November 25, 2024

Joint Public Health

 

Senator Missy Irvin Okay, members, we have what looks like a long agenda, but I think we will be able to go through it systematically. Just good morning. And it's the week of Thanksgiving. And I just personally want to say that I'm so thankful for our staff, for everything that they do. They're tremendous. And they pull us together and make us look good. And I'm really thankful for you guys. And I know we all are. So thank you for all the work you guys do for us, and we just appreciate you so much. Also thankful for our ability to come here and serve our constituents and the great people of the state of Arkansas. And sometimes we don't say that enough. And I'm thankful to have the opportunity and the blessing to be able to do that as we go through this. 

If you have questions, make sure that you pin in to your keyboard so that you can be recognized up here with your microphones. How does that work if they're a member elect? I'm not sure that happens. Yeah. Okay. All right. Okay. And I do know that perhaps we do have some members-elect here, and I'm excited to welcome you. If you will just state your name for us and we are not sure if your mic's are going to work or not. They should just push that button and we will recognize you. [inaudible] Glad to have you. And I know Glen Barnes probably doesn't need the mic either. [inaudible] Well, we're glad to have you. Are there any other members elect with us today? All right. Thank you for both being here. All right. With that, we will go ahead and get started. Do you have any comments? All right. 

We'll need to have a motion to consider to approve the October 28th meeting minutes. Motion and a second. All those in favor say aye. And opposed? Ayes have it. Those meetings are approved. Moving on to item C, we will have the presentation on the Arkansas Poison and Drug Information Center, if they will come forward. As they are coming forward, members, I just want to remind you of an upcoming event that is by the legislature, which is Christmas in the Capitol, and that will be coming up. You'll get an invitation that is for everybody, agencies, lobbyists, members, members elect, every one. Christmas in the Capitol, where we bring gifts for all of the children that are in our foster care system. And so you'll get an invitation coming out soon on that. I believe it's December 12th or 13th, but I hope everybody will come to Christmas in the Capitol and bring gifts for those children that we have in our care. Thank you. Okay. If you'll introduce yourselves for the record, then you may proceed.

 

Speaker Thank you, Madam Chair. Committee, I appreciate you giving us time here today. Arkansas Poison Center and Drug Information Center is a business unit of the College of Pharmacy at UAMS, but it's something that serves the entire state. It touches every one of your districts and every county. I don't want to take too much of their thunder from their presentation, but I wanted to just come and give you this informational presentation today to let you know how it serves your constituents back home. And with that, I'm going to stop talking and let the experts introduce themselves and give the presentation.

 

Senator Missy Irvin All right.

 

Howell Foster Thank you, Madam Chairman. Committee members, I'm Howell Foster. I'm the managing director of the Arkansas Poison and Drug Information Center.

 

Kevan Beth Meadors Hi. Good morning. Thank you all for having us. I'm Kevan Beth Meadors. I am an physician at UAMS and a medical toxicologist that works for UAMS and the Arkansas Poison Center and Arkansas Children's Hospital.

 

Ari Filip Good morning. My name is Ari Filip. I'm also an ER physician and medical toxicologist, and I'm the medical director of the Poison Center.

 

Senator Missy Irvin Excellent. Welcome.

 

Howell Foster Well, I guess I'll go ahead and get started. Let's do this. Well, here we go. So our objectives today is to basically give you all a brief history of the Poison Center, what our role is and discuss how our services provide high value care for the citizens of Arkansas. So what do we do? Basically, we are a resource for the lay public and health care professionals. We're open 24-7/365. Last year, we dealt with just a little over 21,500 human exposure cases. And we also dealt with about 5,800 informational cases. It goes down from a human exposure case to about 59 per day. 

But something that needs to be understood about that, this isn't just one phone call, we give some advice and we stop. We average almost 80 follow up calls a day to these individuals and whether they're at home or in a hospital. And then we average about 16 informational cases a day. We reach every county in Arkansas on a monthly basis for human exposure. So we are truly a statewide service and we are staffed 24-7 by health care professionals. This is basically the group of us. This is the professionals that run the center. There's myself, Dr. Meadors, Dr. Filip and Dr. Erica Leibell, who's on call today. She's not here. We have the pharmacists on one side, the nurses on the right hand side of the slide there at the bottom, and then our public educator, Charlie Stutz. And that is the professional staff. That is every single person professionally that works in the center. 

We've been operating for 51 years. The Poison Center started with a grant in conjunction with the Health Department and operated for one year, the term of the grant. At the end of that, the College of Pharmacy decided it was a worthwhile endeavor and ran the center independently until 1993. In 1993, Act 796 basically created the Arkansas Poison and Drug Information Center and placed it in the UAMS College of Pharmacy. Act 797 was appropriated but not funded. Then in 93, Act 797 got funded and the center went public. Prior to that, we were a professional only center. So we spoke to physicians pretty much in emergency departments. In 93, we began receiving public calls. Then we went in house 24-7 in May 1999. Prior to that, the overnight call was taken by the emergency department. And in September of 99, we got our first federal grant money. I wrote that grant and I've written every other subsequent grant since then. 

We were regionally accredited as a Poison Center in 2005 by the American Association of Poison  Control Centers, re-accredited in 2010, 2015 and 2022. And you see at the end there, there's a seven year gap. They got a system to where we could actually do it electronically and my center was the guinea pig to start that system. So it was kind of an interesting thing for re-accreditation at that time. 

So how has this mission evolved? Well, as I've stated earlier, we started as a professional only center and then in 93 we went to the public. And the number of calls, shortly after that, we reached a point where about 85 to 90% of our calls actually came from the public, and only about 10 to 15% of the calls came from health care professionals. But over time, that has changed in going back to more dealing with health care professionals directly in emergency departments. And let's look at a little bit of why that is. 

In the last 15 years, we've had almost a 23% increase in adult cases, 72% increase in health care facility cases and an almost a 92% increase in suicidal cases, which is going to be the bulk of those additional adult cases that we're seeing. But if you look at this in children, we've seen a 200% increase overall in children in suicide type cases. And if you go to children 12 years of age or less, it's 800%. All I will say to that is I don't know the reasons for it, but we have a serious mental health issue within the pediatric population. And it's not just in Arkansas. It's nationwide. 

As you can see, we took almost 3,500 suicide type exposure cases in 2023, and that required almost 12,000 follow ups. Suicide cases require a lot additional work. I was talking to the health care practitioners and emergency departments in intensive care units. It's much more stressful on the staff as well. Most of the home calls are pretty easy for us to manage and we'll see some data on that in a minute. 

So one of the things that we do provide is a lot of savings or cost avoidance. There are actually two pretty well-done studies that show anywhere from $7 to $13 are saved for every dollar you spend on a Poison Center in the U.S.. These studies are old, and there's a push to get these studies redone or another study done to look at this cost savings. But if we look at that model-- and this next slide is a little bit busy-- if you take that, we take about 21,500 exposure cases a year. About 15,000 of those originate at home. So about 70% of them now originate at home. Our referral rate is only about 15% on those cases, meaning that we keep 85% of those cases at home. We manage them at home. If there's no problem with it, we tell them on the front end. Sometimes you get into something that is not poisonous or is not going to be harm at the dose that they got into it. So we keep those individuals at home. 

If you look at that, it's about 12,750 cases. I do a survey of callers to the Poison Center every few years. I've done it five times since I've been the director. And the one thing that comes out of that: If you ask somebody, "If there was no Poison Center, what would you do?" about 80% of those individuals say they would immediately go to the emergency department. Subsequently, I also poll physicians. And if you asked them, "If a constituent called you and said, 'I have my child at home and they ingested some substance,' what would you tell them to do?" And oddly enough, about 80% of them also say, I would tell them to go to the emergency room. 

So if we do that, and even if there's a margin of error there and just look at 75% of those cases, if they went to the emergency department and we used $2,300 as the average emergency cost for someone to go into an emergency department for pretty much an uncomplicated stay, almost an all day stay, but an uncomplicated stay, that's almost a savings of $22 million. And that's on a budget of about $2.1 million. So in short, Poison Centers save a lot of money. 

We also work with a lot of different groups nationally. We work with the FDA, also the CDC, which is a functioning arm of the FDA. We do some work with the ATSDR, which is a functioning arm of the EPA. We provide data to the American Poison Centers, and we also do a little bit of work with the toxicology investigators consortium or Toxic, which allows us to pool data with other Poison Centers and other toxicologists around the country to learn to better treat patients. We can't poison people and do studies on them, so we have to use the data that we're getting from existing cases. 

We also work very closely with a few of the state agencies. One is the Health Department. We have a very good relationship with the Health Department. If there is a disaster that is poison related, we will be the call center for the Health Department, most likely. The governor also has the ability to stand us up in a disaster if necessary as a call service. The Arkansas Office of the Attorney General, We've been working with them on a few different things at different times. Right now it is what I call gas station marijuana. It's these edible gummies that contain THC derivatives that circumvented the farm bill. The Arkansas State Crime Lab, we work with them on some fatality cases back and forth to make sure we're getting what we think the actual cause of fatality was on the fatalities that we deal with. 

And we also work with the Arkansas Trauma Communication Center. This is a pilot project for snake bites. The physicians are able to actually view through the trauma system snake bites in real time. And that's a very interesting thing. We would like to eventually expand that to other patients potentially. 

So one of the things that was talked about was sharing data with the APC, the America's Poison Centers. They have a system called NPDS, which is the National Poison Data System. Honestly, it's the worst logo I've ever seen. I don't know what that logo means, but it is what it is. What this system does, though, whenever we have a case and we send it to our network, we log it in and we keep a medical record, if you will. Within eight minutes of it hitting our network system, it goes to a national system. Now it is de-identified data. So we're not sending out anybody's names, phone numbers, anything like that. It's completely stripped of all that. It's substance, age, that type of thing, maybe symptoms. This allows for algorithms to run in the background to identify trends. Tide Pods. Poison Centers were one of the first group to really step out and say, Tide Pods are a problem. This was long before the Tide Pod challenge hit Tik Tok and the other online type things. 

These algorithms are pretty interesting, some of them. You know, recently we had a case where we had a food poisoning case that had it was a family of three over near Fort Smith, and they had muscle weakness. Just across the border in Oklahoma, they had someone that had called the Oklahoma Center that also had muscle weakness. And then in that same timeframe, about a six hour window, somebody in East Texas had a food poisoning case where they had muscle weakness. That automatically triggered stuff for us to follow up very closely with those cases to make sure we weren't having a botulism outbreak of some unknown reason. So that's what this system is for. It doesn't, like I said, it doesn't identify the patients. It contacts the center that is related to those for us to do follow up. 

Our education mission, we're in an education center at UAMS. So we do take students, but we also go out and try to educate the public. You know, we try to put ourselves out of business by getting individuals to poison proof their home, but at least have the phone number handy if something goes out. And we annually push out almost 100,000 pieces of information a year. Most of those are magnets or pamphlets. And we go to schools, we go to health fairs, new mothers, those types of things, pediatricians offices. But we also do public education. We, obviously, because we're at UAMS and we have a service unit there, we take students at UAMS. We also take students that are both pharmacy and medical residents. And we're also willing to go out as public staff and give presentations in other places in the state, obviously, given if we can work it into our schedules.  

Research mission. We actually do some research. Presently we have a paper submitted to the Annals of Emergency Medicine on alpha gal related effects, potentially to antivenin. We have two interventions available for snakebite. We had had one for almost 25 years. We had a new one and that came on the market and we were worried, given the number of patients in the state with the alpha gal, that we may have a problem with it. And it turns out our suspicions were correct. We are seeing a significant problem with that product. You know, we're also collaborating with some other states to look at this and also looking for national trends in some data. But we do feel like antivenins may end up being regionalized. We're going to use one here, and in other parts of the country that don't have alpha gal may be able to use the other one. 

We do case reports. If we have interesting cases, again, we will try to get those published. This is our funding history. 1973, again, it was a grant. The UAMS College of Pharmacy funded it until the summer of 93. At that point, Act 797 was a non line item appropriation put into UAMS' budget. And for the most part, that was our budget for the first-- shoot, how many years is that? 18 years, I guess. Yeah, 18 years. 

