Public Health, Welfare and Labor Committee - Senate

The rules in your packet but we do need to go ahead and vote on the rules so do I have a motion motion second all right all those in favor say aye all those opposed all right rules are adopted. Today we're going to hear from two people we are going to hear from us. Becky Keogh. who is with the Arkansas department energy and environment C. secretary of the department and Miskito if you would come forward we've been anxious to hear your what you do and the things that you're interested in and if you want to bring someone with you that's fine and you can introduce yourself and he can also introduce himself for the record. they have amassed rule of keeping it on checking for its funds I'm concerned committee if you are okay with that problem someone is testifying or I'm speaking at the microphone to cheer went on to allow the people to take off the mask on that's all right well as far as you can hear me sometimes it's muffled. To be clear. Is. That afternoon to chairman and members of the committee my name is Becky Keogh service the cabinet secretary for the department of energy environment also significant position and continue to serve as director of the division of environmental quality which is one of the entities of the Department. I have with me sharing the beginning or do some self. Thank you my name is Shane Korea the general counsel or chief counsel for the department of energy and environment and also served as the deputy director for the oil and gas commission hi thank you and you're recognized. Thank you so much again like I said I'm pleased to be here to be available to the committee during the session as well as between the periods As You have constituent issues arise so we we want to be in there to support you to support your district in the state of Arkansas as we look to advance and all but also strong energy outcomes for the state so those are things that we're working on a provided a list of contacts or Department of believe you should it should have a handout before you or an email of course myself. As can be but we also do we link to some of you've worked with before she served as our chief administrator she's more than happy to take your calls or contacts as Shane Lynch and he serves as our chief legal counsel as well as the deputy director of the Arkansas index Commission and one of the entities of the Department It is sitting here all to change right he's the one that you'll see the probably most frequently here monitoring the committee activities and pretty he if you reach out to Michael he will make it your request many immediately as well as other members of the department and we will be as responsive as we can't think that streamlines the process for you as well as for us so thank you for that the. We have people listed that serve in my executive team if you have questions or needs of as we go forward so today we brought forward a couple of. A list of proposed legislation that we're considering the session we what we would like. For you to consider as we go forward those bills that being from being drafted some going to be a lot right now some have sponsor summer we're working on sponsorship and I thought I would explain the person just because of the nature of the proposal and I'm asking that you counsel to this call the other most of these. Six. The items are really designed around of the efficiencies and alignment that we've identified as as a result of being this consolidated department with the entities the entities are. The Division of environmental quality for. The department we have the Arkansas organised Commission. Which obviously goes with a lot of our energy resources in this state we have the pollution control and ecology Commission which serves as an administrator review board for the queue but also what is the rulemaking body we have the. For which is your propane safety regulators making sure that nothing is deliver adequately across the state but also safely and then we also have the Arkansas Geological Survey which is. Works. Geological resource development mapping and also. Actors are quite seismicity issues across the state so with that we have made this call the legislative issues that we need to address the session. It is the authorization to administer of this section for for the clean water act that's would be a it's a landmark piece of legislation for the state and that this would. We put state of the state and federal government implementing regulation that's been the performance of this legislative body historically that the state. Senate delegation of available program so that we can have a lot more local regulation in the state this program has been signal by both the PA and the US coordinators that they're interested in following congressional intent and delegating the for proper now to the state after somewhat twenty years of doing it differently so the first step for the state to take in the Senate delegation would be to provide a legislative authority. To administer it to the appropriate department and the shift of the program we believe will create efficiencies. To those that will state for additional protections that are necessary to protect those that we the things that we value but provide more certainty and consistency is right now the state is covered by three core U. S. court districts so what part of the state you're in you're getting permits from one of three entities with a statewide program we can provide a single permitting agency. So at that point I'm gonna transition. Shane and let him explain a second bill that we've identified that we think would benefit the citizens of the State. Thank you so in addition to the the piece of legislation a sector Q. just reference we anticipate having five other pieces of legislation one of those is kind of an internal shift at this point and it would be shifting the Arkansas mining program from what is currently within the Division of environmental quality to the Arkansas aghast Commission the idea that we could better administer both those programs in one in one shop under the oil and gas commission as both of them deal with resource development extraction programs so we think that those things are very similarly and should be similarly regulated so that's that one proposal we're going to have we also have a few clean up pieces of legislation when Ms codifying some current special language dealing with an exemption for public facilities from a trust fund that's been in the DQ appropriation bill and we're looking at the best way of codifying that into existing law we also have a regulation to rule bill and most of you are familiar with this in the twenty nineteen session there was a bill that directed agencies to change the term regulation to rule that that you all passed and there was a second act that was passed that allowed agencies to do a simplified process where you could file a letter in basically a copy of the rules and change the term regulation to rule the only problem with that is that only worked for agencies that were subject to the administrative procedures act there was not a a substituted or shortcut process for agencies not subject to the administrative procedures act since the pollution control and ecology Commission is not subject to the mystery to procedures act all we're asking to do is basically allow us to provide process so that we can do a global clean up of that term regulation ruled to come into compliance with the act was passed in twenty twenty nineteen as opposed to doing it piecemeal over the next several years. Well so we're going to have an a proposed amendment to the environmental officer program this was an act that was passed in twenty nineteen we've kind of discovered there there is a little need for clarity there is need for clarification dealing with the ability of these environmental officers to enter onto private property we believe that it's actually written to probably right now it's or making sure that were tailoring that narrowly ended providing for process for warrants when needed except for but