ALC-Executive Subcommittee

Members of you start moving to your seats will get started in a couple of minutes. Good morning members calling the Legislative Council executive committee together should you be in here before we start I wanna recognized a group we've had some different groups with those Martha hill has from interned with us we have three for Mitchell Williams and two from Arkansas commitments if you all will stay and we'd like to recognize you receipt you being here today. Thank you. Next we have Matthew Miller going to give us an update on redistricting Matthew I think you've got our attention here we go good morning everyone Matthew Miller with the L. R. I want take a lot of your time today but I did want to provide an update because at long last we have kind of a substantive timeline for when we're going to have some redistricting data which I know everyone has been waiting on me so that important I attended a conference last week in Salt Lake City the NCSL put on concerning redistricting at that conference there were some officials from the census bureau there who gave us a pretty concrete timeline of what was going to happen over the next couple of months the designated state officials for Arkansas who receives census data will be getting on September thirtieth last drives and DVDs of the census data. But the census bureau knowing that states are waiting in that things are a little behind gonna make available on August sixteenth the same data in a somewhat more raw format it's not as acceptable but it will be the exact same data is what is going to be distributed on September thirtieth basically between August sixteenth and September thirtieth they'll be working on taking that data and getting it in the customary format that the state receives it. But we spoke to our vendor city gate at that conference and they can work with the August sixteenth data for the purposes of inputting into our map writing software and doing those types of functions so on August sixteenth or vendor will take that data and start the process of putting it in our map drawing software that'll take a couple of weeks because they have to do some quality control on it just like any download you can sometimes have some information left out and he knows how to check for that so probably around the start of September we'll have our map drawing software with the actual census data within it and at that point we'll be ready to work with that data and if you want to draw a map for work on something you can come and talk to myself Laurie Boeing Michelle Davenport we're all going to be working on that number getting terminal set up and things like that so that we can get this process going. I'm happy to take any questions you might have on this. Any questions from members. I do not see any thank you Matthew for president. I actually have a. Proposal the president budget Senator Hickey and jail fire. The Bill take you see. When recognize yourself for the record president. Hey Jimmy Hickey Arkansas senator Wallace G. O. present this because we had some what yesterday evening we had some The items with the contract to come up so if you decide we're going to approve this and there was some contingencies with it. Thank you Senator Hickey at Telfair bureau of legislative research so you all have in your packet we put together since we didn't have the contract in final form yet and you have a copy of the scope of work from moody's and on top of that is just a cover sheet added that gives the summary of the terms when I go over with you what the the most important terms of this contact our that we do have nailed down and then just let you know a couple things were still trying to work out and so that you can decide what you want to recommend to the policy making subcommittee. So um this contract would be between the bureau of legislative research in metes analytics and it's for them to provide you all with research analysis and reports on two separate budgeting and revenue issues one is examining the COVID stimulus on Arkansas's economy and tax revenues and then the second one is add to deal with personal income tax changes and that will include add dynamic scoring component amenities would come here and present in person to a legislative committee and and they're also going to be giving us written reports on both of these items the maximum contract amount that we've worked out with them is two hundred and eighty eight thousand dollars and that includes all their expenses and travel expenses and the invoice saying that I've a written out here has actually changed since I drafted this last night and threw some negotiation emails with moody's Act we were not comfortable with the fact that they wanted to have us pay then the remaining amount of the contract prior to them coming here to present to you also we have worked it out where we will pay them half upon execution of the contract forty percent upon delivery of the reports and then the remaining ten percent of the contract amount would be paid after they come here to present to you. And this contract if it's approved would be effective this Friday after Legislative Council approval so that they can begin their work right away and they would have those two reports ready for you by September thirtieth. And then the presentation date will be up to the Speaker and the president pro tem to determine when you fall and are ready to hear from them. So a couple of issues that we're still working out that I wanted you to be aware of and we as I said we worked out the invoicing issue there's still an issue I have and. They have into places in their contract draft that they would like to have the date and time and place of their presentation to y'all be and mutually agreed upon we took issue with that initially because it's very difficult for an the legislature to allow third party to impact their scheduling as you know and however with the short turnaround time in metes and is taking time and pulling staff away from other projects to do this so fast for you all they've told us that they need some notice and they need to make sure that they're not on other jobs at the time that you need this year so it's going to be up to you if you're okay with that mutually agreed upon language that's in there so that's one of the issues I need from you. I am another issue was that they wanted three weeks notice before we scheduled any work from them or an appearance and in addition we would be penalized if we didn't give them three weeks notice before it canceled again I pointed out to them that with the difficulty of nailing down legislative schedule in the short time frame that we're looking at three weeks is really hard for us and I think if we get to that mutually agreed upon language for the presentation date then then this issue will be worked out also. And then the final issue and what actually is a bigger deal for us is there governing law provision of ask them in their contract they've stated that New York will be the governing law as a state entity we never agreed to have another state have any jurisdiction over us and an impact because you have sovereign immunity any claims against you should go before the claims commission here in Arkansas so I've asked that they include that language we did tell them that if they per fire that if we were to need to bring a breach of contract claim against them we could take it to New York but that we would not agree to having New York law governing any claims against S. and then we've also asked that there be language included that states that we're not waiving the sovereign immunity of the bureau or the General Assembly so I haven't heard back from them yet on that and and I think what that leaves us with here is asking this committee to approve something in the substantial format and and hopefully we will have the contract for council on Friday. I'll take any questions. A question for Mr they're also Senator Hickey is available to explain in legislative terms. Just what is that again this is for action today will be from the executive committee only it will go to full A. L. C. if approved today for Friday vote but I would like all members understand. Yes members what of course you heard what the contingencies of the contract that were still working on the bureau's working we really appreciate their a detail that they put into that part to make sure that we get our get our Concorde contract the exact way what the what this is actually doing as you all know the intent is that will come back in we will come back in later in the year this fall to do our redistricting and immediately after that it is the intent that will probably go into a special session you know to look at tax cuts. What we're up against this year is of as you all know is there's been multiple stimulus payments that have come in Arkansas come into the nation due to covid bid from PPP loans to just individual stimulus payments that that went to constituents cares money just a multiple of things of that nature. So what we need is we need somebody that is able to extrapolate that to those numbers out that additional revenue that's been skewed so that we can come up with the and the dollar amount of what you know is a prudent tax cut that we can do for the state of Arkansas as you all know when have been reading there's been we've got to a lot of this money is a. As follows and are long term reserve. huge portion of that you know was because of the extra stimulus money that was was pumped in we've had extra sales tax revenue because people use that money to go buy products probably has been some income tax revenue and things of that nature so we're trying to get us a legitimate number so that's what that's what this contracts about. Okay members any questions for Senator Hickey or this state you're in first and moved to Senator Hammer. Thank you Mr on the invoice amount and the method of which you're asking to be pages is based on a hourly rate or is this just a set price. So as we initially asked for hourly rates in metes stated that they work on a just a contract amounts and so it's just that set amount and then they'll invoice in that three phases that I described okay and what I'm wondering is there talking about another stimulus package coming down from the feds and who knows what they'll do between now the time that they would issued this report to us and how is that going to be handled if if they're doing or is this a retrospective look at what's coming to the state so far or is this going to be on going analysis so we'll have at least a real snapshot in time if they drop another big stimulus package that might affect the terms of the contract as far as him wanting more money because they're having to do more than what this covers no Sir it'll just be for what's happened in the past it'll be like what what we kind of you know and again this is a simple simple term but hard hard to calculate how to figure figure is