►
Description
The cost of health care in the United States has been a highly debated topic for consumers, employers, state and federal policymakers, and the media for years.
This webinar, "Surprise Billing and Pharmaceuticals: Two Health Care Cost Factors," will examine the various factors that drive health care costs and provide attendees with various policy options to address cost drivers, specifically focusing on prescription drug pricing and surprise billing. Subsequent webinars will dive deeper into these two issues.
A
Hello:
everyone,
I'm
Colleen
Becker,
a
policy
specialist
with
the
NCSL
health
program
and
on
behalf
of
the
National
Conference
of
State
Legislators
I'd,
like
to
welcome
all
of
you
to
today's
webinar
surprise,
billing
and
pharmaceuticals
to
healthcare
cost
factors,
part
one
of
a
three-part
series,
I'd
like
to
remind
participants
that
ncsl
is
a
bipartisan
membership
organization
of
all
50
state,
legislatures
and
the
territories.
Our
members
include
the
7,000
353
legislators
and
thousands
more
legislative
staff
and
CSL
advocates
for
the
interest
of
States
and
provides
policymakers
the
opportunity
to
exchange
ideas.
A
Today's
webinar
is
a
platform
for
information
exchange
and
again
engagement
over
the
next
60
minutes.
We
encourage
participation
through
our
chat
box,
so
feel
free
at
any
time
to
type
your
questions
or
respond
to
any
questions
in
the
chat
box,
which
is,
in
the
lower
left
hand
of
your
screen,
so
to
begin
building
some
comfortability
with
the
chat
function
and
to
also
learn
who
is
on
the
line
today.
I
invite
you
to
type
in
the
state
from
which
you're
calling
now.
A
And
I
want
to
briefly
mention
how
to
access
the
slide
decks
above
the
presentation.
You
will
see
a
couple
of
tabs
with
one
of
them
labelled
resources.
Here
you
can
find
and
download
a
PDF
version
of
the
powerpoints
used
today.
Another
tab
is
labeled
speaker
and
that's
where
you
can
read
the
bios
of
today's
esteemed
speakers.
You
can
access
these
tabs
at
any
time
during
the
presentation.
Also,
today's
webinar
is
being
recorded
and
will
be
available
on
NC
s
l's
website
within
the
week
and
before
I
introduce
today's
fantastic
panelists
speakers.
A
I
want
to
thank
Arnold
Ventures
for
their
support
of
today's
webinar,
so
our
first
presenter
today
is
mr.
Brooks
Lesure
managing
director
at
manna.
Health
MS
Lesure
has
more
than
15
years
of
experience
in
health
policy
as
deputy
director
for
policy
at
the
Center
for
Consumer
Information
and
insurance
oversight
within
the
Centers
for
Medicaid
and
Medicare
and
Medicaid
Services,
and
earlier
at
the
Department
of
Health
and
Human
Services.
As
director
of
coverage
policy,
she
led
the
agency's
implementation
of
ACA
coverage
and
insurance
reform
policy
provisions.
A
Her
current
work
focuses
on
helping
clients,
understand
the
implications
of
regulatory
and
legislative
policies
across
private
insurance,
Medicaid
and
Medicare.
Our
next
presenter
will
be
Assemblyman
Jim
Wood
from
California
Assemblyman.
Would
a
forensic
dentistry
expert
was
elected
in
2014
to
serve
the
people
in
California's,
2nd
Assembly
District,
and
he
has
been
the
chair
of
the
assembly
Health
Committee
since
early
2016,
Assemblyman
woods
priorities
include
healthcare,
environmental
protection
and
economic
development,
especially
in
rural
areas.
