The 3rd meeting of the Interim Joint Committee on Health and Welfare was held on Monday, August 22, 2005, at 1:00 PM, in Room 129 of the Capitol Annex. Representative Tom Burch, Co-Chair, called the meeting to order at 1:10 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, Ernesto Scorsone, Dan Seum, and Johnny Ray Turner; Representatives James R. Comer, Jr., Robert R. Damron, Bob M. DeWeese, Mary Lou Marzian, Stephen R. Nunn, Darryl T. Owens, Ruth Ann Palumbo, Jon David Reinhardt, Ancel Smith, Kathy W. Stein, Susan Westrom, and Addia Wuchner.
Guests:
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 July 25, 2005 meeting was made by Representative Smith, seconded by Representative Owens, and approved by voice vote.
Next, Representative Burch gave a report of the Subcommittee on Families and Children meeting held early in the day. He reported that the subcommittee heard testimony on the implementation of a new child care contract with the Human Development Institute at the University of Kentucky and one with the Division of Child Care, Department for Community Based Services within the Cabinet for Health and Family Services.
Next Deron Rambo, Director of the Frankfort Disaster and Emergency Services gave a presentation on the "In Case of Emergency" (ICE) Program. Mr. Rambo stated that Frankfort was one of the first cities to encourage citizens to enter an emergency contact number in their cellular phonebook under ICE. A sticker would be placed on the outside of the phone to show there is an emergency contact number in the phone book. He said that eight out of ten people do not have contact information in case of an emergency, and this program could help save time identifying someone.
Next Hatim Omar, M.D., Professor, Pediatrics & Obstetrics and Gynecology, Director, Adolescent Medicine, Department of Pediatrics, University of Kentucky gave a presentation on depression and suicide. Dr. Omar stated that statistics from Suicide Awareness Voices of Education, the Centers for Disease Control, and the Journal of the Medical Association include the following: 1) every 17 minutes someone in the United States dies as the result of suicide; 2) on an average day 84 people die from suicide and another 1,838 attempt suicide; 3) in 2001, 30,622 Americans committed suicide; 4) over 765,000 Americans attempt suicide each year; 5) in 2000, there were 1.7 times more suicides than homicides; 6) twice as many people die from suicide than HIV/AIDS; 7) the rate of youth suicide has tripled since the 1950s; and 8) 95% of suicides occur at the peak of a depressive episode.
Dr. Omar stated that youth suicide continues to be one of the leading causes of death in the United States. Nationwide it is the third leading cause of death in the 10 to 24 year old age group. The rate of suicide varies from state to state, but in Kentucky it is the second leading cause of death for adolescents.
Dr. Omar stated that more teenagers and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia and influenza, and chronic lung disease combined. Nationally within any year, at least eight percent of teens experience significant depression, and most will not seek or receive treatment. One in five teens report having had at least one episode of depression without having treatment. Nineteen percent have thought of suicide, two million make plans to carry it out, 400,000 attempts require medical attention, and approximately 5,000 successfully complete suicide.
Dr. Omar stated that for each completed suicide, there are twenty attempts. When firearms are in the home, suicide completion risk is five times greater since this is the most frequently used method among completers. Suicide prevention recommendations include: 1) define the problem; 2) identify risk factors and causes of the problem; 3) develop interventions evaluated for effectiveness; 4) implement such interventions in a variety of communities; and 5) evaluate effectiveness.
Dr. Omar stated that a program was started by thirty agencies in Central Kentucky in 2000 called "Stop Youth Suicide Campaign." The goals were to improve community awareness of the problem of youth suicide, assess the need in the community and basic knowledge on youth suicide, start a public education campaign targeting parents, teachers, and everyone who has anything to do with teens, improve education of medical care providers that deal with adolescents and improve their knowledge and comfort level in screening and assessing for depression and suicide, and provide around the clock, available help to any teenagers in the area who were suicidal or need help. Over the last four years, the campaign has received a total of 843 e-mails and 513 phone calls from teenagers who were contemplating suicide and asking for help. Admissions for attempted suicide are down as well as completed suicide. There is also an improved awareness in the community about youth suicide. The cost of this program to date is many volunteer hours and $15,729 in donations. The web site is www.stopyouthsuicide.com.
Dr. Omar said that the following were needed: 1) insure parity in compensation for mental health; 2) more education and awareness will lead to more need for help and intervention; 3) funding priorities to programs that actually provide service, not only education; and 4) prevention and screening to lower costs of treatment.
Senator Buford stated that the follow-up services of Dr. Omar's program seem to be effective.
Representative Palumbo stated that she was unaware that ADHD was a risk of suicide before her son committed suicide or she would have watched for the signs. She said that we must make it as difficult as possible for someone to complete suicide. Dr. Omar stated that all mental health issues are considered when a risk assessment is conducted.
