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A
69,
if
there
are
individuals
standing
who
do
not
wish
to
stand,
it's
okay
with
me.
If
you
want
to
be
in
the
room
and
stand
but
and
I
I
did
clear
it
with
fire
marshal.
So
all
right
welcome
everyone.
Thank
you
for
joining
us
for
the
interim
Joint
Committee
hearing
on
health,
welfare
and
Family
Services
today
is
October,
26th
and
I
appreciate
everyone
indulging
the
earlier
time.
We
will
go
ahead
and
call
the
meeting
to
order
and
secretary.
Please
take
the
role.
C
A
A
Second,
all
in
favor
aye,
any
opposed
all
right.
The
minutes
are
approved,
I'm,
going
to
go
ahead
and
consider
the
administrative
regs
that
we
have
on
our
agenda
today.
I
read
through
them
and
they
all
look.
Okay
to
me
did
everyone
have
a
chance
to
read
those
and
are
there
any
questions
all
right?
Okay,
see
no
questions
or
concerns.
I
will
consider
those
reviewed
first
on
our
agenda,
I'd
like
to
invite
Dr
Shanna
babylonis,
with
the
University
of
Kentucky,
to
discuss.
A
Sorry,
a
little
sidebar
discussion
up
here.
Okay,
we
will
hear
an
update
on
House
Bill
604,
which
turned
into
a
little
bit
different
of
a
bill
at
the
end
of
session,
but
did
establish
the
UK
Center
for
cannabis
research,
and
we
are
delighted
to
have
you
this
morning
and
look
forward
to
hearing
an
update
on
how
the
implementation
of
the
center
is
going
and
what,
if
any
changes
the
the
Beto
made
to
the
center.
A
F
Thank
you
so
much
for
the
invitation
so
today
I'll
be
presenting
on
the
UK
cannabis
Center
and
to
provide
some
updates
so
again
just
to
reorient
everyone.
House
Bill
604
established
the
Cannabis
Center
at
UK,
and
that
provides
us
a
two
million
dollar
appropriation
and
we
have
two
years
to
spend
that
money.
So
we
have
through
June,
2024.,
Dr,
capoludo
appointed
the
director
and
the
advisory
boards
and
I
would
just
like
to
introduce
everyone
to
the
executive
committee.
F
So
the
executive
committee
is
tasked
with
establishing
the
research
priorities
and
the
budget
of
the
center
and
I.
Don't
think
that
we
could
have
a
better
collection
of
experts
working
with
us
on
this
effort.
I
I
think
they're,
the
Dream,
Team
and
I'm
so
excited
to
have
all
of
them
here.
But
we
have
a
wide
range
of
experts
across
disciplines
and
we
have
Physicians.
F
F
We
are
also
planning
a
cancer
trial
with
the
Marquis
Cancer
Center
to
look
at
Edible
cannabis
doses
for
patients
with
cancer
and
I
would
just
like
to
highlight
that
this
is
going
to
be
one
of
the
first
studies
of
its
kind.
You
would
think
that
cancer
and
cannabis
have
been
really
well
researched.
Unfortunately,
that's
not
the
case,
and
so
this
would
represent
one
of
the
first
placebo-controlled
randomized
trials.
F
F
We
are
also
pairing
with
a
Kentucky
injury
prevention
and
Research
Center
or
kiprick
to
look
at
large
data
sets
from
the
state.
So
we
are
going
to
be
examining
cannabis,
involvement
in
opioid
overdose,
deaths,
injuries
and
driving
fatalities,
and
we
expect
the
first
data
sets
to
come
in
the
spring,
and
part
of
this
effort
is
to
take
a
look
at
cannabis.
Involvement
in
these
outcomes,
but
also
to
provide
a
baseline
for
us
should
policy
change.
F
In
the
next
few
months,
we
also
published
two
papers
on
a
Kentucky
CBD
analysis,
so
we
looked
at
CBD
products
sold
in
Kentucky
and
online
and
looked
at
the
chemical
constituents
of
those
products
to
really
determine
how
safe
and
how
healthy
and
how
accurate
are
these
products
kind
of
spoiler
alert.
There
were
a
lot
of
label
and
accuracies
and
a
lot
of
THC
contamination,
which
is
really
unfortunate,
but
we
published
those
two
papers
in
peer
peer-reviewed
journals.
F
So
what
we
would?
What
we
would
like
to
look
at
is
the
prescription
drug
monitoring
program
and
the
prescriptions
that
are
prescribed
to
those
patients
before
they
entered
the
medical
cannabis
program
to
see
what
were
they
on?
How
often
were
they
taking
opioids
and
other
drugs
and
then
really
watch
them
in
real
time
after
they
enter
that
medical
cannabis
program
to
see
the
real
data?
So
not
just
a
self-report
of
what
medicines
are
you
taking?
Could
you
go
down
on
your
anxiety
medicine?
Could
you
go
down
on
your
opioids?
F
I
would
also
just
like
to
describe
a
little
bit
of
the
timeline
for
many
of
our
clinical
trials,
so
the
cancer
trial
is
here
listed
as
an
example.
So
we
have
study
startup
items
on
the
left
hand
of
the
side,
and
so
UK
has
a
lot
of
requirements,
internal
requirements
to
be
able
to
start
studies,
especially
in
cancer
patients.
F
So
none
of
these
have
been
finalized
yet,
but
we're
exploring
these
areas
of
lung
inflammation
to
determine
if
edible,
vaporized
and
smoke
cannabis
change,
inflammatory
biomarkers
in
the
lungs.
We
are
also
considering
an
obesity
study,
even
though
we
associate
marijuana
and
cannabis
with
increased
caloric
intake
afterwards
or
the
munchies.
F
We
also
just
recently
launched
a
grant
program
at
UK
so
for
pilot
grants
for
faculty
members
and
the
focus
is
going
to
be
on
controlled
trials
and
public
health
impact,
but
we'll
also
consider
grants
on
very
few
on
basic
and
pre-clinical
research,
agricultural
research,
secondary
analyzes,
the
large
data
sets
and
community
community
research,
and
we
expect
to
have
funding
decisions
made
by
the
board
in
February
and
have
the
data
available
in
in
May.
2024
it'll
give
researchers
approximately
14
months
of
solid
research
time,
and
that
concludes
my
presentation.
If
anyone
has
any
questions.
A
Well,
thank
you.
So
much
I
am
so
happy
to
hear
the
results
of
your
work
and
you
talked
a
little
bit
about
lightning
speed
and
it
sounds
like
you
have
just
hit
the
ground
running.
So
thank
you
for
all
your
work.
I
think
it's
incredible
that
you
have
already
secured
a
two
million
dollar
NIH
Grant.
Thank
you,
which
was
exactly
what
I
thought
would
happen.
A
I
mean
I,
have
I
could
probably
comment
on
every
single
piece
of
the
the
research
that
you
outlined,
but
I
won't
I.
Think
it's
incredible
and
I
I
just
want
to
applaud
your
efforts.
Are
there
anything
any
changes?
You
know
some
of
the
language
changed
a
little
bit
with
the
veto
of
of
certain
Provisions,
but
it
doesn't
sound
like
it's
really
changed
structurally.
What
you're
able
to
do
not.
G
G
A
little
I'm,
sorry
I'm,
Bart
Harden,
the
director
of
government
relations
for
the
University
of
Kentucky
I,
think
there
were
three
basic
components
of
the
veto:
message
that
we
had
I
think
the
first
one
was
I
believe
the
word
research
was
taken
out,
but,
as
you
can
see,
we
are
an
R1
research
institution.
That's
what
we
do.
That's
what
Shanna
and
her
team
were
doing.
Is
research
I,
think
that
had
no
material
impact.
G
The
second,
the
second
piece
that
was
vetoed
was
the
makeup
of
the
boards
that
left
that
to
the
president
of
the
university
to
determine
again
I
think
you
will
see.
We
have
a
very
multi-disciplinary
approach
to
these
two
boards
that
have
been
constituted
across
campus
I.
Think
we've
got
basically
the
same
individuals
that
were
identified
in
the
bill
plus
or
minus
one
here
or
there
so
I.
Don't
think
that
had
a
material
impact
and
the
third
component
was
the
veto
of
no
funding
Beyond.
G
E
G
A
Thank
you,
I
I,
that's
my
observation
as
well.
As
far
as
the
funding
goes,
I
think
that
you
are
more
than
proving
the
the
importance
of
this
Center
and
of
the
state
appropriation
to
to
funding
this
so
I
just
look
forward
to
the
great
work
that
you're
doing
and
we
do
have
a
couple
of
questions.
Senator
Alvarado
thank.
H
H
One
of
the
things
I'm
also
encouraged
by
your
comments,
is
on
a
driving
study,
because
I
think
there's
been
a
lot
of
discussion
about
this.
That
people
can
be
impaired
and
clearly
they
can
be,
depending
on
the
kind
of
THC
content
that
you're
either
ingesting
or
inhaling,
and
if
we
can
start
either
getting
some
kind
of
Baseline
on
where
that
impairment
begins
or
occurs,
that
can
not
only
have
impact
for
the
state.
It
can
have
an
impact
nationally,
really
for
folks,
just
because
right
now
we
don't
have
any
methods
of
testing.
H
That
level
is
the
one
thing
I'm
going
to
ask
you
when
you're
doing
these
studies
and
the
one
thing
that
I'm
concerned
with
when
you're
using
raw
material,
because
I
know
that
we've
got
we've
got
medications
that
are
derivatives
of
this,
as
there
are
for
many
things.
Yes,
cocaine
has
medicinal
purposes.
Lsd
has
medicinal
purposes,
but
we
don't
use
it
in
raw
forms
and
say
here.
Take
it
use
it
on
your
own.
H
We
extract
compounds,
we
purify,
we
figure
out
dosages
safety,
and
then
we
go
ahead
and
give
it
to
folks,
and
we
have
that
in
things
like
sad
of
X
and
epidiolex
and
and
Marinol
on
something
like
this
we're
either
using
raw
material
or
aerosolizing.
Are
you
controlling
the
amount
of
THC
that's
being
given.
H
F
So
that's
a
fantastic
question
and
I
appreciate
that
so
for
our
cancer
trial.
We
don't
want
anyone.
We
don't
want
cancer
patients
to
inhale
anything
like
that's
just
kind
of
antithetical
to
medicine
right,
and
so
we
will
be
using
edible
doses
for
those
patients
and
we'll
try
to
really
focus
on
an
oral
preparation
for
most
of
our
studies.
F
So
we
are
selecting
doses
of
THC
CBD
and
their
combination
based
on
other
literature,
our
own
research
and
other
research,
to
make
sure
that
we
have
really
safe
doses.
That
are
that
we
think
are
reasonable
and
that
that
may
have
some
therapeutic
value.
But
we
are
testing
a
variety
of
Doses
and
we'll
make
sure
that
everyone
can
tolerate
those
doses
before
we
launch
the
study.
H
F
H
So
I
know
there's
others
that
are
kind
of
suggesting
there
may
be,
but
there
can't
be
any
inferences
scientifically
for
that
so
I'm
encouraged
I
mean
this
has
been
the
discussion.
I
think
the
medical
community
at
large
is
has
been
fairly
resistant
because
we
don't
have
the
science
and
therefore
the
state
is
going
to
lead
on
this
science.
I'm
encouraged
by
it,
so
we'll
be
looking
forward
to
a
lot
of
these
results
and
on
the
fact
that
you're
doing
a
driving
study,
I
think
is
a
brilliant
idea.
F
You
and
we're
we're
really
excited
about
the
opioid
study
as
well.
We
really
want
to
know:
can
cannabis
help
with
opioid
withdrawal?
That's
been
a
question
that
we've
received
quite
a
bit
and
there's
obviously
lay
press
out
there.
That
suggests
that
that's
the
case,
but
there's
been
no
controlled
studies.
We're
also
interested.
H
I
You
have
a
question.
Thank
you,
chair,
Moser
I
mainly
just
want
to
express
my
appreciation
and
enthusiasm
for
the
center
and
for
the
project
and
I
just
wanted
to
have
clear.
In
my
mind,
are
there?
Is
this
really
the
only
Center
like
this
in
the
country
and
is
Kentucky
really
leading
the
way
on
This
research.
D
F
So
there
are
so
many
unregulated
products
right
now
that
are
available
for
anyone
to
purchase
online,
you're,
absolutely
correct,
and
so
there's
many
derivatives
of
THC.
So
there's
Delta,
eight
there's
even
Delta
9
for
sale,
hhc,
Delta,
10,
there's
many
different
formulations
of
THC
right
now
that
are
available
to
purchase
online.
Anyone
with
a
credit
card
can
buy
that
and
it's
all
done
under
the
guise
of
the
farm
bill.
Most
mostly,
we
haven't
analyzed
any
of
those
products.
A
J
I,
just
kind
of
at
the
end
of
the
day,
I
have
this
real
feeling
that
you
know
the
DEA
and
the
FDA
are
going
to
weigh
in
on
your
results.
Right,
they're,
gonna,
they're
gonna
have
comments
to
make
I
I
just
wondered.
Are
you
having
I
would
assume
you're
having
communication
all
through
these
clinical
trials,
with
the
DEA,
the
FDA
since
you're
having
to
get
a
lot
of
the.
L
J
Substance
from
them
and
and
and
and
keep
them
informed,
but
I
guess
I
wonder,
would
it
would
have
been
any
help
to
even
have
because
I
know
we're
Statewide
they're
Federal.
Maybe
it
would
be
an
argument
that
there
we'd
keep
them
separate,
but
I
may
see
some
advantage
to
to
you-
maybe
maybe
including
them
somewhere
in
this
group
of
professionals
that
where
they
could,
you
know,
because
there's
going
to
be
they're
going
to
weigh
in
at
the
end
of
the
day,
I
just
thought,
maybe
it'd
be
helpful.
