Senate Health & Welfare Committee

 

2004 Minutes

 

January 13, 2004
January 14, 2004
January 15, 2004
January 16, 2004
January 20, 2004
January 21, 2004
January 22, 2004
January 23, 2004
January 26, 2004
January 27, 2004
January 28, 2004
January 29, 2004
January 30, 2004

February 3, 2004
February 4, 2004
February 5, 2004
February 6, 2004
February 10, 2004
February 11, 2004
February 12, 2004
February 13, 2004
February 16, 2004
February 18, 2004
February 19, 2004
February 20, 2004
February 24, 2004
February 25, 2004
February 26, 2004
February 27, 2004

March 2, 2004
March 3, 2004
March 4, 2004
March 5, 2004
March 8, 2004
March 9, 2004
March 10, 2004
March 11, 2004
March 12, 2004
March 18, 2004

DATE: Tuesday, January 13, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Stegner, Sweet, Bailey, Burkett, Kennedy
MEMBERS ABSENT/

EXCUSED:

None
GUESTS: See an attached sign-in sheet
Chairman Brandt welcomed everyone to the first committee business meeting of the 2004 legislative session, The purpose of the meeting is to determine what should directions, studies or interest committee members have for this year.

During the 2003 legislative session, the committee conducted an in-depth study of the budget of the Department of Health and Welfare. He has asked the Department to present a one-day overview of the budget they prepared for the Governor's office for SFY2005.

Committee members should contact the chairman if they have a specific item of interest to be considered for an in-dept study during this session.

During the interim this year, several items of interest were considered and Chairman Brandt has been working with individual members and task force members. He listed several areas the committee has been involved with, such as, Senator Stegner has diligently worked for several years with mental health issues and, hopefully, has a consensus piece of legislation for this year. Suicide prevention is another issue and is also part of that. The Child Support Program is an issue that all members have had an opportunity to deal within one way or another.

This past year, a prescription drug task force has tried to get an enhanced authorization program organized. There is also a new Medicaid bill of legislation. How in-depth does the committee want to be involved with this issue?

The Developmental Disability Management Program was established last year. Long-term care issues need to be addressed. The Governor has involved the National Governors Association with the issue of long-term care.

The budget aspect, the committee will cover as much as members or JFAC (Joint Finance Appropriations Committee) members request or need.

Chairman Brandt expects this year the Legislature will also be presented with a piece of legislation that will change the way care facilities are surveyed in Idaho.
During the interim, the committee met in December 2003 with the Department of Corrections and the Department of Juvenile Corrections. He would like to determine if there are areas the committee could help the departments regarding shared issues between other departments. Both departments, Corrections and Juvenile Corrections, have very real issues that impact persons with mental health illnesses. It could be that by implementing some mental health care programs, we might save the departments some money.
There is also the prospect of legislation to change the name of the Department of Health and Welfare. This will be a different approach or business direction in regards to how the department does business, and how we can help the director be more of a CEO.
A brief discussion was held about not micro-managing departments, but allowing a department's director to have the latitude to operate the department using very sound fiscal judgement. The committee also discussed the JFAC budget presentation scheduled for February 12; the need to review departmental rules throughly and timely; a focus committee to determine choices; the number of students using substances or medications; service delivery systems; hospice care during the last 60-days of life, and using a living will.
The new Page, Alex Johnston from Nampa, Idaho, was introduced.
Adjourned The meeting adjourned at 9:15 a.m.




DATE: Wednesday, January 14, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Stegner, Sweet, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

None
GUESTS: See attached sign-in sheets
RULES REVIEW: The Department of Health and Welfare's Division of Health presented six (6) rule dockets for adoption.
IDAPA

16-0203-0401

The Division of Health, Emergency Medical Services (EMS) Bureau Chief Dia Gainor presented IDAPA 16-0203-0401, and explained this docket is a request for adoption of temporary rules within the Rules Governing Emergency Medical Services. These rule changes address two issues.

First, they provide the requirements for instructors, education, certification, and agency licensure for a new level of EMS provider called the EMT-Intermediate which was created with legislation passed in a prior session of the Idaho Legislature. The EMT-Intermediate will allow more advanced skills and medications to be provided to patients, and is expected to primarily benefit rural areas that are unable to train or support paramedics.

The second issue addressed in this docket is the repeal of one of twelve (12) requirements for EMS agency licensure in Idaho. The section listing these requirements are on page 9. Subsection 10 on page 11 "local governmental authorization" was accomplished through the EMS agency documentation of compliance with local EMS ordinances and ambulance district rulings as part of their application.

While the EMT-Intermediate rule drafting was in progress last fall, a controversial application was received by the EEMS Bureau. We were confronted with conflicting endorsements of an application from an EMS agency based in a city in Idaho, while the county opposed the application.

The rule provided no guidance for this type of scenario or any other where city and county opinions or ordinances are in conflict. This rule was determined to be an inappropriate delegation of our authority and is beyond the scope of assessing the personnel, equipment, and other agency-specific functions to determine fitness for licensure.

MOTION A motion was made by Senator Brandt to adopt IDAPA 16-0203-0401. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
IDAPA

16-0210-0401

Dr. Kris Carter, an epidemiologist for the Department of Health and Welfare in the Office of Epidemiology and Food Protection, presented IDAPA 16-0210-0401. She reported both Severe Acute Respiratory Syndrome (SARS) and West Nile virus may occur in Idaho this year, but neither is specifically reportable under the current rules.

The Division of Health is updating the Rules on Idaho Reportable Diseases to include SARS and West Nile virus infection on the list of Reportable Diseases and Conditions. We also added the control measures that will be taken if either of these diseases is reported. We added SARS to the list of daycare and school reportable and restrictable diseases.

These additions to the rules will enhance control and prevention of these
diseases in Idaho.

MOTION A motion was made by Senator Bailey to adopt IDAPA 16-0210-0401. The motion was seconded by Senator Brandt, and motion was carried by a voice vote.
IDAPA

16-0214-0301

Elke Shaw-Tulloch, Bureau Chief for the Bureau of Community and Environmental Health in the Division of Health, presented IDAPA 16-0214-0301, Construction and Operation of Public Swimming Pools, and IDAPA 16-0505-0301, Fees for Operation Permits, Licenses and Inspection Services. Both dockets pertain to swimming pools in Idaho.

Because they are interconnected, she discussed both dockets at this time. She provided a fact sheet describing these dockets. (See attachment #1)

These rules do not propose new language. They simply consolidate all rules affecting swimming pools into one chapter, and repeal a chapter that no longer contains any significant language once the swimming pool language is moved.

Docket 16-0214-0301 - This docket consolidates existing language about the construction and operation of swimming pools into one chapter as a result of the repeal of chapter 16.05.05 (docket 16-0505-0301). The movement of language includes: provision of legal authority to establish fees for services; permit and plan review fee amounts; and provision for the waiver of fees. This docket will also allow for the elimination of the reference to chapter 16.05.05. No new language is being proposed.

Docket 16-0505-0301 - The purpose of this docket is to repeal the entire chapter. After the split of IDEQ (Idaho Department of Environmental Quality) from the Idaho Department of Health and Welfare in 2000, and the movement of sections of IDAPA 16 into IDEQ's code, chapter 16.05.05 was left with three substantive sections: 130 swimming pool permits, 202 clean indoor air act regulation waivers, and 900 waivers of fees. Section 202 is redundant with language contained in the rules governing indoor smoking. Only the swimming pool permit and waiver of fees language remains. Proposed changes in docket 16-0214-0301 will move language from this chapter, leaving no substantial language in IDAPA 16.05.05. Therefore, the chapter can be repealed.

MOTION A motion was made by Senator Darrington to adopt IDAPA 16-0214-0301 and IDAPA 16-0505-0301 as presented. The motion was seconded by Senator Ingram, and motion was carried by a voice vote.
IDAPA

16-0219-0301

The Division of Health Administrator Richard Schultz presented IDAPA 16-0219-0301 and IDAPA 16-0219-0302. Both dockets pertain to the Food Safety and Sanitation Standards for Food Establishments. He explained the rules were crafted in response to an updating of the federal Food Code in 2001. The rule changes were negotiated with the assistance of a Food Advisory Committee composed of 16 individuals representing the regulated community. The Committee met last winter and spring and presented draft rules which they reached a consensus on in the summer.

We have significantly changed the appearance of the rules from previous iterations in that we have adopted the federal Food Code by reference in these rules and specified only the modifications we are making to that federal code. This approach has significantly reduced the volume of the rule and thus the associated cost of rule making.

There were three areas of concern that were expressed and all have been addressed:

  • Concern that a person "in charge needed to be present during all hours of operation." That was resolved by adding Section 201 that states that a person in charge or their designee needs to be present during "hours of food preparation and service."


  • A request from a chain grocery store that the rules allow self service to bulk frozen fish. No consensus was reached and in the absence of federal or other guidance on the matter, a conservative approach was taken and the rules continue to restrict that type of self service access.


  • Finally, in the process we failed to involve one group of the regulated community. That group was the correctional facilities/jails. We learned Monday that the rules would cause considerable disruption to the variety of food preparation and service methods used in those facilities. We believe the most appropriate resolution to the concern is a statute that exempts those facilities from compliance with the Food Rules. That statute is being drafted and will be supported by both the Department of Health and Welfare and the District Health Departments.
MOTION A motion was made by Senator Kennedy to accept IDAPA 16-0219-0301 and IDAPA 16-0219-0302. The motion was seconded by Senator Brandt, and motion was carried by a voice vote.
Adjournment There being no other business to discuss, the committee adjourned at 9:15 a.m.




DATE: Thursday, January 15, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Stegner, Sweet, Bailey, Burkett, and Kennedy
GUESTS: Representative Janice McGeachin, and see attached sign-in sheet
MINUTES: Senator Bailey moved to accept the minutes of January 14, 2004, as presented. Motion was seconded by Senator Stegner, and motion carried by a voice vote.
The Department of Health and Welfare's Division of Welfare IDAPA dockets were all presented by the Bureau of Child Support Bureau Chief Terri Meyer.
IDAPA

16-0301-0201

This rule, IDAPA 16-0301-0201, is a pending rule governing Eligibility for Medicaid for Families and Children. These rule changes ensure that TAFI (Temporary Assistance for Families in Idaho) income will be counted consistently when determining Medicaid eligibility to provide eligible households with the same length of Medicaid coverage while ensuring that TAFI households entering the work place will receive Transitional Medicaid (TM) services; clarifies Idaho Code references, financial responsibility and income exclusions.

The fiscal impact of the rule changes are $2,000 for automation (includes development of an ad hoc cost report and programming for rule change). Operational Costs: an annual program cost savings of $78,000 in State General Funds is projected.

Negotiated rule making was not conducted since all rule changes were made in order to assure consistent program operation following the State's legislative increase in the maximum TAFI grant payment.

MOTION A motion was made by Senator Brandt moved to adopt IDAPA 16-0301-0201as presented. The motion was seconded by Senator Stegner, and motion was carried by a voice vote.
IDAPA

16-0301-0301

MOTION:

This rule, IDAPA 16-0301-0301, is a pending rule governing Eligibility for Medicaid for Families and Children. This promulgation makes changes in eligibility language for this program. The changes result in a much clearer statement of the citizenship requirements and the exceptions which are specified in federal law. The referenced federal law, 8 U.S.C.1641(b) and (c) is not new so this update is certainly warranted. Eligibility factors for these programs are governed by the federal provisions which are governed by the federal provisions which are restated in the state's rules.

A motion was made by Senator Darrington to approve Docket No. 16-0301-0301. The motion was seconded by Senator Sweet, and motion was carried by voice vote.

IDAPA

16-0301-0302

IDAPA 16-0301-0302 rule change adds to the requirement concerning submission of a Social Security Number to require that the number be verified. In addition, the method of calculating an applicants countable income is rewritten, adding additional specific calculations to be used to determine income. This is intended to provide uniformity in the method of making the calculations.

The Department of Health and Welfare requested the committee to reject Sections 346, 347, 348, and 349 of IDAPA 16-0302-0301. It was determined these sections will not do what the Department first anticipated.

MOTION A motion was made by Senator Darrington to approve Section 214 of Docket 16-0301-0302, and request the Chairman to prepare a Concurrent Resolution to reject Sections 346, 347, 348, and 349, as requested by the Department of Health and Welfare. The motion was seconded by Senator Bailey, and the motion was carried by a voice vote.
IDAPA

16-0303-0301

This rule, IDAPA 16-0303-0301, is a pending rule governing Child Support Services. This rule change adopts language to implement legislation adopted at the 2003 legislative session and is federally mandated. It provides the means of communication about the availability of parental health insurance as a part of a child support order and provides the means for appealing a medical support order and canceling the order under the conditions specified.

The rule sets forth administrative procedures for the Department to access employment and health insurance information through the use of the National Medical Support Notice, in order to secure health insurance for children as a part of a child support order. It also sets forth either parent's ability to request an administrative review.

MOTION A motion was made by Senator Brandt to adopt IDAPA 16-0303-0301. The motion was seconded by Senator Stegner, and motion was carried by a voice vote.
IDAPA

16-0304-0202

This rule, IDAPA 16-0304-0202, is a pending rule governing the Food Stamp Program in Idaho. Rule change brings current rules into compliance with recent changes to Federal statutes and the Code of Federal Regulations: (1) Farm Bill, 2002, PL 107-171; (2) Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA, PL 104-193); (3) Balanced Budget Act of 1997 Public Law 105-33 pertaining to the Food Stamp Act of 1977; (4) changes to 7CFR271.2 regarding SSI.

These rule promulgation removes the requirement that legal and qualified immigrants receiving disability benefits be legally present in the United States as of August 22, 1996, for food stamp eligibility; adds references to the disability criteria; deletes references to SSI being a means-tested program; updates total number of weekly hours for part-time employment, references to standard income deductions gross monthly income eligibility standards net monthly income eligibility standards and maximum food stamp benefit.

MOTION A motion was made by Senator Kennedy to adopt IDAPA 16-0304-0202. The motion was seconded by Senator Brandt, and motion was carried by a voice vote.
IDAPA

16-0304-0301

This rule, IDAPA 16-0304-0301, is a pending rule governing Food Stamps. The proposed changes brought these rules into alignment with federal language regarding the verification of Social Security Number for eligibility purposes. Additional changes are clarifications of existing requirements and, in some cases, minor corrections or updates to comply with federal requirements, or federally-mandated changes such as those in the Farm Bill of 2002.
MOTION A motion was made by Senator Brandt to adopt IDAPA 16-0304-0301. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
IDAPA

16-0305-0203

This rule, IDAPA 16-0305-0203 is a pending rule governing Eligibility for the Aged, Blind and Disabled (AABD). These rules are being amended to comply with federal law changes which amend income and resource exclusions for the Aid to the Aged, Blind and Disabled program effective January 1, 2003, for both Qualified Medicare Beneficiary (QMB) eligibility and for Specified Low Income Medicare Beneficiary (SLMB) eligibility. Effective January 1, 2003, the SLBM III group is being eliminated. The rules are also being amended to clarify "room and board" and to allow telephone interviews in place of face-to-face interviews. Medicaid coverage for certain disabled aliens is being added to comply with federal requirements.
MOTION A motion was made by Senator Brandt to adopt IDAPA 16-0305-0203. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
IDAPA

16-0305-0301

This rule, IDAPA 16-0305-0301, is a pending rule governing the Eligibility for the Aged, Blind and Disabled (AABD). This docket makes changes in eligibility language for the AABD program. The changes result in a much clearer statement of the citizenship requirements and the exceptions which are specified in federal law. The referenced federal law, 8 U.S.C. 1641(b) and (c) is not new so this update is certainly warranted. Eligibility factors for these programs are governed by the federal provisions which are restated in the state's rules.
MOTION A motion was made by Senator Bailey to adopt IDAPA 16-0305-0301. The motion was seconded by Senator Kennedy, and motion was carried by a voice vote.
IDAPA

16-0305-0302

This rule, IDAPA 16-0305-0302 is a pending rule governing the Eligibility for the Aged, Blind and Disabled. This rule change adds to the requirement concerning submission of a Social Security Number to require that the number must b e verified for eligibility purposes. The further clarifications are to the provisions for determining eligibility after asset transfers and income. There are new references added which relate to the waivered services for aged and disabled, developmentally disabled, traumatic brain injured, and residents of the ISSH (Idaho State School and Hospital).
MOTION A motion was made by Senator Sweet to adopt IDAPA 16-0305-0302. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
IDAPA

16-0308-0301

This rule, IDAPA 16-0308-0301 is a pending rule governing Temporary Assistance for Families in Idaho (TAFI). This promulgation makes changes in eligibility language for this program. The changes result in a much clearer statement of the citizenship requirements and the exceptions that are specified in federal law. The referenced federal law, 8 U.S.C. 1641(b) and (c) is not new so this update is certainly warranted. Eligibility factors for these programs are governed by the federal provisions which are restated in the state's rules.

The rule amendments were made to clarify citizenship requirements and extend eligibility to TAFI for citizens and qualified non-citizens in compliance with federal regulations. The rules were also amended to clarify individuals not meeting the citizenship or qualified non-citizens when all other conditions are met, may be eligible for medical services.

MOTION A motion was made by Senator Kennedy to adopt IDAPA 16-0308-0301. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
IDAPA

16-0308-0302

This rule, IDAPA 16-0308-0302, is a pending rule governing Temporary Assistance for Families in Idaho (TAFI). The purpose of this rule making is to adopt the language regarding verification of Social Security Number for eligibility purposes.

Section 133 is being amended to clarify the Social Security Number (SSN) requirements to align with the federal requirements that the SSN must be verified before an applicant is eligible for RAFI benefits.

MOTION A motion was made by Senator Burkett to adopt IDAPA 16-0308-0302. The motion was seconded by Senator Brandt, and motion was carried by a voice vote.
IDAPA

16-0320-0301

This rule, IDAPA 16-0320-0301, is a pending rule governing Electronic Payments of Public Assistance, Food Stamps and Child Support. These changes will give the Department of Health and Welfare the authority to adjust a food stamp account in order to correct an auditable, out-of-balance settlement condition that occurs during the redemption process as a result of a system error. The rule gives the household an opportunity to appeal and pending the outcome of the appeal, the Department must release the adjustment amount. The program participant is protected by the provision that the out of balance situation must be "auditable" as specified in the rule. This rule change was required by federal regulation.
MOTION A motion was made by Senator Sweet to adopt IDAPA 16-0320-0301. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
IDAPA

16-0414-0301

This rule, IDAPA 16-0414-0301, is a pending rule governing Low Income Home Energy Assistance Program (LIHEAP), This program provides assistance in meeting energy costs for recipients. The amount of assistance depends upon the federal allocation to the state. Each year the rules are amended to coordinate the assistance amount with the federal allocation amount. This docket will take the actual calculation of the assistance amount out of the rules and place it in the manual; therefore, saving the Department the amount required to promulgate new rules each year. It is a logical cost-saving step and has no impact on the award of assistance.

To avoid having to change this rule on an annual basis and to reduce procedural steps in the administrative rules performed by state employees, the benefit determination procedures and the percentages will be place in the Intake Manual used for LIHEAP. A summary for determining the annual benefit will replace the procedures, also, language has been clarified and some renumbering of the section.

MOTION A motion was made by Senator Ingram to adopt IDAPA 16-0414-0301. The motion was seconded by Senator Brandt, and motion was carried by a voice vote.
IDAPA

16-0612-0301

This rule, IDAPA 16-0612-0301, is a pending rule governing the Idaho Child Care Program. This docket finalizes adoption of the three point five percent (3.5%) holdback ordered by the Governor in the program which provides payments for child care for families receiving Temporary Assistance for Families in Idaho (TAFI).

During the 3.5 percent hold back imposed by the Office of the Governor, it is necessary to increase the percentage of the amount families are required to pay for their child care each month. In order to achieve $265,400 in savings by June 30, 2003, it is necessary to increase co-payment by six percent (6%) per child, per month. This will be accomplished in rule change by increasing the sliding fee schedule found in IDAPA, Section 06.12.307 by 6 percent (6%).

MOTION After a discussion, a motion was made by Senator Ingram to reject IDAPA 16-0612-0301, and to hold a hearing. The motion was seconded by Senator Kennedy.
MOTION

A substitute motion was made by Senator Brandt to adopt IDAPA 16-0612-0612-0301. The motion was seconded by Senator Bailey, and a roll call vote was taken.

Senator Kennedy voted Nay Senator Bailey voted Aye

Senator Burkett voted Nay Senator Sweet voted Aye

Senator Ingram voted Nay Senator Darrington voted Aye

Senator Stegner - absent excused Senator Compton voted Aye

Senator Brandt voted Aye

The substitute motion was carried by a vote of 5 Ayes, 3 Nays, 1 absent.

Adjournment The meeting adjourned at 9:45 a.m.




DATE: Friday, January 16, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Stegner, Sweet, Bailey, Burkett, and Kennedy
GUESTS: Representative Janice McGeachin, and see attached sign-in lists
MINUTES: A motion was made by Senator Bailey to accept the minutes of Wednesday, January 14, 2004, as presented. The motion was seconded by Senator Stegner, and motion was carried by a voice vote.
RULES REVIEW: The meeting was conducted by Vice Chairman Compton.


HEALTH AND WELFARE:
The Department of Health and Welfare, Division of Medicaid, presented ten (10) IDAPA (Idaho Department of Administration Procedures Act) dockets for the committee to review.
The Bureau of Medicaid Policy Bureau Chief Leslie Clement presented

nine (9) rule making dockets for the Division of Medicaid, as follows:

IDAPA

16-0309-0212

This morning, I will provide a brief overview of the pending rule docket 16-0309-0212 that describes Medicaid's Traumatic Brain Injury Waiver. Last year, your committee approved these rules as temporary. I respectfully ask the committee to adopt this pending rule as final.

The purpose of this docket is to update the terminology used to describe the department's Traumatic Brain Injury Waiver program in order to improve understanding and clearly describe services. Medicaid staff worked with internal staff and external stakeholders to update these rules for this program that has been in effect since October 2002.

Two positive comments were received on this docket. Legislative Services found no issues with this docket.

The department requests you approve this docket as final.

MOTION: A motion was made by Senator Brandt to approve IDAPA 16-0309-0212. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
IDAPA

16-0309-0215

This next docket is the pending rule, IDAPA 16-0309-0215, that includes amendments to the Medicaid Case Management changes resulting from last year's budget holdback. I respectfully ask the committee to adopt this pending rule as final.

Both Health & Welfare Germane Committees had some concerns about how the temporary rules affected access to case management services, particularly for those individuals with mental illnesses. The Germane Committees directed the department to amend the temporary rules.

