Call to Order and Roll Call
The third meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, August 21, 2013, at 12:00 PM, in Room 129 of the Capitol Annex. Senator Julie Denton, Co-Chair, called the meeting to order at 12:25 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, Jimmy Higdon, Alice Forgy Kerr, Kathy W. Stein, and Katie Stine; Representatives Julie Raque Adams, Robert Benvenuti III, Bob M. DeWeese, Kelly Flood, Joni L. Jenkins, Mary Lou Marzian, Tim Moore, Darryl T. Owens, Ruth Ann Palumbo, Ben Waide, David Watkins, Susan Westrom, and Addia Wuchner.
Guest Legislators: Senator Walter Blevins; and Representatives Jimmie Lee and John Will Stacy.
Guests: Whitney Jones, M.D., Kentucky Colon Cancer Screening Program Advisory Committee; Connie Gayle White, MD, MS, FACOG, Deputy Commissioner of Clinical Affairs, Director, Division of Prevention and Quality Improvement, Kentucky Department for Public Health, Cabinet for Health and Family Services; Wade Jordahl, Family and Children’s Place; Natalie Harris, Executive Director, The Coalition for the Homeless; Jaime Montalvo, President, Irvin Rosenfeld, Medical Marijuana Patient, Chuck Thompson, Heart USA, William Ball, Retired Undercover Narcotics Officer, Dr. Patrick Moore, Psychiatry & Anesthesiology, Matt Simon, Legislative Analyst for the Marijuana Policy Project, Kentuckians for Medical Marijuana; Carol Reid, University of Kentucky; Dr. R. Stephen Amato and Florence Huffman, advocate for children with metabolic disorders; Dr. Charlton Mabry, University of Kentucky Pediatrics; Dr. John Langefeld, Chief Medical Officer, Department for Medicaid Services, Cabinet for Health and Family Services; Bob Babbage and Stewart Perry, American Diabetes Association; Tom Rector, Legalize Kentucky; Mike Porter, Kentucky Dental Association; Paula Willett, citizen; Becki Thompson, Kentucky Colon Cancer Screening Program; Richard Bartlett, Kentucky Hospital Association; Debra Armstrong, Kentucky Cancer Program; Anne-Tyler Morgan, Kentucky Board of Emergency Medical Services; Shannon Buzard, citizen; Idress Kahloon, Lexington Herald-Leader; Dr. Robin Vanderpool, University of Kentucky Rural Cancer Prevention Center; David Adams, Kentucky Citizens Judicial; Mary White, Capital Link Consultants; Crystal and Eric Byrd; and Kim and Larry Calls.
LRC Staff: DeeAnn Mansfield, Ben Payne, Jonathan Scott, Sarah Kidder, Gina Rigsby, Cindy Smith, and Wesley Whistle.
Colon Cancer Screening
Whitney Jones, M.D., Kentucky Colon Cancer Screening Program Advisory Committee; Connie Gayle White, MD, MS, FACOG, Deputy Commissioner of Clinical Affairs, Director, Division of Prevention and Quality Improvement, Kentucky Department for Public Health, Cabinet for Health and Family Services, stated that Kentucky ranked 49th in the United States for colorectal cancer screenings in 1999 and 20th in 2010. The Kentucky Colon Cancer Screening Program (KCCSP) was enacted in 2005 in KRS 215.540 to 215.544. In 2012, the General Assembly appropriated $1 million for the KCCSP. The target population of the program is low income uninsured adults aged 50 to 64. The program objects are to increase colon cancer screening, reduce morbidity and mortality from colon cancer, and reduce the cost of treating colon cancer through screening and early detection. Removing polyps is prevention not just detection. In 2012, a Request for Proposals (RFPs) was sent to all the local health departments, and whoever applied received funding. There are 33 counties that receive funding through the KCCSP. No complications have been reported on any colonoscopy. The goal is to find precancer to save lives and money for the state. The Kentucky Cancer Consortium Resource Plan estimates that treatment of early stage case of colorectal cancer costs $53,179 and late stage case costs $89,690. Partners with the Kentucky Cancer Screening Program are the Kentucky General Assembly, Kentucky Cancer Registry, Kentucky Cancer Consortium, Kentucky Cancer Foundation, Department for Public Health, local health departments, community health care providers, Kentucky Cancer Program, and the Kentucky Colon Cancer Screening Program Advisory Committee.
