Public Health, Welfare and Labor Committee- House

Try to work through and work some of these up. We're gonna try to go uh as best we can in order, we will um put one Senate bill up towards the top without objection, but we're going to start, uh, we're going to pass over HB 1428. That bill has got an amendment. Representative Steiner will be here shortly to run that. So we're going to start with Senate Bill 136. Representative Grahamma, you're recognized to present your bill. Uh, thank you, committee, and with your permission, I'd like to invite someone to the table. Yes sir, please identify yourself for the record and ask your guests to do the same. OK, so. Patrick Bailey, I represent the Goldwater Institute in Phoenix, Arizona, um, and my name is Zach Grandma, I represent District 50 Fort Smith. Uh, so what's Senate Bill 136 does today is an immense current right to try Act to allow genomes specific uh treatment which is individualized, um, so what will actually happen is Let's say you have a specific disease or cancer, they will check the DNA sequences, see what's wrong, and make a individualized plan for you. We're just trying to incorporate that into the right to try Act. Dr. Bailey, would you like to add anything to that? I think you covered it well, surmise it. OK, thank you. Um, I'll take any questions. Any questions from the committee? Anyone in the audience to speak for or against the bill. See none, you're clothes for your bill. I'm closed for my bill, and this is a vote to help people save some lives. So thank you. You have a motion? A motion to pass. Appreciate that. We have a motion to pass any discussion on the motion? All those in favor say aye opposed. Congratulations you pass your bill. Without objection, we're gonna move Senate Bill 17 up and hear that, Senator Love, you're recognized to present your bill. Thank you Mr. Chair, and if I can, uh, I have guests here to present with me. That'd be just fine. Have them identify yourself for the record and identify yourself when you sit down, please. Thank you, Mr. Chair. Senator Frederick Love. Danisha Smith Lynnell Logan. Thank you. You recognize. Thank you Mr. Chair, committee, uh, I'll bring to you SB 17, uh, more affectionately known as Luxus Law. Uh, it's a pretty simple bill. It would have been section 560101 of the Arkansas code. Which deals with the abuse, uh, abuse of a corpse, uh, with this, uh, we'll be making it a class C felony if anyone sells a corpse or any part of a corpse after the final disposition through cremation or burial, and basically you are this bill came to me. I was actually doing some volunteer work at uh McDermott School. And Lux's grandmother, Miss Logan, and you are, you will hear their story. Uh, she came to me and told me about this, and I will be honest with you all. I kind of almost dismissed her because I was thinking. This sounded so crazy. And when, and when you hear the story, you will agree, this sound is so crazy. And then she said, but Ark Arkansas doesn't have a law against it. And I was just like, hm, I said, well, you know what, I'll check on that. I called after I left McDermott school. We were reading the kids that day. I called the bureau. They called me back within an hour and said, Senator Love, we do not have anything on the books that prevents people from the sale of body parts or corpses. have to follow this position. And so Immediately we went to work on drafting a bill and so if I can have Mr. Sheer just with your indulgence with the committee's indulgence, I want you to hear the story firsthand from Mrs. Smith about what happened to her and her family. Smith Thank you all for having me. Um, I had my son in January of 2022. Um, we had a memorial service for him at our local church about a year later, we were approached at our home by the FBI, um, we went to their headquarter where they let us know that they suspected that my son had been trafficked, um, not only one time, but twice he was sold to someone in Pennsylvania and then sold to someone. Minnesota, the way they were transporting these uh body parts were by Facebook market, um, there is a big big network of these people underground, um. And to say the least, this has been very hard to deal with not only losing a son, but then opening back up that wound to know that I don't know what all happened to my son, but to be very grateful that I even got him back because of a lot of people that were involved with this were just body parts, they will never be able to be um identified of who they are, who they belong to, so I do believe this is a just cause to look at. And then Mr. Chair, if I could have also the, the grandmother of Lux if Miss Logan would like to say anything. You recognize. Good morning and thank you for having us. Um, Senator Love is correct. I could tell when I approached him at the event that he did not believe what I was saying, and I really was not expecting to hear back from him, so I do appreciate his due diligence, um, and following up. But as my daughter stated, it was a little over a year. We thought the jewelry pieces that we received and the earn that we received, uh, contained my grandson and a little over a year later, we found out that um it was not him and they could not tell us what was. Presented, um, to us in the jewelry pieces and the urn. And if you can just imagine, um, you're grieving a loss and you, you get a year in and you're, you're finding your footing, um, only for that to be ripped open again and then to be told that your loved one was shipped like an Amazon package or an eBay package or an Amazon package, and you don't know who handled him, what happened to him. Um, it was traumatic. It, it still is traumatic. And we were going to be silent. We were going to deal with it quietly, but when we were told, when the FBI told us that we were the only family that they could identify of all of the multiple body parts and organs and everything that they found, we knew that we had to come forward for those families that will never know if they really have their loved ones in their urn or their jewelry pieces. And for that, we put ourselves out here, um, you, if you can imagine the number of messages that I've received, um, on Facebook. I haven't even shared them with my daughter, um, It's been hard. And so we appreciate this time. We appreciate your consideration. Um, my grandson's name means light scent, and I truly believe the purpose of his birth and transition was to bring light to this situation that has been underground and a million dollar business for those who are involved in it and all they're risking is 15 months in prison if they're caught. That's just not acceptable. Thank you. So Mr. Chair, you in committee, you've heard the story, uh, this is why SB 17 is so important. It's important to those that give their final wishes they want, they want the disposition of cremation and they want to disposition of burial for their loved ones to make sure that those final wishes are carried out. And with that committee, uh, I'm open up for questions. Any questions from the committee? See anyone in the audience signed up to speak for or against the bill. Senior and Representative Richardson Beachy to it. Representative Bentley, Representative Richardson, you're recognized for a motion. We have a motion to pass on the table. Any discussion on the motion? Representative Ladyman. Thank you, Mr. Chairman. Thank you, Senator Love, for bringing this to us. Appreciate it very much. Any further discussion on the motion? All those in favor say aye, opposed? Congratulations, Senator, you passed your bill. Thank you, Mr. Chair. Thank you, committee. Representative Wing, are you prepared to present House Bill 1291. Please introduce yourself for the record, and you're recognized to present your bill. Thank you, Mr. Chair. Carlton Wing, State Representative District 70 North Little Rock and Sherwood. This bill's fairly simple, uh, about 2 years ago, Major League Baseball entered into a first of its kind collective bargaining agreement with the minor league baseball players and in so doing, they uh saw the need and are doing this and in every state which has a minor league team in which these laws apply. how they need to have the players listed as employees under the Minimum Wage Act, and this is no non opposition. This is a certified and approved by both Major League Baseball and by the Major League Baseball Players' Union. The reason being is that they, uh, if you're gonna have to track hours and, and a lot of the other things that would have to be tracked, it would make it very problematic for the players. The players want this as well. They're benefits and salary. of more than doubled, and as well as the uh the benefits that they receive with regards to health care, tuition assistance, housing, those things as well. Uh, so no, no, in opposition and we have two minor league baseball teams in the state of Arkansas, the Northwest Arkansas Naturals, which are affiliated with the Kansas City Royals and of course the Arkansas Travelers right here in North Little Rock, affiliated with the Seattle Mariners. Happy to take any questions. Any questions from the committee, Representative Pilkington, you reckon asked for a question. Thank you, Mr. Chair. Representative Wing, if we don't pass this, what happens? Well, it makes it problematic for the uh both for the unions. And for Major League Baseball as well to be able to handle these situations. It adds a lot of layers of paperwork and things like that to have to be able to track all of the hours like, you know, do workouts count, does travel time count, all of those kinds of things, and the players themselves want this because they have signed on to this collective bargaining agreement that they are already all in favor of. Got you. So, um, to my understanding is because we're, they're basically part of collective bargaining, anything that changes on that, this is just to help. make sure that we're all in line with what's going on in other states and if that contract changes, we will change along with it. Yeah, well, they, they, they've got their own agreement their own collective bargaining agreement. Yes, OK. Any other questions from the committee? Anyone in the audience like to speak for or against the bill. I Representative Winger recognized the clothes for your bill. I'm close. I'd appreciate a good motion. Representative Richardson. You're Regan. Motion to pass on the table. Any discussion on the motion? All those in favor say aye. All those opposed. You guys have it. Congratulations. You've passed your bill. Thank you very much, committee. Representative Johnson, are you prepared to run House Bill 1169? Pass over that today? Representative Nazarenko, are you prepared to run House Bill 1217? You recognize to go to the end of the table. Thank you, Mr. Chair, and uh thank you committee Jason Ajrano, uh, House Representative, District 4. I'll bring to you today, I'm really excited, uh, after speaking with uh the the committee last week. We had a lot of good discussion, uh, over the bill and I stayed there on Thursday and got the amendments uh taken care of and got them engrossed in the bill, so you'll see that those amendments, uh, number one, I used Act 257 and Act 260 and incorporated the language from there on page 15. That was a question that the chairman Jeff Chairman Wardlaw had, uh, that'll that'll cover that as well as the very end, if you look to the last paragraph, uh, on the bill, subparagraph D was added on there, which gives, this is probably the most important part. It gives ALC as well as the General Assembly oversight for everything in that in that compact, which I believe that took care of everything, all the questions going back over those. So, uh, other than that, the only thing I've got to add is that I really appreciate everyone's help, uh, on that, your recommendations and I'll bring that to you. I'm open for questions on uh on House Bill 1217. All right, committee, there is a fiscal impact on this bill. We uh presented this last time that we had the discussion in committee, but we wanted to make sure that you had that in front of you as well. Um, any questions for Representative Nazarenko on the bill? Representative Rose, you're recognized. Thank you, Mr. Chair. Representative Nazarenko, do you feel like the intent of your bill remains unchanged with the amendment. Everything's still going to more or less accomplish what you had intended that it would. Yes, sir, and it actually um Representative Rose, it actually does even more. So I really enjoy it, as I said, I really am thankful for the comments because given the oversight with the ALC as well as the General Assembly. It makes it a good bill even better. So thank you very much. Thank you. Thank you, Mr. And a motion at the proper time. Thank you, sir. Representative Richardson, you're recognized for your question. Thank you, Mr. Chair. Representative Nazarenko, the, the license, is it one license that they'll be able to use across multiple states or will they have multiple licenses that they're approved for. So what they'll do, thank you for the question, Representative, and you still have the ability as no change before. So if, if a licensed massage therapist wanted to only operate in Arkansas, they would have just an Arkansas license if they chose to join the compact, they would enter to the compact, which then gives them reciprocity, if you will, into any member state. And so then they're able to practice in any of those member states, so they would just take their Arkansas license to Oklahoma or wherever the comp. OK, great, thank you. Any other questions by the committee? All right, committee members, we do have someone signed up to speak for the bill. Ms Ashley Smith. You'll come to the end of the table and identify yourself for the record, you'll be recognized to speak for the bill. My name is Ashley Smith. I'm a master in massage therapist, business owner out of Little Rock, Arkansas. I do want to start out saying I do apologize for the other therapist that was here last week to support this bill. They weren't able to make it today. I haven't spoke with any massage therapist who doesn't support this bill. I'm in a massage therapy group of Arkansas and everyone on there discusses this bill and I haven't met anyone. This battle can help alleviate the so-called emergency shortage we have, um, the participation in this initiative is elective, therapists can choose to join by paying an additional fee, but this is not mandatory. Also, the goal is to provide a portal and practice for therapists. However, it is essential to be familiar with the laws of the state where you are practicing. I'm pleased that the compact maintains our high professional standards, which are vital in the industry targeted by criminal human trafficking organizations, so I am in support of this bill. Thank you. Thank you for your testimony. Any questions by the committee? See none, we thank you for coming and testifying today. Thank you. Is there anyone else in the audience that would like to speak for or against the bill? See none, you're recognized clothes for your bill. Thank you, Mr. Chairman. I am closed pending any other questions. Thank you. Alright, what's the will of the committee? Motion to pass. Representative Rose recognized for a motion to pass. Any discussion on the motion. All those in favor say aye. Opposed. Congratulations, Representative Nazarenko, you've passed your bill. Thank you, Mr. Chairman. Thank you committee members. Alright committee, as we move down the agenda, um, Representative Brown, are you here to run House Bill 1244? You recognize to go to the end of the table. Take your time. Committee, we've got a handout. We're going to pass that out and Speaker. You don't have to introduce yourself. Representative Brown, if you will, identify yourself for the record, ask your guests to do the same you're recognized to present your bill. Thank you, Mr. Chair. um. I'm Representative Carolyn Brown, District 67, and I'm here with um Leonie de Clerk and Mr. Clark, could you introduce yourself? Hi, I'm Leonie de Klerk. I'm the president of the Arkansas Nurse Practitioners Association, and I'm a family nurse practitioner. You. committee members, um, I realized that we, um, addressed this um Um, the, the amount of time that nurses needed to remain under the supervision of a uh with a collaborative practice agreement during the last session. However, um, I believe that the The nurses, the nurse practitioners received considerable education, training, clinical practice, and we have a crisis in Arkansas. We have a maternal and child health crisis, and we have a crisis in our rural areas, and we need to get healthcare out to these people and uh I don't want to stand in the way of these well qualified and capable individuals for doing their jobs and providing this service to the people of Arkansas, and I would like to turn the uh microphone over to Mr. de Klerk now and let her. Review with you the um the extensive experience and training that these professionals have. Thank you. So, um, talking about the, Sorry, I apparently I'm really soft-spoken. So talking about nurse practitioner education, nurses have at least 6 years of education as a health care provider before being eligible to take board certification to um certify as a nurse practitioner and then get their license. No is complete undergraduate education and take the national licensing exam as a nurse prior to taking nurse practitioner education, and we realized that all healthcare providers have a bachelor's. degree. However, the nurse is the only one that has a bachelor's degree that leads to licensure as a healthcare professional. So you can't discount that 4 years of education just because it's at an undergraduate level. Um, following the bachelor's degree, nurses complete 2 to 3 years of graduate education to be eligible for certification as a nurse practitioner. Um And for Arkansas, they also have to practice for at least 2000 hours as a registered nurse prior to getting their certified nurse practitioner license. So During that time, because the collaborative practice agreement only relates to our being able to prescribe medications as a certified nurse practitioner with or without a collaborative practice agreement, I can do all of the other functions of a nurse practitioner. I can do assessments, I can make diagnoses, I can do health promotion. I can uh recommend clinical preventive services, the only thing I cannot do is to write a prescription. So, um, So what we're trying to do is to get the number of hours in a collaborative practice agreement before we're able to write the prescription without the collaborative practice agreements down to somewhere that is More um consistent with other states. And I want to give you some background on, on what happened, um, Am I allowed to do this after COVID. So early in the COVID pandemic dozens of nurse practitioners were laid off, uh, from primary care clinics throughout the state. Um, the number of APRNs with a cert with a collaborative practice agreement or a certificate of prescriptive authority, which we had to have a collaborative practice agreement for at that time decreased by 330 from May of 19 to May of 20, although The number of licensed nurse practitioners actually increased by 589. So there was a definite net decrease in the number of nurse practitioners are able to provide healthcare, uh, especially in rural Arkansas. Um, we, as the association received numerous calls and emails from nurse practitioners because what happened was there Patients were left without anyone able to prescribe their medications and a lot of times, not even able to get an appointment, so patients with chronic care needs were not being attended to. Um And I didn't lose my prescriptive authority, but my free clinic closed and the prescriptive authority is also specific to the clinical setting. So, you know, I couldn't go out and provide care to patients in my community, even the ones that I had a relationship for with. Um, We knew that it couldn't happen again. So when Representative Johnson was nice enough to provide the opportunity for us to sign on to a bill with 6240 transition to practice hours in 2021. We agreed, but we also, um, made it clear to to representative Johnson that we believed that was too much. So we are now have 4 years that we have been able to practice with a certificate of full independent practice after um completing the 6240 hours and um we would like to ask to have those hours um decreased. So as far as, you know, like I said, this is for um prescribing. As far as nurse practitioners experience and education in prescribing, nurses complete approximately 2 credits of um pharmacology during their undergraduate program, which is 6, about 60 contact hours and 3 credits during their graduate program, which is about 90 contact hours and our psychiatric mental health nurse practitioners actually um, Complete more um education and pharmacology. We also complete pharmacology education during our specialty courses, whether that's at the undergraduate program or in the graduate program. Um, And I don't want to compare our education to medical education, but I know that's gonna come up. Um, I reviewed the UAMS Medical school curriculum. They do not have a dedicated pharmacology course in medical school, although it is integrated throughout their education. Uh, we also have to complete 8 hours of continuing education in substance use disorder to be able to um get our DEA registration. So as far as safety. I, um, Looked at the publicly available, um, National provider database. That, uh, and looked at both malpractice and adverse action reports from 2015 to 20. 