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A
E
F
A
All
right
we
do
have
a
quorum
barely,
but
so
the
first
item
on
the
agenda
is
approval
of
the
minutes
from
the
October
26
2022
meeting.
We
have
a
motion
for
approval
and
then
a
second
all,
those
in
favor,
please
signify
by
saying
aye.
Anyone
opposed
all
right.
The
minutes
are
approved.
All
right.
You
see
here.
We've
got
a
variety
of
different
things
on
the
agenda.
A
Today,
we've
got
some
testimony,
I
think
from
two
meetings
ago
regarding
our
PBM
discussion
that
we
had
that
we
had
to
table
and
we're
going
to
have
those
folks
come
back
today
and
kind
of
present
a
little
bit
of
information.
The
first
thing
I
want
to
go
ahead
and
address
are
the
administrative
regulations
that
are
before
you
and
it's
item
number
seven
on
the
agenda.
Hope
everyone's
had
an
opportunity
to
review
some
of
those.
These
have
been
before
administrative
regulations
and
review
subcommittee.
A
A
If
not
right,
seeing
nobody,
we
do
have
someone
who's
here
in
the
room.
I
believe
Jennifer
Wiseman
is
here
with
the
Kentucky
a
a.
A
Miss
Wiseman
are
you
here?
Yes,
very
good,
I'd
like
to
come
forward
to
the
to
the
presenter's
desk,
introduce
yourself
for
the
record
and
go
ahead
and
speak
to
this
regulation.
A
G
President
of
the
Kentucky
Association
of
nurse
and
ethicists
and
I'm
here
today
to
speak
in
support
of
this
regulation,
I'd
like
to
just
give
a
brief
historical
overview
of
how
this
regulation
came
about.
I.
Think
it's
important
to
understand
the
process
that
we've
all
worked
on
for
this.
G
Originally
back
in
the
fall
of
2020,
the
hospital
technical
advisory
committee
began
discussing
anesthesia
billing
issues.
These
were
billing
issues
brought
forward
by
facilities,
not
by
providers,
and
the
attempt
to
fix
these
billing
issues
is
what
got
all
anesthesia
key
stakeholders
in
this
state
brought
to
a
table
at
the
direction
of
governor
beshear.
So
we
had
a
meeting
all
anesthesia
key
stakeholders
in
this
state
were
present.
G
That
would
be
myself
and
another
nurse
and
ethicist
representing
the
Kentucky
Association
of
nurse
and
ethicists,
as
well
as
the
Kentucky
Society
of
anesthesiologists,
the
American
Society
of
anesthesiologists,
and
there
were
numerous
facilities,
their
admin
and
legal
teams,
as
well
as
people
from
the
Department.
We
were
all
at
this
meeting
and
the
outcome
of
the
meeting
was
that
the
best
thing
that
would
solve
these
access
to
care
and
billing
issues
by
the
facilities
would
be
to
mirror
Medicare
anesthesia
billing
framework
here
in
Kentucky
Medicaid
regulation.
G
G
The
first
two
steps
of
that
process
were
completed
last
fall
with
two
administrative
regs
that
went
through
relating
to
Physician
Services
and
physician
reimbursement.
The
third
step
of
the
process
is
this
reg,
and
this
one
single
billing
code
that
only
affects
nurse
anesthesis
to
mirror
the
Medicare
reimbursement
rate,
which
is
100
percent.
That's
all
this
regulation
does
I
think,
like
I
said
it's
important
to
know
that
everyone
was
at
the
table
and
agreed
upon
this
plan
back
in
April
of
2021.
This
was
a
fix
for
a
facility
problem.
G
This
was
never
a
provider
driven
initiative
and
this
doesn't
change
anything
about
scope
of
practice.
It
doesn't
change
anything
about
how
people
work
every
single
day.
It
doesn't
change
anything
about
safety.
It
doesn't
change
anything
about
any
of
the
opposition
that
was
actually
brought
forward
during
administrative
reg
review.
So
I
just
wanted
to
make
that
clear
that
this
is
just
a
reimbursement
code,
one
of
the
two
CRNA
reimbursement
codes
and
it's
been
a
long
process
to
fix
this
for
the
facilities
and
I'm
happy
to
take
any
questions.
E
E
And
would
you
touch
on
federal
funds
that
Kentucky
may
be
in
line
to
lose
if,
if
we
do
not
adopt
this
Federal,
if
we
do
not
conform
to
this
Medicare
reimbursement.
G
Yes,
sir,
this
was
actually
addressed
at
the
top
of
the
reg
and
it
is
the
policy
of
the
Commonwealth
according
to
statute,
to
not
turn
away
federal
funds
that
are
on
the
table,
and
when
that
got
mentioned,
it
was
brought
up.
The
last
administrative
reg
review
committee
meeting
also
These
funds
are
already
out
there,
and
the
additional
increase
in
this
reimbursement
rate
is
not
even
going
or
paid
to
Providers.
This
is
paid
to
facilities
or
groups,
and
the
facility
or
group
is
the
person
that
is
losing
out
on
this
reimbursement.
G
A
Any
other
questions
from
members
just
a
brief
statement
for
me:
I
mean
reimbursement,
equals
value
is
what
it
does.
That's
what's
being
changed
here
is
the
value
of
what
Physicians
provide
and
that's
the
concern
I'm
before
you
responds
I,
know
you're,
anxious
to
say
something,
but
that's
what's
being
changed
here.
A
You
know
again,
I
made
a
commented
administrative
regulations,
review
subcommittee.
If
you're
a
young
person
wanting
to
do
anesthesia,
there's
gonna
be
no
incentive
to
do
that
here
in
the
state
of
Kentucky.
At
this
point,
because
you're
going
to
have
Medicare
reimbursements,
be
the
same
Medicaid
be
the
same
really
if
you're
gonna
be
looking
at
it,
it's
decreasing
the
value
of
that
individual.
That's
the
concern
that
I've
got
here
and
that's
that's
the
problem
with
it
I
know.
A
There's
plenty
of
anesthesiologists
I've
talked
to
who've
said
that
your
claims
about
everybody
being
at
the
table
is
not
the
case
and
we're
going
to
hear
from
somebody
here
in
a
second
on
that
issue.
That's
the
concern
that
I've
got
here.
I
would
imagine
if
I
were
if
someone
was
a
radiologist
and
they
were
getting
paid
for
what
they
were
getting
paid
for
services
and
studies.
They
were
going
to
pay
Pas
equal
to
what
a
radiologist
does
for
those
same
readings,
and
for
that
same
that
haven't
involved
them
at
all.
A
H
What
we
would
allow
here
is
a
CPT
code
that
would
reimburse
a
CRNA
for
their
services
without
the
seven
criteria
that
are
necessary
to
use
the
higher
CPT
code.
So
it's
actually
up
to
the
physician
as
to
which
code
ends
up
being
built.
If
the
physician
is
in
fact
available
for
all
seven
parameters,
then
that
code
would
be
built.
If
the
physician
is
not,
then
this
code
could
still
be
utilized.
The
facilities
or
the
groups
could
still
get
reimbursed
for
the
services
they
are
providing
to
the
hospital
to
the
facility
or
the
patient.
H
It
does
not
actually
impact
salaries
of
either
anesthesiologists
or
Physicians.
That's
a
whole
different
discussion
with
contracts
and
Billings
and
all
that
stuff.
But
all
this
allowing
this
CPT
code,
which
is
a
basic
Medicare
CPT
code,
used
all
over
the
country,
will
only
allow
the
facilities
or
the
groups
to
bill
for
the
services
at
a
rate,
basically
Equitable
to
what
they're
doing
it
doesn't
actually
impact
anybody's
salary.
Is
that
correct?
That
is
absolutely
correct.
So
then
I
don't
understand
how
this
is
going
to
disincentivize
anesthesiologists,
who
already
make
significantly
higher
salaries
than
crnas.
H
G
That's
a
great
question
because
I'm
wondering
the
same
to
to
reiterate
how
anesthesia
billing
works
and
I
understand
the
comments
about
value.
Anesthesia
is
built
very
differently
from
any
other
provider
group.
It
is
billed
based
on
time
units
that
you
are
there's
like
a
conversion
factor
of
time
and
the
procedure
that
you're
doing
so
there's
a
complexity
times
time
times,
conversion
factor.
That
is
how
anesthesia
is
billed
and
what
this
regulation
would
allow.
When
you
were
talking
about
the
seven
requirements,
those
are
CMS
mandated
requirements
to
bill
for
medical
direction
of
anesthesia.
G
The
former
regs
that
just
went
through
last
fall
reference,
the
CMS
manual
for
the
specific
documentation
parameters
that
have
to
be
met.
If
the
parameters
are
met,
you
Bill
one
way
if
the
parameters
are
not
met,
you
Bill
the
other
way.
I
made
this
point.
I
tried
to
make
it
very
clear
during
the
last
meeting.
This
code
is
not
a
CRNA
practicing
by
themselves,
independently
code,
while
it
would
be
utilized
in
those
settings
and
already
is
utilized
in
those
settings.
That
part
isn't
changing.
G
This
is
already
how
we
function
every
single
day
with
Medicare
and
if
it
were
gonna
make
the
salaries
the
same
with
a
million
people
in
our
state,
we
would
not
be
making
salaries
less
than
half
that
of
a
physician
anesthesiologist.
There
is
no
synonymous
way
to
say
that
reimbursement
rate
equals
salaries.
In
this
scenario,
this
is
a
cost
that
facilities
are
eating
and
it
was
a
fix
for
a
facility-led
problem.
Thank.
A
I
Yes,
I
am
thank
you
so
much
again
for
letting
me
speak
on
Zoom
I
think
it's
very
important
that
one
of
us
has
heard
please.
A
I
Yes,
sir,
yes,
sir,
so
my
name
is
Dr
box
I'm,
a
practicing
anesthesia
anesthesiologist
in
state
of
Kentucky,
very
quickly,
I
trained
at
UK
and
but
I
currently
work
in
a
community
hospital.
A
couple
of
surgery,
centers,
so
I
really
kind
of
fully
understand
the
different
demands
of
a
Lexington,
City,
sort
of
a
institution
versus
what
happens
in
rural
hospitals
and
Community
Hospitals.
I
I
do
appreciate
all
of
the
questions
that
were
brought
up
because
I
feel
like
they're,
going
to
tie
in
very
nicely
to
our
understanding
of.
What's
going
on,
Ms
Wiseman
mentioned
earlier
that
this
code
does
not
have
anything
to
do
with
value.
This
code
does
not
have
anything
to
do
with
salary
disparity.
This
code
is
just
a
modifier,
so
we
so
we
don't
lose
money.
I
I
feel
like
whenever
a
discussion
like
this
comes
about
where
you
are
reimbursed
for
a
service
you
provide,
you
always
have
to
talk
about
who
is
providing
that
service?
What
is
the
training
level
of
that
person
providing
that
service?
And
what
are
the
outcomes?
You
know
it's
very
hard
to
have
a
conversation
without
without
bringing
up.
You
know,
training
I
work
very
closely
with
all
of
my
CRNA
colleagues,
and
you
know
it's
usually
one
or
two
Physicians
for
about
eight
of
them,
so
they
are
Workforce.
I
They
are
excellent
at
what
they
do,
and
this
does
not
at
all
negate
what
they
bring
to
the
table.
But
the
situation
that
we
are
falling
into
right
now
is
we
are
using
small
little
aspects
of
this
is
better
for
finances.
This
is
better
for
the
way
to
push
this
through,
so
we
can
build
better,
but
we're
not
looking
at
that.
Nobody
ever
talked
about
is
as
a
patient.
If
I
walk
in,
if
I'm
a
Medicaid,
patient
and
I
walk
in
then
I
am
getting
build.
I
The
exact
same
amount,
whether
a
six-year
trained,
Fellowship
anesthesia,
also
taking
care
of
me
or
a
fresh
out
CRNA
with
180
hours
of
experiences
taking
care
of
me
and
now
we're
talking
about
billing
it
exactly
the
same
way.
You
know
I
mean
it's
difficult
to
explain
how
that
can
translate
later
into
the
value.
If
you're,
you
know
I'm
going
to
use
a
completely
different
completely
different
example
for
a
completely
different
industry,
because
I
feel
like
that,
will
kind
of
make
us
understand.
I
I
The
number
of
training
and
this
discussion
does
not
need
to
be
about
that
right
now,
because
at
the
entire
conversation
but
CMS
already
agreed
to
have
the
same
billing
code,
we
are
also
going
to
follow
suit
now
and
have
Medicare
and
Medicaid
follow
that
same
billing
code.