basically wanting to make sure that everybody understands when they can and can't enter onto private property as an environmental officer and our last one is a bill dealing with the solid waste licensing committee or attempting to do there is kind of two fold one reducing the size of the existing committee that's part of four underneath the umbrella of the DQ piece but also changing the burden of those operators as opposed to having to register and re apply every year to making it a two year process so they'll say paid the the same yearly fee they'll just do it two years at a time and each operator will have to file an annual submittal they'll do it every other year so those of the I think the pieces of legislation that we're anticipating at this point time. All right are there any questions from the committee. All right scene thank you so very much we appreciate you being here today thank you all right on our list of Nicks. We have Fund Dr Joe Thompson from the Arkansas center for health improvement and done doctor Thompson welcome. Thank you madam chair members of the committee glad to be back with you you've got a very brief presentation I'll try not to take much of your time this afternoon I want to introduce myself and and our center Michelle kitchens behind me is our new governmental affairs person so she will be with you in and both of us will be available for you and any questions that you may have to the session center it's it's surprising we're in our third decade we've been around over twenty years of not being the lead or involved in it for all the time but over the course of the last twenty years we've been lucky to be able to work with you in your predecessors to advance many the health issues in the state our mission you'll see there on the first page is to be a catalyst we really we don't make anything happen without the help of others we we don't have any regulatory authority we don't have much of a budget we're administratively housed in the chancellor's office of UAMS in in much of our revenue comes from contracts and competitive grants to try to advance the interests of the state you'll see the on the second page that some of the major issues that we've had over the last two decades again much of it with you or your predecessor support and we cut our teeth on the tobacco settlement act and then went through with tobacco control obesity prevention that's led to the governor's healthy active Arkansas initiative the private option now Arkansas Works some one of the more important aspects is the health care transparency initiative that I'll touch on in a second three major areas are trying to improve our health care delivery system probably for the first two decades that's what we spent much of her time trying to improve the access improve the quality lower the costs but we've increasingly recognize that the communities that people live in I call it zip code risk has an impact on people's health and obviously the personal choices around tobacco use of vaping BC physical activity become important on their health care outcomes. Transparency Act some of you in your predecessors a past in two thousand fifteen is probably the most powerful tool that I'm aware of in the nation of any state and its general assemblies and executive branches you have authorized under the authority of the insurance department for mandatory all payer claims database Medicare Medicaid all the commercial plans what they put in one database what they pay for an idea in a five protected way but let's. US researchers track what's going on in our health care system your Medicaid program in the department Human Services utilize that the health department uses utilizes that your state and public school employees Division within a B. D. utilize it as well as the insurance department in addition to the claims we actually have linked much of the health department state also their birth date of their death date is a cancer registry and the Arkansas biosciences institute as well as others are making good use of this data to inform more and better choices you'll see the dreaded covert virus. Profile on the next page and then a year ago we were working on vaping and taping is kind of gone out the window as coronavirus came in no pun intended there but we have provided analytics surge capacity to the health department because of some of the abilities that you've allowed us to do you'll see we have been reporting now since last April or may school district level data zip code level data community level data to inform local decision makers around things that they could decide you'll see a graphic picture of when we went back to school the first of September we had about six or seven school districts in the red zone with more than fifty newly infected residents in those school districts on the top of the next page you'll see where we were when we went back in January we had several districts with more than a hundred per ten thousand residents that's more than one percent of those residents newly infected we publish this information every Thursday and and last week we had many zip codes with more than one percent of singles that code with more than ten percent of its residents newly infected within the last ten days last fourteen days I want to caution I think we're all ready to move forward and be overcome but we're in the dark days right now I think some of the news about the the pipeline of vaccine and so the fulfillment issues are cause for concern we have distribution issues that are cause for concern and obviously we have to take issues there are calls for concern about eighty three year old mom and she's called me every day saying we're going to get my vaccine because she wants it I would anticipate many of your constituents will want it and not be able to get it as quickly as they may others may not want it but probably should be encouraged to consider it so that they get protection over time. We have used the code experience in and monitored you'll see on the bottom of page five the dramatic explosion in the use of telemedicine we use your state and public school employees plan which is the largest to which are the largest to self insured plans in the state to kind of have a window into what's occurring you'll see before March of last year we had fewer than two hundred telemedicine visits happening on a monthly basis and by April of last year was over twenty thousand and so this really is just accelerated the state's availability of telemedicine I do anticipate that to the public health emergency to the criteria were pretty widely blown open on that and you will want to consider ways to to get that back into the sweet spot of where telemedicine works and where we do need to have in person visits with clinicians to get the appropriate care to and can't do surgery over telemedicine and so you need to have some of those in person visits that to occur. Finally in the telemedicine space you'll see the counties in the darkest blue where over twenty five percent of the visits for primary care and mental health services during April through July were actually delivered by telemedicine so this is a new tool it's a new access point particularly for rule our Kansans and I think if we do it right we can make it serve to be able to enable specialist to gain access to rule our Kansans in their place of local delivery as opposed to having to drive to Central Arkansas northwestern Arkansas Jones for to get that care. On the bottom of page five I have a graphic which I think is important and I'll I'll get to in a second but this year you will need to re authorize and REAPPROPRIATE the Medicaid expansion should you so choose under the affordable Care Act we've been tracking hospital closures in the states around us in those states that did not expand and as you can see we had fifty seven rural hospital closures in the states around this over the last several years with really only one closure into queen and that was not so much a closure due to uncompensated care others it issues it was more of a management challenge you may remember when