Call to Order and Roll Call
The third meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, August 17, 2016, at 9:00 a.m., in Room 129 of the Capitol Annex. Senator Julie Raque Adams, Co-Chair, called the meeting to order at 9:04 a.m., and the secretary called the roll.
Present were:
Members: Senator Julie Raque Adams, Co-Chair; Representative Tom Burch, Co-Chair; Senators Ralph Alvarado, Danny Carroll, David P. Givens, Denise Harper Angel, Jimmy Higdon, Alice Forgy Kerr, and Max Wise; Representatives Robert Benvenuti III, George Brown Jr., Mary Lou Marzian, Reginald Meeks, Phil Moffett, Tim Moore, Darryl T. Owens, Russell Webber, Susan Westrom, and Addia Wuchner.
Guests: Ardis Hoven, M.D., Medical Consultant, Department for Public Health, Cabinet for Health and Family Services; Justin Carey, Health Environmentalist, Department for Public Health, Cabinet for Health and Family Services; David Wayne, Environmental Services Director, Department of Agriculture; Dr. Grayson Brown, University of Kentucky Department of Entomology; William Crump, M.D., Associate Dean, University of Louisville School of Medicine Trover Campus, Madisonville, Kentucky; Austin Beck, M.D., Madisonville; Samantha Hays, third-year Trover medical student; Mary Hass, Advocacy Director, Brian Injury Alliance of Kentucky (BIAK); Diane M. Schirmer, Medical Director of Brain Injury Services, New Vista Health, Inc., Lexington; Linda M. Klawitter, MA, CCC/SLP Speech-Language Pathologist, Newcare ADT Program, Louisville; Jennifer Hornback; Alex Nauert, Military Outreach Coordinator, Brain Injury Alliance of Kentucky; Eddie Reynolds, Program Director/Outreach Coordinator, Brain Injury Alliance of Kentucky; Laura Begin, Department for Public Health, Cabinet for Health and Family Services; Tamara McDaniel and Peggy Lucy Moore, Kentucky Board for Respiratory; Chell Austin, Brain Injury Alliance of Kentucky; Richard Morris and Brenda Bowman, CCAK; and Ned Sheehy, AccuTran Industries, Inc.
LRC Staff: DeeAnn Wenk, Ben Payne, Jonathan Scott, and Gina Rigsby.
Consideration of Referred Administrative Regulations
The following administrative regulations were on the agenda for consideration: 201 KAR 9:250 – establishes the requirements for registration and oversight for pain management facilities by the Kentucky Board of Medical Licensure; 201 KAR 29:015 – establishes all fees for mandatory certification and to periodically review and modify those fees charged by the Kentucky Board of Respiratory Care; 201 KAR 46:020 – establishes fees for the licensure of an advanced imaging professional, a medical imaging technologist, a radiographer, a radiation therapist, a nuclear medicine technologist, and a limited x-ray machine operator; 201 KAR 46:070 – establishes uniform enforcement procedures regarding the licensure of an advanced imaging professional, a medical imaging technologist, a radiographer, a radiation therapist, a nuclear medicine technologist, or a limited x-ray machine operator and penalties for violation of licensure requirements; 902 KAR 4:120 – establishes the eligibility criteria, services, provider qualifications, and hearing rights for participants of the Health Access Nurturing Development Services (HANDS) Program; 902 KAR 100:030 – establishes quantity requirements for the labeling of radioactive material licensed under 902 KAR Chapter 100; 902 KAR 100:080 – establishes a list of quantities of specific radionuclides that are exempted from the requirements of 902 Chapter 100; 902 KAR 100:085 – establishes a list of concentrations for specific radionuclides that are exempted from the requirements of 902 Chapter 100; 921 KAR 3:035 & E – establishes the certification process used by the cabinet in the administration of the Supplemental Nutrition Assistance Program (SNAP); 922 KAR 1:320 & E – establishes procedures related to appeals and complaints for benefits and services under 922 KAR Chapters 1 through 5 until April 1, 2017, and Chapters 1, 3, and 5 effective April 1, 2017; 922 KAR 2:020 & E – establishes procedures for improper payments, claims, and penalties used by the cabinet in the administration of the Child Care Assistance Program (CCAP); 922 KAR 2:160 & E – establishes requirements that enable the Cabinet for Health and Family Services to qualify for federal funds under the Child Care and Development Fund, and establishes procedures for the implementation of the Child Care Assistance Program to the extent that funding is available; and 922 KAR 2:260 & E – establishes cabinet procedures related to appeals and complaints for child care benefits and services under 922 KAR Chapter 2 effective April 1, 2017. A motion to accept the referred administrative regulations was made by Representative Marzian, seconded by Representative Burch, and accepted by voice vote.