Representative Marzian asked whether anti-bullying initiatives have impacted teen suicide and the need for mental health counselors in schools. Dr. Omar stated that youth services are fragmented and with teenagers there needs to be a comprehensive approach. He stated that bullying affects both children. There are reasons why a child bullies another child, and both may be at risk of suicide. He said prevention needs to start as early as possible.
Next was an update on the proposed Medicaid 1115 waiver and new initiatives by Mark Birdwhistell, Undersecretary of Health, and Shannon Turner, Commissioner of the Department for Medicaid Services, Cabinet for Health and Family Services. Undersecretary Birdwhistell stated that the cabinet had a $675 million deficit and they have implemented some cost containment actions that have saved the state approximately $249 million, leaving a balance of approximately $426 million for this state fiscal year or from a state stand point, $132 million state funds. He said that the cabinet is focusing on budget actions and modifications to the program to make it sustainable in the future. The waiver would allow the cabinet the flexibility from the federal government to customize the Medicaid program within the limited available resources.
Undersecretary Birdwhistell said that by January 1, 2006, the cabinet will have the infrastructure to administer a flexible, robust Medicaid program. The second phase is to obtain the flexibility to customize the program using the dollars available to ensure recipients receive services needed and improve the quality of care. He said that Section 1115 of the Social Security Act provides the secretary of Health and Human Services with broad authority to permit experimental, pilot, or demonstration projects to allow states to substantially test new ideas and approaches relating to the Medicaid program. The 1115 waiver allows states to develop creative ideas outside the typical Medicaid guidelines to better meet the needs of its citizens The cabinet selected the name KyHealth Choices to reflect the individual's key role in choosing, purchasing, and planning his or her own health care needs. He said that KyHealth Choices is the transformation of the Medicaid program to improve the status of Kentuckians enrolled in the program and ensure a continuum of care and individual choice.
Undersecretary Birdwhistell stated that KyHealth Choices will affect everyone enrolled in the Medicaid program with the exception of those enrolled in Passport. It will cover every health and disability category. It will cover the entire state with the exception of the 15 counties covered by Passport.
Commissioner Turner stated that a work group was formed from the advocacy consumer community that meets with the cabinet to discuss the waiver, offer recommendations, and try to develop consensus. She said that the KyHealth Choices 1115 waiver will focus on two major goals: stretch resources to most appropriately meet the needs of the recipients and encourage Medicaid members to be personally responsible for their own health care. To accomplish goal one the following objectives would be implemented: 1) tailor services to meet individual needs by developing varying benefit packages; 2) ensure Medicaid is the payor of last resort; 3) reduce the number of people without insurance by offering and in- and out-patient benefit to low-income Kentuckians who are currently uninsured; 4) leverage the commercial market and redesign KCHIP and strengthen the Health Insurance Purchasing Program; and 5) integrate Care Delivery. To accomplish goal two the following objectives would be implemented: 1) establish Get Health Accounts (GHAs) where individuals may earn money by participating in certain health practices as identified by the department; 2) assure education and choice counseling to all Medicaid members in an effort to assist them in making the best choice of benefit packages; and 3) structure benefit packages to assure a continuum of care to maximize the use of services provided in an individual's home.
Commissioner Turner stated that the waiver would not cure today's budget problem but the goal is to control the upward slope of the growth line. She stated that the waiver would be submitted to the Centers for Medicare and Medicaid Services on September 1, 2005, and have a meeting with CMS officials on September 7, 2005 to review the waiver. Waiver approval is anticipated in December 2005 with implementation in Spring 2006.
Undersecretary Birdwhistell stated that the federal government is encouraging states to pursue the 1115 waivers to find a solution to balance budgets. He stated that the cabinet wants the flexibility to create benefit plans to be customized with the needs of the people within the income stratus and customized around medical conditions. The details would be promulgated through administrative regulations and/or a waiver amendment. He said that the cabinet wants to take the lessons learned with Passport using the flexible waiver authority, replicate those to the rest of the state's of the population, improve the quality of care, and spread the dollars over the most critical needs possible.
Representative Burch said that the people are the number one priority. Each recipient has to get what they need, not necessarily what they want, in order to stay healthy.
Representative Stein asked why the cabinet had not started the waiver meetings before August 11, 2005. Commissioner Turner stated that the cabinet had been looking at the waiver concept, and it had taken time to come to a conclusion on the direction to take. They were also waiting to see the progress with the waiver applicants in Florida, South Carolina, Vermont, and Massachusetts. Representative Stein asked if CMS was going to offer Kentucky the flexibility after September 1, 2005 to implement aspects that were not included in the original waiver. Undersecretary Birdwhistell said that September 1, 2005 is the deadline to get the first draft to CMS. CMS wants states to submit conceptual designs and then help states write the waiver in a manner to receive approval, but the waiver amendment process is more flexible. Representative Stein said that she was concerned with the phrase "personal responsibility" because children often cannot exercise personal responsibility.
