►
From YouTube: Medicaid Oversight and Advisory Committee
Description
No description was provided for this meeting.
If this is YOUR meeting, an easy way to fix this is to add a description to your video, wherever mtngs.io found it (probably YouTube).
A
B
A
Thank
you.
Yes,
we
do
have
a
quarrel.
My
first
order
business
is
on
your
agenda,
but
let's
have
the
approval
of
the
minutes.
Is
there
a
motion?
Is
there
a
second
motion
in
the
second
all
this
favor
say:
aye
aye
any
obligation
past
you,
namely
thank
you.
We've
got
three
great
topics
this
morning
or
this
afternoon.
A
Excuse
me
this
is
the
third
committee
meeting
and
they
kind
of
run
together
after
a
while
for
somebody,
my
age,
but
first
we're
gonna,
go
suspension
of
prior
authorization
for
behavioral
health
services,
and
I
see
miss
dr
schuster
is
here
if
you'll
come
forward
along
with
your
guest,
if
you
have
any
aren't
we
lucky,
I
am
on
a
roll
today.
A
G
F
Thank
you,
dr
sheila
schuster.
I'm
a
licensed
psychologist
and
executive
director
of
the
kentucky
mental
health
coalition,
and
I
appreciate
very
much
the
invitation
from
the
committee
co-chair
senator
meredith
and
the
members
to
talk
to
you
about
a
favorite
topic
of
mine,
the
suspension
of
prior
authorization
for
behavioral
health
services.
F
F
The
providers
see
them
as
being
costly
time
consuming
and,
more
importantly,
delaying
are
denying
care.
You
may
remember
that
in
excuse
me,
the
2018
general
assembly.
We
had
house
bill
69
from
representative
ken
fleming
that
tried
to
do
a
single
credentialing
but
also
talked
about
a
single
medical
necessity
criteria
which
would
be
so
helpful
because
we
have
six
mcos.
F
There
is
a
fail-safe
for
the
insurers,
so
if
they
come
crying
to
you
that
they're
losing
a
boatload
of
money
because
they
can't
prior
off
behavioral
health
right
now
number
one
remember
that
the
total
spend,
I
think
for
behavioral
health
and
medicaid
is
certainly
less
than
five
percent,
maybe
more
like
two
or
three
percent.
So
we
are
very
small
but
important
when
you
think
about
the
people
we
serve,
but
a
very
small
part
of
that
budget.
F
Since
that
time
they
have
restored
the
pas
for
some
physical
health
services
except
those
related
to
covid,
but
to
date
the
pas
for
behavioral
health
when
we
say
behavioral
health,
we're
talking
mental
illness
and
substance
use
disorders.
Those
have
remained
in
place.
So
we
get
a
monthly
update
or
a
bi-monthly
update
on
that
status
of
the
pas
because
they
are
reviewed
monthly
and
the
dms
would
give
us
a
30-day
notice
if
they're
going
to
be
reinstated.
F
Just
to
remind
you
that
what
we're
talking
about
what
we're
going
to
focus
on
today
is
really
the
severe
mental
illnesses.
Substance
use
disorder,
and
this
also
affects
children
with
severe
emotional
disturbance,
but
where
most
of
my
data
is
around
adults
with
either
smi
or
with
substance
use
disorders.
F
So
almost
every
service
that
you
can
think
of
requires
a
prior
authorization
from
the
initial
services
and
establishing
a
diagnosis
and
a
plan
of
treatment.
And
then
these
other
services,
which
we'll
get
into
a
little
bit
more,
the
most
important
of
which,
at
least
for
our
folks
with
severe
mental
illness,
is
targeted
case
management.
F
We
also
have
day
treatment
programs
that
are
called
therapeutic
rehabilitation.
We
have
therapy
services
again
for
people
with
severe
mental
illness.
We
have
assertive
community
treatment
and
community
support
services.
On
the
sud
side,
we
have
intensive
outpatient
treatment,
iop.
Of
course
we
have
detox,
and
then
we
have
residential
treatment,
either
short
term
or
long
term,
and
every
one
of
those
requires
this
prior
authorization
process
unless
it's
suspended.
F
So
let
me
just
remind
you
that
we're
talking
about
the
covid
period
and,
as
you
all
know,
probably
from
your
own
personal
experiences
and
from
those
of
your
constituents
covet,
has
been
extremely
extremely
difficult
on
the
behavioral
health
of
probably
every
living
being.
I
don't
care
whether
you
have
a
diagnosable
condition
or
not,
and
some
of
us
feel
like
we
may
end
up
with
a
diagnosable
condition
because
of
the
anxiety
and
the
depression
that
comes
with
it.
So
it's
kind
of
what
a
friend
of
mine
called
the
trifecta
for
anxiety.
F
It's
an
unknown
time
frame
of
undetermined
consequences
and
a
total
loss
of
control,
and
that's
really
bad
for
us
human
beings.
We
don't
handle
that
well
and
we
react
with
anxiety,
depression.
We
also
abuse
substances
during
that
time
because
we
self-medicate
those
feelings,
those
uncomfortable
feelings.
We
worry
about
our
kids.
We
worry
about
our
parents
that
sandwich
generation,
I
think,
is
really
feeling
it.
I
have
a
granddaughter
who
is
10,
so
she
can't
get
vaccinated
and
you
know
I
worry
to
death
about
her
in
her
activities,
whereas
my
other
grandchildren
can
all
be
vaccinated.
F
F
A
lot
of
people
went
back
to
using
those
substances,
whether
it
was
alcohol
or
opioids
or
illegal
substances,
the
warmth
of
an
aa
program
or
an
n.
A
program
was
not
there
because
you
couldn't
do
it
in
person
and
it's
really
tough,
particularly
for
people
who
are
new.
In
recovery,
so
this
has
been
a
really
really
tough
time
for
behavioral
health.
F
In
may,
commissioner,
lee
reported
at
this
committee.
These
increases
in
spending,
and
this
is
kind
of
the
covid
period.
So
this
is
the
comparison
of
july
to
february,
19
and
20
to
20
and
21,
and
you
see
mental
hospitals
way
up.
You
see
the
residential
crisis
stabe
units,
we
call
them
a
big
increase.
F
The
psychiatric
residential
treatment
facilities
are
for
youth,
the
prtfs,
and
then
you
see
the
cmhcs,
and
I
don't
know
whether
that
includes
the
billings
from
what
we
call
our
bso
bshos,
the
behavioral
service
organizations
or
not.
I
think
that
those
increases
are
to
be
expected.
Quite
frankly,
if
you
think
about
what's
going
on
during
this
covent
period,
some
of
the
providers
who
do
in-person
therapeutic
rehab
had
to
cut
back
certainly
on
the
those
services
could
not
do
them
in
person,
and
some
of
our
clients
do
not
do
well
with
telehealth.
F
So
we
think
that
prior
auth
should
be
assessed
on
a
case-by-case
basis
and
what
we
hear
from
the
mcos
are
that
they
have
these
kind
of
in
their
head,
because
they're
not
in
reg,
arbitrary
and
preset
limitations.
One
mco
said
well
we're
not
going
to
authorize
targeted
case
management
unless
your
client
is
in
psychotherapy.
F
Well,
if
you
have
an
active
psychotic
disorder,
you
are
not
a
good
candidate.
I
will
tell
you
as
a
psychologist
for
what
we
think
of
as
traditional
psychotherapy,
and
so
they
wouldn't
authorize
other
services
which
again
doesn't
make
a
whole
lot
of
sense.
Another
said
that
you
would
only
need
targeted
case
management
for
a
12-month
period
over
a
lifetime,
and
I'm
telling
you
folks,
I
think
it's
akin
to
saying.
Okay,
you
have
a
diagnosis
of
diabetes,
we're
going
to
limit
the
amount
of
insulin
that
you're
going
to
get
over
a
lifetime.
F
That's
how
important
some
of
these
services
are
to
keeping
our
people
out
of
the
hospital
out
of
jail
out
of
homelessness
out
of
trouble
out
of
suicide
and
to
have
these
preset
arbitrary
limits
is
just
unconscionable.
F
They
don't
take
into
account
most
of
our
cmhcs
and
the
bhsos
are
accredited
by
the
committee
for
the
accreditation
of
rehab
facilities
or
the
joint
commission,
as
well
as
obviously
the
licensure
through
the
cabinet.
So
they
already
have
those
qualifications.
F
But
it
takes
a
long
long
time
for
them
to
be
able
to
do
it.
We
know
that
recovery
is
an
up
and
down.
In
fact,
I've
often
thought
that
the
hardest
diagnosis
that
you
can
give
a
parent
is
that
your
child
has
a
severe
mental
illness
or
an
acquired
brain
injury,
because
they're
the
two
that
are
lifelong
without
true
recovery,
you're
going
to
have
those
illnesses,
your
entire
lifetime
and
again
the
unpredictability,
those
peaks
and
valleys,
and
what
we
try
to
do
as
providers,
particularly
in
your
safety
net,
which
are
your
community
mental
health
centers.
F
F
F
F
F
F
So
we
have
to
wait
until
they're
actually
admitted
and
then
try
to
go
through
the
pa
process,
which
very
often
doesn't
get
approved
until
day,
two
or
day
three
and
the
providers
of
course,
take
a
loss
and
of
course
it
doesn't
make
any
sense
if
they
meet
criteria
on
day
two
or
three
for
that
service.
That
sure
is
hacked
about
it
on
day,
one
one
of
the
things
that
you
learn
about:
behavioral
health
providers
and
again
I
think
dr
alvaro
alvarado-
has
this
firsthand
is
that
we
don't
turn
people
away.
F
F
So
delay
is
is
a
critical
issue.
We
don't
want
people
to
fall
through
the
cracks.
We
want
to
be
able
to
keep
an
eye
on
them
and
look
for
changes,
and
we
want
there
to
be
continuity
of
care.
So
we
have
a
woman.
This
is
a
little
case
study
with
smi,
who
needs
to
learn
literally
the
what
we
call
the
activities
of
daily
living
housekeeping
shopping,
preparing
a
meal.
F
She
wants
to
live
on
her
own
for
the
first
time
and
we
have
a
program
in
louisville
that
is
available
through
wellspring,
which
is
a
bhso
that
does
what
we
call
supported
housing
it's
what
we
could
do
if
we
had
a
medicaid
waiver
for
people
with
smi,
so
it
gets
people
into
housing
with
people
right
there
to
help
them,
learn
those
activities
and
to
keep
an
eye
on
them.
So
she
also
had
significant
physical
health
issues,
which
is
again
the
norm
for
our
people.
F
They
don't
go
to
doctors,
they're
not
always
well
accepted
in
primary
care
settings
or
even
in
the
hospital
ers
on
for
physical
health.
So
the
targeted
case
management
was
used
for
both
of
those
things
and
again
the
mco
said.
Well,
she
shouldn't
need
it
for
more
than
six
months.
Well,
this
is
a
woman
whose
frontal
cortex
her
executive
functioning
is
not
functioning
and
for
her
to
go
alone
to
a
doctor's
office,
she's
not
going
to
be
able
to
tell
them
what
it
is
that
she
needs
or
to
understand
what
she's
hearing
back
from
the
physician.
F
That's
what
a
targeted
case
manager
would
do.
People
with
severe
mental
illness
die
25
years
younger
than
their
peers
without
a
severe
mental
illness.
So
what
what
has
been
the
effect
on
staff?
F
Guess
what
staff
has
more
time
to
actually
provide
services
because
they're
not
hassling
with
the
mcos
they're,
not
on
the
phone
they're,
not
faxing
and
faxing
and
refaxing,
and
so
forth,
and
waiting
they're,
also
not
having
to
stop
in
the
middle
of
a
treatment
progression
to
say:
oh,
wait,
a
minute,
I
got
to
get
a
pa
in
for
that
next
little
group
of
of
services
that
I
need
to
get
approved
and
so
forth.
Service
staff
has
said
the
the
release
of
stress
during
this
period.
F
When
they
haven't
had
to
do
prior
authorizations
has
just
been
remarkable.
This
gives
you
an
idea.
This
is
from
one
of
our
cmhcs,
it's
roughly
an
hour
per
patient
per
week,
that
is
spent
on
just
the
hassle
and
the
paperwork
of
a
prior
authorization.
So
you
start
multiplying
that
with
caseloads
of
20.