basically what what would the state of Arkansas is revenue Revenue would be and it will give absent any stimulus funds absent of covert it happened so we're just looking at it from that standpoint so that we can for this tax cut that we're going to going to be doing to make sure that we can afford whatever whatever the membership process to do so anything in the future and we've been saying this will have to be very prudent like and in the future if we decide that the you know we're gonna look at doing another tax cut here in two years or whatever it may be At that time we will probably have to do another contract to see how many funds had to come in that way. so so we can re adjust that out to get the correct number so can thank you Mr can I get one more Mr. yes we got more make you go okay thank you and this is not a slam on the current staff that we have because we all know we you know limited staff what is it that's prohibiting the staff that we have from being able to do this without having to go outside to get a contract to do this given the fact that they maybe could do a historical look back over prior to COVID measured against the numbers that are coming in now so we we could do it that way what what are the limitations on the staff now I would just say would be the complication the complication of of doing that we had actually talked our some of our staff. You know what we mean we've also got some of the revenue items that we want to. See if we can get taken into account which you know would be the of. Sales tax and possibly be coming off of the. Do you know from the internet and things of that nature we have a you know whatever tax cuts that we've a new she added that went into effect they're also going to take those into account. It's a. It's it's also hard hard to know without. It would be hard for us to calculate it because we don't we don't have the ability to go back in and say we may know how much cures money that we received here. But we really don't understand the financial part of that or the multipliers that we would need to use to back that out same way with all these stimulus payments that people got in the mail box you know what it all that equal how many times did that turn in the economy within those months that we're trying to figure to try to to try to get this number to get there is just to. We feel like it takes somebody that's well versed in the financial field such as moody's to to be able to do that thank you bye Mr. The Speaker Shepherd in representative Dotson to that. Thank you Mr chairman. If I meant to ask you about this or that we're talking about everything else we had to talk about but The couple questions and and germane can answer these as well on the timeline and I stepped in here of late after already presenting it but looks like the initial response be by the end of September and then the follow up would be a month later something like that and I guess the question I would have is in the contract. Could we have some flexibility that if if. If in light of a special session. Our time frame changes that we can you know ask them to expedite that so that we have that information in a timely in a timely fashion. I'm I'm always for that. Not not from a quicker standpoint actually it's a that is one of their worries there they are somewhat concerned that you know since we're trying to push him for the end of September I don't think that if we wanted to say the beginning of September that they'd be able to do it at all so and I guess I'm more thinking of just in terms of. You know I think the end of September that timeline probably is fine but I'm thinking more in terms of as we move towards October and November I think that that will come later that the what we would have that option to ask them. Yes they their concern was the September thirtieth time on a I am actually an initially proposed having half of this due at the end of October and then as far as the presentation that's open this contract will run through the end of the year so anytime between delivery of the report and the end of the year they can come here to present okay and then one of the follow up I noticed in the. In some of the information that that. One of the questions asked relates to smoothing the cliffs but I would I would take by this that. Other other alternatives other questions that the legislature might have as far as tax policy that could be part of what we're asking them to look at. You know if that if that would be the case they were they've been pretty adamant that with those two that they were. They're worried about our our time line. I agree with that and and the contract says that and those are the two questions and the scope of work lays out how they're gonna handle that and they've said that anything beyond that would require an additional work order from them which would be an additional amount. Okay. Representive dot. Thank you Mr chair Service. Welcome way I guess I'm. I'm trying to figure out. Where we came up with doing this because then we pass legislation during the session. To do this exact thing on a long term continuing basis. Are we passing a short term. Contract I guess staff would have to do that I don't know as far as the stimulus funds I don't remember us passing legislation will wasn't with regards to stimulus but just dynamic scoring I believe representative Jett and had had the bill we passed. For us to look at hiring a consultant if I remember correctly I think the bill itself was the to be able to bring to this body so that the That we look at hiring a consultant which I believe we dealt with looking to put out that or if the last month. SO this has nothing to do with what we did last month I was thinking no Sir it does not so much reason so this is a completely new proposal that you're bringing before us today that is totally but is totally based because of the all the stimulus money so that we're able to look at doing the tax cuts come this fall Director Garrity thank you some information. Represent Dotson and we did issue the RFP based on the authorization provided by legislative counsel however under the act DFA does not have that cannot provide us that information until January one they've got to get software ready we asked I reached out to secretary Walter seeing if we could speed that up in light of these requests that were coming and he indicated that to get the software and their programming where they needed to be to be able to give us the information it would re take until January to do that. Do we have an estimated cost Jett on that or is that are if he still out for we still haven't received any bids I think the RP is open until August thirtieth August thirty okay so. Thank you thanks for time that together because I thought this is what we're talking about before yes and and then if may He said this contract hopefully will be done by tomorrow. But you want to prove it today without having a final contract I have a written motion for that so. That's you know if we're going to get this done you know which to be able to do it in the fall. You know we're trying to get this on the road so I will have that with these contingencies in this motion for this committee and then of course it'll come before full LC press to look at that way you know kind of and I hate to do anything in Russia's not my nature but you know the other thing is is is to get this done so I said well why don't we wait till later in the year to have special you know special session but we're going to do these tax cuts we're going to have to figure out exactly what we're going to do to give DFA enough time to make sure we have all the tables you just to make sure all of the financial planner CPA's in that you know all understand this before the next to a tax year so that's the why we're trying to trying to make sure we get it done now in the end you know just to let you all know if they come back and they say well we don't want to we don't want to do some of these things that you all pass then I guest role we walked away from this and then we're going to be in a situation where we're going to try to figure out who else would do it somebody that is capable of doing it. because we don't have the ability we want to make sure that we are have got somebody that's going to give us legitimate numbers so we may have to go to work and figure out what you all want to do as far as you know having a special meeting you know for that so I'm hoping that they will do what the the bureau is requested as far as these contingencies but again if they don't. We may be back in the same situation where we're at well so you know. probably needed to wait till the end of the fiscal year so it's not like that we're really behind where we're at because we we need to wait to the end of the the fiscal year you know to make sure we had all of our numbers and before we could even proceed with this how long is this proposal been in the works as it said. Pretty rush Wilton. We we probably talked to the bureau. Six weeks ago I'm guessing about trying to figure out. How this could be done if we could do it if we could be we didn't feel like that we could do it who would be capable of doing it and then they had to start these discussions discussions with them about what we were wanting exactly so I say six weeks represent Dotson but I'm just grabbing that out there it feels like six weeks six eight weeks ago probably I am thank you yes Sir. Okay that finishes up the members on mobilization non members of you will be assisting because you can't number eighty or center back in you're recognized. Thank you jare senator thank you the the. Proposals to look at the snapshot of twenty twenty. It is it is it also going to include for looking because one of the one of the concerns I have is that there's a change in the federal tax code where child tax payments are coming versus the top child tax credit so. Looking for the FY twenty twenty one we'll look at a lot of people having several hundred dollars or thousands of dollars a month disposal income that they have not at any point in time in the past. But as far as this is our stores is no Sir the you know smaller issues and things like that it's just something that we're working with the F. D. F. and a we may. That may be inclusive of all of our thought process whenever it comes to the tax cut that we're looking to do in the fall to make sure that we can afford it our main thing right here is just this from a macro standpoint the stimulus payment so again it's it's not forward looking as far as this was concerned and that's the next thing again. what. The next time we do this we're probably going to be up against the same issue because as we already know we've got the rescue money out there this going to be providing a large Increasing the way the revenue you know it's coming in the state that will be one time money and I say one time it's probably will be over two or three years and may have a tree and and