24 September of 24. Um, adverse action reports are what the boards report to the national database, basically on revoked, suspended, uh, surrendered, um, licenses and probations. From 2015 to 2024, our physician colleagues, the medical doctors had 451 adverse action reports in Arkansas. The doctors of osteopathy. Had 74 physician assistants had 24 nurse practitioners had 35, so significantly fewer. As far as malpractice payments, which is the other, um, thing that is on that, um, physicians had 427 malpractice payments, and I'm gonna say 190 of those would be things I wouldn't do anyway. Um, Dios had 21 PAs had 2. And nurse practitioners had 12, so we are fairly safe. Um, I looked at the Arkansas State Board of Nursing, um, update for disciplines on a paring licenses from October 23 to October 24, there were 24 disciplines on a PRN licenses, 15 were letters of reprimand. So basically not considered significant enough to have a major discipline of something that was reportable, uh, 7 probations which lasted from 1 to 7 years. One suspension and one voluntary surrender of license and both of those were on out of state licenses. Um, I know that, uh, Representative Johnson and some other representatives have expressed concern about um, Programs that are traditionally, um, considered online programs, but looking at those um disciplines for from uh graduates of Arkansas State. 3 from UAMS, 2 from UCA. 7 from other out of state brick and mortar schools such as University of Tennessee Health Sciences Center in Memphis. 6 from programs that are essentially considered onlineal in Chamberlain, Maryville. 2 that I couldn't figure out where they were from, and only one person who received probation was from an essentially online program. I know that there are concerns about prescribing of opioids. This bill would not affect our ability to prescribe opioids. Um, as I said last. We, I guess, um. As the number of nurse practitioners has increased the number of opioids prescribed has decreased and I actually took the liberty of looking at the um Arkansas PDMP annual report from 2023. Um Which is a really good read. And, and one thing that I noticed was that um 3 of the substances the nurse practitioners cannot prescribe. We're on the top 10 of the prescribed opioids, including OxyContin, which is the 4th most frequently prescribed and is one of the highest ones that is, uh, of interest or that is used for abuse. MS Contin, so long acting morphine is the 7th most prescribed. And fentanyl or Duragesic patches came up to number 10. And these are not things that nurse practitioners could prescribe because they're not used for acute pain, and we can only prescribe, um, scheduled medications other than hydrocodone for acute pain for 5 days. Um, I, the number of stimulants continued to rise. It's been rising for the last 10 years, but we've got to remember that nurse practitioners cannot initiate stimulants except for phentermine, which is used for weight loss and can only be prescribed for 3 months. Um, I also looked for, um, You know, the potential to start a pill mill, I know is also something that is concerning to this body and should be since 2010, 6 physicians, 2 nurse practitioners who were under a collaborative practice agreement and two pharmacists have been found guilty of being in a pill mill or Ava played or been found guilty of being in pill mills in Arkansas, um, and that was DEA, um. Information. So There is no reason to think that this bill would worsen safety in Arkansas. The um documents that I That Um, was, uh, sent out is actually looking at the 2024 state health rankings, which were released in on January 25th, the, um, green. Is um states in which nurse practitioners even have no transition to practice, so they can prescribe all medications immediately upon licensure, the yellow is states where nurse practitioners have a transition to practice that um is. higher than what we are asking for. Let than what we currently have, and the red are um states where nurse practitioners have to have a lifelong contract with a physician to be able to prescribe medications. As you can see, The best 10 states are predominantly Yellow or green. So nurse practitioners having lower barriers to providing healthcare for rural Arkansas does not, would not increase. Um, would not decrease quality of care. Uh, the worst states, as you can see. are primarily red. And Arkansas is unfortunately down among them, and I wish we weren't. But one thing that I do want to draw your attention to and that the final column. Um, which is the opioids per 100 persons. Um Almost all of those except for Kansas. It's red. And in fact, Arkansas, Oklahoma, South Carolina, which actually do have restrictions on opioid prescribing or down in that list if you look at the other states. Um, That have restrictions on opioid prescribing. I'm sorry, I have to find it. Um Well, maybe I don't have it. Uh, Texas is, um, Somewhere around 23. And the uh Louise, the other two states are in the bottom half. And I'm sorry I don't have that with me. Um And, uh, Representative Johnson was saying that he thought that Louisiana nurse practitioners could not prescribe opioids. I did double check their practice act and they can, but they're in a collaborative practice agreement and they're also down in the bottom states. So you're probably wondering why. 22,000 hours is a good choice. And um These are kind of the, the reasons. Um, having that decreased length will decrease the risk posed to a patient and a community if the collaborating physician retires, resigns, or dies unexpectedly, and that has happened, um, and it would also improve access to healthcare because certified nurse practitioners would feel more secure opening a clinic in an underserved or rural community. I know that there's concerns that nurse practitioners are not practicing in rural communities, but I have been tracking data since June of 2022, which is prior to nurse practitioners, uh, getting their certificate, getting the ability to apply for a certificate of full independent practice. There are currently more primary care trained nurse practitioners with um practice sites in non-metropolitan areas, then primary care trained physicians for all 3 years in 201 There were 164 more in 22, there were 219 more and in 23 there were 281 more, um, The number of primary care, uh, physicians in those areas has remained stable, 955, 965, and 957. The number of primary care trained nurse practitioners has increased by 10.6% from 100, 1,109 to 1,238. The num Um, the number of psychiatrists in those areas have also stayed really stable, 50, 51, and 51, while the number of psychiatric mental health nurse practitioners has increased by 57% from 49 to 77, and obviously we need more mental health providers. Um, and I'm not saying that nurse practitioners or go to rural counties because we don't approximately 28% of primary care trained physicians and 34% of primary care trained nurse practitioners practice in non-metropolitan counties, um. If you look at Medicaid, nurse practitioners can take price. 32% of the total Medicaid PCPs, 41% of the Medicaid PCPs and not in non-metropolitan counties. Um 59% of nurse practitioners who are Medicaid PCPs and non-metropolitan counties compared to 30% of physicians and DOs. So MDs and DOs. And from uh 2020 to February of this year, there was a net gain of 776 Medicaid PCPs. Thank you, Representative. Our ward lawyer who's not here for passing that bill, um. But there's been a net net loss of 115 physicians. As Medicaid PCPs. So, um, And, and then The Medicaid, uh, nurse practitioners are the only Medicaid PCPs in two counties, Calhoun and Newton County as well as 40. For other communities in Arkansas. So this is a vulnerable thing and decreasing the transition to practice hours has the ability to secure these communities' futures. Um Currently there are 647 primary uh physicians and primary care residencies in Arkansas, 26% are US uh DO graduates, 29% are USMD graduates and 45% are international medical graduates, and I really hope that they all decide that they love rural Arkansas and want to stay here because we definitely need Um, those abilities. Um So. Are you available for questions? Yeah, I guess I'm available for questions. I've probably talked more than anyone wanted. Well, I think the data. pretty much speaks for itself. It's pretty powerful, um. Does anybody have questions? Thank you for presenting committee. Does anyone have any questions? Representative Richardson, you're ready to ask for a question. Thank you, Mr. Chair. I had a question. Did I hear you say in your testimony that there were 2 people found guilty of a pill mill that were under a collaborative practice agreement. Yes, um, and that was actually a pill mill that was um behind the butcher's shop in Little Rock, there were 2 nurse practitioners. Of 3 physicians and a PA in in included in that, so I just wanted to make sure I heard you correctly there and, and this bill you're trying to move it from board required to collaborative practice agreement, correct? I believe that what we're just simply wanting to reduce the number of hours that the uh advanced practice nurses have to remain under a collaborative practice agreement before they can have full practice authority. Is that correct? I believe the board of nursing, um, Mac Gilmore asked for that to be changed to practice, it strikes language that says under you striking out bored required and adding collaborative practice. In the bill. So, That was a request of the Arkansas Department of Health, Matt Gilmore, and he is probably not here because no one's is Mac. That's right, man. I don't, I don't, I don't need you to have to, to fall. I just wanted to make sure I was reading it correctly. So you, they just confirmed that. And then the, yeah, and that's, that's it. I think that's all the questions I have. Thank you. It needs to Representative Bennet, you're recognized for a question. Thank you, Mr. Chair. Um, I'm not a nurse, um, practitioner. I, I'm not well versed in these things, but 6200 hours down to 2000. That's pretty drastic. Why, why such a drop in hours. That's a really good question, um, so if you look. And let me find my notes. I can explain it, but I probably wrote it out better. So if you look at um My scope of practice, it is much narrower than a physician's. So for example, as a family nurse practitioner, if you compare my scope of practice to that of a family physician, I would have to do 3 other nurse practitioner or um nurse midwifery, um, certifications to be able to do most of what they can do, but I still couldn't do um To, um, surgery, which they can do, um. And, and because of that, um, A family medicine residency at UAMS spends over a year of their clinical experiences in things that are not within my scope of practice as a family nurse practitioner, such as inpatient care, including medical intensive care unit, general surgery, labor and delivery, and so on, which are things that I just can't do because that's not in my education. So my scope of practice is limited to preventive health care, health promotion, management. Of common acute and chronic conditions and procedures that could commonly be performed within a primary care clinic over in a primary care setting. I can practice in other settings, but I can't still have to do things that could be done within that um primary care clinic. Um, resident physicians are able to get a medical license and start moonlighting, um, with the residency director's permission once they complete the step 3 exam, which is usually within their first year of residency, and they could actually become my collaborating physician at that stage because they would have a medical license in the state of Arkansas. And, um, AC, um, 870857 of 2019, which Representative Johnson, uh sponsored to create the osteopathic rural medicine practice, student loan and scholarship actually requires the recipient, so the DA DO student who has got that funding. To practice primary care in a qualified rural community upon completion of the internship year, which is the first year of residency, so 2000 hours unless additional residency time has been approved in advance. Um, and I would think that would be someone that was in a surgical residency. And then if you look at nurse practitioner fellowships that are available, most of those are 6 to 12 months. We don't have any of those in Arkansas, um. They are not Medicare funded like physician residency. So for example, UAMS gets, um, somewhere around $110,000 per resident and pays the residents about $50,000 to $60,000 during their residency each year, um. There is not funding for nurse practitioner residencies. However, you know, if I was to go out of state and do a nurse practitioner residency and primary care or in rural healthcare, it would be about a 12 month duration. I May I respond to Representative Annett's question, um. I failed to amend this language, which I need to do, um. Regarding the question you asked about changing the type of agreement that the APR in practice is under, um, I need to change that language to a board required agreement. So that it would be um more generally, um. more generic. And then, um, The committee, uh, let me just read this. It would just be a more generic determination so that that uh it would be recognized in more states and that other nurse practitioners coming to Arkansas, they could be recognized here. Representative, are you requesting to pull this bill back? Well, do I need to do that or can I just tell you that I'm gonna amend it before I get it to the other side. Tell me what you think is best. That's your call, ma'am. We'll continue with questions and let you think about it. OK. Representative McGee, you're recognized for a question of parliamentary procedure, um, because this is a scope bill and we're getting out of scope week. I mean that that's that thinks of clarity would be good because I would hate for her to pull this down and then we say, well, it's scope bill and we're done with scope week and we can't run again. So I just, I some clarity I think would be helpful. All right, Representative Pilkington's point is well taken. I think that we do only have one additional scope bill uh after this, so we'll continue with questions and then we'll uh we'll see what the will of the committee is. Representative McGee, you're asked for a question. Thank you, Mr. Chair. So, Just going back to the bill itself. In the last paragraph. It, it sort of treats people from out of state different than we treat our nurse practitioners here. And it, it, you know, it says basically from another state or territory they can come and have whatever prescriptive authority they had in the state that they're coming from. And, and that's all over the board and that's not what we've done in this in the past. Can you comment on that? Uh, Representative Maggie, the um prescriptive authority is state specific. So this does not change the prescriptive authority of an APR in in Arkansas that would still be limited to, um, Scheduled 3 through 5 opioids, uh, hydrocodone containing compounds for um chronic pain if needed, as long as the patient was seen by a physician every, uh, 6 months, um. Scheduled 2 medications for acute pain and then refills on Schedule 2 stimulants. That that's existing law, OK, OK. Thank you for your indulgence. OK, I understand. Let me ask you another question. You, you presented a map that shows all these 10 best states and 10 worst states, and you talked about the number of hours that nurse practitioners had in one state versus the other states. I think this map to me is really misleading. It doesn't tell me anything about the qualifications of the nurse practitioners. What it tells me is about the rate of lack of access to care, poverty, probably poverty, lack of education, lack of transportation, all these states in the red are, are, are generally concentrated here in the southeastern United States. So I don't, I don't see how, how this map has anything to do with our discussion. I just don't understand it. Any comments to defend it or I think the speak for themselves. So, Yeah, and I agree there are different cultural issues with um with um Health care in the south and southeast part of the United States. Um But The best performing states. I'll have nurse practitioners who have fewer. Or, um, let's just go fewer barriers on their prescriptive authority and because we take a national board certification exam. I am educated to exactly the same level as someone