Call to Order and Roll Call
The second meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, July 17, 2013, at 1:00 p.m., at the Jefferson Community & Technical College, Louisville, Kentucky. Senator Julie Denton, Co-Chair, called the meeting to order at 1:15 p.m., and the secretary called the roll.
Present were:
Members: Senator Julie Denton, Co-Chair; Representative Tom Burch, Co-Chair; Senators Joe Bowen, Tom Buford, Perry B. Clark, David P. Givens, Denise Harper Angel, Jimmy Higdon, and Alice Forgy Kerr; Representatives Julie Raque Adams, Robert Benvenuti III, Bob M. DeWeese, Kelly Flood, Tim Moore, Darryl T. Owens, Ruth Ann Palumbo, Ben Waide, David Watkins, Russell Webber, and Susan Westrom.
Guest Legislator: Representative Dennis Horlander.
Guests: Dr. Tony Newberry, President and CEO, Jefferson Community and Technical College; Stephen J. Houghland, MD, Chief Medical Officer, and Liz McKune, ED.D, Director of Behavioral Health, Passport Health Plans; Ted A. Cummings, R.Ph., MBA, Regional Clinical Pharmacy Director, and Chris Slocum, LCSW, MBA, Vice President, Clinical Operations, MHNet Behavioral Health, CoventryCares of Kentucky; Dr. Paul Kensicki, Behavioral Health Medical Director, Lori Gordon, State Director of Behavioral Health, WellCare of Kentucky; Mario Lopez, Account Executive, Jonas Thom, Vice President of Community Programs, Humana; Dr. Mark Jorrisch, Secretary-Treasurer, Kentucky Society of Addiction Medicine; April Lawson, Constituent, and David E. Hanna, Ph.D., Interim President and CEO, bluegrass.org, and clinical psychologist; Samantha McKinley, Department for Medicaid Services, Cabinet for Health and Family Services; Joseph Maupin and Matt Ditch, Vanguard Ventures of Louisville; Kara Hinkley and Jacqueline Lindsey, National Multiple Sclerosis Society; Anne Parton, Babbage Cofounder; Shelley Gast, Norton; Jan Gould, Kentucky Retail Federation; Mike Porter, Kentucky Dental Association; Kelly Gunning; Phill Gunning, Valerie Mudd, and David Riggsby, National Alliance on Mental Illness (NAMI)-Lexington; Betsy Dunningan, Acting Commissioner, and Allen Brenzy, Department for Behavioral Health, Developmental and Intellectual Disabilities, Cabinet for Health and Family Services; Marylee Underwood, Commonwealth Council on Developmental Disabilities; Bill Doll, Kentucky Medical Association; Haleh Karimi, Eliason; Gary Thurnauer, Pfizer, Nancy Galvagni and Sarah Nicholson, Kentucky Hospital Association; Ramona Johnson, Bridgehaven; Gwen Cooper, Seven Counties Services; Steve Bing, Kentucky Public Health Association; Heather Dung, Cabinet for Health and Family Services; Karen Lentz, Commonwealth Alliances, Janice Richardson, Rivendell Behavioral Health; Marty White, Capitol Link Consultant.
LRC Staff: DeeAnn Mansfield, Sarah Kidder, Gina Rigsby, Cindy Smith, and Wesley Whistle.
Opening Remarks
Dr. Tony Newberry, President and CEO, Jefferson Community and Technical College (JCTC), stated that workforce development is a primary mission of the Kentucky Community and Technical College System (KCTCS). Over a forty-year period, KCTCS developed programs which meet the specialized workforce needs of the health care community and the needs of the students for careers in fields that pay a sustainable living wage. The $25 million, 100,000 square foot facility provides state of the art classrooms, laboratories, and equipment for 16 different programs that serve students in southwest Jefferson, Bullitt, Carroll, and Shelby counties. Several of the programs were established with seed funding from hospitals and a Department of Labor grant, Health Professions Pathways, expanded the pharmacy technology and medical assisting programs to nights and weekends to meet the needs of employees of the hospitals. The downtown campus enrolls approximately 8,000 students per year. JCTC is home base to a partnership, Metropolitan College, with UPS and the University of Louisville that provides 2,000 students annually the opportunity to work while going to school.
