The 4th meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, October 18, 2006, at 1:00 PM, in the auditorium of Norton Hospital, 200 East Chestnut Street, Louisville, Kentucky. Representative Tom Burch, Co-Chair, called the meeting to order at 1: 11 PM, and the secretary called the roll.
Present were:
Members: Senator Julie Denton, Co-Chair; Representative Tom Burch, Co-Chair; Senators Tom Buford, Perry B. Clark, Denise Harper Angel, Joey Pendleton, Richard "Dick" Roeding, Ernesto Scorsone, and Dan Seum; Representatives Scott W. Brinkman, Mary Lou Marzian, Darryl T. Owens, Ruth Ann Palumbo, Jon David Reinhardt, Ancel Smith, Kathy W. Stein, and Addia Wuchner.
Guest Legislator: Representative Jimmie Lee.
Guests: Stephen A. Williams, President and Chief Executive Officer, Norton Healthcare; Mark D. Birdwhistell, Secretary, Cabinet for Health and Family Services; Pierce Whites, Deputy Attorney General, Office of the Attorney General; Larry N. Cook, M.D., Executive Vice President, University of Louisville and Chairman of the Board of Passport Health Plan; Joyce S. Hagen, President of Passport Health Plan; Pam Helms, M.A., President, and Michael J. Kapfhammer, Board Member, Family Place, Louisville; Rice Leach, M.D.; Holly Devine, Pharm.D., Kentucky Clinic; Randy Gaither, R.Ph., The Kroger Company; Michael Jackson, R.Ph., Florida Pharmacists Association; Don Kupper, Pharm.D., University of Louisville Medical Center; John Armistead, Pharm.D., University of Kentucky Medical Center
LRC Staff: Murray Wood, CSA; Barbara Baker, Miriam Fordham, DeeAnn Mansfield, Ben Payne, Gina Rigsby, Marlene Rutherford, and Cindy Smith.
A motion to adopt the minutes of the September 20, 2006 meeting was made by Senator Buford, seconded by Senator Clark, and adopted by voice vote.
Representative Burch read a resolution adjourning the committee meeting in honor of social worker Boni Frederick, and in deep sympathy for her family, friends, and co-workers.
Stephen A. Williams, President and Chief Executive Officer of Norton Healthcare, welcomed the committee and gave a brief overview the services provided by Norton Hospital and Kosair Children's Hospital.
Senator Denton, Co-Chair of the Women's Health Subcommittee, reported that the subcommittee met that morning at Kosair Children's Hospital and heard testimony from Chris Corbin, Executive Director of the Office of Health Policy within the Cabinet for Health and Family Services, and Dr. Ruth Shepherd, Director of the Division of Adult and Child Health Improvement, Department for Public Health, within the Cabinet for Health and Family Services. They presented numerous accomplishments of the cabinet related to women's health including: 1) funding a mobile mammography screening project in three eastern Kentucky counties; 2) development of the Breast Cancer Awareness license plate; 3) $10 financial incentive for women in Medicaid to get a breast and cervical cancer screening; 4) First Lady's birthday cards to women 65-69 years reminding them to have cancer screenings; and 5) expanding the Breast and Cervical Cancer program which has served over 1,000 women since 2002.
Dr. Shepherd reported that mortality rates have decreased for women for breast cancer, heart disease and stroke. Smoking rates have also declined among women from 28.1 percent in 2003 to 26.9 percent in 2005. The cabinet has implemented a QUIT line that has assisted 500 people to decrease or quit smoking. Initiatives to improve nutrition and increase physical exercise among adults and school children have been implemented. Those include Partnership for Fit Kentucky, walkable communities, and the Governor's Wellness and Physical Activity Initiative.
Dr. Shepherd reported that heart disease, cancer, and stroke remain the leading causes of death among Kentucky women. Smoking continues to be a challenge. Overall, 28.7 percent of Kentuckians smoke, compared to 20.6 percent nationally, and 24 percent of Kentucky women smoke during pregnancy, compared to 11 percent nationally. Improving nutrition and getting Kentuckians active also remain as challenges. It was noted that 80 percent of Kentucky women do not eat five fruits and vegetables each day. Legislative initiatives to decrease smoking and promote a healthy lifestyle were discussed.
Dr. Shepherd emphasized the importance of prenatal care. She reported that the health care costs are higher among babies born about one month premature.
Dr. Shepherd also introduced the concept of "life course perspective". She noted that stressors and risk factors are cumulative over our life span and affect our health outcomes throughout life. For example, good nutrition in preteen years is critical to the prevention of osteoporosis during the later years of life. Therefore, it is important to focus on a healthy lifestyle throughout our entire lifespan.
