Representative Aaron Pilkington I call this meeting to order. Thank you everyone for being here today. We've got a short agenda today. But obviously the discussion during the Public Health meeting, we thought it was appropriate for this subcommittee to convene to discuss it as well. So without any objections from my co-chair, we'll have the Department of Health and Human Services come up and explain the Division of Medical Services discussion on the rules for urgent care clinics. Ms. Pitman, just come down and introduce yourself and feel free to begin.
Elizabeth Pitman Oh, sorry. Good morning, Elizabeth Pitman, Division of Medical Services. And we are here today to further discuss the rule on urgent care that we attempted to promulgate, I believe, last week. Sorry I was not able to be here. Sorry I wasn't able to here for that, but I know Ms. Smith gave you all the information that you needed at that time.
The rule itself was designed to help create better access to urgent care for people that were really being forced to go to the ER when they otherwise didn't want to by allowing some urgent care visits outside of a PCP referral. We did look at whether or not it would take away from the PCP relationship. That was not our intent. We still believe that primary care relationship is central to managing good care, which is why we limited it to only two visits for those that have adn assigned PCP and four for those who don't. We have some other policies in place that ask for hospitals, and we can even add urgent care to that, to assign PCPs if a person does not have a PCP. Additionally we even have some funding for that.
Now I know some of that funding may need to be looked at again, but we do pay about $14 to $15 for a hospital to assign a PCP if there is not one otherwise assigned. So again, this rule was not about trying to erode that relationship, but rather about trying to create better access for people who may need to seek care when a PCP doesn't have an appointment available or it's outside of their normal hours. Because otherwise a PCP referral was required. I know during the committee meeting, which I went back and watched-- so if I missed anything, please remind me and I'll try to address it-- there were some questions around definitions of urgent, or I believe it was emergent clinics and walk-in clinics in our rules as they were written.
We have gone back and looked at that and I'm going to be very transparent today. We looked at what an emergent clinic was. There is not a definition of emergent clinic, nor does it appear to be something that is being billed in our system. We've looked for place of service, provider types, all of those things. So it feels like that is just an old term that is left over in our manuals that probably needs to be cleaned up at some point. Walk-in clinics have been billed as a place of services. We've only seen it billed though about 30 times in the past three years.
So it's a pretty minimally used service. And the primary biller of that, it turns out, was actually a pharmacy walk-in clinic, and they were billing for vaccinations. So it does not appear that that is being used for urgent or emergent care either. So just wanted to give you that information. Is there anything else that you would like me to address about this rule before we get into your questions?
Representative Aaron Pilkington Representative Johnson, do you have a question? If you're okay, Pitman, Ms. Pitman, sorry.
Elizabeth Pitman You are fine. I'm used to everyone calling me Pitman, so feel free.
Representative Aaron Pilkington Sorry about that. We'll start with questions. Representative Johnson, you are recognized.
Representative Lee Johnson Thank you, Mr. Chairman. Appreciate it. I appreciate people being here today. I told Representative Rose it feels like a Wednesday night church service, not a Sunday morning. We got everybody spread out and all over the place, and there's only a handful of us here.
But I do have some questions. Obviously, if you want a definition of emergency clinic, I'm happy to gin one up for you. I've got some ideas around what we might call that. I support this idea. I mean, I didn't mean in the committee to act like didn't support it. I think we have an access issue for patients in Arkansas. And I think the urgent cares provide a good outlet for that. But I also think it's important to recognize that there are urgent care deserts, I suspect, in our state where people don't have access to go to an urgent care.
They don't have that option. And so my question was really more around, from an emergency care visit standpoint, is there a space, like first of all, do we reimburse without referrals for emergency room visits if they don't have a PCP?
Elizabeth Pitman So my understanding is that if they do not have a PCP, yes, you can get reimbursed for that. There are some requirements around making referrals to PCPs after the fact, but there is reimbursement for that visit.
Representative Lee Johnson So tell me about, when you say making referrals to PCPs, and I realize you might not have the answers to all these questions, and you know I don't mean to be adversarial. I just want to try to have a good dialog. We're all down here, so let's try to walk through the issue. When you say there's some stipulations about seeking a referral later, what do you mean by that?
Senator Fredrick Love Hold on for just one second. Representative Johnson, I want to just be clear, just for a clarification before you answer that. You continue to say, and I heard it the last time we had a meeting, you said emergency. You keep saying emergency.
Representative Lee Johnson Yeah, and what I mean is about space. Yeah, go ahead.
Senator Fredrick Love Okay, but emergent clinics and emergency are two different, they're two different things. And so when you continue to say emergency, I'm thinking ER.
Representative Lee Johnson That's what I mean. 100%.
Senator Fredrick Love But urgent care and emergent clinics are not ER.
Representative Lee Johnson It sounds like, if I understand right, we don't have a definition of emergency clinic. We don't know what that is, correct?
Elizabeth Pitman We don't have any emergent clinics.
Representative Lee Johnson I would argue that an emergency room is an emergency clinic.
Senator Fredrick Love Hold on for a second. Emergent. You are saying emergency. Emergent clinics and urgent clinics are synonymous.
Representative Lee Johnson I would disagree, senator, because it sounds like there is no definition of emergency clinic. And if they're synonymous, why do you need two terms in the rule? Why wouldn't you just say urgent clinic? I don't understand that. I mean sounds like the one walkin clinic we have was a pharmacy. So why can't an emergency department be an emergency clinic? We have in many emergency departments in the state, we had fast tracks. We don't have non-emergent care centers in the ER.
Senator Fredrick Love No, yeah, I hear what you're saying, but you're saying emergency clinic.
Representative Lee Johnson That's what the rule said. If you read the rule, it says emergency clinic.
Elizabeth Pitman There is a term emergent clinic in our rule.
Representative Lee Johnson I think it says emergency clinic.
Elizabeth Pitman I think it says emergent. Emergency. But it's not a defined term anywhere and we don't have anyone operating as an emergent clinic. And I'd have to pull the rule to know if it's emergent or emergency, but I think they're designed to mean the same thing. But there's not anything operating as that. So we are bringing urgent care clinics, which is a step down from emergency room.
Senator Fredrick Love Okay, all right. So that's, I guess, when I'm hearing you're talking about emergency and you're talking about urgent care, which is--
Representative Lee Johnson I appreciate the latitude of this and I hope we can have this kind--.
Senator Fredrick Love No, no, no, no.
Representative Lee Johnson Because like I said, we are all down here to try to talk through the issue. And I know that we're foregoing some of the formalities. Appreciate the chairs doing that. But like it's geography. There's two issues, right? There's the geographic term of emergency department, emergency clinic, urgent care clinic. And then there's like, is the problem an emergency or not. Those are two different things, right? So in Arkansas, correct me if I'm wrong, Ms. Pitman, but I believe in Arkansas we have a prudent layperson definition around emergency and non-emergency. Is that correct?
Elizabeth Pitman Yes, sir, that sounds correct.
Representative Lee Johnson And so my understanding of that law is that if a prudently layperson is defined-- my understanding is if you're a prudent lay person, it's an average Arkansas eighth grade education. If you show up to an emergency department and your perception is that it could be an emergency. I got home from work today, my child has a temperature of 104. That's kind of freaked me out. I'm going to the emergency department. We should be able to, in an emergency apartment, treat that person and get reimbursed for that care, regardless of whether it turns out to be a cold, the flu, which isn't an emergency, but the perception of the condition is one of emergent. Is that correct?
