House Standing Committee on Health

Good morning, everyone. Welcome to this hearing of the Committee on Health. The last agenda I might note is a joint hearing of Committee on Health as well as the Committee on Human Resources and Homelessness. On behalf of myself as chair of Committee on Health and Chair Martin, Committee on Human Services and Homelessness as well as everyone else. So thank you for being here. So 9AM, Wednesday, March 18th, and we're in Room 329 of the State Capitol. And by the

way, I know that today is not Saint Patrick's Day. Yesterday was, but I had the shirt on anyway, so this is our work.

Anyway, without further ado, let's begin with first bill on the agenda, which is, excuse me, Senate Bill 2047 relating to pharmacy benefit managers. And first up on the agenda, we have, let's see, state insurance commissioner. Morning.

Morning. Morning, Chair, Vice Chair, Members of the Committee. Justin Chu for the insurance division. I'll stand our written testimony and provide comments.

Thank you. Doctor Jack Lewin? Hello? Offering support. Attorney general's office?

Oh, there he is.

Good morning. Deputy, Christopher Hong. With comments on the bill. Just a simple housekeeping statement. PBMs and pharmacies operate on a contractual basis, so a savings cost to help with any impairment cause issues. Helpful. Thank you.

Okay. Thank you very much. Doctor Jack Lewin?

Good morning, Chair, Vice Chair, Jack Lewin. SHIPNA, we stand on our written testimony in support. Nice support.

Thank you. Hawaii Primary Care Association offering comments. Kaiser Permanente on Zoom.

Chairs and Committee Members. Thank you. John Kirimitsu, here for Kaiser Permanente. We signed on a written testimony, offering an amendment to exclude HMOs from the definition of third party PBMs. Thank you.

Okay. Just to be clear, you're asking for an exemption for Kaiser because you own your own--

Yes. For HMOs that own and operate their own pharmacy because we don't think the intent of the bill is to pursue integrated care models.

Okay. Got it. Thank you.

Thank you.

Let's see. We have, Corey Lejano, Molly Lihola Pharmacy in support, PCMA, Tanya Neil.

Thank you, Chair. Tanya- My name is Tanya Neal. I'm with PCMA. We will stand on our written testimony. I just wanted to make a couple of quick points.

The bill in its original form mirrored the law prior to the repeal for, for agency reasons. The bill today with the third amendment is a very different bill and it expands things, operationally like reimbursement, things that are, bigger than what Hawaii has seen and what our PPMs can implement. And so we've offered some amendments that would clean that up and narrow it back out or narrow it back in, and we're happy to discuss those at any point if anybody would like to have any conversation about them. Thank you.

Thank you. Corey Sanders, Hawaii Pharmacists Association.

Good morning, Chair, Vice Chair, Members of the Committee. Corrie Sanders Hawaii Pharmacists Association. We're totally in support of the amendments that were proposed by the attorney general's office and by Kaiser. John is correct. That's not the intent of the bill to include the HMOs.

Asking for some time to work through the amendments made by PCMA, there's over 20 amendments for us to sit down and come through those. We will stand specifically in strong opposition now to the to section three that changes the pharmacies that would be involved in the bill. It's really to create pricing transparency for the pharmacies that aren't in the PBM network, and the amendments proposed are including the pharmacies only in a PBM network. Also asking for some additional time to work through through some, calculations with the insurance commissioner's office. This is a really significant burden to the general fund.

$1,500,000 in five FTEs is higher than I've seen for PDM oversight in a much bigger capacity in most states. This is just for a very small portion of pricing. So I'm hopeful that the bill moves on, we can work- that work through that by the finance committee. Thank you.

'Kay. Thank you very much. We also have written, testimony from the National Community Pharmacy Association as well as two individuals. Anyone I miss wishing to testify in SB 2047 either on Zoom or here in the audience. Seeing none, members, any questions? If not, I do have a question for the insurance commissioner of Mister Chu, as noted by miss Sanders, you're asking for funds to implement this measure 1,500,000.0 and $5.50 was it? Is that right?

Is that an estimate or is that--

That's correct.

That is an estimate. Right. Okay.

Yeah. So it could go up or or down?

It it could go could go downwards. Depending on the final.

That the insurance commission has ever done before. And if, you know, their responsibility is placed on us, we wanna make sure it's done correctly. So we anticipate five position as we noted. Our- Our testimony highlights the the employees with specific expertise we think would be be would be needed to enforce this measure. And then I just wanna highlight that the appropriation ask is for salaries plus fringe benefits plus the education needed.

So we think if we could implement this measure, since we don't have expertise in the state, it would require some kind of consulting from, like, a third party on the Mainland who already does this to train our staff. And then in addition to all the other incidentals, like, office space and computer equipment. So our our appropriation ask includes all of those things in addition to that.

This- This measure still has two more committees to consider it assuming we if we do pass it out. But yours would still be the closest state office to regulate or to implement this measure. Right? I mean, there's no other state office then.

I- I would need no number of that to- to, like, you know, the legislation to to impact it.

Okay. Thank you very much.

If there are no other questions, let's move on to the next measure, which is SB 2080 proposing a Hawaii join the cycle- psychology interjurisdictional compact. And first up, we have, let's see. We have a written testimony from the office of the assistant secretary of war in support. Tommy Johnson, Department of Corrections, Emeritus.

Good morning, Chair and Members. I'm Doctor Erin Wilkinson. I'm the Mental Health Branch Administrator for DCR. We stand in support of this bill. I do have three additional comments that I would like to add to this.

Currently, we have over a thousand licensed practitioners in the state of Hawaii. However, they don't all practice in Hawaii. So although it may appear we have a lot of mental health providers, they don't all practice. They don't live here to practice. Adopting this would allow them to practice in Hawaii without having to actually physically be here.

In addition, just by adopting this, it doesn't mean that our organizations, facilities, individuals have to use the PSYPACT individuals. But what it does do is- is it allows choice, and it allows access so that we do have the choice to broaden access for our clients. I am here for questions.

Thank you very much. Doctor Jack Lewin, SHIPTA.

Hello. Good morning, Chair, Vice Chair, Members. We also support this. SHIPTA believes that this this measure will expand access to psychology services. It also will allow kama'aina to come home if they've been treated elsewhere and maintain contact with their treating psychologist. We defer to DCCM what the regulatory issues might be, but we think it's a pretty good idea. 40 states are already participating in the compact. Thank you.

