The eighth meeting of the Medicaid Managed Care Oversight Advisory Committee was held on Wednesday, October 25, 2000, at 10:00 AM, in Room 131 of the Capitol Annex. Senator Gerald Neal, Chair, called the meeting to order, and the secretary called the roll.
Present were:
Members: Senator Gerald Neal, Co-Chair; Senator Vernie McGaha, Representatives James Bruce, Jack Coleman, Stephen Nunn, and Dottie Sims.
Speakers: Rhonda Gonzalez, Health Policy Specialist, National Conference of State Legislatures; Dr. Beverly Gaines, Pediatrician, Vice-President of the National Medical Association, and Chair of the Pediatric Section of the National Medical Association; Brenda Fitzpatrick, Director of the West Louisville AHEC; Harold Fenerson, Principal of Central High School Medical Magnet Program; Dennis Boyd, Commissioner, Department for Medicaid Services, Cabinet for Health Services; and Susan Robinson, Mental Health Coordinator for the Migration and Refugee Program at Catholic Charities.
Guests: Peter Hasselbacher for the University of Louisville; Patrick Delahanty for the Catholic Conference of Kentucky; Barbara Wright for the Kentucky Developmental Disabilities Council; Mike Mayes for the Kentucky Pharmacists Association; Ray Peters for the Office of Inspector General; Cindy Upton for the Office of Inspector General; Joyce Frazier for Catholic Charities; Glenn Bryant for the Office of Inspector General; Missy Adkinsson for the Department for Public Health; Sheila Oldham Smith for the Jefferson County Health Department; Mary Reynolds for the Jefferson County Health Department; George J. Graham, Ph.D. for the Northern Kentucky Health Department; Marybeth Crouch for Doral Dental; Jo Crockett Zingg for the Lexington Fayette Public Health Department; Cathy Allgood Murphy for the Center for Accessible Living; David O'Nan for the American Cancer Society; Jan Gould for the Kentucky Retail Federation; Sarah Nicholson for the Kentucky Hospital Association; Sarah Wilding for the Cabinet for Health Services/Department for Public Health; Ann Gordon for the Cabinet for Health Services; and John Cooper for the Kentucky Medical Association.
LRC Staff: Barbara Baker, Robert Jenkins, Kelly Smith, Murray Wood, and Cindy Smith.
The first item on the agenda was an overview of health status disparities by Rhonda Gonzalez, Health Policy Specialist, who works on minority health issues at the National Conference of State Legislatures. She said the National Institutes of Health have defined health disparities as differences in the incidence, prevalence, mortality, and burden of disease and other adverse health conditions that exist among specific population groups in the United States. There are several types of health disparities that are showing up: (1) racial/ethnic disparities; (2) class disparities; (3) gender disparities; and (4) geographic disparities. Some causes of the disparities were identified as: (1) poverty, level of education, inadequate access to health care, lack of health insurance and societal discrimination; (2) lack of complete knowledge about causes, treatment, and prevention of serious diseases; and (3) genetics. Ms. Gonzalez reported that the 1990 census of the U.S. showed that 24% of the population of the U.S. are minorities. The estimate for 2030 is expected to be 39%. Latinos will be the largest minority group by 2005. Disparities exist among racial groups with almost every major disease, including cancer, AIDS, and heart disease. In Kentucky, the majority of the population is white, with about 7% being African American, with an increasing population of Hispanics. Kentucky has a higher percentage of the population in poverty (14%), than the U.S. as a whole (12%). In relation to geographic disparities, compared to urban residents, rural residents have lower rates of insurance coverage, have worse health status, and receive less professional medical attention. Ms. Gonzalez described federal initiatives to eliminate health status disparities. She reported there is also a Healthy People 2010 initiative which has two main goals: (1) to improve quality and extend years of healthy life; and (2) to eliminate health status disparities. She also described the President’s 1998 initiative to eliminate rising health risks that minorities encounter in the following areas: (1) infant mortality; (2) HIV/AIDS; (3) diabetes; (4) childhood immunizations; (5) cancer; and (6) adult immunizations. These key factors are also included in the 30+ goals and objectives of Healthy People 2010. She presented strategies to eliminate disparities such as prevention, early detection, and treatment. She described federal initiatives as: (1) National Health Service Corp; (2) Head Start; (3) Medicaid; (4) SCHIP; (5) Title V; and (6) Vaccines for Children Program. She described various state initiatives which included: (1) Offices of Minority Health; (2) Offices of Women’s Health; and (3) Health Professional Loan Programs. She stated that foundations across the U.S. supporting health programs with the goal of reducing disparities look at four basic things: (1) to encourage cultural competency; (2) to recruit minority health professionals; (3) to eliminate racism; and (4) to promote adoption of healthy behaviors.
