The 9th meeting of the Medicaid Managed Care Oversight Advisory Committee was held on Monday, November 13, 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 Julie Rose; Representatives James Bruce, Jack Coleman, Stephen Nunn, and Dottie Sims.
Guests: Marty White and William P. VonderHaar, MD for the Kentucky Medical Association; Haydee N. Canovas, RN for the NW AHEC-HETC; Michael Duncan and Ed Barnes for the Office of Attorney General; Marybeth Crouch for Doral Dental; Jane Chiles for the Catholic Conference of Kentucky; Susan Robinson for Catholic Charities; Michael Byrne for the University of Louisville; Richie Bottoms, Commonwealth Attorney; Ronald K. Sears and Paul Hays for the Kentucky State Police; Mike Porter for the Kentucky Dental Association; Bill Doll for the Kentucky Medical Association; Sean M. Cutter for McBrayer, McGinnis, Leslie & Kirkland; Jan Gould for the Kentucky Retail Federation; Sarah Nicholson for the Kentucky Hospital Association; Peter Hasselbacker for the University of Louisville; and Beverly Gaines, Pediatrician.
LRC Staff: Barbara Baker, Robert Jenkins, Murray Wood, Perry Nutt, and Cindy Smith.
The minutes of the November 10, 1999, September 21, 2000, and October 25, 2000 meetings were approved without objection.
The first item on the agenda was an overview of the KASPER (Kentucky All Schedule Prescription Electronic Reporting) system by Danna Droz, Director, from the Cabinet for Health Services, and John Cubine, from the Office of Attorney General. This system was created in House Bill 115 of the 1998 Regular Session of the General Assembly and has been up and running for two years. A follow-up was presented on the implementation of that legislation. Ms. Droz explained that the KASPER program only deals with controlled substances. Prescription drugs that are available in pharmacies have a street value between 10 and 100 times the actual pharmacy cost. She stated that most physicians and pharmacists are not aware of the street value of various drugs. Ms. Droz stated there are some educational efforts to try to help them understand the street value of prescription drugs. KASPER is similar to programs in other states. Kentucky and Utah are the only two states that monitor all schedules of controlled substances. Kentucky has the premier program in this area. Kentucky does more with collected data than other states. KASPER was designed to be a source of information for practitioners and pharmacists who need information about their patients in order to give them the most appropriate medical treatment. It was also created to be an investigative tool for law enforcement. KASPER was not designed to prevent people from getting drugs they need for legitimate medical conditions, or to encourage practitioners or pharmacists to cut them off, or to increase the number of pills dispensed. The information received in the system includes: identification of the patient, identification of the prescriber, identification of who dispensed the drugs, name of which drug was dispensed, the quantity of the drug and the date. No information is received about the payor. The following people can get the reports: (1) grand jury can subpoena a report; (2) practitioners and pharmacists if they certify that it is for the purpose of medical or pharmaceutical treatment; (3) law enforcement officials if they certify that it is for a bonified investigation involving a specific individual; (4) licensing boards, but only on their licensees; and (5) Medicaid, but only on their recipients. The reports are not given to anyone else, except by order of the Court. Since the implementation of KASPER, the system has accounted for a large increase in the number of complaints received. As a result of KASPER, over 40 training sessions have been conducted in at least 14 counties, with audiences which included physicians, pharmacists, law enforcement, licensing boards, veterinarians, and several other groups. After every training program, the utilization of KASPER increases. KASPER does the leg work of investigations so that investigators can do the thinking that is required. One important facet in the KASPER program is the increase in efficiency. In the year prior to the passage of KASPER, it took an average of 142 days to complete an investigation, as compared to 116 days during the first year that KASPER was implemented. Over the last year, the average number of days to complete and investigation has decreased to 20 . The decrease in the number of days to complete an investigation is attributed to investigators not heaving to do the legwork. They can go to the database and get the information that they need in order to proceed. Ms. Droz reported that the ability of patients to obtain necessary medication has not been compromised by the KASPER program. The feedback received by people who use the KASPER program has been very positive.
Representative Coleman asked if this system has been useful in identifying the “doctor shopper” group. Ms. Droz said a patient report is provided to physicians or pharmacists who request it. There are also a number of queries or reports that can be run to identify “doctor shopper” violations in a particular area.
Representative Coleman said that the KASPER system is the best of all options available. Ms. Droz said it is the premier program in the country.
