Call to Order and Roll Call
The first meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, June 19, 2013, at 2:00 p.m., at the Northern Kentucky Convention Center, One West RiverCenter Boulevard, Third Floor, Ballroom E, Covington, Kentucky. Representative Tom Burch, Co-Chair, called the meeting to order at 2:05 p.m., and the secretary called the roll.
Present were:
Members: Representative Tom Burch, Co-Chair; Senators Tom Buford, Perry B. Clark, David P. Givens, Denise Harper Angel, Kathy W. Stein, and Katie Stine; Representatives Julie Raque Adams, Robert Benvenuti III, Kelly Flood, Joni L. Jenkins, Mary Lou Marzian, Tim Moore, Ben Waide, Russell Webber, Susan Westrom, and Addia Wuchner.
Guests: Lawrence Kissner, Commissioner, Department for Medicaid Services, Cabinet for Health and Family Services; Tom Awe and Franz Corneille, eHealthPath; Audrey Tayse Haynes, Secretary, Cabinet for Health and Family Services; Dr. Kraig Humbaugh, Senior Deputy Commissioner, Department for Public Health, Cabinet for Health and Family Services; Teresa James, Commissioner, Mark Cornett, Deputy Commissioner, and Elizabeth Caywood, Policy Analyst, Department for Community Based Services, Cabinet for Health and Family Services; Dr. Kevin Kavanaugh, MD, FACS, Board Chairman, Health Watch USA; Dr. Jeremy Engel; Sarah S. Nicholson, Kentucky Hospital Association; Andrea Flinchum, HAI Program Manager, Division of Epidemiology, Department for Public Health, Cabinet for Health and Family Services; and John Giordullo, St. Elizabeth Healthcare.
LRC Staff: DeeAnn Mansfield, Ben Payne, Jonathan Scott, Sarah Kidder, Gina Rigsby, Cindy Smith, and Wesley Whistle.
Medicaid Expansion
Lawrence Kissner, Commissioner, Department for Medicaid Services, Cabinet for Health and Family Services, stated that there has been an improvement in vaccinations and performance measurements since changing to managed care. One area that needs to improve is the number of women getting mammograms. Information was provided on the activities of Coventry Cares, Kentucky Spirit Health Plan, and Wellcare. When a member is transferred to a different MCO or a member voluntarily changes to a different MCO during open enrollment, the cabinet provides the new MCO 12 months of information on the member. The Affordable Care Act (ACA) was passed to provide Americans, including Kentuckians, better access to health care coverage. A major component of increasing access to coverage is new federal funding for states to expand the Medicaid eligibility to 138 percent of the Federal Poverty Level (FPL). The United States Supreme Court made Medicaid expansion optional for states. Expansion is the right choice for Kentucky. Not expanding the program would hurt both Kentucky’s health and taxpayers’ bottom line. On May 9, 2013, Governor Beshear announced that Kentucky would expand Medicaid to more than 300,000 uninsured Kentucky residents.
In the 2012 edition of America’s Health Rankings from the United Health Foundation, Kentucky was ranked 44th overall in the health rankings. Multiple studies show improved health outcomes with increased insurance coverage. Individuals without insurance coverage are more likely to go to the emergency room for treatment. There are currently 640,000 uninsured Kentuckians or 17.5 percent of the state’s population under age 65. An estimated 332,000 of these uninsured individuals will be able to gain coverage through the Health Benefit Exchange, including 276,000 individuals whose income is between 138 percent and 400 percent of the FPL who will be able to get subsidized coverage.
With Medicaid expansion, the other 308,000 uninsured Kentuckians will be able to receive health insurance coverage through Medicaid. From SFY 2014 to SFY 2021, Kentucky will receive $15.6 billion in federal funds and see $802.4 million in savings. The federal government will pay 100 percent of the costs for the first three years, and decrease to 90 percent by 2020. By 2021, there will be a $287.5 million reduction in Disproportionate Share Hospital (DSH) payments for indigent care to state facilities. Not expanding Medicaid would cost Kentucky even more money.
