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Senate | May 12, 2015 | Committee Room | Health Care

Full MP3 Audio File

Ladies and gentlemen please take your seats and we will get our committee meeting started. We will get sergeant at arm to sit you if need be. Thank you very much for being here today. for this meeting of the senate health committee I'd like to introduce our pages who are serving us in this committee and serving us senate this week please stand up and raise you hand when I call your name please pages. Brandon Wales from Nashfil Brandon is sponsored by senator Bryant, Deonte Machine form Feldo. Deonte where are you? And the back of the room he's being sponsored by senator Clark, Kadarius Maccan from Lamilton, I'm sorry, I butchered your name what was your last name? Mackegan, it's nice to see you represented by senator Smith, Rachel Gore, Rachel is behind the post she's from Wellington and she's sponsored by senator Rayburn and Elizabeth White. Elizabeth is at the clear back of the room, she's from Deepak and she's sponsored by senator Suchen. Our Sergeant arms are Donna Blake, [xx], Steve Wilson and we are delighted to have them maintain their order and busy busy committee room today. House bill 13 will be pulled from the agenda, we're not going to consider that today first bill that we will consider is house bill 195 and the primary response from the house is not here but senator Apodaca has graciously volunteered to present this bill, senator Apodaca you're recognized. Mr. Chairman thank you very much I heard all the motoring all over here and the peanut gallery when they said I was presenting this bill, I also filed the senate companion bill for these, actually before this was filed, but being nice we let the house do this first so bill today. This bill came to us with a lot of hard work and a lot of stakeholder agreement, that's another reason we started let them do that house let them do that, but that work our fine. In short medicine is now the point where certain biological, medical products, these are living-cell-based or protein-based drugs which are be happy to get in deeper with you as we go on, I used to treat cancer, immune and neurological disorders, these products will soon and those in a different line of products coming out of this that will be called interchangeable's and I'll give you the difference in a minute between biological and interchangeable, bio similar or interchangeable. This is somewhat like the evolution of chemically based drug markets and generic drugs when they became popular in the market, so we're trying to get ahead of the curve on this, the FDA is responsible for approving the use of interchangeable biological products and when this occurs North Carolina pharmacists excuse me, pharmacist need to be able to substitute these products so the patient can get the cost savings. The bill would update our generic substitution statutes to include interchangeable biologics, the process will be the same with one exception, the pharmacist must provide notice of a substitution to the patient doctor, so in essence we've two things here, bio-similar's which will be prescribed by the doctor directly to the patient, and the pharmacist has no ability to change that. Interchangeables are the equivalent the new generics and these are biosimilar's that can be replaced the name in drug when it becomes available. Right now the FDA has only approved one one drug and it's a biosimilar, right now the others are pending, so basically this bill just also allows interchangeable drugs once approved by the FDA to be replaced the name drug if the pharmacist sees fut and notifies the doctor, that's basically what this bill

does, and I will be happy to answer any questions. Thank you very much Senator Apodaca, Senator Thank you Mr. Chairman, representative Apodaca I notice representative Martin is present these are also a sponsor but just wanted to, what's curious is that, why she did not have an opportunity to speak, but this is, as I understand, your explanation, a good Bill that would like to move 4 or 5 will report well let her back clean up, thank you representative Bingham. Senator Law I believe you have a question. Funny thing about at this, these folks that talked about Biosimilars, and I had the opportunity to talk with them, they were some of the first people I had the opportunity to talk with over where the, few months, and I think it's a really good Bill, and I certainly support Senator Bingham[sp?] on this one. Senator Rayburn[sp?] yes thank you is the notification on the interchangeable a priority or a post priority before or after the fact of the interchange let me tell that out to, Andy are you here? Allan and we also have Candy Phillips Director of State Government Affairs for Sandow's, Mr. Chairman if she might either her or Andy can address this. I am Andy [xx] with [xx] association soon  could you repeat your question if you don't mind I apologize Yes upon modification so in this case Senator Apodaca mentioned the patient will come to the doctor, the physician will write the prescription, he will say not right. When it gets to the pharmacist because the doctor is not chosen the dispensary to get it he can give the patient the interchangeable drug and notify the physician that he is is dispensed. The different part interchangeable so that he has it for future use. Is afterwards? Yes. Speak into your mike Senator please the follow up is to use the past tense. Let's say he informs or informed that means that you don't have to say anything to the doctor before he makes the change of the medication. That's correct. Yes sir. Thank you. Senator to my understanding that is why it is now with your regular generics unless it says on the prescription not t replace they can automatically put in generics as our health plan requires. Senator Macusk. Andy maybe you can help with this or somewhat step if a is shown as dispense as written does the pharmacist at that point in time have the flexibility of substituting it with a bio similar [xx] It is expensive then you must call the doctor I guess we want to make certain of that will still continue as a practice, and, follow up? Follow up if I could, and I don't know if senator Apodaca can help with this or perhaps staff, I gather at this point and time there's only been one bio-similar that has been approved by FDA, is there some time frame for when this is all going to get done because I gather up, until that point in time there won't be a list available to the state board of pharmacy that will be available pharmacist to determine what biosimilars will be substitutable. Miss Chairman, Candy Philips is with us if you will be kind enough you might dare to give us some insight in there. Miss Phillips please come forward and state your name and who you represent. I'm Candy Phillips and I'm with Sanders with the Generic Division of it is and we have to share the company that has the first approve by the similar. So there is actually what is called an FDA propo back that has the list of products if they're biosimilar or if they're interchangeable and our products actually listed all although we haven't gone to market yet as we're in litigation at this point as updated as soon as the product is approved and it's available to anybody. Last follow up.