I
don't
know.
F
Were
required
to
keep
it
with
just
UK
faculty
right,
but
all
of
our
Studies
have
to
go
through
FDA
and
DEA
review
before
we
can
launch
them,
and
so
they
have
a
lot
of
input
at
the
beginning
of
on
on
safety
and
like
the
legal
ramifications
of
what
we're
doing,
the
DEA
does
and
make
sure
that
we're
doing
everything
in
a
proper
way.
After
that,
though,
they
don't
really
have
much
say,
and
so
after
they
grant
us
the
permission
to
conduct
this
study.
Unless
there's
something
that
goes
wrong.
F
J
F
Thank
you
very
much.
Absolutely
and
I.
I
just
want
to
mention
that
I
met
with
the
FDA
commissioner
Dr
caliph
when
he
was
on
campus
two
weeks
ago,
and
he
was
highly
congratulatory
of
our
work
and
just
really
couldn't
wait
for
the
cancer
trial
to
be
conducted,
and
so
he
was
really
encouraging.
That's.
I
M
Yes,
ma'am
just
quickly,
and
thank
you
all
for
being
here
and
thank
you
for
the
presentation.
What
part
are?
Are
there
any
parts
of
This
research
that
will
address
the
control
as
far
as
distribution
should
the
state
legalize
and
then
the
importance
of
that
and
and
I
know
the
the
quality
of
the
material
and
the
ingredients
in
whatever
substance
is
produced
could
be
critical?
M
F
That
wasn't
one
of
the
research
focuses
of
the
bill,
so
we
tried
to
to
stick
with
what
you
all
told
us
to
do,
but
we
are
starting
a
growing
program
to
determine
if
we
can
grow
cannabis
that
matches
the
federal
standard
that
matches
the
international
standard
with
the
College
of
Agriculture
and
we're
exploring
a
collaboration
with
them
to
analyze
that
those
materials
as
well
but
as
far
as
the
distribution
of
cannabis.
We
are
not
looking
into
that.
Okay.
F
A
F
It
would
be
helpful,
it
would
be
helpful
so
if,
if
marijuana
became
a
schedule,
two
drug
researchers
and
Physicians
who
already
study
schedule
Two
drugs
could
just
automatically
then
start
testing
marijuana
and
using
marijuana
in
their
research
studies.
We
have
found
ways
to
obviously
get
the
work
done,
even
though
it
is
schedule
one,
but
it
would
facilitate
research.
A
Okay,
thank
you.
That's
that's
very
good
to
know
and
I'm
just
excited
that
we
were
able
to
put
this
framework
in
place
and
really
put
UK
and
Kentucky
at
the
Forefront
of
research.
It's
critically
important
to
study
the
safety
and
the
efficacy
of
marijuana
as
a
medicinal
product
and
I'm
just
excited
about
your
work
and
congratulations.
Thank.
A
A
Thank
you
thanks
for
being
here
all
right.
Next,
we
are
going
to
hear
about
the
importance
of
biomarker
testing
in
healthcare
and
I'd
like
to
go
ahead
and
invite
Dr
Matt
holder
to
join
the
folks
at
the
table
to
discuss
both
biomarkers
and
the
pharmacogenomics
piece
of
all
of
the
the
testing
that
we're
going
to
discuss.
A
E
I
Q
A
Thank
you.
Thank
you
for
being
here
good
morning
to
you.
Okay,
so
I
think
first
we'd
like
to
hear
about
why
this
is
important.
What
what
is
biomarker
testing?
What
are
pharmacogenetic
testing,
give
us
kind
of
a
little
bit
of
background.
Tell
us
why
this
is
important
and
then
we'll
go
into
the
the
mechanism
of
of
actual
testing.
So
thank
you
very
much
for
being
here.
I
know
you
are
very
busy,
so
I
wanted
to
get
you
up
here
first
or
near
the
near
the
beginning
of
this
meeting
and
please
proceed.
N
Well,
thank
you
very
much.
It's
it's
a
privilege
to
be
here
and
I
want
to
thank
the
committee
for
for
bringing
this
important
piece
forward,
and
you
know
I.
Think
Kentucky
is
known
for
a
lot
of
things,
but
unfortunately,
Kentucky
is
all
too
often
known
for
our
incredible
burden
regarding
cancer,
and
this
is
not
just
a
regional
piece
within
Kentucky.
N
N
N
It
documents
the
burden
of
Kentucky's
cancer
problems,
but
also
it
will
show
you
not
only
a
comparative
to
the
country,
but
also
within
the
state
and
incidents
and
mortality,
but
also
facts
regarding
cost
of
the
cancers
that
we
deal
with,
and
then
there
are
Regional
for
each
of
your
constituents.
There
are
Regional
distributions
of
how
this
is
represented,
so
I
want
you
to
look
at
that.
N
It's
in
the
slides
that
we've
provided,
but
the
good
news
is
the
cancer
mortality
is
diminishing
and
certainly
we've
seen
the
faster
decline
in
cancer
mortality
in
that's
ever
been
reported
in
the
country
and
in
Kentucky.
However,
we
continue
to
have
a
a
tremendous
challenge.
We've
seen
rates
declining
for
a
number
of
reasons,
but
we
need
to
be
more
specific
on
how
we
are
addressing
these
one
of
the
ways
that
we've
done
this.
N
You
all
have
helped
us
with
dramatically
is
recognizing
the
power
of
lung
cancer
screening
and
your
influence
in
in
delivering
the
bill
and
passing
the
bill
through
your
houses.
To
be
able
to
get
this
into
law
has
brought
us
to
a
point
where
lung
cancer
screening
has
had
the
impact
that
we
want
it
to
at
least
it's
beginning
to
show
the
changes
that
we're
we're
striving
for.
N
But
looking
at
this
in
a
different
way
to
say
that
Kentucky
is
not
only
number
two
in
the
country
in
terms
of
hitting
the
eligible
population
almost
three
times
the
national
average,
but
for
the
state
that
has
the
highest
burden.
We
have
one
of
the
highest
incident
and
highest
screening
rates,
and
so
this
is
a
starting
place
that
we
have
to
be
able
to
drive
forward.
N
N
It
needs
to
be
recognized
that
cancer
is
a
genetic
disease.
This
is
not
something
that
we
can
cut
out
of
patients.
If
it's
a
widespread
disease,
it's
certainly
an
opportunity
for
us
to
understand
how
it
gets
started,
though.
We
certainly
recognize
that
changes
in
the
genes
that
control
the
way
cells
grow
lead
to
the
tumors
that
we
find,
and
these
genetic
mutations
are
being
discovered
more
and
more
frequently.
N
N
The
importance
of
this
is
that
all
of
these
other
acronyms
and
identified
mutations
are
beginning
to
develop
drug
targets
that
can
be
specifically
addressed
and
I
will
say
that
I'm
here,
because
10
years
ago,
I
had
a
stage
for
mutated,
tumor
and
I've
been
on
one
drug
for
a
day
every
day
and
that's
the
only
reason
that's
gone.
So
this
is
a
powerful
mechanism
and
these
biomarkers
are
being
recognized
by
the
national
guidelines
that
are
promoted.
The
challenge
is
that
we
have
problems
getting
them
into
practice.
N
Those
barriers
include
lack
of
awareness,
the
complicated
nature
of
being
able
to
get
the
testing
done.
The
mechanisms
to
be
able
to
drive
this
into
the
practice
and
change
the
mechanism
that
our
providers
are
delivering
care,
and
so
I
think
this
is
where
this
policy
change
can
be
able
to
deliver
decreases
in
barriers.
N
It
decreases
in
those
obstructions
that
exist
to
be
able
to
get
this
into
the
practice
of
the
cancer
providers
that
we
have
I
think
it's
important
that
we're
talking
specifically
about
drugs
that
address
the
diagnosed
cancers
and
trying
to
get
them
using
the
the
recommendations
that
are
out
there
from
the
from
the
knowledge
that
we
have
from
the
clinical
trials.
So
this
is
a
a
key
piece
of
information
and
I'm
excited
to
be
able
to
see
you
take
this
up.
Thank
you.
J
A
Q
So
there
are
basically
two
places
to
test
for
biomarkers,
either
in
your
somatic
germline
or
in
your
hereditary
germline
and
I've
I've
put
this
chart
together
to
give
you
an
idea
of
the
differences
and
so
I
think
one
of
the
most
important
things
in
terms
of
somatic
mutations.
They
only
occur
in
some
cells
and
we
think
about
this
most
often
in
cancer.
Another
really
important
thing
to
think
about
with
somatic
mutations
is
that
they're
not
passed
on
to
your
children.
The
diseases
that
are
primarily
associated
are
going
to
be
cancers.
Q
Ninety
percent
of
cancers
are
caused
by
somatic
mutations,
as
you
saw
in
Dr
mullet's
presentation.
We're
exposed
to
radon
we're
exposed
to
Sunshine
we're
exposed
to
cigarette
smoke,
causing
those
genetic
mutations
in
specific
tumor
in
specific
organs
which
results
in
the
cancer,
but
again
that
cancer
stays
there.
When
we
compare
that
to
germline
testing
germline,
you
would
you
or
germline
mutations
those
who
inherit
from
your
parents.
Q
Those
are
passed
to
your
children
and
they're
present
in
all
of
the
cells
about
10
of
cancer
is
caused
by
germline
mutations,
but
there
are
a
variety
of
other
different
diseases
that
that
are
caused
in
this
manner.
Inborn
errors
of
metabolism
are
one
of
them.
You
know
hereditary
cardiac
defects,
malignant
hyperthermia
and
another
important
thing,
and
what
we'll
hear
about
in
our
in
one
of
our
subsequent
speakers
is
these
also
control
drug
metabolism,
so
depending
on
what
type
of
mutation
or
biomarker
you're
looking
for
it
depends
on
how
you
need
to
test.
Q
So
if
you
are
looking
for
somatic
mutations,
you're
going
to
do
a
tumor
tissue
with
the
biopsy,
there
is
an
emerging
presence
of
liquid
biopsies
and
what
those
do
is
they
actually
detect
cancer
DNA
and
that's
been
Shed
from
the
cancers.
So
that
can
be
an
option
for
patients
who
are
not
able
to
undergo
a
tissue
biopsy
in
the
germline
setting.
You
can
use
a
buccal
sample
or
a
blood
or
a
blood
sample.
Q
Well,
basically,
you
could
use
any
type
of
tissue
that
is
available
that,
but
these
are
certainly
going
to
be
the
easier
easier
things
to
obtain
in
terms
of
use
of
these
biomarkers
and
for
somatic
biomarkers.
We
use
them
to
diagnose
Cancers
and
we
also
use
them
to
select
treatment
in
terms
of
germline.
In
some
circumstances,
we
can
select
specific
treatments
for
our
patients.
Q
We
do
it
to
identify
hereditary
cancers
or
other
diseases
that,
before
they
manifest,
and
to
induce
some
prevention
efforts
and
in
terms
of
drug
metabolism,
what
we're
really
doing
is
trying
to
optimize
the
dose
and
prevent
adverse
effects
in
terms
of
cost
somatic
mutation.
Testing
is
a
panel
test.
Generally
it's
about
twenty
five
hundred
dollars
in
in
terms
of
germline
testing.
It
varies
by
the
test,
depending
on
how
many
different
mutations
you're
trying
to
identify
so
I'm,
going
to
focus
a
little
bit
I'm
going
to
focus
my
presentation
on
somatic
or
tumor.
Q
Only
mutations-
and
this
is
in
the
context
of
lung
cancer-
so
what
we
really
are
able
to
do
now.
It's
one
of
the
major
advances
in
cancer
treatment
is
to
identify
patients
at
the
molecular
level.
We
can
take
a
piece
of
their
tissue
or
a
blood
sample.
Look
at
the
mutations
that
are
present
in
their
specific
cancer
and
based
on
those
cancers.
We
may
be
able
to
identify
a
new
drug
that
targets
that
specific
mutation.
Q
I
always
like
to
show
this
slide,
so,
if
you're
not
used
to
looking
at
survival,
curves,
basically
on
the
the
y-axis
is
going
to
be
percent
survival
and
the
x-axis
is
always
going
to
be
time,
and
so
the
study
that
I'm
showing
you
on
the
left
is
a
very
famous
study
that
was
done
by
the
Eastern
Cooperative
oncology
Group
by
one
of
my
good
friends,
Dr
John
Schiller,
and
the
premise
of
the
study
that
was
published
in
2002
was
really.
We
have
four
chemotherapy
regimens
that
are
commonly
used
for
treating
lung
cancer
is
any.
Q
Q
This
is
just
to
show
you
how
many
new
drugs
that
we
have
for
treating
lung
cancer
I
haven't
come
to
them
up
lately,
but
I
mean
there's
more
than
20
different
drugs
that
are
potentially
available
to
patients
with
different
mutations.
The
other
thing
that
we're
learning
as
we
continue
to
follow
patients
and
they
live
longer
and
longer
a
lot
of
times.
Someone
with
an
egfr
mutation
will
progress,
but
they'll
go
on
to
get
an
out
mutation,
and
so
then
we
have
more
drugs
that
are
backups
for
them.
Q
So
I
hope,
I,
convinced
you
that
biomarker
testing
is
very
important
because
to
be
able
to
identify
those
mutations
and
improve
overall
survival
for
our
patients.
You
need
to
do
the
test.
So
this
is
a
study
that
we
did
looking
at
testing
in
Kentucky
between
2010,
2011
and
2012.,
and-
and
this
was
just
single
Gene
testing
for
egfr,
which
was
standard
of
Care
at
the
time.