When
this
happens,
what
is
the
incentive
for
hospitals?
What
is
the
incentive
for
other
private
Equity,
like
surgery,
centers,
to
say,
hey?
We
can
build
the
same.
I
Just
for
Physicians,
like
anesthesiologists,
but
I,
also
think
this
is
setting
like
an
example
for
all
of
the
other
Specialties.
You
know
I'm
about
nine
years
out
of
my
training
and
I
speak
to
a
lot
of
people
from
a
different
different
countries
and
also
kind
of
compare
and
contrast
where
our
landscape
of
healthcare
is
going
and
I
think
that
one
of
the
big
things
I'm
noticing
is
as
Physicians.
We
put
a
lot
of
time.
I
Effort
and
energy
took
a
lot
of
debt
because
we
we
believed
in
having
all
of
that
training
behind
us,
because
that
was
what
kind
of
kind
of
gave
us
value
in
the
entire
scheme
of
the
healthcare
landscape
right.
But
now,
if
we
have
different
types
of
backgrounds
and
different
types
of
training,
we
were
assigning
the
same
numerical
value
to
it.
Then
we
can
distinguish
that,
and
that
brings
me
back
to
what
Miss
Wiseman
was
saying.
I
All
of
the
monetary
money
that
they're
going
to
be
they're,
going
to
be
earning
in
that
time
frame
and
then
to
come
out
and
then
also
work
at
a
hospital
where
your
reimbursement
is
the
same
and
essentially,
at
the
end
of
the
day,
reimbursement
does
Leak
with
value
I
mean
you
cannot
argue
that
that's
the
only
monetary
thing
that
we
can
control
and
compare
and
contrast,
I
worry
that
you
know
know
Kentucky
already
has
a
shortage
of
Physicians.
I
Having
such
a
rule
path
is
not
going
to
incent
it's
going
to
de-incentivize
people,
because
there's
no
reason
to
incur
that
extra
cost
and
you're
also
setting
a
precedence
for
all
of
the
other
Specialties
to
follow.
I
know
that
you
know
we
talked
about
PA
and
PhD
Radiology
stuff
I
mean
we're
already
kind
of
starting
to
see.
You
know
NPS
and
family
practice
and
we're
seeing
that
and
that's
I
mean
we
need
a
full
Workforce.
We
need
that.
I
That's
understandable,
but
at
what
point
are
we
going
to
not
look
at
the
value
that
the
training
is
providing?
There's
no
value
to
go
to
six
years
of
school
when
we
are
going
to
follow
the
exact
same
field
and
do
the
exact
same
thing.
Just
as
an
example.
I
know
we
talked
about,
you
know
you
talked
about
the
seven
different
modifiers
and
how
you
can
build
differently.
That's
actually,
essentially
not
true.
I
In
anesthesia
I
mean
anesthesia
is
very
complicated,
but,
for
example,
if
I'm
taking
care
of
somebody
who's
a
healthy
27
year
old,
who
is
getting
the
appendix
out,
I
will
charge
them
the
same
as
if
I'm
charging
somebody
who's
had.
Four
heart
attacks
who's
a
heavy
smoker
who
you
know,
needs
additional
IVs
and
additional
access.
There's
no
pay
difference
between
the
two,
but
this
modifier
will
allow
us
to
pick
and
choose
what
we
want
to
do
and
then
get
reimbursed
the
exact
same
way
it
to
me.
I
A
D
I
D
Thank
you
very
much.
I
I
feel
your
concern
there
and
I
I
guess
I
would
ask
Miss
Wiseman
real
quick.
One
of
your
main
points
for
for
feeling
like
this
is
okay
to
make.
This
change
was
that
it
would
mirror
Medicare
I
think
you
mentioned
that
right
off
and
that's
some
of
the
the
talk
I've
heard,
but
you
know
I
just
want
to
bring
up.
There's
there's
a
lot
of
situations
where
you
know
Medicare
people
would
want
to
mirror
Medicare
and
then
sometimes
we
want
Medicare
to
mirror
Medicaid.
D
You
know
if
you
know
what
I
mean
you
there's
a
lot
of
CPU
a
lot
of
codes
out
there
and
that
goes
back
and
forth.
That
argument,
does
you
know
it's
like
some
so
to
to
think
that
that
would
be
an
argument,
because
if
we
use
that
argument
and
say
okay
well,
the
reason
we
should
change
this
is
because
Medicare
pays
this
way.
Then,
where
does
it
stop
where?
Where
does
that?
Where?
D
Where
does
that
stop
and-
and
we
could
try
to
put
this
on
an
island
by
itself
but
but
I
don't
see
it
that
way
and
and
I'm
I'm
a
little
concerned
with
that
now
I
don't
go
to
question
two
and
then
you
can
answer
them
both
or
a
comment
on
them
I'm
a
little
concerned
with
what
really
happens
in
the
trenches.
For
instance,
you
met,
you
barely
mentioned
it,
but
you
said
it
already
happened.
D
So
do
do
hospitals
just
forego
the
the
additional
money
and
not
bill
for
the
other
CPT
code,
the
one
that
you're
trying
to
get
or
and
then
just
go
ahead
and
use
what
they're
getting
and
get
the
Lesser
money.
Is
that
what
really
goes
on
in
the
trenches
or
to
or
the
anesthesiologists
get
called
in,
so
that
they
can
bill
the
additional
code.
G
So
to
answer
your
first
question
about
mirroring
Medicare
and
that
being
sometimes
a
good
thing
and
sometimes
a
bad
thing,
the
reason
it's
a
good
thing
for
this
specific
scenario.
I
fully
understand
what
you're
saying,
but
this
was
brought
forward
by
facilities.
This
was
discussed
at
the
hospital
Tac
and
this
was
an
issue
with
Medicaid
patients
seeking
care.
It
originally
came
from
them
going
to
facilities
just
across
state
lines
and
the
way
that
Medicaid
was
as
far
as
anesthesia
billing.
Prior
to
any
of
this
starting
was,
there
were
only
two
codes.
G
There
was
a
code
that
says
an
anesthesiologist
can
personally
perform
the
case
themselves
and
they'll
re
be
reimbursed,
100
percent.
There
was
another
code
that
said,
which
is
this
code
qz
a
nurse.
An
ethicist
can
personally
perform
the
case
and
it
will
be
reimbursed
at
75
percent.
There
was
also
a
clause
that
was
removed.
Last
fall.
That
said,
medical
direction
will
not
be
reimbursed
by
the
department
for
Medicaid.
G
So
when
these
patients
were
having
problems
getting
care
because
they're
going
to
these
providers
and
those
providers
didn't
even
have
an
option
for
a
code
to
submit
there
wasn't
one,
there
was
only
the
two
codes
and
when
you
work
in
a
team
environment,
you
need
more
codes.
So
the
fix
was
to
mirror
Medicare,
because
Medicare
has
all
the
codes
that
could
be
utilized
for
anybody.
This
allows
anyone
to
get
care
across
the
state
line.
If
you
need
to
wherever
you're
getting
your
service,
they
now
have
a
route
to
bill.
G
G
We
just
and
we
submit
this
code,
the
other
half
the
counties
we
work
with
anesthesiologists
and
that's
how
our
hospitals
function.
So
in
that
scenario,
if
they
are
meeting
the
seven
tephra
guidelines,
which
are
very
specific,
then
you
can
Bill
medical
Direction.
That's
definitely
an
option
in
a
usable
reimbursement
code,
but
should
one
of
those
criteria
not
be
met?
G
The
correct
thing
and
the
ethical
thing
is
to
build
this
code,
which
is
where
facilities
now
only
with
the
Medicaid
population,
not
even
the
MCO
population,
but
only
Medicaid
would
default
to
this
code.
If
they
meet
those
requirements
they
can
bill
medical,
Direction
and
Dr.
Bucks
was
just
talking
that
she
works
in
a
team
environment.
It's
usually
one
or
two
anesthesiologists,
with
eight
crnas.
If
there's
one
anesthesiologist
in
five
crnas
guess
what
they
don't
meet.
G
The
federal
criteria
to
bill
for
medical
Direction,
so
one
of
her
crnas
that
facility
would
be
would
be
eating
25
percent,
because
one
anesthesiologist
cannot
medically
direct
five
crnas
and
meet
the
criteria.
So
why?
In
that
scenario,
if
she's
busy
and
can't
get
to
a
room
or
there's
an
added
on
case,
where
there's
five
crnas
and
one
anesthesiologist,
why
are
the
facilities
being
forced
to
take
25
percent
loss?
A
J
Thank
you,
Mr
chairman
I'll.
Try
to
make
this
quick
because
I
think
you
answered
part
of
my
question
in
your
previous
answer.
My
first
question
is:
did
the
hospitals
bring
this
forward.
G
The
hospitals
made
the
suggestion
to
the
Mac
that
we
mirror
Medicare.
J
Okay
and
so
just
to
clarify,
what's
the
incentive
for
facilities
to
continue
hiring
anesthesiologists
versus
a
CRNA
who
cost
them
less
to
to
employ.
G
It's
the
facility's
choice,
it's
the
same
reason,
they're
continuing
to
hire
anesthesiologists
and
we
work
in
teams
every
day
when
Medicare
and
private
insurers
already
contract
for
this
rate.
Anyway,
it's
I
mean
it's.
It's
not
it's
not
going
to
disincentivize
the
hospitals.
This
is
talking
about
less
than
200
patients
in
this
entire
state.
J
Okay,
so
the
the
medical
Direction
piece
of
all
of
this
is
somehow
separate
from
how
the
higher
the
hospitals
higher
anesthesiologists
versus
crnas
I
mean
so
there
are.
There
are
stipulations
in
in
numbers
of
anesthesiologists
Who,
oversee
crnas.
Is
that
what
I'm
understanding?
Yes.
G
G
J
I
Sorry
ma'am
something
that
you
want.
Yes,
ma'am,
I
I,
actually
do
I
just
want
to
clarify
that
a
little
bit
there's
medical
Direction
and
medical
supervision,
and
actually
the
question
you
asked
was
the
exact
question:
I
was
going
to
bring
up
so
my
facility,
the
hospital
that
I
work
in
you
know,
even
though
Kentucky's
an
opt-out
State
and
we
have
independency
rnas
that
work
independently.
We
still
have
Physicians
present
to
oversee
stuff.
We
do
not
build
for
medical
direction,
we
build
for
medical
supervision
and
we
actually
don't
Bill
higher
or
get
paid
higher.
I
The
entire
reason
that
we
have
this
is
just
for
patient
safety
and
outcomes.
Okay.
So,
for
example,
if
I
have
four
rooms
running
and
I
I
am
the
person
in
charge
there
I
don't
have
to
be
there
for
every
single
case,
but
if
there
is
a
need
that
arises,
if
it's
a
it's
a
higher
Acuity
higher
Mobility
patients,
then
we'll
do
it
together.
I'll
be
there
for
induction
I'll,
be
there
for
excavation
me
being
there
or
not.
I
That
does
not
change
that,
but
what
is
happening
right
now,
as
we
speak
in
my
Hospital
in
my
community,
is
that
the
hospital
has
now
hired
crnas
independently
they're.
Actually
every
single
month
are
voting
to
bylaw
change.
The
bylaws,
so
Physicians
do
not
need
to
oversee
and
be
on
call
on
the
weekends
they're
pushing
for
bylaws
where
they
want
two
crnas.
I
Instead
of
one
MD
at
night
we
have
a
bariatric
program,
we
have
a
robust
OB
program
and
we
have
a
thoracic
robotic
program,
the
only
one
in
the
state
of
Kentucky
and
we're
still
pushing
because
they're
saying
that
they're
not
able
to
hire
anesthesiologists.
This
is
comes
back
to
the
exact
same
issue
that
I
talked
about
one.
We
can't
incentivize
anesthesiologists
to
move
here,
we've
already
short
two
by
changing
this
code,
70
of
my
patients
in
this
Hospital
are
Medicaid
Medicaid
patients.
I
So
if
the
hospital
now
realizes
that
hey
I
can
get
three
crnas
for
the
price
of
1md,
with
the
exact
same
service
with
these
there's
zero,
there's
absolutely
zero
incentive
for
them
to
pay
for
that
money.
The
bylaw
are
changing
as
we
speak
every
single
day,
and
this
is
happening
in
my
own
hospital
that
we've
been
here
for
35
years
as
a
group,
and
this
is
changing,
and
the
third
thing
is
exactly
what
you
said:
where
does
it
stop
if
Medicare
and
Medicaid
are
going
to
make
these
changes?
