The 2nd meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, September 16, 2009, at 1:00 p.m., in Room 129 of the Capitol Annex. Representative Tom Burch, Chair, called the meeting to order at 1:10 p.m., and the secretary called the roll.
Present were:
Members: Senator Julie Denton, Co-Chair; Representative Tom Burch, Co-Chair; Senators Perry B. Clark, Alice Forgy Kerr, Joey Pendleton, Katie Kratz Stine, and Jack Westwood; Representatives Scott W. Brinkman, John "Bam" Carney, Jim Glenn, Joni L. Jenkins, Mary Lou Marzian, Reginald Meeks, Tim Moore, Darryl T. Owens, David Watkins, Susan Westrom, and Addia Wuchner.
Guests: Frederic S. Goldstein, President, U.S. Preventive Medicine, Inc.; Andrew Bernard, M.D., Chair, Department of Surgery, University of Kentucky College of Medicine, and member of the Kentucky Trauma Care Advisory Committee; Julia Carter, PhD, President, Wood Hudson Cancer Research Laboratory; Judy Knueven, BSN, M.S.N., CNS, and Kathy Mueller, RN, BSN, MBA, Wood Hudson Board of Trustees; Larry Douglass, MD, Director of Pathology, Wood Hudson Cancer Research Laboratory; Teri Shirk, CEO and President, and Ellen Kershaw, Public Policy, Alzheimer's Association - Greater Kentucky & Southern Indiana Chapter; Steve Olding, Co-Chair, Kentucky Advisory Council on Alzheimer’s Disease and Related Dementias; Cheryl Sipes, Alzheimer’s Association; Beth Jurek, Executive Director, Office of Policy and Budget, and Murray Wood, Legislative Liaison, Cabinet for Health and Family Services; Eric T. Clark, Kentucky Association of Health Care Facilities; Karen Lentz, Johnson & Johnson; Blarr Schroeder, Cincinnati Children’s Hospital; Jan Gould, Kentucky Retail Federation; Sarah S. Nicholson, Kentucky Hospital Association; Prentice Harvey, Norton Healthcare; and Sean N. Cutter, McBrayer, McGinnis, Leslie, and Kirkland.
LRC Staff: DeeAnn Mansfield, CSA; Amanda Dunn, Miriam Fordham, Ben Payne, Gina Rigsby, and Jonathan Scott.
A motion to approve the minutes of the August 12, 2009 meeting was made by Senator Pendleton, seconded by Representative Meeks, and approved by voice vote.
Senator Stine, Co-Chair, Families and Children Subcommittee, reported the subcommittee met that morning and heard a presentation from Anita Jennings from the Cabinet for Health and Family Services regarding the SIAC and RIAC programs. These programs are State and Regional Interagency Councils that provide services to children with an emotional disability. The programs have been in existence for 20 years and utilize $30 million in system-of-care grants that benefit agencies and citizens across the Commonwealth. SIAC makes annual recommendations to the Legislative Research Commission and the Governor concerning how it is serving the youth of Kentucky. The State Fiscal Year 2010 recommendations involve new public health approaches, suicide prevention, and the transition age of youth. Ms. Jennings said that anyone in need of suicide prevention services can access the website www.kentuckysuicideprevention.org or the toll free number at 1-800-273-TALK.
Michelle Blevins stated the Kentucky Impact Program started in 1990 as a grant from the Robert Wood Johnson Foundation. The program utilizes wraparound services for children, youth, and families to identify and coordinate services and supports for children and youth involved in multiple child serving entities and who have a severe emotional disability. Kentucky Impact serves 6,000 children and youths representing all 120 Kentucky counties. Anthony Bixler and Brandon Lane, two individuals who have received Kentucky Impact services, gave accounts of their positive experiences with the program and said that the program had benefitted them a great deal. Also, a Kentucky Impact case worker, Sed Williams, testified and described how children and youth are referred into the program and how the program works closely with school systems.
