The 2nd meeting of the Interim Joint Committee on Health and Welfare was held on Monday, July 25, 2005, at 1:00 PM, in Room 129 of the Capitol Annex. Senator Julie Denton, Co-Chair, called the meeting to order at 1:05 PM, and the secretary called the roll.
Present were:
Members: Senator Julie Denton, Co-Chair; Representative Tom Burch, Co-Chair; Senators Charlie Borders, Tom Buford, Denise Harper Angel, Alice Kerr, Joey Pendleton, Richard "Dick" Roeding, Ernesto Scorsone, Dan Seum, Katie Stine, and Johnny Ray Turner; Representatives Scott W. Brinkman, James R. Comer, Jr., Bob M. DeWeese, David Floyd, Joni L. Jenkins, Mary Lou Marzian, Stephen R. Nunn, Darryl T. Owens, Ruth Ann Palumbo, Ancel Smith, Kathy W. Stein, Susan Westrom, and Addia Wuchner.
Guests: Mary Hass, Brain Injury Association of Kentucky and Chair of the Kentucky Traumatic Brain Injury Trust Fund; Robert Walker, M.S.W., L.C.S.W., Member, Kentucky Traumatic Brain Injury Trust Fund Board; Dr. Roger Humphries, Associate Professor, Chair, Department of Emergency Medicine, University of Kentucky College of Medicine; Kevin Payton, Jason Dunn, Trish Howard, and Jason Moseley, Cabinet for Health and Family Services; Melanie Tyner-Wilson, IFCK-UK/SAFE KIDS; Amy Turner, Legal Aid Society; Sherry Culp and Ann Hollen, Nursing Home Ombudsman Agency; Christina Giles and Sherri L. Wilson, Department for Community Based Services, Cabinet for Health and Family Services; Jan Gould, Kentucky Retail Federation; Allison Cubit, American Pharmacy Services; Karen Hinkle, Kentucky Home Health Association; Cathy Allgood Murphy and Linda Kuder, American Association of Retired Persons; David Allgood and Jan Day, Center for Accessible Living; Gerry Roll and Carolyn May, HPCCM; Bill Doll and John Cooper, Kentucky Medical Association; Sarah S. Nicholson, Kentucky Hospital Association; S. Cunningham, Mental Health Association of Kentucky; Prentice Harvey, Norton Healthcare; Shannon Turner, Commissioner, Department for Medicaid Services, Cabinet for Health and Family Services; David Fleenor, General Counsel, Cabinet for Health and Family Services; Shawn Crouch, Executive Director, Office of Health Policy, Cabinet for Health and Family Services; Tom Emberton, Jr., Commissioner, Department for Community Based Services, Cabinet for Health and Family Services.
LRC Staff: Robert Jenkins, CSA, Barbara Baker, Tyler Campbell, Eric Clark, DeeAnn Mansfield, Gina Rigsby, Cindy Smith, and Murray Wood.
A motion to approve the minutes of the June 8, 2005 meeting was made by Senator Scorsone, seconded by Representative Jenkins, and approved by voice vote.
The first order of business was testimony on All Terrain Vehicle (ATV) Safety by Mary Hass, Brain Injury Association of Kentucky and Chair of the Kentucky Traumatic Brain Injury Trust Fund; Robert Walker, M.S.W., L.C.S.W., Member, Kentucky Traumatic Brain Injury Trust Fund Board; and Dr. Roger Humphries, Associate Professor, Chair, Department of Emergency Medicine, University of Kentucky College of Medicine. Dr. Walker stated that: 1) From 1992-1994, there were 93,207 ATV injuries in the United States, resulting in $643 million of medical care; 2) The average medical cost per injury in 1994 was $6,899; 3) In 2005, the same number of injuries would cost $847 million in medical care, with an average cost of $9,091; 4) The cost of ATV deaths is estimated at $3,500 per ATV sold; 5) Serious injuries and deaths suffered by children under age 16 cost society approximately $2.5 billion annually; and 6) A national safety standard could cut injury and fatality costs by at least $1 billion annually.
