ALC-Executive Subcommittee

Order the Arkansas Legislative Council executive subcommittee. first we're going to. I have a presentation by this deal fire. With the bill are. Do we need to vacate or where she going to present. If you all will will give her microphone there she can present first thank you. You're recognized and identify yourself ready present thank you at Jill there be of Legislative Research. I'm gonna go over the proposed legislative council rules for this coming by any M. and you should all have a copy of them in front of you and then we also email them to you the other day so I'm just going to hit the. Changes that are in this draft all the changes are in red. So the first one is on the very first page. Rule three order of business there's some language added here I am regarding placement on a supplemental agenda and this was at the request of senator rice and representive Wardlaw as co chairs of council just to ensure that anyone who misses the agenda deadline that is in the rules and gives us an imminent need reason for being placed on the supplemental agenda otherwise they'll just need to wait until the next regularly scheduled meeting of the Legislative Council and that has been your practice they just wanted to make sure is emphasized. So the next changes on page three. And ACT one thousand fifty eight passed during the session. Added some provisions regarding and restrict restricted reserve fund set aside many these are request will go through the peer subcommittee stuff place this here it's similar to the request that you already had four and long term reserve and other restricted reserve fund requests the reason it's in your rules is because it has a higher vote threshold and for passage and you'll see that this is drafted in the same way as the provisions right above it where in the peer subcommittee is just a majority of the members present and counsel the higher that threshold kicks in. Right below that on page three at subsea. I am the peer subcommittee will also handle any I am request for distribution of an anticipated discretionary federal funds this was percent ACT four forty six. Following that on page four ACT nine ninety seven was the DFA disbursing office appropriation and included many regarding the American rescue plan act money. And those requests will also go through the peer subcommittee so this is just a signing that. To the to the subcommittee. And the administrative rules subcommittee has just a couple of changes right below that you'll see in for B.. And technical correction decisions regarding the code of Arkansas rules were assigned to the bureau so I've added that here and then at ten seventy six new the new subdivision D. this is a almost a study that was assigned to counsel regarding rules sun set of rules for milk and cattle production and at it has a process whereby agencies over the next year and a half full submit those rules and then at the rule subcommittee and the Legislative Council will make a determination on sun setting those rules. I'm page five. Under the personnel subcommittee. ACT one thousand for which transferred the EBT Board powers to the board of finance that we were told by the chairs to place the ad decisions regarding at the plans plan designs planned benefits et cetera under the personnel subcommittee it seems to be the best fit their. And then you'll see the new subdivision F. ACT seven ninety six assigned a study to the Legislative Council regarding vacant positions of state agencies. And that study is only through this biennium. Also on page five section eight the claims review subcommittee and the litigation reports oversight committee had been combined this was at the request and suggestion of the chairs. And so that those duties of litigation reports you say are just are just written here and then litigation is stricken through so rather than to subcommittees those are now one and they both meet very infrequently so that seem to make a lot of sense. On page six under lottery oversight subcommittee ACT six thirty six AM assigned to review of lands from the scholarship shortfall Reserve trust fund account to the Legislative Council so if place that under the lottery oversight subcommittee. Under the highway subcommittee you'll remember that the last by any and they had a study that was assigned to them in November of last year the Legislative Council and ended its rules to include contracts and rules that were related to that study to the subcommittee and Senator Dismang introduced in you all approved a bill that became an. Which act is the act seven thirty nine and that just sort of solidified that so the changes in red here are from that act that they are rules that you already had in place the only addition is a requirement for public comment and there was no. Emergency clause for this act and there's several you'll see where I've noted there was not an emergency clause and so this subcommittee will need to make a recommendation to council also regarding those as to whether or not you want to proceed with them now or wait until those acts do go into effect. Let's say on page eight. Under. At twelve seven fifteen we have the new medical marijuana advisory subcommittee this languages directly from at six thirty two it's also did not have an emergency clause. The next place that we have changes on page twelve. At the bottom of that page you'll see under rule seven there's a new provision added that states that special meetings of the Legislative Council regarded regarding any of the oversight and rule twenty five which is all related to the emergency powers and will not require the six days notice to call that meeting and that was at the request of the chairs anticipating that some of those may need to be called very quickly. The next change. Is it page twenty. Right at the top ACT eleven and one which did not have an emergency clause and it change one provision regarding rule review and approval if the rule contains a fee or a penalty then it may be not approved by the Legislative Council and the rules subcommittee without having to state a reason currently you have to base that on and it not complying with state or federal law or legislative intent but if the rule contains a fee or penalty promulgated under code section twenty five fifteen one of five then you can just not approve it without stating a reason. So I have that there on page twenty and it also with regard to emergency rules on page twenty one. Okay so now we get to the rule twenty five which is all the read at the back of your rules. There were several acts pass that deal with emergency powers and combine these all into a rule twenty five. The first part of it is at four forty six for an anticipated federal funds this sets forth the that procedure that the Legislative Council would follow in requesting an a detailed plan from the CFO the state and then Your examination of that plan and the time frame that you would have to approve it. Subsection B. deals with M. what we actually just handled back in March I believe when the governor request a renewal of his state wide state of disaster emergency related to public health. So I set that out here that's the procedure they all followed for that and that's ACT four oh three subsection C. is also ACT four oh three in its your procedure regarding executive orders and proclamations related to emergencies. And then. On page twenty four subsection D. is directives of the State Board of Health under those emergency proclamations. When you look at page twenty five the subsection any deals with the COVID nineteen vaccine mandates this was ACT nine seventy seven there are two provisions and that the Court require approval as Legislative Council one deals with the accent nation mandates for a state owned or state controlled medical facility I'm if there is a request to mandate vaccines for cobra nineteen in those facilities they first have to get approval of Legislative Council. And then under. Easy to it's regarding mandating vaccines COVID nineteen vaccines for children and sets up out the provisions under which council would need to be asked for approval that and you'll see in both of these that they expire two years from the date that the FDA approves the vaccine we don't have that date right now so I can put it in because right now there under emergency use all use authorization and father just a applied last week for permanent use so until we have that date I've just got the two year provision in here but we will keep you updated on it. And the rule twenty six. Is from ACT six oh eight this is the only one of them urgency new oversight provisions that didn't have an emergency clause and this deals with review of presidential executive orders under this provision a member can make a request to the Legislative Council to review and act a presidential executive order and then I set the process out here for how you would go through that referring it to the appropriate standing committee and they can make a request for an Attorney General opinion and then provide Legislative Council with a recommendation and if you vote to recommend not to. Or that it's unconstitutional on the grounds stated here than I've also included what happens regarding agencies being able to operate under that executive order so those are the changes I'll take any questions. The membership we have questions on the rule changes that will go to full AOC if adopted by this committee. Senator Hickey go to you first and then Senator Johnson called. Grip. No no no you're okay just wanted July should worry looked at this owned on page three. And I'm struggling to remember I was trying to find a Jekyll my phone came under under C. we've got that the only allocated restricted reserve fund. I believe that's just that's fifty we've got that fifty percent is what that takes for approval. Is that correct yes that was what Kevin and Wendy provided to me okay I think I'm not for sure but I believe there was the only the only fifty percent was supposed to be of fifteen million dollars I think there was another that was on allocated it was supposed to be three fiesta all. Let's say they have. And the fifteen million that that requires a majority yes you're correct on that and then they have. Seventy something million. Seventy five yeah thanks to a that that actually is supposed to be a three fifths on that although I think it's it's under nine allocated I think. Which one is that the seventy five million do they have that is on allocated or is it they don't have it on the spread sheet that they gave to me I can chat with Kevin about that's the only thing is aye those seventy five of if there's any requests that come out that they're supposed to be a three fifths okay. your committee. Member first and insert Johnson get back with you the Speaker Shepherd. You only to can you hear me OK yes go ahead Sir. That just about to follow up on Senator Hickey is question that was one thing I wanted to ask about as well just to make sure that as to the fifteen million which I think Let me to see what the terminology was that was used previously I think it was referred to as general discretionary funds that we put fifteen million over there that I just wanna be clear that that is subject is to a simple majority vote but the other restricted reserve funds would be there continue to be at the three fifths level I just wanna make sure that is a part of what you of what is included in these rule changes yes there it is. Okay thank you. The Committee understand that anymore questions on that okay Senator Johnson you're recognized. chill on page seven. Adam C. act that related ACT seven thirty nine it said the subcommittee subcommittee shall allow members of the public a reasonable length of time to comment. I've always told my lawyer friends reasonable is most litigious word in the English language is there is there are some definition of reasonable defined elsewhere the rules or is that more or less at the discretion of of the chair in the membership it's going to be up to the chairs and that language came directly from the act so I didn't okay I didn't insert the. Okay but that is thank you is there. Representative person you're recognized. Share. Page twenty three four twelve about executive orders and proclamations Act full rate of thank you presentation you mentioned something about review so is that review and approve or just review. On and you're talking about subsection C. yes. And it are you talking about the well for the issuance of an executive order or proclamation and. Let's see it just says review for those and then a request for renewal of an executive order proclamation and saying. State okay the one these are different because it's its review of the executive order proclamation and then when you get to renewal it's whether or not Legislative Council is going to deny the request for renewal so it's not that you're approving it you're either denying it or not denying it and you don't take as a positive action towards it it's only a it's only when it's renewed twenty one twenty yes there we want to renew it then the Legislative Council can decide terminated to the okay all right usually it's just review just says review in the act thank you thank you Mr. Thank you represented virtually any other questions. Senator represent Dotson you're recognized. Thank you Mr chair just to follow up on that on. The way that's worded there on C. one B.. It says it shall be in effect the remaining duration of the emergency to which is related. But if the emergency is extended we still have to renew that particular executive order yes and there's a limitation in the Act again these apple the language from the accident want to interpret them in any way and putting them in the rules but there is a limitation on the amount of time and that those can exist in the act before they have to request for no I believe it's thirty days for a new one and then the renewals also have got the renewals can be sixty I believe. But under request for no wonder to was it be there I think it is yes the executive order proclamation shall be renewed for the same period of time as the emergency. They seem to conflicts C. B. emergency is the first part it is under B. when the governor request a renewal of a state wide state of disaster emergency related to public health he would issue an executive order declaring that emergency then the executive orders here VOL underneath that they are all related to a specific emergency it's confusing because they're all kind of called the same thing in the Act but so when we had the request in March when it came before Legislative Council there it was that an executive order that had declared a public health emergency related to covet nineteen but then under that public health emergency I believe there were five executive orders and the ones that deal with telehealth that dealt with notary publics that type of thing those that's with this part is talking about is those executive orders I don't the only thing that concerns me is under C. one be there where it says the problem exact word approximation shall be in effect for the remaining duration of the emergency. If the emergency is renewed but that particular executive order is not renewed. It would seem to say that it is still in effect. I could add some language that says if approved or if review by the Legislative Council that's the period of time it would remain in effect that was I mean that that would at least clear that up so there doesn't seem to be a conflict there. Is there any discussion on what he's talking about on the language there if you make that adjustment be presented to full council yes any other questions from members. And any other questions unless the Senator Irvin you're recognized. Thank you just a comment on nine under three a I think I'm reading three aid to to kind of be what representative Dotson is discussing and mine correct So that we we are consistency between three A. and one B.. Yes you're right and so I can use that same language there recess out remain in effect unless yep that's what I would do perfect. Okay the no other questions take a motion to approve rules. This. Motion the recognized from Senator Irvin representative Dotson did you have a question first no I had a a motion I need to read this particular one or is it pertaining to rules yes okay if you will do that referred to senate Irvine can I for thank you represent Dotson okay I move that we approve the draft A. L. C. rules as presented today and authorize the bureau of legislative research to send the draft to all members and alternates avail C. in accordance with rule seventeen for consideration at the meeting of the full LC on may twenty first twenty one twenty one. With the changes were discussed. Okay with the. No questions on the motion I have a second from Senator Irvin all in favor aye. Opposed. The rules are proof. Okay did you have something else. Reductions would was yes Mr president about Davis this is a separate item of discussion regarding the July meeting okay let let me make a statement just of first if I can The the block co chair. Representative. You may representative. Wardlaw one I dealt several weeks ago about this is not a normal by any. So before you do that I would like. Richey Wardlaw my culture to just briefly state for the executive committee and publicly of what's expected this by any member council could you do that before that the motion may yes Sir thank you Mister chair you guys we just approved rules and rule twenty five it stated that if we did not take up those expenditures of dollars that they would automatically go into effect within thirty days so with that we we should and. Hopefully we will vote to approve to have a meeting every month of this year so that representatives and senators alike in Arkansas situated to have a say so in every federal dollars spent in Arkansas and to that point my co chairs exactly right this is not a normal by unanimous much like the end of the last biennium where there will be lots of federal funds expended lots of transfers through peer. There be lots of business to take place I first see we would have multiple meetings and some months of hopefully not all but I would I would second representative Dodson's Notion of having a meeting and every single month and not leaving final call to the subcommittees. Thank you Mr is there any discussion questions on my cochairs announcmenet the Senator Hickey if you do that then I'll go to represent Dotson okay. Just wanna make sure I understood you says in the rules right there said that if we don't if we don't take it up that it'll be that money will be approved within thirty days. Is that correct. Yes Sir I knew you were gonna make me find that exact page where I just read up well you don't I don't