House Health Committee, January 12, 2026

Transcript

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1. 0:15:38

   Okay. You ready? It's two o'clock. Good afternoon. It's two o'clock, and we're gonna go ahead and begin, stay on, uh, schedule. Um, as you notice, some of our committee didn't quite make it today. Um, but it is the first day. Uh, we're hearing testimony only today. Um, some of this testimony came up, uh, during our, uh, meetings this summer. Some of this is, uh, testimonies from, uh, issues of last year, but they're all important, and I appreciate everyone that's here in the room.

2. 0:16:13

   And let's begin with the first, and that's Dr. Jeff. He's on here as John. Is it John Jeff or Jeff John? John Jeff. John Jeff. John Jeff. Sounds like a rock and roll singer. Um, I know- I've known Jeff over the years. Uh, he was head of cardiology at Northeast Georgia Medical, um, Center, and now he's at Northside. He's actually nationally known and, um, uh, um, well, well-respected.

3. 0:16:44

   And so if you would like to begin, I would appreciate it. Thank you. Thank you, Chairman Hawkins. Thank you, members of the committee. It's a pleasure to be here to talk about funding for the Office of Cardiac Care. Uh, like the chairman said, I work at Northside Hospital. I'm a cardiologist, and I have no conflicts except I think we ought to be giving the best care for cardiovascular patients in the whole country. Wanna talk about four things. One, the leading cause of death in Georgia and the United States, discuss time-sensitive emergencies, talk about what the Office of Cardiac Care has done, and then hopefully show you that it's woefully underfunded and understaffed.

4. 0:17:24

   So the top four bars there are heart disease, cancer, trauma, and stroke, and that's the same thing in Georgia. These are data from the Oasis database, the most recent data in 20, uh, '24. 30% of Georgians die from heart disease, about 20% from cancer, about 9% from trauma, and about 5% from stroke. And time-sensitive emergencies are the things that we're interested in the Office of Cardiac Care.

5. 0:17:55

   Those top three in red, heart attack, the big heart attacks are called STEMI, ST-segment elevation MI, out-of-hospital cardiac arrest, like what happened to Damar Hamlin and lots of other people unfortunately on our community, and people that then get cardiogenic shock. A heart attack so big that the pumping function of the heart doesn't work, the blood pressure goes down, and everything goes down from that. Importantly, processes of care. Having a process that's repeated over and over the same for every patient actually improves survival in these patients.

6. 0:18:32

   It also removes disparities of care. In the Office of Cardiac Care, the first, uh, hospital was certified in 2018. The law was passed and signed in se- on 7/1/2017, and the directors were really basically des- to devise the levels of care to establish a statewide database. This is critically important. Before this time, we didn't know how many people in our state had heart attacks or how many people in our state had out-of-hospital cardiac arrest.

7. 0:19:03

   This group certifies the emergency cardiac care centers, and it establishes treatment as well as transportation protocols so that our, um, uh, our, our partners, uh, out in the field, the paramedics and ambulances services know where to take patients. They provide a list of those folks, so they know where to take them. And then finally, the law actually has an unfunded mandate to pro- to give grants to improve quality of care, and this is especially important in rural Georgia, where we really need to improve the quality of cardiovascular care.

8. 0:19:40

   These are the three levels of care. Suffice it, the top level, level one, those hospitals have open heart surgery. They can also put in devices that will support your blood pressure called peripheral left ventricular assist devices to keep your blood pressure up, so the cardiologist can go in and stop the heart attack with a stent or a balloon. They have twenty-four/seven cath lab services. They can put in defibrillators such that a patient that's had an out-of-hospital arrest, if they have another one, the device actually shocks them back to life automatically.

9. 0:20:13

   Uh, they have to be able to take care of patients who have comas from out-of-hospital cardiac arrest, so they need neurologists, and they need to be able to treat these people by cooling them to preserve the brain. The level twos have all of that except no open heart surgery, and the level threes, the critical part of this, is getting more level three hospitals in rural areas to have pre-set up protocols so that patients get to the right place at the right time for the right treatment. At three o'clock in the morning, you don't wanna be calling multiple ERs to get a patient that's critically ill to a, to care.

10. 0:20:49

    This is kinda how this works. If you're the patient up there in the top left corner and you have some o- of these time-dependent cardiac emergencies, the paramedics make the decision in the field. If they can get to a level one hospital, they take you there. If they think that you need to be stabilized at a level two or level three, they take you there, and then the physicians at those hospitals facilitate that transfer in a timely way. Time is of the essence in this. The golden hour for heart attacks is about twenty-four hours.

11. 0:21:22

    We've designated, uh, the office has designated twenty level one hospitals, and there's only one open heart surgery program in the state that's not yet certified, and that's pending. Nineteen level two, and there are five pending. Eleven level three, and there are six pending. We hope within the next year, about half of all the hospitals in Georgia will be emergency cardiac care certified, and this is critical for all of us because a third of us die from this.

12. 0:21:49

    This office is understaffed. There are three staff members, and the fourth member is funded by a separate grant. That person is really important. She's the epidemiologist. It's great to collect these data and know where Georgia is so that we can make plans to change that, but we need data specialists to help us dis- to, to facilitate those data, to put them in usable form so that we can share with you. They've collected four years of data. Uh, mortality from STEMI and out-of-hospital cardiac arrest are decreasing.

13. 0:22:22

    I'll show you that on the next slide. We need protocols for cardiogenic shock. If you have a big heart attack and have cardiogenic shock, your chance of surviving is less than 30%. If you have an out-of-hospital cardiac arrest, if you have a, uh, or a sudden cardiac arrest, your chances of walking out of the hospital as a walkie-talkie, as we say, nationally, is about 7%. Those are really bad odds, and the only way to fix this is bu- is by having processes of care and coordinating care between hospitals.

14. 0:22:55

    We're advancing new protocols for anticoagulation and EMS. The, the paramedics are actually activating the cath labs in the hospitals through this system so that when they get the patient to the hospital, they bypass the emergency department, go straight to the cath lab, and get what they need. And for once now, Georgia can say, "We know what the incidence of these terrible things is." This is a page, and I wish I could have brought you, uh, excuse me, this annual report, but our budget, the budget doesn't allow us to print that many.

15. 0:23:27

    In gray here is 2021, in red 2022, and in blue 2023. And I think you can see that all of those terrible things,

16. 0:23:38

    the death rate is decreasing, and part of that is the protocols that we've put up. So now, this is three pairs of graphs, okay? The red ones are cardiac, the blue ones are stroke, the green ones are trauma. The left-hand bar in each of these pairs is the percentage of Georgians that die from those problems. Again, cardiovascular disease, 30%, and the funding for that office is about half a million dollars. Stroke, about 5%.

17. 0:24:09

    I know that they've lost the Coverdell Stroke, but I hope that they will get back to the $3 million level they were. Trauma, about 9% of people in Georgia die from that, and they have a war chest of $22 million. Shown in another way, the font size on this slide represents the relative differences in both the disease state that Georgians are dying from, and in green over here, the funding for those. So Coverdell in the bottom right, uh, super-speeder, and I don't think the, uh, Office of Cardiac Care has yet reached the red-headed stepchild level, so we need to get them at least to that level.

18. 0:24:50

    This slide shows that the Office of Cardiac Care has, um, certified about 38% to date of all the hospitals in Georgia. Stroke has certified about 61%, and trauma about 27%. Now, not all hospitals can be trauma centers, so you wouldn't expect that to be as high. But we need level three centers in Georgia to be certified so that we can take care of the rural folks as well as we can take care of others.

19. 0:25:20

    So in conclusion, cardiovascular disease, the number one cause of death in Georgia and the United States. Between a third and a quarter of us are gonna die from this disease. Processes of care have proven to reduce mortality, and we've shown that in Georgia. The Office of Cardiac Care data prove that. They're understaffed and they're underfunded. So what can we do? We need to get more level three hospitals. Uh, you may know when a hospital is activated for a trauma call, money goes to that hospital because it costs the hospital money to keep a team available 24/7/365.

20. 0:26:00

    It's the same thing with emergencies in, in the cardiac world. They have to be 24/7/365, they have to have people ready for this care, and that fiscal support would help them. And the granting process that is unfunded would help that. Finally, if we can get all the hospitals in the state, I think we can even get more innovative. Georgia is actually known around the country as one of the best places for taking care of emergency cardiac care. In your packet is a second thing besides the slides, this packet here, that has some suggestions for possible budgeting.

21. 0:26:38

    And, um, most of the money in that $3.8 million is to fund this unfunded mandate of grants that I think should be going mostly to rural hospitals. Finally, this is a really cooperative effort in the state of Georgia. The pre-hospital patient, the pre-hospital providers, the hospital providers, people in the cath lab, people in the ER, people in the critical care units all work together. And an example of that is, for 15 years, we've been doing this conference.

