The 1st meeting of the Interim Joint Committee on Licensing and Occupations was held on Friday, June 10, 2005, at 1:00 PM, in Room 129 of the Capitol Annex. Senator Gary Tapp, Chair, called the meeting to order, and the secretary called the roll.
Present were:
Members: Senator Gary Tapp, Co-Chair; Representative Denver Butler, Co-Chair; Senators Tom Buford, Julian M Carroll, Julie Denton, Ray S Jones II, Daniel Mongiardo, and Dan Seum; Representatives Tom Burch, Larry Clark, Ron Crimm, W Milward Dedman Jr, Jon Draud, Dennis Horlander, Joni L Jenkins, Dennis Keene, Stan Lee, Paul H Marcotte, Reginald K Meeks, Charles Miller, Ruth Ann Palumbo, and Jon David Reinhardt.
Guests: Terry Slade, Director of Building Code Enforcement, Rose Baker, Staff Advisor, Al Mitchell, State Fire Marshal, and Van Cook, Executive Director of the Office of Housing, Buildings and Construction; Marty White, Kentucky Medical Association, Bill Doll, Jackson Kelly PLLC, for the Kentucky Medical Association; Catherine Waits, FNP, WHNP, Elizabeth Partin, ND, CFNP, and Sheila Schuster, Ph.D, Mental Health & Health Care Advocacy.
LRC Staff: Vida Murray, Ann Seppenfield, Bryce Amburgey, Barbara Baker, Health and Welfare Committee, John Perry, Staff Economist Office, and Susan Cunningham.
The first item on the agenda was approval of the minutes of the September, 2004 meeting. A motion was made and with a second, the minutes were adopted by voice vote.
Next on the agenda Van Cook, Executive Director of the Office of Housing, Buildings and Construction, told the committee that the office was considering the use of an electronic test for plumbers to provide more frequent testing and faster grading. The test would still use the Kentucky Plumbing Exam Committee's questions; however, the questions would be from a pool so that each test would be slightly different. He said the tests are currently given every quarter in different parts of the state by paper and graded manually. Mr. Cook told the committee that the office was currently using electronic testing for other occupations in its Frankfort office. The Kentucky Plumbing Exam Committee is considering the possibility of changing the practical part of the Plumbing exam as well, because over the years materials have changed, and the practical test should reflect changes such as the use of plastic parts. Mr. Cook said they were hoping to buy an exam trailer so the office could take the practical test to different parts of the state rather than people going to Louisville for that part of the test.
Mr. Cook said regarding the Home Inspectors Licensing Program the nominating committee has met twice and has submitted three names to the Governor's Boards and Commissions office. He said that regulations had to be in place by July 1, 2006.
Al Mitchell, State Fire Marshal, said that electrical licensing was implemented in the 2003 General Assembly. He said that the office was in the process of centralizing all licensing activities. This year the office began converting all license renewals to the birth month instead of June 30th of each year, including HVAC, low voltage, and plumbing licenses. The electrical licensing was implemented without funding and a backlog developed because the expected number of license applications was underestimated. To reduce the backlog, temporary employees were hired, and this caused some problems. Now the office is about 15 days behind on processing applications. Currently, 2,000 licenses are renewed per month. Mr. Mitchell said the office had hired five new people, and expects to hire one more, plus a supervisor. He said that when new licensing programs are added, such as the low-voltage, one new person should be hired. It is estimated that one person could process 3,000 additional licenses annually, approximately 20 per day.
Mr. Mitchell said he is meeting with people to establish low-voltage regulations. He said grandfathering electricians for a low voltage license is problematic because some are not qualified in areas such as alarms systems and sprinkler systems, and grandfathering would automatically put electricians in those categories. There have also been complaints from people who install landscape lights because they will be in the low voltage category.
Mr. Mitchell said the office was going to ask the General Assembly to amend the electrical licensing program to provide licensing for master, journeyman, and apprentice electricians. He said currently master electricians do commercial, residential, industrial, and high voltage work. They want the master license broken down into two categories, a residential and a high voltage, because of the difference in those areas. The office would also like to eliminate the 30-day grace period before a Kentucky license is required for out-of-state electricians who come into the state to work. He said the office would like to convert the existing electrician's license to a journeyman's license to better conform with licensing in Kentucky's surrounding states. He said an electrician is required to work for six years before he or she can take the test to be licensed as a master electrician. With an apprentice program, the office would be better able to document the practical experience before giving the master electrician exam.
