ALC-Executive Subcommittee

A. as representative flowers you want to go down front and present. You would introduce yourself for the record representative in you're recognized speech thank you very much Mister Vivian flowers state rep District seventeen. Prime love and I just wanted to come back since we had. Probably at least two meetings if not more sidebar meetings regarding the proposed rule. Which was somewhat of an offshoot from legislation that I had. Of filed during the session. And the reason I wanted to come back and report back is first of all to say that I'm going to pull. The proposal down at this juncture secondly. Thank members of the committee for your support and interest. In the rule and also to thank Mister Speaker for. and others for connecting me with Carlton Safra we had a wonderful discussion and meeting. About the rules and about of the issues that I was concerned about and I also got a chance to Hear from him his concerns. And so that's you know in I'm pulling it down because Others believe that we can address some of these issues. And oversee concerns without the rule in without the legislation and I think for now it would be appropriate to attempt that but I wanted to leave you with a couple of issues that came out of that meeting. That are some things that we could address and I don't know if it would just automatically come back through A. L. C. since we're not creating the rule OR what that process would look like but since we don't know that I wanted to leave you with these issues and perhaps this is something that we can work on between now. And the upcoming session as in the way a proposal or whatever other rules would apply. I'm just gonna read these off and then I'll just be open for questions if there are any. The first is a potential for employing those eighteen to twenty one or those with limited criminal record working in the facility but not in the gaming for example in the kitchen. the second issue is a proactive work regarding problem gambling problem gambling. The third is a review of our laws regarding gaming misconduct cheating four X. a X. cetera if they rise to the level of criminality to match other gaming states. The fourth issue was to review tourism investment in promoting all three facilities and maybe one day before. And their towns for the traffic generators and job machines that they are. The fifth issue is involvement in the National Council of legislators from gaming states and the six this to ensure the FNA is properly funded the casinos generate tens of millions in revenue. And need to make sure that the twenty four seven staff is right sized and right paid. So I'm hoping that we can work on those issues now and into the next session and certainly if we see that there is a problem because we don't have the structure for proper oversight and proper. structure to address these and other issues that I think that we can look at the legislation that was originally proposed in the future which was very well and significantly supported without be happy to answer any questions. Are there any questions from membership. CNN thank you for your support thank you so much. So with that members we left off yesterday with wanting to hear from the department of ed so we'll start our discussion today with the department of ed Mr Reagan's secretary key are you guys coming for. If you would introduce yourself for the records Johnny Kidd part of education. Greg Rogers for medication thank you guys for coming today I discussion was led war around how to of required schools to spend the amount of money given in a matrix for health insurance on health insurance regardless of the member being a participant or not. Can you guys give us some insight on why that's not been done our why we wouldn't want to do that or why we would want to do that. Well we can try So unlike state government where under the state constitution of the numbers the types of positions the compensation for positions in state government or set by the General Assembly that's so there is a relatively certain number from year to year upon which you can budget of the the permit you per budgeted position per month amount that goes to fund of the portion of the of the BT expenses. For schools you don't have the same type thing with the funding formula it was established as a model. We don't fund positions we don't fund schools we fund students with the foundation funding. Within that model in that prohibits was based on a prototype but that prototype really there's there's not a school in the the state that exactly fits that prototype so the flexibility that the districts have in hiring those positions the numbers of those positions I have a move those around in the course of a year would make it and then you've got two hundred sixty entities out there doing that or so so it would be very difficult to do that in the same fashion that we do the the state the state side of that as far as. Requiring them to spend that money that goes in you know there are so many other funding sources also that which common your federal funds ESA funds amid a number of things that go number fund categories that go into the school districts and. Positions are paid out of these different funds been what type of positions they are so that that's where those the mechanism would just be pretty messy to try to. Do the same or even a similar type scenarios we do a state. couple members are here and they're on our way and I'm getting some text from but one of the issues. You fund schools on five under student basis you correct me where I'm wrong in this. And a lot of schools in the state specially in my area don't even meet the five hundred student men on their in between three