F
You
know
you're
really
talking
about,
and
people
are
doing
the
the
pas
you
know
in
between
when
they
really
don't
have
time
to
do
them.
So
some
of
the
obviously
the
bottom
line
is
we
can
save
lots
of
administrative
time
and
actually
spend
it
on
treating
clients.
F
So
again,
we
have
the
internal
mechanisms
for
doing
this
what's
success,
and
this
is
interesting.
One
of
the
mcos
said
we're
not
going
to
authorize
any
more
targeted
case
management,
because
the
patient
is
not
showing
an
improvement
with
success.
For
many
of
these
patients
is
stabilization,
it's
keeping
them
from
going
backwards,
and
I
call
that
improvement
quite
frankly
if
we
know
where
they
are
and
that
they're
taking
their
medication
and
that
they're
engaged
in
some
meaningful
activities
and
so
forth
and
are
not
getting
in
trouble
and
not
getting
upset
and
so
forth.
F
That
is
absolutely
where
we
want
to
be
able
to
keep
them,
and
so
this
idea
of
what's
the
goal
here
and
again,
dr
o'malley's
article,
I
think,
does
a
really
great
job
of
just
describing
how
difficult
it
is
for
that
patient
when
the
dopamine
overruns
their
ability
to
take
in
what
we
would
think
of
as
normal
demands
of
society,
and
they
really
can't
handle
them,
and
then
they
start
that
downward
cycle,
so
targeted
case
management's
defined
in
in
the
reg.
F
It's
what
you
would
think
it's
getting
them
in
touch
with
every
service
that
they
need
it's
doing
a
comprehensive
assessment
and
then
periodic
reassessments,
because
people
change
so
much.
It's
monitoring
and
follow-up
targeted
case
management
already
by
reg
is
restricted
to
smi
adults.
This
is
not
everybody
who
comes
in
with
any
kind
of
behavioral.
Health
diagnosis.
F
We
were
talking
with
commissioner
lee
back
in
january
of
2020,
so
before
covid
about
the
problems
we
are
having
in
getting
targeted
case
management
approved,
and
it's
not
every
mco,
some
mcos
approve
it
on
a
really
reasonable
basis.
Some
hardly
approve
it
at
all
and
again,
there's
that
difficulty.
If
you
happen
to
have
the
wrong
mco,
you
could
be
in
big
trouble
and
we
started
talking
about.
We
had
some
providers
who
had
hands-on
experience
and
commissioner
lee
urged
us
to
do
a
deep
dive.
F
So
we
put
together
a
study
group
with
dr
alan
brenzel,
medical
director
from
the
department
for
behavioral
health
and
a
number
of
providers
that
really
had
hands-on
experience
and
we
went
to
the
data
people
at
medicaid
and
said
you
know.
Here's
what
we
need
to
look
at
here
are
the
you
know.
Can
we
find
some
people
that
didn't
have
targeted
case
management
and
then
started
to
have
it
for
six
months
and
let's
see
what
what
we
can
find
out
about
er
visits
about
filling
their
prescriptions?
F
You
know
going
in
and
actually
filling
the
prescriptions
can
we
get
data
from
other
sources
about
housing,
status
and
criminal
justice,
and
we
are
in
the
midst
of
doing
that
study.
I'm
really
pleased
phase.
One
has
been
finished,
they've
identified
just
over
8
600
medicaid
patients
that
fit
our
criteria
again,
we're
starting
with
adults
with
severe
mental
illness.
At
some
point,
we'd
like
to
go
substitute
disorder
we'd
also
like
to
do
the
the
children
with
severe
emotional
disturbance,
but
we
are
in
the
middle
of
this
and
they
are
pulling
that
data.
F
F
Here
are
recommendations
that
I
bolded
the
first
one,
because
that's
really
I
I
was
tempted
to
only
put
that
as
my
only
recommendation,
but
I
thought
I
ought
to
give
you
some
leeway
so
continue
the
current
suspensions
of
pas
for
all
behavioral
health
services,
at
least
until
the
end
of
the
year
until
we
know
where
we
are
with
covid.
Maybe
we
have
some
of
the
results
back
from
our
targeted
case
management
study
and,
let's
evaluate
then,
if
the
data
shows
what
we
think
it's
going
to
show,
and
that
is
the
targeted
case.
F
So
we
we
really
need
to
look
at
what
their
incentives
are
for,
keeping
people
out
of
the
hospital
if,
if
we
can't
get
number
one-
and
I
only
reluctantly
give
you
some
other
alternatives,
but
the
other
is
continuing.
F
But
let's
remember
number
one
is
my
best
recommendation
from
the
behavioral
health
community
and
I
am
again
thankful
for
you
inviting
me
and
I'm
happy
to
answer,
try
to
answer
any
questions
and
I've
got
tons
of
data
that
I
couldn't
fit
into.
My
slides,
or
I
would
have
been
talking
to
you
like.
I
was
at
the
smi
task
force
for
two
hours
or
something.
A
I
don't
believe
you're
surprising
anyone
with
that
statement,
dr
schuster
at
all,
but
I
appreciate
what
you're
saying
and
this
addresses
I
think,
a
myriad
of
problems
with
managed
care,
and
wouldn't
it
be
great
if
we
just
had
two
or
three
managed
care
organizations
to
deal
with
instead
of
six,
I
just
had
to
throw
it
out.
F
It
would
certainly
be
easier
for
providers
to
understand
the
rules
and
follow
them.
A
Well
that
it
would
and
for
this
particular
element
of
the
delivery
system,
it
makes
no
sense
to
me
whatsoever
as
to
is
why
you
have
to
have
pre-authorization,
because
I
would
think
denied
care
delayed
carriers
more
expensive
care
in,
but
you
know
how
this
whole
system
works,
the
more
we
can
deny
the
more
we
can
delay
than
the
more
payments
that
the
mcos
don't
have
to
make,
and
you
know
you
gave
the
scenario
about
spending
an
hour
filling
out.
Authorization
forms
well
from
our
perspective:
healthcare
perspectives.
Yeah,
we
don't.
A
A
Cycle
that
we
go
through,
but
I
think
your
points
are
well
taken.
I
will
tell
you
that
I've
had
one
conversation
with
one
of
the
mcos
and
it
may
be
one
of
the
friendly
ones
you
referred
to
already,
but
they
were
not
adverse
to
this
completely.
They
weren't
willing
to
give
carte
blanche
a
privilege
to
this,
but
they
thought
there
was
some
room
for
some
negotiations,
so
I
think
that's
some
follow-up
on,
but
at
least
that's.
F
A
Maybe
we
build
on
upon
that,
but
let's
go
to
questions.
First,
have
senator
carol
senator
carol
chairman?
Can
you
hear
me?
Okay,
yes,
can.
Thank
you.
C
C
All
at
once
as
a
result
of
that
that
suspension
going
away-
and
I
know
that's
something
that
we're
still
struggling
with
from
months
ago-
it's
it's
caused
major
issues
in
dealing
with
epsdt
therapy
services
and
ppec
services
for
children
with
developmental
issues,
and
so
that's
and
it's
not
only
just
the
pas,
but
there
are
situations
where
it's
ongoing
services
where
pas
have
to
be
renewed.
C
You
have
situations
where
kids
leave
an
mco
for
a
different
mco
and
the
provider
gets
no
notification.
So
then
you're
you're
providing
services,
and
then
you
have
to
go
back
and
apply
retroactively
for
reimbursement
and
the
paperwork
just
continues
to
multiply
through
those
processes
and
in
our
organization
we've
had
up
our
staff.
C
I
basically
had
two
people
doing
pas
and
billing
we're
up
to
five.
Now,
some
of
that
has
to
do
with
our
numbers
going
up
on
the
number
of
kids
we
serve,
but
but
the
extra
running
running
items
back
through
the
system.
Time
and
time
again,
it's
just
ridiculous.
What
that
the
time
that
that
takes-
and
my
my
question
is
this-
there
was
some
conversation
with
the
mco.
As
mr
chairman
said.
C
I
think
there
is
some
willingness
to
to
make
some
changes,
but
this
was
a
few
years
ago
about
the
possibility,
rather
than
doing
pas
on
each
individual
client
or
person
being
served,
but
to
to
look
at
the
provider
themselves
themselves
and
certify
each
provider
and
they
they
would
come
in.
They
would
look
at
the
provider
how
they
do
business,
their
structure,
their
credibility
within
the
field
and
then
once
they're
certified,
then
that
pa
process
goes
away.
F
I
think
it's
a
an
idea
that
is
well
worth
looking
at
senator
carroll
and
I
appreciate
you
bringing
it
up.
You
know
I
always
try
to
gather
data,
so
I
sent
out
the
sos
and
said
you
know
tell
me
what
your
experiences
have
been
and
so
forth
and
a
number
of
particularly
the
cmhc
said.
You
know
it
doesn't
make
any
sense.
F
We,
you
know
our
denial
rate
is
one
percent,
for
instance,
on
on
sud,
because
we
so
clearly
follow
the
asam
guidelines
and
those
other
guidelines
and
so
forth,
and
it
seems
to
me
that
if
a
a
provider
of
whatever
type
is,
is
able
to
demonstrate
that
they
have
the
guidelines
and
they
follow
them
and
and
so
forth
that
they
ought
to
be
able
to
earn
their
way
out
of
jail,
so
to
speak
and
be
able
to
yeah,
at
least
with
certain
populations
and
and
certain
services
and
so
forth.
F
C
And
I
certainly
wish
that's
that's
something
we
could
do.
I
mean
it.
We
talk
about
the
the
shortage
of
revenue
and
medicaid
and
there's
no
question
about
that
and
more
people
that
need
to
be
served,
but
yet
our
systems
are
set
up
to
where
it
costs
more
and
it's
costs
that
aren't,
as
has
already
been
stated,
not
directly
related
to
services,
and
I
I
do
think
we
can
do
much
better
in
that,
and
I
think
we
could
do
even
better
than
that
if
we
did
reduce
to
two
to
maybe
three
mco
providers.
B
Thank
you,
mr
chairman
and
dr
schuster.
Thank
you
for
this
testimony
and
this
information
and
for
the
recommendation
to
suspend
the
prior
authorization
for
these
populations,
and
I
just
you
know.
We
know
that
there's
been
a
spike
in
overdose
deaths
throughout
the
pandemic
and
the
cdc
actually
just
came
out
with
a
report
that
had
kentucky
number
two
only
after
vermont
in
overdose
death
during
the
pandemic,
and
I'm
just
wondering
if
you
have
a
sense
of
how
much
of
that
might
have
been
averted.
If
we
had.
B
You
know
with
with
suspending
these
prior
authorizations
sooner
and
if
that's
also,
you
know,
strengthens
your
case
for
continuing
now
to
suspend
these.
F
Yeah,
thank
you
for
that
question,
representative
wilner,
and
I
think
it's
it's
it's
so
difficult
to
know.
We
do
know
that
people
who
are
abusing
whatever
the
substance
is
are
not
making
decisions
with
everything
in
intact
and
we
know
that
they
are
sensitive
to
all
of
the
stresses
that
are
that
are
going
on.
So
if
you
look
at
a
time
like
covid,
that
is
so
bad,
I
don't
know
how
many
of
those
people
were
at
some
point
denied
services.
F
F
So
it's
it's
hard
to
know,
but
knowing
that
pas
put
in
a
delay
mechanism,
one
would
argue
that
having
no
pas
for
substitute
disorders,
particularly
those
that
are
already
known
to
be
moderate
or
severe,
would
make
so
much
sense
to
not
ever
impose
those
pas.
So
I'm
gonna,
I'm
gonna,
go
with
that
as
the
best
recommendation.
I
can
make.
Thank
you
for
the
question
and
we
were
very
concerned.
I
mean
one
of
the
things
and,
and
you
all
know,
I
know
some
of
these
people
that
are
affected.
F
F
H
H
I
think
it's
gonna
really
help
just
because
we
had
people
that
would
come
in
on
a
friday
and
say
I'm
ready
for
treatment
now
and
if
somebody's
coming
with
sud
and
needs
treatment
right,
then
there
you
know
what
you
had
to
say
was
well.
Let
me
check
with
your
insurance
company
and
make
sure
I
get
approval
and
you
wouldn't
get
a
response
till
monday
and
that
person
could
go
home
overdose
and
die
and
that
that
happened
time
and
time
again,
so
we
got
rid
of
that.