we in two thousand fourteen when when you and your predecessors pass the expansion twenty five percent of our Kansans nineteen to sixty four lacked insurance coverage to statewide some counties it was over forty percent so this is that the reason you're saying these other rural hospitals not be able to continue to survive with a high level of uncompensated care that they're having to care for use in the top of page seven a few bulleted list of what we think may become active legislative issues for you have already mentioned the first one which is the re well the covered nineteen mitigation indexing vaccination I mentioned that one Arkansas Works re authorization appropriation we have been evaluating the crisis stabilization units these are new programs that with the governor's support got put in place over the last forty two years in Fort Smith Fayetteville Jonesboro in Little Rock this enables individuals with an acute mental illnesses and crisis becomes into interaction with law enforcement to be taken to a place of treatment as opposed to taken to jail somebody with an acute mental crisis jail is probably the worst place to actually place them there's no care there an uncontrolled situation and so this is increasingly showing promise we are conducting an evaluation right now what we can show at least in the Fort Smith is a reduction in jail days. we've not yet seen a reduction in health care costs we have seen a change in E. R. utilization. In the covered relief bill a couple things to draw your attention to they were federal limitations on surprise billing this is frequently in our state a result of air inlets charges through helicopter transport but that is in the federal bill also is a new rule emergency hospital designation that could let some of our critical asset access hospitals have a two new payment strategy with the Medicare program that might offer them enhanced financial status and then some Arkansas policy objectives which we think will come up once telemedicine that I mentioned the pharmacy benefit manager oversight is likely to be continued source of dialogue your piece of legislation from two years ago was upheld eight to nothing by the US Supreme Court as a state authority to actually regulate PBMs so we anticipate that's a that's a pretty strong Supreme Court decision in support of your decisions and then obviously I'll continue to advocate for the addition of electronic cigarettes to the clean indoor air bill to continue protecting your indoor air space we look forward to working with you we understand it's a it's a complex and fast moving space we'll try to be responsive in addition to the state agencies we off to offer support to your bureau of legislative research so that's another Avenue as well as directly coming to Michelle myself for team to look for to be an available for you because I take questions madam chair thank you for the opportunity all right thank you we do have a question of senator Sullivan you're recognized. Thank you madam chair and first of all. Thank you for your call may and work with me on a few issues I really appreciate it look for the entity which that yeah well you know you talk about telemedicine briefly and you made the comment do it right that was killed the last three sessions is because we didn't do it right and now we have an executive order that doesn't change what is the exact same thing that we tried to do legislatively so. What is what is to do it right line that when we cross that is no longer right. Well let me with the the big offer to engage and help find out how to do it right I think what we see is it because a code nineteen the use of telemedicine has been accelerated maybe by as much as a decade we're ten years ahead of where we would have been before code nineteen hit the governor's emergency authority opens telemedicine up and that emergency forty will cease at some point in time when we fail to still have the code nineteen threats and we will need to move to a new status for how we use telemedicine what content you know what constitutes telemedicine who gets paid for it what's the originating source where you have to be as a patient to receive it and those are all issues that that that broker into the scope of practice space which persons will be glad to at least provide you know empirical evidence frequently that's a political battle that we try to stay out of I think telemedicine is a new delivery system and do delivery mechanism that we're gonna need to look closely at with our insurance companies with a clinical providers with a hospital's to see what makes the most sense for a rule state that has too few providers in the rural parts of the state but increasingly has internet access and potential mode for service per share. I have a yes sure. I would first argue were prior ten years behind not ten years. Ten years where we were so when we are delivering vaccines and I had a good visit with a. Operative health yesterday and it seems that the protocols that we have there's not a lot of oversight in once we distribute the vaccine to weigh up how that reaches out to the spokes and there's not doesn't seem to be a lot of oversight there as they admit. Although we have a lot of oversight micromanagement I might call it with mass we don't have that level of scrutiny on an issue that's probably more vital the life and death issue so do you off track. In any way the that baxeen from the point of of the spoken how we're doing the all track the date on that and how we're doing. So I've had multiple conversations with both the hospital CEOs nursing home CEOs medical directors and as the vaccine was delivered one of their challenges was well they got the number of vaccines that would immunize all other staff for all other patients or staff some patients frequent didn't want it so they ended up with excess vaccine that they had thought it needed to deliver so they turned to first responders or other individuals that were cold outside the one a protocol on the ritual space so I think we've had some delivery issues to your direct question good plan I'm not sure we have good oversight on the execution of that plan down to the shops in arms at this point in time because we've got people that are getting their who work for a hospital in office and they're back in the back room and they're thirty years old and I've already gotten their second action and we have people that are seventy years old who as you said R. eighty three. But I haven't gotten that those are conscious decisions that are made I'm just wondering if you are because your job not the distributee but you track it so are you we do not have a line of sight on with the vaccine has gone to now that's why I'm reaching out to see what's happening on the frontline and I would say we need to allocate this vaccine to those at the most highest risk those on the frontline touching code every day and those are at risk for bad outcomes from code so that we can break the transmission and the burden on our hospitals okay thank you thank you madam chair thank you all right I believe we have another question Senator hammer you're recognized thank you madam chair on page six hundred graft about the proportion of primary care and mental health visits one have you got any documentation and to show that the quality of the care has either gone down maintained or gone up as far as improving. Sir I think that's a great question and answer no we don't I think that's one of the areas which as we have. Dramatically expanded this we need to think about how do we monitor for quality so we make sure we're delivering high quality telemedicine not just substitute telemedicine follow up manager yes thank you. I also noticed on the map that a lot of the areas that are if I'm interpreting this right that are heavily utilizing telemedicine. Are some areas that have the highest percentage of providers already versus those that are out on the delta and in the rural water would appear that there's less utilization in my in my interpreting that corrector I think you've got it you've got a pretty dramatic mix here you