fifty in the five hundred number. So. How could you figure or a or is there an easy way to figure the number of state teachers number of support staff bus drivers lunchroom workers offer that student number that you're to require a amount of money to be spent to health insurance is that possible. You could get a number I don't know Mister chairman how accurate that would be from district to district The other piece that I didn't mention is when when you look at each districts funding resources some districts have access that mills this body is talked about the issue of excess that mills in the past but basically with as as the ages and those that debt is spent down then those mails are repurposed for operating expenses and that varies from district to district so but that goes in as part of their own restricted funds that used to to pay for this position so you could you could you could get a calculation And it might be good for that point in time but I don't know that it would be good for budgeting from year to year because it can change considerably Greg I have some thoughts the ones that will right now there is a statute six eleven eleven seventeen that requires districts payment amounted of insurance it was done in the special session two thousand three where it was set as a hundred fifty dollars and it does go up how much over the foundation funding goes up so this started in January first of twenty twenty two districts will require payment of a hundred sixty eight dollars and sixty four cents minimum towards their teacher insurance so that's that is one mechanism we have got to make sure that there is a minimum pay towards teacher insurance but it's outside the matrix that meant on the only paid if that particular position is obligated are taking the insurance correct correct you only they only had to pay that purpose but not per position has been like like sector was saying the foundation funding is based off an ATM model not of a position law. It also bothers me that you guys page David Branscum all this money and he's not even at the table today. Is there another vital work for the for the agency hi it's very bothersome. We have any other questions remembers. Thank you guys and I'm sure we'll see you again next month with the. Further comment. Thank you. With that we'll move on to the Siegel group. Two guys would introduce yourself for the record and then now we're going to get started. To an available rentals of single. Patrick Klein CO. Kirsten Chapman with Segal about cursing single. Good morning and we're going you're going. All right so We just want to circle back on some follow ups we had from the last meeting in July Is a list of the items that should be pretty quick. We talked about the change of budgeted positions I was covered in our prison Tatian yesterday the bariatric surgery follow up Joanna's got that is a part of her presentation that you'll here momentarily. And then we're going to talk about some of the acts that were passed and finally we compared the of medical discounts in admin fees as a part of a follow up. Okay so we were provided from EVD and you know Jill roughly ninety acts that were passed between twenty seventeen and twenty twenty one Arkansas we did a quick review and then look like anything was. Overly impactful to the planned financially the few acts that that did seem to have more of an impact were pharmacy pharmacy related and what Kirsten walk you through a few of those. Yes so We did have Nick Taylor who was here a month ago. Make some comments on these three acts at nine ninety four PPM passed through versus spread pricing doesn't really impact the plan other than. You the PBMs gonna make the money one way or another all it does is shift the risk either to the PBM or to the plan and then the fees shift with that so it just limits the plans of. Decision or opt options to do the pricing there but is not a huge impact Act eleven oh three on three forty B.. Just protects those of pharmacies that are using the three forty B. program not a huge impact either to the plan either way ACT eleven oh four insulin. is is an issue that we think should be looked that we believe the intent was to limit member cost share but the way it's written in the end says that. everything comes through to the member so it does limit the ability for the PBM to negotiate. Four rebates that could be up to fifty percent of the cost there also limits the ability for. The pharmacies to negotiate because everything's passing through to the member so we think that one in particular could be a big issue for plan sponsors as well as pharmacies. So if we have questions on that. We can talk about that now and I think you had some of the and read about some other states are. They put in laws on how to handle this and you know that so there's caps twenty five dollars to a hundred dollars a month depending on the state so that protects that's the Max that the member would pay out of pocket so right that protects member but it also allows your PBM to get those rebates that are significant right fifty percent so that's kind of eight million dollar number that's been put out there. So. To your point and we've had this discussion it's gonna be important in the future to have some type of actuary look at proposed legislation in the effects to EVD long term and short term before members should present those type bills similar to what education does here and and some of the healthcare bills yeah so many of the states that we work with that's part of our part of our fees to look at on any bill that goes through we provide actuarial and note so that's provided with the bill so people know the financial impact short term and long term so that's definitely