The 2nd meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, August 12, 2009, at 1:00 PM, at Norton Hospital, 200 East Chestnut Street, Norton Healthcare Auditorium, Second Floor, Louisville, Kentucky. Representative Tom Burch, Co-Chair, called the meeting to order 1:05 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, Katie Kratz Stine, and Jack Westwood; Representatives Scott W. Brinkman, John "Bam" Carney, Brent Housman, Joni L. Jenkins, Reginald Meeks, Tim Moore, Darryl T. Owens, Susan Westrom, and Addia Wuchner.
Guests: Dr. Laman Gray, Jr., Medical Director, Cardiovascular Innovation Institute, Distinguished Chair, Cardiothoracic Surgery, Jewish Hospital, Professor of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Louisville; Guy Brock, PhD; Michael T. Rust, FACHE, President, Kentucky Hospital Association; Dr. Melissa Walton-Shirley, Fellow, American College of Cardiology, Director of the Cardiac Catherization Laboratory, T.J. Samson Community Hospital, Glasgow; Margaret Young Levi, General Counsel, Ephraim McDowell Regional Center, Danville; Dr. Hieu Tran, Dean and Professor, Allen Rose, Jack McGuire, and Tom Davisson, Sullivan University College of Pharmacy; Karen Evans, Director, Newburg Youth Service Center, Jefferson County; Janie Miller, Secretary, Cabinet for Health and Family Services; Eric T. Clark, Kentucky Association of Health Care Facilities; Kari Collins, DBH-State Interagency Council; Mary Jane Williams; Jackie Koch; Shane O’Donley, Office of Health Policy, Cabinet for Health and Family Services; Vicki A. Darnell and Shelly Selby, Ephraim McDowell; Michelle Friday, M.D., Lisa Hinkle, Kevin Halter, and Rod Heineman, Our Lady of Bellefonte Hospital; Rhonda Joyce, Hardin Memorial Hospital; Elizabeth Cobb, Nancy Galvagni, and Sarah S. Nicholson, Kentucky Hospital Association; Chip Peal, Frankfort Regional Medical Center; Doug Winkelhake, President, Norton Brownsboro Hospital; Ronnie Coleman, Kool Smiles; Mary Hass, Brain Injury Association; Darla Bailey; Peggy Williams, Majority Floor Leader’s Office; Laura Belcher, Bill Kindred, and Venkata Reddy, T.J. Samson Community Hospital; Steve Johnson, Brenda Clayton, Clay Ford, and Terry Brownson, Wendell Foster Campus; Karen Weller and Karen Hinkle, Kentucky Home Health Association; Tim Marcum, Baptist Hospital East, and Steve Hart, Kentucky Board of Pharmacy.
LRC Staff: DeeAnn Mansfield, CSA; Mike Bossick, Amanda Dunn, Miriam Fordham, Ben Payne, Gina Rigsby, Jonathan Scott, and Cindy Smith.
The minutes of the June 12, 2009 meeting were approved by voice vote. The following administrative regulations were referred to the committee for consideration: 201 KAR 2:045 – establishes the qualifications required for a pharmacy technician to practice under the general supervision of a pharmacist, and establishes the scope of practice for a pharmacy technician; 201 KAR 20:056 – establishes the requirements for 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 20:162 – establishes procedures for conducting an administrative hearing for the denial, limitation, probation, suspension, or revocation of the license of a registered or practical nurse; 201 KAR 20:260 – establishes the organization and administration standards for prelicensure registered nurse or practical nurse programs; 900 KAR 5:020 – establishes the State Health Plan for facilities and services; 900 KAR 7:030 – establishes the required data, forms, and timetables for submission of data on cost, quality, and outcomes of health care services provided in the Commonwealth to the cabinet and fines for noncompliance by specified health care providers; 902 KAR 19:021 – repeals 902 KAR 19:010, data reporting by health care providers, because the material shall be incorporated into 900 KAR 7:030; 902 KAR 47:200 – establishes standards for the posting and removal of warning signs for a methamphetamine-contaminated property and establishes disclosure and appeal procedures for the owner of a methamphetamine-contaminated property if the property is to be leased, rented, or sold; 911 KAR 2:200 – establishes the provisions relating to early intervention services for which payment shall be made on behalf of eligible recipients. A motion to approve the administration regulations was made by Senator Pendleton, seconded by Senator Clark, and approved by voice vote.