Homeless Prevention Pilot Project
Wade Jordahl, Family and Children’s Place, Natalie Harris, Executive Director, The Coalition for the Homeless, and Shawn Ford, Adanta, stated that the Homeless Prevention Pilot Project (HPPP) was enacted by 2005 House Bill 376 with a cost of $96,000 annually. HPPP was designed to offer reintegration planning on a voluntary basis to persons exiting state-operated prisons, mental health facilities, and foster care. The Department for Behavioral Health, Developmental and Intellectual Disabilities within the Cabinet for Health and Family Services developed project guidelines and provides oversight. The project provides case management to participants entering the Adanta Region and Family and Children’s Place in Jefferson County. HPPP objectives offer discharge planning services in one rural area and one urban area of the state, provide access to housing and community services through a single service agency in each area, and prevent 88 percent of the participants served from becoming homeless. The project has achieved a 98 percent homelessness prevention rate. The project has served 306 clients in homeless shelters, jail or prison, foster care, mental institution, and other areas. Approximately 232 clients had housing available after exiting the program. In 2010, HPPP saved $370,800 by keeping clients from returning to prisons and mental health facilities.
Phenylketonuria (PKU) – Autosomal Recessive Metabolic Genetic Disorder
Florence Huffman, advocate for children with metabolic disorders, stated that the managed care organizations (MCOs) have been following Kentucky statutes that require coverage of metabolic disorders foods and formulas primarily for infants and children. When the MCOs started operating in Kentucky, there were problems with coding and payment of metabolic disorders and, therefore, caused delays in payments. The Maternal Child and Health Division, Department for Public Health, Cabinet for Health and Family Services, used funds collected from fees for birth certificates under KRS 213.141 for the payment of metabolic foods absolutely medically necessary during this timeframe. While there has been some improvement in payments, to date there is not an adequate status report as to which MCO is in full compliance. Walgreens Infusion Services, a new pharmacy, started providing services after Plaza Drug in Somerset stopped providing and servicing patients because of nonpayment. Dr. John Langefeld, Chief Medical Officer, Department for Medicaid Services, Cabinet for Health and Family Services, has been working closely with the MCOs’ medical officers.
Dr. Charlton Mabry, University of Kentucky Pediatrics, stated that one in ten thousand births a child is affected with PKU. One problem is that health insurance companies do not want to cover the new food substitutes like other food supplements. In 2002, HB 395 was enacted that required health insurance companies to pay for the substitutes. Patients can lead a normal life, even though PKU is a lifetime disorder.
Dr. Stephen Amato, University of Kentucky Medical Center Pediatric Metabolic Diseases, stated that the PKU newborn screening started in Kentucky in 1968. In 2005, Kentucky expanded newborn screening for inherited disorders that require special foods. The MCOs do not have experience with metabolic disorders and choose not to cover them the same way as medications. Children with PKU age out of covered programs, but their medical conditions do not change.
In response to questions by Senator Denton, Carol Reid, University of Kentucky, stated that there have been issues with the MCOs in Kentucky since November 2011, but not as many with Passport. The problems started when Kentucky Spirit, CoventryCares, and Wellcare resisted coverage in the eastern half of the state. One rationale given by these three MCOs for not covering supplies is that although it may be a Kentucky law, the MCO does not have to abide by this law. Another is the coding for medical foods not being covered. Someone in the Maternal and Child Health Division pointed out that it was covered in other states and should not be a legitimate excuse in Kentucky. The cabinet has had meetings with the MCOs and medical directors. A concern is that, if payments are not initiated by the MCOs or a payment is short of the cost of the foods, Walgreens, the pharmacy providing services, will no longer be able to provide the services.
Dr. John Langefeld, Chief Medical Officer, Department for Medicaid Services, Cabinet for Health and Family Services, stated that he met with all the MCOs’ medical directors where it was agreed that clinically it was important and necessary and that it was a covered service. Ms. Reid stated that payments for these coverage services are not adequate to cover the costs by the pharmacies. Because of coding issues, there is a vast difference in reimbursement for items that are not complete formulas such as amino acid supplements. Senator Denton asked that the committee be provided information by the end of the month about the resolution of payment to pharmacies for coverage of the metabolic foods and formulas.
In response to questions by Senator Stein, Dr. Amato stated that it becomes more difficult for adults to obtain coverage for therapeutic foods.
In response to a question by Senator Buford, Dr. Langefeld stated that as of December 2012, there were 50 to 60 children in the Medicaid program that needed coverage for PKU services. Senator Buford suggested that PKU coverage be carved out of the MCO contract and be paid by the cabinet.
Minutes
A motion to approve the minutes of the June 19, 2013 and July 17, 2013 meetings was made by Senator Buford, seconded by Representative Watkins, and approved by voice vote.