Next, John Cubine introduced Mike Duncan, Director of Special Investigations, Ed Barnes, Manager, Special Investigation, Barbara Whaley, Medicaid Fraud Director, and Jean Ann Myatt. He reported that the Prescription Drug Task Force was created in 1997 as based on some recommendations by the Kentucky State Police. As a result, the 1998 General Assembly enacted House Bill 115. With the cooperation of the Kentucky Medical Association, pharmacists, and the Cabinet for Health Services, House Bill 115 became law. This law did not change the authority to do these types of investigations, but it created a more efficient tool. The Attorney General’s Office wants to assure the Committee that KASPER is not used for snooping. When a request is received, something creating probable cause prompts them to get the report. This has created a less intrusive situation.
Representative Nunn asked how many workers are in Ms. Droz’s office that are able to review the information. Ms. Droz said there are four FTE’s devoted solely to the KASPER program out of nine people. Three of those people are field personnel. Ms. Droz said in order to get their hands around the problem, they really need to employ a systems analyst to do some analyses of the data. She would also like to get to the point of newer technology to cut down on some of the labor costs.
The second topic on the agenda was a continued discussion on health status disparities among various groups - racial, ethnic, gender, and across geographic locations. The Cabinet presented their initiatives to eliminate health disparities. Secretary Helton of the Cabinet for Health Services said that Kentucky is the only state in Region 4 that does not have an Office for Minority Health Care. In fact, Kentucky is one of the few states in the nation that does not have a minority health office. In Public Health, there is a Minority Health Coordinator. Secretary Helton said he is committed to elevating that to the level it should be. The Cabinet is in the process of finding some personnel space and money to establish the Office for Minority Health Care. This will be done through an Executive Order. The office will be modeled similar to the other minority health offices in the nation.
Senator Neal asked what the time table was for the Office of Minority Health to be established. Secretary Helton said it will probably be done around the first of the year. When established, the Office for Minority Health will report directly to Secretary Helton. The primary focus of that office will be data collection, much like the Office for Women’s Physical and Mental Health.
Commissioner Rice Leach of the Department for Public Health presented a power point demonstration on minority health issues. He said the mission of the Department for Public Health is to help people be well. The statutorily mandated services of the Department are enforcement, surveillance, communicable disease control, public health education, public health policy, families and children risk reduction, and disaster preparedness. Dr. Leach reported that the local health departments provide services such as written materials available in Spanish and some other languages, interpreters for foreign languages and services for hearing impaired; and there are also frequent training on cultural diversity. Minority health areas for improvement in Kentucky are in the areas of breast cancer, diabetes, cardiovascular disease, immunizations, HIV/AIDS, tobacco cessation, and infant mortality.
The next item on the agenda was testimony regarding the importance of recruiting and retaining minorities in health professions. The following individuals provided testimony: David Wiegman, PhD., Vice-Dean for Academic Affairs, University of Louisville School of Medicine, William P. VonderHaar, MD, President, Kentucky Medical Association, and Dr. Austin Tooney, Associate Commissioner, Office of Human Resources and Equity, Kentucky Department of Education. Along with Dr. Tooney was Rodney Kelly, Director of Vocational Education.
Dr. Wiegman highlighted the MED (Medical Education Development) Program. They made a commitment in 1987 to not enter into bidding wars for students who were going to be physicians graduating from one medical school or another, but rather to put their resources into creating new physicians. The first requirement is that a student is invited into the MED Program, and cannot apply to it. One of the criteria is that the student has been denied admission to every medical school he/she applied to. They are trying to focus on people that have the qualities and characteristics of a good physician, and also whose education, cultural, and social economic situation has put them at such a disadvantage that they would be a too high academic risk to go straight into medical school. They accept two to five students per year into the MED program.
Senator Neal asked how many students are graduating over all per year. Dr. Wiegman said about 130 students.
