Call to Order and Roll Call
Thefourth meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, October 19, 2011, at 1:00 p.m., in Room 129 of the Capitol Annex. Senator Julie Denton, Co-Chair, called the meeting to order at 1:05 p.m., and the secretary called the roll.
Members:Senator Julie Denton, Co-Chair; Representative Tom Burch, Co-Chair; Senators Tom Buford, Denise Harper Angel, Dennis Parrett, Joey Pendleton, and Jack Westwood; Representatives Julie Raque Adams, Bob M. DeWeese, Kelly Flood, Brent Housman, Joni L. Jenkins, Mary Lou Marzian, Tim Moore, Darryl T. Owens, Ruth Ann Palumbo, Ben Waide, David Watkins, Susan Westrom, and Addia Wuchner.
Guest Legislators: Representatives Keith Hall and Jimmie Lee.
Guests: Dave Adkisson, President and CEO, Kentucky Chamber of Commerce; John Johnstone, MD, Cardiology and Internal Medicine; A. Scott Lockard, Public Health Director, Clark County Health Department, and President of the Kentucky Public Health Association; Dennis and Kathy Nafus, Coalliance; Gary Hill, Administrator and President, Jane Hill, Licensed Clinical Social Worker, and Janet Messer, Lighthouse Counseling Services; Mark Hamm, M.Ed., NCC, LPCC, CEO, Phoenix Preferred Care; J. Michael Benfield, MD, CEO and President, MD2U, Louisville; Allen Rose, Vice President for Business and Government Relations, and Dr. Hieu Tran, Dean of the College of Pharmacy, Sullivan University; Eric T. Clark, Kentucky Association of Health Care Facilities; Betsy Janes, American Lung Association; Nathan Goldman, Kentucky Board of Nursing; Scott Wegenast, AARP; Bill Doll, Kentucky Medical Association; Joetta Venneman, Sisters of Charity Nazareth; Mike Porter, Kentucky Dental Association; Andrea Plummer, Kentucky Youth Advocates; and Anne Joseph, Covering Kentucky Kids and Families.
A motion to approve the minutes of the September 13, 2011 meeting was made by Representative Burch, seconded by Senator Harper Angel, and approved by voice vote.
Senator Denton, Co-Chair of the Health Issues and Aging Subcommittee, reported that the subcommittee met and heard presentations on the Acquired Brain Injury (ABI) Medicaid waiver program. Bob O’Daniel, Amy Head, and Terra Lackey, family members of individuals participating in the ABI waiver program, spoke about the difficulties their family members have encountered receiving waiver services. The family members reported that they ran into numerous problems finding placements and trying to access the appropriate services. Among the problems encountered were inappropriate plans of care, confusing administrative regulations, inconsistent administration of the waivers, a lack of knowledge among case managers about the availability of ABI services, and a lack of clinical expertise among the case managers. Mary Hass of the Kentucky Brain Injury Association suggested the formation of an Acquired Brain Injury Department, not within the Department for Medicaid Services, to bring together all ABI services under one umbrella. There is a new waiver in process with medical enhancements for ABI individuals. It was noted that the number of individuals with brain injuries is growing and that already scarce services will be in even greater demand with the increasing number of veterans returning with brain injuries. A motion to accept the report was made by Senator Pendleton, seconded by Senator Harper Angel, and accepted by voice vote.
Legislative Hearing on the FFY 2012-13 Temporary Assistance for Needy Families (TANF) Block Grant
A motion to accept the block grant was made by Senator Pendleton, seconded by Senator Buford, and accepted by voice vote.
Referred Administrative Regulations
The following regulations were referred to the committee for consideration: 201 KAR 9:091 – repeals 201 KAR 9:090, Physiotherapeutics’ practice licenses no longer exist; 201 KAR 20:161 – establishes the procedures for the investigation and disposition of complaints received by the Kentucky Board of Nursing; 201 KAR 20:370 – establishes requirements and procedures for licensure by the Kentucky Board of Nursing; 201 KAR 22:045 – establishes continued competency requirements and procedures as a condition of license renewal by the Kentucky Board of Physical Therapy; 201 KAR 22:053 – establishes a code of ethical standards and standards of practice for physical therapists and physical therapist assistants; 900 KAR 5:020 & E – establishes the State Health Plan for facilities and services; 908 KAR 3:060 – establishes the Means test for determining the ability to pay of the patient or person responsible for the patient for board, maintenance, and treatment at a facility operated or utilized by the Cabinet for Health and Family Services; 921 KAR 2:040 – establishes the procedures used to determine initial and continuing eligibility for assistance under Title IV-A of the Social Security Act, 42 U.S.C. 601-619, and federal regulations; and 921 KAR 3:090 & E – establishes requirements for the Simplified Assistance for the Elderly Program, a demonstration project administered by the Cabinet for Health and Family Services to improve access to the Supplemental Nutrition Assistance Program (SNAP) for elderly and disabled individuals. A motion to accept the referred administrative regulations was made by Senator Buford, seconded by Senator Pendleton, and accepted by voice vote. Eric Friedlander, Deputy Secretary, Cabinet for Health and Family Services, was present to answer questions about 900 KAR 5:020 & E.