Senator Tapp said that passing the law that created the electrical license took a lot of work and concessions from both sides of the aisle regarding the different licenses and urged the office to tread very carefully before proceeding with such changes.
Rose Baker, Staff Assistant, told the committee that SB 142 changed in licenses for fire sprinkler workers and contractors, mobile home and recreational vehicle retailers, master and journeyman plumbers, and liquid petroleum gas dealers. She said administrative regulations would need to be promulgated for these changes. Other changes in SB 142 clarified that the state is required to be listed as the certificate holder on home inspectors' liability insurance policies and changed the requirement for a fire sprinkler contractor from carrying professional liability insurance to general liability insurance.
Terry Slade, Director of Building Code Enforcement, said the Uniform State-Wide Building Code has been in place since 1980. He said local governments certify smaller buildings and the Division of Building Codes inspects and certifies the larger buildings. In 1983, the office designed a program requiring all building inspectors to take an exam to show they were qualified to be building inspectors. He said the office was currently dealing with an inspector in Eastern Kentucky who had been in the program since 1995; however, he has not taken exams and in the past two years has not renewed his license but is still inspecting buildings and issuing permits. He indicated that when an inspector from his office sees the building construction and has no certificate on file, he or she has to stop the construction. Mr. Slade said there are no penalties in statute to stop individuals from calling themselves a building inspector.
Representative Lee asked who was hiring this inspector and if he was a local inspector. Mr. Slade said the inspector was local and was hired by the City of Hazard to be its building inspector and that he was issuing permits for construction, making inspections, and possibly reviewing plans. However, he has never taken any of the exam modules from the National Certification Program for Construction Code Inspectors that are required by administrative regulation.
Mr. Slade said the office was in the process of writing a letter to the mayor of the city where this inspector was working, to inform the mayor of the liabilities the city faces in using the inspector with no license. He said the office would like some type of penalties to be put into regulations.
Senator Tapp said the office knows where problems exist and should send letters to all entities letting them know that the office is seeking fines and penalties from the General Assembly. Representative Clark suggested notifying the League of Cities and the Kentucky Association of Counties when someone is working without proper certification. Van Cook responded that letters were sent out on a regular basis trying to work something out with this inspector.
Representative Keene asked Van Cook how many inspectors had been hired to date from the money that was allocated in the 2005 budget to hire 51 inspectors for plumbing, HVAC, and building code enforcement. Mr. Cook said that the office was in the process of replacing people who had retired and there was a request for 15 inspector positions to the Office of Budget Management. Senator Tapp said these people needed to be in place for consumer protection as well as for economic development and growth purposes. Representative Clark asked the co-chairs, Representative Butler and Senator Tapp, to pass a resolution on behalf of the committee regarding the urgency of hiring these inspectors expeditiously. Senator Tapp responded that he had instructed staff to draft a resolution before the meeting ends so that it can be voted on and passed out of the committee.
Representative Denver Butler, co-chairman of the committee, said that since the 2005 session the committee had been trying to get the Horse Racing Authority to come to a meeting. He said the media was portraying Kentucky as a dumping ground for running medicated horses at tracks. He stated that since most of the legislation for the horsemen and tracks comes through this committee it would like the opportunity to talk to the Racing Authority about this situation. Representative Butler said it was his understanding that the Authority was talking about eliminating all medication on race days. He said to be able to do that they would have to test all horses on a daily basis and it was his feeling that there were not enough laboratories to do that. He gave the example that Dancer's Image was disqualified as a Derby winner 2 months after the Kentucky Derby when test results came back from California. He said he would like to ask the Horse Racing Authority to come before this committee and inform the committee of the problems, if there are problems. He said some problems are created by people who do not understand racing in Kentucky. Representative Clark added that he had a list of questions for staff to review and submit to the Authority.