Elizabeth Pitman I also lost my mic. Yes, that is my understanding of the standard. I defer to you as a physician.
Representative Lee Johnson What I'm getting at is that like, if we're gonna pay urgent carers, which I support, I support this rule. To be clear, I'm in favor of this rule. I think there's a real access issue in Arkansas, and I want patients to be able to access the system when they feel like they can. And it's not your fault if you've tried to get a PCP-- one of the questions I have is like, How long does it take for a person to get assigned a PCP once they start the process?
Elizabeth Pitman So we don't auto assign PCPs. We have a phone line Connect Care. I'm not sure the exact time, but you can call that phone line at any point and get assigned a PCP. They'll assist you in that.
Representative Lee Johnson Do we know how many Medicaid recipients in Arkansas don't have a PCP assigned?
Elizabeth Pitman Of the ones that are required to have an assignment, it's around 145,000.
Representative Lee Johnson That don't have a PCP assigned? That seems like a big number. How many people are on Medicaid in Arkansas?
Elizabeth Pitman There are about 800-something thousand, but not all eligibility categories are required to have a PCP assigned.
Representative Lee Johnson Of the eligibility categories required to have a PCP, how many of those people are there?
Elizabeth Pitman I don't know the total number of that. I can get it for you. We have about 300 and something.
Representative Lee Johnson So roughly a third of the people that need a PCP don't have one in Arkansas?
Elizabeth Pitman 400-- why don't you just come up here?
Representative Lee Johnson Yeah, let's get everybody to the table and have a conversation.
Representative Aaron Pilkington Please come to the front and introduce yourself.
Elizabeth Pitman She's worried that she's wearing Friday attire, but I think she looks lovely.
Representative Lee Johnson Hey listen, I've got on a v-neck t-shirt from Target. I threw this jacket on out of my car. So it's all good.
Nell Smith I'm Nell Smith. I'm the Deputy Director for the Division of Medical Services, and as a former BLR staffer, this is just unacceptable to me.
Representative Lee Johnson No, it's all good.
Nell Smith The question was, how many have a PCP?
Representative Lee Johnson My question was, how many require a PCP eligibility? She said there were 800,000 people on Medicaid, but not all those people require.
Nell Smith That's right. And so we have about 140,000 that require one that don't have one. And we have abou 400,392 that have one and should have one.
Representative Lee Johnson So roughly a fourth of the people in Arkansas that need a PCP don't have a PCP. 145,000-ish people don't I have a PCP. And so how do those people access the system? How are they expected to access the system?
Nell Smith If they try to access the system, so let's say they try to go to a specialist, the specialist will say you'll need to have a PCP referral.
Representative Lee Johnson And since they don't have one, how do they get that?
Nell Smith They get assigned.
Representative Lee Johnson How do they get that assignment?
Nell Smith They call Connect Care.
Representative Lee Johnson The onus is on them to call ConnectCare?
Nell Smith Yes. And I believe clinics can request, I shouldn't say that. I'm not sure that they can request an assignment. We did find that hospitals can request an assignment and get paid, can bill for that request of a referral.
Representative Lee Johnson Mr. Chairman, I'll just keep asking questions. If someone wants to get in the queue, I'll stop.
Representative Aaron Pilkington I appreciate the discussion and I did not want to slow you on this. But I do have some other people in the queue, I'd like to--
Representative Lee Johnson I'll back up. I do have one specific question--
Representative Aaron Pilkington You're just going to keep going. I got you.
Representative Lee Johnson No, I'm just telling you I have a question for Department of Health. I know they're here. I don't know how long they plan to be here.
Representative Aaron Pilkington Let's get to Representative Richardson next and then we'll go back to you, Representative Johnson.
Representative Jay Richardson. Thank you, Representative Johnson, for letting me speak. So the rule makes sense to me, right? So I understand what you guys are trying to do. And I'm not on Medicare and Medicaid, but I don't have a PCP. I recently had pneumonia for two weeks, and all I need to do is get a checkup. But because I don't have a PCP, I can't find a doctor who's accepting new patients. And it's been a pain in the butt.
So the opportunity to walk into an urgent care and get a quick checkup that would be potentially covered seems like this makes a ton of sense. So I applaud you guys of what you're doing. And I can really appreciate the in-depth that Dr. Johnson is going in to try to really understand how the payments are made back for those individuals on Medicare.
My big question is, when you had open public comment, how was that notification granted? I mean, how do people know to come and speak on this or have questions about that?
Elizabeth Pitman Sure. So we followed the typical state process as required. And we put it out in the paper for public comment in the Arkansas Democrat Gazette. We also put it on our website. I believe we might have sent, did we send this to the association? Sometimes, and we might have done it in this, I'd have to go back and check, but a lot of times when we work closely with medical associations, for example, the Arkansas Medical Association in this case, we send it to those groups to see if they have any comments.
And again, I would have to go back and check. But we are pretty sensitive about our primary care providers in the state. We know that they have a lot of pride in that program. And so a lot of times if we think a rule is gonna impact them, we'll share it with them as well to see if they had any feedback. Now again, I don't know for sure whether we did that in this instance. I do not believe we received public comment on this rule, though.
Representative Jay Richardson. Yeah, that was my question or concern that people weren't aware to come in and make comments. So thank you for your response.
Representative Aaron Pilkington Representative Springer, you're recognized.
Representative Joy Springer Good morning. And thank you, Mr. Chair. And I'm happy that I came to this meeting today because I can echo what Representative Richardson has stated. A few weeks ago, I was at a conference, and I stepped off the sidewalk, and I hurt my back. And I wanted to go to someone that I knew that could help me with the pain that was in my back. I was told that I could not go to that person until I was able to go to my PCP. I have a PCP. And they had to give a referral to that person in order for me to go to have something taken care of my back. So I'm trying to understand why is that available, you know, that sort of thing there for me to have to... I have a PCP, but yet still I can't go to another person to be cared for. So I'm trying to understand the difference here.
Elizabeth Pitman Sure, so in that case for Arkansas Medicaid, where you have a specialist need, now had you fallen off and just needed to go to urgent care, that's what this rule is designed to address. Like, for example, I have stepped off a curb incorrectly and sprained my ankle and had to go to urgent care to get it taken care of because there were no same day appointments available for my PCP. But if I needed long term treatment for that, I also would have had to get to my PCP.
I think in that instance I did to get a physical therapy referral so that I could get physical therapy. Medicaid, this rule would allow Medicaid to operate the same way as what I was allowed to do in that situation. The day I sprained my ankle, I could go to the urgent care to get that immediate treatment. But follow up for that ankle sprain, the Medicaid client would still have to go in and see a PCP and get that referral.
And that is designed, again, to preserve the case management aspect of our PCMH and PCCM programs so that that PCP really understands everything that's going on with that patient's care. The goal of those programs is that that PCP is responsible for managing the quality of that care, making sure to do the follow-up and things of that nature. In the PCMH program, they're paid based on the risk of that client. And so we really want them to coordinate that care and really understand what's going on with that patient.
Representative Joy Springer Well, thank you. I've had the same PCP for years, almost as old as I am. So thank you, I appreciate it.