At that point, we got some CHIP funding via DHS. That's CMS passthrough money. We're only one of nine centers in the country that get that money. In 2009, there was an appropriation increase of $400,000, but it remained unfunded. Those were pretty tough economic times. And if it hadn't been for CHIP funding, I actually think our center would have either closed or at least pulled back 24 hour services. We wouldn't have been able to fund it. Presently, our state funding is we have a direct appropriation from the state of about $1.1 million. We get about $700,000 net CHIP money. We do have to pay a matching amount on that. And then right now the federal grant is about $217,000. And we do some small contracts that really amount for a very small amount of money at about $15,000. 

And with that, I'll take any questions. Appreciate your time.

 

Senator Missy Irvin Yes, sir. We appreciate the information, as always. For our members elect, it's really important. There's a lot of topics that the Public Health, Welfare and Labor Committee covers, and we try to get to all these different types of topics that we can. Are there questions? Let's see. Representative Pilkington, you are recognized.

 

Representative Aaron Pilkington Thank you, Chair. Over here. Thank you. Your presentation today was very informative. First off, I'd just like to give some kudos to your team. Literally, last week, my wife called Poison  Control when she got some bleach splashed in her eye and they were calm and collected and helped her deal with three screaming children and tell her kind of what to do. So I really appreciate that. And especially, too, as someone with Alpha Gal, it's good to know that you guys are taking that in consideration when dealing with snake bites. 

The question that I have is, and I'm curious about this, do you track the number of people who call in which they've they've been poisoned, and how many of those end up being fatal and which are non-fatal? And then y'all's intervention preventing fatality? As I understand, some people may have taken something, there's nothing you can do, what's done is done, unfortunately. But I'm just kind of curious. I didn't see those numbers. And I don't know if that's something you track or not.

 

Howell Foster You know, we actually deal with about 20 fatalities a year. I think Dr. Filip can speak to this a little better than I can because he does all of our fatality reviews. Most of those are in suicidal patients, I'll just be perfectly blunt with you, and the deed is done by the time usually we're involved.

 

Representative Aaron Pilkington Okay.

 

Howell Foster It's very rare that we have an accidental poisoning that leads to a fatality. Not to say that it hasn't happened.

 

Senator Missy Irvin All right. Thank you. Representative Allen.

 

Representative Fred Allen Thank you, Madam Chair. My question is dealing with snakebites. Approximately how many snake bites do you all deal with on an annual basis?

 

Howell Foster You know, it varies a little bit given each season, but 125 plus or minus 25 bites.

 

Representative Fred Allen Are most of the-- follow up?

 

Howell Foster Those are all venomous. Yes.

 

Representative Fred Allen Are most of the snake bites caused by snakes that are in the woods or people that find snakes in their homes or yards?

 

Howell Foster We could cut the snake bite amount probably in half if people would just quit picking them up. But I mean, the other half are accidental. It's folks working in their garden outside in the yard. Children are more prone to stick their hands down and try to pick them up and things like that.

 

Representative Fred Allen Thank you.

 

Senator Missy Irvin All right. Representative Mayberry.

 

Representative Julie Mayberry Thank you, Mr. Chair. First of all, way back in 2015, I had you report to a task force that we had back then, the Alpha Gal Task Force. And back then, when I started talking about Alpha Gal, people thought I was crazy that we have reactions that came from a tick bite to eating mammal meat or anything from a mammal and really stressing how it's in medicines, it's in glycerin, gelatin, magnesium, it's in bovine extract, I mean, all these things. And that just seems so off the charts, like this woman's crazy. 

How many calls do you get regarding this? I mean, it's obviously still on your radar screen, and I'm happy to see that. But do people recognize that it's medicine that's actually causing it? Because most of the time people just think of it as being, I'm allergic to a hamburger.

 

Howell Foster Most of our calls are pharmacists inquiring on behalf of patients that we do that. I can run some statistics whenever I get back. I actually have it set up if the staff will remember to click a certain box. After that meeting, I made a box or dropdown window that if there was an alpha gal related question that they could click it and I can go back and run those numbers. But like I said, the vast majority are pharmacies calling the center, wanting to know if we can help them determine whether or not there's something in there that is animal derived or mammalian derived.

 

Representative Julie Mayberry Right. Well, and that is the hard part, is that it'll list an ingredient as glycerin. But glycerin can come from a mammal or it can come from vegetables. So what is it and is there anything out there in the future that might give more help in that way?

 

Howell Foster Well, I think-- this is my opinion. It's kind of gotten like the peanut allergy now. We will call companies and ask them and they will give us 1 of three answers. We test it and no. We test it-- well, four answers. We test it and yes. Or we don't know, but it's ran on a line that may have mammalian derived products in the line at some point in time. Or they will just flat tell you they don't test it. So it's problematic. Robert Wood Johnson Foundation actually has a big dedicated drug information center now to Alpha Gal and it's been a pretty useful resource. The problem is it's only there Monday through Friday, 8 to 5.

 

Representative Julie Mayberry Appreciate your advocacy. Thank you.

 

Howell Foster Yes, ma'am.

 

Senator Missy Irvin Great information. Representative Johnson.

 

Representative Lee Johnson First of all, thank you. You know, I'm also a practicing emergency medicine physician. I recently used the telehealth visit for a snakebite recently when trying to decide whether to give antivenom. And it was a very useful tool. It worked out really great. 

You know, it makes me feel old to hear you say 1993. I was a first year ER resident at UAMS. The process then, Dr. Simmons was in charge. And the process was the ER residents took all the calls after hours. And so as the first year resident, I was answering the phone from people in the public, and it was the number of the number of calls that you receive and sort of the breadth of the complexity and then maybe not so complex, right? I'd drink six cups of coffee, you know, how long am I going to be awake? I'm not really sure how to tell you. 

But when I think back on those days compared to today when I practice medicine, you mentioned the number of calls coming from health care facilities and how they've increased. I mean, I don't know how many prescription drugs were available on the market in 1993, but I suspect it's increased at least tenfold in my practice time. And so one of the reasons I think that I certainly lean more and I think a lot of my colleagues do too is because there are so many different drugs in the market. It's very difficult to keep up. And we need experts to lean on when people come in and they have taken an overdose of fill in the blank. It's not always a medicine that we're readily familiar with. 

And so do you think that in your experience, would you say that it's a more complicated space today to practice toxicology than it was maybe 20 years ago?

 

Howell Foster Absolutely. One is just due to the severity of the cases and the number of suicides. I started in 93 as well in the Poison Center under Dr. Simmons at that time. And I'm here because of him. But I agree with you. The pharmacopeia is much larger now than it used to be. And the diversity of drugs and the mechanisms by which they work are now much more diverse. So it is much more complicated. There's no doubt about that. 

I will say this. Our staff is highly trained and it takes a long time to get them trained. To get one of my individuals certified, it takes at least 15 months. So when I lose somebody that is certified, it's painful because it takes a long time to get someone up to speed. Pharmacists come in knowing a lot of the drugs, but they don't know the natural products. Nurses come in with a lot of direct patient care sometimes, and that's really important. But they typically don't know the breadth of drugs and the breadth of chemicals that are around.

 

Representative Lee Johnson Well, and this is also true with all the chemicals that are available. People will come in. I'm always leery of the guy walking in with the Wal Mart sack because whatever is in the Wal Mart sack is not good, right? There's a lot of times it's the snake that bit them. But also coming in with these containers of chemicals, cleaners. I mean, this is a very complicated issue. And I can't imagine operating in this state without the expertise that you bring to the table when it comes to dealing with some of these complex things. 

And I'm grateful and always with the follow ups, too, your staff. If you don't know, when you call Poison  Control, they always take your name, they always call back to follow up, check on the patients, see how things went. That's a very quality product you're delivering.

 

Howell Foster Thank you, sir. I appreciate it. Yeah, we try hard.

 

Senator Missy Irvin Senator Hammer.

 

Senator Kim Hammer Thank you, Madam Chair. On the subject of suicide, do you have a heat map that shows where the greatest number of suicides occur in the state by county? And have you done any studies of a correlation of maybe economic situations or other variables that might attribute to why the number of suicides in particular areas? Or is it just all over the place?

 

Howell Foster My gut feeling is it's all over the place. I can actually run numbers by county. I have not done that. That's actually a pretty good idea. I have not thought to do that. But my feeling is just given the sheer number of them and the breadth of them, they're going to come from everywhere in the state. Now socioeconomics, there may be something there, but I do know that age is there. There's no doubt about that.

 

Senator Kim Hammer And by that you mean to the younger side, to the older side?

 

Howell Foster Well, I mean, it's across the board, but whatever's happening with our young, it's just different now. I mean, if we got a kid that was 12 years old that did it, attempted suicide 20 years ago, we would all talk about it immediately. And it's just a common occurrence now. And that's a sad thing. But if you want me to run some numbers, I'll be happy to run you some numbers that I can run.

 

Senator Kim Hammer I'll get with you offline. Just a personal comment. I think the direction our society is going is attributing to a lot of it because of the coping skills. But I hope through the mental health efforts that we're going to try to establish, that will help turn that number down. But I'll get with you offline. I was just curious if you had any comparison charts, but I'll get with you offline.

 

Howell Foster I can d o you some, though. Thank you.

 

Senator Missy Irvin Actually, I think this is a deeper conversation that I think we would like to drill down more. And so if you want to send that, if Mr. Davis wants to send that to me, I'll get it out to all the members of the committee. The different information that Representative Mayberry asked about Alpha gal, as well as Senator Hammer asked, if you don't mind. And then I'll get that to everybody in the committee and who's here today on the suicides that you're responding to, particularly with the children under the age of 12. That's where you've seen a-- was it an 800% increase? So an 800% increase in children under 12 that are committing suicide.

 

Howell Foster Attempting to.

 

Senator Missy Irvin Yes, attempting to. And is that 100% fatality rate?

 

Howell Foster No, ma'am. No, ma'am. Fortunately. I can't give you a percentage number off the top of my head. I don't know the answer to that. But if we're dealing with 20 fatalities a year, it's going to be fairly small.

 

Senator Missy Irvin Okay. And then is that from-- what is the toxin? What are they using?

 

Howell Foster It's almost always drugs.

 

Senator Missy Irvin Illicit drugs or prescription?

 

Howell Foster It's prescription drugs within the home. The last fatality that I can remember, 12, 13 year old girl was Tessalon Pearls, which is a cough medicine. It's prescription. We had another case with methanol, which obviously isn't a drug, where they went out into the garage and drank fuel stabilizer. Most of the pediatric cases, in my opinion, that are suicide in nature are more cries for help than anything else. So it's a gesture.

 

Senator Missy Irvin Okay. Well, I agree with you. We need to wrap our heads around that more. And your information is going to be really critical and vital, I think, to that as we move forward. So any of that information you can get to us, I'll make sure that all members of the committee have it. Thank you.

 

Howell Foster And if anyone wants to reach out to me on county specific data, I'm happy to run it for you.

 

Senator Missy Irvin Okay. Representative Gramlich. And then back to Senator Hammer, and then we'll we got to move on to the next agenda item.

 

Representative Zack Gramlich Okay. Thank you very much. I'm a middle school teacher. I teach sixth, seventh, eighth graders. So I see a lot of this stuff. I've lost a few kids in the past from various things. So, I mean, it affects people like me directly and then affects everyone in that school who's attached to that. I would just ask for one other thing. Not just the number by county, but per capita in that county. I mean, obviously rural might have a different number than our more urban areas. And so if we could get a little bit more granular on the information as well, I would appreciate that.

 

Howell Foster I should be able to run it with census data.

 

Senator Missy Irvin Thank you. Senator Hammer. Last question, then we will move to the next.

 

Senator Kim Hammer Thank you, Madam Chair. And I was wondering, on the drugs that-- there used to be a campaign about, we really focused on drug take back and we really focused on clean out your cabinets. I used to be a hospice chaplain 25 years. And we'd always make sure the drugs were taken out of the home. I'm just curious, as far as awareness, have you seen a decline with what appears to be not as much focus in the advertising world to make people aware of getting rid of the excess drugs? Or have you looked at that to see if maybe in raising awareness of what drugs you have in the home, what drugs you have access to, these kids would have access to, would it make a difference?

 

Howell Foster I will tell you, that's a really good question. And right now, from my perspective, I would say I see it a lot because I'm in different pharmacy groups and they advertise when there are going to be drug take backs within their county and they're actually fairly common. So I see that pretty often. I'm not sure how well that's being advertised on the public side. I would think it's local advertisement and not statewide.