Senator Stine, Co-Chair, Families and Children Subcommittee, reported the subcommittee met that morning and heard a presentation on an overview and update on Kosair Children's Hospital from Thomas D. Kmetz, President of Kosair Children's Hospital and Pediatric Services. The subcommittee learned that Kosair has a proud 117 year history, is the only free-standing Children’s Hospital in the state, and that is the regional pediatric teaching hospital. Kosair has 1,500 employees and operates 261 hospital beds while annually facilitating 45,000 emergency room visits, 50,000 outpatient visits, and 11,000 surgeries. Kosair has a strong and wide presence throughout the Commonwealth evidenced by a clinical presence in every county and by providing services to more than 100,000 individuals from all 120 counties.
Kosair is one of the state’s largest Medicaid providers, serving more than 107,000 children through Medicaid and Passport. Kosair serves over 1,000 families each year through the “Just for Kids” transport team, which is a fixed wing airplane used to transport children in need of trauma care. The children’s hospital also operates a telemedicine network linked to 20 hospitals throughout the state. Their telemedicine focus is cardiology, neonatology, pulmonary, genetics, and gastroenterology. Kosair focuses on child advocacy through Child Passenger Seat inspections, programs dealing with pediatric obesity, asthma, and childhood diabetes. Kosair proudly operates the Kentucky Regional Poison Center, which receives calls from more than 70,000 families from all 120 Kentucky counties annually. Kosair is currently focused on a $208 million “Just for Kids” Growth Campaign initiative to ensure Kosair remains a premier children’s hospital. Kosair has identified and is addressing the following key components that are needed to successfully operate a children’s hospital; sustaining the physician workforce, achieving outstanding facilities, promoting academic programs and affiliations, creating clinical care infrastructure, and fostering participation in research.
The subcommittee also heard a presentation about Pediatric Telenursing presented by Dr. Marilyn Schleyer, Chair of Advanced Nursing Studies at Northern Kentucky University and Dr. Ben Martz, Chair of the Business Informatics Department at Northern Kentucky University. The presenters discussed the issue and challenges of telenursing services in the Commonwealth and presented the subcommittee with possible solutions regarding the delivery of telenursing services involving Northern Kentucky University as a resource. After the June meeting of the Interim Joint Committee on Health and Welfare held at Northern Kentucky University, the presenters explained that discussions began at Northern Kentucky University regarding the growing need for home health visits regarding pediatrics and focused on identifying ways to expand the capabilities of the health care system to allow more home health. Northern Kentucky University believes that it can utilize their Masters in Health Informatics and Masters in Nursing programs to help provide a solution to telemedicine in Kentucky. Northern Kentucky University believes that through information systems technology and the utilization of qualified nursing students that telenursing can be successfully accomplished by qualified nursing students being engaged to provide the hands on part of a home health care visit while Registered Nurses and Nurse Practitioners continue to supply the advanced practice part of the visit. Northern Kentucky University proposes a Pilot Telemedicine implementation that will save money, save time, train better nurses, visit more patients, and improve patient recovery. Northern Kentucky University is looking to partner with an entity to develop and implement a Pilot Telenursing program. A motion to adopt the report was made by Senator Stine, seconded by Senator Clark, and adopted by voice vote.