Q
So
one
of
the
approaches
we
took
at
the
Markey
Cancer
Center
was
to
work
with
Community
Medical
oncologists
because
they
had
the
lowest
testing
rates
in
order
to
improve
testing,
and
so
one
of
the
concerns
in
community
medical
oncology
practices
is
that
they
don't
have
time
to
do
the
testing
they
don't
have,
and
they
don't
know
how
to
interpret
the
report.
So
the
market
Cancer
Center
sent
up
a
set
up
a
molecular
tumor
board.
Q
Our
molecular
tumor
board
is
an
inter-professional
team,
including
a
number
of
surgeons
of
Physicians
from
different
Specialties
Pharmacists
and
genetic
counselors,
and
the
purpose
of
this
molecular
tumor
board
is
to
review
these
next
Generation
sequencing
reports
that
can
come
back.
You
know
and
be
20
pages
long
and
have
20
different
50
different
mutations
and
make
recommendations
to
the
treating
medical
oncologists
as
to
what
might
be
of
the
best
treatment
option
for
that
patient.
Q
So
I'm
sure
I'm,
showing
you
here
on
the
right
in
Kentucky
the
little
the
gold
stars,
our
community
medical
oncology,
practices
who
are
participating
in
our
Precision
in
our
molecular
tumor
board
and
I
show
you
the
numbers
down
below.
We
started
in
2016,
but
in
our
defense
it
was
December.
So
we
only
reviewed
two
cases
in
2016.
Q
So
the
next
thing
we
wanted
to
do
is
we
wanted
to
determine
if
we
were
having
an
A
positive
impact
for
our
patients
by
encouraging
this
testing
and
by
by
helping
interpret
these
reports.
So
the
next
thing
we
did
is
a
case
control
study,
and
so
we
knew
the
patients
that
were
reviewed
by
the
molecular
trimmer
board
and
we
selected
cases
from
our
Kentucky
cancer
registry
and
to
be
a
case
for
one
of
our
controls.
Q
They
were
matched
on
age
year
of
diagnosis,
gender,
where
they
lived,
insurance
and
smoking
status,
and
that
was
just
to
control
control
for
factors
that
could
predict
outcome.
In
addition,
we
also
controlled
for
survival,
so
sometimes
patients
with
rapidly
Progressive
disease
do
not
get
Next
Generation
sequencing
testing.
So
we
we
to
to
be
included
as
a
case.
You
had
to
survive
at
least
as
long
as
the
controls,
and
these
are
our
outcomes
again.
Q
So
we
were
very
encouraged
by
that
this
data
and
to
continue
with
our
efforts
with
our
molecular
tumor
board
and
to
continue
our
our
efforts
for
biomarker
testing.
The
other
thing
that
we
wanted
to
look
at
was
did
your
place
of
residence
matter.
So
if
you
look
at
panel
B,
there
were
26
of
the
patients
reviewed
by
the
molecular
tumor
board.
26
were
from
the
community
51
from
Markey
cancer
center,
and
you
can
see
up
here
that
there's
really
no
difference
in
survival
and
in
panel
C
we
demonstrate
the
same
thing.
Q
A
S
Thank
you
appreciate
that
thank
you
for
this
opportunity.
I'm
Mikey
I'm,
the
director
of
lung
cancer
screening
from
St
Elizabeth,
Healthcare,
Family,
Practice,
doc,
I've
been
in
practice
for
35
years
and
I.
Look
at
things
pretty
simply.
You
know,
I
think
it's
important
that
we
understand
the
terminology
when
we
hear
the
term
biomarkers,
there's
biomarkers,
that
can
predict
your
risk
of
cancer
or
cancer
predilection,
there's
biomarkers
in
Canada,
Tech
cancer
and
it
determines
the
presence
of
disease
and
then
what
we're
primarily
talking
about
today
is
cancer
direction
or
treatment.
S
These
can
be
liquid,
biopsies
or
tissue
biopsies.
That
guide
your
treatment
is
with
respect
to
prediction:
biomarkers
we're
working
with
an
r01
study
with
the
World
Health
Organization,
looking
at
36
panel
protein
that
predict
your
risk
for
lung
cancer,
and
this
could
be
combined
with
screening
to
improve
the
accuracy
and
the
breadth
of
screening.
S
S
These
mceds
can
detect
over
50
Cancers,
and
the
question
is
whether
or
not
the
techniques
cancers
will
decrease
mortality
and
it's
going
to
depend
on
getting
a
lot
of
regional,
National
and
international
data,
but
these
mceds
detect
incredibly
infinitesimal
amounts
of
circulating,
DNA,
RNA
or
proteins,
and
the
public
is
now
aware
of
these
tests.
They
can
increase
screen
rates
as
well
and
they
are
here.
This
is
looking
at
a
pictorial
representation.
This
is
a
tumor
cell
over
here
on
the
left.
S
But
these
tests
are
expensive.
These
are
not
yet
covered
by
insurance
or
not
FDA
approved,
and
you
know
the
question
is,
you
know:
will
these
tests
further
increase
health
care
disparities
because
there
are
expenses
that,
as
we've
mentioned,
Tim
showed
this
slide
already?
I
won't
go
over
this
again,
but
these
are
the
targeted
therapies,
we're
talking
about.
There's.
S
Immunotherapy
is
another
Frontier,
and
this
is
based
on
pdl1.
You
have
a
much
better
chance
of
responding
to
immunotherapy.
These
are
some
of
the
drugs
I'm
sure
you've
heard
about
on
TV,
Devo,
keytrutic,
eccentric
and
finzi
and
Uruguay.
This
is
a
picture
of
Heidi
nathananda
she's,
a
spokeswoman
for
the
white
ribbon
project.
This
just
gives
you
an
idea
what
we're
looking
at
here
this
was
four
years
ago,
and
this
is
a
tumor
left
upper
lung.
S
Now,
four
years
later,
she
just
had
this
scan
three
weeks
ago
and
there's
been
no
evidence
of
disease
for
several
years
now
so
four
years
later,
hopefully,
she'll
be
among
the
survivors
from
the
treatment
of
immunotherapy
and,
as
Jill
mentioned,
I.
Think
and
Tim
did
as
well.
These
tumors
they
develop
resistance.
They
continue
to
evolve,
they
outsmart
the
treatment.
So
these
biomarkers
have
to
be
periodically
retested
and,
and
we
will
develop
some
of
the
therapies
based
on
that
Evolution
and
you
know,
probably
take
combinations
of
therapies.
S
I
won't
go
in
all
the
details
of
this
and
the
interest
of
time,
but
when
we
add
biomarkers
to
traditional
testing,
it
increases
the
sensitivity
and
the
specificity,
and
we
definitely
need
better
prediction.
Models
and
biomarkers
will
be
part
of
that
Dimension
radon
and
a
lot
of
the
rest
of
the
world.
Cooking
oil
is
an
open.
Wood
burning
are
factors
we
know.
Family
history
is
a
factor.
Air
pollution
is
a
big
factor.
Just
to
give
you
an
example.
In
Taiwan,
53
percent
of
lung
cancers
occur
in
individuals
with
no
smoking
history.
S
So
there's
lots
of
other
factors
in
play
here
in
biomarkers.
Will
help
us
sort
that
out
so
Cancer
Care
is
entering
an
extraordinary
era,
and
lung
cancer
has
been
increasingly
at
the
Forefront
of
many
of
these
emerging
Technologies
and
treatment,
and
we
cannot
tolerate
progress
for
some,
but
not
for
others,
and
that's
part
of
why
we're
here
talking
with
you
all
today,
achieving
Equitable,
Cancer,
Care
and
outcomes
is
going
to
be
increasingly
difficult.
Thank
you.
L
All
right,
thank
you
so
much
honorable
members
of
the
committee.
Thank
you
for
allowing
me
to
get
my
comments
today.
My
name
is
Dr
Matthew
holder
I'm,
the
founding
director
of
the
Lee
Specialty
Clinic,
which
is
in
Louisville
Kentucky.
It
is
a
clinic
that
provides
interdisciplinary
integrated
whole
person,
care
for
adults
with
intellectual
and
developmental
disabilities
and
transitioning
youth.
L
L
In
order
to
understand
the
role
of
pharmacogenetic
testing,
I
need
to
tell
you
a
little
bit
about
people
with
intellectual
and
developmental
disabilities.
The
group
of
people
that
we
take
care
of
you'll
know
some
of
the
diagnoses
that
we
see
autism,
Down
syndrome,
cerebral
palsy.
Those
are
the
more
common.
However,
the
the
range
of
diagnoses
that
we
see
span
probably
a
thousand
different,
rare
and
very
rare
and
super
rare
different
disorders.
L
There
are
certain
common
characteristics
that
occur
with
this
population,
so
intellectual
disability
is
one
difficulty.
Communication
is
another
behavioral
and
psychiatric
disorders
is
another,
and
there
are
many
others,
one
of
the
very
common
things
that
occurs
in
this
population,
and
you
can
imagine
if
you
or
somebody
with
an
intellectual
disability,
you
had
something
difficult
happening
in
your
life
and
you
didn't
quite
understand
it
and
you
didn't
have
the
ability
to
communicate
it.
One
thing
that
would
probably
happen
is
you
might
turn
to
a
behavior
to
let
people
know
how
unhappy
you
were
about
it.
L
Unfortunately,
when
this
happens,
it
often
gets
misinterpreted
as
psychiatric
illness
of
some
kind
and
and
I've.
Seen
in
my
medical
colleagues
and
National,
surveys
bear
this
out
that
that
when
patients
with
idd
idd,
intellectual
and
developmental
stabilities,
when
patients
with
idd
go
to
the
hospital
that
they
are
diagnosed
with
psychosis
11
of
the
time
now,
I
can
tell
you
that
11
of
our
patients
at
least
Specialty
Clinic,
are
in
no
way
psychotic.
However,
there
are
lots
of
antipsychotics
being
prescribed
to
this
population.
L
This
is
through
something
that
we
call
diagnostic
overshadowing.
So
there's
a
there's.
A
lot
of
medications
that
are
being
prescribed
here
when
we
see
at
our
Clinic
we
see
patients
who,
who
first
come
in
our
average
patient,
is
on
13
different
medications.
Lots
of
those
are
behavioral
drugs
at
our
Clinic
after
they've
been
there
for
a
while
our
average
patient's
on
11
and
by
the
time
they
graduate
out
from
being
a
patient,
then
they're,
probably
on
about
nine
different
medications.
L
One
of
the
primary
things
that
we
try
to
do
is
to
get
people
off
of
medications
and
one
of
the
big
reasons
why
those
medications
are
prescribed
so
much
is
because
Physicians
don't
really
know
much
about
this
population.
The
training
in
medical
schools
is
pretty
light
and,
like
I
said
it's
a
fairly
rare
population.
L
However,
despite
the
fact,
it
is
a
relatively
small
part
of
our
population,
it
accounts
nationally
for
about
16
percent
of
the
Medicaid
budget,
so
it's
very
expensive
and
the
reason
why
it
has
to
do
with
the
fact
that
when
Physicians
start
treating
this
population,
they
don't
know
where
to
start.
So
we
do
what
Physicians
do
a
lot,
which
is
prescribe
lots
of
medications,
and
we
do
that
very
well.
We
don't
really
get
people
off
of
them
very
well.
So
that's
sort
of
a
little
background
about
the
population.
L
Now
let
me
turn
to
pharmacogenetic
testing
and
how
we
utilize
it
in
working
with
the
population.
So
I
think
everybody
here
actually
has
experience
with
pharmacogenetics
and
I'll
use
caffeine
as
an
example,
because
probably
everybody
here
has
taken
that
drug
today,
but
we
all
sort
of
have
an
idea
of
of
what
this
is.
Most
people
can
drink
a
cup
or
two
of
coffee
and
it
works
out.
Okay,
I'm,
a
lightweight
if
I
drink,
a
half
a
cup
of
coffee
in
a
day,
I'm
going
to
be
up
till
three
o'clock
in
the
morning.
L
There
are
other
people
that
you
know
who
can
drink.
Three
pots
of
coffee
and
they'll
be
able
to
go
to
sleep.
The
next
hour,
like
nothing
ever
happened,
Senator
Alvarado.
So
there
is
a
wide
variety
in
that
particular
substance
of
how
people
process
that
particular
drug,
and
that
has
to
do
with
not
really
tolerance
necessarily
to
caffeine,
but
how
the
genetics
affect
the
way
that
you
metabolize
something
now
imagine.
L
If
I
am
prescribing
that
to
somebody
and
they
are
lightweight,
then
I
run
the
risk
of
over
sedating
that
person
and,
if
I,
over
sedate,
that
person
now
we're
running
the
risk
of
an
emergency
room
visit
of
aspiration
pneumonia
of
all
kinds
of
adverse
outcomes
that
could
potentially
occur
because
I
over
sedated
that
person,
the
counter
to
that
is,
if
I
start
prescribing
that
drug
and
I
don't
see
an
effect.
What
most
Physicians
will
do
is
just
keep
upping
that
dose
more
and
more
and
more
and
more
until
we
finally
see
an
effect.
L
However,
just
because
we're
not
seeing
a
primary
effect
doesn't
mean
that
the
side
effects
aren't
compounding
every
time
we
increase,
that
dose
and
so
with
antipsychotics.
What
happens
over
time?
It
is
a
very
rough
drug.
Over
time
you
end
up
with
movement
disorders
and
again
predisposing
people
to
swallowing
problems,
aspiration
and
that
leads
to
ventilation.
Events
in
hospitals
and
things
like
that
that
are
extraordinarily
expensive,
so
on
either
end
of
this
situation
with
antipsychotics,
there
is
a
very
expensive
outcome.