then that tree and may just fall off the. All the clear of two so we're going to be very proactive and in the way we're doing all this for the next few years. All. I we be better served spending this money and with a forward looking. proposal then then looking back what we didn't twenty twenty since we're looking at doing tax cuts for the future. No Sir because we've we've got to But because with where are revenue the has come in we would again we need to extrapolate that. That money at one time money although it's not really one time since this is a multi multiple year but that one time money that come in we need to know what that generated what that created from all those different sources again from a sales tax revenue income tax of not only from our. You know to set the money that would the cities and municipalities and all that receive but also those individual tax payments that that women those mailboxes as as we know a lot of people just took those and you know went to they're retailer and bought this good but all that good that they normally would have done so thank you yes. Okay we'll continue reminder we've got a loan. Did you day of. Representative Jett you're recognized. Thank you Mr chairman of. The representative senator fully support what you're done I think it's good what you got going is good for the sport of questions for you if you don't care your United conversation yesterday about part of property information of the information to be disseminated the Speaker and I've actually talked about that as well could you tell the committee about the how did this information be disseminated amongst members in the house not will be put out this got some privacy guarded here with it share so under this contract and all contracts that we do with consultants and the contract is with the bureau the bureau owns the ad deliverables which in this case will be then ounces and the reports they'll be brought back I'm metes under the act contract terms we will provide the reports on week once we receive them to the Speaker of the house and the president pro tem and they will then determine which committees committees of the legislature will hear the presentation I am so until it is disseminated fully to all the members of the General Assembly it won't leave the bureau and the Speaker pro tem and that's we always we include that in our contracts and we discuss that with our consultants when we begin a contract so that they understand they'll be in violation of the contract if they share any of their work prior to us releasing it publicly the committee has signed off on that correct yes that's not one of the issues in contention thank you very much. The representative right your last on Q.. Okay Senator Hickey similar to the the last question on the on the results and findings it says in the summary of terms page will be presented to legislative committee do you have an idea which committees that would be of. Well course Speaker Speaker and I would have to discuss that more more than likely will be Revenue and Tax or we do have a of economic tax it. I remember economic tax policy committee of course the. As far from the Senate side not sure about the house we don't we don't have the appointments on that one so. My speculation it'll be that probably work in a very close with the our budget years Senator Dismang in the representative Jean thank you. Okay skewed me I've got one. Right to me up in the no not Senator Hammer okay. Thank you Mr the one thing I wanted to know was you mentioned something awhile ago about internet tax and looking at that in my experience when trying to get information a DFA about internet tax and how much it is nobody really knows what what conversations have you had with DFA about this and also what assurances have you been given by DFA about this that they will be a transparent and open with regard to all the numbers show that they will have full access to the to bring out a accurate report but I did say I haven't had any discussions with them and all that I just know that that's possibly going to be an issue there will have to you don't work with moody's during this process because. My idea which I don't know just basing it on speculation but I believe is correct is that probably during the COVID to during the COVID times there was probably a larger use of the internet to purchase goods and things of that nature so I just think that that that wind up having to be a large part of it as far as those discussions or whether or not you know I would I would think that they're gonna be transparent on anything unless it's a information they can are not release but there they're going to have I will feel that they're going to work with us to to get the numbers that we need to think that by having the support this report at least as a point of reference if things turned out to be different later it would be of value to have that to show that as far as legislative branch we did due diligence to work with the information that they were able to access to be able to have it for whatever tax policies we make I would hope so thank you. Okay Senator Hickey. Read that members of the you have the thing is okay I'm honor I'll read this motion we the we prepared it so that we get it correctly I move that the executive subcommittee recommends to the policy making subcommittee and the full A. L. C. of full ale see the approval of a contract with moody's analytics for the scope of work presented today in the amount of two hundred eighty eight thousand contingent upon agreement by moody's to the pending revisions would to all of her requested by BLR and if the contract is not finalized by Friday July twenty third the AOC cultures will be given the authority to to by AOC to approve the final form of the contract with those terms so just in the event that we can't we can't get this in place by sometime today for to more with those terms that were presented then the AOC chairs could approve it. That's a motion and a second I have a second this is a vote of the executive committee all in favor aye opposed. Congratulations centric you thank you committee. All right understand we're by Senator the we will go to the single group. Your month your come up and the you know the routine combat recognized your cell welcome back. That a lot information yesterday some very good. Questions and Richard you been back this morning. Good morning everyone Patrick Klein Siegel. Matt Kersting single. Trying to be like or not single. A good morning Nick Taylor was Siegel Preciado real being here I'll remind you some of those are a little bit harder bearing and others so little those mocked will pool to you if you. If the volume up we're going all year thank you. The. Yes. Dr. No no I can drive. so again my name's Nick Taylor I'm excited to be here with you today I'm a pharmacist about a pharmacist for twenty seven years I live in Ohio I'm license to practice pharmacy in the state of Ohio my background has been that I've worked in many aspects of pharmacy from local community pharmacies to PBMs worked MPD and now I work with plan sponsors all of the United States as the national pharmacy practice there for several consulting my job is really to help plan sponsors understand what they're buying and designed benefit plans to provide you know clinically advantageous benefit plans for their members and conserve cost So you know kind of looking at you know your pharmacy program of what we've been asked to do we've taken initial look everything I want to talk about is just kind of based on a few meetings that we've had so far and some basic reporting that we've received there's still some more work to do and we will dig into that but I wanted to give you kind of an update of where we're at You know starting out I thought we just talk for a minute about what's happening in the pharmacy industry the PM for tickler on PBMs the market continues to grow and we count somewhere north of thirty individual PBMs are on the market yeah this is creates a an idea that there is a very competitive market the reality is is that three PBMs CVS express scripts and Optum manage somewhere around eighty percent of the market and provide a significant amount of downstream services to all of these other PBMs whether it's through rebate aggregations claim processing they help them with formula Aries retail network negotiation mail pharmacy and specialty pharmacy so these are all services that are available to smaller PBMs and various contracting arrangements with the larger PBMs when we think about specialty pharmacy it's continuing to grow at five percent or more per year now responsible for more than fifty percent of plan sponsors cost just in the first quarter of this year your pharmacy plan cost is increased or whatever twelve percent on a per member per month basis and represents a little bit more than fifty percent of your total plans found what about less than one percent your membership the on specially medications because of the growth in specialty we also have the growth and specially pharmacies their rapidly growing and the largest specialty pharmacies are owned and operated by PBMs which we we know also national retailers have specially pharmacies are setting up specially pharmacies and then our health system so hospitals and the various health systems in the United States are also setting up and managing specially pharmacies in this arena as well. I think the traditional pharmacy market is a prime target for disruption when you think about groups like Amazon entering into the pharmacy space I think with the advent of the pandemic and people seeking alternative delivery methods that you know this is a market that's right for disruption we have pharmacies that specialize run very specific individual drug categories you see advertisements for pharmacies like hims and hers and groups like that that are targeting male and female type of drugs so we continue to see that growing we see Optum are I'm sorry Amazon you know making this move into the pharmacy space and a lot of what we see happening with retailers is about foot traffic in the stores so everybody's trying to drive foot traffic in stores as a defensive measure against Amazon which is delivering everything to your front door often times within hours of you know ordering it shows up at your front door. So we see the even the large national retailers and on TV mail pharmacy starting to grow and expanding options for delivery services to and it's all about gaining market share something around six billion prescriptions dispensed last year and so it's really about you know how much market share can you get of that market. the pharmaceutical manufacturers we talk about farm all the time they're competing for market share of their drugs on for Miller is and the focus is almost exclusively on the largest PBMs to negotiate price rebates and other price concessions when you talk about the three largest PBM somewhere around two