The 4th meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, October 17, 2007, at 1:00 PM, in Room 149 of the Capitol Annex. Representative Tom Burch, Co-Chair, called the meeting to order 1:07 PM, and the secretary called the roll.
Present were:
Members: Representative Tom Burch, Co-Chair; Senators Tom Buford, Perry B. Clark, Denise Harper Angel, Alice Forgy Kerr, Joey Pendleton, Dick Roeding, Ernesto Scorsone, Dan Seum, and Katie Stine; Representatives John A. Arnold, Jr, Scott W. Brinkman, James R. Comer, Jr., Robert R. Damron, Bob M. DeWeese, David Floyd, Joni L. Jenkins, Mary Lou Marzian, Darryl T. Owens, Ruth Ann Palumbo, Kathy W. Stein, David Watkins, Susan Westrom, and Addia Wuchner.
Guests: Susan Harkema, PhD, Associate Professor and Rehabilitation Research Director, Owsley B. Frazier Chair in Neurological Rehabilitation, Kentucky Spinal Cord Injury Research Center Rehabilitation Research Director, Department of Neurological Surgery, University of Louisville Frazier Rehabilitation Institute; Mark Birdwhistell, Secretary, Rob Edwards, Chief of Staff, Shawn Crouch, Commissioner, Department for Medicaid Services, and Mark Washington, Commissioner, Department for Community Based Services, Cabinet for Health and Family Services; Steve Shannon, Kentucky Association of Regional Programs; Tim Veno, Kentucky Association of Homes and Services for the Aging; Kathy Fowler, Vonia L. Grabeel, PHPS; Mike Porter, Kentucky Dental Association; Patty Dempsey, The Arc of Kentucky; Christine Atkinson, Medina Tipton, Vanessa Breeding, and Dewey Crawford, Department for Public Health; Ruby Jo Lubarsky, Kentucky Association for Health Care Facilities; Karen Thomas Lentz, Johnson and Johnson; Rich Seckel, Kentucky Equal Justice Center; Sharon Bertram, University of Kentucky student; Elizabeth Caywood, Department for Community Based Services, Cabinet for Health and Family Services; Patricia Spurr, Kentucky Board of Nursing; and Sarah S. Nicholson, Kentucky Hospital Association.
LRC Staff: Murray Wood, CSA; Barbara Baker, Miriam Fordham, DeeAnn Mansfield, Ben Payne, and Gina Rigsby.
A motion to adopt the minutes of the September 19, 2007 meeting was made by Representative Arnold, seconded by Senator Pendleton, and adopted by voice vote.
Senator Pendleton introduced the Eastern Kentucky University occupational therapist graduates.
Senator Stine, Co-Chair, reported that the Families and Children Subcommittee met that morning and heard an overview of the Complete Streets Program by Tiffani Jackson, Bicycle and Pedestrian Coordinator, Office of Special Programs, Transportation Cabinet and Kenzie Gleason, Bicycle and Pedestrian Coordinator, Lexington-Fayette Urban-County Government. Tom Emberton, Undersecretary for Children & Family Services, Cabinet for Health and Family Services, discussed program and policy changes that the cabinet is undertaking to improve consistency. Mark Washington, Commissioner, Department for Community Based Services, Cabinet for Health and Family Services and Tina Webb, Protection and Permanency, gave an overview of the Child Fatality and Near Fatality Annual Report for 2007. Jason Dunn, Division of Family Support, presented testimony on the Kentucky Transitional Assistance Program (K-TAP) challenges resulting from federal reauthorization. Mark Washington and Sandra Noble Canon, Director, Division of Child Care, discussed the Child Care Assistance Program. A motion to adopt the report was made by Representative Owens, seconded by Senator Roeding, and adopted by voice.
Senator Roeding, Co-Chair, reported the Aging, Disabilities, Independent Living, and Long-Term Care Subcommittee met that morning and heard testimony on an update from Dr. Graham Rowles on the second phase of the Kentucky Elder Readiness Initiative. The subcommittee also heard testimony from Commissioner Deborah Anderson about several grants that the Department for Aging and Independent Living has been awarded. A motion to adopt the report was made by Senator Pendleton, seconded by Senator Harper Angel, and adopted by voice vote.
