Call to Order and Roll Call
Theseventh meeting of the Interim Joint Committee on Health and Welfare and Family Services was held on Wednesday, December 13, 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 10:09 a.m., and the secretary called the roll.
Members:Senator Julie Raque Adams, Co-Chair; Representative Addia Wuchner, Co-Chair; Senators Ralph Alvarado, Julian M. Carroll, Denise Harper Angel, and Reginald Thomas; Representatives Danny Bentley, Robert Benvenuti III, George Brown Jr, Jim Gooch Jr., Russ A. Meyer, Kimberly Poore Moser, Melinda Gibbons Prunty, and Russell Webber.
Guest Legislators: Senator Morgan McGarvey and Representative Tom Burch.
Guests: Wayne Cooper, MD; Steve Guenthner, President and Principal Financial Officer, Almost Family; Gary Albers, Chief Operating Officer, Imperium Health Management; Praveen Arla, MD, MPH, Chief Medical Officer, Imperium Health Management and Medical Director, Bullitt County; Aaron Thompson, Ph.D., Council on Postsecondary Education; Jessica Fletcher, Education Director, Education and Workforce Development Cabinet; Linda Hampton, Executive Director, Governor's Office of Early Childhood; Sally Shepherd, Manager, School Readiness Branch, Kentucky Department of Education; Kate Akers, Executive Director, Kentucky Center for Education and Workforce Statistics, Education and Workforce Development Cabinet; Christa Bell, Director, Division of Child Care, Department for Community Based Services, Cabinet for Health and Family Services; Molly Lewis, Cabinet for Health and Family Services; Denis Fleming; Kelli Williams, Accenture; Trudi Matthews, University of Kentucky; Donna Barney, Legislative Research Commission; and Jill Lee, Office of Inspector General.
Extension for Community Healthcare Outcomes (ECHO)
Wayne Cooper, MD, stated that in 2003, Sanjeev Arora, M.D. created Project ECHO® at the University of New Mexico Health Sciences Center. It is an educational program created that uses videoconferencing technology to create communities of learning focused on specialists sharing their expertise with community providers, who can give their patients improved care in their own communities. Project ECHO® moves knowledge, not patients. Project ECHO® is a lifelong learning and guided practice model that revolutionizes medical education and exponentially increases workforce capacity to provide best practice specialty care and reduce health disparities through its hub-and-spoke knowledge sharing networks. Project ECHO® uses technology to leverage scarce resources, shares best practices to reduce disparity, uses case based learning to master complexity, and uses a web-based database to monitor outcomes. Project ECHO® benefits primary care providers, the health system, and the Medicaid budget. Patients are able to get care from providers they know and trust, which creates improved outcomes, improves quality of life, reduces pain and anxiety, and reduces complications. Fewer visits to specialists saves co-pay and insurance fees. Healthcare dollars are spent in the community and not elsewhere. The ability to provide specialty care in a small town attracts businesses and doctors. Clinician satisfaction and engagement creates a happier, more productive workforce and environment. Clinicians engaged in ongoing learning are less isolated and less likely to leave. Providers receive continued medical education (CME) for free without travel costs or inconvenience. Learning is ongoing, relevant, and interactive. A provider has the ability to take care of patients more effectively with better knowledge, skills, and quick access to specialists for consults when needed. Project ECHO® creates opportunities for research and teaching and professional development across faculties. Higher patient function reduces Medicaid and Medicare and disability payments.
In response to questions by Senator Raque Adams, Dr. Cooper stated that 36 other states currently involved in Project ECHO®. The program could be provided through a private provider, a local health department or a federally qualified health center. Project ECHO® is a tool to use videoconferencing to mentor and train people to provide specific services. The UNM has developed over 40 ECHO® projects and the information already developed is provided at no cost to states. Kentucky can use Project ECHO® for any specialty such as the opioid crisis.
