Call to Order and Roll Call
Thefifth meeting of the Interim Joint Committee on Health and Welfare and Family Services was held on Wednesday, October 11, 2017, at 10:00 a.m., in Room 129 of the Capitol Annex. Senator Julie Raque Adams, Co-Chair, called the meeting to order at 10:03 a.m., and the secretary called the roll.
Members:Senator Julie Raque Adams, Co-Chair; Representative Addia Wuchner, Co-Chair; Senators Ralph Alvarado, Tom Buford, Danny Carroll, Julian M. Carroll, Stephen Meredith, and Reginald Thomas; Representatives Danny Bentley, Robert Benvenuti III, George Brown Jr, Mary Lou Marzian, Chad McCoy, Russ A. Meyer, Kimberly Poore Moser, Steve Riley, and Russell Webber.
Guests: Kelly Gunning, Director of Advocacy and Public Affairs, NAMI Lexington; Michael Gray, Advocacy Coordinator, NAMI Kentucky; Stephanie Pearce Burke, Judge, District Court, Jefferson County; Lara MacGregor, Hope Scarves; Darrin McCauley, Twisted Pink Board Member, Old National Bank; Julie W. McKee, DMD, Dental Program Administrator, Department for Public Health, Cabinet for Health and Family Services; Tara Grieshop-Goodwin, Chief Policy Officer, Kentucky Youth Advocates; Ron Hatfield, Cellarian Health; Jan Bright, Henrietta Bada, Lindsey Meadors, and Bill Bishop, Department for Public Health, Cabinet for Health and Family Services; Mike Bishop, Health Kentucky; Dr. Jerry Caudill, State Director, Avesis, Incorporated; Mary Maupin, Anthem Kentucky Medicaid; Amanda Ferrill and Peg Patton, Mortenson Dental; Carol Hura; Sarah S. Nicholson, Kentucky Hospital Association; Steve Davis, Acting Inspector General, Cabinet for Health and Family Services; Wendy Morris and Rita Ruggles, Department for Behavioral Health, Developmental and Intellectual Disabilities, Cabinet for Health and Family Services; Eric Clark, Chief of Staff, Cabinet for Health and Family Services; Stephanie Brammer-Barnes, Cabinet for Health and Family Services; and Jennifer Wilson, General Counsel, Cabinet for Health and Family Services.
A motion to approve the minutes of the September 20, 2017 meeting was made by Representative Marzian, seconded by Senator Alvarado, and approved by voice vote.
An Update on Tim’s Law (2017 Senate Bill 91)
Senator Adams stated that 2017 Senate Bill 91, Tim’s Law, addresses the problem of individuals with the most serious mental illness revolving in and out of state hospitals, the court system, jails, and out of homelessness. The approach is called Assisted Outpatient Treatment (AOT) and it creates a mechanism in civil court to require and monitor individuals who are eligible for court-ordered outpatient mental health treatment. The objective of SB 91 is for individuals with serious mental illness to receive treatment to improve their lives in recovery and to prevent further court, hospital, and law enforcement involvement.
Kelly Gunning, Director of Advocacy and Public Policy, NAMI Lexington, stated that AOT has been successful in other 44 states. An individual is four times less likely to be involved in violent crimes if an AOT plan is in place. People with untreated illness commit crimes. There is a 44 percent reduction in harmful behaviors such as homelessness, substance use disorder, and mental illness. The number one reason AOT is needed is that it addresses the number one problem with serious mental illness which is the problem of recidivism. The number one reason for recidivism is nonadherence to prescribed treatment. Patients with mental illness are not aware that they are ill and, therefore, do not think they need to take medication. AOT is not about taking away an individual’s rights but to help the individual to engage in community resources that will keep them out of the revolving door of hospitals, jails, or homelessness. There needs to be a mechanism that monitors someone to make sure they continue to be engaged in the system that will cause accountability and compliance. There is a 90 percent failure rate of individuals keeping first appointments after being released from a facility. AOT saves allot of money. North Carolina reported a 40 percent cost savings in the treatment of individuals who were identified as high utilizers. Ohio had a 40 percent reduction rate in spending on individuals involved in the recidivism cycle. Twenty percent of all Medicaid readmissions involved serious mental illness. In one year, approximately 75,000 individuals on Medicaid are readmitted to a hospital within 30 days. The money saved far outweighs the cost to implement AOT programs. States that implemented AOT did not implement the AOT statewide at first but used funding streams from county, state, and local entities. In counties where there were already existing drug courts and mental health courts, it was a natural extension of these courts. Hamilton, Ohio pays a probate court navigator approximately $50,000 a year to oversee AOT treatment individuals from state and local funds.