A
And
finally,
we
will
hear
from
record
here
from
representative
David
Knight
from
Georgia
Representative
Knight
was
elected
to
the
Georgia
House
of
Representatives
in
2004
in
sworn
into
office
in
2005
tonight
proudly
served
House,
District
130
and
currently
serves
as
chairman
of
the
Appropriations
Subcommittee
on
higher
education
and
the
House
sportsmen's
caucus
representative
night
has
been
a
practicing
certified
public
accountant
for
over
20
years
and
holds
memberships
in
the
Institute
of
Certified
Public
Accountants
and
the
Georgia
Society
of
Certified
Public
Accounts
and
with
that
missile
assure
I'll.
Now
turn
it
over
to
you.
B
Thank
you
so
much
Colleen
and
thank
all
of
you
for
having
me
here
today.
It's
such
a
pleasure
to
speak
with
you
I'm,
going
to
spend
a
few
minutes
just
talking
about
some
of
the
factors
that
are
leading
States
to
consider
how
they
might
control
health
care
costs
in
their
states
and
then
give
a
brief
overview
of
some
of
the
strategies
that
states
are
employing
before
turning
it
on
to
our
next
speakers.
B
Further
consumers
are
thinking
and
concerned
about
health
care
costs,
their
affordability
of
coverage,
both
premiums
and
cost-sharing
like
deductibles,
are
a
growing
issue
across
many
forms
of
health
care
coverage,
including
employer
sponsored
insurance
and,
at
the
same
time,
that
health
care
costs
are
a
significant
portion.
They
continue
to
grow.
Hospital
and
physician
services
are
the
largest
drivers
of
health
care
costs.
B
Today,
as
you
can
see
from
the
chart
that
I
have
on
this
slide
and
Hospital
consolidation
and
other
forms
of
consolidations
have
contributed
to
these
costs
and
at
the
same
time,
some
of
these
areas
are
growing
prescription.
Drug
costs
are
a
relatively
small
percentage
10%,
but
the
but
the
growth
trend
is,
is
growing
and
they're
growing
as
a
share
of
healthcare
costs.
B
B
Seeing
states
look
at
the
rates
that
providers
are
getting
and
thinking
about
whether
they
should
have
some
type
of
rate
setting,
whether
in
the
state
employee
plan
parts
of
the
individual
marketplace
or
or
in
Medicaid
and
evaluating
provider
consolidation.
So
over
the
last
couple
of
years,
we've
seen
increasing
consolidation
of
different
systems
and
state
attorneys
general
than
most
states
have
authority
to
review
those
types
of
arrangements.
B
Consolidation
or
lack
of
competition
is
also
of
concern
for
some
policymakers
in
the
individual
market
when
adding
one
sing
insurer
in
a
County,
when
there's
only
one
insurer
tends
to
lower
the
premium
on
average
one
to
four
percent,
depending
on
depending
on
the
market
and
we'll
also
spend
some
time
both
in
this
webinar
and
I
think
future
ones.
Talking
about
protecting
consumers
from
surprised
billing
and
and
concerns
that
people
have
when
they
expect
to
pay
a
certain
amount
for
a
service
and
then
are
surprised
to
find
that
the
service
was
actually
out
of
network.
B
B
There's
been
increased
interest
in
looking
at
the
role
of
pharmacy
benefit
managers,
increased
interest
in
understanding
their
role
in
drug
pricing,
what
what
how
they
serve
and
what
part
they
have
in
in
what
the
cost
the
cost
that
people
pay
when
they
see
the
pharmacist
and
we'll
hear
more
about
one
state
strategy
in
just
a
few
minutes
to
address
the
role
of
the
PBM,
instituting
affordability
review.
So
these
boards
or
Commission
may
look
at
prescription
drug
cross
across
the
system
and
make
policy
or
spending
recommendations.
B
So,
for
example,
Massachusetts
has
been
a
state
with
a
cost
containment
Commission
for
the
last
couple
of
years.
Looking
at
healthcare
costs
across
multiple
payers
in
the
state
of
Massachusetts
and
they're,
increasingly
focused
on
different
parts
of
the
healthcare
system
and
are
now
taking
a
closer
look
at
prescription,
drug
pricing
and
we'll
be
doing
so
moving
forward.