Consideration of Referred Administrative Regulations
The following administrative regulations were available for consideration: 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 20:085 – establishes the licensure periods for licenses by the Kentucky Board of Nursing; 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; and 921 KAR 3:090 & E – establishes requirements for the Simplified Assistance for the Elderly Program, a demonstration project administered by the cabinet to improve access to SNAP for elderly and disabled individuals. A motion to accept the administrative regulations was made by Senator Buford, seconded by Representative Burch, and accepted by voice vote.
Behavioral and Substance Abuse Issues
Dr. Mark Jorrisch, Secretary-Treasurer, Kentucky Society of Addiction Medicine, stated that the Office of National Drug Control Policy (ONDCP) reported that annually nationwide the cost of addiction is $500 billion annually including costs associated with crime, healthcare, and industry. The National Institute on Drug Abuse (NIDA) reports that 25 percent of each Medicare dollar is used to address addiction related illnesses and 20 percent of each Medicaid dollar. Drug use and crime are both down almost 60 percent, the transmission of HIV, Hepatitis C virus, and Hepatitis B virus is down, and employment is up 40 percent among individuals treated for addiction. For every $1 spent on treatment it saves $4 in criminal justice costs, $3 for emergency care, $4 in public assistance for a woman, and $7 in productivity in men. Kentucky’s Opiate Recovery Treatment Outcome Study (KORTOS) reports reductions of 90 percent in opioid use, 78 percent in other drug use, 32 percent in illicit drug use, 37 percent in arrests, and 65 percent in jail time. Approximately 70 percent maintained employment. Someone leaving methadone maintenance treatment (MMT) has a 75 percent chance of relapse and three times the mortality rate of the general population. Treatment works but it needs to be available, accessible, and affordable. The American Society of Addiction Medicine recommends that (1) treatment for any patient with an opioid use disorder should be based on a thorough evaluation of the patient by a knowledgeable and skilled physician, and be designed in an individual manner to best meet that patient’s needs; and (2) pharmacological therapy can be a part of an effective professional treatment for opioid use disorder, and should be delivered by physicians appropriately trained and qualified in the treatment of opioid withdrawal and opioid addiction.
In response to questions by Senator Denton, Dr. Jorrisch stated that it is rare that an insurance company pays for methadone treatment, but Medicaid will cover the treatment. There is no cure for methadone addiction, just medications to control the symptoms.
In response to questions by Senator Buford, Dr. Jorrisch stated that House Bill 1 from the 2012 Regular Session initially put limitations on physicians. HB 1 has had a positive effect on the medical community and helped to deter drug abuse. Physicians who treat people for addiction, psychiatric, and pain disorders are still available, but there are some limitations that need to be addressed.
Stephen J. Houghland, MD, Chief Medical Officer, and Liz McKune, Ed.D, Director of Behavioral Health, Passport Health Plans, stated that the first 30 visits of individual and family outpatient therapy do not require preauthorization, and a review is required prior to the 31st visit. The services are reviewed and authorized typically within two business days, but can allow up to two weeks if a provider needs to gather and provide additional information. There has been a 100 percent authorization rate to date for these services. Inpatient services require an initial authorization as do diversionary services such as intensive outpatient, partial hospitalization, and group rehabilitation therapy. Both inpatient and diversionary services are authorized typically within the first hour received. Pre-certification is available 24 hours a day, seven days a week. Preauthorization for inpatient services is 99 percent and diversionary services are 100 percent to date. Services that do not require authorizations are therapy, crisis treatment for the first 60 minutes, therapy, crisis treatment for each additional 30 minutes, group therapy, interactive complexity, injection, interpretation or explanation of psychiatric or other medical exam or procedure to family, alcohol and/or drug assessment, and mental health assessment by a non-physician. Behavioral health medications that require authorization are antipsychotics, Attention Deficit Hyperactivity Disorder (ADHD) medication, sleep disorder anxiolytics, antidepressants, and substance abuse medication. Foster care children are a fragile population and often require intense behavioral health treatment. Medications play a role in behavioral health, but there also need to be behavior modifications. There is concern about prescribing certain medications to children because the long-term effects on them are not known.
