ALC-Executive Subcommittee

Reshoot you being here the Legislative Council directives subcommittee. As we continue with some important. Work. If all members will take the seat. I will remind you for get started in members in your packet there is a Schedule calendar schedule that it gives you some ideas of of what's going on we'll remind you that we will be taking public comment next Wednesday and Thursday twenty second twenty third After which time we will be. The signing also recommendations so. Be mindful of that we appreciate our guests being back today thank you for being here in your work and the. Okay Patrick I believe you were up for. Thank you let. That right to recognize it thank you. When everyone Matt Kersting with Siegel forget into some of the the additional presentations that we've put together there was some follow up related to the other income that was discussed in our projections last last summer here in August we did some we did some digging into what that included an excuse me I didn't of the print out here so I'm gonna just read it off from my phone the the other income for their the historical information includes the following pharmacy rebates retiree drug subsidy income performance guarantee information or or reimbursements ficus savings interest income and tax offset the vast majority of those dollars that were included in other income related to three items rebates RDS and Feige dollars for a S. C. in fiscal twenty twenty that represented seventeen point two of the seventeen point four million dollars in either income for PSE represented thirteen point three out of thirteen point four million dollars in other income dollars There was a question around the variability that existed in the historical numbers for other income over time as we looked at that for prior year information we're able to isolate much of the volatility coming from the the fake dollars in the fight to savings there was some significant variability year over year that was I seen in the data that we don't have direct line of sight into what drove that differential year over year but from a go forward perspective for other income we included only two items rebates and RDS drug subsidies the reason being I thank it was excluded because it it seems to be directly offset by E. A. P. R. costs and life insurance costs for the ANC projections since these were offsetting items we didn't include them in our projections so those are the only two items going forward in the other income dollars that we used and those were assumed to increase with prescription drug trend in the projections. Okay members we have any questions. Senator Hickey is recognized as I think I'd question that if I remember correctly the so I think my idea was is we were showing more for this coming this call for this coming time period so with what you looked at are you still comfortable with the projections you majored we need to adjust those any yeah I know we are comfortable with what we used in their it includes I rebates get updated over time so there is some some increased assumptions that we do expect to see your year in rebates as well as RDS dollars so we're comfortable with the projections that we've used for that based on historical data that we use to protect them for an and think they're reasonable estimates of what you can expect to see over the next five years what would you say that last there are reasonable estimates over what you can expect to see over the next five years right thank you Sir. Trump. Okay then no more questions. Who's up next. Right so l'anno. What you take over. Sounds good let me just get my screen up in she's always. Hi all. Seventy two. That the presentation of freedom. Okay can everybody see that. You're good up. Perfect okay. One morning I was asked to join from our national compliance practice to give you a little bit of an update on what's going on in the mental health parity space so without thank you no further do I get into that may just. My area. Okay. Okay so the news with mental health parity occurred at the end of last year signed into law in December was the straightening Kerry in mental health and substance use disorder benefit provisions that were included in the consolidated appropriations act so basically I'll once those requirements were signed into law they require group health plans to perform and document it compared analysis of the design an application of what the parity rules call non quantitative treatment limitations and QTL so I know that's a mouthful basically if you go back in time and you think about the mental health care equals the mental health care equals have started to buckets of components of everyone has always related to what's considered financial requirements and quantitative limits of things like copays coinsurance deductibles and those rules have a special task for analyzing Garrity and they were not touched by the new amendments to the law but what happened at the end of last year was this additional amendments to the Kerry law that relates to the other rules that are those that govern what you can basically shorthanded leak out as medical management of mental health and substance use disorder affects so under parity anytime there is a medical management with respect to a mental health or substance use disorder benefit the idea is that it should be comparable not more restrictive than what is being applied on the medical surgical site and so what would happen is that's been the law and then this new law said well you know you can't just we don't want you to just sort of like explain this or walk I ask the department's through this if we come in for an audit we want you plans to actually go through it'll and have this analysis of. How things operate comparably documented in and on hands to right basically to provide to the government to provide support and if they ask and those requirements you can applicables or fact I should say forty five days after the last house so right away in February of twenty twenty one and a C. somehow we have in terms of the signed into law it should be twenty twenty on acts by a just and lasting here so basically the new laws eighteen and we're include core of requirement to have the new documented analysis and then they have lots of other requirements that are more so going to apply to the government but some of which are really going to affect lands of system that it is that the government's supposed to come out with more updates to compliance program guidance that they already have so this is where we see the departments to things like issuing samples you know give us you know whether to act a cues or be seen on their warning signs documents you know plan provisions that concern the government and they think require an analysis things like that are they're supposed to tell us more but they haven't yet of the government's also tasked with the annual reporting to the by the department to Congress about non compliance and they're also supposed to get out more guidance about how participants and beneficiaries can you request this information that plans are supposed to have and then they're also supposed there they have stored now we'll talk about it more in this presentation of a specific approach to corrective actions of the departments aren't handling issues with mental health parity and enforcement and how they want correction to work the same way as they are other requirements and part of that is driven by some of the language that was in the statute. So it seems are this approach to corrective action and the fact that keep in your mind the government has to tell Congress what's going on there or stay here so that's good and the two big considerations offer plans when they think about how you know so how the department's acting in what were seen as a walk in the presentation I think that those factors can get contact what's going on. So in terms of this new law but you know the big thing to think about is that you know basically for all these types of medical management techniques very few plans including ours in the world are wholly self administer at this time so you know most plans involve various different benefit administrators who were involved in different aspects of the you know providing the network providing utilization review type services provided providing an action pharmacy benefits and all of those things include medical management of a mental health and ask you the benefits so for all of those administrators this new requirement under the law the sick leave but plan sponsors in a position of collecting all the compared analysis from their benefit administrators about the services the benefit administrator is provided to the plant So it is a big story after big coordinated responsibility because a plan normally can't sort of alone in a silo have the answers to these questions because they delegate a lot of this work to a benefits administrator so it was very you know as I mentioned the law became effective in February so very important for plans to be getting information collection under way we still have not seen actual guidance there had been hope that the department's what it may be provided template need to provide some more examples because there's lots of thank you TLC where they never really told the regulated community what they think is comparable or is enough of the Department had it done the only thing they have issued is that I think use that they issued in April the main take away an athlete's use where there were some examples of things that the Department they are an example of insufficient explanation so this would be things like if a benefit administrator says they rely on a cost factor but then they don't get any information they don't state actor is they don't give the underlying studies so how examples like that and they take away from the guidance was that the department or state these laws in general have already been in place and plans were supposed to be why so the Department in this epic you guidance and lots of public comments they made sense of kind of a taking the position that they don't think this documentation after it should be a big deal because placida RD thank comply now do you think that's reasonable no because we know that it takes a lot of effort to get this you know it's kind of different to think you're compliant have a you would have a discussion about that versus having you know very formal clear written summaries coming out a lot the major organizations but that's not the Department so that's kinda part of what's going on as you know these are all rules that the department of labor HHS and treasury work out together. For your purposes you know each H. S. What some regard is it is good news because HHS has been aggressively enforcing parity I'm the only but the department of labor has really you there didn't go very much into enforcement on this immediately so you know very difficult for plants to back their direct enforcer of just to give people context because I know not everybody on this call you know works out parity every day but what I'm talking about these angst you tells what I'm talking about medical management there's a very long non exhaustive list that the department for in a federal regulations core examples are prior authorization current review formula every design standards for writers mission how reimbursement rate of the formulas are done if there's you know refuse it okay and tell higher prosperity has been tried or or certain prescription drug levels Senate tried so often referred to as first step therapy policies and exclusions for specific treatments or certain conditions are all some of the major areas where you're kind of you know class need to look and say what's happening in a mental health issue date at any time there is some paper management happening there that you have to also look and compare how that you know is being done here to medical. So as I mentioned we had a little bit I think you've got it and you know so again one of the things that apartment mention the scene over the years or departments of is that you know plans will story just regurgitate a federal rule and state yeah we do it you know we do it like that we look at all the process these you know strategies evidentiary standards and are comparable the way we are comparable and so we can buy and they were saying now that you know you can't just do that you really need to get into the weeds each act shall and how you manage it instantly not to. The department's budget a little bit cold so my voice is a little. Not great today anyway the the department published self compliance tool many years ago they have updated it you're out actually over the years their last update to it was last year and so in April after Hughes they again points to the tool and say that's a good place to look to think about how the plan should be sort of walking through their analysis at any given thank you yeah and what this tool really does is it sort has a four step process the Department outlined in terms of thinking about you know what's the answer shall the applies you know how do you define that thank you TL and the the factors how do you find that factors that are used to you know impose whatever that it is if it's if it's prior authorization was the fact or why you do it defined that and then again there's things like studies reports that have been looked at twenty to those so they do have a you know a server to step process it doesn't work perfectly it doesn't you know sort of always you don't always need to go through all the steps but it's all we have right now in terms of any idea of what their thank you how to write up a summary. you know I mention that that there's things they mentioned that they think are insufficient in terms of a comparative analysis so right generalization and you saying you relied on you know studies or reports but not including that documentation as you know as on the record basically your compared to summary you know another thing you'll see are sort of like if the plan goes to its administrator and says well you know can you provide me the information related to the actual seals under my plan