Public Health, Welfare and Labor Committee- House

One sign up sheet out here on my right. without objection the bills listed in red on the consent agenda will be added. I see no objection those will be added. And again just a reminder committee we will be meeting this afternoon. So we'll get into the bills the first group will do is the concur amendments concurrent Senate Amendment we have one and that is H. B. ten sixty eight. representative Pilkington is not here. Z. outlawing. No all right we will come back to that. Okay we have to bills that were re referred to the Committee first one is S. B. two ninety six representative Eubanks you're recognized. The Amendment. There is an amendment come around. Representive Eubanks in few minutes to look at your committee. But you're recognized to present your amendment thank you Mr chair up when I present this last week representative Dotson had a question and I agreed to have it referred back to committee if the after DHS to check the current statue to see if it would cover the the situation he was talking about his particular Question dealt with the unintentional videotaping or I photo taken photographs of people as to whether they would be Charged with that misdemeanor and said this amendment addresses that and I think somebody else may have had a question about the video taking a photograph or video of the document abuse and I thank that amendment is. This amendment addresses that as well so I make a motion to adopt the amendment. I have a motion and I'll take questions. But we have a motion to adopt the amendment any discussion on the motion. Seeing none all in favor signify by saying aye All opposed nay moshing carries your amendments been adopted. So I guess we need to you're recognized to present your bill is amended. Past the the bill as amended and so I think it's pretty straightforward as to what the amendment does and I think it addresses the issues that were raised last week so if the. I'll try to take any questions and I believe DHS's here as well to try to answer any questions any questions from committee. Seeing none. Anyone here speak against this bill. For the bill. Seeing none you ready close. Yes Sir I'm closing I make a motion do pass as amended. I have a motion do pass as amended any discussion on the motion. Seeing none all in favor signify by saying aye. All opposed nay. Motion carries graduation your bill is passed thank you Committee. Okay the next re referred a bill is HB seventeen oh nine representative Payton. Okay. We'll pass over that for right now. Okay. A vice chairman of president my bill. This is house bill eighteen twenty eight by representative Ladyman. Limits on the consent agenda. You're recognized. Thank you madam chair I'd like to ask mail the Blackwell and Jeff Williams to come to the table to help answer any questions you might have. From the. Okay. I feel identify yourself place. I'm Melanie Jones Blackwell. With the Department of Human Services and the Division of provider services and quality assurance and I'm the director of the office a long term care. Sturch say representative Williams Williams Department service. But. Okay okay Committee this is this bill was brought to me by DHS As something that they needed basically kind of a clean up bill. so HB eighteen twenty eight seeks to give DHS the ability to make rules rule changes regarding eligibility criteria for long term care nursing facility placement without necessitating statutory oil change. So it would make them more efficient that's basically what the bill does you got in front of you it's minor changes. But I'd be asked happy to answer any questions. For any questions committee a representative Payton you're recognized. Thank you madam chair rules still have to be approved through a Elsie's regular channels through the normal process thank you Sir. So of representative Alan recognized. Thank you the manager just a clarification DHS is currently making those routes that right. And the. Yes DHS is. Making that now what it what this bill does is with you bush Michael to tell you sure sorry what this bill does is clarify and. That. DHS's doing it instead of the Division of the NHS which is LTC. Okay. So it's really a reorganization within our department okay thanks. Seeing no further questions of you want to close for your bill. close for the bill and I make a motion to pass I have a motion to pass any discussion on the motion. Not all in favor say aye. All opposed the bills passed thank you Committee thank. Okay committee continuing on the consent agenda. H. B. eighteen seventy one representative Scott. Is not here. Okay we'll pass over that. S. B. five sixty eight representative Boyd are you prepared. You're recognized thank you. Thank you Mr chair committee This bill it addresses some some challenges with licensing of nursing homes that we've we've had previously in the state over the last couple years it does this by three main revisions and the first revision it expands the review of long term care care facility license applications and and request for change of ownership and it also adds a review for changes in management companies and other operators of long term care facilities the second thing it does is it removes the requirement for annual renewal of licenses in favor of long term care facilities to report changes including changes in management companies in other operators and then third current law only provides for and narrowly written grounds that DHS may use due to non application renewal request for change of ownership this bill expense expense those a grounds that it can consider so that said I'd be happy to try to answer any questions. The questions from committee. I none. Okay the representative Wardlaw you're recognized for a question thank you Mr. You know in the past we've had some nursing home owners or operators however you want to put it that have came and purchased some homes and we've had more than a few in the last few years come back to the state is this bill going to help fix that is that the reason for this bill. Representive Wardlaw that is the exact reason for this bill thank you Mr bush. Any other questions from committee. Seeing none anywhere speak against the bill. For the bill. Seeing none really close for you will. Yes Sir I am closed for the bill and make a do pass motion I have a motion of do pass any discussion on the motion. Seeing none all in favor signify by saying aye. All opposed nay moshing carries congratulations your bill is passed. Okay the next item on the agenda is HB eighteen forty three representative Wardlaw. You're recognized to present the bill. Thank you Mr. Pulling my notes of. Eighteen forty three is a very simple bill in no way does it change the license requirements are less than the license requirements but what it does do is take into account the correction officers time of experience that is on the second amendment to that. A one where one. Do you have handout yeah all right I'm being told there is an amendment he's got an amendment. He didn't tell me that in my notes representive you have an amendment to this will let you know that the. That's what I'm being told to. So let's give the committee time to look over the amendment. I guess I read all my notes is that there is an amendment. The representative Tosh on this amendment. Not the one I have. This I mean if I need to I will I didn't know. Hello. Yes my amendment is my name on the back of the member evidently. Representative ward are you ready to present your amendment. I presented my amendment and make a motion do pass on the amendment. motion is do pass on the amendment a discussion on the motion. Seeing none all in favor signify by saying aye. Those opposed nay. Motion carried amendments been adopted you're recognized to present your bill as amended as you see in the amendment and the bill still the only change to the current law. Is taken into account a correctional officer to be a CV SA. And what that's going to do is take into account all their years of experience at the current moment or the way the bill was actually written it only took into account law enforcement these correction officers of work with these people it gives them the same six year or five years of active service and it lets them do the service inside the prisons with that I'd take any questions so represent Wardlaw away I understand and read that it will help them function a lot better a lot quicker on some of these activities that is right. Represent Gonzalez you're recognized for a question they Mr so that's the only thing it does allow correctional officers ability to to do this what about the new language on page two lines thirty three through thirty five. Mr Arkansas immigrated table. Yes. Please elution seventy represent it is adding grounds for denying suspending or revoking license. Sullivan graves said Terry corrections of good morning miss Mister members of the committee representative Gonzalez what that language does earlier in this subsection it sets out that one of the grounds for suspending a license is failing to give the subject of the CVS exam what the results are. With this new language does clarifies that not only does a CVS a examiner have to give the subject of the exam their results they have to tell the subject of the exam what the results are going to be used for as more transparency to the process this entire bill is agreed upon language with the Arkansas state police would regulate CVS examiners. Son John representive sunshine we all like sunshine. Did that answer your question regarding Gonzalez. Any other questions. Seeing none anyone here to speak against the bill for the bill. Seeing none you may close for your bill I'll close I make a motion do pass as amended I have a motion do pass as amended in discussion on the motion. Seeing none all in favor signify by saying aye. All opposed nay the motion carries grads listen your bill is passed. Okay we're going to move on into the regular agenda. H. B. seventeen fifty nine we're going to pass over that. H. B. seventeen sixty representative Johnson are you ready to present your bill. I am thank you Mr chair you're recognized president Lee Johnson district seventy five chair committee members this is a licensure or compact multi state licensure compact very similar to what we have been nursing right now or it provides reciprocity between states that participate in the compact I know it's rather link the bill we started working on this with the psychologist situation that's who brought this to me they're supportive of this idea that they think it helps them facilitate the practice across state lines and will also help provide some support for them we have shortages a care by allowing for some reciprocity in some other states to participate we started working on it back in October talked a lot of different parties out filed about almost a month ago now and let it set out there there were several folks that some questions I think we've got all the questions answered the main question sort of centered around diseases preempt stated toward the to to you know to oversee our psychology board oversee psychologists from out of state it it does not offended that with our attorneys it be a law we don't think that that it does we also talked with some folks about telemedicine the person concerned in my printer telemedicine act so we've added some language out of the very and to clarify that it doesn't present preempt anything here with regard to our state law I just it just really truly facilitates the licensure process