Richard Morris and Brenda Bowman, CCAK, stated that they does not want to tell low-income parents their child cannot be accepted because there are no child care assistance program funds available. Hundreds of child care centers have closed in the past three years because of the lack of funds available to low-income parents through the child care assistance program. The main goal is to maintain high quality within the child care center.
In response to a question by Senator Danny Carroll, Mr. Morris stated that he did not know what happened to the children who no longer were qualified for child care assistance. It is hard to retain employees or even hire new ones without adequate funds.
Minutes
A motion to approve the minutes of the July 20, 2016 meeting was made by Senator Kerr, seconded by Representative Wuchner, and approved by voice vote.
Coordination of Services for Individuals with Brain Injuries
Mary Hass, Advocacy Director, Brian Injury Alliance of Kentucky (BIAK), stated that the mission of the BIAK is to serve those affected by brain injury through advocacy, education, prevention, service, and support. A brain injury is an event that alters the neurological functioning of the brain and lasts long after the event has occurred. A traumatic brain injury (TBI) can result from falls, motor vehicle or bicycle accidents, assaults, or military injury. An acquired brain injury (ABI) can be caused by strokes/aneurysms, brain tumors, anoxic injuries from near drowning, heart attacks, and loss of blood, or infections such as encephalitis. A brain injury can happen to anyone at any time. Some unseen effects include personality changes, seizures, cognitive issues, emotional control, balance and mobility issues, physical speech issues, or decreased quality of life. The severity of the injury is not necessarily an indicator of recovery, but there will always be some long-term impact from the brain injury. Someone with a brain injury has decreased independence, unemployed and financial hardships, substance abuse, family problems, higher rates of homelessness, poverty, and incarceration, increased rate of suicide, and increased cost to the taxpayer. Brain injury directly affects five percent of all Kentuckians. The ABI waivers are currently serving 703 persons with an additional 191 on a waiting list for a total of 894 individuals.
Diane M. Schirmer, Medical Director of Brain Injury Services, New Vista Health, Inc., Lexington, stated that neurologic damage associated with brain injury is a progressive chronic condition. There should be a broad range of treatment options across the continuum to respond to individual needs. Evidence demonstrates that access to post-acute rehabilitation, even many years after the injury, results in significant functional treatment gains and reduced costs.
Linda M. Klawitter, MA, CCC/SLP Speech-Language Pathologist, Newcare ADT Program, Louisville, stated that there are many concerns related to the proposed changes to therapies coming out of the Acquired Brain Injury Medicaid waivers and instead requiring individuals who have suffered an ABI to receive their therapies under the State Health Plan (SHP). Therapies under the ABI waivers enabled these individuals to receive the needed intense therapy to allow them to reach their potential and increase their independence. Under the state plan, these individuals may only be granted 20 visits per year depending upon how much progress they have made when the treating therapist submits documentation and a reviewer enters the information into a system call Inter Qual. The ABI waiver allows intensive therapy at least 1.5 hours per day verses 20 visits per year in the SHP. Many individuals with ABI have many deficit areas and goals that must be addressed through community reintegration. Research and anecdotal evidence suggests that skills addressed in a clinical setting do not necessarily translate to skills needed in the community. Progress from brain injury is a slow and rigorous process, and goals cannot be met in the restrictive cap of 20 visits per year. The brain controls thoughts, actions, and emotions. When a brain injury occurs, many deficit areas are often present, making the need for intense, consistent therapy necessary. Without intense therapy, many clients would be in nursing homes, psychiatric hospitals, incarcerated, or homeless.