B
Promoting
price
transparency
so
requiring
drug
manufacturers
to
provide
additional
cost
and
pricing.
Information
has
been
something
that
we're
seeing
across
the
states
and
that
could
look
looked
at
different
in
different
states.
So
in
some
states
these
are
were
seeing
more
requirements
where
their
specific
requirements
that
all
manufacturers
must
adhere
to
and
then
some
states
are
using
it
more
as
a
stick.
B
So
again,
we'll
talk
in
just
a
few
minutes
more
about
strategies
around
a
prescription,
drug
spending
I'm
going
to
turn
now
to
give
a
brief
overview
of
some
of
the
strategies
that
we're
seeing
on
surprised,
billing
and
surprise.
Billing
occurs
when
someone
who
has
coverage
so
an
insured
individual
in
a
very
inadvertently
receives
care
from
an
out-of-network
provider
and
is
charged
more
than
they
expect
to
pay.
One
of
the
I
think
easiest
examples
to
think
about.
B
Is
a
patient
scheduled
surgery,
their
surgeon,
their
doctor,
they
know,
is
in
their
network
their
Hospital,
where
they're
going
to
get
their
care,
they
know,
is
in
their
network,
but
one
of
the
services
they
receive
during
the
course
of
their
care
is
out
of
network.
So,
for
example,
the
anesthesiologist,
isn't
it
part
of
the
network
and
as
a
result,
when
the
patient
gets
the
bill
for
for
the
coverage,
they
end
up
owing
more
than
what
they
expected,
because
the
price
that
they're
seeing
is
an
out-of-network
cost.
B
And
there
are
many
examples
across
the
nation
and
many
states
are
trying
to
think
about
strategies
to
address
these
they're.
Generally
two
mechanisms
that
states
are
using
one
arbitration
where
the
state
establishes
a
process
where,
in
order
for
there
to
be
an
agreement
between
the
insurance
companies
and
the
providers
and
that's
a
strategy
that
we
see
in
the
state
of
New,
York
and
we'll
see
here
more
in
just
a
moment
on
a
second
strategy
which
is
rate
setting,
which
we
see
in
the
state
Cal
the
state
of
California.
B
So
as
you're
probably
aware,
there
is
a
lot
of
activity
at
the
federal
level
here
in
Washington,
with
Congress
very
much
focused
on
surprise
billing,
as
well
as
prescription,
but
really
focused
on
surprise
billing.
Recently,
the
Senate
Health
Committee,
the
key
Committee
in
the
Senate
passed
legislation
out
of
their
committee
to
address
the
prize
billing
and
the
house
has
a
few
committees
to
act,
but
the
Energy
and
Commerce
Committee
has
also
passed
a
surprise.
B
Billing
has
passed
surprised
billing
legislation
and
so
there's
a
lot
of
focus
on
whether
or
not
Congress
will
be
able
to
pass
legislation
by
the
end
of
this
year
or
perhaps
early
next,
and
whether
or
not
that
legislation
does
pass.
There
will
still
be
a
very
critical
role
for
States
in
trying
to
address
the
price
billing
if
they
choose
to
both
of
the
key
committee
bills
that
have
passed
out
of
Congress
defer
to
state
regulation
so
in
the
current
forms,
which
of
course
could
change
during
the
legislation
legislative
process.
B
B
If
States
choose
to
act,
another
key
area
where
States
will
still
have
important,
Authority
and
surprise
billing,
even
if
we
see
see
action
at
the
Congressional
level,
is
that
the
federal
legislation
may
not
be
comprehensive
and,
for
example,
one
area
that
a
lot
of
states
have
focused
on
are
focuses
on
ambulances
and
in
the
current
bills,
out
of
ENC
and
health.
Those.