Okay. Thank you.

Testimony from the Disability and Communication Access Board in support. DCCA, Board of Psychology.

Good morning, Chair, Vice Chair, Members of the Committee. My name is Christopher Fernandez, Executive Officer to the Board of Psychology. I'm here to stand on the board's testimony, opposing the measure. The board currently feels that there's- may still be opportunity to explore its own chapter for, answers to this situation and and the cause for interest in the compact. You know?

However, the board still pulls these- these positions where it's concerned for the safety of clients or the kind of disconnect that they may experience. So and one of the things that they looked at was that there's no real clear guidance for crisis response in this compact, which could be for the state to decide. However, this compact language is pretty tight. Shut tight, I should say. Sorry.

Several large states have decided not to join the compact, including our neighbors, California, Oregon, Alaska. We also haven't gotten any clear information about the cost of enforcement. There may be additional costs related to traveling out of state to visit other states with regard to infractions and things like that. Currently, we do not do FBI background checks. This will be something we have to implement with the support and lead of the FBI.

We also potentially could move authority over the minimum degree and specialization requirements within the state or at least the state would be falling behind the compact with its with the language now entered into 465. Of course, you know, we also get concerned about what this does to, you know, the- the receivable of- of fees. As you know, the fees are also used to manage our disciplinary section. So thank you for your time.

Oh, thank you very much.

Let's see. Doctor Sean Scanlan, Chaminade University.

Hi. Thanks for allowing me to do this, and I appreciate all your work and what your staff does for this. I'm a career psychologist. I know what it's like seeing people in need in marginalized communities. I'm also the program director of the PsyD program at Chaminade.

This program has been around for four years. It's the primary source of psychologists in the state. I oppose this bill on behalf representing the students, that are local students that are committing their- their- their, you know, finances and their careers, their years to training in Hawaii, to treat people in Hawaii in in rural communities. And this just opens a door for an outside company to come in and and give the services that they're trained to do. We also have to consider the cultural competency, which is a big thing in psychology.

And this assumes that someone from Arkansas can come in and just, you know, after hours at home, telehealth in and help someone who's in need in some rural community. I- I don't think that's fair, and I think that's part of, you know, what we're going through right now. And I think this is something that really needs to be considered. This idea of deficit in psychologists, we actually have more cycles per capita than most of the nation. I think they're, like, three or five.

We might not be strong in mental health providers. And if that's the case, then that means that other providers, which be social workers, which would be mental health counselors, marriage and family therapists, psychiatrists, psychiatric nurses. The other ninety percent, maybe they're deficient once. I'm no offense. But that needs to be considered.

And why is it psychology sign saying, okay. We don't have the resource. I mean, there's a need, therefore, it's on you. You know, there's 200 psychology students right now, and they they want you to consider my statements and also propose this bill. And I'm open for any questions. Thank you.

Thank you very much.

By the way, I- I don't know if we have a timer there. For first time testifiers, it's not I know how intimidating it can be to testify. It's- it's not- It's just guidance. So if you go beyond, no one's gonna drag you out of the room or anything. So just well, but we do ask.

We try and keep it to two minutes, but I appreciate your your comments, though. Let's see. We have written testimony and comments from the Hawaii psychology association, as well as Hawaii State Council on Mental Health in support, HGA in opposition. Oh, sorry.

Hawaii State Association of Counties. Nahelani Parsons in support. Rachel Wilkinson, Hawaii Association of Health Plans.

Morning, Chair, Vice Chair, Members of the Committee. Rachel Wilkinson on behalf of the Hawaii Association of Health Plans in support. As you know, Hawaii continues to face a shortage of mental health providers, and we appreciate the compact's ability to increase mental health services statewide.

'Kay. Thank you. Grassroots institute of Hawaii, Ted Kefalas in support. And we have two other individuals in support. Anyone I missed wishing to testify in this bill? I- I have Hawaii Psychological Association offering comments from Alex Lipton and yeah. Alex.

Okay. Again, anyone I missed on Zoom or in present? If not, members' questions.

I- I do have a question.

Oh, sorry. Chair Martin followed by let's see.

Think about it psychology. So.

You know, I do I am aware that it is hard to get a therapist and not just in rural areas, on a well-being as well. And especially when there's a crisis and you need you know, it's not a matter of planning for a future, you know, distant point might be wanting to get somebody right away, maybe for somebody who's never, you know, had a relationship before with a mental health provider, but some something we can't make in their own mind happen in their lives and they need help. And, you know, I've definitely seen people in my own life, in my network, have a crisis, not be able to find anyone, move through that crisis, but it would have been nice. So if this isn't the solution, what do you think is the solution?

Well, the board has offered in the testimony ideas of perhaps looking at our section on, sorry, temporary permits, for example. So currently, right now, a temp a temporary permit holder can practice up to ninety days in the state. However, the way the language is written in the field or sorry, the chapter, it basically requires us to do a full application for them to apply. So that includes an application form, confirmation and verification of internship and postdoc, graduate degree, you know, a- a lot of information. So it it can be sort of dissuading.

You know, this has also been discussed in Board Meetings as well. So one of the things that the board receives the most in inquiry is inquiries from psychologists, say, from other states who are asking if they can follow for a brief period of time their clients. Most people are vacationing or visiting family for a short period of time, and they can do so through the ninety day temporary permit. We don't have a grace period like California, for example, that would allow for thirty days of unlicensed practice, for example. I don't think the board heavily discussed interest in that part of it, but it does find interest in making the temporary permit situation a lot easier and more accessible for folks who are, for all intents and purposes, in transit, whether in their life personally or, you know, physically traveling to the state.

So that's one thing that the board has looked at. And and that as as the committee may recall, two years ago, the legislature passed a provisional license bill. So that will be going online July 1st this year. And it's still uncertain how that'll address other disparities. So, for example, this may increase the ability to have more trainees in clinics, in the rural, for example. But however, they unfortunately, the board has not been able to gather any data or anything like that until we start getting the licenses going.

Thank you. Thank you, chair.

Thank you, Chair. For the Chaminade University, professor, thank you for being here. The bulk of the testimony that's in support is basically saying that this is needed due to the shortage in mental health providers.

I know your- your testimony lays out why you feel otherwise. Do you feel that this bill, if passed, would directly address the shortage of mental health providers? That's the first question.