in Hawaii or Massachusetts or any other state in this union, and I could if I wanted, go and go through their process and and the um licensed to practice in that state also. Thank you, Mr. Chair. No further questions. Thank you, sir. Representative Rose, you're recognized for a question. Thank you, Mr. Chair. Representative Brown, could you speak to the 2000 hour requirement. I know we have surrounding states to do some things differently. There's some states that do things really well with more hours with less hours. Could you just speak? True that 2000 hours. Just briefly, why is that good for Arkansas? To be Perfectly candid Representative Rose, I am relying on our nurse practitioners to. No, what their capabilities are. And to understand their certification and, um. That's basically I'm relying on them because they are the professionals and they believe that 2000 hours is sufficient or more than sufficient. Thank you, Representative Brown. Thank you, Mr. Chair. Committee, any additional questions? I want to clarify, uh, Representative Pilkington's point of order. So we did look, there is no deadline on hearing scope bills. So Representative, if you want to pull this bill down and amend it, that's definitely your right to do so and we can bring that back at a later time. I would definitely like to do that. We will honor that request. Thank you. Thank you, ma'am. Members without objection, we're going to go back up to the top of our agenda, Representative Steel's in the room. We're going to recognize him to present an amendment on House Bill 1428. We're gonna pass that amendment out, give you time to review it, and then Representative Stein will be recognized to go to the end of the table. I think Committee Representative Trey Steel here. uh, if you would, yeah, please look that amendment over, but as I discussed yesterday. In the uh on the house floor is there some common sense amendment and what this does is this pulls a requirement of 21 inches uh to 23 and pulls the 21, so there's no floor to that bed potentially. So it allows hoteliers to potentially have a lower bed to accommodate for uh for other disabled folks and lifts to get in and out of beds. There again, I think it's good common sense uh amendment. So with that, I would appreciate a good, good vote. Any questions on the amendment? Anyone in the audience here to speak for or against the amendment. We have a motion to adopt the amendment by Representative Pilkington. Any discussion on the motion? All those in favor say I. Opposed You're organized to present your bill as amended. All right. Not a whole lot's changed other than that little piece of uh amendment there and with that, you know, I'll take any questions as the bill that I presented the other day and I'll be happy to answer those right now. Any questions by the committee, Representative Rose? You're recognized for a question. Thank you, Representative Steinley did a good job presenting this, uh, just the other day and I just had a little time to reflect and I was curious, is this something that's required because the federal government doesn't, doesn't already ask us to do this with regards to ADA requirements or anything, right, to my understanding, the ADA requires a mobility accessible bathrooms, but At the same time does not require mobility accessible bed heights. So sometimes they're paired with a uh a 30-inch bed in a bath in a room that has a mobidly accessible bathroom. So this just is gonna create some consistency in uh the hotel groups and uh they're getting a lot of hotels already do this, but what it is, this is gonna create some consistency with this and um. So hopefully that answers your question as you're saying federal guidelines dictate bathrooms but not beds. So people are going into a room that has a bed that's really not suitable for whatever condition they may potentially yes, potentially so. All right. Yeah, thank you, Mr. Stein, uh, thank you, Mr. Chair. Representative, you're recognized for a question. Thank you, Mr. Chair. Thank you, Representative Steinold, for bringing this back. I actually also had quite a few constituents reach out to me about this, ask me why we're regulating bed heights and don't we have better things to do and so, uh, one of them was a former state rep themselves, uh, but as I explained and I think the point arose, Representative Rose is making is that, you know, federally we're required to do this, but I also want to make sure that the the hospitality association does support this bill, correct, and that um this is only to those ADA. rooms, not all rooms, correct? That is correct. So about 4, you know, about every 4 out of 100 have to meet this requirement on the bathroom accessibility, uh hotel groups or hospitality is 100% behind this bill, and uh that answered your questions, representativeilin. Thank you. Any other questions by the committee? See that anyone in the audience signed up to speak for or against the bill. Representative, you recognized close for your bill is amended. I am closed for the bill as amended. What's the will of the committee? Motion to pass by Representative Ferguson on the bill as amended. Any discussion on the motion? All those in favor say ay opposed. Congratulations representative, you passed your bill. Thank you for your patience, committee. Uh, we'll look seeing you on the floor here shortly. Representative Johnson, are you prepared to present House Bill 1251? You will identify yourself for the record and you recognized to present your bill. Representative Lee Johnson, District 47. Uh, members, first of all, let me start by acknowledging that the scope of practice issues are challenging, right? I mean, they're challenging for all of us. Um, I know that y'all have heard from people on both sides of this issue, uh, but these are important things that we have to work through and discuss. We have a healthcare crisis in Arkansas. I think we can all acknowledge that. I think it's important to acknowledge as well we have a workforce issue contributing to that crisis, and so we need to try to do everything we can to address the workforce issue, and that means addressing scope of practice issues, right, trying to make sure that everyone's Practicing to the maximum of their ability safely within their licensure and then trying to make sure we're leveraging every workforce group that's out there to try to contribute to the issues we're seeing and so anesthesia assistants are to me part of the workforce that are in our country that are currently not allowed to practice in Arkansas. They're well trained individuals. These are individuals who have a bachelor's degree, uh, and then have gone on to have a 2 year master's program specifically in anesthesia, um. While they're major in undergrad can be anything. There are certain prerequisites to their training that mirror what we do in medical school. These are individuals that have to take, uh, you know, physics courses, chemistry courses, biology courses, all contributing to their training and preparation for their master's level program, um, currently in our currently in the state or in in the country, there's about 3000 of these individuals trained in practicing and they're recognizing 20 states, including the District of Columbia. Including neighboring states like Texas, Oklahoma, Missouri, so you know, again to me this is about allowing a well-trained group of workers that are here in our country to come into Arkansas and have the opportunity to live and work in the state. I know there are some folks that will be signed up to speak against this bill, and I'm wanting to hear what they have to say. I'm sorry today that I don't have an anesthesia assistant with me, you know, we were able to have someone come in last Thursday, but due to circumstances sort of beyond everybody's control. that person wasn't able to testify in committee and we weren't able to get them back here today. um, but hopefully some of you got to meet her, um, and I'd be happy to answer any questions about anesthesia assistance, their training, how they work to the best of my ability. If anyone has any questions. Thank you, Representative Johnson, uh, Representative Bentley, you're recognized for a question. Thank you, Chairman. Uh. Resent Johnson, thank you. Can you, uh, you know, we get into bed and want anesthesia, uh, this is probably one of the most. I would say acute things that we're doing in the hospital, so I want, can you give us some more is that this person's well qualified to be able to put somebody under and what they're what their supervision is just a little bit more details on that, please. Yeah, so in their training at postgraduate training, they have very specific training around all modes of anesthesiology, how to administer anesthesia, certainly how to intubate. Your intubation is a procedure that's many, many different practitioners can do, including paramedics in the field, right? And so while that is a very important procedure and complicated procedure. It's something that they have been well trained to do throughout their training. And as far as supervision, you know, certainly these are individuals that practice under supervision, right? Just like a physician assistant. You know, if you're not familiar with it, we have in our state APRNs, which are nurse practitioners, which I'm grateful have a pathway to practice autonomously, right? This is something I support, uh, but we also have in our state physician assistants and physician assistants practice under the supervision of a physician. There is a role for both of those individuals in the healthcare team in the anesthesia realm, CRNAs can practice autonomously, and I'm. supportive of CRNAs. They're a great part of the anesthesia team, right? But there's also this group of individuals that mirror what PAs are, what physician assistants are, that could come to our state and practice under the supervision of an anesthesiologist, and that's a well proven mode of treatment as part of the anesthesia care team, and so, you know, allowing those people to come in and practice that way. There's a role for both unsupervised and supervised parts of the health care team. Committee any any other questions? See none anyone uh from the audience. We do have someone sign speak against the bill, Miss Michelle Gonzalez. If you will, identify yourself for the record and you'll be recognized to testify. Good morning. My name is Michelle Gonzalez. Um, I did want to address also there was another speaker, Kasia Pabian, who is here to speak in favor of this as well, but um I guess I will take the lead on this. She had some things to say that I had compliments to. Um, but I'm gonna go ahead and get just speak to what I wanted to bring forth here, which I'm glad Representative Johnson had mentioned about the education. Ma'am, I want to clarify, you said in favor of you're signed up to speak against I'm. No, no, I was just, OK, let me start from the beginning. My name is Michelle Gonzalez. I have a PhD in educational leadership and have been practicing, um, as a CRNA and civilian and military practice for over 26 years. I also have been a nurse anesthesiology educator in two states for the last 15 years and I am on the board of directors for the Arkansas State Association of Nurse anesthetists. I recently retired from the navy after about 23 years of service and have been very fortunate to provide independent anesthesia care for military service members and their dependents as solo anesthesia providers on ships specifically the USNS Comfort and military treatment facilities in the US as well as across the globe. I was recruited from Maryland to Arkansas in 2019 to establish the first doctoral level nurse anesthesiology program at UAMS and the second nurse anesthesia educational program in the state, specifically to meet the future anesthesia needs of the state. I live in Alexander, Arkansas for the last 6 years, and I plan to retire here. Um, my testimony today is informed by my clinical experiences, civilian and military, my educator experiences, um, from two different states as well as my commitment to all of you in protecting your loved ones should they seek anesthesia care here in the state of Arkansas. I am not here to speak on behalf of UAMS or the military. Um, I am here to speak to the growing body of CRAs in the state and to highlight some education, the education of AAs and CRNAs. First off, currently there are 2 well developed nurse anesthesia, educational programs here in the state. Um, there are a total of 137 matriculants in both of these programs with an annual graduation rate of 50 new graduates, CRNAs every year. Um, additionally, approximately 23 students from other anesthesia programs come to clinical sites in Arkansas. Because they have roots here in Arkansas and are more likely to stay here in Arkansas. Additionally, both programs have steadily increased their seats? And the emphasis has been in the last 3 years to recruit and retrain and recruit and retain. Students who are from Arkansas, live in Arkansas, and want to stay in Arkansas. Um, as far as the educational background of CRNAs I just wanted to highlight a couple of things, um, the requirements to matriculate into a CRNA program is a 4-year bachelor degree in nursing, Bachelor of Science and nursing. Um, of which that bachelor of Science encompasses physics, chemistry, biology as Representative Johnson had mentioned that AA programs do as well. In addition to that, Applicants must have at least one year of critical care experience in an ICU. Many times new graduates do not go directly into an ICU, so they have to work their way up to get into an ICU, so they may have more nursing experience than the minimum that we require. According to our certification body, on average, the matriculants across the nation have 3.5 years of intensive care or critical care experience before entering a nurse anesthesia program. When they enter a program, it is a doctoral level of nursing. Practice Is what is the degree that they will graduate with. That is a 3 year. process. Some programs it is extended from 36 to 52 months. It just depends on some additional cert, uh, additional coursework that they have. So a nurse anesthetist, once they graduate from school, on average has Between their BSN, their critical care experience, and their experience in school about 10.5 years of actual patient care experience. Health care, hands-on experience. The prerequisites for AAs require no specific undergraduate training other than a bachelor of science, a bachelor's degree, not even a bachelor of Science degree. Um Specifically one program very well known in the United States actually has, and I quote this, Complete a bachelor's degree in any major that excites your curiosity. That is listed as their prerequisite, end quote. While they're in school they receive about 2000 hours of experience, much like CRNA educational programs. They receive about or they they complete about 600 cases. They complete about between 60 to 100 credit hours. Ironically, the master's degree in nurse anesthesia, which was. Back in 1998, and updated in 2022 to a doctoral level. That was the identical curriculum, so I guess imitation is a sincerest form of flattery when it comes to the development of the educational program. They kind of mimic the CRNA education tract. Um CRNAs have been a very well established. Um Profession with some of the first educational programs formed in 1909 for certification in 1945, um, and. There are approximately 142 nurse anesthesiology programs across the country graduating approximately 3000 graduates annually. This equates to the entire body of AAs across the nation, which graduate from 18 programs about 300 AAs annually. Um, Representative Johnson talked about a workforce issue and recent data suggests that the supply of new graduates entering the anesthesia profession has been increasing faster than the demand for anesthesia care, reducing the shortage of anesthesia providers. This was just released last week, so this is something that I could share with the committee through our representatives here. Um, notably, I spoke about my military experience. Um You know, the VA and military treatment facilities do not use AAs. There's a reason for that. CRNAs are the primary caregivers in military treatment facilities, ships, and on the front lines and have been since World War I. Um, Prior to about the year 2000, there really, so AAA has been around since 1969 when the first program was developed, but there really wasn't a lot of push for this type of provider, um, and in the year 2000, that changed a little bit as CRNAs began to acquire independent practice. Um, so there was now a push to increase anesthesiology assistants. However, anesthesiology assistants are not really going to improve access to care because anesthesiology assistants can only practice where. Anesthesiologist. Can medically direct their provision of care. In Arkansas that equates to of the 393 anesthesiologists who are registered on the medicine board of Medicine. They work in The 8 most populated counties of Arkansas, that doesn't serve the rural and underserved communities in which CRNAs provide almost 100% of care too. So AA cannot work in those areas. They can only work in these well populated areas with physician anesthesiologists directing their care. Um, Additionally, the Centers for Medicaid and Medicare Services does not recognize anesthesiology assistants as independent providers they can only seek reimbursement, and this is where we get into the billing of things, they can only seek reimbursement in Situationss where anesthesiology assistants meet certain rules of being supervised to get Insurance reimbursements from the government as well as private insurers. So they will not improve access to care, um. Additionally, you know, my, my bottom line questions are are. Sorry, I get a little passionate about this. It's something that I, I live, I breathe, I teach. Um, I have been, I have received anesthesia care from military treatment facilities as well as civilians and in rural areas. We really need additional assistance. However, anesthesiology assistants are not the answer to that. They are restricted. They will not improve access to care. There is the potential when it comes to billing to commit insurance fraud if they do not meet very 7 very specific rules of engagement, so to speak, using a military term. Um, so my question to you is, you know, why? With Two well developed programs with approximately 71% of those students who are trained here and remain here, why bring in another provider who does not have the track record of a CRNA with a very well established history, track track record of education and and as nurses have been the number one trusted profession for the last 23 years in a row. Why bring in another type of provider. In this type of system when we're already meeting the workforce demands of the state. Since the VA, the military, and the VA do not recognize these providers. I can present all the data. All the statistics that you want. I love crunching numbers. I've provided some information. But