Interim Joint Committee on Health and Welfare


Minutes of the<MeetNo1> 2nd Meeting

of the 2001 Interim


<MeetMDY1> October 17, 2001


The<MeetNo2> 2nd meeting of the Interim Joint Committee on Health and Welfare was held on<Day> Wednesday,<MeetMDY2> October 17, 2001, at<MeetTime> 10:00 AM, in<Room> Room 129 of the Capitol Annex. Representative Tom Burch, Co-Chair, called the meeting to order at 10:10, and the secretary called the roll.


Present were:


Members:<Members> Senator Julie Denton, Co-Chair; Representative Tom Burch, Co-Chair; Senators Charlie Borders, Tom Buford, Paul Herron, Jr., Ed Miller, Daniel Mongiardo, Joey Pendleton, Richard Roeding, Dan Seum, and Katie Stine; Representatives John Arnold, Jr., Kevin Bratcher, Brian Crall, Robert Damron, Joni Jenkins, Mary Lou Marzian, Stephen Nunn, Ruth Ann Palumbo, Jon David Reinhardt, and Susan Westrom.


Guests:  Libby Marshall, Kentucky School Boards; Bruce Crump, Department for Vocational Rehabilitation, Frankfort; Jack Couch, Kentucky Council of Area Development Districts, Frankfort; William Hacker, Brennan O’Banion, James Carreer, Betty H. Olingis, and Steve Englender, Department for Public Health, Cabinet for Health Services; Carolyn Kates Glass, KYCAN, LaGrange; Charlie Ross, Purchase District Health Department, Paducah; Beckie Stephens, Children’s Alliance, Frankfort; Ronn Padgett and Cash Centers, Kentucky Division of Emergency Management, Boone Center, Frankfort; Stephanie Fightmaster and Andrea Gabbard, Nurses’ Registry, Inc., Lexington; Kelly A. Ranvier, Margaret Pennington, Randy Oliver, Karyn Hascal, and Barb Stewart, Department for Mental Health/Mental Retardation Services, Cabinet for Health Services; Bob Fritz, Christian County Health Department, Hopkinsville; Robert Ray Hicks, Chair, Kentucky MHSPC, Frankfort; Jan Gould, Kentucky Retail Federation, Frankfort; Bill Doll and Marty White, Kentucky Medical Association; Ellen Kershaw, Alzheimer’s Association, Louisville; Lewis Wilkerson, D & R Pharmacare, Lexington; Albert Bracken, Organon, Indiana; Blake Jones, University of Kentucky, Lexington; Darlene Goodrich, Governor’s Office; Stephanie Brammer Barnes, Cabinet for Families and Children; Tonya Change, Lt. Governor’s Office; Julie Brackett, American Heart Association, Louisville; Ronny Pryor, LifePoint Hospital; Sarah S. Nicholson, Kentucky Hospital Association, Louisville; Kim Townley, Governor’s Office of Early Childhood Development; Sheila Schuster, Kentucky Mental Health Coalition; Louisville; Anne Joseph, Kentucky Task Force on Hunger, Lexington; Kathy A. Mefford, Three Rivers District Health Department; Helane Miller, Abbott Labs; Debby Yelder, The Courier-Journal; Darlene Eakin, Kentucky Optometric; Sean Cutter, McBrayer, McGinnis, Leslie & Kirkland law firm; Karen C. Jones, Fritzi Naylor, David Mawn, and Larry Carrico, Kentucky Agency for Substance Abuse Policy, Frankfort; Gary Munsie, Board of Dentistry, Louisville; Greg Kleinke, Oldham County Health Department, LaGrange; John Williams, Mercer County Health Department; Peggy Patterson, Danny Greene, and Hazel Bentley, Northern Kentucky Independent Health Department, Edgewood; Jim Dailey, National Association of Mental Illness, Louisville; Dan Walton, Kentucky Auto Dealers Association, Frankfort; Lyle D. Cobb, Cobb and Associates, Frankfort; Bob Barnett, American Pharmacy Services Corporation, Frankfort; Prentice Harvey, Norton Healthcare; John Brazel, Kentucky Pharmacists Association, Frankfort; Steve Shannon, Kentucky Association of Regional Programs; Samuel B. Gregorio, Division of Laboratory Services, Department for Public Health, Cabinet for Health Services; and Nancy L. Black, Division of Occupations and Professions.


