The 5th meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, October 19, 2005, at 1:00 PM, at Active Day of Louisville - Hikes Point, Medical Adult Day Center, 3403 Breckenridge Lane in Louisville. Senator Julie Denton, Co-Chair, called the meeting to order at 1:25 PM, and the secretary called the roll.
Present were:
Members: Senator Julie Denton, Co-Chair; Representative Tom Burch, Co-Chair; Senators Tom Buford, Denise Harper Angel, Alice Kerr, Joey Pendleton, Richard "Dick" Roeding, Dan Seum, and Johnny Ray Turner; Representatives Scott W. Brinkman, Robert R. Damron, Bob M. DeWeese, Joni L. Jenkins, Mary Lou Marzian, Stephen R. Nunn, Darryl T. Owens, Ruth Ann Palumbo, Jon David Reinhardt, Susan Westrom, and Addia Wuchner.
Guests: Representative Jimmie Lee, Cindy Murray and Frank Willey, Budget Review Subcommittee, Legislative Research Commission; Robin Florence and Candy Bruce, Georgetown Active Day; Janice C. Groves, Active Day Services; Willie Byrd, Legislative Liaison, Options Unlimited; Randy Boldyga, RxNT; Janie Millard, Verified Prescription Safeguards; Robert Tapples, Veriscrip; Dave Sallengs, R.Ph., Branch Manager, Drug Enforcement and Professional Practices, Cabinet for Health and Family Services; Diona Mullins, and Steve Davis, Office of Inspector General, Cabinet for Health and Family Services; Bob Kelley, Merck & Company; Marie Alagia Cull, Cull, Hayden & Vance; Elizabeth Caywood, Department for Community Based Services, Cabinet for Health and Family Services; Bob Napolilli, Seven Counties Services; Robert Carter and Tom Ferree, Commonwealth Office of Technology, Finance and Administration Cabinet; Beth Smith and Carol Estes, Office of Vocational Rehabilitation; Jan Barthle and Barbara Henchey, Mattingly Center; Mike Weinrauch and Bill Cooper, Division of Aging Services, Cabinet for Health and Family Services; Steve Blackstone, National Transportation Safety Board, Washington, D.C.; Desiree Owen, M. Shrader & Associates; Beth McKenzie, parent of son with autism; Linda Heitzman, Melissa Lawson, and Bart Baldwin, President, Children's Alliance; Joan Koester, Active Day - Audubon Park; Patty D. Dempsey, The Arc of Kentucky; Ralph Risimini and Beth Ennis, St. Joe Children's Home; Amy Spears, Children's Alliance and Home of the Innocents; Dr. Anthony Remson, Cypress Medical Group; Sarah Trainor and Deb Miller, Kentucky Youth Advocates; Sheila Schuster, Kentucky Mental Health Coalition; Ronnie Coleman, Schering-Plough; Greta Collin, Active Day - Frankfort; Jill Bell, Passport; Shirley Hedges, Kentucky Foster Adoptive Care Association; Rita Hedges, Freda Conrad, Linda Glover, and Steve Dew, Kentucky Foster Care Association; Marilyn Minnick, KIPDA Area Agency on Aging; Barry Whaley, Community Employment; Sheriall Cunningham, Mental Health of Kentucky; Donovan Fornwalt, The Council on Mental Retardation; Kris Baldock, Active Day; Judy Lambetz, Children's Alliance/Mayhurst; Nathan Goldman and Charlotte Beason, Executive Director, Kentucky Board of Nursing; John McCarthy, Roll Call Strategies; Cindy Monroe, Bullitt County Adult Day; Janice M. Smith, GuardiaCare Adult Day Health Care; Oliver Barber, B&GC of Kentucky; Sonya Sandridge and Elizabeth Bell, National MS Society; Martha Vozos, Cabinet for Health and Family Services; Judy Gully; Prentice Harvey; Stanley Fields and Steven Walentoski, Centers for Medicaid and Medicaid Services; Bonnie Thorson Young, Seven Counties Services; Jean Lucy, Right at Home; Dana Slucher, R.N. with Active Day Services and Member of the Kentucky Association of Adult Day Centers; Kelly Upchurch, President, Kentucky Association of Adult Day Centers; Shannon Turner, Commissioner, Department for Medicaid Services, Cabinet for Health and Family Services; Dr. John Burt, Commissioner, Department for Mental Health and Mental Retardation Services, Cabinet for Health and Family Services; Mark Birdwhistell, Undersecretary for Health, Cabinet for Health and Family Services; Kevin Payton, Legislative Director, Cabinet for Health and Family Services; and Robert J. Esterhay, Associate Professor and Chair, Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Sciences.