The department met with legislators and provider representatives in order to address crisis coverage. As a result of these meetings, this docket was amended to:

  • Allow up to four (4) hours per month of crisis case management without department authorization,
  • Retain the four hours of ongoing crisis management, and
  • Include another four (4) of crisis if more restrictive criteria have been met.


A key outcome of this work was the development of criteria that reflects a "crisis" and clarification of crisis case management services.

Crisis case management means "linking, coordinating, and advocacy" ­ it does not entail the provision of direct services such as crisis counseling, transportation, or skills building which are provided through other channels. Also, these rules require providers to document crisis services and submit written justification when crisis hours fall into the more restrictive category.

This amended docket also lengthens the interval for service plan reviews from 120 days to 180 days. The amended docket also allows licensed clinical professional counselors without private practice licensures and marriage and family therapists to provide case management services.

Rather than keep the temporary rule in place while the pending rule awaits legislative approval, the Department amended the temporary rules with the same revisions which have been made to the pending rule.

This concludes my overview of the amendments made to this pending rule docket 16-0309-0215. The department requests your approval that this docket be approved as final by this Committee.

An e-mail to the committee was submitted, for the record, from Steve Hansen of Idaho Falls, Idaho, dated January 14, 2004. His e-mail reported "Since these temporary rules are at least slightly better than the previous rules, I will not testify in opposition to them."

MOTION: A motion was made by Senator Bailey to approve IDAPA 16-0309-0215. The motion was seconded by Senator Sweet, and motion was carried by a voice vote.
IDAPA

16-0309-0217

I will now provide a brief overview of the pending rule docket 16-0309-0217 that standardizes requirements for submitting reports to the department's peer review organization. This docket was approved as temporary by last year's legislative committees and received two positive comments. I respectfully ask the committee to adopt this pending rule as final.

This rule docket updates terminology regarding the department's peer review organization and provides for the consistent application of penalties for late submission of a review docket. The clarification was made to ensure that all procedures are submitted in a timely manner for medical necessity review to protect the public health and safety.

This concludes my presentation on Docket 16-0309-0217. The department requests your approval that this docket be approved as final by this Committee.

MOTION: A motion was made by Senator Stegner to approve IDAPA 16-0309-0217. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
IDAPA

16-0309-0218

This docket is pending rule docket 16-0309-0218 that removes an extra Medicaid payment for sending information to a national registry. Last year, your committee approved these rules as temporary. I respectfully ask the committee to adopt this pending rule as final.

This rule docket removes the Medicaid payment for the entry of laboratory results into the Clozapine National Registry for participants who require Clozapine to treat mental illness.

In October 2001, the department reduced its payment for this service from $29.07 to $5.00 to bring our payment into line with what other states were paying. After additional research we found that Utah, Wyoming, Montana, and Nevada were not paying for this service at all under their Medicaid programs. Last year, Idaho Medicaid followed suit and elected not to continue the $5.00 administrative processing payment. This is consistent with other reimbursement policies which do not establish an additional reimbursement rate for administrative activities.

The department requests your approval that this docket be approved as final by this Committee.

MOTION: A motion was made by Senator Brandt to approve IDAPA 16-0309-0218. The motion was seconded by Senator Kennedy, and motion was carried by a voice vote.
IDAPA

16-0309-0301

Pending rule docket 16-0309-0301 describes how Medicaid pays out-of-state nursing homes. This docket can be found behind Tab 16 with the text changes reflected on page 200 of your Pending Rules Book. Last year, your committee approved these rules as temporary. I respectfully ask the committee to adopt this pending rule as final.

This rule docket describes the payment methodology used to reimburse out-of-state nursing homes for care provided to Medicaid eligible persons.

Medicaid payment for out of state nursing home care is very limited and generally is only allowed if the care the person's needs are not available in an Idaho facility. Because of the complexity of our current acuity-based reimbursement for instate nursing homes, the department has elected to pay out of state facilities the same rate as they receive from the Medicaid program in their home state. This simplifies their billing and claim submission process.

This concludes my presentation on Docket 16-0309-0301. The department requests your approval that this docket be approved as final by this Committee.

MOTION: A motion was made by Senator Sweet to approve IDAPA 16-0309-0301. The motion was seconded by Senator Stegner, and motion was carried by a voice vote.
IDAPA

16-0309-0304

Pending rule docket 16-0309-0304 details all the dental procedures covered under Medicaid. I respectfully ask the committee to adopt this pending rule as final.

This rule docket restores routine and preventive coverage for adults effective July 1, 2003. Medicaid was able to restore these benefits as a result of a special appropriation at the conclusion of last year's legislative session.

This docket also includes technical changes that reflect new HIPAA (Health Insurance Portability and Accountability Act) coding requirements.

The department requests your approval that this docket be approved as final by this Committee.

MOTION: A motion was made by Senator Stegner to approve IDAPA 16-0309-0304. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
IDAPA

16-0309-0306

Pending rule docket 16-0309-0306 restores some mental health case management hours, as a result of additional funding. I respectfully ask the committee to adopt this pending rule as final.

This rule change reflects benefits added for mental health case management as a result of a special Medicaid budget appropriation for State Fiscal year 2004. You may recall that mental health case management benefits had been reduced as part of the 2003 Budget Holdback. The holdback designated a service cap of four hours of targeted case management per month. With this year's appropriation, Medicaid has been able to restore some of the ongoing case management services that had been reduced.

The department was allocated approximately $148,000 to provide additional mental health case management services. The department increased the number of ongoing case management hours ­ those that do not require meeting"crisis" criteria ­ from four hours per month to five hours.

The resulting benefit package currently allows for:

  • Five hours of ongoing case management,
  • Three hours of crisis case management that doesn't require prior authorization; and
  • Four hours of crisis case management that requires justification and prior approval.


This concludes my presentation on Docket 16-0309-0306. The department requests your approval that this docket be approved as final by this Committee.

MOTION: A motion was made by Senator Bailey to approve IDAPA 16-0309-0306. The motion was seconded by Senator Sweet, and motion was carried by a voice vote.
IDAPA

16-0309-0310

Pending rule docket 16-0309-0310 streamlines the administrative requirements for school districts that bill Medicaid. I respectfully ask the committee to adopt this pending rule as final.

The purpose of these rule changes is to reduce the administrative barriers that have created reluctance among school districts to become Medicaid providers. Over the past year, department staff has been working in collaboration with the department of education and school representatives to streamline procedures that will improve access to care for Medicaid eligible children. By encouraging increased school participation in Medicaid, more children may be served in a familiar environment with services coordinated and managed under a single roof.

We have already seen the positive affect of this rule change. In January 2003, there were just 44 school districts enrolled as Medicaid providers. By June 2003, this number increased to 71 districts. The number of eligible children receiving services also jumped during this time frame, up from 3,300 to 6,400.

School district providers are unique in that they fund the Medicaid state match ­ there are no costs to the state Medicaid program when services are billed by a school-based provider. This is an attractive service arrangement that the department wants to further develop and support. The department has begun working with some private providers and school district representatives to develop protocols and templates for coordinating services. Private providers can play a key role by providing an additional resource during the school hours. Children can be better served by having most of their needed services provided during the day rather than after a long school day. Schools are encouraged to contract with providers and bill Medicaid for all services whether provided directly or through a contract. Many school districts have already established this arrangement in their communities.

The department will continue to work with schools and private providers to support this cost-effective collaborative effort to providing services to school aged children.

The department requests your approval that this docket be approved as final by this Committee.

Jana Jones, from the State Department of Education (SED), presented public appreciation to the Department of Health and Welfare for the excellent work and dedication the department provides to the SED.

MOTION: A motion was made by Senator Stegner to approve IDAPA 16-0309-0310. The motion was seconded by Senator Brandt, and motion was carried by a voice vote.
IDAPA

16-0309-0311

This temporary rule docket 16-0309-0311 addresses Mental Health benefits provided under the Medicaid program.

From a procedural stand point, you are reviewing this docket in the middle of its development. These rules were published as temporary rules in the November Administrative Bulletin. Three public hearings were conducted, and public comments were accepted through November 26, 2003.

As a result of the hearings and comment, the Department has developed amendments to these temporary rules which are to be published in the March Bulletin. You have been provided with a copy of the amendments to this rule docket. The department has informed stakeholders that the amendments are intended to be retroactive to December 1, 2003 ­ the effective date of these rules.

The Department is asking this committee to extend these temporary rules on the condition that the Department precede with the amendments that have been provided to you. It should also be noted that once these amendments are published, there will be additional time for comment and hearing.

In addition, these rules will come before you in the 2005 session for final approval.

The main reasons for these rule changes are to clarify service provider roles in light of staffing reductions in the Department's Regional Mental Health Authority and to address health & safety issues.

The rule changes affect two distinct mental health benefits: 1) Psycho-Social Rehabilitation (PSR) and 2) Mental Health Clinic services.

The first part of the docket changes the PSR rules to reflect the reduction in Department Regional Mental Health staffing. As a result of the reductions, private PSR providers will now perform the assessment and service planning functions previously done by state staff.

Additionally, these rules incorporate service definitions, clarify provider qualifications, and spell out service expectations. Significant clarifications include the requirements that:

  • PSR Agencies personnel coming into direct contact with participants must comply with existing statutes governing criminal history check requirements; and,


  • PSR agencies must provide 24-hour crisis response services for their participants or make contractual arrangements for the provision of those services.


The changes to the mental health clinic rules and related partial care rules were made primarily due to safety issues. Over the past year, the department was alerted to situations where individuals appeared to be at risk when receiving care under this benefit.

Prior to these rules, "partial care" -- a Mental Health Clinic Service -- could be applied to a number of programs. Some of these programs consisted of supplying clients with cigarettes, coffee, and television for up to eight (8) hours per day. And because service expectations were not clearly articulated, many of the safety issues found over the past years have arisen in this service setting.

The rules before you tighten up the definition of partial care services to a structured program of therapeutic interventions. The intention of these rules is to remove any confusion about what services should be provided and to clearly define the expected service outcomes.

This rule docket does not introduce any new federal or state requirements for mental health clinics except for the inclusion of building standards, which were added as a direct result of documented cases of child endangerment due to substandard buildings that were being used as clinics. These temporary rules contain federal and state guidelines that have been in effect for many years. All changes are intended to result in a greater understanding in the provider community of the scope of mental health services as they are required to be.

Based on three public hearings scheduled in Boise, Pocatello and Coeur d'Alene during November, amendments were prepared that further clarify service expectations. The comments received came from the department's Family & Community Services Division, the department's Fraud & SURS (Surveillance and Utilization Review Section), private providers, and individuals and families receiving services under this rule docket.

An area of significant confusion has been the requirement for physician oversight ­ both in terms of expectations for clinic supervision and for individuals' care. The additional amendments the Department is proposing clarify the requirements as follows:

  • Clinics must be under the direction of a physician and must spend as much time in the facility as is necessary to assure that participants are getting services in a safe and efficient manner in accordance with accepted standards of practice, (have used one hour per month).


  • Each participant's care must be under the supervision of a physician directly affiliated with the clinic. The clinic may have as many affiliations as necessary to meet the needs of the participants served. The physician (can be the existing health care physician) who supervises the participant's care does not have to deliver this service on-site.


This concludes my presentation on Docket 16-0309-0311. The department requests this Committee to extend these temporary rules with the condition that the Department proceed with the proposed amendments.

These rules are necessary to accurately describe changes in provider roles and to ensure the safety of individuals receiving services under this benefit.

Representative Janice McGreachin had provided committee members with a letter regarding docket 16-0309-0311. She invited the committee to attend the House Health and Welfare Committee meeting on Thursday (01/22/04) in the afternoon as the House discusses docket 16-0309-0311. (See attachment #1)

The Mental Health Providers Association of Idaho President April Crandall, testified in opposition to Section 469 of docket 16-0309-0311.

Kelly Keele from the Mental Health Providers Association, testified in opposition to docket 16-0309-0311, and provided three handouts outlining his objections. (See attachment #2, #3 and #4)

Laura Seuri from the Mental Health Providers Association, testified in opposition to docket 16-0309-0311.

After a lengthy discussion and review of IDAPA 16-0309-0311, Chairman Compton determined to hold this rule and reschedule for an additional hearing later next week. The Chairman expressed the appreciation of the committee to the people who attended the meeting and those who presented testimonies.

IDAPA

IDAPA

16-0309-0213

This rule, IDAPA 16-0309-0213, was presented by Division of Medicaid Deputy Administrator Kathleen Allyn. This rule implements a state statutory change and subsequent court ruling on state-funded abortions for low-income women.

This is a pending rule that the Division is asking this committee to approve. This same rule was presented last year as a temporary rule and the committee voted to extend it.

In 2001, the Legislature amended Idaho law to remove a requirement that the state pay for abortions to save the health of the mother, Implementation was delayed until July 1, 2002, because of a court suit challenging the legality of the amended statute.

The court upheld the amendment. At the same time, the court ruled that the state law requirement to have two physicians certify the necessity of an abortion violated federal law and could not be enforced by the state. The court's decision was effective July 1, 2002.

The temporary rule before you implements both the statutory amendment and court decision by:

  • Removing state payment for abortions to save the health of the mother.


  • Changing the two physician certification requirements to certification to one physician.


No comments were received opposing the rules, and no hearing was requested.

The department requests you vote to approve this rule.

MOTION: A motion was made by Senator Brandt to approve IDAPA 16-0309-0213. The motion was seconded by Senator Stegner, and motion was carried by a voice vote.
ADJOURNMENT: The meeting adjourned at 10:25 a.m.




DATE: Tuesday, January 20, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Sweet, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

Senator Stegner
MINUTES: A motion was made by Senator Bailey to accept the minutes as written for Thursday, January 15, 2004. The motion was seconded by Senator Compton, and motion was carried by a voice vote.
MINUTES: A motion was made by Senator Ingram to accept the minutes as written for Friday, January 16, 2004. The motion was seconded by Senator Sweet, and motion was carried by a voice vote.
GUESTS: Dr. Erik Olsen. See the attached sign-in sheets.
AARP Prescription Drug Bill - Medicare - Dr. Erik Olsen:

Dr. Olsen of Mesa, Arizona, was elected to a six-year term on the AARP Board of Directors at the 2000 Biennial Convention. During the 2000-2002 biennium he served on the Board Governance Committee and the AARP Insurance Trust of the Health Care Options Program. He also continues to serve as chair of the Convention Program Committee.

Dr. Olsen retired in 1992 as President and CEO of Delta Dental Plan of California. Prior to that he was an executive director and managing editor of the Academy of General Dentistry and served in the United States Army.

Dr. Olsen has received numerous awards and recognitions including induction in the Delta Dental Association Hall of Fame, receipt of the first Hillenbrand Fellowship in Dental Administration and Volunteer of the Week from the Mesa Arizona Independent Newspapers.

Dr. Olsen stated, I'm pleased to have the opportunity to talk and brief you today about the new prescription drug benefit in Medicare. The historic passage of the Medicare prescription drug bill has created opportunities and challenges for MRP, its members and volunteers, but we also believe this has opened a new era of opportunity for Medicare beneficiaries throughout the country.

The law is 681 pages long-about the size of a big-city phone book--and that's what I'll be trying to summarize in the next few minutes. I'll do my best.

The benefit portion of the bill is worth about $400 billion over the 10-year period from 2006 to 2016. Four hundred billion is a very good down payment, it's a good start, and what we like about the legislation is that it puts this benefit into the structure of Medicare. Four hundred billion dollars, however, does not cover all of the need, and we'll be working in the years ahead to try to expand that commitment.

Given that, Congress had to make some choices about where the $400 billion was best spent, and they emphasized two areas, maybe three areas. The first was that they wanted to be sure that those with the greatest need, those at the lowest end of the income scale, were taken care of, and I'm going to talk about the low-income benefit.

Secondly, they wanted to be sure that people who had very high drug costs were taken care of. And third, we wanted to provide incentives to employers who provide retiree coverage to stay in the game, not to continue this trend that we're seeing in which employers drop coverage. So let me deal with those three areas and then I'll talk about the basic benefit itself that will apply to everyone.

With regard to low-income people who are at or below the federally defined poverty level, those folks have to pay no premium, they have no deductible, there is no gap in coverage. They get coverage from the first dollar up through whatever they have to spend, and all they face are co-payments of $1 for a generic drug or $3 for a brand-name drug. So for those at the very bottom of the scale, the coverage is actually excellent. It's virtually first-dollar coverage with the exception of very modest co-pays.

The next level is defined as 135 percent of poverty, and people between 100 percent of the poverty line and 135 percent of the poverty line have essentially the same deal that I've just described: No premium, no deductible, no coverage gap, no cap, and they have to pay co-payments of $2 for a generic drug or $5 for a brand-name drug.

For those between 135 percent of poverty and 150 percent of poverty as

federally defined, there is no premium. There is a $50 annual deductible. The co-payments are 15 percent of the cost of the drug, and there is no coverage gap.

All these co-pays are subject to asset tests. If a couple has assets of up to $9,000 they have the lowest co-pays. If their assets range from $9,000 to $20,000, they have higher co-pays. And couples with assets of more than $20,000 will pay the highest co-pays. This asset test will affect about 12 percent of the people in the low income categories.

So one thing we're pleased with is the low-income benefit, which is really quite generous and should allow people who are poor or near poor to get very good coverage of the drugs that they need.

I also said that the Congress made a very good-faith effort to try to take care of those who have very high prescription drug costs. And essentially above $3,600 in out-of-pocket costs, Medicare will pick up 95 percent of whatever remains. To give you a sense of what this means, one example would be that-let's take someone who has no drug coverage now and has $10,000 in prescription drug costs. If he has no coverage now, he is paying that full $10,000. Under this legislation he is paying about $4,000 and Medicare is picking up the other $6,000.

The subsidy that's provided in this legislation to employers to continue to provide good benefits is very important to us. Some of those employer plans offer a more generous benefit than is available in this package, and we want them to continue to do that. Right now employers are allowed to deduct the costs of those plans from their adjusted gross income, so they have a bit of a tax incentive to do it.

This bill, on top of that, adds a subsidy that pays 28 percent of the actuarial value of the drug benefit they provide, between $250 and $2,250. So that's pretty generous right there. It reduces their cost by about a third.

In addition, this bill makes that subsidy tax free, so that actually adds something. We are hopeful that this will keep those employers in the game in continuing to provide the kind of benefits that they provide now. And I should add, because there have been some expressions of concern, that that subsidy covers not just employers in the private sector but employers in the public sector as well.

So a state government employee or a teacher or anyone else who has retiree benefits through their public employment, those employers will receive the same incentive to continue to provide those benefits, as do private employers. And I think that's very important.

Now let me go to the shape of the benefit for people who are not in the lower-income categories that I described. Once again, this is not as generous a benefit as we would like. What we will see in this legislation, which takes effect in the year 2006, is a premium that will average $35. It may vary slightly depending upon the health costs in your particular region of the country but it should be $35 a month. In addition, they will have a $250 deductible. Once they have met that deductible of $250, from there up through $2,250, Medicare will pick up 75 percent of the costs of their prescription drugs. So it's pretty good coverage up too there: three out of four dollars will be reimbursed.

Most of this bill does not take effect until the year 2006, as I said. People don't have to make a decision until sometime in the fall, maybe November, of the year 2005. So they will have plenty of time to think about this and decide whether or not it makes sense for them. At AARP we're committed to continuing to provide additional information that people may want to take into account in making that decision.

And we actually have on our website now a quick benefit calculator that will let people interactively plug in the amount of what they expect their drug costs to be and then it will give them a sense of how much reimbursement from Medicare they will get under this legislation. And I'd urge folks to use that; it may save them a lot of pencil-and-paper work.

That calculator is very accurate. If you put in the amount that you expect to spend, it will tell you how much of that will be covered. Of course, the more difficult estimate is what you expect to spend. You've got to look at this a bit on the insurance principle. So people may want to feed in not the amount that they're spending now but the amount they want to protect themselves against with some coverage in the years ahead in making their decision.

There are a few provisions of this legislation that will actually go into effect this year. A drug discount card will be available. We haven't seen the final details on this. My guess is that that will give people about a 15 percent saving off retail price on the drugs they buy. That card should cost about $30. Once again, this decision is up to the individual.

Some people may be able to get drug discounts through other vendors outside of the Medicare approved ones that are just as good, and if so, they may want to take a pass on that. It's their decision. But I think for low-income residents, for low-income beneficiaries, there is an additional feature that makes this very good protection for them, and that is both for the 2004 and 2005, the low-income beneficiaries will receive a $600 credit on that card. It's like a debit card for those folks. They have $600 and can use that $600 to pay for their prescription drugs bit by bit until they exhaust the $600, and then they'll get the 15 percent discount.

On balance we think this benefit was well worth supporting. We think it is a good start to where we have to go. We think it will provide good immediate relief for low-income beneficiaries and for those with very high drug costs, and there will be some coverage for everyone else in the beneficiary population. If you spend, for example, in the course of the year, about $3,000 on prescription drugs, after 2006 you'll get about $1,500 of that covered, and that I think makes it worth doing at that level.

So, on balance, great start. We've been trying to get this for more than 10 years. Congress has rolled the boulder up the hill several times only to have it slip away, and I think we finally got it over the hump and it can only get better from here.

Our goal is to make prescription drugs more affordable and this is one major piece. It's a piece that we're going to try to improve over time, but the other thing is we're going to be working on a lot of other things to try to make prescription drugs more affordable for seniors, any number of things: free notification plans, bulk buying plans, trying to help reimportation workable.

So I want you to know we're going to continue this and we're going to continue trying to fight to make prescription drugs more affordable.

Dr. Olsen thanked the committee for allowing him the opportunity to meet with them today.

RS 13644C1 RS13644C1 relates to the Regulation of Food Establishments.

The purpose of this bill is to delete county jails and state correctional facilities from the requirements of the Idaho Food Code. This code, enforced by the Idaho Department of Health and Welfare, is designed to apply to restaurants and other private and public food service entities. State correctional facilities and county jails have their own rules and regulations pertaining to service of food within correctional facilities and jails that are better designed to meet their needs. Implementing Health and Welfare rules on food service would create a significant financial burden on the state and on county governments that would require additional funding from the state general fund and local property taxpayers. This bill will avoid that unnecessary burden.

This bill has no adverse impact on the general fund or on county budgets.

MOTION: A motion was made by Senator Compton to send RS13644C1 to Print. The motion was seconded by Senators Bailey and Ingram, and motion carried by a voice vote.
RULES REVIEW: Department of Health and Welfare, Division of Medicaid:
Docket No.

16-0309-0305

Paul Leary, a Medicaid program manager, presented a brief overview of the pending rule docket 16-0309-0305, and respectfully asked the committee to adopt this pending rule as final.