hundred fifty three hundred million people that they manage and have access to so those pharmaceutical manufacturers want to have as much market share of their drugs and so they're negotiating very aggressively with those PBMs. when we think about drug formularies the range is really from a completely open access for merry getting whatever drug you want whenever you want to getting two very exclusive manage for millers were were narrowing down brand drugs the only have you know one or two options and category and even now getting into situations where were eliminating generic drugs that were traditionally always on for Miller as generic drugs get excessively expensive in some categories we see some movement to eliminate those trucks from from others as well. the other area that's a growing concern and is really kind of peeling out members is the cash paying customer in the discount card business there's companies such as good are acts that are advertising you know come here and you know get lower class so they're using PBMs to negotiate those discounts and what you see advertised on their websites and those programs continue to grow and put pressure kind of on the traditional pharmacy market. so we did an initial Review and kind of look at what you're doing with your plan and the vendors that you use we had one meeting with ET our acts and we had one meeting with Matt impact which is your PM that's kind of working with you really are our goal is to understand the rules of each and and kind of what they do I think you have a unique set up in the market and you know there's some there's some things here that are really good and there's some things that have some room for opportunities that you know we'll talk about but you know basic level EBR axes managing a custom process specific to to the state they are responsible for the creation and management of the of the on going custom for Miller it's our understanding they're managing rebate contracting potentially through an aggregator what you a M. S. U. A. M. as contracts and some direct manufacturer contracts we haven't had an opportunity to dig in in a deeper into that or understand that If the arts creates and manages clinical reviews and prior authorizations that appeals so they're doing all of that work working with in conjunction with Matt impact they manage a custom macalister reimbursement less Lester drugs on on a maximal level cost price list they're negotiating specially pharmacy with a local specialty pharmacy managing especially coupon program and manages a reference based pricing program for multiple therapeutic categories when we look at Matt impact they're essentially just a claims processor they're processing claims reporting on those claims billing and invoicing and collecting payments on those claims for you they do retail network contracting and make you know make sure you have access to your network perform some customer service account management and included on an on site Arkansas based staff specially pharmacy rap programs of the drugs that are not available locally at its at pharmacies they're limited distribution drugs are exclusively distributed through one or two pharmacies in the country. but impact is managing a program to kind of make sure that there's access for those and you know put some competitive discounts rates on those drugs the operating opioid management program and lasting is the on going planned performance reports. Kind of looking out the information for two thousand and twenty You know the formula that you have in places based on what we have seen targets eliminating high cost low value clinical drugs which is what you want to do these are drugs that have excessively or and for hyper inflated pricing that there are significant other opportunities will there be generic or lower cost brand drugs You the other excluding high cost brand medications when generics generic alternatives are available with summer similar clinical ECR advocacy. And provides excludes brand medications a minute many categories to optimize rebate opportunity so it's just you know that the name of the game today is to limit the number of brand drugs in an effort to extract the most rebate value from a manufacturer if they can gain preference on that for Miller. Would you take your question with directors made Senator Hammer you're recognized. Mr I'm content to wait to the end if you're okay with that. Okay thank you. the program uses an extensive prior authorization criteria pre screen patients for access to drugs it's really designed to ensure the right drug for the right patient the right conditions so we don't have any questions about the clinical integrity of any of those programs or how they operate I think roughly when you look at the number of prior authorizations are done in the reporting that we've seen about eighty percent of them are approved and you would say that twenty percent of those that have alternative drugs that they can use and and you know it's it's clinically acceptable so there's no question about how well that's operating or doing and it's clinically appropriate. when we look at the overall plan cost before rebates and plan administration fees is a hundred fifty eight million or forty or eighty two dollars and ninety two cents per member per month this is up five point seven percent from the previous year. based on the reporting and the information we receive we estimate there is an additional ministry of cost about four dollars and thirteen cents per member per month and that split between Matt impact fees and if your excuse manufacturer rebates are estimated at twenty two million for for two thousand twenty or about eleven dollars per member per month so they reduce that eighty to ninety two by about eleven dollars and that's a testament there was some rebate numbers in the report that we had that were missing for a few months so we just conducted an estimate for over three months. the specialty drugs account for about fifty three percent of the plans spend or eighty three point seven million I do want to note that there is about thirteen point six million and manufacturer coupons so these are coupons that you see advertised on TV and and Senator I got retirement says if you have challenges paying for this drug download this coupon or you know go to our website there's money there that's available to offset member out of pocket costs in the specialty drug arena those coupons are extremely valuable upwards of twenty five thirty thousand dollars per drug per patient per year that are available to offset the cost there's a variety of programs to maximize the value of those coupons see raise the member copay optically and then use a coupon to offset those those coupons or about thirteen point six million There's a lot of questions about the you know how long those coupons will be in place so you're doing a good thing and taking advantage of them now many state plans do not take advantage of them and so you know you're you're ahead of that game a little bit we don't know how long those coupons will be available they are marketing programs from drug manufacturers and they do change from time to time so we've seen them reduce the value that's available so that thirteen point six million we always tell plan sponsors that we wouldn't bank on that well as on going savings every year it's something that is nice to have and you want to take advantage of it but we wouldn't bank on it going forward. when we look at the top therapeutic categories inflammatory conditions so drugs like and Brochu mera still are a treating conditions like psoriatic arthritis and psoriasis in those conditions that does drugs alone make up twenty four percent of your plant costs were twenty dollars per member per month the second biggest categorias diabetes at thirteen dollars per member per month or about sixteen percent your plant costs these are all brand drugs these are highly competitive categories of drugs from a competition standpoint from the manufacturer so that means there's a lot of rebates available in these categories and then the last thing we look at is member cost sharing your member closures about sixteen point nine percent of the plant costs that cocksure continues to a road or were lower so as the price of drugs continue to inflate and you and the shift to using high cost specialty medication continues to rise member crasher continues to kind of lower as a total percentage if we just look back in two thousand and eighteen the member crusher was twenty six percent so we're continuing to roll that member cost sharing it's just simply because of the nature of the shift in the use of drugs to these high cost specialty medications some things that I don't have here but you know what to call out your generic dispensing rate the number of prescriptions that are being dispenses generic is something like ninety two ninety three percent of all prescriptions that that is very high it's very high in the market and it's been consistently high since two thousand eighteen it's been you know ninety percent or so so as your costume increase it's not really in that generic category the cost of kind of decreased it's all of the specialty drugs and diabetes are driving that spent and so you know just want to call that out that you have a very hygiene or dispensing rate we often you know advertise Hey that's great but what does that really mean it's just you've. Kind of maxed out the potential and now you're looking at you know how do you you know offset the high cost of the specially medications come. Any questions here because let me before senator Hammer and opportunity. ABC is or increased going on in like diabetes drugs in the specialty drugs. That you saw in this. or send up tick or yeah the the specially drugs continue to for it to rise so your trends are you know they ranged from four percent on a quarter over quarter basis to a size fourteen percent so it's really based on utilization yeah as new drugs come to market and people take those medications then you know you're trends are to go up in the unfortunate part is the pipeline of specialty drugs is the and we're now seeing drugs the you know the average cost of those medications coming markets hundred thousand dollars per year so you know low population of people using them you know so it's not the tens of thousands of people using cholesterol lowering medications that are you know three four dollars of you know for a prescription but you know they're hundred thousand dollar prescriptions that or in the pipeline diabetes it's just a continuous trend towards insulin moving people towards insulin and brand diabetes drugs so we continue to see the generic rate and a diabetes category you know flatten out or decline as members serve as patients move to more branded options and in and to insulin so that's you know as the disease progresses eventually people end up on insulin. Go to my co chair Wardlaw region Wardlaw little bit