LRC Staff: Murray Wood, CSA, Barbara Baker, Tyler Campbell, Eric Clark, DeeAnn Mansfield, Gina Rigsby, and Cindy Smith.
A motion to approve the minutes of the September 21, 2005 meeting was made by Senator Buford, seconded by Representative Damron, and approved by voice vote.
Dana Slucher, R.N., with Active Day Services and Member of the Kentucky Association of Adult Day Centers, welcomed members and stated that the longer a person can remain at home with families, the happier and healthier they are. She said that she assists families if an individual eventually needs to enter a nursing facility.
Dr. Anthony Remson, Cypress Medical Group and family member of an adult day participant, stated that adult day services allows some individuals to receive medical supervision. Nutrition is extremely important and if an individual can attend an adult day center and receive nutritious meals, it could help prevent medical problems. Socialization is important, especially for dementia and Alzheimer's individuals. He stated that the adult day program allows families to keep loved ones at home longer while allowing them to continue to work. It keeps individuals out of a nursing home or extended care facility that would cost the state allot more money.
Kelly Upchurch, President of the Kentucky Association of Adult Day Centers, welcomed the committee to the adult day center.
Representative Marzian asked how much it cost for an individual to attend an adult day center per day. Dr. Remson stated approximately $65 per day. Mr. Upchurch stated it is $56 per day per unit. Each unit is 3 hours of service at a cost of $28. The cost would depend on the plan of care and how often an individual attends an adult day center. He said that the cost of adult day services is approximately one-third of the cost of being placed in a nursing facility, at a cost of $55,000 per year.
Representative Burch asked if there were any other charges other than the $56 per day, and Dr. Remson said no. Representative Burch asked about transportation. Dr. Remson stated that adult day centers provide transportation.
Senator Seum asked about who paid the $56. Ms. Slucher stated that it was paid through Medicaid's Home and Community Based Waiver. He asked if a family member could pay the $56, and she said yes.
Representative Palumbo asked if private pay and Medicaid costs were the same. Mr. Upchurch stated that it would depend on the facility, but they cannot charge private pay patients less than Medicaid patients.
Representative Owens asked why a center would charge private pay more. Mr. Upchurch stated that each center set its own rates, but the rates are not much higher than the Medicaid rate. Normally, each center has a straight rate and writes off the amount Medicaid does not pay for.
Rep. Wuchner stated that it is important for seniors to educate themselves on the services available when they were no longer able to care for themselves. Dr. Remson stated that many patients take advantage of adult day services on a daily basis and that allows caregivers the opportunity take of other responsibilities.
A motion to approve 201 KAR 20:056, 201 KAR 20:057, 201 KAR 20:070, 201 KAR 20:095, 201 KAR 20:110, 201 KAR 20:161, 201 KAR 20:220, 201 KAR 20:225, 201 KAR 20:230, 201 KAR 20:370, 201 KAR 20:390, 201 KAR 20:411, 201 KAR 20:480, 902 KAR 20:320 & E, 902 KAR 20:330 & E, 910 KAR 1:180, 921 KAR 2:015 & E, and 922 KAR 1:520 was made by Representative Marzian, seconded by Senator Roeding, and approved by voice vote.