To promote and protect the health and safety of Idahoans the Department is committed to continually improving systems and process used to identify the right level of care and services required by Medicaid participants in Nursing Facilities.

The Uniform Assessment Instrument is the tool used by the Department to assess whether or not a participant requires Nursing Facility level of care. This tool is criteria based, objective instrument that reflects the participants' physical and mental functional capacity and limitations.

The scoring system for the Uniform Assessment Instrument was quantified for scoring levels of care for supervision. The rules are being amended to reflect current practice and to assure services on the Uniform Assessment Instrument are consistent. This change will promote consistency throughout the Department and help assure those participants are receiving the level of services they require.

This rule docket was published in the August Administrative Bulletin. Two positive written comments were received. Legislative Services had no technical, substantive, or procedural concerns with these pending rules.

This concludes my presentation on rule docket 16-0309-0305. I respectfully ask the committee to adopt this pending rule as final. I will be glad to answer any questions from the committee at this time.

MOTION: A motion was made by Senator Brandt to accept Docket 16-0309-0305. The motion was seconded by Senator Sweet, and motion was carried by a voice vote.
Docket No.

16-0309-0309

Mr. Leary provide a brief overview of the pending rule docket 16-0309-030, and respectfully ask the committee to adopt this pending rule as final.

The purpose of this docket is support the January 20, 2004 Department's commitment to providing both the right price for services and the right services for participants. Additionally, we want our rules that govern our services to be clear to all stakeholders. This docket includes two different Sections of the Medical Assistance rules, Section 121 and Section 146.

Idaho Medicaid has used the same reimbursement methodology as Medicare for Ambulatory Surgical Center. Medicare has recently changed their methodology for reimbursing these facilities and this change is not compatible with Idaho Medicaid's automated system. The Department will continue to use the historic reimbursement methodology instead of the new Medicare methodology. The reference in Section 121 of the rule to Medicare's methodology has been deleted.

The second section of rule being addressed in this docket deals with Personal Care Services. Section 146 of the Medical Assistance rules, was deleted completely and the entire section was reorganized and rewritten in plain language based on ongoing input of staff and provider. In response to public comment a new subsection was added to permit agencies to use a software system allowing personal assistants to register their start and stop times and maintain a list of services they provide by placing a telephone call to the agency system from the participant's home. This does not replace the documentation requirements of these rules.

This rule docket was published in the October Administrative Bulletin. Legislative Services had no technical, substantive, or procedural concerns with these pending rules.

This concludes my presentation on rule docket 16-0309-0309. I respectfully ask the committee to adopt this pending rule as final.

MOTION: A motion was made by Senator Bailey to accept Docket 16-0309-0309. The motion was seconded by Senator Brandt, and motion was carried by a voice vote.
Docket No.

16-0309-0307

The Division of Medicaid Administrator David Roger presented rule docket 16-0309-0307. These rule changes are being made to support the implementation of the Department's new prior authorization process for DD services. Citations have been inserted t refer the reader to the new rules chapter on Developmental Disability Care Management. Other changes have been made relating to targeted developmental disabilities service coordination to align with the terminology governing prior authorization found in the new DD care management rules. This is a companion docket to 16-0313-0301.
MOTION: A motion was made by Senator Brandt to accept Docket 16-0309-0307. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
Docket No.

16-0313-0301

Mr. Roger presented docket 16-0313-0301, relating to Prior Authorization for Behavioral Health Services new chapter. This new chapter of rules provides a coordinated and comprehensive process for Idaho Medicaid to prior authorize Developmental Disability (DD) program services for eligible adults. These rules require an independent assessment of an adult seeking Developmental Disability program services. Based on the assessment, a participant budget is established and the participant, his representatives, or both, will negotiate for the type and amount of services he requires and desires. The Department or its designee will then authorize the medically necessary services, reauthorize such services at least annually, and regularly conduct quality improvement reviews.
MOTION: A motion was made by Senator Kennedy to accept docket 16-0313-0301. The motion was seconded by Senator Brandt, and motion was carried by a voice vote.
Dockets No.

16-0323-0301

16-0411-0301

16-0417-0301

Mr. Rogers also presented dockets 16-0323-0301, 16-0411-0301, and 0417-0301 together as they all relate to prior authorization for Behavioral Health Services.

These dockets all relate to the new chapter of rules provides a coordinated and comprehensive process for Idaho Medicaid to prior authorize Developmental Disability (DD) program services for eligible adults.

  • 16-0323-0301 - This rule change supports the implementation of the Department's new prior authorization process for Developmental Disability (DD) services. The rule change identifies the standard for the Department to assess individuals with a developmental disability for determination of eligibility and participant budget for services.


  • 16-0411-0301 - These rule changes support the implementation of the Department's new prior authorization process for DD services. The rule changes establish the requirement for Developmental Disabilities Agencies (DDAs) to obtain prior authorization for DDA services for all adult participants. They also require DDAs to submit Provider Status reviews semiannually and annually.


  • 16-0417-0301 - These rule changes support the implementation of the Department's new prior authorization process for DD services. The rule changes establish prior authorization for Residential Habilitation Agency services. They also require Residential Habilitation agencies to submit Provider Status reviews semiannually and annually. In response to comments received from the Board of Health and Welfare, testimony presented at public hearings, and written comments submitted by the public and Department staff, several clarifications and additions were made to the temporary rule. This is a companion docket to 16-0313-0301.
MOTION: A motion was made by Senator Sweet to accept dockets 16-0323-0301, 16-0411-0301, and 16-0417-0301. The motion was seconded by Senator Ingram, and motion was carried by a voice vote.
A discussion was held about prescription drug rates. Mr. Rogers explained the rates are posted on the web page for Medicaid. Medicaid has a contract with an entity to update the drug list. Senator Compton reported that counties need to have readily access to the prescription drug rates and information. He requested Medicaid to do whatever possible to help Idaho's small counties with billing issues.
Adjournment: The meeting adjourned at 9:40 a.m.




DATE: Wednesday, January 21, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Sweet, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

Senator Stegner
GUESTS: See the attached sign-in sheets
RULES REVIEW: Department of Health and Welfare, Division of Medicaid:
Docket No.

16-0309-0308

Bureau of Fraud and Investigations Bureau Chief Mond Warren explained docket 16-0309-0308. This proposal is directed to the investigation of fraud or abuse of program requirements by providers. The rule would specifically require that all records must be available during business hours for copying, and that copies may be removed from the premises. Such records are intended for use by the Department investigating provider fraud.

No public hearings were held. Two (2) positive written comments were received.

Jeff Hough, lobbying director for the Cooperative Action LLC, Chubbuck, Idaho, testified in opposition to docket 16-0309-0308. Cooperative Action LLC is a third-party advocate group dedicated to providing a voice for the Medicaid providers and recipients in Idaho. He reported the rules should comply with the recent HIPAA (Health Insurance Portability and Accountability Act). Mr. Hough also presented and explained a copy of a letter addressed to the Honorable Philip E. Batt, dated April 20, 1995, and also a chart related to 42CFR, 1007.5 and 1007.9. (See Attachments #1 and #2)
Gregory Dickerson testified in opposition to docket 16-0309-0308. He stated, I am representing the Mental Health Provider Association of Idaho. First I would like to clarify that we are in agreement with the stated intent of this docket of rules "to clarify (that) the Department has a right to immediate access of records and copying of those records for investigation of fraud and abuse." We are also in agreement that a provider who refuses to release records to fraud investigators should be summarily suspended until they comply with these requirements. However, we are opposed to several revisions to sections 204, 208, 209, and 210, which deal with due process rights relating to the suspension of payments and provider agreements during investigations of suspected fraud and abuse.

This docket of temporary and proposed rule deletes section 204 (pg.268) which describes the Surveillance and Utilization Review (SUR) Committee. This committee functioned to review instances of suspected fraud, abuse, and misconduct and make recommendations concerning corrective actions such as suspension of payments or provider agreements. We maintain that the deletion of this section in these rules removes "an important check and balance necessary for making critical judgments that may tremendously impact the very existence of provider entities that are the subject of such allegations, and the livelihood of the people they employ in reliance on their provider agreements.

Section 208 (pg. 269) Suspension of Payments Pending Investigation has been amended to state "The Department may suspend payments in whole or in part in a suspected case of fraud or abuse pending investigation and conclusion of legal proceedings related to the provider's alleged fraud or abuse."

"Suspect" is defined in Webster's dictionary as "To consider to be guilty without proof."

"Alleged" is defined as "To assert without proof."

Section 208.01 Basis of Suspension of Payment states in part "When the Department through reliable evidence suspects fraud or abuse . . . Medicaid payments may be withheld or suspended."

Since the determination of what constitutes "reliable evidence" at the

investigation stage is a subjective determination at best, and the Surveillance and Utilization Review (SUR) Committee in section 204 has been deleted in this set of rules, these judgments will be at the sole discretion of the investigators alone. It is entirely reasonable to expect that the investigation team be required to appeal to a higher objective authority in providing sanction for these very critical suspensions. This not only serves to protect the rights of those accused, but also serves to protect and ensure the impartiality, accountability and credibility of the investigation's unit.

These rules also delete section 210 (pg. 269) which provides a process for Appeal of Immediate Actions such as suspension of payments or provider agreements. This section stated "the Department shall provide for a hearing within thirty (30) days of receipt of a timely filed notice of appeal." Section 224 of these rules clarify that appeals will be governed under the "Rules of Contested Case Proceedings and Declaratory

Rulings" in IDAPA 16.05.03 . . . As far as I can tell, there is no requirement for the Department to provide a hearing within any specific period of time. We believe that access to timely appeal hearings are also an important check and balance to ensure appropriate protections against arbitrary, capricious and dictatorial enforcement actions. Many providers would be financially ruined and unable to recover from these administrative processes within a few weeks let alone a month or more.

The way in which these pending rules are structured allows for the possibility that a provider accused of committing fraud or abuse could be summarily put out of business based on an unsubstantiated charge with no real recourse or due process rights during the interim. We suspect that there are many more instances of unfounded charges of fraud than complaints that ultimately result in convictions.

In summary, we agree that suspensions are in order in cases where a provider refuses to provide investigators with relevant records necessary to conduct their investigation. We have been under the understanding that this was a fundamental requirement of a provider of Medicaid-funded services all along. This refusal is an overt act that is an incontrovertible fact, as opposed to an unsubstantiated allegation. We disagree with the removal of timely due process protocols described in sections 204 and 210. We respectfully request that this committee amend this rule to restore sections 204 and 210. We also request that sections 208 and 209 be amended to require the approval of the Surveillance and Utilization Committee in cases where suspension of payments or the provider agreement are determined necessary to avoid immediate danger to the public health and safety. This concludes my prepared presentation on this docket.

Kathleen Allyn, Deputy Administrator responded to a question from the committee about the location of the Department's Fraud Unit. In November 2000, the Legislature's Office of Performance Evaluation (OPE) conducted a study of Idaho's Medicaid Program. One of the OPE's recommendations was to move the fraud unit from the Medicaid Division. The fraud unit is currently operating within the Department's Division of Management Services.
MOTION: A motion was made by Senator Ingram to hold Docket 16-0309-0308. The motion was seconded by Senator Sweet.

Discussion: The motion as presented does not kill Docket 16-0309-0308, and a further review will be conducted at a later time.

The motion was carried by a voice vote.

Docket No.

16-0310-0203

Sheila Pugatch, a Senior Financial Specialist, Division of Medicaid, presented rule docket 16-0310-0203, and addresses hospital

reimbursement. The department requests that you, adopt this pending rule as final. Your committee approved this docket last year as

temporary.

As a result of the Governor's 3.5% holdback, we are paying hospitals 3.5% less each month. The Department is requesting that the Committee approve this Pending rule as final.

MOTION: A motion was made by Senator Kennedy to accept Docket 16-0310-0203. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
Docket No.

16-0310-0204

Ms. Pugatch presented docket 16-0310-0204 and it changes the reimbursement methodology for wheelchairs. Your committee

approved this docket as temporary, last year and the department

would now like you to adopt this pending rule as final.

This rule changes how Medicaid pays for wheelchairs for residents of Intermediate Care Facilities for the Mentally Retarded, also known as ICFs. This rule was changed following negotiations between the Department and the ICF industry.

Medicaid -under these rules- directly pays Durable Medical Equipment Suppliers instead of paying the ICFs who previously purchased the wheelchairs. This change has three positive effects:

It eliminates the cash flow problem experienced by small ICFs when a resident requires a highly specialized and expensive wheelchair.

Since Medicaid purchases wheelchairs directly from the suppliers,

costs are reduced because Medicaid reimbursement is less than the retail prices that ICFs paid.

The participant is more readily accepted for admission into the small facilities and keeps the wheelchair, no matter if he moves between facilities or into a community placement.

The Department is requesting that the Committee to approve this

pending rule as final.

MOTION: A motion was made by Senator Bailey to adopt Docket 16-0310-0204. The motion was seconded by Senator Sweet, and motion was carried by a voice vote.
Docket No.

16-0310-0301

Ms. Pugatch explained docket is 16-0310-0301. This rule identifies the reimbursement methodology for out-of-state nursing homes. Your committee approved this rule as temporary last year and the department is asking you to adopt this Pending rule as final.

This rule explains that out-of-state nursing homes are reimbursed using the same rate they receive from the Medicaid program in their home state. Other minor clarifying language has been added to improve understanding of this reimbursement section.

In addition, this docket incorporates Title 42 of the Code of Federal Regulations, Part 447, entitled "Payment for Services," and the Medicare Provider Reimbursement Manual into these rules.

MOTION: A motion was made by Senator Sweet to adopt Docket 16-0310-0301. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
Docket No.

16-0310-0302

Ms. Pugatch reported this next docket, 16-0310-0302 identifies a reimbursement methodology used to adjust interim hospital payments. The department requests the committee to adopt this pending rule as final.

This docket changes how monthly Medicaid payments are paid to hospitals in order to lessen the effect of overpayments and under-payments. The change will improve the accuracy of payments during the course of the year rather than waiting until cost settlement which often occurs two-years after the interim payments are made. The change will improve cash flow for the Department.

The change only affects those hospitals where payments vary by more than $100,000 on their most recent cost report. The Department is requesting that the Committee approve this rule.

MOTION: A motion was made by Senator Darrington to approve Docket 16-0310-0302. The motion was seconded by Senator Sweet, and motion was carried by a voice vote.
Docket No.

16-0310-0303

Ms. Pugatch explained this docket, 16-0310-0303, clarifies Medicaid

reimbursement methodology. The department requests that this committee adopt this pending rule as final.

This rule clarifies four sections in Chapter 16.03.10. The first section clarifies the occupancy adjustment factor. The clarification is to specify that the property rental rates are not included in the total property costs for the occupancy level calculation.

The second section clarifies the extension of the effective date for a special rate.

The third section clarifies that all financial reports are subject to audit.

The last section clarifies the process regarding amending Disproportionate Share Hospital surveys, otherwise know as DSH.

MOTION: A motion was made by Senator Bailey to adopt Docket 16-0310-0303. The motion was seconded by Senator Brandt, and motion was carried by a voice vote.
Docket No.

16-0317-0301

Pam Mason, a Program Manager in the Division of Medicaid, explained

the Department is seeking your approval of docket 16-317-0301. This docket is being presented as a pending rule and applies to Medicaid policy for case management services referred to as service coordination.

This docket is a rewrite of the current four (4) sections of Medical Assistance rules pertaining to case management services for Individuals with Developmental Disabilities; individuals receiving Personal Care Services; Individuals with Mental Illness, and for children who meet certain medical criteria.

The rewrite of these rules combines all four (4) sets of rules into one section. The combination and standardization when possible of all rules governing case management services reimbursed by Medicaid is part of our effort to make our rules more consistent, understandable and accessible to providers.

The chapter defines the requirements for all common functions of case management as well as specific requirements for each type of eligible participant group. This includes eligibility requirements; case management functions; availability and access to services;

provider qualifications; agency responsibilities; required documentation and payment for service limitations.

This rule rewrite was developed during a negotiated process that involved:

1. Medicaid participants who receive each of the four types of case management services;

2. Case management and other interested provider associations;

3. Advocacy groups

4. Individual Service Coordinator's from Service Coordination agencies.

This concludes my presentation to the Committee on this docket. I respectfully ask the committee to adopt this pending rule as final.

MOTION: A motion was made by Senator Brandt to adopt Docket 16-0317-0301. The motion was seconded by Senator Sweet, and motion was carried by a voice vote.
ADJOURNMENT The meeting adjourned at 9:45 a.m.




DATE: Thursday, January 22, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Stegner, Sweet, Bailey, and Kennedy
MEMBERS ABSENT/

EXCUSED:

Senator Burkett
GUESTS: See the attached sign-in sheets.
MINUTES: A motion was made by Senator Bailey to accept the minutes of Tuesday, January 20, 2004, as presented. The motion was seconded by Senator Brandt, and motion was carried by a voice vote.
The meeting was conducted by Vice Chairman Compton.
RULES REVIEW: Department of Health and Welfare, Division of Medicaid, and the Division of Family and Community Services.
Docket No.

16-0311-0101

Docket 16-0311-0101, Intermediate Care Facilities for the Mentally Retarded, was presented by Debby Ransom, the chief of the Bureau of Facility Standards in the Division of Medicaid.

I am before you today to review a temporary rule Docket Number 16-11-0101. The Department is asking to be extended for a year.

This temporary rule sets a cap on beds in community intermediate care facilities for persons with mental retardation at 486 beds. Of that 486, 12 are reserved for time-limited emergency use.

The Department is before you requesting extension of the ICF/MR bed cap for another year.

The Department consulted with the Idaho Association of Community Options and Resources, the ICF/MR association, and there is no objection to this request from the association. I am not aware of concerns from any other group.

MOTION: A motion was made by Senator Bailey to adopt Docket 16-0311-0101. The motion was seconded by Senator Brandt, and motion was carried by a voice vote.
Docket No.

16-0322-0301

Docket 16-0322-0301, Medication Returns from Residential or Assisted Living Facilities, was also presented by Debby Ransom. She explained, I am before you today to review pending rules found at Docket Number 16-0322-0301.

We are requesting that the committee recommend adoption of these pending rules.

There are three changes to these rules:

Subsection 428.01 is being amended to cite to the Board of Nursing rules without referencing specific sections due to changes made to those rules.

Subsection 428.02 is being amended to delete a process which conflicts with the Board of Pharmacy rules.

During the 2003 Legislative session House Concurrent Resolution 17 asked that the Department and the Board of Pharmacy develop rules to allow the return of unused, unopened medications to the dispensing pharmacy for credit. Stakeholders (Trade Associations IDALA, IHCA,

and Pharmacy) and providers were involved in the development of the process and rules.

Subsection 428.04 is being amended to allow residential care and assisted living facilities to return unused or unopened medication to the dispensing pharmacy for credit.

The Residential Care Council for the Elderly and the Board and Care Council voted unanimously to support the rules during the October meeting.

The Board of Health and Welfare approved the rules in their November meeting.

There were two positive comments received. No negative comments and no request for hearing. We respectfully request that the committee recommend adoption of these pending rules.

Michelle Glasgow , executive director of the Idaho Assisted Living Association testified the Association does support the rules with some clarification. The Association has concerns with Section428.02, Medication Distribution System - Each facility shall use Medi-sets, or blister pack, or other system as approved by the department. The Medication System must be filled by a pharmacist and appropriately labeled in accordance with pharmacy standards. "A licensed nurse may fill Medi-sets which must be appropriately labeled with medication name, dosage, amount and time to be taken, and special instructions if appropriate."

Jim Alexander, a pharmacist from Mountain Home, testified in support of the deletion of that section of the rule. He explained the liability involved and the responsibility of a pharmacist in repackaging medications.

MOTION: A motion was made by Senator Kennedy to approve Docket 16-0322-0301. The motion was seconded by Senator Darrington, and motion was carried by a voice vote.
Docket No.

16-0309-0214

Docket 16-0309-0214, was presented by Shawna Kittridge, the Pharmacy Services Supervisor for the Division of Medicaid, presented pending rules regarding the Medicaid Pharmacy Program. The Department is requesting these pending rules be approved as final. This docket of rules was approved as temporary during the 2003 Legislature.

The purpose of these pending rules is to improve and protect the health status of our participants through the provision of quality care. These rules will allow Medicaid to provide our participants with the most effective drug at the right price through a variety of pharmacy management tools.

Idaho Medicaid, like many other state Medicaid and commercial pharmacy benefit programs, has implemented a variety of pharmacy management processes . . . tools. These common management

strategies include generic substitution requirements, prior authorization of drugs and coverage limitations like limits on quantities per prescription and early refills. This rule docket provides for the tools that support appropriate management of the Medicaid pharmacy program. These

pharmacy management strategies are already standard practice in commercial health insurance plans.

These rule changes also allow Medicaid to make decisions based on objective scientific information. This objective scientific information (commonly referred to as evidence-based reviews) will provide the clinical foundation and support for our pharmacy management processes. Medicaid will encourage the use of effective medications at the best price through these management tools. The purpose of this rule docket is appropriate access.

In December 2003, Medicaid processed nearly 217,000 prescriptions. Less than 1,400 required any type of prior authorization. Less than one-half of 1-percent of the prescriptions processed through Medicaid. Approximately 75 percent of those that needed prior authorization were

approved.

Idaho paid $128 million for Medicaid prescription drug benefits in fiscal year 2003. In fact, Prescription drugs were the second most expensive Medicaid benefit following hospital services and accounts for 15% of the Medicaid budget. However, the combined effect of these rule changes helped to avoid an estimated $20 million in pharmacy costs in state fiscal year 2003 and an overall cost avoidance of $32 million in pharmacy costs since 2002 when these rules were initiated.

Amendments to the temporary rule docket were made following legislative approval. The amendments are based on comments received in the public hearing, testimony presented before the Senate Health and Welfare Committee and negotiations during the 2003 Legislative session. For example, as requested the Department has included two new subsections that provide for a 72-hour supply of a covered drug in an emergency and states that the Department will respond within 24 hours to a request for prior authorization.

These rules provide important tools that allow us to continue the delivery of quality care to our Medicaid clients by providing the most effective drug at the right price. Overall these rules will help Medicaid improve the health of our participants by delivering quality care and managing costs.

The Department requests that the Committee approve the rules in Docket 16-0309-0214 as final.

Stan Gibson, a pharmacist in Nampa and past president of the Idaho Pharmacy Association, testified to support Docket 16-0309-0214.

Rick Sutton, a pharmacist for Shopko stores, testified to support Docket 16-0309-0214, and requested the committee to approve the rules.