In response to a question by Senator Julian Carroll, Dr. Cooper stated that he was unaware of any states that have addressed cannabidiol (CBD) oil in its Project ECHO® investment.
In response to questions by Senator Alvarado, Dr. Cooper stated that it could cost $400,000 for 2 to 3 ECHO® projects. Approximately 50 percent of the cost would be given to the University of Kentucky and University of Louisville telehealth networks to collect and monitor data for analysis and outcomes. The other 50 percent could be used for reimbursement of the operational team who would be responsible for all ECHO projects. The managed care organizations (MCOs) could help fund the project by paying a percent or base rate per recipient. The federal government is giving targeted money through Medicaid for the opioid crisis, and part of this money could be used to develop an opioid use disorder ECHO® project in Kentucky.
In response to questions by Representative Moser, Dr. Cooper stated that the University of Kentucky and the University of Louisville could sign a contract with the University of Mexico, at no cost to either university, to acquire software and information about Project ECHO®. Participation for a provider is free so a contract is not needed. Information on a case from providers can be submitted to the University of New Mexico to review before an ECHO® conference call where the case will be presented. The UNM would then send recommendations on the case to the provider by email. To his knowledge, no liability case has ever been brought against the University of Mexico, because its only function is to be a consultant with the provider. The provider would be liable for the care of the patient.
In response to a question by Representative Wuchner, Dr. Cooper stated that part of the overall cost of the ECHO® project is the operational cost to the telehealth network or the university for staff who collect, categorize, and store the data. The same staff would be responsible for all ECHO® projects. One barrier to ECHO® is if an organization is not committed to improving quality and improving patient care.
Senator Morgan McGarvey stated that Project ECHO® is good for taxpayers, patients, providers, and universities. The University of Kentucky and the University of Louisville support the project. A $400,000 investment by Kentucky can start three programs and would start to see the savings immediately.
Post-Acute Value Based Initiatives in Kentucky: Can Successful Kentucky-Based Physician-Led Medicare Accountable Care Organizations (ACOs) be a Model for Lower Medicaid Expenditures and Better Patient Care?
Steve Guenthner, President, Almost Family, stated that ACOs are a value-based payment, care delivery, and coordination models that try to help all disparate types of providers come together and collaborate on best practices and sharing information based on primary care. All Medicare claims data in the ACO are studied and analyzed to find practice patterns and patient flows to look for ways to lower the overall savings. When the Medicare program spends less money, the ACO gets a share of the savings. Quality measures are in place to make it work properly. In traditional payment models, providers are reimbursed a rate based on volume of services provided. The 1915(c) Home and Community Based (HCBS) waiver is not based on whether value is added but the provision of the service. HCBS services built around primary physician care are really key to managing overall costs. Dually eligible beneficiaries qualified for Medicare and Medicaid services consume a disproportionately large amount of resources in both programs. When chronic conditions are not managed properly, the patients go in and out of hospitals and skilled nursing facilities until eventually they are in either a Medicare or Medicaid skilled nursing facility bed. The dually eligible patients and chronically ill patients are where the best opportunity exists for coordination of care and getting the most savings.
In response to a question by Senator Raque Adams, Mr. Guenthner stated that the approximately 50 percent of the Medicare population lives at 200 percent of the federal poverty level or below. Approximately half of these individuals have cognitive impairments and do not understand the difference between Medicare and Medicaid. Praveen Arla, MD, MPH, Chief Medical Officer, Imperium Health Management, and Medical Director, Bullitt County, stated that it is very difficult to be primary care physicians because they are the nucleus for the total care of patients, which is not very easy especially when patients have multiple, complicated issues. Data provided by an ACO is more organized than data being supplied by Medicaid. The data from Medicaid is not being operationalized in an intelligent fashion. Mr. Guenthner stated that the challenge is in the United States Title 18 of the Social Security Act that covers Medicare and Title 19 which covers Medicaid. Things that Kentucky can do in Title 19 can impact hospitalizations and the costs of hospitalizations in Title 18. There are things that can be done in Title 18 that will impact whether a patient ultimately the primary entry to Medicaid nursing home care is through Medicare nursing home care and can be prevented by preventing the hospitalization and save money on the Title 19 side. Setting up risk models on both sides that are focused toward the same goal is the best start because the United States Congress will not have to change the Social Security Act.