you may see you know sometimes you'll see an administrator provide like a big step file of every you know Sir every governing policy that that company has rate and with the departments of the state is kind of like don't do that get it you know you need to get a set of crosswalk like this is the specific and QTL and these are the specific policies that the planet's administrators that are relevant to that so obviously against of the lots of lands would be relying on their industry or show them how to process what that but you know that's where we find having to go back to the ministry or thank you for this you know the zip file of information but we crosswalk because the Department stock and accept this You know and then if they selected not by not not really defining what the factor is or you know sort of but not updating things given a passage of time so lots of times we see that you know when at an approach was decided a long time ago but is there process for how often acts riveted or or refresh to make sure it's actually you know appropriate we also see a lot of times where there's level language in plan documents that's actually not being operationalized OR is being operationalized in a different way that was state ten years ago but somehow it's it's carried over state things like that really need to be updated and I you know workplan document even just thank you L. as written in the last terms because it's you know it's no longer accurate and consistent so they look for all those those kinds of things It mentions the supporting information making sure that when an administrator provides it they also provide or stated will be willing upon request by the department or purchase it to provide the supporting information and then the plan cut it does that it's you know it's prepared and not sense requesting complaints so as we know I'm going the over the years yeah HHS four DO I'll got a complaint from a participant and beneficiary enrolling at plan of date you know Austin follow those things and you know and I can historically of result in what any of the departments whoever has the property or state jurisdiction ultimately opening an investigation on the plant we seen HHS audits where HHS had it you know a very isolated complaints in the past but that sort of led them to be an inquiry with the plan and then they wind up opening like override comprehensive health plan you know audit of that plant based on you know one complaint related to a very isolated aspect of what we see under the new statute is that now if the department yet a complaint related to mental health or substance use disorder benefits they're actually required to ask the plan that was complaint about for their anti shall prepare an analysis so. This is more of more of a now discredited outcome rate this isn't a wait and see anymore so somebody complains it guess that that complaint reaches that the federal Department they're gonna contact plan out starting to request information and then much like we see in the past the fact that makes no law into a broader on it is always very lightly. So we have some things on the horizon you know we knew the departments were allowed to request the information starting in February in fact they were actually tasked with collecting at least twenty particularly the department of labor is super engaged around this and we know that department has collected more than twenty of but we also know each other you know does have active open you know enforcement against Nonfederal plans and is also prioritizing this topic so you know this was a quick Applicability enforcement of these rules even without guidance got it under way immediately. We didn't see any act excuse that the department identified certain enforcement priorities of still one state flag as things they intended to focus on or prior authorization concurrent review standards for provider and mission and out of network reimbursement rates and we have seen that they are asking plans a lot about all four of those topics but I just want to emphasize that it doesn't mean they haven't sort of taking a phased approach to enforcement on the whole so it's not that they're going and only asking about these four things all the time of what they're doing is they're often asking about some or all of these four things and then what they tend to be doing is also looking through you know any written plan document and asking anything and everything about any questions they have you know based on any thank you shall take questions they have based on what they see in writing and then sometimes you know for whatever reason what you know we heard and everyone there it was triggered by a complaint they might be asking about something that's not on this list and he wasn't even you know fact and as an issue an occupant for example you know want everyone in the activities we saw related to it sounds like they received a complaint related to prescription drug coverage for certain adult STD it will ask you the related drug treatments and so that bonds you know many enquiries related to the drug benefit which as you see it's not on this list so so I think it's just give us an idea of some of the topics they're thinking about but it doesn't tell you for sure that that's the only things last about right now. So I mentioned of corrective action and that this parity approach is a little bit different there are consequences for failure to satisfy a comparative analysis requirements now right now for lots of lands they're not asking for a compared to every single and QTL but ways on the last night and they might be asking for on two things are for things or six things depending on that plan eventually you know I would expect the department will just be coming and saying you've got more than enough time I want to see a full analysis but they're not quite doing that yes but when they ask for it other than that they're gonna ask for it and they're going to take a look and then then they can't they basically will say okay we see things that we think make this insufficient and once they do that they're getting plans forty five days after you know this first they say it's insufficient this is the language on the site is the statute I'm gonna tell you what we're actually seeing going on they will give a letter that says we think this is insufficient but will give you like maybe a week maybe two at the most to tell us and the other thing you want to sell so that plans make scrambled say well you know here's master information I can right and then they'll say well. Thank you but we found that with respect to however you know whatever items we do not care in compliance and then the player has forty five days to basically offer what they're going to do to correct their noncompliance of after that point and this we haven't seen play all the way out yet but after that point the Department leader status that was side where they will make a final determination that the plan is not in compliance and I'll have to notify participants of their of the fact that they weren't in compliance and I have to do that within seven days so this is like nothing we have in any other of the help they requirements Mr by the three departments it's just different it's very impressive and the other thing unfortunately that were seen is the you know sort of the enforcement posture is very different so far again particularly on the department of labor but you know I wouldn't be surprised if we see similar added HHS's this continues as well when the when the letters you know what I plan for example place for their information we have the implants that right out of the gate Hey here's our information by the way we were working on this we realized that we were doing something that wasn't right and so we're gonna fix that and here's what we're going to do to fix it and they put that in there you know the first thing they get to the Department anybody who's worked for federal audit in the past training does that usually the departments are like okay thanks you know here's how we're going to talk about your what you propose to do is your corrective action here's the other things you like to see kind of that dialogue what we're C. F. as so if you get this point and they they rule that you're not in compliance what happens. So you have to so this is what we're so you have to notify your enrollees that you're not compliance we also they can last name will show up on their report to Congress at the end of the year on as an actual name not just normally they shot redacted in the House of so that's kinda like some of that change the statute has driven but the other thing is kind of like I'm I was starting to get to was normally if a plans as well he G. here's what I did wrong here's what I think I'm gonna do to correct it what you know what the department is doing is even Act information comes forward in like an initial delivery to the government. The government will still say what we're issuing a finding of noncompliance that so and plans are saying well okay fine because I told you why but that was really tough is they'll stay at your forty five days to give us anything else you want to supplement related to your corrective action so we haven't seen a plan get all the way past the forty five days yet what a lot of plans are very worried about is that they didn't get any seat there he said corrective actions proposed it as soon as you know the second there noncompliance that they're saying that you're not telling me is what I propose is enough obviously some plans are trying to extract things to ask their corrective action plans so a lot of plans are very nervous that the departments are still going to come back and say no final determination on compliance reporting on the last you have to tell your participants and then presumably after that the department's gonna stay you know thank you for your corrective action here's the acts or one or two things I want to do or whatever it is but what we don't know plans are very nervous about that because there very curious as to why it when they are ready before the forty five day clock even started ticking proposed correction in some cases why did apartments aren't at least saying here's what we like about your correction so far here's what we think you need to add to your forty five days to officially gets a plant any yes that's kind of the furthest out obviously this lot really force it just started in February said that this is the furthest out we seem plans guests of ours now forced plan their cap the seller who are in this space or doing things like you know trying to request a quality department to find out what you with what's going on how are you really I have a list because of course last don't want unless the Congress and they don't want to send out notices to their enrollees thank you Boyd at. So I'm. Important things to think about obviously the big takeaway here is a good faith getting a good faith effort under way to collect impaired and analysis of the anticipated that when you go through that after usually there are things that turn out that are questions whether it's our turn was written in the planned out actually operating in practice and that not being clear kind eating to iron out that are actually are fine language of delete an outdated provision or if it questions that come to light as administrator responses are collected that raised questions about you know what it is you're doing are are usually some issues that you know even a plans working on this internally as part of its best practices of compliance it made by issues and it sometimes that sort those out we're all keeping watching for further guidance like to hope that the Department issue some but based on their car on this we're really not sure how soon or not that might come. And then the other thing I want to mention is that there is an opt out of that is available for some public sector plants so for Nonfederal us self funded Nonfederal governmental plans so you know in the past lots of plans didn't opt out and what we're really saying is there is there a growing interest in opt out of for several reasons hearted it is you've heard me describe the obligations under this new law and I think you can probably start to begin to imagine the resource intensive start administrative aspects of of that compliance efforts for this documentation requirements so there's that. There's been lawsuits under parity laws people you know individuals challenging the plans don't comply with the yeah and yes that's another aspect and then the federal enforcement of so all those things I think are kind of making plans lots of plants or reconsider opt out the other thing I'll mention is that you know when a plant does decide opt out they have to renew annually so I think in the past there was a lot of thinking of like well annual the annual renewal is an administrative burden to of the idea with these document compared analysis is there supposed to be retained and be current so every time those and now the state you know for example you know something about medical necessity is based on current guidelines you know those change so there's activity this I'm going like refreshing updating to make sure over the years that comparative analysis doesn't become stale so I think that you know that's another place where lands are weighing things and saying well this is this is no longer is no longer more administratively burdensome for me opt out so so it is thinking about and you know obviously there are some benefits to do it yes the plan has to file electronically it has to notify individuals affected that the plan has opted out there are specific you know opt out requirements that that are you know detailed elements of the election that are included in rules govern HHS of what that has to be elected before the first day of the year and that thing you know with plans are taking this approach is plants can still choose to cover mental health and substance use disorder that affects the way they work they can enhance benefits if they can try to achieve parity voluntarily you know Leding the spirit of a lot but it just helps the plan sort of avoid of