Upon full implementation of the ACA in SFY 2021, Kentucky would see a negative $38.9 million impact to the state. Not expanding Medicaid eligibility would mean that Kentucky taxpayers would subsidize the 20 states that do expand. Choosing the option to allow Medicaid eligible individuals to purchase private insurance would cost taxpayers more than the Medicaid expansion. If Kentucky opts to not expand its Medicaid program, employers would be responsible for up to $3,000 in fines for every employee who received a premium subsidy from the Health Benefit Exchange costing employers an estimated $32 million to $48 million every year.
Kentucky’s Healthcare Connection will help individuals find out if they eligible for services in the current or expanded Medicaid programs or the health benefit exchange. The ACA states that the cabinet must comply with the new Modified Adjusted Gross Income (MAGI) so there will be only one income category of eligibility. There are approximately 50 possible categories of eligibility. The ACA Request for Proposal (RFP) was released June 11, 2013 for seven regions excluding Region 3. The benefits will be the same between the existing Medicaid program and the Medicaid expansion. Benefits are essentially unchanged with the exception of additional substance abuse coverage as mandated by the ACA. There will be no data book for the new population of uninsured, and rates will be based on current rate cells with appropriate modifications that are actuarially sound. If someone is eligible for Medicaid services before going to prison, the prison is currently responsible for all medical costs. Under the Medicaid expansion, Medicaid will cover nonprison hospitalization which will save the prison system money.
In response to questions by Senator Stine, Commissioner Kissner stated that the expansion is MAGI based, but he would find out if assets are also considered and get the information to the committee. On January 1, 2013, the cabinet entered into an 18-month contract with Wellcare, Coventry Cares, Passport, and Humana in Region 3 and is still in the initial contract period under the old Medicaid. The contract allows all of these MCOs to participate in the new Medicaid expansion.
In response to questions by Representative Benvenuti, Commissioner Kissner stated that the other options discussed were to not expand, follow the Arkansas model where the state would take what would be paid to buy an individual insurance through the exchange, expand to 100 percent of the FPL instead of 138 percent, or expand during a different timeframe. It was determined that all of these options would be more costly to the state than the expansion. The Centers for Medicare and Medicaid Services (CMS) stated the ACA requires the expansion of eligilibity to 138 percent of the FPL. If a state chooses to expand after the January 1, 2014 deadline, it will lose the three-year 100 percent funding. The Medicaid expansion may create jobs but it is not a job or economic development program. It is a program to improve the healthcare of Kentuckians.
In response to questions by Representative Moore, Commissioner Kissner stated that the state is improving in the areas of care and coding. Under the current fee-for-service Medicaid program, a physician can submit a claim for one service, such as an office visit, that covers other services without having to submit a separate report of each of the services. This has meant that all services provided were not coded. The MCOs are driven by NCQA and HEDIS scores and require better documentation from providers of each service provided. Information is available on the Governor’s Office web site that shows the number of providers by county. Kentucky currently uses a 70 percent federal funds and 30 percent state funds rate for Medicaid services.
In response to questions by Representative Jenkins, Commissioner Kissner stated that recipient eligibility will be tracked through quarterly wage and tax statements. Because there is good data on medical information for state prisoners, it is easy for the state to track its liability for this Medicaid population. The cabinet had to estimate its liability at the county level because it was harder to track the information. The white paper, Analysis of the Affordable Care Act (ACA), Medicaid Expansion in Kentucky, includes a spreadsheet that shows the financial impact and is available on the Governor’s Office web site.
In response to questions by Representative Marzian, Commissioner Kissner stated that on August 15 the Health Exchange call center will start answering basic questions, October 1 enrollment begins for expanded Medicaid, and the expansion will be effective January 1, 2014. The 138 percent of the FPL equates to $7.25 per hour.
In response to questions by Senator Givens, Commissioner Kissner stated that in 2021 expenditures will become revenue neutral. The greatest concern for the cabinet is that it may have underestimated the number of individuals who are eligible for Medicaid but are not currently enrolled who will enroll. These individuals will be covered at a 70 percent federal, 30 percent state match not the 100 percent federal match. The cabinet has an external quality review organization that monitors the MCOs business plan for quality improvement. The MCOs will have benchmark data that will help show where improvements need to be made and help drive costs down.