H
Fortunately,
with
prior
auths
to
senator
carroll's
point,
I
think
a
better
approach
is
you
know,
mco's,
clearly
trying
to
get
rid
of
people
that
are
spending
too
much
money
on
different
things,
that
people
are
abusing
the
system
and
there
might
be
a
few
that
do
that,
maybe
less
than
one
percent
of
the
providers
we're
burning
the
whole
system
for
that
less
than
one
percent
right.
H
See
an
approach,
senator
carroll,
where
you'd
have
the
top
five
percent
of
the
most
expensive
people
are
the
ones
who
are
then
subject
to
prior
rods
the
following
year.
That'll
keep
you
to
try
to
you,
know
kind
of
challenge
you
against
your
own
peers,
to
try
to
keep
your
costs
down
to
make
sure
that.
But
the
other
thing
in
a
study
that
we
need
to
figure
out,
dr
schuster,
is
how
much
money
is
being
spent.
We
know
that
providers
I
mean
as
a
as
a
practice
just
outside
of
mental
health
issues
as
a
provider.
H
I
had
two
full-time
people
in
my
office
that
did
nothing
but
prior
authors
and
most
offices
have
somebody
either
full-time
or
two
or
it
depends.
How
big
your
practice
is,
how
much
money
would
the
insurance
company
saved
by
not
having
a
full
system
that
does
all
of
this?
You
know
prior
authorization,
they're
spending
a
lot
of
money
doing
that
as
well.
I
know
there
was
one
time
where
years
ago,
united
healthcare
had
done
an
analysis
and
found
that
they
were
spending
more
money
than
they
would.
H
They
were
saving
by
denying
service
and
saying
well
we're
spending
all
this
money
up
front
just
get
rid
of
the
whole
system.
Let
providers
do
what
they
need
to
do
and
they
were
actually
saving
money.
By
doing
that,
so
I
think
it
would
be
wise
to
first
if
we
could
at
some
point
take
a
look:
how
much
do
the
mcos
spend
in
overseeing
and
then
how
much
are
they
really
saving
in
denial
of
services
and
I'll
bet
you
they
probably
are
spending
more
to
deny
than
they
are
just
letting
those
services
go
through?
H
So
I
agree
this.
This
goes
beyond
just
the
mental
health
issues
you
know
is
going
to
be
striking
right
now
and
it's
a
kind
of
a
focus
of
this
interim
by
several
committees
for
us,
but
we
really
need
to
take
a
look
at
the
entire
system.
Is
it
really
worthwhile?
Are
they
really
saving
that
kind
of
money,
or
are
they
just
denying
care?
H
Because
I
think,
ultimately,
you
could
probably
find
a
much
more
targeted
approach
in
finding
your
most
expensive
providers,
who
might
be
spending
too
much
and
targeting
them
for
oversight
than
the
entire
system?
And
we
talk
about
shortages
and
providers
in
healthcare.
I
mean,
if
you
could
spend
that
bit
of
money
on
another
provider
in
your
office,
you'd
be
able
to
provide
a
lot
more
services
for
people
out
there.
A
Thank
you
senator,
I
think,
there's
one
piece:
that's
missing
from
your
financial
equation
there
and
that's
the
investment
off
the
floor
of
those
funds
and
bear
in
mind
that
when
I
started
in
2017
this
is
a
10
million
program.
Today,
it's
14
billion,
so
there's
substantial
investment
income
to
be
realized
by
delay
payment
as
long
as
you
possibly
can,
and
it
may
well
offset
the
expense
of
denying
claims
or
holding
up
claims.
So
absolutely.
H
A
I
Thank
you,
mr
chair,
and
some
of
this
has
already
been
discussed,
but
and
the
fact
that
prior
authorizations
affect
all
health
care.
Not
just
exactly
to
me.
You
gotta
have
accountability
like
like
senator
alvarado
said
abuses
in
the
system.
It
might
be
a
small
percentage,
try
to
go
after
those,
but
so
there
needs
to
be
accountability.
I
I
like
senator
carroll's
idea
of,
but
maybe
there
needs
to
be
an
annual
review
or
something
because
just
because
you
get
certified
doesn't
mean
you
might
not
go
back
and
abuse
the
system,
but
I
like
that
kind
of
approach,
but
I
just
remember
my
husband's
saying
once
somebody's
got
a
bka,
the
limb
ain't
growing
back.
So
why
do
you
have
to
justify
that
every
single
time?
So
it's
the
same
thing
as
some
eyes
of
chronic
illness,
just
like
you
said
diabetes,
so,
but
how
do
you
get
the
the?
I
This
is
a
rhetorical
question,
but
accountability
for
the
for
the
providers
for
not
abusing
because
pas
weren't,
always
a
part
of
the
system.
It
seems
like
in
everything
we
do.
We
go
from
one
extreme
of
the
pendulum
to
the
other.
How
do
we
get
back
to
the
middle
for
balance
to
get
get
the
goals
that
you
need
so
anyway,
if
there
would
be
some
way
to
if
you
could
come
up
with
an
idea
of
how
to
hold
providers
accountable
in
a
situation?
I
F
I
I
I
wonder,
representative
parente,
because
so
many
of
our
cmhcs
are
accredited
by
outside
bodies,
either
jayco
or
carf,
and
I
they
have
periodic
reaccreditations
and
so
forth,
so
there
is
at
least
some
accountability
for
a
good
number
of
them.
Also,
I
think
some
of
you
heard
from
steve,
shannon
yesterday
at
the
smi
task
force,
that
four
of
our
cmhcs
are
going
to
be
ccbhcs,
which
are
kind
of
cmhcs
on
steroids,
with
a
whole
lot
more
ability
to
manage
patients
and
so
forth,
but
with
a
whole
lot
more
accountability
built
in.
F
So
there
are
some
external
mechanisms
in
place,
at
least
for
some
of
them,
but
I
think
that's
a
piece.
Obviously,
we've
got
to
have
that
and
it's
very
hard
to
measure
outcomes
in
behavioral
health.
You
don't
have
an
x-ray,
you
don't
have
a
blood
test.
You
know
it
just
is
harder
to
measure
those
outcomes.
E
Enough
has
been
said,
I
think
we
excuse
me.
We
all.
We
all
feel
the
same
way.
There's
a
lot
being
said,
and
I
could
talk
forever
on
this
subject,
but
I
won't.
I
just
want
you
to
know
I
yeah
as
a
provider,
you
you
watch
the
way
health
care
has
migrated
to
folks
like
the
mcos
that
that
the
provider
is
not
able
to
provide
care.
You
know
I
would
much.
I
would
much
l,
rather
the
mcos
focus
on
the
oh,
the
organization,
part
of
it.
E
There
is
so
I
am
on
board
with
what
you're
talking
about.
I
won't
talk
about
number
one.
I
I
mean
I
like
number
one.
I
think
it's
perfect,
so
I
won't
I
mean
I
won't
go
down
and
talk
about
the
rest,
so
so
no
you're,
you're
good
and
we're
we're
gonna
stick
with
that.
One
all
right.
F
F
Well,
I
I
I
will
say
because
of
your
pharmacy
background,
that
you
know
the
taking
away
the
ability
of
the
prescribers
to
prescribe
what
that
person
really
needs
is
just
wrong
and
it's
so
wrong
in
so
many
areas,
but
it's
particularly
a
problem
with
our
folks
with
severe
mental
illness,
and
I
applaud
representative
moser
and
senator
alvarado
for
trying
for
several
years
to
get
the
mat
pas
removed
for
just
that
reason.
E
I
think
it's
a
great
point.
You
know
so
much
of
what
people
are
getting
is
because
the
provider
just
doesn't
have
the.
I
wish
I
had
a
nickel
for
every
time.
I
got
a
call
saying:
what's
covered,
what's
covered,
you
know
because
they
just
don't
have
you
know
all
this
time
to
do
the
pa.
So
so
it's
just
it's
a
tough,
tough
situation.
So
thank
you
very
much
doc
appreciate.
A
I
would
hardly
embrace
that
first
recommendation
as
well,
but
you
won't
know
we're
not
in
session
right
now,
so
we
don't
have
authority
to
do
anything
other
than
suggest
to
medicaid
that
we
continue
this,
which
I
think
we
would
do,
but
I
would
think
the
next
point,
or
next
position
we
should
take-
is
to
have
the
cabinet
come
next
month
if
co,
chair,
elliot's
agreement,
as
well
as
the
mcos
I'd
like
to
hear
from
you
know
their
take
on
this
and
they
having
a
passive
tried
to
extend
an
olive
branch
to
me
saying
they
want
to
work
with
us.
A
You
know
this
could
be
a
good
litmus
test
for.
All
of
us
is,
what's
this
going
to
look
like
going
forward,
so
I
think
you
have
some
excellent
recommendations
there.
I
will
certainly
embrace
them.
I
know
probably
folks
from
medicaid
are
listening
in
on
this
today
and
hope
they're
paying
attention,
but
we'll
take
this
up
next
month,
coach
here.
If
you
would
agree
and
we'll
we'll
pursue
this,
but
I
understand
the
importance
of
it
and
appreciate
your
testimony.
A
Before
you
leave
coach.
F
A
B
E
B
So
I
was,
I
was
around
in
2018
house,
bill
69.
B
F
Arbitrary
and
less
changeable
from
one
mco
to
another,
and
that
was
representative
ken
fleming's
bill.
So
it
might
be
helpful
for
him
to
come
and
talk
with
you
all
about.
It
had
two
pieces,
one
was
the
central
accreditation
or
credentialing
for
providers,
but
it
also
had
this
piece
and
they
were
giving
it
to
the
department
of
insurance
to
come
up
with
that
medical
necessity,
and
you
get
into
the
mcos
saying.
A
F
F
A
You
dr
appreciate
your
testimony
today
and
we
will
get
maybe
part
of
an
answer
here
today,
or
at
least
some
additional
information,
because
we
do
have
veronica
judy
cecil
deputy
commissioner
for
medicaid
to
testify,
as
well
as
leslie
hoffman.
So
if
you
folks
are
are
here,
are
we
doing
this
remotely?
A
You
folks
are
remotely
if
you
would
identify
yourself
for
the
record
and
please
proceed.
K
Thank
you
and
I
think,
we're
waiting.
Our
understanding
is
that
I
guess
somebody's
going
to
put
up
the
powerpoint
slide
for
us.
A
K
So
leslie,
are
you
going
to
share
yours?
Yes,
I'll,
get
it
okay,
while
she
does
that
just
just
a
few
things
to
kind
of
set
the
stage
for
our
presentation,
we
were
asked
to
bring
some
very
specific
information
and
data,
and
so
that's
what
we
have
in
our
presentation.
K
You
know
we
also
want
to
ensure
our
members
are
getting
the
services
they
need,
and-
and
that's
if
you
know,
commissioner
lee-
that
is
her
number
one
priority
and
the
other
thing
she
wants
to
do
is
make
sure
that
we're
making
policies
decisions
that
are
data
informed.
We
really
want
to
look
at
our
data
and
try
to
determine,
or
you
know,
are
we
seeing
the
outcomes
that
we
should
expect?
K
Are
we
properly
measuring
those
those
the
services
that
are
being
delivered,
so
we
can
determine
what
the
outcome
is.
A
couple
things
to
know.
Dr
schuster
mentioned
that
we're
working
on
targeted
case
management.
We
have
a
work
group
on
that
and
you
know
we
feel
like
that.
That
really
is
a
perfect
way
for
us
to
take
a
look
at
some
of
these
services.
K
Make
sure
that
providers,
the
mcos
and
the
department
all
understand
what
the
service
is?
How
should
it
be
delivered?
Is
it
being
properly
provided
it?
You
know
it
is
a
pa
required.
I
mean
those
are
the
reasons
we're
looking
directly
into
that
for
the
data
we're
presenting
today.
I
just
wanted
to
note
a
couple
of
things.
One
is
we're
presenting
data
based
on
the
date
prior
to
to
the
you
know:
the
pandemic.
K
We
had
mcos
prior
authorized
services
differently,
as,
as
you
all
have
been
discussing
so
some
some
services,
an
mco
may
one
mcm
might
probably
author
that
authorized,
but
another
mco
may
not
so
so
it's
really
difficult,
sometimes
to
get
down
to
as
this
service
was
pre-authorized
by
everybody
or
it
wasn't,
because
there
are
differences
in
what
is
prior
authorized.
