Call to Order and Roll Call
Thesixth meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, November 19, 2014, at 10:00 a.m., in Room 129 of the Capitol Annex. Representative Tom Burch, Co-Chair, called the meeting to order at 10:08 a.m., and the secretary called the roll.
Members:Representative Tom Burch, Co-Chair; Senators Julian M. Carroll, Denise Harper Angel, Jimmy Higdon, Alice Forgy Kerr, Katie Stine, and Reginald Thomas; Representatives Julie Raque Adams, Robert Benvenuti III, Bob M. DeWeese, Kelly Flood, Mary Lou Marzian, Reginald Meeks, Darryl T. Owens, Ruth Ann Palumbo, David Watkins, Russell Webber, and Susan Westrom.
Guests: Audrey Tayse Haynes, Secretary, Cabinet for Health and Family Services; John Langefeld, Medical Director, Department for Medicaid Services, Cabinet for Health and Family Services; Allen Brenzel, Medical Director, Department for Behavioral Health, Developmental and Intellectual Disabilities, Cabinet for Health and Family Services; Mary Hass, Advocacy Director, Eddie Reynolds, BIAK Outreach Coordinator, and Sarah Peterson, Military Affairs and Outreach Director, Brain Injury Alliance of Kentucky; Darla Bailey, President, Kaleidoscope, Inc.; Georgiana Adams, Guardian to Individual with Brain Injury; Stephanie Mayfield Gibson, MD, FCAP, Commissioner, Department for Public Health, Cabinet for Health and Family Services; Kevin T. Kavanagh, MD, MS, Health Watch USA; Jerald Combs, Kentucky Optometric Association; William Reynolds, Kentucky Board of Optometric Examiners; Hollie Sands and Laura Begin, Department for Public Health, Cabinet for Health and Family Services; Michele McCarthy, Center for Behavioral Health; Lisa Jagnow, Department for Behavioral Health, Development and Intellectual Disabilities, Cabinet for Health and Family Services; Howard Shaps, WellCare; and Emily Mills, Frankfort Regional Medical Center.
Approval of the Minutes
A motion to approve the minutes of the October 15, 2014 meeting was made by Representative Westrom, seconded by Representative Meeks, and approved by voice vote.
Consideration of Referred Administrative Regulations
201 KAR 5:055 – establishes requirements for the use of telehealth services in the provision of optometric services; 201 KAR 32:035 – establishes the supervision requirements for marriage and family therapy associates and their board-approved supervisors; 201 KAR 33:010 – establishes fees for dietitian and nutritionist licensure; 902 KAR 2:055 – establishes requirements for reporting immunization results in schools by the public health immunization reporting entity and permits recording and exchange of immunization data; 921 KAR 3:035 – establishes the certification process used by the cabinet in the administration of the Supplemental Nutrition Assistance Program (SNAP); and 921 KAR 3:090 – establishes requirements for the Simplified Assistance for the Elderly Program (SAFE), a demonstration project administered by the cabinet to improve access to SNAP for elderly and disabled individuals. A motion to adopt an amendment to 201 KAR 5:055 was made by Senator Kerr, seconded by Senator Harper Angel, and adopted by voice vote. A motion to approve the administrative regulations as amended was made by Representative Marzian, seconded by Representative Meeks, and approved by voice vote. In response to a question by Representative Palumbo, Mike Rodman, Executive Director, and Dr. Russell Travis, Board Member, Kentucky Board of Medical Licensure, stated the board supports the amendment. Dr. Jerald Combs, Kentucky Optometric Association, and Dr. Bill Reynolds, Kentucky Board of Optometric Examiners, stated that both of them agreed to the amendment.
Opiate Abuse: Current Concerns in Kentucky
Audrey Tayse Haynes, Secretary, John Langefeld, Medical Director, Department for Medicaid Services, and Allen Brenzel, Medical Director, Cabinet for Health and Family Services stated that the most common drug treatment admissions are for opiates. Drug overdose deaths are now more frequent than motor vehicle accidents. Prescriptions reported through KASPER for opiates have decreased since the implementation of House Bill 1 in 2012. A few requirements of House Bill 1 from the 2012 Regular Session were that a physician has to own a pain management facility, has to utilize the Kentucky All Schedule Prescription Electronic Reporting (KASPER) program, and limit the dispensing of drugs containing hydrocodone to a 48-hour supply. The goals of the Governor’s health initiative, kyhealthnow, are to reduce the rate of uninsured individuals, smoking rates, obesity, cancer, cardiovascular deaths, dental visits, drug overdose deaths, and average number of poor mental health days.