being accountable if if the department were to audit You know against them OR in it you know in force action. We're seeing who are deciding to opt out or adding language into their opt out notices that sort emphasize the fact that the mental this substance use disorder benefits are not being changed or reduced but this is sort of an administrative determination to be able to better direct land resources it's like that conoces we're seeing plants start to advance. Fairness it is a lot of this basically about risk mitigation I mean you can opt out of mental health parity and still the same benefits get handsome is just you get rid of all the all the requirements that you have to do to comply and all the potential lawsuits against you and we have seen states do that recently big states your neighbor states of of just opted in and brought that out of the mental health parity it's not saying we're not going to mental health is just saying we're opting out of this requirement we have to comply so it's really just informational for you that you should be considering it and uh And if I summarize that allowing her to. That's right I think it's it's major risk mitigation and you know I know another colleague of mine I was talking you recently so that you know she couldn't in good faith because we you know we're working class were really suffering through these enforcement efforts rate and supplements are really expensive and reasonable really a resource strain and in in good faith it's hard to it's hard to say that it's not a good idea to opt out because there is that what is the side you know you can still offer robust benefits and do your best to comply but you're eliminating such a such a level of respect wait. we ready for some questions. Representative Dotson you're recognized. Thank you Mr chair You're the main question I've got is regarding in QTL. Non quantitative treatment limitations the definition what what does that actually. Main and stand for. Repeat after needs is a little bit choppy from this that I know something about the and QTL definition but yeah the in Q. T. L. definition non quantitative treatment limitations I think is what it stands for if I'm reading correctly but I I I'm not clear on what that actually means maybe put that in layman's terms and just Jan you know it's kinda. Right yes sure handed weighted part is talking about it is any technique that manages the scope or duration of mental health and substance use disorder at either or so you know we a lot of times shorthanded referred we referred to it as any type of medical management. But it is even broader than that I just lie back up on the that it includes some of the the key items listed in the federal regulations as accu two thousand there are even more not like it you know prior auth concurrent review retrospective review for military design which could have you know various layers to that provider and requirements to participate and network provider could actually standards fail first and step therapy policies exclusions network adequacy is a is part of that provider admission reimbursement rate sort of component of the accu T. L.'s that the department's talk about a lot so and there are there are more listed but that kind of gives you an idea and like I said it's a non exhaustive list so they the Department kind always keep that catch all of and anything else that we could find that in your plan manages the scope or duration at all substance use disorder care so the one that you're not thinking about here are copays coinsurance deductibles that limits because those are governed by any other part of the rules thank you. Senator Irvin you're recognized. Thank you and just baseline. Just what okay. Let me just see if I can put this together what's our current baseline of our plan right now. As as a relates to mental health and substance abuse and when you talk about this is this just in relation to the mental health and substance abuse all of these components based on the ACT or is this applied to the plan overall in every area. So so what it does is it requires that you shared as because the idea of the why is that well you know the last started under the premise of that metal substance use disorder benefits for like discriminated against manage more restrictively insider and so what how the law works is it says are you doing any of these things to management thank you athlete Russell question right and then once you say yes you know some mental health has you know prior author concurrent review or or any of these things we've been talking about you know we credential or mental health ask you providers then at that point what the law requires is compared and look at okay well they tell us all about what you're doing with fact Malagasy D. and then tell us all about what you're doing related to mass search so it's mainly and then it okay so this is mainly data collection. And that this is a lot of data collection if you have to comply with this which is why states are opting out because a there's risk mitigation but B. this sounds like a lot of data collection I mean I'm very familiar with fail first and stepped therapy and all those kinds of things and medical management prior auth I'm familiar with all those things but it sounds like. These agencies is federal agencies are also trying to collect a lot of information and data. In order to comply with this law. Right and the data isn't just you know it's not just raw data like it's not like just tell me like how many benefits are subject to stepped therapy on each side of happens it's like saying oh okay so you apply stepped therapy with respect to mental health S. U. D. can you tell us. What are the factors you relied upon to decide you needed to apply stepped therapy to whatever mental health your clients and then can you tell us how you apply those dates and what studies or what research or whatever else you look at to implement this process and now can you go over your medical side and tell us the same thing about all medical benefits that are subject to this and can you give us a list of all side of all the medical benefits and I'll ask the dentists or subject to the state requirement and then the final pieces they do ask the plan to make judgments because then they want the plans of their counsel to stay okay now I collected all this information about how and why these things work and I think it looks okay I can learn from you know is so so that is yes is it tremendous amount of data and and and you know document Burbage collection you know all of that yep got the clear picture thank you. We had gone up and left and any other questions. Okay not thank you for your presentation. Step sherry now sale others have instant results. Mr injured Johnston okay Mister Kaplan Stucky at thank your. Okay. Sure can you okay. Okay great thank you Chad so um Kaplan up based residence you solved and seals Education practice and working for Siegel for almost eighteen years and in this business for about thirty years so it introduction and John C. viewers. Yes hi I'm John study. US president create technology and innovation at COS and I've been in this industry for about twenty five years and I help clients with their websites initial or state owned. So I believe have the presentation before we get into it we wanted to see if you have any questions we're happy to entertain us now or at any point during the presentation if not we can died and who is from the US. I think we're ready for you go ahead with your presentation. Very good thank you so thank you Mr president that and as you know of course that the state's website transform that your account has to similar benefits information website subsections one for state employees one for public school employees and as part of Steele's review of the state plans we took a look at the states and we analyze them at a high level to help determine this act is value to current members and prospective employees and. The number of things you can see here I'm not falling for you and that is consumer driven employed you and that means that benefits website for employees really she just as engaging as any other that's websites your employee C. as side work with ask for news or entertainment or shopping terms of accessibility to information design and tractor this ease of use sort of thing so look at usability it mention designed content accessibility to get to the bottom of the second easily hierarchy how was information arranged organization has a state overall structure navigation how to get from one place to another and is it easy or difficult and any information looking conventions and Developing what sexually as a core part of what we do and we do it for a number of our clients that includes building website architecture Pitsch design and content creation program testing all of the aspects of actually creating Senate sell not just building the technical part of it by the content or is important as well very important obviously and we have that background or statute to create that we have a number of different right website class several dozen of state Rhode Island for example city Los Angeles Sandia national labs Krispy Kreme pay pal lots of others were actually show you a few live website to the end of our presentations you censor some of that work that other folks doing and the way that is website so this is a fairly high level review and was done without the opportunity for us really to talk to you funds that out the goals that website so we don't have an understanding at this point about the audiences for the site to sign what you like its place to know and feel and do as they interact with the sites and has led to measure success in the states so that said we will talk about of course what we learned just looking at the site and the suggestions may just keep in mind that this section really does work in progress to even after launch road work with our clients to go back to have to make this better what content can we improve upon change and and it be examined results from Mercedes is understand how abilities are using access to make improvements as as a things go along so as you're going to feel free to ask questions about what we're describing and that'll get started job. Thank you senator so as you seem funded active you've got a chance review that we we we thought would be helpful for you if we could just bring out some different specific examples there are many of these things for what I would classify is kind of low hanging fruit and some of them are bigger and more structural changes in so again This Is aye intermission is one reiterate kind of our first pass an initial glance an initial review of the site and hopefully you'll find some helpful to us as we go through some of our observations and recommendations. So come going through them you know kind of point by point one thing that we noticed was that you're using currently using rotating banners and of this this routine kind of slides yeah you had on the home page of the website as well as in your some several other other areas one of the things and that we that we see with cross or other appliances that content to steer away from those in this day and age because you're bearing a lot of content behind the second third and fourth of promotions and so there are just a war or a modern ways of highlighting the that information what we found with those rotating banners is that oftentimes many users will not see the second or third or fourth or fifth I don't because it the week for things role they have to be to take action to scroll to the next item so our best practice would be fine other ways to promote that information so that we're not bear any information it's a little bit of a challenge because you wanna make sure also that you don't have a kitchen sink kind of approach we have too much information and because the overall need for the user that's of one and we can show you some of the ways that we so for that another I am here was a call to action buttons it we found at least one instance where the call to action button didn't go directly to the featured information so I believe on the home page of the let's say you have information about open enrollment and it's the there's a button state learn more and when you click on that button you go actually it's the benefits landing page you don't go to the end open enrollment information so our recommendation would be that whenever you're using call to action buttons and links take the user directly to the information that you're promoting as opposed to taking it to at a Leding pager some. Thanks for the help that go find intentional information so basically making it a one step process instead two step process. On the couple of other examples of just some of our best practices would be. The really trying to limit limit the use of afternoons so it can I know we're all you know as professionals were in this industry a lot and the we use your hand all the time but things like ET staff ASC rates and GST rates for example they might have a great need for for for you but for average employee he's or that novice users new hires for example they might not know what those terms mean and so we would encourage to spell out acronyms especially in only use afternoons if they are universally understood and I would say university and should by all employees or in your entire audience not just not just a subset so it at least think of the new hires you know somebody who might not be it familiar with with The state and would they be able to understand it if the answer to that question is no then you need to find a for different way to. make that content accessible. you this is also challenging we we work with other organizations like University Idaho state good example where they have their benefits site it's part of a broader is it it's it's a section within part of a broader website which I know this employee benefit section is also part of your broader transform say. So and you've got things in other sections where you're prior testing content about our office and assume that's always appearing first in the list in the content hierarchy less which it so that the good