The Senator Westwood reported the Health Issues and Aging Subcommittee met and heard a presentation by Steve MacLauchlan, President, Norton Audubon Hospital, about the newly created acute care for elders, or ACE, unit at Norton Audubon Hospital. The goal of the ACE unit is to minimize the likelihood of functional decline in older hospital patients. ACE will have program features such as a multi-disciplinary team of providers, a specially designed environment, and treatment protocols. Programs like ACE have shown increased discharges to home and reduced lengths of stay, need for nursing care after discharge, and readmission rates. Mr. MacLauchlan stated that medication reconciliation is done for every patient. The patient’s pharmacist and primary care physician are contacted to get an accurate list of medications. Mr. MacLauchlan said that for several weeks, a transition coach works to bridge the gap between the hospital and the home by identifying and following up on common post-discharge problems. Medicare is only billed if a patient requires home health services. Mr. MacLauchlan stated there is a multidisciplinary approach aimed at treating the whole person and their family, not just the condition that brought the patient to the hospital. Good therapy for a patient is to allow family members to have stay with them in the ACE unit. Mr. MacLauchlan stated that the elderly population cannot be looked at as a monolith group and Norton’s goal is to identify elderly patients who need acute care and provide the best care possible for each patient. He stated that as more data is published, it has caused organizations see the value of reducing readmission rates. Mr. MacLauchlan stated that payment is made through Medicare, Medicare with Medicaid supplements, or a Medicare replacement product. Representative Moore said that he is encouraged to know that as an industry you are constantly looking for ways to improve patient care; to provide for continuing quality of life after a hospital stay; and to minimize cost. Representative Moore said that he is grateful, as an industry, the innovative ideals are coming from within and not being imposed by government. Mr. MacLauchlan said that because it is being limited to a medical diagnosis group, it was determined that no more than 10 beds would be needed at present, but more could be added. He stated that even if home health is involved, the hospital staff would stay in contact with the patient for a reasonable period of time. Mr. MacLauchlan stated typically there is a 30-day readmission rate.
The subcommittee next heard a presentation by Ms. LuAnn Epperson, President and CEO, Prevent Blindness Kentucky Division, Ms. Darlene Eakin, CAE, Executive Director, Kentucky Optometric Association, and Dr. Bill Reynolds, optometrist from Richmond, on vision screening protocols for children. Currently, all children enrolled in a public school, a public preschool, and the Head Start program are required to have an eye examination by an optometrist or ophthalmologist no later than January 1 of the school year. However, many children fall through the cracks because there is not a mandated grade in which vision screenings must occur. It is up to the discretion of the school district as to when screenings should be scheduled. The presenters recommended that the state establish a unified vision screening protocol in which children are screened during the same years statewide and create a plan to train and certify vision screeners according to national standards. There are already mandatory eye screenings. A child has to be screened twice during their school years, but there is no requirement of what the screening would consist. Dr. Reynolds stated that the cost of equipment would be minimal for a more detailed screening. The problem is not just with cost, it is also the time of the school nurse who performs the screenings. The cost would depend on how detailed of a program is set up. The screenings in schools are currently free. The cost for children who fail the screening would be the routine cost of the eye examination which ranges from $40 to $100, and the cost of glasses, if needed. He said they would like to work with Prevent Blindness America and set up a system to try to bring in volunteers. The proposed federal legislation, Vision Care Act for Kids, would appropriate money to the state for screenings for children. The Kentucky Vision Project has over 300 optometrists who have volunteered to see one child a week for free. House Bill 706 from the 2000 Regular Session appropriated $150,000 to help needy families.