guess you have to find my only question go to page twenty two on the rules. The number twenty five looks like it'd be under two Hey Legislative Council shall meet to review the plan submitted by the chief financial officer within thirty days calendar days of submission of plant if the legislature does not take up this review the plan will be considered approved at that but that's not for the rescue money no Sir okay my my apologies if I misunderstood I thought at first we were talking about that and I knew we must any dollars we we should have a say so in those dollars so in doing that we should have a meeting every thirty days okay thank you Sir thank you for checking on that again that that user will be business take care of that's outside what we consider normal so expect me to represent option recognized for motion thank you Mr chair and just for clarification for everybody this is to move the week of the July meeting. And include that we have an actual ails the meeting in July normally we suspend that so this motion is I move that the July meeting of a L. C. B. moved to Friday July twenty third with the subcommittees to meet the week of July nineteenth through the twenty. Okay understanding motion. Okay I was second for representative Wardlaw any discussion dot on favor I. A post. The meeting changes approved. And we thank you Mr Dyer for her presentation of the rules and work on those next we will go to our presentation on the employee health benefits. Consultation services proposal. Presentation from K. run. To be first. Bring them in. Respire. Do you need to bring care on a. Thank you. Welcome back we appreciate you being here and if we. Good start it. My left over here to identify yourself a year within it is Karadzic ironic right wing or left to right yeah if you recognize yourself you're recognized the others or let them either way sure hi my name's John Colberg I am a one of the co founders of car on and been a healthcare actuary for over thirty years. My name is Gail grovel I am also health secretary you and working with Chiron of been with them for about ten years and I have about twenty five years of experience. I'm George Platt to I'm with C. for healthcare solutions I've worked in all types of aspects of healthcare and IT related to health care managed care and then the previous point I actually worked at a point benefits division so. Hi Tim Hyde CEO of echelon benefits group which is a relatively new insurance agency based here in Little Rock in prior to have been and consulting and healthcare space including working for a local third party administrator focused a nationally but a significant amount of business in the state of Arkansas going back to me personally but twenty years welcome all to executives subcommittee and we will ASCA you're going to start your presentation and when you get ready or questions to we'll do that good thank you. Okay well thank you for having us will take us a little bit a little bit of your time to you she will pull back from toward you just a little bit. It's a better that's very thank you okay thank you for your time for civil we really appreciate the opportunity of showing you what what we can do for you and how we think that we are best fitted for this this project a little bit about Chiron we were established back in two thousand two as a John the mentioned we have about a hundred employees currently all in the United States. So will will show you in the next few slides why within that current is basically but best fitted for this this project especially given the short time and how much amount of work is needed for this project. The first of all going over the a current mission our mission is to empower you to understand and manage the risk of your house plan so in that case we're talking about is TNPSC and what we'll do for you is give you all the tools you need to understand all the risk that is basically associated with the two plans and all the solution will show you options that you have in front of you and for you to pick in so you can make an educated decision as to what is best fitted for for the two plans. How we do that we bring your we bring you a highly qualified consultants and professionals and we put in your hands and in their hands fit to get tools. The team that we have for you today the four of us here also in the back we have Donna a cook with the the C. four division. And we have to serve for the entire team we have actual support they will be here to do all the data analysis grinding of the numbers and we also have special resources among the special resources we have attorneys we have doctors and we also have the former chief of the IRS with us chief actuary of the IRS. One thing that sets current apart is the fact that we are conflict conflict free we do not accept commissions were not paid by any of the health care of vendors By you know we're not accepting any commissions from any healthcare vendors whether it is for this assignment would be for this assignment or any other contract any other contract any other client that we have typically what you see from consulting company is that some association behind the scene where the consultants you will actually receive some payments and commissions from the big healthcare vendors. We do have experience with your plan where the actuaries to be the for eleven years so what that means is like for project where we have a short amount of time and a lot of data to look at when all the data comes in claims or enrollment if something doesn't look right a right we we can actually like to see if it doesn't pass the smell test we also have George with us former deputy executive director and Donna will provide a great experience with regard to the operational side of the BT. We have experience and understand the differences between the two plans PST and EST whether it is on the in woman sighed or on the clean side. And looking at this animation you'll see the experience of the planned spending from two thousand seven to two thousand nineteen your blue line shows you your claims and expenses and verses the Orange Line is the state contribution you can see that their claims and expenses have gone up basically at a faster pace that the state contribution and actually looking at the last few years the sick contribution of been pretty flat so to cover the deficit by the state between the state contribution and claims and expenses typically what you have is the employee of the retired contribution. And also a little bit of other income such as investment income so what the board has been doing in the past is basically using reserve to smooth out the employee contribution increase and going back there you can see back in two thousand thirteen where there was like negative experience in that keys reserve was used to like fill the gap in between the lack of Revenue coming in. but in two thousand fifteen when the experience came up better than expected and you have again then that's where that you can put money back into the reserve so if the prime funding is like a balancing act basically what we're trying to make sure that all claims and expenses are covered by the different sources of revenue and playing with the reserves to some without things from one year to the next. The next year that we would look at is operational controls looking at efficiency and the ability to manage third party vendors C. for uses project management institute to. Processes to do this a service for you we review previous audits documentation including review what you of board governance documents we look at past controls the ones that we know of that were in place to verify if they're still in place we interview staff will go through the whole thing will look at the other entities based on the RP request that. Have other controls that may be useful to bring in to this the situation and we will identify any new or current controls and test for adequacy and how efficient they really are and then finally the result shows up in your report. The next slide skews in the next slide. Shows a comparison of the twenty. to performance audits and you can see there were findings and this is pulled directly from legislative audit findings in Rolling claims staff turn over financial records premium amounts and monitoring third party administrators and they were very weak controls to that point in fact VAT audit lead to like direct hiring to try to help with the the bringing controls and then. I heard doubt and so we spent the quite a few years of building that out by twenty thirteen if you look at the green lights the performance audit found no material exceptions and if it is adequately monitoring third party health and pharmacy claim administration which we feel is an important part of managing the cost of the plan. And then from twenty thirteen four that's what this price will look at is what what's happened since then and what can we do move toward that might impact the. And the final slide I thrown in a couple of examples these of the. Simply six samples but probably everyone has quite a bit of impact and that's. Having control of your enrollment who are your members so one of the problems in two thousand two was the way things are set up there was no clear cut who's in charge of the members and if you have multiple plans in a multi pharmacy and the Romans were going in all different directions we even though we were picked retain multiple plans while I was there and in the pharmacy we still were able to get control by bringing that in house to be due to manage the enrollment and then for that to the carriers and then so that's probably one of the first ones in a single source and Roman and then the second part of that is are they using what you give. Because of their not you still get the same problem so we implemented a heart of a version of enrollment reconciliation so every time we sent the file to load they had to send the file back to us which we run through the process and make sure that there has been no difference between you know they Mr Turner or that an enrollment that we didn't have our record for some reason or somebody sent a form to them they didn't send it to us and they added it so those are things that are will have impact on your cost because you just don't know about now these are two of the simplest types of controls that we were able to build and and will monitor and there's some pretty sophisticated ones we've done. Medicare advantage plans impartial plans since these years and we're happy to have hopefully have the opportunity to bring this to this project. One of the other things we're gonna look at is the different characteristics of the population and the M.. The for example here is experienced with the geographic distribution justice show you what you're looking at is our maps by zip code of where the covered population is and the darker the color the more people that are in that zip code. so for ASC on the right you see the population is fairly concentrated around the center part of the state not not a surprise where's PSE the population spread out a little bit more because the schools are all over the state so they more mayor with the population of the state as a whole and why is that important well healthcare is most often delivered at a local level thank but according to Blue Cross for example if you have people with cardiac issues with the two best cardiac hospitals are in Jonesborough in Fort Smith. So the question is how do we take advantage of the high quality low cost care at those facilities with a population that is not geographically centered around those places. So diving a little deeper into the conversation. Looking out from a market perspective. Obviously we we need to dive deep with the data to look at a macro level but excuse me at a micro level but from a macro perspective. This is a a pretty key time with transparency legislation that is enforced and can and will continue to to expand next year. Where building plan design incentives for members to be consumers of healthcare because today there's no such thing truly as a consumer of healthcare because it's very difficult to be a consumer if you don't know what something costs and that is unfortunately the healthcare system today where we receive care and then find out later what the cost is so it's very important to understand before service takes place what are my options what are the costs how can we transparent with a transparently see the cost before the service takes place and then on top of it making sure there's access to what we deem cons here support so it's a complex industry there's technology you ability to view this kind of information but to have somebody to talk to you to help you find and navigate the system to find the highest quality and at the at the best price which typically go hand in hand it that's very important along with negotiating bundled rates because as all show in a minute most health care claims are divided out between facilities and physicians in anesthesiology and it's all broken apart so negotiating rates that are combined into one payment it makes it much easier from a consumer perspective so can I have an example here of what we're talking about from a benefit design perspective so let's just in this is a hypothetical but say that were scheduled for a two day inpatient stay and my local hospital four miles away from my home regardless of where you live in any state that the numbers that are on this page this is not publicly available information today it is somebody cannot access the state until the service takes place but were operating under the assumption that this and this data is now available to the patient so my local hospital for example and all do not you can you can read line item the line item but basically the facility charges and this is assuming opposed discount so a PPO. Discount is already applied this is not the bill charge this is what ultimately is the responsibility of the state hundred eighteen thousand dollars for the facility charges and then again let's say you're in a situation where the surgeon is not owned by the hospital so they charge separately for their for their work in a seizure which is typically not contracted under a PPO so you're paying the charges there physical therapy all in a hundred twenty eight thousand dollars for that procedure the patient has their out of pocket expense again theoretically two thousand dollars for a deductible six thousand and coinsurance so they owe their full amount eight thousand dollars so ultimately the plans responsible for under twenty thousand dollars now when we add true consumerism aspects of this. Let's say the hundred sixty miles away from the patient's own there's a bundled rates all those line items services are combined into one payment negotiated at seventy eight thousand dollars so the plan design could state all right well we're going to waive the out of pocket expenses for the member to incentivize them to find this this option or to or to choose this option and we're gonna pay for their travel their hotel if they can either we can either health of a transportation to reimburse them for their mileage so the total plan costs for that including not collecting member responsibility and paying for that travel is now seventy eight thousand eight hundred dollars and you can see the significant savings tied to that now third option kind of a middle road is for a hospital forty two miles away from the home so it's not an overnight stay you could travel back and forth again I don't need to go line on the line I know but you can see that may be based on this cost the members we can it charge than their deductible but waive their coinsurance so the plans paying ninety four thousand six hundred which is still a twenty five thousand four hundred dollar savings there to so. The power of the of of having transparent dollars in in and driving patients to seek the best price Associated that that's a plan designed that must be implemented because. When you don't have costs in the in the nature of just going to an in network provider in not having the data behind it the contracts so this next leg kind of shows the the varying and how. Pricing takes place within a network environment of bottom up versus top down pricing the kind of standard is to take the hospitals what is named deems the Chargemaster so every hospital has their own charges for the services they provide completely on regulated from the perspective of they can charge what they want and if that is the basis of negotiation for a quote PPO discount it can vary tremendously so above looking at it from a bottom up racing is the only published rate on a national basis is is the Medicare pricing schedule so if we start there and work our way up we can provide consistency in reimbursement and and be able to eliminate a lot of the varying or reimbursements and we can again drive that consumers and the patients and so you can see in this kind of rough example of you know a PPO allowable of twenty eight thousand verses a bundle to negotiation of eighteen thousand dollars on that one particular theoretical claims a ten thousand dollar savings and you multiply that over the you know tens of thousands of opportunities there's tremendous savings to come from just strictly looking a plan to sign in again this is just one Avenue that is a changing model within the industry as a whole that we would definitely want to look at beyond the again the macroeconomics of your plan specifically. another. Another part of the RP is looking at a different plan designs whether it's other. Companies in large companies in the state or other entities of the state and comparing the the plan designs and one of the ways we do that is look at in actual real value or kind of think it was a benefit ratio that the percentage of the cost paid by the plan versus the participant and so here is a sample comparison we did for a client where's the purple dots represent the of the value so higher value is good for the participant on the And so it in the in the client that were you looking at they had a very high value plan it was pretty close to ninety percent ready eighty eighty nine percent and then we compare that to the cost and this would be the cost for family coverage on a monthly basis total cost and the and then compare that across different entities and you can see for example cut comparable one and three are lower cost plans I am lower value but between the two plans three provides a better value for the dollar than than planned one. and if you look way over on the right hand side to number six there they actually have a better plan in terms of value and it's at a slightly lower cost than the original plan so you know that would be a plan look and see what they're doing that that the claim