the bottom line is, who would you rather have take care of you and your family members. A doctoral level graduate with 7 years of formal education and an average of 3.5 years of critical care experience before they get into a nurse anesthesia educational program. Or a Master of Science prepared graduate with no required health care, no required health care background or experience. I know my choice is clear. Thank you. Thank you, ma'am, for your testimony. Any questions by the committee? Representative Rose, you're recognized for a question. Thank you, Mr. Chair. Thank you for your testimony today. Uh, I had a couple of questions. Uh, you made reference to uh And make sure I'm accurately depicting your testimony, please. You made a reference to the AA training. Mirroring the 2000 hours roughly, I think it was of the of the masters and that's anesthetist degree, is that correct? OK, I'm gonna try and not have to say that word. You can use CRNA. That would be great, thank you. But that that the AA training is mirroring that. It is in attempting to mirror. I'm saying that. My, my first uh question was you referenced um The, the terminology of the these folks just having to obtained a bachelor's that excites them, whereas the CRNAs have gone through a BSN program. Is that correct? Does a BSN have training that is specific to becoming a CRNA, a nurse anesthetist. The Components of a BSN program include 2 years of liberal arts, which is that sociology, sciences, chemistry, physics, um. Biology type programs or classes, and then, um, the Actual two years of hands-on. clinical experiences. The Rotations in those two years of experience do include intensive care, critical care, and emergency options as well as maternal child OB pediatrics, general medical surgical rotations and others. There are very specific criteria that are put out by the national state boards of nursing. That dictate those requirements. I got you. And just to Make sure I'm understanding you correctly. Was there specific training to Being in anesthesia provider, there is the opportunity to have exposure to it. So for instance, in my baccalaureate program, I did an externship after I graduated to rotate into the operating room and to spend time with anesthesia providers and in the operating room environment, which is what encouraged me to pursue this career. Got you. Great. And for me, this is definitely not trying to to disqualify CRNAs. I think that you and your colleagues do an excellent job. And before I move on to my next question, that externship that you did in anesthesia, uh, is that what was required to go on then to do that CRNA master's degree. It was not required. There the requirements for the nurse anesthesia educational programs. Uh, highly encouraged shadowing, um, training in ICU with specific critical care requirements to the the. The higher level of acuity and the sicker the patients, the better those matriculants do within the programs themselves. I follow, so certainly a BSN graduate has uh significant credentials in in nursing and experience, uh, but to go into that master's and SSI program, which is similar to the AA training. They're not specifically required to have studied anesthesia. OK, no, and there is no longer a master's program in nurse anesthesia. They have all trans po s ition ed to a doctoral level program which then not only encompasses the anesthesia curriculum, but leadership, um. Quality improvement, quality assurance, evidence-based practice projects as a requirement for graduation. I had two questions that I've asked, um, opponents of the bill who've spoken to me about this, and I haven't really felt like I've gotten a good uh direct answer. Um, couldn't see RNAs NAAs. Work collaborative, collaboratively together in completing tasks, um, if Arkansas were to open up to AAs, and I want to be very clear. I'm not speaking to oversight because that's typically the response. Well, no, no, CRNAs can't over, over CAAs and that's not what I'm saying. But couldn't tasks simply be divvied up among CRNAs in any AAs that are able to operate in a hospital or a medical institution that would utilize them. And, and provide a more efficient means of, of, of completing the, the, the needs of the hospital or or the physicians at hand or the patients. I just want to clarify that. So you're asking if AAs could work alongside CRNAs to complete the same amount of work. They just couldn't they work collaboratively? Let, let's say CRNAs have tasks 1 through 10, and maybe you feel really, really good about tasks 1 through 7, and you're you're pressed, right? I think everybody feels like in this industry we're short, we have a shortage of of help. Couldn't AA's come along and be like, hey, you know what, we're really good at tasks, 89, and 10. Couldn't you collaboratively work together if there are more, if there's a larger pool of anesthesia providers in the state. Unfortunately, there is a num there are a number of policies in terms of working with AAs. The currently because AAs have a different education, training and background. We are not CRNAs are not allowed to supervise them, and I'm Specifically not mentioning supervision, OK, and as far as collaboration though, nurse anesthetists are trained to be autonomous, independent providers of anesthesia care. So all of the tasks that could potentially be done can be 100% completed by ARNA, but they cannot be done by an AA without a physician anesthesiologist telling them to complete that action. They cannot take that independent thought. They cannot take that independent action because that is the whole premise of their profession is that they are assistants to a physician, anesthesiologist, and can only act on the direction. Of that physician, anesthesiologist, not a CRNA, so I'm afraid that the answer would probably know that they could not work collaboratively collaborate collaboratively and I struggle with the word. It's fine. I have a couple of follow-ups if that's where I'm chair. Uh, let me try and reiterate this just to see, um, and, and I understand your position and I kind of feel like I have a hard time breaking through the wall of practicality on some of this. Um, can I make 11 statement? We, we have no Um, nothing against anesthesiology assistants and their work and their practice, what we really want is anesthesia providers to be doing bedside anesthesia care to maximize the efficiency of the model that currently is in place in the state of Arkansas. Anesthesiology assistants cannot help that model of care, because again, they're restricted to practice under a physician anesthesiologist. We are all about, let's get everybody to work. doing their own cases. We have never been against their, their profession, there is a, there is a place, there is a time and there is a position for them, and many states have used that. However, there have also been some negative impacts on bringing AAs into a very well established, uh, practice with independent CRNAs. I have a letter from a colleague of mine in South Carolina where they had, they had some staffing shortages. They thought bringing AAs in would be the answer to the problem. They brought AAs into the answer to answer the problem and what ended up happening because of the model that anesthesiology assistants work under, which is called medical direction. Basically, the physician has to tell them what they can and cannot do. What ends up happening in a situation is that the CRNAs start to get treated that same way. And when you have been a CRNA for a long time on the front lines. of your hospital or in the military and you're told that you can no longer do something unless a physician is in there telling you what to do, that has a tendency to degrade workforce morale and CRNA's leave that particular site and go to places where AAs do not work, and this is what has happened in a number of situations. What the the follow up is that there were no longer to meet the number of surgical needs, which is the money generating arm of any hospital, um, and they have been repairing that. Because they were not able to get A hiring pipeline into that particular facility. So they basically have been fighting to get CRNAs to come back on board and have slowly, gradually. fine tuned some of the, the scope of practice within that facility to repair this damage, so there was a fiscal impact in the seven digits to this 11 facility where they brought AA's in. Thank you. You got me there when you asked to just make a statement. I'm sorry. I get a little passionate about it, bring me back to the room. Yes, now listen, um, I, I want to go back to You make a good point that the AAs need to work under the direction of the physician. I follow that. And you make a good point that that is different than the autonomy that the CRNAs have. So I want to ask you just First, which is, I hope it's just a yes or no question. Do, do CRNAs assist one another in completing some of the, some of their daily duties or individual tasks serving patients. Yes, because we have the same background, education and training. All right, great. Um Are some of those tasks, things that you could do yourself, but it makes things more efficient to have assistance. In my personal experience, no. So when you're asking for help, it's because you can't do it. No, no, no, if I'm, if I'm asking for help, it's because I need additional assistance to do what I am doing because I feel I owe that to the patient to be primarily responsible for their care. Now, as an anesthesia provider like an AA working under the direction of a physician. Recognizing that there is assistance that's needed. Could an AA simply provide assistance in providing anesthesiology, anesthesia support. To you or a patient, if the doctor said, hey, assist the CRNA with this thing they said they need help with, that you're trained in specifically because I imagine, even though you may be trained separately, that there has to be crossover in some of what you're providing in service to patients. We, we could potentially do that. However, there was a piece of legislation that was just recently passed here. I don't want to ruin your testimony that does not let us do that. We cannot delegate to an unlicensed professional, right? And I'm not asking you to delegate. I'm saying if a physician, the the anesthesiologists themselves who oversees the AA delegates the task, and I heard you say potentially it's possible, which I follow. I understand there's some guidelines. I know that there's rulemaking when things like this happen. Thanks again for the latitude. I'm almost done, Mr. Chair. Um. You had said in your testimony that this absolutely will not improve access to care, and it is my belief that expanding the pool of anesthesia providers could simply provide more efficiencies and more availability to provide anesthesia for those in need. My last question is, and I haven't had this answered very well, because I keep being told that opening Arkansas up to AAs will like force hospitals to have to hire a A's and they don't have an anesthesiologist, and it's going to be this disaster. In your expert opinion, I'll give you the chance to tell me, uh, does opening Arkansas to AA somehow force hospitals to have to hire AAs, whether it's rural or urban. Well, I think it will force them to consider it. To their fiscal demise or detriment, I should say, not demise, detriment because the, the model that AA's work under is only going to serve the most populated areas which are already very densely populated with anesthesia providers. They're currently are not as many positions open as there were 2 or 3 years ago. That shows that the demands that that are there are being met by the supply that is out there, and the current trends show that there are more, more and more. Individuals interested in these programs in. The 6 years that I've been here. The demand for the seats at UAMS alone. I'm just gonna speak some statistics. There were 495 applicants for 16 seats. So there is a demand for these programs. There's probably a demand for AA programs as well. However, we are meeting the demands of the institutions currently. So why bring another provider into the state. And say, Here, here's an option, they're going to consider it, not realizing the fiscal impact that could the unintended consequences of that action. I'm thank you for your, for your answers and your testimony and, you know, you'll notice if you look at this bill, I'm not listed as a co-sponsor, and when I've talked to proponents and opponents. I've just been navigating because I think there's a lot to take in here. But one thing that I want to make a point of is the mention that hey, this is only gonna work in populated area where there's, there's significantly more anesthesiologists and all I'll say is, I don't know that there's just an abundance of anesthesiologists anywhere across state, whether it's rural or urban, uh, my wife had a a bilateral mastectomy a couple of years ago and the anesthesiologist who we thought was great, I think works 1 or 2 days a month, and he had been retired because there was a shortage in need. So I recognize that, but I, I kind of will reject the claim that there's just this an abundance, because I don't think there's an abundance anywhere in the state. And again, providing pathways for expanding the pool of anesthesia providers. I'm beginning to see as a strength in Arkansas, and I thank you for your testimony. I thank you for the latitude, Mr. Chair. You're welcome. Wouldn't you agree? Any, any other questions by the committee of this witness? See Nun, thank you for your testimony. We do have one other person that signed up to speak against the bill. Thank you for your time. Casilla. Casa Kasha. Third time's the charm. If you will introduce yourself for the record and you're recognized to present your testimony. Good morning. My name is Kashaabian. Thank you committee and chair for allowing me to speak. Um, I'm a certified registered nurse nurse anesthetist practicing in Little Rock, Arkansas. I am the immediate past president of the Arkansas Association of Nurse Anesthetists, and I currently sit on the board. I was born and raised in North Little Rock, Arkansas, and have had the opportunity to practice in multiple practice settings including anesthesia care team models and independent practice my testimony today is. Informed by both my clinical experience and my commitment to providing the highest level of care possible for my family and Arkansans. I would like to add um to Doctor Gonzalez's testimony, um, she, she stated that she had many years of ICU experience. I had 6 years of ICU experience before I went into anesthesia school. So HB 1251 seeks to introduce anesthesiologist's assistants into our state anesthesia workforce, as already mentioned, we have a strong cost effective workforce with over 1000 CRNAs licensed in the state, and we have 50 graduating each year. As mentioned, CRNAs do not require physician supervision, which makes us a more flexible and cost effective situation. If AAs were introduced, this would require a physician anesthesiologist to supervise them at a maximum ratio of 1 to 4, as also mentioned, they failed to expand access to care since they cannot practice independently. Currently, Arkansas hospitals use us because of our efficiency and affordability. 87% of anesthesia cases in Arkansas are billed under the CRNA, the CRNA-led model, even when anesthesiologists are present. If AAs were added, hospitals would be required to use the more expensive physician supervised model without receiving additional reimbursements. So you're A's and AA's have comparable salaries, so why introduce a provider that increases costs without improving care. Doctor Johnson alluded that there were about 3000 AA's nationally. There are 78,000 CRNAs nationally, and there are 55,000 anesthesiologists nationally. In Arkansas, we have 1000 active license for CRNAs in Arkansas alone, and we have 340 anesthesiologists. The other point that was mentioned was this bill lacks key oversight and could violate Medicare guidelines. It doesn't provide clear regulations on critical issues like the supervision ratios and the Medicare compliance requirements. The American Society of Anesthesiologists and, and Medicare have agreed on 7 elements that must be documented for the anesthesiologist to bill his or her medical directions services. So in reference to Representative Rose's question earlier. He was asking about if we can do the same tasks together. Well We, we treat patients individually, so if I have a patient and I'm putting a patient to sleep, that's my patient and AA is not going to be walking around the operating room with nothing to do. I mean, we don't, there's not that much money out there to let people that make what we make walking around, so everyone is tied up doing their own one on one case. If there's an emergency. You call for an emergency. There's usually what we call a floater that's out there that can come in and assist if there's an emergency where we run into difficulties, um. So back to that. The medical direction model, the way it works is those 7 requirements that are required for anesthesiologists to medically direct. So for example, most hospitals start at 7:30. Cases start at 7:30 for the day. Let's act like I'm an anesthesiologist and I'm supervising for AAs. It is physically impossible for me to be at 4 places at 7:30. Because you have to go in there and you have to be present for induction. That's pushing the medication that puts you to sleep, securing the airway. And then the anesthetic starts, so it's, it's, it's impossible for that to happen, so that's why this medical direction model is very, very difficult to maintain. There are many studies that show that when an anesthesiologist is supervising two providers under medical direction, the noncompliance rate is 35% if they're supervising 4 under medical direction that noncompliance increases dramatically. The majority of the hospitals in our state that are practicing under an anesthesia care team model, the ratio is usually 1 to 4 or more. And they don't have to meet those Medicare guidelines in Arkansas, we have 3 hospitals that are currently under Medicare, medical direction, and that's UAS Children's and then Children's in Northwest Arkansas. Um, my husband worked at UAMS. He's a CNA. He's been practicing since 1996. He went over there and did not last for for very long for the medical direction reason because he was used to practicing independently and at the end of the case when the patient was ready to be extubated, he couldn't physically pull the breathing tube out of the patient because he had to wait for his anesthesiologist to come into the room. That's one of the 7 requirements that are required under medical direction for billing, so he found that. very frustrating, very limiting to his scope of practice, so he left and went somewhere else, so I think this is one of the things that could potentially cause problems when you have CRNAs and AA's working in the same place. So AAs do not expand access to care. We already have two programs that are