The 2nd meeting of the Interim Joint Committee on Health and Welfare was held on Monday, July 24, 2006, 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, Perry B Clark, Denise Harper Angel, Alice Forgy Kerr, Joey Pendleton, Richard "Dick" Roeding, and Johnny Ray Turner; Representatives James R Comer Jr, Robert R Damron, Bob M DeWeese, David Floyd, Joni L Jenkins, Mary Lou Marzian, Stephen R Nunn, Ruth Ann Palumbo, Jon David Reinhardt, Ancel Smith, and Addia Wuchner.
Guests: Ruth Shepherd, M.D., Department for Public Health, Cabinet for Health and Family Services; Carol Steltenkamp, M.D., Assistant Dean for Clinical Affairs, University of Kentucky College of Medicine and Co-Chair of the Kentucky e-Health Network Board; Nathan Goldman, Kentucky Board of Nursing; Tracey Jewell, Department for Public Health, Cabinet for Health and Family Services; Trudi Matthews, Chief Policy Advisor, Office of Health Policy and Richard Stout, Cabinet for Health and Family Services; Brad Hall, Kentucky Pharmacists Association; Elizabeth Caywood, Department for Community Based Services, Cabinet for Health and Family Services; Jan Gould, Kentucky Retail Federation; Steve Davis and Dave Sallengs, Office of Inspector General, Cabinet for Health and Family Services; Tony Sholar, Rotunda Group; Cathy Allgood Murphy, American Association of Retired Persons; Gene Huff, Marymount Medical Center; Bob Kelley, Merck; Prentice Harvey, Norton Healthcare; Sarah Nicholson, Kentucky Hospital Association; Denise Simpson, Kentucky Impact Services, Seven Counties Services, Inc.; Anne Joseph, Kentucky Task Force on Hunger; Russell Harper, Christian Care Communities.
LRC Staff: Murray Wood, CSA, Barbara Baker, Miriam Fordham, Gina Rigsby, and Michelle Woods.
A motion to adopt the minutes of the June 21, 2006 meeting was made by Senator Buford, seconded by Senator Roeding, and adopted by voice vote.
A report on the status of levels of neonatal hospital services was given by Ruth Shepherd, M.D., Department for Public Health, Cabinet for Health and Family Services. Dr. Shepherd stated that Kentucky's infant mortality rates have improved, and according to 2004 data from the National Vital Statistics System, Kentucky averages 6.5 deaths per 1,000 live births. The smaller the birth weight, the more the baby is at a higher risk of dying, but the survival of babies weighing less than two pounds has increased since 1960 in Kentucky.
Dr. Shepherd stated that neonatology is a new specialty and has developed since the 1960s. By the 1970s there were neonatal units nationwide, but there was no organized system where babies could get the appropriate care close to where they lived. In 1976, a committee that was chaired by the national March of Dimes and involved all the national partners of the pediatric and obstetrician groups, published a white paper entitled "Towards Improving the Outcome of Pregnancy" that made the following recommendations: 1) develop regionalized perinatal care systems; 2) establish three levels of neonatal care for hospitals according to complexity and severity of an infant's illness; and 3) develop a transport systems.
Dr. Shepherd stated that the following services are provided in Level I neonatal nurseries: 1) basic neonatal care; 2) neonatal resuscitation; 3) evaluation of healthy newborns over four pounds and six ounces; 4) management of uncomplicated jaundice; and 5) stabilization of transfer if sick or high risk. The following services are provided in Level II neonatal nurseries: 1) all basic services provided in Level I nurseries; 2) treatment of infants with moderate, short-term illness or high risk; 3) care of preterm infants weighing three pounds four ounces or less; 4) convalescent care for infants recovering from serious illness or severe prematurity; and 5) some offer short-term ventilator care. The following services are provided in Level III neonatal nurseries: 1) treatment of all infants that need care, even the most severely ill and smallest infants; 2) advanced technology such as high frequency ventilation and ECMO; 3) availability of on-site pediatric subspecialists, including cardiac and general surgeons; 4) outreach education; and 5) transportation of patients from outlying hospitals using specialized equipment and staff.
Dr. Shepherd stated that in 1978 the General Assembly enacted legislation that created the regionalizational of the perinatal care program to be ran by the Department of Public Health and allocated $9.8 million. There were six Level III hospitals initially enrolled in the neonatal care program. The goal was to have at least one Level II center in each Area Development District. She said that in 1987, Doug Cunningham, Chief of Neonatology at the University of Kentucky, reported that mortality within 24 hours of admission to neonatal intensive care decreased progressively from 11.3 percent in 1979 to 3.6 percent in 1985. Deaths within the first week of life for outborn infants decreased from 27.4 percent in 1979 to 6.7 percent in 1985.