do have Central Arkansas Pulaski County Faulkner County Salim county that have high utilization as well as hot springs but you also have some pretty rural counties on this map and in important also you have we're the queen is that lost their hospital would you see a high utilize your I think this really is about where that local provider local dot local nurse practitioner said let me make sure I get care for my patients let's put people into telemedicine I think there's an educational aspect here too for clinical work force or how of how to best use telemedicine. So even though we. Because what you just said is if we don't have the providers in those areas that are likely shaded telemedicine is not being utilized so we're still dealing with a provider shortage in those lightly shaded areas is that a fair that's fair I I think ideally telemedicine has a clinical sponsor if you will on both ends of specialist on one end and and of local your pharmacist primary care provider and someone on the other hand it helps that patient optimize the information from the specialist and and we're building it and if you look at where we were last February we didn't have much if any going on that we've got a lot the shape it to make sure it optimizes the care for Arkansans thank you thank measure right thank you all right to the scene over the questions we appreciate you being here I look forward to working with yes we do as well all right ladies and gentleman we are really going to start a committee meeting at this point the chair sees a quorum and. Without objection I would like to allow Senator Trent Garner to go first he's not a member of the committee and the rest of us on the agenda all our and also at a problem statement so if you would indulge me and let me go first I would appreciate it thank you. This is Senate bill twenty seven. The manager. I'm sorry receipt yes you may thank you so much for indulging me and if there's any college bursar issue with that I'll be more apt portrayal The New York Times crunch also managers is a UALR student who is my intern this year that's why sitting over there legislative seeing everyone David not quite uses legislative hopefully get on the right track well welcome thank you very much I just came from a veteran suicide task force that we put together in two thousand nineteen we had meetings all across the states we bonding stakeholders people who were veterans veterans groups discuss ways we can reduce the veteran suicide rates in Arkansas unfortunately some of these things we have shown is that Arkansans want to work states in the nation when it comes to our side rates make sense because we have such a popular population that that would be one of the cases but this is the first of many different steps I'm trying to take to reduce that number the conversation we had on the radio the Department health who came crucially and spoke about the suicide prevention hotline described the great an honorable work that they do and I think that is a vital resource that it that medicines have any mental health or other crisis resource to reach out to to be able to do that this is the first of a two pronged approach I'm taking to help to shore up our the suicide hotline the first is this bill you're seeing today would allow least one of those employees to be a veteran or the training to help veterans we found throughout many different parts for training that peer to peer reviews with veterans thanks to huge difference is pretty simple the person to talk to is with the similar experiences you did have a conversation and relate to them otherwise the second approach was going to be an increase in their appropriation for two more positions that is a mistake on my part I got would be a lot probate completed. It shall be a second point with this approach which operated from the budget within the next week once distracted that way they want to fire anybody who may not have the qualifications right now at those two positions to allow additional people would be there in case the veteran call. Questions opportunity identical to presentation of any questions I'll take with this time all right to Senator him and you have a question you know how many calls committed suicide prevention hotline now that are veteran related yes to see down there so and I try to look up my notes I think I actually can read them about their own here this is pretty expensive in the music scene is incorrectly please correct me department health is that. He called to go to a different category than just say a regular suicide hotline and don't that will be transferred to that thing to be handled differently so there is already a section within that to do that the exact number that cannot be up top it no Sir. Thank you. All right the senator Solomon. Senator Davis thank you manager position it the way it reads now it doesn't appear to prevent someone who's currently filling that role from being trained and being in compliance. Yes Sir it is not then it's not going to cost them to buy their job different language will allow people to be trained and. I move forward yes. Resources to help give you some training I'm sure most the people of art and additional training to state bills also you know even though the law is written that way I would encourage him to hire mandarins limited that respect because it could be all in there are practices okay thank you thank you after any of the questions. All right seeing ninety one one to speak for the for the bill or against the bill. All right the Senator Wallace you're recognized to speak for the bill senator garner I will thank you for bringing this bill Folks who might not be a veteran is very difficult for veteran who's been in combat to talk with someone about his specific issues that are if they cannot relate to his comment that he's been and and and this will help. Thank you. All right of anyone else. Seeing none puts the pressure of the Committee our motion to pass to have a second I have a second all those in favor say aye all those opposed to paste your bill senator it was non controversial. You will. Thank you so much alright ladies and gentleman we are going to Senate bill ninety nine and if the vice chair would take my place please. All right. I'm sure for you your Representative get your guests to introduce themselves and also for the record. Good afternoon everyone I'm Dr Shailendra Singh I'm a practicing dermatologist in Searcy. Correct. Thank. Michael Carrick and government relations director for the state of Arkansas for the American cancer society's cancer action network welcome we're happy to have you all set apart so you're recognized receive your bill all right thank you so much ladies and gentlemen I did have the handout. I just want to tell you that to the left. The margin on the hand that all of those groups support this bill. And I also want to add a little bit to the introduction I have M. S. these two gentleman to be here today because they have extensive Experience working with what we're talking about in Dr scene is board certified in internal medicine and rheumatology geriatrics medicine and he currently practices in circuit Searcy and serves as a board member of the Arkansas when the time the GSFC ation. And then I have Michael Carrick who is the Arkansas government relations director from the American cancer society cancer action network. So we're happy to have them with us today and they do have per. Things to say about this bill. as you look at your bill. I want to take you that stepped therapy is often called. Well first. And it's called Phil first because stepped therapy is a process like this you have the patient was calling Jo Jo those indices doctor his doctors healthcare provider of certain medicine welcome does insurance the sense that they do not want to pay for that description until he tries another less expensive medication they feel like work. When. In the process of taking that medicine and and it certainly this particular person I'm thinking about could not afford the medicine if the insurance company would not pay so when he applied to this