The next item on the agenda was testimony from a group of Kentucky health care providers and educators who work with health disparity issues on a day-to-day basis. These speakers were: (1) Dr. Beverly M. Gaines, Pediatrician, Vice-President of the National Medical Association, and Chair of the Pediatric Section of the National Medical Association; (2) Brenda Fitzpatrick, Director of the West Louisville AHEC; (3) Harold Fenerson, Principal of Central High School Medical Magnet Program; and (4) Betty Bibbens, MD, Consultant with the Central High School Medical Magnet Program. Dr. Gaines gave an overview of health disparities, starting with 1980. In 1980, the Secretary of Health and Human Services, Secretary Heckler, commissioned a study on black and minority health. Dr. Gaines reported that the study identified several major diseases as the primary killers of the African-American population. These included cardiovascular disease, heart disease, cancer, diabetes, infant mortality, substance abuse, and unintentional injury and accidents. She stated that in the late 1990s, HIV/AIDS was identified as the number one cause of death for African/American women between the ages of 25 and 45. It was discouraging that a decade later, the numbers look the same. Dr. Gaines reported that they have seen some small improvements in infant mortality and the number of teen smokers. Overall, they have not seen the type of impact they need to see in the face of the information they have gotten. They have found that African-Americans were disproportionately impacted by cancer, diabetes, heart disease, and stroke. She referred to the Georgetown study, which reported the African-American males and females were the least likely to get aggressive, early interventions. She said that the Georgetown Study is a good example that people are not treated the same.
Senator Neal said it seems that the curriculum in the medical schools, not withstanding trying to involve more diversity in medical school, should have something that deals with these issues in a very significant way with respect to the question of cultural competence. Dr. Gaines said that is very viable and is attempted, but thinks it is ineffective.
Next, Harold Fenerson described the medical magnet program at Central High School in Jefferson County. He said about 58% of the students represent the African-American part of the student body, with 42% majority population; 26 different countries are represented, along with 18 different languages spoken. They have four major magnet programs available to students. The school offers physical therapy, pharmacy, medical office administration, veterinary science, nursing, dentistry, and pre-medicine. Students who attend Central must make application to attend and be approved using two criteria for admission: (1) at least a 2.0 grade point average in their middle school years; and (2) two recommendations from former teachers. Students in the ninth grade will rotate three weeks in each of the programs in addition to others. Within those three weeks, students are given information germane to types of skills, types of education, and courses that students need to take to be successful at the next level. In the sophomore year, students are required to shadow at least 20 hours, which can also be defined as service projects or service learning. Shadowing provides students insight into what is expected. In their junior year, students are provided with mentors. The average family income of students attending Central High School is only $11,000. Students have mentors who are both practitioners, and who are medical students in the various schools that are available to them. During their senior year, the school provides paid and unpaid externships for the students. Students are placed in every medical facility within Jefferson County. One of the challenges noted was that students come from poor families, and that poverty is a factor with their hopes and dreams.
Next on the agenda, Commissioner Boyd provided comments on the application of strategies to eliminate health disparities within the Medicaid Managed Care Program. He said the last census indicated that 92% of Kentuckians were Caucasian, 7% were African-American, and 1% were other. He said the Medicaid population in Louisville is about 33% African-American, while in Western Kentucky, it is about 17%, and in the Lexington area, it is about 15%, along with four or five regions which are less than 10%. In contrasting the national population with Kentucky and its Medicaid population, he stated the one thing he has seen over the past few years in Kentucky is a large influx in the Hispanic population. However, very few are actually on the Medicaid rolls because of the eligibility requirements. It appears that a large majority of the Hispanics coming into Kentucky are young males. They will not qualify for Medicaid, because one must have permanent residence in Kentucky to qualify for the Medicaid program, and also belong to an eligibility group that is standard for any Medicaid eligibility. He said the managed care initiative is now centered on the KenPac program, except in the Louisville area where the Partnership still exists. The area of cultural competency is an issue, and the Cabinet is committed to working with anyone in regard to that issue.
Senator Neal asked if the Cabinet could administratively initiate, through Executive Order, or some other process, a significant portion of what Representative Bather’s bill during the 2000 Session was intended to deal with. Commissioner Boyd said in regard to the Medicaid program, yes, but he feels there needs to be consistency across all agencies. Senator Neal said with the Governor’s Executive Order every agency can be jumped across. Senator Neal asked if this is an issue that Commissioner Boyd would entertain. Commission Boyd said certainly.
Commissioner Boyd closed by saying that the issues of services to minorities to eliminate any disparities and provide cultural competency to this population, need to be addressed by elected and appointed officials. He said the cabinet is willing to work with the legislature, other agencies, and advocacy groups toward those goals.
Susan Robinson, Mental Health Coordinator for the Migration and Refugee Program at Catholic Charities, also spoke at the meeting. She said the population in Kentucky is diversifying rapidly, with counties diversifying because of the influx of refugees into the community. She noted her concern with the Medicaid program is how the cabinet would make sure that the program and its sub-contractors communicate effectively with people of limited English proficiency. She said there are in excess of 186 languages spoken in the Jefferson County Public School systems. Although interpreters and translation to the Spanish language is a very important start, it is not nearly enough. One reason this is important is compliance with Federal Civil Rights laws, and that physicians and professionals are protected from malpractice and negligence claims.
Senator Neal invited Ms. Robinson testify at the next Medicaid Managed Care Meeting because he thinks her statements are something that the state needs to hear.
The next meeting of the Medicaid Managed Care Oversight Advisory Committee will be November 13, 2000, at 10:00 a.m.
The meeting was adjourned at 12:30 p.m.