Arkansas PANS/PANDAS Advisory Council

Is the update from the University of Arkansas for medical sciences regarding the data Michaels are gonna be you. Good morning senator Michael Carrick was UAMS Should be zooming in and we have a sandy Bennett will be online I know she was working to get sent in earlier to give the latest clinic statistics we're also I don't see her. Let's do this Michael for you go just because the screens kind of small for me Would would each person just introduce yourself if you speak over somebody just wait and everybody introduce yourself just for the benefit of those in the room if you don't mind it missed run to see you first when we start would you introduce yourself first and then we'll get representative cloud and go from there. Hi my name is Paul Ryan president of the page foundation. I'm. J. representative Joe clad District seventy one. I have heard of additional assistant and Benton. At the packet parent of advanced child. The bill comes in from the Department of Health. Committee else. Right in in here we have representative join us today representative Jack Ladyman who is the house chair public health just for the record glad to have him joining we got to Dan honey with the insurance department we got Matt Bromley and then we have our guests in the audience is missed anybody. A representative worn is tied up in another meeting he was gonna try to slip over for a little bit but he's tied up in a in a meeting over the capital and with that Michael you want we didn't present please. I am I'm waiting to hear back from sandy she is trying to zoom in at this point in time I don't have a copy of the first it. There should have been technical difficulties. Thank you sandy senator I will if you'll share your screen and share the latest to test exit you have for the clinic. Thank. Sorry my computer is very slow this morning. You use the crank on the right hand side and see if I'll make it go. I telling you. This is slides are coming up one of the things that we're excited about is we're and stick you'll see statistics that show that the clinic is growing it's growing and not only in awareness but also is growing and referrals and Senate is going to show some numbers that show some pretty remarkable growth especially since the clinic in its current format was current systems and people in place has been in place less than six months and so we're excited to to present these numbers St if you would please. Thank you senator screen yes ma'am. Okay. Well you're gonna have if you're with the slides because it this is the best way for me to show you our progress Hey sandy sandy can interrupt user anyway you come closer to you Mike or just a little bit. Yes that's better thank you okay. So you're saying you're going to be the same same slide you'll see again next month and then we will switch over to the new year. But Arkansas our clinic continues to grow we have twenty nine patients today eight. And If you look we're still you know we we don't have any patience on this lower corner yet. And so if we need an area to target for education or awareness of our clinic that would probably be where I would start since I don't know whether those patients are going. As we move into. Our second slide you'll notice that for two thousand and twenty we saw its total of the let the patients and after our December clinic we will be at. Thirty three so we will have tripled our volume this year. And I remember last time we met there was a question about. One engine data on how people hear about us and so I have started just. And the EE collecting that data and right now we have about forty percent that their PCP or their. A physician in their primary world of care is the one that is recommending our clinic. Forty percent per hearing about our clinic from a family member or a friend and about twenty percent are just doing their own search for pans and pandas and stumbling across those and calling. Do you think that is there any reason but shall can't send that to Emily that we could send that out to the we'll be happy to do that okay if you don't mind please that'll make it may will be easier for us to digest no problem all right any up. One of the other things the Senator that I'd like Senator to comment on is the number of patients that are referred that are diagnosed as pants pandas and then those that are not paying standards but have other diagnosis and would you speak to some of those numbers please. Absolutely in our very first meeting you asked for the data to be broken into non pans diagnoses and patients diagnoses and that continues so the blue number is our patients that we see that we are not giving a confirmatory diagnosis based on the clinical criteria for pans or pandas and our hands patients are in the red block. NO one hands patients are. Better identified over here in the other colors you've got a very small block here for our cancer patients. So. That kind of gives you an idea of most of our patients we're we're giving. A non cancer diagnoses that doesn't say that. Just because they have one of these diagnoses doesn't mean they're not also paying. Or a complex mix of two or three of these other diagnosed. A sandy having a hard time and that's excellent work by the way having a hard time read the number so how many or how many Europeans patients in the up taller column there in the middle hello twelve since our clinic started to from two thousand and twenty and ten from two thousand twenty one. Okay and are those numbers represented in the pie chart in the columns. Does that include the out of state That that's everybody right in state out of state that he. Okay. In center in regards to those patients that are referred to the clinic if they don't have a pants pandas diagnosis can you share what is what is provided for those patients there's there's simply not sent home I mean there are provided for services is that correct absolutely the patients that we send away without a handstand is diagnosis they are given most of the time a list of health care providers or mental health professionals in their local area that can help with their other diagnoses are out of state patients that's a little bit more tricky because we don't know or have a list of those providers but we we tell them in there after visit summary what type of therapy they need to look for in their local provider whether it's exposure response prevention therapist or behavior therapist. Or other types of counseling. So no we're not just leaving them to flounder and every patient every single patient that leaves is is doing courage to reach back out to me if they have further questions or if they feel that their child is experiencing a flare that could be more definitive of the clinical criteria for pants or pants. Okay Hey sandy how may do you have waiting to be seen. I have about six currently scheduled and for that I am waiting