and he tries that and during this time many times his health condition is not improving and and in fact the time is being wasted in getting this person will. The patient can appeal. This process but it is very time consuming and it takes weeks and months to navigate the appeal process. And we're not saying let's do away with this we're saying let's Reform Act that's what this is about today. The as I said during this time when they're trying this medication that they're a insurer has said you need to try before we can pay for the one that your health care provider described as sometimes they help the of this patient declines and he or she is delayed in getting the medication that will help and so as I said we want to reform this particular process this is what this is about we won't the right medication at the right time for the right patient and also ladies and gentleman we just didn't you know come up with this idea twenty five states and possibly twenty six and I believe of public doctor seeing will know this he'll know what is twenty five twenty six but if you as you can tell it's not a new is not a new thing twenty five at least twenty five states are doing this today and also That includes Texas Oklahoma and Louisiana. And the we want to dispel the the Repression that you have received that if this passes it will make insurance costs go up and we have one of the gentleman here that we'll talk about that this is a good bill it's a good bill for the people of Arkansas and their health care and with that I'd like to for doctor saying to add please comment. Thank you. Thank you senator Bledsoe four giving me the opportunity to support to and to express my views here I respect good afternoon respected chair and chair committee members and chairperson. Hey I'm here Representative A. R. Arkansas is rheumatologist solution but more important than House insult people that take care of I believe in advocating for patients. The date Arkansas the existing therapy and ensure patients get the right therapy at the right time and to give you it in fact it will have I will share a story of one of my patients so just. I will say this is Mrs Hey she the twenty eight year old school teacher she has been having infirmity back pain that is characterized by CVS of morning stiffness and pain which lasts for several hours in the morning she came to see me and after doing the work up I diagnosis with C. or not get nominated affects us kind of ankylosing spondylitis now she has already tried nonstate entities committee for several years and they were not helping her anymore so the next step according to Arkansas's remit on. American mythology Association is to go to the TNF inhibitors she was young and just got married three months ago and planning a pregnancy so when I look at the overall picture of my patient I discuss with a can of therapy five different enough medication but one of them stands out if the medicine called Cynthia it is approved for treatment of this condition and it has also been studied in pregnant females and found to be safe so a person who is planning pregnancy this was the best choice to make and then I discussed with the patient she was extremely excited she was nervous initially to start with because she wanted her baby she was planning pregnancy and does not want to take any medicine which will affect pregnancy so when we had of a decided to make that decision going to stop this thing she was very excited that she will be finally getting relief from her pain but it was turned out by the insurance because they wanted her to try humana and and build other to TNF inhibitors which are the preferred medicine before she can get Cynthia just to bring to your attention humana and and bill has been shown to associated with. Total loop us in people and pregnant women so there has been several case reports and it has not been specifically stated in this case in this group of patients but so when I got a deny all of which was took almost a week I appealed to having this this patient's medical necessity is that this is the right medicine after a couple of weeks I didn't get it and I'll say no we have reviewed the appeal made and our decision is the patient has to try humana and brought I had a very difficult discussion with my patient and how that how I have my hands but tight and I cannot get permit she deserve to get. After. He said motion decided okay I will delay my pregnancy I was not pregnant I need relief from my pain that was really really difficult discussion for me to have and this outlines that call several of pay and this is just one case I have these difficult discussion almost once a week with one of my patients because it was denied for some reason even after doing up trying to give them that nice person of history personalized medicine which I like to practice I'm sorry sometimes unable to get my patients what they deserve. For this region I urge you to support and update us stepped therapy laws and support as P. ninety nine thank you the tax thing. Thank you senator for the opportunity to speak again on Michael Carrick and the government relations director for the American cancer society cancer action network the senator mentioned the coalition that is behind this while today I speak on behalf of the citizens can also want to speak on behalf of this broad coalition of providers and patient advocacy organizations from our state I'm providing a copy of a letter has been provided to you from our coalition in support of SB ninety nine and while provide the perspective of our organization the story can be told from each organization's perspective as well this issue is broader than only the cancer perspective I'm bringing today. Across the United States approximately one point nine million people will be diagnosed with cancer this year. Sadly six hundred eight thousand will die due to a cancer diagnosis in Arkansas almost eighteen thousand of our fellow citizens will hear the phrase you have cancer and slightly more than sixty two hundred people will die from this disease. We strongly support SP ninety nine. You know we we have an amazing day date and time when scientific breakthroughs are happening so rapidly it's difficult for all to keep up. The cancer diagnosis now can be managed and treated four years ago it may not be possible with the advent of biomarker testing and other advancements in the diagnosis of cancer physicians can learn of specific treatments that are the best for the patient and lead to the best possible outcome for that patient these diagnostic tools have led to the advancement of precision oncology or what others refer to as personalized medicine which provides the best treatment for each patient not a general approach to their funds specific fight with cancer. Patients need the ability to quickly assess their condition with their position and find the best course of treatment for their individual medical needs. Delays in access to the best treatment available that can be experienced as a result of patients have to go through step therapy protocol could pose a significant risk to the treatment of disease. Stepped therapy has the potential to undermine or possibly delay of positions ability to treat patients you could potentially lower the quality of care and lead to setbacks and disease progression percent for patients. Exemptions from stepped therapy do not prohibited insurers from using stepped therapy but seek to balance cost containment was step with patient needs. This Is can't supports SB ninety nine because it protects patients by ensuring the stepped therapy programs are based on clinical guidelines developed by independent experts by ensuring the exit exceptions process for stepped therapy is transparent and accessible to patients and healthcare providers combustibles in the basic framework for when it is medically appropriate to exemptions from stepped therapy. So much spoken about the potential for rate increases however the data doesn't doesn't merit that in states that have passed similar legislation the impact has been described as no fiscal impact that's in