A huge concern is if parents think they could afford to take their child to an optometrist. Dr. Reynolds said that most schools feel their obligation has been met when a letter is sent home to parents stating their child failed the screening. Unfortunately, some parents do not think their child needs further examination and some may not be able to pay for the examination. Schools feel they have done what is necessary when letters are sent home to parents indicating that their child failed the vision screening and should be seen by a physician. He said that there should be better education about available resources if a child is unable to pay for an examination. Dr. Reynolds said that they work with Family Resource Centers to help make the information available. He said that a packet of information on school screenings and available resources should be sent home to parents. Ms. Eakin stated that a list of resources is available from the Kentucky Optometric Association. A recommendation was made to talk to the Kentucky Department of Education about sending out an e-mail to districts urging them to send the information home. Dr. Reynolds stated that there is a need for good protocols on timelines, procedures, and follow-up for an effective vision screening program. Dr. Reynolds stated that the current regimen of an entrance examination and two screenings is sufficient. They recommend a standardized screening that tests more than distance vision. Depending on how detailed the procedure is, it would take approximately two to three minutes. He explained that the school entrance test is a full examination and school screenings are not a full examination. He said that the optometrists are willing to help parents with the cost of the office examination. Ms. Eakin stated there is statutory authority for the Department of Education to have uniformity throughout the state. Dr. Reynolds agreed that parents need information to let them know the examination could be free, so hopefully there might be a better follow-up by parents. Ms. Eakin said that the Sight for Students Program will pay for an examination and glasses all the way through high school. A parent needs to contact the Family Resource Center which will send the information to the Kentucky Optometric Association which will then send out vouchers to families. Ms. Epperson said that the Vision Service Plan conducted a study with 1,500 participants which revealed that one in five 12 to 17 year olds have difficulty seeing in the classroom. She said that 45 percent of the children reported having some type of prescription eyewear. Ms. Epperson stated that the screening and examination go hand in hand to make sure children have good vision for life.
The subcommittee also heard testimony from Dr. Kraig E. Humbaugh, M.D., M.P.H., Director, Division of Epidemiology and Health Planning, Department for Public Health, Cabinet for Health and Family Services, on the state’s plan to handle the upcoming flu season. Dr. Humbaugh reported that the Department for Public Health not only has to prepare for the annual seasonal flu threat, but also the new H1N1 flu strain, more commonly known as the swine flu. The transmission mechanisms and severity of H1N1 are comparable to seasonal flu, but H1N1 has a higher incidence in children and causes more complications in pregnant women and those with chronic diseases. The Governor’s pandemic influenza summit is scheduled for September 3 in Frankfort aimed at government agencies, elected leaders, schools and universities, and faith-based groups. On-line registration for the summit is available. The seasonal flu vaccine is expected to be readily available this year and most will be able to get a flu vaccination. The H1N1 vaccine is expected to be available from the federal government through public health in the fall. But, demand could exceed supply which will require limiting the first shipments to the following priority groups: pregnant women; health care workers; household contacts and caregivers of children less than six months old; children ages six months to four years; and children with a chronic medical condition. Two doses of the H1N1 vaccine will be required for immunity. The delivery of the H1N1 vaccine will likely be complicated by the simultaneous administration of the seasonal flu vaccine.
Tom Davidson, Senior Vice President, Sullivan University, stated the college is a private for-profit institution that was opened in the summer of 2008 with 74 students enrolled. In 2009, 87 students were enrolled. The Drug Information Center at the college gets drug information to professionals in the community.
A presentation on “Can Pharmacists be a Part of the Solution for Health Care Expenditures” was given by Hieu T. Tran, Pharm.D., Founding Dean and Professor, Sullivan University College of Pharmacy. Dr. Tran stated that pharmacist intervention has shown to improve quality of life for patients, to reduce the number of physician visits and hospitalizations, to reduce overall health care dollars spent, and to help prevent misuse of medications and medication errors. The Kentucky Department of Public Health report, Healthcare in Kentucky: A Review of Hospital Inpatient Data Utilization, showed that between 1991 and 2004, dollars spent on personal health care rose 7.5 percent; dollars spent on hospital care rose approximately six percent; and dollars spent on physician and clinical services rose approximately eight percent. In 2007, one day of inpatient services costs an average of $1,390 per patient which is an increase from $910.57 in 1999. The average hospitalization stay ranges from $7,000 to $12,000. Data on pharmacist intervention in clinics who served congested heart failure patients showed: (1) outpatient health care was lower across all cost categories except for drugs; (2) inpatient health care costs were more than $2,000 less; and (3) the mean difference in health care costs was approximately $2,900 per patient. The Asheville Project relating to asthma found the following results: (1) costs spent on medication increased, but overall medical claim costs decreased; (2) emergency department visits decreased from 9.9 percent to 1.3 percent; hospitalization visits decreased from 4.0 percent to 1.9 percent; direct costs savings averaged $725 per patient per year; and indirect cost savings averaged $1,230 per patient per year. Studies show there is a tendency for lower overall health care costs when pharmacists intervene in cases of the most disease states.