A major concern is that because of the requirements to report prescriptions and the inability to monitor heroin in the KASPER system, heroin has become the drug of choice. Most heroin abusers were addicted to prescription opiates. There is a higher overdose death rate for Kentucky women of childbearing age compared to the United States. Also, an increasing number of babies are born with neonatal abstinence syndrome (NAS) due to prenatal exposure to opiates.
Medication assisted treatment (MAT) is an evidence-based approach that involves prescribing medications to an opiate dependent patient and allows an individual to be stabilized and engaged in therapeutic services. Some patients may require ongoing MAT. Kentucky data indicates that buprenorphine is frequently being prescribed in a manner that is not consistent with evidence-based clinical recommendations. A significant amount of buprenorphine is being diverted to inappropriate and illegal use.
In the last several years, Medicaid data has shown a 241 percent increase in the use of all combined buprenorphine products. In 2013, over $22 million was spent on drugs and $20 million in the first six months of 2014. There has been a dramatic increase in buprenorphine seized by the Kentucky State Police (KSP). In 2014, the top ten counties in the number of Medicaid buprenorphine prescriptions were Pike, Harlan, Floyd, Jefferson, Whitley, Clay, Knox, Fayette, Perry, and Laurel. The top ten providers were general practitioners, internists, and family practitioners. There were no substance abuse treatment specialists in the top ten. Some prescriptions were written by out-of-state doctors but were filled by pharmacies in Kentucky. The cabinet is paying close attention to who prescribes buprenorphine medications. In 2014, one Medicaid recipient received a buprenorphine drug product from nine different prescribing providers. The World Health Organization (WHO) has updated the guidelines for reducing opioid related deaths with preventative measures to encourage monitoring opioid prescribing practices, curbing inappropriate opioid prescribing, and increasing the rate of treatment of opioid dependence. Data shows that improving access to appropriate treatment has a significant impact on lowering the number of deaths from substance abuse. All community stakeholders need to be involved for solutions to be effective.
In response to questions by Senator Stine, Dr. Langefeld stated that the drug treatment admissions data include both admissions to a hospital and an emergency room. Drug overdose data include deaths from all opiates including heroin. There is complacency about drug overdoses, because most people do not think it will ever affect them. It has an effect on economic development, courts, law enforcement, and first responders. Secretary Haynes stated that Recovery Kentucky receives some funds through a settlement to the Office of Attorney General but is run by the Kentucky Housing Corporation. Recovery Kentucky works outside a medical model.
In response to questions by Representative Benvenuti, Secretary Haynes stated that marijuana can be a gateway to other drugs. Dr. Brenzel stated that marijuana blocks receptors allowing someone to function during the day. It is a felony to divert marijuana. There is a 75 percent to 80 percent relapse in individuals after treatment of an opioid. Standards of practice need to be followed. Secretary Haynes stated that methodone treatment is regulated by the Department for Behavioral Health, Developmental and Intellectual Disabilities and the Drug Enforcement Agency (DEA). General practitioners are prescribing opioids in a high amount.
In response to questions by Representative Owens, Dr. Brenzel stated that In 2014, approximately 7,400 Medicaid recipients received a buprenorphine drug product from one prescriber but not the same prescriber every time. It is a concern that recipients go to multiple providers for medications. Secretary Haynes stated that 20 percent of the doctors prescribe 80 percent of the medications to Medicaid recipients.
In response to a question by Representative Watkins, Dr. Brenzel stated that training is mandated by the federal DEA, and then additional training hours can be requested from the DEA.
Legislative Hearing on the FFY 2015-16 Temporary Assistance for Needy Families Block Grant
The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), Public Law 104-193, the Temporary Assistance for Needy Families (TANF) program replaced the welfare programs known as Aid to Families with Dependent Children (AFDC), the Job Opportunities and Basic Skills Training (JOBS) program, and the Emergency Assistance (EA) program. The law ended federal entitlement to assistance and instead created TANF as a block grant that provides states, territories, and tribes with federal funds each year to cover benefits, administrative expenses, and services targeted to needy families. TANF became effective on July 1, 1997 and was reauthorized in February 2006 under the Deficit Reduction Act of 2005. The Claims Resolution Act of 2010 (Public Law 111-291) was signed into law on December 8, 2010. The Act extended TANF through the end of fiscal year FY 2011. Since 2012, funding for the TANF program has been extended through a series of extensions.