Next Shannon Turner, Commissioner of the Department for Medicaid Services, and Mark Birdwhistell, Undersecretary for Health, Cabinet for Health and Family Services, gave an update on Medicaid. Commissioner Turner stated that the Medical Management Information System (MMIS) awarded to EDS is scheduled for transition starting December 1, 2005. To keep continuity for the providers, all phone numbers remained the same and the processes remained as close as to the current processes as possible. The Kentucky Medicaid Administrative Agent (KMAA) contract that was awarded to First Health will be fully implemented in January, 2006. She said that the department has a 24/7 nurse hotline with number that can be called to talk to nursing staff. The nurse hotline number is 1-877-844-6970.
Commissioner Turner stated that on October 1, 2005 some utilization review responsibilities were transitioned and to keep continuity for the providers, all phone numbers and contact information remained the same. She said that the Medicaid program still had a $425 million deficit, but the cost initiatives could save more. Undersecretary Birdwhistell stated that the cabinet now had the infrastructure to run Medicaid like a health plan. He said that if nothing additional is done with Medicaid, it will eat up all additional state dollars that are forecasted for fiscal year 2007.
Undersecretary Birdwhistell stated that there are approximately 60,000 individuals taking more than four prescriptions per month. The majority of the prescriptions are for allergies and stomach medications that have an over-the-counter alternative available. He said that 250,000 individuals visited an hospital emergency room (ER) per year. He said that 21,000 individuals visit an ER five or more times per year at a cost of $30 million. In fiscal year 2004, the department spent over $100 million on emergency room visits. The top three diagnoses for ER visits were for upper respiratory infections, earaches, and back pain, and all could have been more appropriately dealt with in a primary care setting. He said that the 1115 waiver will give Kentucky the flexibility to manage the Medicaid program going forward, but the issue is how quickly can we get there.
Commissioner Turner said that there needs to be an urgent treatment center level of care as opposed to the emergency room level of care. She said of the top 50 utilizers of the ER, 49 of them visited the ER over 50 times in fiscal year 2005, almost all of them visited the ER a couple times a month, and only seven had a 30-day consecutive time period not visiting the ER. Most of the top utilizers were between 41 to 50 years of age and overall one-half were between 31 to 51 years of age. She said that two of the top utilizers averaged over 20 prescriptions per month, 16 averaged ten or more prescriptions per month, and the remaining 39 averaged over five prescriptions per month. From this information, there is a strong correlation between a high number of prescriptions and frequent visits to the emergency rooms. The diagnoses for these individuals were migraine headaches, headache, lumbago (lower back pain), and back ache.
Representative Burch asked how many patients that went to an emergency room were directed there by a physician. Commissioner Turner stated that there is no way for the department to track that information through the system. She has been told by individuals that some doctors' answering machines leave a message that if there is a problem to go directly to the emergency room. Representative Burch stated that there are some cases, such as a severe migraine headache, that might justify someone going to the ER. Undersecretary Birdwhistell stated that the new nurse hotline would serve as a triage.
Senator Kerr asked why physicians did not work on weekends. Undersecretary Birdwhistell stated that the physician Medicaid reimbursement fee schedule had not been updated since 1994. It is difficult to encourage physicians to have Saturday after hour office appointments when the fee schedules are 50 percent to 30 percent of what they receive in the commercial market.
Marty White, Kentucky Medical Association, stated that physicians always have someone on call. Some patients are choosing to go to the emergency room instead of calling the doctor who is on call from the physician's office.
Representative Marzian stated that one problem is being able to get in to see your primary care physician in a timely manner. Sometimes it can take up to two weeks to get in to see a doctor and the patient needs medical attention immediately and, therefore, goes to the ER. She said that the provider base needs to be expanded. She asked if over-the-counter medications for allergies and stomach medications would be covered by Medicaid, and Commissioner Turner stated that it is currently covered. Representative Marzian asked about renal dialysis co-payments. Commissioner Turner stated that is a problem and needs to be taken back down to zero co-payments. Representative Marzian asked about Kentucky having to pay back the federal government $43 million as a clawback for Medicaid and Medicare eligibles. Commissioner Turner stated that Kentucky has to pay $77.71 that is multiplied on a monthly basis by dual eligibles. This is the part of the Medicare Modernization Act that funds the Part D prescription drug benefit. Kentucky will no longer pay for drugs for dual eligibles (those eligible for both Medicare and Medicaid) because they will be transitioned to Part D, Kentucky mut pay the federal government a portion of the costs, based on the 2003 drug spending that is trended forwarded with a federal inflation rate of approximately 11 percent.