I
What
is
to
say
that
other
insurance
companies
are
not
going
to
follow,
I
mean
already,
we've
had
pay
parity
on
the
table,
we've
already
had
independent
practice,
and
this
is
just
the
third
piece
of
the
puzzle.
So
at
some
point
we
need
to
stop
looking
at
the
smaller
little
pieces
of
what
is
this
institution
losing?
I
How
much
money
are
we
losing
and
look
at
the
broader
picture
of
an
aging
sick
population
in
the
state
of
Kentucky,
and
we
are
replacing
higher
trained
Physicians
and
paying
the
exact
same
amount
to,
and
this
is
not
just
the
anesthesia
crns
I
want
to
be
very
clear,
but
this
this
push,
this
change
in
landscape
is
happening
throughout
all
the
different
Specialties.
Now
I
can
only
argue
about
my
specialty,
because
what
happens
out
there
in
that
courtroom
in
four
minutes
is
very
different
than
what
I
see
in
my
ORS
every
single
day.
I
So
I
feel
very
strongly
about
the
fact
that,
at
the
end
of
the
day,
value
has
to
be
somehow
measured.
Reimbursement
is
an
excellent
way
to
measure
it.
It
gives
a
very,
very
bad
message
to
Medicare
Medicaid
patients
that
they
cannot
be
equal
with
everybody
else.
That
has
other
insurances
that
you
do
not
get
to
have
a
trained
physician.
I
You
do
not
have
to
get
a
cardiothoracic
trained
anesthesiologist,
but
you
you
get
what
you
get,
because
the
hospitals
want
to
hire
I,
don't
want
to
say
a
less
expensive
help,
and
that,
and
at
the
end
of
the
day
like
it
is
what
it
is
I'm
calling
you
know,
I'm
calling
the
Spades,
but
it
is
what
it
is.
I
If
you
were
an
institution
that
was
for-profit
or
not-for-profit,
you
were
making
the
money,
you
would
not
want
to
hire
a
trained
fellowship-trained
physician
where
you
could
hire
three
more
crnas
to
do
the
same
thing
and
that's
where
we're
running
from
and
I
think
this.
This
change
for
that
reason,
I
think,
is
more
important
because
it's
sending
the
wrong
message
throughout
the
healthcare
field.
J
No
I
think
you
I
think
you
very
clearly
answered
my
question
and
and
probably
the
question
that
everyone
here
has
and
I
I
mean
it's:
it's
creating
a
perverse
incentive
for
hospitals
to
hire
less
anesthesia
anesthesiologists
when
they
can
hire
crnas
and
it's
it's
at
the
end
of
the
day.
It's
a
it's
a
bottom
line,
cost
issue.
A
Right,
thank
you
very
much
that
you
can
that's
the
kind
of
debate
we
had
in
administrative
Regency
regulation,
any
other
discussion
for
members.
Otherwise,
we've
got
other
topics
to
discuss.
A
Thank
you
all
for
being
here
for
presenting
the
information
like
I've,
said,
I.
Think
it's
I,
don't
think
it's
a
good
idea.
This
is
something
that
we're
going
to
be
looking
back
on
and
it's
going
to
be
a
gradual
yeah
degradation.
It's
going
to
be
a
regret
for
us,
so
we're
gonna
have
a
hard
time
attracting
Physicians
to
come
to
the
state
of
Kentucky
all
right
next,
up
topic
on
the
agenda
is,
and
that
makes
the
records
going
to
reflect
that
we've
reviewed
these
regulations.
A
That's
what
that's
on
the
record
as
well.
Next,
we
have
item
number
three,
which
is
reducing
patient
costs
to
rebate
reform.
We
have
here
today
George
Huntley
and
Julie
Babbage.
If
you
want
to
come
forward
actually
I
think
Mr,
huntley's
remote,
correct,
he's
testifying
remotely.
These
are
folks
that
we're
here
to
talk
about
our
when
we
had
our
PBM
day
a
couple
months
ago
to
discuss
a
lot
of
that
they
had
to
be
pushed
off.
So
they're
here
to
provide
testimony
we're
planning
on
providing
at
that
at
that
meeting.
K
K
Certainly
will
and
Julie
are
you
up
there
with
the
slides
I,
see.
K
L
Baptist
longani
here
on
behalf
of
the
diabetes
patient
motion
and
I've,
got
with
me
joining
With
Me
George
Huntley
on
behalf
of
the
diabetes
Leadership
Council
and
patient
pocket
protectors
coalition.
L
Just
briefly
about
us,
we
are
diabetes.
You.
L
George
has
a
hard
stop
in
just
a
few
minutes,
but
just
a
quick
introduction
with
the
diabetes
patient
advocacy
Coalition.
We
have
thousands
of
Advocates
Patient
Advocates
across
all
50
states,
and
we
work
in
tandem
with
the
diabetes
Leadership
Council,
who
works
on
the
front
end
of
policy
with
all
50
state
legislatures
and
today
is
not
about
diabetes.
It's
actually
about
an
issue
that
impacts
all
patients.
We
formed
a
coalition
with
other
disease
states
to
promote
affordability
and
access,
starting
with
rebate
reform,
so
I'm
just
going
to
briefly
introduce
George
who's.
L
K
Yeah,
thank
you,
Julie
and
and
again
Mr,
chair
and
members
of
the
committee.
We
I
very
much
appreciate
the
opportunity
to
speak
today.
In
my
other
day,
job
I'm
largely
a
volunteer
in
this
role.
I
I
am
the
plan
administrator
of
a
self-insured
employer-based
health
plan,
so
I
have
25,
plus
years
experience
of
administering
health
plans
from
an
employer's
perspective,
so
I
bring
that
to
this
discussion
as
well.
Today,
this
group,
this
list,
is
the
member
organizations
in
the
patient
pocket
protector
Coalition.
K
The
the
issue
of
the
impact
of
pbm's
behavior
on
patients
is
far
beyond
diabetes
and
we
formed
this
Coalition
just
this
year.
So
this
is
just
the
the
initial
members
of
this
organization
so
that
we
can
join
our
voices
together
on
these
issues,
impacting
patients,
pocketbooks
and,
and
unfortunately,
also
their
health
Julie
want.
You
can
do
continuous
on
all
right.
You've
seen
this
illustration
of
how
a
drug
flows
through
the
health
system,
if
you
will,
from
a
payment
perspective,
I
want
to
point
out
a
couple
of
things
here.
K
K
If
you
will
with
regard
to
the
drug
benefit,
the
drug
company
at
the
bottom
is
paying
a
sizable
rebate
to
the
pharmacy
benefit
manager
for
access
to
the
formulary,
and
this
is
often
exclusive
access,
so
that
that
movement
coming
across
the
bottom
on
insulin,
that
rebate
is
greater
than
75
percent
of
the
list.
Price
of
the
drug,
the
average
rebate
is
48,
which
means
a
patient.
A
consumer
at
the
top
is
paying,
on
average,
nearly
double
what
their
insurance
plan
is
paying
for
that
same
drug.
K
So,
without
getting
benefit
of
that
of
that
print
plan
premium,
if
you
will
for
the
the
plan,
design,
they're
they're,
paying
double
what
their
insurance
plan
is,
paying
rebates
moving
over
the
pharmacy
benefit
manager
are
largely
passed
up
to
the
insurance
plans.
Now
they're
keeping
a
piece
of
it
we'll
touch
on
that.
K
In
a
moment,
you've
heard
some
health
plans
say-
and
this
is
I
think
even
in
the
September
testimony
that
they
are
using
these
rebates
to
keep
plan
premiums
down
for
all
members
and
I,
don't
know
I,
don't
know
anybody
who's
had
their
premiums
go
down,
I
think
we
can.
K
We
can
largely
agree
it's
having
no
impact
whatsoever
on
premiums
and
we'll
touch
on
that
as
well
in
a
bit
in
a
moment
as
well,
but
they
will
even
suggest
that
it
would
be
unfair
to
do
otherwise
to
not
share
them
across
all
planned
participants,
so
they're
keeping
that
pool
of
money.
Now
our
position,
we
respectfully
disagree
with
that
statement.
It
is,
in
fact
unfair
to
have
the
six
subsidize
the
healthy.
K
It
is
reverse
Insurance.
The
many
should
help
pay
the
costs
of
the
unfortunate
few
and
not
the
other
way
around
the
consumer
who
is
buying
the
drug
at
the
top.
There
is
quite
specifically
identifiable
easily
identifiable
it's
not
a
general
pool
of
money.
It's
a
very
specific
and
personal
payment
being
made
by
a
patient
and
that
patient
should
be
the
one
getting
that
benefit
for
that
discount
or
that
rebate
that's
happening
here.
K
K
They
have
a
lot
of
power,
all
right,
they're,
also
vertically
integrated
with
the
insurance
companies,
the
specialty
pharmacies
and
Provider
Services
that
vertical
integration
is
also
creating
a
market
behavior
that
is
driving
out
Independent
Pharmacies
and
that
is
really
hurting
patients
in
the
rural
markets,
because
they're
not
able
to
access
Independent
Pharmacies,
which
largely
are
the
ones
in
in
the
rural
market.
So
it's
an
uncontrolled
Market
environment,
uncontrolled
Market
power,
Julie
much
to
keep
us
moving.
K
K
The
pbms
will
all
say
that
they
are
passing
95
plus
of
these
rebates
through
to
the
plans,
but
this
this
data.
When
you
look
at
the
Orange
Line
there
showing
the
pbms
hanging
on
to
13
21,
it's
interesting
how
it's
moving
they're.
Clearly
it's
saying
the
pbms
are
keeping
a
sizable
portion
of
this.
A
material
portion.
The
the
Green
Piece,
which
you
can
barely
see
on
that
screen,
is
the
amount
being
passed
through
to
patients
which
is
effectively
nothing,
and
that's
really.
What
we're
here
to
talk
about
today.
Julie
keep
us
moving.
K
The
other
piece
here
is
this
drives
very
perverse.
Behavior
of
the
pbms,
the
lowest
cost
drug
doesn't
win
they're,
actually
creating
barriers
for
low-cost
generics
and
biosimilars
to
be
included
on
formulas
now.
This
is
Medicare
Part
D
data,
because
it's
publicly
available.
However,
it's
the
same
pbms
that
I
just
showed
on
that
last
slide.
It's
the
same
pbms
running
Medicare,
Part
D
that
are
running
the
commercial
plans
and
the
Kentucky
plans.
Etc,
there's
no
reason
to
believe
their
behavior
will
be
any
different
whatsoever
from
2016
to
18.
K
One
in
four
were
included
on
the
formulary.
When
they
were
launched
now
you
would
think
they
would
Embrace
every
single
low-cost
drug
that
would
come
out.
Thank
you
how
it's
it's
wonderful!
That
you're
here,
they're
not
even
being
put
on
the
formulary
in
that
first
year,
in
2020,
less
than
half
were
on
the
generic
tier
of
the
payment
line
on
the
formulary.
So
there
is
no
incentive
for
the
patient
to
actually
take
that
lower
cost
drug,
because
the
the
PBM
doesn't
want
the
patient
to
take
the
lower
cost
drug.
K
These
plans
are
not
putting
on
on
the
formularies
it's
bad
for
patients,
because
they're
not
getting
access
to
the
lower
cost
drug
and
it's
it's
frankly,
it's
very
much
bad
for
the
health
plans
itself
and
the
state
because
you're
not
covering
the
low-cost
drug,
and
you
think
you
are
so
that's
an
important
Point.
We've
made
this
point.
The
average
rebate
is
48
on
all
drugs,
and
this
is
every
drug
app.
This
is
not
a
diabetes
issue.
This
is
a
all
chronic
disease,
all
patients
taking
a
branded
drug
issue.
K
What
happens
with
this
simple
math,
100
list
price
drug,
the
current
state,
the
rebate's,
48
bucks,
the
patient's
paying
a
hundred
dollars,
and
that
PBM
and
the
insurance
plan
is
getting
48
dollars
from
that
patient
in
January.
During
their
deductible
period
with
reform,
the
patient
will
be
paying
52
dollars
as
they
ought
and
the
manufacturers
getting
paid
their
their
net
price.
K
K
What's
this
going
to
cost
a
health
plan-
and
you
know,
we've
heard
that
passing
it
through
passing
rebates
through
to
patients
is
going
to
be
unaffordable.