more follow up maybe what I as thank you Mr this session we saw a couple bills that pushed the ability for specialty drugs of. Maybe by the next time you guys come back and give us the impact. But I was told that we were looking at basically a rough roughly eight million dollar impact over the next two years of from those specialty drugs that were allow from this last session so can you look at that and tell us what legislation legislatively that we've approved I would say look back more than just this last session but what we've approved for specialty drugs and and how that affects the bottom line of the of the injured system yeah absolutely we can look back and look at you know kind of the bills have been passed to the laws of impasse them what that means to you know just those specially drugs in the reimbursement of the specially drugs I thank you. Senator Hammer thank you for waiting with. Thank you Mr and just for my own personal benefit your your background as a pharmacist is a independent pharmacists work for change PPM or what your background again I've worked in community pharmacies I've worked in chain pharmacies and I've worked in in a PVM as well so I've kind of covered the gamut if you will in in my career and I've had and I've been consulting now with plan sponsors for the last five years okay okay what. One of thank you mention was that three PBMs have eighty percent of the market and then any smaller PBMs are pretty much servant to those three of large PBMs is that the result of free market best practice or is that protection of the law for those three biggest ones and when you look at the cost of doing business in the pharmacy world how much of an impact is it on the cost that three control eighty percent of the market. yeah that's a great question you know I think it's it's it's definitely a free market you can you can start up your PC and kind of you know attempt to manage and negotiate with manufacturers and the Goshen eight was retail for you know access to a network in a rate you know it's sizes important right size and scale is important and so if European that has a hundred thousand lives you know drug manufacturer isn't really concerned about those hundred thousand lives they want to work with the PVM that has a million lives were a hundred million lives and so you know those larger PBMs are offering services to the smaller PBMs that they can you know suddenly be much larger in their scale and offer benefits of plan sponsors so you know it's it's a competitive market and there's different services that those smaller PBMs will offer to a plan sponsor that the big TV I'm just don't want to offer you know it's administratively it's burdensome or they will in customer service wise member service wise you know smaller PBM may be willing to do more or you know customize things more to fit an individual plan sponsors so it's really kind of hard to say you know from client to client you know. It's yeah we we have a multitude of different PBMs that are involved and doing good things for those clients but size and scale without a doubt is important in this industry okay to represent ward laws questions of we also passed legislation and senator Bledsoe correct me if I'm wrong because I think it was hers about a physician you know physician issues the prescription based on that physician's best assessment of the needs of that patient. I'm wondering as far as the driver to the cost of the pharmacy side did you do you look at or could you include looking at in addition what represent Walker Wardlaw I should do how much of a factor that may have in driving the cost of pharmacy that a physician is either over written or not able to be over written based on the drug that they right to treat the need can you speak to that yeah I'm not I'm not familiar with the law but we can definitely look at you know what that entails there are various efforts to you know kind of if you will limit the PBMs ability to implement a for Miller I think the most important thing to think about is that as a self insured plans sponsor it your plan you can set up the rules of how you want that plan to operate and the goal is to find a pediatrician operate that plan for you and for and provide you know consistent ongoing value so you know we don't there's no. When we look at the PBMs we don't have a preferred model we don't you know there's transparent pricing they're spread pricing we see or hear all these terms we have clients that have transparent pricing we have clients and pass through pricing we have clients that are and spread pricing it's really dependent on what the client wants with clients that have open from there is closed from others in their own for Miller's we have clients that have pharmacists on staff that review every single drug before it's dispensed and so you know it's just a multitude of different options that you as the plan sponsor control kind of your destiny of what you want that PDM to do and how to manage your benefits so our goal is it in any time we work the plan sponsors to figure out what is the best available solution to meet your needs now and I'm going to get up to you know flexible ongoing contract to best manager played thank you Sir. You senator Bledsoe in in representative Ladyman after that. Thank you Mr chair of the bill that to the senator was speaking on was a. A little bit different in that the physician had prescribed a medicine that he felt would benefit the patient but the insurance company would not pay for it until he had until the patient had tried at least one other medicine lower cost and all of that and sometimes to in the meantime the health of the patient was being compromised and the physician knew that it would be that what he described was better because he hit samples that he the line allow the patient to try and to me it was very short sighted because the patient's health was being compromised and therefore would be costly more closely a anyway so that was kind of the background in my other question would be a I'm assuming they're not ever not every pharmacist is part of a eighty PPM is that correct. you know I think you're from a from a retail pharmacy standpoint you know it's up to that retail pharmacy whether they want to you know have access to a network what about the a pharmacist in the rule communities how did they manage handed they make a living it just seems as if the deck is stacked against them yeah absolutely and and you know I'm very aware and sensitive to the fact of the community pharmacists I live in Ohio in Ohio is been in the news extensively with you know what the you know what's happening there as well You know we don't and again I have no preferred models I'm not you know I am not against anyone constituency I'm not saying that and I would never say that you know you should move or put more pressure on one group or another I think you know the community pharmacy is under a lot of stress from a lot of different avenues if you're in a rural area you can say that you know your limits of how you contract with the PBM of access to pharmacies right so we have many states that have very rural areas and they say we need to have a pharmacy you know within fifteen miles some states said fifty miles because people will easily drive fifty or a hundred miles depending on you know where they shop and those types of things so you know it's the rules of how you want to manage or plan and if you want to set up that there is a preference or a desire to support you know your community pharmacies then that's what you set up and you ask them you know that's what you contract for what the PBMs so I think there's a a perception that when you get into some of the different types of plan designs and plans set ups if you're in a fully insured model there are much more restrictive set ups but in a model that you have today you're really free to contract anyway you want and it's just a matter of finding a Peavey a partner that will contract for you to drive the best value we do have states that have carved out the community independent state based client pharmacies and reimburse them separately right so there is a set reimbursement rate they know what that is that's negotiated and that has nothing to do with the PTO all they do is process claims thank you. I think the other thing about your question about you know stepped therapy with physicians there is always an appeal process it's mandated you know there's to get through those if there are clinical reasons we would advise and I think that your clinical programs you have a place in your prior authorizations are geared towards what's best for the patient and you always run into those situations where I've tried everything else and document that and that that should be approved for that patient so. The bill that we passed was a stepped therapy deal yeah and I think it was a very good for patients especially those who have had their health compromised. The scenario that I talked about. Thank you representative related. Thank you Mr chairman I'm over here. A. I have a question on page number four there we talk about the specialty drug County you know as more than fifty percent of our costs away I see that in it talks about the copay coupons that reduce that amount by thirteen point six million dollars How how to how do we know about that I mean how does that work who applies for those coupons who gets those coupons does it help the employer or the person can you kind of talk about that a little bit. yes so the coupons are can be applied for by a member of patients any they're available to anyone there's no restrictions on them so you can log into the website and download the coupon provide some information I'm not exactly sure how the program here works but it's my understanding would be that someone would enroll the patient they would work with the patient and roll them into this coupon and that coupon is applied at the point of sale to offset the cost of the drug the member or the patient should always pay zero some of those coupons of a five dollar copay so the program is very on how they're set up in the industry and there's there's a multitude of but generally the patient is paying zero four you know five or ten dollars you know based on the the value of the coupons the savings goes to the plan sponsor where the employer because you're what you're doing is you're artificially raising the members copay and then using a coupon to offset it so when you raise that members copay the plan cost goes down and so what the plan actually pays is less. How do we know that if we're taking full benefit of these coupons is there any way to know that I mean. Are we getting all of it or we can part of how do we know that yeah I I you know and again we don't have the information on the reporting detail on the actual program what we have is reporting from mid impact that said you know this was the coupon value that was recorded so I don't have the details but