good job in terms of being consistent across the sections I'm in this is back to the comment that intervention earlier without having the benefit of having conversations with you about your intent the goals in audiences We would just really recommend that you organized content prior to his content around your targeted users point you and so if your targeted users on if you your term user is actual employees accessing their benefits information than private probably having about us in about our office is not the first thing that you want them to see so just again comment on that so I think there's opportunities to re organize content around your users you goals and objectives as opposed to your organization. Next slide is around It just some some comments around design elements you did we found that there are some things that are it could be a little distracting for some users so for example when the green underline seem to be like there fixed with instead of going out to the entire headlines in under this entire sections so our recommendation would be basically using design honest to properly anchor stuff so that it looks. It's so those types of minor details don't distract users from access accessing content that there is not a distraction and then I think the bigger bullet here is around the second pull it on the sly. Which is there's a lot of great benefits information is trapped and he asked hurtling understate in you're looking to a lot of different Piaf's which on the one hand it's great because the website is is a reference place for people to go and find information on the other hand having that content remaining in PDF format. can be a barrier for some people especially people accessing information phones PS are not terribly easy to navigate on your mobile phone you know you have the advantage of them easily principal but the downside is that it's harder to see and find information so our best practice would be to take up the most important pieces of that information from the S. and actually put it in into the HTML so that it's easier scanned and consume especially mobile. All right next slide. So this is the one I would really classified is really low hanging fruit this is a super easy change to make their first there were several instances where we saw the terms of and link means of click here or a weakening just year and we really record recommend avoiding using the that terminology for linking names for several different reasons our best practices that for link means you should always be the strain where you Sir will go over what information it will learn or action they can take and if this is super important special especially for accessibility and for users who would be using like screen readers because the the simple we can name it what maintenance on a big deal for a state users is a super big deal for uses with visibility challenges when you're using a screen reader that click here does not describe the action of where you're going to go in it requires additional contacts thank you have to read the preceding sentence or you have to read the preceding paragraph or or some something similar which makes it very complicated purchases not slightly just rephrasing that sentence and changing we need to be active either now however it can make a difference in a quick and easy change. So we also recommended or found that some content is very varied in terms of the over arching order content organization of for example the preferred drug list is for locals down on your structure in and so we were just recommend again thinking through all of your content and potentially re organizing it in in a way that elevate some of those important information so that thanks certain things like preferred drug lists aren't aren't so very and then we also found some examples where needing appear to be inconsistent so for example using terms like employee benefits versus A. R. benefits and again for novice user especially like somebody like myself who is not as familiar with your plans I don't know if there's a difference between those two are the same thing or if there is a difference why is one code played an office and what's called a ordinance so things like that so our our best practices really easy consistent descriptive terminology it was our goal just avoiding confusion so making it clear and and and so we would encourage you not to use a sentence and use them interchangeably but term stay with that and be consistent. the next of examples or around mobile viewing so on your current state you have the it if you can visualize it on your on your desktop you've got the employee benefits section you've got the that left hand navigation is indebted is part of the page of the content interviewing which is great nights helpful is useful on desktop but when you access your mobile phone assistance reshot for mobile phone that left tended navigation. Is persistent on every single page that you go to and it says the top of the page it takes a really valuable real estate and so there's an opportunity of when you're on a mobile phone in all of you to contest that menu into the over arching that you as well so that's something we would not really recommend and as well in an Also on this slide we have another example about it just a comment around search engine results and you we did a quick couple of quick searches if you search for medical plan for example you get it campus interest three point seven million request and delegation orders to technology technology liaison and when you're searching in a context of viewing employee benefits this is probably the most relevant results and so there's an opportunity there to to to to fine tune your search results to to give users a better and more relevant information. This this last slide with regards to the observations for recommendations it in we think that there's a big opportunity for just reviewing your primary navigation and it in I will give you a couple of examples so in in general are best practice would be that user I know you have different user types you've got public school employees and you also have Arkansas state employees and you have retirees but in a in a primary navigation you're mixing those employee groupings furthest assisting user gains with also content here or is do you have content areas like wellness city or benefits etcetera so our best practice would be how people and we can show you an example of this where you can select your group first your your your user type first and then drill down into topic areas so the example I'm given this example is let's say that I am a public school employee and I'm interested in wellness information so where do I click in any application do I go to public school employee or director well us it it's just it's just kind of confusing because I I might be interested in both of those and I'm not really sure if I should be going to public school employees for proficient well this first it just adds kind of confusion so so again there's a real opportunity for that and then just overall you know general tactic when summary would be that the site is the today's really reference based and it's a primary risk repository for documents which is which is great but there's a I think of a missed opportunity in terms of. This opportunity to what is this is a channel to really helping promote and market value of your benefits. In education place of it as well so again This Is back to injures opening comment about you know we want to be careful because we have had conversations with you about your overarching goals and objectives but based on what we've seen with other import other employers and other organizations you know we we kind of talked a little bit of a leap of faith in terms of what we thought might be important for you so please stay all the recommendations and observations with the little bit of Arkansas and we hope that that's been helpful for you injury you want to just summarize kind of like our overseen does benefits eight best practices right yeah we'll do that and before you go there any questions on any of the observations that time to describe or any of the best practices that he correlated to those. So yes so glad to keep us to separate J. son lysates of a few of our clients and we can follow up I sent you the links to the sites that you others are all publicly available we'll talk about that just a minute so the first year courses hosting a site outside the firewall as a public entity and you are obligated to do that at least that's understanding but you'd be surprised at how many clients are still thinking of keeping this information behind a firewall so easy access anytime anywhere by everyone that could possibly want this information is really important and we're talking about information that's not personalized or assisting for its benefits information as opposed to personalized information is never any T. I. a PH II that we that we included on our websites integrating your intranet contact which is indicating that you have on your internet with less icons and that really means that state has employee facing websites behind its firewall if you're trying to S. it used to do internal HR benefits business that that content and functionality sure coordinated with the in internet site so so that at the time of public benefits station and what function finding inside Nash's and coordinates are easily optimizing for mobile unit talked about John action that four but really we build mobile first and that's really that direction of the web for a number of years now and that is what such a bill first to the scene use easily hold back to the US tablet or smartphone and then only later on a laptop or desktop since the use of mobile devices is growing teams for a certain matters. I'm sure anyone centralize resources a starting point for employee questions. The benefits of state is and terms of eventually changing behavior that would be one of your goals may be trying to drive folks away from calling folks are walking to their office residents not anything or not even a thing because of it and going to the website see that get answer questions or really well constructed website allows for lease payments and even up inspected in place to go to the site and easily find what they're looking for a run that first making a phone call or a sit there trying to log into a site organize your content around please goals and priorities you mentioned that of course it's really all about me me is who is the user whether one of the goals that they have for getting on to the site and how do we address that he wasn't for me what can I find in this state that supports it interesting to me and that's not necessarily instructing information that's based on HR benefits organization style promotions you Senator force really important in an if you build it they will come but only if you guys that have a really robust ongoing communication campaigns we don't know what USA uses statistics are now they may be great but it's not and we're not tracking them there are ways easily tracked and also a lot of ways to create valuable communication campaigns that can get people to the site I interesting and interesting them in what's on that what they could do what you need to them out to be helpful so that Keating condensate and design freshly opting consistently this is really a big deal because once status Lawson works over it's really important to update information based on what's happening alley that roams of course but also as an opportunity to work at this roster under used or new benefits you're providing or changes that you're making to coverage or benefits and updating that content is getting the design every so often folks come back they want to see something different and you. And the the the the that Rauner assesses what folks seeing do when they go on the commercial internet whether you Senator a shopping site or a entertainment site that's the bar that you have to be thank you S. specifically the state and our client because that's the expectation people have they gone to any website for any purpose finally regain acting on the State adolescents regularly that's critical to do we work with our clients to either report quarterly S. as monthly and to describe to them what the analytics actually mean and how we can help them to improve the either the design or the information on the site or the way that the search engine is is categorizing information to be able to get employees to where they need to grow I really want to go. and that's not shall any questions on that or anything else is seen so far. Okay thank you had a question from Senator Irvin she has stepped out so any other questions. A little trouble hearing that could you repeat that representative wouldn't you're recognized. Thank you Mr chairman of. So I appreciate your efforts on all of this and. The first day presentation then and this one. What about the cost do you have any estimate of calls relative to implementing the suggestions on the website. Yeah that's a that's a really big it depends that's not to avoid the question but websites like an automobile can go anything from a mini Cooper or whatever the least expensive car you can think of instance size all the way up to me backwards Hester there's such extraordinary variety and and complexity of building sites that it's a very broad very very broad range we we can create of the sites that have higher levels their information at a lower cost and more in depth information at a higher cost depends on the content density how many pages of texts are actually developing for changes the state the you we just talked about depends on how extensive we need to apply the or if we're doing our you're doing that so surely saying at don't have an answer for the mobile what we would do if you're interested in learning more we happy separately separate occasion really go through what your goals are what you know what your users to do with your open to creating a separate benefits website that links you look for to and from you're if you're a are transforming our doc of website so there are lots of things questions we'd ask that would be able to come back