on the parents to return paperwork for me. When that when we spoke last time Thank you I guess I kinda sorta gave misinformation because I did say that I had like sixteen and I did but many of those I was waiting on paperwork back from the family. So I can't schedule them until I get the paperwork back from the family and some of those patients have and subsequently decided that they're going to stick with their local peace the P. which is either in spite of Arkansas are outside of Arkansas and no longer need to come to our clinic or they have decided that they can wait until later and they want to see what's happening with their current interventions that their local. Hillman provider is doing and we definitely encourage and support that is well. Okay. Michael your intent. No Sir any questions from committee members of the committee. And may I maybe can't see your hand racial just jump in and start if you just identify yourself with I can't see your hand being raised any any questions from any of members. Mr Ryan let me ask you a question of. You're you're able to see the charts that Kathy's presented. Hi Senator I did. Okay. Is that is you can see the charts are being shared with us. I see them yes okay. Based on what you're doing out Arizona's or any additional information you think that we need to incorporate into our data gathering other than what you see up there. I said you can say I'm sorry. The only question I have about these shards from sandy is if sandy ever watched moved to Arizona we're we're we're open for business and because that these are marvelous to have a summer is even though it's a small sample size I love the data that you're collecting and I think over time it's going to be enormously helpful we had to Senator in Arizona we had to go back to the retrospective study and come up with some more numbers I think Michael may have shared that chart with you that because there was already tried to show how many hands kids we were we had our clothing of the thousand at that thousand kids that we had at that point but I this is marvelous work sanity of doing thing I would ask in the future is. You mentioned and this is really true that the allies kids have multiple the disorders and When I have my question would be how many of these kids had multiple disorders at think that might be something where if the if it's not just strictly pants but it's hands and AS the let's say which is not that uncommon that day be reflected in the chart because I think it's important to the point you're making the multiple disorders thank you. I have a question okay. Cat and that one question for you sandy as far as whenever you get the kids coming into the axle clinic and then though what our case we had to go and have like twenty three and be done in order to break down Cameron's genetic background the CP had any gene mutations not certain if the clinics are actually doing that just to throw that out there that was very helpful to know that Cameron can't back to late there certain. What psychiatric drugs that can was actually placed on that made it is psychosis worse and that was due for him not being able to actually methylated so therefore it might his psychosis works with is that thank you Ansett there and the actual behaviors a question is are we actually going to request patients have that done the are we gonna have a geneticist actually come on board to help read the multiple pages that you actually get back with all that information and how is that are going to be handled it shall be done thought about doing the twenty three need to find out the gene mutations of these kids get half. Early what we're doing is we're looking at available land values that have come back from either the PCP or the referring physician and we're taking that into consideration as we see the patients at this time most of the kids that come to us I've already had this done. And or are in the process of getting it so we have not been ordering it at this time. We you know it is in our wheel house that we can added if we need to but this time it is not part of our initial intake process and I've had some parents ask do I have to go do this all over again I'm like no you don't have to go do this all over again but if you have the information please make sure that that is shared with us as part of our NJ. Thank you thank you. Mr right do you all include that in your work up out in Arizona what they were talking about. No no Senator we don't it's a relative expense of process and I Hey thanks any probably would tell you that most of that data is collected their and their medical records anyway some I think what we are pursuing and you should those in Arkansas we have our conference coming up in early March we're asking all the universities to adopt a comment Registry format so that they can share data amongst the guesses separate universities now medical campuses so that we get a idea including it's a lot of us from parents you know I color and common diseases and at pretty much any good thing itself into the Normans I data collection of. Kind of a genetic background of what the parents have the grandparents have the kids have so we're trying to get some kind of a pattern in this community of of commonality so that is what the university is really kind of rely on for a background check for nationally is a is a registry format rather than not twenty three and me. And any other questions of sandy on the documentation this time. Okay excellent Send your Michael anything else that you want to share at this time and and you had mentioned about you know we're going to go thanks to one day a week refresh my memory what the goal is and where we on that yes Sir we are currently expanding we've gone from we're going to be transitioning from one day a month to two days a month with the eventual objective hopefully to be one time a week we're we're making sure our systems and our processes of our. Data collection to where we're consistent with with the other centers of excellence but really we want to make sure that we can take care of the patients and families right to use the old analogy you've gotta crawl before you walk in you got to walk before you can run I think we're we're transitioning from a good crawl to the start of a good walk in once we get that we're going to be taken off running so we're very pleased with the progress we've made so far with referrals any questions from members. Okay and with regards to Dr panda doctor rainy they are going to try to break away from clinic if they are able to join us any time during our time together more world pause the conversation let them weigh in answering questions so for the members you committee just so you know they're on the agenda but it's going to be kind of at their bill to the breakaway from clinic to get into the conversation and then we'll let them go once they get done answering questions