we can certainly look at the details of those programs and if your kind of maximizing the total value that's there the great information if we get that Mr chairman one more of mail order drugs. I know that the cost is reduced if you use mail order drugs you can get a ninety day supply and it's much cheaper comes directly I'm not sure that comes directly from the manufacturer the PBM handles that but how to how does that impact our cost or does it or did you look at that at all yeah you don't have any mail I don't I don't believe you have a mail benefit so you don't you don't your members in the state plan don't have access to a male pharmacy so that's just the plan design you can you know there are states that don't have mail benefits there are states that maximize the benefit of male and so now is just centralized pharmacy that's you know filling prescriptions and hi high volume high scale and and shipping them out very efficiently can you give us an idea the impact if we had that with that reduce our cost yeah we can look at the impact of that you know I think there's just that dynamic in the industry as well is that it's you know there's mail or a ninety day supply and we can look at ninety days supplies or mail either or and you want to maximize that that would give some benefit to your local community pharmacies as well to just be able to dispense ninety days supply and you know can they do that efficiently and drive additional value to so there's different ways to look at that but we can certainly look at ninety day benefits. The great thank you Sir. Representative Dotson you're recognized. Senator Hammer. Thank you Mr on page five. You do a comparison between our acts and Siegel benchmarks yep couple things one who are your clients that you're comparing us against and number two would you give an overall simple explanation of the summary of page five as to your opinion that we are doing well above average below average compared against the clients that you've used to benchmark yes absolutely so that I was that was after I got through round of questions are gonna go to the side but so um C. will clients that we have what we call shape it's a data warehouse and we pull in pharmacy and medical data and and are able to report benchmarks the clients that we looked at our state plans that were kinda aggregated together to say you know this is what we see on a paid claims per member per month The couple caveats here your plan that you're eighty three dollars including the specialty coupon dollars we talked about that thirteen point eight or six million dollars in our benchmarks we don't have that information in there so you know if we included that we would take you know a significant amount of that dollar amount away the when we talk about rebate credits currently on a discounted drug costs you have about thirteen percent of your discount drug costs as rebates we're seeing our plans that have twenty five percent and higher depending on utilization and the nature of the rebate contracts so we feel there is opportunity to you know explore different ways to contract with rebates so it and so now we get to that plant costs you know just artificially looking are optically looking out it looks at your lower but then you factor in member cost share your member closure is much higher than what's the state benchmarks that we have so at the end of the day you're kind of performing rate where others are performing and these are a variety of different PBMs a variety of different set ups some of these are open for Miller is some of these are exclusion for Miller is you know so there's a difference here so we think you're performing fairly well we think that there's opportunity to improve in some categories so particularly around rebates would be an area that you know is that there is significant opportunity a potentially. Mr maybe not now just at the discretion chaired liked for the lead to does not be a member of the committee to ask about this but it would be interesting maybe to get our X. to weigh in on the conversation because I'd like to know on those tours were were under performing what the reason for that is and also put a dollar value to what that is so we could see that factored into the overall goal of trying to get the cost down but I think the interesting have them to weigh in on the conversation cherilus thank you. We we can also create some bench or have we have benchmarks so we can kind of split out me a benchmark ADCC can see individual arrangements out there instead of this kind of aggregating together but as our initial look we wanted to just kind of show you that you know we think you're doing okay but we think there's significant opportunity that you know is potentially out there just based on how your set up. Okay senator Hammer will get get some input on that thank you. Saying no more questions on that. so just a couple opportunities as I said the rebates there are you know focusing on just the two highest categories inflammatory conditions and diabetes these are highly related categories so we think that that you know we we could potentially see much higher rebates in those categories your current P. and a first quarter report of this year reported about person seven thousand an additional rebate opportunity through some partnership with EVR acts around some of the rebate so met impact as a group that's part you know doing rebate contracting and negotiating rebates on behalf of their client in their book of business so there's opportunity that you could you know today now take advantage of potentially up to about seven thousand what made impact on the specialty pharmacy side that impact also in the first quarter reporting reported you could drive additional savings ranging from about a hundred sixty thousand sorry for the type of their to about four hundred eighty two thousand three rate changes on the specially wrapped program so it's just negotiating you know some better rates on that specially wrapped program that would drive additional savings Madam pack does report that they call their method specially pharmacy solutions so it's a network of specialty pharmacies can save potentially up to three million dollars a year on specialty drugs and that's through discounts on those medications and then the last area that I know you talked about extensively yesterday but Medicare and seeking RT us versus an adequate plan that impact is reporting savings of about seven point eight million per year by moving to an employer group waiver planned so you know there's some pros and cons that the you know obviously savings is there the formularies will be a little bit more broader that what is in place today. A single members will have more access but you lose some control of what you can do with the planned so you know but how much control do you need when you're looking at you know that kind of savings potentially so yeah those are just things to explore you on that you know I think just your overall benefit design How restrictive of farm or do you want to feel that that formula's areas limiting your members treatment and access to drugs you know those are types of things that you know what is your benefit plan design or what you want to accomplish with the benefit plan design in the state plan and you know kind of thinking differently about how you contractor on that so those really kind of the opportunities at this point and then you know certainly as we dig deeper into some of the things that you've mentioned then ask us to do and you know we continue to explore you know will will have different recommendations and different thoughts around some of these things. Okay. Any questions. Members of saying no more questions on pharmacy thank you for the presentation thank you. we will move to the clinical. Okay I just remind you my name is Joanna Blake Reynolds and I'm a registered nurse and the director of clinical consulting for singles I was here at the very first meeting a few months ago and we didn't really talk a lot about you looking at your financials but the other part of it is really looking at clinical and what's actually happening are you managing the population are there areas of opportunity for improvement and improving the overall quality of care which will then if well over time and cost savings yes I think a little bit differently than pharmacy Americans medical we're talking about everybody in your populations you're healthy keeping them healthy as individuals that are at rest trying to get them to change their behaviors before they become acute catastrophic claimants and or have long term chronic illness. So what I want to talk about today's we didn't meet with Blue Cross blue shield and we reviewed the clinical programs you have in place we did review your wellness program as well and we are now just getting the claims data so this will be an initial review of what programs in place where we see some opportunities and we want to strategize around and then later on once we get the clinical other claims data will be able to do a better provide analysis. And so what you see for the agenda this morning is we're gonna start with the disease state prevalence I review some market benchmarking so looking at what other states are doing in this space then I'll do a clinical review of what is actually happening with your population with Blue Cross blue shield and then our recommendation and next steps. So really what a data we put here's as your public data so the whole states not just your state health plan but just in general the state affairs in Arkansas what we do see is there is a significantly higher rate of heart disease diabetes and obesity than in comparison to other states across the country and I think you see not whatever you build your wellness program you get getting people out of their biometrics you also have a higher rate of smoking in the population and that is it was also per your wellness program less likely to exercise or eat healthy and more likely to have cancer and cancer we a certain portion cancers around ten to twenty percent are actually directly related to what you're eating your obesity rates so these are all kind of tied together so then what I'd like to show you here is whenever you see sort of our consultants commended the talk about here's all these different ways that we can manage costs some are bundled payment center excellence putting transparency tools and from your members we thought telemedicine really increase during covid but not everything in this sort of area is right for your health plan so that's really where we want to be collaborative and kind of figure out what the right areas are to focus on. This is a twenty eighteen study that we poured in this focus on health management wellness strategies in state health plans. What we're seeing is a lot of state health plans are doing the risk assessments what you're doing biometric screening and then focusing on engaging that population