LRC Staff:  Robert Jenkins, CSA; Barbara Baker, Eric Clark, DeeAnn Mansfield, and Murray Wood; Gina Rigsby and Cindy Smith.


The first order of business was an update given by Margaret Pennington, Commissioner, Department for Mental Health/Mental Retardation Services, Cabinet for Health Services.  Commissioner Pennington said that the department serves people with mental illness, substance abuse disorders, mental retardation and other developmental disabilities, and acquired brain injuries.  The department operates three psychiatric hospitals, two nursing homes, six ICF/MRs, and one substance abuse residential treatment program.  The department contracts for two psychiatric hospitals, one ICF/MR, three personal care homes, and all community services.  The vast majority of community services are provided by the 14 regional mental health/mental retardation boards across the state.  The department budget consists of $179,705,400 from the general fund, $45,723,600 from the federal government, and $186,177,800 from Medicaid funds in the form of per diem payments to facilities, or disproportionate share hospital funds, or other Medicaid resources or funds, for a total of $411,606,800.  These figures are in the current budget after the recent budget reduction of approximately $4.2 million.  The cuts were in the central office administration - $475,000, residential programs - $1.8 million, and community services - $1.9 million.  The contracts for the Community Mental Health/Mental Retardation Boards were left at the same amount as 2001.


Commissioner Pennington said that there are 527 individuals per day in psychiatric hospitals, 720 in ICF/MR facilities, 216 in nursing homes, and 24 in the Volta Program.  The Community Mental Health/Mental Retardation Boards serve 101,391 individuals for mental health services, 8,200 individuals for mental retardation/developmentally disabled services, 21,309 individuals for substance abuse services, 7,364 individuals for unspecified services, and 400 individuals in the Brain Injury Program.


Commissioner Pennington said the department has been involved in four initiatives:  1) Commission on Services and Supports for Individuals with Mental Illness, Alcohol and Other Drug Abuse Disorders, and Dual Diagnoses – HB 843; 2) Commission on Services and Supports for People with Mental Retardation and Developmental Disabilities – HB 144; Kentucky Agency for Substance Abuse Policy (KY-ASAP); and the United States Supreme Court’s Olmstead decision.  In the Olmstead decision, the justices said that a state is in violation of a person’s civil rights and the Americans with Disabilities Act if the state allows a person to remain in a facility when the treating professional believes the person can be served in the community and when the person is not opposed to leaving a facility.  States desiring to comply with this decision should develop an effective operating plan for persons with disabilities and assure that any waiting list moves at a reasonable pace.  Over the last year, a broad-based group of stakeholders met and created a statewide comprehensive plan that was submitted to the Cabinet for Health Services.


Representative Burch asked if the $4.2 million reduction in the budget was able to be made because there were no services available.  Commissioner Pennington said that part of the reduction was: 1) in services that were not on line yet through the Tobacco fund; 2) money that would have gone to the Community Mental Health/Mental Retardation Boards for inflationary raises; and 3) money from hospitals tightening their budgets by cutting out overtime and some maintenance.


Senator Pendleton asked if this meant that only administrative costs had been cut and that services to recipients had not been cut.  Commissioner Pennington said that no units in facilities had been closed and that no reductions in the number of people served had been made.  The central office took an approximate $500,000 administrative cut.  The community mental health centers have had to absorb a cost of living increase within a flat-line budget.


Representative Nunn asked how many people were on the waiting list for HB 144 services.  Commissioner Pennington said approximately 1,750 were on the list.  Representative Nunn said the $4.2 million could have been used to provide services to people on this waiting list.  He said that the legislature appropriated approximately $15 million of state funds that would have created approximately $50 million new dollars for the program.  The executive branch has the ability to take funds from state government agencies to balance the budget, despite the legislative mandate of how the services should be provided.