We're not too sure. There's- There's definitely time zone issues for the people that, you know, if we're looking at the outside psychologists coming in. I mean, we also could be looking at a very small fraction of, you know, making an impact. Again, psychologists are only a small fraction of mental health providers, and then we are looking to add, you know, some I mean, this bill is looking to add some outside to that. I don't- I don't- I have no idea about it.

Next question, sir. Your testimony states that to start, there is associate licensing which passed last year and and has not yet had the opportunity to- to affect communities. Could you give an update on the program? So we it- it was passed last year.

This is a- a provisional licensing.

Has that come to fruition? Is that impacting the industry? Is it helping?

It has I mean, it hasn't even started. So we have lifted in that. Yeah. We haven't even seen the effects of those people in those clinics and practicing.

Okay. Thank you. Yeah. Rep. Garcia, I think the board testified that it's starting July 1st. Got it. Any other questions from members?

Hi. I just have a quick question. This testimony is very similar from last time we were moving this bill in, I think, '23 when I kinda checked the other testimony. The- The points that you guys raised are very similar. Is it the board's sense that our current system for how we license here in the state is just too far from the compact, and we're never gonna be able to, you know, it but, like, you guys are never gonna be able to come in and say support.

You guys are gonna be able to do it. Or is there- is the board talking about any kind of pathways forward to rectify some of the things, like the FBI background checks or these additional costs to administer two programs, that kind of thing. It is important having those conversations about how to potentially do that work and the resources and timeline that it would take for you guys to do that so we would, in the future, be able to enter the compact, or are we just too far apart with some of the requirements in state for what the compact actually covers?

I couldn't say to what degree. Thank you, representative, for the question. I do know that the board has looked at it- it- it's a continuing conversation because we- we- we looked at the the board did. Sorry. Looked at the the training requirements.

Right? So but that was when they were looking at the provisional license. And they they feel that the current requirement of 1,900 hours is conducive to the Hawaii setting, which is higher than the requirements for internship postdoc for a compact privilege holder. So since we can't affect the compact, they haven't really found interest in- in reducing the numbers because they find that for the state, this provides the most safety and effective training for the psychologists that will be practicing in the state. So that's a big- that's a hurdle right there.

We we typically will reach out on behalf of the board to PBLs or other compacts that are trying to work through their issues with regard to such things like FBI background checks. So we can kinda get an idea if and what we would be looking at. Right now, that's kind of still pending, so I don't have any additional information that I could provide on that. But as far as how it could fit into 465 generally, I don't think the board has reached that point yet because it is more focused on trying to fix some of the- the issues that are within 465 right now that could make things a lot better for not only the psychologist, but also clarity for for practice here in the state.

Okay. Okay. Thank you.

If I could stay up there, I- I do have a follow-up question. You mentioned it a couple times, but could you explain the degree the- the differences in degree requirements for those psychologists in the compact as opposed to what our current standards are here in Hawaii?

Yeah. So okay. So according to 465 section seven, a--

This is current HR Hawaii.

Yeah. Sorry. That's chapter 465 regarding psychologists. Section seven requires applicants for licensure to obtain a degree with either APA accredited or is housed within a university that is regionally accredited. So that is the degree.

What kind of degree?

I'm sorry. Right now, the law accepts counseling, clinical, and school psychology, or a combination of the three.

Bachelor's, master's? Doctorate? Yes.

The internship can be either internship and postdoc can be either APA accredited or not. It just has to be within a health service setting and also meet some other requirements within the rules. The major thing is that it's one year internship, and it's one year postdoc, 1,900 hours. That's defined in the rules, and that's equivalating or sorry. In the rules that it's equivalent one hour one year is equivalent to 1,900 hours.

So minimum doctoral degree plus internship experience and compact?

And the compact, I believe, is 1,500 hours for internship and postdoc. I believe the degree difference is- is- is no- no different. But I do think that the compact will allow other specific types of degrees that we may not use. So for example- for example sorry. Forensic psychology or--

Sorry. But these need to be p eight doctoral degrees?

Or they would have to be doctoral degrees, and then we would also have to change section seven to accept those since we do list out clinical counseling and school psychology. So if someone were to go through the compact with, say, a doctoral degree in forensic psychology, they could meet the compact, but not ours in the state.

Okay. Alright. Thank you. Thank you very much. If there are no other questions, let's move on to the next bill, which is Senate Bill 2277 relating to hospital price transparency, Department of Health. State Department of Health.

Oh, okay. I thought I okay.

DCCA, Office of Consumer Protection. Good morning,

Chair, Vice Chairs, Members of the Committee. My name is Dominic Cancarino. I'm an enforcement attorney for OCP. OCP stands on this print testimony and is available for questions. Thank you. Okay.

SHIPT, Doctor Jacqueline.

Morning again, Chair, Vice Chair, and Members. SHIPT would like to offer a bit of maybe a simplification of this issue. When we originally looked at it, it appeared that the regulatory part, whether it be the Department of Health member who's assigned responsibility, would require some significant staffing and support services to be able to address price transparency. Since then, we've had discussions with the Health Care Association of Hawaii and others in the hospital world. And because the feds are requiring this reporting and there are already federal sanctions around it, we think this could be done much more easily at this point, which is to work through the association and have a reporting agency here that places any violations on on the websites that can be seen publicly and take action if we need to.

So I think it's a much simpler process than we thought before, and Shipto would be willing to take this on. I know doctor Fink actually in one hearing was you were gonna have a kind of a humorous exchange, but he said, well, I think Shipta should do this. You know, I said, I think DOH should do it, but we would certainly take that reporting process on. But whether it'd be DOH or SHIPTA, we think it could be handled at least in this initial phase through a collaboration with the Healthcare Association of Hawaii.

Okay. Thank you very much. Speaking of Health Care Association of Hawaii, Health Care Association of Hawaii.

Morning, Chairs, Vice Chairs, Members of the Committees. My name is Hilton Raethel, Presidency of the Health Care Association of Hawaii. We're testifying in opposition The bill is part of a nationwide effort by certain private parties that would increase that would impose competing regulations in states across the country. Hospitals in Hawaii are already subject to federal hospital price transfer requirements administered by the centers for Medicaid and Medicare services or CMS. Layering additional requirements, state requirements on top of the federal mandates would increase the administrative burden and compliance costs for hospitals without improving the information currently available to patients.