Senator Roeding stated that there should be more physicians in the system. He has heard from physicians that say they do not send patients to the ER. Undersecretary Birdwhistell stated that the waiver would give Kentucky the flexibility to meet the needs of the people and spread the dollars farther.
Representative Jenkins stated that ER personnel should be trained to identify repeat patients seeking pain medications. Undersecretary Birdwhistell stated that the perfect scenario is a patient goes through some type of triage and never gets to the hospital.
Representative DeWeese asked what kind of work-up an individual received in an ER. Commissioner Turner stated that during the visits an individual could have radiology and laboratory tests conducted. If an individual is "hospital shopping" and is not in the lock-in program, that individual could go to another ER and have the same full work-up conducted. Representative DeWeese stated that because of liability issues, ER physicians have to take all precautions and run all tests that they feel are medically necessary.
Senator Buford asked the time of day when the majority of individuals were accessing the ER. Commissioner Turner stated the cabinet was checking for patterns. Senator Buford asked for a comparison with the state employee group. Senator Buford asked if the cabinet could share information about someone receiving prescriptions for multiple narcotics. Commissioner Turner stated not from the Medicaid program.
Representative Owens asked about case managers. Commissioner Turner stated that individuals in the lock-in program had case managers.
Representative Lee stated that the cabinet would not need the 1115 waiver to make changes in the emergency room such as contracting with urgent care centers to provide extended hours. He said that because the department has the technology to identify 250,000 who use the ER and to identify those who habitually use the ER, it could be done without the waiver. Commissioner Turner stated that the cabinet was interested in starting this before the end of the year. Representative Lee stated that the case management is a vital part because someone can contact the individual to educate them about accessing the urgent care center and not the ER.
Representative Damron asked if the department had looked at the Veriscrip Electronic Prescription Drug Monitoring System. Commissioner Turner stated that they had met with Veriscrip and had received the April 25, 2005 Prescription Drug Monitoring Pilot Assessment Report. Representative Damron asked if it could be a potential cost savings that could close the gap, and Commissioner Turner stated that there are some cost savings but it could not close the gap. She said that some of the benefits that Veriscrip brings, other than the on-line prescribing were procured in Medicaid's pharmacy benefit administrator contract.
Representative Westrom asked if any diagnostic test on the top 50 ER utilizers had discovered something that would change the original diagnosis, and Commissioner Turner said no.
Next Steve Blackstone, National Transportation Safety Board, Washington, D.C., stated that strengthening Kentucky's graduated driver licensing law would be an important step in reducing needless deaths and injuries on Kentucky highways and help thousands of young drivers to adjust to new driving responsibilities. The National Transportation Safety Board is an independent federal agency charged by Congress to investigate transportation accidents, determine probable cause, and make recommendations to prevent recurrence. He said that the recommendations that arise from its investigations and safety studies are the most important product. The Safety Board has neither regulatory nor grant funds. However, in its 37-year history, organizations and government bodies have adopted more than 80 percent of its recommendations.
Mr. Blackstone said that the Safety Board has recognized for many years that traffic crashes are this nation's most serious transportation safety problem. More than 90 percent of all transportation-related deaths each year result from highway crashes. A disproportionate number of these highway crashes involved teen drivers age 15 through 20 years, young people who have only recently obtained licenses to drive. He said that traffic crashes account for 40 percent of all deaths among the age of 15 to 20 years, making traffic crashes the leading cause of death for this age group; more than suicides or drugs.
Mr. Blackstone stated that nationally in 2003, young drivers between the ages of 15 and 20 made up 6.3 percent of the driving population, but composed more than 13.5 percent of the drivers involved in fatal crashes. More than 20 percent of all highway fatalities occur in crashes involving teen drivers. In 2004, Kentucky teens made up approximately six percent of the driving population and constituted more than 13 percent of the drivers involved in fatal crashes. Almost 21 percent of the deaths in 2004 on Kentucky roads involved teen drivers.