Senator Fredrick Love So, Ms. Pitman, so here we are. Take me, kind of walk me through the Medicaid patients. So, as of right now, the current rule is that I'm a Medicaid patient, I don't have a PCP, I go into an urgent care clinic, I get seen?
Elizabeth Pitman No, sir.
Senator Fredrick Love I can't get seen?
Elizabeth Pitman Correct.
Senator Fredrick Love So I have to--
Elizabeth Pitman Go to an emergency room.
Senator Fredrick Love I have to go to the emergency room.
Elizabeth Pitman Or an urgent care affiliated with a hospital.
Senator Fredrick Love On an urgent care affiliated with the hospital. So that's the current?
Elizabeth Pitman Yes, sir.
Senator Fredrick Love So really, that means people are kind of, we're forcing people to go into the ER.
Elizabeth Pitman I would say that. I think what I did say earlier, is forcing people to go into the ER. And when that's the only thing available, that is appropriate.
Senator Fredrick Love But yeah, and that's what I was gonna say. I guess you get outside of Little Rock or Northwest Arkansas or somewhere like that, you might have only the emergency room. Okay, so now this rule is going to say, hey, we're going to, if it's urgent care available, I'm a Medicaid patient, I can go see an urgent care without a PCP.
Elizabeth Pitman For a limited number of visits. And then we would ask that you have a PCP.
Senator Fredrick Love And the minimum number of visits is two.
Elizabeth Pitman For someone with a PCP, it's two. For someone without a PCP, it is four. And again, that's designed to preserve that PCP relationship because we do find a lot of value in that. It's allowed us to, with the PCMH program, allowed us really address some health disparities in Arkansas. Not to say there couldn't be some improvements to that as well. I know I've talked to Representative Johnson about that. But we do you find a a lot value in that relationship and in that program and want to preserve it.
Senator Fredrick Love So then, why were you saying four visits instead of just--
Elizabeth Pitman For someone without a PCP?
Senator Fredrick Love PCP saying that hey, you can go once, you go twice. Anytime past 2 then--
Elizabeth Pitman So we originally started with just no PCP assigned, you could have up to four. We added the two for those without a PCP and decided to limit that to two instead of making it also four because we wanted to preserve that existing relationship. Again, you might sprain your ankle or have a cold and need to get in. And so we just wanted to have some allowance for that without saying you don't need to have a PCP and have that relationship. So that's how that came about and the reasoning why.
Senator Fredrick Love Well, I'm saying, though, if we want to really get to have a patient establish a relationship with a PCP that can follow their care, then would we not say that after the second visit they need to have PCP? I mean, wouldn't that be, I mean that would be better coordinated and quality of care if we said, Hey, you get two visits, you have to have a PCP. Wouldn't it? I mean.
Elizabeth Pitman No, I do understand. And I mean, I was going to talk to you guys today and hear what the questions were. We may end up actually after we review all of this and what you're saying, pulling this rule back and making some of these changes, I think, that you're suggesting. But I really wanted you guys to weigh in on that before we made that decision on how important you felt like this was to go ahead and implement and then make changes after versus holding and making changes before.
Representative Aaron Pilkington Yeah, and I appreciate the rule. I think I'm very much at the camp of Representative Johnson. I was asking a lot of questions. I do see the need for urgent care. I think like a 26-year-old who probably sees the doctor one time a year or maybe four times, it's like I'm never gonna get a PCP because I can just use the urgent care as much as I want.
And we don't want those people to not get into the system. And then I guess as we've kind of had this discussion, and I'm curious what your take on it is. We have these 145,000 Arkansans who should have a PCP but don't. Is there not an ability for us to like auto enroll them with providers? I mean, I know with the PASSEs we do that. I mean is there not a way to say, hey, if you live in Johnson County, we have these PCP providers that are accepting Medicaid patients, we are going to give those to you.
And then I mean the onus is on those providers to reach out to those people and to establish a relationship. And then, of course, if they want to change their PCP at any time they can. I just feel like that'd be an easier way to kind of get through this. Once again, I like the rule. I think it's a good step. I mean obviously, a nail has gone through my foot working in the yard and I've gone to the urgent care before, so I get it. I've got young kids.
Trust me, I've rushed to urgent cares quite a bit. I totally am with this.
I do like with the way we've done PCMH, I just want to make sure that we are getting those people and so they build a relationship with those providers. So I don't know if you could talk a little bit about auto enrollment, if we can do that through a rule or something like that. So please just kind of help educate me.
Elizabeth Pitman So we have explored auto-assignment. Our system does have the capability, you're absolutely right, to auto- assign individuals to a PCP. We have not pulled the trigger on that yet. I don't know that a rule would be required. Or if we could do it absent one, that's something we would have to explore. There are a couple of reasons we haven't. Obviously, those 145,000 people are not currently engaged with their healthcare for whatever reason.
Auto-assigning them means that that PCP automatically gets that PCCM fee of $3 per month. And as of today that is paid for that case management with the expectation, and I believe rightly so, I believe most physicians are doing this but that they're managing that care for each one of the people on those panels However, these are people that are not engaged and may not come and so we'd be paying that three dollars automatically.
So we wanted to look at really what does that mean for that program and those 145,000 people before we pulled that trigger and started spending that. It seems like a small amount of money, $3 per person. But it's a lot of money when you add it all up. And so just making sure we're being responsible before we do something like that.
Representative Aaron Pilkington Is there a way though to do the auto-assignment and then saying you're not going to receive that fee until you have an initial visit with that patient so that they do come into the system? I mean, I get it. We don't want to enroll someone who's maybe living out of state at this time but is considered an Arkansas resident. We're paying for their Medicaid. They're not seeing the doctor. And then this money is just going to a provider who's just sitting back and collecting. I mean is that possible?
Elizabeth Pitman I think that would be possible with a rule change. I don't know, I think the way the rule's written now, for PCMH there are obviously requirements to get-- you get a basic payment, but then there are requirements on top of that. For PCCM you get that $3 for everybody on your panel, no matter what. And so I think without a rule change, no, that's not possible. With a rule changes, yes, of course all of that is possible. And that's why we haven't pulled that trigger yet.
Representative Aaron Pilkington Great. I'll bring it over to some of my colleagues. I think Representative Magie, you're recognized. Oh, sorry, Representative Allen was first. But his button's not on here.
Representative Fred Allen I am Magie today. Thank you. Thank you for being here this morning. I have a question. Can you explain to me the difference between urgent care and the emergency room?
Elizabeth Pitman I will try my best. So an emergency room is obviously the hospital-affiliated emergency room. They can provide all of the services that the hospital is allowed to provide under an emergency room, which I'll defer to your colleague, Representative Johnson, and my colleague, Mr. Gilmore, in the back there for exactly what that is.
But they are also required under MTALA, and I used to know what that stood for and might know again after we get done talking today, but to treat and to screen and stabilize every patient that walks in the door. An urgent care clinic is a physician's office. They're not licensed as a hospital. It's usually staffed with a physician supervisor and then APRNs and physician's assistants. They're not usually a PCP, although lately I think some have started to become PCPs.
That's not something Medicaid is intending to doing. They offer extended hours, are usually open on Saturdays and Sundays. And you can walk in. They don't require appointments and be seen at any time for pretty much any reason. They do workers comp, physicals. They do flu and strep tests. I've gone for several COVID tests during COVID. I've gone because I sprained my ankle. So that's what they do.