We are particularly concerned that this bill classifies any violation as an unfair or deceptive trade practice, exposing hospitals to significant financial liability, and treble damages that go far beyond the enforcement structure used at the federal level. There is already a federal enforcement measure for hospital price transparency requirements, and CMS has used that for hospitals not in compliance. Not here in Hawaii but they are they are they have gone after hospitals on the Mainland that are not in compliance. So that enforcement measure is already in place at a federal level. The measure does not add value for hospital patients, but would introduce substantial operation and and legal risk for hospitals.

If the legislature does choose to move this measure forward, we have suggested language that would require hospitals to attest to the state that they are in compliance with federal regulations. Thank you for the opportunity to testify.

Thank you. Next we have on Zoom, Steve Fenberg, Silver Plume Strategies. Please proceed.

Thank you, Mister Chair. Thank you, Committee, for your time. My name is Steve Fenberg, and I'm here in support of Senate Bill 2277. I've submitted written testimony that includes some suggested amendments, but I just wanna very quickly address some of the comments that were just made. This bill does not provide does not require anything more or in addition to what the Federal Government already requires of hospitals.

There are no additional requirements. It simply says that a hospital in Hawaii must follow the federal requirements. The so the it would not be competing or duplicative. It would simply say that under the state law, the hospital also has to follow the federal requirements. The the amendments that I've offered, that I've suggested in my written testimony, number one, give it, removes, oversight and enforcement by the department because, we agree it's not necessarily something that has to happen, and it would have a fiscal component.

Wanna be mindful of state budget constraints right now. And then secondly, based on the, the concerns we have heard from hospitals, we are open and suggesting that, we remove the the unfair trade practice, reference that is in the bill. So what you would have left if you adopt these amendments essentially is codification of the federal requirements, which many, many other states have already done, with no real problem, provide some basic, consumer protection by saying that if the hospital is not in compliance and they sue a a patient for a surprise bill to collect on that debt, then the patient has the right to provide a counterclaim that says that they never could have possibly known the price of that service before they were provided the the service, which I think we would all agree is a is a basic consumer protection that everybody has in every other aspect of the economy and probably should apply to health care as well when these are bills that often will put people into serious debt for maybe the rest of their lives. If these amendments are adopted, I think it would be a very reasonable bill and one that would still provide consumer protection within the state.

Thank you. Happy to answer any questions.

Okay. Thank you very much. Let's see. That's all the testifiers I have listed. Anyone else I missed who wishes to testify on this measure on Zoom or present? Yes. Please step forward.

I'm Robert Pickering.

Good morning. Good morning.

Chairman, Vice Chair, this is the brand new dataset that's coming out across the country. Chairman, Vice Chair, this is the brand new dataset that's coming out across the country.

The ability that average consumers to use it, after seeing some limited transparency data already can be a challenge. The collecting of it is one thing. The utilization of it is another thing. So if there's an agency within the state of Hawaii that could make it easily for the consumer to use, insurance companies have the resources to dive into this new data and update

Mr. Pickering, not, not to interrupt you, but I wanna make sure that you're testifying on the correct bill. There's a bill later on this in this hearing that deals specifically with hospital discharge data.

Yeah.

SB 3246. We're not quite there yet. This bill deals with hospital price transference.

Right. That's right. But that's my point. My point is that for the consumer to consume it and utilize it to figure out what the real cost will be, that will evolve over time. Whereas insurance companies have the resources to utilize that quicker and better upon its release.

Thank you. Okay. Sorry to interrupt. Thank you very much. Anyone else wishing to testify on this bill? If not, Members, questions?

Can I have the Healthcare Association of Hawaii, please? So, so this, are the federal required this public disclosure, is that in effect already?

Yes.

So if that, that information is available to patients already?

All hospitals for example have price calculators on the website. So you can go in and actually look up, you know, put in codes or procedures and look up prices. Now pricing is also a function of payers. You know, you have different you know, because Medicare, Medicaid, commercial payers, you know, have ,they have their own arrangements with with with hospitals as well. So it's but, but there are there's still price calculators available.

The federal requirements have been in, the CMS requirements have been in place for a few years and I don't remember exactly when they went into a place but they there was a a comment period and, but they have been in effect for a few years now. It did take a lot of work. The hospitals provide a credible range of services. The charge master that hospitals have has many thousands of of items, if not tens of thousands of items on it because of the range of services provided. So it took a lot of work to actually get in compliance, but we are regulated by CMS.

CMS is enforcing these requirements. There are hospitals on the Mainland again where CMS has actually imposed fines for not being in compliance. So my point is that the compliance mechanism is there and it is working and if hospitals in Hawaii are not complying then you know then CMS would be coming after us as well. But we are working with our hospitals to ensure that they ensure that they are in compliance with these federal requirements.

It would appear to me that it's not really working for the customer. I went to Queen's ER to get stitches, four stitches. I had no idea what it was gonna cost. I was shocked. It was thousands of dollars to get four stitches. And, obviously, I have insurance, but it you know, that went into my deductible, which as a healthy person, I often don't really use health care during the year.

Sorry. What was not working?

I was not given, I had no idea that getting four stitches was gonna cost thousands of dollars. Right? There was no information to the patient about here, you can look up our prices on our website.

Right.

There there was no communication. Right? Patients do not necessarily know about this. I was not informed of it. If, had I known, I might have just walked out and walked to an urgent care if I could find one open.

Well, it is, it is true that getting stitches taken out at a hospital is.

Yeah.

All put in. Yeah getting or getting work done in the hospital. A hospital is a high cost setting. You know hospitals are I assume you went to an emergency room is that correct?

Emergency room.

You went to an emergency room. Emergency rooms are designed, they have to have a lot of services, they have to have a lot of equipment, highly paid professionals, and so.

That's not my point. My point is, I was not told the cost. And I had, I was not told there was a way for me to find the cost. So it seems like there's a missing piece.

No. That's it is true that when, that when you go to unless you ask for a price or a cost, it's so the, you can look it up, you know, but you know, if you're going in and you need stitches or whatever whatever it is, you know, you could use your phone or whatever to look it up. But could we do a better job or of informing patients that pricing is available. Yes. We could do that.

So pricing is available. You're talking about the communication to let people know that they that they could look it up.

Signed with a QR code in every waiting room. I spent hours in there. I had a lot of time. I could've looked it up.

Okay. We...

And things like that would be super helpful.

We are very happy to, are very willing to go back to our members. We meet with them on a regular basis and talk about this to improve the visibility. The reality is health care is expensive. You know, the layers, you know, the the doctors visit for what they can do is generally lower cost. Urgent care is to be the next level.