The subcommittee also received a presentation on the American Reinvestment and Recovery Act (ARRA) and, specifically, how it has benefitted programs operated by the Cabinet for Health and Family Services that serve Kentucky families. Beth Jurek, Executive Director of the Office of Policy and Budget within the cabinet, told the subcommittee the stimulus funds are not recurring funds and that most of the ARRA funding must be completely spent by December 30, 2010. Ms. Jurek relayed to the subcommittee that the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities, the Commission for Children with Special Health Care Needs, the Department for Family Resource and Youth Services Centers, and the Office of the Ombudsman were departments and offices not affected by the ARRA and received no funding.
The subcommittee was given a detailed report by Ms. Jurek concerning the departments that did receive ARRA funding; including the Department for Aging and Independent Living, the Department for Community Based Services, the Department for Income Support, the Department for Public Health, the Department for Family Resources and Volunteer Services, and the Department for Medicaid Services. Details were presented showing increased funding for the Senior Community Service Employment program that provided over $450,000 to Area Agencies on Aging and allowed for subsidized employment for unemployed seniors. Additionally, senior nutrition programs received more than $1.3 million with over $1.1 million of that money to be spent in State Fiscal Year 2010.
Ms. Jurek also stated that funding in excess of $34 million was provided to the Child Care Development Fund and included child care assistance for low-income working families and child abuse and neglect preventive services. The Community Services Block Grant received nearly $17 million and funded programs such as food banks and provided for emergency assistance for basic needs. The Foster Care and Adoption Assistance Program received almost $12 million and funding was provided for the care and support of children removed from parental custody and to restore funding for private child care providers. The SNAP food stamp program received more than $5 million for additional benefit dollars, additional administrative funds to process the increased applications, and to hire interim workers. The Temporary Assistance for Needy Families (TANF) program will only receive funds if caseloads increase and the program received $1.3 million for a three-quarter period. The Department for Income Support and the Child Support Division will receive nearly $29 million for the benefit of children, custodial parents, and local programs. The WIC program will receive approximately $2.5 million for system enhancements. The First Steps program will receive more than $5 million for the benefit of improving the outcomes for infants and toddlers up to age three. The immunization grant program will receive $2.6 million for vaccine assistance and an additional $2 million dollar grant concerning the H1N1 vaccine. The Department for Family Resources and Volunteer Services will receive over $400,000 in AmeriCorps funds and nearly an additional $400,000 for the Corporation for National and Community Service. Finally Ms. Jurek stated that the Kentucky Medicaid Program will receive an estimated $990 million to handle the increase in applicants for services. A motion to accept the report was made by Senator Pendleton, seconded by Senator Clark, and accepted by voice vote.
A motion to accept Executive Order 2009-770 relating to the establishment of the Governor’s Office of Electronic Health Information was made by Representative Marzian, seconded by Senator Clark, and accepted by voice vote. Beth Jurek, Executive Director, Office of Policy and Budget, Cabinet for Health and Family Services, was present for questions.
The following administrative regulation was referred to the committee for consideration: 201 KAR 21:090 & E – establishes a two-year prechiropractic course of instruction to be completed prior to entry into chiropractic college. Senator Denton asked if the chiropractors were for or against the administrative regulation, and Senator Pendleton stated that the chiropractors were for the regulation at the Administrative Regulation Review Subcommittee meeting. A motion to accept 201 KAR 21:090 & E was made by Senator Pendleton, seconded by Representative Marzian, and accepted by voice vote.