22. 0:27:09

    It's very well-known nationally. The Georgia Nursing Association, the Georgia College of Emergency Physicians, the Georgia EMS Association, the Office of Cardiac Care at DPH, and the Georgia Chapter of the American College of Cardiology put this on once a year. You're all invited. We'll waive the $25 fee. Thank you very much for your attention. I'd be glad to answer any questions.

23. 0:27:33

    Thank you, Dr. Marshall. Uh, thank you, Dr. Marshall. Are there any questions?

24. 0:27:45

    Go ahead.

25. 0:27:45

    Dr. Marshall, just on this end here. On this, uh, the slide you show on the designated ECC, Emergency Cardiac Care hospitals in Georgia, you mentioned there were, like, one level one, five pending t- Do you have, like, a map showing those five or, uh, that's what, 12?

26. 0:28:03

    ... pending. I do not have a map of that, but I could get that, uh, for you from the Office of Cardiac Care.

27. 0:28:08

    I was just curious 'cause I, you know, you look at rural Georgia, big swaths of North Georgia, where I'm from, generally, and the rest of the state's pretty... And it may show a little bit different picture.

28. 0:28:23

    I can get that to you.

29. 0:28:24

    Thank you.

30. 0:28:26

    All right. That's all the questions. Thank you, Dr. Marshall.

31. 0:28:30

    Thank you for having me.

32. 0:28:30

    I appreciate you sp- coming today and spending the time with us.

33. 0:28:35

    Thank you, Chairman.

34. 0:28:36

    Thank you. Okay. Up next, uh, Kevin Woody and Jonathan Marquis or Marquez.

35. 0:28:56

    Hold on one second. Do you have the remote?

36. 0:29:04

    Hold on.

37. 0:29:11

    Thank you, Mr. Chairman.

38. 0:29:12

    Thank you.

39. 0:29:12

    I'm, uh, Kevin's warm-up act, uh, today. But, uh, we're gonna talk independent pharmacy for a few minutes. I have a very short presentation about medication access in Georgia, and it's at risk. Um, I'm pharmacist Jonathan Marquis. Uh, today I'm representing 600 men and women, uh, that own their pharmacy, uh, in Georgia. Uh, there's a little known fact, but according to the Joural- Georgia Rural Center, of our 159 counties, there's a pharmacy in 153.

40. 0:29:44

    So there's six counties that do not have a pharmacy at all, and 42 counties only have an independent. So that's roughly 25% of the state. So if this medication access gets a little bit worse, and Kevin's gonna give some specific examples, uh, we could be in some trouble. Looking around the group, and I've talked to you already today, some of you, many of you have a rep- uh, a relationship with your independent pharmacist, and we appreciate that. You trust them. You talk to them.

41. 0:30:14

    You get medication advice for them, and we appreciate that. Um, those that don't have a relationship with your pharmacist, I would be happy to find you a, a good one. Um, that, those statistics tell us something very interesting, that, that independent pharmacists aren't really clustered in cities. Uh, they're, they're in North Georgia. They're in South Georgia. They're in inner cities. They're in rural towns. Um, Kevin's example, he doesn't even have a physician, uh, in his town. He is really part of the safety net, uh, for patients in his area.

42. 0:30:46

    Every day, pharmacists in general, but independent pharmacists fill medications that are lifesavers. Um, insulin, cardiac drugs, antibiotics, very, very important. They're not luxury items. They're necessities. Uh, the problem is, a lot of these medications right now are being reimbursed below cost. Now, I like to say up front, thank you to this committee for so much work you've done on Medicaid and, and sort of getting that system, uh, up to date with regards to reimbursement for all pharmacies, and just starting January 1 of this year, the state health benefit plan, and we appreciate this committee and, and all your work.

43. 0:31:25

    We're still missing a big piece of the whole commercial, uh, insurance business out there. If Kevin were to pay $100 for a medication, many times he's reimbursed $92 or $85 or even $60. No business could, could operate like that. Just think of your businesses yourselves. Um, you've probably seen some of the national sta- statistics. One pharmacy closes every day. Chains have closed. Independents have closed. But what happens when pharmacies close, specifically independents in 25% of the state?

44. 0:31:58

    Costs do go up. Patient have to drive further for their medications. They actually miss their medications according to the statistics. Um, and really once a pharmacy closes, they really never come back in, in my experience. And I like to say, Mr. Chairman, this is really fixable. Um, we're not asking for any special favors. We're not asking for anything different. We really want medications to be accessible, affordable, and reimbursed, um, fairly.

45. 0:32:29

    I like to say if independent pharmacies survive, you know, communities win, patients win, and the state of Georgia wins. Um, with that, like I said, I'm really Kevin's, uh, warm-up act, but thank you again for letting us be here. Um, Kevin, do you wanna switch?

46. 0:32:45

    Sure.

47. 0:32:47

    Yeah.

48. 0:32:47

    Thank you, Jonathan. Mr. Chairman, thank you for just the opportunity to speak. Uh, thank you to this committee for all that you have done even just this past year to, uh, help with the reimbursement model for independent pharmacies and pharmacies in general. Um, as Jonathan said, in, uh, in Claremont, where I live, uh, we lost our doctor's clinic up the street from me back right after COVID, as you're aware, Congressman.

49. 0:33:17

    Um, and, uh, I'm, I'm the provider there. I'm the one that people come to. Matter of fact, New Year's, uh, Eve, all the pharmacies in our area closed, uh, early. And I got a call from a little mama who had her first baby, preeclampsia. Mom's coming home after all the pharmacies had closed, and I jumped in the car and drove 25 minutes to make sure that she and that five-week early, five-pound baby, uh, got what they needed. But that's what we do. We, we try to care for our communities. Um, but as Jonathan said, it's difficult when the reimbursement's not there.

50. 0:33:52

    Uh, you know, we hear a lot about this. It's, it's no new, new story, and I, again, I commend this committee for, uh, making efforts last year just to, uh, even with the state to, uh, to help us to get a fair pricing model. Uh, I had reached out to the congressman earlier this year. I had, or I had filled a prescription for a patient, and, uh, this was on a, uh, marketplace plan, a plan that's subsidized by, uh, tax dollars. And I filled a, uh, a 90-day supply of blood pressure medication for a patient, amlodipine, and I ran that through.

51. 0:34:28

    I was reimbursed 25 cents from the, the plan or the PBM, and the patient had a zero copay So this patient got 90 days worth of medication for 25 cents. I had almost a dollar in the bottle in the label. The state requires me now to have registered and s- or certified technicians. Uh, that costs money. Back when I started, uh, 30 years ago, I, if I didn't have a tech, I'd pull the little girl from up front behind the register and I'd teach her to count by fives.

52. 0:35:00

    Uh, you can't do that anymore. We're the, we're so heavily regulated a- and it costs money, and to continually fill prescriptions like this is just, it's not even possible. I talked with a pharmacist this morning. He said, uh, last year he sold 24,639 claims at a loss. Uh, 2,598 of those were a marketplace plan. And what we're asking is that we bring the same, uh, model for, uh, commercial insurance.

53. 0:35:33

    Uh, I talked to a gentleman today, a very good friend of mine, Stetson Bennett. That name may be familiar to you. His son won our state two national championships. Stetson owns six pharmacies in South Georgia, and just this morning he said, "Woody, I'm gonna have to close one of them." He said, "We just... I'm working it every day. I own the building, uh, and I cannot make enough money to keep it open." He said, "Matter of fact, my wife is a school teacher, and, uh, the reimbursement up until the change that you've, uh, this committee has, has made for state health benefit," he said, "Kevin, I'm having to get my prescriptions filled at Walgreens because I can't stand the loss." That's just incomprehensible.

54. 0:36:13

    Uh, now the PBMs, they're gonna tell you, "Hey, we, we pay those, uh, little guys more than we do ourselves." I've, I've heard that song every time I come down to c- uh, speak before this committee, and, uh, it sounds good. It, it sounds like, uh, they'll tell you that they're the only savior for healthcare. They're what is keeping it going. If it wasn't for them, that we would be, uh... The model they have is what is making healthcare, uh, affordable. But what's funny is, as Jonathan just told you how many pharmacies are closing. Uh, in, uh, the last seven years, the State of Georgia went from 60,000 independent pharmacies to 19,000.

55. 0:36:51

    Two-thirds of independent pharmacies have closed in seven years. At the first of last year, we were seeing one just about every week. Uh, Jonathan met with someone, you may have mentioned it, uh, just this past week, two pharmacies closed. One had, uh, what, served their community 75 years, and the other 48. Uh, this is terrible. This is not because the cost of medication, folks. They're gonna tell you it's because medication costs so much. I have a stack at each of my stores of these prescriptions where I'm being reimbursed 25 cents, 7 cents, 95 cents for 30 and 90 days worth of cheap medicine.