Connecticut Minnesota Oklahoma Virginia in the state of Washington. No significant impact in the states of Iowa Louisiana Missouri and Texas indeterminate impact Georgia Maine New Mexico and Ohio minimal impact in Colorado. California estimated its impact this point zero one percent. Bill Northey has estimated that its impact one it's state public health public employee public school personnel plan similar to our plan for our employees would only be a hundred thirty five thousand dollars but it did not take into account the potential savings that could take place. What is adjournment of the committee I appreciate your time I appreciate Senator Bledsoe answered Wallace for co sponsoring this legislation thank you very much. Thank you Mr Clark Senator hammer you're recognized for a question. Thank you Mr if I may ask your first building was signed up to speak for against this yes Sir with you know that Mr saying the track or sent to speak for and then we've got see here. And when the city with Blue Cross to speak against. Okay and thank god Jett Calkins was sent teen who be neutral okay we have an opportunity applications after they speak for against this Jack. Again. Against okay. I have my eyes are working because all this should be a personal nature where. Well that your questions to be asked after they give testimony okay okay. Can with this question thank you. a couple things with. Who did the fiscal impact studies in the State Street you referenced what was the age of those were done by the state legislative bodies assigned within the fiscal impact within each one of those Kaiser family foundation today summary report of those I'd be happy to provide a copy of that to you so was who was for or against the. By independent legislative bodies similar to what hello definitely we do our fiscal impact okay and then then Senator Bledsoe you know because we've had a conversation but our phones have been just blown up on this deal and emails of occupation which made me about on page five line twelve through fourteen that that seems to be a little bit of a sticking point could you speak to what lines twelve through fourteen on page five specifically address. That would cause anybody concerned. Repeat that line number yes ma'am it is Page five nines twelve through fourteen can. I believe I spoke with someone the second name of we have several amendments Senator hammer I don't know specifically is if this is one but I did speak to that to someone about that particular thing there was a of an issue In their minds anyway and we we have for a I think we have And amendments that we want to place on the bill When we get to the Senate but I'm willing to to talk with that person into the provided it doesn't change what we talked about the major parts of this bill okay and I guess that's what I wanted to make sure is it for what you intend to build to do yes the five amendments that are floating around out there will achieve the same goal but should relieve some of the concerns actively exactly then up I'm sure we'll hear about those but it's important the reason they're still didn't bring them is because of the timing yesterday afternoon was the first time that I had been notified of someone in a large group of being I was sending me some things that they were dissatisfied with that we'll I haven't had a top with that particular group yet but some of those amendments are going to help them but not all of them will help them but some will into the it depends on how much the other. Three or four amendments that they had of what that does to this bill because what we want is we want good patient care in and the so we don't want to change the bill to a the Senate it might not do what we need to do this we form of stepped therapy. For the good of the patience of any insurance companies providers or state agencies and the other twenty five stage where this is going out of business or suffered any financial. Increases to their clients because of it. The filings have been made and requesting rate rate increases stepped therapy is not been referenced and those are thank you they Mr. Thank members are there any other questions. To the house all right see ninety discussed at the site and ask miss green work with Blue Cross to come up she is signed up to speak against. And then Missy if you want to join your B. twelve twenty. C.. In addition sells. Thank you Mr chairman of Max Greenwood a vice president for governmental relations for Arkansas Blue Cross and blue shield. Good afternoon on windy city I'm a pharmacist and vice president of pharmacy and primary care programs at Arkansas Blue Cross correct you are recognized procedure testimony. Thank you we want to thank you for the opportunity to comment address you all today You know. I would. Respectfully disagree that this is reforming stepped therapy I think what this bill does is it basically shifts the costs in our opinion the bill basically benefits pharmaceutical manufacturers at the cost of hardworking or Kansans this is going to impact costs across the board it is going to impose costs for our state and our school employees it is going to impact cost for our self employed groups and it's going to impact cost per fully insured groups. The way manufacturers work is pretty simple they provide coupons to consumers to help reduce the copay at the point of sale. That's great until those coupons are no longer valid. Those coupons to offset the cost of the expensive drug. If you are a member of the self funded group that large employer is going to be charged for that entire cost. This obviously is going to result in an overall increase in cost. Additionally as has already been stated there are new drugs coming out on the market everyday providers can No Way keep track of all of this. If a provider isn't aware of the out of pocket cost that something that is being prescribed is going to cause that member. The patient may fire face such high cost when they go to try to get it filled that they don't feel that prescription. That is going to result and not improvement in care and none of us want that to happen. There is already there is already an appeals process in place it does not take months it is very clear and it is already been legislated through the prior authorization There are also various accreditation guidelines that exist to ensure that people are not waiting months if they need to appeal a prescription drug that they've been prescribed. We all know this is a difficult time in our state and our nation we have heard from many months from employers who are already struggling to continue to offer coverage to their employees an individual members who struggle to fill the prescription drugs and see providers. It is even more important now than ever that legislation is not passed it is going to impact the ability of our Kansans to use or keep their coverage I ask that you vote no on this measure. If there is a need to reform this process we can have a discussion on duty ministry to flee legislation is not needed. I thank you for your time and I look forward to working with you in the future on this and other legislation that comes up during the session. With that I'm going to ask Wendy to speak about more specific information regarding our process and the program in general great thank you. Thank you Max I would just like to share with the committee that in step therapy protocols the. Prerequisite drugs are based you know used with evidence to support. The treatment of date the particular condition for example if a generic product is required to be tried prior to the use of a. Very expensive brand product that particular generic has the indication from the FDA to treat that particular condition so today and in and current process those guidelines in the step therapy protocols are supported by evidence by the FDA indications and standards of of care and guidelines but you know specialist as well as Association societies are around certain chronic conditions. In Arkansas Works population for example applying a generic generic stepped therapy first requirement has helped tremendously