It
will
drive
premiums
through
the
roof.
No
one
will
be
able
to
pay
and
afford
health
care
coverage
ever
again,
and
unfortunately
this
is
a
scare
tactic
and
it's
simply
not
true.
An
Actuarial
study
released
this
January.
So
this
is
new.
Information
shows
that
the
cost,
the
overall
change
in
payer
costs
for
rebate
pass-through
is
less
than
one
percent.
K
That
study
did
not
reflect
any
major
medical
savings
by
having
actually
healthier
patients
on
the
plans
now
in
the
case
of
diabetes
and
I
will
go
back
to
diabetes,
but
it's
true
in
many
chronic
disease
States,
it's
the
heart
attacks,
it's
The,
Strokes,
it's
the
amputations,
the
end-stage
renal
disease,
the
blindnesses.
These
are
the
things
that
cost
plan
dollars.
The
drugs.
Aren't
the
big
thing:
that's
driving
health
care
costs,
it's
it's
the
it's
the
complications
and
the
ramifications
of
poorly
controlled
chronic
disease.
Express
Scripts
themselves.
K
One
of
the
top
three
pbms
in
June
of
this
year
came
out
with
a
study
which
they
ran.
Capping
the
costs
of
all
diabetes
medications,
not
just
insulin
but
all
diabetes
medications,
because
people
with
diabetes
takes
there's
many
many
drugs
out
there
to
you
know
to
address
diabetes.
You
cap
that
cost
to
25
a
month
that
cap
resulted
in
a
lower
overall
cost
of
Diabetes
Care
of
16.3
percent.
That's
16.3
percent.
Overall
plan
savings
was
driven
by
reduced
hospitalizations
because
the
patients
were
better
controlled
right
from
the
pbms.
K
This
is
this
is
a
scenario
where
we
will
likely
save
money
by
passing
through
rebates
at
point
of
sale.
Now,
let's
look
at
it
from
another
perspective.
Okay,
the
drug
spend
is
the
tail
wagging
the
dog
in
a
health
plan.
Drug
spending
is
around
10
percent,
maybe
a
little
bit
higher,
but
it's
in
that
10
to
15
percent
range
of
overall
health
care
costs,
85
to
90
percent
of
the
plans.
Cost
are
the
major
medical
costs.
It's
the
hospitalizations,
the
surgeries,
all
of
those
things,
the
lab
all
of
that
work.
K
The
doctor
visits,
that's
where
the
primary
dollars
in
a
health
care
spend
come
from
not
drugs.
The
purpose
of
drugs
are
to
help
reduce
the
costs.
On
the
other
side,
so
reducing
the
spend
on
drugs
is
a
tail
wagging
the
dog
scenario.
Now
we
know
that
branded
drugs
are
the
drugs.
Are
the
aspect
of
the
drug
part
of
the
plan
where
the
rebates
come
into
effect.
You
don't
have
a
lot
of
rebates
on
generics.
K
So
it's
not
the
entire
plan
year.
It
is
that
finite
period
in
the
first
quarter,
or
so
when
the
plan,
when
the
patient
is
meeting
their
deductible.
That's
what
we're
talking
about
passing
through
rebates,
for
it
is
far
more
likely
that
you're
going
to
save
money
by
overall
plan
plan
plan
savings
from
from
better
healthier
patients.
L
Just
briefly
to
touch
on
our
legislative
principles,
so
we're
working
on
legislation
with
lawmakers
who
want
to
impact
the
cost
of
prescription
drugs
by
by
working
on
rebate
reform.
So
for
us
to
to
support
a
bill,
we
ask
that
at
least
80
percent
of
rebates
be
passed
through
at
a
minimum
that
co-pays
are
calculated
based
on
the
net
cost
of
the
medication,
not
the
list
cost
and
that
there's
a
penalty
for
non-compliance.
So
thank
you
to
Senator
Meredith
for
legislation
this
past
session
on
this
that
met
all
of
these
criteria.
L
Thank
you,
Senator
Alvarado,
chair
Alvarado,
for
your
support
of
that
Senator
Sheldon.
Just
for
all
the
work
you've
done
on
transparency
and
on
this
issue,
I
want
to
recognize
our
attorney
general
general
attorney
general
Cameron,
who
signed
on
to
a
bipartisan
Coalition
of
Attorneys
General
to
regulate
pbms
because
he
wants
to
hold
them
accountable
and
also
just
briefly
recognize
our
own
Congressman
Comer,
and
the
role
that
he's
played
federally
to
bring
attention
to
this
through
the
oversight
committee
and
with
that
I
will
turn
it
back
over
to
George.
K
Just
just
in
closing,
pbms
were
created
for
medical
billing
of
Pharmacy
transactions.
That
was
their
purpose
when
originally
created,
they
don't
make
anything.
They
don't
touch
anything
they
report
only
to
their
shareholders.
They
don't
have
a
fiduciary
responsibility
for
the
health
of
the
patient.
At
all.
United
Healthcare
had
24
billion
in
2021
earnings.
That's
their
earnings,
that's
not
their
top
line.
That's
their
bottom
line,
24
billion
over
half
of
that
was
from
their
PBM
subsidiary,
optim
RX.
K
This
is
big,
big,
big
business,
guys
patients
are
being
harmed
by
pbm's
business
practices.
Patients
pay
a
premium
for
access
to
a
club
that
is
still
closed
off
and
patients
need
your
help.
Patients
are
helpless.
They
can't
battle
OptumRx,
they
can't
battle
United
Healthcare.
They
need
your
help
and
so
I
appreciate
very,
very
much
the
opportunity
to
speak
today.
Thank
you,
Mr
chairman,
for
affording
us
this
opportunity.
K
We
urge
you
to
continue
your
deliberations
and
I
apologize
that
I
have
got
to
run,
but
Julie
I
am
sure
will
be
very
happy
to
answer
questions
as
we
go.
Thank.
A
You
Mr
Huntley,
it's
a
very
good
presentation,
actually
very
clear
and
succinct,
and
you
know
it's
infuriating.
You
know
and
I'm
a
provider
and
I
I
can
tell
you
I.
Just
we
see
costs
of
you
know
everything
go
up.
Price
of
premiums
go
up
every
year
and
the
accusations
is
going
to
cause.
If
you
do
this,
it's
going
to
cause
an
increase
in
that
and
I
think
the
the
estimates
were
three
dollars
per
member
per
month.
325.
A
Medicaid
did
this
and
we
went
ahead
and
took
care
of
this
problem
and
we've
realized
savings
10
times
that
amount
to
the
system.
A
So
it's
clear
and
and
that's
all
money
that
suddenly
has
been
used
by
the
governor
to
expand
services
in
Medicaid
because
wow
that's
how
many
millions
of
dollars
of
come
in
from
this
I've
already
been
told
by
some
of
our
insurance
partners
are
going
to
take
us
to
the
mat
on
this
they're
going
to
fight
tooth
and
nail
so
I'm,
anticipating
a
very
nasty
fight
on
this,
but
I
think
the
proof
is
already
in
the
pudding
here
in
Kentucky
on
Medicaid,
and
it's
already
been
shown
that
it's
going
to
work
and
it's
going
to
benefit
patients
is
the
bottom
line.
A
One
of
the
things
I
want
to
talk
about
also
is
I
said.
As
a
doctor,
patients
would
come
in
to
see
me
I'd
prescribed
them.
A
generic
medication
and
I
know
that
generic
medication
would
be
four
dollars
at
Walmart
and
they'd
go
and
they'd
come
back
and
say
actually
they
charged
me
10
for
a
copay
and
I'm
like
what,
because
they
did
it
through
their
insurance
company,
that
money
went
back
to
their
to
their
insurance
company
as
profit
for
them,
and
so
what
I
started
telling
them
is
don't
bother.
A
Reporting
it
to
your
insurance,
don't
tell
your
insurance
company
that
you're
getting
this
buy
it
on
your
own,
don't
give
them
your
insurance
information
and
if
you
pay
for
it
cash,
it's
40
percent
of
what
it
would
have
cost
you.
If
you
had
gone
with
that
over
a
generic
medication.
That
happens
all
the
time
because
of
these
negotiated
rates.
When
I
get
somebody
coming
in
to
see
me
and
the
insurance
company
says,
I
want
them
on
Prilosec
January
1st
next
year.
You
know
what
we
want
them
on
Prevacid
this
year.
A
Instead,
okay,
I
change
them
over
to
another
stuff.
You
know
medication
for
their
stomach
medication,
only
to
have
the
following
January.
You
know
what
doctor
we'd
rather
have
them
back
on
Prilosec
talk
about
confusion
for
me
for
the
patient.
It
leads
to
compliance
issues,
all
kinds
of
problems
for
this
kind
of
stuff
and
it's
become
nonsense
and
one
of
the
things
I've
often
talked
about
and
maybe
Mr
Hundley
briefly
I
know
you
got
to
go,
but
one
thing
I've
often
talked
to
these
insurance
companies.
A
What
can
you
get
with
the
amount
of
money
that
we've
allotted
for
you
and
then
Pharma
will
have
to
bring
their
price
point
down
to
match
those
those
costs?
And
it's
a
natural
kind
of
you
know
almost
a
free
market
type
of
mentality
to
drug
Cost
Containment
to
offer
vouchers
they
can
contain
their
costs
of
what
they
know.
Patients
and
doctors
call
the
shots
and
no
more
of
this
back
room
negotiations.
Maybe
I'd
like
to
get
your
thoughts
on
that.
Well,.
K
You'd
have
to
create
another
Marketplace,
because
the
consumer
has
nowhere
to
go
to
get
Prevacid
or
paravastatin,
which
does
different
drugs,
but
you
know
they
don't
know
where
they're
going
to
go,
get
that
they're
going
to
CVS
or
Walgreens
or
their
Community
Pharmacy,
and
for
them
to
be
able
to
set
that
price
and
where
they're
going
to
get
that,
there's
got
to
be
a
market
mechanism
for
that
I.
Don't
disagree
at
all
that.
K
A
C
Thank
you,
chairman,
Alvarado
and
just
to
I
guess,
generate
some
points
you've
already
made.
When
I
filed
this
legislation
last
session,
it
was
immediately
killed
by
employers
who
were
going
to
our
respective
leaderships
and
saying
this
is
going
to
cost
us
Fortune
I,
remember
one
employer
in
particular,
said
this
is
going
to
cost
us
seven
million
dollars
and
I'm
thinking
to
myself.
C
It's
your
money
to
begin
with.
You
know
this
is
the
ultimate
Ponzi
scheme.
If
you
look
at
how
it's
structured
and
these
Scare
Tactics
are
what's
keeping
us
from
passing
effective
legislation
that
truly
helps
the
most
vulnerable,
you
know,
no
one
should
make
a
fortune
off
The
Misfortune
of
others,
that's
exactly
what's
happening.
This
is
really
falling
on
our
most
vulnerable
and
here's
a
chance
to
right
this
wrong.
Now.
C
C
It
is
actually
stealing
from
people
if
there's
no
other
way
around
it
and
I
would
hope
and
pray
that,
through
this
presentation
today
and
those
who
are
on
this
committee,
that
other
members
will
share
this
information
I
know
we'll
have
a
chance
to
talk
about
it
again
when
we
come
in
session
2023
because
I'm
filing
the
bill
again,
but
this
needs
to
be
done.
We
have
to
do
something
to
reduce
the
health
care
costs
of
the
average
consumer,
and
this
will
do
it.
I
I
promise
that
it
will,
but
we
need
this
legislation.
Thank
you.
D
Representative
Sheldon
quickly
just
full
support
for
the
legislation.
Of
course,
I
I,
don't
know
why
I
I
think
Mr
Conley
really
puts
it
in
perspective
when
he
said
pbms
were
created
and
it
was
like
late
1960s,
but
to
just
simply
form
a
connection
between
the
insurance
companies
and
and
the
pharmacies.
The
internet
wasn't
too
long
after
that
and
and
that
all
came
about,
and
in
those
days
we
paid
10
cents
a
transaction,
and
then
we
managed
to
get
it
down
to
four
cents.
D
A
few
years
later
and
those
companies
were
called
Envoy
in
DC,
there
was
only
two
in
the
entire
nation.
What
I'm
trying
to
say
is
they
evolved
into
these
multi
Fortune
500
companies
by
creating
some
dilemma
that
they
actually
do
something
other
than
an
I.T
switch
connecting
two
people
together
these
outcomes
and
these
things
that
they
talk
about?
