Call to Order and Roll Call
The 6th meeting of the Interim Joint Committee on Licensing and Occupations was held on Tuesday, November 20, 2012, at 10:00 AM, in Room 129 of the Capitol Annex. Senator John Schickel, Chair, called the meeting to order, and the secretary called the roll.
Present were:
Members: Senator John Schickel, Co-Chair; Representative Dennis Keene, Co-Chair; Senators Julie Denton, Denise Harper Angel, Paul Hornback, Dan "Malano" Seum, Damon Thayer, and Robin L. Webb; Representatives Tom Burch, Larry Clark, Dennis Horlander, Wade Hurt, Joni L. Jenkins, Adam Koenig, Charles Miller, Michael J. Nemes, David Osborne, Ruth Ann Palumbo, Carl Rollins II, Sal Santoro, Arnold Simpson, and Susan Westrom.
Guests: Marty Hammons, Commissioner, Bob Sparrow, Deputy Commissioner and Acting Director of Enforcement, Lisa Moreman, General Counsel and Acting Director of Licensing and Compliance, Department of Charitable Gaming; Soren Campbell, Daniel Bates, Kentucky Academy of Anesthesiologist Assistants; Alexander Montavon, Student, Case Western Reserve University, Washington, D.C.; Heidi Koenig, M.D., Ross Cotton, M.D., Anjum Bux, M.D., Kentucky Society of Anesthesiologist.
LRC Staff: Tom Hewlett, Bryce Amburgey, Carrie Klaber, Michel Sanderson, and Susan Cunningham.
Pilot project on electronic record keeping
Marty Hammons, Commissioner of the Department for Charitable Gaming said that Kentucky ranks in the top six in charitable gaming nationally. In 2011, charitable gaming in the state was a $394 million industry. Of that, $44 million went to the charities. Although receipts are declining, charities are able to retain the money available to them. 2011 also had the fewest number of violations; of the 653 licensees, only 17 did not meet the 40 percent retention required by statute.
Fines have also seen a reduction since 2007. Staff worked with charities to determine the degree of each violation. Some mistakes that were previously fined were reduced to warnings. Staff is now emailing notices and reminders to licensees and this has resulted in all but 17 charities filing annual reports in a timely manner.
The department understands that charities are run by volunteers with other obligations. However, charitable gaming is an all cash industry and it is important to track all money that is passed. The paper work can be burdensome. Financial reports can include up to 25 pages of documentation for one session. Kentucky has 16 licensed distributors with the ability to electronically track their product from their warehouse to the bingo floor. A letter was sent to each distributor asking for input on making tracking easier for charities. Two distributors were interested in helping with a Point of Sale software system that would help charities track the product that is in their inventory, what is being sold, what their payout should be, and what their net should be at the end of each session. This information could be electronically transferred to the department so the charity is reporting on time.
The distributors were allowed to choose the charities they wanted to work with so that a variety of charities could be sampled. There are six charities participating with two distributors. The reporting period started October 1, and will end December 31. Financial reports are due January 31. There are no results of the project to report.
Commissioner Hammons said that he, Bob Sparrow, and Lisa Moreman have witnessed demonstrations of the products and attended an installation of software. The system tells the charity the amount of inventory available and when the inventory becomes low. Products are scanned into the system, which automatically gives the charity the payouts and identifies the net profit.
The department does not intend to mandate this software system. However, letters from the charities participating testify that the electronic tracking and reporting system has improved their ability to report their gaming sessions. Current law does not allow for electronic reporting. This project allows the department, the distributors, and the charities to see what the system can do to make the burdensome paperwork less of a burden for the charities. This allows all parties to have input so that the department does not continue to come to the legislature for changes regarding electronic tracking and reporting.
The program is an option for the charities to use in reporting to the department. The department is looking for ways to make reporting easier for the volunteers who run the charities. The department, as a regulatory body, wants to make sure that the accountability and integrity of the industry is maintained, and at the same time provide a service to the charities.
In response to a question from Representative Clark, Mr. Hammons said when a box of pull tabs is scanned into the system the number of tickets for sale is recorded. Pull tabs are easy to track due to the serial numbers on the box with the seal card matching the serial number. The software will track the box until all tickets are sold and the point of sale is closed out. The system will also allow a partially sold box of pull tabs to be recorded and will pick up sales from the box at the next session. The biggest issue is Bingo paper. Several states do not track paper. What the department has found is that this is a simple way to cheat the system.
Issues relating to licensure of Anesthesiologist Assistants
Soren Campbell, Anesthesiologist Assistant (AA) and representative of the Kentucky Academy of Anesthesiologist Assistants, said AAs have been practicing safely in Kentucky for over 25 years. State licensing was changed about 25 years ago requiring an AA to also be licensed as a Primary Care Physician Assistant in order to obtain licensure. This stopped any new practicing AAs from coming into Kentucky. In other states where AAs practice, there is no other requirement for physician assistant licensure. AAs receive a Masters level education in order to assist for anesthesiologists. AAs do not assist other physicians.