Now,
sometimes
you
do
have
to
prescribe
those
drugs,
it's
just
the
reality
of
it.
L
So
when
we
prescribe
those
things,
especially
in
a
patient
who
can't
really
tell
us
whether
the
effect
that
we're
giving
or
we're
looking
for
is
actually
happening
or
not,
we
have
to
rely
on
on.
You
know,
sort
of
a
gut
check.
We
have
to
know
where
to
start-
and
we
don't
know.
One
of
the
very
very
useful
tools
here
is
pharmacogenetic
testing.
L
Pharmacogenetic
testing
allows
us
to
get
a
profile
of
the
patient
and
look
at
the
way
that
they
metabolize
different
types
of
drugs
and
gives
us
an
indication
as
to
whether
that
drug
is
going
to
be
effective.
A
higher
dose
is
needed,
a
lower
dose
is
needed,
or
maybe
it's
not
maybe
it's
very
ineffective.
L
So
that
gives
us
a
place
to
start
and
it
helps
us
to
avoid
those
those
sort
of
book
end
expensive
problems
that
happen.
When
you
don't
know,
the
other
thing
is,
as
I
mentioned,
we
have
a
lot
of
patients
who
are
on
lots
of
drugs
and
we
try
to
get
people
off
of
those
drugs
when
you're
sitting
there
with
a
patient
who's
on
13
different
behavioral
medications,
it's
kind
of
hard
to
figure
out
where
you're
supposed
to
start
to
get
somebody
off
of
that.
It's
a
very
long
process
and
we
have
ways
of
doing
it.
L
But
it's
difficult
one
of
the
really
nice
tools
again
is
pharmacogenetic
testing,
because
many
times
we
can
look
at
a
particular
drug
and
we
can
and
we
can
see
the
profile
and
say:
oh,
it
looks
like
that
drug
probably
isn't
even
working.
Why
don't
we
start
with
that
one,
and
so
we
can
start
systematically
weaning
people
off
again.
This
is
going
to
save
us
a
lot
of
time,
a
lot
of
Heartache
so
at
really
what
it
comes
down
to
in.
In
my
view,
this
this
is
I
think
the
future
of
medicine.
L
L
But
what
this
ultimately
does
for
our
patients
is,
it
improves
the
quality
of
their
health.
It
stops,
it
reduces.
The
amount
of
missed
starts
that
we
have
as
as
Physicians,
and
it
helps
doing
that
while
decreasing
costs
at
the
same
time
it
more
than
pays
for
itself,
and
so
that's
my
comments.
Thank
you
very
much.
Thank.
A
You
so
much
and
I
hope
that
this
gave
everyone
kind
of
a
background
in
the
importance
of
or
what
biomarkers
and
pharmacogenetics
are,
and
the
recurrent
theme
is
targeted
treatment
and
really
honing
in
on
that
individualized
care
I'm,
going
to
give
Leah
a
couple
of
minutes
to
tell
us
her
story
before
we
move
into
the
actual
testing.
I
know
that
we're
going
to
have
some
questions
so
welcome
Leah.
Thank
you
for
being
here.
Thank.
O
O
Of
course
you
want
to
start
treatment
right
away
because
the
cancers
are
spread
from
my
right
lung
to
my
spine
and
pelvis,
so
the
oncologists
that
we
met
with
suggested
that
we
go
ahead
and
start
one
of
the
standard
protocols
for
lung
cancer
treatment,
my
husband
being
the
researcher
that
he
is
felt
like
there
was
more
to
the
story.
Someone
that's
never
smoked,
shouldn't
have
stage
four
lung
cancer
in
theory
which
led
him
to
do
some
investigation
on
his
own.
O
Where
we
spoke
to
a
second
oncologist
who
said,
please
do
not
start
any
kind
of
treatment
until
biomarker
testing
has
been
completed.
We
know
that
the
time.
Of
course
this
was
December
19th
when
I
was
diagnosed,
so
we
have
all
the
holidays
in
there.
We
know
you're
anxious
to
get
started
on
treatment,
but
please
don't
because
if
in
fact
you
do
qualify
for
a
targeted
therapy,
it
may
not
be
as
effective
if
you've
already
had
traditional
chemo,
so
I
had
biomarker
testing
done
through
Keras
labs.
My
particular
biomarker
testing
was
twenty
thousand
dollars.
O
We
actually
pulled
the
bill
up
for
that
when
I
was
asked
to
kind
of
give
my
perspective
on
this.
So
when
we
were
in
the
hospital,
I
was
in
the
hospital
for
a
total
of
eight
days,
my
husband
bedside
as
I'm
required,
basically
recovering
for
an
emergency
chest
tube
multiple
biopsies
bronchoscopies,
you
name
it
I,
had
it
done.
He
spent
80
to
90
hours
on
the
phone
with
insurance
companies
with
other
oncologists
trying
to
figure
out.
O
O
So
the
biomarker
testing
did
reveal
that
I
have
a
genetically
driven
cancer,
which
is
egfr
Exon
19,
as
my
driver,
which
was
in
a
lot
of
the
different
PowerPoints
because
of
knowing
that
biomarker
testing
result
I
qualified
for
targeted
therapy,
which
was
called
Austin,
martinib
or
trigriso
starting
that
medication.
It
started
about
three
weeks
once
with
my
original
diagnosis
diagnosis.
It
took
about
three
weeks
to
get
started
on
that
therapy.
O
Since
then
my
primary
tumor
shrunk
by
70
and
all
my
yeah,
all
by
my
all,
my
bone
metastasis
totally
have
healed,
and
that
point
a
year
later,
we
decided
to
be
pretty
aggressive
and
do
eight
sbrt
radiation
therapy
treatments
to
my
primary
lung
spot
and,
at
this
point,
I'm
considered
no
evidence
of
disease
and
stable
in
my
journey
of
lung
cancer,
it's
kind
of
a
lonely
cancer
in
terms
of
especially
someone,
my
age.
There
are
not
a
lot
of
young
healthy
non-smoking
women
walking
around
with
stage
four
lung
cancer.
O
Luckily,
for
me,
I
had
two
other
patients
in
Kentucky.
One
is
a
patient
at
UK
Marquee,
one
was
a
patient
here
and
I'm
from
Louisville
was
in
Louisville
as
well,
and
the
one
I'm
speaking
of
now
with
her
name
was
Elizabeth
Moyer
many
people
may
have
heard
of
Elizabeth
or
her
story.
She
was
diagnosed
at
age
30
with
stage
four
lung
cancer.
She
was
a
college
athlete
she
had
never
smoked
and
her
youngest
daughter
was
only
six
months
old.
O
At
the
time
of
diagnosis,
Elizabeth
and
I
became
very
close
friends
and
I
was
actually
with
her
just
hours
before
she
passed
away
for
us
who
had
she
had
a
genetic
driver
of
Alec
positive
was
her
genetic
driver
for
those
of
us
with
these
genetic
drivers
a
lot
of
times
our
cancer?
It
does
we
do
progress.
We
are
never
going
to
be
in
remission.
If
that's
what
you
want
to
call
it
or
totally
cancer-free,
it
will
come
it's
not.
If
it
comes
back
it's
when
it
comes
back
every
time
we
progress.
O
We
need
to
have
this
biomarker
testing
repeated
to
see
if
we
have
another
driver
and
what
therapies
would
be
best
suited
for
our
particular
cancer
Elizabeth
had
over
six
biomarker
testing
test
ran,
most
of
which
were
out-of-pocket
expenses,
so
it
is
extremely
important
that
not
only
is
the
first
time
people
know,
doctors
know,
patients
know
the
first
time
you're
diagnosed.
You
need
to
have
this
biomarker
testing,
but
the
doctors,
the
patients.
O
All
of
us
need
to
know
that
before
we
do
a
second
set
of
treatment
or
move
on
to
another
therapy
that
we
have
this,
this
biomarker
testing-
you
know
repeated
I'm
here
today,
because
I
feel
strongly
of
having
a
whole
team
approach
that
all
of
us
need
to
be
on
the
same
page,
Doctors
Hospitals
patients
oncologists
everyone
to
get
the
testing.
We
need
to
have
the
best
life
possible
even
in
terms
of
quality
of
life,
but
also
longevity
of
life.
R
A
Thank
you
thank
you
for
being
here
and
we're
ecstatic
that
you
are
here
and
this.
This
is
the
point
we
we
want
to
make
this
more
widely
available
and
I
want
to
give
Mr
Remington,
who
came
down
from
Northern
Kentucky
a
few
minutes
to
talk
about
the
actual
testing
and
if
you
can
just
give
kind
of
a
high
level
overview.
I
know
we're
going
to
have
some
questions
and
and
maybe
about
the
specific
testing.
P
A
P
I
usually
talk
fast,
but
after
all
the
other
speakers
I
feel
like
I'm
gonna,
be
the
slow
one
here.
Thank
you
for
having
me
very
humbled
to
be
here.
First
time,
I've
ever
done
this.
My
name
is
Tony
Remington
I'm,
the
CEO
and
founder
of
gravity
Diagnostics
in
Covington
Kentucky
we're
a
cap,
clear
laboratory
licensed
in
all
50
states.
P
P
So
basically,
you
know
from
my
point
of
view.
After
all
these
amazing
speakers,
it's
kind
of
hard
to
talk
about
pharmacogenetics
when
we're
talking
about
cancer
and
but
I'll,
just
kind
of
do
my
best
to
put
it
to
intertwine
the
two
I
think
from
my
point
of
view.
You
know
I'm
in
the
private
sector,
and
you
know
our
main
model
of
sustainability
to
help
people
is,
you
know,
building
insurance
and
getting
paid
by
Insurance,
similar
like
Quest
or
LabCorp.
P
Blood
or
urine
Etc,
we
do
a
ton
of
medical
monitoring,
a
lot
of
addiction
and
Recovery
customers
trying
to
help
those
patients.
You
know
recover
and,
and
because
of
you
know
the
role
I
play
I'm,
not
a
physician,
I'm,
not
a
clinician,
you
know,
I,
look
at
it.
This
way,
I'm
like
how
do
I
save
the
Healthcare
System
money.
P
The
way
to
you
know
get
people
more
interested
in
doing
this,
and
helping
out
and
and
supporting
payment
is
I
think
that
the
Health
Care
system
is
very
reactive
and
we
end
up
spending
a
lot
of
money
on
things
in
a
reactive
way
and
I.
Think
if
you
do,
you
know,
do
more
investing
on
the
front
end
with
pharmacogenetics
in
next-gen
sequencing
with
cancer.
We
can
do
that.
P
You
know
we
have
nexogen
sequencing
technology
as
well
in
gravity,
so
you
know
we
kind
of
came
at
it
where
we're
spending
a
lot
of
money
on
health
care,
a
lot
of
money
on
addiction,
a
lot
of
money
on
recovery
and
mental
health
and
I.
Think
if
we
were
more
proactive
about
that
approach,
we'd
actually
reduce
the
the
cost
to
the
Health
Care
system,
I'm,
trying
to
figure
out
how
to
deal
with
how.
P
Okay,
thank
you.
Yeah
now,
you're
setting
me
up
for
failure
here.
So
so
I
went
over.
Who
we
are.
You
did
an
amazing
job
talking
about
pharmacogenetics.
You
know
the
way
I
simplify
pharmacogenetics
is
it
looks
how
how
you
metabolize
medication
I've
covered
the
United
States
for
25
years
in
the
healthcare
industry,
so
I've
met
thousands
of
Physicians
over
this
25
years
and
you'll
find
that
most
doctors
and
clinicians
that
work
with
behavioral
health
or
pain
management
patients
admit
that
it
is
a
trial
and
error
approach.
P
Like
they'll
openly
say
it's
like
throwing
a
dart
at
a
dartboard
or
spinning
a
roulette
wheel.
That's
that's
very
common
and
you
know
my
passion
and
why
I
got
into
the
laboratory
diagnostic
industry
and
left
kind
of
more
of
the
medical
device
industry
was
we've
got
this
amazing
opportunity
to
get
this
information
it's
a
benign
test.
It
doesn't
have
any
Adverse
Events
and
it
could
prevent
a
catastrophic
adverse
event.
It
can
get
the
right
dose
and
Drug
the
first
time
time
and
it
just
to
me
for
10
years
I've
been
like.
L
P
One
thing
that
no
one
mentioned,
there's
actually
drugs
that
you
just
can't
metabolize,
so
you
can
be
on
a
drug
and
just
not
metabolize
it
period,
no
matter
how
much
you
take
of
it.
So
it's
really
important
to
get
this
information
and
we've
been
passionate
about
this
for
a
long
time.
You
know,
there's
data
out
there,
there's!
No,
you
know
you
will
run
into
really
really
well
respected,
clinicians
that
say
the
evidence
isn't
there.
P
Yet
you
know
the
peer-reviewed
five-year
randomized
trial
data
is
not
as
strong
as
some
people
might
like
it
to
be,
but
there's
a
lot
of
data
on
proof
sources
out
there
that
this
works.
So
that
excuse
me,
you
can
save
the
Healthcare
System
money
at
gravity.
We
developed
our
own
internal
report
so
the
way
our
lab
works.
We
have
all
the
equipment,
we
have
all
the
instruments,
we
have
75
scientists
or
you
know,
science
trained
employees.
P
P
Simple,
like
red,
yellow,
green
light
system,
so
it
is
20
Pages.
The
patient
will
bring
it
to
their
clinician
and
you
don't
want
an
expert
to
go
over
that
and
you
know
we
always
say
this
gives
you
implications
this?