 

Senator Kim Hammer And the number of, say, 12 and under, what percentage would you assign were prescription drugs versus things like you illustrated a while ago where they went in the garage and they got what you know is not a prescription?

 

Howell Foster I would be a guess, but I would guess it's probably 85-90% either prescription or over-the-counter drugs.

 

Senator Kim Hammer Okay. Thank you.

 

Senator Missy Irvin All right. Thank you. We really appreciate you all coming here today. And I appreciate the offer for follow up information to submit to us. Appreciate it very much. Thank you so much. All right. Next, I think what we'll do is on this next item, number D, if you all will all come to the table, we'll try to get extra chairs maybe, or we'll take turns playing musical chairs.

 But important conversation for today is follow up to the legislation that the General Assembly passed. Representative Johnson, and it was my bill as well, on prior authorization. And so these are the different plans that have been submitted to us for review by the PASSEs. And so we'll just let you guys-- there you go. You're figuring it out. Members, in your packet that's going to be items D1, D2, D3, D4, and I think there's a D5. Yes. All right. What we'll do is we'll go ahead and just start with D2, which I believe is Summit. Will that work? Or however you guys want to proceed.

 

Brad Nye Good morning, Chairs, members of the committee. My name is Brad Nye and I'm with Summit Community Care. I think, with the chair's permission, I think it might be easier for us just to present as a group.

 

Senator Missy Irvin Okay.

 

Brad Nye We've really tried to mirror our policy as much as we can. Typically working with our providers, they really like it for us to have a uniform approach. So I think we've done a good job of trying to do that here.

 

Senator Missy Irvin Okay, so let's just all introduce ourselves for the record and then off you go.

 

Corey Cox Madam Chair, members, members elect, Corey Cox with Care Sauce.

 

David Donohue Madam Chair. David Donohue, Market President for Care Source.

 

Mitch Morris Good morning, Madam Chair, members of the committee. My name is Mitch Morris, CEO with Empower Health Care Solutions.

 

Lauren Grounds Madam Chair, my name is Lauren Grounds. I'm the senior director of Med Management operations with Arkansas Total Care.

 

Jack Hopkins Jack Hopkins, Arkansas Total Care.

 

Senator Missy Irvin All right, off you go.

 

Mitch Morris I'll start off if that's okay. So, as the committee knows, Act 575 of 2023 required all health plans to adopt a Gold Card policy designed to reduce prior authorization requirements. As you know, health plans commonly require prior authorization for certain services before they are rendered, general definition of what we mean when we say prior authorization. The provider-led groups or the PASSEs were exempted from Act 575 as long as we prepare a policy designed to reduce and in some cases eliminate prior authorizations for our network of providers. And so that's the policy that we submitted for consideration today. 

The goal in preparing this policy was to find that right balance between Act 575 and those requirements and balance that with the objective to reduce prior authorization, but to balance that new legislation with the key goals and objectives that were established in the initial Act 775 or 2017, which created the PASSE program. By the way, we do appreciate the special provisions in Act 575 that were given for the PASSE program, recognizing the nature of our special needs beneficiaries, which primarily represent Medicaid beneficiaries with complex behavioral health conditions and intellectual and developmental disabilities. So we definitely appreciate those provisions and do think that they appropriately recognize those special considerations for the people that we serve. 

You know, the PASSE program was created to provide quality care with an emphasis on high touch care coordination, but also to help slow the spending growth in Medicaid and help reduce instances of fraud, waste and abuse. A big part of fulfilling these goals is the judicious use of prior authorization. The use of prior authorization for some services is critical to ensuring proper care is provided at the appropriate level. But prior authorization is also helpful, a very important tool in maintaining contact with our beneficiaries so that we know the services that they're accessing as quickly as we can know that to support the goal of care coordination. So this policy does create and it formally documents numerous exemptions to prior authorizations such that any provider in the network that provides those services is not required to pursue that prior authorization. 

But for the reasons that I just stated, the plan is to continue a judicious use of prior authorization in certain circumstances to support the intent of the original PASSE legislation and also to support our very critical job with trying to provide care, coordination and high touch support for those beneficiaries.

 

Senator Missy Irvin All right. Thank you. I think it's important for us to hear from all three or everybody, four.

 

Brad Nye Thank you, Madam Chair. Brad Nye, again with Summit Community Care. I'll just second Mr. Morris' words here in regard to prior authorization and gold carding. We feel strongly that this is a a good first step in policy towards lowering provider abrasion and making sure that our providers can do what they're really there to do, which is to provide the needed care to our complex beneficiaries. 

I would add that at least from Summit's standpoint, this is a first step. We actually have a committee that meets at least quarterly that looks at the data as it comes in and makes determinations if there are additional services out there that may could be gold carded as well. So that's something that we will commit to you all that we'll continue to do. Obviously, the PASSE program in Arkansas is unique because we are owned by Arkansas based providers. We are provider led. So we continue to work with them to help with abrasion and to make sure our members are served. But to Mitch's point, also to make sure that we're meeting the legislative goals of Act 775 for the PASSE program as a whole.

 

Corey Cox Madam Chair, if it's okay, I'm going to let my CEO so you won't hear from Care Source twice. We'll let David speak.

 

David Donohue Thank you. I would just say from the Care Source perspective, the policy that we've implemented, like my colleagues have mentioned, we attempted to align our policies as much as possible for four distinct organizations. But we also looked at the requirements of the act and have tried to implement a policy that will proactively look at authorizations submitted by our different practitioners and try and proactively address those who would meet the criteria and then communicate with them in a transparent way as to what that criteria is, how they would qualify and what our process would be in terms of retrospective reviews.

 

Senator Missy Irvin Okay, so yours is a little different that it doesn't provide like a list of things that are already gold carded in what I'm reading. So are you taking a little bit of a different approach to it or am I misreading that?

 

David Donohue I have not seen what the other PASSEs have submitted in terms of what their requirements are. I will say from our perspective, what we've tried to do is anyone who meets that 90% criteria based on their submissions that they would qualify.

 

Senator Missy Irvin Okay. Okay. So it's more provider focused versus specific instances.

 

David Donohue Apologies. In terms of the criteria for the different codes?

 

Senator Missy Irvin Yeah.

 

David Donohue Yeah. I mean, what we plan to do is look at the different submissions. As Mitch noted, the vast majority of the claims that we receive for our PASSEs are actually non-medical in nature because of the nature of the populations that we support. But so we're trying to look out for the medical claims, in particular the history of the submissions.

 

Senator Missy Irvin Okay. All right. All right. We'll just keep going down the line. Thank you. Appreciate it very much.

 

Jack Hopkins Yeah. I echo the sentiment of the uniqueness of the program. At Arkansas Total Care, we also have considerations of other products, which I think is important to this discussion. And we understand legislative intent to reduce or remove prior authorizations. We also want to echo the, again, the uniqueness of this program, and I think that we accomplish that in our submission. And happy to answer any questions you guys might have.

 

Senator Missy Irvin Okay. We'll start off with Representative Johnson.

 

Representative Lee Johnson Yeah, First of all, thank you. You know, this is a complicated process. As Senator Irvin and I learned through this session, trying to draft a piece of legislation like this is challenging for a lot of different reasons. I think we had good reasons for exempting you from the process specifically, as you stated, related to the nature of the people that are enrolled in the PASSE. Some of the treatments that they receive that maybe by nature necessitate prior authorization every time, right. Just like we did with some of the drugs that we looked at. And so I appreciate the intent of working collaboratively. I mean, that's what we need to try to do as a state, right? 

I think that as we move forward into the next session, you're going to see hopefully some amendments to this legislation because it's hard to get things right the first time. It's going to be a work in progress, just as this is a work in progress for us. A couple of questions about each of your specific proposals. The Care Source proposal, I understand pretty, pretty thoroughly just because it very much mirrors what we were trying to do in the legislation. The two questions I would have for you. One is what Senator Irvin was referencing, that it looks like the other, at least not Total Care, but Empower and Summit have given a list of things that have never required an authorization. They're saying these have always been gold carded primary care visits, you don't have to get prior auth, behavioral health visits, just a laundry list of things. I assume that you also have a list of services that you provide that have historically not required prior authorization. Is that true?

 

David Donohue Yes, Representative, that's correct. If it would be helpful, we can certainly clarify that.

 

Representative Lee Johnson Yeah, it would be helpful, I think, as far as comparing apples to apples to be able to look in addition to the process you've outlined, which I think is very good around gold carding. What are the list of things that you additionally don't require PA so we can compare those to the other PASSEs. And then the other question we have specific to your policy. If you do rescind a gold card in the legislation, we had an appeals process for the providers to appeal a recission. I don't see an appeals process in this. Is your feeling that it would default to the appeals process in the legislation? Have you thought about what the process would be if a provider had their gold card rescinded? What's their recourse if they disagree with the findings?

 

David Donohue Certainly that's a reasonable question. Yeah, we would default to the defined process. But I also think it's incumbent upon us as a PASSE to do that proactive outreach to the provider and have a discussion with them and have an open discussion.

 

Representative Lee Johnson So in ways of feedback, if we could get something like that outlined so that we could understand clearly what the process is. Because I think the way we've written the legislation, you're exempt from all the statute, right? And so if you could say in there that you default to the statutory rescission appeal process. However you wanted to say that, that would be helpful.

 

David Donohue Certainly.

 

Representative Lee Johnson Can I ask more questions? Senator Hammer, you're up for a question. Do you care if I continue to ask some questions? On Total Care, you also have outlined a process that's similar where you're looking at a period of time trying to determine are providers meeting that 90% threshold? And if they are, that's your process for exemption. I think it mirrors a lot what the legislation said, also mirrors what you're trying to do at Care Source. If I mixed y'all up more than once today, it's on me. And then what you've done that I think is interesting that the others haven't is you listed some things that specifically will always require prior authorization. 

And so I think that's also a reasonable list for us to have, right? So if we're going to try to have each PASSE sort of have a mirrored approach, it would be nice for the other three to provide us if there are some things that you feel like based on the nature of the services provided to reduce fraud and abuse that you need to pay every time. Having that list assembled I think is helpful. So I like the way that you did that with Total Care. 

And then on the other two, it's hard for me to see with Empower and with Summit. I don't understand with your two policies how your gold carding anything that you are doing prior authorizations on. So in other words, you've given a pretty expansive list of these are things-- it's my understanding those are things you've never required prior authorization. That's not a reaction to the legislation. That's just, hey, here's our list of things we don't require PAs. If you do require PAs on something, having an outlined approach to how you would give an exemption through a gold card process. If it's in there, I'm not seeing that. And that differentiates those two plans from the other two.

 

Jack Hopkins Yes, sir. So, one thing that I don't have defined in the policy currently, but as we went through this over the past year or so, working to make sure we were properly responsive, we did add some services that prior to that did require prior authorization. So those are not called out in the policy. So we can follow up with that to show you some of those changes. And then I think it's also a good idea, like you were just saying, to identify some of those things or some of the key things that will continue to be managed through prior authorization. And just to comment on that, a lot of those are not like incident based prior authorizations. They're long term, six month, 12 month prior authorization. So I think that would be another good point of clarity.

 

Representative Lee Johnson Yeah, I think that would be helpful to see if you have now in reaction to the legislation in your efforts to-- because I think the task was reduce prior authorizations. I don't think we tasked you with specifically coming up with a 90% gold card.  I'm grateful for that. I think that's a great approach. But another approach could just be, we're going to reduce prior authorizations. Here's what we were requiring PAs for, and now we've added these things to the list in response to the legislation. That would also, I think, be helpful from a clarity perspective. Recognizing you have worked collaboratively, but at the same time you may not have seen each individual plan. I think that would be helpful to align them as best we can.

 

David Donohue Yes, sir.

 

Senator Missy Irvin Yeah. And I appreciate what Brad said about you have an ongoing committee looking at these things, and I think that's really a good point. If you're going to look at this as a team approach, like I would love for you all to all collaborate together to figure out what you like about each other's policies and mirror those and then to have that committee meet and review. Because what I think has happened in the space of health care and prior authorization is that you have the payer and they are contracting third party for prior authorizations. And you're just like, yeah, okay, we're signing a contract. Third party is approving or denying prior authorizations. 

