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October 13 & 14, 2003
University of Wyoming Outreach School
Casper, Wyoming
Senator Charles K. Scott, Chairman
Representative Doug Osborn, Chairman
Senator John Barrasso
Senator Tex Boggs
Senator Cale Case
Senator Mike Massie
Representative Mary Gilmore
Representative Elaine Harvey
Representative John Hastert
Representative Becket Hinckley
Representative Jerry Iekel
Representative George McMurtrey
Representative David Miller
Representative Ann Robinson
John Rivera, Senior Staff Attorney
Gerald W. Laska, Staff Attorney
Please refer to Appendix 1 to review the Committee Sign-in Sheet for a list of other individuals who attended the meeting.
None
All meeting materials and handouts provided to the Committee by the Legislative Service Office (LSO), public officials, lobbyists, and the public are referenced in the Meeting Materials Index, attached to the minutes. These materials are on file at the LSO and are part of the official record of the meeting.
Chairman Osborn called the meeting to order at 8:35 a.m. The following sections summarize the Committee proceedings by topic. Please refer to Appendix 2 to review the Committee Meeting Agenda.
Deborah Fleming, Director of the Department of Health, and Diane Galloway, Administrator of the department's Substance Abuse Division, addressed the committee. Dr. Galloway made a Powerpoint presentation (Appendix 3) on the growth of the drug court program before and after 2002 HB59. Her major points included the following:
• The program has been cost effective at $2,000 - $7,000 per case;
• Reinforcement is an essential treatment feature as relapse is a normal part of recovery;
• Three pilot Comprehensive Substance Abuse Centers (CSAC) have been established;
• Program evaluation includes the tracking of arrest, dropout, domestic violence and youth crime rates;
• Treatment recipients are identified using an addiction severity index;
• 40% of recidivist crime is drug related; treatment is cheaper and more effective than imprisonment;
• The need for treatment far exceeds available resources.
The committee discussed the methamphetamine addiction problem. Dr. Fleming stated that meth is the program's priority because of its permanent health consequences and its significant effect on other crime. The department is developing prevention strategies based on other states' experience.
Committee members commended the program's principals. Senator Scott observed that resources are still inadequate and additional permanent funding must be found, perhaps from an increase in legal substance taxes.
Mike Huston, Executive Director of the Central Wyoming Counseling Center, reported to the committee on that center's CSAC effort (Appendix 4). Through an inter-agency steering committee, the center has been able to provide previously unavailable treatment services. The center funded a case manager position in each circuit court, but would need a legislative change to do the same for juveniles in the district court.
There followed a brief discussion on the lack of access by individual health care providers to HB59 funds. Dr. Galloway stated that the programs rules require contracting with a preferred provider in each county, and that the provider must be an agency, not an individual.
Dr. Galloway and Safa Suleiman, the division's Women's Treatment Coordinator for the tobacco program, reported on the division's "social marketing" effort, which they defined as a process to modify behavior using mass marketing techniques. They showed sample posters and a sample marketing video on CD. Sen. Case expressed the opinion that the materials would not be effective and contained offensive stereotypes.
Rep. Iekel and Diane Harrop, Director of the Wyoming Health Care Commission, reported on the activities of the committee. Three meetings have been held, with two more scheduled for October 27 and November 17. The subcommittee will receive legislation recommendations at the November meeting regarding tort reform and healthcare access/affordability. Follow-up recommendations may be made in January. The Commission will soon have a website which will be updated frequently. Committee members observed that the commission's start-up took longer than expected, but that neither the governor nor committee will be upset if the original deadlines are not met. Ms. Harrop stated that the commission may have only 4-7 recommendations this year.
Rep. Miller reported on the activities of the subcommittee, which has met twice and is scheduled to meet for the last time on October 15th. The subcommittee is considering four legislative recommendations:
• Coverage for adult organ transplants;
• Increase in payments to hospitals to cover 100% of their costs, with conditions;
• Coverage for SSI and SSDI recipients while waiting for Medicare coverage;
• Requiring school districts to seek Medicaid payment for special education students enrolled in Medicaid.