Medical Marijuana
Senator Clark stated that it is continuously said that medical marijuana has no value and is not medicine, yet in 2009 federal stimulus tax money went to some pharmaceuticals to conduct research on a medical marijuana patch in Kentucky. The National Cancer Institute article states that cannabinoid receptors have been identified in the brain. Cannabinoids have been identified as having a role in pain modulation, controlled movement, feeding behavior, and memory. PubMed.gov lists all the studies being conducted on any medication. The government holds the federal patent for uses of cannabinoids.
Jaime Montalvo, President, Kentuckians for Medical Marijuana stated that an article on the United States patent number 6630507 reports that cannabinoids are found to have particular application as neuroprotects in limiting neurological damage following ischemic insults, such as stroke and trauma, or in the treatment of neurodegenerative diseases, such as Alzheimer’s disease, Parkinson’s disease and HIV dementia. Nonpsychoactive cannabinoids, such as cannabidoil, are particularly advantageous to use because they avoid toxicity that is encountered with psychoactive cannabinoids at high doses.
Irvin Rosenfeld, Medical Marijuana Patient, stated that in 1963 he was diagnosed with bone tumors and told he may not make it out of his teenage years. Cannabis was used legally from 1850 to 1941 and prescribed as a muscle relaxer, anti-inflammatory, and pain reliever. After a ten-year battle, he became the second patient admitted into the Compassionate Investigational New Drug Program ran by the federal government. Since 1982, he has received 300 cannabis cigarettes from the federal government for his bone disorder. He has had a legal prescription from a doctor to receive a can of cannabis cigarettes for the past 30 years. There are only four people in the United States that are legally allowed possess marijuana in this country. The federal government has to change the law to legalize medical marijuana. Whether Kentucky does or does not pass a law to legalize marijuana, citizens will continue to use it for medically necessary conditions.
Chuck Thompson, Heart USA, stated that since 2003, his non-profit organization in Paducah has helped 3,200 people receive $17 million of free medications. In 2005, his organization became a 501(c)(3), and in 2007 he received the Governor’s Award for Volunteerism. In 2009, the Department for Public Health contacted organization and became the model for the Kentucky Prescription Assistance Program (KPAP). Approximately $3 million was found for Kentucky citizens through the KPAP. In 2008, acting on a false sale of narcotics tip, the Paducah Police Department served a search warrant on him. He voluntarily gave up seven grams of medical marijuana and pipe. He received probation, had to give a urine sample weekly, and had to attend narcotics anonymous classes. He was fined $4,500 for this offense, and is subject to five years in jail for any subsequent offense. The KASPER program precludes any cannabis use, and, if caught, he would lose his methadone prescription he receives from his pain medication doctor. Because of the law, he is a methadone addict. He is a medicine user, not a drug abuser. Twenty states and Washington, D.C. have legalized the medicinal use of cannabis.
In response to questions by Senator Stein, William Ball, Retired Undercover Narcotics Officer, stated that the most abused drugs today are the pharmaceutical drugs. Since 1980, there are more arrests for heroin use than marijuana. Mr. Thompson stated that because of the KASPER rules restricting cannabis use, people have started to get illegal drugs for pain.
In response to questions by Senator Buford, Senator Clark stated that under federal law, a person can be arrested and charged if caught in possession of marijuana. Kentuckians cannot afford to wait for federal laws to change.
In response to questions by Senator Bowen, Matt Simon, Legislative Analyst for the Marijuana Policy Project, stated that if someone is caught in possession of a small amount of marijuana, the Louisville Police Department will issue a citation only. Senator Clark stated that Dr. Sanjay Gupta stated that there is no factual evidence marijuana is a gateway to heroin. Mr. Rosenfeld stated that the Patients Out of Time is the only organization in the United States to be sanctioned by the American Medical Association and the American Nurses Association to teach doctors and nurses about medical cannabis and provide continuing education credit every two years. Mr. Montalvo stated that the University of Kentucky and the University of Louisville have been contacted and have shown interest holding the conferences, but there are funding issues.
In response to a question by Representative Adams, Mr. Simon stated that marijuana has been an illegal drug for so long and people are familiar with smoking as recreational use. In 1999, the Institute of Medicine issued a report on a comprehensive science-based study on marijuana as medicine, and one conclusion was there are negatives associated with smoking, and there needs to be the development of a rapid onset method of ingesting medical marijuana. Since then vaporizers have been developed that heat the cannabis to a temperature below the point of combustion so there is no carbon monoxide and does not produce any smoke. Vaporizers have all the same immediate effects of smoking marijuana without all the carcinogens in smoke.