is not doing and I hope we make it more efficient. so we're going to get into and show you some examples the technology that we use to to do this analysis but want to let you know that we're hands on so Gillan I develop and help I play a big role in developing and and the coding and so forth of of the models that we're doing it's not that we handed off to some department get back a black box you know we're in we're in the black box doing this so the advantage of that is that as we show you something if you want to say what what we do this this this we can actually do that we can get in there and I even see what we can do so the first thing we're showing you is a a trend model on medical for that we put together for EBT a couple years ago so it only goes through twenty eighteen But the up plan of paid. By persons on the left hand side total dollars on the rate and the average member count is on the bottom right and this we can actually break it down by different groups by plan by claim type by employee spouse child or look at high dollar claims only one of the other more interesting things down as we break it down by disease category. All right and let's go to twenty fifteen I think we should read. So look at twenty fifteen now on this graph each dot represents a major diagnostic category such as neoplasm for cancer We mature babies and so forth the The number of claims as well as the left right scale or is on the scale and then that going up if you have the total dollars paid by the plan and then the size of the bubble represents plan paid per person or twenty fifteen and nothing stands out but let's jump to twenty sixteen twenty sixteen. Every and you can see that neoplasms popped up so we're having more cancer patients. All right angle to twenty seventeen and all of a sudden something really pops out and that is eight is actually a hemophilia patient that received many many millions of dollars in factor treatment And that is actually that was actually bad for the patient now it is better for the plan is better for the patient because it was not well controlled and other patient is having symptoms so it's putting systems in place that can. deal with those issues before you get to this band and while they can actually do something can benefit for the patient it helps patients in the plan. and that's one thing with with looking at the data meal break it down this way that we can identify those things similarly on on the drug side we can look at the drug trends and seeing what's abnormal and what's What can be done about it there the pharmacy trend on the left hand side you see a big negative trend from the plant perspective between twenty thirteen to twenty fourteen and what that is if you take the plan and. Say to select all yeah and the bronze so back then we have the gold silver and bronze plans in that and this is P. SEG and we saw a large migration into the bronze plan and out of the gold plan which which was a high level plan between twenty thirteen to twenty twelve to twenty thirteen and then really from twenty thirteen to twenty fourteen. And that helped let's go back to. It no go to the next one next page the pharmacy utilization. So you have a higher deductible in the bronze plan the bronze plan next article actually went up in twenty fourteen and so on the top right we split the class into type two drugs so we have the generic drugs the brand drugs and the And especially drugs the yellow on top so at between twenty thirteen twenty fourteen that was all the cost of generic drugs fall we saw the cost of brand drugs fall but you the specially drugs did not fall and this is because special drugs are really expensive and when somebody gets one of those the blow through their deductible and out of pocket and then the plans paying everything whereas for your generic drugs and branded drugs it usually comes out the deductible and coinsurance so the plan pays a lot less who just understanding the dynamics of the plan design and how that changes and we go to therapeutic class. So this is the type of drugs so again left to right is the number of scripts number prescriptions written and that up and down is of the cost so in the top left corner is the high cost drugs and those are your anti inflammatory conditions so that was your wire and enroll this is twenty eighteen if you Myra and roll if you with arthritis pain so forth. Important on the far right side or something that stands way out there and that is antidepressants so the most common drugs being prescribed on the PC side where anti depressants it also that same way on the NC what this tells us is that whatever we do we have to have good mental health care because that's where your patients are receiving the most so you need to have a plan to sign that adequately address the needs of the population and this tells us that mental health care needs to be a good part of that. So this is how we use the data to to do that rex of our point. Yeah. another thing that we've done with with that same technology we had a client a few years ago that we mapped all the emergency room frequent flyers we call them people want to the emergency room for primes or more a year And as a result of that that client has now hired for nurses and with those nurses do is go out to patients they may accompany him to the doctors but they will go out to the hospitals and meet them at the hospital and say we're from the plan or not you know we're here to help them guide them through the healthcare system and it really helps cut down on emergency room use because now participants have somebody to call that's a face but actually they trust them a lot of health care you need that that trust relationship between the and the patient and the people who are assisting them and these And these nurses go out and help them they they leave a company them to doctor's appointments and help guide them through you know if people come out of the doctor's office you might have a list of things you're not sure how I understand well the nurses a resource for those patients to do that and so when you have you at someone geographic concentration that may be an option and that be considered a birth control costs and help patients get better. And then the other another thing that we look at is how is the contribution structure in place and what we have done for. he was at the back to. The up in the process Developing an important employee contribution strategy for Essien PSE so this is a model that we have that we had used to develop the rates in a given year and on the top left side anything that you see in gold is really a. At any input that you can change so in wellness incentives on the top left plan design over the benefits design we can change the benefit design and see the impact on rates we can deal with The brand rate structures and we call migration or movement between the plans you know as you incentivize people to change it change the cost factor between the plans people will move and that changes the construct against a company up comes a little circular. And then the employee cost and a lot of times at the board level they were concerned with mostly what was the change from one year to the next. and this gives us a good fresh start to look at what is the philosophy behind the employee contribution structure you don't do you want to pay seventy five percent of the employee cost of fifty percent the dependents just to pick one day of an example out there and we can model all of those designs. instantly and show the impact on participants maybe come up with a transition plan because you know we want to see the contributions going up by two hundred and seventy six dollars an area that would work or how do we transition to something new and then also on the next screen we would also look at that and see what it would do over time. And just say okay if we had this is mine how would work over it environment where costs go up and down every year you know we we test this for different trends and areas what happens if we have a high trend year low trend year and how does that impact the employee contributions structure and then let you know that so that when you if you want to set a policy of our philosophy of coverage that is actually sustainable under different environment. And that's all we had for the prepared I hope we give you a good idea of the types of things we can do for the study and the and the different tools that we have behind ourselves to to accomplish it and we figure we can accomplish a lot the short period of time. You're ready for questions. You're ready for questions now yes go to members first Senator Irvin you're recognized. Thank you Hillman thank you for your presentation a couple different things I I do appreciate the I think deep dive into the membership and to these people are what they look like how their usage of a plan is and then how that can be corrected and improved enhanced more guided I think that's really where I think I focus in on because I feel like. You are a user of the plan you need to be accountable to the way you use the plan so I do appreciate that aspect one of the things that a little bit that I would question though is on page seventeen in the bundled approach and not because I I I know these are trends and I know this is happening but these are charges I just wanted to ask and your presentation charges are different from actually what is actually paid to facilities so do you have I met you you charge a certain amount but as you know you know insurance companies don't pay that full amount that's charged so I wanted this to. I have a little comment on that and then I guess. You know a little it concerns me a little bit when it comes to the approach of patients and. And and how you know the designation on page fifteen is required and so you know because I'm very familiar with the Arkansas heart hospital for instance and how they have clinics all over the state of Arkansas provide actually a very excellent quality of service so you just other things that a little concerning to me so I'd like I'd give you the option to address that. This user to ensure it will start with the you can maybe discuss the fifteen Arkansas cover both it It for first of all let me just emphasize on page seventeen this is a complete hype that will and also my in in in the hypothetical the assumption is that it is actually the allowed amount not the charge but did addressing that so this is a assumed that these numbers are post discount or or contracted amount but yes absolutely and that and that was kind of the point on page eighteen is is the methodology of of negotiating those rates that that deal at the allowed amount to discuss the charges those charges kind of again the point there if you look at this example of a sixty thousand dollar bill charge was actually apologies the sixty thousand I guess got covered up by the logo and then negotiating down off that to the to a twenty thousand dollar amount so yes the and and and you see that quite often where. it you know the the quote discount some percentage there's it without getting in the weeds of the different types of methodologies that are done in contracting I think the point just trying to be made is we don't know what that is right now so the transparency is the aspect we're trying to drive of the cost for up one particular service at different locations very the quality varies let's just try to put the design together so to to educate people before the service takes place of what their options or I don't I don't think people know what their options are and that's just kind of a general health care issue again that's I'm looking at it from a market perspective and taxes stated impacts every employer that's offering benefits sorry no and I understand that I think it's always you know we have to strike a balance up obviously of making sure that these you know Medicare doesn't pay very well at seven I mean you can't just level laws everything and and Hey everybody at the Medicare rights or all these hospitals will close across state of Arkansas so you know we have to understand this into perspective so thank you appreciate it the. But yeah one of the things that Medicare is a bases the mediapad Medicare you might that a percentage of the you know hundred fifty or two hundred percent of Medicare level just it is a common basically right but and was sorry one more time on that so the the Medicare basis as kind of that starting point and and working up because again the charge masters of hospitals quite often the their annual escalators for those charges and they kind of get forgotten about me discount so and and and so the the reimbursement level can adjust annually off of a number that was. Created twenty years ago and it just escalated over time so the consistency level of a Medicare reimbursement and working from there versus a number that may or may not make sense and starting there is is kind of the issue. And then the other thing is that We we pull the quality and so forth from Blue Cross is mission the national website of who they have identified as the high quality hospitals with the with lower cost and that's the blue distinction for to give a they do it in different areas if you look at cancer for example I believe other couple Little Rock and at actually pop up there if you look at different conditions they are different hospitals excel at that those these are the ones that according to Blue Cross where there and then what you know as part of the study we can identify what what criteria that they Okay we're good to Senator Hammer. Thank you Mr in your analogy of the hospitals there Page seventeen. Do you give any distinction to rural hospitals verses those are metropolitan areas and because not sure which one of these hospitals represent role in would be pulling the business away to where we would see unintended consequences of rural hospitals shutting down. That's not the intent I I think for the most part most care the majority of care is is is is fairly minor and stature it really is more about it the bottom line is just understanding the the transparency and understanding the cost it because to for for individuals to make this is V. to have decision making power of of their care and there are many hospitals that they're they have certain specialties of the focus on and others that they don't and and so there are a limited experience typically in it is a higher cost and so if the only decision making process and that is are they in my network there just needs to be more power behind that for for individuals to make those decisions and that that really is all about and and I'm talking more in it And generic form from the perspective of. Transparency in healthcare is very much a hot button point and at this point hospitals have a requirement to post prices pairs do not yet that starts January of next year so we don't know how that's going to flush out we're not sure how that what that's going to look like the decisions are still being made and and and organizations are forming their plans around how to to to to pose that data and make it available for individuals and as a and and what we view as the assignment is to present you with these different options and the pros and cons of them and it's ultimately your decision follows Mr. Thank you and hot buttons and ultimately our decisions but will make decisions on the basis of you know your recommendations are you gonna look at all things of including maybe controversial issues like combine the PSC in the ASC pop Agency populations to see if that could lower the cost overall and what about crossing state lines as far as being able to get insurance or we can be limited to the boundaries and are you gonna bring recommendations about laws that may need to be changed open up avenues the current laws are prohibiting us from being able to take advantage of yeah it would definitely definitely get the the laws that are dressing on the issue of whether reasons we put in tourney on as well as bringing Jordaan who is familiar with a lot of those charging down also have a familiar with all the laws are available and bring on also and having attorneys on staff that we can actually interpret the laws that. You that are in place that we know what has to be addressed okay thank you Mr. Senator Hickey you're recognized. Thank you animal dove tail on Senator hammers last question of I came down here in two thousand thirteen was whenever I started soon after the and we had to put it puts money back in and what we see right now is that were upside down again for lack of better word so from my standpoint we're in crisis management right now and what I want to know is as Senator Hammer ask are we going to get any and all options instead of just you know narrow view I think that's kinda what this legislature is looking for. But in addition to that and I hear what you some what you said about the operational controls I think what we're going to be looking at is we've got all this data that you all are going to give us and it is going to be our decision I understand that but I think what we also we're going to need is is. From a strategic standpoint in the long run that whenever certain triggers are hit that things are automatic or that there are automatically sent to the center The the legislature so that we can make a decision at that time because what what is transpiring you know as this stuff is the the reserves have been tapped in we haven't known about it or whatever so I think they were also to have to have like I say a report that indicates the what possibly we could do to keep this thing solved over the long term. My question is do you all think that's going to be part of your report including including like the long term governance of the board because as you know we passed the act to dissolve the current E. biti Board put and just put it under the state board of finance which I know that that's a huge challenge for them and commend them for you know stepping up to the plate but it's not been our intention that they would be there for the long term however I do know that there's a certain amount of expertise that's needed and we just you know maybe the report could be inclusive of what kind of what type of qualifications you think the appointee should have for board elect at. Check here yes Sir the type thing you're suggesting is what we're talking about with options we're going to provide of the series option but like the point you're specifically talking about the notification to those are all types of things that I would consider operational controls so it's not just about enrollment which isn't like a simple thing but all the way up to making sure that you have the information you require to make the appropriate decisions for and W. variety of that as we do