Representative Stein, Co-Chair of the Aging, Disabilities, Independent Living, and Long-Term Care Subcommittee, reported the subcommittee met that morning at Norton Hospital and heard testimony from Bernie Vonderheide, Lois Pemble, Nancy Trenton, and Sheila Mead, Kentuckians for Nursing Home Reform about concerns relating to the quality of care in nursing homes, adequate staffing, and the legislative agenda for the organization that include: 1) strengthening the existing law on notifying a nursing home about an inspection to apply to all, not just state employees; 2) background checks for all employees; 3) random drug testing for all employees; 4) notification to nursing home administrators if a convicted sex offender is admitted; 5) immediate survey of all long-term care facilities for fire safety systems; 6) public information about results of nursing home surveys; 7) earlier reporting and review of potential abuse by power of attorney of person's assets; 8) full-time positions for nursing home ombudsman and funding; and 9) establish state long-term care ombudsman as a merit position. The subcommittee also heard from Dave Huddleston and Gilda Hill about the Thompson-Hood Veterans' Nursing Home in Wilmore. The staffing was detailed, incentives to decrease staff turnover discussed, and the rate of pay for veterans. The Kentucky Department for Veterans Affairs has just filed a regulation that specifies the sliding fee scale for residents/veterans. The department wants to build a new center in Louisville. Hardin County has submitted a request to the Veterans Affairs but there are $800 million requests ahead of this one.
Representative Burch, Co-Chair of the Families and Children Subcommittee, reported the subcommittee met that morning at Brooklawn Child and Family Services, a provider of residential treatment for children with serious emotional disturbances. The average daily census of clients in private child care residential treatment is 69 and 36 in psychiatric residential treatment. Brooklawn also provides IMPACT Plus services and has a Family Skills Program. The Family Skills Program offers services to help keep children with their families. The subcommittee heard a performance by the Brooklawn Percussion Program, directed by Ed White and funded by a Humana Grant.
Mr. David Graves, President, and Ms. Darcie Mooring, Vice President, gave overviews of Brooklawn's programs, talked about successes, and cost saving efforts. Brooklawn partners with the Department for Community Based Services to meet the needs of children, but the number of children in need continues to rise. There were more than 600 referrals in 2006. For every one child served, five children are turned away. Brooklawn serves children from 90 counties, and only 25 percent of the children are from Jefferson County. Brooklawn would like to expand child protective services to prevent the return of children to out-of-home care, improve existing facilities, and expand to serve young women. During the 2006 Regular Session, the General Assembly approved $2 million for the expansion of Brooklawn, but the amount was vetoed by the Governor. Brooklawn is currently trying to raise funds from other sources and will ask the General Assembly to appropriate the $2 million again in the next biennial budget. After the presentation, the members and audience took a brief tour of the main Brooklawn building.
An update on Passport Health Plan was given by Larry N. Cook, M.D., Executive Vice President of the University of Louisville, and Chairman of the Board of Passport Health Plan, and Joyce S. Hagen, President of Passport Health Plan. Dr. Cook reported that as a result of the Medicare Modernization Act, University Health Care applied to become a Medicare Advantage Special Needs Plan for its aged, blind, and disabled members who are also eligible for Medicare. Without the Centers for Medicare and Medicaid Services contract, University Health Care would have lost the ability to manage pharmacy benefits and ultimately, quality and continuity of care for the vulnerable dual eligible population would worsen. As a Medicare Advantage Special Needs Plan, Passport Advantage is able to manage both Medicare and Medicaid benefits, thereby providing better coordinated care. Approximately 10,000 Passport Health Plan dual eligible beneficiaries are eligible to participate in the Special Needs Plan.
The pharmacy network is essentially the same as Passport Health Plan, so there has been minimal disruption as members transfer from Medicaid to Passport Advantage. Members are allowed to continue care from out-of-network providers, as long as the provider participates with Medicare. Since Passport Advantage is a provider-sponsored organization, contracted providers receive a higher reimbursement. There is added coordination of behavioral health and skilled nursing facility benefits. The shift in approach has been from reactive or medical management to a proactive or care coordination. Targeted interventions are based on a member's health risks and care needs. The plan is successful because it is provider-sponsored which gives them a sense of ownership. The support of advocates is critical for member recruitment and retention. Passport Health Plan was recognized in the top 25 and is the only Medicaid health plan in Region 4 to achieve "America's Best Health Plan" badge as reported in U.S. News, A World Report, NCQA America's Best Health Plans 2005. Region 4 includes Alabama, Georgia, Mississippi, North Carolina, South Carolina, Florida, Tennessee, and Kentucky as cited in the NCQA Accreditation Benchmarks. The rankings are based on clinical performance, member satisfaction, and the National Commission on Quality Assurance Accreditation. The federal Centers for Medicare and Medicaid Services' administrator Mark McClellan stated "The Kentucky Partnership plan is among the highest performing Medicaid managed care demonstrations in the country."