recommendations and you can kind of see that at the bottom Qalat box. The other piece that we were asked to look at this come came through the benchmarking presentation we're we're looking at total cost and I think somebody asked about the administrative costs so what is a call what do you pay Blue Cross blue shield to run the program and how does that compare to other groups So right now the fee is twenty dollars and fifty five cents per member per month. yeah covers claims administration network administration and some medical management and we did look at a a benchmark study for the size of the state and you're in the you're in the range you're actually on the bottom of the range look like we see fees between twenty and thirty dollars PM PM so that's good. And you know some of the groups though they cover different things so that's one thing the other make sure the the look at and make sure that the suite of services or are in line but all in all we think you're in a good spot with the admin fee. And this is a really of a follow but it goes hand in hand with the admin fee it's this is the other big component when you're looking at a Medical Center that you want to partner with and that's what kind of discounts you're getting in the market and that's a much bigger number eight the twenty dollars PM PM probably like of five percent of the total cost but the discounts can have a major impact and we do have a discount out of base that we have access to many consultants do all the big vendors supplied the database with their discounts on a three digits that and so we use your senses some maps. Map the census to the discounts in your area and we did determined based off the discount database that your current vendors providing the best discounts currently you know it's not by a major margin so there are other players that are that are close and you know we'd recommends when you go to your are few process that your actual claims re price by these vendors so you can get it a better look more actual look at at the discounts and again discounts aren't the only thing there's a big piece of it is medical management the. Rage on. All right so that's all the falls we have an and there's no question so what Joanna. DO representation. So we remember recall from July we talked about your high cost drivers where we thought the best places to focus in on in managing your population and one of the items that we talked about was obesity in the cost that that drives up as well as the chronic illness that goes along with that heart disease diabetes and other chronic diseases so one of the questions that was posed back to us was can we take a little bit and you're very after program and see really where you had any return on investment and what what positive results might have been. So what we'll talk about is the very object surgical results so we Siegel look at your claims data to see where the individuals how much they were spending before what were they using from your standpoint and prescription drug standpoint and where they are after we also Courtney with Blue Cross blue shield and they did corroborate the same results that we do see a positive are away from that surgery also talk a little bit about your pre diabetic and diabetic population and then provide some clinical recommendations. So we did pull some just to test X. in general around Arkansas's obesity rates about twenty percent higher than the national average and we have a higher obesity rate within eighteen to twenty four year olds in the C. nationally. And like I said a lot of that drives up into take two diabetes earlier in life chronic illness like cardiovascular disease and associated risk factors. And on the side we just want to put together national statistics you understand a little bit about where that lands in the United States but we also look at the rate of bariatric surgery and what we're seeing is you know while the procedure might cost around a hundred seventy grand there are two particular procedure someone is called a gastric sleeve are they basically make the stomach smaller and then you eat in smaller portions over time the other procedure that's Lamar complex is actually kind of re routing the stomach system so to ruin why procedure that is for your really really high risk individuals and what you'll see when we look at the data is that one doesn't have a faster on it does over time for the gastric sleeve you see a return on investment within the first year and most clinical research shows within four years you're you're having a pretty high return on investment. So what we did was we looked at your particular data and what you're seeing on the screen as twelve months prior to surgeries that's your pre surgical spend twelve months post and we see a forty four forty five percent reduce and medical spend and seventeen percent reduction in our acts you're seeing your visits go down we're seeing less prescription drugs needing to be used within that first year you do see some urgent care and inpatient admissions occasionally after the procedure a lot of individuals are going through an adjustment period and they're needing to get you know their vitamins taking care of sometimes there's some fluid ballot imbalances that happens that's what you might see some in patients in that first year but we did see a positive return on investment within the first year and up to four years you're seeing individuals with reverse diabetes and heart disease. BlueCross BlueShield also saw this at the same results the dates are dramatic decrease in your utilization in our and prescription drug spend with this procedure. And I I did enjoy the site because it's actually showing the reduction in overall BMI