again and I know from my standpoint taking in from a list of all the way up and as they will with the all the actual stuff and him will with the the overall recommendations for managing the planned so I think you're right in line with our discussions up to this point John feel free to yes the other thing is one of the reasons we put in the stress test in the models your stress testing the plant so what happens under hi friends scenarios in so that way you know before going in to you whatever or whatever you adopt a solution that you know how it is prepared in a high transit area a little transit area and different things that happen L. what what can go wrong we need to know that what you're doing a long term plan and when you want to be notified and what are the what are the trigger I think it really an excellent thing to have in there and on the staff one comment that gathering the information that we will be getting to to look at everything associated we don't want to I don't want to make assumptions of what everything is happening to day there may be things in place I'm not aware of so on covering where we see where everything stands today and making there are certain industry recommendations that I could probably talk about right now that would make sense but until we look at a kind of a level set where things are today then we can kind of as I can imagine do macro recommendations specific to to the point. In an absolutely we're gonna lead from my perspective through the kitchen sink at of of everything that it could possibly get things back on track and get out of not only out of crisis mode but have a sustainable future moving forward. Okay and just follow through on my Mr of most everything of course what we're talking about is like strategic but from a tactical standpoint of course you all know we're we're we're we're sitting we're sitting with the deficits State Board of finances in their EBT everybody's kind of all hands on deck do you see that you're saying that you all will be able to Work that you all be able to work you know as decisions are being made by the state board of finance or something that that you could review those if need be as that time because again all that's going to be happening over the next couple of months of the year and and that's one of the values that we had with being in the past and consultant on it we have a lot of the internal structures set up in the modeling and so forth so it's just a matter of updating it for latest data and a lot of cases and then we can run for from there okay thank you. Representative Wardlaw you're recognized. Thank you Mr come over here behind all the seats of. First thing I a couple things Mr Fung if I can on start with page nine you guys had that grass over the past history. I would suspect that in twenty thirteen when you saw that curve go downward that was from the special session where some hard choices were made things were changed and we saw that current go down where if you look forward to twenty seventeen you see that the curve starts going on that upward trend that's when we saw the board started going back and doing most of those decisions that were made prior to their in twenty thirteen what I wanna see out of some things from you guys are the consultant who we hire is how do we put these control measures in place that do not and will not get on done by board four to five years down the road that calls a surplus to become hundreds of millions of the deficit and that's what we saw happen here and you can follow these curves in the on page nine to see that so I guess my first question to you guys is how do we put controls in place that would ensure that what we do from from the recommendations received stay in place. You're going. It's good to see George thank you can pull at my complaint to you for a little bit anyway there you. Okay that's been a good season up yes there are writing things that might be done depending what we find we go in there since I don't know if any of the details are still there or they've been modified or whatever And controls of any type of good now so much stronger and weaker than others but how do you prevent that long term a change of I think an important part of that is. And and possibly yes our recommendations will we can give you recommendations on both a regular taste regulatory changes and legislative changes depending what it was to prevent that type of thing from happening The. The previous legislation left a lot open that allowed some changes and it was placed in the top no fault to anybody necessarily it's just that was how the the laws built over time I think there's an opportunity for. Whoever you select for the shop to make some strong recommendations and for this the committee and the legislature in general to make some important changes that can help with its act which documents so does that we don't end up back here you know a few years. What in with that I think. It goes into what Senator Hickey was say in the bill that he and I passed that moved everything to the department of finance. We. The problem you see here were caused by the board we did away with we're going to have to form a new board this representative of the people in the plan whether be retirees of state employees or teachers are retired teachers at that too so how do we I guess we're looking to you because it's it's going to depend on how we structure that new board to how we keep this from happening again so I think that's the key to all this is how do we restructure the new board to where we get the information from the from the rate payers are the beneficiaries how you want to define those and then how do you do that and Insteel the changes that we keep right they keep our costs within measures what I think definitely who you know whatever governance's and seventeen there is going to be key to that. Unfortunately we're we know from experience I know from experience that over time as the board changes and you know you'll end up with a different set up a new kind of the board keeps growing and going to look becomes a little bit and welding so I think I know that I'll have some recommendations on that I suspect from their respective they'll have something so yes and and and different states handle different ways I mean some don't have boards submittal mistreated yeah. Senate president I think we're focusing more on governments in general it may be afforded maybe something we've seen in other states I think we want to give an answer to you that. Yeah again this act which a tank to prevent this type of thing from happening again where it's almost like looking we just watch it occurring Sir. Thank you Mr. Senator Hickey and then after the Senator Hammer just just just one more thing and of course I I ask you the question if we are you all about your tactical thing if you will be able to work the state board of finance our bureau whoever else you know it's questions coming arise but as far for your overall report what what's the time frame that you all would be looking at on something like that as the why and the RT motion in the RP calls first delivered in October we're trying to finish up a lot of work by the end of August so that we can kind of refined it month of September so that you have it in October okay all right so I mean I understand we put that out but you do think that we have it back up the first first of October or. It has fifteen but we can work with a little bit accelerated data that's what you need I mean okay we're we're like we're here for you I'm trying to I understand in thank you. Senator Hammer. I wanna go back to questions asked while ago and I didn't really hear defined answer part of the challenge is you will you'll be looking at the state employees and you'll be looking at a public school employees two different creatures but we have funding streams going into each one of them yeah do you understand that it's in your scope of work and if so how do you propose that you're going to deal with two separate populations with two different funding streams that are handled County uniquely different. And not create disparity between the plans and again look at the possibility is there benefit to combining the plans and reshaping the funding sources going to it do you see that as part of your scope of work in this R. F. P. or what are your responses and comments to that sure and that's for a state for for us to do that the. We actually we get the data we get it all at individual transaction level so we can combine them and actually look at the core allow for the cost of each of the population just from the the claim service and then actually we can we can break it open about you know regular for combining how rude one so we combining AS MPSC is not a problem we're and we're used to dealing with the different funding sources and the question is do you want to look at changing those funding sources and where the options you have for that. That included in your recommendations yeah okay all right thank you. The members not seeing anymore questions okay you senator Johnson OCU read the first representative Ferguson and centre jobs thank you senator just a quick question someone talked about to use in nurses and with the client did that that It caused any decrease in the cost and the point that that help any if they did it. A repeat that again as someone mention views and nurses to visit patients in a particular plan in a plan that I retired from they also it nurses but the you have to do it through a telephone conference and now the employees really use that Avenue you guys talk about actually live visit the live visitation how did that affect the planned it did that help at all all right yes the the reception has been very well received by the membership If the. For example it and uh it in in non covered world there we go they will get a list inpatient stays from hospital and they would show up and just say who they were we know that they represent the plan and that they were here to help and you have any questions and by and large when somebody's at that point of care where where the need to you know that's a moment that they can impact their life and people are been most people have been open to that as we see a really high uptake and the problem with telephones is somebody called you from a number do you answer it really ill and they can't leave them meaningful voice mail but somebody shows up and they're nurse and the understanding and a lot of times of patients would just impor out well this is this I'm not really sure about the surgery so what we go talk to a different doctor you know It really opens up a lot avenues and we have seen it and I could show you story we actually L. they actually got a letter from my client from a doctor that said the nurse was able to go pick up a medication in a snowstorm for the patient who needed it but couldn't get out it's little things like that that help prevent. Catastrophic claims because they help take care of the little stuff right off the bat and it's it's been successful and I know that there are a number of public plans and in the northeast of started using that group so just just one follow Mr chairman may so the. Are there any could you will probably not but it is the is there any way that could be documented or was there any in terms of dollars and sense stayed. Through that method in the end it's recalls. treated when you use live nurses or we're and one of the groups that we're working with we are currently working in documenting how to how the savings comes into play so it's something we're trying to get a hard documentation on the savings aren't and except that we can we will include that one of the challenges of course and COVID which really change the entire make up over the past year you. John is it okay if I yes that at the risk of jumping into something where I was not involved with that client I have been deferring to a degree the that the discussion point on that slide that you referenced was around would you deem it frequent fliers was in the emergency room so there is a population of people that had a much higher utilization in the emergency room in a particular location and so it was okay there's obviously a service gap here there are people that don't have access to after hours care that other locations do so what can we do to specifically address that location and I was one of the recommendations they implemented so I think it's just an example of exactly what we're talking about a gathering the information specific to every area of the plant around the state and identifying those types of measures to say this isn't a general recommendation for everything it's a specific recommendation for this particular location for this population of people so I think that's kind of the point of what you wear dress at one point yeah. Could I add one more thing to because you're you're kind of looking for specific example I maybe one directly from me Beaty and I might still have that documentation somewhere but just to show how it can make a difference that reduces cost we had When I first became involved with the case manager here at a BC when I came to work we had one member who is with heavily with as minimal course PH our going in an injury like that but they ended up in the hospital almost every week because of that case manager went to their house. And find out what's going on you know we thought maybe it's you know food issues or anything like that and found out the person and it was very rural the the the gentleman was living in. Not much of a house of course you can do about that but we did get permission in the back room which had third floor and all and pretty much entered for it it just kind of one now we went in we've got permission to go purchase an air conditioner. And air purifier system put it in is in that room where he slept and almost cut out his emergency room visits for the year because on site you can see things you're never going to get on the phone and you can really take care of your members that way in reduce costs because the cost to an emergency room visits or getting put in the hospital verses that four five hundred dollar conditioning unit depending or what it what it was at the time that's just to a major success story there so. Sorry to interrupt you Sir. Senator Johnson and then representative right. Thank you. This little bit of a follow up on Senator Hickey and centre hammers questions regarding the two separate. plans and the rural aspect of the State and small rural hospitals and all that course if we're in a situation is General Assembly and looking at subsidies and there's a lot of ways to define that but if we on one hand DO something with the these two plans that might be some sort of consolidation and one of the the effects of that is to cut funding ultimately to more remote rural hospitals in the interest of the economy. Then we're turn around the other hand cream problem that we also probably gonna be called in to fund so is this the first is is yours thirty two maybe take into consideration those broader aspects of of what because we're here because the money I mean we we want good care for all our our members and we are members in some cases but again we're here because both of a financial situation can now speak that. Well of a. Healthcare is a little bit in unique in that. Good quality care is often times cheaper than bad care. and so that's what we're looking for my perspective is where do people get the best quality care. At a reasonable price you but if I always look quality first because if you have bad quality than the cost is actually going to be worse down the road and is considering. We're we're here to present the options if you know and the implications of those options and you got to balance that those different aspects of it is at the it's something that we can we can present the options implications but the ultimate decision is yours. Okay well I just wanna make sure that. That the the big picture costs because we're here yeah we've got you as a ultimately if you're chosen as consultant to help us with what is a it's a bottom line issue but at the bottom line is beyond just these two plans and what their their deficit may or may not be I just want to make sure at least that that's a factor that is is considered in the yeah and and as far as these I very appreciative you say that about the good care being cheaper always said you know we had before part D. Medicare would pay if you had a diabetic problem you have the right drugs to pay to have your leg amputated but they wouldn't pay for the drugs that might keep you from getting your leg amputated so I want us to be both both good care and and affordable Care Act and thank you for that thank you Mr thank Johnson read the riot thank your the last question again we do have another presenter after this okay thank you for that one after you do that thank you Mr chairman just a short one of the follow up on Senator hammers question you know a few minutes ago if if you did a combined the public school employees with the state employees and let's just say that right now it was four hundred dollars for a single only On public school and wishes say nine hundred dollars on family. Then it will say something like a full forty on on state and maybe twelve hundred dollars on a family if you combine the two are we looking at an increase on one of the two. It. One of the decision if we combine the two what it gives us is basically the total amount of money that is available for come. Advocating towards the cost of the plan is in PSC altogether so behind the scene there's also the decision of how do you advocate that big bucket of money but if right now you have more money coming on a per person basis from the AC side compared to the PSC side there will be some winners there will be some some users out of the the employee population. In one corner winners and losers basically some people make it less contributions to their premium will go up and some maybe get more into the premium will go down. But he will level out the differences between the two plants with a good contribution. So one of the things with the modeling that we do is show you okay if you do this is what the impact on people are and and here's impact if you do it one way or another way and you can see those and and we can actually bring a model in and let you play with a will what we do that's what we do this with this if a lot of times we do that with a working session and then you walk away with all right now I'm educated on the real caught him down issues that's the point what we're trying to do it and there's also a snapshot in time but when you project out on the long term basis of the decisions that are made and you implement a lot of the recommendations and ultimately