But through that process, those contracts perhaps may have been written in a way to reduce and they just really strangled health care for a lot of individuals. And they use prior authorization as a process to strangle down that health care for patients and created a nightmare for any provider that's just trying to practice medicine and help their patient. And I think that's where we have come to a place and now we're peeling it back and going, wait a minute, we can't just sign a contract with a third party vendor to do our prior auths for us without understanding what they're doing, why they're doing it and how they're doing it and how it's affecting the patient population that we're supposed to be providing coverage for. And it's affecting the partnership between the providers and the payers and in a way that's actually not healthy or beneficial for the patients. And so I think that's actually what happened in this whole world and why you've seen prior authorization legislation. 

I mean, I started it in 2011. Actually, Representative Mayberry, it was because of a tick bite. Because the person that was denying the referral treatment for toxicology screening for Lyme disease argued with my husband on the phone that he was just some stupid little hillbilly country doctor that didn't know what he was talking about. And they were in New York and there was no such thing as tick borne diseases. I'm not making that up. That is what led me to the first prior authorization legislation that I passed because we know that that's not right. 

So I think this world has developed and kind of gotten a little out of our grasp when those kinds of things are happening. So I really appreciate the intentionality that all of you put into this and this policy, just like Representative Johnson was talking about. And I do think, as you go through this, that was one of my questions. Did you look at this and go, whoa, why are we requiring a prior authorization of this when we're treating people, you know, that have trachs and need trach supplies? Absolutely they need that. That doesn't need to be-- that's a common sense kind of a reaction. And that's how I felt. Like prior authorization just kind of threw common sense out the door. And it was just this contractual agreement with a third party vendor to do so without any intentionality, consideration of the patient population that they were serving. 

And again, that's one of the reasons why we wanted to carve you guys out of it, because we recognize that you are there for a very specific population that we desperately needed assistance and help with in managing. So I think those are just important takeaways and I appreciate the different approaches and I think I think it will develop and morph. And I hope that it will with you as well. And we can continue this partnership. Mr. Hopkins?

 

Jack Hopkins  Yeah. I would just say that I think the administrative burden is applicable to both payer and provider. So if there's service codes or items that we think are redundant, we're definitely pursuing those, specifically on commercial, less on PASSE,  more commercial, which I think is a greater interest.

 

Senator Missy Irvin I like that. Mr. Nye?

 

Brad Nye Thank you. And I just wanted to say we appreciate you bringing this legislation forward. To your point, it did make us look internally in more detail than I think we had previously at CPT codes and whether PAs were appropriate or even serving the purpose that they were there for. So we do appreciate that. And I did just want to follow up to Representative Johnson's question about some of Community Care's specific list that we've presented. You are correct that some of the items on here were items that we have been gold carding since the inception of the PASSE program. But we did, much like Empower, add additional on. And so we'll make sure to break that out in a clear way so you can tell what was before and what's in response to the legislation.

 

Senator Missy Irvin I think that would be so helpful, I mean, for everybody, I think for y'all and for us and for providers out there. All right. Senator Hammer.

 

Senator Kim Hammer Thank you, Madam Chair. First of all, I'm not sure, Mitch, it may have been you that said this about legislative intent. Appreciate that comment because in other committee meetings and other areas, not every individual or group recognizes or gives us the respect for legislative intent. So appreciate that comment first of all. Second, on retrospective review, can you talk, any one of y'all talk about that just a little bit?

Because my understanding or my thought of retrospective review, is it going to be so much on the actual things that happened that didn't get prior approval that may result in what I would call a clawback from the provider because they did something without it. Or can you just expand on that a little bit? Anyone of y'all?

 

Mitch Morris Yeah, I would say the clawback situation is pretty rare for us. I mean, mostly what you see is looking back, oftentimes it's concurrent versus retrospective. So it's a long term admission in many of those cases where an individual has been in inpatient or residential status for a period of time. And so it's more of a concurrent than it is a retrospective. Usually when a retrospective from a clinical perspective happens, it's us trying to work with that provider in cases where maybe the first three days did not require a review but once it hits a certain level, then we need to understand the clinical nature of that stay so that we can consider what's next in that course of treatment. Do they need to stay longer? Is it time for discharge? So but the clawback situation, especially from a clinical perspective, is a very rare occurrence.

 

Senator Kim Hammer Okay. And I'm working on memory, which right now isn't working too good, but this goes back to a situation about six, eight weeks ago where a constituent presented to a hospital down in my area to get treatment for PAN and PANDAS, and the primary insurance company said no. But one of your-- I can't remember which one of you all stepped up said, Yeah, we'll take care of the cost of covering the treatment for PAN and PANDAS, which itself is kind of an expensive treatment. And so I'm just wondering, and what I'd want to be careful about is that in a situation like that, if there was a retrospective review where now it would come back on the individual or come back on the facility or the provider in cases like that, how would that be handled?

 

Mitch Morris Well, never on the individual in our case. Providers are prohibited from applying a balance of a bill to a Medicaid beneficiary. So in the case of the PASSE or Medicaid, the beneficiary does not get stuck with a due amount. But you raise an important point when you're talking about multiple payers, multiple sources of coverage that can sometimes on a case by case basis get pretty complex. One provider approves payment-- I mean one payer approves payment, one does not. And those can get really complex. And I mean, like you said, what we try to do is, especially with our local providers, is work within reason and sometimes come to an agreement based on those specific circumstances that have presented. Those are pretty rare, pretty rare. But surprisingly enough, you do run into other coverage, multiple coverage situations in Medicaid.

 

Senator Kim Hammer Right. And that was, which that's a separate subject is that y'all were willing to do but the other primary provider which is the name brand provider refused not to do it. So I appreciate you all doing that. We will get together in a specific conversation about that. Last question would be this, When it comes to your community reinvestment dollars and the moving toward this prior authorization gold card standard, do you see that that's going to have any direct impact on the community reinvestment dollars that you have, or will this help manage those better? And just will the two ever connect in any way or fashion? And if so, how?

 

Mitch Morris At this point, I don't see any connection between those two programs at all. I don't know if anybody else has--

 

Senator Kim Hammer I didn't know if through the savings or the cost--

 

Jack Hopkins I think the heart of your question is, is this going to raise MLR to where our community reinvestment dollars are tied up? We're not necessarily attaching this to an increase in MLR at this time. We think we know our providers fairly well and we think we know what our spend is. And that goes along in conjunction with our partners at DHS. So no, I don't think those two things are tied.

 

Senator Kim Hammer Okay. Thank you.

 

Senator Missy Irvin All right, Representative Johnson.

 

Representative Lee Johnson Yeah. Just one more quick question. Recognizing that you're each four independent entities, I'm assuming there are some rules and regulations about how much transparency you can have in collaboration with what you're doing. I know y'all are trying to work together, but are you all able to respond to each other's proposals now that they're on the table and you can see them? To what extent can you work together and what restraints are there from you all working together collaboratively?

 

Jack Hopkins I don't want to speak out of turn here, but I think that's important for the four PASSEs to have the ability to be differentiated from each other. That gives greater options to our members specifically. So I don't want to give off the notion that we could or should be collaborative on every single aspect. But where things make sense to be collaborative, of course we have those ongoing relationships between the four of us.

 

Senator Missy Irvin Thank you. All right. I see no other questions. I, again, thank you so much. Appreciate the work with us. We really, really appreciate it because at the end of the day, we want the best for our patients and our constituents. And Mr. Hopkins, I will see you in the field. Okay? Thank you, guys. And also, I need four motions to recommend to approve these policies. So we will go with D2. Do I have a motion to recommend to approve D2? So moved. Second. All those in favor, say aye. And nay? Ayes have it. That is approved. 

I need a recommendation-- do I have a motion to recommend to approve exhibit D3? Motion and a second. All those in favor, say aye. And opposed? Ayes have it. That is approved. Do I have a motion to recommend to approve D4? Motion and a second. All those in favor, say aye. And opposed. Ayes have it. That is approved. And finally, do I have a motion to approve item D5, recommend to approve this policy? So moved and seconded. All those in favor, say aye. And opposed? Ayes have it. That is recommended and approved. Thank you. 

Also there are public comment sheets posted out there and if there are members of the public that want to comment, please sign up on those public comment sheets. All right. Thank you. Moving onto the next item, item E. We have a rule. Moving to rules for review.

 

Lauren Ballard Good morning. Thank you, committee. Lauren Ballard, Chief of Staff, Department of Energy and Environment.

 

Bailey Taylor Bailey Taylor, Chief Administrator of Environment, Department of Energy and Environment.

 

Senator Missy Irvin Okay. Thank you, ladies. Please proceed.

 

Lauren Ballard Okay. Thank you. We are here today to present some amendments to rule 36 of the Pollution Control Ecology Commission. This is the first step before it goes to the full Rules Committee. And these rules govern our Tire Accountability Program. That's the used tire program as it's more commonly referred to. And these modifications essentially bring the rule into conformance with the law that was passed in 2023. So that was Act 713 of 2023. In addition, it also goes through and makes a few technical corrections to some names and things that changed after transformation. Now, we thought that now was a good opportunity to do that. So we incorporated those changes as well. 

And as far as the changes that brought the rule into conformance, there were a number of those, including the amendment that reduces the tire districts down to four tire districts. There was the ability for the tire program to enter into those interlocal agreements, the ability for the boards or the requirement that they draft and revise business plans that they would submit. And actually that's already been done, has actually already come through the Arkansas Legislative Council. And a limitation on fees where the used tire program is the one who is seeking a permit. The limitation of a requirement of fee for those permittees, since they are going to seek reimbursement for them anyway. And again, those are all part of Act 713 of 2023. So we are happy to answer any questions or provide any more information if needed.

 

Senator Missy Irvin All right. Thank you. Are there any questions? All right. Seeing no questions, without objection, this rule is reviewed. Thank you, ladies. Thank you. Next, Item F, DHS.

 

Lori McDonald Good morning. Lori McDonald, DHS Chief of Staff.

 

Elizabeth Pitman Good morning. Elizabeth Pitman, director of Division of Medical Services.

 

Senator Missy Irvin Good morning. Please proceed.

 

Elizabeth Pitman Hello. Today we're here to present the follow up rule to a rule we have already brought to you. This is a rule regarding emergency medical technicians as other licensed practitioners. When we brought the first rule to you, I believe last year, it was regarding the provision of triage and transport by emergency medical technicians. That rule was approved by CMS and sent through. But through that approval process, CMS wanted us to go in and add EMT as what we call 'other licensed practitioners,' which is just a mechanism that CMS recognizes them as a paid provider type in Arkansas Medicaid. So this is that rule to follow it up. It was approved by CMS. It retros back to the same date as the previous rule. So there won't be any discrepancy in the time frame for paying these services and there's no additional financial impact to this rule. I'm happy to answer any questions.

 

Senator Missy Irvin Any questions from members of the committee? All right. Thank you for the follow up. And seeing none, without objection, this rule is approved.

 

Elizabeth Pitman Thank you.

 

Senator Missy Irvin All right. All right. Thank you. If you'll just introduce yourselves for the record, you may proceed.

 

Thomas Tarpley Good morning. Tommy Tarpley, the deputy director for the Division of Developmental Disability Services.

 

Jennifer Brez’ee Jennifer Brez’ee, director of the Division of Developmental Disability Services.

 

Thomas Tarpley Good morning. This rule involves updates to the two autism services programs done by Arkansas Medicaid. First is the autism waiver, which provides one on one intensive intervention services in natural environments to children with an ASD diagnosis. And then also applied behavior analysis therapy services, also known as ABA therapy services available to children under the EPSDT program. 

In the packet you'll see the renewal of the 1915c autism waiver. This renewal is required every five years. CMS approved the renewal included in the packet effective July 1st, 2024. It also includes updates in the Autism Waiver Medicaid Manual. Finally, on the ABA therapy side, it includes inclusion of the ABA therapy services as an Arkansas state plan service as required by CMS, and also establishes the ABA Therapy Medicaid Manual, which includes parameters around eligibility criteria, service delivery requirements, clinician qualifications and other things in accordance with CMS rules. Finally, the ABA therapy side will become effective with an anticipated effective date of January 1st, 2025. And I'm happy to answer any questions.

 

Senator Missy Irvin Okay. Representative Ladyman.