Senator Scorsone stated that without details in the waiver application, the legislature does not know what will be submitted to the federal government. He asked the cabinet if all beneficiaries currently in the Medicaid program would be subject to the transformation. Commissioner Turner said that everyone would fall under the 1115 waiver, but certain populations would not be affected by the benefit package. Senator Scorsone asked if long term care would fall under the waiver, and Commissioner Turner said yes. Senator Scorsone asked if the cabinet would meet the budget guidelines by a global budget of the entire population or a per capita cap. Commissioner Turner said that there is no per capita cap, but a waiver requires budget neutrality. Senator Scorsone asked what would happen to the current 690,000 recipients. Undersecretary Birdwhistell said that right now all recipients receive the full spectrum of 30 services whether they need them or not. Over time and based on individual needs, the services will change. Everybody will not receive all services unless necessary. Senator Scorsone asked about the framework of services. Undersecretary Birdwhistell said that many of the components will be detailed in administrative regulations. Senator Scorsone said if the KCHIP is working, why put this under the waiver. Commissioner Turner stated that KCHIP is a Medicaid look alike program, which means some children are receiving services they do not need. Senator Scorsone questioned why the abuses to KCHIP could not be detected and addressed rather than turned over to a separate administrator by contract.
Representative Owens asked if there would be an increase or decrease in the match rate with the 1115 waiver. Commissioner Turner said that there would be a decrease in 2007-2008. He said that he was concerned that recipients would be responsible for paying additional money for more expensive plans, and asked the what the difference was in the basic plan and a more expensive plan. Commissioner Turner said that currently there is a $20 co-pay for certain people who participate in KCHIP with unlimited benefits. Under the waiver, a recipient would have the choice to purchase the basic plan or opt to pay more for plan with more benefits.
Representative Marzian asked what would happen if someone needed services other than from a primary care physician. Undersecretary Birdwhistell said that a person would choose services from a list designed for his or her specific needs. Representative Marzian asked what happened if a recipient needed services not chosen from the list but needed later such as mental health. Undersecretary Birdwhistell stated that there would be an external review. Representative Marzian said that the Kentucky Medicaid Administrative Agent (KMMA) would work with the cabinet to manage the EPSDT program, renamed the "Children's Health and Prevention Program", and cautioned not to make treatment difficult because of prior authorization. Commissioner Turner stated children are the main priority in Medicaid but the federal government still requires medical necessity under EPSDT. Undersecretary Birdwhistell said that renaming the program puts the program more in line with Passport. Representative Marzian asked if Medicaid covered nicotine patches. Commissioner Turner said there is not enough funding.
Senator Denton said that a recipient would receive a basic benefit package and from there services would evolve as needed. Commissioner Turner stated that the goal is to have a continuum of care. Senator Denton asked if optional populations and services would need a waiver. Commissioner Turner said the cabinet already has the authority to address optional populations and services through other existing waivers. Senator Denton asked if a private insurance company administers the KCHIP, would a family be able to purchase a family plan. Commissioner Turner stated that is something the cabinet could look at along with the Medicaid buy-in for individuals with disabilities. Undersecretary Birdwhistell said that an option would be to match KCHIP for small businesses.
Senator Denton asked if the 1115 waiver is approved, would it do away with the current Supports for Community Living waiver services and Home and Community Based waiver services. Commissioner Turner said that it would be better for the population to be served under one broad waiver authority. Senator Denton asked what it would take to balance the budget in 2007-2008. Commissioner Turner said $300 million state general funds for the next biennium. Senator Denton asked if the budget could be balanced by dedicating all the surplus revenues, and Commissioner Turner said no.
Next Dr. James Holsinger, Secretary of the Cabinet for Health and Family Services gave an update on the implementation of 2005 Senate Bill 2.
Secretary Holsinger stated that Governor Fletcher had appointed members to the Kentucky e-Health Network Board that was created to help develop a secure statewide electronic network for patients, physicians, and other health care providers to access and transfer medical information. The members appointed were Barbara Asher, Frank Butler, Dr. Ford Brewer, Bobby H. Dampier, Marsha L. Donegan, Dr. Robert Hughes, Bruce Klockars, Dr. Jack Lord, and Dr. Kimberly Williams. Dr. Lee T. Todd, Jr. and Dr. James R. Ramsey will serve as the board's co-chairs. The board will also be composed of twelve individuals who will serve by virtue of their position in the General Assembly or the administration. Further information regarding the Kentucky e-health Network can be found at http://ehealth.ky.gov.
A motion to approve 201 KAR 9:018 was made by Representative Marzian, seconded by Representative Nunn, and approved by voice vote. Lloyd Vest, General Counsel of the Kentucky Board of Medical Licensure, was present to answer questions.
There being no further business, a motion to adjourn at 3:05 was made, seconded, and approved by voice vote.