Rep. Hinckley reported on the activities of the subcommittee. The subcommittee concluded that no legislation is necessary to address the medical provider payment backlog, which the division has substantially reduced. The subcommittee does intend to present several bills, but needs to meet again briefly to finalize them. The topics include:
• Semimonthly payment of temporary total disability;
• Defining the age of majority for cutoff of children's benefits as age 18;
• Revising temporary light duty requirements.
The subcommittee had also considered creating a definition of "injury date" as a response to several Supreme Court decisions, but will probably refrain from that pending further study.
Chairman Scott asked that the subcommittee present its bills for consideration by the full committee at the next day's session, as the agenda for the December meeting will be very full.
Sen. Case asked if work injuries caused by a third party, such as a motor vehicle accident, still affect an employer's claims experience for premium purposes. Wendy Tyson, Administrator of the Employer Tax Division of the Department of Employment, explained that subrogation recovery from third party lawsuits is deducted from the employer's claims experience. However, claim costs affect an employer's premium only for the first three years post injury and frequently the third party recovery comes after that time, too late to benefit the employer. Sen Case stated his belief that employers should not be penalized when the injury is clearly the fault of a third party, as in many motor vehicle accidents.
Sen. Scott added that workers' compensation represents an historic compromise between employers and employees to provide compensation for work injuries regardless of fault, that experience based premiums were an important reform in 1993, and that employers are in a better position than anyone else to minimize the risk of motor vehicle accidents involving their employees.
Sen. Case reported on the activities of the subcommittee, referencing the Buck Report (Appendix 5) commissioned by the subcommittee. Key findings include the following:
• Wyoming's schedule of benefits is comparable to other states;
• Wyoming's benefits exceed most surrounding state government employees and Wyoming private employers;
• The package of benefits improved significantly due to last year's decision to begin paying 85% of the premium for dependent coverage;
• Fewer than 100 employees quit the health plan after they were required to begin paying 15% of the individual premium;
• There has been some movement toward the higher $750 deductible option;
• The sick leave policy has the most possibility for cost savings;
• The current third party administrator has not implemented many cost control techniques, which should be considered when the contract is up for renewal.
Sen. Case related that, according to the study, $8.4 Million spent on the best cost control options now could result in $22 Million in savings later. Changes to consider include an employee-controlled medical savings account, combining vacation and sick leave to a single form of personal leave, and converting accumulated sick leave to paid time off or long-term disability.
The committee discussed generally the pros and cons of a unified personal leave policy. There was general agreement that the subcommittee was not charged with proposing legislation, and that any legislation would be premature because the benefit schedule is not statutory and the executive branch has not had a chance to respond to the Buck Report.
Rex Gantenbein, Director of the University of Wyoming Center for Rural Health Research and Education, reported to the committee using a Powerpoint presentation (Appendix 6) on the results of a state planning grant. The purpose of the grant was to conduct a healthcare access study. Significant conclusions included:
• Over 70,000 people, or 14.1% of the state population, do not have any type of health insurance;
• 9% of the population has been without health insurance for more than one year;
• 72% of employers offer health insurance to full-time employees;
• Fewer than 10% of employers offer insurance to part-time employees;
• Less than half of small employers (< 10 employees) offer health insurance to their employees;
• Most uninsured people do not have insurance because they are unemployed or because their employers don't offer health insurance.
Dan Perdue of the Wyoming Hospital Association and Mike Sellers, president of the Wyoming Organization of Nurse Executives, addressed the committee.
Mr. Perdue described the "magnet hospital" certification program of the American Nurses Association. Certification is a four-step process that costs approximately $25,000 and requires a dedicated full-time staff position. The facility's chief nursing officer must have an MSRN degree, which only United Medical Center and Wyoming Medical Center have at this time. The Planetree Foundation is another entity that certifies hospitals, focusing on patient care issues, especially patient and family education. Certification costs $12,000 – $25,000. No Wyoming hospitals are certified magnet or Planetree facilities.