K
I
also
want
to
note
we
do
put
it
in
our
managed
care
organizations.
We
dictate
what
the
medical
necessity
criteria
is.
So,
for
instance,
as
dr
schuster
mentioned
for
substance
use,
we
dictate
that
mcos
are
to
use
the
a
sam
criteria.
K
We
also
dictate
for
services
either
interqual
or
millemen,
and
if
those
don't
cover
a
behavioral
health
service,
then
we
further
dictate
the
criteria
that
the
mco
is
supposed
to
use.
So
I
wanted
to
make
sure
everybody
was
aware
of
that.
You
know
when
the
pandemic
hit,
we
quickly
moved
to
telehealth,
but
as
noted,
some
services
really
need
to
be
delivered
face-to-face,
and
so
I
think
we've
worked
definitely
over
the
last
year
and
a
half
with
the
different
provider
types
and
the
different
services
that
are
being
delivered
to
try
to
determine
what
works
best.
K
What's
appropriate.
You
know
in
the
beginning,
for
behavioral
health,
some
of
the
service
couldn't
be
delivered
through
telehealth,
but
professional
standards
changed
and
allowed
for
some
of
those
services
to
be
delivered.
So
we
were
we're
very
much
eager
to
cover
those
services
to
get
to
ensure
that
our
members
are
getting
the
services
they
need.
D
This
is
a
list
of
our
behavioral
health
medicaid
covered
services
as
veronica
and
dr
schuster
have
mentioned.
Most
behavioral
health
services
required
a
prior
authorization
before
the
public
health
emergency,
but
all
have
been
removed
during
the
public
health
emergency
and
continue
to
be
removed.
Today,.
A
D
D
Okay,
okay,
so
this
is
slide
three
and
this
is
the
utilization
of
behavioral
health
services
with
prior
authorization.
Just
like
veronica
said
we.
We
ran
this
report
april,
the
1st
of
2019
to
march
the
31st
of
2020,
and
I
want
because
I
wanted
to
make
it
very
comparable
for
you,
I'm
as
you're
aware
we
do
have
some
delays
in
our
payment
claims
and
reporting
as
you'll
see
here,
the
members
are
one
million
six
hundred
and
thirty
eight.
D
Ninety
one
claims
four
million
two
hundred
twenty
seven
six,
five
one
and
the
total
cost
is
541
million,
six
628,
five,
sorry
257..
D
So
the
slide
just
right
below
it
says
the
utilization
behavioral
services
without
prior
authorization,
and
that
would
be
the
following
year
up
to
march
the
31st-
and
that's
not
today,
that's
up
to
march
the
31st,
because
I
wanted
to
give
the
best
comparison.
I
could
you'll
see
that
the
members
are
1
million
559
336
claims
are
4
million,
642
745
and
the
total
cost
is
591,
764
893
and
then
on
the
next
slide.
That
shows
the
differences,
so
our
member
count
actually
went
down,
but
those
receiving
services.
D
The
claims
went
up
with
the
total
cost,
of
course,
going
up.
One
thing
I
would
like
to
mention
is
that
when
the
the
public
health
emergency
first
occurred,
there
was
a
delay
we
saw
in
providers
billing
for
about
six
to
eight
weeks,
and
we
are,
I
believe
that
that
was
probably
where
the
providers
were
trying
to.
This
is
how
I
operate
today
and
now
I've
got
to
learn
how
to
operate
in
another
way
and
what
does
virtual
look
like?
What
is
my
capacity?
D
What
staff
do
I
have?
What
platforms?
Who
can
do
this
from
home?
You
know
those
kind
of
things,
so
we
did
see
a
lag
for
about
six
or
eight
weeks
and
then
that
started
picking
up
so
with
that
said,
I
think
this
is
one
of
those
reports.
This
information
is
one
of
those
reports
that,
as
we
keep
running
it,
it
will
become
more
accurate
and
again
I
was
only
able
to
pick
up
to
about
march
the
31st
for
this
year
next
clock
next
slide.
D
We
added
this
in
senator
meredith.
I
thought
you
might
be
interested
in
this.
This
was
the
behavior
of
expenditures
by
provider
type
with
and
without
pa.
So
this
is
a
percentage
of
change,
and
so
the
percentage
of
a
change
is
the
relationship
between
the
original
amount
and
the
amount.
Now,
so
we
call
that
a
percentage
of
change,
it's
it's
a
formula
that
we
complete
so
as
you
can
see
like
the
community
mental
health
centers
that
dr
schuster
spoke
about
was
a
negative
13.5.
D
I
did
list
on
this
page
and
the
next
page,
a
variety
of
ones
that
I
thought
you
would
be
interested
in,
but
I
did
not
list
them
all,
because
there's
probably
about
50
on
the
report
that
I
ran.
So
if
there's
something
specific
you're
looking
for,
you
can
proceed
to
the
next
slide.
Please
that's
just
the
second
page.
So
one
of
the
things
that
I've
mentioned
too
is
the
prtf
and
any
of
the
inpatient
residential
type
of
settings.
D
It
seemed
like
they
had
a
decrease
during
the
the
public
health
emergency,
any
of
those
that
were
one-on-one
or
any
of
the
licensed
services
by
practitioners
seem
like
after
they
caught
on
to
the
virtual
piece,
and
it
seemed
like
those
were
all
going
fairly
well,
so
I
think
that's
it
go
proceed
to
the
next
slide.
Please
yeah,
that's
it
so
those
that
was
just
in
a
nutshell
for
you,
based
on
the
ask
of
medicaid,
but
I'm
always
willing
to
drill
down
or
look
at
other
things.
D
A
Appreciate
that
good
information,
I
think
probably
the
the
biggest
question
hanging
out
there
is-
is
how
much
of
that
increase
is
what
I
would
call
coven
induced
that
it
certainly
has
put
stress
on
folks
that
we've
already
acknowledged-
and
it
may
be
a
two
or
three
year
period
before
we
can
really
get
a
good
handle
on
what
the
impact
of
this
could
be.
But
I
do
appreciate
the
information
representative
parente.
You
have
a
question.
I
Yes,
thank
you.
This
question
is
for
oh
gosh,
veronica.
Yes
veronica.
You
said
that
medicaid
dictates
using
the
asam
criteria.
I
K
There
absolutely
is,
and-
and
you
know
I
think,
the
difficulty
so
some
of
it
obviously
is
inconsistency
of
what
is
pre-authorized
and
what
isn't,
because
we
don't
dictate
that.
So
if,
if
a
mco
wants
to
prior
authorize
targeted
case
management,
for
example-
and
in
my
understanding
there
were
only
two
mcos
prior
to
the
pandemic-
that
prior
authorized
tcm,
but
so
they
get
to
they,
we
do
give
them
the
ability
to
make
the
decision
as
to
what
services
they
prior
authorize.
K
So
there
may
be
confusion
over
that,
and
then
there
are
two
you
know
for
especially
for
the
physical
services.
Miliman
and
interpol
are
the
primary
and-
and
I
don't
think
that's
any
different
from
in
the
commercial
world,
but
you
know
beyond
that.
Then
we
definitely
for
both
adults
and
children.
We
we
dictate
what
is
to
be
used.
So
you
know
we
we
hear
about
providers
struggling
with
understanding
what
the
criteria
is.
We
we
try
to
deep
dive
into
that,
and
part
of
that
is
monitored
through
appeals.
K
You
know
we
try
to.
We
definitely
monitor
appeals
to
see
what
are
the
you
know,
top
issues
that
are
going
on
that
helps
generate
our
inquiries
to
the
mcos,
to
make
sure
they
are
utilizing
the
appropriate
medical
necessity
and
and
then,
through
generally,
through
complaints
that
we
receive.
So
you
know
when
we
do
receive
a
complaint
from
a
provider
saying
that
the
mco
isn't
isn't
or
has
has
created
their
own
criteria.
You
know
we
go
back
and
make
sure
that
the
mco
is
is
doing
it
appropriately.
I
So
maybe
you
just
answered
the
question,
maybe
that
maybe
you
all
need
to
I
mean
I'm
just
thinking
out
loud,
but
maybe
y'all
need
to
determine
whether
they
are
allowed
to
pre-authorize
or
not
so
they're
all
playing
the
same
game
by
the
same
rules
I
mean
that's,
what's
so
bad
for
everybody,
but
that's
just
right.
That's
just
a
thought
and
just
another,
a
follow-up
comment.
I
know
dr
schuster
said
that
stabilization
is
the
goal
for
for
the
mental
health
and
it
was
a
decrease
of
521
percent
over
that
year.
A
Thank
you,
senator
carroll,
danny
carroll.
You
have
a
question.
C
Thank
you,
mr
chairman,
commissioner,
getting
not
really
so
much
on
the
mental
health
field,
but
with
epsdt
in
dealing
with
pas.
We've
had
this
conversation
before
and
I
think
I've
brought
it
up
pretty
much.
Every
year
I've
been
in
the
legislature,
epsdt
services,
therapies,
ppec,
are
are
my
understanding
and
I've
had
a
former
commissioner
actually
stat
this
in
committee
that
the
mcos
do
not
have
the
ability
to
deny
these
services
with
with
the
ppex.
There
is
a
leveling
tool
that
comes
from
the
cabinet
that
is
completed.
C
All
of
these
services
are
provided
upon
prescription
from
a
physician,
but
yet
year
after
year
the
mcos
continue
to
deny
these
services
based
on
medical
necessity
and
nothing
changes
with
that.
Can
you
comment
on
that
and
why
is
that
still
happening?
C
And
it
you
know
it's
it's
just
another
one
of
those
things
that
just
takes
more
time
to
to
get
the
process
through
to
be
able
to
serve
all
the
children
that
need
to
be
served
and,
and
the
mcos
use
these
use
this
as
a
a
way
to
to
avoid
payment
and
therefore
the
whole
purpose
of
etsdt
to
give
the
children
what
they
need,
as
recommended
or
as
prescribed
by
the
physician,
who
knows
the
children
and
knows
the
issues
that
have
and
know
what
their
needs
are.
K
As
you
pointed
out,
epsdt
services
do
have
to
be
prior
authorized
because
there
has
to
be
a
determination
of
medical
necessity
in
order
to
comply
with
the
federal
requirements.
So
it
you
know
all
of
those
services
have
to
be
prior
authorized
with
denials.
You
know
there
should
never
be
blanket
denials
and,
if
that's
happening
again,
we
would
see
that
in
the
data.
K
I
would
hope
we
would
see
that
in
the
data
that
reflects
that,
so
that
we
can
then
check
in
to
see
what's
going
on
with
with
that,
and
we
we
always
look
for
examples.
I
mean,
I
think,
the
the
most
difficult
thing
that
happens
is
that
we
hear
there
are
problems,
but
we
can't
see
it
in
the
data
and
we
can't
we
can't.
We
can't
hold
the
mco
accountable
unless
we
have
examples
of
what's
going
on.
K
We
just
can't
do
it
anecdotally,
so
we're
always-
and
I
know
providers
get
tired
of
us
doing
it,
but
we're
always
asking
for
exam
specific
examples.
So
we
can
go
back
and
trace
it
through
the
process,
trace
it
through
the
system
and
and
try
to
determine
what
is
going
on,
because
that's
the
only
way
we
can
hold
them
accountable,
but
it
I
agree
with
you.
E
K
I
I
think
reoccurring
denials
or
blanket
denials
are
not
appropriate.
It
should
be
based
on
the
individual
and
that
individual's
need.
It's
about
the
member
and
the
services
that
they
need
and
that's
what
we
always
strive
to
do.
K
But
that's
why
we
have
an
appeal
process
and
that's
why
you
all
passed
an
external
third
party
review
opportunity
for
providers
to
to
be
able
to
push
back
on
on
those
denials.
C
Okay,
that
that
has
not
been
my
understanding
at
all
of
the
way
epsdt
works
that
it
that
they
did
not
have
that
ability
and-
and
former
medicaid
commissioner
said
that
an
open
committee
back
a
couple
years
ago.
So
that's
that's
a
little
confusing
and
that's
just
not
not
the
way.