Doesn't
you
never
want
a
patient
to
get
the
Rapport
and
actually
change
their
drug
or
dose
right,
but
this
gives
them
training
wheels
guide
to
try
to
get
the
drug
and
dose
right
the
first
time,
and
we
want
to
make
this
report,
so
anyone
in
the
room
could
understand
it
right.
A
P
H
You,
madam
chair
and
I,
see
members
of
the
kma
here
today.
I
hope
they
can
get
an
hour
of
CME
for
this
lecture,
because
I
I
find
this
stuff
fascinating.
I
know
some
of
our
members
of
our
committee.
May
not
it's
a
lot
of
science,
and
this
is
stuff
that,
for
me,
I
think
is
the
next
step
where
we're
going
in
healthcare.
H
We
often
will
look
back,
probably
in
20
years
and
think
why
won't
they
do
doing
this
stuff
when
they
could
have
been
and
we're
going
to
be.
Looking
at
the
old
way
of
doing
chemotherapy
for
Cancer
Treatments
is
just
barbaric
which,
like
you
said
just
trial
and
error.
Try
it
see
what
works
see,
what
kills
people,
what
doesn't
and
try
to
advance
the
next
step
and
we're
getting
a
lot
fancier
at
this
Leah
I'm
impressed
by
your
story.
My
wife
is
44
when
she
was
diagnosed
with
breast
cancer.
H
It
is
scary
even
for
a
medical
family,
a
lot
of
bad
memories
for
me
going
through
that
you
feel
helpless,
because
you
can't
do
anything
for
your
wife
and
so
it's
tough
to
do
that.
I
know.
Men
tend
to
want
to
take
control
and
figure
things
out,
I'm
sure
your
husband's
in
that
same
role,
I
found
myself
in
that
same
role
and
I
would
go
to
her
meet
her
medical
visits.
H
Only
to
have
the
documentary
say:
is
it
okay
for
him
to
be
here
and
I'd
say
you
know
what
I
need
to
just
step
out
and
let
her
kind
of
do
her
own
thing
as
a
patient,
so
it
can
be
very
difficult,
so
I'm
glad
that
you're
here
and
glad
things
are
working
out
well
had
a
very
good
friend,
we
were
just
commenting:
Dr
n
Aaron
James
was
a
physician
vegetarian
guy
in
fabulous
shape
stage.
Four
colon
cancer
died
from
it.
H
I
went
to
his
funeral
about
a
year
and
a
half
ago,
I'm
sure
this
would
have
helped
him
as
well
for
a
lot
of
this
kind
of
testing,
because
there
was
nothing
else
that
really
triggered
for
him.
For
that,
the
reason
we're
even
covering
this
topic
for
those
who
are
wondering.
Why
are
we
going
over
this
we're
trying
to
get
coverage
for
these
tests?
Some
of
our
insurance
carriers
are
covering
tests.
H
Some
are
not,
and
so
we're
trying
to
get
to
make
this
across
the
board
on
pharmacogenetics
I
think
it
would
require
a
one
once
in
a
lifetime
test,
and
that
gives
you
and
your
doctor
the
pathways
that
you
can
use
for
drugs
and
treatments
and
what's
appropriate.
What's
not
what
works
better
for
you?
Well,
I
can
drink.
You
know,
probably
not
healthily,
so
six
to
eight
cups
of
coffee
a
day
and
not
have
the
same
effects
as
a
half
a
cup
for
you,
because
my
Pathways
I'm
sure
are
different
in
that
regard.
H
Early
detection,
Dr,
mullet
I
think
you
shared
a
little
bit
of
a
personal
story
as
well.
I'll
share
mine
today,
I
got
diagnosed
with
a
DVT
about
five
six
weeks
ago,
I'm
currently
on
thinners,
not
really
an
explanation
for
it.
I
kind
of
diagnosed
myself
contacted
my
doc
said:
hey
man,
I
think
I
probably
need
an
ultrasound
as
I'm
laying
there
I
see
my
DVT
right.
What
goes
to
your
head
hyper
coagulable
States.
It
could
be
a
malignancy
of
some
sort,
so,
fortunately,
everything
came
out.
H
Unfortunately,
so
I
feel
very
good
about
that,
not
having
any
other
symptoms,
but
but
as
those
tests
get
fancier,
we
can
start
using
those
tests,
as
a
marker
is
almost
as
a
pre-diagnosis
or
to
start
catching
things
at
a
very
early
stage,
and
so
I
know
a
lot
of
our
our
MCO
friends
or
insurance
company
friends
are
watching
and
listening
to
this
and
thinking.
Oh,
how
much
is
this
going
to
cost
us
I'm
asked
I'm
going
from
it.
How
much
is
it
going
to
save
you
if
you
catch
something
at
a
stage?
H
One
level
you
can
get
that
thing
out
and
avoid
the
years
of
potential
chemo
treatment,
hospitalizations
Etc.
For
me,
it
costs
950
to
get
that
test
done
and
it's
getting
fancier
as
we
go.
So
it's
not
quite
the
twenty
thousand
dollar
test
that
you're
you're
talking
about
and
the
more
we
do
it,
the
more
we're
going
to
see
that
price
drop
and
come
into
into
range,
so
I
think
again,
it's
very
important
to
look
at
early
detections
on
these
kinds
of
things.
H
A
lot
of
these
are,
after
people
get
diagnosed,
it's
the
biomarker
testing
to
direct
therapy.
We
have
that
availability.
There's
also
now
an
availability
to
look
at
this
stuff.
Prior
now
you
might
have
to
rip.
You
know
that
isn't
a
once
in
a
lifetime
test,
you
have
to
get
them
repeatedly
because
things
can
change.
You
develop
a
new
tumor
or
a
cancer.
H
Now
the
markers
are
present
in
your
bloodstream
and
you
have
to
get
those
done,
but
I
think
there's
an
opportunity
for
that,
and
obviously
people
in
your
family
that
might
have
a
potential
for
this.
We
should
be
able
to
cover
those
tests,
at
least
for
those
folks,
to
make
sure
that's
done
in
Kentucky
we're
making
a
lot
of
success.
H
So
the
reports
from
our
from
our
physicians
and
our
pharmacists,
who
presented
a
lot
of
the
information
and
where
Kentucky
is
trending,
we've
been
a
bad
state
for
cancers,
I
think
we're
starting
to
see
some
light
at
the
end
of
the
tunnel
and
our
colon
cancer
diagnosis
rates
are
going
way
up.
We've
had
a
huge
effort
from
the
state
funding
towards
that
now
we're
doing
it
towards
lung
cancer,
major
opportunities
to
make
some
strides
in
this
and
be
a
leader
on
this
I
think
and
so
again.
H
I
know
if
we
propose
this
there's
I
know
this
legislation
that
we're
planning
on
bringing
forward
this
upcoming
session.
I
know
those
who
will
try
to
oppose
this
and
again
I
would
encourage
you
think
of
how
much
you're
going
to
save
on
this.
If
we
catch
people
early
in
a
state
with
as
much
cancer
as
we
have
instead
of
treating
people
on
the
back
end
of
this
catch,
it
early
get
it
out
early,
get
treatments
early
and
avoid
those
hospitalizations,
and
you
know,
and
not
to
mention
the
deaths
that
we're
going
to
have.
H
A
C
Thank
you
actually,
I
think
this
is
for
me
personally,
one
of
the
most
fascinating
presentations
that
that
I've
had
up
here
as
a
state.
Senator
and
I
really
want
to
express
my
appreciation
first
of
all,
to
whoever
is.
Is
writing
this
bill
and
to
you
guys
for
coming
up
and
sharing
this
extremely
important
information
with
us?
I
just
I
have
a
question
and
then
I
have
a
couple
of
comments.
I'm
going
to
start
with
my
comments.
First
I
personally
was
diagnosed
with
breast
cancer
at
the
age
of
47.
I.
C
C
The
only
thing
I
really
had
to
pay
out
of
pocket
for
was
the
genetic
testing
on
my
tumor
and,
if
I
remember
correctly,
I
think
I
paid
1300.
It
may
have
been
2300
yo.
It
was
around
there
and
and
for
me,
I
paid
it
happily,
but
think
about
how
few
people
in
this
state
get
the
option
of
making
that
decision
at
this
point,
because
it's
not
covered
by
your
insurance
and
therefore
it
is
Out
Of
Reach
to
you.
C
In
my
case,
this
genetic
testing
was
actually
able
ultimately
to
impact
my
decision
making
on
chemotherapy
and
actually
saved
me
two
rounds
of
chemo,
which
would
have
cost
a
heck
of
a
lot
more
than
that.
Thirteen
hundred
dollars
that
I
put
out
of
pocket
I'm
much
not
even
to
talk
about
quality
of
life
and
everything
else
so
I
mean
for
me
it
was
essential.
I
have
a
friend
right
now
who
is
battling.
You
know
stage
four
breast
cancer.
C
Every
time
they
biopsy
her.
Her
genetics
are
changing
on
this
tumor
and
every
time
it
changes
they
are
able
to
change
her
targeted
chemotherapy
and
preserve
her
life
because
she's
responding
when
she
never
responded
before
and
every
time.
She
calls
me
and
says:
do
I
really
need
to
spend
this
money
again?
C
My
answer
is
absolutely
yes,
because
it
has
that
much
of
a
potential
impact
on
your
treatment
and
your
outcome
and
personally
I
think
the
fact
that
these
aren't
covered
by
insurance
companies
at
this
point
is
a
real
shame,
because
they
do
impact
treatment
and
outcome.
I
want
to
make
sure
everybody
in
this
room
understands.
This
is
important.
C
You
know:
The
Disappearance
was
very
short-lived.
Now
we
watch
it
disappear
and
literally
we
have
patience
that
year
after
year,
it's
not
coming
back
and
I.
Look
at
these
studies
and
I
think
of
what
I
experienced
as
a
diagnostician
just
20
years
ago,
and
the
difference
that
this
is
making
it
is.
It
is
amazing
just
to
watch
these
images
now.
I
have
my
one
question
that
I
am
going
to
ask:
does
anybody
up
here
speaking
have
any
idea
if
we
can
use
any
of
this
pharmacogenetic
testing
to
try
to
predict
addiction
to
alcohol?
C
P
I,
my
only
answer
would
be
I'm
not
assigned
I
mean
I
have
a
great
group
of
phds.
That
would
probably
give
you
a
much
better
answer.
I.
Think
the
predictability
like
there's
going
to
be
algorithms,
that
you
use
where
you
use
you
know
all
the
demographics
and
the
genetic
results
and
your
zip
code
and
your
you
know
we're
working
on
those
type
of
things.
P
I
can't
look
you
in
the
eye
and
say:
yes,
there
that's
happening,
but
I
think
because
we
do
so
much
addiction
you
you
feel
like.
That
would
be
a
really
helpful.
That's
a
missing
piece
So!
My
answer
is
I.
Think
it's
possible,
but
I
can't
look
you
in
the
eye
and
say
that
you
know
it's
coming
tomorrow.
Thank.
L
No
I
I
was
I
was
going
to
say
something
quite
similar
to
that
in
so
much
as
I.
Don't
know
that
we
can
say
directly
right
now,
but
that
this
information,
the
information,
that's
provided
by
this
type
of
testing
into
this
line
of
of
thinking
and
research,
will
provide
that
answer.
I'm
fairly,
certain
of
it
and.
P
The
only
thing
I
want
to
add
is
the
cost
to
do
this
is
so
much
different
than
it
used
to
be
in
a
good
way.
You
know,
I
mean
the
cost.
You
know
we
10
years
ago.
Insurance
companies
would
pay.
You
know
ten
thousand
dollars
for
testing
if
it
was
a
network,
you
know,
and
we
you
know
that
was
just
you
know,
I.
That
was
not
my
lab.
You
know
when
I
represent
other
labs,
I
mean
you
know,
you're
talking
hundreds
of
dollars
to
do
pharmacogenetics
now.
P
So
you
know
if
you
want
some
advice
at
that
point,
you
know
when
you
look
at
this
and
I
think
same
thing
with
next-gen
sequencing,
it's
much
more
expensive
to
do
that.
Your
cost
of
goods
are
probably
five
times
higher,
at
least
to
do.
You
know
cancer
versus
pharmacogenetics,
but
it's
not
twenty
thousand
dollars.
So
you
know
I
think
there's
hope
here
that
this
is
Affordable
and
it
will
cost
justify
itself.
As
you
all
mentioned,.
T
N
Well,
I,
thank
you
for
your
question.
Senator,
Kerr
and
I
think
that
it
is.
It
is
important
that
we
understand
that
there
are
genetic
drivers
that
are
present
for
many
of
these
tumors
colon
cancer
in
particular,
and
Kentucky
has
a
high
population
of
patients
with
what's
described
as
Lynch
syndrome.
It's
a
genetic
driver
of
types
of
colon
cancer.
There
are
polyposis
syndromes
that
exist
often
familial,
but
many
of
these
are
sporadic.
They
would
be
developed
because
of
again
a
mutation
that
develops
perhaps
there's
some
some
process
there.
N
The
recommendation
now
is
for
45
years
old
for
colon
cancer
screening
to
begin,
and
you
know
I
think
as
we
look
at
this
even
in
lung
cancer
or
other
factors,
there
are
risks
associated
with
moving
that
screening
earlier
the
risks
of
of
undergoing
a
procedure
that
may
not
be
necessary.
That
may
cause
problems,
and
so
we
really
have
to
stay
within
the
guidelines
for
that,
but
I
do
think,
as
our
genetic
testing
expands
there's
a
few
features
that
we
haven't
really
touched
on
here.
That
I
think
are
critical.
N
But
the
other
piece
of
this
is
that
this
in
this
information
endures,
even
though
our
development
of
new
drugs
and
new
testing
is
evolving
and
one
of
the
interesting
features
I
think
Keras
Labs
was
mentioned
in
one
of
the
features
that
they've
talked
about
is
holding
on
to
this
information
on
patients.