Gary Albers, Chief Executive Officer, Imperium Health Management, stated that to move to value-based reimbursement sounds like a very easy concept, but to instill the disciplines physicians need to be successful at better quality and better outcomes has taken his company approximately three years. Imperium saved Kentucky $20 million in the Medicare program last year by using these disciplines. There is an opportunity to do the same in the Medicaid program. Patients need to be treated the exact same way whether they have commercial insurance, Medicare, or Medicaid. A coordination of the continuum of care to expand access to primary care providers need to be replicated in the Medicaid program.
In response to questions by Senator Alvarado, Mr. Guenthner stated that the Centers for Medicare and Medicaid Services contracts directly with ACOs not insurance companies. Mr. Albers stated that six ACOs have over 400 providers in Kentucky who provide services to 70,000 Medicare patients. Several hospitals, home health network, large multi-specialty clinics are part of the ACOs. Realizing savings is a continuing process. Patients need to be educated on how to be involved in their health care so doctors are able to treat them to the best of their ability. Dr. Arla stated that ACOs show physicians how to create efficiencies in operations to get to the end goal. Physician practices are different and need to be standardized into quality and outcomes that have never been done before with data on the back end. Applying this to the Medicaid program will allow increased savings, increased quality, and improved long-term outcomes. Aligning the Medicaid program and shifting resources onto the Medicaid program will produce a huge windfall. The classic Medicaid program will never be able to get the buy-in on the physician level. Mr. Guenthner stated that a Medicare-shared savings model is driven by the primary care physician making better decisions, patients getting better, and costs go down. Dr. Arla stated that the primary care physician is the gatekeeper. Having the right information can change the way a physician chooses to treat a patient.
A motion to approve the minutes of the November 15, 2017 meeting was made by Senator Alvarado, seconded by Representative Gibbons Prunty, and approved by voice vote.
Consideration of Referred Administrative Regulations
A motion to amend the agenda to add the following referred administrative regulation was made by Representative Wuchner, seconded by Representative Moser, and approved by voice vote: 201 KAR 2:380 – establishes procedures for board authorized protocols by which pharmacists may initiate the dispensing of non-controlled medications or other professional services. Craig Martin from the Kentucky Board of Pharmacy stated the administrative regulation would allow pharmacists under protocol with physicians to initiate the dispensing of certain medications. A motion to approved 201 KAR 2:380 as amended was made by Representative Bentley, seconded by Representative Wuchner, and approved by voice vote.
Jessica Fletcher, Education Director, Education and Workforce Development Cabinet, stated that all children need to read on level by the third grade. Poor readers are at a disadvantage in the workforce, because 93 percent of employers say reading and writing skills are mandatory for employment. Between 15 and 20 percent of students are dyslexic.
Representative Addia Wuchner, stated that during the 2012 Regular Session, House Bill 69 was codified into law that defined dyslexia and required administrative regulations be promulgated for district-wide reporting on the use of Kindergarten through third grade response-to-intervention (RTI) implementation in reading, mathematics, and behavior. During the 2017 Regular Session, House Bill 307 revised the definition of dyslexia and required each school district to develop a policy related to its response-to-intervention (RTI) system was not enacted. Approximately 70 to 80 percent of people with poor reading skills are likely to be dyslexic, and 1 in 5 students has a language-based learning disability. A bill will be introduced during the 2018 Regular Session relating to dyslexia and response to interventions that improve student learning known as the Kentucky Ready to Read Act 2018. Investment in appropriate and effective interventions provide a significant return on investments for schools and society over the course of a child’s lifetime. Assessment and evidence-based screening allows teachers to identify and adjust instruction with appropriate interventions that are essential to struggling readers. In education, RTI is an approach to academic and behavioral intervention used to provide early, systematic, and appropriately intensive assistance to children, screening, and interventions for children who are at risk for or are already underperforming as compared to grade appropriateness. All children deserve the opportunity to succeed in school and life. Children with reading problems need to have a different way to learn.
