Call to Order and Roll Call
The 5th meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, October 20, 2010, at 1:00 PM, at the Brown & Williamson Club, Papa John’s Cardinal Stadium, 2800 S. Floyd Street, Louisville, Kentucky 40209. Representative Tom Burch, Co-Chair, called the meeting to order 1:10, and the secretary called the roll.
Present were:
Members: Senator Julie Denton, Co-Chair; Representative Tom Burch, Co-Chair; Senators Tom Buford, Julian M. Carroll, Perry B. Clark, Denise Harper Angel, Alice Forgy Kerr, Joey Pendleton, Katie Kratz Stine, and Jack Westwood; Representatives Bob M. DeWeese, Joni L. Jenkins, Mary Lou Marzian, Tim Moore, Darryl T. Owens, Susan Westrom, and Addia Wuchner.
Guests: Dr. Don Miller M.D., Ph.D., Director, James Graham Brown Cancer Center; Dr. Richard Goldstein, M.D., Ph.D., Vice Dean of Clinical Affairs and Professor of Surgery, University of Louisville School of Medicine; Demetra Antimisiaris, PharmD, Assistant Professor, Director of Geriatric Pharmacotherapy, Department of Family and Geriatric Medicine, University of Louisville; Kevin T. Kavanagh, MD, MS, Board Chairman, Health Watch USA; Dana Stephens, Director, Infection Prevention and Control, Saint Joseph Health System; Kraig E. Humbaugh, M.D., M.P.H., Director, Division of Epidemiology and Health Planning, Kentucky Department for Public Health, Cabinet for Health and Family Services; James Ramsey, President, University of Louisville; Hope McLaughlin and Nick D’Andrea, University of Louisville; Mike Weinrauch, Commission on Children with Special Health Care Needs, Cabinet for Health and Family Services; Eric T. Clark, Kentucky Association for Health Care Facilities; and Charles George, Kentucky Chamber.
LRC Staff: DeeAnn Mansfield, Miriam Fordham, Ben Payne, Jonathan Scott, Gina Rigsby, and Cindy Smith.
Approval of the Minutes
A motion to approve the minutes of the September 15, 2010 meeting was made by Senator Carroll, seconded by Representative Jenkins, and approved by voice vote.
Consideration of the Referred Administrative Regulations
The following referred administrative regulations were on the agenda for consideration: 201 KAR 2:330 – sets out the conditions whereby a pharmacy may operate temporarily in an area not designated on the pharmacy permit pursuant to an executive order issued by the Governor as authorized by KRS 315.50; 201 KAR 20:057 – establishes the scope and standards of practice for an advanced practice registered nurse; 201 KAR 20:070 – establishes the requirements for the licensure of nurses by examination; 201 KAR 20:110 – establishes the requirements for licensure by endorsement and establishes the requirements for a temporary work permit for an applicant to practice nursing while the application for a license is being processed; 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 20:225 – establishes the procedures for reinstatement of a nursing license that has lapsed or has been subject to disciplinary action; 201 KAR 20:230 – establishes requirements and procedures for the renewal of nursing licenses; 201 KAR 20:240 – establishes fees for nurse licensure, examination, renewal, reinstatement, and continuing education; 201 KAR 20:370 – establishes requirements and procedures for nurse licensure; 201 KAR 20:411 – establishes the requirements relating to a sexual assault nurse examiner course and the credentials of a sexual assault nurse examiner; 201 KAR 20:470 – establishes the requirements for dialysis technician training programs and for credentialing dialysis technicians. A motion to accept the administrative regulations was made by Senator Buford, seconded by Senator Carroll, and accepted by voice vote.
Cancer Vaccines
Dr. Don Miller M.D., Ph.D., Director, James Graham Brown Cancer Center, stated that cancer is a major public health problem in Kentucky. Kentucky’s cancer incidence and death rates are 40 percent greater than the national average and the gap is not narrowing. The Bucks for Brains has funded 14 endowed positions, the Kentucky Lung Cancer Research Program has taken Kentucky from no lung cancer research ten years ago to 26 laboratories that work on lung cancer research, the tobacco excise tax has been important in recruitment of new faculty, the coal severance tax has supported the dataseam project, and support of the translational research program. Gardasil was developed at Georgetown University and is the first 100 percent effective cancer vaccine, but costs $360 per person. The university is in the process of developing a tobacco-based vaccine for cervical cancer that would be much less expensive to produce. Since 1999, approximately $50 million has been invested in building the drug development program and approximately $80 million in federal funding has helped support drug development research. The university has a satellite cancer research center located in Owensboro that concentrates on natural products, particularly those produced in plants.
The Owensboro Cancer Research Center recently received a $3 million grant from the Leona Helmsley Foundation. Advanced Cancer Therapeutics is a biotech startup company owned by the University of Louisville, the James Graham Brown Cancer Center, and local investors. The company is financed by local investors and pharmaceutical partners. The company will allow the center to develop two to three new drugs per year. Early clinical trials will be done with Kentucky patients. In 2011, the center will submit an application to become an NCI designated cancer center.