Clyde Dailey, state director for AARP Idaho, testified and submitted the following written comments.

Jim Alexander, an independent pharmacist in Mountain Home, testified in support of Docket 16-0309-0214.

Clyde Dailey testified and explained that on behalf of AARP Idaho's 150,000 members I wish to thank you for this opportunity to testify before you today. AARP has long advocated for quality medical care. As the Committee is well aware, prescription drugs are an integral factor in the effective treatment and prevention of disease. As such, there is a wide range of drugs available which purport to treat the same condition.

After careful review of Idaho Department of Health and Welfare Medicaid rules that will permanently establish its Enhanced Prior Authorization Program, AARP Idaho supports this rule. This unbiased, scientific approach identifies the most effective drugs in today's health care market and protects the safety of the consumer.

Jim Baugh, executive director of CO-AD (Comprehensive Advocacy Group), testified about Docket 16-0309-0214 and Docket 16-0309-0303 at the same time. He did not ask the committee to reject the pharmacy rules, but did sound a cautionary note about this particular type of activity. He is concerned about the increased cost of drugs and prior authorization.

Dan Fuchs, submitted the following written comments to support the pharmacy rules: His written comments are:

I am a member of the Idaho Board of Health and Welfare, and I have been a licensed pharmacist in Idaho for 17 years.

My family owns and operates five (5) pharmacies in the Twin Falls area. Our five pharmacies serve thousands of Medicaid clients annually, and that number grows every year. I have watched Idaho Medicaid struggle to meet the rapidly increasing demand for prescription medications. And, I have watched the cost of those medications rise just as quickly.

Medicaid has correctly recognized, in my opinion, that only a carefully managed pharmacy program can effectively deal with this problem. Medicaid has taken steps that will give the state the opportunity to manage costs and still make sure Medicaid patients receive the important medicines they need.

I urge the committee to approve the rules that allow the Medicaid Pharmacy Unit to manage the prescription program.

One of the issues you are looking at is the rules' docket for operation of the prior authorization program. The prior authorization program creates a little more work for me, but the value I get from the program, as a taxpayer and a pharmacist, is far more important. The prior authorization helps Medicaid manage costs and still deliver needed medications for clients. I do not see it as a roadblock to good health care, but using the same practices as private health insurers.

The prior authorization process is fast and barely noticeable to my customers. Medicaid pharmacists are quick to respond if there are problems.

I understand that the program has saved the Department millions of dollars. I ask that you support this important program by approving the rules before you today.

Jeffrey K. Edwards, MD, St. Mary's Clinic in Cottonwood, submitted written comments to support of the pharmacy rules. His written comments follow:

As a licensed family practice physician here in Idaho, I strongly urge you to support the proposed pharmacy rules currently under review by the committee.

As a doctor in a small rural Idaho community, I want to talk to you briefly about the importance of a Medicaid pharmacy prior authorization program. You may know it as the Enhanced Prior Authorization Program, but whatever its title, it is extremely valuable to me as a physician and most importantly to my clients.

The pharmacy rules for the Enhanced Prior Authorization Program (EPAP) ensures the best health outcome for Medicaid clients by selecting the most effective drug at the right price.

The prior authorization program has three main components:

  • Evidence-based clinical review process
  • A pharmacy and therapeutics committee
  • An automated system called SmartPA that reviews prior authorization requests in seconds, making the process quick and convenient to pharmacists and doctors; and transparent to the Medicaid client.


The prior authorization program is a tool, working in conjunction with the Pharmacy and Therapeutics Committee, prior authorization gives health care professionals, like me, the information we need to ensure that Medicaid clients receive quality care at the best price. It provides physicians with the latest research on the efficacy and safety of drugs. It promotes something we call best practice medicine . . . or the best use of pharmaceuticals in patient care. And, it still provides me with the flexibility to prescribe the medicine my patients need.

The Division of Medicaid has made successful efforts to streamline the prior authorization process. In fact, virtually all my prescriptions for Medicaid clients pass through the system without delay. If a prior authorization is needed, it only takes minutes to submit the necessary information for the request.

I strongly encourage you to support this program because it provides the basis for quality care at the right price for Idaho's Medicaid clients.

MOTION: A motion was made by Senator Stegner to adopt Docket 16-0309-0214. The motion was seconded by Senator Brandt, and motion was carried by a voice vote.
Docket No.

16-0309-0303

Shawna Kittridge, the Pharmacy Services Supervisor for the Division of Medicaid, also presented Docket 16-0309-0303.

I am here today to present pending rules regarding the Medicaid

Pharmacy Program in Docket 16-0309-0303. The Department is requesting these pending rules be approved as final.

One of the Department of Health and Welfare's goals is to improve the health of Idahoans. Medicaid provides services to some of the most vulnerable Idaho populations--elderly, children, and people with disabilities. The goal of the Medicaid Pharmacy Program is to provide quality care to Medicaid participants with the most effective drug at the right price. This rule change promotes the health and safety of Medicaid participants by assuring that objective research plays a primary role in our prescription drug program.

The rule supports the use of the most current expert objective research. This objective research, also known as evidence-based reviews, compares the relative safety, effectiveness and clinical outcomes of medications within a group of similar medications or drug class.

Evidence-based information allows the Department to make prior authorization and other program related decisions based on good science. Idaho Medicaid has joined with other states and countries to obtain current evidence-based drug class reviews from the Center of

Evidence-based Policy at OHSU. Dr. John Santa will provide further information regarding the Drug Effectiveness Project in a moment. The main point is that the use of national credible evidence-based reviews allows the Department to "globalize the evidence and localize the decision."

To localize the decision, the Department builds on the knowledge and expertise of fellow Idaho medical practitioners. This rule describes the membership, appointment and responsibilities of the Medicaid Pharmacy and Therapeutics Committee. This Committee is made up of practicing Idaho physicians, pharmacists, and health care practitioners (such as

Nurse Practitioners or Physician Assistants) who currently prescribe medication for our Medicaid clients. One of the Committee's roles is to make recommendations to the Department regarding the Enhanced Prior Authorization Program. Specifically, this Committee recommends which medications will not require prior authorization within a group of equally effective medications; thus, localizing the decision of the most effective drug after a global evidence-based review.

Additionally, in an effort to obtain the right price for medications paid for by Idaho Medicaid, this rule adds guidelines for a supplemental rebate program. Supplemental rebates will enable the Department to purchase prescription drugs in a cost-effective manner. Supplemental rebates will be in addition to rebates Medicaid currently receives. Supplemental rebates allow for price competition to occur after a thorough scientific

( evidence-based) review.

This rule change is based on comments made during the Public Hearing, 2003 Legislative rules presentations and meetings with a Legislative Task Force regarding the previous Docket No.16-0309-0214, dealing with pharmacy management tools. This rule was amended in response to information received during the comment period and consultation between the Legislative Task Force and Department staff.

Above all, through the use of evidence-based practices, establishment of a Pharmacy and Therapeutics Committee, and a supplemental rebate program, we will assure that objective research plays a primary role in our prescription drug program. Our program provides Medicaid participants with the most effective drug at the right price. The Department requests that the Committee approve the rules in Docket 16-0309-0303 as final.

John Santa, MD, a specialist in Internal Medicine testified and presented a project overview of drug effectiveness, a project of the Center for Evidence-based Policy, Oregon Health and Science University.

Dr. Santa explained he spends most of his time on the project, the Drug Effectiveness Review Project that I would like to briefly familiarize you with.

This project provides Idaho and other participating organizations with the most current, comprehensive, rigorous review of evidence regarding the comparative effectiveness and safety of selected prescription drugs. It does so in a way that is independent, scientific, and objective enabling local decision makers to evaluate all of their decision options.

The project is a collaboration of private and public purchasers, like Idaho, who think it best to do this information gathering step together. Each Participant, including Idaho, has a vote in selecting the drugs to be reviewed and identifying the key questions regarding these drugs. The project will be guided throughout by local decision makers with input from stakeholders in their state or organization.

The Center for Evidence-based Policy provides support to the Project by facilitating the collaboration, including contracting with Evidence-based Practice Centers to review and report on the drugs and key questions identified. Evidence-based Practice Centers (EPC) are designated as such by the federal government (Agency for Healthcare Research and Quality) as centers of expertise in studying important and difficult health issues in an independent, scientific, objective way. The EPC searches and sifts the world's information bringing order to what otherwise can be a very chaotic and complex process.

Let me share an example of the sort of information dilemma facing all of us that this process better informs. See ACP Journal Club, January 2004, "Carvedilol was more effective than metoprolol tartrate for lowering mortality in chronic heart failure."

I have attached a more detailed paper summarizing the key elements of systematic reviews. Such a review would find as many studies as possible like the one I have just shown you, look at all the important details in each of those studies and synthesize them. The Project would also update the reports every six (6) months to keep the information current. The commitment to regularly update is unusual in American scientific efforts. Additional detail is also attached on the process for systematic reviews. (See Attachments #1, #2 and #3)

Clyde Dailey, state director of AARP, testified to support Docket 16-0309-0303.

Peter Kozisek, MD, medical director of the Family Practice Medical Center in Boise, testified to support Docket 16-0309-0303. He has been very impressed with the work Medicaid has done throughout the past several years on this program. He has found the Medicaid staff very helpful, very efficient, and very accessible to physicians. The department has a very efficient and cost-effective Medicaid unit.

Roseanne Hardin, J.D.,LSW, submitted the following written comments:

As the current chair of the Board of Directors of the National Alliance for the Mentally Ill-Boise Affiliate, NAMI-Boise, I am writing to recommend that your committee not approve the above identified temporary and proposed rule as proposed by the Department of Health and Welfare as written. Our organization, made up of consumers of mental health services and family members of persons with serious and persistent mental illness, has grave concerns that this move to a prior approval/formulary approach will place persons in danger, and in so doing, greatly increase the cost of medical services required by these persons.

As you know, nearly one in five Americans at some point in their lives will be personally impacted by mental illness and nearly all of us have a family member or close acquaintance who is negatively impacted by mental illness. We all know that mental illness is caused by a chemical imbalance in the brain. We no longer believe mental illness is caused by bad parenting or lack of will power or initiative. The additional good news is that treatment, including psychotropic medications, do work and recovery is possible.

Older psychotropic medications, which are less costly, even when seemingly chemically effective, do generally have significant side effects which impact the patients' ability to tolerate the drug. People cannot tolerate these side effects and stop taking these drugs. Newer generations of medications are often more tolerable to patients as they do not result in the patient being "spaced out," fidgety, without sexual drive, and lessen the very common weight gain which may be dangerous to physical health. No medication works if it is not taken by the patient.

We at NAMI-Boise request that the proposed rules be amended to create a "mental health carve out" that would allow for final determination in the prior approval process to be left with the prescribing medical care provider, the individual who actually knows and works with the patient. Absent this fundamental patient-care provider right, it is likely fewer persons with mental illness will take, tolerate, and thus benefit, from the medications covered by Medicaid for their mental illness.

Medications that are not taken are a waste of money. Psychiatric crises that may have been avoided with appropriate medications, and the ensuing cost to all community, county and state systems are also a waste of money, but more significantly, a waste of human dignity and spirit.

It is recommended that the sections of Medicaid rule addressing prior authorization of pharmaceuticals in IDAPA 16.03.09.810.e and 814 be amended to create a "mental health carve out" which would allow final determination of the appropriateness of Medicaid covering the cost of the prescription be retained by the care provider who prescribes the medication, not the P&T (Pharmacy and Therapeutics) committee or a physician employed by the state agency.

It is certainly recognized by NAMI-Boise, that the Legislature has a duty to be prudent in the approval of publicly funded medications for persons in our State. The Legislature also has the duty to be compassionate and wise; two values not conflict in this instance. To be effective, medications must be able to be tolerated. If you have a loved one with mental illness, the best medication is the one that is effective to control symptoms and not create side effects that can't be tolerated.

Please consider these issues in review of these rules.

MOTION: A motion was made by Senator Brandt to accept Docket 16-0309-0303. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
Docket No.

16-0611-0301

Chuck Halligan, a program manager for Children and Family Services with the Department of Health and Welfare, presented two rules governing Family and Children's Services. The first docket he discussed is docket number 16-0601-0301, a pending rule. He explained, I would ask that the committee consider adopting these pending rules as final.

This docket had no hearings and two positive comments. The intent of these rules will make them more consistent and understandable, in particular by adding clarification around the word parent and certified adoption professional.

We had made some changes to the word parent in a previous docket through an omnibus clerical correction. Upon further review we needed to add better language around the word parent and other grammatical changes were incorporated. The addition of the term certified adoption professional was added and clarifications of the sections related to that

term was edited. Again, I would ask that the committee consider adopting these pending rules as final.

MOTION: A motion was made by Senator Ingram to accept Docket 16-0601-0301. The motion was seconded by Senator Kennedy, and motion was carried by a voice vote.
Docket No.

16-0601-0401

Mr. Halligan explained the second docket is number 16-0601-0401, a temporary rule. I would ask that the committee consider extending these temporary rules. This docket had no hearings and no comments were received. This temporary rule is the result of a foster care reimbursement rate increase passed by the legislature last year. As you can see in the

chart on page 82, there is a modest increase in the rate foster parents are reimbursed for the care they provide to the state's most vulnerable children. Although financial incentives are not the most important factor in recruiting and keeping foster parents, and Idaho's rates are still below the national average, your efforts at increasing the reimbursement rates are appreciated by Idaho's foster parents.

I would again ask that the committee consider extending these temporary rules.

MOTION: A motion was made by Senator Kennedy to accept Docket 16-0601-0301. The motion was seconded by Senator Sweet, and motion was carried by a voice vote.
ADJOURNED The meeting adjourned at 9:50 a.m.




DATE: Friday, January 23, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Stegner, Sweet, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

Senator Ingram
GUESTS: See the attached sign-in sheet
MINUTES: A motion was made by Senator Bailey to accept the minutes of Wednesday, January 21, 2004, as written. The motion was seconded by Kennedy, and motion was carried by a voice vote.
RS 13729 This concurrent resolution would reject certain pending rules of the Department of Health and Welfare relating to determining and calculating income concerning eligibility for medicaid for families and children. The effect of this resolution, if adopted by both Houses, would be to prevent the agency rules from going into effect.

If adopted, the Senate and House of Representatives concurring therein, that IDAPA 16.03.01, Sections 346, 347, 348 and 349, rules of the Department of Health and Welfare relating to eligibility for Medicaid for families and children, adopted as pending rules under Docket Number 16-0301-0302, be, and the same are hereby rejected and declared null, void and of no force and effect. This concurrent resolution has no fiscal impact.

MOTION A motion was made by Senator Compton to send RS13729 to Print. The motion was seconded by Senator Stegner, and motion was carried by a voice vote.
SB 1215 Michael J. Kane, from the Idaho Sheriff's Association, presented SB1215 relating to the regulation of food establishments; amending Section 39-1602, Idaho Code.

The purpose of this bill is to delete county jails and state correctional facilities from the requirements of the Idaho Food Code. This code, enforced by the Idaho Department of Health and Welfare, is designed to apply to restaurants and other private and public food service entities. State correctional facilities and county jails have their own rules and regulations pertaining to service of food within correctional facilities and jails that are better designed to meet their needs. Implementing Health and Welfare rules on food service would create a significant financial burden on the state and on county governments that would require additional funding from the state general fund and local property taxpayers. This bill will avoid that unnecessary burden.

This bill has no adverse impact on the general fund or on county budgets.

Richard Schultz, Administrator of the Division of Health for the Department of Health and Welfare testified and had no objection to SB1215.

MOTION: A motion was made by Senator Compton to send SB1215 to the Floor with a Do Pass recommendation. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
RULE REVIEW: Vice Chairman Compton conducted the rules' review of the Department of Health and Welfare, Division of Family and Community Services and also for the Office of the Director.
Docket No.

16-0603-0301

This rule, Docker 16-0603-0301, was presented by Substance Abuse Program Manager Pharis Stanger, for the Department of Health and Welfare, Division of Family and Community Services.

He explained he is here to discuss Docket 16-0603-0301 with pending changes to the Rules and Minimum Standards Governing Alcohol/Drug Abuse Prevention and Treatment Programs. He explained, I am asking you to adopt these pending rules as final.

Our mission at Health and Welfare is to promote and protect the health and safety of Idahoans . . . in my part of the department we focus on substance abuse. A year ago, this committee approved temporary rules that standardized treatment for Drug Court participants. These rules are now accepted in courts and communities across the state.

We distributed the temporary rules to all approved alcohol/drug treatment providers, drug court coordinators and trial court administrators. We received two (2) comments throughout the year that did not necessitate additional changes to the rules.

We are excited about our partnership with the Idaho Supreme Court to continue the success of the Drug Court Program in Idaho. We again ask that you adopt these pending rules as final.

MOTION: A motion was made by Senator Brandt to accept Docket 16-0603-0301. The motion was seconded by Senator Sweet, and motion was carried by a voice vote.
Docket No.

16-0613-0301

and

16-0613-0302

Docket 16-0613-0301, Rules and Minimum Standards Governing Emergency Assistance for Family and Children, was presented by Mardell Nelson, a Program Manager for the Division of Family and

Community Services, Department of Health and Welfare.

She explained, I am here today to present rule changes to Docket Number 16-0613-0301, a pending rule for which I am seeking adoption of the repeal of the entire chapter. Docket 16-0613-0302 is the pending rule for which I am requesting adoption and final approval for Emergency Assistance for Families and Children. No hearings were held and no comments were received on these rule changes.



Part of our mission at Health and Welfare is to prevent child abuse, neglect and out-of-home placement of children. This non-substantive rule change helps us do that by standardizing the use of Emergency Assistance funds we use to help families address immediate crises that put children at risk.

First, the pending rules will allow direct service providers in all Department programs, not just licensed social workers in Children and Family Services, to authorize these one-time funds on behalf of families. This expedites the responsiveness of the Department to resolve the families, emergency conditions, precisely when timeliness is critical to child safety and well-being. This also increases our ability to intervene early and divert families from a longer term and more intrusive services such as Child Protection or Temporary Assistance.

Additionally, these rules specify the types of Emergency Assistance services that are to be available statewide. This clarification assures that children at risk and their families receive individualized services, based on their presenting needs and it assures that this array of emergency services is consistently available, regardless of where the family lives in the state.

The Department of Health and Welfare is charged with providing families in crisis with timely, appropriate and accessible services in order to preserve the safety and stability of vulnerable children. The rule changes and clarifications before you will help us in achieving this important

outcome.

MOTION: A motion was made by Senator Stegner to approve Dockets 16-0613-0301 and 16-0613-0302. The motion was seconded by Senator Sweet, and motion was carried by a voice vote.
Docket No.

16-0614-0201

Docket 16-0614-0201, prevention to minors' access to tobacco products (refusal to renew retailer permits due to unpaid civil money penalties) hearing was rescheduled for Monday, January 26, 2004 at 8:30 a.m.
Dockets No.

16-0501-0301

and

16-0501-0302

Gary Payne, PhD, with the Department of Health and Welfare, presented two dockets, 16-0501-0301 and 16-0501-0302.

This pending rule, Docket 16-0501-0301, pertains to the protection and disclosure of the Department's records. This docket repeals the current chapter of rules and is being rewritten in Docket 16-0501-0302, which will comply with HIPAA (Health Insurance Portability and Accountability Act) requirements.

Dr. Payne explained this Docket 16-0501-0302, is a pending rule and is adopting a new chapter of rules to govern the disclosure of Department records. The new rules specifically comply with HIPAA requirements. These rules have been extensively reviewed and in some cases amended after they were initially published in April as temporary rules. Access to documents is extensively regulated by state and federal law. These rules implement those laws.

MOTION: A motion was made by Senator Kennedy to adopt Dockets 16-0501-0301 and 16-0501-0302. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
ADJOURN: The committee adjourned at 9:05 a.m.




DATE: Monday, January 26, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Ingram, Stegner, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

Senators Darrington and Sweet
GUESTS: See an attached sign-in sheet
MINUTES: A motion was made by Senator Bailey to accept the minutes of Thursday, January 22, 2004, as written. The motion was seconded by Senator Stegner, and motion was carried by a voice vote.
A motion was made by Senator Bailey to adopt the minutes of Friday, January 23, 2004, as written. The motion was seconded by Senator Stegner, and motion was carried by a voice vote.
RULES REVIEW:

Docket No.

16-0614-0201

Terry Pappin, a program specialist in the Division of Family and Community Services, Department of Health and Welfare, presented Docket 16-0614-0201. She explained that she is responsible for oversight of the Idaho Tobacco Project. Docket 16-0614-0201 is the pending rules governing Prevention of Minor's Access to Tobacco Products.

This rule was presented to the Legislature during the previous session as temporary. I am here today to ask you to adopt the pending rule as final.

Three hearings were held on these rules. There is a typographical error on the summary page in you binders. All hearings were held in December 2002. No written or verbal comments were received.

The first change in the rules is to require permittees to pay outstanding fines prior to renewal of the annual permit. The state auditor recommended this change be made to improve the rate and timeliness of fine payments. The change will increase permittee awareness of the

law, and the need to comply with the law.

A technical change was also made changing the date used in the formula to determine the number of inspections.

I request that you adopt these pending rules as final to provide the Department clear authority to enforce tobacco inspections and collect fines from retailers who sell tobacco to our minors. It continues to be a vital building block in the efforts to keep Idaho minors safe and drug-free.

A brief discussion was held about the number of penalties and fines; the federal block grant; enforcement efforts to prevent young women and young men, under age 25-years, from using tobacco products; the removal of cigarette vending machines, working with Idaho's Indian Tribes and law enforcement authorities, and changing the word "shall" to "must."

MOTION: A motion was made by Senator Kennedy to adopt Docket 16-0614-0201. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
Docket No.

27-0101-0205

The Board of Pharmacy Executive Director Richard Markuson presented four (4) rules.

Docket 27-0101-0205, relates to controlled substance prescription forms authorized by House Bill 331.

This rulemaking recognizes revised controlled substance prescription forms authorized by House Bill No. 331 in the 2001 legislative session, as well as Senate Bill No.1417 in the 2002 legislative session. The proposed rule changes outline the requirements for controlled substance prescription blank forms, as well as discipline to be assessed by the Board of Pharmacy in the event practitioners fail to follow the requirements of statute and rule with respect to controlled substance prescription blanks.

Robert Seehausen, Chief Executive Officer of the Idaho Medical Association (IMA), testified he has no problems with the rules.

Dr. James Scheel, from the IMA reported he has no objection to the rules.

MOTION: A motion was made by Senator Bailey to adopt Docket 27-0101-0205. The motion was seconded by Senator Brandt, and motion was carried by a voice vote.
Docket No.