A presentation on prevention in the health care system was given by Frederic S. Goldstein, President, U.S. Preventive Medicine, Inc. Mr. Goldstein stated that the latest mortality statistics from the Centers for Disease Control and Prevention (CDC) show that the U.S. life expectancy reached approximately 78 years and the age-adjusted death rate dropped to 760.3 deaths per 100,000. He said that there are three prevention components for a solution to health care problems: (1) primary – prevent illness; (2) secondary – early detection; and (3) tertiary – chronic condition management. Five unhealthy truths tell the story of the rise of chronic disease and its impact on health and health care in the United States. The first truth is chronic diseases are the number one cause of death and disability in the United States. Chronic diseases kill more than 1.7 million Americans per year and are responsible for 7 out of 10 deaths in the United States. Approximately 133 million Americans, representing 45 percent of the total population, have at least one chronic disease. The second truth is patients with chronic diseases account for 75 percent of the nation’s health care spending. The CDC reports that the United States cannot effectively address escalating health care costs without addressing the problem of chronic diseases. For every dollar spent by an employer for health care for a person with chronic disease, the company can expect to spend $2 to $3 additional dollars for lost productivity. The third truth is two-thirds of the increase in health care spending is due to increased prevalence of treated chronic disease. The fourth truth is the doubling of obesity between 1987 and today accounts for nearly 30 percent of the rise in health care spending. The number of children and youth who are overweight has tripled since 1980. On November 12, 2008, the New York Times reported a new study finds striking evidence that children who are obese or have high cholesterol show early warning signs of heart disease. The fifth truth is the vast majority of cases of chronic disease could be better prevented or managed. The CDC estimates that 80 percent of heart disease and stroke, 80 percent of type 2 diabetes, and 40 percent of cancer could be prevented if only Americans would stop smoking, start eating healthy, and get in shape. Management of chronic disease could also be significantly improved. Chronically ill patients receive only 56 percent of the clinically recommended preventive health care services.
According to the CDC, in 2007, 69 percent of adults in Kentucky were overweight or obese and 16 percent of high school students were overweight, based on self-reported height and weight. Eighty-seven percent of high school students and 82 percent of adults in Kentucky consumed fewer than five fruits and vegetables per day. Sixty-nine percent of Kentucky high school students did not attend physical education classes. Fifty-six percent of adults in Kentucky were not engaged in sufficient moderate or vigorous physical activity. The Miken Institute study finds prevention, early detection, and chronic condition management could positively impact the U.S. economy by over $1 trillion annually. If passed, S-803, The Healthy Workforce Act of 2009 sponsored by Senators Harkin and Cornyn, would give tax credits to employers. It would allow premium differentials for participation, allow premium rebates, allow the use of incentives, implement comprehensive prevention programs for state employees, implement chronic care management for Medicaid, and implement comprehensive prevention for Medicaid. In 2008, the CDC reported that chronic diseases such as heart disease, stroke, cancer, and diabetes were among the most prevalent, costly, and preventable of all health problems. Leading a healthy lifestyle greatly reduces a person’s risk for developing chronic disease. Access to high-quality and affordable prevention measures, including screening and appropriate follow-up, are essential steps in saving lives, reducing disability and lowering costs for medical care. The nation needs to evolve from an illness model to a wellness model. With the U.S. health care system changing rapidly, health care plans need to ensure that all Americans have access to affordable, high-quality preventive services. In 2007, 19 percent of adults aged 18-64 in Kentucky reported having no health care coverage.
Senator Stine stated that for the past several years she and Representative Wuchner have prefiled physical activity bill to help stem the childhood obesity epidemic in Kentucky. She said that the youth need to get physical activity. If Kentuckians can stay healthy, it would help control health care costs and save money.
Representative Glenn asked if other states had any youth programs that have been effective targeting obesity. Mr. Goldstein stated that Yale has a program called ABC that has short bursts of activity during class throughout the day. With this program, grades went up, weight was controlled, and there was approximately 44 percent reduction in the use of medicines like Ritalin. Portland has a program called the Walking Bus where seniors walk children to school.
Senator Denton stated that everyone has to change their lifestyle and behavior. Senator Denton stated that you have to spend money to save money when it deals with health care. Mr. Goldstein said that out of a $1 billion of stimulus money set aside for prevention by the federal Department Health and Human Services, $650 million will be used for programs that can address the growing incidence of chronic disease.
Representative Carney stated that physical education can help with mental illness. He said that we must find a way to make sure we get physical education and activity back into the classroom on a regular basis. An ounce of prevention is a pound of cure, and we have not been using every tool available for prevention.