If
there's
no
actionable
mutation,
that's
present,
but
there's
a
mutation.
That's
there,
a
drug
develops
a
year
down
the
road.
N
They
can
look
over
that
library
and
say
Dr
Miller.
You
had
a
patient
last
year
that
had
this
mutation
now
there's
a
drug,
that's
available.
You
might
think
about
this
in
the
conduct
of
your
care,
I'm
a
surgeon,
so
it's
a
medical
oncologist
that
would
be
doing
that,
but
they
might
call
me
because
I
was
the
surgeon
that
perhaps
diagnosed
an
earlier
stage,
disease
and
so
I
think
that
this
information
is
persistent,
and
so
it's
really
important
that
we
have
the
ability
to
look
back
on
it.
N
And
the
final
piece
about
this
is
that
genetic
testing
for
families
and
genetic
testing
for
patients
accumulates
this
data
and
so
we'll
begin
to
look
at
patterns
of
treatment
that
are
effective
if
we
have
more
patients
that
undergo
these
tests,
if
we
don't
open
the
door
to
let
these
tests
happen
with
low
with
less
barriers,
pre-authorization
the
cost
assist
Financial
toxicity
for
patients
and
so
forth.
Then
we
won't
get
that
information
that
will
give
us
the
patterns
of
treatment
that
will
allow
us
to
Direct
Care
in
more
precise
ways.
A
All
right,
thank
you.
So
much
I
I
really
appreciate
this
presentation.
We
do
have
a
couple
of
more
questions,
but
we
also
have
two
more
presentations,
so
I'll
give
everyone
an
opportunity
who
has
indicated
that
they
have
a
question
but
we're
going
to
have
to
speed
things
up
a
little
bit
representative
Bentley.
D
Q
So
I
could
take
that
question
if
you'd
like.
Thank
you.
The
advertised
turnaround.
Time
is
two
weeks
that
can
take
a
little
bit
longer,
depending
on
whether
it
can
get
out
of
pathology
quickly
or
not,
but
the
goal
is
to
turn
it
around
in
two
weeks
with
I'm
going
to
go
to
your
third
part
of
your
question.
Whether
Foundation
medicine
is
the
only
test.
There
are
a
number
of
commercial
providers.
Q
That
I
would
consider
would
be
standard
care,
including
Karis,
Foundation,
Tempest
and
most
of
those
are
paid
for
by
Medicare
and
varies
a
little
bit
with
private
insurance
and
then,
with
regard
to
the
number
of
genes
that
are
on
the
test.
That
varies
a
little
bit
with
the
test,
but
it
ranges
from
about
350
on
Foundation
up
to
more
than
500
on
a
Keras
and
the
other
thing
I.
The
kind
of
the
trend
in
testing
is
to
do
the
whole
exome.
D
Q
Q
We
don't
really
know
all
the
answers
to
that
yet,
but
that
also
to
me
encourages
further
testing,
because
the
more
the
other
trend
is
that
a
lot
of
this
testing
is
is
going
into
large
databases
and
persisting
like
Dr
Irmo
was
describing
so
the
more
testing
that
we're
able
to
have
the
more
repeat
testing,
especially
after
immunotherapy,
the
more
likely
we
are
able
to
identify
those
resistance
patterns
which
are
generally
used
by
pharmaceutical
companies
to
design
new
drugs.
Thank.
U
I
just
have
a
comment
in
regards
to
Dr
mullet's
presentation,
showing
the
success
in
encouraging
lung
cancer
screening
and
the
success
that
we've
had
there
and
I
just
want
to
make
a
call
group
is
that
we
really
need
to
look
at
these
screening
measures
being
covered,
not
subject
to
deductible
some
plants
cover
it.
Some
don't
and
you
can't
ask
a
group
of
asymptomatic
people
to
go.
Get
these
tests,
knowing
that
they're
going
to
get
bills
in
several
hundred
and
thousand
dollars
range.
V
The
the
question
I'm
going
to
ask
is:
do
you
pay
attention
to
the
patient
and
I
will
tell
you
why
I'm
asking
the
question
is
of
my
own
personal
experience.
I
went
to
dermatologist
several
times
and
he
gave
me
a
clean
bill
of
health.
The
last
time
I
went
I,
said
Doctor.
What's
this
oh
I
didn't
see
that
and
I
had
a
melanoma,
they
was
removed,
then
I,
believe
it
or
not
went
back
to
this
guy
and
he'd.
Give
me
another
clean
bill
of
health
and
I
said:
what's
this
on
my
nose?
V
V
Q
V
Cancerous
tumors
as
well,
he
is
now
going
to
Anderson
in
Houston
for
another
opinion
on
it,
and
but
the
the
last
thing
I'm
going
to
ask
is
because
it's
very
personal
is
my
son:
what
do
a
dermatologist
two
years
ago
and
complained
a
problem
here
with
his
arm
no
problem.
He
now
has
stage
four
melanoma.
J
V
N
These
are.
These
are
there's
a
human
behind
this
DNA
test
that
we're
doing
there's
a
family
behind
that
patient
and
so
the
more
we
recognize
that
the
more
important
these
tests
are.
But
I
I
certainly
recognize
your
point
and
recognize
that
we
need
to
continue
to
hone
those
human
skills,
as
well
as
our
science.
P
You
know
and
I'll
just
say
as
a
non-clinician
I
mean
I
I,
think
medicine's
complex
and
there's
a
lot
of
endpoints
that
a
clinician
has
to
deal
with
today
that
they
didn't
have
to
deal
with
20
years
ago.
So
I
have
a
ton
of
respect
for
providers
and
also
the
insurance
companies.
I
mean
they're
all
trying
to
get
it
right.
But
it's
so
complex
now
for
a
clinician
that
you
know
they're
on
a
clock,
they've
got
10
minutes
they
get
another
like
their
model
is
so
different
than
it
was
a
long
time.
P
A
A
You
know
we
certainly
need
to
take
into
consideration
the
patients,
the
providers
and
the
insurance
companies
who
are
trying
to
do
this
right,
trying
to
trying
to
provide
coverage
in
in
a
way
that
makes
sense,
and
so
that's
really
what
this
discussion
was
about.
That's
what
the
the
upcoming
legislation
will
be
about,
and
I
just
really
want
to
thank
everyone
for
being
here
today.
This
has
been
great.
Thank
you.
Thank
you.
Thank.
E
A
All
right,
we
are
really
honored
to
have
with
us.
The
Kentucky,
Hospital,
Association,
nancel,
Nancy
galvani
is
here
and
thank
you
so
much
for
your
patience
in
in
putting
up
with
our
I
knew
that
we
were
going
to
have
a
lot
of
great
discussion
around.
That
topic
went
a
little
bit
long,
but
thank
you
for
being
here
Nancy's,
going
to
talk
a
little
bit
about
the
the
relatively
new
federal
transparency
law,
transparency
laws.
What
that
what
that
is
and
what
it
means
here
in
Kentucky
Nancy.
W
Thank
you
so
much
chairwoman,
Mosher
chairman
Alvarado
and
the
committee
members,
and
it's
a
great
presentation,
and
certainly
a
very
important
topic,
so
no
problem
at
all
happy
to
have
listened
to
that.
So
thank
you
for
having
us
today
to
talk
about
the
important
issue
of
Health
Care
transparency
and
what
hospitals
are
doing
to
make
prices
more
transparent
and,
of
course,
when
we
talk
about
transparency,
we're
really
focusing
on
making
available
information
to
Consumers
so
that
they
can
shop
for
care.
W
But
what
patients
really
want
to
know
is
you
know
what
is
the
cost
going
to
be
to
me,
and
so
something
to
keep
in
mind
is
that
the
patient's
out-of-pocket
costs
aren't
determined
by
the
hospital
either.
The
patient's
private
insurance
plan
or
the
government
program
that
covers
the
patient
is
determining
the
out-of-pocket
costs
and
a
patient's
insurance
company
really
is
in
the
best
position
to
tell
the
patient
if
they've
met
their
deductible,
whether
the
provider
is
in
network
and
what
the
patient's
out-of-pocket
costs
are
going
to
be.
W
Kentucky
hospitals
really
have
a
long
history
of
helping
our
patients
anticipate
their
out-of-pocket
costs
and
pay
for
them.
Our
hospitals
have
financial
counselors
that
provide
estimates
on
request
and
hospitals
have
financial
assistance
policies
to
help
the
uninsured,
the
underinsured
and
low-income
patients
pay
for
hospital
care.
W
Last
year
the
federal
Hospital
price
transparency
rule
took
effect,
although
hospitals
have
had
their
charge
Masters
on
their
websites
for
many
years.
This
Rule
now
requires
hospitals
to
post
five
types
of
standard
prices
for
all
of
the
items
and
services
that
are
offered
by
the
hospital,
and
these
include
the
gross
charge,
the
discounted
cash
price,
the
hospital's
negotiated
price
by
each
third
party
payer
that
they
have
a
contract
with
and
the
de-identified
third-party
payer
minimum
and
maximum
negotiated
price.
W
This
information
must
be
displayed
in
a
machine
readable
file.
That's
located
on
the
hospital's
website,
that's
downloadable,
along
with
the
description
of
the
item
and
any
code
used
for
billing
and
I've
actually
gone
out
and
looked
at
these
files,
and,
as
you
can
imagine,
they
are
voluminous
and
not
helpful
to
any
patient
attempting
to
understand
their
costs
for
hospital
care.
W
W
Our
hospitals
are
working
diligently
to
meet
these
new
federal
requirements.
Cms
recognizes
the
heavy
I.T
lift
involved
in
doing
this,
particularly
to
our
small
hospitals
that
have
to
rely
on
vendors
because
they
don't
have.
I
t
staff
in-house,
so
CMS
has
been
working
collaboratively
with
the
hospitals
to
achieve
compliance.
W
The
compliance
deadline
for
the
machine,
readable
file
of
standard
prices
was
delayed
until
July
1st
of
this
year
to
align
with
the
federal,
no
surprises
act,
which
I'll
talk
about
in
a
minute.
There
are
6093
U.S
hospitals
and,
as
of
June
this
year,
only
160
that's
2.6
percent
of
all.
The
hospitals
in
the
nation
per
CMS
were
not
in
compliance
with
that
rule.
W
W
A
good
faith
estimate
is
a
notice
of
the
person's
expected
charges,
including
any
discounts
or
adjustments
such
as
through
a
finite
financial
assistance
policy
that
the
hospital
would
have.
These
estimates
can
be
requested,
but
they
are
required
to
be
provided
upon
scheduling
of
a
service.
An
individual
has
the
right
to
go
through
a
new
federal
dispute
resolution
process
if
their
actual
bill
charges
are
substantially
in
excess
of
the
estimate
and
the
federal
government
defines
that
as
a
charge
that
exceeds
the
estimate
by
four
hundred
dollars.
W
And
this
diagram
kind
of
shows
this
new
process
this
year,
each
individual
provider
is
required
to
submit
their
own
good
faith
estimate
to
the
patient.
So,
for
example,
if
a
patient
is
having
outpatient
surgery,
the
hospital
scheduling
it
would
provide
the
hospital's
estimate
to
the
patient,
but
the
patient
would
have
to
go
to
the
other
providers
involved
separately
to
get
their
individual
estimates.
W
For
example,
the
surgeon
that
changes
next
year
in
2023,
the
scheduling
provider
is
considered
the
convener
and
is
responsible
for
notifying
any
co-providers
or
co-facilities
getting
their
estimates
and
presenting
a
Consolidated
estimate
to
the
patient.
So
on
this
slide
you
can
see
the
hospital
would
be
reaching
out
to
the
surgeon,
the
pathologist,
the
anesthesiologist
saying
this
procedure
is
being
scheduled.
W
There
are
very
tight
time
frames
involved
with
only
a
few
business
days
allotted
by
the
federal
government
for
this
communication
and
exchange
of
data
to
occur
and,
as
you
can
see
here,
it's
basically
one
business
day
to
turn
all
that
around
three
business
days.
To
get
the
information
back
to
the
patient,
there's
a
totally
different
process
that
will
apply
to
insured
patients
when
a
provider
or
facility
notifies
an
insurer
that
an
enrollee
is
scheduled
to
receive
a
service.
The
provider
will
send
a
good
faith
estimate
of
expected
charges
to
the
insurer.
W
Cms
has
indefinitely
delayed
implementation
of
this
Advanced
cob
until
CMS
issues,
more
regulations
on
how
data
will
be
exchanged
between
providers
and
plans.
Cms
has
just
issued
a
request
for
information
on
September
the
16th
seeking
comments
on
standards,
provider
burden
and
a
whole
host
of
issues
related
to
this
requirement.
W
Now
there
are
several
factors
that
have
to
be
considered
when
we
talk
about
Hospital
prices.
First,
we
have
to
recognize
that
Health
Care
does
not
operate
in
a
free
market.
Essentially,
health
care
costs
are
dictated
by
the
federal
government,
the
federal
emergency
medical
treatment
and
active
Labor
Act.
What
we
call
them
tala
requires
hospitals
to
treat
anyone
who
comes
through
the
hospital's
emergency
department,
regardless
of
the
ability
to
pay
Kroger,
Best,
Buy
Walmart
any
other
business.
W
Would
click
would
quickly
be
out
of
business
if
they
were
required
to
provide
their
goods
and
services
to
anyone
who
walked
through
their
doors,
regardless
of
ability
to
pay?
Eighty
percent
of
the
patients
in
Kentucky
hospitals
are
covered
by
a
government
program
Medicare
or
Medicaid,
neither
of
which
cover
the
full
cost
of
care.