Mr. Blackstone said that nationally from 1997 through 2004. 54,246 people died in crashes involving teen drivers, and 1,538 of these were in Kentucky. During the same years, 46,880 teen motor vehicle occupants died in motor vehicle crashes, with 1,067 of them in Kentucky. The cost for each highway fatality is over $977,000. Those not directly involved in crashes pay for nearly three-quarters of all crash costs, primarily through insurance premiums, taxes, and travel delay. Therefore, in Kentucky, teen-involved fatalities cost over $1.5 billion, and teen motor vehicle occupant fatalities cost approximately $1 billion.
Mr. Blackstone stated that studies conducted by federal agencies, states, and private organizations have shown that 16-year old drivers are more likely to be involved in single vehicle crashes, more likely to be responsible for the crash, more likely to be cited for speeding, and carry more passengers in vehicles than older drivers. The crashes mostly occur from 10 p.m. to midnight on Friday and Saturday nights. Although young drivers only drive 20 percent at night, over half their fatalities occur at night. A study published in the Journal of the American Medical Association concluded that the risk of death increased significantly with each additional teen passenger transported by the teen driver. In single vehicle crashes involving teen drivers, two-thirds of the fatally injured passengers were also between the ages of 15 and 19 years of age. He said that learning to drive is a long-term process. Once the mechanics are learned, extensive additional training must be "on the job," preferrably without unnecessary distractions, and with the assistance of more mature and experienced drivers. As skills and maturity develop, new drivers can then proceed to full licensure.
Mr. Blackstone stated that based on research by the NTSB, NHTSA, and others, the NTSB recommends that the basic elements of a graduated driver licensing (GDL) program include: 1) A minimum six-month holding period for the learner's permit, during which a licensed driver who is at least 21 years old supervises the permit holder; 2) At least 50 hours of supervised driving practice with a licensed driver who is at least 21 years old; 3) A minimum period of six months without at-fault crashes or traffic violations, and accelerated penalties if the driver has an at-fault crash or traffic violation, before proceeding to the intermediate or provisional license; 4) Once completed, an intermediate phase begins that includes restrictions on nighttime driving, driving with excessive passengers, and cell phone use; the nighttime driving restriction should prohibit the intermediate or provisional license holder from driving unsupervised at night; the passenger restriction should allow no more than one other passenger in the vehicle, unless accompanied by a supervising adult at least 21 years old; and the cell phone use restriction should prohibit the use of any interactive wireless communication device by learner or intermediate license holder while they are driving; the intermediate phase should include a minimum of six months without at-fault crashes or traffic violations, and accelerated penalties if the driver has an at-fault crash or traffic violation before proceeding to the full license; and mandatory seat belt use and zero tolerance of alcohol use is recommended at each stage.
Mr. Blackstone stated that Kentucky has one of the nation's weakest teen driver licensing laws. Arizona, Arkansas, Kansas, and Kentucky are the four states without an intermediate licensing phase. Also, Kentucky does not have nighttime, passenger, or cell phone use restriction, no minimum amount of supervised driving requirement, and no crash- or violation-free driving requirement.
Mr. Blackstone concluded by saying that beginning drivers should be introduced gradually to the driving experience, and be provided the maximum time to practice under the safest possible real-world conditions. He said that young drivers should be given the opportunity to gradually develop the skills needed for full licensure with a strong support system that involves parents and guardians. Bad habits and behaviors need to be identified and corrected as quickly as possible. A comprehensive GDL program is one of the most effective actions that the Kentucky legislature can take to save both young lives and the lives of others involved in crashes with young drivers. He also recommended stiff penalties for DUIs of drivers of all ages and improving child passenger safety by adopting a booster seat requirement for children up to age 8 years of age.
Senator Denton asked about booster seat legislation. Mr. Blackstone stated that the NTSB recommends adopting a booster seat requirement for children up to age 8 years of age.