Changing licensing to allow AAs to practice in Kentucky is endorsed by the Kentucky Society of Anesthesiologists and the Louisville Society of Anesthesiologists. The Kentucky Medical Association remains neutral on the issue and the Kentucky Academy of Physician Assistants prefers that AAs have their own licensure. AAs fall under the PA licensing statute, which causes some confusion, not only in name recognition, but also job responsibilities. The Certified Registered Nurse Anesthetists (CRNA) are opposed to changing the licensure. The AAs and CRNAs practice under the same anesthesia care team model with anesthesiologists involved in the care of the patients. One argument against licensure of AAs is that AAs are not safe; however, there is no study that shows that outcome. There is a study that was done in Cleveland of 50,000 cases where half were done by AAs and the other half by CRNAs that showed no difference in the number of adverse events.
AAs were designed by anesthesiologists to work as a team member. AAs are reimbursable. The Centers for Medicare and Medicaid Services (CMS) identify both AAs and CRNAs as “anesthetist” in their code of federal regulations. AAs are also eligible to work in the VA system. Last year, the House and Senate Licensing and Occupations committees passed similar legislation to revise licensure requirements for AAs, but no compromise was reached.
Daniel Bates, President of the Kentucky Academy of Anesthesiologist Assistants, stated that he is forced to work in Cincinnati, Ohio because he does not have a PA license. The CRNAs, who are opposed to licensure of the AAs, have the same role as AAs in the anesthesia care team. CRNAs go through nursing’s anesthesia school to become anesthetists while AAs go through a pre-med school that is connected with a residency program for anesthesiology. Kentucky’s duplicate certification requirement is restricting AAs from practicing. Case Western Reserve University has expressed an interest in opening an AA program in Kentucky. This would be possible if AAs are able to work in Kentucky without the dual licensing requirement.
Alexander Montavon, AA student in Case Western Reserve University’s Masters of Anesthesia program in Washington, DC, said he graduated from Eastern Kentucky University with a bachelor’s degree in Chemistry and Bio-Chemistry. He then enrolled in the AA program, which began with a five week didactic schedule including classes in physics, as well as using the anesthesia machine and monitors that are part of the practice of anesthesia. There is also a class in pharmacology to learn the class of medications AAs use, and a physiology class to learn how diseases affect the anesthesia care of patients. In the last five months he has earned 300 hours of clinical experience. He wants to take the skills he has learned and return to Kentucky.
In response to a question from Representative Burch, Mr. Campbell said the modern anesthesia model uses a team composed of an anesthetist that is in the operating room with the patient. The anesthesiologist sees the patient pre-operatively to make the anesthetic plan and is present for the induction, emergence, and other critical components of the anesthetic. CMS allows anesthesiologist to supervise up to four operating rooms. The nurse anesthetist does the same type of anesthetic work that the AA does. With health care reform there are expected to be more patients, therefore the demand for AAs will grow in the future. Billing for all members of the anesthetist team is typically done by a physician group.
Dr. Heidi Koenig, University of Louisville, President of the Kentucky Society of Anesthesiologist stated that she was speaking for the society rather than the university. The M.D. anesthesiologist role is focused on safety and patient well-being, as well as preparing patients for surgery. AAs and CRNAs are necessary. AA programs are well integrated with rigorous testing and national certification in place. Kentucky’s duplicative requirement prevents well trained, nationally credentialed health care practitioners from practicing and taking care of patients.
Dr. Anjum Bux, Chief of Anesthesia at Ephraim McDowell Hospital in Danville and Kentucky representative for the National Society of Anesthesiologist, said the society is supportive of the AA licensure. A 2006 study conducted by the Legislative Research Commission noted that AAs are not allowed to practice as generalist physician assistants. The generalist physician assistants follow a different educational curriculum, geared toward their specialty. Allowing AAs licensure in Kentucky will add to the anesthesia care team, allowing better care and enhancing patient safety. With the patient population growing, allowing AAs to work in Kentucky will not result in fewer jobs for other practitioners but will allow more access to rural hospitals that are not easily covered.
Dr. Ross Cotton, anesthesiologist at Norton Health Care, said anesthesiologists take care of critically ill people every day. Health care is a changing profession that currently requires good mid-level caregivers. There is a shortage of people qualified to work on anesthesia teams.
In response to a question from Representative Westrom, Dr. Koenig said the Kentucky Medical Association (KMA) has remained neutral on this issue. There is a need for more providers and the KMA is in support of team based care. The mid-level provider is where patient care can be expanded.
Senator Schickel and Representative Keene recognized Representative Hurt and Representative Nemes for their service to the Commonwealth.
Senator Webb commented that during a previous meeting a regulation concerning the race day administration of Furosemide had been found deficient. However, the Governor overrode that decision and passed the regulation by executive order. Since that order went into effect, state veterinarians have improperly administered Lasix at least four times. This topic is worthy of further discussion.
Senator Thayer commented that he enjoyed working with Representative Nemes during his service.
There being no further business to come before the committee, the meeting was adjourned at 10:56 AM.