56. 0:37:29

    The problem is, is this is actually, uh, very tactically done by the PBMs. Uh, why not pay a personal fair dispensing fee for a medication that's cheap and generic? Uh, the National, uh, Association of Community Pharmacists has published the cost to dispense medications. They do that each year. Uh, a couple years ago, that cost was about $12. Now, I think it's $14 per prescription. Uh, but yet we continually have prescriptions that are at 25 cents, 30 cents.

57. 0:38:02

    Um, I had, um... I began to think about this because everybody wants to talk and blame this on the drug companies. Well, if, if the cost of prescriptions is that extravagant, and, and some are expensive, then all the pharmacies should be changed and cl- going out of business. But this morning when I pulled up the most recent, uh, list of the Fortune 500 companies, it was amazing to see who was in the top 10. Uh, when I looked at that, uh, Elevance Healthcare Insurance was number 20.

58. 0:38:35

    Uh, Cigna and Express Scripts was number 13. McKesson Health, who owns a PBM, was number nine. CVS Health was number five. UnitedHealthcare was number three, only edged out by Amazon and Walmart. So it's amazing the companies that are paying me and we're going out of business, somehow they're, they keep rising to the very top of the Fortune 500. Three years ago, when the congressman allowed me to speak to this committee, uh, I think CVS Caremark was at number 16.

59. 0:39:07

    Uh, and if, if the whole healthcare system is suffering, as they would say, then how do they keep rising so high and all the ones who are actually providing the service are going out of business? Uh, we need to fix this. We need to do something with this model. I will say UnitedHealthcare, though they're number three, uh, typically reimburse a little better, but you must remember, UnitedHealthcare doesn't have retail locations. We've got to quit letting the fox watch the henhouse. Uh, there's the problem.

60. 0:39:38

    When the one who is divvying out the money is also divvying it out to themselves, we have a problem. And I'll, I'll close with this, and I thank you for your time. One of the things that I ask my pharmacist to do, and I have a stack this tall, is every time we, uh, get a claim that is a net zero, not a loss, now that's a lot more, uh, if I went by a loss, but just a net zero, I mean, the chances that a PBM when I transmit a claim would get lucky enough to reimburse me at exactly a 0.00 cents from what difference of what I bill.

61. 0:40:14

    I mean, it, it never happens. I mean, I think it happened three times in my career. This last year, just in the commercial market, we found, uh, just tons. Uh, I'll have four or five a day where when I run the claim through, if you don't count the bottle, the time, the label, just the cost of the ingredient, it's net 0.00. Now, nobody's that good. Hey, if they, if, if they were that good, they should go buy a lottery ticket. Nobody's that good. It's time to stop letting the fox watch the henhouse.

62. 0:40:45

    We need to come up with a different model. We need PBM reform, and we need us to be able to be concerned about treating our patients, not whether or not we're gonna get paid. Thank you again, Congressman and the committee, for the time to share.

63. 0:41:07

    Thank you.

64. 0:41:07

    Okay, go ahead.

65. 0:41:09

    Represent- Thank you, Ch- Chairman. I had a patient that called me, and believe it or not, that patient was on their way to pick up their prescription.

66. 0:41:20

    Mm-hmm.

67. 0:41:21

    And I was talking to them on the phone, and the person at the pharmacy said, "I'm sorry, I don't have the name brand." And that patient said, "No, I want the name brand."

68. 0:41:33

    Mm.

69. 0:41:33

    They said, "Well, you have to go to a different pharmacy." So that patient said, "Okay then, so I'll go to the different pharmacy."

70. 0:41:42

    Yes.

71. 0:41:42

    And I said, "Uh, you having to go to a different pharmacy just to get the name brand?" And the patient said, "Yes." I said, "Do you mind if I stay on the phone?" And the patient said, "No, you can stay on the phone." And they went to the second one. That second one said they didn't have the name brand, and sent them yet to a third.

72. 0:42:07

    Mm-hmm.

73. 0:42:08

    I said, "There is no way you should be going to three different pharmacies, and none of them have the name brand. What is wrong with this picture?"

74. 0:42:21

    Mm.

75. 0:42:22

    So I went and wrote a letter to the pharmacy that said that they did not have the name brand, because I was curious, did they or did they not?

76. 0:42:35

    Mm-hmm.

77. 0:42:37

    No patient should have to go through three different pharmacies.

78. 0:42:43

    That's correct.

79. 0:42:44

    My question to you-

80. 0:42:45

    Yes

81. 0:42:46

    ... is, is it the drug companies or is it the insurance?

82. 0:42:51

    It's the insurance. Uh, the contracts state that if we have a medication in stock, we must fill it. And so when you run claims, like, let's say, a name brand prescription that may cost $300 and the PBM reimburses you $20 because that's what the generic costs, uh, the pharmacy cannot sustain that loss, so the only legal way to not break that contract is not to stock that drug.

83. 0:43:17

    Oh.

84. 0:43:17

    Happens all the time. These PBMs are creating a, a, um, almost like a, um, a manufacturer back order that's not there. If I have that product, I am bound by law and bound by that contract to fill, fill that prescription. Matter of fact, I ran into that this week. I had a pa- When I reached out to Jonathan, I had a patient, two, uh, two patients that got, uh, GLP-1 prescriptions, uh, Mounjaro. Both of them were diabetic. And for a year, I have eaten a $48 loss per prescription, almost $100 every month for this family.

85. 0:43:53

    They get two other little prescriptions that I probably make two, $3 on, and I lose $100 every month. And so when the, the, those prescriptions were hard to get, I, I felt like it was not a good decision to, uh, to try and keep those, to maybe offer an alternative, because they may get it this month and they may not next, which is not healthy-

86. 0:44:13

    Mm-hmm

87. 0:44:13

    ... for these patients. But the only way for me to survive is to not have those in stock. I could order those things from a secondary wholesaler and get those, but I cannot keep paying $100 per month for that patient to get their prescriptions. And we noticed a, uh... My wife's an accountant. She came to me the first of last year and she said, "Kevin, why do we have a $100,000 cash flow loss?" And it was those drugs. We're not being reimbursed. They're, we're getting coupons that we wait four to six months to be reimbursed from.

88. 0:44:47

    And when it's all said and done, after I settle it in six months, I'm still losing $50 per box.

89. 0:44:55

    Follow-up, Chairman?

90. 0:44:56

    Yeah, go ahead.

91. 0:44:57

    Um, so in order for the, the pharmacist to stay in business, they have to not stock those drugs, basically.

92. 0:45:07

    Sure.

93. 0:45:07

    Is that what you're saying?

94. 0:45:09

    Uh, yeah. I'm saying that if a prescription costs a fortune and it's not something you normally would stock, that you would special order for someone, you, they, pharmacies will not order it because they cannot afford to order it and lose money.

95. 0:45:24

    Oh.

96. 0:45:24

    But they can't turn a patient away if they have it. We've got to fix the paying model.

97. 0:45:30

    Thank you.

98. 0:45:32

    Thank you. Any other questions? I see none. Th- thank you so much. Thank you. Oh, hold on. Uh, Representative Mitchell, is that you with- I, I've been fully briefed by, uh, Representative Kelley. Okay. Thank you very much for coming today. I appreciate it. Thank you, sir. Okay. Uh, next we have, uh, Penny Bonds. She's a, uh, director of Head Start, 9th District.

99. 0:46:09

    Good afternoon, and thank you for inviting me to speak today on behalf of Head Start. I wanna start out and just briefly tell you a little bit about the, what Head Start is, for those of you that do not know. Head Start is a federally funded program that was originated in 1965 as a part of President Hoover's War on Poverty. The mission of Head Start is to promote school readiness for young children from low-income families by enhancing their cognitive, social, and emotional development.

100. 0:46:45

     Head Start serves pregnant women, p- Children from six weeks of age up to four years of, four years old. And currently and nationally, there are 750,000 low-income students being served by Head Start. In the State of Georgia, there are currently 20,000 students that are being served in 400 different locations, and there are 6,000 people that are employed by Head Start.

101. 0:47:16

     Um, you can see when you look at the chart above that I have it broke down by congressional district, how many students are served in each district. In most rural counties, you will find that Head Start is the only childcare provider. So our families, if they want to go to work, then they have nowhere else but Head Start to place their child.

102. 0:47:43

     As far as Ninth District Opportunity, we are a community action agency. We are located, our central office is in Gainesville, Georgia. We are a non-profit corporation funded in 1967, and we do services in 27 different counties. In addition to Head Start and Early Head Start, we work-- we pr- do the Community Service Block Grant, the Energy Assistance LIHEAP program, Weatherization, Homeless, and the housing programs.