Dr. Shepherd said that during the 1980s challenges to regionalization were hospital competition, managed care systems/networks, increasing numbers of uninsured, shrinking financial resources for public health with increased patient loads, and deterioration of regionalized referral patterns. In 1993, the March of Dimes reformed the perinatal committee and published another white paper "Towards Improving the Outcome of Pregnancy II" that made the following recommendations: 1) refocus on what happens outside hospitals; 2) medical home concept; 3) health promotion and education; 4) preconception and interconception care; 5) risk reduction and screening and awareness; 6) access to services; and 7) coordination of activities within a region such as planning, monitoring, data collection, and provider education. She said that in the 1990s, Kentucky also refocused on outreach education and training. There were improvements in teen pregnancy rates, early and adequate prenatal care, coverage for pregnant women and infants, and participation in medical homes.
Dr. Shepherd stated that the State Health Plan is revised yearly, and in January 2006, the Certificate of Need (CON) process was made less restrictive for Level II nurseries to improve access to neonatal care. She said that CON requirements for Level II neonatal intensive care unit (NICU) should be 8 beds. The formula for the cap on the number of Level II NICU beds in the ADD is the number of births divided by 1,000 multiplied by four. Currently, there are 217 Level II NICU licensed beds licensed in Kentucky. Other requirements are that the utilization of existing Level II beds in the ADD must exceed 70 percent and an applicant must document that they would provide care consistent with the most recent edition of the "Guidelines for Perinatal Care" (AAP/ACOG). The CON requirements for Level III NICU beds are that the utilization of existing Level II beds in the ADD must exceed 75 percent and applicant must document they would provide care consistent with most recent edition of the "Guidelines for Perinatal Care" (AAP/ACOG). The formula for the cap for number of Level III NICU beds is the number of births in the ADD divided by 1,000 multiplied by one. Currently, there are 117 Level III NICU licensed beds in Kentucky.
Dr. Shepherd said that Kentucky's premature live births rate has risen to 14 percent since 1993. She said that Kentucky's Healthy People 2010 prematurity goal is 7.6 percent. The average infant mortality rates per 1,000 live births by race in the United States between 2000-2002 were 5.7 for whites; 13.5 for blacks; 8.9 for native American; 4.8 for Asians; for an average total of 6.9 according to the National Center for Health Statistics. Kentucky's rates for the same timeframe and source were 6.4 for whites; 10.7 for blacks; 6.4 for Asians; for an average total of 6.7.
Dr. Shepherd recommends 1) forming a perinatal task force to study best practice from other states, examine and suggest improvements to our current system, determine quality indicators and data collection, and develop strategies for new challenges; 2) establish a voluntary reporting system so the state can aggregate and analyze data; 3) look for ways to expand effective programs like HANDS that improve birth outcomes; and 4) continue to work on access to health care coverage for pregnant women and infants.
Representative Nunn suggested that the cabinet look at new ways to improve the early childhood initiatives.
Representative Burch said the changes in the State Health Plan allow for an increase in Level II neonatal beds and asked how the cabinet would ensure hospitals, especially in rural areas, maintain consistency with the American Academy of Pediatrics and American College of Obstetrics and Gynecology Guidelines of Prenatal Care. Jeff Barnett of the Certificate of Need Office, stated that there are nine hospitals statewide delivering over 500 babies that have no Level II neonatal services, and the cabinet became concerned with the frequency and distance the babies had to be transported. One of the CON requirements is to maintain consistency with the guidelines identified. Representative Burch asked how the cabinet would guarantee the Level II facilities would deliver the quality of services needed if there are no inspections required. Dr. Shepherd stated she would like to collect additional indicators from hospitals in addition to utilization data and determine what should be quality indicators for Level II nurseries and have a voluntary reporting system to get the information almost immediately to a facility is having problems. The problem with regular inspections is that the Office of the Inspector General does not routinely inspect hospitals that are joint-commissioned certified. If there is a complaint, they could refer to the guidelines for perinatal care and address the problem. Representative Burch asked if the cabinet thought a facility would voluntarily give information about high incidences of infant deaths in order to correct a problem. Dr. Shepherd stated that the cabinet would determine what the quality indicators should be and have all nurseries report them and compare what each nursery is doing.
Representative Burch asked about the number of current applications and if they were statewide. Mr. Barnett stated that there are six applications to establish Level II beds since the lifting of the moratorium. The cabinet thought it was time for the change in the State Health Plan because there has not been a change in Level II beds since 1996. Several applications are from central Kentucky. Representative Burch asked what the fiscal impact would be to Medicaid to add an increase in Level II beds, psychiatric hospital beds, physical rehabilitation hospital beds, MRI radiation equipment, and prescribed pediatric extended care. Mr. Barnett stated that CON Office has worked with Medicaid and providers and that this would not have an adverse effect from an economic standpoint. The changes would increase access and have a savings in cost avoidance by making the level of care more appropriately delivered in the areas that need it most.