of all right moved out from item C. one ask Jody intricate you would come to table Michael I want to ask you to stay there if you don't mind please. And Jody if you would introduce yourself for the record please. Hi am Jody insured I'm the executive vice president of the Arkansas hospital association nice to see you today on this chilly Monday but it's a beautiful Monday so of at your comfort level you remove the mask or keep it whatever you feel comfortable doing a reason asked Jody and to be here this morning is because of the conversation we had at the last meeting dealing with acute onsets in situations especially dealing with the adult population and just to set the tone for the discussion on item the of we're we're getting our pediatric with the clinic that's in place at children's you know as was illustrated while go from crawl to a walk we're we're making progress in that area but we have to deal and have a conversation about our adult population of fact over the weekend I visited with a couple parents who have adult kids and the difficulty of dealing with kids when they hit an acute situation and one thing I also want to say and I'll I'll get to the get to the conversation here second we are and I know we've been working on this I think somebody commented since two thousand fifteen sixteen when this journey began and sometimes it seems like we're not getting anything done but retrospectively if you look back with actually got quite a bit done not as much or at the pace that some would like and I understand that especially from in the situation that I'm dealing with a child or an adult that that has this diagnosis one of the things came up in a meeting last week or last month was about how do we deal with this I know you a mess has somewhat of a structure in place but I did want to have an open air conversation about what is our best pass wait best pathway Ford as far as making sure that the adults are going to get as much attention as the adolescents are Mr Ryan I wanted you in the conversation of because. As I wanted to hear what is it that you're doing in Arizona kind of being the mother ship if you would what are you doing in Arizona in order to deal with those that have aged out does it have acute situations that are classified as adults reason I got Jody and here's because she's with the hospital association she doesn't represent all the provider groups such room dales and others but she does have a good lay of the land and I wanted her in the conversation to see what we need to do moving forward Mr Ryan what do you guys do out in Arizona and what is your insides first how we deal with the adult population specially when they present with an acute situation. Well first senator you've had a issue that's really near and dear to my heart and that like a grandson like most of these parents and grandparents on the line was affected quite have believe with this disorder years ago and there were times when we didn't have clinics centers it was really nothing existing that and he's come out of it very very well in some ways because the center never saw that has taken that we call transitional care concept and applied that to him as an adult so I'm I'm I'm sensitive this enough that our conference in March chosen as another major subject something we call transitional in there so we take these kids and all these centers up to the age of eighteen and then we essentially don't have an answer for them so in included constructing this and get everything we do it paces you know every university that is in our umbrella partnership in the country all does the same thing to keep it as a standard of care so everyone's going to have a shot at this transitional care program funding in March but they're all aware of it now last call because we talked about it we we we need to do a transitional care that's a based on all the universities agreeing on a certain standard of care that's the entity care prop right now luckily for us exist at the university of Wisconsin the reason it exists is Medicare I'm sorry Medicaid gave them up a bunch of money back and think for years ago and said set up a transitional care for kids with autism and they did And is got a staff of three four people full time at the university of Wisconsin which will become our model it's an outstanding program it takes these kids teachers and in a living concepts how to cook. I don't care for your room out to make your doctor's appointments how to take your medicine it's really. R. O. program is is beautiful I went to Wisconsin for a couple of days and sat down with the directors of that program which happened right now to be run a motion by nurses quite good at it by the way have been doing for a while and and have us all structure forms procedural dissertations on how you do this with with your beings it needs some assistance so I'm excited about that I think we've got lucky in the sense that there is just wonderfully effective program and that's we're gonna adopted the United national sense darting in March Arkansas will undoubtedly as they are with everything that we do you know my heart's my heart of my body may be in Arizona but my heart's in Arkansas and you guys are definitely I am so very biased towards Arkansas you've done an unbelievable job in a very short amount of time and senator Hammer United at the John offline about this and you know where I'm coming from on that you will definitely be a leader that as you will be in the I. B. IG trial that I'll describe a little while in the instance that you're you're going to get the leader she helped role of everything we do in the country but that is a major goal in March starting that we're gonna have was tries to present that to other staffers in our bridge in the darkness and the Arkansas as the Arizona's we're gonna adopted as our standard hopefully will take about a year probably take to transfer it but I don't see a lot of differences in the intent which is to basically teach people to do this on their own because mom and dad aren't around they go off to college they go into their eighteen they want to be free they leave the nest and all of a sudden they don't have any way of getting of meds IV AG's doctors appointments the CVT there be even though their parents can cover them insurance wise so there's no inability to get it. there's just a a practice of your lifestyle to make sure that does happen on the road but I I'm very excited about that natural we're doing. So the model that you're building out is it going to be adaptable to panda pandas. Of adults modeled after what they're doing with the Altez to some clinic I kinda lost it there for second reading you practice exactly right we're just going to it's sort of the same life techniques that are learn how to how to basically make sure your medical coverage is maintained at a level that you have at home so yes it'll be pretty much