The next order of business was testimony on the mental health services budget crisis by Dr. Sheila Schuster, Executive Director, Kentucky Mental Health Coalition, Jim Dailey, National Alliance for the Mentally Ill, and Carolyn Kates-Glass, Kentucky Consumer Advocates Network.


Ms. Kates-Glass said that without the services provided by the Community Mental Health Centers to consumers, the recidivism rates will continue.  Recovery is possible but not without treatment, and treatment is not possible without funding.


Mr. Dailey said that the mental health care system is already underfunded and does not need more budget cuts.  He said as treatments improve, individuals are allowed to return back to the community and become deinstitutionalized.


Dr. Schuster said that the safety net of services provided throughout the state by the Regional Mental Health/Mental Retardation Boards (Comprehensive Care Centers) was already stretched to the breaking point even before any budget cuts were announced.  Kentucky ranks 44th nationally in per capita spending on mental health and substance abuse.  The Commission on Services and Supports for Individuals with Mental Illness, Alcohol and Other Drug Abuse Disorders, and Dual Diagnoses identified this as its number one priority.  The problem is to be systematically addressed with a significant infusion of funds over the next ten years, but budget cuts in state general fund dollars would move Kentucky in the wrong direction.  The impact of the budget cuts will depend on whether the Comprehensive Care Centers had anticipated the cuts and had made plans to accommodate the reduction in revenue.  If money is taken out of a budget, it will eventually hurt the recipient’s services.  While current services may be maintained, the ability to serve more individuals may be sharply curtailed.  The issue is whether treatment decisions are being made in terms of clinical indicators and the needs of the consumer, or whether they are being altered because of the reduction of available resources, personnel, and programs.


Dr. Schuster said that the cuts could result in more people: 1) being hospitalized; 2) being sent to jail; 3) deteriorating; 4) becoming homeless; and 5) having a diminished quality of life.  She said $1.8 million was cut by not funding needed repairs to institutional settings.  She questioned if the lack of funds make the repairs no longer needed.  Consumers are impacted when less available funds jeopardize or delay programs, such as the Police CIT Training, Consumer Peer-to-Peer Support Services, and the Kentucky Medication Algorithm Project (KYMAP).  The Comprehensive Care Centers, the public safety net for mental health/mental abuse services, are in danger of collapse because their infrastructure has been seriously eroded by years of underfunding, coupled with increased mandates and the demand for services.


Dr. Schuster said that the 1994 Budget Act created 18 Crisis Stabilization Units but only ten have been funded.  She said that the ability to recruit and retain professional staff is seriously jeopardized by the financial situation of the Comprehensive Care Centers and their inability to pay competitive salaries.  Administrative services can only be cut so much until the infrastructure of the system and the ability to deliver clinical services is affected.  Each region should have flexibility in determining how dollars are spent to meet the identified needs in that area.  An already fragile system cannot withstand further deterioration of its funding base.


Representative Burch asked if there were adequate services throughout the state to take care of individuals with mental retardation and developmental disabilities.  Dr. Schuster said that it takes time to get a provider network and services in place.  Some areas of the state may not have adequate resources along the continuum of care readily available for purchase.


Senator Mongiardo asked about the waiting list for substance abuse was to get into acute detox.  Dr. Schuster said it varies from area to area throughout the state.  Almost every region identified a lack of substance abuse, both detox and residential beds, for both adults and youth.  Senator Mongiardo said that without rehabilitation, detox is a long-term process and the recidivism rate is close to 100%.  Dr. Schuster said that drug courts are only effective if you have available community-based services.  Senator Mongiardo said the money being spent on detox is being wasted because of the lack of funding for rehabilitation.


Senator Roeding asked how much money has been saved from institutional savings and how the savings are calculated.  Mr. Dailey said he would find this information.


The next order of business was an update on progress of the Commission on Services and Supports for Individuals with Mental Illness, Alcohol and Other Drug Abuse Disorders, and Dual Diagnoses.