would come down To mark gales phrase you may be able to eliminate any of the from the losers where you're able to lower the costs for everybody by implementing those measures and that's ultimately the goal and we're trying to accomplish is not a snapshot in time. If there's more than just a funding there's also like looking at the entire plan with the plan design with a matter of of the negotiation with the doctors and so if there's a reduction of in overall costs of this level so then combine the phone may make everybody a winner in the sense that overall anyway you have more money than you had before to call over or you have a higher percentage of your total costs covered by the state and that is in the PSE contribution basically. Okay membership does not saying any more questions. Did you have any reference that you wanted to yes thank you for the opportunity we love to help you with this thank you appreciate your presentation thank you thank you members we're gonna. Take a five minute break and we'll have our next presentation. Which will get started again. Okay we're back from a break and we would like to welcome Segal consulting for the presentation of their proposal and we will ask if you will pull the microphone your way lighted up and recognize yourself and. if you go across all four in the you're recognized president. But push your button and it lie to my customers. Patrick. Can be here was. Join available in a single. Thank you here today. As president. I already started Sir okay. Hey there this can be A lot of feedback good to be back to skip that trade in the. What kind. Your term is. Yeah. And like yesterday. The better. If it's a problem we don't need to I need computer we have handouts for everybody if that's. Well good all right. Right we're ready. First officer thank you all for giving us the opportunity to come today and present to you really appreciate the opportunity we recognize it's a massive project in a you to undertaking that you all are going through right now just introduce ourselves can be counted the senior vice president at Siegel I am in charge of public sector practice for the east throughout the Midwest pretty much all the way the west coast manslaughter large state accounts working under president public sector has done that my entire career. Yeah. Thanks Patrick line nine fellow society of actuaries with fifteen years of experience with Segal and I worked primarily with public sector St Clair. I'm not cursing I'm a vice president and consulting actuary with Siegel I've been with the firm for nearly eighteen years I spent the majority of Mike or the early part of my career about fifteen years in the corporate space I've since transitioned over to exclusively public sector. Enjoy. Registered nurse thank you Missy go about a year and a half of prayer that a ten years of benefits. Running their clinical programs as well as being responsible up to the board but I've been a nurse for twelve years. Okay so we try to organize a presentation to give you a little bit history a single item on which people know or don't know about us our experiences some of the history a lot of this is in our fees so we can try to bring in too many details. then we got on the road then we'll get into you know address the project things that are important stuff. The next pages you know I guess we try to figure out how we organize our teams for these projects we basically have a national practice for specific subject areas so like our pharmacy practice which has a number of farm dis their national so we we would pull them and they're not in the regions same thing for clinical Joanna and our our medical director they're all in actual practice loop line so in general we do have some national resources think it's spread across the country because we need to have critical mass together on top of that we have a regional structure and our land office will service the account it's our primary public sector flagship of Office we do probably ten to twelve states that office large small wide array and it's it's a hundred percent public sector so from the team we put together you know we we pull national people that we think are appropriate for your team of people that are gonna work on your account that have time to do it we don't do a bait and switch you know it's you get issues here you know like this with this which is what the bill from but in general we don't divisions which are in that kind of stuff and then we do a national workgroups between Siegel this will be a talk with colleagues in the west about products we're doing if we need this so Kuester a question something we have we can send out the group and get answers backs we share things nationally and then you know we customize the team for you guys so what we thank you know you need it will be the you're asking for we try to put our team together to do that so that said we come to the sign to put in the book are we kind of a claim management team so you can you know call any of us at any point in time after could be your pretty much your day today on it you know working hundred percent of the case and myself in that day to day and enjoy and that will be addressing all the clinical issues and all the the wellness program the clinical management programs all that stuff related to the plan which which we view as being really important to the success of the program. The. I discussed briefly how we work together Patrick would be in your dated a guy with me man joined the no. Well Patrick to primary contact time in them you know will will be needed as needed day to day. Yeah this is I mean this is a massive project huge scope and it's a tight time frame so project managers can be very important so I'll be your dated a contact of facilitate all the weekly calls will be here for all the meetings monthly the first one the first things that will do is after we have a kick off meeting will will revise our project plan we've we've drafted something but I'm sure we'll learn more as we come up go long I will get that revised and that'll be something that we track and send out updates regularly. We touch touch base a little bit on on single but here's here's a few key aspects of our company so we've been doing this for a long time eighty years in the employee benefit consulting space another unique things that were employee owned privately held so we don't react to stockholders we don't have really anybody to answer to you and You know we're at risk for own work so we make sure that it's peer reviewed in high quality And then public sector is really our bread and butter thing kinds can talk about that the next next line. And then you know we do have. The expertise to run as a plan and consult a plan requires a lot of different talents so Yemen actuary but I really consult with and I work day today with pharmacists with medical directors with you know claims management people with R. P. procurement process like the vast array of people that you need to have a different set of skills so it's not just you know crunch a Munch numbers and throwing things out all kinds of stuff going on and and to manage program appropriately so hopefully see that our team and how we present ourselves lease and how we go through the proposal so public sector manage and we think it's a huge advantage because it's not just yeah we can work public sector anywhere in the business that's all we do is public sector yes the from not Siegel Siegel has the union branch or a multi employer branch that does that Seagal has a private sector the public sector is almost approaching almost half of our artists and it's been growing The thing that is you know we look at legislation or a pass like that it's not just how it impacted how it impacts. A public sector entity it's a lot different than how it impacts the private sector entity. So you know everything's kind of tailored you know for doing a benchmark consignments like you know how do you compare to other states no and it's just everything is customized to the to the public which is it's just a different animal so and for us it's like I mean I love working public sector people sometimes think public sector you know is somewhat lagging private sector and we talked and that medical history in private sector this is not true public sector can do all kinds of stuff and with the size of the plant you can really push the market you can be proactive you can have kind of a a cutting edge approach and a lot of the states are actually in the way so we hope that that would be one yes. So with that said I'd like to be the death but here's our public sector map this is kind of like what state we work with so seal cross the board works with thirty seven states right now and that's plans specific states It's kind of complicated what kinds of colors and boxes Wallace but the ones that have the blue box or just Pacific Lee health benefits a retirement clients at the the triangular or the. Whatever that is this. Diamond. So in this state I think it is the key is we we cover you were pretty much around you from the health you know yet Kansas Texas Mississippi Illinois and I have one of those are clients that surrounds you besides that I mean I've had clients for twenty years my biggest claims problems the North Carolina had them since you know nineteen ninety something. So With that being said you know we hopefully we can two new turn you guys under colored some point. So on this page we try to give you a sampling of all or. It's kind of our our broadridge of what we do for the states you know you can have a state client the seller work on them and you do you know an OPEB valuation or something which in our aspect yeah we do that as a portion of our bills but we don't do it I mean if you want somebody to work on health playing somebody it's a health actuary that those healthcare consulting with hundred percent different than a retirement actually that does open up related work. So in this page these are our actual state health plan to get twenty one state health plans we work with. the vast majority of our you know hundred thousand plus there are couple smaller ones New Hampshire Why isn't always a decent sized in this group here from Atlanta we work on behalf of the states. So we're just gonna go through and pick out a couple examples states that we thought would be relevant to this so that you can just get a feel for you know this kind of stuff we do Texas is one of our new accounts and using the reference hopefully called them and talk to them Jennifer body year and a half to two years now and we do a lot of different things for them we do procurement to do clinical management consulting we do actuarial work and I guess I'll just let. No I that I think Texas is a good example of how we work together as a team at Siegel everybody at this table here as touched taxes in some capacity in the work that we do we do the actuarial pricing for them we do clinical work joint works on that Patrick we'll talk a bit about some of the benchmarking of an example I'm not on the next slide one of the bigger things you've done for them is is moved out to Medicare advantage for the retiree population which I needed them nearly two hundred million dollars a year and ninety will savings are bigger plan and then Arkansas but there's still opportunity there as as we see at night and that's to some of the things that we bring to the table as we're looking at this for you you know we'll have a a broad team at a look at all aspects of the program and and provide opportunities for savings in what was unique about Texas too and they came to us was talking about the quality of care if you will move that Marco. Just let I think a big yeah so it wasn't just about the negotiate discounts the best discount you can get as large claim it doesn't have to have to happen because we did the right thing up front so part of what I did was a qualitative analysis of their value based care and then identified through a gap analysis where we going to tackle some of those areas of opportunity right now we're working through as cancer second opinion so we're looking for partnerships where we can actually impact the cancer care and rural Texas. There's a lot of stuff going on at the moment just like to say but I mean when she's getting calls from the Director at home at twelve o'clock talking about transplant patients what I'm gonna do with this person who's changing from my prior under the new vendor and how we can transition it would have to do it and so she's like you know. Helping out as much as she can. And one of things ma'am mention is benchmarking we know that that's a big part of the the squad the in the inside the scope that they'll be a lot of benchmarking looking at historical information so I mean we take a different approach we're going to show your copays deductibles out of pocket Max's all those components but no we like to look at it another layer deeper and you know this example for them where we we scaled back the this is the I. T. RSS plans compared to other states that they want us to compare against what we did is we normalize for plan design so just not everyone to an actual real value of a hundred percent and then you could see the allowed cross of this this really shows the efficiency of the plan not cost sharing it's the top line cost and it just shows how will they manage are planning and others yeah the goal is really to compare them from the top line perspective to everybody else you are you do you have the most efficient vendors you know are you utilizing the right medical management programs all that kind of stuff that's not you know you're gonna pay twenty percent and we had exhibits that we can show on premium cost sharing a lot so that's easy stuff you know the real question is are we running efficiently as we can with the dollars that we get allocated to us so that was really the goal that was just one ACT one one slide out of a package of a hundred. In Wisconsin is another example They were most similar because there is an ask for a. A strategic plan and I know we provided the link and our response was about a hundred fifty pages but we look at everything you know from top to bottom one of the things we on the next slide. They're different because they have they have a bunch of pocket HMO is spread out all throughout the state and twenty vendors we looked at it and said maybe we can collapses down to four regions and we also analyzed the savings for self insurance So that we picked up the state of Wisconsin it was. I don't think they're in this the end of the dire financial conditions are emergency relief and that kind of stuff that are stand that you're in that position but they did what a long term sustainable program so they **** the really coming take a high level look at everything so we did look at everything we look that no all your different agent knows what's the quality near each of us you know are these one better than the other ones are they giving the right services we looked at a lot of. Medical data so on top of the financial stuff there's a lot of clinics and we look that we also looked at what kind of plan as I'm sure you have in general what would be the best use of your money should you be fully insured to be self insured with you the whole everyone else's and you know it was a massive project and the first project with them and we've been with them now for six years so they've been a great client we did use them as a reference as well we've got a good reference from. So next only through here because we're trying to look at things with our kind of similar to the situation so in Illinois they were actually in much worse financial conditions and you were I mean claims are still being held in Illinois right now so they were a vote eighteen month backlog and paying their claims the vendors so we put in the when to look at their program came up some recommendations and they had something similar to you for retiree medical they had a full C. O. B. plan they're doing RTS for retirees over sixty five. similar you the cost really high. So we had a a very suspect retiree community we had unions to deal with we help them understand the plan options that are out there help them explain the positives of what they got they did move to a Medicare advantage plan and it saves them three hundred million dollars a year now the Beck so that a hundred and twenty five thousand retirees but it's a lot of money and the differences now seven years later they have satisfaction rates that are well over ninety percent the program. So it's not that they're jamming a plan on somebody and they don't like it you know it's like it's explain well and the retiree people or saying doctor there seem before open passive PPO network by the take Medicare they take if they don't you can still get reimbursed for it so it was it was a wonderful program we help with communications the whole ball of wax and I don't know if you look that have looked at it but this marble hikers three look at something that probably should investigate as part of the and I'm sure we would investigators were doing the project. There's not a lot of the. Free money left I mean we got to try to get as much as you can so I think that's one of the places that you really not cut back on retirees and you offer tremendous value and you maximize your federal funding for all that stuff so it's it's a win win win for everybody which is rarely can get that I guess we'll talk about other things we briefly seeing because I mean we obviously don't know your plan like the back of her hand. Yeah we you know we realize that got to groups that's happened different funding mechanisms got three different plans that have a decent spread so I think we would have some recommendations on design their but you know from our research looking at board minutes open enrollment packs this is what we know so far. Joining a talk. You have your wellness credit for what we can tell when we're doing research in fifty dollars for enough biometric screening health assessment factors association and that is a good start to a wellness plan but there is sort of a road map that we can build out for longer strategy that has more impactful credits going towards really getting people back into the doctors we kind of learned during the whole that can go get those biometric screenings anymore and we had a big drop in preventive care especially around women's House so that was considered a non essential service for most of last year it's really starting to focus on the population getting them back into those preventive services and maybe not so much focused on a plyometric maybe a good next step in your phone. Two analysts like about a later we have some slides and you know what we do on the clinical side and things that we see that you can do