In response to questions from the committee, Mr. Sellers stated that the national recession has reduced nurse turnover, but that Wyoming is 51st in pay among the 53 states and territories, that the turnover rate at the Evanston hospital is approximately 25%/year, and that nurses earn two to three times as much in California. Bob Kidd of the Wyoming Hospital Association added that hospital nurses' pay in Wyoming is not as low compared to surrounding states, but that non-hospital nurse pay brings down the average.
Sen. Massie asked if this report is coming from a coalition of interested groups as requested by the Healthcare Commission. Mr. Sellers acknowledged that it is not, that nurses are advocating mandatory magnet certification but the hospital association is advocating a more flexible approach. Sen. Boggs observed that the turnover figures are meaningless unless the hospitals also include in the figures the use of contract or traveler nurses. Sen. Massie expressed his frustration at the lack of consensus recommendations from the associations.
Deborah Fleming, Director of the Department of Health, and Joann Blevens, Deputy Administrator of the Community and Family Health Division, reported to the committee and presented a handout on workforce issues for public health nursing (Appendix 7). There are public health nurses in all 23 counties, with 113 state positions and 120 county-funded positions. The program is characterized by increasing demands for service, an aging workforce (average age 51, 30% eligible to retire within five years) and non-competitive salaries. The department recommends:
• Annual salary market studies;
• Funding for annual salary adjustments to decrease turnover;
• Tuition reimbursement for state employed nurses;
• Continuation of state payment for 85% of dependent health insurance.
Representatives of the Wyoming Nurses Association addressed the committee regarding magnet hospital designation and the nursing shortage (Appendix 8). They stated that the nursing shortage in Wyoming is one of the worst in the county, that empirical data shows a correlation between nurse staffing levels and quality of care, and that magnet hospital certification results in a 7.9% decrease in patient mortality along with other quality improvements. They advocate mandating magnet designation for hospitals, prohibiting mandatory overtime, enacting whistleblower protection for nurses, and requiring public reporting of healthcare quality indicators for hospitals.
Ms. Blevens agreed with Sen. Massie's observation that workplace improvements would possibly cause some inactive nurses to rejoin the workforce. Sen. Scott summarized the nurses' presentations by noting that job satisfaction, safety conditions and excessive paperwork seemed to be the common concerns, and that regulatory enforcement mechanisms may be necessary. Ms. Blevens agreed with that summary. Wendy Curran, however, stated that each hospital could better come up with staffing solutions and that education would be better than regulation.
Rick Miller, University of Wyoming Vice President for Government, Community and Legal Affairs, Thomas Buchanan, Academic Affairs Vice President, and Robert O. Kelley, Dean of the College of Health Sciences, addressed the committee. They summarized the requirements and status of the WICHE (Western Interstate Commission for Higher Education) and WWAMI (Washington, Wyoming, Alaska, Montana and Idaho) programs with a handout (Appendix 9).
The WICHE program is for all health-related disciplines. Participants in medical school are required to pay approximately $14,600, while the program pays a "support fee" of $23,700. Participants may attend any of 17 participating schools. There is no pay-back or in-state service requirement, or linkage to the Wyoming Family Practice Program. Twenty-nine students are currently enrolled.
The WWAMI program is an M.D. program through the University of Washington. There are ten available slots for each academic year. Students pay UW tuition ($7,158/yr for '02-'03), with the state paying the difference. The state share must be repaid at 8% interest over 8 years if the recipient does not return to practice medicine in Wyoming for three years.
Issues involving the programs are their increasing cost, whether service/pay-back requirements should be added to the WICHE program, whether the pay-back interest rate is too high and whether the programs should be tied to practice residencies in Wyoming. The Board of Trustees is considering changes; Sen. Scott suggested creation of a subcommittee may be indicated to consider legislative changes.
Sen. Massie and Rep. Iekel reported to the committee on the work of the Strook Commission. The commission has six subcommittees investigating ways of expanding healthcare access for the working poor via such means as expansion of the KidCare program, overhauling Medicaid and creating a statewide insurer. The commission has been active in the last two months and has two more meetings scheduled. Sen. Scott requested that the subcommittee attempt to have proposed legislation for the committee's December meeting.