Emergency rooms are the type of thing you're talking about. Yeah. It is the it is a costly setting to get something like that done. But absolutely, we're willing to go back and talk to our members to come up with something like that and provide them with that information.

Any other questions from members? Seeing none, I, I do have a question for Doctor Lewin. Doctor, if I heard your testimony correctly, which is always questionable and what times, but I wanna make sure that I heard you say that your office would be an ideal local state agency that can certify that hospitals are indeed complying with the federally required disclosures as far as pricing and and other transparency requirements. Is that correct?

We'd be willing to take that that task on. It, it wouldn't immediately solve the issue that was raised by representative Martin, but we would certainly be willing to to work with the Health Care Association on reporting on the status of of of price transparency across our hospital system.

And would SHPDA also be the right office to perhaps receive consumer complaints about violent possible violations?

I think that's already established as part of the federal regulatory process. So we don't wanna replace that. But to the extent that that federal process is serving our citizens properly, we would be willing to take a look at another layer of reporting.

And maybe post complaints on your website or some publicly accessible.

That could be, that could be done. Thank you.

Alright. K. Representative Amato

Thank you. A brief follow-up. So Mister Raethel said that CMS monitors these hospitals and verifies that there's compliance with price transparency. Okay. So I heard that correctly. My question is, does CMS monitor Hawaii hospitals? Do they then how often do they verify that hospitals are providing transparency on their website so people can try and estimate what their care is gonna cost?

I can't answer that question, Representative, but thank you for it. I think that the whole process of price transparency from a consumer advocate point of view across the country appears to be lagging from what the ultimate goal is to be. So it is in process, but I think that there there really are lots of areas where we could improve upon it and and really make, make clear to consumers before a procedure. That's not gonna work very well in the emergency room setting. But in other settings, we wanna make make sure people have access to the pricing and not be surprised there.

Absolutely. Thank you. I don't know if, Hilton, you can expand upon that. How do they, how does CMS handle enforcement of compliance on that? Can you, can you explain that a little bit?

How do they handle the.

Well, you you said that, well, CMS monitors for transparency. So how do they handle this compliance making sure the hospitals are being transparent?

They, they do monitor every hospital across the country on a regular basis. I don't know the exact cadence. I could probably find out. But we do know that CMS is and because it's all online, exactly how they do it and how frequently they do it, we don't know.

We do know that again because of the instances we've talked about that they, they have a process or if if a hospital is not in compliance, there's the general in like with a lot of enforcement, they'll do a written notification and then and expect a response within a certain time frame.

If they don't get the response or if the issue is not remedied then they, then it's escalating to the point where they can issue monetary penalties. So there is that process that it is in place and has been used by CMS and every all the hospitals in Hawaii are subject to that compliance process.

Thank you. I would love to learn more about that. Do you think you could email the Chair or the Committee some more information on how that process actually works so we can be better informed.

Yep. Absolutely. We're very happy to do that.

I appreciate it. Thank you, Chair.

And I'll and I'll share whatever information I receive.

Thank you.

Any other questions from Members?

let's move on to the next bill, which is SB 2425 requiring health insurance carriers to honor a patient's assignment of benefits to a substance abuse substance use disorder treatment provider. First up, on Zoom, the attorney general's office. Oh, that not on Zoom.

No. They do that all

the time. Yeah. You do that all the time.

So did you, Christopher on same comments as the first bill? Whenever you're dealing with contracts, it's useful to have a non insurance savings clause to kind of

deal with any potential. Thank you. Insurance

commissioner?

Morning, chair, vice chair, members of the committee. Justin Chu for the insurance division. If I could just highlight a few comments in our MRN testimony with we provide comments. Just note that all of previous testimony previous committee did amend the definition or amend the measure to say, a validly executed in compliance with this title. We note that the measure still does not say what is a valid assignment of benefits.

Right? So when we're enforcing, this law and someone says that, you know, an insurer has not honored our our written assignment of of assignment of benefits, can that can that assignment benefits be scribbled on a napkin, or does it have to be notarized and provided by the individual, the enrollee, as opposed to a provider? So we just like some clarity on what what makes a written assignment valid. Second, we note that the the measure states that even under the subsection, needs to be issued within thirty days of receipt of a claim that meets the requirements of 43113108. Four 3113108 is our clean claims law, which provides certain timelines that ensure must pay the provider once a claim is submitted.

However, the definition of claim is very specific. Alright. So the definition of a claim implies that the claim is submitted by an individual or pursuant to a contract or agreement with an entity, meaning that they are a participating provider. However, we understand that this bill is to pay payments to nonparticipating providers. Right?

So then because of the definition of the word claim, a nonparticipating provider would would not be able to take advantage of the certiority requirement. And then we we also note that the bill does contain some duplicative enforcement language. Subsection b states that any violation of the act constitutes an unfair and deceptive trade practice. Then in the next subsection, subsection e, it says that if a health insurance carrier does not provide an explanation of benefits as required by this section, it shall be considered a violation of state insurance law, which we think is too clear. If I may continue.

Fine. Finally, we're just unclear about when when a violation of that explanation of benefits would occur. There's no timeline. So it says upon request, but we're not sure how how long after that request the the explanation benefits need to

be made. Thank you. Okay. Thank you very much. Let's see. On Zoom, the Ohana Addiction Treatment Center, Elliot Smith.

Aloha, chair Takayama, vice chair, and members of the committee. Thank you for the opportunity to testify. My name is Elliot Smith. I'm the CEO of the Ohana Addiction Treatment Center on the Big Island, and I'm here in strong support of SB 2425 SD two. So this bill is about whether Hawaii families can actually access substance use treatment here at home.

Right now, many cannot, and families are often forced to come up with $30,000 or more upfront just to get a loved one into treatment. Because even when an assignment of benefits is signed, reimbursement is still sent to the patient instead of the provider. That leaves families financially desperate. It puts patients in early recovery in the middle of money and pushes too many people to the mainland away from their Ohana because local treatment becomes impossible to access. In the substance use disorder setting, this is not just a billing issue.

It's a patient safety issue, an access to care issue, and a claims transparency issue. So people leaving treatment are in one of the most vulnerable moments of recovery. They should be focused on staying sober, rebuilding trust, and reconnecting with life. Instead, they can end up holding a large reimbursement check while the provider that delivered the care is still unpaid and the family's left in confusion and conflict. There are real stories here in Hawaii of relapse, overdose, and death after large reimbursement checks were sent directly to people in early recovery.