27-0101-0302

Docket 27-0101-0302, relates to preparations containing ephedrine or salts of ephedrine as prescription drugs, is a fee rule.

The current rule treats "preparations containing ephedrine or salts ephedrine" as prescription drugs. The proposed rule sets out specific criteria for ephedrine products that can be sold without prescription. These criteria include maximum dosage requirements and label disclosure and warnings.

Fee Summary: Pursuant to Section 67-5226(2), Idaho Code, the Governor has found that the fee or charge being imposed is justified and necessary to avoid immediate danger. An immediate danger is inherent in ephedrine products if they are sold in dosage amounts in excess of the rule or containing synthetic rather naturally occurring ephedrine alkaloids. The fee charge under this rule is necessary to fund testing of these products to ensure compliance with the requirements of the rule.

Mr. Markusen asked that this rule be made final.

MOTION: A motion was made by Senator Stegner to adopt Docket 27-0101-0302. The motion was seconded by Senator Kennedy, and motion was carried by a voice vote.
Docket No.

27-0101-0303

Docket 27-0101-0303, this pending rule allows the return and use of unopened drugs.

This rule change allows return and use of unopened and unused drugs. This change responds to House Concurrent Resolution (HCR) No.17 directing the Board of Pharmacy and the Department of Health and Welfare to develop necessary statutory and rul changes to allow the return and use of unopened and unused drugs.

Section 156.02 - Defines the annual report of the registered pharmacist-manager.

Section 156.03 - Defines the responsible pharmacist manager.

Section 156.04 - Defines the responsibility of the pharmacist manager.

Section 156.05 - Defines the return of drugs or other items. In the interest of public health, drugs, medicines, sickroom supplies, devices and items of personal hygiene shall not be accepted for return by any pharmacist or pharmacy after such drugs, medicines, sickroom supplies, devices and items of personal hygiene have been taken from the premises where sold, distributed or dispensed, except that unopened "Unit Dose" packaged medications for in-patient of residential or assisted living facilities, licensed skilled nursing care facilities, and hospitals may be returned to the dispensing pharmacy for credit provided the medications are liquid medication that have been supplied in manufacturer sealed containers and remain unopened, or the medications are in unopened "Unit Dose" packaging. In addition, the following conditions set forth in Subsection 156.05b.

HCR No.17 was passed during the 2003 legislative session, and this rule does comply with HCR17.

A discussion was held regarding these rules of the Board of Pharmacy and a possible conflict with the rules of the Department of Health and Welfare's Medicaid rules work together, long-term care facilities, the safety of drugs, and a pharmacist's option to refuse to accept the returned drugs.

MOTION: A motion was made by Senator Stegner to adopt Docket 27-0101-0303. The motion was seconded by Senator Ingram, and motion was carried by a voice vote.
Docket No.

27-0101-0304

This rule, Docket 27-0101-0304, relates to a list of acceptable pharmacy which are part of the required library in each pharmacy.

This rule change expands the list of acceptable pharmacy references which are part of the required library in each pharmacy. This change is necessary to implement an expanded list of acceptable pharmacy references now recognized by the Board of Pharmacy.

Section 152.01 - Required Books - The latest edition and supplement(s) of the following: Idaho Pharmacy Law and Rules; A current pharmacy patient counseling reference; Facts and Comparisons; one (1) of the following current pharmacy references - Facts and Comparisons, Clinical Pharmacology, Micromedex: and one (1) other current pharmacy reference of your choice (book or computer diskette).

MOTION: A motion was made by Senator Brandt to accept Docket 27-0101-0304. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
Docket No.

19-0101-0301

This pending rule, Docket 19-0101-0301, was presented by Executive Director Mike Sheeley of the Board of Dentistry, and it relates to the Dental Association's Principles of Ethics, Code of Professional Conduct and Advisory Opinions.

The Board of Dentistry's pending administrative rules are intended to accomplish the following matters:

  • To incorporate the American Dental Association's Principles of Ethics, Code of Professional Conduct and Advisory Opinions ("Principles of Ethics") by reference into the Idaho Board of Dentistry's professional standards. A copy of the ADA's Principles of Ethics is included in these materials. The ADA's Principles of Ethics address such areas of dental practice as patient self-determination, patient confidentiality, standards of care and dentist veracity. The ADA's Principles of Ethics are currently applicable to all Idaho dentists who are members of the Idaho State Dental Association or the American Dental Association. A violation of the Idaho Board of Dentistry's professional standards can result in disciplinary action against a dental licensee. See Attachment #1)


  • To specify those dental specialties which are recognized and licensed by the Idaho Board of Dentistry. The Idaho Board of Dentistry currently licenses six (6) dental specialties and the Board members determined that those specialties should be expressly identified in the administrative rules.


  • To define advertising terms and delineate what conduct constitutes false, misleading or deceptive advertising. At present, the Idaho Dental Practice Act [Idaho Code § 54-924(4) and (9)] specifies that false, fraudulent, misleading and deceptive advertising is proscribed and may provide grounds for disciplinary action against a licensee. Enforcement of the advertising provisions in the Idaho Dental Practice Act requires the Idaho Board of Dentistry to specify those matters that constitute impermissible advertising conduct.


Jerry Davis, Director of the Idaho Dental Association, reported the vast majority of dentist support the rules.

MOTION: A motion was made by Senator Kennedy to adopt Docket 19-0101-0301. The motion was seconded by Senator Stegner, and motion was carried by a voice vote.
Docket No.

15-0120-0301

This pending rule, Docket No.15-0120-0301, relates to rules governing the Area Agency on Aging, and was presented by Sarah Scott, program operations manager for the Idaho Commission on Aging.

The proposed rule changes eliminate many existing requirements regarding the day-to-day operation of Area Agencies on Aging (AAAs). This will allow more flexibility in the AAA's provision of services to the elderly through implementation of consumer choice programs. These AAAs are not state agencies but are subject to federal laws and rules.

MOTION: A motion was made by Senator Kennedy to adopt Docket 15-0120-0301. The motion was seconded by Senator Stegner, and was carried by a voice vote.
ADJOURNED: There being no further business to discuss, the committee adjourned at 10:18 a.m.




DATE: Tuesday, January 27, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Stegner, Bailey, Burkett, Kennedy
MEMBERS ABSENT/

EXCUSED:

Senator Sweet
Guests: See attached sign in sheet.
Convened: Chairman Brandt convened the meeting at 8:34 a.m.
Gubernatorial Appointment Gubernatorial reappointment of Suzanne Budge Schaefer to the Hazardous Waste Facility Siting License Application Review Panel to serve a term commencing March 6, 2003 and expiring March 6, 2006.

Steve Allred, Director of Idaho Department of Environmental Quality, gave the introduction of Suzanne Budge Schaefer to the Committee members. He stated the Review Panel consists of ten members: three representatives from state agencies, four from the community, and three selected by the Governor. Suzanne has an undergraduate and Master of Science degree in Geology. Her experience includes working on the US geological survey. She has spent time in Houston and Oklahoma on an oil patch. And she worked briefly at INEEL. She has been in Boise for 15 years and has been working mainly on regulatory environmental issues.

Senator Stegner addressed Suzanne asking if her other positions would conflict with this appointment. Suzanne did not believe there ever would be, however, if a case should come up she would be sure to disclose that information to the Governor, and would be replaced at his wish.

Senator Darrington gave a history of the Hazardous Waste Management Act, and the creation of the Hazardous Waste Advisory Panel. The Hazardous Waste Plan says the State of Idaho will not be more stringent than the Environmental Protection Agency (EPA) in regard to RICRA, and the RICRA amendments.

The Committee will vote on the Gubernatorial Appointment of Suzanne Budge Schaefer at tomorrow's meeting.

Senator Compton commented on the value and institutional memory of senior Senators who provide valuable insight to those in the Legislature, especially freshman Senators. He stated that Senators Darrington and Ingram have such extensive knowledge and experience, they are an example of why term limits are not a good idea.

Briefing Idaho Department of Environmental Quality Director Steve Allred addressed the Committee members on the underground storage tanks issue. Mr. Allred stated that Idaho is not properly protecting its groundwater. The State is responsible for underground storage tanks (UST) once they leak. The reason many tanks are leaking is due to inadequate installation, not being installed properly, and they are not being insured.

Orville Green, Administrator, Waste Management Remediation, DEQ, referenced DEQ Annual Report 2003, on page 5, a discussion of the Underground Storage Tank program summary: federal rules that owners/operators must abide by, and the leaking underground storage tank program. Since 2000 DEQ has seen the completion of 226 leaking underground storage tanks, however, during the same time frame, 105 new leaking tank sites were identified.

Chairman Brandt asked how many tanks out of the 105 are still in use? Mr. Green stated 197 leaking UST were on record through July 2003. Mr. Green stated that 226 tanks have been cleaned up since 2000. DEQ maintains a running tabulation of active/non-active sites.

Chairman Brandt stated that a rule addressing primacy and new regulations for existing tanks was rejected by the Senate Resources and Environment Committee last year. He asked whether the new leaking tanks were a result of not having adequate regulations. The rule last year would've required an extra piece of equipment put on the tanks. Would these 105 tanks been required to have this piece of equipment? Mr. Green stated these tanks would have required this equipment, under the federal rules, several tanks were cited for not having this equipment. 17% of the facilities inspected were cited for this reason. The purpose for the UST rules is preventative, not responsive.

Last fall EPA, Environmental Protection Agency, enacted an aggressive inspection of UST in Idaho. Erik Sirs, Project Grants Officer for UST and LUST Programs, Enforcement Compliance Officer, EPA informed the Committee of the results of the inspections. He gave background of the UST program in Idaho, results of Idaho Initiative, and Significant Operations Compliance, a national measure that states how Idaho is doing.

The UST program has two components. The first component is prevention, compliance and enforcement which is federally run. The second is LUST which is state run.

The Idaho Initiative was developed due to previous years field experience indicated there was a low compliance rate occurring in the state. It is EPA responsibility to administer the compliance program within Idaho. Mr. Sirs brought in other EPA inspectors from around the region to assist in the project.

Chairman Brandt asked Mr. Sirs how many inspectors there were to perform the inspections as he told the Senate Resources and Environment Committee last year. Mr. Sirs stated that Idaho has one federal inspector and two for the Region.

Mr. Sirs stated the regional area selected for the project included: Idaho Falls, Pocatello, Couer d'Alene, and Boise due to large population centers and gave a large snapshot of the state. He tried to choose sites that had not been inspected before. Letters were sent out two weeks in advance indicating what information the inspector wanted to see when they came on the site. 94 inspections were performed. 20 facilities passed, 33 written warnings were issued (may have involved field citations) and 47 field citations with monetary penalties resulted. A total of 146 violations were recorded for the 94 inspection sites.

Mr. Sirs referenced a graph depicting Enforcement Results in various categories of pie charts.

Violations

  • Insurance Related 8.4%
  • Upgrade Violations 27.4%
  • Corrosion Protection 13.7%
  • Release Detection 49.5%
  • Temporarily Out of Service 1.1%


Chairman Brandt recollected that nowhere in a written rule is it required, even federally, that sensors be included, it is strictly interpretation. Mr. Sirs stated the rules require two things for line leak protection: monitoring for catastrophic (3 gallons/hr.), and/or annual tightness test, monthly monitoring (electronic sensor), visual inspection (logging number in a chart). Chairman Brandt restated that if a facility had other equipment installed, monitored it properly, they wouldn't need the sensor. Mr. Sirs stated this was correct.

Mr. Sirs stated UST compliance is an issue of significant importance, ground water resources are the primary source of drinking water and EPA is the agency currently responsible for UST compliance. EPA has requested additional resources to conduct other inspections to see if the trend holds true. On the national level, the Energy bill is still in question, and the enforcement section could assist the state with resources.

Senator Compton asked for clarification on 3400 tanks available for review in the state. He asked if the 94 inspected were primarily service stations. Mr. Sirs stated they were. Senator Compton asked how he came up with selecting this two-percent sampling. Mr. Sirs stated it was at random, based on area, he looked for a large amount of facilities within a large area for the purpose of ease of use in conducting the quantity of inspections.

Chairman Brandt asked Mr. Sirs if he found a visibly leaking UST during his inspections. Mr. Sirs reported not one leaking tank was found.

Chairman Brandt referenced an Idaho Statesman article entitled "EPA inspectors find evidence of leaking fuel tanks in Idaho", which gave numbers that didn't coincide with the chart before the Committee at present. Mr. Sirs stated the numbers in the article differ slightly because of some last minute data that was entered into the current chart.

Senator Bailey asked for clarification on the citations issued during the inspections. Mr. Sirs stated that the citations issued were for violations of regulations not for contaminating the water.

Senator Darrington stated that the UST are just one type of problem that could spoil the water quality. He also asked whether there has been any study on the correlation between those violations and underground leaks.

He stated the important thing is that the Committee is assured and the industry is assured that the things checked have validity and make a difference to the whole program.

Discussion among the Committee members included: the fact that Idaho has no program; the facilities haven't been inspected before; the results are alarming, and is there any chance that those inspected didn't have the adequate records on hand; and what the state of Idaho needs to do to prevent ground water contamination from UST.

Senator Bailey asked what is entailed in the clean up of a site. Mr. Allred stated that the tank is ceased use, repaired or removed; contaminated soil around the tank is removed, but the most costly is what is in the ground water and removing it. $2.6 million was spent cleaning up these sites, some of the money was state funds. He stated the problem is with the lack of personal responsibility and accountability. He reiterated there is a need for a program to make people personally accountable.

Chairman Brandt stated there is a need to protect the water. He is frustrated with regulations that change all the time, what is good today isn't necessarily good tomorrow. He thanked the EPA for validating the direction last year when the inspection question was brought to the Senate Resources and Environment Committee. However, when the rule was before the Committee they were told there was one inspector, yet there were twelve inspectors, plus the administrative staff to handle the inspections. He stated the Idaho Statesman article made it sound like Idaho had fourteen leaking tanks, when in fact there were no leaking fuel tanks found at all.

Senator Kennedy stated that he didn't want the EPA or DEQ to think that this legislative body does not feel it should accept the responsibility to do a fair share in prevention responsibilities of protecting the ground water. He stated it was necessary to revisit the matter, to see if there are reasonable regulations to allow our state to join the other states to adequately protect the ground water.

Suzanne Budge Schaefer, Idaho Petroleum Marketers and Convenience Store Organization, introduced Bob Franklin, Charlie Jones, and Dennis Baird (see sign in sheet). Suzanne distributed handouts to the Committee: "Idaho UST Enforcement Initiative, October 27-30, 2003, EPA Region 10, Submitted by Idaho Operations Office December 3, 2003" and "Overview of Underground Storage Tank Regulation in Idaho" and an EPA Memo (see attached). She stated that Idaho has been a success story with an 85% clean up rate, there are declining claims, and declining leaking sites. She stated that Idaho has 3548 active tanks, 9157 closed tanks which is 61% closure rate. She reported approximately 3000 tanks are insured. She said there is a case to be made that the federal regulations have been very effective in the state of Idaho, regardless of whether there is a state program. Currently they must comply with the federal rules, to get insurance, if they don't have insurance they do not operate. She stated that the rules haven't changed but the interpretation of the rule has changed which is what causes the frustration.

58-0101-0301 Martin Bauer, DEQ, presented 58-0101-0301 Rules for the Control of Air Pollution. This rule is an annual update of federal regulations incorporated by reference into DEQ rules.
MOTION A motion was made by Senator Ingram to approve 58-0101-0301. It was seconded by Senator Brandt. The motion was passed by a voice vote.
58-0105-0301

Orville Green, DEQ, presented 58-0105-0301 Rules and Standards for Hazardous Waste. This rule is an annual update of federal regulations incorporated by reference into DEQ rules. There was no negotiated rulemaking, no comments were received, no changes.
MOTION A motion was made by Senator Bailey to adopt 58-0105-0301. It was seconded by Senator Brandt. The motion passed by a voice vote.
58-0108-0301 Toni Hardesty, Administrator Waster Quality Division, DEQ, presented 58-0108-0301 Idaho Rules for Public Drinking Water Systems. This rulemaking is to specify a fee standard in rule text, and to make drinking water operator certification rules consist with Waste Water Operators certification rules. The program will operate on fees collected.

Senator Bailey stated that he would like to see meetings offered in North Idaho. Senator Ingram asked who conducts the tests and who collects the fees. Toni stated legislation is proposed to transfer the responsibility over to the Bureau of Occupational licensing.

MOTION A motion to approve 58-108-0301 was made by Senator Brandt. It was seconded by Senator Kennedy. The motion passed by a voice vote.
58-0108-0302 Toni Hardesty, DEQ, presented 58-0108-0302 Idaho Rules for Public Drinking Water. This rule is an annual update of federal regulations incorporated by reference. There are minor revisions to the public notification rule of consumer confidence. To incorporate by reference this rule. Majority of changes in rule are corrections and housekeeping.
MOTION A motion was made to approve 58-0108-0302 by Senator Brandt. It was seconded by Senator Darrington. The motion passed by a voice vote.
58-0102-0303

Toni Hardesty, DEQ, presented 58-0102-0303 Water Quality Standards and Wastewater Treatment Requirements. This rule is a correction to conversion factors and internal citations in Section 210, Numeric Criteria for Toxic Substances. Corrections in errors in section 210.
MOTION A motion as made by Senator Kennedy to adopt 58-0102-0303. It was seconded by Senator Darrington. The motion passed by a voice vote.

Senator Darrington stated that as these changes take place, it is important to make sure these rules are maintained under the Health and Welfare Committee.

ADJOURNMENT Chairman Brandt adjourned the meeting at 10:30 a.m.




DATE: Wednesday, January 28, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Bailey, and Kennedy
MEMBERS ABSENT/

EXCUSED:

Senators Stegner, Sweet, and Burkett
GUESTS: See the attached sign-in sheet
Gubernatorial

Reappointment:

Gubernatorial Reappointment to the Hazardous Waste Facility Siting License Application Review Panel:

Suzanne Budge Schaefer of Boise, was reappointed by Governor Dirk Kempthorne for a term commencing March 6, 2003 and expiring March 6, 2006. She is the manager of SBS Associates, LLC, in Boise.

Her educational background includes a Master of Science in Geology from Colorado, and a Bachelor of Science in Geology from Logan, Utah.

Mrs. Schaefer's previous work experiences include: The Galltin Group in Boise; Corporate Relations Vice President of AIA Universe Insurance Group in Boise; Executive Director of the Idaho Council on Industry and the Environment, Boise; Scientist, Geosciences Group, Idaho Falls; Geologist for Conoco, Inc. in Houston, Texas; Geological Intern for Sohio Petroleum in Denver, Colorado; Graduate Teaching Assistant for Colorado School of Mines in Golden, Colorado; Geological Field and Laboratory Assistant for the U.S. Geological Survey, Denver, Colorado; and, Consultant for the Colorado School of Mines Core Lab in Golden, Colorado. Her political affiliation is Republican.

MOTION: A motion was made by Senator Ingram to approve the reappointment of Suzanne Budge Schaefer to the Hazardous Waste Facility Siting License Application Review Panel. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
Chairman's Conference: Chairman Brandt had received a memorandum from the Idaho Legislature's Joint Finance-Appropriations Committee (JFAC) co-chairs, dated January 14, 2004, seeking the committee's help in focusing on cost containment goals concerning the Department of Health and Welfare's Medicaid program. The JFAC memorandum follows:

Over the past several years, the Legislature has enacted a number of cost reduction initiatives intended to curb Medicaid costs. Attached is a list of some of the more recent examples. Despite these initiatives, anticipated savings have not been realized, and expenditures continue to rise, surpassing appropriations in fiscal years 2001, 2003 and 2004.

One weakness in the Medicaid program that has hindered the budgeting process is that the agency has not routinely provided the Legislature with information on the extent to which it has achieved the cost savings anticipated by cost reductions. Such reporting is necessary to keep the Legislature informed of the impact of its policy decisions and to assist the Joint Finance -Appropriations Committee in identifying budget needs. JFAC will be directing the Department of Health and Welfare this year to respond to those questions this year.

Another challenge to cost containment efforts by the Legislature are the sometimes inconsistent intentions which develop between three committees JFAC and the House and Senate germane committees. In some instances, there is not a consensus to support the necessary changes in rules and regulations that are required to implement cost reduction measures that were intended in the appropriation bill from the previous year, which essentially takes the department off the hook, or at a minimum places the Department of Health and Welfare in an awkward position.

We need your help this year in focusing on clear cost containment goals in the budget process. For the past twenty years the average increase in the General Fund Medicaid budget has been nearly 14%. We are no different than other states in seeing a disproportionate amount of our resources chasing significant caseload and health care cost increases year in and year out. We also know the choices are difficult.

As you know we set aside time at the close of the budget hearing process for the germane committee chairs to address JFAC. We would like to enlist the help of your committees in examining what cost control policies would be most appropriate for reigning in the spiraling costs of Medicaid. Specifically, we would appreciate an actual committee vote on potential cost control measures, then have you present those results during your JFAC presentation the second week of February. Some of the issues could include, among others:

1. Reducing or freezing provider rates

2. Reducing or restricting eligibility

3. Reducing or eliminating certain Medicaid benefits

4. Implementing a co-payment system

5. Identifying long-term care reduction strategies

6. Continue efforts to shift other relevant state programs to Medicaid

7. Implement some form of provider fees.

As always, we look forward to working closely with you in the coming session. Your input is crucial for finding common ground on how best to stabilize a program that continues to increase in funding requirements beyond our means.

Committee members reviewed and discussed the JFAC memorandum and the chart "Medical Assistance Program, Anticipated Savings from Medicaid Cost Reduction Initiatives." (See Attachment #1).

The committee suggested the chairman contact the Department of Health and Welfare and discuss the seven (7) items listed in the JFAC memorandum. What programs in Medicaid have federal mandates and cannot be changed, and does the Department believe the seven items are obtainable?

ADJOURNED: There being no further business to discuss, the committee adjourned at 10:05 a.m.




DATE: Thursday, January 29, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Stegner, Sweet, Bailey, Burkett, Kennedy
MEMBERS ABSENT/

EXCUSED:

None
GUESTS: See the attached sign-in sheets
Vice Chairman Compton conducted the committee's business meeting today.
MINUTES: A motion was made by Senator Bailey to accept the minutes of Monday, January 26, 2004, as written. The motion was seconded by Senator Sweet, and motion was carried by a voice vote.
Department of Health and Welfare Director Deputy for the Department of Health and Welfare and also Administrator of the Division of Financial Management David Butler presented a high level overview of the Department's 2005 budget request.

He explained, as in the past the Department has five appropriations. This year's request is a very plain and straightforward request. Simply put, it is maintenance of the current operations budget.