adopted we're hoping within a year that the major universities we have lots of meetings offline adopt the scent separation remodeling side about that really that off within the the next year twenty twenty two and having that done and you guys again will be in the leadership of the format doesn't mean you you by the way that you wait till the end of twenty twenty two to implement it you can implemented along the way I know that your doctor clothier there is one of the leaders in the country of this concept but right now it needs a vehicle and that vehicle is something we could take years to try to construct but since it existed Wisconsin it's been working for years that we've opted to take that is the model and and then converted to a pants pandas will correct. The and and let me have to pause but not disrupt recognized representative Denise Ennett sitting over here to the far right I'm sorry did she earlier so on recognized Shizhen room as well thank you of the. The the the presentation March. were you a less aware of that or or yeah they're they're by the judge that it's primarily Dr oriented Senator Hammer but it's actually got other folks from around the country we have people who collected Adult range from the folks that have pets pandas we have we have this quite a bit a lot of research probably too much to discuss today I don't want it you're meeting up but I think it it's a very robust program works and an Arkansas again we'll be right in the middle a leading at because of cloth years Dr clothiers interest in it so he's he's invited to the conference as are Dr panda and we're and the doctor rainy is that Arkansas is in trouble part of that conference. And I guess. What what I'm trying to get my mind is. Listening to the testimonies of some of the adult parents that their child has an episode on the weekend and they need a place for them to go to get them stabilized knowing that they are paying or pandas diagnosed adult. And in the framework of what you're talking about does it include dealing with an acute setting or is it dealing with long term living skill sets with a panda pandas diagnosis. Well I think it's both Senator so in the ninety ninety then ninety five percent that they are not getting heavy tree but like IV IG I think your your primary care physician is you know what they would be on a weekend of the kid got strep throat I mean you you'll have a path to the PCPs to take care of a whatever flair that kids having that's I think the design of the of the Wisconsin program so what if I was kinda normal guidelines if you get really sick you got covid on the Saturday it would be a call I think those the considerations on the IV IG folks or folks getting every medication that I think you're cute part of it comes into play in most places you go to the ER room and they have been instructed how to handle the pants pandas patient I know in Arizona we have a lot of B. R. training I hopefully that are we'll talk about Arkansas a minute by I think they've had a chat with your your department at the Arizona children's I'm sorry Arkansas children's hospital so I think they're in in sync with each other I know pandas quite was aggressive but very cognizant of the R.. qualifications so I know he's had chat with them but the it's the continuing conversation that is targeted towards as pandas kids so he gets calls on the weekend I think it was a while for thank you type situation but in most cases you one of the follow up very normal flaring of some disease including COVID what do you do when you're a normal human being on a weekend I think those people on the transition program will be instructed pretty much the same way about who to call it's pretty thorough program. if I may speak to that Dr Pande and Dr rainy are very much in agreement treat the flare as if you know your treatment The Dallas whether it's strep throat whether it's covid whatever it is treat what is going on we'll deal with the pains later and that is the the model that we were following. Are any questions from any of the members. Okay with regards to and then we'll we'll move on then if there's no other court if there's no questions but one reason everyone had Jody in here was because. If you one of this story shared with me by a parent was that they're working with their child of it is on the weekend the child gets totally uncontrollable you know to the point of hurting himself hurting the parents or the staff you know where the where the child may be living In in in an acute situation like that. Is it a matter of just taking them to the E. R. or is there any maybe in the model you're talking about Mr run any relationship with maybe psychiatric hospitals where they could be designated places to. To take you know the child in order to get the situation under control or are we just going to have to educate the E. R. departments and and what happens if the child is to combat it for the E. R. department. Bills. sorry great deal. I was just going to mention I I don't think it's an official agreement or anything but I do know Rivendell in Benton has gotten more familiar with hands and and does and several of my patients have gone in there I can tell you that care they get compared to four years ago when I started this journey has improved and the medical provider that's they're not the psychiatrist is connect with me on several occasions about my my kiddos so I know that's one safe place I don't think it's the perfect place and they know that but I will tell you is I do know they have been beneficial. I have to say on that as well. as far as their Rivendell goes we've personally had to execute that states with Cameron lasting seven days each state Got to be very close friends with ceremony claims she has had was head of the missions there and was talking with her and she has gone to her CEO at Rivendell to try to figure out how they can further help crosses patients that have banned and or you know pandas so with that being said one thing that I know that they're still waiting for is whenever they have a patient come through their facility a. What do they need to do in order to get that particular patient the proper care that they actually need so they're basically waiting on us to get them a a plan to follow and I have a handstand this patient to come through their door so that's one thing that we definitely need to address I know our situation with the stays that we've experienced we've had four different psychiatric hospitals I'm in agreement with Natalie Richmond Dale is more willing to help and do what the actual doctor that is treating the fans patients that they'll continue that patient of that the care and in patient facility but some with the stays that so they process patients but you know. Get uncontrollable we definitely need to leveraging dell NO what we expect them to do and who to call how to follow protocols and so make sure we get