across states and again I'd be happy to try to answer any questions if anyone has any. Any questions from committee. Seeing none we do have two people signed up to speak for the bill. So patient dean then would you come to the table. And. Your support. I think they were mainly here for questions if anybody had any both the people for the psychologists estate so you're good. When white are you good. All right anyone who speak against the bill. Seeing none. You may close your bill some clothes from a bill Mr chairman thank you. Representative Bentley. I have a motion to do pass on the floor any discussion on the motion. Seeing none all in favor signify by saying aye. Those opposed nay motion carries resolution the bill is passed representative Johnson yes you have. H. B. eighteen sixty two yes are you prepared to run that bill I am Mr chairman to get it from me make sure I have it this is the one on behalf of providers. Of the thirty requiring certain yes that's it eighteen sixty two yes Sir I'm ready to run that the members that's quite a ways down the agenda but why we've got the representative here I want to write this bill. Thank you Mr chair so you're recognized to present HB eighteen sixty two thank you committee I appreciate the privilege to run this at it while I'm sitting at the table this bill helps facilitate behavioral services in our Medicaid fee for service population currently are are recipients of Medicaid or only allowed three Baybrook business before the required have a referral from a PCP sometimes that's difficult to get we're having some challenges sometimes getting those referrals timely we talked to DHS about that worked with the behavior health providers and I came to agreement that we would extend that from three visits to ten visits so we're still require PCP referral we're not cutting them out of the patient center medical home all we're trying to do is facilitate more behavior of visits before that PCP record referral is required then I'll be happy to try to answer questions on that if anybody has any. Any questions from committee. You may need more time. Representative Wardlaw you're recognized for a question to you somebody from DHS to to other someone from DHS to come for please introduce yourself and who you represent. Thank Mister Clark what was for member services so all session we've been asking for more visits and primary care to help and I know primary cares not related baby help Mister chairman by like to lead the way on this we've been asking for more visits primary care and and you've you've came and basically agreed to for and your going promulgate that in rules but here we're jump in seven. And we're not we are having problem behavior health folks going to E. R. but we're having a whole lot more trouble with our Medicaid population showing up in New York so why the despair and seeing those numbers and why without a referral are we going to seven. Sure I can give it a little in for information on that of course would be Heber health know when you talk about therapy usually that's going to be a larger number of business over time as they work through those issues with depression or anxiety or whatever and we were in we do recognize there sometimes this there's a unique issue here of that as long as they can get that PCP referral they can continue those visits and the issue has to do with the timing of getting that PCP referral so just based on what we are hearing about the issues the some providers having with getting those that's what we thought it was appropriate go ahead allows us to additional time for them to get those referrals because this is and this is not a hard cap as long as you the referral you can continue those visits that payable health rider and so it's not a hard cap in the same way that we have that hard cap on PCP visits. Thank you Mr. Any other questions from committee. Representative Gonzalez you're recognized for a question thing Mr Izzard expected cost increases associated with this. At this point I would be a double check of it what are fiscal impact the estimate was of my understanding was that there is an increase we expect the minimal because in most cases there is that piece of referral soon or later it's just a question of how long does it take to get it and so once they get it they still get those visits anyway if that makes sense if if I could address a little bit too right now what's happening in the current status these are not folks are committee are these folks are going to get behavioral services in an outpatient setting and the folks that are providing the services of feeling compelled to continue to provide those free of charge because they feel like they're into this with these patients the cost for a moral thing to do it is there is credits delays because they're asking for the for for the PC peas office and it I mean just to be honest it takes some time to get this back in this not always prompt and and so this is this is to try to mitigate some of that delay in trying to offset some of that I I I do agree I think most the services are being paid for Vince leach this is creating this time gap or people feeling compelled to keep providing them because they feel like they're needed and it's it's delaying that process. Yes you're recognized for follow. You think part of that delay is that we don't have enough PCP providers and state what would help we. I think we don't have electricity providers in the state absolutely how much that would have this problem who knows but we absolutely more PCB with riders no doubt. Any other questions representative Payton you're recognized. Thank you Mr. Seems to me that were taken the referral for granted and just assume in the. It's got to come so I mean it why do we require the referral at all if if for say and. I can I can try to say you know the initial ask was for no referral that was my initial asking the in the process and I think there's some fair arguments trying to leap in the PCB into the process right at some point I think that the PCP needs to first of all be aware that this that this is happening as part of the care of the patient the global care the patients so taking them completely out of the loop I think it's probably probably more than we need to be doing I think at some point you need to have that feedback back and forth in the peace be the behavioral therapist I also think that to keep the behavior health folks accountable at some point the PCP needs look and say okay I do think it's appropriate that this patient is getting bad role services right I mean I understand we have an inspector general try to try to follow all that but but there needs to be some checks and balances at some point on the behavior health guys so that they're not just a deed not not I think it would but there's a potential for them just see people see people see people there's no one overseeing that to say at some point a second set eyes to say yeah this this is really needed so I do that I do buy into the concept that at some point we need that PCP referral is just what's the right numbers at three businesses fifteen businesses at ten visits to me this was a good first compromise step after visiting with DHS about it propers a dead answer and I agree I think it's important that you have B. C. B. you weigh in on it but I think the further down the road you put it. The the less authority you're given to the PCP to say no yeah Larry thank you thank you Mr. Represent Wardlaw you're recognized for a question thank you Mr. Dr representative Johnson do you agree that ACT five sixty nine which was house bill twelve fifty for the session and made nurse practitioners PCP that should help with this process because now you have more authorized people to write those referrals I agree that more PCPs well facilitate this process just thank you. A representative Dotson you're recognized for a question. Thank you Mr chair and I'm sorry you you may have said this while I was talking to earlier but is this is this does this take off is there still cap on the total number of visits or is there does this take off the cap of the total number of his associates ten how many could they go up to and that's a good question is ten until they have to have that referral as far as how many business a person can have under Medicaid total I don't know that there is a cap on the total I don't know the answer to that this isn't this isn't trying to cap the number of visits is trying to just intervene in the PCP referral requirement right so instead of having three and now we're not gonna pay for any services until we get a PCP referral is sort of holding the services hostage waiting on that peace be referred all it measures visits to ten as far as the global member business that you can have or that's allowable under Medicaid I just don't know the answer to that there's twelve for PCP right if I'm. Instant market if I remember I is probably best I believe that is the numbers I just wouldn't count toward those twelve or it does that this would not count towards that okay all right thank you. Any other questions from committee. Seeing none. Anyone here to speak against the bill. For the bill. Seeing none you a close for you bill has some questions about Mr. What's will Committee resentment you're recognized. I have a motion do can't do pass by representative Bentley any discussion on the motion. Seeing none all in favor signify by saying aye. All opposed nay motion carries graduation bills passed thank you Committee. All right committee we're going to move back up to the top of the regular agenda. And representative Pilkington is still not here so we'll pass over fourteen forty H. B. fourteen forty. Representative Miller is not here. So we'll pass over HB fourteen twenty eight. Representative McCollum. Is not here so we'll pass over sixteen seventy six. Representative Pilkington H. B. twelve sixty three Passover. H. B. eighteen hundred representive Lowery. Is not in the room. actually I had a request from representative Lowery to move that to the afternoon. representative Beatty is in the room are you prepared to run H. B. eighteen ten representative BT. You're recognized to present your bill. This is the. Do you have someone to help you present. Yes Mister would you please introduce yourself and who you represent. I represent the. Thank you Mike on it is now. I'm Jeff Royston I represent eleven of the USA company we manufacture of a medical device for severe seizures and the medical devices actually of the in Houston's. And my my role is I'm I'm the health economics and reimbursement person for for the company. Representative be recognized to present your bill representative power baited president bill eighteen team Mr chairman this a bill that would require reimbursement rates by Arkansas Medicaid program for the vagus nerve stimulation therapy system devices basically what this bill is asking for is a rebirth reimbursement I think that may be an amendment not I don't know if that's been engrossed in the bill or not. that amendment came through discussions with members of the committee that that reimburse would be equal to one hundred percent of the Medicare average comprehensive payment rate for the basin or simulation therapy device and procedures A little. A little bit about the the procedure the therapies designed to treat medically refractory seizures and inconsistent to implanted components of cults generator electric and the implant procedures typically performed in a one to two hour hospital outpatient setting by trained surgeon studies have