Representative Fred Allen Okay, so in an ideal world, if a person is ill, would it be more advantageous for them to try to go to the urgent care or try to the emergency room?
Elizabeth Pitman So we would like them to have the option to go into urgent care if, for example, they're experiencing respiratory symptoms and think they might have the flu or strep throat or COVID, but it's not rising to what we would consider to be an emergency, you know, something you would want to go to the emergency. If you're like me, you try to avoid the emergency room.
No offense to all our wonderful emergency room physicians out there, but I don't like to go. It's long wait times and it smells like a hospital and it's just not my favorite place to be. So I would prefer to go to urgent care. So we want to have that available where it is available for our clients. I would go to an emergency room, like when my stepdad, I'm gonna share his story of falling off a 50-foot cliff. He clearly needed to go to an Emergency Room for that.
So, you know, I think there's some very clear examples. And then there's also what Representative Johnson said. You have to use sort of a reasonable standard of if I'm sitting at home and my child is sick with 105-degree fever, I'm probably gonna take my child to an emergency room. I'm probably going to go straight there. Think of Monopoly, don't pass go, do all that stuff, go directly to jail kind of thing. I'm going to the emergency room because it feels like an emergency.
Representative Fred Allen I appreciate you. Appreciate you too, Dr. Johnson, for the work that you're doing in this area. Thank you all so much for allowing me to ask a question.
Representative Aaron Pilkington Representative Johnson, you're recognized.
Representative Lee Johnson Thank you, Mr. Chairman. Appreciate the committee's patience with all the questions. I do have a few more. So when we talk about urgent cares, and I know the Department of Health's here, do we have a sense of how many urgent cares operate in the state and where they operate?
Elizabeth Pitman I do not. And I will defer to Mr. Gilmore, but I'm not sure urgent cares are licensed as urgent cares.
Representative Lee Johnson Can the Department of Health come and address that?
Representative Aaron Pilkington Please come to the front and identify yourself.
Matt Gilmore Matt Gilmore, Department of Health. I apologize. I didn't wear a tie today. But to your question.
Representative Aaron Pilkington You're recognized.
Matt Gilmore I'm sorry. Thank you. To your question, Representative Johnson, we don't have a licensure process for urgent care clinics, facilities, whatever you want to call them. We do for hospitals with emergency rooms, as you well know. In my mind, I kind of liken them to a physicians’ clinic.
You know, we don't license physicians' clinics. We don't license PT clinics. We dont license various types. We license the provider, the care professional. And so if there's issues there, so that's how we would track. But I don't know if we have a way to track the number of urgent care clinics either just because there's not a licensure or a registration process for that. But as far as the oversight, it would be through that healthcare professional. But as far a number, I don't have a number.
Representative Lee Johnson So we do license pharmacies.
Matt Gilmore We do, yes sir.
Representative Lee Johnson And so there was a lot of discussion in the last year about pharmacy deserts, correct? But we don't have any way of knowing whether there are urgent care deserts in our state or not?
Matt Gilmore Not that I'm aware of them. I'm not aware of a process that-- I've asked around a little bit this morning, just checking. But there's not a way for me to get a number.
Representative Lee Johnson I mean, I don't know. I think common sense would tell me as I drive through rural Arkansas that there's not a lot of urgent cares operating in rural Arkansas. And when you look at a map of Arkansas and you get outside the urban areas, most of the state is rural. And so my concern about limiting this to urgent cares and again, let me be clear, I support this rule. I think it's the right rule to do. I just want to make sure we're acknowledging that there are places where the only urgent care in big air quotes is the emergency department. A
nd we shouldn't be penalizing patients for showing up there. We shouldn't penalizing hospitals for, to your point, the Emergency Medical Treatment and Active Labor Act, EMTALA, requires us to see patients at a hospital setting for free. We can't even ask for information. We can't even ask them if they have Medicaid until we have seen them and done a medical screening exam. So we don't even know. Like we don't even know until after the fact.
And a medical screening exam includes EKGs, chest x-rays, lab work, urinalysis, CTs. I don't know if you're having an emergency until I've ran some tests to find that out. And until I decided whether you've had a life-threatening emergency or not, anyone that shows up on a hospital campus, we're required to take care of them and we can't even ask them.
And then once we've gone through all that process and we go back in and we say, hey, do you have insurance? Oh yeah, I have Medicaid. It's at that point that I have to get a referral from a PCP to say, hey, oh, by the way, I just saw this kid, did a chest x-ray, did bottle signs, did a flu swab, did a strep screen. They've got an ear infection. I think they need some antibiotics for their ear infection, can you give me a referral? What if I can't get ahold of that doc? What if it's two in the morning? That doc, I know they're supposed to have somebody on call, but I'm just telling you, you can't always get a hold of these people.
What if I get hold of them and they're like, no, you can't see them, send them to the clinic. Okay, I'm gonna take this prescription for antibiotics for this kid that I know needs it and I'm not gonna give it to them because I'm going to have to send them to their primary care doctor. Does that make any sense at all to me? I don't think that makes any sense. That's a rhetorical question. You don't have to answer that.
But like, I don't understand why we've created this process around care management when we've got whole swathes of the state where the only access point is the emergency department. We shouldn't punish the hospitals. We shouldn't punish the patients. We should be able to reimburse for that in a fair mechanism. I don't wanna break the bank of the State of Arkansas. If there's an outside the box way to reimburse for non-emergent problems in the emergency department, I'm all for that.
But I don't have any more questions for Department of Health. That was my main question. I know you showed up here and I didn't want you to feel left out. So I just want to make the point that while we're looking at this rule, and when we're talking about, when I have colleagues who-- I appreciate it's a Friday. We got a sparse turnout. I'm grateful for the people to be here.
But when I had colleagues sitting in here talking about patients showing up to the emergency room where they don't need to be, and it creating a burden on the system, that's not factual for a lot of Arkansas. There's a lot hospitals right now in Arkansas. The ones that are converting to rural emergency hospitals, they want these patients. They're happy to take care of them. There's a big difference, and to your point, I appreciate that a lot of hospitals in Arkansas if you show up, there's gonna be a long emergency room wait. That's primarily urban hospitals.
If you show in most of the rural hospitals in Arkansas are seeing 20 or less a day in 24 hours, less than one patient an hour. You're not gonna wait in a rural hospital in Arkansas, because there's not a waiting room full of people. You're gonna show up and get seen. And so I don't know. It felt important to me at the time when this rule came up. I do have more questions.
And I'm happy to talk, to let other people chime in. So the question about auto enrollment, so do you have a concern about workforce when it comes to auto enrollment? If we have 145,000 Arkansans on Medicaid who don't have a PCP, are there enough PCPs to accommodate 145,000 if you, yes, tomorrow turned around and auto enrolled all those? Is there capacity on the system?
Elizabeth Pitman We would have to, I think, analyze that. And just so that we're clear for who can be a PCP in Medicaid, and I know you didn't ask this, but that includes physicians that are pediatricians, family physicians, I believe. They're required to be obstetricians, APRNs, FQHCs. And now we are about to open it up to physicians' assistants as well. So there's a large number of provider types that can be PCPs. In Arkansas, I would have to look at exactly how many have full panels already and how many have open slots. That's something when we decided on the other basis not to look at auto-assignment, that's not something we explored further. But it is definitely something to explore before we decided to do that auto- assignment.