Jennifer Hornback, seven-year brain injury survivor and college student, stated that a quote by Laurell K. Hamilton says “There are wounds that never show on the body, that are deeper and more hurtful than anything that bleeds.” Just because a wound is not visible to the eye, does not mean the struggles someone goes through does not exist. As with many other brain injury survivors, she has had to face struggles of depending on support systems to help recover after her family was told she may never be functional again. If it was not for the help and support of speech therapists, occupational therapists, psychologists, and behavior therapists, she does not know how she would have coped with life after she woke up from her coma. No brain injury is alike just as no two people are alike. Like everything else in life, recovery takes time, patience, and energy. Recover is not something that can happen overnight. Recovery is a lifelong process that continues even when all of the visible scars have healed.
Alex Nauert, Military Outreach Coordinator, Brain Injury Alliance of Kentucky, stated that the BIAK Military Traumatic Brain Injury Program works independently, and with other veteran service agencies to actively seek out Kentucky veterans and their family members affected by a mild military TBI and connect them to the resources needed in order to maximize their recover and future success. Kentucky veterans needs often go unnoticed because many people assume that all veterans are federally assisted from the Department of Veterans Affairs. However, many Kentucky veterans acquire brain injuries from non-military related incidents that are not covered under federal assistance such as automobile accidents, brain diseases, falls, and unfortunate accidents. Co-occurring symptoms of post-traumatic stress and traumatic brain injury are fatigue, insomnia, depression, irritability, and anxiety. To qualify for Veterans Administration (VA) benefits a veteran must be properly discharged, have wartime service, be permanently and totally disabled or over the age of 65, and demonstrate financial need. All other veterans must access the same services as all Kentucky residents. To date, BIAK Military Outreach has met and assisted over 120 Kentucky veterans who had a known acquired brain injury, both service and non-service related. As we continue to be reminded of the vast number of veterans who go undiagnosed with a TBI or PTSD mental illness, the Commonwealth of Kentucky must seize the opportunity to pioneer a remedy for this situation. We can show that we care by allowing not only the veterans that have had their brain injuries diagnosed, but also the veterans that are yet to be diagnosed to have access to the same Medicaid services provided by the Commonwealth. Regardless if a Kentucky veteran received a brain injury abroad or on the Homefront, service-connected or non-service connected, they all need to be considered under this continuum.
Ms. Hass stated that the Department for Medicaid Services (DMS) administers the Acute and Long-Term Acquired Brain Injury Medicaid waivers. The Department for Aging and Independent Living (DAIL) administers the TBI Trust Fund and the Traumatic Brain Injury Behavioral Program. The Department for Behavioral Health, Developmental and Intellectual Disabilities (DBHDID) administers the ABI unit at Eastern State Hospital and Community Mental Health Centers. This multi-layer approach adds another layer of bureaucracy for families to navigate. When families are in crisis, they just want to know who to call for help. Services are hindered by a lack of coordination, communication, and policy decisions that conflict with other departments. BIAK proposes the services provided by DMS, DAIL, and DBHDID for individuals with brain injuries be combined in a new department within the cabinet that would have a unified mission and purpose and would be able to coordinate the work of the ABI Medicaid waiver and TBI Trust Fund. All brain injury services located in one department would better serve persons who have a brain injury, save money in administrative costs for use for those who need it, offer a centralized approach that is more efficient and effective in helping people, and align policy and definitions. Rehabilitation is recovery.
Eddie Reynolds, Program Director/Outreach Coordinator, Brain Injury Alliance of Kentucky, was available for questions.
Senator Adams stated that now is the time to work with the cabinet to streamline the process.
In response to questions by Representative Burch, Ms. Hass stated that she would try to get statistics on how many of the five percent of Kentucky residents diagnosed with a brain injury are receiving treatment. The Affordable Care Act has allowed people who have not had insurance in the past be able to receive services now.