They
change
them
like,
like
the
wind,
we'll
get
five
outcomes
this
year,
be
five
different
outcomes
the
next
year.
D
There's
no
so
I
I'm
gonna
make
it
one
step
simpler
than
Senator
Alvarado,
I'm
gonna
say:
go
back
to
a
a
fee
transaction
pass
through
you
know,
and
if
they
want
to
charge
10
cents
or
call
quarter
just
let
us
know
what
you
want
to
charge
per
transaction
and
let's
get
rid
of
the
rebates,
because
we're
just
never
going
to
ever
reel
them
in.
But
this
is
a
good
start.
I
think
you'll
see
some
legislation
next
next
session.
D
J
Thank
you,
Mr
chairman.
Thank
you
for
this
presentation.
I
have
a
quick
question
and
well
it's
probably
a
really
long
answer,
but
if
we
are
able
to
pass
some
legislation
to
control
these
rebates
and
and
do
some
rebate
reform,
how
will
the
340b
program
be
affected?.
K
From
my
perspective,
I
don't
believe
it
will
impact
it,
because
we're
talking
about
passing
through
rebates
in
what
would
be
considered
a
commercial
plan
that
would
impact
kentuckians,
so
you're,
talking
about
the
state
employee,
benefit
plans,
you're
talking
about
the
plans
through
the
the
exchanges
in
Kentucky,
anything
that
is
addressed
by
the
insurance
commissioner
within
within
the
state.
If
you
will,
the
340b
program
is
designed
for
patients
who
are
you
know
in
the
poverty
levels
and
things
like
that
that
doesn't
impact
the
incentives
there.
K
It
also
doesn't
impact
the
pharmacies
ability
to
purchase
those
medications
for
those
340b
patients
from
the
drug
companies
that
doesn't
impact
that
that
transaction
doesn't
get
in
the
way
of
that
that
you
know
that
transaction
at
all,
so
it
really
should
have
no
impact
on
340b,
okay,.
J
Is
it
not
true
that
the
340b
program,
I'm,
trying
to
figure
out
how
to
ask
this
question,
is,
is
expanded
now
to
facilities
versus
individuals
and
that
they
also
are
incentivized
to
use
the
higher
cost
brand
name
drugs.
K
I'll
I'll
give
you
what
I
know:
okay,
so
the
340b,
that's
all
I
can
give
you
the
340b
program
is
a
follow
the
the
drug.
Not
it's
follow.
The
excuse
me
follow
the
institution
or
the
pharmacy
and
not
the
patient.
So
the
pharmacy
has
the
ability
to
purchase
this
drug
at
340b
prices,
and
so
they
then
can
turn
around
and
sell
that
drug.
K
However,
they
really
want,
and
some
very
good
players,
if
you
will
good
Community
pharmacies
etc,
for
the
the
low
income
are
passing
most
of
those
those
discounts
through
and
the
patients
who
really
need
it
can
get
it,
and
there
are
some
egregious
players
that
are
taking
that
drug,
that
they're
buying
for
five
bucks
and
charging
150
for
it
and
so
they're.
That's
that
absolutely
is
happening
today.
K
This
law
won't
this.
This
issue
of
passing
rebates
through
to
get
into
a
commercial
patient
won't
impact
it,
but
a
separate
Dialogue
on
how
340b
is
playing
out
in
the
marketplace.
It
has
gotten
out
of
control
and
the
numbers
of
of
of
pharmacies
and
institutions
that
can
purchase
through
the
340v
program
have
have
grown
exponentially
over
the
past
decade.
K
To
the
point
where,
naturally,
when
that
happens,
people
are
trying
to
make
a
buck
and
and
you
it
winds
up,
getting
exacerbated
and
and
a
bit
out
of
control
similar
to
what
this
rebate
situation
is
today
as
well.
That's
worthy
of
a
conversation
I'm
not
exactly
sure
how
to
address
that
in
this
in
this
environment,.
J
L
Just
add:
we
had
worked
with
the
White
House
and
the
Trump
Administration,
and
obviously
there's
some
some
federal
play
here
to
to
reel
that
in,
but
as
George
said,
if
you're
getting
the
medication
for
pennies
on
the
dollar
and
then
turning
around
and
selling
it
for
much
more
to
our
most
vulnerable
citizens,
that's
absolutely
a
problem.
There
are
certainly
people
who
are
doing
it
the
right
way,
but
there
are
entities
that
need
a
greater
regulation
for
sure.
A
Great,
thank
you
all
very
much
appreciate
that
presentation.
Next
on
the
agenda,
we
have
Mr
Jim
Musser,
who
I
think
is
with
the
Kentucky
Hospital
Association
Jim.
If
you'd
like
to
come
forward-
and
hopefully
it's
a
very
brief
discussion
on
Pharmaceuticals
and
white
bagging-
also
part
of
the
discussion
that
got
postponed
from
two
meetings
ago,
Jim,
if
you'd
like
to
introduce
yourself
to
the
record
and
we've
got
two
other
presentations
after
you
and
we've
got
a
hard
stop
at
one
o'clock.
A
M
M
Let
me
start
by
saying
good
afternoon
to
you
and
to
chairwoman
Mosher
and
the
rest
of
the
committee,
and
thank
you
so
much
for
having
us.
This
is
an
important
issue,
but
before
I
get
to
the
white
bagging
I'd
like
to
talk
a
little
bit
about
a
Greek
lesson
and
I
know
that
may
sound
very
strange
for
the
committee
on
Health
and
Family
Services,
Health
and
Welfare
to
be
talking
about
Greek
lessons,
but
there's
an
important
concept
involved
in
what
we're
going
to
be
talking
about.
And
if
you
don't
remember
it
for
too
long.
That's!
M
Okay!
As
long
as
you
remember
it,
while
I'm
here
with
you
today,
and
that
concept
is
the
Greek
word
Telos
the
Telos
of
something,
and
there
can
only
be
one
whether
it's
an
individual
or
an
institution.
It
is
the
one
thing
for
which
it
was
created.
So
if
we're
talking
about
a
knife,
the
Telos
have
a
knife
is
to
cut
or
Pierce
something.
M
M
M
The
white
bagging
process
is
actually
subject
to
a
number
of
safety
concerns
that
could
result
in
either
an
ineffective
at
best
or
dangerous
at
worst,
treatment
for
the
patient,
there's
potential
waste
of
very
expensive
drugs,
and
it
potentially
disrupts
the
patient
provider
relationship.
Could
we
show
Slide
two
please
the
way
the
treatment
process
typically
works
is
that
medications
are
going
to
be
delivered
by
a
licensed
distributor
to
the
hospital
to
ensure
the
pedigree
and
integrity
of
the
cold
chain.
M
The
prescription
requirements
are
sent
to
the
hospital
or
Health
Systems
Pharmacy,
which
then
prepares
the
medications
for
Infusion.
On
the
day
of
treatment
prior
to
that
treatment,
there's
another
clinical
consultation
to
ensure
that
those
drugs
that
have
been
prescribed
are
still
the
right
ones
that
there
hasn't
been
a
change
in
the
patient's
status.
That
would
require
an
update
to
the
treatment
plan.
M
M
Things
could
end
up
sitting
on
a
loading
dock
and
later
being
moved
on,
and
if
the
drugs
weren't
properly
stored
and
the
provider
isn't
aware
their
safety
concerns
for
the
patients
and,
quite
frankly,
if
we
harm
the
patient
by
doing
that,
their
liability
concerns
and
who's
responsible
for
the
liability.
If
we
had
inadvertently
harmed
a
patient
for
many
infusions,
the
patient's
required
to
have
the
lab
work
done
prior
to
the
infusion
to
ensure
the
therapy
is
appropriate
and
the
appropriate
dose
is
administered
next
slide.
Please.
M
M
The
very
expensive
dose
may
be
completely
wasted,
and
the
facility
may
make
the
determination
that,
because
treatment
is
urgently
needed,
they
will
use
their
own
stocks
from
their
own
Pharmacy
to
create
the
drug
and
Infuse
it
right
then,
and
then
they're
not
going
to
be
reimbursed
for
that
by
the
insurance
company
Slide
Five.
Please.
M
Many
health
systems
are
safety,
net
organizations
and
it's
within
their
mission
to
ensure
patients
have
access
to
medications,
regardless
of
their
income
by
removing
the
safety
net
organization
from
the
procurement
and
billing
process
providers
lose
the
ability
to
make
sure
that
patients
who
face
financial
difficulties
really
have
the
ability
to
afford
the
medication
large
mail
order.
Pharmacies
do
not
share
the
mission
of
safety
net
providers
to
ensure
patients
can
afford
their
therapy.
M
As
simple
as
that,
under
the
white
bagging
model
inventory,
control
costs
will
increase
for
the
provider
who
Bears
the
cost
of
intake
and
storage
increases,
equipment
costs,
their
staff
and
Facilities
cost
all
without
compensation,
and,
ultimately,
that's
likely
to
have
an
adverse
effect
on
the
patient's
access
to
care.
Really.
The
bottom
line
is
when
white
bagging
is
a
threat
to
health
and
safety
and
of
patients.
M
M
M
M
It's
not
wrong
to
make
a
profit,
we
don't
hate
the
insurance
companies.
We
want
them
to
be
profitable.
Their
Telos
is
different.
It's
to
serve
their
shareholders
and
that's
a
good
thing.
It's
what's
made
our
society
prosperous,
and
we
want
our
patients
to
have
health
insurance.
We
want
them
to
be
covered.
We
want
them
to
have
the
ability
to
cover
their
treatment.
M
We
would
ask
that
you
continue
to
work
with
us
to
serve
our
Telos
of
caring
for
the
patient,
as
I
often
say
to
you.
Every
one
of
our
patients
is
one
of
your
constituents
and
we
want
the
best
outcome
for
them.
So
please
work
with
us,
as
as
we
try
to
address
this
issue
and
make
sure
that
we
get
a
handle
on
white
bagging
before
our
patients
are
damaged.
M
Thanks
again
for
having
me,
if
I
don't
get
another
chance
to
speak
to
you
before,
then
hope
everyone
has
a
very
Happy
Thanksgiving,
despite
all
the
bad
things
going
on
in
the
world
today,
we
really
do
have
a
lot
to
be
thankful
for
in
this
country.
I
am
thankful
to
be
here
and
thankful
for
your
attention.
Thank.
A
You
Mr
muster
appreciate
your
comments
and
your
presentation
in
the
extra
time
I
think
we're
going
to
move
forward
to
the
next
one.
But
that's
again
look
for
some
of
this
information.
It
was
in
last
year's
Bill
and
probably
be
finding
some
language
regarding
this
topic.
Moving
forward
in
the
bill
will
probably
be
presented
in
the
upcoming
session
as
well.
So
thank
you
very
much.
Next,
we
have
item
number
five,
a
discussion
of
the
2023
regular
session.
It's
a
bill
request,
203
relating
to
cost
sharing
for
prescription
drugs.
A
We
have
Dr
Dave,
Almeida
who's.
The
government
Affairs
director
I
think
he's
on
remotely
as
well
Mr
Almeida
if
you're
there.
If
you'd
like
to
introduce
yourself
for
the
record-
and
please
begin
your
testimony.
Thank.
N
You
thank
you
Senator
Alvarado,
representative
Mosher,
members
of
the
committee.
My
name
is
Dave
Almeida
I'm,
the
regional
director
of
government
affairs
from
Leukemia,
Lymphoma,
Society
and
I
appreciate
the
opportunity
to
speak
with
you
regarding
the
challenge.
That's
facing
many
patients,
which
is
the
high
out-of-pocket
costs
associated
with
the
medications
at
the
pharmacy
counter.
N
By
way
of
background,
the
Leukemia
Lymphoma
Society
represents
the
over
1.3
million
blood
cancer
patients
and
survivors
across
the
United
States.
Our
mission
is
to
cure
Leukemia,
Lymphoma,
Hodgkin's,
Disease
and
myeloma,
and
improve
the
quality
of
life
for
patients
and
their
families.
The
problem
that
we
are
trying
to
address
is
the
high
out-of-pocket
cost
sharing
for
prescriptions,
which
is
too
high
for
many
patients
to
access
the
medications
they
need.
This
is
compounded
by
other
drug
benefit,
design
features
such
as
co-insurance
and
code
reduction
and
high
deductibles
and
copays.
Here's
how
this
works.
N
Insurance
carriers
use
two
vehicles
to
pass
on
the
cost
of
medications
to
their
patients.
One
is
called
a
copay
which
is
a
flat
fixed
dollar
amount.