with the laws of see here a few options for either helping you reach out to say you have now if you can keep it as part of a larger state we're building a standalone publicly available so. so we are servicing here's a range of what we can provide if we have a couple more medicine and you're open for that we want to share it with you class apple S. as in Sam okay. Mr. Well. I understand all your explanation of a. You can you can give a rough estimate of what what it will cost to do this. I mean is it is it is it five hundred thousand is in a million two million what. Sure so Senate so that respectfully and if we could just ask it is to to do this like we gave a number of different recommendations so so for example and and and I think the the the mileage varies on on each of them so for example changing the names from click here to something else like making that change as something very easy easy that whoever's managing the website today could could do very easily and that it would just it would really cost you anything so so I think we need to kind of look at it like it if you're asking a question like what what is it typically costs for us when we develop websites like these for clients if that's your question I think that we we did we can answer that question but if you're asking about for the specific recommendations that that we what would it cost to implement those John I think the answer just a ballpark and you know it's like okay to do the the clean up the website and fix on the links unless the it's like fifty thousand dollars it's not like a huge amount to do that to do a whole full scale redesign. We have a million dollars we went crazy with it could go up to a million and a half to two million dollars but that's probably not what you want to do that so probably a reasonable number what would you say John for just the a sample. Yes. Just a little bit count we're actually building a website scratch the numbers to be considered in lower probably be starting out in the highest fighting just going up to the low six inches so somewhere between seventy five thousand maybe a few hundred thousand better and again that's Penzo broadly on what it is that you want to say that you have United design how much mission center in terms of actually helping you implement the the the suggestions United Johnson custody from zero to see for example if you want us to work with you to help me design the site architecture you would implement that very expensive this many twenty five thousand Bucks thirty thousand or so and that's really just based on our time our intent wasn't to sell it we were just trying to show you here's what others are kind of doing for websites and to make it more user friendly and sometimes vendors will have in the contracts like Blue Cross might have an allocation for communications that you can use vendor money to do with enhancements and yes give me any money any firm could do their communications work so we're just trying to give you a your your website's pretty familiar with like a lot of states and some states. Our traditional stored documents and you link them some ways and they're they're meant to fit into the state system states are now starting to redesign them to make a more like like Andrew and John were saying they're like. Everybody so familiar with now like how the you do in your phone and how everything links and it's quick and quick and people are so impatient you know so it's like it's gonna be right away so it's like people of redesigned at the put the important stuff up front make it easy links all that kind of stuff so that's kinda what they're talking about no it's been a lot of time going through some specific to your website which you know probably the more important part of this you know you're probably better off to try to do something that's a little. Bigger a little more you know I enhance seen something that would get somebody gays and and it goes into if you started to a wellness program or if you're making any changes to that for trying to incentivize the diabetes program all that's that's really nice them your website the link and do stuff like that. Mr chairman just one comment that I wouldn't asking from the standpoint of being critical realty to the costs Areas where there is improvement and we'll work on that in house to do it and so and on just a quick follow up between that the contract you have in the in house team do you think that many of these recommendations can be incorporated in the work you're already doing to revamp the website yes we did thank you thank you Mr and if I could jump on that real quick we're very aware that our web resources need to be improved I think that anybody who's used this state website probably is aware that what the consultants touched on is exactly one of our issues where it becomes this kind of document repository where we have this old stuff that's been around for a long time one thing that we've identified in the B. D. is that we are very paper intensive process and so we're really trying to improve our web resources to get people to enroll online to engage online we think that that if we can succeed in that will reduce our costs internally from just all the paper the fax machines the kind of old technology that we're using so I thought it was a great presentation and it's it's definitely an area of emphasis for us. If you like we can take just a few medicines some of the samples and they give you so somebody is about the things that are you currently working on to consolidate states so let us know if your agency that we were happy to walk you that just as you say Sir few months. Senator Rapert you're recognized for a question. Thank you Mr chair of just I'm that secretary Pfizer and and your you're here you know we can't see all when you're sitting back here you're trying to hide from us I think but anyway but one thing that just in talking about this and I appreciate your comments and your knowledge mint because if you are gonna have a wellness program this is got to be a mobile apps and it's got to be tailored to me because I'm on this plan and so it is a nightmare and I've gone through this and it's a nightmare so much to where you know it's it's one it's hard to navigate that's hard to comply and then also to have your you know other people that are maybe on your plan like your spouse go through it is also challenging so I think if you can get it to where it's mobile out and that can be customized and then the other thing too is that once the changes are made to the website do you probably should have a tutorial with anybody that's on the state plan so that what Jake Mr bleed said so that you can actually teach people how to use the mobile and device or the web site see I can't see all and. That well it's fine just hi everyone is in the middle server vacancies on but anyway so that people can you know have a tutorial so that they can actually go through the tutorial so like in the Senate you know or the house of representatives that can be editorial that we do you know upon orientation that you actually sit down and go okay here's how you need to engage with us and and and that and you're gonna have to train people and teach people how to do that so that's not going to be a transformation saying that I think you'll get a lot of mileage out of that in a word to use your paper load in your paper work and then every agency every state employees should to have to go through that and be taught how to use it yeah and and I I agree entirely and and I think that's a great a great kind of comment on the direction we need to be moving in. We're dealing with a lot of time to just almost culture change with a lot of if you look not just at state agencies but the school districts to human resources offices in a lot of really good employees have been there for a long time or very knowledgeable but their understanding of the process is paper based forms it's picking up the phone and calling somebody. And getting an education or training program out there because we can make a beautiful website we can we can invest time and resources and make an awesome. But if we can't get people using it then we fail to making sure that education component there I think it's a great point the other thing too that I would recommend and I'm not sure because I haven't looked at the website and recently but is and and it may have been a recommendation here have to step out for a call but isn't making sure that people that are on the plan know exactly. The the details about how much you know what things cost me so that they can make more of an informed decision about their own health or their own choices or whatever and I don't know if you can do that but I think if people have more information because what happens if they call us like I got a phone call you know well how much is the state putting in the state needs to put more money in well the state our taxpayers so you know and and then you also disable okay you know what is so if there's a way that people have the power you know it can be a more empowered with the information about you know this whole system and how it's operating in what's being put in I think it might be easier for them to understand that front changes that need to be made and and how you present that information in a more personal way that says okay these are the choices you're making this is exactly what the breakdown is and how this all flows I don't know I mean if you could figure out a way to do that I think so how are in people's information might be helpful yes you're absolutely right again Blue Cross has a my blueprint you know because with an individual it'll depend on you know where they are in their deductible or their Max out of pocket what plan they're on and so you know I might put some information on a website that specifically that payable to you and somebody might misinterpret it so it gets a little complicated but Blue Cross has an app that were looking at that impact our or pharmacy benefits manager also has an app that we're looking at I just recently had experience where because we've got a former guys in our office I had a prescription filled I mean that's really expensive and they said well if you'd gone down the street to the other pharmacy it would have saved you twenty Bucks because of just the pricing strategy. That the the two different pharmacy chains had signed with the manufacturer that's information I'd love to give people so that when they're in the doctor's office there ask where you want your prescription filled they can see like which which opportunity gives them what will which pharmacy gives the best opportunity to save money I think this whole conversation is a great thing to go but you're I think the challenges of getting there on an individualized basis are going to be tough I think we can do it but it might take some logging in it might takes and security and that sort of thing well and and just follow up last question but and even if it's not specific to them but if it's information that says you know your if you're a smoker you know the MP this this may increase your your premiums may increase them or the plan is it or something like that to where they have a little bit more of a tie in you know some I don't know if that's information that. That can help motivate behavioral changes if they have the information we have that makes sense yeah we have benefits that we make available to people that people just don't know about so they don't take advantage of you know we we we've rolled out things over the years but not told people about them you know if you're on the high deductible plan for example our HSA all you have to do is sign up for it and the state puts money into it right that's free money right you know and and to my mind I wanted when I realize that I was like why doesn't everybody. it's just a matter of communication and it's a matter of of really taking advantage of the resources like the websites to emphasize yep yep that's a good point yeah that needs to be included to. Thank you also about developing their communication strategy not just creating stuff so let's say and what is a great thing to have an Aston that overall communication strategy we understand why you're doing what you're you're talking to a master's in content are we sending that channels using creating plans or that you're not going to necessarily move the needle in terms of behavior change strategies critical. That's the end of our presentation as agent catus drives three options to this is the the if you are also right there please follow up with some others you may want to take a look at. President of ray you're recognized for a question. Thank you Mr chairman this questions for. secretary ventures she's still here I can't see from over here. I was just wondering the the website that's been discussed here the transform dot A. R. dot gov benefits page was this was this a site that was designed by an A. or is this a site that was. Whose work product is this. Yes thank you I am a kind of did the skeletal work and put the the pieces together we're able to go in and make changes to it on going so we don't have to go back there hosting the site but but they they put the skeleton together and we keep changing as we go okay thank you. Seeing no further questions and no further business for today we stand adjourned. there is one more. All right you guys are recognized to do the last one. Yeah and resulting cut out now if you want okay very good thank you very much for your attention to this year. Yeah thank you very much. Okay a joint available rentals the Segal and we're gonna go through some clinical analyses and recommendations and tomorrow we'll do a deeper dive into some recommendations as well but as promised we wanted to dive into your other key cost drivers so if you recall when we were here last time I talked a lot about obesity and diabetes and pre diabetes as one of your number one cost drivers oncology musculoskeletal is also a key. Right now out of sorry. So oncology musculoskeletal is also key cost driver this is not uncommon for almost all plans we see these as the top three areas of spend there's also some