Representative Burch asked how the babies were transported to Level II nurseries when necessary. Mr. Barnett said by ambulance or helicopter. The Institute of Medicine has predicted there will be 500,000 premature babies on an annual basis. Representative Burch asked if the state evaluated Level II and Level III nurseries. Dr. Shepherd stated that the information is collected from birth certificates and university centers. Representative Burch asked if the cabinet was comfortable that all the Level II nurseries are providing the best service possible. Dr. Shepherd stated that she did not have the information to say one way or the other.
Representative Wuchner asked if there is a direct correlation, especially in the premature or preterm births, with the hesitancy to make referrals to high-risk obstetric/gynecologists that are coordinating with the neonatal services hospitals that would have the high-risk service or are there not enough of the high-risk obstetrics and gynecological services to coordinate with the Level II and Level III nurseries. Dr. Shepherd stated that most of the obstetricians and gynecologists are happy to consult with perinatologists when necessary, but the mother does not always have to be transferred because most of the information can be handled by phone. Dr. Shepherd stated that in centers who have perinatologists, there is a hesitancy to transfer to other centers that might be able to handle the baby better.
Senator Buford stated there are not enough Level II or Level III facilities. Hopefully, the changes in the State Health Plan allowing more Level II beds will allow more access and availability of parents to their child.
Representative Palumbo asked about the definition of early entry into prenatal care. Dr. Shepherd stated it is entry into the first trimester. Representative Palumbo asked about the length of time recommended between pregnancies. Dr. Shepherd stated approximately 18 to 24 months. Representative Palumbo asked if babies statewide had specific problems that caused premature births. Dr. Shepherd stated that it is a multi-factorial problem. Representative Palumbo asked what the average weight of a low-birth baby. Dr. Shepherd stated five pounds and eight ounces.
Representative Nunn asked if there is a way to gauge the impact of the Spanish infant mortality rates. Dr. Shepherd stated that the information from the 2005-2006 would indicate the Hispanic population is rising, and many outreach efforts are aimed toward them.
Representative Marzian asked if the problems could be because of a lack of adequate health care. Dr. Shepherd stated that between KCHIP and Medicaid there are more pregnant women covered in Kentucky than the national average. They can also receive some services through health departments. Dr. Davis stated that nine percent of women of child-bearing do not have insurance coverage from one source or another. Representative Marzian asked about the strategies to help women accomplish longer periods of time between pregnancies. Dr. Shepherd stated that it is filtrated through all the public health programs where there are allot of high-risk individuals. The Centers for Disease Control and Prevention recommendations were just released several months ago and will be disseminated to the public.
Senator Denton asked why the March of Dimes would not include the Hispanic information in the 2000-2002 report. Dr. Shepherd stated that the birth certificates used for the reports did not have a broad array of ethnicity recorded. The birth certificate was changed in 2004, and the department is receiving better information.
Representative Burch asked the number of obstetrics and gynecologists were still practicing in Kentucky. Dr. Davis stated approximately 400 to 500. Representative Burch asked if the health departments provided prenatal services. Dr. Shepherd stated that most health departments had contracted with local obstetricians to provide care but some health departments do still see prenatal patients.
Senator Buford stated that more money needs to be allocated to the health departments.
Representative Wuchner stated that one problem that has been found is that working mothers cannot take time off work for doctor appointments, and, therefore, do not have the adequate prenatal care needed in the first trimester. There are prenatal vitamins available over-the-counter that women can take.
Representative Burch asked why there is a big disparity because African American and white low-birth weight and premature incidences and what are some ways to identify the problems. Dr. Shepherd stated that Institute of Medicine published a report on prematurity and low-birth weight that dealt with this issue and they could not come up with any specific reasons. Dr. Shepherd stated that the Healthy Start project in Louisville and the HANDS program have helped to decrease infant mortality. Dr. Shepherd stated that the post-neonatal mortality in African Americans is on the rise.
An update on the e-Health Network Board was given by Carol Steltenkamp, M.D., Assistant Dean for Clinical Affairs, University of Kentucky College of Medicine, and Co-Chair of the Kentucky e-Health Network Board. Trudi Matthews, Chief Policy Advisor, Office of Health Policy, Cabinet for Health and Family Services was available to answer questions. Dr. Steltenkamp stated that Senate Bill 2 enacted by the General Assembly and signed by the Governor on March 8, 2005, created the Kentucky e-Health Network (KEHN) Network Board. Senate Bill 2 also created the Healthcare Infrastructure Authority, a partnership between the University of Kentucky and the University of Louisville to lead e-Health efforts. The board began meeting in November 2005 to develop a plan for a statewide e-Health network. The board is attached to the Cabinet for Health and Family Services for administrative purposes.