Representative Marzian said that the Commission is developing a ten-year plan to deal with mental health, substance abuse, and dual diagnoses issues.  She said that the Commission found a disarray of services.  The Commission brought together all the cabinet secretaries and found that mental health and substance abuse problems cut across all cabinets.  The 14 regional mental health comprehensive care centers were asked to convene regional planning councils across the state and use stakeholders to create plans to send to the Commission.


Senator Borders said that everyone across the state had an opportunity for input into developing regional plans.  He said that the Commission did not get caught up in the budget.


Representative Nunn said that the Commission needs to find out how much of the $50 million requested is state funds and whether they could be used for a federal match, enabling the General Assembly to know all the facts when deciding how to appropriate funds.


Senator Roeding asked if northern Kentucky had any crisis stabilization units for adults and/or children.  Dr. Schuster said there has been no funding for a crisis stabilization unit for northern Kentucky.  The language in the 1994 Budget Bill was permissive language that established crisis stabilization units, one for adults and one for children, in each of the 14 regional mental health regions.  As funding becomes available, the units will be funded.  Only 18 out of 28 have been funded.  The units cost approximately $400,000 each.


A motion to approve the minutes of the September 25, 2001 meeting was made by Senator Buford, seconded by Representative Damron, and approved by voice vote.


The next order of business was an update on substance abuse by Mike Townsend, Director, Division of Substance Abuse, Department for Mental Health/Mental Retardation Services, Cabinet for Health Services.  Mr. Townsend said the primary issue causing problems in health care and criminal justice systems is substance abuse.  The Division of Substance Abuse is responsible for the prevention and treatment for chemical dependency with a budget of approximately $34 million.  The network of services are provided by community mental health/mental retardation boards and their affiliate agencies.  Prevention services are provided through regional prevention services in each of the 14 community health centers.  Early intervention programs are funded through mental health centers and private non-profit boards that consist of juvenile justice programs, student assistance programs for youth in school, and assessment of teenagers arrested for drinking.  There are an array of services provided through the community mental health centers or affiliates that range from social setting detox programs to short-term residential programs for co-ed and specialized programs for pregnant women, and two adolescent substance abuse residential treatment programs.  There are intensive outpatient programs that consist of group and individual therapy, and that are rendered in a day treatment setting in lieu of residential services.  There are case management services for people who have multiple problems.


Mr. Townsend said that programs focused on in the past year include the pregnant women and KIDS NOW outreach to health departments and private physicians to identify and assess women coming in for prenatal care and refer them to an appropriate assessment for prevention or treatment services.  He said that drug courts, through the criminal system, are effective, but there is a problem in that the treatment resources are not sufficiently available.  There is a six to nine month waiting list for the treatment.  The criminal justice system is the safety net for individuals who do not have access to treatment.  He said that a treatment outcome study is required when any program is funded with state or federal funds.


Senator Roeding asked about the self reporting aspect of the substance abuse treatment outcome study.  Mr. Townsend said that research shows that self reporting is very reliable.  The University of Kentucky has an independent contract with the state that conducts the follow-up.


Representative Burch asked if there is an overlap of services.  Mr. Townsend said that the Division of Substance Abuse works with the HB 843 Commission, Kentucky Agency for Substance Abuse Policy, and the Department for Public Health.  Eighty percent of out-of-home placements are substance abuse-related.


Senator Miller asked for the total amount of the contract was with the University of Kentucky.  Mr. Townsend said it was approximately $250,000.  Mr. Townsend said there also are contracts with Eastern Kentucky University and technical assistance programs in Louisville and Lexington to provide support for training or follow-up evaluations.  All funds, except administrative, are contracted through regional mental health center boards, non-profit boards, or universities.


Senator Mongiardo asked an electronic medical records system would be beneficial.  Mr. Townsend said a lot of programs are moving toward electronic client data sets and medical records.