In response to questions by Representative Moore, Dr. Houghland stated that Passport has been fortunate because of the consolidation and the number of providers available. There is some concern about the Medicaid expansion in general and in particular around substance abuse treatment because under the Affordable Care Act it is mandated to be covered in a more comprehensive manner. There are current problems with adequate access to substance abuse treatment, and currently substance abuse treatment is only available for children through EPDST services and pregnant women. The concern is that the problem will be magnified after the expansion. People need to be encouraged to take advantage of available preventive care services. Education on preventative care has an important impact on patients and families. Incentives for Medicaid recipients to obtain preventative care will keep them from utilizing as many services in the future. Most evidence supports that incentive programs for preventive care are more effective when patients rather than doctors are incentivized. If patients can become engaged in preventive care, health outcomes and expenditures in healthcare will improve.
In response to questions by Representative Flood, Dr. Houghland stated that currently Medicaid services are primarily geared toward women. The safety net allows someone who has not had another payer or received Medicaid services to access behavioral health services through the Community Mental Health Centers (CMHCs).
In response to questions by Senator Givens, Dr. Houghland stated that the comprehensive behavioral health population has not increased yet, because they were already Medicaid recipients.
In response to questions by Senator Denton, Dr. Houghland stated that suboxone and buprenorphrine are covered by Medicaid but need prior authorization to ensure appropriate treatment and monitor outcomes. Treatment is generally approved for up to six months. The progress of the member is monitored to ensure that the treatment is necessary for a longer period of time. Providers have guidelines and criteria for minimal and maximum doses, but are allowed to contact Passport for exceptions. When foster children are reassigned to another MCO, the expenses stay with the MCO who approved the services unless services are changed by the new MCO.
In response to questions by Representative Owens, Dr. Houghland stated that part of the psychotropic drug intervention program is to distribute reports on utilization patterns to doctors and members.
Ted A. Cummings, R.Ph., MBA, Regional Clinical Pharmacy Director, and Chris Slocum, LCSW, MBA, Vice President, Clinical Operations, MHNet Behavioral Health, CoventryCares of Kentucky, stated that the three types of providers allowed to provide Medicaid behavioral health services are CMHCs, IMPACT Plus, and independent practice physicians. Individuals with behavioral health issues need access to services immediately. CoventryCares received approximately ten percent of Kentucky Spirit’s membership raising ConventryCares membership to approximately 280,000. After the Medicaid expansion begins in January 2014, there is a potential to add 30,000 to 45,000 more members to CoventryCares, and the current number of qualified providers will not be sufficient to provide care. Individuals who are independently licensed such as clinical social workers or clinical psychologists are not eligible to provide services in Kentucky limiting access to care, particularly in rural areas. Authorization is required for high levels of care in hospitals or residential treatment facilities, IMPACT Plus services, and 12 service codes that are offered at the CMHCs. Authorization is not needed for evaluation services. IMPACT Plus services are established by administrative regulations and authorization is given within 30 to 60 days of assessment. There were 26,000 authorization requests of all types of services with 93 percent approved immediately, three percent partially approved, and three percent not approved from January through May. Approximately 3,475 requests per month are received from CMHCs.