in increasing the use of generics in that population on average a generic cost approximately twenty dollars per prescription on average a brand drug um for a similar. Your treatment to poor condition. Averages over four hundred dollars per prescription. Six we have and I feel a very successful in increasing the use of generic drugs with this population and in fact today over ninety one percent of the prescriptions that are used by this population are in fact generic. even a small decrease in the use of those generics replaced by the use of brand drugs increases costs significantly if we were to drop to eight ninety percent of generic dispensing rate it results in an increase of nine and a half percent of the total drug cost so there are strong arguments to support the use of step therapy protocols but I would also like to echo miss screen what's comments that we also understand it's very important to have a transparent exception process in place because protocols and drug formularies and. PSA's exor our recommendations that you cannot create a program for military or guidelines that are going to match every potential scenario and we take very careful steps and create I have a very thought thoughtful process on how we want to create the protocols to begin with but then secondly how we manage exceptions to those protocols. Thank you that we've got a couple questions here senator Solomon you're recognized pursue the question Sir. Thank you Mr chair when you said you have an appeal process do you know what the appeal process ratio is. Know what you have people apply for an appeal in there some are accepted some are denied you know what that number is correct so in our book of business we received a relatively small number of request to pre empt the stepped therapy protocol but we do approved over sixty percent of those request okay and you also said you have a The last thing you talked about with a. The call for Review stand process review I forget the word to use but so do you have the ratio of of that. So we we have an is an established this exception exception request for a call racial for those when somebody apply for an exception that you grant versus not granting. Right in with respect to step therapy protocols we are granting those exceptions over sixty percent of the time okay for the Nile and those are both the same number that correct okay thank you thank you Mr. All right senator hammer you're recognized third received a question. Thank you Mr First of all the current cost. Of insurance is that the drugs that are currently being used now correct I mean the rates are set based on historically which drugs have been used in last year two is that right. That is correct okay so I guess one of I need help and maybe I'm just fog and a little help here is how is it going to increase the cost. To the overall insurance plan and you heard what they said while ago that the fiscal studies were not done by one side or the other but independent sources tell me how it's going to increase the cost because what I perceive that you guys want to do is get away from what you're paying now so you can get lower shot I don't understand how it would cost to plans to go up especially based on. Give me just a minute ago. I think the opposition to this bill is not necessarily intended to reduce the cost today but to be able to maintain the process and the approach that we have to managing cost and utilization utilization but basically just means use of certain drugs we are challenged every day by the introduction of new products to the market if you watch the evening news You know the. You know Lester Holt's hosting NBC nightly news there are countless commercials for new drugs on the market our efforts in establishing step thirty therapy protocols or any protocol related to use of of these medications is to provide information to both the customer and the provider. Related to a more cost effective or lower cost alternatives and also to help insurer that standard of care supported you know treatments first line treatments are you know made available to that member when. A generic is equivalent to a particular brand rag in terms of efficacy and how the FDA has approved that medication. It's very helpful we believe to alert that patient into that provider that there is a lower cost generic alternative that could be tried in as opposed to you know advancing directly to the higher cost brand therapy there are always exceptions to that process and you know again that's what we have very established and monitored exception request process okay by the can I continue Mr Raskin tend you. Sir are thank you. Because I've got a friend who is got a child that's on one of these list and what she's saying is happening hers they got her child at this level finally and what her insurance companies want to do is buster my term you don't Lane turned all the way down to the very bottom and then start working back up in the drugs in order to get him to where he is now successfully her concern is the adverse effect is going to have on her child. Because of taking the child away down here so what you're trying to keep it from going up here it doesn't say it seems like you all don't mind going down here if that I'm not trying to be I'm just trying to understand. Why if if the cost of the plans are maintained right now what would you want to take that person and put him all way back down here which is going to put probably a whole lot of people in your appeals process and I can't imagine that your billion turned around timely in order to address their needs so would you speak to that sure and and our intent is never to Remove coverage of a product that the patient is receiving that and from which they're responding the goal of step therapy protocols is. Predominately applied to the initiation of treatment. So newly diagnosed condition for example. Instead of. You know covering the higher cost brand drug it is a new treatment Ishant and standard of care supports the use of perhaps an older generic product that is what the protocol is based on okay. You mentioned that you. There's twenty five states that this is being done elsewhere does BlueCross BlueShield have representation of all twenty five of those other states and if so administratively why has it not been done in those other station why was it required legislatively in order to get it done. Or do you know. Senate bill I mean as you know every blue plan as an independent plan they have their own medical policy and they differ from plan to plan hi I can't answer your question but I will be happy to try to research it for you. Mr if you live to argue about those five amendments floating out there and hoop police it yes so the five amendments out there what are the intended to do that's going to affect this. Affect the bill. I don't know. The Amendment came to the Sponsor of the bill myself as they had talked with me we have a map there we've agreed to certain things and hopefully some of those things will fit into a lot of other. Areas. And. The. Are you all the ones responsible for sending out the email to somebody blowing up our phones in our emails telling us that the the cost is going to go up have you all set out to your provider group. We have sent information to our customers we believe it's our responsibility to let our members know of legislation that could impact their cost yes Sir we did set up communication okay I'd like a copy of that because I'm getting one liners from people and I can look to see what they based their one liners on and some of them are cookie cutter like put your name in here and send it to us so I'd like you to copy whatever's been sent out to the constituents to see what which you gave them the calls them to start blowing up our phones and emails the way it has I'd like to see that please I'll be happy to but I believe that's the same information that we furnished you earlier before the meeting but I will double check and send it to you senator and what information did you provided you provided through email or how did you get that to me I believe it