that clear so Serik and present that to the CEO and we can move forward with that psychiatric care there. Which run mess it up here in Arkansas we've got a model dealing with law enforcement Jody and help me out on this or one of the representatives but we have a we have a template in place here in Arkansas where a criminal or somebody that is We have to confront of for reason they don't necessarily take come to the jail but they take him to an acute crisis treatment center to determine if their actions are related to drugs or whatever that that's kind of a model that we have and I think we've got four of them in the state that are geographically displaced throughout the state. Is there and I'm asking my code Jody in Mr Ryan sandy or anybody else is is it or should it be something that we should spend time exploring looking at developing relationships geographically with other places in the state if revenue Dale's you know Central Arkansas that's fine. You know should we look at trying to set up a network of institutions that could receive kids and just focus on educating them so that if geographically of which sandy you noted in the in the southeast corner of the state you have no patience doesn't mean they're not there they may be there that's up we need to focus on education wise. But would we be better off taking that map that sandy had developing relationships with the subtleties working on training them so that the parent does have an out route you know of a controlled situation they could go there. Is that. Is that good bad or ugly or I'm open it up for feedback. Well center I'm I'm going to jump stand you just a little bit if I could you're not unique in that respect it I think it's all great to set up the center and and you guys a day to get a marvelous job with that in a very short time frame but we actually in Arizona we actually went out to the multiple spindles here as a result is bridge about twice the size of Arkansas at all over the course of the year our doctors in that case in person but in this case you could do it virtually have a grand rounds session with the medical people in those facilities beg the question that remained else asking is a really good question and that can't remember the young lady's name okay it mentions that it I and I think now he mentioned it to I think it's a really good idea to get those people face to face with the admissions people in the our people in those particular hospitals is probably a forty five minute conversation to be honest with their that they give the mayor with the docks at the center but they also get a real live discussion I've got a you know kids here's the situation what should I do we should I call when do you want to get called that that does two things it sets up in a nice we're working protocol because every environments a little different state yet at reading of articles top with every environment you have a a kind of a formula to handle those kids or adults that are having a flare and the second is charged to get the state from me you're with the directors of the center such that they're on a first name basis doctor day engine race who were our rating and panda of actually conducted those kind of gave the folks there business numbers their cell numbers so they had access to in the State. The result on a weekend or evening something was Billy bad happening all those folks around the state could actually call them a probably sandy's I mean there there's got to be some responsiveness to that situation because it isn't like something happens eight to five on the weekends so it's that kind of relationship which doesn't take all that long to do if you have a dedicated kind of mission say over the course of the year that they have a virtual conversation quality grand rounds but it's a conversation with those folks and they and they kind of tall of you know in this situation world what's the best way to handle that particular encounter so I would I would suggest that it's not uncommon and I think it actually helps me arise this state US president sought the section that you're showing that you exist and they're there for their benefit it's it's a little aggressive for the world of medicine but it's really a good aggressiveness you knowledge of familiarization it's a comfort level for all these folks that are saying I get a can I don't want to do it and I sure would like a conversation with somebody who does so I I think it answers that question that's the way we did a. All the questions remembers. Thank you still muted. Thank. Can you hear. Go where you were you trying to ask your questions are going to share comment. Okay any questions for well. A. The Dever. Hey Deborah are you on muted are you muted. Okay. I can see your lips moving but we can hear that on our end or in the. Never see if you can if you get on muted or whatever come back in. Our any other questions for me other members. Sure would be unrealistic to ask Jody and maybe to talk to some of the. Facilities will have conversations see which ones might be interested in working out Michael and we'll we'll see what kind of bill that we can get a no representa Ladyman might be a good one talk about you sure can't I don't think that may doctor any doctor candy and I have to call about doing some video recordings of just general education about independence to put on our website. Right now that they do not have to be the time band with two to go to many places but they could probably. Create some band with to do a grand rounds bison that is in the discussion space for the coming year. Okay. Represent Lehman. I think your suggestion on there your suggestion about using these acute response centers I believe that's what they're called I know that cute hospital hospitals around the state but those four centers were set up for just this kind of a response and I know we have one of those in Jonesborough in my district and they work very well there there twenty four seven they've got trained people there that to recognize different types of problems so I I think I'd be a great idea and I think they would be willing to learn how to recognize this inquisitive short term facility and then they could send them you know placed in the right position so that's great great idea okay. All right up there were we able to get your senate down there are you good nope okay of. If you got a question one ask. If you want to. She got your email ma'am. Okay Hey Deborah if you want to email Emily. Of your question or whatever you wanna get asked will get asked for comment will get read if you want to read if you want to send it to a family okay. Right. any other discussion on this item. Senator if I might this is locals and radiates just you know about using the crisis response centers are I think with whatever they're called that are spread around the state I guess I would say one you know my understanding of the