clinical recommendations that we can make to kind of tackle some of the cost here. I want to go through this there's a lot of numbers in here we did a lot of different analyses but really what I wanna kinda drive home from a clinical standpoint is what is actionable within the data for you as a health plan. So as we look at the first spotlight we broke down your cancers by what type of a cancer but prevalence that you have in this is not uncommon that we see skin breast prostate colon cancer as a typical type cancer from a prevalence standpoint lung cancer is also pretty high for you as well which we know you have a high smoking rate in this state so that's not uncommon to see what I did break down was I want to talk a little bit about preventive cancer screening and what happened during the pandemic so if we recall a lot of services were put on hold a lot of individuals were not able to get their cancer screenings we are seeing later stage cancers getting caught now the people are getting caught back up on their preventive care screenings so one thing as we talked about that communications strategy we are encouraging most health plans to take a look at their cancer screenings and do a communications strategy around getting people back into the doctor and so we did pull your numbers to look at your preventive cancer screenings and see where you're compliance rates are so like breast cancer at a forty two percent of compliance reasons that forty one percent and then forty two percent in twenty nineteen C. of twenty twenty and twenty nineteen it's pretty low so would like to see that number come up a bit and prostate cancer could be higher as well you're only about fifty six percent compliance colon cancer we can always see that number to be low because it's the every ten year screening that number is and always very reliable what we are seeing some health plans do with colon cancer screening is mailing kids home to individual patients so now we can do things with color guard for you can do a test at home to see if you need a colonoscopy Act really helped drive up some compliance and catch early stage colon cancer so that that's really what I wanted to kind of hit high level to start with oncology is remind us that we need to get everyone back in for their preventive care screenings. As we move forward and we look at a couple geo maps that we did you want to kind of show you where your prevalence of cancer is setting and when you look at the dark red that really shows where the higher patient count is not surprising you know whenever you look at the map on the left obviously were this a bigger cities are you have more individuals but then whenever we look on the rate and we look at the total membership in each county we do see in the role communities you have high cancer prevalence as well whenever you normalize that so it's really about you know if you're going to do any type of pilot programs or communication strategies you might wanna look at where people are living a type of cancer there and highly focus on that. we look at this map we split everything out from a PM PM cost standpoint the map on the left is looking at the cost of cancer bycounty and again the darker color is going to be your higher cost counties which if you think about the map we just saw you have higher prevalence in the cities but you have some higher costs and some the rural communities is amended talk about why that is whenever you break down where they're actually spending their money so in some communities they might not have access to care into the shop an emergency room that's going to higher cost individual. and that's really what I'm kind of showing in these two maps really identifying and and we saw this and diabetes are gonna see this and other analyses to whenever we get further away from the city's for accessing higher cost and utilization. I'm so This breaks it down even further when we talk about what we've been calling medically underserved areas so we're looking at the amount of primary care preventive care screenings and a hospital's emergency room urgent care by individual County and what we are really showing is that in those counties where people are medically underserved or fully underserved. They tend to spend a little bit more on their care so we did break that down for you here by type of cancer but I really want to focus on this next side to talk about where the receiving care so we look at the first column fully underserved. We're spending more and we're going to the emergency room more and you're spending more than regency room I also broken down high tech imaging that's going to be your MRI CT scans and what you actually see it kind of flips so whenever you get more access to care you're getting more of those screenings but what you can do in that area is making sure people are utilizing these things appropriately through what we would call a utilization management program so Blue Cross blue shield can offer you support around high tech imaging to make sure people that are getting M. arise are supposed to get MRI's versus CT scans so good example is what we actually see sometimes care is delayed and breast cancer treatment because individuals are waiting for a pet scan when they really could get an MRI and start treatment or CT scan and start treatment. So these are the type of programs that you can put in place to kind of control appropriate care utilization and will bring down some of your spend. So we broke it down by each type of hydrating cancers you can kind of see where everybody the encounters where they're spending their money and what you can actually do about it. Something else to talk about we talked about the communication and how you can get people back into their screenings with cancer about twenty percent of the time people are misdiagnosed on the initial diagnosis and then mistreated so they get the wrong treatment based on what's seen in the it's in the path ology read. What we're seeing in the market place is a lot of people are partnering with large cancer centers lake and a city of hope you have you AM us here so you have different universities they're very good cancer centers. Virtually they can offer a second opinion to your counties that are more world your patients have to actually physically go to that center and so that's something that we would recommend exploring is partnerships where you can offered second opinion for cancer diagnosis and then through your carrier so whatever carrier that may be your Blue Cross blue shield they have options to turn on what we would call a utilization management program for the actual treatment selection so when a physician goes to selected treatment we have NCCN guidelines that's sort of the gold standard of what you would do you you look through those treatment pathways and sometimes the physician ends up not picking the most appropriate and appropriate cost as well as quality treatment what we're seeing is like carriers are wrapping these and see see and guidelines through a partnership where they actually have to walk through that before they're approved for treatment so it helps out physician guide them to the appropriate treatment then they also offer like a peer to peer supports of the physician does understand why a different treatment is being recommended they can speak to an actual oncologist nationally to kind of help them work through that so that's how you get really premier cancer treatment to your entire state versus just in those sort of more served areas. So that is a recommendation around actual oncology care and treatment and also and and the whatever you think about where a lot of the care is being delivered from a. Drug standpoint. A lot of cancer care has shifted out of the hospital so when people are going into the hospital they're getting surgical cares when they need like an actual tumor removed but most of the care we're seeing drugs by mouth rates they're taking pills instead of kings team of therapy the traditional way that you would think of. so when we think about that that's why we want people to be on the right treatment because so much of what ends up happening is if they're on the wrong treatment the and up in patient in a more dire situation that we want to avoid. So that was sort of the overview on what we see in cancer treatment I want to pause and see if there are specific questions around oncology. Members any questions on everything on the board Senator Irvin you are recognized. Thank you and I just going to go back to Page two on your maps really quickly you said the top left it is distribution of cancer patients by county and then the top right is the prevalence of cancer patients compared to total membership so. For some reason I mean I like I'm looking at my county in particular which is why it's over here but then dark red over here and so it's a little confusing as to why it does two things. Hi should correlate more because we have had a tremendous amount of cancer in that county with individuals in fact I've contacted the department of health because of the high instances of colon cancer and different types of liver cancers and I've asked actually asked the department of health to do some investigation into it because of what's going on there but so I just didn't know if you know that to me they're saying there's there needs to be a little more correlation there probably that one on the left side. Is less relevant because of the number actual numbers and we look at your plan you're so big you know that if your role or a less populated area it'll show up late the one right size when you really want to focus on because that's like giving the population its there what percent of people actually have the cancer so your site a high percentage that's why stark in this right right okay that's what made the first ones that is the big picture where is the cancer but in from head count number of lies okay so that that was my question yeah because the right one made more sense to me okay so this is the head counts okay and then the second thing to like when you talk about treatments and and those kinds of things you know I am. So I actually pass legislation to increase the net to move the cancer screening up from fifty to forty five when it comes to colon cancer but I received a letter from Blue Cross blue shield that this is going to cost you know X. millions of dollars but I mean my my thought about that is well when we rather prevent somebody from getting cancer or finding it early on preventive medicine house to save money so we we know that it also saves lives and so I'm I'm kind of confused by the letter I received from Blue Cross blue shield basically saying that my bill is going to cost you know millions of dollars when it's actually the national trends to start screening individuals at the age of forty five and then also the legislation also would to pay for the the color guard which is very effective and so I I applaud those comments that you made I just it's not squaring with the literature they're sending me or the letter they sent me saying you know you've just cost us all this money when I'm like we're supposed to be saving lives and trying to prevent you know more expenses down the road if we don't catch it early which is preventable and treatable and so. There there probably needs to be some more discussion with our Kerrier when it comes to that because it was absolutely the right thing to do and an African American and individuals we're seeing colon cancer a lot earlier than the age of forty five I mean we're looking at thirty five and forty year olds you know that are getting stage four colon cancer so I don't I don't not sure if our plan can tailored towards you know are African American participants and subscribers because there are there are clear differences and and what's happening and UAMS I mean they're very much involved with that and research and information on that but I'm not sure if plans have taken that approach or not that is incredibly concerning to me it is and so miss but that and to the health plans like Blue Cross cigna UHC all of them follow you you have preventive task force so they have to look at the United States prevent task force and say is it grade a grade B. creates the recommendation based on when that comes out and there's a comment period you can go and kind of like are you against or for it the look at all the national research. So all of the coverage policies they're created by the carriers follow that recommendation the Blue Cross is coming back and saying based on what we were told we are following that's probably what they're looking at is whether it was a great et or great the recommendation as health plan you can certainly choose to redefine that so we do have other health plans that they changed mammogram age they keep it at a lower one versus the higher agents recommended we have other health plans that go against the recommendation for M. arise for breast cancer screening to so that is something that you can do so that's from that angle and then from saying like genetically who's more at risk that could be a communications strategy so what we see as you can create personas of people and say where you fall in the demographics and are you more prone to this selects Kian communications that way to get people in you can do campaigns like that so that's really where where I would recommend okay I want to do something like that thank you. Thank you saying no more questions on that he or she okay. So the next review we did is musculoskeletal so remember these are going to be procedures that are with your sort of joins if you're thinking about need or hip replacement and spine fusion and shorter those are gonna be you're very kind of costly large procedures then anything in between so if you have somebody that had you know that broke a bone they fell something happen or trauma that's all mixed in those top numbers so we typically see you know like I said hips knees and spines or you're you're more expensive higher prevalence and remember also obesity can wear on the joints over time. As well as any over use injuries if you have you know people on the plan they're doing a