in our state. UAMS is new. It, it hasn't, it's only graduated two classes, so we would like the opportunity to continue to recruit and graduate CRNAs in our state and keep them here. So in conclusion, I ask that you think about how you who you would want standing at the head of your table, putting your mom, your dad, yourself, your children to sleep, no matter how big or how small the procedure is when seconds count. I know what my choice is. I ask for your vote against HB 1251. Thank you. Thank you, ma'am, for your testimony. Any questions by the committee? See you then. Thank you for being here and for testifying I'm Michelle went first. Is there anyone else in the audience I'd like to speak for or against the bill. So you know Representative Johnson, you're recognized close for your bill. Thank, thank you, Mr. Chairman and committee members. You know, this is not about how well trained CRNAs are. CNRA CRNAs are excellently trained. A lot of the testimony here, I agree 100% with their training, um, this is not about, um, you know, who, who can and can't do certain aspects of a job. This is about providing flexibility to our system and options, right? If you have a toolbox in your toolbox, there might be a traditional wrench that you use. And there's also going to be a Docket Ranch, right? And sometimes you're going to want to reach for the traditional ranch because that's the tool that fits. Sometimes you're going to want to reach for a socket wrench because that's the tool that fits, um, which tool you reach for depends on the job, the situation. No one would say that a ranch, traditional wrench and a socket wrench are the exact same things or that they're exactly the same sophistication of a tool, but there's a place for both those tools, right? Um, some of the testimony I heard, you know, she mentioned that we have 2. RNA schools in this state, that's great. That's great. We don't have an anesthesia assistant school in the state. Part of the reason is because we don't recognize that group, right? I think what I heard the testimony was is that there were 400 applicants for 16 slots. That means that there's a lot of interest in our state and people coming and training for anesthesia in the health care, and yet there's only a handful of people that are accepted into these programs, you know, there was testimony around who provides anesthesia in the state. Certainly CRNAs provide the vast majority of nonphysician anesthesia because there are no anesthesia assistants in the state, right? Um, as far as who comes and who lives here, you know, the young lady that we had here the other day, she went to school at the University of Arkansas. She loves this state. This is where she came to college and would love to return back to the state. So there are plenty of people in the surrounding states that are looking for the opportunity to come back to Arkansas, but can't. There is no requirement in this bill to make hospitals use this model. It sounds Like to me, there are definitely hospitals that want to use this model, but CRNAs are not happy participating in that model, which to me points more towards the demand for anesthesia assistance assistance, right? If we want to give our hospitals the freedom to use whatever model they want and CRNAs aren't wanting to come and work in this model, why wouldn't we give them the option of having anesthesia assistants come and provide this for our hospitals. Um, you know, to me this is again about providing an opportunity for well-trained individuals to come to our state and work, and I'd be happy to answer any questions members might have about the bill. You have a motion, a motion to, I'm close but I have a motion to pass, OK?it members, we have a motion on the table to pass any discussion on the motion? Seeing none, all those in favor say aye. All those opposed. Congratulations, you passed your bill. Thank you, members. Committee members without objection, we're gonna go back up our agenda and we're gonna pick up at House Bill 1218 Representative Mayberry. Representative Mayberry, are you wanting to run 1218 or 1241. You recognize to present House Bill 1241, if you will identify yourself for the record and ask your guests to identify themselves for the record. State Representative Julie Mayberry, District 92. So Can you, can you hear me? My name is James Hunt. Um, I'm a physician here in Central Arkansas and father of a young man with Down syndrome. Hi, I'm Ashley McMillan, and I am a dentist here in central Arkansas and provider of services to patients with special needs. Members, I'm gonna let them do a lot of explaining of this bill because really this is their brainchild, um, but I, I love this bill because Of the things that I'm getting ready to tell you, first of all, we're going to help meet a critical dental need in the state of Arkansas that we're facing with individuals with special needs. They're really struggling to get the care that they need, um. For good oral health. We're also going to buy this bill train a whole new generation of dentists and helping them understand how to meet the needs and how to care for those with special needs. This bill will also save taxpayer dollars because we've come up with a clever way to reduce cost, and I hope that that speaks loud to many of you that we're going to provide excellent care and save some money. We're also going to prevent some of our children and adults with special needs from having worse situations because they're dental care is not being taken care of, and that will eventually lead to more complicated health situations and then something that is not going to be found in the the words written here in this bill. But I'm telling you that we are going to lower the stress for families. And we are going to improve the overall mental health of families raising children with special needs. They often are struggling to find the right doctors and the right care. And when we can more easily find that care, you're going to help them in such tremendous ways, and you will hear from some people who will share those exact experiences, but I'm going to let Dr. Hunt talk first. Thank you, ladies and gentlemen of the committee, I appreciate you uh granting us time to speak to this today. Uh, there, uh, Arkansas does an awesome job of providing safety net services, medical and dental care for our loved ones under the age of 19. Um, after the age of 19, support for that very vulnerable population. I'll, I'll talk about here in just a second, uh, fades off to a dramatic degree. And what We're left with are populations of human beings are Kansans, um, who are the most vulnerable populations we have, those with moderate to severe intellectual developmental disability or complex behavioral issues. Those who have um severe uh and complex medical issues such as transplant patients or or cancer patients uh that are on Medicaid and those who have complex cranial facial conditions that are, that are near completion of their cleft palate repair, for example, who fall through. the cracks, who don't have the support to for their dental, their oral health care needs, and they're left with having to seek that care in emergency departments or in hospitalizations or leave the state even to provide that care. the only child God gave me and my wife is now a young man with Down syndrome, is 22 years of age. Um, and Al has received uh dental and medical care through Arkansas Children's until he aged out. Um, unfortunately, Al now um as a 22 year old man like uh many of his aged peers who may require sedation or anesthesia services in order to to complete a normal oral health care for the rest of us. Doesn't have access to that care. There, there are currently not institutions in Arkansas that can provide at scale, uh, the services, um, I am an anesthesiologist by training and by trade. But anesthesia care is not covered under adult Medicaid care for oral health care, um, so patients like my son can't access the sedation or anesthesia care that they need. Unfortunately, um, In scenarios in which they do uh managed to gain access to an OR setting or a surgical center setting in Arkansas, the costs to provide care for somebody like my son, um, can be easily over $11,000. Um, this and our goal in providing a different pathway is to save some of that money that, that, that, that cost is frankly exorbitant and is not sustainable um for any state, but there are pathways in which we might be able to provide oral care. With sedation or anesthesia services when needed in a scenario that can provide the expertise and safety mechanisms and do so at scale at a much lower cost and that's the point of this bill. Hi everyone. Thank you so much. I want to echo Dr. Hunt and thanking you all for giving us time and listening to us, I'm very short, so um I think they can probably hear. OK, perfect. Um, again, my name is Ashley McMillan. Um, I am a dentist. I am an Arkansas resident and native Little Rock native, and I have been a dental practitioner in Little Rock for the past 10 years. I have spent the entire decade of my career taking care of patients with special health care needs, whether it be patients needing dental treatment prior to head and neck radiation or chemo pre-transplant or post-transplant kidney and liver, whole organ, stem cell, you name it, medical complexities are what I have spent my time doing from a dental perspective. More recently, I have been going to the OR and providing care for patients who could not get dental care in a conventional setting. Most of us without neurodivergent diagnoses can't tolerate dental care in the conventional dental setting, um, so you can imagine for patients with special needs being able to tolerate what is previously been thought of as a traumatic experience, um, I can tell you right now in 10 years there's not a day that goes by where I don't get a text message, a phone call or an email from physicians, families, fellow den fellow dentists and my colleagues that have nowhere to send these people and my knee jerk reaction and response is unfortunately always out of state. It has, it has reached a crisis level for these patient patients and their families, and while I do believe. in the private market. I don't see it fixing this problem and I haven't seen it fix this problem in the last decade. And if this bill passes, it would create a start of a solution for a very real and very large problem that, as I said, is at crisis level for these families. The advantage to doing something like this in a training environment is that I believe in sustainability of anything and not a band-aid patch solution for anything that is temporary and in order for something to be sustainable, you have to train the next generation of clinicians and providers to be comfortable with administering this type of care, and that is what I have dedicated my career to is dentistry and education. and I, I want us to be able to train the next generation of Arkansas dentists to go out in the rural community and elsewhere because travel was difficult for these families, so this is the start of a of a solution to a big problem that could be scaled over time when you do it in an environment like this. The last thing I want to leave you with is whether you think that it affects you or not, we are all one adverse event from being a patient with neurodivergent diagnoses, we are all one early Alzheimer's diagnosis away. traumatic brain injury, one stroke, or one car wreck away from being in this patient population and not being able to receive dental care in a conventional setting without anesthesia. Um, I want to thank you so much for your time um and hearing our passion for this and uh we appreciate your support. Any questions from the committee? Representative Rose. Thanks, Mr. Chair. Thank you for your testimony. Uh, thank you for your presentation. Uh, I was looking at page 2 lines 13 through 20 of the bill, and I can get through the minutia. It, the line 19 says, Uh The reimbursement cost is to be 1% above actual costs incurred. Is that industry standard? I'm not, I'm not an expert in this area. Do you know why it's a percentage above direct costs by any chance? We, we modeled um development of, of this model off of specialty specialty clinics that are are medical home models that are already present in Kentucky and Tennessee, um, and our goal was to provide for the cost of staffing the space, um, the difference between this scenario and what's typical in a hospital or surgical center setting is that this doesn't require contribution to overheads or facility fees that are that are typically associated with with tertiary centers. So by eliminating that we're asking only for the cost of staffing the space, the 1% overage accounts for consumable materials that may that may increase the price from year to year. So do you know if that 1% is Federally reimbursed. I, I'm not quite sure I understand the question I'm just wondering if you, if you know. Yeah, how that is reimbursed. Like if we're requesting 1% above direct costs. Is that reimbursed or is that 1% at the burden of the state or how that is recouped. The 101% would be the cost to DHS or Medicaid. OK. Do you have anything else to add to that? Well, I, I mean, if, if you would like someone from Medicaid to come to the table and explain, but it would, it would be billed to Medicaid, and I would think that the um application of Federal versus state would still absolutely apply. Well, I think, I think, I think what you're doing here is, is, is, is very admirable and I think the service that you both provide in your professions is excellent. I just saw that 1% above actual cost and that just kind of stood out to me and I didn't know where that specific number came from and and who's paying for it. If, if you think there's an expert who can more specifically address that, I'd be open to it, but if, if you feel good about where we're at, I'm fine as well. Representative, are you making a request for someone from Medicaid to come to the table. Uh, if they're here, that'd be great, I guess, yeah, thank you, Mr. Chair. You're welcome. OK If you will, please identify yourself for the record and you'll be recognized to answer the question. Good morning, Janet Mann. I'm DHS and Medicaid director. Thank you. um. I don't know how that works. So, um, it, it will be subject to state and federal approval, the 1% above cost. We do not currently pay that way in a clinic setting, um, or in a hospital setting, so it would, it would be subject, we would have to file the appropriate paperwork and work through, um, those details. So I don't know if it would be or would not be approved. Um, I would like to add, if I may, Mr. Chairman, um, the states that, um, Doctor and I'm thank you, Doctor Hunt, um, referenced with Kentucky and Tennessee are primarily managed care states. So we would need to look at how they are administering the program. Does that answer your question? Follow up. You recognize if you said it would have to be approved. And so if it were not approved, does that mean that 1% is not covered or the whole 101% would not be covered. The entire, it would not be eligible for federal reimbursement. So we would have the cost would have to be considered for 100% SGR or we would have to seek an alternative payment model. Could you explain that in real simple. minded layman terms. yeah so our medical claims that clinicians file every week are paid with a combination of state and federal funds to make the 100%. Currently, the state puts up 29 cents on the dollar while the federal government supplies 71 cents on the dollar if my math is correct to make 100%. So when we would apply for that approval, we would be seeking approval for them to pay the bulk. of the bill. So if it's not approved, then I think that the entire bill would be subject to 100% of state general revenue. I was about to say, so then what typically happens if it's thrown out by we usually seek an alternative payment methodology or seek some type of condition so that it can be approved. We um we treat most of our, um, funded appropriation as matching money we don't tend to use it for 100% SGR. So I was gonna say if we pass this. With the best intent And Do you have, do you have, I'm not asking to be for or against, I'm just saying if, if we pass this, what would be your expectation of whether These things would be approved or not. I really don't know. OK. I, to be fair. All right. OK. Thank you. Thank you, Mr. Chair. Thank you. Representative Bentley, you're recognized for a question. Thank you, Chairman, and Janet so, so do we have any type of, uh, I'm looking for a physical impact on this. I'm definitely supportive of what we're doing. So is there antifisical impact that you can give us at this point or any, any idea what we're looking at. We, um, we have struggled with a baseline for a physical impact because of knowing the cost for each individual case. We have, um, we've been working on this issue. I think, um, as representative Mayberry and Doctor Hunt and and others have testified, this is really um a statewide problem and we're trying to find a way to address it statewide. We currently have some things that we've been working on. This is a different look at it with tied to um a dental school. So we just don't have a baseline of how to make an estimate yet. Thank you, ma'am. Representative Johnson, you're recognized for a question. Thank you, Mr. Chairman and thank you all for your presentation. These microphones, man, am I the only one that has trouble getting him out of here without, yeah, uh, so, you know, um, and I'm gonna start with some commentary and then a question, um, so one of the things that I've tried to break away from recently is I tend to hear a problem and describe the solution more than I'd describe the problem, right? I tend to jump to, here's the solution, but what I'm hearing for sure like and this is to you, director man. Do you agree that there's a problem right now in this state with how we're delivering care for this subset of patients around dental health. We have recognized that there is an issue and trying to address it when a lot of these patients are in the past. We've been working with the passes. We've been working with UMS and we've been working with other, um, clinicians to try to address it and not saying it, it's perfect, but, um, we have been working on it. So you would agree this is a problem as a state that we have a responsibility to address and fix. Yeah, and Dr. Hunt, I, you and I've visited before, I'm trying to understand a little better how um and and I know you some of this new testimony, can you outline again how we got from where we were, where we were sort of supplying some of this care and the history of that and now where we are, where there's this gap. Historically, Arkansas Children's Hospital absorbed the role of providing, providing care, including anesthesia services for adults in these complex populations, um, uh, Arkansas Children's, um. faded out that support by 20 over a period from about 2018 to 2021 and as of, um, as of the last two years, they will not accept patients over the