103. 0:48:19

     But as far as Head Start goes with Ninth District, we are in 20 Northeast Georgia counties. We are, um, the second-largest Head Start provider in the state with an enrollment of 2,488 students, and we employ 422 staff. Um, one of the things that we like to talk about is that in the year '24, '25, 39% of our employees were current or previous parents. So we are f- getting these low-income families in, sending them for their education, and then they are becoming employees in our centers.

104. 0:49:01

     But when you talk about Head Start and health, which is what I've been asked to talk to you about today, at each of our centers, we are required to have family support staff. Because when the majority of the families come to us, they do not have a medical or a dental home. Um, a lot of them come to us, they're not enrolled in Medicaid or in SNAP or any other type of benefits. So when they come, it is our place to help them locate medical and dental homes, to help them get enrolled in Medicaid, to address social determinants, and then collaborate once we do get a medical home with the children's-- with the physicians, because we serve 14% of children with disabilities.

105. 0:49:51

     A lot of those are medically fragile, and so it's up to us to work with those providers to get care plans. Um, this slide talks a little bit about the federal health mandates, because you're probably wondering, why do we do that? In order for us to keep our funds, we are required within the first 90 days that a child is enrolled to ensure that they have a physical exam and a dental exam.

106. 0:50:21

     And we are also required within the first 45 days to ensure that every child receives a developmental screening, a hearing, and a vision screening. But we run into a lot of issues with that, especially with vision. In the State of Georgia, more than one in five preschool-aged children have a vision disorder. And you can see that in '24, '25, we screened 1,782 children.

107. 0:50:54

     228 of those students needed follow-up, but 95 of those students left without follow-up. So for this year, we have screened 1,931 with 305 needing follow-up and 106 currently without. And you're probably asking, "Well, why is so many of these children not getting the follow-up?" It's because of the Medicaid reimbursement rates.

108. 0:51:26

     Most of the providers for vision, if they will even see the children, then they will not-- Medicaid does not pay for the child to receive glasses. The reimbursement rate is so low. I'll give you one example. In Gilmer and Union Counties, there are 28% of our children who did not receive follow-up treatment. Although there were vision providers located within, within these counties, they do not accept Medicaid.

109. 0:52:01

     So therefore, if they- if there is a student, which is the majority of these students that you see that are screened, are on Medicaid, they are having to drive long distances to find providers that will even see these children. And we all know that vision is so important. I mean, that's-- they have to have that to academically grow. You'll see a picture of a little girl in one of our counties that we were able to partner with Prevent Blindness to provide a glasses voucher for this child.

110. 0:52:35

     And her mom said when she looked in the mirror when she got her glasses, she said, "Just look at how beautiful I am. I can see good now."

111. 0:52:47

     Um, we also face the same issues related to dental. Um, f- There is eighty-seven counties in the state of Georgia that are designated as dental provided shortage areas, which means low-income residents experience limited access to dental care. Even in communities where there are dentists present, these dentists will not accept students or children that are on Medicaid due to the low reimbursement rate.

112. 0:53:20

     Also, what we find is that when our children are screened, because they have not had preventive care, that they have a lot of dental issues, and a lot of them require sedation dentistry, which requires the families to travel long distances, which they do not have the funds to do, and there's a six to ten month, if then, waiting list to get in for that care to be performed. As you can see, in twenty four-twenty five, we had two hundred and eighteen students that left us without follow-up that needed it.

113. 0:53:59

     And so far this year, we have two hundred and thirteen students, and that is just unacceptable. Um, one of the things that we had was in one of our programs, we had a little boy who came to us, and he was having severe behavior issues, throwing chairs, um, and acting out, um, hurting other students. Well, what we found when we did his dental screening was he didn't need mental health referral, and he didn't need a referral to the school system for special ed.

114. 0:54:33

     He simply needed to have dental work completed. So we found partners that would work with us that would donate funds to get this child the dental care that he needed, and guess what? He came back to school, his behaviors decreased significantly. But we shouldn't have to be looking for local churches and local organizations to provide the care that these children need.

115. 0:55:04

     As far as health goes, in the state of Georgia, there are sixty-three Georgia counties that do not have a pediatrician and nineteen counties that do not have family medic-medicine physicians. Just like I stated before, that leaves our parents who are already struggling. Some of our families have to decide, "Do I want to provide food for my family, put gas in my car to take these children to long distances for care, or them just do without care?" And unfortunately, the majority of them just do not get the care that they need.

116. 0:55:45

     Last year, ninety-six students left us without a current physical.

117. 0:55:54

     So to reiterate, some of the health barriers that our families face are insufficient healthcare providers serving children from birth to age five, limited participation of providers in Medicaid due to the low reimbursement rates, fragmented vision coverage where Medicaid may cover eye exam but then does not cover eyeglasses, which create barriers to completing the treatment, and then severe shortages of dental providers accepting Medicaid, particularly in rural areas across Georgia.

118. 0:56:36

     And then, of course, like I've stated, the geographical barriers requiring families to travel long distances to get the care that they need. So I, of course, am an educator, so I do not have all of the answers by no means. But I do feel like that we need to increase the Medicaid reimbursement rates to incentivize greater pr-provider participation in our rural counties. We also need to advocate for the recruitment and retention of healthcare providers in rural Georgia and then maintain and strengthen Express Lane eligibility.

119. 0:57:16

     Most of our families receive SNAP, TANF, and WIC, so it should not be so hard for our families to apply and get Medicaid. They sh-- If they're eligible for these other programs, we should be able to leverage that information to help them. And then we need to invest in parent education and outreach initiatives that emphasize the importance to our families of timely oral medical vision and hearing screenings and follow-up.

120. 0:57:50

     And then the last thing, there is currently a federal bill that I would like to encourage all of you to reach out to, um, your s-senators to encourage. It's H.R. two five two seven, which is the Early Detection of Vision Impairments for Children. And basically, this bill will establish state and community-based progress across the United States to address children's vision and eye health.

121. 0:58:25

     Thank you again for your time and letting me come to speak. I would like to encourage all of you, if you've not ever been to your local Head Start agency in your area, to please go visit. There are many ways for you to get involved, and it takes all of us working together. Um, in the packet that you got, you will find my business card as well as Ms. Boswell's, who is the Assistant Head Start Director. And if you have any questions, we would be glad to answer them for you.

122. 0:58:57

     Representative Silcox. Thank you, Mr. Chairman, and thank you so much for coming and sharing with us today about your wonderful program, Head Start. Thank you. Um, I was curious if, if there are any federally qualified health centers in your area. Not in the 20 counties that we serve that I'm aware of. Okay. 'Cause I think that would be a big help, you know? Yes. Um, I've, I know I've toured those before and, um, they, you know, take people just based on their ability to pay. Right. Um- We do partner and have contracts- Mm-hmm ...

123. 0:59:28

     with the local health departments. Mm-hmm. And they see our students as well as Help a Child Smile Dental. We bring the dental bus on site to most of our centers. But the problem with that is that's great for the care at that moment in time, but then when they need follow-up, those places do not provide that follow-up, and then when they leave us and go to the public school, we have not done them due justice because we've not linked them with a permanent medical provider or dental provider.

124. 1:00:04

     So we've actually provided the screening, which meets our mandates, but it's not helped the family to establish that ongoing care. Do you think that the state should provide more incentives to get, um, physicians to locate in rural areas? Most definitely. That is lacking, and physicians that are willing to accept the Medicaid reimbursement rate, because it's not a lack of the number of physicians in most of our counties, it's just the ones that are willing to see our children.

125. 1:00:36

     Thank you. That has been a problem, um, for medicine and dentistry. You know, the federal government unfortunately promises healthcare, but they don't want to really... I shouldn't say they don't, shouldn't say they don't want to pay for it, but they just don't pay enough. Right. Our, our federal FMAP in this state's about 34 cents on the dollar, so our state is carrying over one third of the cost, and it's a situation where patients sign up and, uh, you know, you, you never know what that cost is going to be.

126. 1:01:10

     Let me ask you this. Years ago, one of the ENTs told me that hearing tests were not covered by Medicaid under a certain age. Is that correct still? Yes, that is still correct. But that has gotten better with more children needing tubes. Uh-huh. Now, um, we are able to screen every child for hearing, and that's why I did not bring that up, and most of the ENTs that we deal with in our 20 counties will see our students. Um, mainly it's the vision and the dental that we are finding the lack of.

127. 1:01:45

     Yeah, I've got a good friend, an ENT that, uh, doesn't even bill Medicaid. He just does it free. Yes. In some practices they can absorb that. In cer- certain practices they can't. A lot of those practices that can are ones that take quite a bit of time with the patient. So if you have four or five Medicaid patients in one day, it's over half a day, and the overhead, just like we heard from the pharmacist, is just exorbitant. But, um- Right. And then another main issue with the hearing and the vision, if a child comes to us with a diag- or with a disability that we are suspecting, the school system will not take that child and screen them if they do not have a hearing and vision.