You know, opponents may call this niche, say families can just handle the check afterward or raise fraud concerns, but that ignores the reality on the ground. Substance use disorder is not niche in Hawaii, and the patient should not be the payment middleman, and the family should not be the claims department. The fraud rhetoric does not change what this bill actually does. S b 2425 s d two is limited to OCA licensed residential and detoxification substance use disorder providers. It doesn't remove prior authorization, medical necessity review, audits, denials, or recoupments.

Opponents also talk about parity and network access, but parity on paper, it's not parity in practice. If families still have to front huge sums to get care, private residential capacity remains limited, and loved ones are still being pushed to the Mainland. Most importantly, this bill is narrow and very reasonable. It's limited to OCA licensed residential and detoxification substance use disorder providers.

Mister Smith, I'm gonna ask you to please wrap up your testimony if you could.

Absolutely. It doesn't set reimbursement rates, and it doesn't remove all the fraud protections I referenced before. So Hawaii families deserve better, and I respectfully urge your support of this bill. Thank you.

Thank you. Rachel Wilkinson, Hawaii Association of Health Plans. In opposition? Alright. Thank you. HMSA, all the now.

Morning, chair Takayama, vice chair of HMSA. We appreciate the opportunity. We stand on our testimony and opposition of this measure. While HMSA supports the efforts of our residents seeking substance use disorder treatments, we feel that on the heart of this, the assignment of benefits, the reason why health plans enter into agreements and contracts with providers is primarily to ensure that quality of care is delivered and received as well as predictable and affordable costs to the members. In terms of some of the comments made about access, nonpar facilities for SUDs in the state, at least for the commercial lines, is eight out of, I believe, 92.

So this really doesn't improve or increase access, at least as what's being represented. The other concern that we have, at least in terms of assignment of benefits when it comes to substance use disorder facilities, is that we've seen huge cases of fraud just in 2025 alone. The Department of Justice at least alleged that there was a $650,000,000 scheme involving 41 substance abuse treatment facilities in Arizona, largely in the Medicaid space and for patients that were recruited from homeless communities and tribal lands. Also in 2025 in the Central District Of California, operators of True Health LLC run a $2,700,000 back scheme. We have other cases cited in our testimony.

What we worry about and what we feel that allowing for an assignment of benefits may lead to is higher out of pocket cost for patients, lower clinical quality due to inadequate oversight, greater vulnerability to fraud, and destabilization of our provider network undermining long term access to sustainable coordinated care. Hearing the testimony from previous stakeholders as well as legislators' concerns about the out of pocket or excuse me, the money is going directly to SUD patients. I believe HMSA has at least kind of in theory figured out a path to address that specific concern. And if that is the main concern of the legislators, I hope that you all will find that being able to pay for the commercial space within the commercial space for a nonpar providers directly to the facility. Some of the HMSA is actively looking into it.

I'm available for any questions. Thank you.

Thank you. See, that's all the testifiers I have listed. Anyone else I missed? Machine with SB 2425 here or on Zoom. Seeing none members members' questions?

Sorry. I did not question. I'm from HMSA. I just wanted to clarify what you're suggesting HMSA has done. My thought is if if the insurance company does find the service reasonable and chooses to pay benefits, you are then trying to you are paying the provider directly rather than patient. Is that what you're saying?

So in the nonpar space, represent thank you for the question. Because the contractual agreement does not exist between the facility or the provider and the insurer, we're not able to pay them typically directly. So for this very specific car ball with substance use disorder, we're investigating how we can make that possible. That should a patient seek care at a nonpar facility, that we would be able to pay the facility directly if the main concern is that large sums of money are going into the hands of someone going through a substance use disorder or treatment journey.

This is not

We haven't figured out how to do that yet.

I mean, I can't promise that it would happen tomorrow, but I'm confident that within a short period of time, we will be able to do this. There is some precedence for this to be able to be done.

Thank you. Thank you, chair.

Okay. Thank you. Any other questions, members? Seeing none, let's move on to the next bill, which is SB 2431 relating to health savings accounts. And first up, we have a Hawaii Department of Taxation.

Good morning, chair, vice chair, and the committee. Robert Alviwal, capital DOTAX. We stand on our waiting testimony providing comments, and I'm here

to answer any questions you may have. Okay. Thank you. Let's see. Tax Foundation of Hawaii on Zoom, not present, offering comments. All of our independent living Hawaii, written testimony, offering comments. HMSA?

There are vice chair members of the committee. We just wanted to offer some comments on the measure. We appreciate the intent of finding ways, especially given some of the federal actions, making some of the health care plans a little less affordable. But we do wanna point out that health savings accounts, at least from our understanding, were never designed to be, funded by insurers. Typically, these are programs or accounts that are funded by employers and employee distributions.

So we weren't sure if the measure was intended to be a tax credit available to the employer, employer as opposed to the insurance point on this measure. Thank you for the operating adoption, Scott. Thank you.

Let's see. We have written comments from the Hawaii Medical Association, HMA. Anyone I missed wishing to testify on test speed 2004/31 on Zoom or in present in person? Members, any questions? Alright. Let's move on. Next bill is SB 3,133 relating to preventive preventive medicine. First up, we have DCCA Insurance Commission.

Morning, chair, vice chair, members of the committee. Justin Shoop for the insurance division. We stand on our written testimony, providing comments, just noting potential for.

Thank you. Okay. Thank you. Let's see. Jack doctor Jack Mullen?

Well, again, chair and vice chair and members. Ship strongly supports this measure based on the changes that have happened in our nation's capital that could cash out on whether we're getting the guidance that we need. So we really would like to see the preventive services process. We would prefer to DH do a DOH on its inability to manage this, but we believe this is an important measure right now to protect the access to preventive services in Hawaii. Thank you.

Thank you. Department of Health.

Good morning, chairs and vice chairs and members of the committee. I'm Nathan Tan. I'm with the disease health control division in the Department of Health. I am

testifying on the behalf of the department, and we have submitted rest written testimony and some strong support about this measure, which protects children and families in Hawaii by ensuring continued access to communications and other certain clinical preventive services. We offer amendments to help strengthen this measure. This measure includes a committee of health professionals, and we offer an amendment that they are protected in providing recommendations based on good evidence in in science. I'll be available for any questions, and thank you for the opportunity to testify. Thank you.