The Department's overall 2004 appropriation was $1.292 billion; this year's request is $1.453 billion or a 12.4% increase.

The 2004 appropriation required general funds of$375.8 million, while the 2005 request is $415.7 million, or a 10.6% increase.

The increases are primarily made up of Personnel Cost Rollups or benefit increases, medical inflation, increased Medicaid caseloads and the 2% change in employee compensation or CEC. We also have two new expansion decision units, as well as, the annualization of startup costs for the CHIP B and CHIP Access card programs.

The Division of Family and Community Services (FACS) has the most

changes. This year, we are transferring the Sheltered Workshops from

FACS to the Division of Vocational Rehabilitation. This transfer moves

almost $3.8 million from the FACS budget and out of the Department.

Within FACS, we also have two new expansion decision units. These

decision units are for funding in the Infant & Toddler program and the foster care program. The Infant & Toddler program provides early intervention services for children up to three years of age who have developmental disabilities. This funding will bring the department into federal compliance for meeting our timeliness in providing service access. The second decision unit, for foster care, is requesting a 5 percent (5%) increase in the amount paid to foster care parents. Currently, for a 10-year-old child, we pay $286 per month compared to an average of Idaho's neighboring states of$413, or 44% less. This increase will move the amount to $300 per month and will still keep us 37% less than our neighboring states. The general fund costs of these programs are $220,000 for the Infant & Toddler program and $161,500 for the foster care program.

Within the FACS appropriation, we also have an increase in employee

compensation of $1.1 million, and an increase in employee benefits cost of $1.4 million.

The general fund impact for this appropriation is a $1.1 million reduction.

Again, this is due to the transfer of the Sheltered Workshops to the Division of Vocational Rehabilitation.

The appropriations for Indirect Services, Welfare and Health have no

material increases outside of the change in employee compensation totaling $573,300. Personnel cost rollups of $763,000 and the annualization of the CHIP program in the Division of Welfare for $421,200. The overall increases for these three divisions total $1.5 million in general funds.

The final appropriation is Medicaid. Medicaid has an increase of$39.4

million in general funds.

Most of the increase is caused by three simple facts. The first being, more people will be enrolled in Medicaid next year, . . . which leads into the second, meaning we will pay for more services, and . . . the third, the cost for many services are also increasing.

More people . . . More services . . . and providers charging more for those services. That accounts for $35.3 million or 90% of the general fund increase in our Medicaid request.

The remaining $4.1 million is related indirectly to the CHIP expansion

approved by the Legislature last year .The cost for services in the new CHIP B and CHIP Access Card programs will be covered by a combination of funds from the state's premium tax fund and the federal government.

However, we anticipate that interest in the new CHIP programs will also

drive up enrollment in the current CHIP program and Medicaid's Pregnant Women and Children program. This is often referred to as the woodwork effect. The state share of increased costs for these two programs would be $3.4 million - which will come from the General Fund.

Finally, Medicaid has $130,000 for annualization of Chip program

supplemental request and $230,000 for the combined CEC and Personnel cost rollup.

Again, as a high level recap: the 2005 budget . . . is maintenance of current operations budget with an overall increase of$39.8 million in general funds primarily found in six (6) items that increase costs and one that reduces cost.

The additions are:

  • $35.3 million for the "normal," annual increased cost of doing business in Medicaid;


  • $550,000 for the annualization of Chip B & Access Card supplemental;


  • $3.4 million for woodwork effect associated with the new Chip B & Access Card programs;


  • $2.3 million for personnel cost rollups or increases in benefit costs;


  • $1.8 million for CEC or Change in employee compensation; and, $381,500 for the two new expansion decision units I mentioned;


  • Those increases are reduced by $3.8 million and the transfer of the Sheltered Workshop program and funding out of the Department to the Division of Vocational Rehabilitation.


The committee discussed "required vs. optional" Medicaid Services. In FY1993, expenditures for federally required services amounted to 75% of the overall Medicaid budget with the cost of optional services 25% of the total. The FY 1993 total was $300.3 million.

In FY2003, expenditures for federally required services dropped to 44% of the overall Medicaid budget with optional services expanding to 56%. The FY 2003 total was $869.6 million.

Required Services - Idaho must ensure that Medicaid clients receive the health care services required by federal guidelines. These mandatory services include physician visits, family planning, laboratory tests, health screening services for individuals under age 21, hospital inpatient and outpatient services, and prescription drugs for children and pregnant women.

Optional Services - Idaho also provides a number of optional services, such as prescription drugs for adults; expanded personal care services; full coverage of prosthetic devices for adults; dental, eye, and hearing services for adults; heart, liver and other organ transplants for adults; payment for services at long-term care facilities for the mentally retarded; adoption and expansion of a children's health insurance program; services for developmentally disabled adults; mental health services for adults; chiropractic and podiatry services; physical therapy; enhanced pregnancy services; and services from ambulatory surgical centers.

The committee reviewed a chart about the Department's 2005 appropriations: (See Attachment #1)

  • Medicaid - 73.8%
  • FACS - 10.1%
  • Welfare - 8.4%
  • Public Health - 4.7%
  • Indirect Support - 2.7%
  • Councils - 0.3%


A Medical Assistance Program, expenditure by service category, listing of what services are required (federal mandated/state services), and the actual and estimated percentages were also reviewed. (See Attachment #2)

In January 2004, the Department released news that Idaho benefits from $1 billion dollar investment. Information on Health and Welfare's investment in every Idaho County can be found online at http://www2.state.id.us/dhw/ "Health and Welfare's Per Capita Investment in Idaho." The news release reported: Last year, Idaho counties received more than $1 billion from the Department of Health and Welfare programs that help people in need. That investment benefits every one of the state's 1.3 million residents.

It's important for people to know that the Department's investment benefits all Idaho residents. This is wise use of taxpayer dollars because the money spent in the community often stays in the community. Those dollars are spent again and again to help create jobs and create an infrastructure that provides healthy and safe communities.

A discussion was held pertaining to complaints Health and Welfare had received during the last year, such as:

  • The number of complaints the Department had received from small providers about late or timely payments during the last year?


Mr. Butler stated, "we receive complaints on a periodic basis." He informed the committee that Senator Ingram brought one group of providers before us, pressing us about late payments. We did our research and found out that, on average, we paid that group every 22-days. Their claim was the payments were at 40-days. Mr. Butler reported, "yes," we are late on some payments, but any billion dollar industry will have a lag-time, but for the most part we are timely. The average payment rate is 22-days, some later and some shorter, but overall payments are made within 22-days.

  • If a payment is late, does Health and Welfare pay interest on the late payment? Is there a statute in Idaho Code governing the Department paying interest on late payments?


Mr. Butler reported there is no obligation for the Department to pay interest unless it is stated in the contract.

  • Senator Bailey referred Mr. Butler to Idaho Statutes, Title 67, State Government and State Affairs, Chapter 57, Department of Administration, 67-5735 - Processing ­ Reimbursement of Contractor: "Within ten (10) days after the property acquired is delivered as called for by the bid specifications, the acquiring agency shall complete all processing required of that agency to permit the contractor to be reimbursed according to the terms of the bid. Within ten (10) days of receipt of the documents necessary to permit reimbursement of the contractor according to the terms of the contract, the state controller shall cause a warrant to be issued in favor of the contractor and delivered. Contracts let or entered into by or through the division of purchasing are exempt from the provisions of Section 67-2302, Idaho Code; provided, however, that late contract payments may be assessed interest by the vendor at the rate set forth in Section 63-3045, Idaho Code, unless another rate is established by contract."


  • Section 67-2302(3), Idaho Code, State Government and State Affairs, Chapter 23, Miscellaneous Provisions: "Unless specifically provided by the terms of a contract that details payment requirements, including penalties shall be due automatically when bills become overdue. It shall be up to each vendor to calculate and invoice interest at the time payment is due on the principal."


  • Section 67-2302(17), Idaho Code, "Each state department, institution and agency head shall be responsible for prompt payments. In all instances where an interest payment has been made by a state agency because of a late payment, the responsible state agency head shall submit to the joint senate finance-house appropriations committee of the legislature at the time of that agency's budget request hearing an explanation of why the bill is paid late and what is being done to solve the late payment problem."


Kelly Buckland, Director of the Idaho Independent Living Council, explained that in 1996 Governor Batt started the Medicaid Reform Council, and they made recommendations about changes to Medicaid. The Medicaid BUY-IN program for Idahoans with disabilities was recommended by the Council. The Medicaid BUY-In is a program that helps people to work by permitting them to buy into Medicaid while working. For people currently on Medicaid, there is no incentive to work more than part-time because if they earn even one dollar too much, they will lose their Medicaid coverage. That coverage pays for the supports and services that people with disabilities need to go to work. With Medicaid BUY-IN, when the eligible person goes to work, they pay a premium, based on a sliding scale, which enables them to retain their coverage. The program encourages independence instead of trapping people in dependence and poverty.

Mr. Buckland requested the committee, when they meet with JFAC (Joint Finance Appropriations Committee), to support the Governor's request in his State-of-the-State address, "many Medicaid recipients are penalized if they have a job." I say we remove of the penalty, and to enable Medicaid recipients to work without losing health care benefits and services that help them remain independent. I urge your support of this common sense change."

Joyce McRoberts, Deputy Director for the Department of Health and Welfare, informed the committee members that today the Department started the "Any Door Initiative" project in Moscow, Region II.

ADJOURNED: There being no further business to discuss, the committee adjourned at 9:50 a.m.




DATE: Friday, January 30, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Stegner, Sweet, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

Senator Ingram
GUESTS: Representative Janice McGeachin, and see the attached sign-in sheets.
The meeting was conducted by Vice Chairman Compton.
The committee reviewed two rule making dockets for the Department of Health and Welfare.
Department of Health and Welfare The Department of Health and Welfare previously presented two rule making dockets, 16-0309-0311 and 16-0309-0308. The hearings were rescheduled for a final review on January 30, 2004.
Docket No.

16-0309-0311

This rule, Docket 16-0309-0311, relating to Medical Assistance rules governing psycho-social rehabilitation (PSR) and partial care services, was first presented on Friday, January 16, 2004, by the Division of Medicaid, Bureau of Benefits and Reimbursement Policy Bureau Chief Leslie Clement.

She explained. Two weeks ago I presented this rule docket 16-0309-0311 regarding Medicaid's Mental Health rules.

When I first presented this rule docket, you heard testimonies from the Mental Health Provider's Association. You also heard that Medicaid was responding to some of these concerns through rule amendments that we had begun to draft. Additionally, Representative McGeachin testified about her concerns regarding the appropriate role for paraprofessional.

Your committee requested that ­ because of the issues expressed ­ that Medicaid staff and the providers who testified sit down and sort through these issues.

I'd like to briefly review with you, the twofold purpose of these rules:

  • There was a need to reflect changes in provider and department responsibilities as a result of staff reductions in the Regional Mental Health Authority; and
  • There was a need to clarify service expectations and provide service definitions in response to health & safety concerns, particularly for services provided in Partial Care settings.


The rule changes relate to two distinct mental health benefits: 1) Psycho-Social Rehabilitation (PSR) and 2) Mental Health Clinic services.

The first part of the docket identifies changes to the Pycho-Social Rehabilitation (known as PSR rules), reflecting the reduction in Regional Mental Health staffing and the resulting changes in the roles and responsibilities of private PSR providers. The functions of assessment and service planning have been transferred to the private PSR providers.

Additionally, these rules incorporate service definitions, clarify provider qualifications, and spell out service expectations. Significant clarifications include the requirements that:

  • PSR Provider Agency personnel coming into direct contact with participants must comply with existing statutes governing criminal history check requirements; and,


  • PSR agencies provide 24-hour crisis response services for their participants or make contractual arrangements for the provision of those services.


The changes to the mental health clinic rules and related partial care rules were made primarily due to safety issues. Over the past year, the Department was alerted to situations where individuals appeared to be at risk when receiving care under this benefit.

As I mentioned in my previous presentation, prior to these rules, "partial care" ­ a Mental Health Clinic Service ­ could be applied to a number of programs. Some ­ included what might be considered babysitting, others included a lot of television watching, and some including boot camp type services. And because service expectations were not clearly articulated, many of the safety issues found over the past years have arisen in this setting.

This rule docket does not introduce any new federal or state requirements for clinic except for the inclusion of building standards, which were added as a direct result of documented cases of child endangerment due to substandard buildings that were being used as clinics. These temporary rules contain federal and state guidelines that have been in effect for many years. All changes are intended to result in a greater understanding in the provider community of the scope of mental health services as they are required to be.

These temporary rules, effective December 1st were published in the November Administrative Bulletin. Three public hearings were conducted and public comments were accepted through November 26, 2003.

Last week, Department representatives met with representatives from the Mental Health Provider Association to discuss how to address concerns with the rules and related service issues. Our meeting was very productive. We found a great deal of agreement regarding the need to have our rules reflect the best possible outcomes for individuals receiving mental health services. We also agreed to commit to monthly meetings to jointly draft amendments to the temporary rules that are before you in order to address some inconsistencies and make changes.

The outcome of this meeting was an agreement to ask Legislators to extend these temporary rules with the understanding that the Department will work with stakeholders to amend these rules.

The Department is committed to continued negotiations with stakeholders in order to produce rules that reflect best practices with the primary goal of meeting the needs of individuals with mental illness with the best outcomes. The resulting rules will be in compliance with applicable state and federal laws, protect the health and safety of the recipients, are cost effective, and recognize resource limitations.

A work group is scheduled to meet on February 5, to begin reviewing amendments. Members of the work group include representatives from the Family and Community Services Division, Medicaid, Mental Health Providers Association, Fraud & SURS, Consumers and Advocates. The group will meet at least monthly until rule amendments accurately reflect the desired outcomes. The amendments will be published and hearings will be conducted. The amendments will not go into effect until they have received public review and providers have had time to make necessary changes in their business practices.

The Department presented this rule docket to the House Health & Welfare committee last week. At that meeting, the Department and representatives from the Mental Health Provider Association asked the committee to extend the rules. However, the House Committee decided to hold its decision until after the meeting on the 5th in order to see what progress is made. Two members of the committee (Representative Garrett and Representative Henbest) asked to join the work group. A mental health provider who represents Representative McGeachin's concerns will also join the work group.

Although we know that improvements can be made to this temporary rule docket, and we are committed to making those changes, we still believe that it is in the best interest of the individuals receiving these services for this committee to extend the temporary rules. Without these rules, we will lose ground on our ability to ensure safe care. Some services will continue to be provided by unqualified staff, and some qualified staff will be unable to provide services. I'd be glad to share additional impacts if this committee would like further information.

This concludes my presentation on Docket 16-0309-0311. The Department requests that the committee extends these temporary rules with the Department's assurance that it will continue to work with stakeholders on amendments that will address areas of concern.

I will be glad to answer any questions that the committee might have regarding this docket.

Written comments received by to the Senate Health and Welfare Committee to be included the minutes are:

My name is April Crandall and I am President of the Mental Health Provider's Association. Representatives from our association have met with Department of Health and Welfare staff regarding the PSR and Clinic rules for community mental health services Docket 16-0309-0311.

We met with the Department on January 22, and I would like to compliment the Department on the willingness to meet and to commit to continued meetings and negotiation.

  • We agreed that there was much work to do together to mold community mental health services that are quality services for those with mental illness and services that are a good value for taxpayer dollars. We discussed our concerns with Partial Care (Day Treatment Definition), Physician Requirement, and unfunded mandates. We agreed to discuss these further.


  • We agreed to ask the Health and Welfare Committees to extend these Temporary and Proposed rules with the commitment to work on amendments together.


  • We agreed to schedule monthly meetings with other stakeholders at the table to produce amendments that reflect quality services that are reasonable in compliance with federal and state laws and that is within the capability of the private providers.


  • We agreed to published rules with scheduled hearing and have effective dates that would give time to include changes as discussed with the stakeholders. The Department agreed to do a reimbursement analysis to possibly include a reimbursement increase in the July budget set for next year.


  • We agreed to look at the future possibility of accreditation standards, using resources up front to ensure quality services and to poor quality or misuse of taxpayer dollars. We are going to look at better communication strategics and to decide when enforcement begins on the disputed areas in the temporary and proposed rules. The decision was that disputed areas would not be enforced until they were resolved.


  • We ask you, as the Health and Welfare Committee, to extend the temporary and proposed rules with the idea of amendment negotiation.


I'm available for questions on community mental health services, differences between mentally ill individuals and mentally handicapped (developmentally delayed) individuals. Thank you.

MOTION: A motion was made by Senator Bailey to adopt Docket 16-0309-0311. The motion was seconded by Senator Brandt, and motion was carried by a voice vote.
Docket No.

16-0309-0308

Mond Warren, Bureau Chief of the Bureau of Audits and Investigations

for the Department of Health and Welfare, presented these pending rules, Docket 16-0309-0308, for adoption as final rules.

These rules govern the Department's activities relating to investigation of Medicaid fraud and abuse and have been amended to help the Department protect the program funds and clients from fraud and abuse.

These rules have been amended to cleanup language due to federal rule changes and restructure the rules and make them clearer. In the changes we have clarified the department's ability to access and copy records of services provided to Medicaid clients.

Changes have been made to clarify the Department's ability to deny

payments or exclude providers for failing to provide access to records. This language is consistent with federal regulations and is clarifying existing authority.

Changes have been made to clarify and standardize the appeal process for department actions. The Department is attempting to consolidate rules, and appeals are defined by the Rules Governing Contested Case Proceedings.

Clarifications have been made on the Department's actions to mirror the federal regulations when suspending payments to providers for fraud. This is not adding authority, but holding the department more accountable in these types of actions.

We did not receive any public comment or opposition to the pending rules.

I presented these rules to this committee last week and heard opposition or testimony from two groups. One did not oppose the rules, however, opposed the organizational structure of the fraud unit.

I have met with the second group, the Mental Health Providers Association. They represent a group of providers who are trying to provide needed services. They understand rules to address fraud and abuse within our vulnerable program are necessary to stop those providers who will drain program resources, and cast distrust on their profession and the services they perform. Their concerns were relating to the repeal of Section 204 which discussed the referrals to a Surveillance and Utilization Review Committee, and the repeal of Section 210 which provided for a hearing within 30-days for an immediate action when suspending payments or a provider agreement. The committee described in Section 204 is no longer in existence, and I have committed to the association to further define the process for decision making when suspending payments to providers. With this commitment, the Mental Health Providers Association has agreed to support these rules to allow the Department to stop unnecessary waste and abuse, provided Section 210 is restored.

The Department does not oppose restoring this section.

Mr. Chairman and members of the committee, when I presented these

amendments to you last week, I also heard discussion of due process,

concerns with suspending providers, HIPAA violations with access to

records, and nonspecific discussion regarding the department being "heavy handed" or retaliatory with providers. This greatly surprises and concerns me, and I would like to discuss with you the business of fraud investigations to hopefully address any concerns you may have.

First, due process is fundamental in our appeal processes. Our appeal rules provide due process, and appeals are heard by an independent contract hearing officer. Our independent hearing officer is required by contract to set a hearing date within 30-days of an appeal. To address the concerns of the association, I am recommending we restore Section 210 to ensure a hearing within 30-days. The Department will also look at amendments to the contested case rules, and I will commit to involving the association with those revisions.

I also serve as the Bureau Chief over the HIPAA (Health Insurance Portability and Accountability Act) Privacy Office for the department. The Department's ability to access records for the purpose of fraud investigations is in no way a violation of HIPAA regulations. HIPAA provides authority to access these records for the purpose of treatment, payment, and operations.

I also heard concerns about suspending provider payments and my staff being "heavy handed" with providers. I have seven (7) staff responsible for investigating fraud within a program which in one week, processes over 150,000 claims and pays out over 17 million dollars. In only one week!

Over 85% of these claims are received and paid electronically, which ensures fast payment and little or no human oversight or intervention. With over 15,000 providers to watch over, if a single provider wanted to submit fraudulent claims it would not be difficult to submit them electronically and fraudulently obtain a large volume of money. This was the case in the newspaper article on Sunday and provided in your handouts, where a social worker was able to steal more than $150,000 billing for clients she never saw. This type of example is not often encountered and is considered the "exception."

I am sorry to bring this news to you, but we do have white collar criminals within our vulnerable program. These are thieves masquerading as health care providers. They are, however, the exception to the 15,000 providers in the program. Unfortunately, they often turn out to be our trusted health care practitioner, members of your community, your constituents, or even members of your church. Not so long ago, one of these exceptions had been given the title by her community of the "Business Woman of the Year," and later was sentenced to over two years in prison for stealing from our program.

Many of the provisions in these fraud rules are written for these providers who are the "exception," and they are vital for us in order to protect program dollars and clients.

The Department has always had the ability to suspend provider payments. The revisions in front of you actually tighten this ability and raise the burden from merely "suspecting fraud and abuse" to now we must show "reliable evidence" of fraud and abuse. It also clarifies the notice requirements and how long a suspension may last which was not previously defined.

If you will refer to the chart, Provider Investigations, which I have provided to you, it shows the results of fraud cases opened in the last three years. (See Attachment #1).

There have been 659 fraud cases opened in the last three years. Of those cases,

  • 199 cases or 30%, were closed and we were able to unfound the allegations made against a provider.


  • 53 cases or 8%, resulted in provider education or clarification of processes.


  • 223 cases or 33%, resulted in a recoupment action. Keep in mind often a case is not opened unless there is some likelihood a problem or overpayment exists. These cases recouped over 2.7 million dollars.


  • Even with less restrictive payment suspension requirements, only four (4) of 659 cases resulted in a payment suspension action. This is a little over ½ of 1%. In those cases, three of them have already been prosecuted for healthcare fraud in federal court and the fourth has been referred to federal prosecutors for review. These four providers are considered the "exception" for which we need the ability to suspend a provider and stop fraudulent program dollars from going out the door.


In looking at these figures, I believe they clearly show the Department is

committed to pursuing fraud and abuse in the program, however, they show we do not use the "heavy hand" approach I have heard rumors about. We deal with those providers who are "exceptions" appropriately, in order to protect our program resources and vulnerable clients.

To further discuss the way my staff approach such actions against providers, my office was cited by the legislative auditor's office in a final audit finding, as being "slow to react to fraud and abuse" for not suspending payments to a provider they determined was submitting fraudulent claims. My office would not agree to issue such a suspension until we had gathered all of the facts, and were absolutely sure it was necessary to protect the program dollars or clients. Giving the provider the benefit of the doubt. In the end, a suspension of payments was not warranted and allegations against the provider were unfounded.

My office continually undergoes review and scrutiny regarding practices and effectiveness.

  • Annual legislative audits review cases, resolutions, staffing qualifications, and our investigative approach.