128. 1:02:27

     Right. And they want it to be a past, which means if they need glasses, they've got to have glasses. If they need tubes, they need that. Well, if there's no funds to provide glasses for those children, not only are they suffering there, but then they can't get the services for their disabi- diagnosed disability that they need. Right. Right. I want to thank you for coming today. Thank you. And I appreciate your testimony. Thank you. Okay, you see why we're having these people come in.

129. 1:02:57

     Uh, I think you realize the importance of everything we're hearing today. And next up, Dr. Brad Wesselman. Uh, he's with the Children's Care Network. So as we're getting settled, I just want to make sure that we are mindful of everybody's time, and thank the chairman for inviting us to testify today. And thank you for the opportunity to share, um, about the Children's Care Network, um, with the committee. Um, very proud of the Children's Care Network. My goal today is to tell you a little bit about us, and then, um, bring to the fore some issues that we're facing, um, through the providers that, that we represent, um, th- for us to come up with solutions that we can work on together.

130. 1:03:38

     Um, so again, thank you very, very much for, um, your time today. So the Children's Care Network, a lot of people are not aware of. We are Georgia's only pediatric clinically integrated network. Um, and the reason that, um, pediatrics is emphasized is because it is a long-term investment. Um, uh, the vast majority of what we do is preventative, and the goal is to create a healthy, happy, um, workforce for Georgia and a great place for our, our families to be raised. Um, we were founded in 2014 as an incorporated subsidiary of Children's Healthcare of Atlanta.

131. 1:04:09

     And what a clinically integrated network is designed to do is it's got, it's got three main things. Number one, improve quality of care for patients. Number two, decrease inappropriate utilization. And number three, provide community benefit. And so we're uniquely positioned to serve the state by supporting those healthy, happy families. Um, we are led by a physician-driven board of directors. Um, more than half of the people on the board of directors are community-based physicians, and we're one of only seven CINs in the country that hold URAC designation, which is the Utilization Review Accreditation Commission, that says that we do meet all of the standards for clinical integration.

132. 1:04:45

     Um, we have over 1,600 physician members. Um, 625 of those physicians are independent physicians, not affiliated with a large system. Um, we are, um, our participants do include Emory, Morehouse, and Children's. And I think what's most important on this slide is that we take care of over 965,000 children in the 23 counties surrounding Metro Atlanta. That's fully 60% of the pediatric lives by census, um, uh, in the Atlanta area.

133. 1:05:19

     So, um, how do we manage those lives? Um, as a part of a clinically integrated network, the physicians actually have to make an investment in making this happen. And so, um, we are on over 22 different EMR platforms. So we have a long way to go in terms of improving, um, technology in, in the, uh, healthcare space. Um, but we actually support, um, at the cost of $700,000 a year, a population health management tool that all of our billing data goes into in order for us to track care gaps that the childrens that w- that we serve have, in order for us to reach out to those patients and proactively bring them in for services to make sure that we're not missing diabetes, that we're not missing depression, um, that we're not missing the opportunity to vaccinate.

134. 1:06:07

     Um, we do contract with the payers as a part of that clinically integrated status, and we get additional data from the payers around things like pharmacy fills or out-of-network utilization that allow us to track the full picture for a child, not just if they're touching our doctors, but touching other physicians in the state and beyond. And we take a very data-driven approach to what we do with children. We've looked at all of our, um, uh, utilization across the state and basically what pediatricians, um, be they subspecialists or generalists do, 60% of what we do is offer well-child and preventative care.

135. 1:06:45

     Um, about 13% of what we do is basically asthma and respiratory disease. 13% of what we do is mental behavioral health, and the rest is, um, particular subspecialist-driven conditions. And so we've driven our programming around those four pillars of care. The successes we've had with this approach, and it's a very physician-driven approach, every practice that is a member of the network has to have a quality champion that is a physician in that practice that is the point of contact between me and those practices.

136. 1:07:18

     Um, we have had year-over-year improvements in well-child visits and vaccinations. During COVID, you saw a 20% decline in, um, well-child visits. We did not see that in our network. That was flat. We did not see those patients miss out on care opportunities. If you look at, um, the, um, difference between doc- uh, patients who come to our physicians versus patients who do not, um, there are marked differences in the number of patients that have to go to the hospital for an asthma visit or ER for an asthma visit and for behavioral mental health visits because the vast majority of our physicians have gone through additional mental behavioral health training in order to fill the gaps in the behavioral mental health space.

137. 1:08:00

     Um, we've seen, um, system wi-wide improvements in access for medical subspecialties. 75% of the subspecialists that are net- uh, in our network will get a patient in within 14 days. Um, we support the rural health initiatives. Um, uh, we have, uh, multiple, um, rural physicians that are gonna be entering our network in the coming, uh, weeks, and we've initiated a social determinants of health screening program, um, across all of the offices that'll be going into place this year.

138. 1:08:31

     So all that to be said, um, as I said, we're in a unique position to be a partner to the members of this committee to continue to elevate the healthcare for children across the state and wanted to bring to your attention some issues that we're facing, um, apart from reimbursement, um, that we would love to partner with you all in finding solutions for. Um, the first one is making sure that the providers are held to what I would call actionable measures, and I'm gonna give an example of that. Um, basically, in an agreement with a payer, when a, um, physician is judged on quality or a network is judged on quality, there are measures all of which go back to the primary care doctor.

139. 1:09:14

     One of those measures that's a part of almost every contract we're in right now is metabolic monitoring for a child that's on an antipsychotic, meaning that we have to do lab work to make sure that that is not hurting that child, and in addition, we have to make sure that they have the appropriate psychologist or psychiatrist to be, um, doing the major, um, uh, interventions with that child, which involve therapy. Here's the problem. Primary care doctors don't write the vast majority of antipsychotic medications, and the payers who are holding that to that measure don't have a way to tell us who's on those medications in a timely fashion.

140. 1:09:53

     So despite that, when we started working on this measure, only 7% of the kids that were on antipsychotic were getting that monitoring. We've put in things into place that have allowed us to do that for 40% of those kids, but not a single payer that is mandating that we are responsible for that measure can provide us a list of the kids that are on these medications. We're having to do that on our own. So the goal here is to encourage the CMOs and the commercial payers to utilize metrics that are measurable, actionable, and can actually be supported by the data that they give us.

141. 1:10:30

     All right, the second issue is around timely notifications, and I'm gonna tie this back to another metric, and that is that we're supposed to see a child, um, for a behavioral mental health who's been in a behavioral mental health hospitalization or in an ER situation within seven days after their discharge. 97% of inpatient ment- behavioral mental health does not occur within our network. And so we're not notified when a child is in a behavioral mental health inpatient facility or when they've been seen by an out-of-network facility in an ER for those types of issues, yet we're supposed to arrange that follow-up and coordinate their care within seven days.

142. 1:11:17

     This is super important around general medical conditions as well. We've actually created some pathways, and we would love to see this duplicated in the treatment of kids with asthma who have been admission-- uh, admitted. We know the vast majority of those patients, and we've actually managed to decrease the readmission rate for asthma from seven percent to two percent in one year by notifying the, uh, doctor of record of that hospitalization and asking them to complete a checklist within three days of hospitalization so that we can keep those kids out of the hospital.

143. 1:11:51

     So again, the opportunity here is to require either timely notification from a facility that they have seen a patient that is attributed to me as a primary care doctor, um, that is my other role. I am still a practicing primary care physician in the Decatur, Lithonia area. Um, or, um, to require the CMOs to share data when those hospitalizations have occurred, um, so that we can act on those within that seven-day timeframe, which is not just a random mandate. It really does drive better care if we can get them in that quickly.

144. 1:12:23

     Another opportunity here would be to expand required participation in the ADT alert system, um, to include behavioral mental health facilities. I just wanted to be clear, this is not, um, that anybody is doing anything wrong, but for a behavioral mental health facility in particular, they are re-- they are notifying the referring physician of the hospitalization. Oftentimes, though, that is not the primary care doctor. That is an ER, and the ER is not gonna do anything with that referral information.

145. 1:12:54

     The third issue is, um, not so much on payment, it's on payer obstacles. And what I mean by that is administrative burden that's been placed on practices. Those administrative burdens create access issues for patients, but they also create revenue stream, um, issues for small businesses, and the vast majority of the d-docs in the network are small business owners. Sixty percent of my primary care physicians are one and two-doc practices that see majority Medicaid. Seventy-five percent of the doctors in my network do accept Medicaid.