The next order of business was the Medicaid update by Marcia Morgan, Secretary, Cabinet for Health Services, and Kathy Kustra, Governor’s Medicaid Steering Committee.  Ms. Kustra said that the Kentucky Medicaid outpatient drug costs for fiscal year 2000 are $433,359,510 and $568,021,354 for fiscal year 2001.  Approximately $275 million are spent on the top 100 drugs.  Some reasons drug costs are dramatically rising are new and better drugs and increased utilization of new therapies and overall drug use.  She said that KRS 205.5634(3) provides that the commissioner may prior authorize any product that the commissioner determines may pose a significant safety issue or impose an inappropriate financial burden upon the Medicaid program.  Any drug at any time can be placed on prior authorization.


Representative Nunn said that this statute had been in place for several years and the cabinet has had the ability to do something.  Secretary Morgan said that the cabinet has had the ability to manage the pharmacy program better.  Ms. Kustra said that one problem has been with prior authorization.  Senator Denton said that KRS 205.5634(3) could have been used at any time had the administrative regulations written by the cabinet been changed to allow the statute to be acted upon.  Representative Burch said that part of the deficit has been caused because drug companies put the most expensive drugs on a formulary, leaving it to the state to find a way to get them off.  Senator Roeding said that the General Assembly needs to be involved in writing the administrative regulations from the beginning.  Ms. Kustra said that KRS 205.5634(3) left several key terms undefined and the emergency administrative regulation defines them:  1) dosage form; 2) inappropriate financial burden; and significant safety issues.


Ms. Kustra said the prior authorization process will have the following changes: 1) new Drug Prior Authorization Request Form to be used by prescribers and pharmacists; 2) new Brand name Drug Override Request Form submitted by the prescriber; and 3) all prior authorization forms will be handled by fax.  These changes will become effective December 1, 2001.  Changes in the regulation will place a very strong emphasis on the use of generic drugs.  Prior authorization will be required for a brand name drug if there is a generic drug that contains identical amounts of the same active drug ingredient in the same dosage form and that meets official compendia or other applicable standards of strength, quality, purity, and identity in comparison with the brand name drug and/or unless the drug has been specifically exempted based on clinical review.  Senator Roeding was concerned that there could be a delay in treatment if a recipient had to start with a generic drug instead of a brand name drug that could be more effective.


Senator Mongiardo was concerned about the immediate turnaround and cost if a physician has to fax in a request for prior authorization.  Ms. Kustra said that the routine turnaround time is 24 hours, and there is an urgent fax line for emergencies.  The cost will be based on the number of transactions.  The Medicaid program cannot have a co-pay or preferred drug list because of the rebate laws.  The cabinet plans to limit the number, as much as possible, that will need prior authorization.  Senator Mongiardo asked whether, if it takes 24 hours for prior authorization, the cabinet will provide transportation for an individual to return to the pharmacy to pick up the prescription.  Ms. Kustra said that this had not been worked out.


Ms. Kustra said that other changes in the regulation are: 1) if presented with a prescription requiring prior authorization, the pharmacist will be required to submit a prior authorization request or to notify the prescriber or the prescriber’s authorized representative that the drug requires prior authorization; 2) the prior authorization maximum approval period is extended to 365 days; 3) the prior authorization is to be patient and NDC specific; 4) the dispensing maximum is a 32-day supply except with prior authorization or for certain designated drugs; 5) prior authorization may be required for compounded drugs; and 6) prior authorization will be required for early refills or duplicate or replacement prescriptions, unless the department designates that point-of-sale overrides are allowed.


Ms. Kustra said that the MAP-573 form currently allows residents in nursing facilities to be exempt from most drug prior authorization.  The Department for Medicaid Services will designate specific drugs or drug classes that will not be exempt from prior authorization through the use of the MAP-573 form such as the preferred drug list and Brand Name Drug Override Request Form which will be required for recipients in nursing facilities.


Ms. Kustra said that the Pharmacy and Therapeutics Advisory Committee has been created by executive order.  This committee will serve in an advisory capacity to the Governor and the Medicaid program on the development and administration of an outpatient drug formulary.  The Governor will appoint 12 voting members: 9 physicians and 3 pharmacists, all of them will be current Medicaid providers; and two nonvoting members: the Medicaid Medical Director and the Medicaid pharmacist.  Public meetings will be held in the Public Health Auditorium at the Cabinet for Health Services Building in Frankfort.  The committee will meet every other month and on specially called meetings.  A public notice of the meetings and agendas will be posted on the Department for Medicaid Services website at least 14 days prior to the regularly scheduled meeting and as soon as practicable prior to a special called meeting.