 

Representative Jack Ladyman Thank you, Madam Chair. Over here. Just a question. You had a comment when you had the the public comment period that had to do with telemedicine. Was that just an oversight? You agreed with the comment. They said that some of the services would not be covered if they were done by telemedicine and then you agreed with the comment.

 

Thomas Tarpley Yes. After discussion, that particular service, we agreed with the provider that submitted the comment that those services could be provided by telehealth when appropriate.

 

Representative Jack Ladyman All right. Thank you.

 

Senator Missy Irvin Okay. And I actually have a question. One of the pieces of legislation-- Senator Hammer's not here, but I think he stepped out-- that we looked at during the session, we actually passed, but it was vetoed, with behavioral health Behavioral Analyst Certification Board in this manual. And one of the concerns back during the session, and I think the legislation that passed addressed that, was what is the communication process between the national board and the state of Arkansas? When you have a provider who may be under investigation, what's that process of communicating with the national board for the protection of the family and the patient?

 

Thomas Tarpley So there would be no known communication that I know of between DDS. I'm not sure on the Medicaid enrollment side as to whether there's any communication there. I would have to defer to DMS on that specific issue.

 

Senator Missy Irvin Okay. Melissa? Thank you.

 

Melissa Weatherton Hi, Melissa Weatherton. I'm director of Medicaid Specialty Populations. And Senator Irvin, you're correct. This was one of our concerns that I think we talked about during the last session. Just not having a state entity like we do for the other types of clinical services we provide. And I do not believe that we are contacting the national board with an issue. But I'll also say that since we have set up this program, we have not had anything rise to the level that would be submitted to some sort of oversight board. We take action based on, you know, under the Medicaid regs, we can take action of suspending or just stopping their ability to provide services for us.

 

Senator Missy Irvin When somebody has been reported to a board for an ethical violation or they're under investigation of violating the law, we have a board in the state of Arkansas that will deal with that licensee. Well, in this, we don't have that. And so there's a concern there and we don't know what that communication process looks like. So somebody could be under the national board being investigated or looked at, but what is the process between you as Medicaid and that national board entity? There is no process there. And I think that's a real issue and a problem. 

I understand these national board certifications or whatever, we want to move to that, but that remains my concern. Because our job as a committee, in my opinion, it really should be about consumer safety, public health interest and making sure that we are doing our job, that those that are licensed, but if there is no license and there is no entity, there's no place for anybody to go to, that creates a problem. Or we've just bypassed that and washed our hands of it. But at some national board, well, okay, if that's the case, we've got to have a process of communication that's established that we know so that you can take action. That's the concern. And I think it's been a concern by the president of their board, who worked with Senator Hammer and Representative Clowney. I believe Representative Cindy Crawford also may been involved with that. 

But I think it's really important that we look at making sure we have established that, especially in behavioral health, if people are not licensed. So I would ask that we kind of revisit that. And I know it's in the process of what we're approving here today, but I think you would have had a lot of public comments about that on this rule. And they just told me they missed, they just completely missed it. They just missed the deadline and they just missed that it was coming through. So my ask is that you would reach out to Mr. Rocky Hayes and have a conversation with him about that. And I think that would be helpful and beneficial. 

Again, one of the reasons why we bring public health rules here to this committee first before we go to Rules so that we can work through this, because they're always, usually sometimes complicated. So if you don't mind doing that for me, I would really appreciate that. Are there any other questions from members of the committee? All right, seeing none, without objection with that caveat that you reach out and just check. I would appreciate that. Thank you so much. Without objection, this rule is reviewed and approved. 

All right. Item H. Do we have anybody that's going to present item H? Okay, So, members, this is a motion to approve. Item H requires us to approve Arkansas legislative study on mental health and behavioral health to approve this study. So do I have a motion and a second? All those in favor, say aye. And opposed. Ayes have it. That is approved. Okay. Next we will go to item I. Okay. Thank you. Okay. If you will introduce yourselves for the record, please proceed.

 

Tom Masseau Sure. And I think we have a PowerPoint or some documents to bring it. And also, we do have some packets of information that we can leave with whomever after we get done if you would like.

 

Senator Missy Irvin All right. Please proceed.

 

Tom Masseau Okay. So I am Tom Masseau. I'm the executive director of Disability Rights Arkansas. So they're working on the PowerPoint, so we'll just go ahead and begin.

 

Senator Missy Irvin That's fine. We all have it in our packet.

 

Tom Masseau Perfect. Okay, thanks. So as I mentioned, I'm Tom Masseau. I'm the executive director of Disability Rights Arkansas. I've been the executive director since 2013, and I have been involved in the disability rights movement since 1987.

 

Thomas Nichols And I'm Thomas Nichols. Apologize. I'm Thomas Nichols. I'm the director of legal and advocacy services. I've been with Disability Rights Arkansas since 2016, and I've been a practicing attorney since 2009.

 

Senator Missy Irvin Thank you.

 

Tom Masseau So I just want to kind of briefly give you an overview of Disability Rights Arkansas and the work that we do and then turn it over to Thomas to kind of get into the nuts and bolts of the programmatic work that we do. Disability Rights Arkansas, our mission is to advocate for and enforce the legal rights of all people with disabilities here in the state of Arkansas. And we are part of a larger network called the Protection and Advocacy System. And the Protection and Advocacy System was created in the early 1970s. 

And it was-- here we go-- and it was created in the early 1970s. And interestingly enough, it was Geraldo Rivera who was a journalist who borrowed a key, went into a state institution, Willowbrook, and exposed all of the maltreatment and issues that were happening in that facility. And as a result, there was a settlement that was reached in 1975 over the conditions in the facility because there was a lack of oversight and accountability in how individuals were being treated. As you can see, kids and adults were unclothed with bruises. They were eating with their hands and they had broken bones. And they languished throughout the institution with little to no treatment, no education, and just sat there with no oversight or accountability. 

And then in 1975, Congress passed the Development of Disability Awareness Act, which granted authority for independent organizations to go into these facilities and monitor and teach and to ensure that individuals were treated with dignity and respect and they were getting the services that they required. The protection and advocacy system is independent from state and federal government. We are, like I said, we go into these facilities with our access authority that Thomas will talk about. And then in 2025, we're going to be celebrating as a network 50 years of being around advocating on behalf of individuals with disabilities. 

Every state and territory has a protection and advocacy system. There are 50 nonprofits. Four of them are in states and state government, one in a law school, two in legal aid. But the remaining 50 are nonprofit organizations with a board of directors all doing the same work in terms of advocating on behalf of individuals with disabilities. Here in Arkansas, we're going to be celebrating 47 years. We received our first grant in 1977, and in 1980 we were incorporated as Advocacy Services Inc. And then in 2010, we changed our name to Disability Rights Center of Arkansas. And then in 2014, we changed to Disability Rights Arkansas. 

Our budget, we have a budget of $2 million, a board of directors with 11 members and a staff of 24. As a result, we are funded by nine different nine different grants that come into the agency, as I mentioned. And the first one was the Developmental Disability Awareness Act. As with all disability and all human service organizations, we like acronyms. So I'm going to do my best to make sure that I spell them all out. But the first one was the Protection and Advocacy for Developmental Disabilities. And that program came about in 1977, which essentially authorized who we are and what we do. And that program sits within the administration on community living, which is within the Department of Health and Human Services.

 Our client assistance program, that came about in 1984, and that runs through the Rehabilitation Services Administration through the Department of Education. And that program allows us to advocate on behalf of individuals who are going through the vocational rehabilitation services system here in the state, who have been denied or trying to get services through that program. 

The next one is the protection and advocacy for individuals with mental illness. And that came about in 1986. And that program is housed through the Substance Abuse and Mental Health Services Administration and allows us to advocate on behalf of individuals with serious mental illness living in a state facility or in a community receiving treatment or services. 

The fourth one is the protection and advocacy for individual rights. And that program came about because there were family members whose loved ones acquired their disability or gotten into an accident, and they were not eligible for those other three programs. And so Congress wanted an entity to be able to help them advocate so they came up with the protection and advocacy for individual rights in 1993. As I mentioned, that program covers all the ones that are not eligible in the first three. 

We also operate a program called the Protection and Advocacy for Assistive Technology. That came about in 1984. That gives us $50,000 to serve the entire state, to assist individuals trying to gain access to assistive technology services and devices. 

The next one, the protection and advocacy for beneficiaries of Social Security is a program that came about in 1999. And that allows us to advocate on behalf of individuals with a disability receiving SSI, SSDI, who are trying to maintain or gain employment from age 16 to 64. The next program came about is our protection advocacy for traumatic brain injury. That, again, that program gives us $50,000 to serve the entire state of Arkansas to assist individuals who acquired their just their traumatic brain injury after birth. 

The next program, Protection and Advocacy for Voter Access is a program that came about as a result of the Bush-Gore issue and allows us to assist individuals trying to access their polling location, educate election officials to ensure that voters with disabilities know their rights and are able to access their polling place and also work with the state officials as well. 

Our last program that we have is a relatively newer program. And it's strengthening protections for Social Security beneficiaries and the Representative Payee program. That program is operated through the Social Security Administration. And I forgot to mention that the protection advocacy for beneficiaries of Social Security also runs through the Social Security Administration. The Representative Payee program is a relatively new program. All of our cases are directed through the Social Security Administration. Any individual who works in that program has to be cleared through Social Security Administration. We cannot provide any information to the public, to anybody, based on our security. We get directives from Social Security to go out and look at beneficiaries and to ensure that the funds are being spent appropriately and they're not being exploited. So that is the work that we do under the Representative Payee program. 

So with all of those nine federal programs, what do you do? How do you manage and serve the entire state on a budget of $2 million? Well, we investigate allegations of abuse, neglect and exploitation in public and private settings. We provide representation and advocacy for individuals with disabilities regarding their rights. And we do that by developing priorities and objectives at the beginning of every year. We solicit input from the public. We look at our cases. And we also work with our board. And the board comes up with our priorities and objectives every year. Our current year priorities, we have seven of them and they're listed up there. Abuse, neglect, exploitation, education and employment, institutionalization of youth, access to Medicaid or assigned to a PASSE, voting self-advocacy, training and outreach and education. 

And this is the part that I'm going to hand off to Thomas Nichols to talk about the cases and the work that we do.

 

Thomas Nichols Thank you all. So again, my name is Thomas Nichols. I'm the director of Legal and Advocacy Services. And so in that role, I supervise either directly or through other managers all of the case and project work that we handle at our organization. We have several different types of cases that we handle. Kind of some categories that they fit into, obviously when someone calls our office, that's going to be a separate case types or intakes where we try to find referrals for individuals if we are not able to assist them. That's the first. 

The second would be assistance with self advocacy. Nothing is more powerful than being able to help an individual with a disability be able to help themselves and to give them the tools that they need to become better advocates. And so we always try to find opportunities to assist individuals if they need information or resources to be able to go and do for themselves. Technical assistance, that is assisting people who are not individuals with disabilities, whether it's a family member or a third party. In some cases, we've assisted providers with evaluating how policies or location circumstances might affect an individual with the disability. Individual advocacy. That's what you all would probably consider a case, right? That is, we're representing an individual as their lawyer or we're representing an individual as their advocate, trying to help them achieve a goal that falls within our grants and our priorities. Investigations. 

So probably the most well known thing that we do is we investigate abuse, neglect and exploitation, public and private settings. So that is naturally going to be its own case type, whether we are told about a situation that rises to the level of abuse and neglect or whether we discover circumstances that appear to be abuse or neglect through our monitoring activities that I'll talk about in a moment. 

And the final case type is not even a case really. It's projects. So we do a significant amount of research, education, outreach. We have helped many of you all who had questions about policy. And all of that falls within our systemic efforts to try to make the world a better place for people with disabilities as a group, and that falls within our projects category. So as I mentioned earlier, obviously someone calls our office. We treat that as an intake. I don't have the numbers in front of me, but I think over the past fiscal year, we had approximately 1,800 calls to our organization seeking assistance. And so obviously, with a staff of, I believe, 24, we are not able to assist all 1,800 of those individuals. And so we try to make sure that somebody doesn't walk away empty handed if they're looking for assistance. So we try to find resources for them. We try to refer them to people or organizations or agencies who can assist them. We also try to develop explainers, self-help guides, frequently asked questions to try to give people those tools ahead of time. And like I mentioned earlier, we provide technical assistance to third parties even if they don't have a disability, if it will help make the world a more accessible and better place for the population we serve. 