In response to questions by Senator Denton, Mr. Slocum stated that detoxification is covered by the CoventryCares’ medical plan. Substance abuse services are covered for EPDST children under age 21 and pregnant women under MHNet. Senator Denton requested information on the percentage of detoxification requests for adults that are approved on the physical health side. CoventryCares has a good relationship with the Department for Behavioral Health program manager for IMPACT Plus. Approximately 93 percent of IMPACT Plus initial requests are approved in full. CoventryCares has a regularly scheduled monthly meeting with a coalition of providers to review issues, and there have been no complaints about one-half of intakes being denied coverage and on-going treatment is flagged for termination after six months. CoventryCares and hospitals review cases against medical necessity criteria on a regular basis. If the criteria are not met and denial for continued stay at a facility for a child has been made, there are processes in place for review and recommendations for an alternative level of service are given.
In response to questions by Representative Benvenuti, Mr. Slocum stated that CoventryCares’ health plan uses InterQual level of care criteria and MHNet uses its own internal criteria approved by the Department for Medicaid Services. Mr. Slocum agreed to meet with providers who have cases that met InterQual criteria and were denied coverage. There are several medical directors on the health plan side who review cases from hospitals and use InterQual criteria, and a nonauthorization decision would come from the physician. MHNet has a Kentucky licensed psychiatrist review behavioral health claims and CoventryCares has Kentucky licensed medical directors who review physical health cases. The medical directors are not board certified in a mental health specialty, but are board certified medical physicians qualified to make appropriate decisions. Behavioral health concerns were discussed with officials at the Department for Medicaid Services and the Department for Behavioral Health, Developmental and Intellectual Disabilities about adding more members to the current Medicaid population without having adequate number of qualified providers.
Senator Denton requested that all of the MCOs provide the committee with information on behavioral health and substance abuse services, including IMPACT Plus, showing initial authorization required, how quickly authorizations are given, how often preauthorization is granted, services that do not require authorization, denial rates, and behavioral health medications that require authorization.
In response to questions by Senator Higdon, Mr. Cummings stated that there is a generic drug available for suboxone that is a less expensive pill form. The brand name drug is abused just like the generic drug. The pharmacy system that fills a prescription can track if someone has filled prescriptions for other opioids during the same time that person has filled a prescription for suboxone. Every month comparisons are made to see how many generic suboxone pills have been dispensed to members who have also received other opioids.
In response to a comment by Senator Higdon, Representative Burch stated that IMPACT and IMPACT Plus were established because there were no services available for children. The purpose of the programs is to bring services to the child instead of the child going to the services. Senator Denton asked that all the MCOs provide information to the committee on the denial rates for IMPACT Plus from the time each one began providing services through July 2013.
In response to questions by Senator Denton, Mr. Cummings stated a short-term opioid prescription is normally used for medical procedures. Prescribers are notified if monthly pharmacy reports show that someone has been prescribed several opioids in a short period of time.
In response to questions by Representative DeWeese, Mr. Slocum stated that CoventryCares is meeting with all hospitals that have discrepancies in payments.
In response to questions by Representative Benvenuti, Mr. Slocum stated that a claim would be denied if a provider did not get prior authorization for services. The provider can appeal the denial by submitting medical records and relevant information. Denial can also occur when a person is in the hospital and further care is not authorized. A different physician will review the case, talk to the original provider, and allow additional information to be provided before a decision is made about the appeal. If the appeal is denied, a provider can ask for a state hearing, but there could be significant costs to the provider.
Dr. Paul Kensicki, Behavioral Health Medical Director, Lori Gordon, State Director of Behavioral Health, WellCare of Kentucky, stated that it has licensed behavioral health staff geographically located near each CMHC. Additionally there are foster care and guardianship case managers across the state. WellCare staff meet with IMPACT Plus providers every three weeks, CMHCs monthly, and the Kentucky Hospital Association quarterly. The mission of case management is to coordinate timely, cost effective, integrated services for individual, physical, and behavioral health needs of members to promote positive clinical outcomes. The purpose of case management is to decrease fragmentation of healthcare service delivery, facilitate appropriate utilization of available resources, and optimize member outcomes through education, care coordination, and advocacy services for the medically compromised populations served.