and you're seeing eighty percent had improvement in their weight so their their BMI within the first year we had a few individuals that we don't have the data so it's it's a diagnosis code and it doesn't always get attached a claim to do that based on what the physician diagnosis code was pre surgery and post surgery and we only had six individuals that were. Worsen and so those are individuals that had some immediate post operative complications it's gonna take a little bit more time for them to recover and that's typically your highest BMI range so very morbidly obese individuals that are going through the the more complex surgery it's going to take about forty five years for them to really see the full results. I want to do is take a little bit and you're pre diabetic population or actual diabetic population as we talk about how much a BC actually contributes to overall spends we see about twenty percent of healthcare spending is related to a lifestyle in ruby city caused illness and we did look at the national diabetic statistics so I wanted to just have that in comparison to what we're gonna show you shortly but what we do see is thirty five to sixty four year old Arkansas sixteen percent are diagnosed with diabetes and five point four percent are diagnosed with pre diabetes that is higher compared to most benchmarks that we have then your part that's the whole state and in your particular health plan. You have over sixteen thousand diabetics that's nine point one percent of your population is diabetic we typically see closer to six percent in our populations. And I did break it out by type one and type two because we know type one with individuals are born they cannot make their own insulin there's not really much we can do about that it's just getting making sure that they have the resources that they need we're type two diabetics some of it is lifestyle driven up a little bit can have some underlying genetic cause to as well but whenever you start to really work with individuals on their weight their diet physical activity we can actually see individuals come off of some of these prescription drugs. Insulin and other Hello that you might take for diabetes can range anywhere from four hundred to five hundred dollars a month so if you think of reducing around twenty to forty percent of that how much money you could actually save if you have an individual in a new trick medical nutrition program directly related to diabetes. So we did add a spotlight on your state with this geo mapping which I think is pretty interesting to look at so the the chart on the left in the green is the prevalence of diabetic so obviously it's very highly concentrated on where the cities are more highly populated areas but then if you look at the rate what we did and if you remember whenever we first came here we talked a lot about social determines of health access to health care and how these things can really impact your over all I'm healthier population it's on the right we looked we compared at the zip code level for the county's to say what is your social index here this is lack of access to food transportation of pharmacies within your region and you can actually see it you're spending much more on the counties that have less individuals because their higher cost diabetics so they're on the higher cost medications they probably don't have access to the rate care that they need and or the food and pharmacies that they need to take care of themselves. On this side we broke down by county the fully under services the partially underserved counties within your state and you can see how the relative costs on a PM PM basis is much higher in these counties so if we take for example like Polk County it has a very high cost PM PM cost comparative if we're looking in the county that we're in right now. The reason I want to show you that is there are some states that we've worked with that have done focused pilots on their highest cost diabetics you could potentially look at these counties and focus a lot of your efforts around education medical nutrition subsidized food and your you're gonna get the highest R. O. Y. on on those particular programs. And this out we broke out your nondiabetic versus pre diabetic and your diabetic so anytime you do a diabetic program it would you would also want to do a pre diabetes program the individuals that are pre diabetic that means they're hemoglobin A. one C. or their blood sugar is a little bit off and a little bit too high as well as the their BMI as high and then you have another chronic illness me like hypertension for example that would be considered pre diabetes if you want to focus of full programs you think of weight loss and bariatric population meant better manager diabetics that means they're checking their blood sugar more often they're controlling their hemoglobin A. one C. backing down on their medications and then those individuals that are pre diabetic or your healthy healthy at risk individuals we want to keep them or push them out of that pre diabetic states we don't want to convert them over to diabetes and so we want to get just quantify that a little bit for use within your population what you're spending on a medical PM PM for pre dive a nondiabetic versus a pre diabetic versus a diabetic and you can really see it keeps going up from there and that's what we want to kind of stop that a little bit back people down. So some recommendations first what we would recommend to continue to promote and fund the bariatric program in talking with lacrosse blue shield we have a lot of individuals that go through the initial coaching program utilization management very tight we showed a positive are wise we would not recommend