Representative Moore asked about the definition of a chronic disease, and whether it is more behavior oriented, choice-based, or congenital in nature. Mr. Goldstein stated a chronic disease is something that an individual will have for life. Representative Moore asked at what point does government have the ability to force changes in choice and should we have a denormalized health insurance premium schedule based on chronic diseases based on personal choice and behavior. Mr. Goldstein stated that is up to each state legislature to decide what is best for the state. There are ways to incentivize behavior that may not necessarily go that far.
Representative Wuchner asked if there are studies that show a cost savings in lifestyle changes, and Mr. Goldstein said that the Milken Institute has this information.
Representative Burch asked how you can keep food and beverage companies happy at the same time while pushing for lifestyle changes among people. Mr. Goldstein stated that there has been a shift as the population begins to recognize purchasing habits.
A presentation on the Kentucky Trauma Care System and the Kentucky Trauma Care Advisory Committee was given by Dr. Andrew Bernard, General Surgeon, Chair, Department of Surgery, University of Kentucky College of Medicine. Dr. Bernard stated that injury is a major and growing global public health problem. For each death, many more are disabled temporarily or permanently. Injury is the leading cause of death for persons aged 1 through 44 years in Kentucky and the United States. Kentucky’s traffic deaths alone exceed 800 annually. The economic cost is substantial. Nationally, lifetime medical cost of injuries occurring in one year estimated $80.2 billion. Trauma centers are part of a broad integrated public health framework. Injury is predictable and preventable; interventions have been proven to be effective. Research demonstrates that in states or regions with trauma systems odds of injury-related death are 15 to 20 percent lower, quality of care in included facilities is substantially better, formal protocols for prehospital and hospital care can improve patient outcomes, trauma systems are beneficial to public health, motor-vehicle crash (MVC) related mortality rates are 17 percent lower.
Kentucky has trauma system legislation but no funding to enact or implement components. The four major trauma system components are: (1) trauma data system establishment and expansion; performance improvement; (2) education for trauma care providers; (3) trauma center development; and (4) protocol-based injury care for EMS and hospitals. The Kentucky Trauma Advisory Committee (KyTAC) is an all-volunteer group overseen by William Hacker, M.D., Commissioner, Department for Public Health, Cabinet for Health and Family Services. The KyTAC is comprised of health professionals, policymakers and leaders in the trauma care community in Kentucky and by its nature is neither partisan nor affiliated with any particular interest group. This makes the KyTAC an appropriate group to manage the system, initiatives, and its funds. TraumaBase, vended by Clinical Data Management, serves as Kentucky’s injury data repository, will combine hospital and EMS data and allow reporting, performance improvement and prevention. Education costs for the Rural Trauma Team Development Course, Trauma Nursing Core Course, and Pre-hospital Life Support is $60,000. Consultation visits are extramural reviews of all aspects of a trauma center’s functions and resources. Consultations occur prior to final “verification” visits and are intended to provide guidance during final stages of preparation to become a trauma center. Verification visits are required before new trauma centers are verified. Level 3 consultation and verification visits cost approximately $10,000 each and are payable to the American College of Surgeons Committee on Trauma. Level 4 consultation and verification visits are approximately $2,500 and is anticipated that fees will be payable to KyTAC.
Representative Glenn asked why there was no trauma center in Northern Kentucky. Dr. Bernard stated that trauma patients in Northern Kentucky would be taken to the University of Cincinnati. Representative Glenn asked why there was no trauma center between Paducah and Louisville. Dr. Bernard stated that it relates to resource availability and institutional commitment. A workable system needs to be developed. There are vast underserved and uncovered areas throughout the state.
Representative Carney asked if hospitals contract with private helicopter companies. Dr. Bernard said it varies by hospital. Representative Carney stated that ambulance services will need to be addressed in the future. Dr. Bernard stated that the protocols should be made with the director and medical director of the EMS and representation from the hospital.