Representative Marzian asked if there was any data on the reduction of teen deaths in states that had passed the graduated driver's license law. Mr. Blackstone stated that a number of studies in different states that have shown reductions in crashes involving the teens ranging from 25 to 60 percent although the studies often involved a variety of different factors and definitions.
Next Mark Birdwhistell, Undersecretary of Health, Dr. John Burt, Commissioner of the Department for Mental Health and Mental Retardation Services, gave an update on the situation at Oakwood ICF/MR. Undersecretary Birdwhistell stated that Oakwood, located in Somerset, has approximately 1,200 staff and 300 residents, and has an annual budget of approximately $54 million. Oakwood has been under supervision by the United States Department of Justice (DOJ) since 2001. In 2004, Kentucky entered into an agreement with DOJ that detailed long-range plans for improvement.
Undersecretary Birdwhistell stated that in the last six months, Oakwood had received five "Immediate Jeopardy" Type A citations by the Office of Inspector General (OIG) in the Cabinet for Health and Family Services. Because of the citations, the federal Centers for Medicare and Medicaid Services (CMS) issued a letter of termination of Medicaid funding effective September 14, 2005 with a 30-day transition period. Undersecretary Birdwhistell said that the cabinet had appealed that decision and are in discussions with CMS and OIG officials. Federal funding will continue during the appeal. However, the appeal is not a contract extension and federal Medicaid funding can be terminated at any time if it is determined that the health or safety of Oakwood residents are at risk. He stated that during the appeals process, CMS expects continued progress on Oakwood's improvement plans and will subject the facility to additional reporting and monitoring requirements. The appeals process would also provide the cabinet time to consider and implement new management and clinical strategies for Oakwood for the short and long term.
Undersecretary Birdwhistell stated that the cabinet had instituted a short-term crisis management team at Oakwood that consisted of a combination of existing consultants employed through various contractual methods, loaned cabinet staff members from the central office, and long-time state employees. He said that the following safety measures were implemented: 1) An order was given to Oakwood management by Secretary Holsinger to implement actions to bring Oakwood into compliance; 2) the cabinet entered into a partnering relationship with Lake Cumberland Hospital and the local health department to provide clinical staff; 3) the cabinet formed a Mental Health and Mental Retardation and Safety Council to oversee the health and safety of individuals residing in state run facilities, to develop strategic plans and request for proposals (RFP), and to assist the cabinet with the Department for Medicaid Services and the Department of Justice; 4) the cabinet assembled an interdisciplinary team of physicians, nurses, and clinicians to carefully assess the clinical needs of each resident; 5) training was conducted on abuse and neglect by Department for Community Based Services staff and the Interim Facility Director; and 5) the cabinet conducted investigation training stressing data collection and not making a conclusion.
Undersecretary Birdwhistell said that the cabinet identified 11 Supports for Community Living (SCL) slots and 11 facility beds available in the community. The cabinet requested 100 SCL slots from CMS specifically earmarked for Oakwood residents. He said that the focus had been to "safe size" the Oakwood population. Thorough individual assessments are on-going and alternatives are developed through a partnership with existing and new providers. He said that the cabinet will procure a senior management team to replace the interim crisis management through an RFP. Residents would be consulted and team planning would be utilized to insure the safety of all residents involved.
Undersecretary Birdwhistell stated that the cabinet had considered the following regulatory changes: 1) an expansion of SCL staffed residences from 3 to 4 beds; 2) an expansion of group home maximum, number of Medicaid funded residents from 3 to 8; and revising Medicaid regulations to adjust the rate structure. The cabinet plans to send letters to parents, guardians, employees and staff, to have a DOJ quarterly review, and face-to-face meetings with legislators and parents. He said that the commitment of the cabinet is that the quality of life and safety of the residents must continue to improve.
A motion to approve the FY 2006 Substance Abuse Prevention and Treatment Block Grant was made by Representative Brinkman, seconded by Representative Jenkins, and approved by voice vote.