Dr. Walker testified that statistically West Virginia, Kentucky, Mississippi, and Wyoming were essentially equal in terms of ATV death rates between 2000 to 2002. All four states were rural and had considerable opportunity for off road use. Each state shared similar economic and health problem characteristics and had limited services for persons incurring ATV-related injuries. While West Virginia had the highest rate per 100,000, Kentucky actually had the greatest number of ATV deaths in the nation at 109 with Pennsylvania next at 73. In terms of actual deaths over the 2000 to 2002 period, Kentucky exceeded states with eight times the Kentucky population. He stated that the data from the ATV-Related Injuries in Kentucky 2000-2003 by the Kentucky Injury Prevention and Research Center showed that the largest percentage age group for hospital discharges relating to ATV injuries was the 16 to 24 age group. The same report showed that almost two-thirds of the ATV crashes reported by police occurred among youth under age 25.
Dr. Walker said that there is too little data about the use of helmets either for on road or off road ATV driving. Preliminary data suggests that very few drivers use helmets. The Consumer Products Safety Commission suggests that improved safety could result in substantial cost savings to society.
Dr. Roger L. Humphries, Associate Professor, Chair of the Department of Emergency Medicaid at the University of Kentucky College of Medicine, testified that in the mid 1980s, the Consumer Products Safety Commission (CPSC) began regulatory proceedings to evaluate the hazards of ATVs, and the results made it clear that changes were needed. In 1988, the CPSC and the ATV distributors signed legally binding ten-year agreements known as consent decrees. For each year between 1988 to 1998, 30 to 40 percent of all ATV-related deaths and injuries occurred in children under 16 years of age.
Dr. Humphries stated that a 1999 survey reported that: 1) There were 5.89 million ATV drivers and 3.91 million ATVs; 2) 60% of the owners live in rural areas, compared to 22% of all U.S. households; 3) 40% of households with an ATV have more than one ATV; 4) Southern and Midwestern states have more than the average; and 5) median income of ATV owners is higher ($45,000 vs. $34,000). He said that the reason children are at greater risk when riding ATVs is because of immature psychomotor skills and strength, lack of cognitive development to operate ATVs safely on a consistent basis, use of adult ATVs that were not designed for children's bodies, ignored engine size and age restrictions, and an increased risk-taking behavior.
Dr. Humphries said that the presence of a passenger affects the ability of the operator to be rider active, making quick body weight shifts combined with acceleration and braking. Approximately 54% of drivers report carrying passengers frequently or sometimes despite safety warnings, and younger children are more likely to be passengers. Children under 16 who ride ATVs have a risk of death that is 4.5 to 12 times greater than adult comparison groups. He said that KRS 189.515 prohibits the operation of an ATV on a public highway unless the operator possesses a driver's license, the vehicle has at least one headlight and two taillights functioning, the operator complies with all traffic regulations, and at least one of the following conditions applies: to cross the highway or engage in occupational use such as farming, mining, logging, etc. The statute also prohibits operation on private property without the consent of the landowner, no operation on public property without the approval of the appropriate government agency and the use of approved protective headgear, children under 16 must be under direct parental supervision to operate an ATV, and engine restrictions are based on age.
Dr. Humphries stated the following recommendations should be made to the ATV laws: 1) Ban anyone under 16 from riding an ATV; 2) Strictly enforce the engine size-age restrictions and roadway use prohibitions; and 3) Require safety courses and licensing similar to other motor vehicles. Kentucky needs a comprehensive strategy involving education, legislation, and better enforcement to solve this critical problem that continues to threaten the health of its most vulnerable citizens.
Representative Marzian asked about statistics that Medicaid and uninsured patients with brain injuries who end up on Medicaid. Ms. Hass stated that approximately 37 percent of people injured will eventually be on Medicaid. Over $7 million will be spent over a lifetime for a severe brain injury.
Senator Kerr asked about other states ATV laws. Ms. Hass stated that West Virginia passed legislation last year and had already seen a reduction in fatalities. Ms. Hass did not have any statistics on other states.
Representative Burch stated that parents should be more responsible with their children's use of ATVs.
Representative Stein asked how much ATV accidents affected the budget of the University of Kentucky. Dr. Humphries stated the total hospital fees, not including professional fees, per patient per ATV accident is approximately $13,000.
Representative DeWeese asked about the effect of enforcing existing laws. Dr. Humphries stated that enforcement would help but the laws need to be stronger.
Representative Westrom asked that the Co-Chairs of the Health and Welfare Committee contact that the Transportation Committee Co-Chairs and request that the ATV presentation be presented at a future Transportation Committee meeting.