Aaron Thompson, Ph.D., Council on Postsecondary Education, stated that the 2018 legislation provides the ability to put skills in place to help all teachers identify problems and be able to intervene earlier. It will be a continuous process to learn and develop the skills.
Senator Raque Adams stated that most schools are not equipped to deal with the problems caused by dyslexia.
In response to questions by Representative George Brown, Mr. Thompson stated that dyslexia is a brain disorder. A large number of children have problems but go undiagnosed. Allot of children with reading problems have found other ways to learn so no one will know about the problem.
The Race to the Top-Early Learning Challenge Grant-Update
Linda Hampton, Executive Director, Governor's Office of Early Childhood, stated that in December 2013, the Governor’s Office of Early Childhood was awarded a four-year, $44.3 million Race to the Top-Early Learning Challenge (RTT-ELC) grant from the United States Department of Education and the federal Department of Health and Human Services. The purpose of the grant was to improve access to high quality early care and education for more children through seven RTT-ELC projects. The projects were grants management, redesigning the Tiered Quality Rating and Improvement System (TQRIS), integrating Kentucky early childhood standards, United Way Born Learning Academies, Kentucky Strengthening Families, responsive professional development, and integrating data into the Kentucky Longitudinal Data System. The Kentucky Governor’s Office of Early Childhood partnered with the Education and Workforce Development Cabinet, the Cabinet for Health and Family Services, and the Kentucky Department of Education. House Bill 234 from the 2015 Regular Session implemented a quality-based graduated early care and education program rating system for providers.
At the beginning of 2016, Kentucky had only spent 13 percent of the grant funding in two full years of grant implementation. After intervention from the Education and Workforce Development Cabinet, in partnership with federal project officers from the United States Department of Education, and the federal Department for Health and Human Services, Kentucky had spent 35 percent by the end of 2016. In January 2016 a Corrective Action Plan was implemented, and Kentucky continued to show growth in its spending pattern spending more in 2017 than the first three years of the grant combined.
In August 2017, Kentucky applied and received a no cost extension to extend grant deliverables to December 31, 2018 for the grants management, redesigning the TQRIS, and the United Way Born Learning Academies projects. A validation plan is due June 30, 2018. The sustainability plan’s purpose is to communicate goals, obstacles, and resources and plan the next steps for acquiring resources.
Christa Bell, Director, Division of Child Care, Department for Community Based Services, Cabinet for Health and Family Services, stated that 93 percent of the $44 million grant was allocated to build and redesign a new tiered quality rating and improvement system and to help all types of child care providers, both licensed child care providers, public preschool and Headstart, to improve quality of care and education in the classroom. In January 2017, 6.79 percent of programs on the child care side were at high quality in Kentucky, but as of December 2017, 38.9 percent of programs have attained high quality as a result of the efforts of the grant. The goal for the grant is for Kentucky to have 45 percent of child care providers at high quality by June 30, 2018. The cabinet partnered with Lakeshore Early Learning to provide actual classroom materials to help providers score better in rating on the environment rating scale. Approximately $12,547,030 of non-monetary incentives was invested into developmental screening tools, classroom learning materials, curriculum and assessment tools, and no-cost training sessions to help achieve a higher quality rating.
A Level 1 provider meets regulatory standards. Everything above Level 1 means a provider has demonstrated additional things that fall in the standards that would indicate that the provider is at a higher quality than just meeting the regulatory standards. There are eight child care service regions with 2,212 programs as of December 5, 2017. Northern Bluegrass, The Eastern Mountain, and Cumberland regions have crossed the 45 percent threshold for high quality.