States design and operate programs to assist needy families so that children can be cared for in their own homes; reduce the dependency of needy parents by promoting job preparation, work, and marriage; prevent out-of-wedlock pregnancies; and encourage the formation and maintenance of two-parent families. Kentucky’s TANF cash assistance program, the Kentucky Transitional Assistance (K-TAP) program, falls under all provisions of TANF including the participation and work requirements and the five-year lifetime limit on benefits. The Department for Community Based Services (DCBS) provides TANF services to participants. Kentucky is divided into nine service regions that provide direct service delivery, including eligibility determinations, to all 120 counties. The Division of Family Support develops partnerships with other state agencies, local governments, community-based organizations, and employers to provide linkages for services to reduce barriers to employment for the Kentucky Works Program participants. All contracts are monitored annually for contract compliance.
Families are provided tools to become self-sufficient while ensuring children are protected and valued. Before the five-year lifetime limit expires, adults will become involved in work activities and become self-sufficient. The services offered under the plan include cash assistance to needy families with children; supportive services such as child care and transportation for Kentucky Works Program participants; post-employment supports such as the Work Incentive Program (WIN); family services to needy families so children may be cared for in their own homes or in the homes of relatives and to encourage the formation and maintenance of two-parents families; and the Kinship Care Program to provide cash assistance to a caring relative as an alternative to placement with a non-relative. Projected federal funds for FFY 2015 and FFY 2016 are $181,287,700 per year. A motion to approve the Temporary Assistance for Needy Families Block Grant was made by Representative Flood, seconded by Senator Harper Angel, and approved by voice vote.
Traumatic Brain Injury
Mary Hass, Advocacy Director, Brain Injury Alliance of Kentucky, stated that Kentucky has a fragmented system of care for people with a brain injury. Providers have demonstrated the need for a centralized coordination effort at the state level to streamline and coordinate the specialized supports and services to Kentucky citizens with an acquired brain injury (ABI). The goal of BIAK is to establish an Office of Brain Injury within the Department for Aging and Independent Living (DAIL) in the Cabinet for Health and Family Services to create a coordinated system of care, revise the ABI waivers, and develop an enhanced fee structure that pays for the more difficult individuals in Kentucky. DAIL has the brain injury expertise and staff needed to maintain and hold the sole responsibility of setting policy and overseeing all brain injury services. Currently, brain injury services are split between the Department for Medicaid Services (DMS) and DAIL. DAIL has been designated as the lead agency on brain injury but only has oversight of the Traumatic Brain Injury Trust Fund and the TBI Behavioral Program. DMS controls the two ABI waivers, Michelle P waiver, Kentucky Transitions waiver, and the Home and Community Based Services (HCBS) waiver. The Department for Behavioral Health, Developmental and Intellectual Disabilities (DBHDID) controls the Supports for Community Living (SCL) waiver. Eastern State Hospital’s Neurobehavioral Brain Injury Program has a contract with DBHDID. An Office of Brain Injury would reduce administrative burdens on providers and save state funds currently spent on duplicative services, supports, and administration.
Brain injury services are divided into the Traumatic Brain Injury Trust Fund, the TBI Behavioral Fund, the Acquired Brain Injury Long Term Care waiver, and the Acquired Brain Injury Acute Care waiver. There are not enough TBI waiver providers to provide services for individuals with more difficult and medically complicated brain injuries.
Eddie Reynolds, BIAK Outreach Coordinator, stated that the 2004 Kentucky Brain Injury Prevalence Study reported that an estimated 214,000 Kentuckians have a brain injury. The Kentucky Traumatic Brain & Spinal Cord Injury Project, Kentucky Injury Prevention and Research Center FY 2010 final report stated that brain injury plays a role in the death or hospitalization of 23 state residents per day. The cost for hospitalization for brain injuries is $264.5 million, and taxpayers pay 43 percent of the total. Individuals with brain injuries learn that each brain injury program has a different application and set of admission criteria, there are long waiting lists and not every region in the Commonwealth offers brain injury services. If a brain injury survivor has severe neurobehavioral issues there are limited options available. Currently, most Kentuckians with severe issues are being served out-of-state which separates them from any family support. The new neuro-behavioral unit at Eastern State Hospital will not open until April 2015. Providers of community-based neurobehavioral programs are discouraged from coming to Kentucky. A single point of entry coordinated case management system can help guide an individual and his or her family members when applying for needed services. It would also create a system that addresses the needs of persons with severe neurobehavioral issues and provide a quality system of community-based care.