Representative Marzian, Co-Chair, reported that the Women's Health Subcommittee met that morning and heard testimony from Dr. Thomas Tucker, Chair, Department of Epidemiology, College of Public Health, and Senior Director for Cancer Surveillance, Markey Cancer Center, University of Kentucky, about the Kentucky Breast Screening Program. The subcommittee also heard the story of Anna Lou Lindon, a five-year breast cancer survivor. Shannon Pratt, MPA, Government Relations Director, American Cancer Society, provided an overview of the services provided by the American Cancer Society. A motion to adopt the report was made by Representative Marzian, seconded by Senator Buford, and adopted by voice vote.
A presentation on spinal cord injuries and neurological rehabilitation was given by Susan Harkema, PhD, Associate Professor and Rehabilitation Research Director, Owsley B. Frazier Chair in Neurological Rehabilitation, University of Louisville Frazier Rehabilitation Institute. Dr. Harkema stated that the mission of the Kentucky Spinal Cord Research Center is dedicated to developing successful spinal cord repair strategies in the laboratory that can be taken to the clinic in a timely and responsible fashion. The Kentucky Spinal Cord Head Injury Research Trust receives funds from a surcharge added to each speeding ticket and the collections go into a fund that total $3 million per year. The distribution of the funds is overseen by board members of the University of Louisville and the University of Kentucky. The funding is used for faculty development, graduate student and post-graduate support, and individual research grants. The Kentucky Spinal Cord Research Center at the University of Louisville would not exist without the "Bucks for Brains" program and the Kentucky Spinal Cord Head Injury Research Trust. The center's vision is the successful treatment of spinal cord injury.
Dr. Harkema said that Kentucky has received $44 million direct grant funds to support the programs. Nine faculty members have received grants totaling $5.2 million this year and anticipate this number will continue to grow. The collaborative center is composed of engineers, neuroscientists, physicians, occupational and physical therapists, nurses, graduate students, and undergraduate students. She said that locomotor training is a new rehabilitative strategy that is designed to retrain walking that has come from research over the past 15 years. Frazier Rehabilitation Institute and the University of Louisville is a lead center of the NeuroRecovery Network that is funded by cooperative agreement with the Centers for Disease Control and Prevention and the Christopher and Dana Reeve Foundation. The NeuroRecovery Network directs rehabilitative care for seven national rehabilitative centers across the country. As of August 2007, there were 133 patients.
Representative Floyd asked if occupational therapists work with patients and are training at U of L. Dr. Harkema stated that both occupational and physical therapists work with patients and work in the research program.
The following administrative regulations were referred to the committee for consideration: 201 KAR 8:220 - establishes the standards for the Kentucky Board of Dentistry's clinical examination; 201 KAR 20:251 - repeals 201 KAR 20:250, 201 KAR 20:300, AND 201 KAR 20:330; 201 KAR 20:280 - establishes the standards for the development and approval of programs which prepare graduates for admission to the licensure examination and to facilitate endorsement of licensure status to other states (KBN) (Amended at ARRS); 201 KAR 20:310 - establishes standards for faculty of programs of nursing which prepare graduates for licensure as registered nurses or practical nurses (Amended at ARRS); 201 KAR 20:320 - establishes the curriculum requirements for prelicensure registered nurse programs (Amended at ARRS); 201 KAR 20:340 - establishes the standards to be met by students in prelicensure registered nurse and practical nurse programs (Amended at ARRS); 201 KAR 20:350 - establishes the standards for programs of nursing to assure the provision of adequate facilities and resources for conduct of the program of nursing (Amended at ARRS); 201 KAR 20:450 - provides procedures for the implementation of an alternative program for nurses who may be impaired by illness, substance abuse, or a physical or mental condition (Amended at ARRS); 900 KAR 6:030 - provides for the adjustment of expenditure minimums for capital expenditures and major medical equipment in the Certificate of Need program; 902 KAR 45:075 - establishes the responsibilities of tanning facilities and the procedures for their registration and monitoring (Amended at ARRS); 902 KAR 45:120 - establishes the permit and inspection fees to be charged to hotels, manufactured or mobile home communities, recreational vehicle communities, youth camps, and private water supplies (Amended at ARRS); 902 KAR 105:010 - defines terms used in 902 KAR Chapter 105 regarding