Individuals who want to give brief presentations or comments about agenda items may do so if a 72-hour written notice has been sent to the chair or vice-chair.  The Committee will make a recommendation to the Department for Medicaid Services regarding whether a drug poses an inappropriate financial burden to the department based on a review of:  1) the cost of the drug compared to other drugs used for the same therapeutic indication; 2) the cost of the drug compared to other drugs of comparable efficacy and safety used for the same therapeutic indication; and 3) whether the drug offers a substantial clinically meaningful therapeutic advantage in terms of safety, effectiveness, or clinical outcome over other available drugs used for the same indication. 


The Secretary of the Cabinet for Health Services, in consultation with the Commissioner of the Department for Medicaid Services and the Medicaid Medical Director, will review the recommendations of the Committee regarding the likelihood of a significant safety issue and the financial burden posed by the drug to the department and make the final determination whether a drug poses a significant safety issue or an inappropriate financial burden.  If the Secretary does not accept the Committee’s recommendation, the Secretary will present the basis for the final determination at the next scheduled Committee meeting.  A notice of the Secretary’s presentation will be posted on the department’s website 14 days prior to the meeting.  A public notice of a prior authorization determination will be posted on the department’s website and the manufacturer of the drug may appeal this determination in accordance with KRS Chapter 13B.  The appeal must: 1) be in writing; 2) state the specific reasons the manufacturer believes the final decision to be incorrect; 3) provide any supporting documentation; and 4) be received by the department within 30 days of the date of the public notice.


Ms. Kustra said that with the pharmacy program now exceeding $600,000,000, it is vital for the Medicaid Program to have the support of two key boards or committees that can complement each other but that can focus on different areas.  One would focus on formulary development and administration and the other would focus on drug utilization review (pro/retro), disease management, provider education, and interventions.  Changes currently being made in Medicaid will increase the need for expertise in the areas of drug utilization, disease management, educational strategies for recipients and providers, and intervention strategies for recipients and providers.


Ms. Kustra said that the changes will allow the Drug Management Review Advisory Board (DMRAB) to focus on other areas of expertise, other than the formulary, which are critical to Medicaid.  The advice and support of DMRAB, as well as the Pharmacy and Therapeutics Advisory Committee, will be essential to improve and assure the viability of the Kentucky Medicaid pharmacy program in the future.


Senator Roeding said the educational strategies should not be continuing education but focused educational strategies.  Ms. Kustra said that DMRAB’s work will be important in the educational area.


Representative Lee said that the Medicaid funds should be used effectively to serve more people.  Representative Burch said that it costs approximately $1 billion for nursing homes services and pharmacy costs.


The next order of business was an update on the accomplishments of the Kentucky Telehealth Board by Representative Steve Nunn, Rob Sprang of the University of Kentucky, and Jay Vetter of the University of Louisville.


Mr. Sprang said that the Kentucky TeleHealth Network (KTHN) brings together all three medical schools in Kentucky and rural healthcare facilities to help serve medically underserved individuals.  The KTHN provides an infrastructure that can be used to help address health–related problems.  Not only can patients and clinicians be brought together, but the network could become the basis of the development and implementation of a weapons and mass destruction preparedness plan.  The KTHN includes members of the Kentucky TeleCare Network.  Representative Nunn said that KTHN has sites in 37 counties.  Thirty sites are already active and 14 will be active before the end of December, and more counties are being added by the Board of Directors.