Representative Benvenuti stated that individuals with TBIs should not be included in the Medicaid population because they need more intensive and specialized care.
In response to a question by Representative Wuchner, Ms. Hass stated that there needs to be a one-stop, centralized case management system. Severity does not predict an individual’s outcome.
In response to questions by Senator Kerr, Ms. Hass stated that stroke victims would be included in the five percent of Kentuckians diagnosed with a brain injury. Services are available for these five percent of Kentuckians.
In response to questions by Senator Alvarado, Ms. Hass stated that children can receive services under the Michelle P waiver and EPSDT. The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. EPSDT is key to ensuring that children and adolescents receive appropriate preventive, dental, mental health, and developmental, and specialty services.
In response to questions by Representative Brown, Ms. Hass stated that there should be one entity who would oversee all brain injury services to maximize funding. There is good data available on how to go forward with this proposal. Representative Brown stated that there needs to be a study conducted to show where the funds would be used if under one department.
Overview of the University of Louisville Trover Campus
William Crump, M.D., Associate Dean, University of Louisville School of Medicine Trover Campus, Madisonville, Kentucky, stated that data from the Health Resources Services Administration (HRSA) Data Warehouse, HPSA Find Results stated that as of July 29, 2016, 81 percent of the 120 Kentucky counties or 68 percent have a health professional shortage (HPSA) designation. HPSA area means that each citizen in these counties has to share their doctor with more than 3,500 neighbors, when a busy family physician typically cares for about 1,800 patients. The purpose of the University of Louisville Trover Campus is to provide first-class medical education in a small Kentucky town and place more graduating medical students in practice in small Kentucky towns. Approximately 58 percent of Trover Campus graduates choose rural practice. Recruitment of one doctor to a small town adds $1.6 million per year to the local economy. Approximately $1 million from coal severance funding per year supports 60 Pathways students and produces 10 new doctors per year.
Austin Beck, M.D., Madisonville, stated that he graduated from Murray State University and Trover. He did his residency at Madisonville Baptist Health. The physician shortage is a real problem in rural areas. Individuals from small towns often lack confidence to go into the medical career because of incurring a huge debt and the inability to pay it back. Doctors in rural settings often need to know more about specialties such as obstetrics, because they may be the only doctors available in a community. There needs to be a continuity of care.
Jennifer Hays, third-year Trover medical student, stated that it is difficult to receive one-on-one education during clinical years at larger universities. Surgery rotation is a great time to learn, and the one-on-one experience provided at Trover is invaluable. Students are able to establish a personal relationship with patients.
Senator Alvarado stated that funds for the graduate-medical-education program have been cut which affects residency programs in all teaching hospitals. There is a need for more funding for residencies in small towns. Dr. Crump stated that Kentucky is losing doctors to other states because there are not enough residency positions available.
In response to questions by Representative Burch, Dr. Beck stated that he was able to keep tied to his local community by attending Trover. He will be able to set up his practice through the support of the local hospital and Trover. Dr. Crump stated that it a personal connection with the community is established. Dr. Beck stated that approximately $100,000 to $112,000 of the $180,000 medical debt goes toward tuition, the rest goes toward other expenses. Medical school is a full-time job, so there are no other opportunities to earn money to help with expenses.
In response to a question by Representative Westrom, Dr. Crump stated that students are taught that they cannot care for others if they do not take care of themselves. Dr. Beck stated that Trover taught him to take time for himself and take time off when needed. Ms. Hays stated that with the help of good nurse practitioners and staff, doctors are able to take time off.
In response to a question by Representative Brown, Dr. Crump stated that rural high school scholars live at home instead of living on the University of Louisville campus to help them realize they do not have to leave home in order to accomplish something great. Students from small towns tend to set their standards lower, and the goal is to show them it is possible to earn a degree.
In response to questions by Senator Danny Carroll, Ms. Hays stated that if resources are not available at the high school to help a student enter the medical field, resources are available through the internet to help prepare them for college. Dr. Crump stated that there is a need to have rural high schools more involved with local hospitals.