Health Care Association of Hawaii.

Representing the Healthcare Association of Hawaii. We are standing on our testimony written testimony in support of this measure. Thank you. Thank you.

On Zoom On Zoom, Hawaii Islands Republican women, Jamie Detwiler.

Aloha, chair. Can you hear me?

Yes. We can. Please proceed.

Thank you so much, sir. Aloha chairs, vice chairs, and members of the committee. Jamie Detwiler, Hawaiian Islands, Republican women. I'd like to also add that I am a retired healthcare administrator and a licensed social worker with over 33 years of experience directly in medical ethics, patient safety and risk management. Thank you for the opportunity to testify in strong opposition to SB 3,133 SD two.

While I do support preventative health care, preventative health care, which comes in many forms, I have grave concerns about this bill. It places excessive authority in the hands of a select group of unelected bureaucrats named in this bill as Hawaii Preventative Services Advisory Committee. It could also lead to centralized control over medical decisions and care guidelines. As a result, it may introduce biased advice, impose unwelcome mandates, and diminish informed consent. Furthermore, I'm also concerned about the broad immunity provisions in this bill that protects the Hawaii preventative services advisory committee, as well as other clinical practitioners named in this bill, for example, as pharmacists.

If there are adverse reactions or medical errors, there is no recourse for the patient. Where does it say that the patient is protected by any medical errors or adverse events? The bottom line in if this bill is passed is it will open the door for additional advisory committees to be established throughout our state, and it will give a government entity unfettered power and authority over our citizens. In closing, may I respectfully remind this committee that mandates have a limited lifespan, which is not the case for constitutional law. Thank you for the opportunity to testify.

Thank you. HMSA.

Chair, vice chair, members of the committee, we'll then obviously say, we stand on our written testimony providing comments. We do support the intent of the measure and appreciate being able to discuss some of our concerns with DOH. Three things that we'd like to highlight, Section 43110 a found on 4321 found on pages six and seven. Current federal regulations that apply to the USPSTF preventive service mandates impose limitations of coverage, and it's not clear if these same limitations would be imposed should this measure pass. Primarily within that section, making clear that coverage for out of network providers is not recover are not required and additionally clarify that insurers are not precluded from imposing cost share for services received, from an out of network provider.

On page 16 line 18, the proposed states that preventative services cannot be denied based on medical necessity or subject to prior authorization except as permitted for reasonable medical management. We know that there is no definition for reasonable medical management, at least from what we understand. And lastly, the section dealing with network adequacy found on pages 14, lines one through eight. We feel that this would be duplicative as this measure should be covered by existing statute relating to network adequacy. Thank you for the opportunity to provide these comments available for questions.

Thank you.

Let's see. We have a written testimony in support from the Hawaii Academy of pedia pediatrics as well as the Hawaii Medical Association. Let's see. Cheryl Toyofuku?

Welcome. Good morning, chair Takayama and the members of the House Health Committee. My name is Cheryl Toyo Toyo Fuko and my grandmother. I'm a retired registered nurse, and I'm a health advocate. Over thirty years ago, I did transition to more natural nontoxic health care.

And so I'm in opposition of SB three s b h I think it's s b two. So, anyway, after years of coming to the legislature just to try to educate a little bit more about the dangers of vaccines, it seems that, for this particular bill, specifically, it does address vaccinations as a preventive health care, preventive medicine. Disregarding other more effective health care methods to help improve our God given immune system versus using artificial immunity like vaccinations to have an advisory committee, made out of members of preselected organizations that promote vaccines. It seems to be that they're eliminating other organizations that are genuinely trying to help Hawaii and our keiki and our Mo'opuna with better health. We know that there's chronic illnesses with our children now and the childhood schedule for vaccinations have escalated dramatically.

I remember as a grandma just only getting three, but now they have sometimes up to 70 something doses of 16 different vaccines. I know it has come down a little bit, but it's still vaccines are toxic, as many of you know, with some of the ingredients like apertino cell lines, mercury aluminum, formaldehyde, so forth. So this seems to be an unnecessary bill, and there is a lawsuit with the American Academy of Pediatrics right now because of the vaccine sick fraudulent safety issues. So thank you very much.

I oppose it.

Thank you.

Thank you. And thank you

for coming from Pro City. Kim Coroner in up. Oh. Pleasure.

Morning. Morning. I strongly oppose SB 31 b three, SD two. I feel this is a reaction to the recent changes in the vaccine recommendations by the federal ACIP committee. And as Cheryl noted, I I feel that is this is one-sided because, though, there's nothing in in any of those committees that actually are talking about natural methods or healthy, healthy immune boosting methods.

And so I I strongly oppose this bill, and I feel that we don't need our own Hawaii based ACIP Type Committee. But if you do decide to create one, you please make them viable for their recommendations, especially when it comes to vaccines because there has been so much there has been so many, heightened cases. And that that is where I stand. I oppose. Thank you.

Thank you very much. Let's see. Just for the record, I note that there are written written statements in opposition from two other individuals and in support from six individuals. Sure. Yeah. I was just gonna say, anyone else wishing to testify, please step forward.

Thank you, chair Toni Yamamoto, and thank

you, committee, for the opportunity to speak to this important bill.

I think, you know, when I

read through the bill Sorry.

Could you tell

us I recognize Gary thank you, Gary Cordery. I'm actually testifying in strong opposition to this bill. I think the idea of bringing agencies together in wisdom is a wise thing for society. We would reason together and come up with good outcomes.

But the idea of of this advisory committee is essentially made up of the committees that all share the same ideological perspective about health care and vaccinations statewide and nationally. I also believe that this particular piece of legislation is in direct response to the West West Coast Healthcare Alliance protocol or OPERA golf that governor Green has joined Hawaii to in response to national CDC policy. Those those policies are actually looking at the effects of vaccinations for decades now and shouldn't be just simply dismissed because there's an idea that we should vaccinate all the children based on an old old protocol. In fact, when the protocols came in 2021 from the Department of Health regarding COVID mandates here in Hawaii, the only PhD virologist in the state of Hawaii was dismissed because she actually raised concerns about the Department of Health public policy. And one of the questions I have about all these advisory committees, although I'm I'm certain they love the people of Hawaii, Do any of them are any of them PhDs or or or hold doctorates that can speak authentically to what kind what we're calling an an expert in the field?