was sent that the members were signed I taxed or perhaps email I also sent a copy to Mr price and to Senator Bledsoe early this morning okay thank you. I think Senator center so when you're recognized her. Thank you for the proponents of the bill have a studies that indicate the cost don't race do you have studies censuring states to that indicate the cost to go up. Senator we adopt an afforded any of this information for you have the information for you if you're in those twenty five states you know what the cost no we don't we we are an independent plan we we do not see the information on and other blue plants financial information. We don't have anything to do with that okay so you're. Claim that costs may rise is unsubstantiated. I would not necessarily say that it's unsubstantiated what we know and what I can cite very specifically. Is with the step therapy protocols that we have related to use of a generic prior to a single sourced brand drug. just simply replacing one generic prescription. With a brand product as opposed to using the generic first to understand response and impact to treatment. The cost increases over four hundred dollars per understand but you'll have it's obviously true brought no substantiated evidence that that's actually the preponderance of workers you just don't know that there may or may not but there's no evidence to substantiate that that people are going to end mass start using Name brand versus non name brand drugs or should know study after the tests that we we have access to a large amount of clean data okay in the claim data indicates that. You know and we're able to to track the number of claims that are written for a brand drive before the generic is tried and it is it's very evident to to us that by removing that stepped therapy we have more patients starting treatment on the brand and not being made aware that there are generic alternatives to that particular drive that date with you can providers don't have that with me. Provided. Thank you very more. Questions. All right. Max when the bill is to silence Mr Hopkins to come up. Thank you Mr chairman thank you. All right Jack will recognize yourself. Arkansas Senate in Arkansas and let me start by saying when I put neutral down it's up to show that we're not wholly opposed to the into legislation specially the transparency of pertinent bill to show how we arrived at the criteria we do however there are some aspects that we would for a conversation about we think that we can get to an end point with the ultimate intention of the of the bill namely to those things are the turnaround times are listed and Blue Cross alluded to those those questions the the the. Authorization laws been in effect for about four years now and the time line on that is thirty days for time I appeal and seventy two hours in the case of an emergency and again that's a an accreditation requirement for us to be a qualified health plan on the exchange and offer plans on the exchange so effectively what we would like to see is this law this legislation mere those turn around times and Specifically on that is because of the additional requirements for us to have staffing to turn those appeals around to be compliant with the law and that's where the real cost for us comes in on the administrative side on the drug side of things our request to be again to allow for the generic equivalent to all the same reasons that stated before I came up here so without reaction everything that they've already stated I'm happy to take any questions from members you're recognized for a question Sir. Jack you've been around place long time yes Sir. We won't support center but so that. What assurances are you given us that if we let this thing out of committee that. There can be of a point of medium where it doesn't just water this thing down because and and trust me I understand you guys need to stay in business we don't want to see the rates go up to everybody we won't try to keep it down but the same time we all have personal stories that we're getting that we have that tell us that some people feel they're gonna be adversely affected they have to be taken off what they have that's working now in order to just be put down to generic and. So give us some reassurance from the things I'll mention again NCQA accreditation that allows for peer to peer review and appeal to us that would be a doctor the doctor review external review outside of our organization that could make it make it because or make a argument against a denial on in a specific case and that's and that's within the medical necessity definition of those accreditation establishment so what we're doing here is extending what what the medical necessity industry standard is intended to be on another step we believe that there's administrative processes out there already that could solve the issue that we're trying to in this legislation. Do those aligned with the twenty five other states where this legislation exist you know if if if they are communities offer on exchange they have to be they have to be approved by NCQA which would be an agreement that yes Sir. Okay so you feel left with what you're proposing that'll that'll be the middle of the road compromise to give everybody what they need I don't think that the as part of legislation goes and and removing our ability to required generic it is a step too far and it will increase costs it's it's been shown that on our side of things that of course is if you require of brand name original actors can be cost of personal and I think the the that the cost of that clearly. Thank Mr thanks. Members or any other questions. All rights in the province for excused centerpoint so you're recognized. Thank you Mr chairman thank you members of the committee I do want to say that I received the some updated information the bill doesn't change the current law regarding generic substitution are substitution of an interchangeable biologic and then we have agreed to an amendment to allow exemptions for self insured so I just want to take that and ladies and gentlemen I think the the testimony has proven a point that if twenty five other states can do it so can Arkansas and I would appreciate a good vote. The Bill yes all right members was the pleasure of the Committee. The motion to pass their Wallace the second. Second by Senator Sobell Sullivan all in favor say aye. Opposed. Congratulations center Bledsoe your bill passed. All right thank you so much now we're going to. Senator Hester as bill Senate bill eighty eight. Thank you. Senate bill eight an act to amend the composition the Arkansas border hearing instrument dispensers and for other purposes this is a clean bill from small language last session we haven't heard of any controversy on it the medical society seems to be okay with it and we're just redefining who can be on the board and what it takes to a make votes on the board happy to answer any questions all right. The thing with that would you please introduce yourself for the record. Health representing the board thank you so much all right. Questions. All right. Seeing no questions. is there anyone in the audience would that would like to speak for this bill. Is there anyone in the audience would like to speak against this bill. All right seeing none are you close for your bill senator. Does that make a motion to pass alright motion to pass all those in favor say aye second skews me second. Senator Wallace. All those in favor say aye all those opposed senator You bill has passed. All right Senator Wallace we ready first Senate bill twenty one. Okay we'll pass over that one today and okay that let me see let me look around the room I think I'm missing rose mediums. If you see her. Wait a minute ten. All right we can't seem to find the miss. Okay all right ladies and gentlemen since the. We. Yes okay let's do that let's recess for about ten minutes all right ten minutes and we'll be back. M. and we are just we're going to adjourn we have a a problem that we need to rectify before we go forward so thank you so much for being here but we are now it adjourned.