been published demonstrating that the appropriate utilization of the VNS therapy significantly reduces epilepsy related medical costs by reducing patient visits to health care facilities you have a decrease ER visit by about ninety nine percent. Decreased hospitalization by seventy percent and then decreased inpatient days by about sixty seven percent. Unfortunately due to low Medicaid rates many hospital administrators are unable to offer this they're free VNS reimbursement by Arkansas DHS is is low it's approximately three hundred and sixty six or three hundred sixty three dollars right now and it forces many hospital administrators in key areas of Arkansas to discontinue providing this care and service to members regardless of their payment class that therapy is considered outpatient elective procedure which allows the op hospital administrators latitude in say New. When a patient's local hospital declines this procedure The patients have little options for this subset our Medicaid population challenges distance and cost of traveling for a for the procedure and then the cost of the of the therapy Arkansas Medicaid currently like I said we bring versus three hundred sixty three dollars per case to acute care hospitals except for Arkansas children's and UAMS this severely limits most of the state's Medicaid recipients even though the number of V. and e's recipients of Medicaid in Arkansas is a small population approximately fifty to one hundred per year hospitals don't want to refuse members and their communities about their unable to cover the cost of the device they're often left with no choice so that's the need for the bill with that I'll entertain questions. Any questions from committee representative Payton you're recognized. Can you tell us the cost of the device and is this the one that's implanted under the skin okay. That there's there's several different different devices that are on the market no no it is one of the the manufacturers of the device but there's several different ones my research what I looked at they range in price from fifteen thousand to thirty thousand dollars a device. and then I think there's a replacement call somewhere in ten years eight to ten years on a battery and that cost is six two six to ten thousand dollars I have a follow up Mr yes you're recognized so currently I mean the patient or the patient's family somebody has to raise that money. Get it done what's here now. Medicare's paying for this now and in the state I thank you the children's hospital you a mess of the only two facilities or cover the cost but I'll defer yeah yeah what what's what's happening is very different than other states is that we were told initially I've been at this for about eighteen years and in the beginning we were told to send all the patients over UMass Arkansans Arkansas children's And as you went through the process their patients that couldn't go there patients that just went to the regular hospital anyway and and received a three hundred dollar reimbursement three sixty three but over the years hospitals just said no one by one and where it all funnel down even and Baptist Baptist a couple years ago said that you're the first device we've ever had to say no to. And so they move every case to you a mass and you I mass is still under costs too because their cost to charge ratio is lower so they they put up a real fight even taken the cases will still take but it's it's it it still leaves a lot of patience that are in you know Northwest Arkansas Jones Burrel anywhere around even the even in Little Rock there's no patients going through that are new everything's a battery change and so other states and in the funding is already there if you go to the fifty schedule for Arkansas DHS Medicaid actually does reimburse quite a bit more for surgery center they're not anywhere close to cost but the problem with that is when they bring and when you bring in Medicaid you're also bringing in Medicare and Medicare's outpatient deductible for part B. services is twenty percent which is too much for a lot of patients to afford or wouldn't be if they went to a hospital so another at a critical acts we've actually went to gone to critical access facilities in Arkansas because on paper they get a hundred percent cost to and we did in plant these and grab that over in the northwest corner for quite a while we were taking all the patients that were in the northwest corner over almost all the way in Oklahoma just to get them covered and that didn't work out because there's too much for float there too small facility to handle that so the reimbursement on paper is there it's just it's not there at the acute facility where it is anywhere else in the US and so that's what we're asking for is just to be that outpace reimbursement to be placed at Medicare rates in and to that block and the reason why we're asking for Medicare rates we would still have to bring the cost down but which we would as a manufacturer to help defuse that but we we do have a disproportionate share Medicaid cases here in Arkansas so. Thank you thank you Mr president of Boyd you're recognized for a question. Thank you Mr chair representative Betty he's mentioned ER's and how people are using the emergency departments because of the you know lack of this technology here so do you have any cases were like you know somebody's going multiple times a month and what that's costing Medicaid that might show us in just just out of curiosity anything like that. I don't have the specific a specific case this year you if you have information that would yeah outside light only we don't have the local data but we know that there are studies that are showing that like you said the ninety nine percent reduction in medic and an ER visits in the seventy percent reduction and hospital inpatient admissions I with this we know those are expensive and we also know we also there's another study that was run had sixteen hundred patients that were just Medicaid patients I don't believe Arkansas was one of the five states that they look that but it shows that the device pays for itself in a year and a half to so it you know and it's a small subset of patients that system it's just more logistics than anything else if you look at the schedules there's you know the if you go to service like I said there's a lot more reimbursement and it's a hundred percent of cost at critical access facilities here in Arkansas. And that would just add that it's this is this device is kind of the last resort this is when the medication and other treatments and therapies are not working so this is you know this this is kind of one the last resort and the cost is not just the outpatient visits an ER visits also the cost of what they're doing now is they're just adding the next medication to it which ends up costing the state there to those are expensive medications some of these patients have fifteen to twenty different methods when the studies show that once you get to the fourth medication you're pretty much not not responding to medication to. A. Represent Ferguson you're you're recognized for a question yet I get another different types of epilepsy is there a certain type of epileptic patient that this's six is recommended for particularly or yes it's it's it's FDA approved for partial onset refractory seizures so that any any apple of C. type in that particular section it's it's FDA approved for it's been at the approved since nineteen ninety seven and there's really not been an issue anywhere in the US with coverage I've covered and I've dealt with pretty much all most the states and there's it's not it's not an issue of coverage it's not and if the issue of wanting to get it covered it's just here it's more logistics where is that reimbursement and so and if you know we had a solution for Northwest Arkansas or all these other areas with that are under served and then we wouldn't have facilities walking away from us one by one it's it's it's not easy to talk to a surgeon that looks at as we come back to them and ask them if they're willing to try something else and they just look at us like they just walked off because they can't they can't serve the patient. I yeah I guess I I'm trying to understand or you act I think what I hear you saying their dual eligibles Medicare Medicaid is mostly is that some are SSI yes summer do eligible some of are just flat out Medicaid patients yeah they lose their jobs for having seizures all these years and then this is the last resort a lot a lot of times you know they wait a long time before they even recognize that the N. S. as an option and right now the the the the providers out in the community there they will they won't even recommended to their patient because they know they can't get it through. Okay just Mr chairman I would I would like to hear from DHS at the proper time. And. A representative board did you have another question. You're recognized Thank you Mr chair at I'm just gonna throw out both questions that that I have right there so one you had mentioned the what I presume would be on label uses for partial onset seizures and I just wanted to make sure if we approve this if this somehow opens the door for more patients that might have an off label use and then to The if we have this one hundred percent Medicare payment rates do we actually think that that's going to be adequate to get the access I'll answer the first question it is the the way that DHS has their authorization set up because he's per these provide these are prior authorized cases so that's never been an issue for off label if there's something that they don't feel that they want to cover off label that's their that's their determination and so there are indication that's actually been on label that might they might even say that they don't wanna do this at the approved be an asset at the approved for depression as well so but they may say and all the players that that don't believe that they want to pay for it say we just don't pay for this and it won't make the odd the prior authorization. And you know so it's not a question of whether or not it can easily be excluded and it can also easily be excluded just of the N. S. and other not other devices in those classes. So I have lots of state examples because we've had to go through this with many states but this is this this this this is a very unique situation because it's still only three hundred sixty three dollars they only pay DHS only pays for the procedure itself and doesn't recognize the cost at acute care facilities the second question sorry. If we go with one hundred percent of Medicare rate do you really think that that's adequate to to solve the access John yes Sir yes Sir yes Sir it's it's below cost but we can work with the hospital facilities to make sure that works. All right I don't see any other questions for you but we would I would like to ask the ages to come to the table. With this questions. So. It also if you would yell at them come up right now on that. Please introduce yourself and who you represent the company so. Thank you Sir Clark what was part means services and also Janet man who's director of our division medical services she was in the waiting room I believe she's on her way up here as well. All right. The. Someone have a question from DHS. Representative Ferguson you're recognized well of course the first question I was asking I don't like to do stuff in statute if we can fix it I mean this seems like something that would not have to be done and statute if DHS was agreeable to the changes