Smoke Free Kentucky
Representative Susan Westrom stated that she planned to prefile legislation for the 2012 Regular Session relating to smoking in all public places and places of employment. In order to educate themselves and their constituents, she encouraged members to read the information about secondhand smoke at phillipmorrisusa.com web site. Secondhand smoke creates a safety issue in any enclosed space. Ordinances across the state are being enforced with very few problems. Smoke-free policies in the work place are no different than policies that regulate safety in the work place.
Dave Adkisson, President and CEO, Kentucky Chamber of Commerce, stated that while the Chamber is not typically supportive of policies that focus on a particular business or industry disproportionately, the body of evidence on smoking and its negative impact on public health and the economy are too significant to ignore. According to the Centers for Disease Control and Prevention (CDC), Kentucky is second in the country in the number of adult smokers with 24.8 percent. Kentucky is first in the nation in smoking prevalence among both middle and high school students. The business community now sees the effects of smoking on the workforce in terms of absenteeism and lost productivity, insurance premiums for Medicare, Medicaid, and public employees, and tax bills.
The CDC estimated smoking-attributable health expenditures to be more than $1.7 billion annually in Kentucky, and the smoking-attributable economic productivity loss in Kentucky at more than $2.6 billion annually. Kentucky also ranks 48th among the states for workplace exposure to cigarette smoke. According to the Cabinet for Health and Family Services, in Kentucky 26.5 percent of pregnant women are smokers compared to 10.7 percent nationally. Reducing smoking prevalence by one percentage point could prevent 1,300 low birth weight babies and save $21 million in direct medical costs in the first year.
A survey sent to Chamber members this past summer showed the 70 percent supported the provisions in the proposed legislation, 15 percent supported some form of a statewide smoking policy, and 9 percent said they opposed all forms of a statewide smoking policy. The attitude in Kentucky is changing toward smoking and the health effects can no longer be ignored.
In 2004, smokers enrolled in the public employee health insurance program had to pay a higher premium than non-smokers. In 2005 and 2009, the General Assembly increased the excise tax on cigarettes, increasing the tax from three cents per pack to sixty cents. Private companies now have the same right as state government to offer lower priced health plans to non-smokers and can offer non-smoking incentives without fear of litigation. In the 2010 Regular Session, the General Assembly passed legislation funding the Medicaid smoking cessation program.
John Johnstone, MD, Cardiology and Internal Medicine, stated that smoking causes a litany of life threatening diseases such as heart problems, cancer, emphysema, and upper respiratory disease. There is no safe level of smoke and the correct action to take is to ban smoking in public places. Approximately 74 percent of non-smoking Kentuckians are subjected to the long-term life threatening conditions by the 26 percent of Kentuckians who do smoke. According to the World Health Organization, E-cigarettes should be regulated by the United States Food and Drug Administration (FDA) or as a tobacco product. The product is imported from China, and there should be no exception to the rules. Smoking regulations would make a difference in mortality rates, disability rates, and the cost of health care.
A. Scott Lockard, Public Health Director, Clark County Health Department, and President of the Kentucky Public Health Association, stated that the goal of the Smoke Free Kentucky coalition is to protect every Kentuckian from the proven dangers of secondhand smoke. The coalition is dedicated to passing as many smoke-free laws as possible at the local level, and passing a comprehensive, statewide law to ensure that all workers and patrons across the state are not subjected to secondhand smoke. Currently, there are 31 communities that have passed laws that at least provide some level of protection from secondhand smoke in the workplace. Local communities have found that smoke-free regulations and laws are very popular, well received, and easily enforced. The Kentucky Public Health Association which is comprised of public health professionals across the state and the Kentucky Health Department Association which represents the state’s public health departments both strongly support the legislation. Exposure to secondhand tobacco smoke is a major public health problem in the Commonwealth and the solution is simple. Every Kentuckian has the right to breathe clean air.