I alluded to this earlier, abuse and neglect. So we monitor facilities. We sometimes will just show up at facilities to talk with the residents, to talk with the staff, to provide education and access to resources to the individuals who are living there or receiving services. And we're also looking out for signs of abuse or neglect or exploitation. And this is one of the areas that we work in that's expressly mandated by the federal law that created our grants. And either through our monitoring activities or based on information that we receive, at times we find it appropriate to investigate, which is another mandated role that we have as the protection and advocacy system for the state. 

We can investigate sometimes as the primary investigators if the state has not been made aware. Obviously, we always let the state know when we receive information that rises to abuse or neglect and we've been able to substantiate it. Sometimes we go back in after the state or other agencies have investigated an incident because we believe that the investigation might not have been as thorough as those individuals might have deserved. As a result of our investigations, we are permitted under our federal laws to do public reports or private reports. We can report those to the public through publishing a report on our findings, or we can report it privately to state or federal officials. 

Our access story. I won't dive into this, but federal law gives us that ability to be able to go into institutions, public and private, anywhere where individuals with developmental disabilities, mental illnesses, or any other disabilities after the passage of the PAIR grant that Tom mentioned. We're permitted to go into those facilities if individuals with disabilities live or receive services at those locations. That's not all we do. We have a staff of five who handle abuse, neglect and exploitation. And granted, that is not enough to handle the types of the number of potential investigations and monitoring that we could do. But we also handle cases outside of that. 

We have one full time attorney who is handling special education cases. And I tell all of our other lawyers that none of them are immune because this happens to be our number one request for assistance. Just between August and now, we received over 150 requests for special education assistance. And that's just the start of the school year. Special education cases take a lot of time. As you might be aware, there's typically hundreds of pages of records. Every single situation is a niche issue, a niche issue of a niche area of law. And so they take a lot of time and a lot of effort. But we have a great relationship with our Department of Education and we try to handle as many special education cases as we can. However, we don't receive a grant that is just to assist with special education like we do for access to vocational rehabilitation services or access to voting or access to assistive technology. Those are very specific subsets. So we are having to use our grants, which we could use for monitoring and investigations for people with developmental disabilities, mental illnesses, having to carve out some of that to use for what is clearly our most demanding area of individual representation. 

We also work in employment, whether it's trying to get people access to vocational rehabilitation services through our state organizations like Arkansas Rehabilitation Services or Division of Services for the Blind. We have a grant that's just to represent people who are having difficulties with that. We have two advocates who assist with that, and they also assist with helping people who have barriers to employment. As Tom mentioned, under our protection and advocacy for beneficiaries of Social Security grant, as long as somebody is receiving Social Security, we can help them work to get off of that benefit through employment by helping them remove barriers to employment, whether they have a job and are looking to advance in that employment, whether they're seeking employment, whether they are subject to employment discrimination. 

We've helped individuals file complaints to the Equal Employment Opportunity Commission and help usher them through that process. So really beginning to end, if there's an opportunity for someone to go to work and they have a disability, we should be a place to call if they're having difficulty accessing those services. Because the state has wonderful resources in place to be able to give an individual what they need to be able to go back to work, so that should not be a barrier. 

We also help people who are under guardianship rights. It can be fairly easy to get a guardianship in our state and it can be really difficult sometimes to remove a guardianship, especially if that guardianship is abusive, neglectful or unnecessary. Right now we are assisting several individuals who were subject to exploitation by their guardians. We've assisted people with terminating guardianships that should have never been put in place in the first hand. Sometimes guardians who haven't reported to the court in well over a decade, whether it's an accounting or a report to the court of how the individuals are health wise. And we also assist those individuals when there is a violation of the ward's Bill of Rights. You all passed a ward's Bill of Rights with the guardianship reforms that happened several years ago, and that has allowed us to be able to get in and assist individuals who are being abused or neglected by their guardians. 

We also assist with access to Medicaid. The individuals you had here just moments ago from the PASSEs. All of the PASSEs, they are all familiar with our work because we have carved out an area of Medicaid that is, again, I feel like I've said niche, this is probably the sixth time, but it is a very niche area of not just the law, but of Medicaid law. It's managed care organizations that are subject to contracts and different regulations than typical Medicaid providers. But they're also subject to the regulations that all Medicaid administrators are subject to. So our state's legal aid organizations, they have developed the expertise to be able to handle all Medicaid. 

So we've carved out this one little place to be able to provide people assistance. And right now we have one attorney who is probably 90% of his caseload right now is handling individuals who are trying to get services through our state's PASSEs. We also look to help people who are needing services, whether in the PASSE or not, who are trying to get it through the early periodic screening diagnosis and treatment program that is characteristic of Medicaid. 

And also we have an assistive technology grant in many of those. Much of that assistive technology can be provided through Medicaid. And so we put that in our Medicaid category as well. 

Tom mentioned our Representative Payee program. This is a fascinating program. It allows us to go in and audit Representative Payees. For those of you who aren't aware, if an individual is receiving Social Security income from the federal government, somebody can manage that for them. Sometimes it's a family member. Sometimes it's a facility. Sometimes it's just an organization. And so they are required to keep an accounting, just like most guardians would. How are you spending this individual's money? 

If you are the person who is managing it, and for a number of years we handled auditing representative payees every so often based on when Social Security would tell us to. And then it worked so well and produced issues that Social Security could then follow up on and in some cases prosecute that they decided in 2018 to provide us a grant that is actually our second largest grant, allows us to go in and audit, open the books of those representative payees, audit them, make sure they're not stealing anyone's money or mishandling anyone's money or abiding by all of the regulations. 

So again, another extremely niche area of the law, the Social Security POMS, which are the operations manuals that representative payees have to follow. And like Tom said, all of that, we can't even use our own laptops for it. We have to do it all on Social Security laptops, provide that information directly to Social Security. They have to have their own database that actually belongs to Social Security. So it's not one that we get to report about what we do, as much as we like to talk about what we do. But that program is active and is in existence and very much a value to our state and the federal government as well.

 

Tom Masseau Yeah. So that is an overview of who we are and what we do. We're happy to take any questions or--.

 

Senator Missy Irvin Thank you. I have a question. So when you talk about Social Security, is that anybody who is on Social Security disability funding or also just regular Social Security or both?

 

Thomas Nichols So for our protection-- so we have two grants for Social Security. The Representative Payee one, right now, we're only handling those cases directed by Social Security to look at. And those are always going to be SSDI, Social Security Disability Insurance or Supplemental Security income if they have a Representative Payee. Our other grant, were you asking about our auditing grant?

 

Senator Missy Irvin Yeah, well, both. Like as it related to Social Security funding.

 

Thomas Nichols So for our other grant protection and advocacy of beneficiaries of Social Security, where we could remove barriers to employment, that is specifically SSI, SSDI. So no survivor's benefitsy.

 

Senator Missy Irvin Gotcha, Gotcha. Gotcha. Okay. Okay. So that's SSDI, correct? Okay. That was what I was curious about. So, for example, like I actually had this happen, but a financial institution contacted me because there was an individual who was being taken advantage of by somebody. And I eventually tried to visit with-- it was an elderly person and they were basically being scammed by someone. And so is that a case that you would be able to help? It was an elderly individual and it was a financial institution that, I mean, I think he's the one that personally called me but then tried to get him help.

 

Thomas Nichols Well, and so that's where working through kind of the algorithm that we have in which grant where we even be able to serve them. So if they have a representative payee,  we go in and audit the books because representative payee should be the one who's handling those assets.

 

Senator Missy Irvin  I gotcha.

 

Thomas Nichols And then if it were a barrier to employment--

 

Senator Missy Irvin Gotcha. Yeah. Focused on SSDI. Yeah. Okay. Perfect. Thank you so much. Okay, we will move to Representative Ladyman.

 

Representative Jack Ladyman Thank you, Madam Chair. Madam Chair. I'd like a point of order before I ask my question.

 

Senator Missy Irvin Yes, please.

 

Representative Jack Ladyman There's a group here I'd like to introduce in the audience. And you all have a handout that talks about their organization, but they're very interested in the rights of disabled individuals in Arkansas. The name of the organization is Families and Friends of Care Facility Residents, and this is made up of volunteers and parents and other interested individuals for people who are in Human Development Centers. So my question-- I have a number of questions. Madam Chair, if you want to cut me off and let someone else and put me at the bottom of the list, just yell and I'll stop.

 

Senator Missy Irvin But do you want other questions first and then I'll come back to you?

 

Representative Jack Ladyman No, let me ask.

 

Senator Missy Irvin Okay. Okay. That'll be fine.

 

Representative Jack Ladyman It's a burning question.

 

Senator Missy Irvin Your handouts are handout 11, 12 and 13. And those are from Representative Ladyman.

 

Representative Jack Ladyman You all cover a lot of bases, a lot of things you're into. My questions primarily have to do with people with intellectual and developmental disabilities. And one question, you had your priorities for 2025 and under different headings abuse and neglect was the first one. You mentioned that you go in and monitor facilities. So why do you only monitor abuse and neglect in facilities? What about people that are disabled that are not in facilities out in the community? When they get out there, why do you not monitor those?

 

Thomas Nichols We do, Representative Ladyman. And we've monitored schools, we've monitored supported employment locations. We've monitored HCDS settings, settings in which home and community based services are occurring.

 

Representative Jack Ladyman What I'm really talking about are like group homes and those kinds of things, places or individuals who are in living quarters and they have people that come in for 24 hours or 8 hours or whatever, because a lot of these folks from HDCs move into those programs. And some of them, quite honestly, fail to operate in those programs and have to go back or they have difficulties. And we see data about the facilities. I don't see any data about people that are out in the community as far as failures or abuse. I don't see anything. So do you do that? Do you have those numbers for people that are not in facilities?

 

Thomas Nichols Well, what I would hope is that the state would publish those numbers because the state is also investigating abuse or neglect as well.

 

Representative Jack Ladyman I'm asking you if you do.

 

Thomas Nichols We've not gathered that information. You know, we've developed a database that has investigations conducted of abuse and neglect for children who are in psychiatric residential treatment facilities, because that was one of the focuses that we had one year. We thought that the state should publish this data and so we are publishing it so that other states have an opportunity before they send children here, or people who are in this state have an opportunity to learn more about those facilities before they send children there. 

I don't believe we published a database on human development centers yet or places where people with intellectual disabilities are receiving home and community based services. But we have gone there. We just haven't done a data collection project about it yet. Is that something that--

 

Representative Jack Ladyman Well, I know that your employees show up at Human Development Centers. And so what is their process? What's their procedure? I mean, why do they show up? Do you only come if you get a written complaint about someone or do you just show up or how does that work? What's your process?

 

Thomas Nichols Well, frankly, that's the way it has been lately because we would love to have a ongoing monitoring presence at every facility in the state. But as of late, the more complaints we receive from a facility, we're generally going to be going to that facility more often.

 

Representative Jack Ladyman So you don't go to a facility unless you receive a complaint.

 

Thomas Nichols No, I'm saying that that, frankly, is how it's been happening for the past year or so is that we have had more incidents that we've had to investigate rather than being able to consistently monitor. But we still go and monitor at the state hospital. We still go and monitor at public and private locations. Like I said, we did have an initiative that but for loss of some personnel recently, we had a monitoring project at facilities or locations like you suggested where people are receiving home and community based services.

 

Representative Jack Ladyman Let me move on to access authority. You mentioned that under the Developmental Disabilities Act and the Protection and Advocacy System, it has reasonable unaccompanied access to facilities to conduct fully investigations of incidents of abuse and neglect. Do you only use access authority when there is an incident of abuse reported? And it says reasonable. What's the definition of reasonable and who decides what reasonable means?

 

Thomas Nichols Well, that's not defined by the statute, reasonable unaccompanied access. We can only rely on what the local districts in the circuits have said is reasonable.

 

Representative Jack Ladyman So how do you determine if you can go into the HDC unaccompanied and go in and talk directly to an individual? How do you determine that if the law doesn't determine it?

 

Thomas Nichols I's very difficult to say based on this hypothetical circumstance.