B
Ambulances
are
not
addressed,
and
so
States
will
continue
to
have
opportunity
to
fill
in
the
gaps
that
may
be
left
by
by
whatever
federal
legislation
does
pass,
so
there
will
certainly
be
a
robust,
as
always,
a
role
for
the
states,
regardless
of
what
we
see
happen
at
the
federal
level.
Last
I'll
just
leave
you
with
a
map
of
a
number
of
the
states
that
have
passed
legislation,
whether
just
partial
protections
or
more
comprehensive
protections,
and
many
more
states
continue
to
think
about
advancing
legislation
during
their
session.
A
Thank
you,
Miss
Latour
and
as
a
reminder,
please
enter
your
questions
in
the
box
on
the
bottom
left
hand,
side
of
the
screen
and
we'll
address
it
during
the
Q&A
portion
towards
the
end
of
the
webinar,
and
next
we
will
hear
from
Assemblyman,
Jim
woods
and
Assemblyman.
Please
tell
us
a
little
bit
about
what's
going
on
in
California
related
to
surprise
billing.
A
C
First
of
all,
thank
you
very
much
for
the
opportunity
to
participate
today.
I
think
you
need
to
back
up
a
few
years
to
really,
as
we
understood
it
in
California,
when
we
were
working
on
this
particular
piece
of
legislation.
It's
something
that
had
plagued
us
in
California
for
39
years
and,
as
you
heard
earlier,
from
Brookes
masseur,
it
basically
comes
down
to
this
patients
thought
they
were
doing
the
right
thing.
C
I
thought
they
were
going
to
an
in-network
facility,
which
they
were
only
to
find
out
that
somebody
provided
a
service
that
was
not
in
the
network,
so
it
could
have
been
an
anesthesiologist
or
radiologists,
pathologists,
whoever
that
the
patient
never
met,
they
didn't
choose
and
had
no
control
over
choosing
them.
What's
interesting
as
well
as
we
as
we
looked
at
this
more,
you
might
just
say:
well,
that's
just
you
know
that
this
the
we
can
blame
the
doctors.
C
A
because
I
was
a
practicing
dentist
general
practice
for
over
almost
30
years
now
and
I
found
myself
a
part
of
networks
that
I
really
didn't
recall
or
had
any
idea
that
I
was
a
part
of
and
then
but
I
certainly
did
know
the
ones
I
wasn't.
Apart
of
basically
the
scope
of
the
bill
of
affected
non-emergency
services.
So
these
are
people
that
went
to
emergency
inward
network
facilities
for
surgery
and
then
found
that
they
were
being
later
balanced
till
by
an
out-of-network
doctor.
C
California
protects
in
many
ways
emergency
services,
and
we
really
did
want
to
have
consistency
there.
But
at
the
end
of
the
day,
after
a
year's
worth
of
work
on
this,
we
really
didn't
actually
come
up
to
a
way
to
have
it
incorporated.
So
there
was
absolutely
consistency
between
the
two
that
has
led
to
a
building
was
introduced
in
2019
to
actually
address
the
emergency
services
that
we've
found
and
that
bill
is
still
going
through
the
process.
You
heard
a
little
bit
about
ambulances
not
being
and
no
services,
not
being
a
part
of
the
federal
legislation.
C
Air
ambulances
were
not
in
California.
They
are
now
that
bill
was
reassigned
in
October.
We
have
heard
cases
where
sometimes
the
air
ambulance
bill
was
actually
more
expensive
than
the
treatment
the
patient
received
in
the
hospital
and
people
thought
that
you
know
they
have
no
control.
If
you're
in
an
automobile
accident
or
some
other
medical
emergency,
you
don't
have
control
over
which
air
ambulance
might
swoop
in
and
take
you
off
to
the
hospital.
Now
that's
significant.
C
And
there
are
a
couple
of
providers,
but
I
would
venture
to
guess.
Nobody
knows
who
is
part
of
there
who
is
part
of
which
network
as
far
as
air
ambulances,
so
other
goals
were
to
make
sure
the
patients
only
got
built
for
the
in-network
cost
sharing,
especially
when
they
went
to
all
to
effort
to
go
to
an
in-network
facility.