In response to a question by Representative Burch, Dr. Miller stated that there is no scientific evidence that nine to twelve year old girls who get the Gardasil vaccine will become more sexually active.
In response to a question by Representative Moore, Dr. Miller stated that the presence or absence of a cervical cancer vaccine has nothing to do with the incidence of cervical cancer. Cervical cancer screenings are less universally utilized in parts of Appalachia as they are in the rest of the state and the country. The sooner someone is diagnosed with cancer the sooner they can receive treatment. The Kentucky Cancer Program has had a long emphasis on smoking cessation. Research is being conducted to find better ways to help individuals stop smoking.
In response to questions by Senator Clark, Dr. Miller stated that radon is the second most important cause of lung cancer, and the center is looking for better ways to detect radon and avert its affect. The financial benefit to holding a patent on a medication or treatment is the university receives half of the royalties and half goes to the scientist who invents the medication or treatment. The university will receive 30 percent above the royalties from the Advanced Cancer Therapeutics biotech company.
Medical School Partnerships
Dr. Richard Goldstein, M.D., Ph.D., Vice Dean of Clinical Affairs and Professor of Surgery, University of Louisville School of Medicine, stated there has been an increase in medical student class size from 142 to 160 per year and 75 percent of these students are from Kentucky. Approximately half of the students who graduate stay in Kentucky to practice medicine. It is important to educate and retain medical students in Kentucky. The relationship between the Louisville Veterans Hospital and the University of Louisville School of Medicine is beneficial to both the veterans and the medical students. The first of four planned student housing complexes will break ground within the next few weeks. Each housing complex will include an on-site faculty member. The University of Louisville has a self-insured plan that spends $43 million in health care costs to cover 9,600 employees. The PharmD helps them understand medications prescribed for diabetes and teaches them how to treat the disease.
In response to questions by Senator Denton, Dr. Goldstein stated that the chronic disease management program at the university began in March 2010. There are no co-payments for the treatment of and medications for diabetes, hypertension, or lipid lowering medications for the approximately 420 people in the program. The diabetes chronic disease program could possibly help save $2 million per year.
In response to questions by Senator Carroll, Dr. Goldstein stated that the cost for each individual in the University of Louisville’s diabetes chronic management program is approximately $10,000 per year. With better management this amount could be reduced by $2,500 per year. There is no coordinated aligned delivery system and some patients do not know why they are on certain medications. All people in the program meet with the pharmacist to make sure they understand why they are on their medications and how they can better manage their diseases. If a person understands how to manage the disease and have the correct medications, it helps reduce emergency room visits. If overall cost can be reduced to the health care plan, it can be delivered at less expense per month to all 9,600 employees.
In response to questions by Senator Stine, Dr. Goldstein stated that the medical school recognized the need to be more responsive to the healthcare needs of the state. Family medicine and internal medicine have struggled to make rural health or primary care something that is attractive to medical students. It is difficult to determine if a medical student may be predisposed to practicing primary or rural health care.
Polypharmacy
Demetra Antimisiaris, PharmD, Assistant Professor, Director of Geriatric Pharmacotherapy, Department of Family and Geriatric Medicine, University of Louisville, stated that polypharmacy is the use of five or more medications at the same time. The signs and symptoms are mental status changes, not eating or sleeping, generalized pain, and falling. Approximately 2,216,000 hospitalized patients experienced an adverse drug event. Approximately 30 percent of older persons are admitted to the hospital due to medication-related problems. The more diagnoses and the more drugs a person has, the more risk there is of an adverse drug event. There are too many drugs available and there is poor monitoring and follow up with a doctor.
Senator Carroll stated that Kentucky uses two times more medications per patient per year than other states. Complications associated with the use of unnecessary drugs would be reduced if physicians were required to use the Kentucky All Schedule Prescription Electronic Reporting (KASPER) System. Professor Antimisiaris said that KASPER is very innovative and helpful. Prescription drug abuse is a huge problem, and most people do not need all the drugs that are available. In response to a question by Senator Carroll, Professor Antimisiaris stated that the problem is doctors do not have enough time to check the KASPER System before prescription drugs are prescribed.
Representative Westrom stated that the Veterans Administration is exempt from using the KASPER System. A way to save money is to have a PharmD specialist in every hospital and clinic. Professor Antimisiaris stated that PharmDs do not have a Medicare cost code, but could be used to help monitor patients.
In responses to questions by Representative Owens, Professor Antimisiaris stated that medical learners and nurses are taught how to use references and check for drug interactions. People assume that if a doctor prescribes a medication, it is needed and do not look at routine use of medications until there is a problem.