The
other
is
called
coinsurance,
which
requires
the
patient
to
pay
a
percentage
of
the
total
cost
of
their
medication,
which
could
be
hundreds,
if
not
thousands
of
dollars.
So
to
summarize,
co-pays
are
by
and
large,
within
the
financial
reach
of
patients,
whereas
co-insurance
is
by
and
large,
outside
the
financial
reach
of
patients.
N
What
we
know
about
patients
when
they
are
not
able
to
afford
their
medications
is
that
they
engage
in
behaviors,
which
are
not
conducive
to
Good
Health
outcomes.
They
may
ration
their
prescriptions.
Say
by
example,
take
one
pill
every
other
day,
as
opposed
to
one
pill
a
day.
They
may
take
their
prescription
as
they're
directed
for
30
days
and
never
never
return
to
the
pharmacy
to
have
that
prescription
refilled
or
worse.
They
may
walk
away
from
the
pharmacy
counter
without
that
prescription.
N
The
solution
that
we
are
offering
to
solve
this
problem
is
as
follows:
we
are
asking
the
insurance
carriers
that
half
of
the
plans
they
offer
must
pay
must
be
copay
only.
We
go
further
and
cap
those
co-pays
at
100
for
silver,
gold
and
platinum
plan
per
prescription
per
month
and
150
for
broad
plans
per
prescription
per
month.
This
would
apply
pre-deductible,
which
is
very
important,
because
it
means
that
the
patient
can
benefit
from
the
copay
prior
to
meeting
their
deductible,
and
it
applies
to
all
carriers
and
individual
and
small
Market
graphically.
N
This
is
how
this
plays
itself
out
again.
Without
protections,
patients
pay
full
cost
until
they
max
out
the
deductible
with
protections
per
prescription.
Spending
is
steady
and
predictable
and
that's
what's
best
for
patients.
Essentially,
the
bill
would
allow
the
patient
to
use
two
criteria:
When
selecting
a
Health
Plan,
not
just
one.
They
can
select
the
health
plan
that
meets
one
their
medical
needs
and
two
their
financial
needs
as
well,
and
with
that
Mr
chairman
I
will
conclude
my
remarks
and
take
any
questions
you.
A
May
have
thank
you
very
much
as
Mr
almed
I
appreciate
that
any
questions
for
members
of
the
committee,
you
should
have
a
copy
of
a
build
draft
there
and
then
something
for
us
to
review
and
open
to
taking
any
feedback,
as
you
review
that
it's
a
very
brief
bill.
But
this
is
a
real
problem.
Actually
people
that
have
a
lot
of
chronic
illnesses
and
you
know
a
lot
of
malignancies.
It
becomes
a
real,
real,
big
topic.
Any
questions
from
members
of
committee
representative,
Mosher.
J
N
So
they
would
apply
it,
they
would
apply
it
to
the
deductible,
but
onto
the
bill
they
would.
The
page
would
be
able
to
take
advantage
of
the
co-pay
prior
to
meeting
their
full
deductible.
But
yes,.
J
Okay
and
and
this
would
apply
to
just
sorry-
I-
haven't
read
the
bill.
J
N
Any
no
to
all
all
chronic
conditions
that
have
to
use
especially
medications
that
are
particularly
you
where
we
see
the
particularly
use
of
co-insurance.
So
it's
not
just
exclusive
to
Leukemia
Lymphoma,
okay,.
D
Just
quickly
the
the
Caps
that
you're
talking
about
putting
on
the
medications
is
that
per
individual
per
month,
or
it
sounds
to
me
like
the
way
it's
written
it's
per
drug
per
single
drug
per
month.
So,
if
I'm
on
three
drugs
in
a
particular
level,
whether
bronze
silver,
whatever
each
drug
is
going
to
be
susceptible
to
that
cap,
is
that
is
that
is
that
right?
That.
A
Thank
you
for
your
brevity
and
for
a
succinct
presentation.
We
appreciate
that.
Thank
you
for
your
time.
Thank
you
all
right
and
last
on
the
agenda.
We
have
today,
but
definitely
not
least,
is
presentation
on
the
aware,
Recovery
Center.
We
have
Mr
Brian
Holzer
who's
here.
If
he
wants
to
come
forward
and
Mr
Holz,
if
you
want
to
introduce
yourself
or
Dr
Holzer,
should
we
introduce
yourself
for
the
record
please
and
begin
your
testimony
whenever
you're
ready.
A
O
Try
this
again
chairman
Alvarado,
chairman
Moser
members
of
the
committee.
Thank
you
very
much,
I'm
honored
to
be
here.
My
name
is
Dr
Brian,
Holzer
CEO
of
aware
Recovery,
Care
and
I'm
very
excited
to
be
able
to
introduce
our
company,
which
is
coming
to
Kentucky
here.
In
a
few
short
weeks,
I've
been
in
healthcare,
my
entire
career
I'm,
a
medical
school
graduate
I,
did
your
your
residency.
O
I
went
on
to
get
an
MBA
and
I've
had
the
privilege
of
working
for
many
several
many
great
companies,
the
last
of
which
brought
me
to
Louisville
Kentucky,
where
my
wife
and
three
kids
now
call
home
very
proudly
but
aware.
Recovery
Care
is
different,
there's
a
greater
purpose
and
a
mission
and
a
meaning
for
me
for
this
company,
and
it
is
a
company.
That's
changing
lives
in
ways
that
I
think
we
all
can
appreciate
giving
the
growing
epidemic
with
regards
to
drug
addiction.
O
I
want
to
talk
to
you
a
little
about
the
company
and
the
company
Journey.
We.
We
are
an
in-home
addiction,
treatment
company.
This
is
a
people
first
in-home
first
company.
We
provide
in-home
care
for
folks
and
their
families
recovering
from
addiction.
We
do
it
with
a
full
clinical
care
team
that
includes
licensed
professionals,
addiction,
Psychiatry,
psychotherapy
care
coordinators
are
either
nurses
or
social
workers,
and
they
surround
and
support
a
team
of
paraprofessionals
that
will
include
Certified
Recovery
advocates,
as
well
as
family
educators.
O
This
is
a
model
that's
delivered
over
the
course
of
a
calendar
year
and,
ultimately,
our
mission
is
to
heal
a
home
when
we
do
so,
we
do
believe
we
do
so
over
the
course
of
that
year.
We
are
a
Pioneer
with
regards
to
this
model.
This
is
a
model
in
which
we
believe
we're
the
only
skill
provider
delivering
this
care,
thus
far
in
the
country.
We
also
believe
that
we
will
not
be
the
last
as
folks
continue
to
recognize.
The
home
is
an
important
level
of
care
with
regards
to
recovery
from
addiction.
O
The
company
was
founded
in
2011
in
Wallingford
Connecticut
by
our
founder,
that
is
now
the
chairman
of
the
board.
He
was
a
gentleman
25
years.
Sober
working
in
Pharmaceuticals
literally
had
a
dream.
One
night
of
a
better
way
to
deliver.
Addiction
therapy
woke
up
quit.
His
job
ultimately
worked
with
a
Yale
research
to
developed
the
model,
it's
very
close
to
the
model
there
that
is
there.
Today
he
ran
five
patients
to
the
model
in
the
early
days.
O
The
fifth
patient
is
now
our
co-founder
and
as
a
direct
report
of
mine
in
the
company
in
2015,
the
company
had
50
employees
and
100
clients
in
one
state
delivering
the
model
on
a
fee-for-service
basis,
at
which
point
anthem
of
Connecticut
stepped
up
to
the
table
and
provided
a
monthly,
bundled
rate
for
our
services.
Again,
our
program
is
a
year
in
length
and
the
way
the
monthly
bundle
rate
works
is
any
member
that
is
on
the
service.
For
more
than
14
days.
O
On
a
given
month,
we
receive
payment
on
a
total
monthly
bundle
rate
that
is
inclusive
of
all
the
Care.
We
provide
over
the
course
of
that
month
that
opened
the
floodgates
so
to
speak.
We
now
have
16
value-based
contracts
that
include
big
named
insurance.
Companies
like
Blue
Cross,
Blue
Shield
of
Massachusetts,
as
well
as
Florida,
blue
and
Anthem,
has
been
continuing
to
support
our
expansion
as
we
move
from
early
days
of
Connecticut
to
New,
Hampshire
and
Maine,
and
ultimately,
they've
supported
our
expansion
to
Indiana
Ohio
and
soon
to
be
Kentucky
fast
forward.
O
Six
years,
as
I
said,
we
are
50
employees
and
100
clients
in
one
state
we're
now
750
employees.
We
are
going
to
have
an
active
census,
approaching
1800.
we're
on
Pace
to
do
almost
3
500
emissions
next
year
alone
and
we're
just
getting
started
those
750
employees
525,
which
are
direct
care
providers.
They
are
living
Heroes.
O
Ninety
percent
of
them
are
in
recovery
themselves
and
as
part
of
their
journey
in
recovery,
their
their
wake
up
every
day
to
contribute
to
the
recovery
of
others,
and
that
develops
the
true
culture
and
the
outcomes
that
I'll
speak
to
you
with
in
a
second
in
two
weeks,
we're
having
a
ribbon
cutting
in
St
Matthews
in
outside
of
where
I
live
to
to
celebrate
our
10th
state,
which
will
be
Kentucky
and
I'm,
proud
to
say,
moving
forward
that
Louisville
Kentucky
will
be
the
new
Regional
headquarters
for
where
Recovery
Care.
O
It's
important
to
note
that
currently,
our
population
is
commercial.
Only
we
serve
18
to
65..
We
have
16
value-based
contracts
on
the
commercial
side
of
the
equation.
I
am
so
thrilled
to
bring
this
to
Kentucky
and
I.
Believe
all
the
elements
are
in
place
for
us
to
use
Kentucky
as
a
springboard
to
be
able
to
launch
into
additional
populations
both
on
the
Medicare
side
and
the
Medicaid
side,
which
you
all
know
all
too
well
that
that
is
a
population
that
needs
this
even
more
than
the
commercial
population
from
a
sheer
numbers
perspective.
O
O
Often
the
care
teams
will
start
their
day
at
5
PM,
because
that's
what's
going
to
be
most
convenient
for
folks
with
work,
family
and
school
responsibilities
because
we're
in
the
home,
there
is
no
re-entry
that
you
would
typically
see
with
higher
levels
of
care
and
what
I
mean
by
that
is.
When
you
remove
someone
from
the
home
and
you
put
them
into
a
Recovery
Center
while
that
may
be,
that
may
be
what
works
for
that
individual.
You
are
moving
them
from
the
home
with
the
environment.
O
We
treat
addiction
like
a
chronic
disease.
That's
very
important.
I
have
looked
at
our
model,
I
have
no
background
in
mental
health
or
Behavioral.
Health
never
worked
in
the
space,
my
background's
in
post-acute,
Home
and
Community
Services,
but
I
often
look
at
how
we're
delivering
this
care
and
I
say
we
should
be
delivering
this
type
of
care
for
all
chronic
diseases.
Addiction
is
a
chronic
disease,
no
different
than
heart
disease.
O
It's
a
lifelong
disease
and
there
are
three
elements
to
our
model.
We
have
a
medical
component,
a
behavioral
component,
a
pure
supportive
component.
Those
three
elements
together
make
us
unique.
When
you
look
at
all
the
models
of
care
that
are
in
the
traditional
traditional
models,
we
aim
to
heal
the
home,
not
just
the
client.
We
have
an
entire
dedicated
track
to
the
family.
The
family
are
in
crucial
allies
to
the
importance
of
the
sustainable
recovery
for
the
individual,
we're
in
the
home.
Obviously,
our
Target
population
right
now
is
an
employed
individual
with
stable
housing.
O
We
do
believe
this
will.
This
will
apply
to
a
Medicaid
population.
It
will
require
member
selection
with
regards
to,
though,
with
some
form
of
housing,
we
go
into
dormitories
on
the
school
front
and
we're
absolutely
able
to
deliver
this
in
a
manner
in
which
we
are
not
interrupting
work,
school
or
family,
and
ultimately,
we
can
heal
the
home
as
we'll
talk
about
shortly.
Our
model
does
include
in-home
detox
in
our
first
phase
that
detox
can
start
on
a
Thursday
and
on
a
Tuesday
and
in
a
confidential
Anonymous
fashion.
O
Someone
can
continue
with
the
care
in
their
home
and
not
miss
a
day
of
work,
as
you
can
imagine
from
an
employer
standpoint,
this
is
a
no-brainer
from
labor.