to disease management. and adding incentives and rewards to these type of programs are great to get people to engage in a biometrics but the next step is really getting them engaged in changing their behavior so how can you get people to change what they're eating or the increasing physical activity and engaging in healthy behaviors like preventive care we do have some people some health plans I have added on site clinics that tends to get a little bit difficult because you're talking about investing in brick and mortar you're also talking about hiring your own physician in managing that that sometimes and go against your your network providers that you already have in place that's a very specific recommendation that some health plans have taken that's not always something we recommend though because there's quite left. Transparency tools really help individuals kind of navigate through so they can make better decisions based on how they spend their money and your health plans money and somehow BlueCross BlueShield is building an application right now that can be ability available to your population later into next year so that'll help individuals be better consumers of health care. Your networking center of excellence sometimes like I said that's not always a great tool for people depending on the local network and because of your deep relationship with the university you're not wanting to really steer people away from that telemedicine like I said and twenty twenty that is something that really took off a lot of individuals not only just patients but providers got very comfortable using telemedicine tools and what we're seeing is there's a ton of different what we call digital therapeutics of these are tools that are focused on a chronic condition and helping individuals better manage their disease with these type of tool some talking about sending a digitally connected with commoner to an individual that that is connected into an application through artificial intelligence it more tracks and monitors what that person is doing provides individualized feedback they can actually make some lifestyle changes that will improve their overall management agencies we're starting to see all these kind of therapeutics come to the market place and we are seeing carriers like Blue Cross partner with them so that they can be turned on within your health plan and I'll talk about what's available to your population as an option through Blue Cross and a little bit but the other part of this it's kind of interesting is it is driving behavior change people more connected their phone we're also seeing these companies connect back into the health care system so like in the medical record the doctor will actually be able to download all of your results for the last month they can really see how you're managing your diabetes or hypertension what's your weight fluctuation then they can provide more precision medicine to your patients so really it rather than prescribing where every diabetic gets its what Nick Taylor is a diabetic would get persons which man would get. So this is just an area of opportunity that you know we see this in the market place everyone's kind of pushing this way and so what kind of talk about you what is available to your health plan where you can maybe get leverage on this technology. Okay so wellness programs over time have been kind of a difficult area to get people to engage and sometimes whenever they do engage in wellness program they're not actually driving clinical outcomes or you're not seeing that the population so one of the things that's great about your current wellness program as you've raised awareness within the population the people are now seeing their biometrics your every year there understanding with better about what that means for their overall health but what's that sort of next step to push them into actually making this behavior change so if you look kind of across the spectrum getting people into houses health assessment preventive screenings and really engaging with the primary care is is the next most important area and then engaging in those health coaching programs or the digital therapeutic Punit programs like I talked about not really gonna drive behavior change so if you think about you quit re realign some incentives you could reading engaging different programs around behavior economics we're actually getting people to make those lasting changes. This is just a case study of a single client that was a city client the had collective bargaining and union employees and so we have this area of opportunity to increase engagement but what we did was not only just drive people into working with the vendor but then we held that vendor to specific clinical performance guarantees so it's not just about did you engage twenty to thirty percent of population out of that population did you reduce you know five percent weight loss did you bring down hemoglobin A. one C. by one point on diabetic and if not then they should be paying the feedback because the program did not do what they said it was going to do so this is just an example of a of a program that we walked into and you can see sort of the one year results in blue and then the orange or two year and I want to point out specifically are the two plus A. one C. test in twelve months that's getting people to be compliant with going to the doctor getting that draw on their comply with controlling their blood sugar as well so now that they know their number there actually controlling the blood glucose you can see the big jump that we had in this on this program. So what I'm gonna jump into right now if there's not any questions on what I talked about from the market is just what was the result of reviewing your actual clinical medical management program with Blue Cross. So just as a reminder prior to the views about three years ago you issued in are you are recognized my understanding and your medical management was with active help and then it went over fully to Blue Cross blue shield so what that means is there's sort of two pieces to medical management so everyone is utilization management that's that prior authorization process. Testers ordered it comes in clinicals reviewed and then you look against evidence based measures to say is this the most appropriate service for this members condition or does it need to be stepped down or is it experimental and is not covered by a health plan that's one piece of what's happening and everyone has that on their plan the other part of it is case management or clinical management and that's where you have you know your registered nurses your registered dietitians they're working with the individual population and typically you split that out based on the members condition whether it's a cute catastrophic situation and maybe a solder goal and will wrap up or is it a chronic condition you're going to need to coach that member over time you break that up between transplant on college G. neonatal ICU high risk maternity so that Sir you're very specialty conditions that sometimes or upcycle and then you have the general population that might have any cute catastrophic event so emergency room motor vehicle accident burns things like that that bring them into the hospital and Dr high cost limits. Right now the way things shifted over from active to Blue Cross blue shield you have a very specific programs around geriatric that our case managers are managing in that specialty you also have a program around the catapult wellness where a lot of nurses are calling out on this biometric screenings. Then based on staffing the really only able to do a general case management in the highest risk buckets here thinking of your very high cost containment your highs rescinded rules are doubly inpatient and they're not able to really dig into what we would call emerging rest for sure that moderate risk population if you think about yourself as you engage with the healthcare system if you're already very cute you have a ton of doctor surrounding you you have social workers and hospitals you kind of are already there were you're getting the assistance you need but if you're not emerging risk or your brand new diagnosed with a cancer for example you're looking for help and so we see more engagement and serve that moderate risk area and what what I would like to talk about a little bit is how do we kinda realign some that staffing efforts maybe away from calling on just biometrics but focusing on the highest risk biometrics and getting them in the right program and then using those case managers to really focus on a moderate risk where they can actually maybe prevent an inpatient admission or at a catastrophic event down the road. So a couple different strategies that are of either available through Blue Cross or things that we can work on there's enhanced oncology management strategy that would include clinical quality metrics and outcomes there's a couple different areas of opportunity within oncology to save money but also improve quality the number one would be hi tech imaging is a very high cost area and we see a lot of individuals getting unnecessary pet scans and MRI's there's not really a quality control that you have on your plan around high tech imaging today specifically related to this area so that is something that there are different programs in the market place BlueCross BlueShield has used a I am in the past and handsome College E. where they actually step in and review that and work with the member to steer them to a lower cost alternative the other area of opportunity with oncology a second opinion services about twenty percent of the time if you have cancer your misdiagnosed because someone mis read the path ology and then there for your mistreated so there are different programs out there we can offer second opinions to members there's also programs where BlueCross BlueShield can put tighter utilization management controls in place utilizing criteria to make sure they're on the right treatment plan and within those treatment plans and naked speak to this is well pharmacy if there are. Medically effective programs treatments but then there's lower cost alternatives that have the same clinical outcomes and so whenever a position is looking to prescribe this or maybe four or five different treatment options for that number and sometimes they go with what they know what they're used to so there are programs in place for you can put some utilization management controls and and then if they can do a peer to peer with the physician up across or they get the access to the clinical criteria and they're able to choose at lower cost alternative the other area with oncology is actually where the sourcing that medication you can also have programs in place where are they getting it and if you're not home versus in fusion at an outpatient center or an office setting all three of those have widely different costs and different