146. 1:13:26

     Um, but it's not the amount of payment, it's actually the drag on that payment actually being, making its way back into the practice. So the first barrier that we have is that credentialing of physicians takes an inordinate amount of time. If you have a new physician that you're gonna support in a practice and you're asking them to be credentialed by a plan, that can take six months to a year. So you have a patient that's available to see patients that need access, but you can't actually have them up and running for billing in your practice.

147. 1:13:57

     The second part of that is once you have a provider credentialed and they are seeing patients for you, they have to be actually added to a payer roster. Until they're added to that payer roster, a check will not be cut. So I have a provider this year who reached out to me who had been seeing patients in good faith with a provider-- with a payer in the state. He had not been paid for six months. He had accrued two hundred thousand dollars in debt and had to take a loan out on his home in order to pay his staff while he was waiting for the administrative issues to be resolved at a payer level.

148. 1:14:31

     So what we'd like to do is create a mechanism for oversight of that process and require local, timely resolution of those issues with regards to credentialing, pa-payment timeliness, and peer performance in supporting their pr- uh, products. And that leads into the last issue that I'd like to share with you all is just the upcoming CMO rollout. Um, as we see, um, the, um, process drag out, which I think has been a very thoughtful process, and I appreciate, um, the time delays, however, are creating a lot of anxiety amongst the provider community because the transition last time, um, was so difficult.

149. 1:15:09

     Let me give you a couple of examples of that. If we have a payer that is not going to be re-upped, one of the incumbents is not staying, um, we have tremendous concerns about how that patient is gonna be transferred to a new, um, provider of those services for the state. And so, um, oftentimes, if that, um, CMO is not gonna be contracted with that patient's existing provider, they're gonna be randomly assigned to another provider within their ZIP code, and they're gonna have to start over with a new physician. The other thing that's happening is that we can't create contracts and value-based plans and, and quality programming with pro-- um, payers when we don't know who those payers are going to be.

150. 1:15:49

     Um, my third concern is that as the incumbents that are not gonna be re-re-upped lose the mark-- leave the market, are they gonna pull resources from Georgia, um, in order to, um, make a graceful exit? Um, so the opportunities here are to align on a common rollout framework, communicate that to the providers to allay that anxiety and help them create transition plans for patients, and then uniform standards for the new CMO implementations, and then also collaborating on a shared process to monitor the outgoings-- ongoing support from the non-renewed CMOs to protect that continuity of care and make sure that those patients know where they're gonna go when the, um, execution of those plans takes place.

151. 1:16:32

     The last thing that I wanna do is, again, thank you all for your time and just off-offer the opportunity for collaboration. Um, I have a very, very engaged network of very dedicated providers. I have a fifty percent open rate on my communications because this is very physician-driven quality r-work, and we would love to share with you all that opinion and engagement on anything you all need to support efforts that you're moving forward where you would benefit from our knowledge and opinion. And then we have aggregate data on nine hundred and sixty-five thousand pediatric lives in the state.

152. 1:17:07

     Um, we have over three million encounters in our, uh, population health management tool. If you need data to support initiatives that, um, would move the work of this committee forward, we are poised and ready to work with you. Um, so with that, I'm happy to take any questions. Thank you. You do have some. Representative Mitchell? No, it's Representative Davis. Oh, Davis. Representative Davis? No, no, no. Oh, oh, I'm sorry. Well, go ahead. It's okay. Did you have one or not?

153. 1:17:38

     No, I did not. I have the lights blinking here. You, uh, uh, Representative Silcox, you got one. Thank you so much for coming, and thank you for all this information. I was curious 'cause you s- you commented that y'all do not write the majority of, um, of prescriptions for antipsychotics. Who, what specialty, um, writes the majority of those? So the majority of the kids that require an antipsychotic are in crisis, so they're gonna be presenting to an emergency department, an urgent care. They're gonna be presenting to a, um, behavioral mental health facility that does a 23-hour, um, assessment.

154. 1:18:14

     Um, fantastic- So it would be a psychiatrist? ... facilities. Yeah, psychiatrists that are writing- Okay. Okay ... for those patients in crisis. Okay. Here's an example of where having that kind of knowledge would be super important. Mm-hmm. So let's say I have a patient that's in crisis at midnight. They, um, are, um, violent. They're gonna present to one of our great community partners, which is Peachford Hospital. They're gonna be evaluated there. They're gonna be stabilized. A part of that stabilization's gonna incur- include medication. Um, that patient's gonna be self-referred. They're gonna drive in to that unit, maybe with my direction, but they're in crisis.

155. 1:18:48

     They're not necessarily gonna tell those folks, "My pediatrician is the red-headed guy with glasses that's out at Snap Fingerwood's Pediatrics." Mm-hmm. They're gonna forget that. Um, and so, um, in that crisis situation, I may not know about that unless I'm notified by, by the physician or the facility until six months later when that child comes in for their well-child visit, and I say, "Have there been any visits to a hospital or ER in the la- since the last time I saw you?" "Oh, yeah. I went to the hospital.

156. 1:19:18

     I was put on the white pill." I don't know what that is. I've got no notification of that. And we know that 97% of, um, those encounters do not occur within our network. Okay. I appreciate that. Also, um... Sorry. Thank you, Mr. Chairman. Also, I know a lot of the, um, issues you mentioned about credentialing, um, and particularly the selection of payers, you know, is, is just a, you know, part of the administrative rigor of, uh, the bureaucracy helping direct healthcare in the State of Georgia.

157. 1:19:55

     So I think those are really hard things to overcome. Um, I know the Department of Community Health is doing the best they can, but, um, it's really hard 'cause they have an RFP process, as you know, every year. So it's hard to know if there's gonna be a change in payers. Um, and certainly as far as credentialing is concerned, I know my husband is in practice himself and has worked both in academic as well as private practice, and credentialing is a issue for physicians throughout the state. So thank you very much. No, thank you. Appreciate that. And again, I just wanna emphasize, everybody appreciates the thoughtfulness of the process.

158. 1:20:29

     Um, I think to the degree that we could be given, um, once it's known, scheduling so that we can prepare and again help to keep those holes from happening, that would be tremendous. Mm-hmm. Representative, who do I have? Clark. All right. Thank- Representative Clark. Thank you, Mr. Chair. Um, you, um, mentioned that these children are going into the hospital, and, um, once they're going to the hospital, then they go, um, I guess to, like, a facility, and so the paperwork is not showing you as a primary care provider but instead the referring physician, which is usually an ER.

159. 1:21:10

     Correct. Is this just a matter of changing a line on a form that is filled out or it, does this require more? 'Cause it seems to me, like, when I've taken my kids to the doctor or the hospital or anything like that, which I've had to do unfortunately, um, a few times in their life, we fill out the paperwork, and they ask who the primary care physician is. Uh, so is it just that the information's just, are we asking and it's just not getting relayed to you, or are we just not asking?

160. 1:21:44

     Like, what is the- It's- ... where is the- It, thank you ... disconnect? It's a great question. I, I think the di- the difference is between physical health and behavioral mental health. Mm-hmm. So if you're gonna present to an endocrine doctor, an endocrine doctor is going to send me a note as the, um, referring physician or the- Okay ... PCP of record. In behavioral mental health, it's different. Those kids are in crisis. Oftentimes the PCP is not, um, uh, e- e- even top of mind. Um, but, um, uh, also, um, the setup on the behavioral mental health side has not been one to communicate with the PCP.

161. 1:22:20

     It has been one to communicate with the referring provider. Okay. Um, so yes, I do think that there needs to be a shift in how that information is captured. Um, I'm not saying don't communicate with the referring provider. I'm saying communicate with both, um, because, um, in order for me to be the quarterback of care, I need to know that there's a need for that care. Um, the ADT system might be a way to, to obviate that, and then we're working very hard to create better relationships with the behavioral mental health facilities for them to recognize the need.

162. 1:22:51

     Um, as I said, they actually were like, "Oh, you want to know that?" Of course we want to know that. Okay. All right, thank you. Thank you. Representative Newton. Uh, thank you, Chairman, and thank you for your and your team's, uh, support of, of pediatric k- patients. Um, I, I'm curious, these were both about CMOs. You're talking about Medicaid as the first two- Mm-hmm ... issues on, uh, A- AD- ADT, the, uh, admission discharge transfer. Actually, this would be commercial and Medicaid in terms of benefit. Um, these metrics are- Okay ...

163. 1:23:22

     both commercial and Medicaid type metrics. Um, and, um, so, um, it would be cross-cutting for both commercial and Medicaid CMOs. Well, the CMOs seem easier since we do as a state entity-

164. 1:23:34

     Pick those as opposed to a, an employer insurance plan who might pick their, their private insurance or their employer-sponsored insurance. I'm just really a little shocked that they... This isn't already required, that you couldn't, you couldn't... They have, they have to approve the medication before the pharmacy hands it to them, if they're, if they're getting a medication, eith- to approve it for payment. There's a group purchasing number on the cards and all, and then the same thing within 24 hours. I'm sure every hospital in Georgia has made sure that the Medicaid was up to date, and they've gotten approval for a certain number of days of care or at least an initial approval.