A presentation on cancer research at the Wood Hudson Cancer Research Laboratory was given by Julia Carter, PhD, President, Wood Hudson Cancer Research Laboratory; Judy Knueven, BSN, MSN, CNS, and Kathy Mueller, RN, BSN, MBA, Wood Hudson Board of Trustees. The Wood Hudson Cancer Research Laboratory, located in Newport, Kentucky was incorporated in 1981 as the only independent not-for-profit cancer research institute in the state of Kentucky and is a member of the Association of Independent Research Institutes (AIRI). Wood Hudson approaches the cancer problem in three ways: (1) to study clinical cases to better understand cancer biology and treatment; (2) to study environmental causes of cancer; and (3) to provide training for tomorrow’s scientists and physicians. Wood Hudson has the support of the Northern Kentucky Chamber of Commerce and numerous individuals, organizations, businesses, and foundations throughout the Commonwealth. Forty-seven grants have been received from ten Kentucky foundations including nine from the James Graham Brown Foundation.
Wood Hudson has contributed in many areas of cancer research including lung cancer, breast cancer, colon cancer, and prostate cancer. The laboratory houses 780,000 tissue specimens obtained during surgeries performed at St. Elizabeth Medical Center and the St. Luke Hospitals in Northern Kentucky. These tissue samples are the focus of ongoing cancer research at Wood Hudson and are a rich resource for cancer research in the future. The laboratory is working to procure funds to house these tissue samples in a climate controlled safe storage facility. Since 1985, Wood Hudson scientists have collaborated with scientists from the United States Environmental Protection Agency (USEPA). Over a 27-year period, 215 college students have been involved in research at Wood Hudson through the Undergraduate Research Education Program (UREP). These students have gone on to become physicians, scientists, and professors in Kentucky and throughout the United States.
Currently, approximately $13 million, including the tobacco settlement money and the state excise money, for lung cancer research is given exclusively to the University of Kentucky and the University of Louisville. Federal stimulus money might become a source of funding for lung cancer research, construction of a tissue bank, and development of information technology resources at Wood Hudson.
Senator Westwood asked if Wood Hudson would be able to partner with the University of Kentucky and the University of Louisville to share research development and funds. Dr. Carter stated that Wood Hudson has partnered with the University of Louisville on several projects. Senator Westwood asked what is involved to keep the 780,000 tissue samples usable. Dr. Carter stated for cancer research to be effective on archive specimens, the specimens need to be stored at 80 degrees or below according to the National Cancer Institute. According to the International Agency for Biospecimen and Environmental Resources Repositories require specimens to be stored between 65 degrees and 72 degrees. Both the National Cancer Institute and the International Agency for Biospecimen and Environmental Resources Repositories require a sprinkler system be in place. It is crucial that the specimens be stored in a climate-controlled sprinkler system. Senator Westwood asked if the specimens are being stored in a climate-controlled sprinkler system, and Dr. Carter stated that right now they rely on room air conditioners but there is not a sprinkler system which is a liability for Wood Hudson.
Representative Wuchner asked if the $300,000 requested would be one-time money for construction and technology. Dr. Carter stated yes, and then $150,000 per year for three consecutive years.
Representative Watkins asked about the number of researchers available at Wood Hudson currently, and Dr. Carter stated there are currently seven and they are recruiting for two additional researchers because of recent vacancies.
Representative Westrom asked about concerns of taxpayer dollars going to a not-for-profit.