Mr. Vetter said that the vision of the KTHN is to increase rural Kentuckians’ access to health care services and health care education through interactive-video telecommunications technology.  The Board has created a technical infrastructure to provide clinical resources to help serve Kentucky’s 104 medically underserved counties.  There are four operational training centers in eastern and western Kentucky and two universities.  Competitive requests for proposals were issued twice to every hospital and public health department statewide.  They were requested to provide information on area needs for the types of services provided through the telehealth network.  The maximum funding commitment has been reached but other sites have been encouraged to make the commitment in funds to become active members of the network.  The KTHN has applied for and is awaiting approval for federal subsidies to help offset some of the costs of the communication lines that will connect these sites back to the two universities.  The KTHN has partnered with the Pikeville College of Osteopathic Medicine to pursue telemedicine contracts with the federal prisons located in Kentucky.


A motion to adopt 201 KAR 17:030, 201 KAR 20:070 & E, 201 KAR 20:110 & E, 201 KAR 20:162, 201 KAR 20:225, 201 KAR 20:240, 201 KAR 20:370, 201 KAR 20:470 & E, 902 KAR 20:145, and 902 KAR 20:370 & E was made by Senator Borders, seconded by Representative Marzian, and approved by voice vote.


A motion to accept the Community Mental Health Services Block Grant was made by Representative Marzian, seconded by Senator Herron, and approved by voice vote.


A motion to accept the Substance Abuse Prevention and Treatment Block Grant was made by Senator Herron, seconded by Representative Marzian, and approved by voice vote.


The next order of business was a presentation on Bioterrorism Preparedness by Dr. Rice Leach, Commission, Department for Public Health, Cabinet for Health Services, and Ron Padgett, Division of Emergency Management.


Dr. Leach said that the Department for Public Health, Emergency Management Systems, state police, National Guard Military Affairs, Department for Mental Health Mental Retardation Services, FBI, and everybody that has a role have been working to mount a coordinated law enforcement and public health response to bioterrorism.  State public health laboratory and state university laboratories have processed a lot of samples and have not detected any pathogens to date.  The law enforcement agencies are the group that work 24 hours a day, with the training and experience necessary, to collect evidence and ship specimens through the appropriate chain of custody to a diagnostic laboratory.  The Centers for Disease Control protocol is being followed.  Laboratory data will be used to protect citizens at risk but will also be used in a way that enables law enforcement to deal with criminals.  Local health departments, physicians, and others are part of a team that works with people exposed to suspicious substances.


One problem is that physicians are prescribing antibiotics to patients just because they request it.  This reduces the amount of available antibiotics, increases the chance of organism that are resistant to a good antibiotic, and exposes patients to the risks associated with taking powerful antibiotics.  The biggest problem is fear and anxiety associated with the presence of an unknown threat.  The Department for Mental Health/Mental Retardation Services has developed guidelines on how to deal with fear and anxiety, and the Department for Public Health has shared the guidelines with the public health community and is working with the Kentucky Hospital Association, Kentucky Medical Association, hospital infection control, nurses, and others to get information out as they need to manage patient care.


The Centers for Disease Control is asking each state to determine which short-term resources are needed.  The CDC is looking for non-recurring money to help.  Dr. Leach suggested using money for the overtime, supply costs associated with laboratory testing, and expenses incurred by the law enforcement agencies to deal with the biological threats.  Kentucky is still short on training, laboratory capacity at both the state and local level, and sufficient epidemiologists or medical detectives.  Enhancements need to made to the information systems so laboratory information can be shared in a timely fashion.  Mr. Padgett said Kentuckians need to educate themselves about bioterrorism and necessary precautions to decrease the fear of the unknown.


Senator Denton said that people have overreacted, which has placed a burden on the law enforcement agencies.  Dr. Leach said that he did not know the exact procedures used by the post offices for suspicious packages.  Dr. Leach said that he did not know how the university hospitals are handling the stocking of Cipro.  He said that the CDC will fly in an airplane load of supplies, including antibiotics.  There are other antibiotics that work against Anthrax if it is not resistant.


Representative Burch said that since 1998 he has introduced legislation on bioterrorism.  The public needs to be informed that in most cases it would be better to stay home until the threat has been identified.