In response to questions by Representative Adams, Commissioner Kissner stated that the current contracts require quality statistics to drive improvements in performance measures. Money needs to be spent upfront on services that could result in savings later. The indigent population cannot afford to pay co-pays or other financial obligations to receive health care. Legislators were not consulted during the RFP process. Medicaid is the payer of last resort. The national Medicare average of 76 percent is what Kentucky pays providers for Medicaid services. The Department of Insurance is responsible for prompt payments to providers. Approximately 77 percent of provider payment disputes have been resolved or are actively in the process of being resolved. Dual eligibles do not have to be transitioned into Medicaid managed care.
In response to questions by Representative Waide, Commissioner Kissner stated that the Medicaid expansion model will pay for itself and get a positive revenue return.
In response to questions by Representative Wuchner, Commissioner Kissner stated that by spending $24.9 million in 2014, the cabinet will get a positive general fund and revenue savings of $87.7 million.
In response to questions by Representative Wuchner, Commissioner Kissner stated that ACA requires states to maintain the current level of the basic benefit structure already in place for a two-year period. On January 1, 2014 the maintenance of effort portion is gone. It will be tough to change the Medicaid core benefits, but changes could be made to optional benefits, such as pharmaceuticals.
In response to questions by Senator Stein, Commissioner Kissner stated that improvements in one or more health related conditions will impact other conditions.
Preparing Healthy Foods
Franz Corneille stated that eHealthPath is a systemic approach to better nutrition and eating healthier. The International Association of Diabetes states that diabetes and obesity are the biggest public health challenge of the 21st century. The USDA conducts a study every ten years, Impact of Meals Away from Home, which states one meal per week away from home adds two additional pounds per year. One problem from eating away from home is the lack of vegetables and fruits served in restaurants. The percentage of adults with a Body Mass Index (BMI) of 25 or over has not increased much between 1962 and 2010. Unfortunately, the percentage of adults with a BMI of 26 or over has increased. In 2012, approximately $61 million was spent on weight lost programs, and 95 percent of people regain the weight lost within six months. It is important to learn how to cook and eat nutritional meals at home.
In response to questions by Representative Adams, Tom Awe, Chairman and Co-Founder of eHealthPath, stated that one of the design principles incorporated into the program is to be able to have it available online to make it easier to use. The objective is to do something that is beneficial.
Hospital Acquired Infections
Dr. Kevin Kavanaugh, MD, FACS, Board Chairman, Health Watch USA, stated that a carbapenem-resistant enterobacteriaceae (CRE) is virtually resistant to all antibiotics. Infections in the bloodstream have an almost 50 percent fatality rate. Four percent of United States hospitals and 18 percent of long-term care facilities have reported at least one case of CRE. The Center for Disease Control and Prevention (CDC) recommends surveillance of close contacts, isolation of patients in dedicated rooms, and dedicated staff taking care of patients. If one facility in a region performs poorly, it places all facilities at risk. The National Institute of Health (NIH) adopted a more complex and expensive decontamination process, using robot-like machines to spray germ-killing hydrogen peroxide into the tiniest of crevices in all affected rooms and equipment. In some parts of the world, CRE appears to be more common, and evidence has shown it can be controlled. Only a few types of facilities are reporting CRE infections. Critical care hospitals and nursing homes are not required to report.
Administrative regulation 902 KAR 2:020 states that a report shall be made immediately by telephone if in the judgment of a health professional licensed under KRS Chapters 311 through 314, or a health facility licensed under KRS Chapter 216B, there is an unexpected pattern of cases, suspected cases, or deaths which may indicate a newly-recognized infectious agent, an outbreak, epidemic, related public health hazard, or an act of bioterroism, such as smallpox. The definition of an outbreak is when the number of infections is above the facility’s baseline, and the definition of a baseline is up to the facility. To prevent the emergence and further spread of CRE, a coordinated regional control effort among healthcare facilities is recommended. Transparency is the right thing to do in matters of public health. There needs to be more oversight and responsibility for CRE reporting.
In response to questions by Senator Stein, Dr. Kavanagh stated that the opposition to reporting initially started with having mandates. It is hard to tell if MRSA is increasing or decreasing in the pediatric population because of the lack of a good data reporting system.
In response to questions by Representative Westrom, Dr. Kavanagh stated that infections are transmitted primarily by contact. The number one recommendation is transparency. Currently, the CDC does not mandate reporting. Another recommendation is to get health departments involved, funded for education, and engaged in prevention.