Senator Scorsone asked if Passport would implement the same Deficit Reduction Act changes as the rest of the Medicaid population. Ms. Hagen stated that the 16 counties included in Passport are exempt from the changes to KyHealth Choices. Senator Scorsone said maybe the state should change to the patient-centered approach if it is working so well for Passport. Ms. Hagen explained that Passport has had since 1997 to make the changes work. Senator Scorsone said educating recipients is an integral part of change and asked how long it took Passport to educate their population about changes. Ms. Hagen stated that for the first years the basics of managed care were done. After that the members started taking care of their own healthier outcomes. Dr. Cook said that when AmeriHealth was hired, they already had approximately 400,000 Medicaid recipients in multiple markets. Passport has been able to be successful because it has been able to import many of AmeriHealth's existing programs and newsletters, incorporate a 24/7 nurse line, be a sole source provider, has a stable population, and address issues of diversity and cultural competency. Senator Scorsone asked if the cabinet sought to use Passport as a model for the rest of the Medicaid population. Dr. Cook stated that Secretary Birdwhistell is trying to use some of Passport's formulas of success. Senator Scorsone asked whether Passport adopted a rigid restriction on the number of visits to physicians and the number of prescriptions per month. Dr. Cook said no, and Ms. Hagen said they have been working with providers on the preferred drug list for eight years, and as a result, the pharmacy trend is zero to three percent. Senator Scorsone asked how Passport kept their trend so low. Ms. Hagen stated some ways were 1) outreach and education conducted with providers; 2) formulary and rebate programs; 3) high-volume physicians have PDAs that show the preferred drug while they are with the patient; and 4) counter detailing with provider offices to show duplication of medications that could be harmful to patients. Dr. Cook emphasized Passport's whole model is health oriented instead of disease oriented.
Senator Buford asked if there were any communications with the cabinet to expand the number of counties Passport serves. Dr. Cook stated they would like to serve more then 20 percent of the population, but did not want to include counties without studying data about the population and determining the methodologies that would be successful.
Representative Owens asked if access to hospitals and providers had a bearing on which counties Passport would want to include in its expansion. Dr. Cook stated Passport is a provider organization and every hospital in the region is a willing participant in the program. Passport would seek the support of the provider community first before adding any other counties.
Representative Marzian asked how many calls the 24/7 on-call nurse receives. Ms. Hagen said she would have to get back to the committee with that information. Representative Marzian stated that the access to an on-call nurse is very helpful to recipients.
Representative Burch asked how long Passport has been operating, and Dr. Cook stated since 1997. Representative Burch stated that Passport's model plan could work anywhere in the state where there is a provider base and facilities available.
A discussion on Family Place was given by Pam Helps, President, and Michael J. Kapfhammer, Board Member of Family Place, Louisville. The Family Place began in 1977 when a consortium of public and private agencies came together to find a solution for child abuse. Their efforts created the services that today serve as model programs that help end family violence. Through the years, Family Place has helped nearly 30,000 children and family members in the community. The Family Place has three major programs: 1) Children's Program - provides specialized child care for children from birth to age five who have been abused or affected by family violence; 2) Family Treatment Program - provides unique, family-based, long-term mental health treatment for child sexual abuse within the family; and 3) Visitation Center - provides court-ordered supervised visits between children and their non-custodial parent. The budget is 38 percent for children's programs, 17 percent for family treatment, 10 percent for juvenile treatment, 12 percent for administration, 11 percent for fundraising, 11 percent for visitation center, and 1 percent for community education. The source of funds come from rental income, program income, individuals, special events, foundations, corporations, organizations, Prevent Child Abuse Kentucky, federal food program, state, federal, and local contracts, and umbrella organizations.
Senator Denton asked if the services were Medicaid reimbursed, and Ms. Helms said no, because they do not provide medical-oriented services.
Senator Clark asked the annual budget, and Ms. Helms answered approximately $1.4 million. Senator Clark asked about the amount of the General Assembly appropriation in 2006. Ms. Helms stated the appropriation was for $200,000 for 2007. Senator Clark asked if children were placed there by state agencies. Ms. Helms stated most were there from cabinet referrals, but not all. Senator Clark asked they received a per diem per child from the cabinet, and Ms. Helms said no. Senator Clark asked where abused children would go if the Family Place shut down, and Ms. Helms stated there is no other place that offers these services in Jefferson County. Senator Clark stated that the problem is only going to increase and more appropriations are needed.