COVID you know obviously it's a huge negative for the world but in general it offered up an opportunity for plans so telemedicine in the the point solutions that opened up give plants a lot of options right now that help you get the rural areas prove your access there's a lot of issues that it's perfect for state right now. Thank you. Yes. What one of the things that we are asked to talk about is the Senate bill one concern or standing that this is passed so they'll be a shift in responsibility for the board. And you know we worked with all different types of boards it's very common for an election to change you know someone to change hands and a whole board be removed and also work with a brand new team there's some examples there below with North Carolina and in the state of Kansas but you can ask for us to address and from our perspective you know we're going to serve whatever party is responsible so I don't internal mechanics of why things moved or didn't move or you know what's happened in the past you know in general it's always good for a board that can control the financing of it to be in control just in general so we do we have had you know like I said my biggest class in North Carolina they were just a specific board for the plan for number years I think close to twenty years about four years ago they moved under the treasury department and so far it's been successful so another one was the state of Kansas right now that within the last year they just moved they were in the department of Medicaid and health and Human Services department name and under the department administration the things change vendor stand and people of reasons on why they moved to different apartments and from our perspective you will support you know whatever department is in charge of and do our best in the game as much information as possible. So this is kind of like you know I guess we're talking about Wisconsin earlier and I guess in a really set up but in general states are really different I mean everybody's yes every state has their own nuances and on uniqueness I mean Wisconsin was one of those that I mean who has managed care competition modeling more with you know fifteen HM assuming that's just almost nonexistent maybe in some parts of California. some place of a dominant medical plan that that push the whole market some places of a nice Nicks we've got a few different vendors that can now be competitive and push the market a little bit you know it's it's it's different so I guess our our thoughts are yeah it's complicated there's lots of moving things look at and nobody fits in a box we don't have black boxes we disclose everything we were happy to show you our models that reason we we we don't hide things so we're fully open transparent there's nothing there's nothing vested for us to try to hide anything. So my perspective you know there's a lot of stuff going on states you know. Chronic diseases are spiral and you know you got all kinds of issues with the network shrinkage and like you know and then you got the big latest legislative changes with the transparency and no surprise billing which is you know probably the biggest legislative change from ACA that number is ready for so it's a huge issue for a lot of state Yes we mention a few things like point solutions in telemedicine in what we've really seen during act COVID was everyone had to transition to some sort of virtual care the other thing that we saw was a huge infusion of cash into this point solutions base we've got over five hundred the market place a lot of your big vendors like the cross BlueShield United our resellers of some this point solutions but are they really the right ones just because it's big dinner turnkey something with taxes that we did is we focused on their highest cost I. medics we're trying to get the diabetics actually off their medication working with a point solution vendor that they're focused on medical nutritional therapy and actually reversing diabetes that's the type of a you know analysis that we've been partnering with you to kind of focus on what's the right solution for your population it's really sort of a digital connection but then get them back into the actual human healthcare delivery systems while he had a couple of points listens or pop up yes so one of the things that two things that we really like right now is musculoskeletal there's the digital virtual physical therapy where you actually can wear sensors and prevent yourself from getting into surgery and then it behavior health so everyone's been stressed that this pent up demand for a long time we've also had a lack of providers in the country prior to stressful events that we went to renouncing text based therapy we're seeing areas of opportunity where people can get specialist they were able to access before virtually and then if you need to go physically on site it connects you back into that system that's something that you people maybe are not as comfortable talking about things out loud we're seeing especially the younger generations are utilizing that text based therapy. Another area we see as something that's potentially some to explore further on the retiree coverage philosophy that you have mentioned Medicare advantage number times about this presentation so far we see that is potentially is not an option and something that can be explored further on the table but and we have broad experience in the retiree world coming from the corporate space I've I've worked with a number of of plans that have moved to the private exchange a vendor arena as we have experienced there where we're comfortable with with walking through the advantages and challenges of any such change in in that space and you know there's there's obviously a lot of political challenges associated with any change to retirees so we'd like to learn more about what some of the the roadblocks may be in in any of those transitions and will help you work through any of that and and recommend that the best path forward into the major goal for us is to help you get to the best plan you can and the best benefit you can offer your members and then while we're doing that try to get to all aspects of your state and you got a lot of rural areas are probably under Sir you got you know people are getting their certain medications that they should be gotten there may be obstacles to actually people getting care because of some cost structures some your plans and maybe for some people and I care so just by the nature of the way the design so we'll do whatever we can that the offer the best value for money use your use your strong as vendors you could possibly do you know is your. Is your pharmacy under the the best vendor for you there's a ton of money it's being spent pharmacy we're seeing every year we repair pharmacy very safe ten percent right off of like that from a retirement and maybe send under your with so you know there's a lot of there's a lot of. Pseudo low hanging fruit that I think you know something that you have to take advantage of help cut the whole I mean if you can cut half the whole by just being efficient with the right providers and not hidden benefits of members that's great room can you can you put a diabetic program like to assess and they actually go off their medication I mean we were here providers talking about the we always there is let's manage the diabetic the planet check them look against one liners keep second rate these guys won't office and they do for sixty percent of the people that come off their meds. So that's what that's a win win so. But. Yeah so I the next letter talking about social determinants of health and I'm sure you've heard a ton about that this year got a lot of late but as a registered nurse this is something I've been doing my entire career when somebody comes in and you have a treatment plan whenever we're getting them home or getting complying with their medication it's more about where they live with their socio economic statuses an access to healthy nutrition transportation their pharmacy even in their neighborhood because we know that that's a big issue right now I'm and what you'll see is a lot of vendors and other people are coming in with these heat maps and it's great we do have the data we can do that we can look and see where the gaps are and we can look and see where you're medically under served what we're not seeing is a lot of people come to the table with solutions to how do we address those issues and that's something that we would be able to partner with you do that evaluation and they're actually working with it a few other large state clients to then say in certain areas let's focus on what's lacking is a primary care that's lacking create a collection of different primary care providers and during behavioral health in a research to address issues in the community are people actually using you know ambulances to get to the merging zero because they don't have access to what they need in their area or they don't pharmacy locally something that's kind of interesting I've Walmart by me and D. and that's a telemedicine vendor now Walmart is going to be a provider of care but then they also have the pharmacy they also have the ability to get things in food to different people so that's something that you know we felt we need to address but just I it's not a a tagline it really is something that in healthcare you know as a nurse I've been addressing for people for years. And what we did to you as we did look at your on statistics in the state this is not the health plans as the whole state to statistics and can started to talk a little bit about the rise of diabetes in our country and your state is higher than the national average if you look at how it's up tick throughout the years and we want to kind of illustrate that a little bit and then say as you look at the strengths that are in your state so you have eighty percent of households that has access to broadband internet we're talking a lot about that virtual connection probably within your health plan you may be higher than the rest of the status as well and that's different ways that we can kind of connect people like we said to these diabetes vendors that are actually getting people off the medications. And you have a high education high school graduation this is that another opportunity to utilize health literacy and educate the population on their disease and how what they eat can really impact their health care. on the next flight we this is actually a large city that I'm working with that were doing exactly that so in certain pockets of their state it's very for all you don't have access to a lot of primary care and they are out to bid with their medical vendors they have to in place for their health plan and then they want outside of that health plan a larger strategy for the whole state and this is an example of a strategy that we've developed with them and their medical director I'm not sure if you have a physician or nurse on staff with your health plan if you did that's what we would do is we would partner with them to develop that strategy for you. And it says like far reaching changes to right when you start doing this kind of stuff that impacts the whole state right I mean the dependence of the people you know people they work with you know people they hang out with everybody starts acting differently you can see if you can start with I mean you guys are the big the big bad in town road and it's like you are the one that can drive the market so if you can influence people to do the right things and make changes you know it'll impact the rest of state we had a similar engagement in Alabama we were working so work with both the plans there where they have a big vendor and their whole approach was we're going to they actually got the vendor to invest in funding the community. So the actual vendor supported them in partnership to go out and do you know a mobiles mobile something here mobile something there you know do a the trying to get the football coaches involved to be part of the speech to get it going to I mean is the stuff that you can do as a state that does more than just the plan itself yeah this particular strategy is. Somebody does have an urgent care visit or they call in for telemedicine Senate nursing home to actually drive elapse and how do we get the medication there seemed a circuit in emergency but then that nurses also assessing home assessing social situation and getting them connected back into the system so that's something that you know the old doctor house call that you think about now we have all these levels of licenses and we can have the doctors practicing at the highest level and any of nurse practitioners yeas nurses physical therapists that were then pushing back into the home. So we spent a lot of time going through just our history and stuff that we do and things to look at and I can spend the next few slide menu going through court specifics on the project you requested and you know the aspects of it I mean hopefully from what we went through you lease the comfortable in that kind of stuff will look at and you are pro which I guess overall our philosophy so does this next site is really go through the product on this is our is effectively a proposal in a not show on what we plan to do and working with you this this incorporates in in what we feel to be a logical flow all of the points that you're looking to address that were brought up in in the R. F. P. and and we've organized in a way that we think make sense and we broken up into four phases as we think about doing this and this is really just the way we would we would attack this type of approach an analysis that we need to walk to the first is really to understand history and in the market and and do a review of your program we're coming in will need to learn a lot we don't go through that process and and go through the files that that you have available will pull together the historical review of your program over the past fifteen years with vast FOR will compare you again some of the other states that we have access to through our broad database some colleges and universities that we have access to number them in in the area and we'll give you a sense of what the the demographics looks like so what whose enrolling in a plan whose opting out line what's the socioeconomic status of those individuals that are in and out and that'll sort of give us some information relative to how we move forward and so that'll that'll take us with that history that'll take us to the second phase of the project will will just will go through we'll go through what we found with you we'll we'll we'll have a sit down and and from the information we have at the conversations will have we'll set some goals objectives and really bring forth the strategy right so we'll go through a lot of that information will go over the things what what are the odds from what we found it in this in this background right and you can give us some information it'll help us sort of mold some of the the opportunities that we see for you walking through all of those will will bring into that no joy out of. From a clinical perspective to talk through some of the things that might make sense and that'll give us an idea of how we can serve organized some of the next phase of really just going through this opportunity review what are the opportunities that we see what bottled up to the top in those conversations that we had with you to see you know what might make most sense for the state and we'll go through that will do the analysis of that from a network analysis perspective ACO Centers excellence and and and such telemedicine as John mentioned I will go through the contribution strategy who's being left out of the program whose opting out is there a way to incorporate salary banded contribution structures or tearing ratios that need to be adjusted to get more families into the plan is example design concepts will talk about that from from both an active in a retiree population this Medicare advantage this private exchange makes sense and where persons already asked you can walk through all of those aspects of your plan structure and value based design your well being strategy so all of those pieces will come to to play I will go through the pros and cons of those of those opportunities with you which lead us to ultimately after additional conversations a recommendation that will have for you so will will bring forth a set of opportunities will to rank them based on the feedback we've we've heard from you and we'll walk through the things that we make we think make more sense and and the recommendations won't necessarily be for just today is gonna be long term recommendations that allow you to fees in some of these changes we understand some of these changes will be difficult to incorporate some of them as Ken mentioned there's some low hanging fruit that we think there's opportunities in the short term others may take more time and we'll walk through a strategy with you to sort of incorporate that into the program over the years and and obviously on an ongoing basis would be here to help you implement any of the changes that we recommend and again the key is you know it's like component by component in the same positive negatives all will will put out there with you know what's the impact on people is this a very disruptive event is this something that's not disruptive is a benefits so you have kind of like the plus minus negative you know what's the what's the what's this canyon and then fly. What's the financial impact of and so if you do something like that what's it worth financially as like you know something that is somewhat disruptive but has a large dollar value may be worth it you know it's definitely something to look at but something that you know doesn't make disruption is a large bill even that's probably worth it right so I mean we'll we'll try to give you all the different spectrums and if there's other components of the things that you want to look at that you think are elements of a review you know like or look at this really need to know how it impacts acts you know so as you go through your analysis can you just make sure you incorporate that angle on it and just make sure you look at that what you do it so it is like I said amendment everything's different so for us it's like it's it's it's great coming into it a state we haven't really worked in that much I mean we have clients we don't personally work on it but we have clients in the state the people working for us it's like a fresh for you to come in and look at it out of the gate is exciting it's a fun project for us you know. And if we can help mold you know another state and you know it can be a benefit everybody we're