Representative Westrom asked for a more detailed explanation on pharmacist intervention and how the pharmacist participates as a member of the team of professionals. Dr. Tran stated that when a patient comes to the clinic, he works with the nurse to take vital signs, weight, and medication history, and screen for drug interactions, and make recommendations about medications. Representative Westrom asked if the pharmacist worked for a physician, worked independently, or worked at the hospital. Dr. Tran said that the pharmacist is part of a team.
Representative Meeks asked how many graduates will stay and work in Kentucky. Dr. Tran said 52 percent of the first class in 2008 are from Kentucky and 61 percent from the class that started in July, 2009. Dr.Tran stated that approximately 50 percent of the University of Kentucky pharmacy graduates will remain in the state. Dr. Tran stated that pharmacists can have a great impact in Kentucky. Representative Meeks said that the data showed the cost of physicians in the intervention group was twice as high, but the cost of the physician in the controlled group was three times lower and asked if this was just trading off costs. Dr. Tran stated each category itself may not give a clear picture of the contribution of the pharmacist. Representative Meeks asked if they anticipate over time that it would change as the working relationships are worked out. Dr. Tran said the pharmacist profession would love to be a full part of the healthcare team. Mr. Davidson stated that the college is researching several doctoral programs in both education and medical sides.
Representative Carney asked what could be done about rising pharmacy costs. Dr. Tran stated contracts need to be renegotiated with insurance companies and the Federal Drug and Food Administration needs to review their rules on drug approval and revamp itself, and pharmacist intervention. Mr. Davidson said that medical therapy management works.
Representative Owens asked if there is an average attrition rate for all medical schools, and asked how their pharmacy college has been able to retain all enrollees. Dr. Tran stated that the national attrition rate is three percent for professional degrees. Dr. Tran stated that there is a remediation process so every student has a chance to succeed. As a faculty, they are responsible for the success of the students. The faculty is required to monitor the class for any student who is at risk of failing. Mr. Davidson stated the college is two years ahead in the accreditation process.
A motion to accept Executive Order 2009-661 relating to the State Interagency Council for Services to Children with an Emotional Disability, and the FY 2010-11 Community Services Block Grant Application was made by Representative Owens, seconded by Representative Meeks, and accepted by voice vote.
A presentation on the Newburg Middle Youth Services Center, Jefferson County Public Schools, was given by Karen Evans. The Kentucky Family Resource and Youth Services Centers (FRYSC) were established as a component of the 1990 Kentucky Education Reform Act (KERA). There are 820 FRYSCs serving 615,917 students in 1,163 schools with approximately 46 percent eligible for free school meals. Schools where at least 20 percent of the student population is eligible for free or reduced school meals may compete for FRYSC funding. FRYSCs are strengthened by community partnerships in their ability to provide vital programs, services, and referrals to students and their families. The partnerships are critical in efforts on behalf of student to promote early learning and successful transition to school, academic achievement and well-being, and graduation and transition into adulthood. Each center offers a unique blend of programs and services to serve the special needs of their students and families. The goal of the FRYSCs is to meet the needs of all children and their families as a means to enhance student academic success. On April 15, 2008, Senate Bill 192 was signed into law allowing changes to the FRYSC core components. Family Resource Centers serve children through age 12 and coordinate: (1) preschool child care; (2) after-school child day care; (3) families in training; (4) family literacy services; and (5) health services and referrals. Youth Services Centers serve students older than 12 and coordinate: (1) referrals to health and social services; (2) career exploration and development; (3) summer and part-time job development (high school only); (4) substance abuse education and counseling; and (5) family crisis and mental health counseling. Ms. Evans stated that a child cannot be successful if they are not at school, and she works with students and families to address problems that would prevent a child from attending school.