have you talk with them and you do you understand the issues and I guess why are you not willing to just do it there you know. Other channels besides statute and have you done a fiscal impact on. Sure and I think we do understand will better especially during the discussion this morning and I do apologize for a baby we this one just flew Mr Clinton the rate are we did not catch this until yesterday I know some are staff for the three state yesterday to discuss but so we've been taking a look that between last night and this morning our concern is number one I think we agree that we are concerned about things when the statute within does create a precedent for other devices to seek similar treatment but our concern is it's not so much the payment for this device itself because it is a relatively small number of people it is not a significant impact I think our estimate of someone that neighborhood maybe a hundred thousand dollars Arkansas or is more that in order to do this we will have to file a state plan amendment with CMS NJ's Medicaid state plan we do that for them to accomplish this that's going to open up our entire reimbursement system the CMS scrutiny including the supplement payments we make to hospitals and other providers and for those of you follow this CMS has been taking a very close eye on supplemental payments the last couple years they put a rule out that to try to really clamp down on it they pull the rule back we know that still concerned for the CMS staff and then add to that uncertainty we have a new administration Washington and so we have some concerns. Again not directly on this but prefer the process really of opening that up and is CMS going to start second guessing some other things in the state plan related how we pay hospitals as a really that's that's our Arkansas R. AG I guess back my question is if you had time to look at it enough to see if you'd be willing to fix it with that statute which is to to they're not meet their needs not yet but I've asked our folks look at that and see is there some other change we can make that would involve a state plan amendment that help maybe meet the middle conducive thing to try to address that. Representative. Senate Boyton. You're recognized for a question. I just wanted to clarify with Mr why aren't you gonna have to open up the state plan amendment after the session anyhow I mean. For other parts of the state plan yes for that piece the state plan we so far we've not had anything that would require us to open up that piece the State Plant and that's the part like so the has reimbursements to hospitals up little payments. Representative Bentley you're recognized for a question. Thank you chairman of market where it's a long day we can you briefly with some new members on this committee that need to understand why the reimbursement rates are different you a missing children's in whether it provided one of the funding is different to them differ from every other hospital in the state. Hello Gert regarding Medicaid right every flee because I know we're sure but it really is very pertinent to this bill if Mister if I can bring this man to the table she's much more quick to explain that and I am. If you would come to the table. Please introduce yourself and who you represent. Good morning is on okay yes I'm Janet man and the director of medical services for Arkansas DHS so to answer your question on hospital reimbursements it's very complicated we pay a per diem in the state and then for inpatient or outpatient we pay a secretary fee at the end of the year over the next at the end of the year we then calculate supplemental payments and for supplemental payments those are additional payments based on the services provided and so we do those on the inpatient and outpatient basis for UAMS and for children being a teaching hospital in a children's hospital they are treated differently they do have a higher per diem and we do cost settle with them and do a supplemental payment for the services that they do provide so the private hospitals do what is called the access payment for their supplemental payments on the in patient model in the outpatient model the public hospitals are cost settled. A little bit differently so CMS allows us to treat hospitals in three categories. Public government non state and private so based upon those three categories for you PL is how we try to design and maximize our reimbursement and I know that a lot of information I hope I've I've tried to answer your question what the long and short of it you're missing children's got a lot more money out of Medicaid then the rest of our hospitals correct or incorrect. That's why they're able to provide the service one of the hospitals are not the if they do get a higher reimbursement but when we costs settle with them they do put up some of the state share to help pull down the federal share in the in patient and out patient private hospitals also put up the access payment so. Yes it could be I just don't know the numbers off hand. To address it obviously they do or that's what I can provide the service as one that I know we have new members here that I don't understand is that this pertinent to me but also Forget my other question now on this bill but I think it's very important being the small amount of folks that we have I would hope that you guys could work this out I would in a I'm I'm for the bill on a vote for the bill but we need to get this taken care of I think it's a cost savings in the long run it again it shows the disparity of are constituencies ours we don't live close to little rock's is very hard for patients to get in here so I would hate to think that would you know bring this disparities are constituents at the rest of the state we can make this make this happen I think it's something that when you make to do so anyway thank you for answering questions. Representative more you're recognized. Thank you Mr chair and I'll try my best to make this my life question this important intriguing issue up so miss man sicher the table now have you in and you oversee the medic medical side of the Medicaid budget have you done a cost analysis to to see I mean I what a call the cost benefit analysis whatever it is to see will this pay for itself do you believe and at we have done an initial cost analysis at that Mister white referred to we M. I went with my clinical staff yesterday afternoon we authorized twenty five of of these procedures last year in using that analysis the cost is approximately a hundred and seven thousand dollars of state share that you when you didn't match that to federally it's approximately four hundred to five hundred thousand dollars my can but as Mr white said my concern is not necessarily that cost it's what it does to it changes my whole reimbursement methodology so where we currently. Deliver the service in patient even though it is prescribed to be done out patient most of ours are done in patient which is paid through a per diem so therefore we pay for each day they're in the hospital a set fee no matter what services are delivered to change that reimbursement methodology for this procedure only not for overall procedures for the hospitals I I know several years ago I was not here at the time and Arkansas Medicaid and the legislature looked APR DRG which is a different methodology for inpatient hospital which pays according to the procedure delivered verses just a straight per diem so changing that methodology for that one. Procedure I have to open up the state plan as Mister white indicated and I have to change that methodology and then some all of my inpatient methodology all of my outpatient all of my fee schedules for every procedure delivered by Arkansas Medicaid would be subject to review that is my largest concern it as Mr white said is not necessarily the cost of this procedure. One quick follow up Mr yes you're recognized so just sold me just ask one other question related and then you give me a quick answer so is there another way to do this that would meet the needs that doesn't open up the state plan amendment we are looking at it to reimbursement and I have to follow the state plan in the statute to reimburse so I don't have I don't have a yes or no answer yet we're looking I just don't have an option right now but I will make may I. Follow at so. One of the things the hospitals do you get to do at the end of every year with that supplemental payment is they do get to include the cost that they were not reimbursed for to have that they do recover some of the cost I can't say that they recover hundred percent of their cost they have an option to get some of that back. But that's not going to cover the cost. Wardlaw you're recognized for a question thank you Mr. I feel understand why we're worried about this review if we're doing everything right. And we had this one more procedure then why are we so worried about this review I mean what is CMS going to see that we're doing wrong or what are they going to see are asked to change that we foresee because foresee something because you're saying you're telling us that you're worried about it so tell us what you're worried about anytime you open up the reimbursement section of the State Plant I'm always cautious I'm always risk averse so anytime inpatient or outpatient is reviewed and supplemental the formula and the methodology that is specified makes it makes me cautious makes me nervous because I don't know what they want to do because the rule that did get pulled back we don't think we'll be re issued but they are still very interested in all of our supplemental payments and supplemental payments have been under scrutiny from for many years in many states so I'm being cautious I can't I'm not gonna sit here and say that I think we're doing something wrong but also I think I have a. Eight a duty to try to protect us also and not open this up to risk or open this up for additional money at work and maybe I'm wrong but yes you're recognized for follow. So I know a few years ago maybe it was a year ago we we were reimbursement above Medicare allowable on some items some items at that I deal with by the way DM me and we went back and you guys adjusted that payment back out to match Medicaid payments and under Medicare. Allowable so when these guys brought me this bill one of things I told him was that it needed to be at least Medicare allowable or less because I knew that that scrutiny there was there so what I'm asking you is is there scrutiny what we're paying something else to a hospital above the Medicare allowable where they're going to come back and take money back in is that the scrutiny that you're alluding to that you're worried about when you open this for for review are is there something else I don't know that it's the scrutiny of being above Medicare because you're correct we came with you with an emergency rule I think a very beginning of the pandemic on Danny specifically we have to submit every year a upper payment limit demonstration on DM me to CMS for review unfortunately we owed some money back because it was above and we have continually gotten that to be less money that was the certain section of four point one nine I think see your date. So opening up the in patient and out patient section they can then review and edit any portion of our supplemental payments that go to any hospital and in we do several different things we we do an inpatient and outpatient access payments which uses a broad based tax to collect the state's share which is always under scrutiny and up it