age of 12, um, for in these in these complex categories for anesthesia services, um, and as, as a dovetail during the same decade period, um, UAMS was performing some ad hoc or ad lib cases. Um, and I had the good fortune to be involved in some of those um some of those cases, but no consistent care over time. We did attempt to have a series of trial cases at UAMS this past year, um, we did about 11 cases over a 6 month period, um, but the waiting list was, was several 100 long behind that. Um, and the cost of our concerns over the cost and continuing to do that caring in conversation with DHS that makes it fairly apparent that we need a, we need a different model. If I can have a follow up, do we have a sense of how many people, individuals in Arkansas, this affects. Do we know how many? How many adults, kids fall into these categories. didn't mean to stump anyone. I'm sorry, I was, I was looking, yeah, about 15,000 I believe. Within the the there are about 15,000 individuals in the state of Arkansas who are in some sort of neurodiverse condition, some sort of developmental delay, who, who need routine dental care, um, and would you agree that that's a subset of the population we as a state have a responsibility to care for. I'm looking at Doctor I know your answer, Janet. I think, I think I did. I would ask your answer too. I think, I think we've, I think we've recognized that we've been trying to take care of these patients. Yes. OK. I don't, I don't have any more questions, uh, if there's. A comment time. Uh, Ashley to respond to one of the questions you were asking if you don't mind. I just wanted to emphasize that this particular model, what people don't realize is that when you take something like this out of the hospital or the major institutional setting you you can save about $10,000 per case because you're not posting a facility fee um for that particular case, which drastically reduces the burden on the state and so we've tried to be as creative and compact as we can and effective with the way it's been packed. So just something to keep in mind. Representative Pilkington you recognize for a question. Thank you. I just want to make sure I understand that comment correctly. So you're suggesting there's a cost savings associated with passing this legislation. Correct. OK, got it. OK. All right. Representative Rose, you're recognized. Yeah, I have a question, but now with what you've just said, I kind of would love for you to speak to that a little bit more. You're talking cost savings and I'll just prequalify. Part of my concern is I had a, and I'm not sure uh Miss Mann, how familiar you are with it, but I just recently had a constituent who was trying to get an eye transplant. They're trying to go through Medicaid and some things. It just didn't work out. Different physicians, different funding opinions, etc. and it was difficult was she was of the belief should be able to get this going blind. And she's not able to get the transplant unless she's raising money and she's actually independently raised money and is finding a pathway to find the surgery, but we weren't able to do what we hoped we could be able to do and what I don't want to see is do something like this with excellent intentions for people who have absolute need and then for whatever reason, whether it's cost or formulas or something, we're not able to provide what we're hoping to be able to provide, but now you're saying there's cost savings. Can you speak to that? You should have led with that. with this room here. Can you speak to the cost savings. I, I want you to speak to that because of the anesthesia charges and all those things. Um, so currently, uh, when, uh, Medicaid cases are billed, uh, for anesthesia services or, or operative services in an OR setting and, and we've referenced UAMS. It's not just UAMS, other tertiary centers in in the space, um, would operate the same way. There are, there are fees outside their physician or provider fees, there are fees associated with the facility itself and there are fees associated with anesthesia services. Currently Medicaid does not pay for anesthesia services for dental care, uh, for this population set those services are paid for out of facility fees and um uh and other fees that are assessed by the hospitals or or the surgery centers, um, so the, the primary cost savings associated with something like this is frankly removing the overhead associated with a tertiary center like a Baptist or a UAMS surgery center and paying simply for the staff and their and the consumable equipment, the things, the medications or, or, or the endotracheal tubes, those kinds of things that we might use, so the, the cost of the overhead cost associated with it is eliminated. And who's currently bearing that cost? The, the hospitals and the state. Um, I, I don't want to use the radioactive term of applying for some kind of a statement that gives us a fiscal impact, but I'm wanting to know if, if we can like do we have Hard number that you can put in front of us if we know how many people this is, can you accurately say what the cost savings will be. I cannot, um, testify to the cost savings, I can give you some of our statistics from some of the work that has been done and paid for by DHS or Medicaid, um, recently is, um, anywhere from a range of $22,000 to $13,000 and some people that they do see do not even need anesthesia. If this is a case by case, um, situation depending on the client and what they are going to need. So I, um, I just That's what my team was texting me on statistics. You said you couldn't speak specifically to the cost savings. Does that mean you can't speak specifically to how much it would save or that it would save. I, I don't know how, so my, my struggle was, I don't know how they calculated their cost and then to put the 1% over that to then be able to compare it to what we've been paying. We've struggled with getting that baseline, and I just asked her when, when we were, um, talking, I'd love to see her numbers on how they calculated the cost savings because I think. And from what we've been paying and what we've been trying to negotiate and deliver the service, it does have, you know, a vast range depending on the need. I yield back to any other members who might have questions about this because I'm still thinking through some things. Thank you, sir. Any other questions from the committee, Representative Johnson, you're recognized. Yes, so it's an interesting concept. I'm over here frantically Googling, because I do think like so Dr. Hunt, this question is for you and maybe for Director Mann or whoever else could answer it. When a person gets to the dentist and sees a dentist or they charge a facility fee and a pro fee for that or just the pro fee for the dentist. Just the den right, and so, but these procedures are because of the nature of these individuals, they're having to receive some and sometimes general anesthesia to have these procedures done. So these procedures have to be done to an ambulatory surgery setting. Currently, yes, sir. OK. And so if I understand correctly, when a person has a procedure at an ambulatory surgery center, there's a fee for the services of the physician or provider CRNA, whoever's doing the procedure, right? And that's the professional fee and that has a cost of X. Uh, just in brief Googling, would it surprise you if that cost is, you know, less than $250 on average. For each provider provider, yes sir. And for the facility fee, would it surprise you to know that the average collection for a surgery center facility fee is around $1000. That would be a little surprising, yes, sir. Well, that's what Google says. I don't know I mean just rough hit napkin back of the napkin math. I mean, if, if you're saving $1000 per case at a surgery center and you're asking for 1% overage on the pro fee 1% of $250 is $2.50 which is less than 1000. So I do think, I mean, I do think that's that's good with that. I'm quick that way. I, I do think that there's some opportunity in this model for cost savings. whether the 1% is the right number or not or what the model is. I think that's, I think there's a lot of, like, again, this is, I don't, I don't want to trust the state's budget to napkin back of the napkin math. Uh, so I'm very interested, like I think a lot of members are in what the actual, you know, cost is and what the cost saving is, it is the 1% ride, and I think there's a lot of math that would need to be done for me to feel comfortable that this is the right solution 100% for the problem. I know there are other solutions being discussed. out there and you know, I think it's, I think that we can all agree this is a problem we have to address, but do you agree there could be other solutions besides this one that might also address the issue. Sir, I'm, I'm open to any solution that helps provide care for. My son's peers, um, it's such a desperate, uh, uh, and, and demoralizing uh phenomenon in in our state currently. Thank you. And what I will say that's not captured in those cost savings is that the dental model is different than the medical model and that we build parent codes that include all of our consumables. We do not a la carte charge like in a a facility setting where you charge nurses every single thing that's utilized is scanned and added to the total fee. Dental codes don't work that way. The code consumes every cost that is entailed to provide that service, so I just wanted to keep that that's some unspoken cost savings that are are hard to Specify and quantify, and I wanted to mention that. Representative Pilkington, you reckon ask for a question. Thank you, Chair. So just to the sponsor, so. We were our I guess Janet because you say you guys are having trouble getting a baseline. I mean, is the fiscal Service division of BLR just came back and said we just can't calculate this number, I mean. I can't answer for BLR. I'm talking when I say physical impact for us, it's internal at DHS, so I, I don't know Julie, have they told you that they're not able to to calculate this. We've had many discussions, Zoom meetings and and all that and I, I. I'm, I'm waiting too. Um, so. And, and I understand as a legislator, you want to know dollars and cents, um, and, and I understand hesitancy on that, um. But this is a problem. I needed Doctor Hunt to be here. He is a very busy physician. And this is the one day that he could be here and you all needed to hear from him because this is really his idea and his heart and and trying to meet this need and so um we have people who are here to speak on behalf of this bill and some other concerns, and I would appreciate it if we could let some others come to the table and share some perspectives, um, continue to ask questions. I never say that any bill that I present is perfect, and if there are ways to make it better, we certainly want to make it better and I understand some hesitancy to make sure that we've got DHS doing, doing the numbers, but I think maybe this will help DHS give us some better numbers to, to evaluate this as well, yeah, and I, I, I'm not particularly against this bill. I think it's a good thing. I just, you know, I don't want to end up having issues in the interim when we're not in session because we've done something and next thing you know it's blowing a hole in GR, so I think the way that this is, I think it's. A marvelous idea that we need to absolutely explore and I believe that there's some cost savings behind it. You've got the hospitals turning around and saying, you know, sorry, Medicaid's not going to pay enough for this OR room and so where, where are these kids and adults who who need this specialized care, where are they going? And their problem's not going to just suddenly get better. It's gonna get worse and then they're in the ER and possibly having hospital stays from something that really Really big picture if we're training our dentist, which is the hope of, of this facility if we are training our dentists in the beginning. And how to handle some of our children with special needs who might be scared of a sound of a whirling whatever or the smell of something or whatever it might be, or maybe they can't sit still. If we're training them earlier on. Some of them might not end up needing anesthesia because they will feel more comfortable walking into the doctor's office and they will feel more comfortable having the general care and then they won't have the major problems that really require the surgery on down the down the road. That's what I love about this is because we're training a whole new generation on how to handle and take care of our most vulnerable. I, I agree, Representative. I just was really the main question was, can BLR produce a sheet for this on, I don't think BLR will, but DHS, that was my. Our committee, I want to uh kind of clarify some of the questions that are being asked. We have checked into this, so pursuant to House Rule 38S, any member at any time can ask for a physical impact. We do have a member of the committee that has suggested that they would like to make that request just to honor the members of the public who are here not only testifying currently but have signed up to testify. We have two. I'd like to move forward, allow those members of the public to be heard, to testify on the bill while they're here and then we'll recognize Representative Bentley to make a request at the at the proper time. All right, we do have one more question of the committee, Representative Allen, you're recognized for a question. Thank you, Mr. Chairman. Thank you, Doctor McMill, and thank you, Doctor Hunt for what you're doing. My question is this. What the benefit Our way any cost. Especially if it's your kids or someone that you know. Let's go through this. Representative Allen, you're asking that question of the father of a of a young man with Down syndrome. The, the benefit absolutely outweighs, outweighs the cost, but the, the point in doing the bill was we want to control the cost. OK. Thank you so much, but my, my point was this that whenever somebody is struggling with an illness, any type of illness, uh, whatever the insurance pay or whatever the person pays, uh, and I've seen people that will spend their last dime. To save their kid and make sure their family get good health care. So my point is this, um, I don't think that when we look at this cost should be a factor. Because what the people that's gonna benefit from this. It's going far outweigh what any cost would be and the earlier you start treating people with diseases. The, the, the less expensive it is when you get further on down the road with the disease, that's when the cost becomes a factor. So if we can get in right now and take care of this and take care of those patients that need it, then the cost will be reduced. But you all agree. Amen. Thank you, Representative. Any other questions of the committee? Representative Ladyman. This is a staff question, I think, but, um, physical impact would only be required if it negatively affected the budget. I believe the requirement that would be nice to know what the savings are, but I don't think the rule would require it if it negatively impacts the budget. Do you know the answer to that? So the rule that we have looked up and cited just allows any member to make the request, and then it will be redirected to the appropriate agency or um place for a fiscal impact. So we have had a request made so then they would determine whether it's required or not. Correct? OK. Thank you. All right, we do have um see no further questions, we do have two members of the public that are signed up to speak for the bill, uh Tracy McClurg. Thank you Thank you, Mr. Chair. You're welcome. If you will sit down and just identify yourself for the record and you're recognized to present your testimony. My name is Tracy McCarrick. I'm here with Is your mic on, ma'am? Hello. Thank you. Thank you. You say your name for the record and you're recognized to present your testimony. My name is Tracy McClark. I'm here on behalf of the bill. Um, I'm here with my family, my husband Jimmy McClerk and my son Braden McCarrick and my daughter Faith McClark. Um, both my kids are special needs. They've been seen at children's since they were. born. My son was premature. He was a pounding 3 ounces when he was born. I He has been seen for dental. there and now it's no longer able. He gets seen, he's legally blind in his right eye and it's being put to sleep every year for his eyes, and we were Up until 2 years ago we were. Doing that With dental getting to sleep they were doing it at the same time. So we were getting that care. Same time, no extra cost, anesthesia was putting him to sleep with Doctor Lowry. And they are Now children will no longer see him. We do not get care in the state of Arkansas for my son or my daughter. We are having to go to Tennessee at Lavonner. My daughter has a, she is missing her number 2 chromosome and has a disease called amylogenous imperfecta. She's missing all the enamel on her teeth. We are having to go to Leonner about once a month. It's very Stressful, very financially draining, not just financially, it's just, it's just hard on her that we we go to Children's for everything else and we can't go for that. She had back surgery at children's. A few months ago. And um, We can't go for that, um, it's just a shame that the state of Arkansas does not provide care and we're having to go out of state for the care. I do have private insurance. I do have Medicaid. I'm setting, I mean, I'm just trying to here to. Help the citizens I have a lot of I worked at a hospital in Wasville. And I'd have a lot of Friends and family that are in the same boat as me. And so I'm just here to ask for your support. Thank you, ma'am, for being here. Thank you for testifying. Any questions of the committee? And my daughter, um, does not require anesthesia. So Doctor Howe and Doctor, she hasn't seen Dark Hunt, but Doctor Howis representing the bill as well. She goes to the water and just uses nitrous. But nobody in the state of Arkansas. We've tried going to Fort Smith, we've tried going to other places in Little Rock, um, but she doesn't have to go to ambulatory settings to get this care. She can just do nitrous. They used to do that children's, but they will no longer even offer that care for her. Sorry, I just thought I would throw that in there because y'all y'all mentioned the inventory and anesthesia. My son does require anesthesia. My daughter does not. No problem. See, no questions. Thank you for your testimony. Thank you for being here today. Uh, next up for the bill, we have Doctor Burke's Burke. My name is Berk, so, uh, I am the Turn your mic on, please, and if you will identify yourself with the record and you recognized to present your testimony. Thank you, thank you for, thank you for allowing me to be here. My name is Berk So. I am a general dentist and the dean of the of the Lion College School of Dental Medicine. Uh, this, this is, we're, we're obviously talking about a, a big problem. And many solutions have been have been provided in the past and