Please go ahead. So what's the time frame. What's the FDA looking at I mean we have one but of course you said that's in litigation but does the FDA have a time frame for compiling this list I know it should be ongoing but what does it look like. So as far as when we launch right now we're looking probably like September and there are other four products pending, that they do and they are expecting a new [xx] another six products to be reviewed this year, so we are expecting to be reviewed sometime next year the FDA has reported that they have two pending applications as well for interchangability so we are looking at this products as in at market by the end of this year I think North Carolina is doing the right thing to get ahead of the curve. Ms. Fibs[sp?] if I may ask you a question, is there a normal time period it takes for FDA approval? there is what's called Basufa[sp?], so there is a federal law that requires that they review the application within 20 months from the date that was filed or the day if it was accepted by the FTA. So there is a required timeline, 80% of all applications must meet that requirement of the FTA.  Thank you. Senator Robinson. thank you Mr. Chair and I'm certainly for people having prescriptions that can be cheaper. One question though you mentioned and I guess you mentioned the purple book. Will that also list side-effects and remedies for that the position would have access as well as the pharmacist. And that's actually will not be in the probable that will be located on our label, so you have to have what's called the label, which is that white pamplet has all that information listed. Further questions for members of the committee? Senator Davis you're okay, senator Birmigham[sp?] Thank you Mr. Chairman. I just wanted to see if I could get a copy of that purple book the lady there mentioned of it. I'd be happy to provide you with the to the website. Thank you very much. [xx] here either. That is not a blue bucket [xx], Further questions from members of the committee? Seeing  none, Senator [xx] move for favorable report to House Bill 195. Any further questions from members of the committee? All those in favor, please say aye Aye All opposed may say no. The bill will be referred to the senate. Thank you Senator Apodaca. Representative Martin, did you want to make a few comments in passing this Bill as now received a favorable report? Yeah [xx] the bill we will consider is house bill 158 the [xx] team, scan cancer prevention act and I would like to say how honorable we are to have where is Susan Fulghum, the widow of Dr. Jim Fulghum and Emily Robertson, the daughter of the late Dr. Fulghum. Miss Fulghum is back seated next to senator, what's your name again? From White county and also representative Penalton from white county they are standing beside Miss Fulghum, and we are certainly delighted to have you and please have a seat for the moment and we would go through formalities we've got in the bill, and then we will call you forward to make some comments. Representative Lambeth, representative Holly is going to, senator Turker what is the senator Trovial we have the time here today to keep the house going, house bill 158 before senator Turker and representative Harry. Thank you Mr. Chairman, thank you members of the committee for the opportunity to bring this bill forward to you that gentleman and Mark Albert, representative in the house as we continue on this is have been a long term proposal that has been here for five years, ever since I have been here, I want to tell you how pleased I'm to bring this committee at this time. From a personal note, I began to 10-12 years ago my wife and daughter gave me a gift certificate to a salon for pedicure and being a certainly one who will secure my own self esteem I don't mind saying that. And so I started to go and get those done and continue to have those done once a month ever since, so you guys

who are not securing your own masculinity ever try it. Does it work?  Yes sir. it's fine you need to help people your age sir. It ain't right I begin observed there were turning base across from me in this nail salon and along round prom time young girls would come in and literally coming out of those turning birds looking like lobsters and I was an involved parent my daughter is 28 now but I was involved in her softball and her basketball and in her or academics and pretty much all her life and growing up, is she okay there and I was there almost every time I could be there, but that was certainly ignorant to the fact before it, a cannon bulb could do to someone's skin, I did not realize that it was four taking times stronger than ultraviolet ray this we have in the sun, I did not realize that teens and young adults who begin tanning before the age of 35 have a 59% chance, higher chance of getting skin cancer. I did not know that treating skin cancer was at $8.1 billion industry and I did not know that the more than 400 thousand cases of skin cancer in the US, about 6000 of them are Melanoma. Now I've had more surgery, I've got a big scar on my forehead from having surgery there on a serious note and then on another note soon after the doctor tells me that's when I started doing front Lobotomy and then changed my mind. But at this rate, I have been burnt and cut and scarred well over 50 times much from