has a limit of up to six percent we are not near the six percent the cost settlements. That we do we we reimburse up to cost I don't know if that's compared to Medicare I would have to go back and study that again I just trying to get through my list to be able to answer and so those are my concerns specifically. Thank you Mr. Your question represented Ferguson recognized yeah and that I may not personally I mean that I would like to find a way to make this work because I do think they're important devices for people having seizures and I guess I guess I don't March all just to say we don't know how we can do this is I mean if it's mostly being done in patient could you move it to the R. G. methodology or is there some easier way to. Pay it instead of opening up the state plan and pay the supplemental payment yes ma'am and it would be very hard to move one procedure to DRG without opening the State Plant the current state plan for inpatient reimbursement is a per diem methodology and I I could go back and look I don't have the twenty eighteen report in in front of me I know it was done prior to me getting here with a P. R. D. R. Jeez and I don't know the outcome I was not part of those conversations of why that was not pursued that it would be the entire inpatient reimbursement methodology that we have to get a P. R. D. R. G.'s. Did I I am maybe just ahead time to think of a solution I mean are you offering a solution I guess I'm not here yet I'm saying we're still looking at I don't have any good information at and I don't want to mislead the committee that I can make it work when I don't have a specific answer yet. Representative Gonzalez you're recognized for a question they Mr. I believe is maybe earlier this week last week we just passed a bill out of here to require Medicaid pay for this continuous glucose monitors did that not open you up to the same scrutiny that that this is going to and and if so what does it matter if it's already opened up and them to it. If it does have that affect men I don't remember you all come in a certain speak against that one were wary at them yes I but from looking at that bill we already cover glucose monitoring this set the conditions of how to cover it and I don't remember it having a specific fee attached to it I can go back and look but if it does have a payment fee of a hundred percent of Medicare or at a different type of payment then it could open that up yes but those monitors are also not done an inpatient or outpatient settings that may not up in the same section of the reimbursement manual. Because glucose monitors. Can be done in a doctor's office or other so somewhere else so. But I get I will get some clarification just to make sure. Any other questions from committee. Seeing none. Thank you for your comments thank you. Anyone here to speak against the bill. For the bill. Seeing none representing very close for your bill. I am Mr chairman I would I would ask that Mr Oyston re join me at the table to address a few of the questions that the committee I had for DHS and in rebuttal with that would be fair yes you're recognized thank you thank you very much yeah I just just to clarify on this I know there's been a lot of discussion about this being an inpatient procedure if this was an in patient procedures hospital would not have the leeway to just tell us now this is a completely almost hundred percent outpatient procedure hospitals that are not you a mess they do get the supplemental payments but they get distributed amongst all the facilities and so there's no reason for any particular hospital take risk and that's why they've been telling us no there and and in as far as. You know methods or methodologies for figuring out a payment mechanism I think that I have a solution for this admitted it there's a couple of things there's the DM this this is considered the Emmy and implantable The Andy and other states where it's reimbursed separately for the two of us device cost as a DM me light on and and maybe that can be set to manually price that way it's not shown as a fee schedule and then also and then on top of that the secretary rate can stay the same that way nobody you know that's where it's it's in place that's what other states have done other and I'll give an example like Indiana they did it that way they said it tests to a certain level of cost is seventy five percent of cost then they use their U. P. L. which is their supplemental pay methodology to pay extra for the surgery itself so there's a way to do this it's just a matter of sitting down and and and and on and in outpatient setting that that's why I'm here because the hospitals do have the latitude to say all of this is outpatient we can't afford to provide the service so. Okay we have a motion on the floor by representative Wardlaw do pass. Any discussion on the motion. Seeing no discussion on the motion on favor signify by saying aye. All opposed nay. Motion carries grads congratulations your bill has passed thank you Mr chairman thank you members committee thank you Mr. All right moving on down the agenda. Kenneth Ferguson representive Ferguson is not in the room I don't see him. representative Furman S. B. for sixty three are you prepared to run that bill. The you're recognized to run S. B. for sixty three. Sixty three yes. Sixty three all right thank you Mr chair and members and I was gonna run off the the Committee. That might be a good thing hopefully we'll stick I'll be I'll be as brief as I can Senate bill four sixty three is senator Johnson's bill it deals with abortion reporting and inspection procedures if passed it will require the state to record or report suspension of a physician's license related to abortions to the CDC. Make a class A. misdemeanor to notify an abortion facility about an upcoming inspection. It would make it a class A. misdemeanor to conceal or remove from the facility any information that is relevant to an abortion facility inspection. It would require these inspections be conducted by two people at the same time. Any cases of abortions performed for rape or incest it would require any company police report to be shown at that time. And it would also require abortion providers to report numbers of abortions performed in the case of life of the to save the life of the mother to the CDC for reporting purposes. That's those short quick of it this any questions I'll entertain. Representative Ferguson you're recognized for a question. Yeah of a particular have a concern about a police report in the case of incest I I I think a lot. I can see how a good number of patients would be reluctant to file a police report in those situations particularly if it's a you know close family member a map I just think that's. I mean that would I think that's just too restrictive personally why why would you require that I think it's important for two reasons one because that is a very. No. Tragic situation but if these things are reported then the perpetrators free to continue the abuse and this is how we you know stop these things from happening so having these this requirement to have the report well hopefully and the abuse but and also so we have accurate numbers because these Statistics are always being debated you know it when we're talking about rape incest life of the mother is like the hot talking points for the abortion argument I think it's important we have accurate data we talk about these matters. I just I just know that many times in says victims don't really want to confront that are even face that issue until some time twenty years later at I think that's just. You know it I think it's just unnecessary but. hello just meant representative. Okay anymore questions from committee. Seeing none we we do have one person signed up to speak against the bill. A care and music. Please introduce yourself and who you represent. Good morning my name is Karen music. I'm representing the Arkansas abortion support network which we started to simply walk paste patients into their abortions. We've turned it now we've become more radical as we've gone along watching the horrendous things happening here in the House I want to read a short story from a woman that share this with us one of our clients I'm a twenty four year old single mom my normal routine is working and taking care of My Baby girl who is three. I decided to let a friend of mine live with me she talked me into one party I met a guy who seem nice satin drink with him after a while in only two drinks I wasn't able to sit up and I'm good with my drinks usually. I woke up naked and alone in a house I'd never been to. He told me I wanted to stay the night so he let me. He said I asked for sex but I knew better I began to get sick and then knew I was pregnant. At what point was she to have gone to the police and made a rape report knowing what we know about how difficult it is to get any prosecutor to pick up a rape case when somebody had a drink this is a reality that women live with. Most women have conflicted feelings about rape. I've been fed stories since I was a child about the virtue of a woman that would rather die than be raped I'm not so sure that's the right answer either. This proposed law has restrictions and punishments solely to make obtaining abortion more difficult there's no other reason. Forcing someone to become pregnant against their wishes might be a crime to consider punishment. But not the medical clinic that has become the last hope for this woman. Abortion providers are some of the most compassionate professionals you will ever meet. Please vote no on this for sixty three. Thank you for your comments. A committee I I need to take a ten minute recess we've got some people coming that will run a bill I wanna give some time to get here. So let's take a ten minute recess. Okay. So we'll come back ten minutes. We're going to. I sent out. Yeah. Yeah. Okay committee two minute warning if you would start getting in your seats. One start in two minutes. Hi members if you would get your see we're getting ready to start. Email in the hallway come on in and getting your C.. One two three four five six we get plenty. Okay want to call us back in the session. Represented Fuhrman you can continue we have no one else. Signed up to speak. On your bill. There anyone here in the audience who would like to speak against the bill. For the bill. Seeing none are you ready close for your bill. I am secretary thank the committee for their time and ask for a good vote that I'm closed. I have a motion room from representative Wardlaw which motion. Of do pass in discussion on the motion. The question Labor Day nice for discussion yeah I'm glad we dismiss so that Jerry Kaski get all the back in the ring to vote for this. But at this is I know you all want to pass all these abortion bills but this is a terrible bill because they're a young girl that is a victim of incest is not going to reported to the police because what's going to happen the and the stepfather whoever's just going to abuse and beat up the mother and the girl I mean this is bad legislation Abigail the please quit voting for all this horrible stuff. Any other discussion representative Alan you're recognized thank you Mr chairman I agree with my colleague represent great I realized that we didn't have to take a recess to recess was to get J. **** people back in a row room it was about Senator Chesterfield come to run have Biel so I think that at some point in time we need to be truthful about things and call the for what it's worth. Well I have a comment on that. representative