Representative Burch stated that the FRYSCs are one of the best programs that benefit children and families statewide.
Representative Owens asked how the centers work with the Cabinet for Health and Family Services to identify children who are eligible for KCHIP. She stated that they help families either fill out the on-line application or mail the application to the cabinet. Representative Owens asked about the turnaround time for approval by the cabinet after an application is received. Ms. Evans stated between two to three weeks.
Senator Harper Angel stated that she was proud of the accomplishments that the Newburg Middle Youth Services Center has made.
A presentation on the Kentucky Pilot Project for Primary Percutaneous Coronary Intervention (PCI) without onsite Coronary Artery Bypass Graft Surgery (CABG) was given by Dr. Laman Gray, Jr., Medical Director, Cardiovascular Innovation Institute, Distinguished Chair, Cardiothoracic Surgery, Jewish Hospital, Professor of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Louisville and Guy Brock, PhD. Primary PCI is a proven, life-saving intervention for patients experiencing an acute myocardial infarction, if it can be provided in a timely fashion. The safety of PCI has improved greatly over the last two decades, with fewer the one to two of every 1,000 cases requiring emergency open heart surgery. Allowing eligible hospitals without emergency open heart surgical facilities to perform primary PCI will reduce the time until intervention during an acute myocardial infarction and could ultimately save patients’ lives.
Two hospitals, without emergency back-up open heart surgical capabilities were allowed to perform primary PCIs for more than three years. The two hospitals selected, T.J. Samson Community Hospital in Glasgow and Ephraim McDowell Regional Medical Center in Danville, were of similar size and similar distances from hospitals with onsite emergency back open heart surgical capabilities. Recommendations are that primary PCI should be performed in facilities that have an experienced cardiovascular surgical team available as emergency back-up for all procedures. The results suggest that there is no significant difference in any of the outcome variables studied between the two facilities included in the pilot study and other facilities nationwide both with and without onsite CABG. Facilities without onsite CABG meeting the operator and institutional requirements set by the American College of Cardiology and the American Health Association can be considered for providing primary PCI to patients. The facilities will need to be continually monitored with regard to outcome quality measures to ensure patient care is held at a high standard. It is recommended that the performance of the facilities be reviewed biannually by an independent, external group.
Elective PCI is more controversial because the patient can wait and have the PCI performed at a facility that can provide the most comprehensive cardiac medical care. Whether more comprehensive cardiac medical care is associated with better outcomes is not well established. There is a need to weigh outcomes and increases in direct and indirect effects on quality of life. Few studies have investigated outcomes when elective PCI has been performed at facilities without surgical back-up capabilities. It is difficult to empirically define which facilities should be allowed to perform elective PCI. There is a need for data associated with facilities without emergency back-up capabilities that perform elective PCI and an evaluation of the population of individuals who undergo elective PCI. Recommendations are: (1) allow the top facilities in Kentucky without open heart surgical back-up who meet the standards set by the American College of Cardiology and the American Health Association for performing primary PCI and have successfully demonstrated competency in performing primary PCI to enroll in a pilot study to test the safety of elective PCI; (2) monitor patient outcomes as in the primary PCI study; and (3) conduct a two-year non-inferiority trial with six-month interim analyses by an independent, external center.