WellCare remains committed to providing ongoing services within the 14 CMHCs and ensuring that the needs of its member population are adequately addressed. Additional services have been implemented within the CMHC contract structure and WellCare will continue to support efforts toward physical health integration. Services codes for substance abuse treatment are currently contracted and will be supported according to benefit design. In addition to previously existing services, WellCare has contracted for services that include intensive outpatient, partial hospitalization, adult and child crisis stabilization, mobile crisis, peer support, and supported employment. WellCare will continue to support efforts to provide addictions treatment as allowed by the Kentucky Medicaid benefit plan. WellCare agrees that addiction is a chronic, complex disease characterized by relapse and remission, with behavioral and biochemical and genetic components. Addiction cannot be cured with six months of treatment. Suboxone is one important tool that, when used properly, offers hope to addicts and their families and reduces stigmatization. Suboxone Film is currently on the WellCare preferred drug list. Prior authorization is required every three months with no cap on duration of treatment. The prior authorization process requires evidence of therapy, clinicians to regularly monitor eKasper reports and urine drug screens, and annual attempts to reduce doses of medication. WellCare does not require prior authorization based on diagnosis but based on covered service and provider. Prior authorization is not required for routine outpatient services provided at the CMHCs. Prior authorization is required for psychological testing, electric convulsive therapy (ECT) and crisis stabilization, intensive outpatient services, partial hospital services, inpatient hospital services, residential treatment services, and IMPACT Plus services.
In response to questions by Representative Benvenuti, Ms. Gordon stated that WellCare contracts with a few facilities for higher level outpatient such as partial hospitalization. There are no barriers for hospitals to provide traditional outpatient services. Dr. Kensicki stated that, because the company uses a child psychologist with a group that is not licensed in Kentucky, the child psychologist only provides consultative reviews during the appeals process. WellCare agrees that it is important to have people with specific medical expertise in specific areas reviewing cases.
Mario Lopez, Account Executive, Jonas Thom, Vice President of Community Programs and Behavioral Health and licensed professional clinical counselor, Humana, stated that since January 2013, Humana and CareSource have been serving Kentucky Medicaid recipients, including dually eligibles for Medicaid and Medicare, in Region 3 under a national partnership. Humana CareSource knows that behavioral health care is essential to wellness and the welfare of communities. According to the 2012 America Health Rankings, Kentucky ranks 48th in the nation in poor mental health days, defined as the number of days in the previous 30 days when a person indicates activities are limited due to mental health difficulties. Humana is partnering with Beacon Health Strategies, a National Committee for Quality Assurance (NCQA) accredited managed behavioral healthcare organization that specializes in the treatment of mental illness and substance abuse on a fully integrated basis. Humana is executing a fully integrated model that includes care management, medical management, pharmacy, nurse triage line, disease management, and community providers. Each of the teams coordinates benefits and integrates care across the health and wellness continuum that includes acute and crisis services, psychiatric emergency care, inpatient services for children and adults, and crisis stabilization, and residential care and extended care units with EPSDT special services. Humana’s continuum also includes a full array of outpatient services including psychiatry, intensive care management services, counseling, group counseling, therapeutic rehabilitative services for children and adults, and day treatment services for children. IMPACT Plus services are covered and care for substance abuse needs of members who are children and adolescents under age 21 through EPSDT special services, pregnant women, including detoxification in medical hospitals and medical detoxification facilities when medically necessary. Services are provided through a comprehensive network of providers that include agreements with all IMPACT Plus providers as well as the three CMHCs in Region 3. Humana has agreements or contracts with nine hospitals, thirty-six private psychiatrists or psychiatric groups, Central State Hospital and Eastern State Hospital, Western State Hospital, and four medical facilities in Region 3.