position and I know I have a full understanding but those are you know primarily used for people who law enforcement would otherwise interact with you realize it's not really a law enforcement issue it's a mental health issue in order to keep them out of being in a jail and have them in a setting that's better for them or they can be better taking care of I assume most of those are adult but I don't know that that's true but those are those are a few issues that I think I would need to be explored one what's the capacity in are they already near maximum capacity such that you know treating someone with this war less well known and more complicated illness would be very difficult for them or not into do you want do you want to we want what parents want their fans Bandow's children diagnosed children diagnosed with that to be in that same study with you know those people it might be a great solution but they have to have capacity into you will want to make sure it was a good setting for the individual diagnose the bandstand was maybe if if you know if they were no longer a child they were an adult maybe would be less Less difficult but those are just something that came up in my mind sure and and I appreciate that of the I think what we're trying to speak to is the model itself just kind of duplicating the concept over into where we could utilize for facilities I'm not sure but some of those are actually in hospital settings am I right on that. Most of them are actually not within a hospital settings and they're outside of our purview but a lot of times hospital personnel have good relationships with those folks and kind of consult if you will on the medical needs and that seems to be a model that works pretty well I think yours is the only one that's technically on a campus. Okay to what we'll do. The general consensus on take away from this question is is in in conceptual terms it's a good idea before the next meeting we'll try to we'll try to have that frame worked out and maybe identify some facilities Rivendell being one of them that would be interested in and try to build out and because representative Ladyman sheer will will up talk to him about what could be the Northeast part of the state and will bill that conversation out for the next meeting okay. moving on to item he. Which would be a discussion developing statewide network of collaborating physicians I do want to kind of loop this into F. and before we were going to kind of combine these two a little bit because that term collaborating physicians is utilized in the language of the bill so what I'm gonna ask Dan if you would go down and have a seat at the table. If you would name and title for the record please Sir. Is this on now okay yes I'm Dan honey on the compliance counsel the Arkansas insurance department. Okay one of the discussions we had last meeting was about the phrase collaborative agreement and that being a criteria or gatekeeper for reimbursement of panda pandas diagnosis and you know prescriptions can you can you share what the we had a private conversation with the share with Charles position is let let me go ahead and and mention what what I wanted to talk about rule one twenty seven which is the the rules we have promulgated at the insurance department and this is a. This is in as as required by a no at ten fifty four a few things that I wanted to refresher once recollection on is this rule only applies to ten fifty four this does not apply to the Medicaid peace and also this requirement or or this of this mandate that of that carriers insurance carriers must pay for I. G. I. V.. Only applies to health insurers care fully fully insured health insurance into the Arkansas state and teachers plans does not apply to self funded plans so a lot of times you usually self funded plans what what they cover is determined by the particular employer for example if you know Walmart decides that they want to pay for this their their ministrations would do that a lot of times the. When we passed a mandate in the that that applies to insurance companies a lot of times it's sort of the if the self funded plans will often follow because there's it's sort of a drug it helps to drive the market would want to mention that basically this rule has lifted most of this most of the languages comes comes up comes straight out of a. Straight out of the the the statute and the the key provision here of it has to do with those are section for a coding fee for valuations it says every plan insurance plan shall permit appropriate claims coating fees or charges for healthcare related services including evaluations performed by medical fires in association or collaboration with the centers for excellence or the true true and and in a in a collaboration with our cultural is hospital so as this is as things are currently set up and I think that's this what Mr K. brought probably bill to speak to is that. We have not clearly define what Association and collaboration as far as providers that are not associated with that are not part of the solution center for except and so we were in order for. Providers out in the state who are not specifically tied in with the center for excellence we probably need to set up some kind of a a system or a a a protocol to we're. We can get providers out of state qualified in order to get them paid as well. Okay. The the roll you guys have the role drafted yes it's rights it's this rule is that it's actually been drafted it's gone through the process we've had a hearing on it is already effective it will be effective January first okay. It was done at last month's rules yes yeah we we of we okay I could be there so okay all right so beginning January first then right now and here's where I see the lay of the land you tell me if I'm wrong with. UAMS center being the center of excellence anybody or anyone to go through their process it is determined to need IV IG because they've been determined they are the only collaborative agreement right now or in the only institution that would comply with the language of the rule for reimbursement purchase point yes at this point okay so. What we need to do and miss run I kind of like you to weigh in on this too. In my opinion what we need to do is determine how we're going to build out that collaborative agreement or that collaborative arrangements or let's just have a conversation about what that's going to look like because if there's not a collaborative but say between you M. S. and position XYZ out there and physician ex wives the orders I B. I G. because they think that this patient of theirs has pander pandas. Is that or will that not be. Reimbursable or payable if there's not that collaborative arrangement between the center of excellence and physician XYZ yes Senate let me speak to that real quick and I think you as per our conversation that. The carriers get obviously whenever there is