very physical job there to fall within you know having early onset arthritis and potentially have some of these procedures on the bottom we did break it out so what can fall into lake NY is is an injury but we want to break it down by actual like plan procedures the planned hip or knee replacement and spine fusion and then we look over to the rate the A. L. O. S. is the average length of stay. This is something to key in on and say you know are they following standard of care procedures are people getting in and out appropriately what we historically used to see especially in need they would inappropriately have them in the hospital too long and then they would send them to a rehab facility versus home versus physical therapy very highly cost inflating cost overall and so when you look at your knee replacement or having a higher average length of stay at three point four some of that could be the complexity of the individual but it should really be more like to. So when we think about this what we see other health plans do to tackle some of this cost is they go into something called a bundled agreement or bundled arrangement with a center of excellence. This could be something that you work with Blue Cross blue shield on but really where the most successes is carving out an outing your own network for center of excellence we also have some plans they get really aggressive in the incentivize with travel and that's where you're going to get the most savings for you say this is our premier knee replacement center that you have to go to get our care so we did want to kind of call that out that you we are seeing at least in the knee replacement your average length of stay is kind of high we're hip replacement he sees like only two point four days and spine fusions about four and just think how aggressive those two procedures are and then me is actually pretty is more of a standard procedure these days and you're you're hitting kind of three point four and that's kinda high. I'm sorry did I break it down a little bit more to show you the other procedures that happen in twenty twenty. And then I read then we look at twenty nineteen so remember in twenty twenty all this got pushed off because of Covin. So what we saw is most health systems in the first like three to four months of the pandemic delayed a lot of these procedures and some people actually didn't end up going for their secretary said they found other means of treating or the pain sort of subsided so you can kind of overtime repair some things or physical therapy we are seeing people they're accessing physical therapy virtually now through applications like zoom so you can actually wear wearable devices and have your virtual visit you can utilize an application where you actually don't need a physical person walking you through your therapy and so we saw a lot of that early on the pandemic procedure started to pick up towards the end of the year because honestly that's where a lot of health systems make a lot of money so it's something that is coming in churning pretty quickly and that really is a big revenue source for a lot of facilities so we saw that pick up at the end of twenty twenty. but we did want to look at like some of the numbers based in twenty nineteen whenever you prepay and I make have full services so we took a look again at sort of the fully served a community the partially and medically underserved communities to look at the overall cost with a but with muscular skeletal on like cancer it's sort of it happens in the procedures done so they're probably traveling already for these procedures so that's not something that's going to have a huge impact on cost rather where you want to tackle muscular skeletal like I said is that center of excellence but then also preventive care again so we're talking through physical therapy what we are seeing is like is that something you can consider is a virtual physical therapy option through an application for people also anything that you put in place around the city is going to help prevent some of these over use injuries and then like I said you could take a look at establishing no partnership with a different network or placing a COE in to kind of curse of the cost so that's really what we did for the take aways as muscular skeletal does anyone have any specific questions on that. Members. So just you know I I just want to stay in I think there's a balance that has to be struck because when I hear center of excellence you know that really doesn't pertain to the excellent physicians or the excellent delivery of care service it's actually more of a negotiated we get a better price there so just wanna make sure we have a balance right and I want to make sure that people have and physicians and patients have with their physicians the the ability to make their decisions you know for themselves and to defined I care because I I know that these terms are used nationally and those kinds of things and I understand that there's needs to be you know a degree of medical management and I think that you can engage in a lot of areas I just feel like it's necessary to state that you know we see we see that we understand that but you we have to strike a balance due because at some point you know it's not going to be acceptable to me yes a center of excellence is defined as an out of state treatment facility for our Arkansas citizens we've seen actually places do that and that's that's not supporting you know our local physicians it's not supporting our local hospitals and it's not supporting those people and those patients and the care and the the thought that they're gonna have to travel now out of state to get a hip replacement or a knee replacement so I just wanna make sure that I state that to balance that because we have to weigh all of those different aspects I think we're making decisions and I know you're probably familiar with that and are used to that too because there this may sound really great on paper implementing it and the replications from it may be different where we see savings here by. We may not see you know we may see a and and negative effect over here so for us I just think that necessary and probably needed to the stated not necessarily question I think by travel she meant she wasn't suggesting out of state suggesting a rural area may have to travel into the city you know maybe in state travel it's just not in the backyard. Yet at the very very first statement to in these the strategies that reporting out here what we're seeing nationally that's not may not necessarily be something that you want to try it even in the first year it might be something a long term strategy one thing I'll say is that from a center of excellence whenever the carriers say this is the center of excellence you're looking at every year or the meeting this quality metrics and then with Blue Cross they do with the plus and the plus means that they're also saving money so that's within their based network you do a carve out or an after tacking it something else on you're working with a vendor that yes it is in negotiation they also have to meet all those quality metrics as well so they wouldn't we would never recommend putting in something just because it's a cheaper cost when they do that sort of see we bundle that I talked about they also wrapped around the pre and post care and that's where we see really great member experience because then they don't have to worry about anything I don't have to go find my own physical therapist I know up front you're the total cost of my and and procedure plus the physical therapy at the other thing from a member experience that we get a lot of really positive feedback on like I said this is a more aggressive strategy it's just something that we're seeing nationally happened shore NO one I understand that I mean but there's also key decision making factors in that so if you do a bundle payment where they going to cut the costs from are they going to call the costs on you know you getting a lesser quality actual joint replacement inside your body because we've seen that happen right and so and then I'll make cause problems down the road where you have to repeat the surgery because we we we were chancy on actually find a quality hip or knee joint replacement that we put in your body that's where we save the costs from so you have to be really careful about that and and those things all need to be discussed in on the table and that's that's what I'm saying is that you have to understand all the components in that and you want to make sure we're not cutting because. House where it actually could be detrimental to the patient verses improvement for the patient thank you. Okay saying no more questions on musculoskeletal we would do a one cent correct and we're going to stand there you're recognized thank you Mister allow I want to pursue a little more for just a second. Senator was questioning we're continually fighting a battle relative to the cost and if we're going to be a good employer we need to take care of our clientele we need to take care of our employees and in the in their best interest. Your will will you all be back. tomorrow morning Thursday. At that time we'll it in the final analysis. I'm concerned about the services that are provided to our employees I'm also concerned about the cost to our employees and the cost to the taxpayers of the state. We are continually almost up to a hundred million a year or. To supplement what we originally budgeted for the are you gonna give us an analysis of how we can deal with those increased costs or what they will be what I don't understand is why we continually end up having to come back and re fund these programs well look at Arkansas Blue Cross blue shield Amanda and the hello they make money. So so what are we what why can't we get a handle relative to the cost. Overall I'm not just talking about what I'm primarily concerned about to the state employees and public school teachers. We continually have to go back and raise this in ways that we give our teachers the two thousand dollar raise and we turn around and take it away and increase health premiums. So we're not we're not gaining ground so are you all going to make some recommendations relative to that it also. Have you all taken into consideration we passed that seven ninety six which deals with the employee vacancies over two years and as you very well know we fund a hospital or healthcare plan through the six hundred dollar A month contribution or five hundred dollars or five hundred dollar month contribution have you all taken in consideration that we may eliminate four hundred and seventy positions that are over two years old which will cost or program approximately two point eight million have you all thank are you all looking at that. So we did we did do an analysis on the unfunded positions but the the fact that there could be a raft of what four hundred position that that's new information to us but. But I will yeah okay. You have a look at that. You might need to love another consultant the last three million more so the the other the other questions what. What is wrong. That we continually have to come back and we're fund this program. We're we're we've fallen short well he does like to know what we need to do to be more accurate enough to have to continually come back of Mr believe in and secretary thank you come back in here and tell us this border that board now we've turned it over to the board of finance who has no experience whatsoever in the health insurance for the bill now we're asking them to look over city this pro. So there's a couple things going on one you've got the expense side and unfortunately you know medical trend is higher than CPI unit runs around five percent so yeah and I think you know we look back in history the plan your transaction better than market so you had that's the expense side and then the other side of the revenue right how much are you funding so I think for a while the revenue got stagnant the expenses continue to grow and that's why we need to come back. So there's no stopping you know if we can't just say the expenses are at four hundred million we're gonna keep those there for ever and ever that's unrealistic but understand that but how those BlueCross BlueShield continually make a profit. And their servers servicing people with healthcare. I mean the man what what why why are we ending up in the home I mean I understand understand the cost is increasing and I understand that very well. But. What what can they deal with it in a profitable manner and we can deal with it and have to come back and supplement. We are we are recommending a strategy for you guys on how to go forward as a lot of a long term planning three four year look out so if you're always looking to next year to next year when you come out of the deficit also give a big increase in that that's what's going on I mean in general you in funded at all standard amount each year and and and plan for that so wasn't like all saying you had a. A massive Claims filed claims bagels and a lot more because it was on the funding side so you know why you were in dissipating that funding level yes let us let me culture responding. Thank you Mr chairman. Representative wouldn't want problems we found we face the same problem in twenty thirteen the plans have have not initiated any kind of revenue stream on a constant basis so when you got to last year their way of fixing it was cut out the pharmacy for the retired beneficiaries and I was gonna save our member right forty million dollars roughly and that was their their way of increasing revenue to the plan at that time instead of increasing their premiums are increasing to stay contributions they were cutting a benefit so one of our problems have been and if you're looking recommendations are gonna get tomorrow is that we have to have some sort of triggered to increase revenue at a set given pace going forward we're Blue Cross is done is done that to all their plants if you're member of any of the Blue Cross friend you've experienced rate increases over a year's state employees and teachers have not had that hit they've had it hit all at