being in a tobacco patch in East and North Carolina with no skin protection and growing up. So I cannot tell you since this Bill has been introduced is the number of young women who've come forward and told me even on the lobby of staff here. A young woman the other day and a Ford dealership gave him a receipt, a letter from a dermatologist said I could have shaded windows in my pick-up truck because I had had skin cancer, she began to tell me about having normal the aye use 30 years old and walk in you could see where the surgery had taken part. Ladies and gentlemen this is a real problem in our society in all the gym full groom new skin prevention act makes it so that if you're under the age of 18 years old you would not be able to go into a turning bath and get [xx] like a lobster for prom any more and actually I hear from folks in that industry that now they spray on pants or even more comfortable and certainly or safer. So with that I'll be glad to answer any question but we are so proud to this so proud Doctor Jim and mark of pushing this forward from the house on two sessions and now this session as we get it before the Senate we feel like that we have wit 21 sponsors to be able to get this to pass and get it into law in North Carolina and save people's lives. Thank you Rep. Hurley you have in remarks to make. Excuse my voice got allergies today I am very proud to have co-sponsored this bill if prier sponsor I thought with doctor Full Jim could stand with anyone better I realized am very fair skin and and you know when you are fair skin you have to really be careful, I have a place in my neck right where my seat belt was and it was and how doctor Mark Hallow he is a physician assistant that I served with tell me I definitively need to see my dermatologist and it was sickle cell I've had another one on my arm. So I do not want children to have Melanoma, I do not want them to have any kind of skin cancer and regardless of your skin tone you can still get cancer, so I know we've heard complaints from a lot of mothers but I feel if they really saw what happened to this children who have gotten skin cancer then they would definitely be for this bill I would appreciate your support. Mr. Chairman just in reference quickly the North Carolina Dermatologist Association, The Pediatric Society, The Medical Society, The Child Society, The Task Force the American Cancer Society all this organisations are behind this and their is data to support this bill we also have

a dermatologist from UNC and we also have someone from the indoor turning business would like to speak on this, but that would be all our comments Sir thank you Senator Tucker and Representative Holly, am going to open up the questions first of all to committee members and I see Senator Roy first, go ahead Sir. Certainly I have seen children. I've seen children that have gone into these tanning booths and just think it's really a terrible things at the appropriate time I'd like to move with a favourable motion. Thank you sir. We will hold up on that thank you senator Weigh further questions from members of the committee? Hearing none I am going to ask Doctor Diana Machain from the UNC School of Medicine, Pediatric Dermatology Department if you will please come up and state your name and who you represent for director then go ahead with your comments.  Hi. I'm Dr. Diana McShane. I'm a pediatric dermatologist from Eastern North and I have I have been proud to be asked to come and speak of others today are melanoma is one of the most deadly skin cancer today we take care of [xx] as Senator Tucker mentioned. There is about 400, 000 new skin cancers every year, and in study of young women aged somewhere between and 19 and 30, 76% of their melanomas can be attributed to tanning beds, tanning beds specifically. Tanning beds are known to cause skin cancer, there is no question in the dermatological literature about that and we have the ability to protect our most vulnerable members now in society, those people who are children under the age of 18 and I support this bill. Thank you very much. Mr. Michael Holzer, representing the Indoor Tanning Association. Michael, please state your name and who you represent. Thank you Mr. Chairman and members of the committee. My name is Michael Holzer, I'm here on behave of the Indoor Tanning Association representing over 800 business small businesses in the sate, and I urge you to oppose this legislation. This legislation will regulate a large number of these tanning salons out of business. This industry is already heavily regulated by the State and the Federal food and drug administration, the state already requires a signed prior consent form for anyone under the age of 18 signed in person before a teenager can attend. over regulation and taxes are killing this industry. Since 2010 across the United States, across the country over 3200 indoor tanning salons have closed. North Carolina already has provision for a teen tan banning, it's called good parenting the session regarding whether a teen should tend should be up to the parent and not the government. I had you oppose this slashslahing[sp?]