Chesterfield was here earlier to run her bill. And represent Chesterfield if I'm wrong you tell the committee I told you that we would not get to your bill to this afternoon. But if we passed over a lot of bills we might possibly get to that. We passed over a lot of bills representative Bentley told me that she was going to be in communication with you. So I want you to be able to run your bill this morning is that correct not to hit that is correct. Thank you. You're not recognized represent about. Any other discussion representative Johnson you're recognized. Thank you Mr chair At I just re re went through this bill real quick and just wanna make sure that advise aware that this doesn't require. As far as I can tell anyone other than physicians or facilities to report and document things is that I mean. I know you can't comment on that but that's my reading of the bill and just wanna make sure everybody. Is on the same page with that before we vote thank you. Representative Allen did you have another discussion. It's a moot point. Any other discussion. Seeing none. The motion is do pass all in favor signify by saying aye. All opposed nay. Hi seven your bill is passed. Local. Representative Wardlaw. The representative Wardlaw. Representive Eubanks. Representive Eubanks. Representative McGee well. Representative Dotson yes. Representive Miller. Representative Miller. Representative Payton yes. Representive Bentley. Representive great. Representive gray. Representive Gonzalez. Yes. Representative Boyd yes. The Allen or no. That was a no yes. I'm sorry. Yeah. Representive Coleman yes. Representative Pilkington. Representative Pilkington. Representive wing yes. Representative Penzo is. Representative Perry. Representive Davis. Representative Davis. Representive cloud. Hard yes. Representative Ferguson. Sure Ladyman yes. Later. Congratulations representative your bill is passed thank you Mr chairman thank you Committee. The centre Chesterville you're recognized to run S. B. five eighty. Sure. You're recognized to present your bill thank you Mr chairman ladies and gentlemen of the committee it's always fun to be in public health. Never a dull moment I hope mine is a lot less controversial and I don't get any hard nose. My bill is very simple I think the key up to it is in the first pick personal line which says may is is totally a permissive bill that will allow online instruction for those individuals who are in cosmetology school the push back was that people thought it was mandatory that is not true if you don't want to do online you don't have to for those of you who are concerned about your hair being cut properly only the theory maybe talk online not the practicum. Only the theory. We had individuals who will retire who were disabled veterans we had single moms to asked us to please pass this bill and once again it is not mandatory but it will allow for some flexibility for those who need it the most I would appreciate a good vote and happy to take any questions. Representative Alan you're recognized for a question. Motion at the proper time. Any questions from committee. The president Gonzalez you're recognized for a question is because I missed a few. Yeah I'm going down now. Did not Penzo. Hello so so who creates the curriculum is that is that already available will occur again is already available gets to decide if if they participate or not is that the students or the or the schools they get to decide if it's online or or in classrooms it is the schools and get to determine how they want to present the information to their students okay thank you. And any other questions. Representative Ferguson you're recognized. At think what I'm hearing you say it's very much like the Iberian program where they can do a lot of the book work part online but then the clinical part is standing clinic is that is that what you're saying that is after the sort of the academic part they can do it online but often with actual cutting here and learning the process is to be in person okay thank you. Any other questions from committee. Seeing none is there anyone here to speak against the bill. For the bill. Seeing none Senator you ready close for your bill ladies and gentlemen I appreciate a good vote thank you I chairman for getting me back thank you representative Bentley for texting me at home I appreciate your time and I would appreciate a good vote thank you so much thank you for coming back representative Alan you're recognized for a motion keeping in the land with my heart no this is so hard to pay. All right committee The motion is do pass any discussion on the motion. Seeing none all in favor signify by saying aye. Those opposed nay motion carries congratulations senator your bill has passed thank you so much Mister chair thank you ladies and gentleman of the committee especially thank you to representative that they could get me back here from all. And thank representative tensile. Okay a representative guns on this. They do favor the. We're back. All right go back to the. I will go back up the agenda we're on SB one fifty three by Senator Gilmore. I think representative ray was going to run that I don't see him in the room. is B. two sixty two representative eaves was not in the room. The two ninety five SB two ninety five that is represented Lundstrum. Ninety year. S. B. five fourteen. I don't have the representative for that one. Representive Bryant were you ready to run S. B. five fourteen was at your bill. You're not reading. But your bill okay. We'll get to you eventually. Skin. Representative Bentley S. B. five twenty seven. By Senator Gilmore. You're recognized from the bill. Five to seven. Seven. Thank you chairman college this is a very very simple will does three simple things for abortion facilities in Arkansas to also posed in their lobbies are in there facilities the. Branscum kicking it skews me back to my notes just for human trafficking so the poster I was employed after you guys should just eight and a half by eleven poster about human trafficking make sure they're handed the lowers card and make sure there's written transfer agreements with that payment service in the hospital and that's it and it shall I would be happy to take any questions. Any questions from committee. Seeing none. We have no one signed up to speak for against the bill. Anyone here in the audience it. One speak against the bill okay you're recognized please come that. So you were on the bill so you're recognized the please introduce yourself and who you represent. My name is Karen music and I represent the fully volunteer Arkansas abortion support network. We're volunteer founded and funded we help people. With paying for their abortions even if that's necessary. It feels so frustrating to be here up again about another abortion bill. The language in this bill even includes a written agreement with a hospital agreeing to treat patients with unforeseen complications. Related to an abortion. We know emergency rooms across the state are fully capable of taking care of any of the very rare occurrences that there are abortion complications. This is not necessary this is another effort to try to punish women and the clinics that are there to give them the only help that they have it keeps women alive it keeps women alive. Please vote against this additional bill. Thank you for your comments is anyone here would like to speak for the bill. Seeing none are you a close for your bill. I am calling this is a bill to provide continuity of care I think the help for the for the safety of women I thank him and we all know human trafficking is a big issue thank god that posters a simple thing the lowers cards another good information for women that are in these clinics and it really supervise just like we did with my midwife bill we want transfer agreement so there's continuity of care and people will take care of it simply all the bill does And with that I'll make a motion to pass. I have a motion of do pass by representative Bentley any discussion on the motion. Seeing none all in favor signify by saying aye. All opposed nay. Guys have it congratulations your bill is passed. Representative Gonzalez you're recognized run S. B. one fifty three. No go ahead go ahead you're recognized. A committee this is S. B. one fifty three by Senator Gilmore. You're recognized to present the bill they Mister Committee this this. Is a pretty simple bill it waves the national filing fees permit fees license fees associated with formation of a business if you meet certain requirements if you're on any of state assistance or underneath two hundred percent of the federal poverty level. So we'll just helps get people get people to work at it removes that barrier to entrepreneurship going into business for yourself. One fifty three. S. B. one fifty three. any questions from committee. The money more time read the. Represent Ferguson you're recognized for a question I am sorry I have thoroughly read the bill how will they prove that when it the CD questions about not a this is just City license or is this not licensed to practice in everything I mean this occupational licensing I'm confused. Yes it's occupational licensing and business registration fees with the with the St one follow the Secretary of State. And so what kind of documents would they have to produce to prove that. I guess any documents that you're that you're on state assistance representative. If if you look down their own line eighteen talks about department Human Services and workforce services would you all like to come to the table answer the question. Please introduce yourself and who you represent. Thank you Mr Clark what form him services and I'm sorry because of this bill is is the question about how the eligibility would be checked. Yes question how that information will be be shared with the licensing entity I guess have complicated will that be for sure is that I'm something to make a couple of options of course one would be that the individual if they have some documentation showing their receipt of public benefits they can present that the agency and that's or session between them that licensing agency we've also talked with the sponsor about that for state agencies we want to verify a lease for Medicaid we do have an option where we can create a situation where an employee that lost the state agency will have access to our system is just a yes no response they can see is this person on Medicaid or not and they can use that to verify lease for Medicaid and there's no privacy. We rules around that are I mean I'm for the the is amended it's a good idea just trying to figure out logistically how it'll work there there are very strict limitations on how we do it but there is a way to do it and it it may help you out on the bottom that to implement this the the licensed entity will promulgate rules of that will go through R. A. L. C. rulemaking process will. So it would go through the rules process yet the licensed entity has to create rules to implement it yes. A representative Payton you're recognized for a question. Thank you as I read through the summer I don't. I don't understand how this can be fair and equitable that we would. Charge one citizen to R. fifty five are dollars for all license applications out like that and then encourage another one to sign up on public assistance so that they don't have to pay the fee. Or if I want to start a car lot somewhere instead of putting a license to my name I'll just put it in a family member's name that that's on welfare hiring this just doesn't seem