I don't believe that's in here in any place. In addition, this legislation seems to empower pharmacists to to give vaccinations at Longs or CVS when they they do not know the personal health scenarios, they don't know the personal health histories of people coming in for vaccinations. This actually provides and and requires them to know how to provide the injection, but does not speak to the possible side effects that are that are possible when people have these injections. I also agree that when you have a policy like this, it is more of a framework. This is a framework for the health department of the state of Hawaii to continue to consolidate policy matters against the will of the individual citizens.

We have seen over the last three years numerous people and agencies and groups oppose these kinds of policies. And now it appears as though we're creating an agency to be able to say, well, that's just exactly what they're doing. I I recall every the mayor, the governor all said well, Chair Libby said, CDC said. They all use the authority of another agency or another person to justify public policy, and I believe that's exactly what's gonna transpire here. There'll be a consolidation of public health.

Advisory committee will be used and say, then all these experts have decided this is a good thing. And yet, is there anybody who really knows what these and the impact of these policy? I I don't believe that's true. Mister Carter, I'm

gonna ask you to please wrap up.

Okay. Thank you. Finally, I believe this this this element about accountability is vital. The fact that this bill actually sets aside liability for the advisory committee's decisions and health care decisions applied by the Department of Health using their wisdom is flawed. There is currently a lawsuit from CDC, and there's also a lawsuit from Jennifer Smith with the state of Hawaii right now.

And and we have yet to hear from d how the DCCA DCCA is going to embrace the proposed merger between Pacific Health and HMSA. These are all reasons to defer this bill until it's clarified and made far more articulate at the the people's concerns or address. So thank you, chair, committee. Appreciate that very much.

Thank you. Anyone else wishing to testify on this bill? HP I'm sorry. SB 3133. Seeing none, members, questions? Doctor Nguyen, please.

Thanks for being here. You mentioned in your testimony due to some of the policy changes in Washington, DC and the casting doubt of certain vaccines. Could you please elaborate on what you meant by casting doubt?

I think that, they're among the in the physician community, you know, we do rely on on certain processes that really evaluate the current science to determine what is best for populations. We do recognize there are people with immunologic conditions and so forth that can't receive vaccines or shouldn't receive vaccines.

That there

are a lot of, there are contraindications. We have all that together, but we we do come together, in in professional societies to try to do our best to estimate what is in the best interest of society. It isn't no one's forced to do the to to see these services, but we try to give the best advice possible. And I think that there's, you know, there's obviously a doubt cast about whether these these processes are are confidently conducted. I believe they are.

So do you feel that there's there's a differences opinion out there and a variety of conspiracy theories and so forth?

And do you feel that the CDC currently has, I guess, cast doubt on the efficacy of of vaccinations and and and the federal health care oversight committees have casted doubt? Yes. Okay. Okay. Thank you.

Any other questions, members? Seeing none, Department of Health. I do have a question. Several testifiers raised question of of why, the department is asking, that there be no liability on the part of advisory committee members. Can you talk about why you're suggesting that they'd be shielded from liability?

There'd be no liability. Well, I I I think,

you know, the

the purpose of the advisory committee is to ensure that recommendations are based upon the best available science and evidence. I think what we've heard today, but this is a very contentious issue. So, you know, providing that protection is to ensure that that those recommendations are made for that reason based upon evidence

and the best

science of the level. For that reason, we feel it's important that health care providers that serve on the committee, that the members that serve on the community are provided protection to lead. So we suggest. Thank you. Okay. Thank you.

Any other questions from Members? Seeing none, let's move on. SB 3246 relating to hospital discharge data. And sorry. Doctor Jack Lewin?

Thank you, Chair, Vice Chair, members. To some extent, the the conditions around this bill have changed in the sense that I, I am happy to say that SHPDA has access to the Waima hospital discharge data comprehensively collected by the Healthcare Association of Hawaii. They're in WALIMA system. We don't have the resources to, you know, to fully analyze all of that. But I wanna use this bill just as an opportunity to describe to you where the data gaps in the state are at this time.

As you know, you and thank you for creating the all pair of claims database. It's taking forever to get that operational. It is gonna become personally operational this year after many years of in development. But it will be lacking the data from the Medicare Advantage population of, of Kupuna, and it will be lacking most of the commercial health insurance data because the APCD mandate includes basically EUTF as the commercial population.

What we'd like to see is the whole population in a, in a deidentified privacy assured database that allows us to really track what we're doing in health care, monitor how we're doing.

And so we we this bill gives us an opportunity to describe what the gaps are in current data and what we're gonna need to really fulfill the obligations of the AHEAD grant, for example, in the future to meet the requirements that CMS has on us.

We're gonna need the additional data, and we'll need the ability to not only have the data, but to mine it effectively and report back to the public on how we're doing and across the spectrum of the common causes of morbidity and mortality. So thank you for the opportunity at least to provide that, that educational summary.

Thank you, doctor. Navian Hawaii, Richmond Bazaar in support. Healthcare Association.

Chairs, Vice Chairs, Members of the Committee, Hilton Raethel representing the Healthcare Association of Hawaii. We appreciate the intent of this measure. However, we believe it is not necessarily, it's not necessary. There's already an established mechanism for sharing hospital data with both public and private organizations. The research and analysis that happens every single year.

We get inquiries from local and national organizations to share the data, and we haven't we or again, have an established mechanism for doing that. We've spoken directly with the proponents of the measure and understand the specific data they want to assess.

We are working with them, if you just heard from testimony, to provide access to the data through the existing processes. Our goal is to ensure appropriate access to data while avoiding additional costs for administrative measures, administrative structures that are not needed, and we would suggest that this measure be deferred as we move forward with our discussion. Thank you.

Thank you. Robert Pickering in Intellimed

Good morning.

Morning.

Proposed this bill personally. It has nothing to do with my company. I started visiting Hawaii thirty years ago. I bought a ranch twenty years ago, and it's be, Hawaii has become my second home. I spent at least half of my time, if not more, here.

I stand by my testimony. I could share one thing as of a week or two ago. I've been visiting with Hilton and his staff about how we can work together to increase the value of what they've already started. This just mandates that every hospital has the obligation to submit the data. Currently, the current system, it's a voluntary thing.

So if each hospital were choose for some reason not to participate, they can drop out. That would leave various departments within the state of Hawaii the inability to gather the data they need for planning, monitoring, and understanding what's going on in the acute care, outpatient, and freestanding clinics. If you have any other questions that I can answer, I'd be happy to answer them.