 

Representative Jack Ladyman But, sir, what I'm hearing is that some of your people show up at HDCs and wander around the site. Okay? They don't normally let just everybody go in and wander around where these people live. This is their residence. If you're just going out there without any reason, why are you doing that?

 

Thomas Nichols I'm sorry if I gave you the impression that we just go there without reason. I mean, we've been doing this for 40 years now.

 

Representative Jack Ladyman Well, it does happen, okay? It has happened that people go to the sites, they really don't have a complaint. So I'll move on. Guardianship. You talk about you assist with terminating and or limiting guardianship when abusive neglect or unnecessary guardianship exists. How do you monitor and investigate abusive, neglected or unnecessary guardianships? What's an unnecessary guardianship?

 

Thomas Nichols Well, it's usually one where an individual had a transient illness or disability that has resolved and they no longer-- usually a provider with permission from the individual will contact us because the individual is totally capacity. They have capacity and so they do not require a guardianship anymore. And so we can't terminate them ourselves. We have to go to the court and give the court evidence in order to--

 

Representative Jack Ladyman Well, you made a statement that I totally disagree with. You said getting a guardianship is easy. Speaking as a person that's got a guardianship, it's not easy even if you're a parent. So I disagree with that statement altogether. Madam Chair, I'll stop and put me back in the queue and let someone else ask a few questions.

 

Senator Missy Irvin All right. Senator Chesterfield, you're recognized. Welcome.

 

Senator Linda Chesterfield Thank you. Thank you, Madam Chair, for allowing me to ask a question as I am not a member of the committee. I appreciate it. Could you tell me, do you work with rehabilitation services in the state of Arkansas and in what way?

 

Tom Masseau So, yes, we do work with Arkansas rehabilitation services on employment, looking at ways to increase competitive and great employment. We're a member of the State Rehabilitation Council. We provide input into the state plan that gets submitted every year to Rehab Rehabilitation Services Administration. There's oftentimes where we get calls from some of their clients who are trying to access services.

 

Senator Linda Chesterfield And so you do work hand in hand with them.?

 

Tom Masseau And so then we advocate for that individual to get the services that they're entitled to under the law.

 

Senator Linda Chesterfield You survey the state as to how they're doing in treating our people who are disabled. How is Arkansas doing?

 

Tom Masseau And what do you mean by survey the state? In what area?

 

Senator Linda Chesterfield By that I mean you go to various parts of the state providing services, you monitor various entities to see how they're treating our disabled. How is the state of Arkansas, in your view, doing in providing for its disabled citizens? Or is that considered a loaded question?

 

Tom Masseau Well, it's pretty loaded, but I'll let Thomas respond.

 

Thomas Nichols Well, so--

 

Senator Linda Chesterfield Are we doing a good job? I know we can do better. Everybody can do better.

 

Thomas Nichols Yeah. If I were to be completely fair, there is more work for us to do than we have time in the day.

 

Senator Linda Chesterfield And staff to do.

 

Thomas Nichols Yes. Absolutely.

 

Senator Linda Chesterfield What area of the state provides you with the greatest challenge?

 

Thomas Nichols The areas where there are a dearth of services. Right? Like East Arkansas, southeast Arkansas, some of those areas that are somewhat provider deserts, especially with regard to a lot of our education cases. A lot of times they're very open to bringing a behavioral health professional like independent behavioral health professionals in in order to provide really substantive consultation for a school--

 

Senator Linda Chesterfield So the poorest areas of our state are the ones that provide you with the greatest challenge in providing the needs for the individuals with disabilities. Is that what you're telling me?

 

Thomas Nichols Yes.

 

Senator Linda Chesterfield All right. Thank you. Thank you, Madam Chair.

 

Senator Missy Irvin Thank you. Representative Wooten.

 

Representative Jim Wooten Thank you, Madam Chairman. Let me state from the outset, I'm not a member of this committee. But I have constituents, and from them I've heard that it's not necessarily fair to say that we're failing in some of our HDCs? My fundamental concern is your board of directors prioritize, according to your statement, each year what you're going to do and look at. And my concern is how many members of the board of directors do you have that have people with disabilities that are in institutions?

 

Tom Masseau Currently?

 

Representative Jim Wooten Currently.

 

Tom Masseau Currently none. My board consists of individuals with disabilities, family members with individuals who live in the community. There are individuals just of the general public. It just varies.

 

Representative Jim Wooten Okay. Did they set the goal that's part of your mandate to eliminate the HDCs in the state of Arkansas?

 

Tom Masseau So our priorities there is looking at eliminating the abuse, neglect and exploitation in the facilities. There is not a priority that says that we are going to--

 

Representative Jim Wooten You don't have a goal to do away with the HDCs?

 

Tom Masseau No, I've been in this state for 11 years, and if they were going to close, they would have closed a long time ago. I don't see any-- in the foreseeable future, what we're advocating, our goal is to ensure that individuals who are in the facilities are free from abuse, neglect and exploitation. They're getting the appropriate services that they need to eventually, if they can, to move into the community.

 

Representative Jim Wooten Follow up, if I may, Madam Chairman. You don't have a goal established to do away with them, but yet you measure how successful you think they are in doing their performance without abuse? Or do you just go in and evaluate and make suggestions, recommendations, or even so far as rule violations or law violations are concerned?

 

Thomas Nichols I would love it if we could go to facilities and look at things like education, active programing, supported employment, transition services, social opportunities. But we believe that the abuse and neglect should take precedence over that.

 

Representative Jim Wooten Well, I agree with you. But the problem that we're facing is one that so many of these individuals, they can't respond to anything. But yet the recommendation seems to be at times to close the facility, to put them back out in community based oriented or private homes or community based facilities is the impression that's being left with residents. And that's where they have a great deal of concern. They have a great deal of concern relative to the salaries and compensation of nurses and others in care facilities. And yes, I look at the governor's budget. And it was $65,000,603 last year, for this year, and for the next year. 0%. One of the only items in the Department of Human Services. So it looks like to me, from an outsider looking in, that a goal of your organization, maybe not of yours personally but of your organization, is to do away with the human developmental facilities in the state of Arkansas. Is that a correct assumption?

 

Thomas Nichols I'm sorry you're reaching that conclusion right now. Our infrastructure-- I don't know if you heard the conversation that I had with Madam Chesterfield, but we have a dearth of services all over the state, whether it's supported employment services, whether it's education services, whether it's access to community based services. Right now we are struggling in order to try to make sure that our PASSE organizations are actually providing the services that they promise to provide. And that's not always the fault of the facility or the PASSEs, but a result of the workforce shortage that exists. And so I don't think that our state could withstand closing all of our facilities considering the community supports and services that are in place right now. Perhaps if we get to a time where we are not overwhelmed with abuse and neglect investigations and we're not overwhelmed with representation, trying to get services from the PASSEs and where we're not overwhelmed by trying to get access to special education and related services, maybe then we could talk about whether the facilities are necessary. But that is so outside the realm of our work plan, of our strategic goals. We're talking past each other here.

 

Representative Jim Wooten Okay. So you're saying that you do not have a goal, one more time, that you do not have a goal to close these facilities in the state of Arkansas?

 

Thomas Nichols That is not in-- it is not the will of the legislature. It's not the will of the executive. It is not the will of the judiciary. That's been tried a decade ago.

 

Representative Jim Wooten Do you work for the state or do you work for the federal government?

 

Tom Masseau So we are a private nonprofit. So we do not-- yes. We don't work for the state.

 

Representative Jim Wooten Is it maintained by the state?

 

Tom Masseau No.

 

Representative Jim Wooten By the federal government grants?

 

Tom Masseau No. We just receive the grants from the departments. We are not part of the state. We're not beholden to the state. We're not part of the federal government. We don't act on behalf of the federal government. We are a private nonprofit entity. And if I may just follow up with Thomas. He mentioned there are so many issues across the state. Our budget is $2 million. And as Thomas mentioned, the number one calls that we get are focused on education. I know the focus is on our monitoring efforts, but we do so much more and serve so many more people in the work that we do in trying to ensure that they're safe, that they're getting the education supports, that they're getting opportunities for employment, that they are getting access to health care services. 

There is so much more to what we do than monitoring the abuse and neglect. And I appreciate your comments, but there's a lot of opportunities here in the state. And if we just focus solely on the HDCs, all these other services and supports that people may need go without any attention. So I think we're trying to spread our resources where we can, but there are so many opportunities in this state to do that.

 

Representative Jim Wooten I just want to make sure that you're aware of the fact that there's a thought process out there that says what your goal is. And in order that you can guard against that, because in my opinion, these facilities are desperately needed and need to be maintained and need to be funded adequately.

 

Tom Masseau Yeah, I'm aware of that thought. I've been here for 11 years and it's been reminded of me daily, so I'm fully aware of that, the thought that's out there.

 

Senator Missy Irvin Thank you. Thank you, Representative Wooten. Yes, sir. Sorry. We just need to move on. And I'm trying to give everybody latitude. It's a really important subject. Representative Mayberry.

 

Representative Julie Mayberry Thank you, Madam Chair. So during one of our Children Aging and Youth Committee meetings earlier in the year, we had a woman who uses a wheelchair for mobility come and make an emotional plea to legislators about access. I mean, I'm talking physical access-- ramps, elevators, where a sink is, where the soap dispenser is in the bathroom in public restrooms and all that, and just how difficult it is to make those changes. The only way to really make those changes, it's federal law. And so you have to report something to the Department of Justice, which there's really no way to enforce anything. And that's the frustration. 

So we did hold a committee meeting, talked about lots of different ideas, things that are in place to try to help in some ways. But I've been trying to figure out how could someone in the state of Arkansas make more of a local complaint? 

So actually, this came up in a discussion with Girl's State that the one Girl's State representative, her mom uses a wheelchair for mobility, was a former Miss Wheelchair Arkansas. And it was something that even the teenagers were very committed to making sure that we do something about. And the idea in that little meeting was to work with the fire marshal's office, since they're the enforcement of what is done. But it is difficult, easy when it's a future build but difficult when it's an older building. And the belief out there that if it's an older building or built before-- I forget the exact date, 90 something-- if it was built before then, that they don't have to comply. And that's really not the situation. They do have to comply. 

So my question to you is how possibly could Disability Rights Arkansas be used some way in that? Is there maybe a Department of Justice grant that could be utilized to hire an attorney that just deals with this? So someone in the state of Arkansas that's saying, look, there's no parking spot, there's no ramp to get into this building, I can't wash my hands, I can't use a bathroom. I don't go to this football game at the high school because there's no bathroom there for me to use. 

I mean, that's what we're talking about. If there was no bathroom for everybody in the public to use at a football game, you wouldn't have anyone attending, right? Everybody would stay home because in a 2 or 3 hour time period, you're probably going to have to use a bathroom or the concession stands definitely would close down without a doubt. Is there an option? Is there something that maybe just thinking outside the box that we can use you to to help with?

 

Thomas Nichols Yeah, we want to be in a position to be able to help people with physical accessibility issues. We used to do a lot of physical accessibility issues when our board developed that priority and they might again. We actually do have in our strategic plan working through one of these access cases because as you might be aware, if the facility, if the place if the business, if the area says no, your option is you got to sue them. If they say no, the Department of Justice can come in and sue them or they can sue privately. But that's about the extent of it. 

If they don't have a building authority there, and we've had some success handling cases by referring them to those building authorities in larger cities like Little Rock and Hot Springs and and Fayetteville. They have some building authority that can go in and evaluate those cases. But you're right. And you know, when you mentioned the state fire marshal, it is a bit more challenging when you have something that is older because those plans have already been approved. That building has already been built. And they had to make those changes. 

But I would also say that on the front end, I think there could probably also be more done. Because I believe the state fire marshal, when they approve these plans, they're approving the plans. So the architecture develops plans, they approve it to make sure it's accessible, but then I don't know that they then go once the building is finished to make sure that those plans actually adhere to the final product. So if there's some change that's made in the building process, we've seen in some cases schools get built without having the secondary eyes on it. And so it could be years before you find out that one of these places is inaccessible. 

So how can we-- if they call us, one thing that we will absolutely do is contact the place that is inaccessible, provide them our FAQ on accessibility, provide them with the Department of Justice guide on accessibility, and follow up with them to make sure that they either have or are intending to make those changes. But you're right, we use a lawyer to do all of that, and litigation is awfully costly. And if that's your last resort, it is very costly and expensive. More so than just staff time. But we have also helped people make complaints to the Department of Justice, and they have a mediation process at times that they can employ. 