  • November 2000, the Office of Performance Evaluations (OPE) Review noted our efforts comparable or exceeding other states and, therefore, recommended we not establish a Medicaid Fraud Control Unit. This is raised because last week I heard concerns about the need for a certified unit in the Attorney General's Office. The OPE recommended against this approach, and recommended the fraud unit be transferred out of Medicaid and into the Division of Management Services. This division is the finance and accountability arm of the Department.


  • There was a 2002 review by the Center for Medicare & Medicaid Services (CMS). The Medicaid Alliance for Program Safeguards team reviewed our compliance with federal regulations to include our ability to suspend payments to fraudulent providers. We were commended on our efforts.


  • In August 1999, the Healthcare Financing Administration (HCFA) Program Integrity review commended my staff on their efforts preventing and detecting fraud and abuse in the Medicaid program.


  • And finally, the most apparent scrutiny of all, the providers in this state. If due process was not upheld or providers were approached with a heavy hand, you and I would both have heard this quite clearly from providers with specific examples, not general comments. Comment was made by one member of the Senate Committee last week that he was surprised to hear of such concerns. I must say that not allowing due process, or unnecessary actions by my staff would not be tolerated by the provider community, nor myself. If raised, I would appreciate the opportunity to respond to specific concerns or examples.


As Senator Bailey pointed out last week, enforcement agencies are often looked upon negatively. I agree with him whole heartedly. Having

investigated 659 providers in the last three (3) years, I would anticipate my staff would not be popular with a few providers, but these would be the exceptions and not the typical providers investigated.

I am also the Bureau Chief over the Internal Audit section in the Department, responsible for reviewing internal controls and ensuring the department is accountable. This task along with fraud investigations are not popular functions, however, I can assure you that with this charge, we will do our best to protect our program resources and dollars.

The Department has received numerous letters from significant providers in our program, commending my staff on the professional approach used during the investigations, even when they were required to refund a large amount of dollars overpaid. I have attached some of those letters for your review. To quote one physician who repaid an excess of $10,000, and said he was pleasantly surprised and pleased with the Medicaid auditors and went on to say "You are to be commended on such personable staff in a department that is often derided by others as being distant or secretive to its contracted providers." These are examples of how the majority of our provider contacts are resolved.

Chairman and members of the Committee, I am proposing to you that these rule amendments provide us with the necessary tools to protect our valuable and limited program resources. They help bring us one step closer to addressing the unfortunate "exceptions" we encounter within our program, which can quickly drain our program resources. I am asking you for your confidence and support in these efforts and to adopt these rules as final rules to further help the Department protect our program funds and clients from fraud, with the exceptions of rejecting Section 210 which address the concerns of the provider association.

Thank you and I will stand for questions.

Greg Dickerson, a representative for the Mental Health Provider Association, testified to support and adopt these rules, with the exception of restoring Section 210, and the commitment made to revisit Section 204, and draft the due process the Department currently uses and replace it. He appreciated the efforts of the Department to work with providers.

Douglas K. Merkley, a private attorney from Pocatello, testified about his objections to Docket 16-0309-0308. He expressed grave concerns about the process of the Department's fraud investigations, especially the section of suspending payments to a provider. This can cause a business to shut down. Prior to due process of appeals. Mr. Merkley reported he represents several clients in his area who has had problems dealing with staff from the Department's fraud unit.

Committee members discussed the proposed pending rules governing fraud investigations and the suspension of payments during an investigation. The Department's actual proposed changes to Sections 204, 208, 209, and 210, Docket 16-0309-0308, are shown below:

Section 204: SURVEILLANCE AND UTILIZATION REVIEW (S/UR) COMMITTEE (Reserved). Instances of suspected fraud, abuse, or other misconduct may be referred to a review committee organized by the Department. The committee shall consist of health professionals and other staff appointed by the Director or his designee. The committee may also consult with other professionals as determined necessary by the committee. The function of the committee will be to review and make recommendations concerning corrective action.

Section 208: SUSPENSION OF PAYMENTS PENDING INVESTIGATION. "In the event that The Department identifies may suspend payments in whole or part in a suspected case of fraud or abuse and the Department has reason to believe that payments made during the investigation may be difficult or impractical to recover, the Department may suspend or withhold payments on any pending or subsequently submitted claims while the provider continues to participate in the program pending investigation and conclusion of legal proceedings related to the provider's alleged fraud or abuse."

Section 209: INTERIM PROVIDER AGREEMENT SUSPENSION. In the event that the Department identifies a suspected case of fraud or abuse, and it determines that it may summarily suspend the provider agreement when such action is necessary to prevent or avoid immediate danger to the public health or safety, the Department may summarily suspend a provider or employee of a provider. This provider agreement suspension temporarily bars the provider from participation in the Medicaid Program pending investigation and Department action. Such a finding will be incorporated in the order. The Department will notify the provider shall be given notice but the order of the suspension. The suspension is effective when issued immediately upon written, electronic, or oral notification.

Section 210: APPEAL OF IMMEDIATE ACTION (Reserved). When payments have been suspended or withheld or the provider's agreement is suspended pending investigation, the Department shall provide for a hearing within thirty (3) days of receipt of any timely filed notice of appeal.

Written comments received by the Department of Health and Welfare regarding fraud investigators were submitted into the record:

Bret Hamilton, administrator, Teton Family Services, Inc., in Pocatello, regarding the Fraud Unit. (See Attachment #2)

Carl E. Wood, Jr., Evergreen Pharmaceutical, Inc., in Kirkland, Washington. (See Attachment #3)

Stephen DeNagy, M.D., Family Care Center in Idaho Falls. (See Attachment #4)

Jeff Hough, lobbying director for the Cooperative Action, LLC, submitted written comments from Bill Southerland, president of the Idaho Assisted Living Association (IDALA). (See Attachment #5)

Mike Ponkow, administrative director of the Cooperative Action LLC in Chubbuck, Idaho also submitted written comments requesting the committee to reject this rule and ask the Department of Health and Welfare to formulate a new better defined rule that the providers can comply with. (See Attachment #6)

A Letter of Opinion from William A. von Tagen, Division Chief, Intergovernmental and Fiscal Law, Idaho Attorney General's Office, was introduced. The letter addressed the question "whether the placement of the Department's Bureau of Audits and Investigations within the Division of Management Services sufficiently insulates the Bureau from the influence of the Division of Medicaid." Based on the following analysis, I believe it does. (See Attachment #7)

Mr. Warren read Section 212 - Civil Monetary Penalties - "Pursuant to Under Section 56-209h, Idaho Code, the Department may assess civil monetary penalties against a provider, any officer, director, owner, and/or managing employee for conduct identified in Subsection 211.01 through 211.09 of these rules. The amount of penalties shall may be up to one thousand dollars ($1,000) for each item or service improperly claimed, except that in the case of multiple penalties the Department may reduce the penalties to not less than twenty-five (25%) if the amount of each item or service improperly claimed if an amount can be readily determined. Each line item of a claim, or cost on a cost report is considered a separate claim. These penalties are intended to be remedial, at a minimum recovering costs of investigation and administrative review, and placing the costs associated with non-compliance on the offending provider."

MOTION: A motion was made by Senator Brandt to reject the change in Section 210 and accept the rest of Docket 16-0309-0308. The motion was seconded by Senator Darrington.
SUBSTITUTE MOTION: A substitute motion was made by Senator Burkett to reject the rule making and have them go back and try again.

Discussion: Senator Burkett - thinks this rule making is completely confused. It gets back to the distinction between fraud, on the one hand, and then the rule also refers to misconduct, abuse - both financial abuse and potential client or patient abuse. He thinks we need something different for fraud. People suspected of fraud, it might be appropriate to suspend payments for 30-days, wait for a hearing, then after a hearing finding probably cause you move onto the next step.

Senator Compton asked Senator Burkett if he was rejecting the docket entirely? Senator Burkett responded, "yes," the changes. The motion was seconded by Senator Bailey.

DIscussion: Senator Burkett explained that Mond has told us it is working pretty well right now, and that he can operate under this rule. Senator Burkett believes the Department should come back next year with a rule that is drafted correctly. He also believes the Department should have two sets of rules. One set of rules for misconduct, abuse and bad practices, and a different set of rules governing Medicaid fraud.

Committee members express their difference of opinions relating to the proposed changes and the effects on the Department's fraud unit.

After a lengthy discussion, review, and consideration of the above listed pending sections in Docket 16-0309-0308 (Sections 204, 208, 209 and 210), Senator Bailey withdrew his second to this substitute motion.

The motion died for lack of a second.

SUBSTITUTE MOTION: A substitute motion was made by Senator Kennedy that this committee rejects the proposed changes being made to Section 210 and 204, and that the committee approves the adoption of all the other rules in this docket (Docket 16-0309-0308).

Discussion: Senator Kennedy explained the motion is to reject the changes being made to rules 210 and 204, and to approve the other amendments being made by Docket 0308 (16-0309-0308).

The motion died for lack of a second.

AMENDMENT TO SUBSTITUTE MOTION Senator Burkett made a substitute motion that the committee rejects the changes to Section 209, the changes to Section 210, and the changes to 204, and would accept the further remaining provisions in this rulemaking (Docket 16-0309-0308).

The substitute motion was seconded by Senator Kennedy.

Discussion - The committee members held a general discussion relating to providers, suspended payments and suspension of contracts, immediate danger and safety of a client, and why do the rules need to be changed. If Section 209 is returned to the rules, how it was before these proposed changes were made, the Department could still suspend a provider's agreement. The changes proposed by the Department were intended to clarify the rules, to make it clearer on the grounds which they would suspend a license.

Senator Burkett restated his substitute motion - the motion was to reject Sections 209, 210, and 204, and approve the remainder of the changes to the temporary rules 0309-0308 (Docket 16-0309-0308).

Call for Vote: The substitute motion failed.

Senator Brandt restated the original motion to reject Sections 210, and accept the rest of the docket (16-0309-0308).

This motion was seconded by Senator Darrington.

A roll call vote was taken on the original motion:

Senator Kennedy voted Nay Senator Stegner was absent

Senator Burkett voted Nay Senator Ingram was absent

Senator Bailey voted Nay Senator Darrington voted Aye

Senator Sweet voted Nay Senator Compton voted Aye

Senator Brandt voted Aye

The original motion - 3 Ayes, 4 Nays, 2 absent and excused

SUBSTITUTE MOTION: A substitute motion was made by Senator Kennedy to reject the proposed changes to Sections 204 and 210, and approve the rest of the docket changes in this docket (16-0309-0308).

The motion was seconded by Senator Brandt.

A roll call vote was taken:

Senator Kennedy voted Aye Senator Ingram was absent

Senator Burkett voted Nay Senator Darrington voted Nay

Senator Bailey voted Nay Senator Compton voted Aye

Senator Sweet voted Aye Senator Brandt voted Aye

Senator Stegner was absent

This substitute motion carried, 4 Ayes, 3 Nays, 2 absent and excused.

ADJOURNED: There being no further business to conduct, the committee adjourned at 10:40 a.m.




DATE: Tuesday, February 3, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Ingram, Stegner, Sweet, Bailey, Burkett, Kennedy
MEMBERS ABSENT/

EXCUSED:

Senator Darrington
MINUTES: A motion was made by Senator Bailey to approve the Minutes as written for the Committee meetings held on January 27, 28, and 29, 2004. Senator Compton seconded the motion. The motion passed by a voice vote.
GUESTS: See the attached sign-in sheet.
Gubernatorial Appointments Gubernatorial Appointments for the Commission for the Blind and Visually Impaired

Kelly Pierce, Chairman, Commission for the Blind and Visually Impaired presented three appointees to the Committee. The Commission consists of five members. David Hand is a re appointee. Jim Solom, and Bruce Zimmerman are new appointees.

David Hand, of Boise, Idaho is up for reappointment to the Commission for the Blind and Visually Impaired to serve at term commencing July 1, 2003 and expiring July, 1, 2006. Mr. Hand has been with the Commission since 1998, when he filled an unexpired term. This will be his second three-year term. He has 27 years experience in the Idaho Lodging and Restaurant industry. Since 1964 he has worked on the "talking book," reading on a recorded device. He stated he wants to repay the Commission for the benefits he has received from the programs.

Senator Ingram asked Mr. Hand about funding of a program entitled "News Line Program." A program that records newspapers being read so the visually impaired can stay updated on the latest news. The program needs $26,000. Mr. Hand informed the Committee members that The National Federation of the Blind was introducing some legislation this session in regards to this issue, and that any involvement by the Commission in this regard would be improper. Mr. Hand stated he was working to disseminate information to the right people.

James Solom, of Lewiston, Idaho, is up for appointment to the Commission for the Blind and Visually Impaired to serve a term commencing on July 1, 2003 and expiring July 1, 2006. Mr. Solom has 22 years of Executive experience in Communications, having worked for and with several large communication companies. He also has 12 years teaching experience at the University level. He came from southern California to Idaho to work on building an IdaNet, which runs from Moscow, Idaho to the Canadian border. He also worked on running a DS3, high speed network, from Couer dAlene to Boise. It was while working on this project that Mr. Solom lost his site. He attended a school in Boise for four months to learn Braille, and to use Voice activated computers. He is now pursuing a doctorate degree in Education from the University of Idaho, and anticipates graduating in 2005. He stated the Commission for the Blind and Visually Impaired has provided him with invaluable resources and his wish is to provide assistance, and mentor to others with visual impairments.

Senator Stegner asked about options for tutoring for the blind at the University of Idaho campus, as well as the lack of a Braille printer for blind student use.

Bruce Zimmerman, of Hidden Springs, Idaho is up for appointment to the Commission for the Blind and Visually Impaired to serve a term commencing on July 1, 2003 and expiring July 1, 2006. Mr. Zimmerman has held many corporate positions, has taught at the university level, and is currently a consultant and professor at the University of Phoenix, Boise center. Mr. Zimmerman was accompanied by his three-year-old German Shepard guide dog. He anticipates assisting those who have lost their sight due to age, illness or physical trauma in the area of accessibility. He would like to improve the travel options for the visually impaired, as well as, make technology available for those who could benefit.

The Committee members were impressed with the character and experience of each Commission appointee.

MOTION Senator Compton made a motion to confirm the appointments of David Hand, Jim Solom, and Bruce Zimmerman, to the Commission for the Blind and Visually Impaired. The motion was seconded by Senator Ingram. The motion carried by a voice vote.
Rules Review Rules Review: Commission for the Blind and Visually Impaired
15-0230-0301 Lisa Van Ry presented 15-0230-0301 Business Enterprise Program. This rule proposes that the penalty be removed in the rule that penalizes vendors participating in the Blind Enterprise program when they withdraw funds from their private retirement accounts. The new rule confers a benefit to the blind vendors in that they will now have access to their retirement accounts and place their funds with an investment broker of their own choosing, thus having control over their own financial future.

There was no discussion on the rule.

MOTION Senator Stegner made a motion to adopt Rule 15-0230-0301. Senator Ingram seconded it. The motion carried by a voice vote.
15-0230-0302 Lisa Van Ry presented 15-0230-0302 Business Enterprise Program. This rule incorporates by reference the Commission's Business Enterprise Allowable Cost Manual, which sets forth performance standards for the operation of a primary location, and provide for discipline of vendors who are not operating in compliance with those standards. The rules are needed to provide standards for the operation of snack bar, vending and cafeteria sites (that constitutes primary locations under the Business Enterprise Program).

There was discussion on the rule relating to the Allowable Cost Manual. The Committee would like to see the date and edition of the manual stated within the rule. The reasoning being the Commission could change the manual without approval of the Legislature. Mr. Stevenson, Department of Administrative Services, stated the Commission has statutory authority to change the rule as they see fit. He recommended the Commission issue a temporary rule with the change, to incorporate the date and edition of the Allowable Cost Manual, for the legislature to approve.

MOTION Senator Stegner made a motion to approve Rule 15-0230-0302 with the strong recommendation that the Commission modifies the rule and bring a copy of the manual referenced to the Committee next time. The motion was seconded by Senator Bailey. The motion carried by a voice vote.
Rules Review Bureau of Occupational License (BOL) Rules Review
24-0601-0301 Rayola Jacobsen presented 24-0601-0301 Rules Governing the Board of Hearing Aid Dealers and Fitters to the Committee. This rule adds required sections; clarifies application fees and license fees currently being assessed; clarifies continuing education requirements; and amends sound field testing requirement. Rayola stated there were no comments received on this rule.
MOTION Senator Brandt made a motion to approve Rule 24-0601-0301. The motion was seconded by Senator Ingram. The motion carried by a voice vote.
24-1001-0301 Rayola presented 24-1001-0301 Rules of the State Board of Optometry. This rule clarifies required examination and acceptable requirements, and clarifies the continuing education requirements and the record keeping required for continuing education. Mr. Roger Hales, Bureau of Licensing, stated a reference in section 275, 02, c, implements a date (1986) prior to which there was no national exam entitled "Treatment and Management of Ocular Disease Examination." There was no discussion on the rule.
MOTION Senator Bailey made a motion to approve Rule 24-1001-0301. The motion was seconded by Senator Sweet. The motion carried by a voice vote.
24-1201-0301 Rayola Jacobsen presented 24-1201-0301 Rules of the State Board of Psychologist Examiners. This rule changes the date on an article incorporated by reference; corrects an e-mail address; clarifies application procedure; amends exam section to comply with national testing; amends service extender section to clarify documentation required; and amends educational curriculum requirements. There was no discussion on the rule.
MOTION Senator Brandt made a motion to approve Rule 24-1201-0301. Senator Ingram seconded it. The motion carried by a voice vote.
24-1401-0301 Rayola Jacobsen gave the floor to Roger Hales, BOL, to present 24-1401-0301 Rules of the State Board of Social Work Examiners. This rule adds definition for psychotherapy, clarifies practice of social work at each level, clarifies examination procedure and endorsement requirements, amends continuing education in cases involving illness, clarifies continuing education ethics requirements, allows continuing education from social services agencies, and defines competent practice for social workers.

Due to public comment, changes were made to proposed text as follows: include definition for supportive counseling; revisions were made in practice of social work; the word endorsement was added to 350; and competent practice for social workers is defined.

Mr. Hales described the three levels of a social worker: Baccalaureate social worker, Master social worker, and Clinical social worker. In section 010 (03) Definitions, page 256, psychotherapy can only be practiced by Clinical social workers, or Master social workers under the supervision of a Clinical social worker. Another distinction was made regarding independent practice of social work and private practice of social work and the Clinical Practice Exemption, Section 201(04) Practice of Social Work, (04) page 257. The exemption allows a longer period of time to meet the requirements, and expands the number of supervised hours to receive training.

TESTIMONY Greg Dickerson, Mental Health Provider Association, testified before the Committee. He opposed this rule last year, and was back before the Committee to support it after revisions made to the content. He stated the rule raised the expectations from social workers. He thanked Rayola Jacobsen for the work she did on getting everyone together.

Senator Ingram asked Mr. Dickerson if he felt anyone had been excluded or alienated by the rule. Mr. Dickerson stated with the agency exemption clause, Master social workers can claim supervision by other Clinical professionals. This allows flexibility. He stated it was critical to revise the rule to clarify the definitions of social workers.

TESTIMONY Linda Burch, National Association of Social Workers, testified in support of the new rule.
TESTIMONY Robert Payne, IBOL, testified the charge given to the Board last session was daunting. The rule affects the health, safety and welfare of the state. He commended Rayola Jacobsen, and said they could not be where they are (in agreement) without her. Mr. Payne reported the organizations were in support of what the rule is trying to do, and the citizens and practitioners will benefit.
TESTIMONY Ray Millar, Department of Health and Welfare, Division of Family and Community Services, testified in support of the rule. Last years rule brought concern regarding the scope of practice for social work and the ability of the IDHW and private behavioral health agencies to quickly come into compliance with new social work practice restrictions. The negotiated rulemaking session result was to include new language to include a practice exemption that allows time for public and private agencies to come into compliance. He stated he is in support of the Board's continuing efforts to improve the standard of practice for social workers and asked the Committee to approve the rule.

Chairman Brandt stated there was written testimony submitted to the Committee members from Larina Warnock, and Bob Willhite.

MOTION Senator Ingram made a motion to approve Rule 24-1401-0301. The motion was seconded by Senator Brandt. The motion carried by a voice vote.
24-1501-0301 Rayola Jacobsen, BOL, presented 24-1501-0301, Rules of the Idaho Licensing Board of Professional Counselors and Marriage and Family Therapists. This rule makes provisions for supervision guidelines and definitions for both counselors and marriage and family therapists; deletes grandfather provision as the grandfather period has passed; requires ethics as part of continuing education. There was no discussion on the rule.
MOTION Senator Brandt made a motion to approve Rule 24-1501-0301. It was seconded by Senator Bailey. The motion carried by a voice vote.
24-1701-0301 Rayola presented 24-1701-0301 Rules of the State Board of Acupuncture. This rule corrects the Board address and changes the effective date for continuing education requirements for renewal. There was no discussion on the rule.
MOTION Senator Brandt made a motion to approve Rule 24-1701-0301. Senator Ingram seconded it. The motion carried by a voice vote.
24-1901-0301



Rayola presented 24-1901-0301 Rules of the Board of Residential Care Facility Administrators. This rule incorporates by reference the ACHA Code of Ethics; adds facility language to conform to Idaho Code; strikes temporary permits as law does not allow for extensions or emergency permits; and adds violation of Code of Ethics as discipline. Rayola stated there is still a "pending" permit, a one-time, no-renewal permit for use in emergencies.

Senator Stegner brought to the attention of the Committee and Ms. Jacobsen, the lack of a date and edition inclusion into this rule, as well, as on page 272, in regards to documents/manual references.

MOTION Senator Stegner made a motion to approve Rule 24-1901-1301. The motion was seconded by Senator Brandt. The motion carried by a voice vote.
ADJOURNMENT Chairman Brandt adjourned the meeting at 9:55 a.m.




DATE: Wednesday, February 4, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Sweet, Bailey, Burkett, Kennedy
MEMBERS ABSENT/

EXCUSED:

Senators Stegner and Ingram
Senator Clint Stennett, and see the attached sign-in sheets.
MINUTES: A motion was made by Senator Bailey to approved the minutes of Friday, January 30, 2004, as written. The motion was seconded by Senator Kennedy, and motion was carried by a voice vote.
Gubernatorial Appointments: The Department of Environmental Quality Director Steve Allred introduced the Idaho Board of Environmental Quality. Two members have been reappointed by Governor Dirk Kempthorn.
John R, "Randy" MacMillan, Ph.D., is Vice-president of Research and Environmental Affairs for Clear Spring Foods, Inc., in Buhl, Idaho. He received his Doctor of Philosophy in fish pathology from the University of Washington, and Master of Science in fish biology from Michigan State University.