Representative Burch asked how many angioplasty procedures are done each year. Dr. Gray stated that Jewish performs 1,000. Representative Burch asked if a smaller hospital would be able to do as many, and Dr. Gray stated the recommendation is the cardiologist performing the intervention has to have performed a minimum of 75 angioplasties per year. Representative Burch asked about measurements of outcomes of procedures. Dr. Gray stated they are hard to measure. The American College of Cardiology recommends all hospitals have to fill in a database on every patient and the data should be made public. Representative Burch asked how a patient would know where to go to have the procedure if the information were not available. Dr. Gray said his recommendation is that the information be made available to the public, but, is not being done currently.
Representative Moore asked if the procedure is offered 24 hours a day, do all hospitals have the expertise and staff around the clock to offer this or would it be an undue burden. Dr. Gray said that the two pilot project hospitals had 24-7 coverage and met the criteria. Any hospital should have to meet the same criteria as the two pilot hospitals to perform the procedure. Representative Moore said that people should not have to make a two-hour trip to another hospital if there is a cardiologist on call certain hours of the day. Dr. Gray stated that cardiologists are on call but not always at the hospital. Janie Miller, Secretary, Cabinet for Health and Family Services, said that when the pilot project began, the cabinet promised to bring recommendations to the committee for consideration. The cabinet will make a decision whether to expand the pilot program, how to expand it, and under what conditions will it be expanded through the regular regulatory process.
Senator Buford stated that it is unacceptable to have to drive long distances for the procedure that can be handled by qualified facilities that are closer. The time delay could cause death and or other complications. Dr. Gray said that his personal opinion should be allowed in qualified centers without surgical back up in the case of the acute myocardial infarction.
Representative Owens asked when the pilot would become permanent. Secretary Miller stated the cabinet will analyze all the data and input and have recommendations within the next three to four weeks.
Representative Housman asked when the pilot study expires. Secretary Miller stated the two pilot hospitals would continue to perform emergency angioplasty procedures. She there is nothing in the administrative regulation that sunsets their ability to continue to perform the procedures. It would take action by the cabinet through the regulatory process to allow them to perform elective procedures and expand the opportunity to other hospitals to perform them on emergency and or elective basis.
Representative Meeks stated that some of the information is conflicting amount the number of procedures that would be required per year. Dr. Gray said that the cardiologists perform the procedures in other hospitals, therefore, meet the required number of procedures per year.
Representative Housman asked what percentage of the angioplasty surgeries would be performed as elective or emergency procedure. He asked if the surgery results in a cost saving or cost increase. Dr. Gray said that it is not a cost increase. If a patient needs the procedure, it will be done. Representative Housman asked if the procedure is a preventive step and a patient does not have the procedure and it leads to AMI, will that increase healthcare cost in the future. Dr. Gray stated that if a person with coronary disease does not have an elective or emergency procedure, the highest probability is the patient will have a myocardial infarction or die. Death rate for heart disease has plummeted because of angioplasties and surgery. Representative Housman asked if it comes down to a battle of certificates of need. Dr. Gray stated that if the procedures are performed in unskilled places, it could increase the death rate.
Senator Stine asked if there is a higher complication rate having to transport a patient to another hospital, would a hospital not go ahead and perform the procedure. Dr. Gray said that doing the procedures is the best practice.
Representative Wuchner asked if the outline for the standard of care for acute and elective procedures in outlying hospitals should be begin a pilot and then extend to having those services in place at the hospital. Dr. Gray said that it is correct.
Senator Buford stated that elective surgery is not cheap, and therefore, many individuals cannot afford the elective procedure. He said that the bottom line is to deal with the life of an individual and then decide how much someone’s life is worth. There has to be better access.
Dr. Melissa Walton-Shirley, Fellow, American College of Cardiology, Director of the Cardiac Catherization Laboratory, T.J. Samson Community Hospital, Glasgow, stated that T.J. Samson Community Hospital and Ephraim McDowell should be approved for elective procedures. She stated that 90 percent of the angioplasty procedures performed are emergencies.