An update on Alzheimer’s disease was given by Teri Shirk, CEO and President, Alzheimer’s Association – Greater Kentucky & Southern Indiana Chapter, and Steve Olding, Co-Chair, Kentucky Advisory Council on Alzheimer’s Disease and Related Dementias. Ms. Shirk stated that Kentucky has the first State Plan that addresses Alzheimer’s disease in the nation. There are 5.3 million Americans that have Alzheimer’s and 80,000 are Kentuckians. This number is projected to grow to $120,610 Kentuckians with Alzheimer’s by 2030. A new case of Alzheimer’s occurs every 70 seconds, and by 2050 an American will develop Alzheimer’s every 33 seconds. One out of eight baby boomers in Kentucky will develop Alzheimer’s. Alzheimer’s is a deadly and fatal disease that impacts families and caregivers. Research has shifted to early warning signs and early intervention using medications to alleviate symptoms. Approximately 70 percent of persons with Alzheimer’s are cared for at home. Nationally, ten million family and friends provide 8.5 billion hours of care. Key supports for families are home care, dementia-appropriate adult day, respite, counseling and training, and Medicaid safety-net assistance. Seventy-one percent of Kentucky nursing home residents have cognitive impairment. Only a small number of nursing homes and assisted living residences provide special dementia care units. Alzheimer’s is the seventh leading cause of death in the United States and fifth leading cause of death for those over age 65. In Kentucky, there has been a 58 percent increase in the number of deaths from Alzheimer’s between 1999 and 2008. Kentucky’s dilemma is Alzheimer’s numbers are exploding, care and treatment services are not keeping pace, there are waiting lists for many aging programs, Adult Protective Services caseloads are overwhelming, and state resources are strained.
Mr. Olding stated that the State Advisory Council on Alzheimer’s Disease and Related Dementias was established by state law in 2000. Its primary purpose is to monitor policies and services affecting residents of Kentucky with dementia, their caregivers and families as well as identify areas of possible improvement. The goals of the council are: (1) to promote public and professional awareness and education of dementia and access to services and programs; (2) to identify and recommend improvements in the delivery of services that enhance quality of life for persons affected by dementia and their caregivers; and (3) to seek ways that Kentucky can secure additional federal and private funds for services and programs. The all-volunteer council is working on two priority issues contained in the State Plan, dementia training and data collection. Due to the lack of funding, additional questions relating to family caregivers and cognitive impairment cannot be added to the annual state Department for Public Health survey. The council is in the process of prioritizing the most important type of data needed and identifying other potential sources to gather information. The Alzheimer’s State Plan recommends offering training to state employees who interact with persons with dementia and their families and caregivers. As the numbers of clients with dementia continue to grow, topics like disease basics, effective communication, safety and protection will become increasingly valuable to train the staff of the Department of Aging and Independent Living. Although the state’s current budgetary constraints pose a real obstacle to the council’s work, fundamental and incremental progress can be achieved with continued support from the legislature.
The warning signs of Alzheimer’s include: (1) memory changes that disrupt daily life; (2) challenges in planning or solving problems; (3) difficulty completing familiar tasks; (4) confusion with time or place; (5) trouble understanding visual images and spatial relationships; (6) new problems with words in speaking or writing; (7) misplacing things and losing the ability to retrace steps; (8) decreased or poor judgment; (9) withdrawal from work or social activities; and (10) changes in mood and personality.
Representative Glenn asked how to determine early signs of Alzheimer’s or dementia. Ms. Shirk stated there is a difference between what is normal aging and Alzheimer’s and dementia. She said it is a repetitive loss of repeated activities. Representative Glenn asked if caregiver courses are offered. Ms. Shirk stated the Alzheimer’s Association function to provide family caregiver training to professionals and to families on a regular basis for free or a nominal fee. Representative Glenn asked about dementia training. Mr. Olding stated that the Alzheimer’s Disease State Plan requires that the Department for Aging and Independent Living staff be trained in dementia. The council wants to extend this requirement the Kentucky State Police, sheriff departments, and EMS. Representative Glenn asked if the police should be required to receive annual training. Ms. Shirk stated that currently first responder training is provided statewide through a national grant to the Alzheimer’s Association. The national grant will not been renewed after 2010. There is no mandate for training for the majority of caregivers. If an institution has a dementia care unit, which there are very few of in Kentucky, there is a mandate for eight hours of training.
There being no further business, a motion to adjourn at 3:02 p.m. was made by Senator Pendleton, seconded by Representative Wuchner, and approved by voice vote.