a new mandate during the legislative process the the insurance carriers you know Blue Cross and United and all them that they were I think they were concerned about a and and rightfully so with having providers out of the state if they were going to provide this service that they be qualified or you know trained in the it's not just that that that they have some there should be some kind of protocol in place and I believe that what we're talking about here is the possibility of of having you a mess come out with some some guidelines under which if if a provider out of the state wanted to build divide the service that they need to you know verify that they've undergone certain training or that there's they they have the of requisite knowledge in order to be able to provide the service of appropriately. Right how do you all handle that out there in Arizona what you're. What you would want your structures far as your center of excellence and physician in outlying areas of Arizona in which what's that template look like. So I Senator harkens back conversations we have when I visited you folks and I I'll tell you whatever resulted does and not by statute it's by agreement essentially we didn't need statute we have a pretty high percentage rate I think the average rate is ninety five percent whether it's Medicaid or I haven't selfinsured folks I'm. We went with the N. I. H. actually to our Medicaid folks I years ago and we had a long chat about what works qualification of providers is probably not a great way to go those folks change they come they go they get educated so it's really not all that. Easy to administrate I don't think it I think they felt the same way so our docks and age room with Medicaid we so what do you think's going to work and the the main consideration they had all right I think most insurers have yes if you have providers and if you remember this conversation Senator feel very strongly about this if you have providers who just give this out I. B. I. GI out because they don't want to take the time with the kids or it's an easy solution it It that's the folks that the at the Medicaid people were very concerned that a couple providers there is on that that they had been tracking because they've given out I. B. A. G. like it was candy and so that that was their main concern is having an ability to see with insurance companies will BlueCross BlueShield being the biggest one that we had chats with the time the the idea that they wanted to track the over provider or the misdiagnosed type people so the agreement we have which they rode into I think one of the rules is that the the center of excellence was used as a validator so any insurance company Medicaid provider of folks said I had to authorize you the payment or the issuance of an I. B. IG I couldn't. I'd send the center of actions will file you could do it by a file review you could do it by hello hello this is their new tools now that you can use to review questionable files so you know Blue Cross who comes up says that well I don't with the providers giving out a lot seems like a lot or this is the first one to avoid this case looked really shaky to me that they have the ability to send that to the center of excellence for review in the center of excellence job and I've had chats with a doctor and a doctor ready about this that they would take that file review it they have really three options they say that looks fine usually they know that PCP by now they have confidence in them that's one of the other things by getting out in the State of face to face but they look at the file they say great that's it does everything else they could now I bet you makes sense second cases a centers absent no way in the world that that that prescription Bribie IG makes a I had a sense to me if they have ability than to talk to that their primary care physician or neurologist who wears subspecialists as to why you doing that they have a chat much like of a review on the phone would be and the third is a sale my gosh this is a very serious case we want to see this kid in that in our clinic that probably is the lowest common denominator in the sense that you don't really want to have this kid travel OCD kid driving a car airplane something to go to a clinic I mean that really is kind of a in this disease spectrum one of the things you stay away from so I would recommend it we we've done very rarely here has that question come up I think part of that's because our wages program is been very robust yours will be over the next twelve months I think you have the same of the fact that everybody will know you exist and in the in the State PCPs and subspecialists I don't know that you know your doctor. Panda I'm comfortable with the fact that he's there he has certain requirements for IV IG they're not something necessarily you can put in a document because these kids very in and as now they would tell you in a huge amount they are all the same it's not like a year it's a cookie cutter disease it's a psych test to be a site medicine joined at this way of a multi discipline clinic it's complex so I find that writing rules and this are tough probably not all that enforceable maybe not all that helpful I think it agreement where you have a center like this with the expertise exist that it's of it's better that you have a rule or a simple application that if a file is questioned by Medicaid and I'm sure your state follows up a prescription habits of physician just like everybody else does or you see a indication of maybe over prescription may or may not be accurate that you have the ability to send that script that file to the center of actions for their comments there there approval not approval of that particular case that's the way I do it I think it's simple I think it works I think it's a generally accepted happens then it doesn't have to tractors issued by position by position about who's moving to Missouri tomorrow I find that that Arkansas will want to move anywhere else anyway but the folks that moved around with the brand new ones that come into practice this is just really really difficult to apply a rule of written rule like that so I would suggest doing it like we do here it's also the same way document does it in in New Hampshire I mean that's center or that main clinic is kind of the basis of knowledge you trust that base of knowledge to make that judgment call on either trouble summer questionable prescriptions not everyone by the way But you would do it on one square the official designators of Medicaid or insurance companies would have a question. Then you got a response well I I didn't. Having of the experience there that's the that that is in lightning and I don't really disagree with anything he said there it's a it's probably just a matter of a of course Medicaid is one thing in the of course they'll be coming out with their rules I know that that mark