This
is
a
no-brainer
and
we've
been
well
received
in
all
of
the
markets
that
we've
gone
to
thus
after
the
expansion
from
Connecticut.
Lastly,
because
of
our
monthly
bundled
rate,
this
is
a
value-based,
risk-based
Contracting
model.
We
have
upside
and
downside
risk
written
into
our
model,
we
believe
in
taking
risk.
O
Real
quickly,
I
won't
go
through
the
details
of
this
slide.
Other
than
say
we
have
a
four-phase
model.
It's
a
Loosely
Loosely
speaking,
because
recovery
for
one
individual
is
recovery
from
one
individual.
The
path
of
recovery
will
differ
for
each
individual
and
our
model
is
flexible.
Loosely
speaking,
the
first
two
phases
are
six
weeks
in
in
length.
The
third
phase
of
more
in
a
maintenance
phase
is
six
months
in
the
last
phase
of
a
community
or
engagement
is
more
of
three
months.
O
What
I
want
to
highlight
is
more,
if
you,
if
I,
just
leave
you
with
the
following
the
quotes
at
the
bottom
of
each
of
the
face,
the
nuances
in
the
art
and
the
articulate
nature
of
this
model
is
such
that
the
founders,
even
back
in
2011,
ultimately
looked
at
a
broken
traditional
levels
of
care
and
that
they're
not
stitched
together
and
my
background
again
is
post-acute.
O
It's
the
same
thing
in
the
hospital
to
Post
Acute
side,
someone
stays
five
days
in
a
hospital,
they're
stabilized
and
then
they're
discharged,
and
they
get
may
get
touched
by
four
or
five
different
companies
in
90
days,
none
of
which
talked
to
talk
to
each
other,
all
of
which
litter
and
send
it
on
a
fee-for-service
basis.
Addiction
is
no
different,
and
so
what
the
aware
Recovery
Care
model
does.
Is
it
stitches
together
the
levels
of
care
into
a
continuous
longitudinal,
chronic
disease
care
model?
O
Think
of
it
as
Residential
Treatment,
Without,
Walls
connected
to
PHP
or
partial
hospitalization,
Without
Walls
connected
to
intensive
outpatient,
Without,
Walls
connected
to
outpatient,
Without,
Walls
and
all
flexible,
with
integrated,
Care
Management
and
support
along
the
way.
The
other
way
I
describe
it
as
addiction,
as
as
many
of
you
know,
is
more
like
an
EKG
pattern,
there's
periods
of
Engagement
and
disengagement
during
the
natural
course
of
recovery.
When
you
don't
have
a
longitudinal
care
model,
when
you
have
periods
of
disengagement,
you
have
high
risk
for
relapse
and,
ultimately,
another
level
of
care.
O
We
are
no
discharge,
no
discharge
model
in
which
we're
caring
for
that
individual
of
the
course
of
a
calendar
year,
therefore,
can
manage
periods
of
disengagement.
In
fact,
when
there
are
periods
of
disengagement,
we
have
an
entire
team
dedicated
to
engaging
the
disengaged.
Those
team
members
are
called
client
engagement
Specialists.
They
do
nothing
but
Engage
The
disengaged,
and
we
have
about
a
25
percent
recapture
rate
of
folks
that
are
disengaged
that
get
will
get
back
into
the
engagement
and
ultimately
complete
our
program.
O
Last
two
slides
I
just
want
to
highlight
our
outcomes,
which
are
unparalleled
because
of
the
nature
of
our
program.
There
really
is
no
comparison,
because
there
are
so
few
models
that
will
wrap
this
amount
of
care
around
a
member
for
a
long
period
of
a
longitudinal
period
of
time.
We
get
measured
by
our
insurance
providers
by
retention
rates,
think
about
it
think
about
it,
also
as
a
completion
rate,
and
so
when
you
look
at
Folks
at
six
months
or
24
weeks,
two-thirds
are
still
on
our
service.
O
That
is
that
is
six
months
after
the
start
of
the
program
at
12
months,
we
still
have
more
than
half
of
the
individuals
that
have
completed
the
full
12-month
program.
There
will
be.
There
will
be
appropriate
completions
prior
to
12
months
of
folks
that
have
reached
their
treatment
goals,
and
so
it's
not
that
we
aren't
completing.
You
know
48,
it's
that
52
percent
of
folks
are
still
on
our
service
and
need
of
our
program
are
going
through
the
full
12-month
program.
O
The
course
for
someone,
starting
with
detox,
will
be
closer
to
12
months
versus
someone
that
has
already
been
in
a
facility
for
30
to
60
days
may
not
need
the
full
12-month
program
and
we
will
customize
it
with
that
regard.
These
are
unparalleled
completion
rates
that
you
will
not
see
in
the
treatment
industry
because,
again
and
I've
worked
for
insurance
and
I've
worked
for
hospitals
and
I
really
appreciate
some
of
the
earlier
discussion.
You
need
two
things
to
create
sustainable
change
in
healthcare.
O
In
my
experience,
you
need
clinical
transformation,
you
need
payment
reform
and
they
need
to
work
together.
You
need
both
and
ultimately
here
we
have
a
model
that
will
work
with
both
sides
in
a
fashion
that
I
think
both
sides
can
be
successful.
This
is
truly
a
model
that
can
deliver
on
the
Triple,
a
cost,
quality
outcomes
and
patient
experience
and
I
believe
moving
forward,
starting
with
the
state
of
Kentucky.
O
We
will
make
the
leap
from
a
commercial
population
and
be
able
to
work
copacetically
with
the
Medicaid
plans
in
the
state
of
Kentucky
and
be
the
very
first
state
to
be
able
to
put
this
in
the
homes
of
folks
with
Medicaid
Insurance
in
the
state
of
Kentucky.
Lastly,
I
just
want
to
speak
just
a
bit
about
the
post-treatment
outcomes.
These
are
the
types
of
things
that
predict
for
sustainable
recovery.
These
are
the
types
of
things
you
would
want
to
look
for.
O
The
last
phase
in
the
maintenance
phase
of
our
community
re-engagement
phase
of
our
model
is
entirely
dedicated
to
giving
the
client
the
tools
and
resources
to
support
sustainable
covering
the
community,
and
so
we
work
very
hard
to
create
connections
to
AAA
n,
a
and
other
community
therapy
groups.
As
you
see,
our
engagement
with
pcps
is
very
high
and
again
as
I've
seen
in
healthcare.
O
The
engagement
with
the
PCP
is
in
the
teens
when
our
clients
leave
our
program,
it's
nearly
90
and
that
supports
giving
them
the
best
shot
for
sustainable
recovery
and
sort
of
a
lifelong,
a
lifelong
sense,
and
let
me
conclude
with
some
outcomes:
Anthem
has
been
following
us
for
six
years
now
with
their
own
actuary,
Department,
not
ours,
and
we
get
sent
this
data
and
ultimately,
obviously
it
has
supported
their
desire
to
see
us
in
more
markets
for
them
in
more
States.
O
But
what
you
see
here
that
I
have
rarely
seen
in
my
entire
healthcare
career
is
that
those
outcomes
are
sustained
even
after
our
services
stop
and
in
healthcare.
As
you
all
know,
things
tend
to
work
when
you
throw
a
bunch
of
resources
at
something,
and
things
tend
to
stop
working
when
you
pull
those
resources
away
and
folks
tend
to
regress
back
to
their
baselines.
That
is
not
so
with
a
rare,
Recovery
Care,
and
that
is
why
Anthem
is
so
excited
and
supportive
of
our
expansion
across
more
markets.
O
So
let
me
conclude
with
the
following:
I
I
feel
very
strongly
been
involved
in
a
lot
of
different
things.
I've
again,
I
worked
for
Amgen
on
the
biotech
side.
I've
worked
for
a
large
Blue
in
Pittsburgh,
as
well
as
health
system
and
Kindred
Healthcare
is
where
I
moved
here
for
for
for
Louisville
I've
seen
a
lot
I
haven't
seen
anything
like
this
I
do
believe
that
aware.
Recovery
Care
is
going
to
change
the
conversation
with
regards
to
how
we
view
addiction
treatment,
we're
here
to
partner
we're
not
here
to
threaten
traditional
levels
of
care.
O
Two-Thirds
of
our
senses
comes
from
referrals
from
higher
levels
of
care,
and
we
spend
a
lot
of
time
care,
coordinating
referrals
that
we
cannot
treat
due
to
Insurance
to
our
partners
in
the
states
that
we
enter.
We
heard
a
partner
we're
here
to
be
part
of
the
conversation
and
again
this
is
one
of
those
wonderful
topics
where
you
don't
need
two
sides
to
the
conversation.
What's
good
for
members
of
this
committee
will
be
good
for
insurance,
companies
will
be
good
for
Hospital.
O
A
You
Dr
Holzer,
and
we
had
a
chance
to
talk
privately,
is
very
exciting.
We've
had
a
lot
of
discussions
about
the
need
for
transitional
housing
with
people.
They
go
through
substance
use,
I
again,
I've
shared
that
I've,
one
of
the
directors
from
Isaiah
house
was
a
big
kind
of
provider
in
the
state
and
with
really
good
success
rates,
but
the
difficulty
is
once
they
get
discharged.
Is
that
that
housing
issue
and
that
transitional
problem
that
continues
to
be
a
problem
for
a
lot
of
folks
out
there.
A
This
is
exciting
and
the
numbers
are
exciting,
and
so
you
know
I
think
there's
going
to
be
some
some
we
have
an
opportunity.
There's
a
lot
of
money
being
thrown
up
is
probably
right
now
in
the
State.
There's
a
lot
of
grant
money
available
that
this
would
be
something
I
think
for
them
to
be
able
to
take
a
look
at
also
at
the
Attorney
General's
office
through
a
lot
of
the
opioid
abatement
task
force
and
the
grants
that
are
coming
every
year.
So
there's
some
really
neat
things.
Man.
O
Think
it's
going
to
be
first
in
class
with
regards
to
our
ability
to
actually
enter
the
Medicaid
Mark
and
improve
out
our
value
and
so
we're
working
very
hard
with
local
nonprofits
to
be
able
to
appropriately
tap
those
Grant
dollars
in
ways
that
I
think
will
reflect
the
value
you
can
deliver
in
new
populations.
That's
phenomenal
representative
Moser.
J
O
J
O
We
have
16
value-based
contracts
that
reflect
contracts
with
insurers
in
the
various
states
that
we
operate
so
Florida
as
an
example
would
be
supported
by
Florida.
Blue
I
can't
mention
it
today,
but
we
have
a
very
large
National
insurer
that
we're
about
a
week
away
from
signing
it'll
be
a
second
insurer
for
Kentucky
as
well:
Blue
Cross,
Blue,
Shield,
Mass,
Tufts,
again,
eight
or
nine
large
payers
across
the
states
on
a
fee-for-service
basis.
Our
model
would
be
40
to
42
000
over
the
course
of
the
year.
O
I
don't
want
to
draw
any
comparisons
from
from
Residential
Treatment,
but
you
can
do
the
math
in
terms
of
recidiven
rates
and
the
cost
of
of
a
very
streaming.
We
feel
very
good
about
our
pricing
model
from
from
the
monthly
bundle
rate
purpose,
which
is
reflective
of
all
of
our
bundle
old
contracts.
The
rate
that
we
receive
in
each
of
the
phases
reflects
what
the
insurer
is
used
to
paying
for
that
level
of
care.
O
So
what
they're
used
to
paying
for
residential
treatment
in
Phase
One
roughly
reflects
the
rate
that
they'll
pay
for
our
model
and
then
it
tears
down
over
the
course
of
the
four
phases
to
reflect
the
lower
amount
of
intensity.
As
someone
gets
from
active
crisis
into
maintenance
now
those
rates
don't
reflect
the
fact
that
we're
providing
a
fully
loaded,
coordinated,
longitudinal
care
model.
It
is
just
as
you
think
about
in
the
early
days
of
showing
value
to
a
payer
they're
used
to
paying
for
x
and
residential
treatment.
O
O
P
So
I
wanted
to
ask
you
about
that
intensive
phase,
one,
the
intense
phase
that
you
called
residential,
Without
Walls
I'm,
just
wondering
about
you
all
not
being
able
to
control
that
environment
and
especially
in
that
phase,
how
you
deal
with
the
fact
that
the
clients
could
still
access
the
drug.
O
Look,
that's
that's
something
that
continues
over
the
course
of
the
entire
year
and
I.