. Thank you. Thank you Mr. Houser. Are there any other members from the public who wish to be heard on this bill? I'm going to recognize her after we've taken the vote. Seeing no members from the public I'm going to recognize Senator McKissicks. I have to make remarks at this time. Your working on a similar Bill several years ago and there was a lot of push back, but this legislation is long overdue and I'm glad to see it finally being voted on and as protecting the lives and safety of these kids who do not understand the risk they're exposing themselves to, just to get a tan. Thank you Senator McKissick, Senator Lowe, are you ready to make your motion? Senator Bingham has a question first, pardon me. Mr. Chairman I don't have a question but if I may just make a comment. I'd like to say that, as Senator McKissick mentioned, Doctor [xx] had worked on this long before and his admission there was a lot of push back I'm just glad to see we've come to this day and it's a wonderful thing for North Carolina. Secondly I'd like to say that Senator Tucker's pedicure hadn't improved his appearance that I can tell from observation but so it's appreciate him, make me aware of that and all reconsider that said, it's made such a marvel improvement on that thank you Mr. Chairman.   The Mellanoma surgery where I had didn't do a lot for me except save my life. Senator Wayne Senator Tucker, Representative Harley I just want to thank you all for bringing this forward and pushing and pushing to finally got it

here because I know you've worked hard on it. I know Senator Tucker haven't been around here, you didn't give up, you kept going and I just wanted to thank you personally for doing that. Thank you Seeing no other members of the committee who wish to ask questions or make a statement, Senator Lowe you're recognized for your motion. Move at favorable report Senator Lowe move to favorable report to House Bill 158, all those in favor will please say aye, Aye! All oppose may say no. The bill carries and now this time ladies and gentlemen Miss Mary Susan [xx] you're recognized to speak to us and we thank you very much for your courage and for being here today. Thank you very much floor is yours Okay, thank you Mr. Chairman and members of the committee. My name is Mary Susan I live here in Rowley and I'm a retired obstetrician gynaecologist. I'd like to also introduce my granddaughter [xx] Robertson who is here with my daughter Emily Robertson. So, Margaret can you say good morning? This is Margaret, her grandaddy would be mighty proud of her today . As you know, my husband Jim Funjum, was a member of the North Carolina house represent us during a 2013-2014 session, he was also a Neurosurgeon and and of course an early supporter and sponsor of the legislation before you today. I'm going to keep my remarks today very brief, and I thank you for this vote of confidence before I begin I would like to thank all the members of this Senate who signed on as sponsors of this legislation. I particularly thank Senators Tucker and maritive and catus for their leadership and I also want to thank senator Phill Barger and senator Tom Podaca for their leadership and their willingness to review this bill closely and give it a full debate and of course Reps. Lambith, Stam, Hurley and Representative McElraft deserve many thanks for their leadership on behalf of this bill, and as well I want to thank the 112 members of the House who recently voted to support this legislation. I think we've already thanked the many associations who have worked ceaselessly to see this bill come to fruition. Jim supported the bill before you today because understood as do the devastating impact that skin cancer is having on young people especially young women. As a doctor and a scientist he was familiar with the overwhelming amount of irrefutable scientific research linking even the modest or infrequent use of tanning beds to increased skin cancers, including of course Melanoma which is often fatal. and as a healthcare professional Jim also knew the most effective healthcare is prevention, and he knew keeping children out of indoor would help save millions of dollars and healthcare costs. As a father he knew that laws that protect children from tobacco, alcohol, and other adult substances parents keep their children safe, particularly when those children become teenagers and begin to spend more time on their own. He saw this bill as a way to build on the partnership between government and parents to make sure that children have the best opportunity possible to become healthy, productive, responsible adults. Since his passing our family has been blessed with the support of many friends and colleagues that support and love has made losing him enormously easier. the approval of this Bill is also a great comfort. To see one of the issues he cared so much about continue and gain support is both a testament to him and his work in the legislature as well as a tremendous gift to our family. On behalf of our family, and on behalf of Jim, I cannot thank you enough for your support for your support in this legislation. Thank you. Thank you Dr. Paulson, it would be out of place for us to all stand. Thank you very much, final Bill today is House Bill. Mr. Chair? Senator Robinson. Could I have a comment just before you continue please. Please go ahead. I wanted to wait to this chance because I want to thank is Fulghum, Dr. Fulghum because I had the opportunity of getting to know Jim Fulghum when