Representative Aaron Pilkington I'm going to go out of order. I would like to explore that idea just for the record.
Senator Fredrick Love All right. So, I guess my question to you is going to go to Representative Johnson. So are we not reimbursing when we see patients in the ER?
Elizabeth Pitman No, we do.
Representative Lee Johnson Well, can I make a caveat of that?
Elizabeth Pitman Yes.
Representative Lee Johnson If they have a PCP and I don't seek a referral, do you reimburse?
Elizabeth Pitman We reimburse for the screening, but we would not reimburse for the subsequent.
Representative Lee Johnson If I see this kid in this scenario and I diagnose him with an ear infection, that's not a medical screening exam. A medical screening exam is I don't do any treatment by definition. The only way I can bill for a medical screening is, say, I screened you as non-emergent, I'm not treating you. So I take issue with that point because the majority of hospitals in Arkansas are not getting reimbursed for these visits.
Okay, so the only they get reimbursed is AFMC reviews them, and if AFMC says it was an emergent condition based on a prudent layperson's assessment, then they call it an emergency, and they'll reimburse us without a referral. If AFMC reviews them and says this was non-emergent, I don't get paid. And I spent a significant portion of my career reviewing AFMC denials and appealing those denials. And I can tell you, I take issue with the fact that at AFMC, you've got medical professionals, doctors, nurses, reviewing and assessing prudent layperson perceptions and denying them because of a prudent layperson.
Don't tell me that a mom doesn't think it's an emergency when a kid's had a fever for three days. We deny this because the duration of the symptoms have been too long, they could have gone to the primary care doctor, denied. And you say, well, I came in because I thought my kid got bit by a spider. I know that's no big deal. I know there's no antivenom for black widow or brown recluse spider bites. There's no treatment. But if you're just a mom at home, you don't know that.
Well, I showed up and it was a spider. Well, spider bite is not an emergency, denied. So like a question that I have of many is like, what is the denial rate for emergency department visits for prudent lay person non-emergent? And what's the condition for the denial?
I don't know that, or expect you to have the answers, but I'd love to have another committee meeting where we look at the volume of these denials and you bring that data back. Because I'd like to have AFMC here to talk about their process and how many denials are given and how many patients seek care in the emergency room and we don't reimburse.
Elizabeth Pitman We can definitely get you that information in that process. He is right about the process for payment, to answer your question. So we pay for the screening. If you do have a PCP and they do not do the referral, we don't pay for that visit.
Representative Lee Johnson And if we treat them, it's not a screening.
Senator Fredrick Love So, just so I can get this clear. For those that have a PCP, you will reimburse for, but for those that do not have a PCP--.
Elizabeth Pitman That's the reverse.
Representative Lee Johnson I want to clarify that. They'll reimburse if you have a PCP only if I get a referral. If I don't get a referral, they won't reimburse.
Elizabeth Pitman For someone without a PCP, we do reimburse. But there is a requirement that they help the person get a PCP. And we pay the hospital, I think, $15 to call Connect Care and help that person get a PCP assigned. Again, we probably need to talk about whether that's adequate process or not, but that's how that works today. For someone that has a PCP assigned, what he is talking about would apply.
Representative Lee Johnson The only way that we get paid in the emergency department is, if we don't get a referral, it goes to AFMC for review. AFMC reviews it. If they say this was not, the prudent lay person wouldn't consider this an emergency, they deny the claim.
Elizabeth Pitman I'm happy to look at that particular issue and have more information. If you have specific examples you could send us, I think that would help us.
Representative Lee Johnson You can talk to any hospital in the state. I mean, most hospitals in the state. Like I'd be curious, Hospital Association is not here. But a lot of hospitals, my hospital, have decided that the referral process is too onerous and would just eat the cost. Because we've already incurred the cost by the time we see them and take care of them and at this point the process of trying to-- because a good question is, What do we reimburse to an ER visit?
Elizabeth Pitman I don't know that off.
Representative Lee Johnson And how does that compare to what we reimburse for urgent care?
Nell Smith Give me a minute and I'll get that.
Elizabeth Pitman Smith has that.
Nell Smith It might take me a minute, so if you wanted to carry on.
Representative Lee Johnson Sure, I have more questions if the committee is okay with that.
Representative Aaron Pilkington No, no, no. You're good. I've got other members and I know, Representative Johnson, you're gonna be on a roll.
Representative Lee Johnson Let me just make it clear. I'm happy to let other members talk. I'm not leaving here today until I've had a full conversation because I drove five hours round trip on the Friday before Memorial Day and so I'm here.
Representative Aaron Pilkington No, I agree.
Representative Lee Johnson So I'm like happy to take turns, and I want to take turns. But don't say, hey, we've been here 40 minutes.
Representative Aaron Pilkington No, no, we're going to be here as long as we need to be here. I'm fine with that. I just, there's some people waiting in the queue and with your extensive knowledge of expertise, I just know we can go down a lot of rabbit holes, which we should. Representative Barnes, you're recognized.
Representative Glenn Barnes Thank you, Chair. I have a question. When it comes to urgent care and emergency room, for its prices, the cost, would it be fair to say normally the emergency room cost is much higher than urgent care?
Elizabeth Pitman I mean, I don't want to give you exact numbers, but yes, we typically see higher cost in an emergency room than in a physician's clinic, which is an urgent care setting. So, that is one of the things. It's primarily, though, about access. And I think we are open to the idea of looking at how we could reimburse for non-emergency visits in a hospital that is closer to pay on parity, I guess is the word I'm trying to say, with urgent care clinics in hospitals so that we can create this access that that Representative Johnson is talking about.
Representative Glenn Barnes So from a management purpose, the administrative side would be pushing more for urgent care if it's really not an emergency.
Elizabeth Pitman Yes, sir. We always push for the appropriate level of care where appropriate. Yes, Sir. And that's in any setting. So yes, we would always prefer urgent over emergency if that is appropriate.
Representative Aaron Pilkington Representative Rose, you're recognized.
Representative Ryan Rose Thank you. Mr. Chairman. I want to go back to a portion of the conversation from just a few minutes ago. We were having a discussion about the clients being referred to a PCP or getting a PCP. And I can't remember, so I'm not going to quote, I can't remember which side of the conversation said it, but there was some kind of an understanding, I believe anyway, in order to have the hospital be reimbursed, they needed to more or less get the client connected with a PCP.
Elizabeth Pitman No sir. There is a separate reimbursement for helping a client get connected with a PCP. We do require that you refer that client to a PCP to get reimbursed. I don't know that there's a requirement that the client actually get the assignment. And that I would actually have to clarify.
Representative Ryan Rose So, in that same vein, who is technically, by rule or by department policy, who is responsible for getting these Medicaid clients who require a PCP, who's responsible for giving them a PCP?
Elizabeth Pitman So we actually have a contract with AFMC to do Connect Care. It is a phone line. I think it used to be operated by the health department, but when we rebidded, it went to AFMC. It is a phone line, and they connect individuals with primary care providers who have open positions on their panel. That's who's responsible. So it's the agency's responsibility, and we've taken that on.
Representative Ryan Rose How does the client know that that's supposed to happen?