Physician services, injections, targeted case management, emergency services, assessments, and group counseling, as well as collateral services, do not require any prior authorization. Substance abuse case management requires no authorization, but does require a review for a continued stay at 90 days. Prior authorization is required for all inpatient services and other acute intensive levels of care such as extended care units, psychiatric residential treatment facilities, intensive outpatient, and therapeutic rehabilitation and day treatment programs. IMPACT Plus services require an initial review for eligibility and prior authorization. Prior authorizations for acute and outpatient services have review timeframes that are dependent on the level of crisis and acuity of the situation. Every effort is made to execute a timely authorization process for members and providers. A request for a member presenting to an emergency room or requiring immediate hospitalization or emergent care is processed within a two-hour timeframe from the time of the initial request to the time a decision is given. Non-emergent care has a 24-hour turnaround time. Pre-service reviews have up to 48 hours if needed for a final determination. The timeframe for outpatient services or IMPACT Plus decisions is 48 hours from receipt of the request. Turnaround times for behavioral health requests are successfully met more than 97 percent of the time. Humana’s approval rate for behavioral health authorizations is over 99 percent for all inpatient and outpatient services.
Kentucky’s CMHCs have met the needs of people with serious mental illness, developed significant service and care management resources, become an integral part of its communities, and responded to the needs of families. Since January 2013, Humana has conducted weekly operational calls with the CMHCs to answer questions and address operational issues. Humana will partner with the CMHCs in the development and implementation of various pilot programs that will improve the use of evidence-based practices and recovery-oriented services. Humana will collaborate with the CMHCs to develop a crisis services model for intensive children’s services to make the authorization and billing practices easier to assist in keeping children in crisis in the community as well as reduce hospitalizations.
Most members with non-severe mental illnesses see their primary care physicians (PCPs) for outpatient healthcare, yet PCPs do not frequently offer behavioral health services within their practices. Access to behavioral healthcare will be increased by adding integrated depression and anxiety treatment capacity through the use of Health Behavior and Assessment Codes and Screening Brief Intervention Referral to Treatment (SBIRT) practices. The codes and practices will assist PCPs in delivering a range of widely disseminated evidence-based practices and coordinate care across providers.
Eastern State Hospital Issues
April Lawson, Constituent, stated that her brother, David Ray Clarkson, Jr., started hallucinating and became suicidal in May 2012. A mental health petition can be requested if someone presents a danger to himself or others. On May 30, 2012, he was transported to Eastern State Hospital because he was suicidal. Communicare was his regular doctor. On May 31, 2012, there was no assessment on record even though he was just assessed the day before. On June 4, her brother overdosed by taking all of his prescriptions at once. She felt like he should have been admitted because he needed more time for the medication to start helping him.
Senator Higdon stated that KRS 202A.028 states that following an examination by a qualified mental health professional and certification by that professional that the person meets the criteria for involuntary hospitalization, a judge may order the person hospitalized for a period not to exceed 72 hours.
David E. Hanna, Ph.D., Interim President and CEO, Bluegrass Regional Mental Health-Mental Retardation Board, Inc. (bluegrass.org), and clinical psychologist, stated that if a judge orders someone to Eastern State Hospital, commitment criteria found in KRS 202A for hospitalization of the mentally ill would be used to evaluate the patient to see if that person needs to be committed to a facility. KRS 202A.026 prohibits involuntary hospitalization unless a person is (1) mentally ill and presents a danger or threat of danger to himself, his family, or others as a result of the mental illness, (2) can reasonably benefit from treatment, and (3) for whom hospitalization is the least restrictive alternative mode of treatment presently available.
In response to questions by Senator Kerr, Dr. Hanna stated that the outpatient agreed order is misunderstood. The challenge is weighing the patient’s civil liberties against someone else making decisions on their behalf. The Bluegrass Regional Mental Health-Mental Retardation operated Eastern State Hospital since 1995. The University of Kentucky will assume the vast majority of the operation of Eastern State Hospital and bluegrass.org will take care of outpatient services.
Betsy Dunnigan, Acting Commissioner for the Department for Behavioral Health, Developmental and Intellectual Disabilities, Cabinet for Health and Family Services, stated that on September 10, 2013, all the patients and furniture will have been moved to the new Eastern State Hospital facility. On September 11, 2013, the Bluegrass Community and Technical College will take control of the old facility.
There being no further business, the meeting was adjourned at 4:12 p.m.