In response to a question by Representative Marzian, Professor Antimisiaris stated there needs to be a better system to achieve better drug surveillance and coordination.
In response to comments by Representative DeWeese, Professor Antimisiaris stated that electronic health records will help.
In response to a question by Senator Carroll, Representative DeWeese stated that the e-Health Board has met several times. There is $40 billion in the stimulus package that gives physicians an incentive to move toward electronic health records. Senator Denton stated that in January or February 2011, there will be federal grants available to help doctors obtain software to participate and help meet the five-year requirement. Professor Antimisiaris said that consumers need to be aware that the pay incentives to doctors could create more polypharmacy problems.
Hospital Acquired Infections
Kevin T. Kavanagh, MD, MS, Board Chairman, Health Watch USA, stated that the Centers for Disease Control and Prevention estimates that there are 1.7 million hospital acquired infections each year that cause nearly 100,000 deaths. The cost to Kentucky’s health care system is approximately $392 million to $462 million yearly. Methicillin-resistant Staphylococcus aureus (MRSA) is the most common health acquired infection in facilities. Kentucky has the sixth highest rate of clostridium difficile infections in the nation at 21.8 infections per 1,000 patients. Evidence indicates that with focused efforts, these once formidable infections can be greatly reduced in number, leading to a new normal for health care-associated infections as rare and unacceptable events. The combined tools of healthcare payment, oversight and accreditation, and public reporting are emerging ways to increase adherence to hospital acquired infections prevention practices.
Kentucky does not track individual hospital acquired infections but requires reporting of outbreaks. Dr. Wright, MD, MPH, Deputy Assistant Secretary for Healthcare Quality, Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services, stated that state initiatives on public reporting of healthcare-associated infections play an important role in the federal effort to prevent healthcare-associated infections. Measurement can also provide institutions and the public with information for comparisons across facilities and regions to better understand current risks for hospital acquired infections as well as risks over time. Data would allow public health officials to identify local and regional facilities requiring improvement. The National Healthcare Safety Network is a standardized reporting service provided free to facilities by the CDC.
In response to question by Senator Harper Angel, Dr. Kavanagh stated that of the 28 states that require public reporting of hospital infection rates, he did not know how it affected Medicaid budgets. Requiring states to use the National Healthcare Safety Network would eliminate duplicative work.
Dana Stephens, Director, Infection Prevention and Control, Saint Joseph Health System, said the primary focus is keeping patients, health care providers, and employees safe through scientific-based systematic approaches. The goal is to completely eliminate preventable health care associated infections. The rules that govern are infection prevention and control programs, accreditation, licensure, statutes, and regulatory are complied with daily. In January 2011, the Centers for Medicare and Medicare Services will require hospitals to use the National Healthcare Safety Network, the Centers for Disease and Control Prevention national data base for surveillance. Currently hospitals do not get paid for health care associated conditions from Medicaid, Medicare, and other payors. Hospitals are focusing resources on the elimination of health care associated infections through adherence of evidence-based prevention practices and collaboratives aimed at reducing infections. More research and data is needed to learn how to prevent infections across all settings and engaging all stakeholders in the dialogue. Daily attention to prevention efforts and active participation in a collaborative approach across all health settings to reach the ultimate goal of zero preventable infections is attainable.
In response to questions by Senator Carroll, Ms. Stephens stated that the Saint Joseph Healthcare System is participating in the National Healthcare Safety Network. Currently, Saint Joseph reports healthcare associated MRSAs in the critical care units.
In response to questions by Senator Westwood, Ms. Stephens stated that Saint Joseph Healthcare System absorbs the cost of hospital associated infections not covered by Medicaid even though some infections could be the patient’s fault.
In response to questions by Representative Westrom, Ms. Stephens stated that most hospitals cannot afford to test every patient for MRSA, especially since testing would not decrease MRSA infections.
Kraig E. Humbaugh, M.D., M.P.H., Director, Division of Epidemiology and Health Planning, Kentucky Department for Public Health, Cabinet for Health and Family Services, stated that while individual hospital acquired infections are not required, by law all outbreaks are to be reported to the Department for Public Health. The Kentucky Department for Public Health was awarded $276,125 grant from ARRA to establish a Healthcare Associated Infections (HIA) Prevention Program starting September 1, 2009 and ending December 31, 2011. With the initial funding, Kentucky has established a statewide multidisciplinary leadership committee (the HAI Advisory Group), hired a full-time experienced Infection Preventionist to coordinate and oversee the HAI Prevention Program, developed and submitted a Kentucky HAI Prevention Plan to the CDC and the federal Department for Health and Human Services, conducted a current baseline needs assessment survey for Kentucky healthcare facilities, and identified two specific HAI prevention targets consistent with the national HHS priorities.
Adjournment
There being no further business, a motion to adjourn at 3:46 p.m. was made by Senator Harper Angel, seconded by Representative DeWeese, and approved by voice vote.