Denny Nafus, Veteran of Vietnam war impacted by secondhand smoke, stated that he is not against anyone who wants to smoke, but he does not think innocent people should have to be exposed to it. When he was in the service, he received a package from the military that contained a Bible, toothbrush, toothpaste, and cigarettes. Veterans from the Vietnam and Gulf wars cannot be around secondhand smoke due to exposure to Agent Orange in Vietnam and burning oil fields in Afghanistan. Kentucky leads the nation in smoking related deaths and needs to set an example by passing comprehensive smoking legislation that will prevent secondhand smoke in public places. There needs to be legislation that would protect all employees from the effects of secondhand smoke no matter where they work. Veterans have a high incidence of smoking prevalence, and we need to provide better health care services for them.
Representative Burch stated that businesses usually are not affected negatively by enforcing smoke-free regulations. Since tobacco farmers export tobacco to other countries, smoke-free regulations would not affect them as bad financially today as it would have in the past.
Senator Denton stated that every Kentuckian has the right to clean air, and this is a public policy issue that needs to be addressed.
Impact Plus Procedural Concerns
Mark Hamm, M.Ed., NCC, LPCC, CEO, Phoenix Preferred Care, stated that part-time services are not in the best interest of the children. Phoenix Preferred Care is a small Impact Plus provider who provides behavioral health services. In September 2010, 907 KAR 3:030 was promulgated that incorporated the new Impact Plus user’s manual. Impact Plus is a collaborative community-based model and the process should involve the providers and recipients to determine best practices. However, neither the providers nor recipients were involved in the process of updating the new Impact Plus user’s manual. There were some stipulations within the user’s manual outside of the realm of 907 KAR 3:030, in particular caseload limitations for case managers. If the intent of the 15 caseload is quality, then the mechanisms for ensuring quality control are already in place. Impact Plus providers are audited annually by the cabinet that have the ability to place providers on probation, revoke contracts, and make a provider operate under a Corrective Action plan.
Gary Hill, Administrator and President, Lighthouse Counseling Services, stated that every client deserves to receive the best services available.
Jane Hill, Licensed Clinical Social Worker, Lighthouse Counseling Services, stated that the Impact Plus providers and recipients were not included in the process to update the user’s manual, but have to follow its mandated policies of the contract. Caseloads were decreased from 25 to 15, and because agencies are paid per case by the Department for Medicaid Services for Impact Plus services, the department cannot pay case managers the same amount to serve 15 clients as it has for 25 clients. Therefore, the experienced case managers serving these clients will not remain in these positions due to the drastic reduction in their income caused by lower caseloads. The restriction will impede the quality of care.
Janet Messer, Lighthouse Counseling Services, stated that agencies had to sign a contract by June 30, 2010 and agree to abide by the mandates of the Impact Plus user’s manual that would not be updated until September 2010. Guidelines established in the user’s manual restrict services. The purpose of Impact Plus is intensive out-patient therapy to avoid out-of-home placement and foster care to avoid detention, hospitalization, or residential treatment. When there is an increased number of out-of-home placements and hospitalizations due to a lack of opportunity and time availability to serve clients through intensive out-patient services through Impact Plus, the cost to the state increases for foster care and hospitalizations. The fee for Impact Plus services has not changed since 2000, but the requirements have been changed.
In response to questions by Representative Westrom, Ms. Hill stated that changing the caseload from 25 cases to 15 cases would affect the case managers financially. If children could not receive Impact Plus services, there would be a lot more hospitalizations, out-of-home placements, and detention.
In response to questions by Senator Denton, Ms. Hill stated that case managers are paid per member per month. Provider contracts are always renewed in June of each year. Providers were not included in the process and creation of the manual because there were only internal cabinet meetings. Lighthouse Counseling Services has experienced an 11 percent decrease in the number of clients served with the current number of case managers. Providers cannot stay competitive if the same wage is paid for 15 clients as 25 clients. Case managers do not provide treatment but make sure families have services that are needed and perform administrative tasks to continue to request continuation of services for the families. Case managers have to be social workers or in a social worker related field.