They
cover
between
85
and
90
percent
of
the
cost,
not
the
charged
amount.
W
Normal
businesses
in
a
free
market
could
not
operate
much
less
make
a
profit.
If
so,
many
customers
were
paying
less
than
the
businesses
costs,
hospitals
have
narrow
lines
of
service,
such
as
elective
surgeries,
where
the
revenue
from
that
service
covers
all
the
other
money
losing
services
in
the
hospital,
such
as
Obstetrics
nicu's
and
emergency
departments.
The
communities
need,
by
necessity,
hospitals
are
forced
to
cost
shift
to
a
small
pool
of
patients
who
have
private
insurance,
but
even
the
ability
to
cost
shift
is
severely
limited
because
Kentucky
has
such
a
Consolidated
Health
Insurance
Market
in
Kentucky.
W
Two
insurance
companies
dominate
the
market
with
90
percent
of
the
market
share
between
them,
and
that
means
the
hospitals
have
little
negotiating
power
when
it
comes
to
the
negotiated
rate
insurers
pay.
Now.
The
truly
good
news
is
that,
despite
all
these
issues
that
tend
to
Cloud
pricing
Kentucky
according
to
financial
advisor
Motley
full
is
the
least
expensive
state
for
health
care,
and
this
is
in
line
with
many
other
reports
over
the
years,
including
from
the
Rand
Corporation,
showing
Kentucky
consistently
with
some
of
the
lowest
prices
in
the
country.
W
Simply
looking
for
the
least
expensive
service
may
be
a
great
benefit
for
the
insurance
company,
but
there's
really
not
much
incentive
for
the
patient
patients
typically
look
Beyond
price
to
Quality
and
what
their
physician
recommends
for
that
patient's,
unique
medical
needs,
shopping
for
a
surgical
procedure,
isn't
like
comparing
one
Honda
Civic
to
another.
One,
keep
in
mind
that
hospitals
are
reactors
within
a
System
created
almost
exclusively
in
Washington
D.C.
W
Even
the
State
Medicaid
Program,
which
is
a
federal
state
partnership,
is
completely
dominated
by
Washington.
Medicare
was
instituted
in
1965,
but
the
program
hasn't
really
changed
much
in
more
than
50
years.
What
has
changed
are
the
mounting
regulatory
burdens
placed
on
hospitals
and
providers
that
continues
to
make
the
system
more
complicated.
W
All
hospitals
must
employ
armies
of
staff
to
handle
the
highly
specific
Billing
System
for
reimbursement,
and
these
administrative
burdens
are
being
compounded
with
growing
with
the
growth
of
Medicare
Advantage
plans,
escalating
prior
approvals,
audits,
denials
and
appeals
required
by
third
party
payers,
and
that
kind
of
overhead
contributes
significantly
to
the
cost
of
running
a
hospital.
So
those
inside
the
hospital
charged
with
dealing
with
these
administrative
burdens
laid
on
them
by
the
federal
authorities
and
the
insurance
companies,
are
highly
sympathetic
to
the
difficulty
that
patients
have
in
navigating
the
Health
Care
system.
W
A
W
I'll
say
a
couple
things:
the
machine,
readable
file,
which
of
course
is
a
nightmare.
If
you
try
to
look
at
it
that
wasn't
designed
for
consumers,
but
that's
designed
to
be
downloadable
and
we
believe
shopping
tools
are
going
to
be
created
from
that.
So
we
think
this
is
really
in
its
infancy,
and
you
know
these
things
are
only
now
starting
to
be
developed
and,
of
course,
with
the
whole
Advanced.
Cob
I
think
that
that
will
be
very
helpful
to
individuals,
because
that's
really
going
to
tell
people
what
they
want
to
know.
W
What
what's
it
going
to
cost
me?
But
again
you
know
we.
We
have
to
figure
out
how
all
that
communication
is
going
to
happen
to
where
that
per
you
know,
all
those
estimates
can
come
in
and
those
good
faith
charges
and
then
the
insurance
companies
going
to
look
at
my
plan.
You
know,
what's
my
deductible
and
tell
me
what
I
need
to
know
so
I
think
the
market
hasn't
had
time
yet
to
adjust
to
all
of
these
things
you
know
being
out
there,
but
I
I.
W
Think
when
you
look
across
I
mean
there's
a
lot
going
on
here.
As
you
can
see
between
you
know
the
machine,
readable
files,
the
online
price
estimator,
anybody
can
go
out
that
you
don't
have
to
register.
You
don't
have
to
sign
up.
You
just
go
online
and
put
your
information
in
that's
going
to
give
you
a
good
idea
of
what
your
cost
is
going
to
be,
and
then
you
know,
of
course,
if
you
have
a
specific
procedure,
you
can
reach
out
to
the
provider.
W
You
know
under
these
you
know
the
uninsured,
the
self-pay
and
the
self-pay
there's
a
lot
of
people
with
the
high
deductible
plans.
They
fall
into
this
group
that
today,
you
know,
can
get
that
information,
so
we
really
feel
like
there's
a
lot
going
on
and
we
need
to
stop
and
let
this
play
out
and
see
you
know
what
else
do
we
need
before?
Quite
frankly,
we
feel
you
know
we
pass
any
more
requirements.
A
K
Yes,
thank
you,
hey
I'm,
sorry
I
wanted
to
ask
if
this
will
affect
it
seems
like
it
can
take
hospitals
so
long
to
get
bills
out.
So
will
this
help
this
sort
of
pre-work
process
help
get
bills
out
any
faster?
Are
there
any
regulations
about
the
speed
or
pacing
of
billing
anybody
who's
had
a
baby
in
recent
years
know
there
are
so
many
bills
from
so
many
places
they
trickle
in,
and
you
never
know
when
they're
done
right.
W
W
Time
so
I'll
say
this:
certainly
the
avanciob
for
insured
patients.
You
know
that's
going
to
list
everything.
That's
on
there.
It's
not
you
know
you're
going
to
get
one
for
the
hospital
one
for
something
else.
This
idea
of
the
convener
where
today
for
the
good
face
the
estimate
that
starts
next
year,
the
hospital.
If
you
were
going
to
the
hospital
the
hospital,
would
be
giving
you
the
total
charge,
the
hospital
charge,
the
obstetrician
you
know,
whatever
would
be
on
there.
That's
going
to
be
on.
W
You
know
one
good
faith
estimate
for
the
insured
EOB,
that's
going
to
be
the
same
thing:
it's
not
just
piecemeal
by
provider,
but
it's
going
to
be
Consolidated,
so
I
do
think
that
that
would
let
you
know
what's
expected,
because
here's
the
other
thing
today
with
the
good
faith
estimate
you
know,
and
that
year
today
you
know
we
aren't
it's
not
Consolidated.
When
that
becomes
Consolidated.
You
know,
and
everybody
gives
their
estimate
the
hospital
The
Physician
the
anesthesiologist,
whatever
everybody
has
to
be
within
four
hundred
dollars
or
that
individual
has
the
right
to
dispute
it.
W
A
X
Thank
you,
madam
chair
I
can
be
brief.
This
is
one
of
the
worst
examples
of
government
overreach
I've
ever
seen
in
in
my
lifetime.
It
does
absolutely
nothing
to
improve
the
quality
Care
rendered
for
anyone.
It
has
no
value
to
the
consumer.
The
average
consumer
is
not
going
to
use
this
information,
so
we're
spending
literally
millions
of
dollars
to
provide
a
database
that
has
no
value
to
anyone.
X
It's
ridiculous
appreciate
your
presentation,
but
one
of
the
points
that
you
had
I
thought
was
most
interesting
was
on
our
commercial
Market
that
we
it's
monopolated
by
by
two
carriers,
but
yet
we
have
six
insurance
companies
that
want
to
manage
our
Medicaid
Program.
Don't
you
think
that's
rather
ironic,
and
can
you
can
you
give
maybe
some
insight
as
to
why
there's
that
disparity
between
the
current
commercial
market
and
Medicaid.
A
It
all
right:
okay.
Next
we
have
our
friends
from
the
Kentucky
Medical
Association
Dr,
Mona,
Lisa
Taylor
is
here
to
talk
about
prior
authorization
requirements
and
some
legislation
that
we
had
filed
last
year
and
are
continuing
to
talk
about
so
I
appreciate
your
being
here.
Please
introduce
yourself
for
the
record
and
proceed
when
you're
ready.
Y
Thank
you,
chair,
Moser,
co-chair
Alvarado
and
members
of
the
committee
for
the
record.
My
name
is
Dr
Mona,
Lisa
Taylor
and
I'm,
a
board-certified
Internal
Medicine
physician
and
the
current
president
of
the
Kentucky
Medical
Association.
It's
an
honor
to
speak
to
you
today
regarding
prior
authorizations,
now
just
some
background,
the
earliest
iterations
of
prior
authorization
date
back
to
the
1960s.
This
is
when
a
lot
of
patients
ended
up
in
the
hospital
and
required
treatment
there
and
confirmed
diagnosis
by
two
Physicians
before
they
could
get
treatment
for
their
medical
condition
like
diabetes.
Y
Now,
at
the
time,
they
started
utilizing
prior
authorization
as
a
check
on
medical
necessity
for
services
and
treatments
provided
and
as
quality
of
care,
improved
our
care
moved
out
of
the
hospitals
and
now
we're
in
more
outpatient
settings.
So
prior
authorization
also
changed,
and
now
it's
required
for
basic
Services
procedures
and
medications
that
I
utilize
to
help
take
care
of
my
patients.
Now
in
2022,
this
is
a
Health
Plan
cost
Control
process
Physicians.
Y
Other
health
care
providers
have
to
obtain
Advance
approval
from
a
health
care
plan,
and
you
have
to
provide
them
a
certain
amount
of
information
to
get
your
service
or
medication
delivered
and
approved
for
the
patient.
Now
this
sounds
really
simple
in
concept,
but
unfortunately
it
gets
really
complicated
and
convoluted
and
it
can
be
extremely
time
consuming
and
so,
as
a
result,
this
ends
up
impacting
our
patients
quality
of
care,
as
well
as
the
pay.
Y
The
physician
has
an
additional
administrative
burden
which
takes
away
from
their
opportunity
to
take
care
of
the
patient
in
front
of
them.
So,
looking
at
some
survey,
studies
in
2021,
the
AMA
actually
did
a
survey
with
1
000
practicing
Physicians
and
they've
got
some
very
interesting
numbers
that
I'd
like
to
share
with
you.
Y
Eighty
percent
of
the
time
actually
end
up
abandoning
the
treatment
all
together.
They're,
like
you
know
what
forget
it.
The
insurance
said
no
I
I,
don't
want
to
do
this
anymore,
and
when
that
does
happen,
or
if
it
doesn't
happen
a
lot
of
times,
Physicians
have
noticed
that
these
Pas
do
impact
our
clinical
outcomes
and
so
a
sobering
result.
That
we
saw
from
this
study
is
that
91
of
the
time,
these
clinical
outcomes
are
impacted
by
these
prior
authorizations
and
for
some
patients
and
34
percent
of
cases.
This
delay
in
care
might
cause
death.
Y
It
might
cause
a
hospitalization
injury
or
other
life-threatening
events.
This
is
pretty
significant
now
for
the
Physicians
and
the
providers
that
I
work
with.
What
does
this
mean
for
our
offices?
Well,
I
can
tell
you
40
percent
of
physician
staff.
We
have
people
who
just
work
exclusively
on
a
prior
authorization
practices
report
that
they
complete
41
Pas
per
physician
per
week.
I
spent
90
minutes
in
the
clinic
today
before
coming
here.
I
already
had
three
prior
authorizations
on
my
desk
this
morning,
so
such
disruptions
lead
to
physician
burnout.
Y
They
add
to
the
administrative
burden
and
they
take
away
again
from
the
patient.
Who
is
in
front
of
you
now
these
survey
numbers
are
numbers
and
I
recognize
that
and
I
could
probably
bore
you
for
hours
with
multiple
stories
about
patients
who
have
been
impacted
from
prior
authorization,
but
one
story
I
did
want
to
share
with
you
was
a
girl
that
I've
been
seeing
she's
in
her
early
30s
we've
been
seeing
each
other
since
2017.
Y
Y
Those
are
the
things
I
have
to
do
to
show
that
we're
doing
all
these
good
things
and
to
help
with
our
pain
and
she
did
eight
weeks
of
physical
therapy
and
she
still
didn't
have
any
relief,
so
I
put
her
in
for
an
MRI
which
did
get
approved,
thankfully,
and
it
showed
degenerative
disc
disease
with
a
disc
bulge
on
L5
that
was
pushing
on
her
nerve.
So
I
sent
her
to
the
spine
surgeons,
who
said
okay?
Well,
let's
try
pain
management.
Y
First,
let's
try
an
epidural
in
your
back
and
see
if
that
helps
so
she
got
about
three
or
four
of
those.
It
helped
calm.
The
pain
down
some
she's
been
able
to
manage
it
since
then,
and
then
in
2021
one
morning
she
ends
up
waking
up
and
she
can't
get
out
of
bed,
and
so
she
ends
up
in
the
hospital
for
about
three
days
with
this
intractable
back
pain
and
this
difficulty
with
her
Mobility.
Y
Y
She
comes
back
to
see
me
May
of
this
year.
She's
like
Dr
Taylor.
This
is
getting
bad
again,
like
the
pain
is
to
the
point
that
it
was
last
year
when
I
went
to
the
hospital.
Thankfully
she
works
from
home,
so
she
can
adjust
her
position.
She's
sitting
she's
standing.
She
might
lay
down
in
the
middle
of
the
day
and
then
get
her
work
done
later.