Think,
ultimately,
of
all
the
heroes
that
we
have
on
our
Direct
Care
staff,
keep
in
mind.
We
have
90
of
those
in
recovery
and
we
assign
two
peer
recovery
Advocates
to
every
client,
they're
called
Certified,
Recovery
advisors.
I
will
admit.
Many
of
these
folks
do
not
have
degrees,
have
previous
felony
convictions
and
have
and
are
going
through,
their
Reclamation
phase
of
their
life
and
ultimately,
when
you
send
someone
in
that
is
previously.
That
is
not
in
a
white
coat.
O
I've,
worn
white
coats
there's
a
place
for
that
there
and
there's
not
not
a
place
for
white
coats.
When
you
walk
into
someone
an
active
crisis,
they
will
respond
to
the
credibility
of
someone
that
has
been
there.
That
looks
like
them
and
was
them
not
too
long
ago
and
that's
what
they
received
with
regards
to
those
two
peer
recovery.
Advocates,
those
folks
know
where
the
bottles
are
hidden,
they
know
when
they
say:
I
haven't
been
drinking
and
they're.
Already
back.
Looking
in
the
garbage
can
and
see
the
empty
bottles.
O
O
It
is
someone
that
looks
like
them
that
can
walk
into
the
home
and
said:
look
I,
don't
know
if
what
worked
for
me
will
work
with
you,
but
we're
going
to
find
it
and
is
that
level
of
connection
that
leads
to
I
think
our
outcomes
and
sort
of
the
sustainability
of
the
model,
particularly
early
days
when
the
risk
of
someone
using
is
high.
The
other
thing
I
will
add,
is
we're
not
we're
not
a.
O
If
someone
falls
off
the
wagon
so
to
speak
and
starts
using
it
again.
There
is
no
shame
a
bestowed
on
the
individual
by
the
care
teams.
This
is
very
much
a
situation
where
it
does
happen
and
our
folks,
from
a
very
empathetic
perspective,
work
to
get
the
individual
back
essentially
on
the
path
towards
recovery,
and
that
is
not
always
the
stance
taken
by
traditional
levels
of
care
and
group
therapy
providers,
and
so
like
there's,
no
Panacea,
absolutely
folks
will
ultimately
relapse.
O
O
Q
You
I'm
I'm,
wondering
about
Staffing
I
would
think
it
would
be
very
staff
intensive
yes,
but
it
sounds
like
you're,
including
people
who
have
been
through
the
programs
and
are
an
example
and
and
also
know
what
to
smell,
and
what
to
look
for.
O
Yes,
no
one
in
the
right
mind
would
create
a
model
like
this
today
you
wouldn't
get
funded
for
it.
This
is
why
you
don't
see
many
of
these
models
and
I'm
not
sure
you'll,
see
too
many
of
them
moving
forward.
I,
don't
believe
this
is
a
model.
I,
don't
believe
this,
the
intensity
of
service
providing
lends
well
to
Virtual
or
Telehealth.
It
is
a
component
of
our
model.
We
support
it
because
not
everyone
wants
to
see
us
three
days
a
week
in
the
home,
but
ultimately
we're
a
people
first,
in-home
first
model.
O
As
a
result,
it
is
labor
intensive
and
part
of
the
reason
why
I
was
brought
on
is
to
build
this
in
a
scalable
fashion
that
can
be
done
in
more
markets
and
profitably.
So
moving
forward,
I
think
what
I
have
seen,
because
I
have
no
background
on
this
I
get
to
learn
from
all
the
wonderful
people
in
my
company
is
the
is
the
treatment.
Community
is
very
tight
and
the
friends
in
front
family
referral
situation
with
regards
to
employees
is
very
strong.
Our
former
chairman
goes
to
meetings
with
my
head
of
medical
Affairs.
O
It's
just
part
of
the
community
and
the
ethos
with
regards
to
our
company.
As
a
result,
you
see
a
lot
of
friends
and
family
referrals
with
regards
to
that.
With
that
said,
in
Kentucky
we
are
working
very
closely
with
several
non-profits
to
be
able
to
build
up
the
Workforce
Development
piece
of
this.
It
is
a
very
big
selling
point
to
New
Markets
that
we
enter
in.
Not
only
are
we
able
to
treat
a
hard
to
treat
population
of
people,
but
we're
able
to
also
recruit
train,
give
people
jobs
of
hard
to
employ
people.
O
I've
got
people
that
have
turned
living
Miracles
turn
their
lives
around
former
heroin
addicts
that
were
homeless.
That
then
ended
up
getting
meeting
their
wife
in
detox
and
then
ultimately
working
for
our
company
and
now
Equity
holders.
You
know
that
is
one
of
many
many
stories
of
folks.
So
we
have
a
path
here.
O
We
can
employ
hard
of
hard
to
employ
people,
giving
them
a
career
track
and
ultimately
give
them
part
of
part
of
their
sustained
recovery
will
be
their
ability
to
contribute
to
the
recovery
of
others
and
that's
what
we
stand
for
so
there
is.
You
know
every
home
care
business
is
dealing
with
staffing
issues.
I
just
think
we
offer
something
different
and,
as
word
gets
out,
I
believe
will
be
a
destination
of
choice
for
folks
that
want
to
contribute
to
this
recovery.
Community.
A
You
all
right,
that's
the
last
presentation
before
we
conclude
I
have
a
few
remarks.
I
want
to
make
so
I
think
we're
not
planning
on
having
any
further
meetings
you
for
Health
and
Welfare
in
Decemberists.
This
is
likely
the
last
meeting
and
it's
the
last
meeting
for
Health
and
Welfare
ever
really,
because
after
some
changes,
at
least
in
the
Senate,
we've
and
I,
think
it's
going
to
happen.
A
Also
in
the
house,
there's
going
to
be
some
changes
in
the
committee
structure,
so
we
know
how
we
rank
on
child
abuse
as
a
state
and
we
try
to
devote
more
time.
We
know
that
these
meetings
are
not
quite
the
meetings
representative
verch
used
to
have
years
ago,
where
they
would
go
five
or
six
hours,
we're
pretty
limited
on
time
frames
anymore,
probably
no
more
than
two
hours,
and
so
in
order
to
be
able
to
dedicate
more
time
to
a
lot
of
child
welfare
issues
and
family
welfare
issues.
A
A
So
let
me
start
off
by
saying
it's
been
my
absolute
honor
to
serve
on
this
committee
with
all
of
you
with
the
staff.
It's
been
very
dedicated,
really
the
unsung
heroes
of
Frankfort,
a
lot
of
the
staff
that
all
the
magic
that
happened
to
these
committees,
making
sure
the
microphones
work
that
the
cameras
are
working,
that
the
people
are
online
able
to
dedicate
all
that
happen
because
of
these
individuals.
A
I
want
to
thank
you
all
for
your
your
tireless
effort
and
work,
making
sure
that
our
bills
are
done
properly
on
time
and
handling
a
lot
of
our
neurotic
requests
when
session
is
in.
Thank
you
all
for
that,
and
really
thank
you
all
really
also
for
serving
on
this
committee.
I
know,
I
have
a
lot
of
passion.
I
know
all
of
you
have
a
lot
of
passion
when
it
comes
to
Health
Care
issues,
and
it
always
comes
through
and
I've
taken
a
lot
of
Pride
I.
A
Think
in
the
things
that
we've
been
able
to
accomplish
all
right.
There
isn't
as
much
partisanship
here
I
think.
A
lot
of
this
is
mostly
policy.
It's
it's
trying
to
make
sure
that
we
do
good
things
for
the
health
care
outcomes
of
the
people
that
we
represent
in
the
state
and
I.
Think
we've
done
a
lot
of
good
work
and
there's
more
work
to
come
as
these
as
these
committees
change,
and
so
many
of
us
might
be
on
different
committees.
Split
up.
A
Who
knows
it
might
be
some
chairman
coming
out
of
this
committee
as
well,
that
will
be
serving
as
well.
I've
also
I
want
to
recognize
a
lot
of
members
that
are
going
to
be
either
they're
retiring
effectively
from
the
general
assembly.
Today,
we've
got
six
members
that
have
been
members
of
this
committee
for
a
long
time
and
a
lot
of
great
work
and
a
lot
of
selfless
commitment
to
the
people
of
the
state
as
well.
I
know,
Senator
Alice
forget
Alice
was
here
earlier.
A
I
know
she
had
to
depart
tremendous
work
in
God,
speak
to
her
and
her
retirement
with
her
and
her
husband,
representative,
Birch
I
know
you
want
to
make
a
few
remarks
I'm
going
to.
Let
you
make
some
here
in
a
few
minutes,
sir,
but
many
many
years
here.
In
fact
you
may
have
been
here
when
this
committee
was
founded.
I,
don't
know,
but
to
be
perfectly
honest,
you've
I
know,
there's
been
a
lot
of
hours
of
testimony
that
you've
heard
in
a
lot
of
policies.
A
We've
gotten
done
because
of
your
hard-working
commitment
to
the
state
as
well.
Representative,
Mary,
Lou,
margian,
I,
know
of
Mary
Lou's
still
here,
but
she
was
here
earlier.
Obviously,
a
nurse
Anna
stalwart
and
her
beliefs
in
defense,
of
Louisville
and
and
in
the
practice
of
medicine
and
nursing
in
the
State
representative,
given
Linda
Gibbons
printy
as
well
Melinda
we're
going
to
miss
you
and
she's
been
been
great
here
as
well,
and
Representative
Steve
Sheldon.
A
One
of
our
pharmacists
also
is
going
to
still
help
us
in
trying
to
get
some
bills
drafted,
I
think
moving
forward
for
next
year
and
then
representative
Susan
Westrom,
also
a
fellow
colleague
in
in
Fayette
County.
All
of
you
have
a
chance
to
get
to
know
all
of
you
a
lot
of
your
providers
and
folks
who
are
dedicated
to
this.
It
takes
a
special
individual
to
serve
on
this
committee.
I.
Think
a
lot
of
our
colleagues
sometimes
don't
want
to
sit
through
a
lot
of
the
testimony.
It's
very
emotional.
A
Sometimes
people
have
to
express
themselves
and
it
takes
special
people
to
enjoy.
This
I
can
say:
I
think
that
all
of
us
enjoy
this
the
testimony
it
can
go
on
for
two
hours
and
we
don't
get
bored
I,
think
a
lot
of
times
when
we
can
hear
a
lot
of
things
and
learn
a
lot
of
things.
So
thank
you.
All.
It's
been
my
absolute
honor
to
serve
with
all
of
you,
representative
virtue
on
a
few
remarks.
F
Foreign,
thank
you
Mr
chairman
one
is
first
I
want
to
say
what
an
honor
has
been
to
serve
with
the
members
of
this
committee
and
I.
Wish
you
all
the
very
best
in
the
future
out
of
my
49
years
as
a
legislator,
47
of
them
was
a
member
of
this
committee
and
I
had
the
honor
of
serving
as
its
chairman
for
30
years.
So
we've
made
a
lot
of
progress
in
those
times,
but
one
thing
I
do
not
want
to
forget
is
the
staff.
F
They
were
the
backbone
for
many
of
the
things
I
was
able
to
do,
and
in
fact
they
he
might
say.
The
encouraged
me
to
do
some
of
the
things
I
did
and
but
I'll
miss
this
place,
but
I'm
also
looking
forward
to
spending
some
time
with
my
grandkids,
my
great-grandkids
and
and
some
of
my
friends
have
still
left
and
thank
you
very
much.
Mr
chairman.
J
Thank
you,
Mr
chairman
and
I
just
want
to
Echo
the
sentiments
of
chairman
Alvarado
and
just
say
what
a
pleasure
it
has
been
to
work
with
everyone
in
this
configuration
of
our
committee,
I'm,
not
exactly
sure,
what's
happening
on
the
house
side,
but
we'll
we'll
continue
working
for
great
help
policy
and
and
great
changes
here
in
Kentucky,
so
I
just
want
to
Echo
the
sentiments
and
thank
everyone
for
all
of
your
work
and
we're
going
to
keep
some
of
our
friends
who
are
retiring
on
speed,
dial
and
and
just
you
know,
continue
working
hard
as
we
always
do.
J
Thank
you
also
to
our
staff.
I
appreciate
greatly
all
that
you
do
and
all
that
you
put
up
with
when
we
are
fast
and
furiously,
Drafting
and
and
working
on
on
policy
here
in
Kentucky,
especially
during
the
session.
So
thank
you
all.
We
will
see
everyone
in
January.