The committee recessed at 5:20 p.m. In the evening the members toured the Wyoming Medical Center's Trauma Center and the Wyoming Community Health Center.
Chairman Scott called the meeting to order at 8:05 a.m.
Several presenters addressed the committee regarding the use of information technology to improve provision of healthcare in Wyoming.
Dr. Coye, CEO of The Health Technology Center, testified before the committee. Mr. Bernstein, co-Chair of the Government and Policy Division of Manatt, Phelps & Phillips, LLP, testified by speakerphone. They made a Powerpoint presentation (Appendix 10) and proposal to create a Wyoming Healthcare Information Technology Corporation.
Dr. Coye and Mr. Bernstein reviewed problems identified in previous studies of the healthcare delivery system which could be substantially resolved by information technology systems:
•One in ten medical tests is a duplicate;
•One in four prescriptions is unknown to the treating physician;
•One in five tests is repeated because the original is lost;
•One in seven admissions results from missing ambulatory information;
•An estimated 1/3 of medical costs would be avoided if providers shared information;
•45% of patient visits involve the administration of some incorrect care;
•Only 5-8% of doctors use a computerized health information system.
Dr. Coye and Mr. Bernstein therefore proposed creating a private/public non-profit corporation to oversee implementation of a statewide system of computerized health care information management, to include digital records sharing and 'best practices' treatment guidelines. Funding could be from state and federal public funds, private grants and subscriber fees. Three main stages of the program would be creation of a connectivity infrastructure, planning and implementation of the system among all providers, and alignment of the information sharing pathways. Savings would be significant, and would accrue 11% to the providers themselves and 89% to patients, third party payors and government. Mr. Bernstein believes it would take 6-8 months to plan the system, two years to implement, and two more years to bring all health care providers along.
The committee generally discussed the benefits and feasibility of such a system, foreseeable problems including cost, security, and Wyoming's sparse population. Dr. Coye and Mr. Bernstein believed that the exact cost could be calculated in the first few months of the project, but estimated the total cost of the system at $400 - $500 Million over five years. They stated, however, that would include federal funds, money that would be spent otherwise on technology and some private contributions. They also estimated the cost at $50,000/year/physician for five years.
Dr. Elwood, President and CEO of The Jackson Group, addressed the committee with a Powerpoint presentation (Appendix 11). He stated that the healthcare system has crashed due to excessive costs, unpredictable quality, fragmentation and inaccessibility. 45% of patient care is documented as inadequate. He recommends adoption of a system of universal electronic personal health records, the collection of outcome data by health care provider or facility, officially sanctioned evidence-based treatment guidelines, payment for performance instead of for service and doctor visits on-line.
Mr. LaBenne addressed the committee. He agreed that the system is near a crash. The pace of change is accelerating and healthcare is constantly more IT-intensive. IT implementation is generally complex and difficult, and must be integrated among all parties. Health care providers spend only 2.5% of revenue on IT, compared to 6-7% in most industries. Medication management is an example of where IT would be very beneficial. 49% of medication errors are at the prescribing stage, 11% at the transcription stage. A well-designed IT system could eliminate almost all of those, or 60% of all medication errors.
Mr. Wallace is president and CEO of the National Alliance for Health Information Technology, which represents 150 health care organizations in the promotion of information technology in healthcare. The Alliance was formed 18 months ago in response to the Institute of Health study that concluded that medical errors cause 44,000 to 98,000 deaths per year in the U.S. Mr. Wallace stated that much work has already been done, and that Wyoming need not 'reinvent the wheel' on healthcare technology. Highlights of the Alliance's findings and recommendations include:
• IT systems should be 'off-the-shelf,' not created from scratch;
• Problems in IT systems are generally not technical but leadership failures;
• The medical business model is flawed because the payor is rarely the beneficiary;
• Treatment standards are coming, and they work;
• A unique patient identifier is a necessary prerequisite; Wyoming could lead the nation in addressing this preliminary step.
Joe Coyne, Executive Director of the Converse Area New Development Organization (CANDO) addressed the committee. CANDO has formed a coalition of five providers, including three hospitals and two clinics, to research and purchase common patient information sharing software, and to jointly develop staff recruitment and retention policies.