Margaret Young Levi, General Counsel, Ephraim McDowell, Danville, stated that the Veterans’ Hospital and St. Claire Hospital already perform angioplasty procedures. She stated that she agreed with the pilot study except they should be able to perform elective angioplasty. She said that the procedure should not have to be performed on a certificate of need basis.
Michael T. Rust, FACHE, President, Kentucky Hospital Association, stated that the two pilot hospitals wish to expand their services to treat not only emergency but elective patients. Other hospitals want the opportunity to offer both emergency and elective angioplasty because they have the staff and feel that they can demonstrate a need for the service and meet minimum quality requirements. In order for all the hospitals to be allowed to perform these procedures, the State Health Plan need criteria for cardiac catheterization must be changed. The Kentucky Hospital Association (KHA) convened a committee that considered the results from the two pilot hospitals, the national guidelines, volume standards, and need criteria adopted in other states. From this process, KHA developed recommendations for revising the State Health Plan cardiac catheterization review criteria. KHA’s recommendations would allow the two pilot hospitals to immediately begin performing elective procedures by granting them expedited CON approval. It also would allow other hospitals to establish both primary and elective angioplasty services if they meet certain criteria instead of expanding the existing pilot program where hospitals could only perform angioplasty on emergency patients for two years before elective procedures could be performed. He said that many of the recommendations are very similar to those contained in the pilot study report.
Representative Wuchner asked that with the support of KHA, the two pilot hospitals were asking for an expedited CON and extension of allowing the new standard of care to dictate in allowing hospitals to expand services, and everyone said yes.
Representative Burch asked how many angioplasty procedures were performed at the two pilot hospitals and how many deaths or complications occurred. Vicki Darnell, Chief Operating Officer, Ephraim McDowell, said of the 330 procedures performed between the two hospitals, there were no deaths or complications.
Representative Burch asked if this was enough. Dr. Gray stated that a hospital should not be able to perform elective procedures before proving competency in emergency procedures. It takes commitment of the hospital and physicians. The two pilot hospitals should be allowed to perform elective angioplasties because they have proven they can perform the procedures.
Dr. Michele Friday, Our Lady of Bellefonte Hospital, Ashland, stated that the State Health Plan should be changed to permit therapeutic catheterization to be performed in facilities without on-site open heart surgery backup. Recent research has documented that every delay in accessing primary percutaneous coronary intervention (PCI) for a patient experiencing an acute myocardial infarction (AMI) increases the mortality rate by seven percent. The transfer does not only place the patient at higher risk, but also is extremely costly. Early intervention provides economic benefits to all involved. Cardiovascular disease is the leading cause of death in Kentucky. Improving access to life-saving treatment for an AMI reduces mortality and morbidity and will allow Kentucky to improve the standard of care. Numerous national studies have proven that PCI procedure success, complication, and mortality rates are virtually identical between sites without and with on-site surgery backup. The outcomes of the Kentucky Pilot Project for Primary Angioplasty are consistent with the national findings. The proposed change would ensure access to PCI services for the minority and medically underserved rural populations. Currently, the administrative regulation is keeping AMI patients from prompt, immediate access to lifesaving care. Our Lady of Bellefonte Hospital is principally concerned with providing a complete spectrum of services and high quality of care to the patients it serves. Our Lady of Bellefonte Hospital requests that the distinction between diagnostic and therapeutic catheterizations be omitted from the State Health Plan. It also recommends that the definition section of the cardiac catheterization review criteria be revised to note that a primary angioplasty procedure performed for a patient on an emergency basis by a licensed provider of diagnostic catheterization services not be considered a therapeutic procedure.
A motion to adjourn at 3:54 p.m. was made by Representative Carney, seconded by Representative Wuchner, and approved by voice vote.