Representative Marzian stated that it is hard for the state police to enforce existing laws against riding ATVs on the highway because people will say they were merely crossing the road.. Dr. Walker stated that children lack the cognitive ability and mature judgment needed to operate an ATV.
Senator Denton asked if citations were given when children were brought into the hospital. Dr. Humphries stated that, to his knowledge, no citations were given. Senator Denton said that if the laws are not being enforced now, there is no reason to believe they would be enforced if they were tougher.
Next was a Medicaid update by Shannon Turner, Commissioner of the Department for Medicaid Services, Cabinet for Health and Family Services. Commissioner Turner stated that benefit management began with the pharmacy benefit management contract that has been operational since December 4, 2004. The second contract awarded was the Medicaid Management Information System (MMIS), which pays claims, warehouses data, and enables the department to run reports. The new vendor will take over the legacy information system December 1, 2005, with the new system being operational in the fall of 2006. The third contract is for the Kentucky Medicaid Administrative Agency (KMAA). The MMIS and KMAA contracts have been awarded and are in the implementation phase.
Commissioner Turner stated that public forums had been held in Bowling Green and London to address concerns about the $675 million deficit and how it would effect services and eligibility, co-pays for prescriptions in optional eligibility categories, and co-pays per year for someone with chronic conditions. She said that there are two different kinds of waivers, 1915 and 1115. An 1115 waiver is a demonstration waiver that has more flexibility. Kentucky's waiver would allow flexible benefit designs, co-pays based on income, mandatory education, and disease management requirements, among others. The waiver must be detailed in a document that is sent to the federal government, and there is no flexibility outside of that document. The waiver would have federal oversight. The cabinet has a web site where answers to questions from the public forums are posted.
Representative Burch asked if someone's financial situation is taken into consideration when determining co-pays. Commissioner Turner stated under federal law there is a mandatory eligibility population that can be charged $1 to $3 and an optional eligibility population that can be charged more. As of now, the department must operate under a statewide requirement where each person in each group is treated the same. Commissioner Turner stated that recipients have been encouraged to see one primary care provider who can make sure all the medications currently being taken are necessary.
Senator Scorsone asked if the waiver application had been submitted to the federal government, and Commissioner Turner said no. Senator Turner asked if the legislature would have input in the development of the application, and she said they would come back before the committee and present the concept paper before it is submitted to the federal government.
Representative Nunn asked how a flexible benefit package would save money. Commissioner Turner stated that someone would only receive medicines and tests that are medically necessary for a particular population. Beyond that, a person would need prior authorization for medicines over the number allocated for that population. Representative Nunn asked who is exempt from co-pays. Commissioner Turner said children, pregnant women under 18, native Americans, Eskimos, and Pacific Islanders, and people receiving institutional level of care. Representative Nunn asked if all of these groups have been identified. Commissioner Turner stated that children and pregnant women are identified, but as far as ethnicity, the department must rely on the recipient's word.
Senator Kerr asked if the average number of medications for Medicaid recipients is still 26. Commissioner Turner said that a perspective drug utilization review edits program has been implemented that helps catch duplicate prescriptions from being filled.
Next, Senator Stine gave a report of the Subcommittee on Families and Children meeting held early in the day. Dr. Steve Davis, Deputy Commissioner, Department for Public Health, Cabinet for Health and Family Services gave an update on the First Steps Program. Dr. Tom Emberton, Jr. Commissioner, Department for Community Based Services, gave an agency overview. Jason Moseley, Division of Policy Development, Cabinet for Health and Family Services, discussed the implementation of 2005 House Bill 298, relating to elder abuse. Betsy Farley, Director, Division of Child Care, Cabinet for Health and Family Services, presented an overview of the Child Care Market Survey. Last was a discussion on the provision of child care resource and referral services.
Next, Shawn Crouch, Executive Director for Health Policy, Cabinet for Health and Family Services, gave an update on Certificate of Need. Mr. Crouch stated that the cabinet is in the process of converting the Office of Certificate of Need to the Office of Health Policy, which will include the Division of Certificate of Need and the Division of Health Policy Planning and Development. He said that entities are required to apply for a certificate of need before obtaining a license before providing new services or building a new facility. The application is processed based on the demographic health care needs of the community with the goal of avoiding increased healthcare costs. The State Health Plan is a document that includes the criteria used for approving applications, and by statute physician offices and clinics are exempt from the CON process.