helping out thousands of people. So. And then this next largest sort of incorporates the way we think about consulting around run healthcare programs we we do have sort of three areas of focus that we look at it's really the three legged stool to consulting and and we try to adjust it we we obviously can work through the plan design management and sort of the the cost saving solutions around there but we want to sort of shift focus as well to other opportunities around vendor management around health management and hopefully we've sort of incorporated some of that and and the way we think about benefits and in some of these discussions we had we don't come in here pretending to know everything we will obviously learned some things along the way and and we'll work with you and and and come up with ideas that make more sense holistically FOR your program to to to improve the financial process prospectus of it for the long term interests at around vendor management too when you're making changes we don't want the members take a kind of lost in those changes so part of what we do is you looking at this high cost claimant's being sort of ahead of the game with them to ensure that their game transitions of a provider if it's not appropriate really walking you through you know this is an area that this member needs this type of care so good examples we had a heart transplant a patient was one years old if the compound a medication just because of the size of the child every month it was getting denied by the pharmacy so we had we walk through and then we made sure that that member doesn't have to go through that anymore so working directly with the health plan and the vendors to making sure that they're getting that medication not being impacted by formulaic formula every change. This group has a lot of different stuff on it obviously you know and there's all kinds of things involved in it And reviewing plan you should look under every rock every stone see what your opportunities are so I think the slide all those simple has a lot of you know a lot of stuff I saw on your. You're asking I guess was plan design related with plants we offer you know what should they contribute which designed the benefits the click the other two legs are we think we had tons of alien so that's what we really focus on you know what would vanish you have in place what programs do you need to know what you Miss clinically all that stuff that impacting you saw during the flight of forty percent was from. Other aspects that you know forty percent of the cost so I mean you can you can change designs change contribution save two percent three percent whatever you know whatever that number ends up being but I mean that's forty percent of the pie so if you can impact that that's all that's a lot of fun. So that's pretty much our representation we have just the one closer and you know. Why us of course no. We think we're. The premier public sector consulting firm I feel like we have you know the competition baseball I think we serve our clients great I mean we have not lost the client since I've come to Segal and. Ten years now. So we keep adding we keep so I think we're all to responsive we do our best to be reacting no we we stand talking or proactive so the three main points there were independent I mean after you mentioned nothing that mention to that's important you know we don't have any vested interest there's there's no precedent or do not have anybody from the plan in here anybody that works for the stay with our legislative finds that many that's the miss a hundred percent of the time they were going to give a fresh look at everything and we're responsible enough with their own liability insurance and it's like it goes against us so you know when I can put anything at risk so we're open honest no black box I mean we we show you everything. In our experience I mean from the map you can see that we have a wide depth and breadth of experience. And you know I didn't just throw that out there and say oh these are the people who work and Kim you're gonna get the people to work on so we're going to work on your case we have capacity we've we've staff for a we're ready for it we're excited to have an opportunity to work with you. I think our approach is very complicated we don't drive things down anybody's throat singing I think we have a open approach where it's give and take the best you know of of all us with the best to you guys and see what's out there so I think we're very consultation of our credibility is there. In the thinking check with any of our clients happy you can call any of those twenty one we gave you three will happy to give you more and your we talked about before you know specialization public sector which. In order to be the death I probably have so in our perspective we would love to work with you guys And we look forward to the opportunity and. Any questions you might have. The questions from members. Senator Hickey you're recognized of. Great thank you for presenting I don't know if you heard I was going to ask you basically the same question that is the previous vendor but you all have covered some of it so of course what I've heard is is most everything that we're going to do is look at it from a strategic standpoint and as I know from what you all put in your report you also see that were in what I call a short term crisis. As you probably know we had transferred the governance of this on a temporary basis to the state board of finance do you all see that or have any problem that you'd be working you know there's some questions that come out of that from like the things that need to be done on the short term do you have any issues with working with them during that process through through through us of course through our bureau but to. I just wanna see if see if there's any issues with that if questions were to arise now we don't have any issues dealing with you know. Anybody that would help make it successful right so if they have something we need to do for a different group you know whatever we have to do right so we don't have any you know any issues and you know. when I make conflicts. At. And most of the most the members in this room have been here long enough and again we had some issues were we had to bail out the. The teachers system back in I think it was two thousand fourteen and. Excuse me we're back in worse shape than we were are we are now than we were then. One of the main things that I know that a lot of us want to do is to make sure that that does not happen again you all did touch on on governance but I think that the one thing that pollution that we want to see is that we would have some type of the recommendation from you all own how to structure the governance that's you know all stakeholders or involved however that what expertise that we do need from the strategic standpoint that we will get back in the shape. And in addition to that. I would like to see that recommendations are given to us that Triggers are put in place and we may have to pass legislation for that whatever I say triggers you know I don't really know how to structure something like that but it you know it looks like to me that if claims exceed the money coming in you know a new or you get so much into your catastrophic reserve that either premiums at that point would go up or or you know that there's some some mechanics or that or that would be reported to this body what we would have to make decisions whether the premiums would increase or whether dollars would have to be put in you know from this level. So do you all see that is part of your. Part of your analysis and report that you would do or sent over the on that's a huge component of it all Sir it's that's a large component of it all I mean in general so the way we would start the whole thing is we set up. The financial structure rate help what you're doing right now right we have some recommendations on how to properly fund. And we have a lot of. Benchmark funding examples rate from all other states this is how they do it this is how they put a contingency funds is how they doing over serving all the stuff we've done it for multiple states and you know we presented for multiple states on it because everybody's looking at reserve levels which would be funded at and every board's approval rate so it's like there's a lot of. It's a lot of back and forth on what can be done now the hard part is in no legislatively one is actually more money coming fund for the legislature and Heidi control that aspect of it so we could have recommendations but that's usually legislative thing that you will work with a recommended approach for that I'm here. But but but but our our bread and butter is really like you know we don't miss our actual numbers men generally just don't with I mean if I'm off of percent that's a lot. So we're on I haven't had a planned or under in twenty five years. So we won't miss I mean there may be some high dollar claims or things like that but you're big enough to you should be able to swallow us up as the size your plan so so I would definitely feel comfortable that from financial aspect you'll be covered on that and then how to fund it will recommend ways to fund it we also better understand the political environment how everything works and what would what's feasible for you with the level that you know is affordable to the state as a mean there's out this limitations on how much can be funded and something will recommend how you might be able to do the I don't know how your your school systems funds probably partially state partially school system that kind of stuff so there's definitely methodology for that to look at. To answer questions I mean pretty pretty much just a couple follow as a follow ups and one of our other members with other vendor done this at I think from our standpoint to that you know at this point we would consider all things on the table so you know we would kind of expected if you will see some things that even if they are out of the box that we need to look at that I believe now would be the time that we would we will want to look at that to see. Also as far as the timeline I appreciate your what you broke that out in your phases within the within your proposal. Do you and I do see with your October the October that's in the R. F. P. that's actually when we meet so you know I would hope that we would be able to get the report you know. Yeah we have a little bit earlier you know then that just I want to point that out because like I say that's actually when we meet so we probably would need the report you know at least around the I'm sure you want to draft report will earlier than that I mean I will like like Patrick mentioned I think at the at the get go we'll get everything timeline set up right and then kind of work backwards to make sure so we have to put more people on it early on to make sure that we have more time at the end that's fine you know it's definitely a lot of work in shorter time and it's a quick time frame and I and I recognize that and it's a huge project I recognize the condition you're in you know and I have to act and okay we'll put our reputation online to meet your needs so I mean we're gonna do everything we can to. And we're not going to miss a up all right and I appreciate you saying it because of expected put online. Thank you Sir. Going to represent a person. Thank you Mr chair. I believe it was Mr Runnels. Who mentions something about diabetes. With a particular client and also I guess this rule in person nurses could you experimentalist hounded U. S. help this client take some of their members of. It lessen the use of a debating medicine. Yes so something that's newer that we're talking about is medical nutritional therapy and the ADA as well as the European diabetic association about the three or four years ago came out and said we should actually be focusing on nutrition first before medication historically we start putting people on medication right away and almost not teaching them about their diabetes so what we did with Texas is we I didn't and now says of their highest cost ibex who is on actual injectable insulin at the type two diabetic the by making lifestyle changes we could potentially reverse that back focusing on that group getting them some digital support as well as a physician led model. And what they did was focusing on lifestyle changes you have a position that's reading your biometric screenings almost daily versus seeing them every three to six months and so if you're able to change your lifestyle and then D. prescribe insulin at the same time you're keeping that pledge very very steady and that way the bodies able to recover and get you actually off the medication that was specifically around the diabetes and I I have about six clients that we're working on that type of strategy right now so it's really something that's different a different approach to diabetes hello what does that the diabetes thing I mean so everybody's like oh how can you pay for a let's see our land that I miss the cost all that kind of stuff right so we started working because we have some larger clients I've negotiated deal with them to go you know let's just do this simple right we don't want this what would happen and Trendall all that let's just do it right you spent this much an insulin before right. When you spend after and then your fees are guaranteed that that delta I'm interested and informed spend are going at least cover those fees so I get all the medical benefit all the better claims because you get healthier people but if you can cover that you can bring it back on for now or and they said okay. So you you can do stuff that actually do impacted and and a lot of those programs like you know how do you get people to participate right they start doing it and they quit well this one. Why would we want to participate. A meeting actually get off to Madison Mr mentions getting Office and it's like when the first one they're talking about reversing it I remember about you know three years ago I sit in a meeting with you H. C. about a Medicare advantage plan we asked medical director there because there are all by managing diabetes I'm like do you think that you can reverse that. And he's like well you know United he wouldn't really say anything that might come out okay so in your opinion off the books what do you think he says yes I think you can reverse the. So I was the first time he said it in the law so and so so hopefully. This become more common and we're going to do this because like why you will manage if you can reverse it and that's a huge life change there's a couple other things clinically so the continuous glucose monitors got a lot of popularity if you saw some commercial during Super Bowl they're starting to kind of advertised that what is what we've been doing seeing vendors to as well we've been working with them around wearing that for two weeks and seeing exactly what your lifestyle is doing to your pleasure real time and then adjusting their medication and or what they're eating to make sure you're managing it very well but the key about it is is it's not walking and saying you have to have a whole thirty diet and all organic and vegetarian it's about where do you live what do you have access to you and what is your culture or the food that you need to have because that would that's what you grew up eating but how do we just a few of those ingredients that you're actually getting lower net carbohydrates lowers your blood sugar that's really where that focuses run that the individual's entire lifestyle but not forcing them into something that is a multi can't fit into thank you also said something about nursing was that in person was that via telephone or virtual it's going back to in person which is which I think is great so traditional home health care is I have an issue so I need an infusion nurse comes in does the infusion and that's done it's paid for by insurance the flip of this is is coming actually caring for that individual assessing their home and their family members and then it connecting to a doctor virtually so then they don't have to leave the home for the care Medicare advantage plans did that last year during COVID they were doing thank you Karen cancer care in the home and actually having true acute medical care and home because it a new shift is really staying in your home an aging how so how can we get people to not be in the queue Care setting physicians are also going in the home but a little bit less and like I said that telecommunication of the doctor being at the office and then having the nurse physically drawing laughs going to get the medications so that's something that you know we're gonna see Walmart kind of shifting to. With that me and D. we've seen signal by anti live Amazon cares come to the market place that we have all these different things that are happening but what usually happened was acute care via telemedicine now it's shifting to primary care via telemedicine with in home care. Thank you Mr chairman. Thank you going to Senator Irvin next. Hi thank you. I'm. So I think one of the things that I wanted to at. Kind of focus in a little bit is being able to utilize what's currently available within the state of Arkansas and I think a lot of times what I get nervous about in sitting and presentations from Consultants is we go to something that we know which is a contract and a vendor to provide the service and we're going to say yeah that's going to save us money whereas a lot of times down the road we in the legislature see where those contracts don't really save us money you know and so we constantly don't see a return on investments and so you know I know I'm very familiar with. The I think. The network that we have existing in Arkansas on being able to utilize that for what you're talking about because it actually is happening in a lot of places and we do have people that are reversing for their patients and that are utilizing that and so for me I'm interested in making sure that you know it's not a can approach but that it's one that's unique to our state and you need to our economy and to the people that we have providing the healthcare that's really important to me from the Legislative perspective because we have to make all things work and so you one of the things I think I guess you can respond to that because we actually are doing something similar to a Medicaid program that I redesign we we redefine this year discussing exactly kind of what you're talking about and really going into the home and connecting those people within our home model and inside I appreciate what you're talking about and I appreciate the fact that you as a consultant will actually drill down and talk about nutrition and talk about being