Chairman Scott requested comment from the public on the presentations before the committee considers possible legislation. He suggested volunteers from the committee will probably work with members of the Health Care Commission to draft specific legislation for the committee's December meeting.
Wendy Curran, Wyoming Medical Society. The Society has already formed a task force on development of e-records. One of the biggest questions involves compatibility of various computer systems. Indications are that there is a 40% decrease in physician productivity during implementation of the new technology. Veterans' Administration experience is that some decreases in productivity may be permanent. Treatment guidelines are already being developed, usually by practice specialty groups.
Dan Perdue, Wyoming Hospital Association. The Association favors development of healthcare technology systems and wants to be involved in their development. The Association has two subcommittees studying tort reform and accessibility. "Best practices' treatment guidelines are the coming trend, but require very advanced electronic data transfer and database capability.
Chairman Scott summarized the morning presentations and comments. Significant savings and care improvements are possible through technology. One of the major barriers to implementation is that the users of the technology systems are not the primary beneficiaries of those systems. Any system would have to accommodate the characteristic mobility of the patient population, must be a patient-centered system and must be compatible with existing IT systems
Chairman Scott called for a bill to authorize a healthcare technology feasibility study. The study should concentrate on the connectivity piece of a statewide system as described by Dr. Coye, especially standards for the interconnectivity of existing IT systems. The study should provide for a unique patient identifier, and address privacy and security concerns. The study should be conducted by the Health Care Commission with a major contractor, hospitals, nurses, patients, doctors and their respective associations all represented and involved. The study should also address whether funding for implementation should be public or private.
Reps. Osborn and Gilmore volunteered to work with the Health Care Commission to draft such a bill. Sen. Scott suggested that Drs. Coye and Elwood might also volunteer to help. Sen. Scott requested a bill draft in time for the committee to consider at its December meeting. There followed a general discussion about funding for a study and whether it should be done through the existing Health Care Commission, the Education Committee or the Labor, Health and Social Services Committee.
Sen. Massie, Rep. Osborn and Rodger McDaniel, Director of the Department of Family Services, presented draft bill 04LSO-0155.W1 (Appendix 12) to the committee. The bill authorizes a study and calls for a department plan to address family service support needs in Wyoming.
Director McDaniel explained that the study was conceived in response to the Child and Family Services Review required by the federal .Adoption and Safe Families Act. The review found that the full array of family support services are not universally available in Wyoming; that schools and communities generally do not address issues related to juveniles returning from residential placement; that the judicial system is not designed to deal well with juvenile and family issues.
Sen. Massie explained the bill, which calls for funding of a study and development of a family services support plan to be presented to this committee by October 1, 2004. The bill would appropriate $200,000 for the development of the plan and require the executive branch to contribute and equal amount. There followed a general discussion on the merits of the bill and its funding method.
Sen. Massie moved to amend the bill on page 3 at line 5 by inserting before the word "students" the words "pre-school children and K-through-12". The motion passed. Sen. Scott moved the further addition of the word "parents." The motion carried.
Rep. Robinson moved to add a new paragraph (vii) and renumber existing paragraph (vii) as (viii) on page 3: "(vii) That encourages and supports family stability; and" The motion carried.
Sen. Massie moved to amend subsection (b) on page 3 to require a preliminary plan by November 1, 2004, and a final plan by October 1, 2005. The motion carried.
Rep. Iekel moved to amend page 4, line 16 by adding the word "primary" before "responsibility". The motion carried.
Sen. Massie moved to amend page 5, line 10 to read "…Before submitting the preliminary and final plans…", to change "plan" to "plans" on line 12, and to change "the plan" to "each plan" on line 15. The motion carried.
Sen. Scott moved to amend page 5, line 19 by inserting after the word "may" the words "utilize existing resources and" and to amend page 6, line 5 by deleting the rest of the sentence after the word "act". The amendment carried.
Rep. McMurtry's motion to sponsor the bill carried 10-2-2, with Sen. Case and Rep. Gilmore voting "no" and Sen. Barrasso and Rep. Harvey excused.