the medical imaging profession and those individuals, other than practitioners in the healing arts, who operate sources of radiation, including nuclear medicine technologists and radiation therapy technologists (Amended at ARRS); 902 KAR 105:030 - establishes uniform curricula standards for institutions teaching persons to operate sources of radiation (Amended at ARRS); 902 KAR 105:040 - establishes uniform standards for the certification of individuals who operate sources of radiation for human diagnostic and therapeutic purposes while under the supervision of a medical, osteopathic, or chiropractic licensed practitioner of the healing arts (Amended at ARRS); 902 KAR 105:061 - repeals 902 KAR 105:060; 902 KAR 105:070 - establishes uniform enforcement procedures regarding the certification of operators of sources of radiation and penalties for violation of certification requirements (Amended at ARRS); 902 KAR 105:081 - establishes uniform requirements for the certification of the limited x-ray machine operator certificate and limited podiatry x-ray machine operator certificate (Amended at ARRS); 922 KAR 1:300 - establishes basic standards of care and service for child-caring facilities. (Deferred from September meeting); 922 KAR 1:310 - establishes basic standards for child-placing agencies. (Deferred from September meeting).
An update on the 2007 Senate Bill 59 "Boni Bill" was given by Mark Washington, Commissioner, Department for Community Based Services, Cabinet for Health and Family Services. Commissioner Washington stated that 120 front-line protection and permanency staff have been hired since April 2007. The department is proactively addressing upcoming retirements and resignations and looking at greater equity in caseloads. He said that the department conducted an national safety conference for key human services leaders and managers to join forces, network, and share models of best practice in creating a lasting culture of safety. The requirement to provide a state criminal background check for protective services investigations and to assess staff safety concerns within one hour after receipt of a request will be operational by the end of 2007. An RFP to procure emergency alert technology for front line staff will be developed in November, and depending on the RFP responses, the safety alert technology should be operation by the spring of 2008. Requests for construction and renovations of office space for improved security for staff have been made to the Finance and Administration Cabinet. A final report of recommendations by the cabinet's safety workgroup will be submitted by November 15 and will also be part of a 2008 budget and legislative request.
Representative Burch asked about the discrepancy in the August and September reports about the projected dates for hiring the safety liaison staff. Commissioner Washington stated that the 24/7 operation required personnel classifications that are not currently in the department. In order to make sure that the system is fully operational when is goes live 24/7, it may require extra implementation time.
Representative Arnold asked if neutral locations are being utilized for visitations, and if so where. Commissioner Washington stated the department has assessed all the visitation sites are statewide and some are not neutral. Commissioner Washington said that workers have accessed the Family Place in Louisville where a clinician can observe the parent and child in foster care. Representative Arnold stated that it would be harder to find neutral locations in rural areas. Commissioner Washington stated there are several visitation centers located on neutral sites and part of the contract involved an evaluation of the facility and service. The evaluation will be used to put together a model visitation site that will become part of a RFP process. They plan to have centers in all areas by 2008.
Representative Owens asked about the number of front-line protection and permanency staff that have been authorized to be hired versus the number that have been hired. Commissioner Washington stated the national standards for caseloads are 12 to 1 per worker on investigations and 15 to 1 per worker on an on-going cases. Approximately 300 additional social workers are needed to meet the national standards. Representative Owens asked if additional funds would need to be appropriated, and Commissioner Washington said yes.
Representative Floyd asked if the criminal background checks are conducted on parents involved in the social service cases, and Commissioner Washington said they are conducted on the alleged perpetrators. Representative Floyd asked how the social security number and permission for a background check is obtained to conduct a criminal background check. Commissioner Washington stated that in the past criminal background checks have been conducted through the Administrative Office of the Courts. The difference with the new system is it will involve a national database.