Of course, if the facility or the organization or the business or the place is amenable to having a mediation, then that's totally free of charge except for staff time. So there's a few different ways, but I would love it if the state developed an office that has some enforcement authority for those cities that do not have the building authorities to go in and challenge those places that are physically inaccessible and make them adhere to those laws. That would be wonderful.

 

Representative Julie Mayberry  We can talk about this for a long time, but just wanted to kind of open it up and maybe we can talk afterwards. Thank you. Just looking for solutions. Thanks.

 

Senator Missy Irvin Thank you. Okay. Circle back to Representative Ladyman. And I think I will give you a copy of the handouts that he has provided with the families. I think it's a great opportunity for collaboration and discussion with the list of all these individuals, and I hope that that continues. I think it's an important balance and I really appreciate-- I helped start the Social Security Disability Fraud Unit working with SSDI. And so that was very interesting to me because that is a huge component of SSDI. There's so much money going out the door every week and I'm close with the people that the director-- very close with him. And my father actually worked there as a physician who reviewed requests for disability. 

But really important to start that Social Security disability fraud unit making sure that people know, okay, well we need to get you back to work. And I think that's really a focus that I didn't know about that you work in and I think a really important one, particularly those that are managing those funds for those elderly population. And I have personally witnessed that and seen that kind of real exploitation and abuse. And it's devastating and tragic. Representative Ladyman and then I think that's the last question we have. You're recognized.

 

Representative Jack Ladyman Thank you, Madam Chair. Well, let's go back to the human development centers where I stopped a while ago. And maybe this will give you an idea of what Representative Wooten is referring to here. In 2015, your parent corporation presented a suggestion to Congress to eliminate all sheltered workshops nationwide. These programs provide purpose and independence for people with intellectual and developmental disabilities who are not capable of obtaining competitive employment. Why would your corporation want to eliminate these workshops?

 

Thomas Nichols Are you referring to the National Disability Rights Network?

 

Representative Jack Ladyman The P&A, your parent group. You said you were in 57 states. Is that group.

 

Thomas Nichols Our parent organizations is the federal--

 

Tom Masseau So yeah. So National Disability Rights Network is not our parent association. They are a membership and all of the 57 states and territories are members of. They don't dictate the work that's happened in the state. All the protection advocacy systems, you know, identify their own priorities and objectives based on their individual state needs. They are a member association, just like any other member association that develops public policy within Congress.

 

Representative Jack Ladyman But you do collaborate. I think a member of your group went to Washington and presented before a committee recently. Saw the video.

 

Tom Masseau Yes.

 

Representative Jack Ladyman But this particular, eliminating these workshops. Congressman Steve Womack-- I've got a video I can show you-- he opposed that because it's a good thing. And this money would have gone away for all states. So, I mean, you collaborate with this national organization, right? So do you collaborate on your goals? Are your goals similar to their goals?

 

Tom Masseau So our partners' directives are unrelated to the National Disability Rights Network's goals. We, again, look at what the needs are of the state. And the board focuses on what are the needs of the state. And, I just want to clarify some. You had mentioned that we had somebody speak in Congress. That was unrelated to our national associates. That was a request from a member of Congress to present unrelated to our national association.

 

Representative Jack Ladyman Well, there were statements made in that committee meeting in D.C. about closing human development centers. Yeah, it's a video you can look at. Let me move on.

 

Tom Masseau Yeah, I'll look at that.

 

Representative Jack Ladyman Also in 2015, your organization, I believe I got that right, sued the state of Arkansas to require the state to close the Booneville Human Development Center. Why did you do that?

 

Thomas Nichols We didn't sue the state.

 

Representative Jack Ladyman Do you know who did?

 

Tom Masseau In 2015? No. We had no-- and I can verify--

 

Representative Jack Ladyman You go look it up. It's out there. So is it the goal of your-- I don't what you call them, I call them your parent corporation-- to close all human development centers? And if so, why? Representative Wooten already asked you that about Arkansas. But it is the goal of your oversight group, your-- what do you call them?

 

Thomas Nichols Our technical assistance provider.

 

Representative Jack Ladyman Is it their goal to close all human development centers?

 

Thomas Nichols I don't have any insight into what their--

 

Representative Jack Ladyman Well, I'll tell you, there's seven states that have-- I may have the number wrong-- 6 or 7 states that have already closed all their facilities. And they have major problems out in the communities where these people have gone. I know of cases right here in Arkansas where a person went out of the HDC, went to a group home, had to spend nights in jail three times, because the people in that facility could not deal with his situations. So those kind of things are happening all over. And it is the goal of this, whatever this national entity is, to move everybody into a community setting. And a lot of people work in a community setting. But as Representative Wooten said, there are individuals that cannot function in the community. And it does not turn out good. And I know situations like that. So let me ask you this. Do you promote the HDCs as a service option to people with INDD when you're trying to place them or help them or whatever? Is that an option that you all would look at, to place people in an HDC versus a community setting?

 

Thomas Nichols We're not doctors. So we don't place people in a facility and we certainly do--

 

Representative Jack Ladyman So nobody comes to--

 

Thomas Nichols We certainly don't dictate their care.

 

Representative Jack Ladyman So no one comes to you and asks for help to place an individual with DD or intellectual disabilities? Nobody comes to you?

 

Thomas Nichols But we don't get to make those decisions for them. Right? So we--

 

Representative Jack Ladyman No, I'm not talking about--

 

Thomas Nichols As a lawyer, we are--

 

Representative Jack Ladyman Do you lay out a continuum of care?

 

Thomas Nichols No.

 

Representative Jack Ladyman You don't tell them, Hey, this is the place to go? You don't do that? People don't come to you?

 

Thomas Nichols We don't tell people where to go receive their care.

 

Representative Jack Ladyman Well, let's move on. Do y'all request FOIA's from the HDCs?

 

Thomas Nichols No, we request them from the privacy office at the Department of Human Services.

 

Representative Jack Ladyman How often do you do that?

 

Thomas Nichols  I could not give you an estimate. It wouldn't surprise me if it were weekly. We ask for all kinds of information that we believe should be public and have asked DHS to share.

 

Representative Jack Ladyman So you're asking at least weekly for an employee from an HDC?

 

Thomas Nichols If I had to guess, I believe that it would be weekly.

 

Representative Jack Ladyman Yes. Well, lastly, who has oversight on your organization? I know the HDCs, they have two organizations that come in and do audits. I've seen those audits, at least the one in Jonesboro, and they always pass in flying colors. Who audits you?

 

Tom Masseau So we are, again, a private, nonprofit organization. And every year we submit our program performance reports to our funders. And they review them. They do their due diligence. We have financial audits every year. But again, nobody oversees us. I mean, we report on our every year, like I said, our nine federal reports. They're all public information.

 

Representative Jack Ladyman And you send those to your funders meaning federal organizations?

 

Tom Masseau They're required part of--

 

Representative Jack Ladyman But you're working in the state of Arkansas with Arkansans. We need to do what Arkansans need and want, not what the federal government wants. So there needs to be some oversight. When you're working in Arkansas, you need to have some, I think, some input into this body so that we know how you're implementing. And I hate to get on you like this because you're doing good work in other areas. 

But I think in the HDCs, based on what I'm hearing and Representative Wooten said a similar thing, there are some issues in the way you work with the HDSCs. It is out there. This organization that I talked about a while ago. They can give you those situations if you're interested. So there needs to be some communication between you all and this body so that we know that your work and your goals align with what the state wants. So while you're standing there, I do appreciate your coming and I appreciate the information you presented. Thank you, Madam Chair.

 

Senator Missy Irvin Thank you. Are there any other questions from members of the committee? All right. Thank you guys so much. Appreciate the presentation and all that you're doing. Thanks.

 

Tom Masseau Appreciate it.

 

Senator Missy Irvin Thanks. Okay, folks. Members, we will move down our agenda. The next we have is a bunch of ISPs. So just as professional courtesy, we generally approve these ISPs as a matter of professional courtesy. It doesn't mean that we all like them, are all going to vote for them. That's going to be determined during the session. So if there's any one in particular that a member wants to take out of this, we're going to batch this. If there's a member that is a sponsor of one that wants to pull it out of the batch and discuss it, happy to do so. If there is a member that wants to pull one out that's not a sponsor of one of them and discuss, we're happy to do so. So I'm just going to offer that. And so does anybody want to pull anything out of any of these ISPs and discuss them individually? All right. Seeing none, then we will batch these. And without objection, these are adopted. 

And again, the offer is, you know, we do have subcommittees. And if you're a sponsor of an ISP and you want to bring it before one of the subcommittees, just let me know. I will work with the chair and Representative Johnson. We'll work with the chairs of those subcommittees. And if it's an issue, you want more information about it, you want to bring it to light and you want others to talk about with you, we're happy to help you get that scheduled. All right. Last item on the agenda is a status update of Act 974. If Ms. Franklin can come forward, we will present that. Thank you.

 

Mary Franklin Good morning. Mary Franklin, director of the Division of County Operations, Arkansas Department of Human Services.

 

Kristi Putnam Good morning. Kristi Putnam, Secretary, Arkansas Department of Human Services.

 

Lori McDonald Hey, Lori McDonald, DHS Chief of staff.

 

Mary Franklin Good morning, members. We have provided an update to you in the form of a handout that you got earlier, and I'm happy to walk through that handout or happy to answer questions, however you'd like to proceed.

 

Senator Missy Irvin Just, members, if you want to just do a highlight overview, it's already 12:30. I don't want to lose members, so go ahead and just provide us a little bit of an overview.

 

Lori McDonald Certainly. This document walks through the different requirements related to work and training in the SNAP program. It walks through general work requirements which apply to 16 to 59 year olds, where generally they need to register for work, take a suitable job if it's offered, not voluntarily reduce hours or quit. And it also goes into further detail about how the able bodied adult without dependents, often referred to as the ABOD, time limit is part of that general work requirement. And this group is a subset of all the individuals that have the general work requirement in SNAP. 

And if you're an ABOD, you are between the ages of 18 and 54 with able bodied and without dependents in your home. And if you are part of that group, you can only receive SNAP for three months out of a 36 month period unless you are meeting that work requirement or are exempt from it for some other reason or doing an activity that is an allowed activity. On page two, we have provided a list of those who have been discontinued in SNAP related to that able bodied adult without dependent time limited work requirement. The first closures for that after the pandemic happened in October of 2023. And to date, there have been 4,907 closures related to not meeting that ABOD time limit. 

We do offer at this point in time a SNAP employment and training program that is voluntary. And in 2024, fiscal year, federal fiscal year 2024, we have served 2,561 individuals in that program. We have referred over 20,000, 20,519 to that program during that same time and are continuing to and understand the intent, we believe, of the Act 974, which is to encourage those to work and seek training that will improve their ability to work where they might normally be exempt from that general work requirement.

 

Senator Missy Irvin All right. Any questions from members of the committee? All right. Seeing none, we appreciate that you're here to present this report. Look forward to continuing to work with you on all of this. Members, I'm not sure if Senator Chesterfield is still here. She's gone. But I want to recognize Representative Deborah Ferguson. Deborah, you have been an incredibly valuable member to this legislature and particularly to public health. And there is nobody else that has such a great level of expertise and knowledge and compassion for the people that are patients than you. And you have just been a tremendous source of inspiration, mentorship and knowledge and friendship to me personally. 

And I just I am going to miss you so much. I think we all are going to miss you so much because you just really have brought an incredible amount of expertise and knowledge to policy, particularly for this legislature. And so we're going to miss you. I'm not sure if you're going to be here in December or not. So I saw that you were here and I wanted to take that opportunity. But you have just been amazing. And I personally, and I think I can speak on behalf of everybody in the legislature, you have been a wonderful colleague, and we're going to miss you so much. Thank you so much for your work. Don't be a stranger. I'm going to call you all the time. I would say the same thing with Linda Chesterfield. I know she served on Education, but she was so, so important on public health issues as well. So thank you again. 

If there's any other business to come before the committee, the marathon Public Health November committee meeting on Thanksgiving week, you get brownie points for being here. Members, we are adjourned.