he came in and we shared a lot of the same concerns about prevention and health care, and this bill is so very appropriate. I too know young people who've gone into tanning places, and without parents permission and got tans and have had problems, but I just wanted to commend you and just tell you how much I enjoyed working with Jim Fulghum and how much he cared about healthcare issues, and we really appreciate that. House Bill 437, Create Permit Exemptions/Home Renal Products. Representative Dobson Thank you Mr. Chairman for allowing this bill to be heard today. Members of the committee I appreciate the opportunity to be here. This is a a fairly complicated but straight forward bill but if you endorse me I'll try to briefly explain it. House Bill 437 concerns something called Peritoneal Dialysis. Its a type of dialysis foe patients who are undergoing something called instate renal disease therapy. These patients are able to self-administer their dialysis treatment and their supplies are delivered right to their door. The ability to self administer allows them to live a more stable lifestyle. This bill seems six to streamline the industry of the supply chain for the delivery of this supplies right through the patient's door. I won't go into details of the process I would just say there are at least 4 cheques along the supply chain to make sure the order is accurate and the patient is getting what they need the most recent cheque was added in May of 2013 So, if you endorse me Mr. Chairman, before I get to what I'm asking to change today. I want to tell what will not change with this bill. These manufacturers maintain strict control over all products from the time they're manufactured, sent to the replenishment center for storage, delivered to the distribution centers, until they're delivered to the patient's home, ending with a literal last check by the deliveryman before it goes to the patient's door. Those steps will not change with this process. All dialysis solutions will still be manufactured and packaged at a production facility under the jurisdiction, inspection and supervision of the US food and drug administration, so as you can see clearly in the bill that provision will not change, it's still got to have FDA oversight. Also the dialysis drugs are lawfully held by manufacture and agent of the manufacture that is properly licensed by the North Carolina Department of Agriculture and Consumer Services, so there's been a lot of discussion, a lot of people brought to the. table, the department of open the bag and one of those stakeholders, they had some concerns that we address their concerns with that provision in the bill as well, so the department open the bag the FTA will still have over sight even with this bill. So there is still very tight controls so I want to tell you what will change with this pharmacy permit exemption. At the end of the process, after the patient has already received their dialysis and independent currently, an independent contract pharmacist is required to do a weekly retrospective inspection of what took place. This bill does seek to exempt [xx] dialysis from the pharmacy permit mandate, and I'm want to tell you why I'm asking for all of that today. As a result of this bill the retrospective are after the fact inspection will no longer be required. This would not unduly affect the patient or create a lack of oversight for the following reasons. As I said earlier addition cheque was added in May of 2013, many regulations are still in place and third most importantly the inspection is retrospective meaning its after the back so it's not going to benefit, this inspection does not benefit the patient. It doesn't provide any additional benefit six other states are already doing this, Georgia's governor just signed it on the beginning of this month so they became the sixth state to do this it has a 24/7, the counties also have a 24/7 pharmacy availability lab for their patients and as I said not only into this legislation to bring all the stakeholders to the table to reduce unnecessary regulation but at the same time make sure these patients are receiving the supplies and the care they need in a timely manner, the final part of this bill has something to do with the delivery, and this was added late

into to the bill but basically what it does if the patient requests that their products be delivered to their dialysis center, then this allows the to do that it's done in routing and they follow the right procedure, so that was the final provision. It passed the health committee unanimously it passed the house floor 111 to zero and I think it's a good bill to protect patients but also reduce unnecessary regulation, thank you Mr. Chairman for allowing me to present this Bill to today. Thank you Representative Dopson, are the questions from the committee? Senator Barn Thank you Mr. Chairman, Representative Dopson do you know of anybody who has objections to this bill? I would just say that no one has come to my office with concerns. Mr. Chairman. Senator Barn. I was going to move for favorable report on these Senator Woodard at any right I'll go ahead and move for a favorable report. We'll hold that brief someone put you into queue but thank you for your question. Senator Woodard. Mr. Chair thank you. I was just going to thank Rep. Dopson. I think this is a great bill and appreciate the work he's done on it and I was going to move for a favorable report further questions Senator McKissick?  