Michael Gray, Advocacy Coordinator and Legislative Agent, NAMI Kentucky, stated that if individuals follow treatment plans, they are able to lead normal productive lives. AOT courts can help people who suffer with mental illness by helping them in the right direction.
Stephanie Pearce Burke, Judge, District Court and Drug Court, Jefferson County, stated that the Kentucky District Court Judges Association was in opposition to SB 91, but she has seen that AOT can be easily implemented. It needs to be started as a pilot project to learn how to implement it appropriately statewide. The model that will work best for Kentucky is to operate it within the confines of existing mental health courts, regular drug courts, or veterans’ treatment courts. SB 91 is an unfunded mandate, so there is no ability to create new courts to hear cases of individuals who are still in hospitals. Jefferson County has a designated judge who hears all mental inquest warrants in hospitals for patients who have been involuntarily hospitalized or who are awaiting a hearing on a petition under a 72-hour hold. Approximately 85 percent of mental inquest hearings are held in hospitals before an individual is released. AOT is only needed for a small number of individuals who have been involved in the court system continuously and are not compliant with the treatment plan after being released from a facility. There needs to be a good coordinator who works with the individual, treatment team members, and the judge to conduct the mental inquest hearings. Seeing a judge each week is the key to the success of AOT, because the individual and treatment provider are accountable for steps taken or not taken to adhere to the treatment plan. Judges listen to individuals, and it helps the individual to remain on the treatment plan. The Administrative Office of the Courts (AOC) created the petition, application, and transfer order forms the day SB 91 went into effect. Circuit Court clerks could designate someone in its office to temporarily serve as the coordinator until funds are allocated for a full-time coordinator.
Ms. Gunning stated that individuals who do not adhere to the treatment plan do not stay off the radar for long.
In response to questions by Representative McCoy, Judge Burke stated the requirement in KRS 202A.0811(6)(b) says to set a date for a hearing within six (6) days from the date of the examination by a qualified mental health professional to determine whether the respondent meets the criteria for court-ordered assisted outpatient treatment set forth in KRS 202A.0815, excluding weekends and holidays, to determine if the respondent should be court-ordered to assisted outpatient treatment. The statute needs to clarify when to set the hearing if the examination was five days prior to the petition. Hearings in the hospitals are not open to the public. There are no other counties besides Jefferson County that send judges to hospitals to conduct hearings. Ms. Gunning stated that in Fayette County there is a judge that comes to the hospital. Videoconferencing could be used to see patients in the hospital, but it is more effective when an individual has to appear in the courtroom in front of the judge. Ms. Gunning stated that allot of individuals are paranoid of the video screen.
In response to a question by Representative Wuchner, Judge Burke stated that she does wear her robe for a hearing at the hospital to help have the same effect as if someone was appearing before her in the courtroom.
In response to questions by Representative Moser, Judge Burke stated that the court is connected to medical team is through the Assistant County Attorney who is on the mental inquest warrant (MIW) docket and through the clerk who will call the hospital and obtain information and schedule the hearing. Ms. Gunning stated that in Fayette County there is a coordinator who is in contact with the medical team for the mental health court. Judge Burke stated that a person cannot be held in contempt if they fail to appear in court. A summons can be issued for someone in the sheriff’s office to transport a person to court, but the sheriff’s office does not like to take someone into custody if they are not under arrest. Ms. Gunning stated that in Ohio, someone from the treatment team is sent to the individual who is not compliant.