Dr. Steltenkamp stated that some short-term projects include: 1) Privacy and Security project; 2) e-Prescribing Partnership Grants; 3) e-Health Payor Collaboration; and 4) Fall 2006 e-Health Summit. She stated the board is in the process of forming an advisory group consisting of health care Chief Information Officers, community leaders and clinicians knowledgeable about e-Health that would develop preliminary recommendations. The board is also working on a business plan.
Representative Nunn stated that it has taken seven meetings to finalize the board's mission statement. He stated that e-health has been a slow process but the board is making progress. National leaders in e-health have spoken at the board meetings and told of experiences with e-health systems. He said that e-health can curb costs in health care and Kentucky can be in the forefront of the e-health revolution.
Senator Denton asked about the progress of the pilot in Louisville. Dr. Steltenkamp stated a group has been formed for the e-Health Trust Model, but she did not know the progress. Ms. Matthews stated that the group was still working on a business model.
Senator Denton asked if everyone was abiding by the federal guidelines, and Dr. Steltenkamp stated that they were still waiting for federal guidelines.
Representative DeWeese stated that e-health could make practice safe and less expensive. He asked if electronic prescription writing was being done in Kentucky, and if so, how much. Dr. Steltenkamp, stated yes, it is, but at a minimum due in part of the expense and some because of the reluctance to change.
Representative Damron stated that there is a study that was done by the University of Louisville that stated there is technology for real-time. He stated that the KASPER system had a two-week delay in reporting that could cause major problems. E-health could reduce medical malpractice. He asked if the board was looking to purchase new software for the state. She stated that no subcommittee had been formed yet because the board was waiting for national standards. The board did not want to waste money purchasing a system that would not be compatible with the national standards. Representative Damron asked how far the cabinet was from having e-KASPER, and Ms. Matthews stated approximately six months.
Senator Roeding stated that e-KASPER is moving forward and that a pharmacy puts in a report every 8 days. He stated that purchasing the software will be a huge expense to the state and the software is not ready. He said that the $90,000 community partnerships should be spread throughout the state, and Ms. Matthews stated that someone would be able to apply for a grant within the next two months.
The following administrative regulations were referred to the committee for review: 201 KAR 20:370 - establishes requirements and procedures for nurse licensure and registration, 201 KAR 20:411 - establishes the requirements relating to a sexual assault nurse examiner course and the credentials of a sexual assault nurse examiner, 201 KAR 25:031 - establishes continuing education requirements for a podiatrist, 201 KAR 36:030 - delineates the requirements for continuing education and prescribes methods and standards for the accreditation of continuing education courses for licensed professional counselors and licensed professional counselor associates, 201 KAR 36:070 - establishes the educational requirements for licensure by Kentucky Board of Licensed Professional Counselors, 900 KAR 5:020 - updates the State Health Plan, 900 KAR 6:050 - establishes the requirements necessary for the orderly administration of the Certificate of Need Program, 902 KAR 20:091 - establishes licensure requirements for the operation and services, and facility specifications of a community mental health center, 902 KAR 55:110 - establishes criteria for reporting prescription date, providing reports to authorized persons, and waiver for a dispenser who does not have an automated recordkeeping system (KASPER), 906 KAR 1:110 - establishes quality of care and licensure standards for critical access hospitals, 908 KAR 3:060 - establishes the "Means test" for determining the ability to pay of the patient or person responsible for the patient for board, maintenance, and treatment at a facility operated or utilized by the cabinet for the mentally ill or mentally retarded pursuant to the "Patient Liability Act of 1978", 921 KAR 3:060 - establishes the procedures used by the cabinet in determining if an intentional Food Stamp program violation, or IPV, has occurred and the penalties that shall be applied for an IPV.
Representative Burch asked about inconsistencies with statutes in regard to personal care beds. Mr. Barnett, Office of Certificate of Need, Cabinet for Health and Family Services, stated that the cabinet did not perceive any inconsistencies because personal care beds were not removed from the process in 900 KAR 6:050.
The committee reviewed Executive Order 2006-693, relating to the expansion of the Telehealth Board, pursuant to KRS 12.028. The committee accepted the reorganization order and the accompanying reorganization plan.
Senator Denton announced there would not be a committee meeting in August. There being no further business, a motion to adjourn at 2:22 p.m. was made, seconded, and adopted by voice vote.