In response to questions by Representative Marzian, Dr. Crump stated that every $50 invested in a free clinic saves $1,600 in a hospital or emergency room visits. It is a wise decision to invest in primary care.
Update on Kentucky Zika Virus
Ardis Hoven, M.D., Medical Consultant, Department for Public Health, Cabinet for Health and Family Services, stated that Zika is a viral infection primarily spread by the bite of a mosquito, but can also be transmitted sexually. It is an ongoing epidemic in Central and South America, the Caribbean, Pacific Islands, and United States territories. The current risk for Kentuckians is an infection acquired when traveling to a country where there is active transmission. The first locally acquired cases in the continental United States have occurred in Florida. As of August 16, 2016, there have been 19 confirmed cases in Kentucky, and all were related to travel. The symptoms of Zika are a mild rash, fever, joint pain, and conjunctivitis, but 80 percent of have no symptoms. The only way to diagnose Zika is with a specific laboratory test. The greatest risk is to pregnant women or women who become pregnant while infected. No vaccine is currently available to treat Zika.
In May 2015, the World Health Organization (WHO) reported the first local transmission in the Western Hemisphere. In January 2016, the Centers for Disease Control and Prevention (CDC) Health Advisory alerts the presence of Zika in 14 countries in the Americas. On February 9, 2016, the Department for Public Health (DPH) activated the State Health Operations Center (SHOC) for Kentucky. There has been extensive collaboration between local health departments and epidemiology staff regarding persons who have traveled to endemic areas and meet criteria for testing. The cabinet has regular communication with the CDC regarding positive tests, the development of the pregnancy registry, and recommendations for and monitoring of affected or potentially affected infants. The DPH has included the Zika virus infection among the conditions and diseases requiring notification to the local departments and to the state. The DPH is working with blood banking agencies to protect the blood supply and partnering with multiple agencies to enhance mosquito surveillance and control.
Justin Carey, Health Environmentalist, Department for Public Health, Cabinet for Health and Family Services, stated that the DPH and Public Health Protection and Safety (PHPS), Department of Agriculture, have purchased additional traps to be deployed throughout the state for increased surveillance to be completed by Environmental Health Strike Team members. The surveillance is being done in conjunction with Dr. Grayson Brown and the University of Kentucky’s Department of Entomology. The DPH and local health departments’ environmental health staff are conducting in-depth inspections at the homes of all travel-associated Zika cases. The inspections focus on identifying and reducing breeding sites and areas that can harbor adult mosquitoes. Local health departments have drastically expanded mosquito control activities and messaging throughout communities and clinical health programs.
David Wayne, Environmental Services Director, Department of Agriculture, stated that the KDA's Division of Environmental Services sprays for mosquitoes at the request of local officials and local health departments. Eight KDA employees spend an average of 3,100 hours treating some 100,000 acres each year. The department also maintains a contract for aerial applications to address unusually high mosquito infestations. The division operates ultra-low-volume (ULV) fogging machines for mosquito control in parks, summer camps, and other outdoor areas where people congregate. The KDA and the DPH have entered into a Memorandum of Understanding that would allow DPH to utilize the agriculture department's ULV equipment to target areas with known cases of Zika virus.
Representative Wuchner suggested that the local health department have information available to the public, law enforcement, and first responders of areas being sprayed for mosquitos. Dr. Hoven stated that transparency of information is necessary.
In response to a question by Representative Moore, Dr. Hoven stated that the cabinet is going to areas where there is a chance of someone being infected by the Zika virus.
In response to a question by Representative Westrom, Dr. Hoven stated that someone who comes home from a Zika-infested area has to use repellants for three weeks. Good practices are to drain standing water and wear light color clothing.
In response to questions by Senator Wise, Dr. Hoven stated that the cabinet has invited all stakeholders including the Kentucky Office of Homeland Security to participate in discussion on how to stop the spread of the Zika virus. Dr. Grayson Brown, University of Kentucky Department of Entomology, stated that genetically modified mosquitoes is a new technology and has been proposed for use in Key West along with other places.
Adjournment
There being no further business, the meeting was adjourned at 11:24 a.m.