In response to a question by Representative Wuchner, Judge Burke stated that an individual can have a support person with them throughout the process. It could be very beneficial to have a program structured like CASA that would provide assistance to individuals. Ms. Gunning stated that certified peer specialists are used in Fayette County.
Metastatic Breast Cancer
Lara MacGregor, Hope Scarves, stated that October is breast cancer awareness month. No one dies of cancer found in the breast, because it is treatable and survivable at this point. Metastatic breast cancer is a stage 4 cancer and is terminal. Approximately 30 percent of people diagnosed with early stage breast cancer will have it become metastatic with a life expectancy of two to three years. There will be 111 individuals who die from metastatic breast cancer daily. There are no records of how many individuals who have metastatic breast cancer, because someone is only counted for the original diagnosis. While it is important to celebrate individuals who are in remission, it is just as important to raise awareness of individuals who are dying of cancer. There needs to be more research conducted to understand why and how the cancer metastasizes. Questions need to be raised about where research dollars are being spent. Breast cancer is painful and very terrifying for not only the patient but for family and friends. It can tear families apart. The same amount of individuals die of breast cancer today that did 30 years ago.
Darrin McCauley, Old National Bank, and Twisted Pink Board Member, stated that his wife, Janice, was diagnosed with stage 3 breast cancer that metastasized in her lower spine and bones. She took extra precautions by staying healthy because there was a family history of breast cancer. More research needs to be done on metastatic breast cancer.
Senator Adams stated that there needs to be a review of where the money donated for breast cancer is spent.
In response to a question by Senator Thomas, Mr. McCauley stated that less than ten percent of breast cancer funds goes to metastatic breast cancer research. Two and a half years ago the General Assembly appropriated $132.5 million to the University of Kentucky to build a health disparities clinic because there are significant health disparities in Kentucky. Mr. McCauley stated less than ten percent of money donated to breast cancer goes to metastatic research. Ms. MacGregor stated that the organization she founded, Hope Scarves, has raised $150,000 for metastatic breast cancer research. Medical hospitals in Kentucky are interested in conducting clinical trials that are accessible to more people.
In response to questions by Representative Marzian, Ms. MacGregor stated that National Institute of Health budget appears to fund a large amount of breast cancer research, but a small percent is spent on metastatic breast cancer research. Thirty percent of funds are needed to research metastatic breast cancer and treatments. There needs to be a better understanding between the difference of early breast cancer and metastatic breast cancer. Once it goes beyond the breast it is hard, if not impossible, to cure.
Senator Alvarado stated that someone’s odds of dying increase when they have metastatic cancer. In 1975, breast cancer survival rates were 65 percent, in 2010 it was 83 percent, currently is 89 percent. Allot of focus has been on early detection. One in eight women are diagnosed with breast cancer. The medical community is becoming aware that individuals need to stay on medications longer to help the cancer from reoccurring.
In response to a statement by Representative Wuchner, Ms. MacGregor stated that there needs to be an awareness of all preventive access to care.
Representative George Brown stated that individuals need good health insurance that will help individuals receive the best treatment and care.
Update on the State Dental Health Plan
Tara Grieshop-Goodwin, Chief Policy Officer, Kentucky Youth Advocates (KYA), stated that approximately a year ago the KYA partnered with Delta Dental of Kentucky to conduct an updated survey of children’s oral health in Kentucky. A dentist and assistant performed a random sample of screenings statewide and found there was a higher percentage of third and sixth graders that needed dental care. Two out of five third and sixth graders had untreated cavities and over half of third and sixth graders did not have sealants. One recommendation of the report was to develop comprehensive goals and objectives for an updated state oral health plan. The Cabinet for Health and Families Services has begun updating the state oral health plan.