to take that away or do anything with that. You can expand your nutrition benefits if you take a look a lot a lot of the nutrition plan language is very focused on individuals that are already diagnosed with a chronic illness you can expand that benefit I've done that with other clients where we expanded to individuals that are in pre diabetes or in a different chronic illness bucket that you're trying to prevent them or prevent that cardiovascular risk over time and it's it's not a very expensive service and you can cap that you can say you get twelve visits or six visits you're with nutritionist that's really gonna pay off in the long time if you have individuals that are preventing from a chronic illness. Then around diabetes management strategies so there's a lot of different programs out there Blue Cross blue shield I particularly partners with on do well there other programs Livongo over to that we've worked with in the market place where they do a couple things first of all to getting individual supplies of diabetic supplies for free to pay for an engaged member to get those of resupply ship to them they get a very nice digitally connected commoner that goes directly to an application over time the application learns how that individual functions and they'll they'll actually push recommendation so if your blood sugar dropping after you work out are you not eating enough before you work out or or you eating too much at a certain time of day that's causing a pleasure to go up and down the whole goal is to keep you very study. They also have our medical nutritional therapy so virtual access to physicians virtual access to nutritionists that can actually work with you in concert of changing your lifestyle and start to bring you off of some of those really costly insulin's. And as we think about that we worked with other states where we've negotiated renegotiated contracts we've gotten vendor allowances to help pay for some these programs they're also on a per engage basis they're not paying costs the whole population just individuals engage with then you can also negotiate some performance guarantee supporting some real clinical record around that program and if they don't achieve no reduction in hemoglobin A. one C. or weight loss and you would actually get that feedback and we have helped a lot of clients do that the other are part of that is a pre diabetes programs of the CDC did consider that a preventive service a hundred percent out no out of pocket for the members and we've had a lot of pre diabetic programs of the last ten years have been very successful at preventing individuals from converting to full diabetes and so we recommend that you would look into those programs and potentially implement that and like I said one strategy is you could pilot it and your highest cost counties you see positive results and you can rolled out more broadly. and then you can also collaborate and communicate with the health plan programs utilizing social determines health screening tool civil what we what I showed you in that case that county map BlueCross BlueShield also does that so as we think about how we educate our members on their health plan if you're sending out broad communications a lot of individuals are not engaging right programs because it might not apply to them and then you end up with information overload so another great communication strategy isn't really doing a social determinants index on everyone but not up against your claims and then targeting communications based on age communications modalities whether they like email applications or snail mail phone and then also really focus in on where those individuals can make real lifestyle changes that will impact their overall health. I'm so right now those are our current clinical recommendations based on looking at diabetes and obesity and in the next session we're gonna look more into your musculoskeletal span as well as oncology we'll talk more about that at this time I'd like to see if anyone has any questions. Senator recognized thank you Mr over here by the post D. the takeaway is that the money that we're investing in this based on your research is money well invested based on the results that is producing is that accurate yes both nationally we see that but also within your actual plan you're seeing early return on investment within your one and then full with it you're fully paid for that procedure in four years actually reversing chronic illness I'm not sure this is an all wheel house but let me ask you we have a cap on the amount of money that we spend had have you can you or is in your will house or contract that you can do an assessment. As to how much we ought to open it up to or should we keep a cap on their in order to get to return on investment that we need that will create the savings were looking for. Yes I have not seen other plans capped this that was kind of interesting to me and and discussing with Blue Cross blue shield you haven't hit that cap yearly that doesn't mean that eventually you won't so I are recommended like I said recommend we recommend in the past not to have a cap because usually once you cover it you have those utilization management controls in that are preventing inappropriate utilization of the procedure like I said I've not seen a cap before. Okay and on the counties that you identified in the numbers that are socially with those counties are those that are currently covered in plans are that a make sure Medicaid patients or those those are your your plans as your actual data right so when you throw that in and and maybe this is an in your will house again but when you throw the Medicaid population in there the cost to say the the does