I
said
we
gotta
get
an
MRI,
I!
Guess
Sandra
did
this
mine
surgeon
again
they're
like
we
got
to
get
an
MRI
I'd
put
the
order.
Y
In
already
it
was
the
middle
of
may
I
get
a
message
back
at
the
end
of
the
month.
This
has
been
denied.
Okay,
here's
the
phone
number
call
the
phone
number
they're
like
you
actually
called
the
wrong
number.
Here's
the
correct
number
call
that
number
it's
an
automated
service.
I,
don't
have
a
human
to
talk
to
find
the
name
of
the
company
that
wants
the
information,
find
that
off
of
Dr
Google
call
them
tell
them.
What's
going
on
they're
like
well,
she
hasn't
completed
six
weeks
of
physical
therapy.
Y
We're
gonna
deny
that
so
I
then
spend
my
time
writing
a
letter
outlining
all
the
details
of
her
treatment.
I
submitted
this
on
June
8th
six
weeks
later
at
the
end
of
July
I.
Finally,
get
the
thing
approved
it's
now.
This
disc
bulge
is
now
pushing
more
on
her
nerves
so
now
she's
having
burning
nerve
pain.
That
is
going
all
the
way
down
her
leg
and
hats
impacted
her
quality
of
life
all
summer.
Y
Y
So,
unfortunately,
I
have
to
tell
you
the
overuse
and
misuse
of
Prior
authorizations
is
across
the
board.
It's
commercial
insurance.
It's
Medicare!
It's
Medicaid!
It's
all
of
them
in
particular,
they've
noticed
with
Medicare
Advantage
plans
that
a
lot
of
times
Services
get
denied
when
if
the
patient
had
regular
Medicare,
it
probably
would
have
been
approved
they.
This
has
gotten
to
the
point
that
the
house,
the
United
States
Congress
I,
should
say,
has
actually
recognized
this
and
they
unanimously
passed.
House
Bill,
3173,
improving
seniors,
timely
access
to
Care
Act
with
326
bipartisan
sponsors.
Y
So
Kentucky
Physicians
did
respond.
Favorably
to
this
bill
and
representative
Moser
was
kind
enough
to
file
House
Bill
343
last
year
during
the
session,
and
this
largely
mirrors
the
Texas
bill,
and
so
this
would
require
any
state-regulated
health
benefit
plan,
as
well
as
Medicaid
manage
organizations
to
establish
an
automatic
approval
process
or
exemption
for
prior
authorization.
Y
So
if
the
physician
meets
certain
thresholds
like,
for
example,
every
time
I
order
that
MRI
of
the
lumbar
spine,
the
insurance
company
can
see
hey
you've
already
done,
the
conservative
treatment
you've
done
the
six
to
eight
weeks
of
physical
therapy.
You
got
that
x-ray.
Okay,
we
know
90
percent
of
cases
you're
doing
all
the
things
that
we
want.
So
we
will
approve
this
procedure
for
you.
Y
So
as
a
result
of
this,
this
is
a
priority
for
the
kma
in
the
upcoming
legislative
session
and
I
know.
Some
of
the
concerns
against
this
type
of
legislation
would
be
in
regards
to
cost,
as
well
as
fraud,
first
off
in
regards
to
cost
insurance
carriers
Say.
By
making
this
change,
this
will
be
more
expensive.
I
actually
have
data
to
say
it
would
be
opposite.
Y
Y
That
cost
to
me
is
10.92
or
14
each
for
every
single
prior
authorization
that
I
do
and
keep
in
mind
we're
doing
about
41
of
those
a
week
so
and
that
does
not
take
into
account
what
my
patients
are
going
through.
I've
already
told
you
about
my
patient
personally,
who
spent
all
summer
with
this
diminished
quality
of
life,
her
suffering
her
missing
work,
her
being
unable
to
maybe
even
do
those
vacations
and
trips
and
all
those
cool
things
that
we
all
want
to
get
back
into.
Y
The
second
concern
that
I
know
will
address
is
fraud.
Well,
with
this
setup,
insurers
would
have
the
ability
to
review
every
singles,
patient
or
prescribers
exemption
status
every
six
months
if
they
see
that
the
physician
is
no
longer
meeting
that
90
requirement,
they
no
longer
have
that
exemption
for
that
particular
procedure.
Y
Additionally,
if
the
insurer
notes
that
the
physician
is
gaming,
the
system,
if
you
will
that
there's
not
a
medical
necessity
or
it's
not
an
appropriate
order
of
a
procedure,
they
can
also
revoke
that
exemption
status,
so
it'd
be
a
checks
and
balance
type
system.
So
I
do
want.
To
conclude
with
some
of
my
remarks,
the
kma
has
approached
the
insurers
and
they
have
come
to
the
table
and
we've
had
discussions
about
this
and
how
important
it
is
and
to
their
credit,
the
insurers
have
been
willing
to
discuss
the
issue,
ask
questions
and
express
concerns.
Y
While
we
haven't
really
had
any
breakthroughs
just
yet,
we've
at
least
been
able
to
come
to
the
table
and
have
a
conversation
and,
like
we've
mentioned
representative
Moser
filed
House
Bill
343
last
year,
we're
hoping
to
file
something
similar
this
year.
In
that
vein,
to
help
address
prior
authorization,
I
hope
you
will
have
a
chance
to
read
it
and
have
a
chance
to
reach
out
to
us
and
help
ask
any
questions
and
I
do
challenge
all
of
you
to
contact
Physicians
and
providers
in
your
districts.
Y
A
Of
course,
thank
you
so
much
that
was
a
wonderful
presentation.
Dr
Taylor
and
I
can
feel
your
compassion
for
your.
Your
patience
and
I
know
that
this
is
a
recurrent
theme
throughout
Kentucky,
so
many
providers
are
just
trying
to
get
the
care
that
their
patients
need
in
a
timely
manner,
and
this
you
know,
while
it
it
may
help
contain
costs
for
insurers,
I.
Think
in
the
you
know,
in
the
short
term,
in
the
long
run
it
really
does
not.
It
has
the
opposite
effect.
It
delays
care
for
patients.
A
A
The
delay
in
care
I
think
you've
outlined
it
all
very
well,
but
it
also
drives
up
the
overall
cost
of
Health
Care
and
so
I
think
that
this
is
another
measure
that
we
can
take
a
look
at
and
we
are
working
closely
with
our
insurance
providers
to
come
to
some
sort
of
reconciliation
about
how
to
best
do
this
and
again
trying
to
put
some
common
sense
policies
in
place
that
that
improve
health
care
and
and
remove
another
layer
of
bureaucracy.
So
Corey
I
know
that
you're
at
the
table
here.
Z
H
H
This
is
crucial.
It's
important.
We
talk
about
trying
to
find
savings
and
we
found
Savings
in
our
PBM
systems.
We
just
had
a
hearing
last
month,
we'll
have
a
little
bit
of
carryover
for
the
next
meeting
as
well.
People
that
couldn't
have
a
chance
to
testify
on
the
order
of
about
480
million
dollars
in
Medicaid
alone
per
year,
so
about
300
per
member
in
savings
that
we've
gotten
and
that's
money
that
patients
don't
see.
You
know
the
state
just
got
because
we
made
some
reform
to
some
changes.
H
That's
36
of
our
insurance
burden
in
the
state
64
are
getting
it
some
other
way.
So
if
we
want
to
find
savings,
There's
an
opportunity
to
find
Savings
in
health
care,
PBM
system
is
broken.
We
need
to
fix
it
and
that
needs
to
come
up
in
this
upcoming
year
as
well,
but
we
certainly
don't
want
to
I
mean
in
a
time
of
burnout.
H
People
often
worry
about
what's
causing
burnout
for
docs.
My
opinion
is
the
burnout
it
you
know
we
blame
covet
and
all
that
and
that
that's
fine
we're
you
know
we're
pretty
resilient
individuals
as
Physicians,
and
we
we're
used
to
getting
a
lot
of
stress.
We've
been
trained
that
way
to
handle
it,
but
ultimately
I
think
it
comes
down
to
prior
authorization.
Issues
for
most
providers
is
I
can't
do
what
I
need
to
do.
H
For
my
patients,
someone
else
is
calling
the
shots
on
a
phone
somewhere
and
they're
looking
at
a
screen,
and
let's
face
it,
care
is
very
individualized
for
people
there's
not
a
algorithm.
You
have
back
pain.
So
here's
what
you
need
to
do
and
this
this
person
you're
taking
care
of
fits
into
that
everybody's
story
is
different.
We
don't
trust
the
physician's
judgment
anymore
in
society,
our
insurance
companies-
don't
trust
physician
judgment
anymore,
and
it
makes
it
really
really
difficult
to
practice
medicine,
and
so
you
don't
have
fun
at
your
job.
H
It
leads
to
burnout
and
the
amount
of
hours
that
go
into
this
I
mean
when
I
had
a
practice.
Two
full-time
individuals.
Just
doing
this
so
appreciate
you
coming
here,
we
may
need
your
help
when
session
starts
up
again,
because
we'll
get
resistance
on
this
issue
as
well
and
I
think
the
Texas
model
would
probably
be
a
good
one,
so
all
members
be
prepared.
This
is
coming
our
way
next
session.
Thank
you
for
being
here
and
appreciate
your
testimony.
C
Thank
you,
madam
chairwoman,
and
and
thank
you,
Dr
Taylor
for
being
here
today
to
discuss
what
I
consider
to
be
an
extremely
extremely
important
subject,
because
we
are
wasting
millions
of
dollars
of
Health
Care
money,
doing
things
like
prior
authorization
and
requiring
patients
that
need
services
to
wait
and
wait.
While
your
office
staff
and
their
office
staff
fight
back
and
forth
for
weeks
at
a
time
over
what
they
will
or
will
not
cover.
C
You
know
you
had
a
patient
coming
with
back
pain
and
your
first
thought.
Well,
let's
get
an
Imaging
study,
that's
not
appropriate.
We
now
know
that's
not
appropriate
unless
certain
circumstances,
you
have
risk
factors,
you
have
a
history,
you
have
other
things
that
that
make
it
appropriate
at
that
time,
so
we
wore
wasting
Health
Care
to
others,
but
I
think
we
are
now
to
the
point
where
we
understand
well
enough,
what
the
indications,
what
the
appropriateness
criteria
are
they're
published.
C
So
if
you
don't
know
them,
you
can
look
them
up
and
read
them
that
we
no
longer
need
to
spend
this
money
trying
to
control
utilization.
What
we
need
to
do
at
this
point
is
open
utilization
up
to
patients
that
need
help
and
keep
our
doctors
from
having
to
fight,
day
and
night
and
tooth
and
nail
to
get
their
patients
the
studies
they
need.
So
thank
you.
I
just
want
to
tell
you
a
hundred
percent
a
hundred
percent,
understand
and
agree
that
this
not
only
helps
our
doctors.
C
AA
Thank
you,
Chad
chairwoman,
Mosher
I
wanted
just
to
come
from
a
number
standpoint
and
I
appreciate
the
presentation
and
your
example
that
you
went
through
with
your
patient.
It's
quite
telling
and
and
I've
I've
seen
some
things
going
through
on
our
within
my
family
and
so
forth.
But
from
another
standpoint,
can
you
provide,
or
do
you
know
of,
and
maybe
Texas
went
through
this
process
in
terms
of
applying
some
type
of
a
cost
allocation
to
each
process?
AA
So
we
can
get
it
under
understanding
of
exactly
what
what
the
how
much
money
we're
talking
about.
You
know
the
co-chairman
Alvarado
mentioned
over.
You
know
400
I,
guess
80
million
dollars
on
the
PBM
and
so
forth,
which
is
a
very
strong
number
that
we
need
to
really
pay
attention
to,
but
and
I
know
insurers
go
through
a
risk
management
approach
and
they've.
Obviously
they're
they're
behind
to
to
you
know
their
employees
and
to
their
stockholders
if
they're,
if
they're,
publicly
owned
and
are
privately
owned
and
so
forth.
AA
But
to
put
as
I
mentioned,
to
put
some
some
some
juice
behind
this
and
to
tell
a
story:
do
you
have
information
or
is
that
information
can
be
obtained
from
a
Kentucky
point
of
view,
using
models
from
other
states?
So
we
could
say:
hey
this,
what
it
means
in
order
to
go
through
this
process,
so
we
can
use
it
for
negotiation
purposes
or
whatever
right.
Y
No,
that's
a
great
question.
Representative
Fleming
I
think
we
are
still
waiting
on
some
more
numbers
from
Texas
since
this
law
passed
in
2021.
It's
just
now
getting
implemented
over
the
summer
time.
So
I
think,
with
a
few
more
months
we'll
be
able
to
better
speak
to
the
the
costs
that
they've
been
able
to
save.
AA
And
I
would
appreciate
that
yeah
if
Falcon,
you
know
present
it
formally
or
informally,
but
provide
it
to
both
Chambers,
maybe
this
coming
spring,
because
that
would
that
the
numbers
would
really
tell
a
story,
and
it
was
really
support
the
story
that
you
just
articulated
into
in
terms
of
providing
quality
care
for
that
individual,
as
well
as
keeping
your
sanity
and
paperwork.
So
thank
you,
madam
chair.
A
A
I
will
I
would
like
to
announce
that
the
next
interim
Joint
Committee
hearing
on
health,
welfare,
welfare
and
family
services
will
be
held,
November
15th,
that
is
Tuesday
instead
of
Wednesday
and
that's
at
11
A.M.
So
there
has
been
a
date
change
and
a
time
change
to
to.
Please
take
note
of
thank
you
so
much
for
your
presentation.
Thank
you
to
everyone
who
stuck
around
for
the
entire
meeting
I
think
we.