Next on the agenda, LRC staff, Barbara Baker, and John Perry explained to the committee findings in the study of Expanding Prescriptive Authority for Controlled Substances to Advanced Registered Nurse Practitioners (ARNP). Ms. Baker told the committee that House Bill 595 in the 2004 Regular Session originally expanded the prescriptive authority of Advanced Registered Nurse Practitioners to include controlled substances. However, the bill was amended to direct LRC to complete a study on possibly expanding that authority in the future. The study would measure ARNP education relevant to prescribing controlled substances in Kentucky and gather opinions of interested and affected parties. The study group conducted surveys of ARNPs and physicians across the state. Additionally, they interviewed numerous interested parties such as the Board of Nursing, the Board of Medical Licensure, the Coalition of Nurse Practitioners and Nurse Midwives, the Kentucky Medical Association, and other associations representing both physicians and nursing. The study's research showed that the Federal Drug Administration (FDA) created two schedules of drugs non-schedule drugs such as antibiotics and antihistamines and a scheduled drug list numbered 1 through 5 and rated on each drug's potential for abuse, dependency, and legitimate medical purpose. The study found that there were more prescriptions for controlled substances per capita, written in states where ARNPs were give advanced prescriptive authority. Ms. Baker said the physician and ARNP pharmacology courses at the University of Louisville and the University of Kentucky were similar in content. She said 44 states and the District of Columbia allow ARNPs to prescribe controlled substances. Currently the ARNP may perform physical exams; however, if a patient needed a scheduled drug prescribed, a physician, who has not seen the patient, had to write the prescription.
Proponents of the legislation say it makes the ARNP more accountable and opponents say it increases the opportunity in Kentucky to add to an existing drug problem. John Perry said the survey showed a difference of opinion on whether ARNPs should be granted authority to write prescriptions for scheduled drugs; however, everyone agreed that there should be some type of collaborative agreement between the physicians and the ARNPs if the nurse practitioners prescriptive authority was expanded. He said current research was unclear whether the greater number of prescriptions in controlled substances was attributed to the ARNPs or new physicians. He said the study did show that states that granted the authority to ARNPs did have a higher rate of scheduled drugs prescribed.
Representative Crimm asked who determines whether a specific drug is prescribed, the ARNP or the physician, and asked who carries professional liability insurance for the ARNP. Ms. Baker said the ARNPs make the decision to prescribe drugs. She said the study did not cover medical liability. Representative Lee asked how the ARNPs in states where the expanded authority practice, and in those states that have expanded authority, were there more patients getting drugs or were the same number of patients getting more drugs. Ms. Baker said some practice independently; however, they must have a collaborative agreement with a physician in order to write a prescription. Mr. Perry said there was no data to show that per capita amounts of drugs are higher. Representative Marcotte asked what some of the terms were in collaborative agreements. Ms. Baker said that a copy of a basic agreement was on page 59 of the study. Representative Draud asked what the training and qualifications were for a nurse practitioner. Ms. Baker said a nurse practitioner has a Baccalaureate degree and the ARNP program is a two-year, Master's level program.
Marty White from the Kentucky Medical Association (KMA) and Bill Doll from Jackson Kelly PLLC representing the KMA congratulated the LRC staff for time and effort put into the study. Mr. White said the KMA House of Delegates, the KMA governing body, is made up of 200 physicians. Several years ago it adopted a policy that opposes granting prescriptive authority for narcotics for any non-physician practitioner. He said for the past two years the KMA has been opposed to expanding the prescriptive authority for ARNPs due to concerns that if there are more prescription writers there will be more prescriptions on the street. Nevertheless, the KMA is committed to sit down and talk to the ARNPs concerning this area.
Chairman Butler said he thought there was a turf battle between the physicians and the ARNPs. Mr. White said the prescription abuse fears are well documented. Mr. Doll said that drug diversion was a problem without adding another portal; at the same time the physicians acknowledge that this is worth sitting down and discussing. Senator Tapp said this was an opportunity to take the skill and knowledge physicians have and combine it with the ARNPs' knowledge and care to give better health care. Senator Denton said the KMA needs to understand that Kentucky is one of only six states that does not allow this and the KMA should try to find a consensus because other states are making it work.