C
I
understand
it
at
all
and
it's
not
it
really
so
much
with
so
much
blanket
denials
from
what
I'm
getting
what
what
what
we
deal
with
and
what
other
providers
do
with
it's
just
in
the
numbers
of
therapies
that
that
they
feel
are
needed
and
again
these
are
doctors
that
have
nothing
but
notes
in
front
of
them
that
don't
see
the
children.
So
that's
that's
a
little
concerning
in
itself
and
not
the
way
I
understand
epsdt,
but
thank
you
for
your
input.
A
Thank
you,
senator
carroll.
I
have
a
question
from
a
couple
more,
but
let
me
post
one
to
you.
You
know,
given
the
testimony
you've
heard
today
and
given
the
fact
that
we're
seeing
an
uptick
in
the
covid
virus
due
to
the
delta
ovarian,
have
you
all
had
any
discussions
about
continuing
this
through
the
balance
of
the
calendar
year.
K
So
I
did
want
to
mention
if
you're
we're
not
aware,
but
the
health
and
human
services
secretary
did
extend
the
public
health
emergency
they
can.
He
can
only
do
it
for
90
days
at
a
time,
but
but
we're
happy
to
hear
that
it
has
been
extended,
because
it
does
give
us
a
lot
of
flexibility
during
this
time,
and
we
did
I
wanted
to
explain
about
during
covid
and
what
we've
been
doing
with
prior
authorizations.
K
We
do
not
want
to
create
barriers
to
care
so
with
behavioral
health.
We
continue
to
evaluate
it,
and
you
know:
we've
determined
that
we're
not
ready
to
put
a
pa
back
on
yet
and
during
this
emergency,
knowing
the
behavioral
health
impact
of
covid,
you
know
I
I
can't
say
we're
going
to
do
it
through
the
end
of
the
year,
but
we're
going
to
continue
to
evaluate
it
and-
and
we
understand
the
door
that
has
been
open
for
folks
to
get
the
services
they
need
as
a
result
of
it.
A
Well,
certainly,
the
reason
this
was
a
gen
item
today
was
talk
specifically
about
the
pas
and
we've
kind
of
gone
beyond
that,
and
there
certainly
are
some
issues
that
need
to
be
discussed
further,
but
even
with
the
extension
for
another
90
days,
I
would
recommend
the
committee
that
we
invite
the
mcos
here
to
talk
about
this
and
try
to
get
all
these
issues
on
the
table,
but
I'm
very
pleased
to
hear
we've
got
additional
90
days,
but
senator
alvarado.
You
have
a
comment
question
just.
H
Question
real
quickly
do
do
the
mcos
report,
commissioner.
Do
they
report
to
you
all
their
their
denial
rates?
I
mean
because
I'm
looking
at
you've
got
what
400
about
a
10
increase
in
claims,
50
million
dollars
more
in
costs
less
members.
Do
they
report
to
you
every
year
what
their
denial
rates
are
on
these
services.
H
K
H
That'd
be
worthwhile
to
know,
because
we'd
probably
get
back
kind
of
back
into
that
date
off
of
these
numbers
from
the
year
to
year
comparison.
The
other
thing
is
also
the
extra
50
million
dollars
of
cost,
for
this
did
that
come
out
of
what
the
mcos
have
allocated.
Did
the
cabinet
pump,
50
million
or
more
from
from
federal
funds
where
that
extra?
Where
do
we?
How
do
we
absorb
these
costs
for
the
increase
in
the
past
year?.
K
Well,
that's
the
beauty
of
the
capitation
payment,
so
we
pay
a
capitation
to
the
mcos
and
they're.
You
know
required
to
spend
90
percent
of
what
they
receive
on
health
care
services.
So
they
are,
they
are
held
to
90
medical
loss
ratio.
Our
actuary
does
evaluate
you
know
if
we
would
see
a
significant
increase.
You
know
based
on
covid
or
we've
added
a
service.
K
Then
our
actuary
we'll
take
that
back
and
look
to
see
if
there's
a
need
for
any
changes
or
an
amendment
to
the
rate.
We've
not
seen
a
need
for
that
yet,
but
we
are
always
evaluating
it.
So.
H
That's
very
important
so
so
this
50
million
comes
out
of
the
captivated
amount.
The
mcos
have
received
I'll
be
curious
to
see
what
their
medical
loss
ratios
look
like
this
year,
if
they're
at
percent,
which
many
of
them
often
put
that
out
first
and
then
do
the
rest
back
ended
in
if
they're
able
to
meet
their
same
losses
or
if
they're
going
to
be
operating
at
a
negative
amount.
If
they're
not,
that
would
give
a
pretty
good
argument
to
continue
what
we've
been
doing
and
seeing,
and
is
it
really
producing?
H
You
know
the
kind
of
losses
that
they're
going
to
claim,
because
often
when
we
have
these
kinds
of
discussions,
the
claims
from
the
mcos
are
well:
hey,
listen!
You
know
we
have
to
provide
services
within
this
amount
of
money
and
we
can't
do
it
if
we've
added
50
million
in
the
past
year
and
their
medical
loss
ratios,
don't
look
any
different
or,
if
they're
still
profitable
at
large
amounts
and
able
to
maintain
it
without
the
prior
roths.
That
makes
a
pretty
strong
argument
to
get
rid
of
this
process
altogether.
H
So
I'd
be
curious
to
see
what
those
are
the
denial
rates,
because,
if
they're
spending
a
lot
of
money
denying
these
things
and
really
not
going
to
affect
their
profits
at
all
and
still
be
able
to
provide
the
care
and
provide
more
care
for
folks
and
less
hassle
to
our
providers,
that's
a
win-win
for
everybody.
H
So
I
I,
if
you
have
the
denial
rates,
that'd
be
good
information
for
us
to
have,
and
if
this
this
was
absorbed
by
the
mcos
to
see
how
their
profits
look
like
this
next
year
will
be
interesting
to
see.
Thank
you.
A
Thank
you
senator
last
question
on
this
subject:
representative
wilner.
B
Yep,
thank
you
very
much,
mr
chairman.
I'm
given
the
testimony
we
heard
earlier,
I'm
trying
to
sort
of
wrap
my
brain
around
mcos
setting
what
seemed
like
arbitrary
limits
like
no
one
should
get
more
than
12
months
of
targeted
case
management,
and
so,
where
that's
you
know
not
part
of
the
medical
necessity
criteria,
and
so
I'm
just
wondering
who
is
putting
those
restrictions
in
place.
K
So
you
correct,
all
services
should
be
based
on
the
individual's
need
there
should
there
should
not
be
arbitrary
limits.
What
might
happen
is
that
an
mco
may
authorize
a
certain
period
or
a
certain
amount
of
services
and
would
like
the
provider
to
come
back
and,
and
so
they
can
do
a
check
to
see
what's
going
on.
Is
there
something
else
we
need
to
do?
Are
they
at
the
appropriate
level
so
that
that
conversation
can
happen?
K
We
we
do
tell
mcos
that
you
cannot
just
set
an
arbitrary
limit,
so
if
they,
if
they
hit
12
and
say
no-
and
we
have
no
limits
in
our
in
our
state
plan-
then
that's
not
appropriate
and-
and
we
do
have
those
conversations
with
them.
Sometimes
when
we're
when
we
can
see
that
happening
and
again,
a
lot
of
that's
based
on
provider,
complaints
and
making
us
aware
of
it.
K
It's
to
appeal:
it's
it's
to
afford
yourself
of
the
appeal
process,
they're
both
on
the
member
and
the
provider
side
and
again
we
closely
monitor
that
we,
we
are
always
looking
at
how
many
appeals
are
coming
through.
What
are
the
top
reasons
and
we
go
to
the
mcos
and
we
have
those
conversations
with
them
about
what's
going
on
to
see
is:
is
there
something
systemic
happen
happening
with
that.
A
K
A
A
That
discussion
with
them
when
they
appear
before
our
committee
as
well,
I
think
there's
a
lot
of
questions
that
need
to
be
answered
and
as
we're
ending
or
into
this
rfp
situation
with
the
mcos.
I
think
now
say
ample
time
to
do
it
so
appreciate
everyone's
questions
appreciate
the
testimony
today
and
your
time,
and
we
look
forward
to
continuing
discussions
on
this,
but
thank
you
for
your
time
appreciate
the
information
moving
right
along
next
item
is
the
kentucky
trauma
network
and
mr
bartlett.
This
is
here
along
with
excuse
me,
dr
kosich,.
A
A
G
I
thought
the
light
was
on
sorry.
I
work
for
the
kentucky
hospital
association,
I'm
the
trauma
coordinator,
we're
on
contract
with
the
cabinet
for
health
and
family
services
to
provide
assistance
and
support
for
the
trauma
program,
and
I
made
the
present
presentation
on
the
seventh,
but
that
was
more
on
the
trauma
fund.
This
presentation
will
be
driven
around
the
data
and
its
impact
on
the
trauma
system
and
and
the
medicaid
system,
and
dr
kasich
is
prepared
to
deal
with
that.
She's
representing
kiprik.
A
Glad
to
have
you
both
here
today,
I
I
asked
this
to
be
an
agenda
item
in
the
report
that
mr
bartlett
gave
a
couple
of
weeks
ago.
Last
week.
Maybe
time
flies
you're
having
fun
was
to
our
budget
review
for
human
services,
and
most
of
you
know
that
we
passed
this
legislation
back
in
2008.
His
number
has
been
funded.
So
while
we
have
a
trauma
network,
we
really
don't
have
a
trauma
network
and
I
think
there's
some
real
implications,
negative
implications
for
us,
because
that
doesn't
happen
particularly
for
the
medicaid
program.
L
L
Right
and
I
teach
at
uk-
and
I
want
to
acknowledge
our
epidemiologist
laura
daniels,
who
prepared
some
of
the
data
in
this
presentation,
so
I'm
going
to
as
succinctly
as
possible
recap
dick's
presentation
from
the
7th
of
july
for
those
who
haven't
had
a
chance
to
look
at
it
and
look
at
some
trauma
system
data
and
its
impact
on
medicaid,
as
well
as
medicaid's
impact
on
the
trauma
system.
L
L
L
The
trauma
system
has
never
really
been
funded
by
the
state.
We
did
have
some
money
thanks
to
commissioner
mayfield
several
years
ago,
from
unencumbered
federal
pass-through
funds
and
the
national
highway
traffic
safety
administration
provides
us
with
one
year
at
a
time
funding
to
support
the
state
trauma
registry.
L
So
you
know
that
trauma
centers
have
to
go
through
what
we
call
a
verification
process
and
there's
lots
of
literature
on
state
trauma
systems
in
their
contribution
to
outcomes
from
serious
injury
once
again
trauma
for
these
purposes
is
a
life
or
limb,
threatening
injury
that
you
have
to
deal
with.
People
talk
about
the
golden
hour,
ideally
for
these
serious
injuries,
individuals
would
reach
definitive
care
within
60
minutes.
That
is
not,
unfortunately,
always
the
case.
L
So
the
trauma
system
pair
max-
that's
I
could
talk
about
this
all
day,
but
I
won't
you
can
see
that
a
slight
majority
of
the
trauma
system
pair
mix
comes
from
various
government
funders,
including
medicaid
38,
is
from
commercial
insurance
and
6
is
what
we
euphemistically
refer
to
as
self-pay,
which
typically
results
in
very
little
of
any
funding.
It's
important
to
note
that
before
medicaid
expansion,
that
category
was
often
as
high
as
40
percent
of
the
trauma
payer
mix.
L
They
I've
got
these
slides
backwards
again.
So
I
want
to
point
to
this
very
useful
map
from
our
colleagues
at
the
kentucky
transportation
center,
which
looks
at
fatal
crashes
by
county.
This
is
a
highly
aggregated
metric,
but
this
is
the
standard
metric,
so
you
can
see
the
dark
blue,
dark
navy
areas.
Those
are
areas
with
seriously
elevated
fatalities.
L
L
So
if
you
look
at
where
hospitals
are
currently
in
the
state
trauma
system-
and
I
thank
dick
for
this
map
that
you
can
see
that
this
doesn't
quite
match
where
these
fatalities
are.
Some
of
this
has
to
do
with
the
population
in
these
areas.
I
am
pleased
to
report
that
we
do
have.
Can
you
see
precursor?
L
L
Kevin
huntington,
I
think,
you're,
probably
familiar
with
the
cincinnati
hospitals,
have
trauma
services.