Sarah Peterson, Military Affairs and Outreach Director, Brain Injury Association of Kentucky, stated that there is a need for a state system for veterans who do not feel comfortable with the Veterans Administration (VA) or who currently do not receive services. The VA system is trying to keep up with the demand to provide services to more military personnel.
Georgiana Adams, guardian to individual with a brain injury, stated that when her boyfriend received a brain injury in 1996, there we no long-term care residential rehabilitative facility available for him to receive services. Services stopped when she took him home from the hospital, and it was very difficult to navigate the system to know where to find the help and funding needed. Her friend was finally sent out-of-state to receive the care he needed and could not get in Kentucky. She questioned why someone with a severe brain injury has to go out-of-state to receive services.
Darla Bailey, President, Kaleidoscope, Inc., stated that Kentucky needs one office where all services can be accessed by an individual with a brain injury.
In response to questions by Representative Benvenuti, Mr. Reynolds stated that Kentucky does pay 43 percent of the cost for hospitalization of brain injury patients. Ms. Hass stated that providers do not want to come to Kentucky because there is no guarantee of the number of patients that will need services, therefore, there is no guarantee of a specific amount of reimbursement for services that are provided.
Kentucky Ebola Outbreak Preparation
Stephanie Mayfield Gibson, MD, FCAP, Commissioner, Department for Public Health, Cabinet for Health and Family Services, stated that sporadic Ebola virus outbreaks typically occur in tropical regions of Sub-Sharan Africa with mortality rates from 25 percent to 90 percent. The 2014 Ebola outbreak in West Africa is the largest to date. Of the five subtypes of the genus Ebolavirus, Zaire and Sudan strains cause the most severe illness and have higher case facility rates. No Ebola virus cases have been reported in Kentucky, but the Department of Public Health (DPH) is providing training and information to local health departments, healthcare providers, and hospitals on how to report potential Ebola cases. The DPH is working with CDC and the Department for Health and Human Services (DHHS) to ensure all Kentucky-specific Ebola virus disease guidance is current. The transmission of the Ebola virus occurs through direct contact with infected body fluids such as blood, urine, sweat, breast milk, and semen. The time it takes for a person to develop symptoms after being exposed is approximately eight to ten days. Infected persons are not contagious until someone begins to show signs and symptoms of the disease. No one can get the Ebola virus through the air, water, or food. Currently there are no specific FDA-approved vaccines, antivirals, or other medications. Experimental treatments have been tested and proven effective in animal models, but have not yet been studied in randomized clinical trials in humans. The Center for Disease Control and Prevention (CDC) is working with state health departments and partners at ports of entry into the United States to prevent the introduction of the disease into the country.
In response to questions by Senator Stine, Commissioner Mayfield stated that the contaminated equipment is disposed by incineration as recommended by the CDC guidelines. The Department of Defense (DoD) mandates that Soldiers be monitored for 21 days after returning from an infected country. The 101st Airborne military personnel deployed to West Africa would be trained in the use of protective gear and on the disease itself although U.S. military personnel are not and will not be in direct contact with Ebola victims. ZMAPP needs to be studied more in controlled conditions, so it is too early to tell if the drug will help cure individuals with the Ebola virus.
In response to a question by Senator Thomas, Commissioner Mayfield stated that the DPH would start an investigation if a potential Ebola virus case is reported. The privacy of the patient has to be protected. The individual would be monitored by the health department for 21 days. Kentucky receives less than one percent from travelers to foreign countries.