Next Amy Spears, Board Member of the Home of the Innocents, and Linda Heitzman, Board Member of Brooklawn, reported on out-of-home care issues. Ms. Spears stated that the Children's Alliance represents 6,471 children in out-of-home care in Kentucky. These children have been abandoned, abused, neglected, or are medically fragile. The children are coming the child welfare agencies at younger and younger ages and many are severely and emotionally disturbed. She said that the child welfare agencies in the Children's Alliance statewide now care for children who ten years ago would have been placed in a psychiatric hospital. Without a rate increase, child welfare agencies will not able to provide for the children placed in out-of-home care by the state. Without rate increases, the infrastructure will weaken to the point that some agencies will have to dramatically reduce the number of children they care for or close the doors. Once an agency closes the doors, it is almost impossible to recreate the agency. Ms. Spears stated that private child care provider rates had not increased in five years. She asked the legislature to provide additional funding for the growing number of children the agencies care for and add $6 million to the line item for a rate increase.
Ms. Heitzman stated that if a child is left unsupported, it is easy for them to break and be cast aside. But if a child can provided a thorough assessment, treatment driven by the assessment, a nurturing environment, and follow-up care, they are strong and nearly impossible to destroy. She said that the child welfare agencies consider it a joy and a privilege to be a partner with the legislature in the process of raising, strong, balanced, happy, healthy Kentucky kids.
Next, Shirley Hedges testified that Kentucky Foster Adoptive Care Association had the following requests of legislators: 1) Change KRS 438.311 that relates to the use of tobacco products by youth because the cabinet's policy states a birth parent can purchase tobacco products or give approval for a child to use tobacco products regardless of his or her age; 2) Reinstate the previous policy on respite care because respite providers are used on a limited basis and should not be subjected to annual health checks or stringent training that professional foster parents complete; 3) Raise the per diem per child because the present per diem is based on the 1998 USDA cost of raising a child; 4) Amend the vehicle sales tax to include children in out-of-home care because now only a biological or step-parent can transfer a car to a child and not be required to pay sales tax; 5) Allow interested resource homes who want to pay their own premiums at no cost to the state budget to participate in the state medical insurance plan; 6) Support of a Foster Parent Bill of Rights; 7) Support of adoption subsidies; and 8) Extend health insurance or Medicaid coverage for out-of-home care and adopted children to age 23 as long as they are in vocational training or college.
Next Willie Byrd, Legislative Liaison, Association for Persons in Supported Employment, Beth McKenzie, family member of supported employment participant, and Bob Napolilli, Seven Counties Services, reported on the supported employment initiative. Mr. Byrd stated that supported employment enables people with the most severe disabilities to obtain and maintain paid employment in typical community businesses. The services and supports are customized to fit the individual needs of the employee and the employer. Supported employment is a win-win situation for growth in Kentucky's economy and better lives for people with disabilities.
Mr. Byrd said that extreme shortages in funding for long-term support services have resulted in waiting lists in almost every county. With no funding for new program development, people who could benefit are either at home waiting, or are in programs that do not maximize their employment potential. According to supported employment provider data, at least 2,500 people need supported employment. He said that in 2002, Kentucky began to eliminate waiting lists for supported employment through a line item in the budget. The Office of Vocational Rehabilitation will request $500,000 in the 2007-2008 budget to continue the progress. With the increased funding, the Office of Vocational Rehabilitation would be able to assist in developing new support employment providers, eliminate barriers based on disability type and county of residence, increase the existing supported employment provider network to better serve the people, and direct new long-term funding for supported employment in every county. Some services provided with supported employment funds include skills training, co-worker training, job coaching, employer support, and follow-up services.
Ms. McKenzie stated that it took much time and effort to get a paying job for her autistic son because no one wanted to hire him. She said that there needs to be more supported employment opportunities and employers need to focus on a person's strengths not their disabilities.
Representative Burch stated that employers need to be educated better on how to deal with people with disabilities.
Mr. Napolilli stated that it should not be as difficult as it is for participants in the program to find employment. It is a statewide situation that affects thousands of people.
Senator Buford suggested that they meet with the Gene Strong, Secretary for the Economic Development Cabinet, and Mr. Byrd stated that he would.