Senator Mongiardo asked how contagious anthrax is.  Dr. Leach said that it cannot be spread from person to person.  Senator Mongiardo asked about other methods of spreading the disease, such as hand to hand contact.  Dr. Leach said that spores are a powder and anything that can carry a powder is a vehicle of transmission.  Someone would need to be technically advanced to infect a large number of people with anthrax.


Representative Nunn said that communication is one of the most important components of communities and asked about the state of communication among the responders and the Department for Public Health.  Dr. Leach said that the responders and the Department are having a lot of meetings to make the procedures better.  Mr. Padgett said that potentially infected people are getting into the system quicker.  Representative Nunn said that the public does not need to know everything unless there is something that poses a real threat.  Dr. Leach said that the media has been helpful in getting the information to the public.


Representative Westrom asked if animals responded to biological chemicals the same way as humans.  Dr. Leach said it depended on the organism that is dropped.  Animals respond differently to some organisms than humans.


The next order of business was an update on public health by Dr. Rice Leach, Commissioner, Department for Public Health, Cabinet for Health Services.  Dr. Leach said that the Department defined services mandated by statute as “core services” and those mandated by the budget appropriation as “preventive services.”  The category of services that is authorized by not mandated is “local option services.”  Services that health departments perform and that are not available from any other provider as communicable disease control, surveillance, including birth and death certificates, paying Department bills, and performing the regulatory functions that allow dairies, food vendors, and others to go about their business.


Dr. Leach said that with the current decline in general fund revenue, mandated services will be maintained at a “reasonable” level.  If adjustments need to be made in services to patients, every effort will be made to retain services for immunizations, prenatal care, and well child care.  The Department’s budget was reduced by $3.7 million from non-recurring funds.  The fundamental problem is to simplify the way health departments are allowed to give the Department a budget, and simplify how health departments receive funds.  Discussions of the Chapter 13A process with the notice of intent and hearing identified a lot of things the Department had been doing without statutory authority.  Local health department directors have complained that the state is unable to make as many reviews of environmental health programs, finance and recordkeeping, etc. as before.  A team is being put together to work on these problems. 


Dr. Leach said that the Department issued a public health order that requires health departments and pharmacists to work out ways to ensure compliance with the Pharmacy Practice Act.  The Early Childhood Development funding has shown results in infant mortality and neural tube defects.  There has been a decline in Medicaid revenue for personal preventive services since patients are seeing private doctors.  This decline in revenue has been offset by tobacco funds.


Representative Nunn said that the public health departments are the least appreciated public agency in state government but have the greatest responsibility for the public’s health.  A high priority is to make sure health departments are funded to provide the necessary services to each community.


A motion to accept Executive Order 2001-1173 relating to the reorganization of the Kentucky Developmental Disabilities Council was made by Senator Herron, seconded by Representative Marzian, and approved by voice vote.


The last order of business was an update on the Kentucky Agency for Substance Abuse Policy (KY-ASAP) by Larry Carrico and David Mawn.  Mr. Carrico said that the process has increased the level of collaboration and cooperation among all of the community entities and reduced the level of substance abuse in 12-17 year olds.  He said that $1.6 million dollars will be sent to Cohort I Designated Boards.  The KY-ASAP philosophy is: if you want to have impact in reducing alcohol, tobacco, and other drug use in communities, those decisions need to be made at the community level.  Administrative regulations have been promulgated.


Representative Marzian asked if each community would submit data to show the effectiveness of programs.  Mr. Carrico said that the process being put into place is a planning process rather than a programming process.  The KY-ASAP local boards’ charge is to develop a comprehensive, strategic plan around the issues of substance abuse prevention and treatment.  The boards have been asked to incorporate the recommendations of the HB 843 Commission into their plans as appropriate for the treatment issues.  The boards are not implementing agencies but rather are coordinating agencies, so the programs are taking place among agencies within the communities.  Those agencies should be in a position to supply data on the effectiveness of the programs that they are operating.  The boards will be required to report to the state agency every six months on collaboration, coordination, and programming effectiveness within the community.


There being no further business, a motion to adjourn at 12:53 p.m. was made by Senator Denton, seconded by Senator Roeding, and approved by voice vote.