Healthcare Associated Infections and Hospital Acquired Conditions
Kevin T. Kavanagh, MD, MS, Health Watch USA, stated that dangerous infections such as Ebola, CRE, Methicillin-Resistant Staphylococcus Aureus (MRSA), C. Difficile, and other dangerous bacteria place an entire facility at risk. Public reporting promotes quality of the health care system and transparency promoted the rapid adoption of stronger protocols to confront the outbreak of Ebola throughout the nation this year. A health acquired infection (HIA) outbreak is the occurrence of two or more HAIs that are epidemiologically linked or connected by persons, place, or time; or a single case of a HAI not commonly diagnosed such as a postsurgical group A Streptococcus infection or healthcare-associated Legionella infection. Administrative regulation, 902 KAR 2:020, Section 12: Healthcare-Associated Infection Surveillance, states a healthcare facility in Kentucky that participates in the Centers for Medicare and Medicaid Centers (CMS) reporting programs shall authorize the Center for Disease Control and Prevention (CDC) to allow the Kentucky Department for Public Health to access health care-associated infection data reported to the National Healthcare Safety Network (NHSN). In Northern Europe, less than five percent of staph cultures are MRSA positive and 50 percent in the United States. MRSA is reported to the NHSN for only bloodstream infections. According to NHSN data, Kentucky has the fourth highest incidence of MRSA in all 50 states.
The National Nurses United (NNU) union has testified before the United States Congress regarding the protection of nurses and how to help prevent the spread of the Ebola virus. Surveillance and isolation of Ebola is advocated and felt as being mandatory. The desire not to have mandates has led to not having standards. A definition of contact precautions should state that a single patient room is preferred for patients who require contact precautions. The current outbreak of Ebola has demonstrated the need to take more precautions for suspected infected patients as well as confirmed infected patients. Because of the billing complexities of facilities, non-payment of HAIs is an ineffective tool to deter the reporting of HAIs.
Kraig E. Humbaugh, MD, MPH, Senior Deputy Commissioner, Department for Public Health, Cabinet for Health and Family Services, stated that gaining awareness of a potential public health problem from the outset allows more time for a thoughtful, considered response, and more strategic use of limited resources. The Kentucky Revised Statutes require the cabinet to implement a statewide program for the detection, prevention, and control of communicable disease and health hazards. Every physician and advanced practice registered nurse shall report all diseases designated by the cabinet as reportable. Kentucky administrative regulation 902 KAR 2:020 establishes who should report the specific diseases and outbreaks and how each should be reported. Healthcare associated infections (HAIs) are only reportable as outbreaks. Reports can be made to either the DPH or a local health department. In 2013, there were 9,689 investigations of reported diseases.
The DPH assists in determining whether an outbreak is occurring, assists in providing guidance for control, determines if facility outbreaks are interrelated across county and state lines, and analyzes and uses the data in public reports. The objectives for updating 902 KAR 2:020 were to make reporting reflect the impact of diseases on the community, revise the list of individual reportable diseases to be more consistent with federal notifiable diseases, and gain better awareness of HAIs. HAIs can happen any place that health care is provided. Risk factors of HAIs include the use of medical devices, surgical procedures or implants, or improper infection control precautions, and are often caused by multidrug resistant organisms (MDROs) that are difficult to treat. A system will be established to issue a public health advisory for reporting a disease felt to be an emerging public health threat. HAIs are mandated to be reported routinely for hospitals participating in the Centers for Medicaid and Medicaid Services (CMS) hospital IQR program. Data submitted to CMS through the National Healthcare Safety Network (NHSN) would be required to be submitted at the same time to the DPH. The CDC’s NHSN is the nation’s most widely used healthcare associated infection tracking system. The system is free, secure, standardized, and used to benchmark progress of infection control efforts. The Kentucky Health Information Exchange (KHIE) enables safe, secure electronic exchange of patient health information among participating providers and organizations statewide.
In response to a question by Representative Westrom, Dr. Humbaugh stated that facility data will be available but not patient information.
Emily Mills, Frankfort Regional Medical Center, stated that hospital data is transparent. Any occurrence of MRSA in the blood has to be reported. The patient could have contracted MRSA outside of the hospital, but if the virus is found in a hospital patient’s blood, it has to be reported. Not all facilities have the same electronic reporting system, so information is reported differently. The goal is to have providers use best practices. Data collection and reporting has to be accurate.
In response to questions by Representative Westrom, Ms. Mills stated that a patient that has been treated for MRSA and released from the hospital no longer carries the virus. But if that same person is admitted again at a later date, they could potentially carry a new strain of the virus with them to the hospital. Dr. Humbaugh stated that some people with MRSA are isolated to prevent the spread of the virus. Ms. Mills stated that patients in the hospital need to be educated about infections.
There being no further business, the meeting was adjourned at 12:24 p.m.