fair and equitable for the government to be picking winners and losers and and you know given some people a free pass in charge and others. How can hi what's your response to that. All representation if you want to file a bill that would remove all the lessons of fees that support you on. So I am sorry that's what this does yeah I mean is it yet it's not. Yeah it does does help them out if they are you know if it is someone that's that's on any type of assistance are below two hundred percent of the poverty level I do believe in giving people a hand up to help them get out of that instead of staying on that assistance so I think this is a first. Got a good decent step in that direction thank you. Representative Bentley you're recognized for a question just a quick question this is just the initial fee right so the second year that the fees or everyone it says it is to initial fee that's correct okay. And it only is the initial fee there's no other advantages right no. The other questions. Seeing none. We have no one signed up to speak for against the bill anyone here to speak against the bill. For the bill seeing none red clothes for your bill closed like a motion to pass. I have a motion do pass any discussion on the motion. Representative Wardlaw you're recognized I too would echo representative Gonzalez's remarks you know too many times we give a hand out not a hand up in this bill absolutely in my opinion takes a really good step in the direction of getting a hand up and getting these people off of that assistance and back into being a productive member of society and it is only for that first year and and from what I see from it the reason it is that first years we expect them to be out of that the second year in a bill to pay those license to move forward so with that I'll be voting yes and would encourage members a committee vote yes. Any other discussion from committing. Seeing none motion is do pass all in favor signify by saying aye. All opposed nay. Motion carries resolutions. Sounds like a hard no to me but the bill still passed congratulations. All right Committee we're gonna try to go on until about eleven thirty give you time to get over and get ready for the session so we're going to keep moving on down the agenda. Representative Brian what the bill are you here to refer to president. Eighteen seventy five. If you're prepared to present the bill go ahead you're recognized. Committee is eight H. B. eighteen seventy five. You're recognized representative thank you Mr chair committee this this bill probably looks familiar to you this is the appreciate bill that we discussed at length I had a Cody wait here with parchment. Talk to you about apprenticeships the the great benefits that we have the state the opposition to this was occupational license regarding cosmetology and the barber's obviously very protective of their industry very of a respectful to that we have few minor concerns up front excellent work with I believe each committee member received an email from Mister Paul Wilson that the show support of this bill Language to exclude the board of of licensing for barber shops and cosmetology was added into this bill it does meet CFR date requirements request by Reprezent Payton. And if you have any other questions available. Any questions from committee. With the message. And the. Okay any questions from committee. Seeing none. Anyone here to speak against this bill. For this bill. Representative very closely bill. President Bentley you're recognized for motion. I have a motion of do pass any discussion on the motion. Seeing none all in favor signify by saying aye. All opposed nay. Motion carries it. Congratulations representative your bill is passed. Okay committee we're gonna go back to the front page. Of the agenda. H. B. seventeen oh nine under the re referred bills to committee there is an amendment for that. Bill. And that's going to be coming around the just a minute. So. Will give me some time to look at that. Per S. H. B. seventeen oh nine. The Bill. Okay of the amendment will be the bill. Representive fate seventeen oh nine. Let's give me just a few more minutes. Mr sheriff I could ask representative board to join me. All right representative Payton you're recognized to present the amendment. Okay thank you Mr members if you'll remember a few weeks back everybody was very enthusiastic about this bill to try to find a way to reduce the cost insulin to citizens of our state and so we got it out of here in a form that was maybe not quite is workable as we had hoped but we certainly discovered a lot of information regarding the pricing of insulin and how it goes through a lot of middle men and We have several ideas that we hope to put into an interim study but this bill is an idea that should help that we can do now and so basically what's happening with the pricing of insulin and many other drugs. Is a shell game that falls between the manufacturers and the retailers which would be the the drug stores there are several middlemen that are negotiating huge contracts and getting rebates and kickbacks and things like that from the manufacturers and basically hold my manufactures and the end consumers hostage in that in that shall game so what this bill seeks to do is to require the. The manufacturer that offers those kick backs and rebates currently to the middle man. To do those kick backs and rebates in a way that they flow straight to the end user and payer so if you walk up to the counter the drugstore. And your by and your insulin. And. The retail price is two hundred fifty dollars but there's a hundred and fifty dollars for the rebates in there then you should be able to realize that benefit and so we're just forcing it. That if a manufacturer offers any incentives coupons kickbacks rebates things like that that it has to flow through to the end user or and payer if it be your health insurance to be in the payer than it's gonna benefit you. And we will have ideas for interim study that are related to this subject but all that representative board help me out here with any questions or maybe he has something to say but he's more familiar with that than I am thank you. You're recognized represent one thank you Mr chair so I just want to draw your attention to part for that that's an interesting thing so normally what happens when you're filling a prescription and you to a commercial insurance not you can't none of this works for Medicare part D. plans or Medicare or Medicaid plan so this is only commercial type plans normally you would bill the health care and then if they presented you with a coupon you would bill the coupon secondarily with what this does is it allows the billing the coupon first to make sure that that comes off the the price and ultimately is is passed on to the patient. There's one more part I'd like to add that that we maybe didn't. We discovered a lot in this and if you're questioning whether or not this could interrupt the supply of insulin because the manufacturers may not Want to to participate we have a manufacturer that we have kannst confirmed currently refuses to participate in the kickback schemes that are going on and the manufacturers that do are forced to do it I think they will look at the have a the welcome this as a way to break that cycle not Jane but there is a manufacturer ready to step in and and not for and do this without in it without participating in the kick back rebate shell game. A I got one question And maybe I don't understand the process here but if you don't talks about the Attorney General may investigate violations bring suit but. I mean that's the enforcement but how would this get reported I mean how would you know. That that this is not going to the end user can you kind of give me some would that be up to the pharmacist to report that or how would you know that. Mister chair I don't one hundred percent know that you would but they're all all kinds of things that happen in markets that we don't know of but if it is it's illegal you can't have a kick back and or rebate or whatever unless it ultimately goes to to the patient ma'am the the goal is to drive insulin patient insulin prices down insulin has gone over the last couple decades amend it is gone from I mean it is expected actually increased in price and it's a challenge for patients at the cash register and what it when you look at the system it just seems to come back to let me the I'll let me give an example here that was given to the federal government it's not regarding insulin it's regarding EpiPen but it would be the same thing so what was given and these are rough numbers but this was testimony you know three or four years ago I can't remember exactly that was given to Congress about an EpiPen and so let's say the total price that B. pen was roughly six hundred dollars at that point time and so what was given in testimony again I'm rounding but roughly like. Two hundred fifty dollars or something went to the manufacturer twenty dollars went to the pharmacy supposedly and five dollars went to the wholesaler and so the question is where did the rest of the where the rest of the dollars go right and so the the idea was they went to the middle man and it was a non transparent system but that was testimony that the manufacture of of EpiPen gave to the Congress and so this is what we're trying to do is those discounts that are going back to someone else we wanna make sure that they they flow on to the patient or you know what like representative Payton said there is a brand of insulin that has been discovered and I didn't know about it until we went through this process and found there's a an insulin that does not participate in this rebate game and as I understand it At least with one of. Insurance plan it's less expensive to to do that even you know without the discounts on the alternatives the the ones where they're rebates so. If I could remind the committee to been a couple weeks and I know I wouldn't remember that I didn't think about till he was site mentioning it but the US Senate did a an investigation into insulin prices and why they're so high and when I first presented two weeks ago or three weeks ago I read you an excerpt from their findings in a result and that their findings of state at at the end of a paragraph about the PBMs benefit from the retail price being high because that's how they're able to negotiate these kickbacks rebates and coupons that they capture in the process. Right to represent Gonzales you're recognized for a question they Mr represent the number I'm sure the insulin is not the only drug that is rebated this way or or we the setting up of an egg unequal system here where we're singling out the insulin manufacturers and say and you can't make a profit we're we're other drug manufacturers can. So the manufacturer still going to set their price I'm sure to be negotiated as it currently is it's just that they won't be able to set a price the then has the hidden. Kickbacks that were negotiated outside of of what we see so with. Insurance plans and and Medicare and Medicaid everybody else need to know what the true prices and I I use the term fair market value last time I'm not trying to to set the price I'm just saying that we need to establish what fair market value is so yes if if insulin here as a trial balloon or as a as a small segment of the pharmacy industry if we discover that there's a great benefit to doing it this way then then we will need to look at other opportunities maybe with other drugs this manufacture of insulin the we met with. they