The
goal
also
was
to
help
control
healthcare
costs
and
therefore
helping
with
premium
costs
as
well.
C
The
other
goal
was
to
make
sure
that
you
know
just
basically,
you
were
only
responsible
for
what
the
end
in
network
costs
were
going
to
be
of
interesting.
A
part
of
this
was
that,
and
this
was
pushed
back
from
the
insurance
industry.
We
wanted
to
be
sure
that
that,
if
you
did
see
an
out
of
network
doctor-
and
you
end
up
paying
the
in
network
price,
that
that
would
actually
apply
towards
your
deductible,
even
though
that
doctor
or
that
facility,
actually
just
the
doctor,
was
not
a
part
of
that
part
of
the
network.
C
Why
should
you,
as
the
consumer,
have
to
pay
additional
towards
your
towards
your
deductible,
especially
in
a
situation
where
it
was
a?
It
was
an
out
of
network
providers,
so
that
was
there
was
a
lot
of
discussion
on
that,
but
at
the
end
of
the
day
that
was
included
in
the
bill
and,
as
you
see
on
the
slide
on
the
facilities
included,
hospital's,
annular,
ambulatory
surgery,
centers
and
other
other
settings
as
well.
C
What
they
should
be
so
now,
the
way
it
works
is
that
the
out-of-network
provider
isn't
supposed
to
bill
until
after
they
know
what
the
inner
end
network
cost
is
going
to
be,
and
if
they
did
do
that
and
build
anyway
they're
supposed
to
refund
the
patient,
and
if
it's
more
than
30
days
has
happened
there,
they
actually
are
going
to
be
charged
interest
for
that.
Not.
C
The
results
you
know
we've
actually,
actually,
we
believe
they've
actually
been
pretty
good,
based
on
the
actual
rates
public
paid
by
public
and
private
payers
instead
of
the
billed
charges.
Is
that
because
what
I
mentioned
so
the
way
it
works
in
California?
Is
that
it's
that
that
they're
reimbursed
at
either
a
hundred
and
twenty
five
percent
of
the
Medicare
rate
or
the
average
contracted
rate?
And
that's
basically,
you
know
how
similar
services
are
in
a
similar
geographic
area
are
which
are
reimbursed
now.
C
The
state
is
the
one
who
actually
went
and
created
the
methodology
for
this
because
a
lot,
this
information
is
proprietary
and
when
I
was
practicing
dentistry,
I
didn't
know
what
my
fellow
colleagues
contracted
rates
were
with
certain
clans,
and
that
is
that
is
protected
and
confidential.
So
there
was
significant
discussion
about
how
we
protect
that
information,
and
so
we
have
allowed
these
state
regulators
to
have
oversight
on
this
and
actually
come
up
with
the
methodology
to
do
that.
This
also
created
called
an
independent
resolution
process,
basically
a
way
to
protest.
C
It's
an
appeal
process
that
gives
doctors
out
of
a
way
to
appeal
for
a
higher
payment.
We
have
to
make
their
case
and
it
goes
through
the
Department
of
managed
health
care
and
Department
of
Insurance
the
pending,
and
that
depends
on
who
oversees
that
particular
entity
and
in
California
it's
will
more
complicated,
I
think
that
it
might
be
in
other
stage,
but
basically
that
process,
which
is
is
binding.
It
still
permits
the
either
party
to
litigate.
C
C
We're
monitoring
this
closely.
We
have
pretty
strong
network
adequacy
protections
in
California
through
our
insurance
code
and
our
knox-keene
Act,
and
the
protections
are
there
basically
to
make
sure
the
consumer
receives
the
care
that
they
need
when
they
need
it.
This
reiterates
the
insurers
obligation
to
comply
with
existing
network
adequacy
requirements.
