there was M. right around to hold on I can tell you 3000 204 people so it's very exciting news we are utilizing and 37.$6000000 and that we have available in the and trust fund we will be asking for on going funding for this endeavor during and fiscal session and so I think just want to put that on your radar that and we will need on going funding but we do have a plan to serve these additional 3000 people ever the next 3 years all right thank you we have 1 question senator Hammer. Recognized thank you make sure can you tell us or give us some expectation what that ongoing funding cost is going to be. I'm 37000000. At that does does that take into account any new ones that would be added because of the growing list or do you have that projections are you even a white project how many might be added. Either through attrition or can you anything on that no that's a really good question so on December 1 when the governor announced this we had and as of that date 3204 and four and then on January 11 already had and 46 more people sign up and I think I've watched this before when we will people wait so long and then only and are able to give out more slots it lets more people come and sign up so I know representative Ferguson I talked about this trying to make some projections and talk to you and that's about it as well there really is no way for us to know who is out there that has not come forward in need of Medicaid services that's been taken care of by family or different circumstances I've been to this point and you have to have for my waiver I am a diagnosis prior to 22 and again there are ways that people get brain injuries that that unfortunately make them intellectually disabled prior to age 22 as well and then births you know babies are born every day that have disabilities that qualify for my waiver program so I do anticipate that Senator Hammer that the number will continue to rise that we will continue to have some wait list in the future so this money is just to serve those 3200 that have been waiting this whole time thank you all right last question chairman laid up Director whether to start senate. I think people are looking at this wrong way they say we say eliminate the waiting list that's not possible that list will never be eliminated I think we need to start saying clear the waiting list and they will always be people coming on as you said but people think we can clear this to 0 I don't believe that can ever happen the do you agree with me I deal. I thought if I just actually as important keep this in mind it shortens the amount of the what the law the waiting time is right now for these first people are going to get on the waiver because these actions they'll been waiting for 11 plus years where as we get to the end of this 3000 bill been waiting for 3 years and that's that's a drastic difference that would make. We'll thank you so much we appreciate you being here and seeing no other questions of you are dismissed thank you all right ladies and gentleman we're going go to rule and I and if we're of the myth of the Chuck Thompson and Shelly Matthews would come to the table and would also those here for J. come to the table Lawrence you and Terry Paul we have 4 chairs for people. And a. Okay rule I. A Chuck Thompson Shelley Matthews if you with a dent a dentist by yourself for the record we will start with the. Thank you senator but Bledsoe Charles Chuck Thompson attorney with Arkansas Department of. Thank you I'm Sally Matthews at nurse with the Arkansas department of health all right you're recognized. Thank you senator Bledsoe thank you because you're Ladyman what you have before you is an amendment to the license lay midwives rules this is not the certified nurse midwives are there separate rules under nursing board this is in reference ACT 135 which is the automatic licensure update that was done this last session so this is strictly in compliance with that and update some definitions as to who uniformed service member ensuring that credit Rick received during military services goes towards a national licensure and including also ensuring that extra time for C. could you add 1 for those that are deployed so I'd be happy to take any questions we have a public comment period we had no public comments all right thank you a single questions without objection we will. Without objection the real stances Review thank you so much thank you all right next. We have road J. a if you would identify yourself for the record we will continue thank you madam chair on Larson I'm general counsel with the department of health thank you members of the committee also have Terry policies are environmental health branch chief here with me to answer any specific questions we are here for review of the retail food establishment rule this rule at as a definition to implement ACT 1040 the food freedom act it also modifies the portion of the rule that requires a certified food protection manager to allow for 1 year to comply for newly permitted establishments and it also referred removes a requirement radiates to contact retail food establishments every 6 months to confirm that the nature of the operation has not changed we had a public comment period it just ended at the end of July January we did have a few comments from a fire safety folks regarding sprinkler systems but Mr Paul came up with a solution to that problem and he can answer any further questions about that thank you all right thank you seeing no questions without objection this rule stands is reviewed and thank you so much for being here and ladies and gentleman of the committee I just want to thank you for staying to the end of the agenda and to we hope that the you will be safe and well and we'll see you again soon thank you so much with that of ejection this meeting is adjourned. Thank you yes all right.