Dr. Kraig Humbaugh, Senior Deputy Commissioner, Department for Public Health, Cabinet for Health and Family Services, stated that Healthcare-Associated Infections (HAIs) are infections that patients acquire during the course of receiving healthcare treatment for other conditions. The organisms which cause these infections are often multidrug-resistant organisms (MDROs). HAIs are a challenging public health and community health problem. Approximately one out of twenty hospitalized patients will contract an HAI. The CDC has identified eliminating HAIs as a winnable battle. With additional effort and support for evidence-based, cost-effective strategies that can be implemented now, there can be a major impact on our nation’s health.
The mission of the Healthcare-Associated Infection (HAI) Prevention Program in the Department for Public Health is to provide resources and support for reduction of HAIs in Kentucky. A multidisciplinary collaborative group plans and executes prevention activities statewide. There is an integration of laboratory activities with HAI surveillance, prevention, and control efforts in identifying emerging pathogens. The HAI Prevention Program staff collaborates with local and regional partners to identify specific prevention targets consistent with federal goals. The program facilitates the implementation of evidence-based practices for infection prevention and control in all healthcare settings through educational and training activities, consultation, and provision of resource materials. Kentucky has a model program, Long-Term Care Collaborative Statewide Project, to teach long-term care facilities to how to do a better job of surveillance, determine the burden of infection, how to report infections voluntarily, and help identify the facility’s strengths and gaps.
The department supports a very comprehensive infection control prevention program in every facility across the state rather than looking at individual HAIs. In 2012, there was an increase in reporting in hospitals and long-term care facilities. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires hospitals to conduct yearly risk assessments to determine what types of prevention should be done based on surveillance data. Every hospital should have an infection control program. Kentucky law requires outbreak reporting.
In response to questions by Representative Benvenuti, Dr. Kavanagh stated that an infection only has to be reported if in the judgment of a healthcare professional it needs to be reported.
Jeremy Engle, family physician at St. Elizabeth Physicians in Bellevue, stated that Northern Kentucky and Kentucky in general should continue to develop a new social contract between its leadership and its citizens placing health above all other priorities. Individuals can be saved from heroin and opioid overdoses if resources are available. Kentucky needs to address treatment, harm reduction, primary prevention, and recovery.
Legislative Hearing on the FFY 2014-2015 Preliminary Child Care and Development Fund State Plan
Teresa James, Commissioner, Mark Cornett, Deputy Commissioner, and Elizabeth Caywood, Policy Analyst, Department for Community Based Services, Cabinet for Health and Family Services were present to answer questions. A motion to accept the preliminary Child Care and Development Fund State Plan was made by Senator Buford, seconded by Senator Harper Angels, and accepted by voice vote.
Legislative Hearing on the FFY 2014-2015 Community Services Block Grant
Teresa James, Commissioner, Mark Cornett, Deputy Commissioner, and Elizabeth Caywood, Policy Analyst, Department for Community Based Services, Cabinet for Health and Family Services were present to answer questions. A motion to accept the Community Services Block Grant was made by Senator Buford, seconded by Senator Harper Angels, and accepted by voice vote.
Legislative Hearing on the SFY 2014 Preliminary Social Services Block Grant Annual Plan
Teresa James, Commissioner, Mark Cornett, Deputy Commissioner, and Elizabeth Caywood, Policy Analyst, Department for Community Based Services, Cabinet for Health and Family Services were present to answer questions. A motion to accept the Social Services Block Grant was made by Senator Buford, seconded by Senator Harper Angels, and accepted by voice vote.
Consideration of Referred Administrative Regulations
The following administration regulations were referred to the committee for consideration: 201 KAR 2:074 – establishes requirements for pharmacy services in hospitals or other organized health care facilities; 201 KAR 20:059 – establishes limitations for the prescription of specific controlled substances by advanced practice registered nurses; 201 KAR 20:500 – permits nurses to practice in states participating in the Nurse Licensure Compact; and 921 KAR 2:015 & E – establishes the provisions of supplemental programs for persons who are aged, blind or have a disability. A motion to accept the administrative regulations was made by Senator Buford, seconded by Senator Harper Angels, and accepted by voice vote.
Adjournment
There being no further business, the meeting was adjourned at 4:30 p.m.