The
concern
was
that
that
insurance
companies
would
simply
stop
contracting
with
doctors.
We
haven't
seen
that
we
have
seen
that
I'll
get
to
that
in
the
next
slide,
but
we
have
seen
some
things
that
do
cause
us
some
concern,
and
you
know.
C
Ultimately,
we
really
do
want
insurance
companies
and
doctors
to
contract
with
one
another,
which
is
to
the
benefit
of
consumers
there
there.
Maybe
there
are
some
unintended
consequences.
Anything
we
do
at
a
legislative
level
is
is
a
potential
for
that.
We
we
have
seen
that
health
plans
are
have
not
just
said
we're
not
going
to
contract
with
doctors
that
there
may
be
some
anecdotal
cases.
There
anecdotal
evidence
of
that,
but
the
reality
is
that
that
is
not
an
end
mass
issue
and
we're
still
working
with
a
Department
of
managed
health
care
to
see.
C
If
that
is,
does
become
the
case
that
we
need
to
have
a
either
response
by
the
regulator
or
or
a
legislative
response,
because
absolutely
not
be
intent.
We
do
know
that
there
may
be
an
issue
with
anesthesiologists.
We
know
that
at
least
one
plan
decided
to
use
this
as
a
way
to
really
hammer
down
the
fees
and
significant
in
some
areas,
but
it's
not
been
widespread.
C
In
fact,
it
was
a
geographical
issue
where
one
group
of
anesthesiologists
had
a
significant
component
of
the
market
and
any
Cal
know,
and
when
you
got
control
of
you
know,
control
of
the
market.
You
can
pretty
much
set
the
price
as
you
want,
and
but
we
are
looking
at
that
we
are.
We
don't
want
this
to
be
an
issue
and
we
be
pursuing
clean
up
legislation
and
we
are
working
with
anesthesiologists,
but
also
it's
interesting
that
you
know
miss
Brooke's
masseur
talked
about
New
York
and
the
other
other
style.
C
Basically,
the
the
rates
have
been
that
the
doctors
have
been
asking
for
80%
of
the
at
the
80
percent,
great,
like
I'm,
trying
to
I
lost.
My
I
lost
my
phrase
for
that
my
apologies,
the
80th
percentile,
so
that's
a
pretty
high
reimbursement
rate
and
at
the
end
of
the
day,
while
there
is
some
evidence
that
New
York
citizens
have
seen
some
relief
from
this
there's
also
been
associated
with
a
significant
increase
in
the
cost
of
care
to
people
in
New
York,
and
that
is
an
unintended
consequence.
C
D
Obviously
there
is
a
focus
on
the
ever
increasing
cost
of
prescription
drugs
and
it
is
it's
playing
out
with
problems
of
access,
quality
of
care
and
then
certainly
a
never
ending
cost
to
state
for
its
managed
care
or
its
state
health
plans,
or
even
conventionally
we're
seeing
this
all
over
the
board.
But,
prior
to
this,
if
you
look
at
the
landscape,
a
lot
of
the
states
have
come
in
and
you
know
we're
dealing
with
issues
such
as
fiduciary
duty.
Oh
it's
night
pricing.
D
You
know
something
as
an
oversight.
You
know
in
seventeen.
In
Georgia
we
in
2017
I,
one
of
the
Louisville
passed
protections
against
copay,
call
max
gag
clauses,
retaliation
transaction
fees,
specifically
a
16.
It
was
a
pharmacy
label
rights
where
we
saw
the
PBMs
were
recouping
for
clerical
errors,
and
you
know
basically
taking
an
advantage
of
these
types
of
errors
going
back
in
hindsight
collecting
from
performances.
D
Another
space
there's
a
complete
lack
of
transparency.
You
know,
and
basically
the
females
are
adopting
new
methodologies
that
they
arguing
like
pricing
and
basically
ignoring
the
law.
Now
in
17,
we
came
in
into
the
pharmacy
Patient
Protection
Act.