Director Fleming and Aimee Lewis, Coordinator of the Pharmacy Plus Program, distributed and explained a spreadsheet (Appendix 13). They demonstrated the effect of the waiver budget, and yearly expenditures 2003-2009 for elderly Medicaid recipients and elderly Medicaid recipients in nursing homes.
The department requested direction from the legislature as to whether it should proceed with the waiver request from the Centers for Medicare & Medicaid Services of the U.S. Department of Health and Human Services. Sen. Scott suggested the department stop negotiations with CMS unless it guarantees cost neutrality. Rep. Osborn made a motion to transfer Pharmacy Plus funds to the Prescription Drug Assistance Program. The motion carried.
Rep. Hinckley presented several bills approved by the workers' compensation subcommittee. 04LSO150.C1 (Appendix 14) contains several minor amendments:
• clarifying that "age of majority" for termination of children's survivor benefits is age 18;
• providing for payment of temporary total disability benefits semimonthly instead of monthly;
• making a technical correction to statutory references in W.S. 27-14-403(e)(i).
Sen. Case moved that the committee sponsor the amendments bill. The motion carried, with Sen. Barrasso and Rep. Harvey excused.
Rep. Hinckley next presented 04LSO149.C1 (Appendix 15), amending the act's temporary light duty provisions. Department of Employment Director Cindy Pomeroy explained that the changes were necessary due to underutilization of the program, which facilitates injured workers' early return to work.. She distributed figures and a graph (Appendix 16).
Sen. Massie moved to amend the bill on page 4, line 8 by reinserting the stricken language through the word "employee" on line 9. The motion carried. Rep. Robinson moved to add after the reinserted word "or" on line 8 the words ", with the consent of the employee,". The motion carried.
Rep. Hinckley moved to amend page 3, line 15 by inserting after "on a" the words "light duty work agreement". The motion carried.
Rep. Hinckley moved to amend page 3, line 1 after the word "injury" by inserting "but not to exceed the temporary total disability award under W.S. 27-14-404(a)". The motion carried.
Rep. Hinckley moved to amend page 6, after line 18, by inserting a new paragraph: "(vii) The temporary light duty award under this subsection and the balance of a temporary total disability award under paragraph (vi) of this subsection shall not be charged to the employer's experience rating established under W.S. 27-14-201(d)." The motion failed.
Sen. Case moved that the committee sponsor the bill. Rep. Hinckley seconded the motion. The motion carried, with Sen. Barrasso and Rep. Harvey excused.
Rep. Hinckley reported that the subcommittee had also considered a third bill that would further define injury in response to several Wyoming Supreme Court decisions but, upon request of the division and consultation among the subcommittee members, decided that it would be better to reserve that topic until the general session.
Rep. Iekel and Dr. Brent Sherrard, M.D., State Health Officer, reported to the committee and distributed a handout (Appendix 17). The most immediate known threats to public health include bioterrorism, pandemic influenza and SARS. A Model State Public Health Act is under development to assist the states. Recent statutory changes to the public health emergency statutes were reviewed. Additional changes are needed in the area of environmental health enforcement authority; Rep. Meuli is drafting a bill on that subject.
Chairman Scott asked for an update of the medical malpractice insurance situation. Wendy Curran, Wyoming Medical Society, reported that:
• The Doctors Company has been granted a premium increase of 10-25% by specialty;
• OHIC is writing all coverages but has asked for a rate increase that has not yet been publicized;
• Farmers Insurance is ceasing all medical malpractice coverage;
• The Colorado Physicians' Insurance Company is considering withdrawing coverage for its doctors while working in Wyoming without an additional-cost rider;
• Last year's volunteer bill is not working because the clinics where the volunteers work cannot obtain the required coverage.
The committee agreed that its next meeting will be December 1 and 2 in Casper.
There being no further business, Chairman Scott adjourned the meeting at 4:55 p.m.
Respectfully submitted,
Senator Charles K. Scott, Co-Chairman
Representative Doug Osborn, Co-Chairman