In response to a question by Representative Wuchner, Ms. Bell stated that in 2018, the focus on the three regions are additional supports in the curriculum and screening assessment tool. Regions have different cultures that hinder progress.
Total incentives paid to providers for 2017 was $5,665,973. County data was not recorded for some payments made prior to January 2017. There is a cost to provide quality care and education. Additional incentives are paid for programs who serve children in the child care assistance program (CCAP).
Sally Shepherd, Manager, School Readiness Branch, Kentucky Department of Education (KDE), stated that the KDE targeted specific areas of need based on the environment rating scale and also through feedback from the five regional training centers across Kentucky who are the professional learning technical assistance part of KDE for early child care. Trainings were created around block play centers, dramatic play centers, and visual and performing arts centers, because children learn best through play. Teachers and staff members were trained on how to incorporate literacy into every single area in the classroom. Administrators are being trained on early childhood in general, Kentucky All STARS, and preschool. Staff were also train in Kentucky’s initiative in social emotional development. Because preschool regulations regulate quality, all preschool programs automatically come into the Kentucky All STARS at a level 3. For the grant, public preschools were required to be at 65 percent statewide at the highest quality, and it has already been exceeded.
Ms. Hampton stated that the 170 Born Learning Academies was allocated $989,325 to encourage families to take an active role in getting their child read for kindergarten starting from birth and offer practical ideas to turn everyday moments into learning opportunities. Through a series of six free workshops, parents, families, and caregivers learn about child development and how to spark learning opportunities during ordinary routines like bath times and grocery trips. The workshops are open to all families with children from birth to age five.
Kate Akers, Executive Director, Kentucky Center for Education and Workforce Statistics (KCEWS), Education and Workforce Development Cabinet, stated that KCEWS operates and maintains Kentucky’s longitudinal data system that collects and integrates education and workforce data so policymakers, practitioners, and the general public have access to the data that is needed to make informed decisions. KCEWS system includes information from public kindergarten through 12th grade, public and private postsecondary institutions, teacher preparatory institutions, workforce data, and now early childhood providers. The privacy and confidentiality of the data is very important. KCEWS has a data sharing agreements with each entity. The data is brought into the system and then given back as aggregate outcomes about the individuals in each program. The building of the longitudinal system on the early childhood, kindergarten through 12th grade, and workforce sides is very critical. The Early Childhood report is an interactive report online to find information about a specific county, the challenges and successes of early childhood, and general population information for each county.
Representative Wuchner stated that The KIDS NOW initiative was established in House Bill 706 and was sponsored by Representative Tom Burch. The Interim Joint Committee on Health and Welfare heard testimony from national experts at every meeting in 1999 on early childhood issues to educate members on the importance of early childhood education. House Bill 706 passed unanimously by both legislative chambers in the 2000 legislative session. At that time, it was the most comprehensive package of early childhood legislation in the nation, addressing the needs of the whole child – health care, family assistance, high quality education, and community involvement. The initiatives in the bill were funded with 25 percent of the Kentucky Tobacco Settlement Funds. Kentucky was the only state to appropriate tobacco settlement funds to early childhood education. Representative Burch has supported early childhood issues throughout his 33 years as a state legislator and continues to do so today. He has received several awards for his service and we honor him again today for his service to the children of Kentucky. On behalf of the Early Childhood Advisory Council, Ms. Hampton presented Representative Tom Burch with a certificate of appreciation for his six years on the council and his tireless dedication to early childhood development. Representative Burch thanked the co-chairs and the committee, and the council. It was not well known at the time how much information a baby starts taking in starting at birth. There was unanimous support from all stakeholders and legislators. The most important value in this world is children, because the children are future leaders.
There being no further business, the meeting was adjourned by 12:30 p.m.