Also,
a
lot
of
people
from
the
southern
tier
of
counties
do
go
to
tennessee
for
trauma
services,
so
lots
of
car
crashes
and
fatalities
in
kentucky.
Some
of
this
has
to
do
with
topography.
Frankly,
but
it's
important
to
note
that
most
the
large
majority
of
motor
vehicle
crash-related
deaths
today
are
are
seen
deaths.
They
are
at
the
scene
of
injury.
They
are
not
deaths
that
occur
once
the
person's
gotten
to
the
hospital
and,
in
fact,
once
trauma
patients
get
to
the
hospital.
L
They
are
very
likely
to
survive,
which
is
once
again
another
reason
why
having
access
to
post-acute
services
is
so
important.
We
see
a
similar
injury
pattern
over
time
in
the
military.
If
you
know
anything
about
military
injuries
that
a
lot
more
people
survive
these
days,
but
with
very
serious
injuries
trauma
care
is
very
expensive.
Part
of
this
has
to
do
with
the
types
of
patients
we're
talking
about
a
non-trauma
center
injury.
Patient
is
likely
to
be
an
older
female
patient
with
medicare
coverage.
L
Drama
systems
are
accountable
to
their
verification
authorities,
so
this
is
once
again
from
our
friends
in
arkansas.
These
are
2014
estimates.
I
have
not
attempted
to
inflate
them
or
do
anything
fancy
with
them.
This
is
just
multiplying
the
extent
to
which
costs
exceed
reimbursement
by
level
of
care.
The
dollar
numbers
are
from
the
arkansas
study.
I
think
arkansas
is
close
enough
to
what
we
do
in
kentucky.
I
mean
we're
not
talking
about
new
york
or
california
that
at
least
we
can
relate
to
it,
and
then
the
number
of
patients
are
kentucky
numbers.
L
L
The
it's
important
to
note
that
medicaid
has
supported
a
substantial
increase
in
access
to
post-acute
care
and
in
the
interest
of
time,
I'll
skip
most
of
this,
because
I
think
I
may
be
telling
you
stuff
you're
very
familiar
with.
But
if
you
look
at
the
last
bullet
point
seriously
injured
patients,
patients
with
injury,
severity
scores
above
15.
L
the
discharges
to
post-acute
care
increase
to
verging
on
half
of
these
patients
and
for
some
of
these
patients
at
the
point
of
hospital
discharge,
they're
not
actually
ready
for
much
in
the
way
of
rehab.
Yet
so
the
their
ultimate
access
to
rehab
is
probably
higher,
but
because
of
the
nature
of
trauma
registry
data,
we
don't.
We
aren't
able
to
link
patients
across
care
sites,
so
other
ways
that
trauma
systems
help
save
medicaid
and
medicaid
helps
save
trauma
systems
money
with
medicaid
expansion.
Patients
have
access
to
more
routine
outpatient
settings.
L
They
can
actually
go
to
a
clinic
or
to
a
doctor's
office
instead
of
fetching
up
at
the
emergency
department
with
the
injuries
that
do
not
require
hospital-based
care
and
by
reducing
the
proportion
of
uninsured
trauma.
Patients.
Medicaid
expansion
helps
hospitals
actually
get
paid.
Now,
arguably,
maybe
not
enough,
but
at
least
they
are
not
looking
at
a
40
percent
uninsured
rate.
I
need
to
point
out
trauma
registry
data
record
encounters
of
care
and
can't
be
linked
across
care
sites
by
patients
because
they
are
de-identified
as
a
matter
of
state
law.
L
So
in
summary,
we
have
a
lot
of
traumatic
injury.
We
know
that
trauma
systems
reduce
death
and
disability
from
traumatic
injuries,
medicaid
can
benefit
trauma
systems
and,
conversely,
trauma
systems
benefit
from
medicaid
expansion.
I
should
point
out-
and
this
is
a
subject
possibly
for
future
discussion.
Many
states
have
developed
sustainable
state
funding
models
for
their
trauma
systems.
If
you
want
to
know
about
that
once
again,
this
is
a
somewhat
different
topic,
but
I'm
happy
to
discuss
them.
Pharma
systems
need
oversight,
they
need
administrative
support.
L
They
need
people
like
dick
bartlett
here
who,
with
the
best
will
in
the
world,
is
not
going
to
be
available
to
do
this
forever.
It's
expensive
for
hospitals
to
participate
in
trauma
systems.
We
are
deeply
grateful
that
they
do,
but
we
only
have
27
reporting
to
the
state
trauma
registry
out
of
what
93
hospitals
in
the
state.
So
it's
a
distinct
minority.
L
We
have
the
potential
to
add
hospitals.
We
have
to
sometimes
sweeten
the
pot,
but
we
do
what
we
can
and
being
an
academic
person.
I
have
not
just
a
list
of
references,
but
also
a
disclaimer.
Any
mistakes
here
are
mine
alone.
This
presentation
has
been
reviewed
by
a
bunch
of
people
and
I
appreciate
all
their
input.
So
with
that,
I
am
delighted
to
answer
questions
and
I'm
sure
dick
is
as
well.
A
Thank
you.
I
appreciate
the
presentation
you've
done
exactly.
What
I
asked
mr
bartlett
to
do
is
to
tell
us
how
this
could
save
the
medicaid
program,
money
and
folks
in
this
committee.
I'm
sure
they're,
tired
of
hearing
me
say
that
you
know,
I
think
the
medicaid
program
financially
is
the
biggest
it
ever
should
be
right.
Now
it's
at
14
billion
and
there's
enough
money
there
to
take
care
of
everybody.
If
we
spend
it
the
right
way
and
by
not
having
a
trauma
network
in
place,
it
costs
there's
a
cost
associated
with
that.
A
H
Thank
you,
mr
chairman,
and
thank
you
for
the
presentation.
This
is
something
that's
been
presented
to
us
so
many
times
before
I
mean
begging
for
the
funding
to
help
fund
the
system,
two
principal
questions,
how
much
money
or
would
be
the
ask
right
now
for
the
budget.
G
This
gets
this
gets
the
presentation
we
did
on
the
7th
seventh
we've
looked
at
this.
We
did
some
strategic
planning
of
this
thing
and
it
depends
upon
how
far
we
want
to
go
in
our
strategic
planning
that
we
did
a
number
of
years
ago.
We
actually
come
up
with
a
proposal
that
gets
to
to
about
1.2
million.
G
We
didn't
think
that
that
would
be
a
reasonable
ask.
We
didn't
think
that
would
fly.
So
what
we
presented
on
the
seventh
was
a
proposal
that
looks
like
321
thousand
roughly.
That
would
support
the
trauma
registry.
The
trauma
data
analyst
some
educational
programs-
outreach
activities.
It
would
support
because
right
now,
I'm
kind
of
in
a
limbo
funding
situation
in
our
situation.
Here
it
would
support
a
trauma
coordinator
and
it
would
help
to
support
our
trauma
symposium,
our
educational
efforts
and
those
are
the
kind
of
things
we're
looking
at
now.
G
If
we
get
into
a
little
more
ambitious
program,
the
chairman's
has
an
associate
that
left
his
hospital
and
went
down
to
georgia,
which
has
a
very
innovative
super
speeder
program
and
they've
gone
to
the
point
where
they've
actually
created
additional
funding
to
provide.
Stop
the
bleed
training
in
kits
in
public
schools.
G
They
are,
they
are
providing
additional
targeted
education
to
ems.
They
are
helping
to
create
stability
in
the
trauma
system,
they're,
providing
some
reimbursement
for
that
unreimbursed
care.
So
I
think
it
depends
upon
how
far
we
want
to
go
with
it.
Like
I
said
we
tried
to
be
reasonable
about
this.
We
we're
just
trying
to
get
some
money
into
the
budget
to
provide
some
stability
for
a
program
without
any
money.
As
I
said
in
the
last
program,
you
know
I'm
74,
I'm
not
going
to
do
this
forever,
but
I
am
all
you've
got
trish.
G
G
But
if
I
decide
to
step
aside
or
god
forbid-
I
get
hit
by
a
car
on
the
way
home.
There
is
nobody.
We
need
to
provide
stability
for
this
trauma
system,
to
help
it
and
to
continue
it
and
to
grow
it,
and
I
would
love
to
take
the
approach
that
georgia
has
done.
I
think
it's
been
very
innovative.
It's
been
very
helpful.
H
And
every
time
that
goes
into
the
fund,
the
second
thing,
if
you
can
go
back
to
your
fatal
crash
rate,
I
just
found
it
just
remarkable
if
you
want
to
pull
up
that
map
with
all
the
counties,
the
turquoise-
and
this
is
by
where
the
accidents
occurred,
or
is
it
where
the
people
reside
that
were
involved
in
the
accidents?
H
H
So
I
find
it
so
interesting
because
I
think
I
see
the
two
lines
I
see
where
interstate
75
comes
straight
down
and
that
those
are
the
least,
and
that
would
be
contrary
to.
I
would
think
I
would
think
intuitively
would
have
where
the
interstates
run.
You'd
have
more
accidents,
but
interstate
75
runs
straight
down
that
very
light
turquoise
and
64
almost
entirely
across
there,
with
the
exception,
maybe
of
clark,
county
and
montgomery.
H
The
same
thing-
and
I
found
that
interesting.
So
a
lot
of
these
are
happening,
obviously
in
back
roads,
smaller
roads,
where
there's
interstates
and
probably
higher
velocities
we're
not
seeing
nearly
as
many
accidents
and
enough
of
a
small
one.
So
I
was
just
curious.
I
found
that
as
an
interesting
point
of
observation.
G
But
think
about
the
western
kentucky
area,
the
dark
area
there
is
interstate
29
heading
down
towards
from
from
paducah
and
those
areas
down.
South
you've
got
interstate
65,
you've
got
interstate
75
and
then
you've
got
the
band
across
the
center
down
in
the
south.
Center
area
is
the
parkway
that
runs
between
bowling
green
and
those
communities
across
the
southern
tier.
So
these
are
the
areas
and
I
think
it
has
to
do
quite
frankly
with
the
speed
and
then,
if
you'll
flip
to
the
next
map,
julia,
the
one
we
did
on
the
maps.
G
The
problem
that
I've
got
is
that
I'm
trying
to
develop
trauma
centers
to
help
in
some
of
those
areas
in
western
kentucky
I
had
a
couple
of
and,
and
they
they've
backed
away,
we're
going
to
do
a
trauma
development
course
down
there.
In
november,
my
regional
coalition
down
there
is
going
to
lead
that
we're
going
to
try
to
instill
some
interest
in
growth.
In
that
particular
area,
we
had
a
trauma
center
in
madison
madisonville.
G
They
chose
years
ago
to
opt
out
we'd
like
to
try
to
encourage
them
to
come
back.
Warren
county
bowling.
Green
medical
center
has
stepped
up.
They
are
interested
we're
going
to
try
to
again
fill
in
some
of
those
gaps
along
the
parkway
along
in
the
south
and
we're
going
to
try
to
fill
in
a
couple
of
those
in
the
northeast,
but
you
know
it.
This
is
a
tough.
This
is
a
tough
situation
because,
as
we
said,
this
is
not
a
money-making
proposition.
G
Now
I'll
be
very
honest
with
you.
There
are
a
couple
of
states
where
a
couple
of
systems
have
really
leveraged
the
activation
charges
and
have
charged
a
great
deal
of
money
and
so
forth.
We
don't
have
that
situation
here.
I've
got
trauma
centers
that
are
not
using
the
activation
charge,
they're
doing
it
because
it's
the
right
thing
to
do,
they're
doing
it
because
it
it
in
the
mind
of
their
public.
G
It
makes
their
facility
step
up
as
a
little
bit
better
than
the
rest
they're
doing
it,
because
it's
the
right
thing
to
do,
and
I
appreciate
that
and
so
we're
going
to
try
to
encourage
that.
As
I
said,
I've
got
three
and
probably
five
facilities
that
are
in
the
development
stage,
they're,
either
in
the
just
beginning
or
they're,
actually
submitting
data
to
julius
registry.
We
require
them
to
have
a
full
year's
worth
of
data.
G
We
want
to
make
sure
that
they're
doing
it
and
they're
doing
it
right
and
when
we
come
in
to
verify
or
or
the
college
of
surgeons
comes
in
for
the
higher
level
ones.
We
want
to
make
sure
that
what
they've
done
is
going
to
stick,
that
the
process
of
of
quality
improvement
is.