Now
that
was
prohibiting
mandatory
no
order
again,
the
guide
clauses
call
backs.
D
D
Those
listening
that
there's
two
sides
of
the
states
the
size
of
the
equation,
that
the
states
need
to
look
at
dealing
with
PM's
and
the
issue
of
pharmacy
and
cost
then
is
on
the
P
one
side.
The
other
is
on
provider
side.
So
we
n
a
multi
focused
approach
and
Hospital
323
basically
went
back
into
the
PBM
code
and
it
updated
the
pharmacy
protectionist,
strengthening
cutting
out
any
of
the
loopholes.
D
So
what
what
we
basically
were
doing
when
we
were
trying
to
make
sure
that
we
want
the
steering
because
what's
happening
is
these
teams
are
basically
feeding
the
mouths
of
these
policies
that
they
own
and
or
affiliated
with
and
financial
interests?
In
and
say
that
was
the
purpose
of
3:23
that
we
did
it
within
the
PBM
code,
but
I
think
the
game-changer
was
was
when
we
looked
at
the
other
side
of
the
equation
of
Europe,
which
was
233,
and
that
was
I.
D
In
other
words,
anything
outside
of
patient
care
purposes.
And
what
it
does
is.
It
prohibits
pharmacies
from
receiving
self
building
codes
from
their
affiliates
and
billing
for
the
same
and
it
it
also
had
provisions
in
there
about
prohibiting
pharmacies
from
knowing
drugs.
When
a
physician
indicates
a
direct
pharmacy
consultation
which
can
be
waived,
but
it
also
mandates
that
the
requires
pharmacies
to
disclose
affiliates
to
our
board
and
gives
the
board
of
pharmacy
oversight
really.
D
So
we
wanted
to
also
make
sure
that
we
were
focused
on
patient
choice
and
I.
Think
that's.
What
we're
seeing
all
across
Georgia
is
an
access
issue,
especially
in
rural
areas,
not
only
our
lawyers
but
a
lot
in
rural
areas,
and
we
wanted
to
make
sure
that
we
were
focusing
on
patient
choice
again.
The
game
changer
was
the
oversight
getting
the
oversight
of
this
law
to
the
Pharmacy
Board.
So
that's
where
we.
D
We
think
that
as
the
states
afford,
if
Georgia
goes
forward,
but
I
also
told
you
other
states
to
drink
outside
of
the
box,
because
if
we
look
back
over
the
last
five
years
across
the
state,
especially
everything
that's
going
on
within
the
PBM
specific
drug
arena,
issues
of
spread
pricing
certainly
was
coming
on
over
higher
on
other
states
that
are
on
here.
We're
starting
to
see
these.
A
D
A
And
then
so,
our
first
question
and
I'll
start
I'll
pose
this
to
our
state
respondents
and
then
Miss.
Brooks
is
sure
if
you
would
like
to
chime
in
after.
So
we
understand,
there's
many
important
voices
to
bring
to
the
table
when
discussing
these
issues,
and
so
how
are
you
bringing
or
how
did
you
bring
stakeholders
together
to
to
discuss
them
and
what
was
that
process,
like
maybe
start
with
assemblymen?
What.
C
Yes,
thank
you
appreciate
that
that's
a
great
question.
They
are
bill,
a
be
72
related
to
surprise.
Billing
actually
came
about
because
of
the
defeat
of
a
bill
the
year
before
I
made
it
clear
when
that
bill
was
being
debated,
I
would
bring
stakeholders
together
to
actually
do
that,
and
we
indeed
did.
We,
we
invited
to
put
all
around
the
table
insurance
companies,
providers
and
state
government
around
the
table
with
legislators
on
both
sides
of
the
aisle
we
might
bill.
D
D
There's
no
access
to
you
know
anything
that
they
do
so.