convenience for the member within the area of on oncology those there's a lot of opportunities we can explore and speak with. And then another a condition that we would focus on I saw within your high cost claimant's was surgical musculoskeletal conditions and that's not uncommon for most health plans you know we see a lot of hips knees and spine fusions that kind of go through this process depending on age and and type of job that people have but what you know we tend to see is there if you go to a surgeon you're you're gonna probably going to surgery so once you get that amri you're at that high level you're moving on to secretary different procedures like spinal fusion we actually have a poor outcomes after they have that spine fusions of something called president backs engine for example the people are in worse pain later the goal of some of these programs are two folded one is to prevent people from going to surgery as much as possible through things like physical therapy there's different pain devices that are nor of stimulators that get you off opioid medication and physical activity activities of building up the muscles around that injured or chronically ill joined again people back to you know a proper state of living but then if you do need to go to surgery the other area of opportunity is around utilization management so what type of device are they using secure getting hip replacement with type of joint or the using and what you can see is there's a lot of cost disparity within that area as well as different quality measures that's another area that we can explore with you with your health plan. Diabetes management obviously is a big driver for that you saw that in your drug spend that's the whole country right now is has been on the up tick so that's not uncommon but what we're seeing and Blue Cross partners with a company called on do well but there's multiple companies in the market place there that digital therapeutic that talked about that utilizes devices to track and trying to members diabetes and then give them those recommendations on how to improve it's kind of interesting is there's also those continuous glucose monitors if you've heard of of tax con and and a couple other three Sally breath because the other one what we're seeing is people are starting to prescribe those for maybe like two weeks see what you do in your lifestyle that actually impacts your diabetes in a negative way and then does optimize through you know re prescribing insulin or deep prescribing insulin actually getting people off of medications so this is a huge area of opportunity we see with a lot of our state clients and a lot of our corporate clients as well where they're focusing on diabetes getting people to change their behaviors and attempting to get them off insulin. the bariatric program was another area that I think we can explore I know that's pre legislated how much money people it's a lot of for the health plan for the year and then how many people get to go through the plan go through the coaching aplikasi what we are kind of spoke with them about as well is that we might need to re look at that funding mechanism because once individuals go through very after surgery all that pre work and then if they have complications that can eat up some of the funds and then you have some other people they're kind of waiting in line to get that procedure and from a clinical standpoint that technology is very very advance and it was even ten five ten years ago the quality outcomes are pretty good and what we see is out once your BMI is at a certain level any of these other weight loss programs are really not gonna make a clinical clinically significant impact to reverse disease so we do believe you know I as a clinician and a medical doctor they work with we do believe in health plans having bariatric surgery available as one of many letters to control cost. And then I talked about shifting that focus of case management so we'd really like to shift some of the case managers are working on the biometric population over to that met or emerging rest case management so they really can get involved with individuals to prevent those acute catastrophic events. And to really that's kinda wrapping up a recommendation you may stop just a minute good question can Senator Hammer you're recognized thank you Mr got a couple cut me off whenever the. We dump a ton of money in our state through our tobacco settlement money and through minority health initiatives and we just we don't a ton of money. Did you do or would you or could you do a comparison of where our money through the tobacco settlement is going in our state and the outcomes based on the money going where it is versus what other states have done with their money that have better outcomes than we do to see if we need to realign the way that tobacco settlement money is is being applied because education seems to be the underlying focus of everything that you're saying so I'm just is that something you look at possible you may have to run that through the chairs to get that approval yes senator Hammer a we will discuss some have not sent them there the we'll be looking at our own this at this time but we will discuss that so you have something else I do thank you the on the bariatric surgery we've got reports from some of our agencies that shows that it's not an effective program because the following complications from the bariatric surgery actually have driven up the cost so I hear little conflicting information from what you're saying what data do you have to show that bariatric surgery is actually a benefit and I'm thinking in areas of obesity and diabetes and the other spin out could you expand a little bit more on your statement on that. Yes with bariatric surgery one it's compliance of individuals still have to maintain compliance postoperatively to reap the benefits of that procedure clinical research does show that it reduces if you are compliant and you maintain that weight loss you do have a reduction in the severity and complications of diabetes and hypertension and remember that those diseases also leads to chronic kidney disease and end stage renal disease leading to dialysis cost so really that's the goal of the programs we can take a look specifically at your state first or other state benchmarks and be able to bring that back next time so we can kind of show you that rate okay you might need to run that through the chairs of it's going to expand your scope and then the last thing is you keep referencing BlueCross BlueShield which to me is the comparison of the PBM conversation while ago eighty percent of the market. Do you or have you looked at other areas of providers such as share cared ministries are those that place a greater responsibility on the participant to be more accountable for their health outcomes than being depended upon like a Blue Cross blue shield that is managing that person's care and have you done a comparison cost between the two approaches to providing health insurance and how that impacts the cost as well yeah so like I talked about is your health plan needs to manage your healthy healthy at risk chronic and acute your Blue Cross program you need the network you need a medical management as cost controls for people that are utilizing that health care system then from a prevention standpoint having these other programs in place like a prevention program like the on do a program I talked about our share care at any of those type of programs you're always gonna it's going to be an investment and that the outcome is avoiding cost later so at times that can be difficult for health plans to say I don't really see that are a why because we're investing in something to hope something doesn't happen later but again as a nurse I will always say to people that you're the best cost discount is the service that didn't have to happen because you get the right thing up front so I do believe that there's it's a mixture you need those cost controls in the back and when people have to utilize the healthcare system you also need to try to prevent people from meeting to utilize the health care system thank you Mr. The. Quickley Ashcombe. Musculoskeletal conditions someone who is deal with that for many many years and and end up talking to a lot of people on it I would be interested. We're all flying or whatever else to get more information on. What is effective in doing that and still create patients over the years so much I had I don't anybody I just was in so much pain don't cut it off I think it. You go in the all of them have to go through and I say for liability wise they go through the extensive testing expensive testing and and all before you can get to a level of basically even treatment is that some area of savings that you're talking about. Yes so wait and are part of the clinics are and and then there are different areas like rheumatoid arthritis that we can't prevent because that's genetic I'm and then some individuals or is predisposed to chronic arthritis may god I think is that every joint replaced in his entire body as a mechanic for twenty five years and so that's the result of his job wear and tear injury so there are different areas of focus and when you want to place out musculoskeletal you want to think of like wait an overuse injury and those are around prevention and education and and physical therapy whenever you have somebody with chronic overtime and actually whenever so when you turn twenty two you start losing point five percent of of of function in your spine just naturally that's natural aging so we all are are there at some point but it's about what we do to either prevent ourselves from having that long term issue ending surgery and or if you do need surgery how do you make sure people are going the right procedure done with the right surgeon for the calling outcomes there's there's a pretty broad strategy that you can put in place to tackle all kind of for those areas musculoskeletal. Thank you the thing no more questions see thank you. so you know at the end like I said our next goal is to get that we have the claims data in house from start to review that to see where their areas of opportunity we can dig in deeper to really find out you know is there out of network utilization we can work on other areas of steerage where we can get people to at a different level of care like home infusions versus outpatient infusions and then really work on that against benchmarking and develop a long term strategy this is just illustrative of strategies report on with other clients that's what we would hope to be able to bring back over the next couple meetings once we get into that deeper data analytics. Any other questions. Any questions from committee members. C. nine will go on to the next. You got so this will be a long meeting. Thank you that sorry seeing no more content no more questions of we stand adjourned thank you guys thank you thank you.