Is
there
and
it's
real
that
the
trauma
advisory
committee
that
they've
got
within
their
own
organization
is
looking
at
cases
learning
what
they
did
right
and
wrong
applying
those
lessons
and
making
the
system
better.
G
A
Senator
I'm
going
from
memory
here,
but
I
think
the
georgia
program
is
23
million
and
it's
funded
exclusively
through
their
super
speeder
program.
So
I
think
that's
a
reliable
funding
source,
but
I
concur
with
mr
bartlett's
a
position
on
this.
If
we
can
go
possibly
a
half
a
million
dollar
ass
this
time
and
kick
this
thing
off
and
work
on
legislation
for
the
funding
and
again,
I
would
hope
it
would
go
towards
the
super
speeder
initiative,
because
I
think
that
makes
sense
or.
G
Something
I
mean
some
states
do
do
other
ways
of
doing
it.
This
one
just
seems
to
be
a
process
that
wouldn't
hurt
the
average
person
I
mean
if
you're
going
to
go.
If
you're
going
to
go,
you
know
25
miles
over
in
a
residential
area.
You
deserve
it.
If
you're
going
to
go
90
in
a
in
a
70
zone
or
95
plus
which
some
of
them
are
out
there
doing,
and
it's
gotten
worse
during
the
pandemic,
then
I'm
sorry
you
deserve
it
and.
A
I'm
sure
there's
direct
correlation
between
high
speeding
and
in
trauma
cases,
and
it's
consistent,
my
philosophy.
If
you're
going
to
juggle
chainsaws,
you
know
you
should
be
paying
for
when
you
lose
your
arms,
but
that's
my
thinking,
but
I
appreciate
your
testimony
today
and
hopefully
maybe
this
will
be
the
last
time
you
have
to
do
this
before
us
and
we
can
move
this
thing
forward,
not.
A
Thank
you
folks,
appreciate
it.
Last
but
not
least,
today
is
our
medicaid
pharmacy
benefit
integrity
and
the
folks
we
have
presented
today
actually
presented
a
couple
of
years
ago,
and
I
thought
it
was
a
very
interesting
presentation
they
had,
and
this
is,
I
think,
before
we
finally
made
the
decision.
We
go
to
a
single
source,
pbm
we're
still
having
that
discussion,
but
we're
there
today.
So
the
landscapes
changed
a
little
bit.
A
We
had
some
legislation
that
we
found
last
session
that
was
going
to
address
a
portion
of
this,
so
I
thought
it
was
timely
that
they
speak
again
about
what
they're
able
to
do
to
help
us
bring
some
integrity
to
our
pbms
and
this
whole
prescription
medicine
portion
of
the
medicaid
program.
So
if
you
introduce
yourself
for
the
record
feel
free
to
proceed.
J
J
Just
want
to
start
out
by
saying
you
know
we
are
in
the
pharmacy
data
analytics
space
in
exclusively
and
and
the
commonwealth
has
set
off
on
a
very
interesting
journey
with
the
the
implementation
now
of
senate
bill
50
and
the
single
pbm
model.
Here,
it's
it's
it's
something.
We
are
not
aware
that
any
other
state
is
doing
so
we
are.
We
are
keenly
interested
in
the
outcomes
and
of
of
this
structure
and
and
want
to
explain
to
you
a
a
our
solution
or
solutions
like
ours.
J
That
can
be
really
a
compliment
to
ensure
that,
first
and
foremost,
the
the
structure
that
you
all
have
implemented
here
is
is
working
well
for
the
commonwealth
and
for
the
state
and
and
potentially
it
can
serve
as
a
as
a
model
for
other
states
as
well.
So
with
that,
I
think
I'll
turn
it
over
to
gary
to
talk
about
our
company
here,
a
little
bit.
M
M
I've
run
my
own
independent
pharmacy
and
at
the
conclusion
of
that,
I
wanted
to
basically
put
the
brain
of
a
pharmacist
into
a
piece
of
software,
and
the
scary
thing
we
got
was
part
of
my
brain
in
there,
but
we
found
it
was
inadequate,
and
so
we
started
adding
to
our
clinical
staff
and
we've
developed
a
piece
of
software.
Really
that
can
tell
you
just
about
anything
about
your
pharmacy.
M
Spend
your
drug
utilization,
your
adherence
and
compliance
to
the
regulations,
dangerous
drug
combinations
can
be
identified,
coordination
of
benefit
issues
can
be
identified,
a
whole
host
of
things,
and
I
mean
ultimately,
I
can
tell
you
know
in
most
states
you're
you're
very
concerned
with.
Is
it
competitive
price
wise?
You
know?
Are
we
getting
a
good
deal
and
I
concur
with
chris
that
we're
very
impressed
with
what
you've
done
in
this
state.
M
You've
left
responsibility
with
the
managed
care,
which
is
great
because
they
really
do
or
should
drive
drug
utilization
and
improvement
in
that
area.
It's
not
just
about
all
cost
per
unit,
it's
also
correct
utilization
of
the
medications
and-
and
I
I
do
think
that's
an
environment
where
that
can
can
be
improved.
M
You
know
when
you
look
at
really
patient
utilization
of
medications
and
correctly
utilizing
them,
though
the
most
important
individuals,
the
pharmacists
and
engaging
that
patient-
and
you
know
we
went
into
this-
we
represent
the
payer,
but
we
also
really
recognize
and
value
the
importance
of
the
pharmacy
provider,
and
we
think
that
part
of
what
you've
done
with
your
bill
is
that
you've
at
least
shown
value
to
the
pharmacy
provider.
M
But
when
we
come
in
we're
very
objective
and
we
serve
the
payer-
and
we
want
to
give
you
as
much
information
as
you
can
possibly
digest-
to
improve
your
pharmacy
benefit
plan,
both
in
terms
of
cost
patient
safety
and
then
in
your
provider,
network
and
accessibility,
and
so
our
software
can
do
just
that.
You
know
when,
in
our
experience
we
we've
had
experience
with
federal
employee
health
plans.
M
We
continue
to
show
value.
It's
not
always
about
just
cost.
You
know
the
total
cost
the
price
per
unit
on
the
medication.
Sometimes
it's
just
it's
a
very
complicated
benefit.
You
think
about
that.
There's
over
forty
thousand
drug
entities
that
potentially
could
could
be
utilized.
You
have
this
issue
of
prior
authorization
and
pharmacy,
which
is
a
huge
issue
as
well
as
in
behavioral
health.
M
But
we
think
the
best
solution
is
to
have
ongoing
monitoring
really
ongoing
auditing
of
the
performance
of
the
pbm
and
the
whole
prescription
benefit.
Then
you're
not
chasing
dollars.
That
really
are
yours
and
there's
there's
a
high
cost
to
that,
not
only
in
the
money
that
that
has
gone
out
of
your
system,
but
also
in
terms
of
the
personnel
and
those
that
you
have
to
hire
to
help.
M
You
recover
that,
and
then
you
get
into
the
world
of
sitting
in
in
meetings
for
a
year
and
a
half
with
lawyers
and
arguing
about
you
know
which
end
of
the
deal
is
correct,
so
that
can
be
prevented
and
in
our
experience
with
some
of
the
the
largest
pbms
in
the
country,
we've
gotten
to
a
point
with
them.
Once
they
realize
that
they're
going
to
be
accountable,
that
it
truly
is
going
to
be
transparent
and
that
they're
going
to
have
to
rectify
errors
going
forward,
we
actually
see
them
over
performing.
M
If
you
can
believe
that
that's
a
hard,
it's
a
hard
thing
to
believe,
I'm
with
a
pbm,
but
we
actually
see
some
of
the
big
three
overperforming.
So
we
think
putting
in
monitoring
on
an
ongoing
basis
can
really
improve
your
program.
Save
you
money.
Yes,
we
always
find
money.
We
have
a
federal
employee
health
plan
that
I'm
just
amazing,
we've
been
with
them
for
seven
years
and
we
just
continually
find
these
issues
and
it's
just
because
it's
complicated
the
pbm
is
actually
perform
over-performing
on
their
contract.
M
But
there's
always
these
issues,
there's
changes.
You
know
patients
come
in
and
out
of
the
program.
Eligibility
is
a
is
a
concern,
so
you
know
I
could.
I
could
list
a
whole
litany
of
of
issues
that
have
to
be
monitored.
M
We
are
a
force
multiplier.
You
know
just
like
special
forces.
We
bring
a
whole
team
of
of
clinical
experts
and
data
analytics
experts,
and
I
t
experts
that
can
enable
your
your
medicaid
department
to
really
see
what's
important.
They
can't
look
at
it
all,
but
you
certainly
don't
want
to
go
to
the
pbm
and
accept
their
quarterly
report.
As
your
report
card,
it's
always
done
from
their
perspective,
so.
J
Thank
you
and
and
just
quickly,
so
our
solution
is
a
it's
a
software
as
a
service
solution
with
the
with
the
pharmacy
bench
pharmacist.
But
what
it
does
is
it
takes
when
the
pbm
submits
to
the
payer.
In
this
case
the
department
of
medicaid,
it's
invoice.
They
also
submit
a
claims
file.
J
It's
been
up
for
21
days
with
a
new
pbm,
very
promising
model,
but
it
would
be
a
shame
to
wait
for
a
full
year
to
see
and
and
then
conduct
it
on
to
see
what
could
have
been
improved
all
along
the
way
and
our
solution
fits
neatly
in
the
current
pa
current
time
frames
for
everyone,
the
pharmacies
still
will
have
the
exact
same
experience
at
the
at
the
pharmacy.
The
patients
will
still
get
their
drugs.
J
E
He's
reading
minds
again
appreciate
the
presentation
just
couple
real,
quick
questions.
If
you
had,
I
think
we
have
the
commissioner
online,
maybe
here
at
the
sea
deputy
commissioner,
so
would
would
should
she
have
any
reservation
or
should
she
have
any
concern
about
you
guys
I
mean
what
would
your
what's
your
have
you
talked
with
her,
I
mean,
what's
your
play
to
her,
I
mean
what
you
know,
how
are
you
going
to
convince
her
that
this
is
a
good
idea
for
her.
E
M
And
you
know,
and-
and
she
gave
us
a
good
report
in
terms
of
her
experience
with
the
med
impact
and
your
current,
your
new
pbm-
and
I
can
tell
you
from
my
experience-
and
I
shared
that
with
her-
that
their
portal
and
their
reporting
is
superior
to
most
others.
But
here's.
The
issue
is:
there's
too
many
claims
to
look
at
and
it's
their
data,
and
so
you
wouldn't
do
an
audit
and
ask
a
company
to
audit
themselves,
and
so,
from
our
perspective
again,
as
I
said,
we're
a
force
multiplier.
M
M
E
And
just
have
you
have
you
decided,
I
know
us
going
to
a
single
pbm
has
probably
made
things
a
little
bit
simpler.
I
would
think
to
even
though
it's
probably
I'm
sure
it's
the
same
number
of
claims,
but
coming
from
one
person.
So
I
can
see
how
this
model
would
be,
maybe
helpful
to
you
guys
and
us
too,
to
show
the
rest
of
the
country
what
what
we
could
do,
but
I,
how
do
you
get
paid,
how
you
get
paid?
Let's
talk,
how's
that
work.
M
Well,
we
get
typically
we're
paid
a
per
member
per
month
basis,
and
you
know
we'd
have
to
look
at
that
with
you
and
talk
about
it.
Some
customers
do
it
per
claim
it
really.
In
the
end,
it
washes
out
to
be
about
the
same.
M
M
M
C
I
do
mr
chairman,
and
he
may
have
just
addressed
it
somewhat.
So
as
far
as
is
there
any
value
at
all
to
doing
just
spot
checks,
random
checks
of
different
batches?
C
Do
you
all
ever
do
that
in
an
effort
to
cut
down
on
cost,
when
a
an
agency
doesn't
have
the
the
financial
ability
to
to
do
full
audits,
but
but
is
there
any
value
to
that?
Do
you
all
have
statistics
that
that
show
how
effective
that
might
be.
M
We
don't
have
statistics
to
support
that.
I
would
tell
you
that
it's
much
more
difficult
and
again
one
of
the
advantages
of
our
system
is
it
changes
the
leverage.
M
So
it
used
to
be
the
pbm
contracted
with
the
manufacturers
they
contracted
with
the
pharmacy
network.