Julie Watts McKee, DMD, Dental Program Administrator, Department for Public Health, Cabinet for Health and Family Services, the goals of the 2006 Statewide Oral health Strategic Plan, Healthy Kentucky Smiles: A Lifetime of Oral Health, were to increase the number of dental professionals to underserved areas to assure access to care, to increase and sustain funding for oral health programs, to recognize stakeholder involvement to expand awareness and education, and that oral health should be a full component of coordinated, integrated, and comprehensive services. There is still a problem with childhood dental decay. There is a disproportionate percentage of dentists statewide. Insurance coverage for dental services is always changing. Approximately 50 percent of Kentucky’s children have KCHIP, and a huge problem is that there are still counties that do not have dentists who accept Medicaid. The cost of a dental education has skyrocketed leaving some dentists with over a $237,000 college debt. The updated oral health plan is undergoing final edits and revisions and should be released on November 1, 2017. There is a need to educate everyone on the dental needs of the population. Oral health literacy is needed for individuals to make good decisions about oral health. Children need to be taught good oral health habits and break bad cycles. There is also a need to have more oral health education in the medical and nursing fields. Good oral health reduces some morbidity of chronic diseases.
Some key points to prevention are to expand the Department for Public Health’s Dental Hygiene Program, to promote the use and training of silver diamine fluoride, to create consistent oral health education in health departments, and to review school pre-entry screening requirements. Good data and metrics drive good policy. Goals can only be met with sustainable funding. Everyone will benefit from the oral health plan.
Representative Riley stated that it is difficult if a county only has one dentist available. Dr. McKee stated that children in pain, especially dental pain, cannot learn.
Senator Alvarado stated that there has been a dramatic reduction in cavities rates in children in Clark County because of dental varnishings. Dr. McKee stated that dental varnish is different from silver diamine fluoride that arrests current decay and eliminates pain. Medicaid covers dental varnish for children up to the age of 19 years.
Consideration of Referred Administrative Regulations
The following administrative regulations were referred to the committee for consideration: 902 KAR 20:360 & E – establishes licensure requirements, standards, and procedures for abortion facilities that comply with KRS 311.727 and adds new transport agreement requirements; 921 KAR 3:025 – sets forth the technical eligibility requirements used by the cabinet in the administration of SNAP; and 921 KAR 3:042 – establishes technical eligibility requirements used by the cabinet in the administration of the SNAP Employment and Training Program (E&T).
In response to questions by Representative Marzian about 902 KAR 20:360 & E, Steve Davis, Acting Inspector General, Office of Inspector General, Cabinet for Health and Family Services, stated that it is important to main the status quo until litigation and final ruling is complete. The ultrasound legislation has been on hold until the federal court rules in the case.
Jennifer Wilson, General Counsel, Cabinet for Health and Family Services, stated that 902 KAR 20:360 & E relates to transfer and transportation agreements. It references the ultrasound portion, but the primary changes are made in Section 10. Mr. Davis stated that the administrative regulation is a cross reference to a statute with the ultrasound provision. Mr. Davis stated that EMS does not have to have a floor plan for every outpatient service, but the administrative regulation is a safety measure that is meant to help provide advance notice to providers who seek to address emergencies and be able to get to the patient promptly. There is a certificate of need (CON) law that applies to allot of categories of facilities including ambulatory surgery centers. When the law was adopted in 1998, abortion facilities were regulated as ambulatory surgery centers. The cabinet is implementing the provisions of KRS 216B.0435 enacted by the General Assembly.
A motion to accept the referred administrative regulations was made by Representative Benvenuti, seconded by Senator Alvarado, and accepted by voice vote. Representatives Marzian and George Brown requested to be recorded as voting against 902 KAR 20:360 & E.
There being no further business, the meeting was adjourned at 11:47 a.m.