You
know
one
of
what
I've
done
is
trying
to
put
together
the
stakeholders
from
starting
primarily
with
you
know,
the
beneficiaries
of
patients,
and
then
you
know
the
providers
and
look
at
it
from
a
perspective
of
what's
best.
What's
the
best
outcome
from
the
healthcare
world,
you
know
for
the
health
of
the
patient
and
so
a
little
bit
differently
dealing
with
the
pdms,
because
there
they
in
and
my.
C
I
would
agree,
we
had
a
bill
in
California,
a
bill
that
I
did
related
to
PBMs
and
I
would
completely
agree
with
a
representative
night.they.
They
didn't
want
to
come
to
the
table.
They
wanted
to
kill
all
the
efforts
that
we
were
trying
to
do
on
behalf
of
consumers,
and
that
made
it
really
difficult
when
you
have
a
stakeholder
who
doesn't
doesn't
want
to
be
a
part
of
the
process.
B
The
I
think
the
two
examples
you've
heard
are
really
reflective
of
how
so
many
of
these
policies
are
successful
in
getting
across
the
finish
line.
As
we
know,
healthcare
issues
are
complex,
and
so
you
do
want
a
variety
of
stakeholders
that
are
going
to
be
affected
to
have
a
voice
in
how
the
policy
is
shaped
so
that
you,
as
a
policymaker,
are
seeing
the
various
sides
and
unable
to
incorporate
incorporate
those
views.
B
I
think
there
are
times
when
you
have
a
stakeholder
who
doesn't
come
to
the
table,
and
so
it's
important
to
make
sure
as
a
policymaker
that
you
get
that
you
at
least
understand
that
perspective
and
bring
together
the
the
willing
participants
to
get
to
the
best
the
best
solution,
and
we
all
hope
that
on
solving
these
issues,
that
most
people
share
the
common
goal.
If
even
if
they
differ
on
the
best
way
to
get
there.
A
C
We
we
chose
that
because,
quite
frankly,
we
were
not
sure
that
the
arbitration
would
work
and
I
think
what
you're
seeing
play
out
in
new
york
is
pretty
good,
pretty
good
evidence
that
we
were.
We
were
on
the
right
track
now.
It
may
be
that
the
rate-setting
methodology
may
not
be
perfect
and
certainly
there's
openness
to
exploring
that.
C
However,
when
you
see
that
in
new
york
that
the
the
rising
costs
to
the
system
have
have
been
as
in
an
effective
of
this
sort
of
baseball
style
of
arbitration,
they
have
I
think
we
I
think
we
took
the
right
track
and
we're
open
my
doors,
always
open
I,
don't
I,
don't
pretend
that
everything
we
do
is
perfect,
but
my
goal
is
always
is
to
protect
consumers
and
decrease
cost
to
the
system.
So
we
chose
it
because
we
thought
it
would
be
the
most
effective
and,
and
so
far
I
think
we
sin.
A
A
And
I
can
kind
of
fill
in.
Here
too,
we
do
have
an
extensive
website
at
NZSL
on
bulk
purchasing,
so
I
recommend
everybody
go
to
the
ncsl
website
under
the
hull.
Portfolio
and
you'll
find
some
information
there
as
well,
and
then
I
have
another
question
and
all
it's
open
to
the
panel
with
regard
to
the
setting
of
rates
have
any
States
been
approached
by
a
group
called
Fair
Health,
and
do
you
have
any
experiences
to
share
I.
B
D
A
A
All
right
well
seeing
none
I,
will
go
ahead
and
conclude
this
webinar
and
give
you
your
eight
minutes
back
in
your
day.
So
thank
you
again,
all
of
us
all
of
you
for
joining
us
and
special
thanks
again
to
our
speakers
and
to
Arnold
Ventures.
It's
been
a
pleasure
and
please
don't
hesitate
to
reach
out
to
NZSL
staff
with
additional
questions
if
they
come
up
after
the
webinar
webinar.
Thank
you
and
have
a
great
day.
Everyone.