many different people in Arkansas are working on this. This provides a small solution, but something that can build toward the future, so I, I appreciate your, your review of this, and I appreciate the families that have been impacted intimately by this and so thank you for for reviewing this. Sorry, you prepared to take questions from the committee? Yes, sir. Representative Johnson, you're recognized for a question. Yeah, just a brief question. I should probably know this, but I don't. When, when will the dental school be up and running, and if this bill were to pass, when could they start taking care of some of these folks. So we will start, we'll, we will start our first class on June 30th of this year. And we'll have a class size of 80 students, uh, roughly 40, roughly 50% of the students will be Arkansans, uh, that, that from, from all over the state. And so we're we're excited that to, to expose them to the treatment of individuals with special health care needs so that they can go to their communities and provide that care. To answer your question on when, when we will be able to provide this service, it, it should be first part of next year and I think I heard testimony that there were around 15,000 Arkansans that could potentially need, you know, some sort of dental care and there's a special setting. I'm assuming you're not going to be prepared to handle 15,000 folks, but you would be this proposal would make you a part of hopefully a bigger solution. correct. And to, to be clear, the numbers that I have are, are 67,400 Arkansans are, are Individuals with special health care needs, so it's in in the data that I have seen, it's much more than 15,000 if I had a I have a follow up just but would you agree that a percentage of those like the young woman that was able to testify about her daughter. Some of those would require general anesthesia, some wood, and some might be able to just walk into the dentist office and get care without any special treatment. It's hard for me to believe that. I mean, it's hard for me to believe there's 67,000 folks that need this kind of specialized care, I would assume that the percentage, while that may be that many people with special needs, the percentage needing this very specialized care under general or deep anesthesia would be smaller than that, wouldn't you agree? Yes, sir. Thank you. Any other questions from the committee? See none. Thank you, sir, for your testimony. Thank you all. Is there anyone else in the audience that would like to speak for or against the bill? If you will both please identify yourself for the record. Let us know if you're speaking for or against the bill and uh tell us any organization that you may represent. Good afternoon now. Uh, my name is Gina. I don't think you're my son. OK, now my name is Jainna Moxley, and I'm a mom. I'm Eric Moxley speaking on behalf of our daughter, Mary Madison and speaking for the bill, can honestly say Dr. Hunt has helped our daughter. And it's a challenging thing. I mean, I, I tell you, when you have a child that has All the different things we, our, our daughter has autism as a primary diagnosis. So as you can imagine if you've been around anyone with autism or do you have children or family members or maybe friends. There's a lot of things that they process a whole lot differently than we do. So what we think of as a normal dental visit, we go get in a chair. It's a pretty routine thing. I can tell you we've tried that with her multiple times to try to try to overcome that, and we haven't really been able to do that on the dental side. So we've been one, our daughter's been one that has to have sedation every time she goes in, we were able to do a lot um as the other mother mentioned about trying to get multiple services done at Arkansas Children's Hospital at one time, so that it's efficient for our daughter and also for the healthcare system. So we were able to do that, but now they're not taking anyone over 12, so the options we have are to go out of state, Saint Louis, Atlanta, you know, there may be some other options, but we were also one of the pilots that Dr. Hunt mentioned at UAMS, so we're very fortunate that we're able to do that last year and the reason we had to do that is because my daughter had to have open heart surgery and needed a dental clearance. And that's some of the things we probably don't think about here. This is basic care that probably are on most people's mind, but we're talking about things for potential procedures to make sure you prevent infection because the importance of oral health is significant for all of us, right? But we know if we don't take care of that, that there could be a whole lot more significant issues in the future. You might wind up with a hospital stay due to an infection you may not catch. When we're talking about cost, I mean, it, it's pretty easy to look at the difference between what the dental school is talking about maybe in an outpatient setting versus going to a facility like a UAMS or a Baptist and the charges that would be incurred there, but there's also some intangibles that will show up later that you may not think about because of some of the preventive care that can be done. And I was just thinking about this because I, I'm in health insurance industry. I've been for about 30 years. And I was just thinking about some of the questions that we're asking. Certainly there's a way that we could all get together and establish. Some type of fee schedule for this or some type of cost and maybe you differentiate it depending on what the individual needs, you know, if it's a basic cleaning, maybe it costs one thing and if it's more comprehensive, maybe it's like, you know, uh. Inpatient stays at the hospitalists differentiated by intensity. So I was just thinking a little bit about the job. I'm really here as a father, just, just to protect the population. We've been here our our entire lives and my daughter's growing up with a lot of others individuals with special needs that need the same care, so Dr. Hunt's son, you know, we know how, we know a lot of others that this could benefit, that are having to figure out how do we cover this? When you go to another city, there's a lot of expense involved when you're talking hotels, meals, all the things. A lot of people can't afford to do that. So in exchange, they don't get the care they need. So we just ask for your support. I really appreciate the time, chairman and the committee, and you guys looking into this. Thank you both for being here and testifying. You're recognized me. I would just say at the dental school, how wonderful could that be to young Dennis who's upcoming. Let them be familiar with our kids, we still call them kids even though they're young adults. How awesome, because if you don't know someone with autism or Down syndrome or any kind of disability, hang on, because you will, um, and it's very unfortunate, but I think this is the right thing to do and uh we appreciate your support. We appreciate what these dentists and the anesthesiologists have to do and are willing to do and wanting to do. We appreciate that and our like he said, our daughter has to has special anesthesia and it it's a big deal and we had to jump through hoops to have her teeth cleaned in X-rays to have a sternotomy for open heart surgery. So thank you all for your time. Thank you for testimony. Are you able to answer questions? Sure. Representative Allen, you're recognized for a question. Thank you, Mr. Chairman. I want to say that I appreciate what you all are doing. I have walked the halls of Labana. I've been to Saint Jude Hospital when I was in pharmaceutical sales, and I understand and I see the needs of those students of those kids that really need this kind of help and I appreciate you all coming up here advocating for, for your kids and other kids around the state of Arkansas because this is much needed and I, I understand where we have to talk about cost, but we also have to have a humanity side of. us too because we actually have people in our society that need this care and just because it's not your family member today that's not saying it won't be your family member tomorrow or later on today. So I'm going to uh urge my colleagues to support what Julie Mayberry and what you all are trying to do, and Dr. McMillan, I really appreciate you and we miss you at UMS. We really do. Thank you all for coming. Thank you. Representative Rose, you recognize for a question. Thank you, Mr. Chair. Mr. and Miss Mock slave is the last name, Mr. Mr. Moxley, thank you for your testimony today. Thank you for uh advocating for your, your, your child, your children, and, and others facing the same challenges and I believe the whole committee of hearts go out to you and I hope that your daughter's recovery from surgery is going well. Uh, and I love, uh, Representative Allen, and I appreciate his heart and Representative Mayberry's. Um, I mentioned before, I don't know if you were in here, I have a constituent who is trying to get a cornea transplant because she's going blind and due to a number of circumstances funding wasn't available for her. And originally it was believed to have been there for her. And so the challenges that are faced, especially a family like yours, if you were told, hey, we're going to be able to do this. You've lined up heart surgery only to go in and maybe a few days before, a week before be told sorry, the funding's not there, we're not going to be able to this. Maybe you're in a financial situation where you just can't if the funding isn't there through Medicaid or another mechanism. I guess the question I have for you is I think we all see the validity of supporting families and patients that are facing these challenges. Don't you think we should get it right if we're going to do it. 0, 100%. 100% I think we owe it to you and your family and families like yours that we do this right to where you're not in a position that you're told sorry we can't do this, the funding's not there. Well, and I'm a mom and you know how moms talk and we go, my daughter, I take her to therapy on a daily basis. And the parking lot is our chit chat time. You wouldn't believe that what we talk about number 12 is the cost, the need, how are we going to get this done? Well, do we sell this, do we sell that? What do we do? So yes, get it, get it right the first time. Yeah. And there's a, there is a way to do it. Well, and I would say, wouldn't you agree, Representative Mayberry and her team, they've obviously done a great job putting this together and we just want to make sure that we know what the numbers are. I think that's the consensus here. And I want to say thank you for your for your testimony today. Thank you for having us. Thank you. Thank you, Mr. Chair. Representative Johnson, you're recognized for a question. I know it's been a long morning in committee, but this may be the only opportunity we have to ask some of these parents these questions, and I do have a specific question around your daughter. I think I heard you say that children said they wouldn't see her after the age of 12. Is that right? And, and how old is your daughter? She's 2. She turned 22 actually last Friday. OK. Um, I just am curious, I guess, and you wouldn't be able to answer this about the shift in policy there and why age 12 and I know you're trying to bring Children's Hospital to the table. to hear testimony, that's probably not reasonable at this point. There's a lot of people want to talk, but just was while you were here, you want to make sure I clarified that and, and when did they notify you of that age change? Um, let's see, I guess it was about maybe 6 months, 8 months prior to knowing, hey, we're gonna have to have, you know, this heart procedure, we're gonna have to have this done. We're gonna need a dental clearance and so I start getting on the telephone to call children's where we had been before and had been put. To sleep for X-rays, for MRIs, etc. Oh, I'm sorry we can't see you anymore. Well, you told us children that we could go there until we were in our 30s. 0, I'm so sorry. So now what do we do? So we have to travel. You know, XYZ here, here, here and here, and then luckily, Doctor McMillan, Dr. Hunt, let's try this. Let's do this. Worked beautifully, could not have been any better. Yeah, I think Representative Johnson just, I think it's a demand issue to have the dentist on staff at Children's. I think there were some issues there and they had a reduced staff so they had to deal with those patients at a certain age and younger because I didn't have the ability to continue to take care of those over from a volume perspective is part of what I think we heard. So partnership with the dental school, I think, would be excellent because I don't think it's, it's necessary that dentists don't want to do this. There are some out there that definitely do, but it's complicated when you have to have anesthesia that accompanies the surgery or or the procedure it's not a surgery, but it, but it works out very, very well. And, and you know, Doctor Hunt, he, he's, he's fantastic. He understands his population better than anybody I know. So I just say that that partnership could do a lot of things, I think for Arkansas. And if you think about it, think about people that come into the state for jobs and employment and those kind of things that's, there's, this is prevalent. Autism is very prevalent. A lot of other things are from a neurotypical standpoint, they look at that and I think, you know, years ago when, when I, I'll use this as the autism mandate for insurance was passed. I think that helped tremendously people not leaving our state because some of the different companies we work with. or I've worked with in the past. There have been people that have left our state just for those reasons that we didn't have the ability to take care of those with special needs. Thank you. Thank you. Thank you for your testimony. Any other questions of the committee? See no, thank you for being here today. Is there anyone else in the audience that would like to speak for or against the bill? Representative Mayberry, before you uh are recognized close for your bill. I do want to recognize Representative Bentley. She had a, a suggestion slash question request. You recognize Representative Bentley. Thank you, Chairman. I agree. I think we all, we all want to address the situation. I think we have some things just kind of hanging in the air, and I want to make sure we do it right. I think it will help DHS to do it right if we get a fiscal impact, so I am going to request a fiscal impact so we can make sure this is done correctly and I love the idea of the medical school and moving it forward, but I think that would be helpful to get things done correctly and sustainable, so moving forward we don't start this and then stop it because I'm I'm tragically hearing that children just had to stop this, so I, I really want to dig into that too. So, um, to get it done correctly, I'm gonna ask for that. So we can do a pause and make sure we do this correctly, make any changes that we need to, and I appreciate that. Representative, are you agreeable to that? I do want to take a moment though, um, the couple that just left brought up a really important point, and I'm sorry that the Arkansas Dental Association could not be here today. There was illness and and all that. We have been working with them. I hope that's kind of Understandable that we've been working directly with them. They've been heavily involved in this and support this idea, um, but something that one of the dentists kept stressing that again you may not think about, but to have certain surgeries, you have to have dental clearance. And so it may not even be that there's something really wrong dental wise with someone. But they have to have that dental clearance in order to have as, as was mentioned, their, their heart operated on or some other type of procedure, so that's extremely important, a transplant or whatever, and right now they're not able to get that care, so I, I just wanted to bring out that and make sure that you all heard that from that family because there's, there's a lot of information that you have to take in as a legislator. I understand that. I appreciate you all listening to the testimony today, um, and I would welcome, um. The the whatever you all wish for me to do. Thank you, Representative. So we are going to honor that request, uh, pursuant to House Rule 38s, we will have staff refer this to the appropriate entity and ask for that fiscal impact, and I believe that you you'll be notified, I think within 5 days of that impact, and then we'll get you back on the agenda to bring that back before the committee. So thank you for presenting. All right, committee without objection, we're gonna move back up the agenda. We're gonna pick up House Bill 1171. Representative Moore. You prepared to present your bill today? You reckon I'll go to the end of the table. Committee, we go on at 1:30. Uh, we've got a big agenda. I think we're 4 or 5 pages, so we're going to continue to roll along and hear as many bills as we can, um, before we go into session at 1:30, so we'll try probably for another 45 or 50 minutes to hear and see what we can get cleared off of our agenda. Representative Moore, you are recognized to present House Bill 1171. Please identify yourself for the record. Thank you, Mr. Chairman Kendra Moore, District 23, House Bill 1171 seeks to authorize and abbreviated independent assessment process for the past clients. Arkansas currently funds home and community-based services through a section 1915i State plan amendment. The 1915 I funded services are required by federal regulations to have a third party conduct this independent assessment. Of each client to determine their needs for services. This independent assessment is completed through a contract that DHS has with the company Optum. The assessment has to be face to face and it must be completed every 12 months. It's a lengthy assessment that in most cases takes more than an hour of the patient's time. The independent assessment involves the standardized functioning assessment tool, and it asks a series of questions about the client's level of functioning. In almost all cases, the independent assessment determines that the client does in fact need either tier 2 or tier 3 level services. Because this assessment has to be renewed every year, the approval rate is even higher. We're asking that DHS continue that full assessment process for these first time assessments. However, for reassessments establish and abbreviated process and DHS agrees with this approach. This would still involve a face to face on these reassessments because federal regulations does require it. So the major adjustment in this bill is the allowance for that abbreviated assessment. This abbreviate assessment lowers costs to the state on that Optum contract by being able to complete 2 or 3 of these assessments an hour instead of just one, and with that I'll try to answer any questions. Representative, any questions of the committee, Representative