DHS what we pay in there this is just a snapshot looking at these two populations yes okay all right thank you Mr. Of cochair Senator Rice. Thank you are there any states that you've looked at that have what I would call by in. By patients that would have some investment in a bariatric procedure for their health and you said they are I. It is positive but sometimes to follow all the things that go along with it There are those that have a making this some before in a neighboring state those that went. Out of the country there is a industry we all know out of country that does various procedure but bear after being one of them I know a positive result from one which strictly for cost and didn't have insurance that another one was education and did have insurance but it was still cheaper I don't know what the the details were there but but because of supposed complications that Is there. Advantage to having when we're looking at overall sustainable cost of the program. Is there is a room for by in. Is that a seven day juice. Sir are you looking at member cost share or and every member call shares one I'm calling by. So what I actually see usually is you have a center of excellence network for your bariatric and if you go to that person Senator they actually reduce the member cost share because they want to make sure they're engaging the right facilities. Now with most controls that are put in place individuals for are required to go through intensive counseling for six months is nutritional and talking behavioral therapy have to quit smoking and they have to be with a physician led exercise program for at least six months do you can be approved so that's the current utilization management you have wrapped around that procedure and then after they have to continue the additional thing that that you have that I've not seen in other states as you have an actual care management program or Blue Cross requires not just saying that you physician lead but they're working with that Blue Cross coach as well so you do have a lot of those controls in place already I've not seen it where it's almost like more member cost share or there that the members putting kind of like that financial skin in the game we usually see it go the other way per your reducing member out of pocket to encourage them to go for that procedure. Okay thank you thank you Mr. Senator Hammer you're recognized thank you you made a comment while ago also about that and I interpreted what you said as far as access to the provider that maybe specializes in this did you identify where access to providers was the issue because some of these counties you know our role county's number one and number two the program you're talking about that we you would recommend that we would implement are those going to be the responsibility of the carrier the provider or who's going to bear the burden of making sure that those programs are are actually carried through. So related to the diabetes program or bariatric surgery the service of the look let's start with the diabetes okay yes Sir for the diabetes program that map is is showing you where they're medically underserved Celeste access to physicians clinics different things like that so in recommending a digital Davies program it kind of closes that gap a little bit for individuals because they can access the physician through telemedicine and through the application they can talk with all the clinicians that they need those programs you can partner with Blue Cross blue shield to turn on something that they have within their kind of formulary of options and then they would manage that contract on your behalf. We have also done where we've done that contracting for other clients and went out procured an actual Davies vendor just particularly for that service but if you can do it either way so he can do as partnership through Blue Cross blue shield or you can go out to the market place and procure and we've done that with clients. Yes when you say that part what I struggle with incorrectly where I'm misinterpreting is I would have thought would cross BlueShield in the carriers that were paying money we're paying to would do that already in order to keep the costs down because it be beneficial to them and to us why what is that is it that way in other states or why would they not do that already and we would have to have another contract with them to do what they ought to be doing anyway in order to get costs down yes a nationally most health plans have a traditional diabetes or disease management program that's telephonic you you have nurses diabetic educators and coaches that calls and letters and try to work with someone over the phone the digital market place has all been individual are companies that have created these really with Patton's have created these really amazing tools and digital platforms. What the health plans have not done is created their own what they've done is made partnerships and reseller agreements to then basically added to and two add on a program so every health plan in each state has a different partnership I mentioned quite a few like Livongo over to until amat is another one said what they've done is they've found the best of the best in that area and because they impact on that technology they have to do it as a reseller intends to the contract it's more about the tack that went behind it versus the actual clinical program okay thank you Mavis of Mr I really appreciate lead to let me ask questions not be on committee but maybe that's something to explore thank you. Any other questions from the members. Seeing none as the end of the presentation today right yes. So thank you guys and seeing no further business we stand adjourned.