I'm not very familiar with Peritoneal Dialysis, my mother actually was on that more than a decade ago, about two decades ago. The thing I'm wanting to understand, and if you can help me clarify this, I'm familiar with the way the dialysis is normally been delivered. I thought when I originally read this bill in the summary that what you're doing was basically allowing the fluid rather than to be delivered to the home would be for patient to pick it up from dialysis center, and from the dialysis center not to have a permit to do so. Now, I'm I mistaken in that impression or can you help me with that, because that when I thought was one of the primary provisions that I had summarized, from reading this over. Mr. Chairman with your permission I'll just say that, you're partially right in your assessment. Really there's two portions to the Bill, the second portion Deals specifically with the delivery of the products. But I don't think it will be fair to say that the first portion has to do with the second portion. The first portion is a different assessment. The second portion you're right, if a patient wants to have it delivered to the dialysis center as opposed to delivering into their home, and my question when I was talking about this was, why would a patient want it delivered to the dialysis center, may be a safety issue, they may need help administering it, there was a numerous reasons that I was given. So, at their request, I think I'll have to authorize it in writing, several things that they've to follow there to be able to have it delivered to the dialysis center as opposed to their home. So, that's the second part, the first part really is independent of that second part, this deals more with the pharmacy permit exemption and the inspection retrospectively. And that kind of clarifies it, because I was really, he had to mention that part of the pick up, so I wasn't quite sure I were in a primate language I can see there, thank you Robinson. Thank you Mr. Chair just a couple of questions and in the analysis of the bill it says the dialysis and drugs only by the manufacturer and a plan to receive a position or that the patient's position who must get that order or we still maintain the patient's position. I'm sorry Senator Robinson, can you put me to the line on this so I can see? The analysis? Yes in the analysis on the page, first bullet says the do you see where I am? The dialysis or drugs are  Right. Yes, mum. Or deliberate and I'm just talking about who gave those order is that the patient's position or can it be a position at the manufacturer, who gives the order? my understanding is the physician will still have to write the prescription and it will be an open-ended prescription, they'll have to go back every time, it's just an open prescription and when they run out they work with the manufacturer to make sure that they have what they need. [xx] Final follow up Senator Robinson No that helps because I want to

make sure we stay at patient's position, who is in charge of prescribing given the order for the medication. Further questions for the members of the Committee? Senator Wade Thank you, Mr. Chairman, one quick question. Who"s still responsible for showing the patient how to administer it if they burn it directly from the manufacturer, who the doctor or whose liability is that at that point. Thank you for the question Senator I'll pre phase my comment with saying that is not addressed in this bill I would just say they are able to self administer this product, they have to the dialysis center to get training, the techniques and everything that they need before they are allowed to do it on their own, so it's on the dialysis center as my understanding. Follow up. Follow up. So they wouldn't be able to get a for this without the doctor already going through all that with him, is that correct? That is correct, I think in addition they have may be in consultation doctor at the dialysis center, they have to get training as well. Further questions from members of the committee senator Heist. Thank you Mr. Chairman, before the motion just a quick comment I want to say that patients dealing with estidreno disease. This is a very difficult process that they are going through, there's coming the dialysis centres as we discussed on many other issues are still under stiff kind of needs, so they're very limited in areas where they can be located, representative a lot of individuals have had to grab still more than an hour to be able to get to we diagnose to centre of this process and the more they say we can do the none we have the manufacturers with patients be able to do this type of things at home and not have to make that trip more than an hour sometimes on a daily basis to get through this process it's very beneficial to the patients, and that being said Mr. Chairman I'll move for favorable report on the bill. You brought the motion and discussion, hearing none all those in favor, of a favorable report of house bill 437, please say aye aye, all opposed may say no, thank you very much, we've had quite a day here especially with Mrs. Fortune and her family here, the bill before the business, before this committee we stand adjourned. Thank you Mr. Chairman, members of the committee.