Representative Westrom was concerned that some supervised visitations have occurred at McDonald's. Commissioner Washington stated that the visits could have occurred because of the lack of a more appropriate place for visitation. He said that studies have shown that supervised visitation can improve reunification and reduce the length of time children spend in foster care.
Senator Roeding asked if the cabinet had utilized churches for visitations. Commissioner Washington said that the faith-based community and churches have shown interest, and he hoped that they would respond to the RFPs in the future.
Representative Burch asked why the counties with already higher caseloads increased caseloads from August to September. Commissioner Washington stated that it should be based on a two- to three-month trend, not month by month. Representative Burch asked how many social workers had quit or retired since April 2007. Commissioner Washington said that the department has a 12.9% quarterly turnover rate. The department plans to appoint one person per region to monitor the turnover rate, but he has no way of knowing how many will chose to retire. Representative Burch said that the department should conduct a survey to find out the number of people who plan to retire within the next couple of years in order to be prepared.
Representative Damron asked if changes had been made in the personnel process to replace workers quicker. Commissioner Washington said that the cabinet now has "quick-fill" positions that helps the department fill the positions faster.
Representative Westrom asked if exit interviews are conducted when a social worker leaves their position, and Commissioner Washington said yes. He stated that the number one reason workers have left is lack of support from management and supervisors, not salary.
Representative Wuchner asked how long a new hire spends with a supervisor to learn to manage a caseload. Commissioner Washington stated three months, which is half of their employee probation period. She asked what the caseload was after three months, and he said it varied, but this is one of the areas the department is studying.
Representative Burch asked when the department anticipated that the entire $6 million appropriated in the Boni Bill will be fully expended. Commissioner Washington said that would come as part of the budgetary process during the 2008 Regular Session. Representative Burch asked about a breakdown of how the money is spent, and Commissioner Washington stated it is provided in the monthly report.
Senator Kerr stated that she applauded the social workers for the tremendous job that they do everyday.
A presentation on community mental health centers was given by Steve Shannon, Executive Director, Kentucky Association of Regional Mental Health and Mental Retardation Programs (KARP). Mr. Shannon stated there are 14 regional community mental health centers (CMHCs). Last year 1) 163,000 Kentuckians were served in community mental health centers; 2) 9,356 Kentuckians were employed by CMHCs; 3) 312 citizens served on CMHC boards; and 4) CMHCs had an annual payroll of $187,120,000. The CMHC statewide network was established in statute. He said that community care and support dollars are state general funds allocated to the CMHCs to help provide services to clients who have no payer source such as Medicaid, Medicare, KCHIP, or private insurance. Without an increase in funding, wait times for initial and follow-up appointments will increase, there will be reductions in locations of service sites, layoffs of staff and not filling open staff positions, restricted access to some services, and increased use of group therapy rather than individuals sessions. Individuals will have to spend their days in jail, hospital emergency rooms, institutions, homeless shelters, alternative school or suspended from school, or on the streets. In conclusion, KARP believes that the lack of funding to meet the growing cost of doing business in providing quality behavioral health care challenges the sustainability of services across the Commonwealth.
Representative Westrom stated that the services provided by the community mental health centers are a safety net for communities and funding is vitally important.
Representative Burch said that the public needs to be kept aware of the mental health issue at all times to remind them of the need for help.
Senator Roeding said Northern Kentucky has a e-health system, "Health Bridge" in place where patient records can be accessed within minutes.
Representative DeWeese said that due to budgetary restraints, one problem is there is less ability to do early intervention. He said that it may cost the state more upfront but, but early intervention treatments will save the state money in the long run.
Representative Wuchner expressed concern about services for mental health and the statewide problem of access to medications for inmates once they are released. She said that 90 percent of those incarcerated is mental health and dual diagnosis issues.