165. 1:24:14

     Why is... What is the holdup? Is it just an administrative choice or-

166. 1:24:18

     It is a-

167. 1:24:19

     ... that they're not sharing that information with somebody who clearly needs it m- more than six months later, as you said?

168. 1:24:24

     Right. And, and that's the situation, is we're getting it six months later. Um, this is data management issues, and a lot of it is the data that is shared with us is adjudicated claims-based data. What do I mean by that? Once the claim is paid-

169. 1:24:39

     Registered, yeah

170. 1:24:40

     ... that can take anywhere from 60 to 90 to 120 days. The difference in the data and the reason we've invested the $700,000 a year in the population health management tool is that is billing data that is submitted at time of service. So my data is in real time, so I can tell you that the encounter occurred within two weeks. The problem on both the commercial and the CMO, um, data side is that that, the reports that are provided to us are adjudicated claims-based data, so it's old.

171. 1:25:11

     By definition, it has already missed the timeframe by which we need to intervene.

172. 1:25:16

     If I could follow up, we, we didn't fix that with our most recent CMO outreach to, to say clearly these... 'Cause w- we tell them if they want to apply to be a CMO provider in Georgia, what the rules are. Is this something we would have to go back now and ask to add to a contract that we've already-

173. 1:25:35

     It is, it is something that I would reexamine. I think that the issue here is that some of the metrics that I've shared with you are metrics that have only been put in place for, um, one to two weeks, uh, one to two, um, years. So the metric, the data to support the metrics isn't there. The metrics are important. We see tremendous benefit when they're met, but the data, uh, mechanisms are not in place to support the metrics as they stand.

174. 1:25:59

     Well, thank you. I hope we can get that, that, um, the, especially admission, discharge, and, and all, just the initial in- involvement for, for a transition of care after an admission is crucial. And I, I know y'all, I'm glad y'all wanna take it on and be responsible for it. I do think that is the main role. I think y'all provide care and do all this billing and stuff. The insurance company is just a data... It's about all they do, is data and money, right?

175. 1:26:24

     One thing that we've done to try and get around the adjudicated claims is when they authorize an admission-

176. 1:26:31

     Right

177. 1:26:31

     ... notify us of authorization. We've had some limited luck with that, but there are some companies that can't support that data report either.

178. 1:26:40

     Can or won't.

179. 1:26:43

     Thank you very much.

180. 1:26:44

     Thanks.

181. 1:26:44

     Great questions from the committee. You know, I think we could go on for two days with this. I mean, I've-

182. 1:26:50

     Happy to come back.

183. 1:26:51

     Being a provider, I've seen the problems, and, and being past president of Georgia Dental Association, heard a lot of problems with the, uh, filing of claims, the difference between the claim forms, between the CMOs, a number of things. But thank you very much for coming today. I appreciate it.

184. 1:27:06

     Thank you. I appreciate it.

185. 1:27:08

     Uh, next up is Lynn Durham, uh, with CORE. And before the ninth district leaves, I want to let y'all know that we're working with the Board of Dentistry right now on the sedation permits. We're gonna, uh, working to streamline those because the dentists that, that need to sedate these patients have to have a permit by law. And so when you're out in the rural areas, that means you're taking time off and doing this and that, and we're working on, with the Board of Dentistry right now on a streamline on that, and we'll have legislation this year to address that.

186. 1:27:40

     That would be wonderful.

187. 1:27:41

     Yeah. Okay. Lynn?

188. 1:27:45

     Yes, sir.

189. 1:27:46

     Thank you.

190. 1:27:47

     Thank you so much. I am Lynn Durham. I'm president and CEO of Georgia CORE, the Center for Oncology Research and Education, and, um, we are, I'm very happy to be here today to tell you a little bit about the House Study Committee on Cancer Care Access that met this summer. Chairman Hawkins championed that for us, which we are grate- very grateful for. Um, Representative Silcox was on that committee, Representative Clark, also Representative Mathiak, and Representative Green. And so we are very pleased to have all of them, um, hear what's going on in the cancer care community in our state and the gaps to access that some Georgians face, especially our rural Georgians, and how they have a hard time, um, getting access to cancer care.

191. 1:28:28

     So, um, just to tell you a little bit, um, in Georgia now, we have 48 Commission on Cancer accredited cancer facilities, which is fantastic, but most of them are in Metro Atlanta. And so we do have some around the state. I'm very, I wanted to call out Colquitt County just had their accreditation, um, for the first time. And so, um, there's a lot of great cancer care happening in our state. It's how people access that cancer care. So I wanted to, um, talk a little bit this summer, uh, those three meetings that happened, um, just to tell you a little bit about the people who were part of that.

192. 1:29:04

     These were all, uh, organizations that had representatives speak to the committee. So, um, Chairman Hawkins and his staff, Morgan and Graham, did a great job making sure, um, the committee heard from a lot of people about cancer care, not just some. And so that included health systems, universities, nonprofits, um, associations, and state agencies. And, uh, it was wonderful to hear those folks. The, the man on this slide is, um, actually a member of the committee, Spence Mullis from Dublin, Georgia, who is a cancer survivor and shared his incredible story of, of getting care in, um, rural Georgia and what is needed.

193. 1:29:42

     So the committee, I'm not gonna go through all of these, um, but they made a lot of recommendations which we are ve- very grateful for, and a lot focused on cancer prevention and screening activities. We wanna make sure that all Georgians have access to cancer screenings. And we know that they don't at this point. So, um, Georgia receives about $148 million a year in tobacco settlement funds, has since 2001, and about 9% of that money comes to cancer-related activities.

194. 1:30:13

     What we have always asked for the legislature is if we could have a higher percentage of those funds go to prevention and early detection. We know that more Georgians can either be prevented from having cancer or they can be found early where we can save lives more likely, and then it also costs a lot less than having a stage three or four cancer. So what we can do to make more, um, early screening possible for folks all around the state. The committee also, um, encouraged enhancements to cancer prevention programs.

195. 1:30:46

     We have five regional cancer coalitions that serve the whole state. They are working directly with patients to ensure they have access to screening, and we wanna make sure they have the resources they need. Uh, establish a statewide cancer screening navigation. Navigation is proven to get people to cancer screenings, so that is, uh, an option. And then encourage support for the Georgia Cancer Control Consortium. The Control Sy- Consortium is a group of, we call it a coalition of the willing. It's people in the cancer care community all across this state who work together with the Georgia Health Policy Center, which the director is here today.

196. 1:31:21

     And we, um, really look at, we write a cancer plan for the state, but we also really look to see how we can improve cancer care in Georgia. I wanted to take a moment to talk about one particular speaker. His name is Dr. Harsha Vyas. Um, Dr. Vyas is, uh, a sole practitioner in Dublin, Georgia. Um, he says that there are no other medical oncologists. He's a medical oncologist. There are no others for at least a 50-mile radius to his, um, clinic. And he talked about the issues that sole practitioners are, are having, especially in rural, uh, Georgia.

197. 1:31:56

     I am hoping and praying this video works, um, and we just took a few of his clips to, um, give him, uh, to, to... Whoops, mm-mm, it may not be working. It's contacting. But as that's trying to contact, I'll say some of the areas he talked about were the oncology workforce. Um, we talked a l- The, the committee talked a lot about the need for, uh, oncology work, more oncologists in the state. Mm, it's not gonna let me do it. It's saying it's...

198. 1:32:27

     Ch- ch- ch- ch- ch. I'm sorry. It's not gonna let me do it. So I'll just talk through it and then ask you all to, um, please, if you go to the House Study Committee websi- the, um, legislative website and under the House Study Committee, it has his full testimony. But, um, what he talked about was oncology workforce shortages, where especially in our rural areas, it is very hard to recruit and retain physician, not only physicians, we're talking about nurses, we're talking about navigators, um, social workers, and others to be able to work with their patients.

199. 1:33:00

     So, um, that is a problem. The number of fellows in all of Georgia, we only have seven oncology fellows a year. Seven out of, for 11 million people. And so wanna make sure that we can get more fellowships, more residencies for internal residents, um, internal residency, internal medicine residencies, so we can have more physicians in, in Georgia, in rural Georgia. Um, the reimbursement rates in the rural areas that don't allow them to pay off their student debt. These doctors come out with hundreds of thousands of dollars of student debt, and they need reimbursement rates to be able to practice.