like this year at a previous meeting and and they're they're working on something but as long as you know the center for excellence UAMS can of can coordinate and get the word out to the insurance carriers and just everyone get on the same page about how we're going to deal with this because you know it's it's a rare enough disease or condition that it would be unlikely that you're just gonna have a provider who's you know he had as he mentioned handing out this treatment like candy at the it would probably be something that that could be trackable or our of our phone or maybe a flag would go up if if if if if the the carrier saw one particular provider of. Prescribing this of this this treatment you know in in your in order to mount so that the I mean I'm I'm curious to see what Mr Kate has to say but that that sounds like a a reasonable approach it in and if the carriers will get on board so the rule as written that's been adopted creeks that. Pathway Ford. Used Mr Ryan's explanation I believe so yes okay. R. as a Medicaid I'll get hold of mark running waiting on the Medicaid rule and I suspect that the that the rule will be will be similar is in a similar language to what we have but us you know we're certainly happy to to give whatever input of is of Israel is requested okay. A response Michael no we we certainly or or willing to work you know what Mr Ryan said and the expertise in the team in Arizona have that's that's a great play book to work from and Arkansas our objective is to learn from their success and find out how we replicated here in Arkansas and the things that that were mentioned about working with providers for education training and awareness those are things that are that we've committed to do and sanding is mentioned earlier some of the things that we've been discussed and so how we do this going forward if you know we're gonna learn and we're going to replicate a lot of what they've done in Arizona that Mister Ryan is has mentioned and what's been done at Dartmouth and other places. What would be. The any any questions from committee members. Senator Hammer yes Sir. I have a question as far as we're. We're putting things back toward the center of excellence at the UAMS nice to gauge which I think right believe we should be doing but I think at some point we're going to need to hear from the positions there Dr Hans and and doctor a rainy and also miss Bennet if they're gonna be able to have the man hours to do this we talk about the this is not an eight to five illness and certainly it's not it be great if we could have some kind of a hot line established so that those practitioners spread out all through the state would have some place to call it would help for their reassurance if if they are contemplating giving a very expensive medication and just to have someone that they can talk to have a short consultation and in such a yes I think that this is this is indicated in this situation I mean degraded if everything was eight to five or nine to five but that's not going to be the case and I think we're putting potentially putting a lot on our center of excellence there but but we need we need to have some kind of Avenue for practitioners out of the state I think. At that point. About building out a network of collaborative physicians. Because of a thank sandy you said you had thirty six. The chart you had a while ago you had thirty six that were That right. Senator I think the number was actually thirty three patients this year and we're moving to a second day a month in January those days are already booked with February beginning to start so what we're trying to do is we do as we increase our capacity is or is similar line increase the awareness of the state to where we can manage that increase lotus it comes up part of it is systems and processes and making sure that we are able to handle the additional volume that comes on because as Dr cloud mention this is not a this is not an eight to five diagnosis this is something that there will be questions about to throughout the day and night and we want to make sure we're doing what we can to to educate healthcare providers throughout the state to where there is some level of comfort in treating but also in in in making a referral if and when that's necessary okay I'm a recognized represent a minute segment. where and Dr cloud I'd be curious to hear your response this after recognized representative Ladyman but if you have physicians in the state that have a strong interest in this the process for developing that collaborative arrangement with those positions so that the center of excellence I just. Wondering to what Dr Klaus said about being the capacity of the center of excellence based on the number of recipients that we're going to be getting and if there's benefit to developing out the network of collaborative or positions in the state geographically to where they could help provide some relief working in conjunction with which you M. S. I'm all recognize Center a representative Ladyman and then represent cloud if you want way back in on that feel free represent Lehman. Thank you senator Hammer and I thank Dr class talk about same thing and I'm going to mention here but you know the crisis centers we talked about the one we have in Jones were on I don't know but the others up in there is a concern about the people that they bring in there but the center is we're low local law enforcement would bring people that they know does not need to go to a jail or could they they need to be evaluated it is mostly adults but that's what it's there for is there twenty four seven but the people that run that center that has a contract with the county is mid south health systems I'm sure you're familiar with them they've got eight positions in that office in that a man that Senator so it's basically an extension of their system where they put people into that area and and the description of what they do it's a medical group practice located in on Intel's will specialize in health care coordination and child and adolescent psychiatry so you know they're they're kind of in that field I think and they the capacity issue there they would actually like to utilize that response center more for more different things. And I think they be interested in getting qualified to do this such as an example what could be done. But not cloud you have anyway in. Simply stated I think the more the merrier and being sympathetic to the the prices of the algae and the potential conundrum that practitioners may have trying to decide whether or not to prescribe this and the cost of it thinking and being sympathetic toward insurance providers also I just think it would be great if there could be yeah collaboration there the insurance providers would have confidence in a network of practitioners and and feel confident that yes if they say I have a G. is indicated in needed