An update on Medicaid cost savings with the Kentucky Health Choices program was given by Mark Birdwhistell, Secretary, and Shawn Crouch, Commissioner, Department for Medicaid Services, Cabinet for Health and Family Services. Secretary Birdwhistell said that reimbursement rates for dental services for children has been increased. Approximately 150 foster care children fall under the category of medically fragile and are being managed by the Commission on Children with Special Health Care Needs the Department for Community Based Services. The cabinet has taken the clinical expertise from the Commission on Children with Special Health Care Needs nurse staff and partners them with the social workers and they provide targeted case management services for the 150 medically fragile foster care children. Nurse from the Commission on Children with Special Health Care Needs have been assigned to each of the regional offices so they have a nurse consultant to be available for the social services staff.
Senator Roeding asked about foster care children and their total Medicaid care. Secretary Birdwhistell said that a foster child is automatically eligible for a medical card.
Representative Burch asked how the cabinet increased dental care services to children by 33 percent. Secretary Birdwhistell said the cabinet restructured the reimbursement rates for orthodontic services to match Passport, redirected the savings to pay for more services and they also increased reimbursement rates for pediatric dentists. Representative Burch stated one recommendation would be to have a dentist in every health department or at least have one on a regularly scheduled basis.
Secretary Birdwhistell said that a major part of the cost containment has come from co-pays. By having a Pharmacy Benefit Administrator (PBA), the cabinet was able to purchase medications through a multi-state discount pool. Approximately $31 million was saved in supplemental rebates by using the discount purchasing pool. Overall, there has been a 3.3 percent reduction in the trend of the rate of growth in pharmacy expenditures. He said that the intent of the cabinet is to flatten out the level of growth. With adjustments to the formulary and the availability to the PBA, the cabinet is saving approximately $2.6 million monthly. There has been a three percent (3%) reduction in the number of prescriptions per person which is down to 3.6 prescriptions per person per month. There has also been a 4.75 percent drop in cost per prescription. There has been a 42 percent increase in cost avoidance by making sure claims are being paid by Medicare, private insurance, or some other source before they are paid by Medicaid resulting in a savings of $1 billion. Approximately $22 million was received in estate recovery.
Secretary Birdwhistell said by implementing the InterQual practice criteria, the cabinet has saved approximately $20 million in one year on occupational therapy services, radiological services, and physical therapy services. Approximately 250 suspicious claims are being reviewed to see if they are appropriate, and they have seen a savings of $500,000 per month. He said that there are 471 individuals in state facilities and 184 in community settings. The consumer direct option has saved the state money and individuals are receiving more services.
Representative Burch asked that the secretary and commissioner attend next month's committee meeting to present more information on the Medicaid cost savings.
Representative Brinkman asked about payers of last resort and the savings seen by Medicaid. Secretary Birdwhistell said the cabinet was not taking full advantage of Medicare reimbursement for services before payment by Medicaid.
Senator Roeding said we are making progress on the uninsured and wanted to know where we need to go next. Secretary Birdwhistell said the cabinet needs to maintain the Medicaid-eligibility base and look at who are the uninsured population.
Representative Burch asked if it was accurate to state that approximately 40 percent of the population nationwide is covered by Medicare, Medicaid, or SCHIP. Commissioner Crouch said it depends on the state. Representative Burch said that our state could be close to having government-sponsored insurance coverage. Secretary Birdwhistell said there is a closer linkage between government insurers and commercial insurers and there is a role for each one of them. The healthy risk pool should be kept in the commercial market.
Representative Damron asked about Medicaid's emergency administrative regulations that had been filed after the cut-off date for printing the Administrative Register so they are in effect for about one month before the public knows about them. He also asked about the concerns the Kentucky Hospital Association had expressed about the administrative regulations. Commissioner Crouch stated the regulations had a clerical error and replacement emergency regulations will be filed. Representative Damron stated that in the future the regulations need to be filed in time to be placed in the Register. Commissioner Crouch said that he had spoken with a representative of the Kentucky Hospital Association about sending a notice to all providers about the emergency regulations so they would not have to wait until the Register was published.
There being no further business, the meeting was adjourned at 3:28 p.m.