200. 1:33:34

     And so he asked to look at that. The lack of trained staff I mentioned, and then no mandated rural oncology rotations in medical school. He really advocates for our medical schools in Georgia making sure that students have to go to rural areas to have rotations. The fi- financial constraints are many. He talked about insurance reimbursements, um, for hospital affiliated practices are higher, and he is one person. And the story he tells about trying to work with payers, he has no leverage.

201. 1:34:06

     He has nothing that makes them do what they need to do to pay him. And so it's very hard, and he spends a lot of time, and his staff spends a lot of time just trying to get reimbursed for what they're giving. Um, the high cost of cancer drugs and that fear of not being reimbursed. If they get a cancer drug, they order it, and then they're not reimbursed at a rate, they're out all of that money. We heard that from the independent pharmacist, and it's very, uh, hard on them. Pharmacy benefit managers, we've heard a little bit about that today.

202. 1:34:36

     That's, that's no surprise. And then the 340B drug program. For him, he's one of the very few independent oncologists in our state. And so it's very hard when all the other doctors are hospital affiliated and he has no leverage to be able to get what he needs. Um, prior authorization and step therapy, those, those barriers that are put in the way by insurance companies and, and how much it takes, um, of his staff and his time to do that. And then infrastructure. We know rural infrastructure.

203. 1:35:06

     Transportation was the very first thing he said and talked about it a lot and how difficult it is for patients just to get to his office or get where they need to go for, um, their therapies. Uh, primary care, uh, demands on specialists. He says his ecosystem, it's not just that there aren't other oncologists in the area, there aren't other specialists or there aren't other people that, um, as many primary care doctors as needed. So a lot of times he has a patient coming in with a cold or High blood pressure or diabetes, that's not what he should be treating.

204. 1:35:40

     He should be treating on col- on cancer, but because he may be their only doctor. Broadband availability and what that does, and then, um, he really advocates for the need for healthcare nodes throughout our state where patients can go, um, and get infusions or get, um, see primary care doctors or others. And so he spoke a lot about that, and I, I really do encourage you. I'm so sorry that didn't work, the, the link, um, but he, uh, speaks really eloquently about that, and it's about 20 minutes total, uh, his video.

205. 1:36:13

     Uh, on oncology workforce, uh, just wanted to bring the... These are the recommendations directly from the committee. Expand physician loan repayment programs, and they increase the amount of loan forgiveness available, especially for rural physicians practicing in rural areas. Encouraging additional oncology workforce opportunities and those rural rotations we just talked about to go to medical school, and then additional residency and fellowship opportunities. And then addressing insurance reimbursement to include rate increases through Georgia Medicaid for those oncology-related codes and making sure the geographic practice cost index is accurate.

206. 1:36:53

     One other big item that came through is Georgia Cancer Center's pursuit of NCI, National Cancer Institute designation. In Georgia, we have one NCI-designated comprehensive cancer center, that is Winship. They are exceptional. We are so fortunate to have them, but we only have one. North Carolina has three. Texas has four. Other states are, Alabama has at least two. And what we need, um, those, uh, N- NCI-designated cancer centers receive federal funding for more clinical trials, more, um, advanced research, and, um, just ways of serving patients.

207. 1:37:30

     And so it, Georgia Cancer Center is pursuing that, and I hope the legislature will, um, back them on that. But really, if we could get two hospitals in our state and get Georgia Cancer Center this designation, it would improve geographic access for patients, but especially in that clinical trial area. Address disparities in cancer outcomes, um, by expanding specialized care availability, really enhancing the state's research infrastructure, which is so incredibly important, and then stimulating regional economic growth, um, for the Augusta area.

208. 1:38:04

     And these are lastly the few other recommendations that didn't fit nicely into a category, but simplifying Medicaid access for pediatric patients in particular. Um, incentivizing hospitals and providers to report cancer screening numbers and rates, so we really know, um, how a hospital is serving their community in the way of cancer screenings. Encouraging the use of mobile cancer screening units. Um, you're hearing more and more about them. It's about $10 million just to get one on the road. Um, but when we have them, we need to make sure they're utilized fully and that patients are being seen, especially in our rural areas.

209. 1:38:41

     And then Georgia CORE has a program called the, um, Cancer Trial Finders program, and what we do is have a navigator who works with doctors and hospitals all over the state to find clinical trials for patients. It's so hard. So many times rural patients in particular don't even try to go on a clinical trial 'cause they don't know how to find them and they don't know where to go. And so we have a, a program where we can help get them to clinical trials that could save their life and/or the lives of someone else. So in conclusion, um, we just wanna make sure all Georgians deserve access to cancer clinical trials and to, uh, cancer prevention, screening, early detection, and treatment.

210. 1:39:20

     Um, cancer is still the second leading cause of death in the state, and we need to keep that in mind and do everything we can to reduce the barriers to access that they have. And I'll say on behalf of the cancer community, we pledge to do all we can that doesn't take legislative action. We know there are things we can do that we don't have to have legislative action for, but we're coming to you to say, "Can you please, um, work with us and help us on the things that do need legislative action to make sure we're closing those gaps and make sure that all Georgians receive quality cancer care when and where they need it?" Thank you so much for hearing me today, and I'll be happy to answer any questions.

211. 1:39:58

     Representative Clark.

212. 1:39:59

     Um, thank you, Mr. Chair. Thank you for being here. Uh, my question is about the screenings and when and who can get them.

213. 1:40:06

     Mm-hmm.

214. 1:40:07

     So, um, right now, um, if you have a, a PCP, normally they tell you the schedule-

215. 1:40:13

     Yeah

216. 1:40:13

     ... for all of these different things. But if you don't have a PCP, which a lot of people in our state do not-

217. 1:40:18

     Right

218. 1:40:18

     ... they might not be familiar with what age they can do this or, you know-

219. 1:40:22

     Mm-hmm

220. 1:40:23

     ... all of these things. When we have these mobile units or when we're increasing our screenings, are, um, people being... Like, how are people supposed to know that, yes, this is a screening that you should be getting because you just turned this age-

221. 1:40:38

     Right

222. 1:40:38

     ... without having that wider healthcare community or ecosystem to guide them?

223. 1:40:46

     Yeah. It, it, it is very difficult, and unless they were just really proactive and said, "Oh, I'm gonna go look at the American Cancer Society website and find it," which most people don't, um, then it is very difficult. Our FQHCs around the state are very good. It's in their workflow, their, their cancer screenings, and know at 45 you should be getting your colorectal cancer, you should be getting your prostate cancer. At 40 you should be getting your mammogram. So those FQHCs do try to do that. Um, one of the recommendations actually from the committee is that our public health clinics, um, they do not, um, really have it in their workflow to remind people of cancer screenings.

224. 1:41:22

     And we really would like our public health clinics to be more proactive in making sure people who come to see them understand and know when those screenings are needed. We just, uh, and gratefully to you, um, the, uh, last year in the amended budget, uh, you gave Georgia CORE tw- $250,000 for a colon cancer screening statewide campaign. Um, that has been very successful. We've had over 100,000 hits to our website that gives all the information. We've had, uh, tons of social media. But it, it really is, um, a lot of work trying to reach people who have no other way of knowing or finding out when those screenings are due.

225. 1:42:01

     But we want to do everything we can to, to get the word out.

226. 1:42:04

     Thank you.

227. 1:42:05

     Thank you.

228. 1:42:06

     Thank you, Lynn. You know- ... we, we did learn quite a bit this summer. A lot of good recommendations, but most of these recommendations were tied to revenue requests.

229. 1:42:16

     Mm-hmm. Yes, sir.

230. 1:42:17

     We have Chairwoman, uh, Darlene Taylor here. And thank you for coming today.

231. 1:42:22

     That's all right.

232. 1:42:23

     Uh, she's very attentive on this. And, you know, when we were going through this, we were not sure where the, uh, subsidize, uh, subsidies, uh, were gonna end up with the ACA plans and all. Uh, the House has passed that-

233. 1:42:36

     Yes

234. 1:42:36

     ... uh, on to the Senate. So maybe we'll see some money freeing up and be able to do something and, and, and not everything, unfortunately.

235. 1:42:45

     Sure.

236. 1:42:45

     I wish we could. But, uh, maybe we can hit on a couple of these things.

237. 1:42:49

     We would love to work with you on that. Thank you.

238. 1:42:52

     Thank you. I want to thank the committee for coming today, um, for your patience all today and all last year. I know that sometimes I sort of rush y'all. I just go, I start pointing 'cause, uh, I'm very attentive about the clock, and I, and I apologize about that. But, you know, two hours, and then we have so many of you on other committees, we start losing, losing votes, then we can't pass anything. So I apologize to you if I seem short sometimes and sort of cut you off. Um, and I, I do apologize.

239. 1:43:23

     But I value all your questions and your knowledge, and thank you so much. Thank you for everybody else that attended today. This meeting's now adjourned.

240. 1:43:33

     Am I good?