Senator Tapp said committee staff was passing out the resolution regarding the hiring of 51 people for the Office of Housing, Buildings and Construction. Senator Carroll made a motion, seconded by Representative Clark. The resolution was adopted by voice vote.
Sheila Schuster, Ph.D, representing the Kentucky Coalition of Nurse Practitioners and Nurse Midwives commented that the quality of the LRC study was outstanding. She said the goal of the ARNPs was to increase access and to make sure that there is high quality health care. She said this means assuring accountability of the prescriber as part of the increased access to care. Ms. Schuster said Hawaii is passing legislation to grant the increased authority, leaving only four or five states that do not give ARNPs increased prescriptive authority. Cathy Waits, FNP, WHNP, told the committee that nurse practitioners are required to have both classroom coursework and clinical hours of instruction, and beginning in 2006, five continuing education units in pharmacology annually. She said ARNPs do not prescribe medications frivolously, and each case is considered individually to give the patient the best care. She said not all controlled medications are for pain; cough syrup with codeine, some seizure medications, hormone replacement drugs, and even some diarrhea medications are "scheduled drugs." She told the committee that in rural health clinics a doctor is not always on-site, and an ARNP cannot write a prescription for pain in an emergency situation such as for a broken bone. She said full prescriptive authority would also benefit Hospice patients whose condition could deteriorate rapidly with no warning. Beth Partin, ND, CFNP, told the committee that complaints and disciplinary action against ARNPs have been few in number. She said that ARNPs take protecting the public seriously and provide safe, quality care to their patients, which was well documented in the LRC study. She said that the U.S. Drug Enforcement Administration provides DEA numbers only to persons who can prescribe scheduled drugs. ARNPs in Kentucky cannot get a DEA number. Therefore, the ARNP's name is not on the prescription label, and some patients are reluctant to take their medication because the name of their ARNP is not on the label. She said ARNPs want to be responsible for their work. They carry their own liability insurance and claims are low. She said that the collaborative agreement in place since 1996 is working in other states, and if a physician felt like the ARNP was not qualified for writing scheduled drug prescriptions he or she would name that in the agreement. ARNPs want to serve their communities and want to work with all interested parties for legislation to increase prescriptive authority.
Representative Meeks asked how many nurse practitioners have left the state and what was the anticipated impact on the cost of health care in the state if nurse practitioners are able to prescribe. Dr. Schuster said she did not know how the Board of Nursing tracked that information but she had heard an anecdotal report of an ARNP in Senator Williams' area who is struggling to stay in his area but had just taken a job in Tennessee. She also said they hear from instructors in the ARNP programs that nurse practitioners can go to any state that surrounds Kentucky, except Missouri, and have full prescriptive authority. Ms. Partin said in rural areas, ARNPs cannot sign scheduled drug prescriptions so a patient has to leave and come back to get an approved prescription from a physician, which is costly to the patient in time and travel. There is also emergency room cost when the clinic is unable to provide care. Dr. Schuster said having a front-line primary care provider reduces medical cost. Representative Miller asked how many physicians have been sued for prescriptions. Dr. Schuster said there was no difference in the malpractice suits in states that granted ARNPs full prescriptive authority and those that did not. Sharon Mercer, Executive Director for the Kentucky Nurses Association, said regarding people leaving the state, in the past week she had received two calls and the week before that one call. She said typically about six weeks before education programs are finished she gets calls because people do not want to come back to Kentucky and practice if they cannot practice fully. Dr. Schuster said the ARNPs were well trained and well educated and wanted to be held accountable. She said the ARNPs were aware that Kentucky had a substance abuse problem and they want the Board of Nursing to have the oversight. They pledged to work diligently with the KMA and Secretary Holsinger to get the wording down so everyone is assured that there is increasing access, but with quality and oversight. Senator Tapp said this needs to be addressed early in the interim and it was better when the two sides can come together with a compromise and let the committee know. He said he would like to see a piece of legislation drafted and before the committee at another meeting, either October or November.
There being no further business the meeting was adjourned at 3:10 PM.