once and to any thirteen and they'll have it hit all at once now the date it needs to be an incremental increase over time that doesn't have a gap in order to ensure the viability of our plants and I think that is definitely in the recommendations going full. And I and I agree with that when we discuss that that's what I'm trying. That's what I'm trying to avoid is we've talked about in meetings and and you and I relative to the need to be able to do that without having ever for three or four five years ago background into what we ran into with the teachers several years ago and I will submit Jake for this the letter he sent out yesterday one of the bullet points in that letter was exactly that make sure we put in statute where this plan is funded year in and year out L. own increase basis that matches that five percent medical costs or whatever that percentages at the time whether CPI our medical index or whatever but make sure it's funded year in year out and we don't come back every seven to ten years and have to hit this initial bop of millions of dollars. Thank you a person. Yes. Thank you. Saying no more questions I believe we're ready for diabetes and obesity. Yes this will be the last discussion on the clinical sites today and like I said we'll get you very nuanced tomorrow whenever we talk about overall recommendations but diabetes obesity are something that you can tackle that will also have spillover another clinical categories of we I talked a little bit about musculoskeletal where obesity can really wear on your joints as well as actually certain cancers are lifestyle related so whenever we start to think about improving nutrition and reducing the strain of a PC in diabetes on your plan we're also talking about how it's gonna impact other areas of spend. But when we think about diabetes we did take a look at an NYC or pharmacist actually took a look at where you're spending in within the Davies category from a pharmacy standpoint and he's not here today but you're spending a lot on high cost injectable insulin so that's actually injecting yourself with a needle what that means is your diabetics are actually at a much higher risk than what we see international book of business and there is an area of opportunity there if we talk whenever we talk about the recommendation around tackling obesity and diabetes as we start to improve nutrition and lifestyle factors there are programs in place where physicians will start to back down hi injectable insulins and get people on different medications so does calibrations we see continuous glucose monitors connected applications there tied to overall dietary recommendations they're really personalized those individuals we start to look at that we were seeing actually in our book of business for seeing improvement in overall spend and the type of medications that they're on so as we think about what we want to do with diabetes and obesity we did take a look at what's called an area deprivation index. So this is that social determinants of health so what's wrapped in these calculations are you they scale the the zip code on a one to ten ten being your highest responding your lowest risk looking at things like overall access transportation reliable food sources pharmacies are clean water and that's how they are kind of risk score of the area deprivation index that we look at is than the cost and then as we look at utilization factors so it is kind of interesting so in the highest disadvantaged area we have individuals that are going to the emergency room more often and what we do see is when individuals are at either a higher clinical rest or they just have less less access to services like primary care and all of those other social factors they will end up popping up as a high cost claimant not really taking care of themselves very well and the and up in the emergency room another thing that there's and Gemma studies recently that talked about overall pay equity and when you look at individuals that have diabetes if they are living somewhat paycheck to paycheck and they're struggling to get access to reliable food sources they will end up in emergency room with low readings of their blood sugars they and up in this emergency situation sort of towards the end of the month whatever the running out of funds and we do see that can drive up your emergency room visit in an area that's highest disadvantage so that's something that I wanted to call out just illustrate if we think about diabetes and obesity but what I really want to talk about is. What we're seeing is T. impax impactful programs and when we set recommend putting in a diabetes prevention program and or no PC programmer diabetes management we're not saying go out and bid for the cheapest program or or just you know let's do this one partnership we actually talk about whenever you're looking at this you want clinical performance guarantees that are tied to actual things like weight loss at the individual level we don't see an aggregate report on your entire population that says Hey reduced you know five percent weight loss in two thousand people we want to see it on the individual level that you're actually negotiating to get the feedback if that program didn't work so this is what we're recommending and like I said if if you a lot of the clinical recommendations can be long term these we think are really immediate and you're gonna get a quick are why we see actually within six months some R. O. Y. around weight loss programs and people have diabetes they're doing these things. So about ten years ago the CDC approve the diabetes prevention program it's been a validated multiple times the clinical research and Milliman validated it what we see now is they have digitized not so there a lot of vendors that are I've taken the actual CDC approved program and the pretty on a digital platform. You can choose to incentivize different enrollments in key milestones but whenever you follow the CDC curriculum you as a health plan actually don't have to pay the fee unless the member needs a milestone to so that's an incentive for you as a health plan to put something in place as relatively low risk because you're not paying unless you're getting something out of what's actually going on with that member so that's one way to tackle diabetes by catching those people that are early on in diabetes prevention and then diabetes management when we think to add additional management program what we're talking about is a digital glue commoner that's very smart and intuitive having taught people how to use that it's not easy to use some of these older machines and you know I remember having a notebook where we actually throughout grades to teach people how to write down and track and walk in with the physician now those can connect your smartphone and application they are all driven by artificial intelligence with coaching behind it the artificial intelligence actually as you put your numbers and you also put in what you did that day so did you work out what did you Eads that it becomes more intuitive to you as an individual and can provide some actual personalized recommendations and we're seeing through that and adding a continuous glucose monitor for some type two diabetics through these programs we're seeing people reduce their overall A. one C. and actually improve management of their diabetes then we have a more aggressive programs like I said they're really focused on that lifestyle and when you look at individuals there in those more aggressive programs they actually have physicians that are reading their biometrics every day and they are taking down the insulin Asa member improves their lifestyle so you reduce the need for those more high cost injectable insulin. But like I said what we would suggest is established a quantifiable performs guarantee there tied to the individual member or you get the feedback if they were not successful at the end of that year in the program. Now you also could consider just piloting and you know we've done All of those slices of the data and previous presentations where we look at your highest cost I better X. in certain counties we could say let's tackle those individuals first so you are you know focusing on the highest cost face risk members and that's from an obesity diabetes that's really a comprehensive approach and we'll talk a little bit more tomorrow about how you can consider incentivizing some of these things in a kind of revamping where the wellness dollars are going. And and and based on the the diabetic population and you have for your group there's some substantially bill savings that you can she for the program you know if if you know best in class engagement somewhere in the neighborhood of twenty percent for the overall population if you're able to achieve that with an estimated savings of between ten and twenty percent per engaged member we would estimate that you'd see the potential savings for the overall plans by between one and two percent which translates to roughly ten to twenty million dollars on overall plans been for your program. The ready for questions yeah representative Godfrey you're recognized. Thank you Mr chair just a quick question and you may get into it more tomorrow it's a little bit micro and but I know that certain racial and ethnic populations tend to be more vulnerable to diabetes and I wonder if you have any recommendations are best practices for the cultural relevance of these approaches at you know engaging community and cultural partners to and just kind of get the word out about in a mitigating some of those risks yes that's a good point and a lot of you know your nutrition what you is based on your culture where you grew up and it's very meaningful for people so two things the diabetes prevention program I was talking about digital platform there's opportunities for local partnerships a lot of local YMCAs stands up as well so that's something that we could do if you're more interested in something that's localized like that instead of doing a national program we could then evaluate what you have in your backyard and start to look at how do we drive your members into those programs communication going to say that again because that's going to be key here as well then whenever we look at lifestyle changes when we're evaluating what the rate partnership is if you're looking at the nutrition programs you want to hear from the vendor that they are individualizing that nutritional approach and it's not walking in saying everyone has to eat whole foods and kale and go to you know the most expensive type of diet rather what do you like to eat what's within your financial boundaries as well and building and died around that and that's sort of where I think honestly the healthcare system is or all of us has failed we try to do one size fits all with nutrition for too long and I think that we're seeing vendors that are really customizing that to the individual so if you're looking for a partnership that's what I would recommend. Senator Irvin you're recognized yeah I think the third key get takeaways because again this kind of goes back to my question on the website and individualized information and being able to pilot even you can look at where your heart high cost I've addicts are in pilot I like that idea to you is like a a first step to try to really integrate that idea because I feel like with diabetes and obesity it really is lifestyle changes and you can save tremendous amount of money for both you know the the person and the plan if they don't have to have maintenance you know medications for that so in the end you see those results and so to me this abuse if I got to if I had to choose which would be the the biggest Code bang for our Buck not necessarily maybe not and price that like actual changes for people this is where I would start because this will help everybody I think you know and and I think that's a benefit that even if you're not in one of these categories that an individual would be able to enjoy having that as a benefit like what is my nutritional you know what is not your nutritional portfolio how can I improve my nutritional portfolio and how how do I go about doing that I think everybody can benefit from that so for me I would love for us to focus on this because it helps everybody you know and and I. I'm at anyway I just I love this part of this thank you and unlike you know corporations we have a lot turning employees think about your teachers there on your plan for ever so to me this is an investment that pays off and in such longevity for your teachers we've also seen programs where the nutritionist like so if you have an like teachers they're eating school lunches or what's in the school we've seen programs that Senator sent in to the school cafeteria and a sticker on and say this is approved for this program so it makes it kind of simplified for those members you seen we've had partnerships where they go into the grocery stores that are in that neighborhood and stay at your local Kroger here's what you should eat so we can make it more simple for people then it's easier for them to be compliant with that too. Okay any other questions. Thank you for your presentation the MS obesity and diabetes is just reaffirmed what my doctor told me this morning so. Thank you for that if it puts a little more incident I did find the the studies in the surgery cost and all interesting looking at so thank you. We have nothing else. The nation's recommendations tomorrow members look forward to seeing you back them to do Preciado questions and all information and my culture as. We will be thank you Mr chairman will be getting those recommendations tomorrow I just want to members to be aware of the public comment on those recommendations will not be until Wednesday and Thursday of next week so we will not be taking any motions for adoption until after the public comment period so if you'll notice on the schedule believe there's a meeting in the first part of October and that's where we'll be taking those recommendations and motions so with that appreciate you guys come in and look for the C. N. R. by. Thank you thank you we're adjourn thank you.