Next, Dr. VonderHaar addressed efforts within the physician community to recruit minorities into the profession, and shared some initiatives the Kentucky Medical Association (KMA), along with the American Medical Association (AMA) has undertaken to address cultural diversity. Diversity is an important issue to the KMA. From committee appointments to advocated legislation, KMA has continued to bring culturally diverse perspectives into the organization’s decision making. He reported that current initiatives to encourage minority participation in the KMA included the Board of Trustees and most committees having minority members serving in various roles. Minority representation and cultural diversity are considerations in establishing who will serve on various committees. KMA also administers the Rural Medical Scholarship Fund which has been instrumental in funding medical education in exchange for a student’s commitment to practice in a rural area of the state underserved by health care providers. Since the scholarship fund inception, it has placed more than 600 physicians in rural areas, which often have large Medicaid populations. Most recently, the KMA House of Delegates addressed the issue of race and ethnicity by directing a KMA committee to be formed to conduct a physician and allied health workforce study. This study is designed to gather and distribute data to various effective institutions that can use it to plan strategies that address work force needs.
Dr. Tooney said his Department has been extremely concerned about the issue of cultural diversity and equity as it relates to students and educators. While they have specifically focused on encouraging minority students to pursue a field in health services, they have been paying particular attention to the achievement gap that currently exists with minority students and white students. As a result, they have developed a plan to address the achievement gap which involved bringing together citizens from Kentucky, including students, to help develop the plan. In January, they will initiate five pilot projects which will look specifically at the problems and try to discern what types of things are causing the achievement gap and if those things deal with diversity or equity issues. He stated that those things will be addressed. In addition, the Board and the Department are concerned with how the Department looks to the public. They have expanded their efforts to increase the number of minorities at the Department of Education. They have recently received a grant in the amount of $2 million to focus on advanced placement classes. He stated that there is a significant shortage of minority students in advanced placement classes. Two years ago a Division of Educational Equity was established. As a result, they have done professional development within the Department. They are also providing professional development relating to equity issues with local school districts. Local school districts are required to produce a consolidated plan which shows what efforts they are going to make as far as the curriculum is concerned for the ensuing year. They are required to address equity issues within those plans. Those plans get reviewed by the staff. The staff also assists the local school districts with training. They have established a system of scholastic audits. They have made sure in the design for those audits that the issues of cultural diversity and equity are addressed. When an audit is undertaken within the school district, that is one of the strands that gets close scrutiny. In addition, as far as curriculum is concerned, they look closely at what happens with the textbook selection and the materials that are approved and used by local school districts to make sure that they reflect the diversity of society.
Next, the members received comments and responses by Beverly Gaines, MD, Pediatrician, Vice-President, National Medical Association, and Chair, Pediatric Section of the National Medical Association. Ms. Gaines said her overall feeling about the information presented at the meeting was that it requires further study. Its impact and effectiveness needs to be studied. On paper, it always looks good, but there is a problem in the community. There is a problem with competence among providers, as well as a problem with information on providers. The effectiveness of everything done from the early childhood programs to practicing physicians needs to be studied in a very thorough way.
Senator Neal said there will be more discussion on these issues. Ultimately, this information will be taken and put into a framework that is useful for others to review as well.
Last on the agenda, Susan Robinson of Catholic Charities testified relating to access to Medicaid Services. At the last meeting Ms. Robinson spoke briefly regarding the linguistic difficulties that immigrants and refugees experience in accessing Medicaid services. Ms. Robinson began her testimony by having a doctor speak in Samali as an example of the difficulty of language barriers in medical care. She presented examples of children who were denied medical care because they could not speak English, or they did not have interpreters who could stay throughout the appointment. Outpatient follow-up appointments have never included an arranged interpreter as required by Title VI. Title VI is part of the Civil Rights Act of 1964 that protects people on the basis of race, color, and national origin. People who speak limited amount of English, or no English are included in the national origin part. The HCFA guidance memorandum that recently came out outlines what a written plan should look like and indicates the posting of the availability of free interpreter services. Some other problems they have identified in Kentucky are: (1) telephone access when speaking languages other than English; (2) important documents are mainly written in English, and very few times in Spanish; (3) Community Based Services, which serves as the enrollee for Medicaid, communicated in English only. She stated that she was promised a written plan in May, 1999, from Seven Counties regarding their intention to address the special needs of the refugee population and non-English speaking people, and that she is still waiting for the plan. She proposed options to deal with these issues, including: hiring bilingual staff and utilizing community resources that have interpreter services, such as the Red Cross. There are also telephone language lines which are better than nothing, but the Office of Civil Rights has determined that is the least cost effective method and that 60% of the facilities that subscribe to a telephone interpreter line do not use it when necessary. Another option would be to make the cost of interpreters reimbursable to providers, or Medicaid could provide interpreters.
The meeting was adjourned at 1:13 p.m.