In response to questions by Senator Buford, Mr. Simon stated that there have been federal raids in the last several years in states that did not license or regulate dispensaries. In 2009, the United States Department of Justice released the following statement: As long as states operate in clear and unambiguous compliance of state law, they will not be targets for federal prosecutions. There has not been a federal raid on a state-licensed, state-regulated medical marijuana dispensary and the federal government has never targeted individual patients or caregivers. Because all prescriptions are federally regulated, all the states that have effective medical marijuana laws use the term recommendation or certification rather than prescription. The dispensaries are not in compliance with federal law because all marijuana possession, transfer, or sale remains illegal under federal law.
Senator Denton stated that she wanted to be on record that she would not be party to any action taken after she leaves the meeting when the Senate reconvenes.
Dr. Patrick Moore, Psychiatry & Anesthesiology, stated that prescription drugs are the gateway to heroin.
In response to questions by Representative Benevenuti, Dr. Moore stated that Dr. Sanja Gupta said that only 94 percent of the United States research conducted is oriented toward the negative effects of medical marijuana. Representative Benvenuti stated that Kentucky needs to start making medically evidence-based decisions. Mr. Montalvo stated that United States patent number 663057 reports some of the medical benefits of marijuana. The National Institute on Drug Abuse has only received funds for studies against the use of medical marijuana.
In response to a question by Representative Owens, Mr. Simon stated that doctors cannot prescribe medical marijuana only recommend its use.
In response to a question by Representative Watkins, Mr. Rosenfeld stated that his doctor is only one of three doctors licensed in the United States to prescribe medical marijuana.
Representative Moore stated that over half of applicants do not qualify for military service because of drug use. Marijuana is a prohibited substance in the military, and there will be a tremendous conflict if a state legalizes it but the military prohibits its use. Legalizing marijuana is a major military readiness issue with serious ramifications and it is seen as a detriment to recruitment if it is legalized.
In response to questions by Representative Wuchner, Mr. Simon stated that medical marijuana has not gone through the three phases of medical clinical trials for new medications. The National Institute on Drug Abuse’s (NIDA) mandate from Congress is to study marijuana as a substance of abuse not as a potential medicine. Studies have been conducted in other countries on medical marijuana, but studies have been heavily restricted in the United States. Senator Clark stated that because cannabus is a Schedule I drug, the federal government disallows its study.
In response to questions by Representative Adams, Mr. Rosenfeld stated that the main active ingredient in marijuana that makes a person euphoric is THC, and another ingredient is a cannabinoid (CBD) that takes away the high. Scientists can grow marijuana plants marijuana with the CBD that does not cause any euphoric effect but has medical properties. Dispensaries in some of the states that allow the use of medical marijuana have different types or strains of the plant in order to treat different diseases. Representative Adams asked Mr. Rosenfeld to provide summary of the states that allow medical marijuana and how the transition was handled.
In response to questions by Senator Denton, Mr. Rosenfeld stated that juicing a marijuana plant does not cause psycho-altering affects. Juicing a plant means to take a natural plant and make a juice out of it that takes away any euphoric affect. Juicing does require more of the product. There are different costs for the different strains of cannabis because of the how much is involved in growing the different plants.
Consideration of Referred Administrative Regulations
The following administrative regulations were available for consideration: 201 KAR 2:020 – establishes the examination and application requirements for obtaining a license to practice pharmacy in Kentucky; 201 KAR 2:030 – establishes conditions, forms, and examination requirements for licensure by reciprocity (KBP); 201 KAR 20:400 – establishes requirements that govern the delegation of a nursing task in a safe, effective manner so as to safeguard the health and welfare of the citizens of the Commonwealth; 202 KAR 7:330 – establishes requirements for examination, certification, and recertification of the AEMT; 202 KAR 7:520 – establishes standards and criteria governing the allocation of emergency medical services funding assistance to eligible applicants; and 202 KAR 7:540 – establishes standards and criteria for EMS data collection, submission, and compliance of ambulance services furnished to the KBEMS. The Kentucky Board of Nursing sent a letter to the Administrative Regulations Review Subcommittee Regulations Compiler Wednesday, August 21, 2013, requesting the withdrawal of 201 KAR 20:400 to continue its study of the issues and questions raised by the board. A motion to accept the administrative regulations was made by Representative Marzian, seconded by Representative Jenkins, and accepted by voice vote.
Adjournment
There being no further business, the meeting was adjourned at 2:45 p.m.