Pilkington you recognize and asked for a question. Thank you, Chair. Thank you, Representative Moore, for bringing this bill, but I'm curious, so I see that we're not striking out anything. We're just prohibited of doing this beforehand, or is this just we're forcing DHS to do something that they would have been able to do in the past because I don't say that we're striking out any rights that prevented them from doing it. Yes, thank you for your question, Representative Pilkington. If it's OK, Mr. Chairman, I'd like to invite Mr. Joel Randall now to the table. If you will, sir, please identify yourself for the record. You'll be recognized to answer the question. Thank you now. My name is Joel Landreneau and I'm the executive director of the Arkansas Council for Behavioral Health, and it is our organization that is advocating for the passage of this bill. The abbreviated the independent assessment process has been in place since about 2018 and as Representative Moore indicated, it can be quite lengthy, uh, and perhaps it needs to be lengthy for the initial assessment for determining whether or not somebody needs home and community-based services. It's the reassessment that we're targeting for some sort of an abbreviated assessment process. This was on our counsel's legislative agenda for 2023, and we didn't run this bill then because we had some assurances from DHS that the process would be examined and looked into, and they are doing some work in that regard, but it, it's taking a long time and we're 2 years in from the time we first began to advocate for this. So what we're now doing is, although they are in support of it, they also have two other requests. Make of the feds in amending the 1915 I. One is the creation of a new level of service called therapeutic care 3 therapeutic Communities 3, and then the rehab day programs. What they want to do is minimize the number of requests of number of times that go to the federal government to request amendments, so they want to lump them all together and this bill is basically to make sure that this portion of that doesn't get forgotten, so we're hoping to add impetus, if you will, you know. there's no deadline here, so we're not setting a timeline. We do expect that the entire request would be completed by late summer or fall of this year, so we're not really concerned about the timeline, so, so much as to just add some impetus to make sure that this doesn't get forgotten. Got you. So my DHS is in support of this, even though they hadn't done it yet. That that is my understanding, yes. OK, OK. That's, that's helpful. Thank you. Any additional questions by the committee? See none. Any, is there anyone in the audience that would like to speak for or against the bill? See no Represented Moore, you recognize the clothes for your bill. Thank you, Mr. Chairman. I am closed for my bill and appreciate or I would make a motion to pass. That's a proper motion. Any discussion on the motion? Seeing none, all those in favor say aye. All those opposed. Congratulations, Representative Moore, you've passed your bill. Thank you, Mr. Chairman. Thank you, committee. Committee members, we're going to go back down, uh, the schedule kit to try to catch up where we had left off. Representative Johnson, are you prepared to present House Bill 1253? Yeah 1285. Representative Pilking Pilkington House Bill 1403. To amend the Arkansas Health and opportunity for me act of 2021. You to go to the end of the table and present your bill. I don't know about y'all, but I can, I can never keep track of the numbers I need. If you will identify yourself for the record and you're recognized. Yeah, this is 1403, correct, Chair. Thank you. Yeah, this is a very simple bill. If you'll look on page On page one, the really the issues were striking out hospital-based community bridge organization, and just making it community bridge organization, um, over the interim, as we talked about the our Homes program and some of these specially focused, there were some health care entities that wanted to participate but were not able to because they were not a technically a hospital-based program, uh, talking to the hospital association and Pearl McFish at UAMS about these programs, uh, you know. We asked but there's if they could potentially partner with hospitals and at the hospital-based Community Bridge Association be a partner in this, and it just as we went further into it, it seemed like that was not. feasible and so I just want to strike this little bit of language out so that we uh basically can have other healthcare entities if they want to participate it, but they're not a technically a hospital if they're like a home health organization or something like that, they would be able to, to apply for because a lot of them do things that these bridge organizations were hoping it would do so and with that, that's for a good vote. Any questions by the committee? See none any members of the public wish to speak for or against the bill? See none your regular clothes for your bill. I'm closed for my bill. Thank you. Would you like to make a motion? Yes, sir. Thank you. Motion to pass. We have a motion to pass. That's a proper motion. Any discussion on the motion? Seeing none, all those in favor say aye. All those opposed. Congratulations representative, you passed your bill. Representative Ladyman, are you prepared to present House Bill 1439? You reckon to go to the end of the table. Thank you, Mr. Chairman. You will please identify yourself for the record and you're recognized, uh, Representative Jack Ladyman District 32. Uh, members, uh, House Bill 1439 is, is basically just a cleanup bill that makes uh Applying for a license for a private care agency, uh, much easier right now. There's there's a duplicate process, um, where they have to go to DH to uh Department of Health and get a license. They have to go to DHS and get a, uh, What is it? Additional certification. So basically what this bill does is it eliminates the certification process, it streamlined streamlines the process for a license that's basically all it does. So it makes the process a lot easier. For people who are trying to be a private care agency. With that, I'd be happy to take any questions. Thank you, sir. Any questions by the committee? See none. Is there anyone in the audience that would like to speak for or against the bill? See no representative you recognized clothes for your bill. I'm clothes for my bill and I make a do pass motion. That's a proper motion. Any discussion on the motion? Seeing none, all those in favor say aye. All those opposed. Congratulations representative. You passed your bill. Representative Bentley, are you prepared possibly run HB 1537 while I'm down here. It's down the list, I know, but Without objection, you're recognized to run House Bill. 1537, did you say? Yes, 1537. Y'all are ready. Thank you, Mr. Chairman, for letting me do that. Jack Ladyman, District 32, uh, again, this is a cleanup bill for DHS. Uh, and basically what this is. Ah, there, there is a community homes for individuals with intellectual and developmental disabilities. Uh, there's a code for that. And basically nobody has used that and what DHS would like to do is is eliminate that, uh, code because nobody uses it, it's unused. They want to get it out of their system. That's basically all the bill does. So I'd be happy to take any questions. Any questions from the committee? Representative Richardson, you're can ask for a question. Thank you, Mr. Chair. Just the family 1 and family 2, what are they going to be coded as now? Do you know? Well, it would just eliminate both of those. Uh, what this is a program where uh disabled people could go into a home. And there's two different levels of that, of families is basically what that is. Nobody's used this, um, DHS is here and you'd come and help this explain it if you need more explanation, but basically it was going if you're moving 1 and 2. I was just wondering because I'm, I'm assuming they're still using the program, just what will it be? They're not using the programs an unused at all, at all. They're just different definitions for 1 and 2. Any additional questions? See none. Is there anyone in the audience that likes to speak for or against the bill? See no one, you're recognized clothes for your bill. I'm closed for my bill. Make a motion do pass. That's proper motion and discussion on the motion? See none. All those in favor say aye. All those opposed. Congratulations representative, you passed your bill. Thank you, Mr. Chairman. Representative Bentley, are you prepared to present House Bill 1454? You to go to the end of the table. Members without objection, we're gonna go back up and do 1441st and then we will come back and do 1454. Representative Bentley, if you will, identify yourself for the record and you are recognized to present House Bill 1440. Thank you, Chairman. Thank you Committee Representative Mary Bentley, District 74. This is a uh 1440 is a bill that was brought to me by the health department just to tighten up some of our registrations, some of our codes for massage therapy if you guys want to pull it up. So, uh, they're really, you know, we've had some situations in our state, we've had some uh untold characters and some things in massage therapy, so they wanted to tighten up the registry rolls and make it a little bit easier for them to catch those those bad actors that we have out there, and that's really the the junk stuff that we can bring Matt up here if you guys have some more questions. for the Department of Health. That's really agreed upon language with the AG's department and then to make sure we tighten up our registry and we can catch a bad actors if necessary. Any questions by the committee? Representative Pilkington, you're reckon asked for a question. I didn't know you're going to run this one today. I just, could you kind of help walk me through these mechanisms that are going to make it easier to catch these bad actors, you know, we, we had some bust in Russellville recently and so I just want to make sure if I get asked by my constituents about it, I can specifically kind of talk about it and I'm trying to read through this real fit real quick so I'm just the agency up here, they can get more details. You will please identify yourself for the record and you recognized to answer the question. Thank you, Mr. Chair. Charles Thompson, attorney with the Arkansas Department of Health, appreciate you, Representative Bentley. Appreciate you, Representative Pilkington. What it boils down to is right now when we register a massage establishment, the law only allows us to ask their name and where they exist at their address. So they come in and so if they want to change their name or change ownership or anything, we have no idea what's going on. So you have people that that engage in bad activities, maybe law enforcement takes care of that for a little. a while and then they come back under a new name. So we don't know who's in those buildings. So this gives us the ability to ask for more information at the time of registration, get a little more information, kind of know who actually owns and operating these businesses because right now the law doesn't allow us to ask much. What's your name? Where are you? That's all the law allows. This tightens it up allows us to ask for some more information. OK, great, thank you. That's appreciate that. Thank you, sir. Any other questions by the committee? See none. Is there any member of the public that wish to speak for or against the bill. Seeing non-representative, you reckon that's close for your bill. Uh, thank you, Chair. I'm closed for the bill, and I'd like to make a motion to pass. That's proper motion. Any discussion on the motion? See none. All those in favor say aye. All those opposed. Congratulations representative. You've passed your bill. You're recognized to present House Bill 1454. Thank you, Chairman. Thank you. State Representative Mary Bentley, House Bill 1454 is a very simple bill that allows a private entities to engage with another source for them to be able to get a background check. So right now we have, we can do background checks, but sometimes it may take 3 to 5 business days for them to get it back. So if you're really in a crunch for an employee and you want to get that done a little quicker. just ask asking for another avenue for them to pay a little bit more money and get that instantly back. So some entities you can get it back within an hour or so just allows us people to go to another store to get a background check if they want to pay a little more money and get that a little quicker. So it's really all the bill does, and I take any questions if we need it. And there's no known opposition I know to this to this bill. Thank you. Any questions by the committee? Seeing none, or is there anyone in the audience I'd like to speak for or against the bill? See none, you reckon that's close for your bill. I'm close to my bill. I make a motion pass. That's proper motion any discussion on the motion? All those in favor say aye. All those opposed. Congratulations, Representative, you passed your bill. Thank you. Representative Rose, are you prepared to run HB 145678. Could I? Yes, sir. 178. 0 boy. Thank you Mr. Chair. Thank you committee. If you will identify yourself for the record and you're recognized to present your bill. Yes, sir. Representative Ryan Rose, uh, District 48, Van Buren and Fort Smith presenting HB 1456. this bill updates and modernizes the state Kidney Disease commissioned by transitioning it into an advisory council under the Arkansas Department of Health. The change ensures that the program operates more efficiently while maintaining the mission of assisting Arkansans suffering from kidney disease. Uh, our belief is that this bill will streamline government, improve oversight, and ensure better coordination between the advisory council and the Department of Health. The goal is not to eliminate services, but to better integrate. them into our state's health infrastructure, and this will improve access to kidney disease treatment and support, and I'm open to any questions at this time. Thank you, sir. Representative Pilkington, do you have a question? Oh, sorry, no problem at all. Any questions by the committee? Seeing none. Is there anyone in the audience that likes to speak for or against the bill? See nonrepresentative, you're recognized close for your bill. Yes, sir. Thank you. Just want to reiterate that this will modernize the administration of kidney disease programs in Arkansas. Appreciate a good vote and make a motion to pass. That's proper motion. Any discussion on the motion? Seeing none, all those in favor say aye. All those opposed? Congratulations, Representative, you passed your bill. You're recognized to present Senate Bill 187. Yes, sir. Thank you. Again, Representative Ryan Rose, District 48, Van Buren Fort Smith. This is Senate bill 178. You may see the word surrogacy in there, and this is not talking about I want to clarify you said 178, but I've got Senate Bill 187, is that? Now 178 sponsors Justin Boyd. I'm sorry, I, I announced the wrong bill just to clarify for the record, you recognized to present Senate Bill 178. I had it marked wrong. Yes, sir, no problem. Thank you. Uh, you'll see the word surrogacy in this bill and it's talking about a medical surrogate, somebody who can fill in, and I'll get into that in a little bit, but fill in for somebody in the absence of somebody who is mentally capable and has a capacity to make medical decisions for themselves. This has nothing to do with pregnancy. Uh, so today I'm bringing forward Senate Bill 178, Representative Ryan Rose, District 48, Van Buren and Fort Smith. This is a follow-up bill to a bill we successfully passed two years ago, the legislation addressed critical gap in health care decision making, allowing a surrogate to step in when an incapacitated person has no legal guardian. Uh, this is helping those Arkansans who have no body and no things more or less. Uh, in the implementation of that law, we discovered a hurdle with financial institutions, they were reluctant to provide necessary financial information. They had fears. Having to do with federal privacy laws, and so SB 178 is designed to solve that problem, ensuring that banks and financial institutions can comply with medical surrogacy requests without any legal risk. And this also will put safeguards in place to prevent any abuse, and at this time I'm open to any questions. Thank you, sir. Any questions by the committee? See none anyone in the audience I speak for or against the bill. Seeing none representative, you recognize the clothes for your bill. Thank you, Mr. Chair. Thank you committee. SB 178 is targeted as a common sense solution to a very real problem in our healthcare and financial system and a vote in favor of this would help us resolve that problem. So at this time I'd appreciate a good vote. I'm closed for my bill. Would you like to make a motion? Motion pass. That's a proper motion. Any discussion on the motion? Seeing none. All those in favor say aye. All those opposed. Congratulations representative, you passed your bill. Thank you, Mr. Chair. Thank you, Representative Johnson, are you prepared to run House Bill 1458? I am. You will identify yourself for the record and you're recognized to present your bill. Thank you, thank you, Mr. Chairman. Representative Lee Johnson, District 47 members as part of our centralized credentialing verification service through the medical board. We collect a certain amount of information on the provider. This is a process we put in place to try to help streamline credentialing for physicians trying to get credential in our state to practice. It came to the attention of the Department of Health and the Medical Board in the spring of 23, that collecting information on a provider's DEA number and putting that into a database. Uh, might be in conflict with federal law. The Attorney General looked at this and it's made the recommendation that we no longer collect the DEA number as part of our, uh, credentialing process. Now that doesn't mean that some hospital or someone trying to credential a physician couldn't ask for that. It's just we can't, um, it's the opinion of, of my understanding is that the opinion of the AG and, and others involved that this is something we need to stop doing. And so this is just removing that particular. piece of information from the credentialing uh. process. Any questions by the committee? Seeing none. Is there anyone in the audience that likes to speak for or against the bill? See no representative you that's closed for your bill. I'm close for my bill. I make a motion to pass. That's a discussion on the motion? So you know all those favor say I post. Congratulations, you passed your bill. Committee, as we move down the agenda, uh, seeing who's available, who's in the room. Uh, Representative Johnson, you have one more, uh, HB 1532. Pass over that today. All right, uh, committee, thank you for your hard work today, seeing no other business, we stand adjourned.