Next was a report on the Prescription Drug Monitoring Pilot that used the VERISCRIP system in two pilot sites in eastern Kentucky. Robert J. Esterhay, Associate Professor and Chair, Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Sciences presented the finding. VERISCRIP is a real-time electronic prescribing system that has been proposed by the vendor for use as an electronic controlled prescription monitoring system, or as an enhancement to an existing system. Current Kentucky law requires pharmacies to report controlled substance prescriptions every two weeks. Legislation would be needed to require all controlled substance prescriptions to be reported differently.
The pilot project had physicians typing controlled substance prescriptions into a computer and printing out a bar-coded paper prescription. The patient would take this prescription to a pharmacist who would compare the paper prescription to information in the computer system. This permits "real-time" prescription data.
The report included an assessment of costs associated with this approach and commented on implementation costs, less diversion of controlled substances, and improved patient care. Resistance from prescribers was noted.
Dr. Esterhay stated that many physicians have adopted e-prescribing in practices. E-prescribing will be driven by the Medicare Modernization Act and will run its own course based on reimbursement. In the end, the state must address whether the cost is worth the benefit at this point and time.
Representative Damron commented on two recent studies regarding electronic prescribing and health information technology.
Representative Burch asked how many doctors were in Kentucky. Dr. Esterhay stated about 9,000. Senator Buford stated approximately 5,000 practice and the others just keep their licenses. Dr. Esterhay stated there are approximately 1,500 pharmacies. He said that approximately 50 percent of practitioners have some form of clinical technology such as e-prescribing, physician order entry systems, or electronic health records systems.
Representative Burch said that if the pharmacist is the ultimate person to fill a prescription, it should be implemented in the pharmacy not a doctor's office. Dr. Esterhay stated that pharmacies now report every two weeks in a batch mode. Representative Burch stated that it could not cost as much to reimburse the pharmacist to fill a prescription as it would to reimburse each physician. Mr. Sallengs stated that many pharmacies submit routinely submit prescription claims through a switching agent prior to filling the prescription to make sure everything is right and standards will be met.
Next was an update on KASPER by Dave Sallengs, R.Ph., Branch Manager, Drug Enforcement and Professional Practices, Cabinet for Health and Family Services. Mr. Sallengs stated the KASPER program began in 1999 and 21 states now have Prescription Monitoring Programs (PMP). KASPER is considered the national model for a PMP. KASPER is a tool for medical professional and law enforcement personnel to use to fight the illegal diversion of legal controlled substances. KASPER has proved an effective tool for the medical community to intervene before chronic use of controlled substances becomes a legal issue. He said that an anticipated volume of 2,000 reports per year grew to an actual number of over 800 reports per day with more than 575,000 reports provided since 1999. The volume necessitated technology intervention, and in 2003 the General Assembly appropriated $1.4 million to enhance the KASPER system.
Mr. Sallengs stated that Enhanced KASPER (eKASPER), a secure web-based product, went on-line in March, 2005, and is available to users 27/7. A user may request an eKASPER report from any computer with web access. KASPER has bank and Homeland Security level security. The cabinet dictated identity management procedures for access to the eKASPER system. The largest increase in eKASPER usage is from emergency room-based physicians, and is much more valuable to pharmacists. Future planned enhancements include "real time data collection", higher levels of security, more proactive use of KASPER data (quarterly trend reporting), data sharing with other states, and KASPER system integration with e-prescribing technology.
Representative Nunn asked why KASPER is not permissible to be used in court. Mr. Sallengs stated that there is no legal requirement in the state for positive identification when someone picks up a prescription.
Representative Burch asked if law enforcement can use information if a doctor prescribes more than the expected prescriptions for pain medications, and Mr. Sallengs said yes.
Representative Damron asked how long it would take if a doctor accessed KASPER to check and see if a patient was doctor shopping. Mr. Sallengs said approximately 30 days, but he recommended doing a six-month background check because a doctor shopper usually has a history or pattern.
There being no further business, a motion to adjourn at 4:36 p.m. was made by Representative Jenkins, seconded by Senator Denton, and approved by voice vote.