Elizabeth Pitman I mean, they get a packet that tells them that they need a PCP assigned and how to do that. But as Ms. Smith said, and as we all know, a lot of people don't, 26-year-olds, as Representative Pilkington said, who don't think they're ever gonna need a doctor, are probably not gonna call that line and get a PCP assigned. So then when they do engage with the healthcare system, they have a lot difficulty accessing that care, that's when they then come back. But our welcome packet does tell them that they need a PCP assigned and how to get that information.
Representative Ryan Rose So, if I'm understanding correctly, the process is once they become a Medicaid client, they receive a packet. And they need to communicate to AFMC and say, hey, I need a PCP, and then that happens.
Elizabeth Pitman They can get their own PCP. But yes, if they would like assistance, they can use the Connect Care line to help get a PCP. They can go to their own primary care physician and get on their Medicaid panel. They could walk in. But they can also call our line to know who is available in their area, who's taking clients, that sort of information, who sees patients with disabilities or has a Spanish-speaking person on staff that can help them. They have all that information.
Representative Ryan Rose And so I'm going to stop on this point after this. But what I remember is that there was a significant challenge communicating with Medicaid clients when we began having a conversation about disenrollment three years ago. And I remember asking then, like, how are we communicating this to Medicaid clients? And there was a discussion about a PR campaign and some other things.
What I'm hearing is somewhere between a third to a fourth, I think I heard somebody said 174,000, somebody else said 145,000 more or less, Medicaid clients who require a PCP and don't have one. And I guess my thing is, you say we're giving them a packet. Well, for at least 25 to 30% of the time, that's not effective. What are we going to do about it?
Elizabeth Pitman Yes sir, we hear you. And we've had concerns around that as well, which is why we've looked at the potential of doing auto assignment, which was where they would automatically get a PCP assigned. But again, we have to communicate that to them. So as an agency, we are looking at better ways to communicate with our clients. We're targeting specific groups. For example, pregnant women have been a big emphasis.
So we're starting some new information campaigns for pregnant women. If these prove to be effective, there are things like text messaging to the women about what services are available, call centers that are available to them throughout the state, things of that nature. It involves focus groups with women to find out things that they think would be beneficial.
So we'll take those things and apply them across all our population groups as we learn. So we're working to make more effective means of communication with our clients. We realize that just mailing packets is not always the best way to do it.
Representative Ryan Rose Has there been any effort to reach out to that 140 to 170,000 people and say, Hey, you need a PCP?
Elizabeth Pitman I don't think there has.
Representative Ryan Rose Has there been any kind of secondary information delivered to them?
Elizabeth Pitman I don't know that there has. We're happy to explore ways we could do that. That would be more effective than another mailed packet, but I don't know that we have done that.
Representative Ryan Rose Okay, I'm gonna hop out. Thanks, Mr. Chair.
Nell Smith We also did, as part of the, when we were building out the auto assignment in our system, we had notices. Notices were part of that to say, hey, you haven't been assigned. We're about to auto-assign you, and you have a chance to choose somebody if you'd like. So that was part of it, that whole process.
Representative Aaron Pilkington Representative Beaty, you're recognized.
Representative Howard Beaty Thank you, Mr. Chair. Not a member of the committee, but wanted to come in. I heard some discussion today, and I want to follow up kind of along Representative Johnson's point. I heard you say earlier we could look at some type of reimbursement for the hospitals, similar to the urgent care. He makes a valid point. Once you cross that interstate headed south, there aren't many urgent cares down in my neck of the woods in South Arkansas.
And so the hospital ER is the resort on weekends or after hours for our citizens to go. All the hospitals that we have, the ones that we had problems in the state right now, financial strain on the hospitals, my question is, why are you telling me we could look at that? Why haven't you already looked at that? Why don't you have a plan before us that we could at that would help these hospitals and address this problem on reimbursement? Why don't we already have that? Are you waiting for the legislature to tell you that you need to do that?
Elizabeth Pitman No, sir, we were not-- I was speaking specifically to the urgent care issue that was raised last week. So we were not aware of that particular concern from Representative Johnson until last week. So we're working on that now.
Representative Howard Beaty We're aware now and we're working on that?
Representative Aaron Pilkington Representative Beaty, I think we're gonna have a follow-up committee meeting to talk about these issues with the emergency rooms and everything. So just FYI. I don't know if you were here earlier when I think Representative Lee had suggested that idea. And I think we're gonna run with that.
Representative Howard Beaty Sounds good. Thank you, Mr. Chair.
Representative Aaron Pilkington All right, Representative Johnson, you're recognized again.
Representative Lee Johnson Thank you, Mr. Chair. And thanks to the committee for the latitude. And I'll try. Like, I don't want to be here for another hour and a half either, committee. But we are here and we referred this to subcommittee for a reason. We were all here on the day of the Public Health Committee and we had a relatively short meeting that day. I was happy to have the discussion that day. But if this is the format then I want to take advantage of that. I do have quite a few questions and I know that these meetings are recorded.
But I'd like to have some data that I don't think you have ready today. And a lot of that is around the 145,000 and whatever that number is. Like it would be great to see demographics on that. What percentage of those people are children versus adults? What's the age breakdown? Are they male or the female? What are the demographics? What's their backgrounds? And then how long have they been enrolled in Medicaid without a PCP? Have they been in the Medicaid program for five years and they still don't have a PCP? How many times have they tried to access the system? Okay. I mean, that's important data, right?
If we're sitting here saying that, if 145,000 Arkansans can only-- we're saying, look, the condition for you to access to the system is you have to have a PCP, and the only information we're giving them about how to get a PCP is the initial enrollment packet with the number to call, how many times are they butting their head against the wall? And how many times have they getting frustrated and showing up at the ER knowing that we are leveraged and we have to see them, right? And so, how many visits and where are these visits? What is the reimbursement difference between an urgent care visit and an emergency department visit?
And is there a way to come up with a new definition around how we define emergency department visit? I'm sure our hospitals, like, something's better than nothing. And, you know, the $13, $15, whatever the dollar amount is there that we're reimbursing for a professional fee for that service, if we didn't have to have a PCP referral to get it, because we have to take care of it anyway, it'd be great. So, like what is the price difference? What are we really saving by not allowing our hospitals to bill for these services, especially in rural areas?
Is there a way to designate our critical access hospitals and make a difference and say, hey, if you're a critical access hospital, you don't have to get a PCP referral. How many PCPs are taking Medicaid in the state? So that's knowable, right? So every PCP that takes Medicaid is enrolled in our PCCM program, is that correct?
Elizabeth Pitman Yes, sir.
Representative Lee Johnson And those people, if I'm correct, they get $3 per member per month for every patient they have, whether they see them. I understand the intent is to do care coordination, but do we have any accountability around care coordination? Do we know that they're, and I'll wait for an answer on that one-- do we have a system where we can say, I mean, is the $3 conditioned on some sort of connection with the patient, or do they just get it automatically?
Elizabeth Pitman Believe they just get it automatically today. There is no quality measure associated with that $3.
Representative Lee Johnson Are PCPs capped? Can they enroll as many people as they want in PCCM?
Elizabeth Pitman They cannot. We have a default number that we enter into for them. They can lower or raise it depending on their own ability to see patients.
Representative Lee Johnson So what is that default number? I think it's 2,000.
Elizabeth Pitman I thought that was lower than that, but we will get it for you.