A discussion on the role of pharmacists in the health care system was given by Brad Hall, Executive Director of the Kentucky Pharmacists Association, Wendy Johnson-Deitemeyer, Pharm.D., Alyson Schwartz, R.Ph., John Armistead, R.Ph., Randy Gaither, R.Ph., and Don Kupper, R.Ph. They discussed the role of pharmacists in the Veterans Administration health care system, in disease management, in the hospital setting, immunizations, and in bio-emergencies.
Representative Owens asked Ms. Schwartz what other training she had besides pharmacy school. Ms. Schwartz stated that she has a Doctor of Pharmacy degree, but she also attends additional seminars to further her training.
Senator Denton asked how Kentucky makes sure there are safeguards in place that newborns are not given the wrong medications. Mr. Armistead stated bar-coding is the best method to make sure the right patient is receiving the right medication, although only five to seven percent of the hospitals use this method. Some hospitals use a double check system.
Representative Burch asked how to handle the problem of a pharmacist refusing to fill a prescription on ethical or moral grounds. Mr. Armistead said that everything should be done in the best interest of the patient. Representative Burch asked if a pharmacist should be denied a license if they refuse to fill a prescription. Mr. Armistead stated that if a pharmacist has a personal or religious reason to not fill a prescription, the pharmacist should bring it to their supervisor's attention to avoid a potential conflict. But in Mr. Armistead's opinion, you should not refuse to fill a prescription in front of a patient. Mr. Hall stated that from the Association's perspective, a pharmacist should assist the patient in finding another pharmacist and/or pharmacy to fill the prescription. Representative Burch asked how many years it takes to become a pharmacist. Mr. Armistead stated the minimum training is six years.
Senator Denton asked if Kroger filed insurance claims for immunizations, and Mr. Gaither said they are a Medicare mass immunizer, but they do not bill many commercial insurance companies because they do not reimburse for the administration fee. She asked about the cost of a flu shot, and he said $30, which is based on Medicare reimbursement fees for the vaccine plus the administration fee. She asked if the shot is administered to children, and he stated the program is only for adults 18 years and older, but they can administer the shot to children with a prescription. Medicaid prices are different. She asked if the pharmacist would be able to handle an allergic reaction to a shot, and he said it is in the protocol. She asked if Kroger advertised this service, and he said yes.
Representative Wuchner asked if there was a private setting available. Mr. Gaither said some stores provide a private counseling room for shots and education.
Senator Roeding stated he was proud of his profession and the way they are helping to improve access to health care. Pharmacists need to be qualified and trained to lessen the chance of liability.
Representative Burch asked if many people knew about a potassium iodine tablet that is available at the health department for exposure from a dirty bomb. Mr. Kupper stated if there was a higher level of exposure, the tablet would not help. There is a statewide emergency plan to cover exposure to any biological, radiological, chemical, or natural disaster. Senator Denton stated that it is difficult to have protocols on events that have never actually occurred before, such as a nuclear bomb.
The following regulations were referred to the committee for consideration: 201 KAR 20:056 - establishes the requirements for advanced registered nurse practitioner registration, renewal, and reinstatement programs; and recognition of a national certifying organization; 201 KAR 20:057 - establishes the scope and standards of practice for an advanced registered nurse practitioner; 201 KAR 21:015 - delineates the minimum standards of professional and ethical conduct which all chiropractic licensees shall maintain; 201 KAR 21:025 - establishes the duties of the officers, field personnel, and administrative staff - Board of Chiropractic Examiners; 201 KAR 21:051 - establishes procedural guidelines of the Board of Chiropractic Examiners hearings and the processing of complaints against licensees; 201 KAR 21:055 - delineates the characteristics of institutions which are approved by the Board of Chiropractic Examiners; 201 KAR 21:085 - establishes the preceptorship program - Board of Chiropractic Examiners; 201 KAR 21:100 - establishes minimum standards for recordkeeping and issuance of itemized statements - Board of Chiropractic Examiners; 902 KAR 20:390 - establishes certification requirements for the employment of paid feeding assistants in licensed nursing facilities and skilled nursing facilities - CHFS; 908 KAR 3:050 & E - establishes the patient cost per day for board, maintenance and treatment at facilities operated by the cabinet - CHFS; 921 KAR 1:380 - specifies the process by which an individual may apply for child support services, the scope of services available, and the process for an interstate case - CHFS; 921 KAR 1:390 - establishes the requirements for the establishment of paternity for the Child Support Program - CHFS; 921 KAR 1:400 - establishes the requirements for the establishment, review, and modification of child support and medical support orders - CHFS.
Ms. Jan Scherrer voiced her concerns about 902 KAR 20:390 relating to paid feeding assistants. Senator Denton asked Steve Davis, Office of Inspector General, to speak with Ms. Scherrer about her concerns. Senator Denton explained that the administrative regulations will go into effect as scheduled.
There being no further business, a motion to adjourn at 3:34 p.m. was made, seconded, and adopted by voice vote.