In-Home Primary Care
J. Michael Benfield, MD, CEO and President, MD2U, Louisville, stated that the MD2U was founded in July 2004 and its mission is to offer quality primary healthcare to the homebound and home limited and provide the most convenient, detailed and service-oriented medical care, thereby improving and revolutionizing the healthcare delivery system throughout communities nationwide. MD2U values and is committed to quality in-home medical care in a supportive, team-oriented environment. Over 180 house calls are made per day. Patients are homebound or have limited access to get out of the home. Services provided at home are medical and physical history, blood and urine testing, x-rays, ultrasound, echocardiogram, Doppler ultrasound, and end-of-life care. MD2U accepts Medicare and most insurance including Medicaid. There is no extra fee or charges for the service. MD2U helps decrease hospital readmissions and length of stay, trips to the emergency room, and medical transportation costs. It improves efficiencies in the primary care provider office and medication management. MD2U’s objective are to 1) partner with the Commonwealth to expand healthcare access to Medicaid patients that need them the most; 2) identify the sickest patients that overutilize Medicaid resources by obtaining care in high cost settings such as the emergency room; and 3) establish cost savings-share program. The MD2U model for primary care in the home will help to significantly reduce overall costs of healthcare and result in increased patient satisfaction and clinical outcomes.
In response to a question by Representative Wuchner, Dr. Benfield stated that the company uses house call codes when billing insurance companies. While there company has some trending data, it would like to have more resources to track the data.
In response to questions by Representative Watkins, Dr. Benfield stated that nurse practitioners who have a collaborating physician, usually not physicians make the home visits. Approximately 150 patients are required to have a viable practice.
In response to questions by Representative Wuchner, Dr. Benfield stated that his company uses a billing system with different house call codes. MD2U like to have more resources to trends and outcomes of patients.
In response to questions by Representative Westrom, Dr. Benfield stated that MD2U has 75 employees. Laboratory work is outsourced to other entities. No preapproval is needed from the payor to see a patient at home.
In response to a question by Representative Burch, Dr. Benfield stated that MD2U bills the insurance company $170 but only receives $119.10 per patient.
In response to a question by Senator Harper Angel, Dr. Benfield stated that the company conducts background checks of employees and also relies on the licensing process for nurse practitioners who go into the homes. No background checks are done by the company on employees in laboratories for lab work outsourced. They rely on the background checks conducted by those entities.
In response to questions by Representative Waide, Dr. Benfield stated that he wants to know how to expand services in the Kentucky Medicaid Program. Physical therapy is not provided by MD2U.
In response to questions by Senator Denton, Mr. Latta, Chief Information Officer, MD2U, stated that MD2U is in the process of contracting with the new three managed care organizations (MCO). The biggest problem is getting the MCOs to understand the services MD2U can provide.
Allen Rose, Vice President for Business and Government Relations, and Dr. Hieu Tran, Dean of the College of Pharmacy, Sullivan University, stated that in July 2008, the College of Pharmacy opened. In 2011 the Sullivan University College of Pharmacy (SUCOP) received full accreditation from the Accreditation Council for Pharmacy Education (ACPE) and the first class graduated. In Kentucky, between 1991 and 2004, the amount spent on personal health care rose 7.5 percent, hospital care 6 percent, and amount spent on physician and clinical services 8 percent. In 2007 in Kentucky, one day of inpatient services costs an average of $1,390.10 per patient an increase from $910.57 in 1999. The average hospitalization stay ranges from $7,000 to $12,000. The SUCOP has pharmacists practicing at Jewish Hospital, Baptist East Hospital, the University of Louisville Hospital, Kosair Children’s Hospital, and Floyd Memorial Hospital. While costs spent on medication increase, overall medical claim costs decreased because; patients with emergency department visits decreased from 9.9 percent to 1.3 percent; hospitalization visits decreased from 4.0 percent to 1.9 percent; direct costs savings averaged $725 per patient per year; and indirect cost savings averaged $1,230 per patient per year all because of the pharmacist intervention group. In 2009, the SUCOP established the International Center for Advanced Pharmacy Services (INCAPS) to provide medication therapy management for people enrolled in the Kentucky Retirement System. Within two months 417 patients were seen, and of those patients, there were 326 medication related problems. The most common issues were drug interactions and improper drug selection. The university supported the Louisville Metro Public Health and Wellness Department in their immunization efforts. SUCOP is part of the CDC grant from the School of Public Health. The SUCOP wants to be a part of the collaborative care in the Commonwealth.
There being no further business, a motion to adjourn at 3:27 p.m. was made by Representative Housman, seconded by Representative Wuchner, and approved by voice vote.