able to remove people from their medication versus just managing it be a. You know you only get three prescriptions per month or whatever because that doesn't work you know it and and so I do appreciate that that component of it I think. You can just respond to my comments I'm not sure if I really have a question about it I guess at the end of the day my that's where I'm giving you my input that I don't want a cookie cutter approach ands because we because I'm afraid if we go down a cookie cutter approach we have unintended consequences that I don't think any of us would like for that to occur whether it's getting off the ditch again and the funding mechanism or you know going with the easy can't methodology you know I'm more interested in an integrated approach yeah I don't think. I will very little of what we do is a candid approach cookie cutter so I think as we go into this state if you can utilize as much as you can that's in the state and available and there's a lot of governmental programs that are funded in you're doing things that you can take you back you know some states are doing all their health assessments and biometrics through the department of public health you know me that works great you know a lot of states are doing centers of excellence the you know maybe you got a couple hospitals that you should be directed more people to in your state I don't think there's anything that we would really come in and drop something in from outside because who says we work in your state you know so I think is there something that maybe somebody doing nationally that could help you maybe. You know but I think a hundred percent we build off of that I mean we wouldn't taxes we're looking at all the CEOs are popping up in taxes the various aspects what are people doing I can we partner with on what kind of arrangement can be made with so yes my impression is that. I don't I think in general we never do that I thank you in the whole project is seeing what your state looks like what's available in your state no other thing you should be doing you know and then. If there's something that you don't have that somebody can't do then okay then maybe there's something else that we should be back on you know or even if there's something where there's this good program out here maybe you know you have a can do something to help you with that or something I don't know you know. Yes so currently and I can't say who it is because we're in negotiation trying to figure this out right now but I have to stay clients and one as highly concentrated pretty large city with a lot of disparities are working with the university health systems in those areas to say what's the partnership that we can do specifically around this population and one in particular has a lot of pollution Italian speaking where a lot of vendors come in the Spanish and then they're not addressing three quarters of this client population so we're actually partnering with those university health systems to see how we can and people tend to trust your provider calling you before vendors calling you to rate so that's what those partnerships that we're trying to build based on that's clients local health care needs and we are working on that night is another strategy that I have experience with two in my prior life I did do that Chicago as well. Thank. The S. the best I can a question of college you couldn't stay. And this thought I am asking for free and they on this is actually. Is if I can can we answer with the front. if you're actuarial recommendations are wrong. How long do you have ownership of your recommendation. You mean doing better are these at risk or guarantees like that or is that what you're asking the church that the best that I could get from. We will we would put our fees at risk to a certain portion yes we'd be happy to do that Like I said we're not off that much so I mean The I don't really know the whole answer when ninety it makes me want to propose what you want us to put at risk that's I'm happy to negotiate something like the In my opinion you know all our fees are always at risk I mean if you don't like what we did we all get paid you know like I mean everybody's like oh it's got me again we're going to sue and do any of that stuff means like if we do a lot of work that you don't think it's worth it. I don't want the money then so I mean Oper fees at risk for the work we do and I'll stand behind all our team thank you senator Johnson you're recognized. Thank you Mr chairman first of all thank you for your presentation I. Specially noting that you talked a lot about health care not just but insurance and that's important to me but I want to echo something Senator Hickey said remember reason we're here is we we're dealing with a crisis we got the numbers don't line up right and I ask the same question to to the other interviewing I want to ask your group is the same. Will you be looking at the fact that we as a state government have. Responsibilities that go beyond just these insurance plans for example we have a crisis in the rural hospitals and keeping them open and making sure that everyone of those particular is a state or served and if we quote fix the a teacher in state for insurance programs but create another problem here by some policy that would adversely affect those rural hospitals and then we turn around and have to out of another pocket subsidized keeping them going then we haven't really solved anything and I'm just. So I'm really looking at the dynamic of your study have you and would you calculate things like that into your Financial analysis when you come back with the what we're definitely sensitive to you know the moving parts right there's a lot aspects and thank you look at me a lot of our presentation we really focus on you know vendor management health management all that stuff that's like. Not just trashing somebody's reimbursement you know I mean you can't just say Arkansas the plan by all the hospitals they can twenty percent cut and reimbursement I mean if this doesn't work you know and hospitals will play to road rules that you look into you know you don't want a network issue the first is solidify your network you want a fair reimbursement rates and then I think you want your members to have access to things that improve their life. You make it better so what good options that are affordable. And can be the best value for the state rate I mean and we understand that there's a lot of different. Opponents. Disproportionate shares and hospitals and in medical education means all kinds of different stuff going on does it help you know it. Thank. You know I mean and it's very important to keep those rural hospitals open and moving because they're caring for the community and it's about keeping independent practitioners independent so when we are value waiting at that something to take a look at and make sure they're not impacting them and negative way happens with pharmacies to rate to get independent pharmacists usually have a higher reimbursement level and the the chain stores that's the dynamic you have not but that's not uncommon to have Yeah I also think it's important I mean we built into our project plans are amended order for which one they'll be sort of internal feedback it'll come back to us as we sort of explore some opportunities will be going through some of these things that will find as we're doing our store or review some of the market opportunities exist and you know the extent that there's something that we find that we think might make sense and you tell us that no way this is gonna hurt XYZ and and this population over here we'll we'll look into that further and and come up with a way that can make that work or or scrap it right that my needs just come off the table is something that would the recommendation for the program. Thank you very much thank you Mr Senator Bledsoe you're recognized. Thank you so much Senator Johnson really ask my questions but to I was I was here in two thousand fourteen and went through the last crisis. And I just wanna be sure that what we do of. That not only do we. Help with this crisis but that future crisis is are avoided and so again the the rule hospitals in the independent practitioners and all that they're very important give me an idea of what you think can be included in your proposal like we heard that that trigger is and all that it might help us avoid something like this in the future if you could speak to that. Just a little bit okay I guess you know from a. From the first up I guess we need to go to figure out what happened in the past right so kind of know what in two thousand fourteen was there anything happen in two thousand six or you know I mean what's the history in general and and how did it happen and then we can definitely put in place elements that can make that not happen you know for sure you maintain a surplus reserve we have to find out there for negative conditions people call it different stuff clean fluctuation Reserve training management is all kinds of different names for it but you have to manage that and that's like an excess funds above your reserve and typically will sometimes see clients dip into that but we never have to go through it you know and that's a year where it's a big year you know we had one client that you know their high dollar claims went up three times with the head near before it was a monster year but they never dipped too far into that because you know as a as a percent of the total claims is only a couple percent but still couple percent on a million dollars liability so we do put in place you know. A level and then what's the the variance on that level what's the you hello hello what's the probability that could actually go that low you have to have three to four bad years in a row which with with actually no reaction rate almost like you're letting it run and it just runs you out of business you know so it's like. Monitoring it right is important Hey I mean every quarter you should be looking at your financials to make sure we're where we headed you know and then what's the projection get updated I think for almost everyone of our clients were doing. Orderlies with a five year forecast every single time investors like built in and that involves working late money every and is there cares Act money coming in is there you know are you a subsidy money is there a website yeah it's a lot of sources of funds and chemistry getting all your sources you know in and to get reimbursed you know are we getting the appropriate my rebates. I mean it's thirty percent of your pharmacy dollars now you should be getting in rebates a lot of money in Centerville act about cricket all the PPM Sullivan Africans I mean there there's making money like everybody else but going to make sure that you get the right calendar month so I don't exactly at your question with me it's like if of a stable funding method that you that that is accurate and you hit you know I mean if you look at the claim trends over time it's not like they're all over the place I mean for a plan your size pretty predictable when we do train service that come out every single year we have the same you know we have like I said before we haven't put anybody under we haven't missed that doesn't mean we want in the future some point in time you know but I think we have a. I think we're I think we're good as actuaries and then not only would actually of the practical application of consulting on top of it you know I mean even after twenty five years thirty years right omitting consulting for the last twenty. So I happen to be an actuary which helps me council because they can understand financial behind everything we're doing. I mean I can understand that the giants doing how it impacts people so this is different allowance so and and you know our ideas not to put something in place that have you in a crisis four years later so a lot of things we discuss their long term solutions and Joanna everything she's talking about is this health healthcare which is trying to improve the future health and so you know anything we put in place it's not gonna be a one or two year stop gap it's it's a long term approach in Askin said our projections go out five years so if there was some kind of financial issue down the road you know we'd be able to identify it sooner rather than later so in our financial letters were project and we're showing that we're saying if your trend is plus or minus six percent over the next few years here's what your financial conditional look like. So yeah when you projected out five six years if you Miss two years high three years in a row you could be in a financial condition so if you're going through that and you're one U. two points I better start digging into it right I mean get ahead of the curve rates you know wanna wait three years out on sale next year we're gonna hit panic you know we need to get a hundred fifty million from legislate you know whatever the numbers are. So and you can have you can't assume stop gaps in there I don't necessarily like them where it's like you know if you get below a certain level we could do it all alone or borrow from legislation we pay it back over the next year you can do things like that I don't typically like to put stuff like that and. Thank you sentiment. Senator Hickey who the last one I have on the board move your to your left. Just question I ask you few earlier of course you said you don't public sector which I can see but with with our situation as you know it's it's fluid and I'm only about a year and have six more questions I should ask you so my things go be flexibility what you're going to get with us over the next few months especially with the the state board of finance that just being transferred over them you're only getting calls it or you know if we hire you back and forth or and to be fair to you all is that something that you're going to be willing to do because I mean you may you may get sick today from us who knows you got a hundred thirty five legislators here that are going to have constituents they're gonna be calling them and things like that so we're going to have certain questions we have to get that so is that something that you're comfortable with yeah we're basically anticipating that it would be something like the okay I'm just looking at the nature of the project and the. Comments. We got to be on it means a lot of stuff going on this one. So thank you yeah one of the resources to do it and you know we're expecting a lot of calls and honestly it's like we want a lot of calls the selected can help us frame what it should look like we will recommend it back in and try to tell you what to do I mean this is all about get given take great like what's the benefits what's good in your state would you guys do that would you like when people like with what they like you know there's all kinds of stuff you know yes three plan options what people think about you know is a good spread in numbers like on the right kind of plans that would look like you know the people like it today's payment to they argue about it is it is the premium dollar in is like there's a lot of things to look at the more information we can get from you guys and through these phone calls the better you know it's just going to help us consult we don't want to do is we we don't want to take and we won't take calls from the press about things or you know what do you think about what's going on from the papers and that kind of stuff so we stay out of all the anything like that that comes up we directed back to you'll. So. All right I want us to talk to somebody you know thank you. Okay members not saying any more questions for Segal consulting we thank you for your presentation today and answered all the questions and will dismiss you this time and thank you step out thank you thank you very much. Wardlaw it is unrelated to the okay I think we are to have the other contractor come back into question represent Senator Hickey just asked to be asked of them as well to see if they anticipated the that number of exchange between the legislature and there be a. Anybody opposed to that. And again if you have any other questions for or single Wallace them step back and be fair. A. Mr take care that. members you thank you see we appreciate car on stepping back in we had a. Question or maybe two that didn't get ask you to be fair we want to. let that so This Is Senator Hickey you're recognized. Yes just just one question that that had occurred of course we've already talked about where we're at the you know the time frame for time frame that were owned course working with the public sector you probably probably know this but you know there's gonna be a lot of questions is this is ongoing and like I say I want to be fair to you all if we hire you are you are you flexible enough that you're gonna be able to take questions even if it was on a day to day basis from Marlboro that's that's normal. Right well want to make sure because I know what we were what we actually like the increased along because that helps us give the product a benefit you the most right okay and and just add to that there are three of us that are just across the river. We can hear when right okay all right thank you appreciate it. The members didn't see anyone else I think it was. All we had we appreciate you coming back in just to be fair were you were able to answer the same question thank you to ask you step out at this time thank you thank you. Members we've been here for. Three hours Amona wanna take another break up. Thank another break for about ten minutes and we'll be back. Good thank you come back after a break We were. Finish up first I I will thank Mr Lee is not here that helped us in going through the initial. Consulted. Possibility list. I can say that we are impressed with both presentations. in the there can't be but one we realize so what is the committee's pleasure. Senator Irvin you're recognized. Thank you Mr chair both presentations were phenomenal and we really appreciate the time that everybody took him presenting to our legislative subcommittee I move that we authorized the bureau of legislative research to enter negotiations with sequel for consulting services agreement incorporating the terms and conditions of the RFP for employee health benefits consulting services and the consultants proposal in response to the RFP to be submitted to the LC policy making subcommittee for review with the A. L. C. having final approval of the contract. I have a motion and a second Senator Hickey and discussion. All in favor aye aye opposed. Motion carries the consulting will be from Segal consulting. We have been in business. With no other business again thank everyone presenting today for your time and efforts and we are Jr.