They
contracted
with
the
payer
and
they
did
everything
they
could
to
keep
them
separated,
and
so
nobody
had
any
leverage
and
so
in
this
you're
actually
evaluating
each
and
every
claim
each
billing
cycle
identifying
the
mistakes
and
holding
them
accountable
for
what
needs
to
be
corrected
and
suddenly
the
shoes
on
the
other
foot.
You
have
leverage,
you
know,
there's
lots
of
companies
out
there
that'll.
J
And
and
one
other
thing
to
say
in
in
many
audits
and
almost
all
audits,
and
certainly
the
audits
in
this
space.
The
reason
for
this
sampling
and
the
and
the
just
quick
dive
into
a
small
sample
set
has
been
because
of
the
cost,
because
it
was
a
very
manual
process
right.
It
was
pulling
that
information
and
and
having
individuals
go
through
it.
As
gary
said,
we've
created
a
software
solution
that
does
that.
That
runs
more
than
a
hundred
different
algorithms
against
every
single
claim
that
is
analyzed
and
that
and
and
the
software
actually
can
consume.
J
All
of
that
and
then
just
point
the
clinical
pharmacists
to
where
the
red
flags
are
where,
where
are
the
things
that
have
kicked
out,
so
it
does
the
complete
analysis
and,
and
and
much
of
it
is
fine
right-
I
mean
much
of
any
particular
invoice-
is
fine
and
so
we're
the
the
software
can
help
identify.
Okay,
where
are
all
of
the
ones
that
are
not,
and
that
way
in
any
sampling.
J
You
could
miss
a
number
you
could
miss
most
of
of
what
was
a
problem,
and-
and
this
software
is,
is
what
is
so
powerful
and
now
in
2021
to
be
able
to
allow
you
to
re-educate.
Every
single
claim
that
has
come
through
rather
than
you
know,
spot
checking
a
a
smaller
subset.
M
I
tell
you
something
that
I
would
rather
do.
Is
I'd
rather
make
you
a
beta
test
site
for
a
great
idea,
because
you
are
the
first
and
for
us
it's
it's
worth
it
for
me
to
discount
your
price
beyond
what
we
give
ohio
or
some
of
the
other,
the
other
states,
your
model,
I
believe
in.
I
really
do
so
I'd
like
to
see
it
succeed.
C
H
Chairman
I
had
a
couple
of
independent
pharmacists
in
my
district
who
wanted
me
to
ask
you
a
specific
question,
and
I
know
that
when
we
ran
this
bill,
this
concept
during
the
last
session,
a
lot
of
the
independent
pharmacists
were
worried,
saying:
hey,
we've
got
a
new
pbm,
let
them
get
their
feet,
wet,
let
them
kind
of
get
established
and
then
let's
determine
things.
But
this
is
their
question
and
I'm
not
sure
if
you
can
answer
it,
but
they
said
you
know
they
wanted
to
know
if
you
had.
H
If
you
had
spoken
to
med
impact
about
the
work
that
you
want
to
do
in
kentucky
and
whether
or
not
that
impact
had
any
kind
of
opinion
about
that
kind
of
work,
I
know
you're
kind
of
an
auditing
firm,
so
I'm
not
sure
that
you're
able
to
do
that,
but
they
wanted
me
to
pose
that
question
for
you.
So
I
was
wondering
if
you
could
answer
that.
J
Big
problems
for
the
pbm,
let's
say:
there's
significant
overcharging
and
that's
a
big
dollar
amount,
and
it's
it's
hard
to
pay
that
back.
Of
course,
that's
problematic
for
the
system,
so
we
would
certainly
be
willing
to
to
speak
with
that
impact
to
understand
to
help
them
understand
what
we
do
and
that
we
are.
We
are
not
coming
in
trying
to
villainize
them.
J
Certainly
I
mean
they
they're
they're
brand
new
and
on
the
ground
and
and
we're
hoping
they
can
be
very
successful,
but
but
that
we're
here
to
help
analyze
the
data
along
the
way
to
catch
small
problems
when
they're
small
fix
them
before
they
become
big.
No.
H
Problem,
they
just
said
that
they
thought
that
the
pharmacy
community,
at
least
portions
of
it,
might
feel
more
comfortable
if
they,
if
they
indicated
that
they
wouldn't
be
inhibited
by
the
by
your
guys's
work,
so
it
might
be
worth
considering,
but
that
was
something
they
had
requested.
I
asked
today,
so
I
appreciate
you
all
being
here
and
presenting
your
information.
Thank
you.
I.
M
I
I
think
senator
alvaro
just
asked
it,
but
similarly
similarly-
and
I
think
you've
already
answered
it-
would
this
add
another
level
of
bureaucracy,
another
layer
of
bureaucracy.
Are
you
trying
to
minimize?
I
J
In
my
opinion,
absolutely
not
so
I
I
have
a
long
history
before
this
company.
I
was
actually
a
state
procurement
guy,
so
I'm
one
of
those
people
nobody
likes,
but
but
one
of
the
hallmarks
of
any
system
is
when
you
get
an
invoice,
you
look
at
the
invoice
and
you
have
somebody
who's
verifying
yep.
This
involves
voice,
looks
good,
let's
pay
it
the
problem.
Historically,
that's
not
kentucky's
problem.
This
is
the
problem
in
the
industry.
The
problem
is
the
invoice
may
in
a
1.6
million
dollar
medicaid
program.
J
1.6
million
live
medicaid
program.
That
invoice
may
be
tens
to
hundreds
of
thousands
of
claims
in
a
given
in
a
given
cycle.
Well,
how
is
that
individual
supposed
to
really
go
through
that
and
understand?
Is
this
fully
ready
to
pay
and
and
and
it's
certainly
no
one's
fault-
it's
it's
it.
The
the
technology
has
not
been
there
to
be
able
to
do
it.
Our
system
works
within
that
same
payment
window
that
the
that,
whatever
that
contract
says
today,
whatever
the
contract
with
the
med
impact.
J
Now,
I
guess
the
med
impact
now
has
with
each
of
the
different
mcos
right
relative
to
that
payment
cycle,
and
we
can
we
can.
The
system
can
sit
in
there
and
just
inform
that
same
project
manager
that
same
contract
manager,
who's
approved
that
invoice
better
inform
them
about.
How
good
is
this
invoice?
Where
are
the
issues?
And
where
are
the
things
we
could
question
pay
what
you
should
pay?
They
provide
an
absolutely
valuable
service,
these
drugs
are
being
dispensed
and
and
and
they
it
needs
to
be
paid
for
and
the
system
needs
to
keep
moving.
J
A
Started
on
this
journey,
a
few
years
back,
we
asked
the
department
of
medicaid
to
carve
out
prescription
drugs
and
immediately
said
no,
no,
no
we're
not
going
to
do
that.
I
understand
why
they
didn't
have
the
resources
to
monitor
the
program,
but
they
also
would
acknowledge
that
we
thought
there
was
at
least
a
half
million
dollars
in
costs
that
were
not
accounted
for
and
once
we
got
into
it,
I
think
they
realize
there's
tremendous
potential
savings
here.
A
That's
why
we've
evolved
this
single
source
pbm,
which
I
think
is
a
good
move,
and
my
interest
in
this
is
giving
the
cabinet
a
tool
to
do
exactly
what
you
folks
are
doing,
because
if
you
don't
do
it,
they
have
to
find
some
way
to
do
it
and
again,
I
don't
think
they
have
the
resource
to
do
not
a
criticism
of
them.
It's
just
they
don't
have
the
resources,
so
this
appears
to
be
real
time
online
auditing
of
this
whole
process
that
could
benefit
everyone.
A
It's
just
another
safeguard
and
I
still
think
there's
tremendous
potential
savings
in
these
dollars
that
we
haven't
seen
yet,
and
I
think
these
folks
can
potentially
do
it.
I
see
that
the
deputy
commissioner
cecil
still
on
the
line.
I
appreciate
you
hearing
this
presentation
and
would
hope
you
would
see
this
as
an
effort,
our
part,
to
help
the
department
of
medicaid,
rather
than
humble
you
folks,
in
doing
what
you
need
to
do,
but
you've
done
a
commendable
job
so
far
in
getting
the
single
source
pbm
up
and
running.
K
Further,
thank
you
senator
meredith.
Certainly
you
know
we
we
have
listened
to
them.
I
would
say
that,
as
as
they
noted
were
day
21
into
the
single
pvm
and
I
I
think
it
is
again
very
important
to
know
what's
different
with
this
model,
and
you
all
gave
it
to
us,
you
prescribed
it
into
the
statute,
which
is
full
and
absolute
transparency.
K
As
you
know,
we
implemented
the
fee
for
service
reimbursement
model,
so
it's
the
lowest
of
logic.
It's
something
we've
been
doing
in
fee
for
service
for
quite
some
time,
and
we
really
do
feel
like
we've
done
it
very
well
to
be
good
stewards
of
the
taxpayer
money,
and
so
we,
you
know
we're
constantly
evaluating
those
drug
prices
and
ensuring
that
it's
being
paid
appropriately
and
we
definitely
hear
from
providers
when
they
think
it's
not.
But
you
know
we've
got
a
monitoring
plan.
K
We
absolutely
understand
the
desire
of
the
legislature
to
understand
that
we're
holding
the
med
impact
accountable,
that
we
can
demonstrate
what
the
cost
is
and
the
savings,
and
so
we're
going
to
have
a
robust
reporting
plan
with
this,
so
that
we
can
bring
to
you
all
that
information
and
that
data
again.
We
should
be
making
decisions
based
on
data,
and
we
plan
to
have
a
lot
of
data
for
us
to
be
able
to
measure
the
success
of
this.
A
And
I
guess
that's
what
scares
me.
What
intimidates
me
a
little
bit
is
that
the
amount
of
data
that
you're
going
to
receive
that
you
haven't
received
before
and
I
think
that's
going
to
suggest
that
we'll
be
doing
that
retrospectively,
which
is
is
not
entirely
bad
but
not
entirely
good.
I
really
like
the
idea
of
being.
You
know
real
time
as
much
as
we
can
be
with
this,
and
I
think
that's
one
of
the
advantages
these
folks
can
give
us
to
that.
A
So
I
would
appreciate
you
continue
to
dialogue
with
them
and,
let's
see
if
we
could
develop
some
type
of
relationship.
K
A
E
E
Late
we
want
to
get
out
of
here.
I
don't
want
to
leave
without
the
deputy
commissioner
and
at
least
lead
the
commissioner.
They
have
done
a
great
job.
Implementing
and
medi
impact
is
now
we're
taking
ownership
of
them
right.
They
are
the
white
horses
ridden
in
and
they're
our
state
pbm.
E
So
I
don't
want
to
take
anything
away
from
those
guys
but
to
to
understand
how
important
it
is
to
audit
you
don't
have
to
go
very
far
but
themselves
pbms
audit
providers
weekly
all
over
this
state
and
take
thousands
and
thousands
of
dollars
of
what
they
consider
inappropriate
money.
So
I
I
don't
know
that
we
need
to
sit
here
and
argue
whether
you
need
it
or
not.
I
I
think
to
hold
medi-impact
accountable.
They
probably
you
know
nobody
likes
to
be
audited.
E
I
don't
like
being
audited,
but
it's
part
of
the
process
right.
So
so
you
know.
I
think
this
is
something
do
we
do.
We
have
an
auditing
firm
that
that
we
can
believe
in
maybe
maybe
not
we'll
do
an
rfp,
we'll
still
procure
it
and
we'll
figure
out
what
it
is
or
not.
But
this
does
seem
like
a
very
reasonable
approach
to
take
and
to
for
people
to
be
concerned
about
it
for
the
any
provider
that's
concerned
about
it.
We
deal
with
the
pbm
audits
all
day
every
day.
E
In
my
case
several
several
times
it
seems
like.
So
I
just
want
you
to
know
that
I
do
think
it's
a
good
idea,
but
I
do
think
you
have
to
work
together
with
medicaid
and
with
medi-impact,
because
they're
there
are
people,
you
know:
they're
they're,
good
folks
and
they're
they're
they're,
making
senate
bill
50,
look
great
and
they're
doing
a
good
job
along
with
deputy
lisa
or
deputy
commissioner
veronica
and
and
lisa
lee.
So
I
just
want
to
make
sure
I
get
that
on.