Mr. Crouch stated that some of the facilities covered are hospitals and hospital beds, nursing homes, personal care homes, ambulatory surgical centers, rehabilitation agencies, adult day health care, and ICFMR. Some services include home health, hospice, ambulance, MRI, megavoltage radiation, cardiac catheterizations, organ transplant, and open heart surgery. He said that on June 30, 2005, Governor Fletcher issued Executive Order 2005-615, which prohibits the CON division from processing applications for new facilities or services, with some exceptions. The exceptions include applications that qualify for non-substantive review, such as rehab agencies and nursing facility bed transfers, applications to establish MRIs at hospitals or hospital-owned facilities, and applications to alleviate emergencies. The current moratorium expires December 30, 2005.
Mr. Crouch stated that the State Health Plan incorporated in the Kentucky Administrative Regulations includes criteria for granting certificates in all service categories based on need in the county and Area Development District. The State Health Plan is a triennial plan that is updated annually. The plan must be updated prior to the end of calendar year 2005 based on state planning data and public input and research on best practices, utilization data, and costs data from other states. In July and August, the cabinet solicited public opinion from public forums and survey responses. In the fall of 2005, the State Health Plan will be drafted, administrative regulations filed, and legislation requested.
Representative Burch asked about promoting competition in the medical profession. Mr. Crouch said any time that there is patient choice, there is some inherent competition. Representative Burch asked how competition would benefit a patient. Mr. Crouch stated that there are differences in providers and outcomes.
Representative Owens asked about CON in other states. Mr. Crouch stated that some states have done away with CON and others have put barriers to services in place.
Senator Borders stated that there is no competition for someone to care for Medicaid patients. Mr. Crouch said that all factors have to be taken into account.
Next was the legislative public hearing for the SFY 2006 Social Services Block Grant. Commissioner Tom Emberton, Jr., Department for Community Based Services, and Jason Moseley, Division of Policy Development, Department for Community Based Services, Cabinet for Health and Family Services, were present for an overview and questions from members. Mr. Moseley stated that the block grant enables the state to consolidate a number of programs into a single grant. The amount of funds received is based on a statutory formula based on the state's population. The state has the flexibility to determine which services are provided, who is eligible for the services, and how the funds will be distributed. The block grant originates from Title XX of the Social Security Act, and the funds are used to support state-mandated social services programs administered through the Department for Community Based Services. Services provided are adult protection, alternate care and general adult services, child protection, home safety services, juvenile services, and residential treatment services. The cabinet anticipates receiving $23,900,000 for this block grant. A motion to approve the SFY 2006 Social Services Block Grant was made by Senator Roeding, seconded by Senator Borders, and approved by voice vote.
Next, was the legislative public hearing for the FY 2006 and 2007 Community Services Block Grant and Community Food and Nutrition Program. Commissioner Tom Emberton, Jr., Department for Community Based Services, and Jason Moseley, Division of Policy Development, Department for Community Based Services, Cabinet for Health and Family Services were present for an overview and questions from members. Mr. Moseley stated that the Department for Community Based Services is the state agency designated to administer the Community Services Block Grant and Community Food and Nutrition Program. Both the Community Services Block Grant and Community Food and Nutrition Program are federal formula grants awarded to states through the United States Health and Human Services with no state matching funds. Kentucky will receive approximately $10.1 million. The purpose of the block grant is to help individuals secure and retain meaningful employment, attain adequate education, make better use of available income, obtain and maintain adequate and suitable housing, obtain emergency services, establish linkages within the community, and remove obstacles and solve problems that may block individuals from achieving self sufficiency. The department contracts with 23 community action agencies who receive 95 percent of the block grant funds for provision of services. A motion to approve the FY 2006 and 2007 Community Services Block Grant and Community Food and Nutrition Program was made by Senator Roeding, seconded Senator Borders, and approved by voice vote.
Next a motion to approve 900 KAR 6:030 and 921 KAR 2:006 was made by Senator Roeding, seconded by Representative Nunn, and adopted by voice vote.
There being no further business, a motion to adjourn at 3:05 p.m. was made Senator Roeding, seconded by Senator Pendleton, and approved by voice vote.