have virtually no market share because they're there shall the market through these rebate programs and having more competition in the market should drive the price down but at least. We would be able to discover what is fair market value and if we do that in a small sample with insulin that it may be something that we wish to. Apply across the board to to many other drugs yes. Follow Mr yes so so you're okay with setting up an equity for for drug prices but not necessarily for license fees a wrecker represent Gonzalez got take a staff to stab at this to see where you're going so that so I think that what I don't want to put words in representative pains mouth but what he said is there's this insulin manufacture that we know exist that doesn't have a lot of market share that if. The provides an alternative where we know with the pool the prices because it doesn't participate but if you get into other or medications there are not necessarily alternative so if it's a brand name medication where there is no other alternative than it could create other issues and so I think if we see what happens in a specific subset of the market I think that's why insulin is chosen and why insulin fits the bill plus it goes back to you know why representative Payton started looking at this in the first place which was because President Trump is you'd the executive order and it seemed to work and so that caused him to go well what can we do in Arkansas to to do that because what that executive order was working I I hope that answers your questions about the equity issue in this situation well and I'd like to add that we're not talking about inequity when it comes to the consumer the Arkansas citizen we're trying to create equity in the fact that the pricing would be uniform and it would be fair and it be transparent thank you. Representative Dotson you're recognized for a question. Thank you Mr chair and in its original form I was very much opposed to this bill Because I viewed it as a price fixing that bill if I'm understanding this new amendment. Correctly. You're you're not telling anybody what they have to charge for it you're telling them where their discounts have to apply to the end user so that the customer is getting the benefit. That's exactly right thank you thank you Dotson. Representative when you're recognized for a question thank you Mr chair so you earlier you had mentioned that the manufacturers X. because oftentimes people does fall into habits this is what the business practices and if you're gonna play the game this is how the game is played and so you indicated that the the manufacturers of probably followed each other in that suit there's at least one manufacturer that would welcome this because it brings clarity and simplicity is it your impression that the manufacturers would would appreciate this type of a structure to help streamline this process. Mr let me try to answer that and I will be a little more complicated the short answer is yes but let me explain the insulin market yeah so you got prescription drugs right and then we've got this subset on insulin and then within insulin you have different insulins that work a little bit differently but they all work to lower blood sugar right but one of the things Mr Payne I don't think you referred to is that what they've done with patents so it's simple if you go back and you look at no one in and humility and okay or or noble in our in human are I mean if any time I worked in a hospital the hospital pharmacy would dispense whichever one of those was it they got the best price I mean they were just considered interchangeably but what happens once you leave the hospital environment and go out into the the retail drugstore mail order pharmacy what have you you could just substitute whichever one was the better patient because it uses what's it about similar technology so it's not a a small molecule it's one where we use biology to actually make the the insulin if you will and so were those were you know. Forty dollars a vial or something I mean they've just grown exponentially and and prices and so even though the in essence they were the same I mean technically they're not the same but as far as the therapeutic effect in the way you use them the way prescribe them they were the same okay so they you know so there are multiple influence well beyond noble and in and and your money and the the market is grown where again they're they're very similar but you can't just substitute them because a patent rules and other rules that have been put in place but what this does. Is it allows again a same type medicine something you'd expect the same therapeutic benefit to compete were again in in other markets you know there is only one brand name drug that only works this this way and until there's a generic available you can't so doesn't fit what size it doesn't fit the normal brand generic it's their branded products but they really do the exact same are for all practical intents and purposes same thing I don't know those long winded answer but I hope that provide some clarity why insulin makes sense to the starter. Thank you and that is that's clarity as to why it's been three weeks getting this amendment ready. Representative McGee you're recognized for a question. Thank you Mr our follow up give me follow up this little bit of a representative wings questions about the manufacturer so that is one company that manufactures they're all Ford we will have there been any communication with other companies that produce insulin with that. There's been communication with their representatives the lower lobby and right now we suspect that they're going to welcome the change that could change because I just got them a shot of this amendment this morning but I mean I can speak from the car industry with the rebates the manufacturers have. I have wanted for many years to move away from the rebate model it's like a cocaine once you get on it you can't seem to get off in the rebate model ends up working against the manufacturers much as it does the consumer. And representative McGee just I and I don't want to unless representative Payton has had specific communication with that insulin manufacture I've not talked to them I don't know that they know about this I think we're making an assumption that they will like this you know because it it seems to fit their business model but it's certainly not like we were trying to develop legislation for them I just think it was something we found in as we filed the the original bill and we started working through it and then we started looking at an amendment I think that that company popped up and I think on our mind the it should work well so thank thank you Mr thank you representative Dotson you're recognized. Thank you Mr chair representative Payton I'm. When you first ran this bill you seem to be very concerned that you were Not everybody was here to be able to oppose it that you'd said that were opposed to it and. To what you just said that you just gave them the amendment this morning so I'm kind of concerned why would it why we're trying to get this done if no one knows that you're you've massively change the bill And they may be okay with it but they may not be. I guess so I'd like to say we've kept them in the loop I didn't have this in my hand until late you're Steven when I gave it to the bill drafters but it follows the narrative of what we've been discussing for several days and We had discussed the fact that that this manufacturer is. Not participating in the in the rebate model. And that the others are and it was expressed to me. A week or ten days ago the others would like to find a way out of the of the rebate model no that was through their lobby who is not this bill it could it could change but the. But anyway I'm confident. This is a form that we can can do that will bring down the pricing I'm not confident that everybody's gonna be in love with it that could come up between now and the time it goes to the Senate committee but we are short in the session and and it seems to be the expressed will of this committee to get things moving even when I was trying to throw the brakes on a couple weeks ago to we can get it right this time I'm sitting here telling me I think we've got it right last time I I was sitting here saying that we we don't have it yet and my fact I I did not make a motion and I think I did not vote may affect of I did express a very quite no when the when we voted Hendren last out but I do have confidence that this is the right thing to do this time and that we have discovered some other things that we can pursue an interim study though the reason I'm not bring in those proposals in the bill form is because they need to be fleshed out more they need to be studied more there's and I'll just say one I'm in love with because I'm an auctioneer is a reverse auction where the PBMs have to bid the price down in the open bidding form. For for different things that in their drug list so others the House doing it and I think one of the state's doing the reverse auction that's something I want this committee look at an interim study there's a. Another proposal were this allows a pharmacist basically to do substitution and some of that can be done to rule making I think but anyway I would appreciate that we get this moving and I have shown more than ample willingness to back up and re referred to committee if we find out that that we're doing something that's unworkable. All right committee chair yes you have all of the I think you're probably correct you have more than enough members of the committee that are supportive of this to pass it if they were all here what would you be willing to possibly pull this down till after lunch or after session and bring it back first thing. I mean I hate to waste the committee's time all those that are not here would need a full explanation do we have members here they're going to roll call it You're not allowed to ask questions. Any other questions. C.. Seeing none are you ready close for your men. Yes Sir I move that we adopt the amendment. I have a motion to adopt the amendment own favor signify as our discussion. All in favor signify by saying aye. All opposed nay. Motion carries your members been adopted you represent your bill is amended especially chair move that we. Do pass as amended. All right motions do pass any discussion on the motion. Representative Coleman you're recognized. Thank you and I did this get a text from submitted far existed that they you know discussed the amendment this this morning they might be in agreement with that they need more time to look at it so in reverse of what representative Dotson said I think you'd be good to look at it this afternoon rather than that of the I mean I agree everything that you've said a lack the hello so like to hear you know people have got some legit of opposition to get on board the. Thank you. What your decision. And I'd like to say that it's the same people that I sent it to because I wanted them to see it and I want them to have it and it's the same people that I referred it back to committee for and if if if they identify some major problems with that I'll be happy to do that but I'm asking that we vote on. Thank you great clothes Macon motion. I thought I'd made a motion do pass as amended okay I have a motion do pass as amended in discussion on the motion. Seeing none all in favor signify by saying aye. Those opposed nay. And seven resolution bills passed okay committee we're going to recess until after the session.