Representative Lee Johnson Well, I guess the point I'm trying to make is, is that if there's a finite number of PCPs taking Medicaid in Arkansas, if they're capped at whatever that number is, if it's 2,000 PCPs at 2,000, that's really hard math this time of the day, but we may not have the capacity to auto enroll 145,000 people because we don't have enough providers.
Representative Aaron Pilkington But there are some providers that are not allowed to cap their Medicaid, is that correct?
Elizabeth Pitman Not allowed to? You mean FQHCs?
Representative Aaron Pilkington My understanding is, special qualified health centers cannot cap their amount of Medicaid.
Elizabeth Pitman I'd have to check that.
Representative Aaron Pilkington That would be good to know for the next meeting as well.
Elizabeth Pitman I'll check all of that.
Representative Lee Johnson These questions that I'm asking, they're not rhetorical. Like, I want us to have it as a committee meeting where, and y'all know they're not adversarial, like, I'm not trying to be a jerk up here. I just think this is --I'll lean over to Representative Rose. I mean, of all the things we've discussed, I knew the answer to all these questions, except I did not know that there was 145,000 people in Arkansas that didn't have a PCP. Like, that number shocks me. That number shocks me.
And so like, how long have they been waiting? And are we really gonna punish them if we don't have enough PCPs? Like let's not give them four urgent care visits, let's give them 100. I mean, let's send them to FQHCs. How do you say to someone, like you need blood pressure medicine, but we can't give you a PCP. Like the other question I would have is how often are people calling Connect Care, and the PCP they're assigned is more than 30 miles from where they live?
Elizabeth Pitman I don't know the answer to that either. We will get you metrics on all of the PCP caps for different provider types and limits, what we think the capacity is.
Representative Lee Johnson If you're living in rural Arkansas, and we're saying to you the only way you can access the health care system is if you have a PCP. And there's not a PCP within 45 miles of your house, how's that person going to get health care? And apparently there's 145,000 Arkansans that aren't accessing the system, because we won't let them, because they don't have a PCP. And if the math doesn't work and there's just not enough, that's a deadend game. I mean, how are we going to get Arkansas healthier if we can't get people to providers?
Elizabeth Pitman No, I hear you. We will come prepared to discuss all of that for the next time.
Representative Lee Johnson The other question I would have is how, when it comes to PCCM Inpatient Center Medical Home, one of the questions that I heard was, I think Representative Springer may have said, why do we have this set up where you have to call the PCP? I mean, the spirit of that is that this idea that the PCP is the care coordinator, right? That's the captain of the ship.
That's the person that knows what's going on with their patients. Well, if we're not getting that from the PCP, because the PCP has 2,000 Medicaid recipients and can't keep up, because the PPCP participates in PCCM but doesn't participate in PCMH and doesn't have any accountability back, like, what's the point? And so how many primary care docs are actually participating in PCMH versus just PCCM? And of the ones that are participating in PCMH, how many are meeting their metrics? And how many of them are pediatricians?
And how many of them are family practice docs? And how many of them are seeing adults? And what are the criteria for that? And I believe, and this is not a rhetorical question, the Medicaid Sustainability Review Report made some recommendations around updating, consolidating our PCMH and PCCM programs. Is that correct?
Elizabeth Pitman Yes, sir, it did.
Representative Lee Johnson And how much progress have we made on following through with those recommendations?
Elizabeth Pitman Those were recommendations. So we haven't decided which recommendations to adopt or not to date.
Representative Lee Johnson So I would encourage us if we're going to have follow-up meetings to look at, to specifically look at that section of the Medicaid Sustainability Review Report and try to dive into what were these recommendations. We paid a lot of money to Guidehouse to come in and make some recommendations around creating sustainability, which I think, as responsible stewards of the budget, we need to make sure we're doing. And so how many of those recommendations have we followed? And this is a very specific one, and this ties into this idea of like, how do people access the system? So I don't have any more questions today. I would love to have a followup meeting and I want to be respectful of everyone's time. I would like to have a follow-up meeting. I think that'd be beneficial. But as far as that goes, I guess I'm done asking questions today.
Representative Aaron Pilkington We will have a follow up meeting. I'll work with DHS and the committee to find a time that allows you to get the data you need to answer these questions. And so, I mean, I know we've asked a lot of you today. Who would have thought urgent care clinics visits would create this discussion?
Elizabeth Pitman I did not.
Representative Lee Johnson I will make a motion that-- I don't know if we need a motion out of this committee for this rule. I'll ask Caitlin, but I'm perfectly fine taking action on this rule. And I would make a notion that we recommend we approve and review this rule and send a recommendation back to the Public Health Committee. I agree, we ought to make it four. I think the rule's a good rule. I think that we oughta move forward with that rule. And I would make that motion if that's something we need to do.
Representative Aaron Pilkington I don't want to take your motion at this time because I got three other people in the queue. And since this is the only item on our agenda, as soon as we approve or not approve of this, we're done. So I will take it at the proper time.
Representative Lee Johnson I appreciate the latitude the chair and the committee and I don't have any more questions today. Thank you.
Representative Aaron Pilkington Representative Barnes, you're recognized.
Representative Glenn Barnes Yes, thank you, Mr. Chair. If you would, can you get us information on, especially those rural areas, those doctors that are close to them that do not take Medicaid?
Elizabeth Pitman Get information on who is enrolled as a Medicaid provider and we can try to get a percentage of how many physicians. I think we'll have to work with the health department to find out how many physicians are licensed to make sure we get that information. And then we'll slice and dice those metrics as best we can and try to provide you that before the next meeting.
Representative Glenn Barnes Thank you. I think that's important because some doctors have opt out. There was a small percentage probably, somewhere like nine percent. But if that's in our rural area normally, that's the area that's affected by these metrics. I'd like to know that number.
Representative Aaron Pilkington Representative Rose, you're recognized.
Representative Ryan Rose Thank you Mr. Chairman. There was a discussion earlier about the reimbursement difference between, if I understood correctly, urgent care and emergency room reimbursement rate. You said you could get that. Were you guys able to get that?
Nell Smith Yes, so an emergency room coverage flat fee is $51. For non-emergency services in an ER, it's $12.
Representative Ryan Rose Wait, say that again.
Nell Smith $51. It's a flat fee for emergent. And this is in addition to the the treating. You know, there's their procedure codes based on what happens to the patient once they're there. But it's the flat fee for emergent conditions of 51 versus $12 for non-emergency.
Representative Ryan Rose I asked her to repeat it because I'm still wanting to make sure I understand it. You said it's $51--
Nell Smith That is the emergency room coverage condition code 80. Sorry, yeah, emergency room coverage.
Representative Ryan Rose And then it's $12 for--
Nell Smith Care at the ER that is considered non-emergent services.
Elizabeth Pitman So the way we pay hospitals, I just want to be clear, is we pay a facility fee and then we pay a professional fee. So all this is the facility fee. So I don't want it to come across as that we're paying for an emergency at $51. That's not accurate. They would then bill us for the labs, the tests, and the physician's time on top of that. So before we can answer that, can we review that and get back to you? I just don't want this committee to think we're paying emergency rooms $51 when somebody walks in with a heart attack or something of that nature. That's not accurate.
Representative Ryan Rose Sure. And I follow that. What I'm still trying to get at was the primary question was the reimbursement rate for emergency room visit versus an urgent care.
Nell Smith And that's something we're going to have to get back to you on.
Elizabeth Pitman I don't think we have that today.
Representative Ryan Rose Okay. So can we absolutely have that?
Elizabeth Pitman Absolutely.
Representative Ryan Rose In clear language for the lay person. Dr. Lee follows all of this very clearly, but for at least me, maybe everybody else in the committee will get it too, but at least for me, I'd really like it to be clearly delineated so that we know exactly the difference. And I understand that it may be reimbursed slightly different because of maybe urgent care does it this way and ER room emergency room does it this way. I would just still like to see that breakdown.
Elizabeth Pitman Yes, sir. We'll get you that as best we can.
Representative Ryan Rose Very clearly. And thank you, and I appreciate that. I had a follow-up. I think the follow-up was that you discussed that you were exploring ways to communicate to those 100-some-odd-thousand-plus clients who do not have a PCP. Can you, when we have our follow- up meeting, can you share with us the ways that you're contemplating doing that and then maybe the road map for how you can then begin implementing those? Because I'm good with us discussing, hey, we're going to have some ways, but I'd like to know what the ways are and how. I think Representative Beaty may have made the point. Do you need us to take action and make that happen? Are you waiting on us? Or can you do it and let's figure that out.
Elizabeth Pitman We can and I just want to be clear we're working on ways to communicate with all 870,000 of our beneficiaries. We feel like we need to work on that across the board.
Representative Ryan Rose And I'm more than understanding that some of this is an individual responsibility, right? You cannot force people to make good decisions. But for those who are trying to make decisions, I want to make it available to them in the best way that we can. So, all right.
Representative Aaron Pilkington Representative Ferguson, you're recognized.
Representative Kenneth Ferguson Thank you, Mr. Chair. Just for clarification. Would this rule affect individuals-- yes, right in front of you. Will this rule effect individuals who are Arkansas Works? I ask that question because some people on Arkansas Works do pay a premium based on certain criteria. So how does that?
Elizabeth Pitman So the individuals on Arkansas Works, which is now ARHome, that are in a qualified health plan, they get PCPs through their qualified health plans. So what we're talking about today does not impact them. Also, we no longer require premiums on ARHome. The federal government said we can no longer do that. So they do not pay a premium any longer. They just pay co-pays.
Representative Kenneth Ferguson So it doesn't affect them at all?
Elizabeth Pitman This rule does not affect them. They do get a PCP assigned through their qualified health plan.
Nell Smith Thank you. Just one caveat to that. It does affect people who are in ARHome who are not in a QHP. So medically frail individuals are required to have a PCP.
Representative Kenneth Ferguson Okay. All right, thank you. Thank you, Mr. Chair.
Representative Aaron Pilkington Representative Springer, you're recognized.
Representative Joy Springer Thank you again, Mr. Chair, for allowing me to participate and answer questions. And thank you all for being here. And thank Dr. Johnson for all those questions that he asked because I was kind of following along with him. I do have one more to add to the data that he requested. Knowing that we have a maternal health problem, another good thing would be how many of those 140,000 persons are women of childbearing age. So that we may be to address that by knowing that and getting them registered for the program in advance of them having to have problems.
Elizabeth Pitman Absolutely. We'll get that.
Representative Aaron Pilkington All right, seeing no other questions, I believe Representative Lee Johnson has something he'd like to say.
Representative Lee Johnson Sorry, thank you. And I want to be considerate of DHS in this process. Like I don't want to move this rule forward if you think there's an opportunity to improve the rule before we move it forward. This is not an, we've used the word emergency a lot, this is not an emergency that we get this rule out of this subcommittee. If there's benefit in holding the rule and waiting until after the next meeting, I'm happy to pull down my motion and we can just hold this rule and we let the chairs of the Public Health Committee know we're still in the process of reviewing it. Would that give y'all more time to look at the rule?
Elizabeth Pitman It would give us more time to look at the rule and determine whether or not to pull the rule. But I will be again completely transparent, if we pull and change the rule, we will have to start over with public comment.
Representative Lee Johnson I understand that. So I'm happy to hold my motion if you can commit to not pulling the rule. Because I'm not ready to say this isn't the right rule yet. Because as it stands, I like it. Send it forward. But I don't want to miss the opportunity to make it better.
Representative Aaron Pilkington So you're pulling down your motion?
Representative Lee Johnson I'm waiting for them to say they're not gonna pull the rule.
Elizabeth Pitman We won't pull the rule unless we--
Representative Aaron Pilkington Let me ask it this way, Ms. Pitman. Some of the changes and ideas that have been brought up today, we could just require a new rule in addition to, we wouldn't need to necessarily add on to this. Basically, if the urgent care rule passes, it's not like doors close, you can't do anything.
Elizabeth Pitman That is accurate. And I do think we need to come back in and clean up the emergent care and walk-in clinic language regardless, because that means nothing. So I think that gives us an opportunity to work on some of these other rules as well.
Representative Lee Johnson So I'm willing to pull down my motion and then give them a chance to look at the rule closer if everyone in the committee is okay with that.
Representative Aaron Pilkington Do I hear any objection from the committee on that? All the senators? Yes, Representative Ray, you're recognized.
Representative David Ray Question to that. And I would lean on Representative Johnson on this. But did you get the commitment from them at the table that you were looking for?
Representative Lee Johnson I would say sort of. What I heard is this rule needs to be cleaned up because we don't have a definition of walk in clinic or emergency clinic.
Elizabeth Pitman It's emergent.
Representative Lee Johnson Does this rule need to be revised to reflect that? Does that revision require a whole new public comment period or is that technical cleanup?
Elizabeth Pitman That revision by itself, I'm not giving the firm legal opinion of it, in my legal opinion, it's not a substantive change to the rule.
Representative Lee Johnson You know, I'm looking for a commitment that I recognize you need to clean up the rule, that you're not gonna pull this down and let us start from scratch. Because this committee may decide that this is the absolute right rule to move forward with. We already have the public comment. You know I don't wanna lose the opportunity to pull trigger on this rule that I think is a good rule. So I understand Secretary Putnam is not here, the governor's not here. You work for people. Just understand that I think it's my expectation and maybe the expectation of the committee that this rule not get pulled down until we can meet again.
Elizabeth Pitman We'll just hold it until the next meeting.
Representative Lee Johnson Okay. And I would make one request to the chair that, I would love to attend the next meeting, how and when that gets scheduled. My July schedule is a little rough. And so June or August, I don't know how urgently we want to look at this.
Representative Aaron Pilkington I know we were trying to get this on the next ALC. So, but let me, I made the commitment to work with DHS and this committee to find a time in which we can meet. So it won't be the Friday after ALC or something like that. So we can work as a committee to try to find the time that works for y'all. Because obviously, you've got a different timeline and things have to go through a certain process, so it's not like you can just show up Monday with Post-It notes on it and it change. I get that. But Representative Johnson, we will work to make sure that you're able to attend that meeting.
Representative Lee Johnson Thank you, Mr. Chairman.
Representative Aaron Pilkington All righty. Seeing no other questions, I appreciate y'all being here today. I'm sure this was more than you thought you're gonna get into today on urgent care clinics. But I appreciate your time and I appreciate all the information you're going to be providing this committee. So, I think we can tell this is going to be a pretty active subcommittee during the interim. So, but we're excited to work hand in hand with y'all and try to find the best outcome for Arkansans. And so with that, with no objections, we are adjourned.