Dr. MacMillan has performed extensive research on fish health and aquaculture issues and has published many scientific articles and papers. He has served on many task forces, committees and associations studying water quality, fish health and aquaculture issues.

Dr. MacMillan was originally appointed to the Board of Environmental Quality on July 1, 2000. He lives in Twin Falls, Idaho. Dr. Macmillian has been reappointed by Governor Dirk Kempthorn for a term to expire on July 1, 2007, and his political affiliation is with the Republican party.

Senator Darrington asked Dr. MacMillan about his work with toxic elements and fish. Senator Darrington reported his committee will soon be hearing proposed legislation relating to aquaculture terrorism and increasing the criminal penalties for those terrorist acts.

Leonard N. "Nick" Purdy, Jr., is a fourth-generation cattle rancher who owns and operates Picabo Livestock Company, Purdy Enterprises, and the Silver Creek Convenience Store in Picabo, Idaho. He received his Bachelors of Science in Agricultural Engineering from the University of Idaho.

Mr. Purdy is a past director of the Idaho Cattleman's Association, served on the Board of Directors of the Idaho Nature Conservancy, and was awarded the National Environmental Stewardship Award, the Department of Interior Stewardship Award, and is in the Southern Idaho Livestock Hall of Fame.

He was originally appointed to the Board of Environmental Quality by Governor Dirk Kempthorn on July 1, 2000, and reappointed for a second term beginning July 1, 2003. His area of interest and expertise is water. He has been reappointed by Governor Dirk Kempthorn for a term to expire on July 1, 2007, and his political affiliation is with the Republican party.

Mark P. VonLindern of Lewiston, Idaho was reappointed by Governor Dirk Kempthorn to the Hazardous Waste Facility Siting License Application Review Panel to serve a term commencing March 6, 2003 and expiring March 6, 2006.

Mr. VonLindern is a graduate from the University of Idaho in Civil Engineering, and is a licensed engineer. He has been Public Works Director for the City of Lewiston and Grangeville, Idaho. Formerly he worked for the Idaho Division of Environmental Quality as a water quality engineer and then Regional Administrator of Region II.

Currently he is the Environmental and Manufacturing Manager for Alliant Techsystems, a manufacturing operation in Lewiston. His primary responsibilities include managing the department to exceed environmental compliance requirements and setting future environmental direction for the location.

Mr. VonLinder is active in a number of environmental organizations and serves as Chairman of the Nez Perce Local Emergency Planning Commission, Vice Chairman of the Clearwater Basin Advisor Group, and has previously served on the Hazardous Waste Facility Siting Panel. His political affiliation is Republican.

A brief discussion was held about appointments to the Board of Environmental Quality, and the creation of the board after the separation of the Division of Environmental Quality from the Department of Environmental Quality and was established as a department. Also, discussed was political affiliation of board members. Senator Darrington explained that Idaho is not a party registration state, you are what you say you are, and the individual's party of choice can change as they determine.
DEQ LOAN PROGRAM Toni Hardesty and Bill Jerrel presented a summary about Idaho's State Revolving Funds (SRF) which is administered by the Department of Environmental Quality. Mr. Jerrel outlined the loan program's background, SRF requirements, the loan status, and the path forward.

Background:

  • Two (2) separate loan funds -Water Pollution Control (Wastewater) Loan Fund & Drinking Water Loan Fund.


  • Wastewater Loan Fund established in 1987 Amendments to Clean Water Act & Idaho Code, Title 39, Chapter 36, authorized federal funding through federal fiscal year 1994.


  • Drinking Water Loan Fund established in 1996 Amendments to the Safe Drinking Water Act and Idaho Code, Title 39, Chapter 36, authorized federal funding through federal fiscal year 2003.


  • Purpose of both funds is to provide perpetually a revolving source of low interest loan funds for design and construction of wastewater and drinking water projects (loan repayments go back into the fund to be re-lent to others).


  • Each Fund receives:
  • Annual Congressional Appropriation (approximately $6.5 and $8 million)
  • Annual 20% State Match appropriated from Water Pollution Control Account ($1.3 and $1.6 million)
  • Loan Repayments (Principal & Interest)
  • Interest on Repayments (Cash in the Fund-invested by State Treasurer)


  • Federal Funds are in form of a "Capitalization Grant" that comes from EPA.


  • Capitalization Grants require:
  • Annual Priority List of Projects Approved by DEQ Board
  • Schedule by which federal funds are awarded


  • Loan Terms - repaid within 20 years of project completion; interest rate must be below market (3.5% for FY04).


SRF Requirements:

Some Major Project Requirements

  • Engineering report prepared by Licensed Professional Engineer
  • Environmental information Document (EID)
  • DEQ issues a finding - (Categorical Exclusion, Finding of No Significant Impact Environmental Impact Statement)
  • Must be bid like any public work's project
  • Loan closed at the end of construction (Revenue Bond, LID Bond or Promissory Note issued)


Loan Status:

Total Amount Loaned:

  • Wastewater SRF - $176 million. Drinking Water SRF - $40 million (See Attachment #1)


Total Amount Capitalized Through State FY04:

  • Wastewater SRF - federal ($102 million); state match ($20 million); Repayments *$71 million); interest on Fund ($10 million.
  • Drinking Water SRF - federal ($45 million); state match ($12 million); repayments ($1 million); interest on Fund ($16 thousand).


Status of Federal Grants - received Federal FY03 funds; Federal FY04 funds not released; Federal FY05 in President Bush's budget 35 percent (35%) cut for wastewater SRF.

Projected Need for Loan Funds:

  • Wastewater - 2000 Needs Survey $181 million; FY03 - $41 million; estimated FY04 - $12 million.


Current legislative forecast for Water Pollution Control Account. (See Attachment #2)

Path Forward:

Alternative means of Capitalization for loan funds.

  • Leverage funds through Treasurer's Bond Bank
  • Sell part or all of portfolio - bond bank or private sector.
  • Request establishment of a group to investigate and consider alternative sources of capital.


Director Allred requested the committee to consider an interim legislative committee to meet with DEQ and others to study the Loan program. Senator Brandt agreed to send a letter to pertinent committees for their interest in forming an interim committee.

RS13677 This proposed legislation, RS13677, allows the Department of Environmental Quality (DEQ) to use a portion of the interest revenues from wastewater (CWSRF) and drinking water (DWSRF) loans for operating the programs.

Currently, the programs are funded by 4 percent (4%) of the annual federal contributions (approximately $13.8 million per year). This level of federal contribution is expected to decrease and will not provide sufficient resources for DEQ to manage the programs as the total funds managed have increased to more than $150 million. This funding mechanism will allow the programs to be self supporting.

There is no fiscal impact to the general fund. A reduction in the SRF funds available for future loans would be in the amount of the funds used to administer the program. DEQ envisions no increase cost to borrows. The current "at or below" market interest rate will continue.

MOTION: A motion was made by Senator Compton to send RS13677 to Print. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
RS13694 This proposed legislation, RS13694, relates to the protection of public health and requires the use of licensed professionals for operating water and wastewater utilities, and testing backflow assemblies. This legislation provides for the transfer of licensure responsibilities for Drink Water and Wastewater Professionals from the Department of Environmental Quality to the Bureau of Occupational Licenses (IBOL).

It sets forth the policy, title, required license and definitions. Additionally, it provides for a board, to be appointed by the Governor, with qualifications, number, terms of office, removal from office, procedures, powers and duties. It states finances, fees, providing for the issuance of licenses with an annual renewal. It provides for the revocation or suspension of licenses, violations and penalties. It establishes that an emergency exists and that this act shall be in full force and effect on and after its passage and approval. The IBOL will provide administrative, legal and financial services to the board.

There will be no fiscal impact to the General or Dedicated funds. This will be a self-supporting program funded by operator licensing fees.

MOTION: A motion was made by Senator Compton to send RS13694 to Print. The motion was seconded by Senator Darrington, and motion was carried by a voice vote.
ADJOURNED: The committee adjourned the meeting at 9:55 a.m.




DATE: Thursday, February 5, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Sweet, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

Senators Stegner and Ingram
GUESTS: See the attached sign-in sheets
MINUTES: A motion was made by Senator Bailey to accept the committee's minutes for Tuesday, February 3, 2004, and Wednesday, February 4, 2004, as written. The motion was seconded by Senator Sweet, and motion was carried by a voice vote.
Gubernatorial Appointment On Tuesday, February 3, 2004, the Senate Health and Welfare Committee approved three (3) gubernatorial appointments to the Commission for the Blind and Visually Impaired. The appointments were approved, and Floor sponsors assigned are:

Appointee Floor Sponsor__

Bruce Zimmerman, Hidden Springs Senator Kennedy

James Solem, Lewiston Senator Stegner

David Hand, Boise Senator Burkett

Gubernatorial Appointment: On Wednesday, February 4, 2004, the Committee considered the gubernatorial reappointment of John "Randy" MacMillan, from Twin Falls, Idaho, to the Board of Environmental Quality. His term will expire on July 1, 2007.
Gubernatorial Appointment: On Wednesday, February 4, 2004, the Committee considered the gubernatorial reappointment of Leonard "Nick" Purdy, from Picabo, Idaho, to the Idaho Board of Environmental Quality. His term will expire July 1, 2007.
MOTION: A motion was made by Senator Darrington to recommend the reappointment of Randy MacMillan and Nick Purdy to the Idaho Board of Environmental Quality. The motion was seconded by Senator Sweet, and the motion was carried by a voice vote. Senator Gannon will be Floor sponsor for Mr. MacMillan. Senator Stennett will be Floor sponsor for Mr. Purdy.
Gubernatorial Appointments: On Wednesday, February 4, the Committee reviewed the gubernatorial reappointment of Mark P. VonLindern, from Lewiston, to the Hazardous Waste Facility Siting License Application Review Panel for a term expiring March 6, 2006.
MOTION: A motion was made by Senator Compton to confer with the Governor's reappointment of Mark P. VonLinder to the Hazardous Waste Facility Siting License Application Review Panel. The motion was seconded by Senator Bailey, and the motion was carried by a voice vote. Senator Stegner will be the Floor sponsor.
RULES REVIEW: The Board of Medicine Executive Director Nancy Kerr presented four (4) rule making dockets.
Docket No.

22-0103-0301

1. DOCKET, TYPE AND PURPOSE:

A) Docket 22-0103-0301 is a pending fee rule of the Idaho State Board of Medicine. The rule is adopted as a pending rule by the Board of Medicine and is presented for review by the 2004 Legislature.

b) Rules submitted for consideration by the 2003 Legislature and

due to some last minute concerns the rules were requested to be disapproved by both the House and Senate Health and Welfare Committees to allow the Board to make further revisions.

c) The rules were published in the Administrative Bulletin for the State of Idaho on October 1, 2003, as proposed fee rules and notification was provided to every licensee of the Board in the Board of Medicine newsletter in the summer of 2003.

d) Public hearing - held in November 2003 and changes were made the proposed rule as result of the public input.

II. OVERVIEW:

a) The rule revises and updates the scope of practice definitions and provides clear requirements for the delegation of patient services by the supervising physician, and provides method for requesting the approval of special procedures.

b) The rule provides for patient safety by limiting the numbers of physician extenders that a physician may safely supervise and provides for required review of education, training, and experience of each physician assistant assigned.

c) Provides that a copy of the delegation of services agreement be filed with the Board.

d) The rules also define committee membership requirements and clarifies the responsibilities per the 1993 resolution of the Board of Medicine.

e) No fees are increased nor is an increase anticipated, in fact the Board anticipates being able to reduce fees with on-line renewal.

f) Provides housekeeping and grammar changes.

III. SUMMARY OF CHANGES - PROPOSED:

Sections:

000 - Grammar changes and corrects omission of graduate PA

010.02 - Names of accrediting agencies listed

010.04 - Addition of education and training listing to each Delegation of service agreement.

011 - Adds the requirements for the committee membership and responsibilities.

021 &022 - Clarifies the application process and limits the application pending period.

028b - Scope of practice language changed to reflect agreed language.

Concerns expressed were " and other anesthesia services associated with the operating room." The interpretation was that PA's would be allowed to perform all forms anesthesia delivery.

028d - Supervising physician definition reiterated in scope of practice.

033 - Delegation of services agreement changed to include education and training of physician assistant, and clarification of process to approve specialized procedures and periodic review of the plan and services.

037 1-2 I Removes trainees from the discipline and adds failure to report

violations of the rules as grounds for discipline.

053 - Adds delegation of services agreement requirement for graduate

physician assistants.

Rules are listed as fee rule. No additional or increased fees are charged or anticipated. Language is changed to reflect range of fees.

PENDING RULES:

000 - Grammar changes.

010 - Corrects the accrediting agency name and requires review of Delegation of Services (DOS) agreement by the Board.

028 - Clarifies scope of practice and changes wording to agreed language. Clarifies the limitation of supervision to three (3) PA's with a waiver allowing up to six to be supervised.

030 - Adds listing of PA education and training on all DOS agreements, and provides requirements for special procedure approval.

036 - Grammar changes and clarification of graduate application.

037 - Removes redundant language, adds graduate PA"S to discipline

requirements.

MOTION: A motion was made by Senator Kennedy to accept Docket 22-0103-0301. The motion was seconded by Senator Sweet, and the motion was carried by a voice vote.
Docket No.

22-0104-0301

DOCKET, TYPE PURPOSE:

a) Docket 22-0104-0301 is a pending fee rule of the Idaho State Board of Medicine. The rule is adopted as a pending rule by the Board of Medicine and is presented for review by the 2004 Legislature.

b) The rules were published in the Administrative Bulletin for the State of Idaho in October 1, 2003, as proposed fee rules and notification provided to every licensee of the Board in the Board of Medicine newsletter in the summer of 2003.

c) Negotiated rule process for the AT and PA highlight needed changes to these rules.

II. OVERVIEW:

a) The purpose of the rules is to update the rules for supervising physicians as required by changes to the PA rules and to add the requirements for directing physicians as required by the changes to athletic trainer's act and rules.

b) The rule provides for patient safety by limiting the numbers of physician extenders that a physician may safely supervise and provides for required review of education, training, and experience of each physician assistant assigned.

c) Defines fee range for the registration of directing physicians.

d) Clarifies the responsibility of supervising and directing physicians, directs complaints to the appropriate licensing board and limits scope of practice to that of the supervising physician or directing physician.

III. SUMMARY OF CHANGES:

a. Proposed Rules: Section:

000-007 - Changed to reflect current statutory guidelines for rule format.

010 - Definitions added to reflect addition of directing and alternate directing physician, clarifying existing definitions and adding correct statutory and rule references.

020-022 - Clarifies responsibilities of supervising and directing physicians related to professional group supervised, directs complaints to the appropriate licensing board.

030-40 - Defines registration requirements and sets fees for directing physician category.

SECTION - PENDING RULE:

010 - Corrects typographical error and removes limitation on numbers of professionals licensed.

019 - Clarifies definition of available supervision.

020 - Removes requirement for recording of review, clarifies limitation on number of licensees supervised.

040 - Clarifies fees as they apply to all supervising physicians.

Adds fee for directing physicians and clarifies fees as they apply to all supervising physicians(including interns and externs).

MOTION: A motion was made by Senator Brandt to accept Docket 22-0104-0301. The motion was seconded by Senator Bailey, and the motion was carried by a voice vote.
Docket No.

22-0110-0301

I. DOCKET, TYPE PURPOSE:

a) Docket 22-0110-0301is pending fee rule of the Idaho State Board of Medicine.

b) The pending rules before the house are the result of negotiated rule-making process with chiropractic physicians association, athletic trainers association, and physical therapist association representatives. Licensees of the board were notified of the rulemaking process in the summer 2003 newsletter.

c) The rules were published in administrative bulletin 03­10 and a public hearing was held in October 2003.

II. OVERVIEW:

a) The purpose of the rules is to update the rules for athletic trainers to reflect changes of House Bill 199.

b) The rule provides for a more formal defined relationship with the directing physician to be defined as the Athletics service plan or protocol.

c) Defines the duties and responsibilities of the directing physician, clarifies the licensing types, allows for two-year renewal, and clarifies the renewal process including continuing education requirements.

d) Clarifies appointment and responsibilities of the Board of athletic trainers, and designates that a contact person for the Board of Chiropractic Physician's be assigned.

e) Clarifies the complaint process has it relates to the directing physician and the athletic trainer.

f) Requires the scope of practice to be consistent with the practice of the directing physician.

g) No fees were increased nor is there increase anticipated.

III. SUMMARY OF CHANGES:

a. Proposed Rules: SECTION:

001-007 - Format and wording changes as per state requirements.

010 - Definitions clarified, addition of service plan and Chiropractic Physicians Boards.

011 - Rules added for removal of board member for cause and removal of references to registration.

012 - Scope of practice defined and limited to scope of directing physician.

013 - Defines the requirements for service plan. Written agreement/plan

between AT and physician on what services will be provided, addressing situations outside of scope of practice, and reviews.

014 - Defines responsibility of directing physicians.

015 - Registration requirements for directing physicians.

016 -030 - Clarifies requirements for licensure and application requirements.

040 - Clarifies the license renewal and expiration requirements and clarifies license types. Defines the requirement for continuing education.

050-051 - Defines inactive license status and the application of inactive fees to full licensure status. Changes fees to range of fees.

052 - Defines grounds to refuse licensure or take other licensure action.

061 - Changes fee to range. No additional or increases in fees are listed or anticipated.

b. PENDING RULES: SECTION:

012 - Addresses the issue concerning recreational athlete with agreed language.

013 - Clarifies the form and format for service plan.

014 - Defines methods of availability of direction, identification requirements and complaint procedures.

015 - Clarifies directing physician registration requirements and provides fee range for new category of "directing physician."

030 - Defines application process and removes reference to registration.

040 - Clarifies the license issue, renewal and expiration terms.

052 - Adds the practicing beyond the scope of the directing physician to grounds for licensure action.

Appendix A - Removes patient and returns wording to athlete.

MOTION: A motion was made by Senator Kennedy to approve Docket 22-0110-0301. The motion was seconded by Senator Brandt, and the motion was carried by a voice vote.
Docket No.

22-0111-0301

I. DOCKET, TYPE PURPOSE:

a) Docket 22-0111-0301 pending fee rule of the Idaho State Board of Medicine. The purpose of the rules is to comply he statutory requirements of the new respiratory therapy act passed by the 2003 Legislature.

b) The pending rules are the result of negotiated rule-making process with the polysomnographer's association and respiratory therapist association representatives. Licensees of the board were notified of the rulemaking process in the summer 2003 newsletter.

c) The rules were published in administrative bulletin 03­10.

II. OVERVIEW:

a) The purpose of the rules is to update the rules for respiratory therapists to reflect changes of Senate Bill 1165.

b) The rule provides addition of Polysomnographer permit types and related terminology definitions.

c) Defines permit requirements and grounds for discipline for permitted polysomnographers.

d) Clarifies appointment and responsibilities of the Board of respiratory therapists and provides dual licensure permit requirements for polysomnography representative.

e) Provides for two-year licensure renewal process.

f) Provides an uniform grounds for refusal to issue or renew a license or permit and suspension and revocation of license or permit.

III. SUMMARY OF CHANGES:

a) Proposed Rules: SECTION:

00-07 - Grammar and format changes, addition of polysomnography to rule authority.

010 - Addition of polysomnography terms to definitions..

011 - Clarifying the RT Board membership, responsibilities, terms and

grounds for removal of board members.

031 - Adds the permit requirements for PSG and corrects terms used,

clarifies inactive RT licensure, defines application and continuing

education requirements for permitees.

033 - Defines exemptions as related to RT licensure.

034 - Clarifies language and removes annual licensure requirement.

035 - Includes PSG in definitions of grounds for licensure action, clarifies

and provides standard terms for grounds for license action.

046 - Provides range for fees charged, clarifies application of inactive

license fees to reinstatement cost.

046.02 - Provides fee range consistent with RT fees for PSG.

046.03 - Clarifies dual license status with no additional license fee

required.

b. PENDING RULES: SECTION:

011 - Correct grammar and typographical errors.

032 - Clarifies requirement for all applications.

035.05 - Corrects terminology, clarifies supervision requirements.

035 - Clarifies action as related to PSG respiratory care.

MOTION: A motion was made by Senator Sweet to adopt Docket 22-0111-0301. The motion was seconded by Senator Bailey, and the motion was carried by a voice vote.
DISCUSSION: Chairman Brandt and committee members discussed two rule dockets previously presented by the Department of Health and Welfare. These two dockets, relating to food regulations and Senate Bill 1215, may require an additional hearing. No date was scheduled at this time.
ADJOURNED: There being no further business to discuss, the committee adjourned at 9:15 a.m.




DATE: Friday, February 6, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Stegner, Sweet, Bailey, Burkett, Kennedy
MEMBERS ABSENT/

EXCUSED:

None
GUESTS: See the attached sign-in sheets
MINUTES: A motion was made by Senator Bailey to approve the minutes of Thursday, February 5, 2004, as written. The motion was seconded by Senator Ingram, and the motion was carried by a voice vote.
Gubernatorial Appointment: The Department of Environmental Quality's Chief of Staff Jon Sandoval introduced Jay F. Kunze, of Pocatello. Dr. Kunze has been reappointed by Governor Dirk Kempthorn to the Hazardous Waste Facility Siting License Application Review Panel to serve a term commencing March 6, 2003 and expiring March 6, 2006. Dr. Kunze is currently the Dean of Engineering, Professor of Engineering, Nuclear Reactor Administrator, and Associate Director of the Idaho Accelerator Center, for the Idaho State University in Pocatello.

Dr. Kunze received his PhD in Physics (high energy experimental) from Carnegie Mellon University. He is a Licensed Professional Engineer and Mechanical Engineering in Idaho and Missouri. He was previously also licensed in Colorado, California, Nevada, Utah and Montana.

His work experience includes 20 years at the Idaho National Engineering Laboratory, 15 of those in nuclear engineering and five in geothermal and energy conservation engineering, most in project management positions. His geothermal work included environmental analysis and environmental report preparation. He directed the drilling of the first new geothermal wells in Boise, which launched the Boise downtown and state office building heating projects.

His political affiliation is Republican.

MOTION: Consideration for reappointment will be discussed on Tuesday, February 10, 2004 at 8:30 a.m.
RS13954 RS13954, relating to a Woman's Right To Know, was presented by Representative Janice McGeachin.

The purpose of this legislation is to help ensure that a woman receives information about fetal development, and the possible effects of an abortion on her health. To provide procedures when abortions may be performed and to provide for certain information to be made available to anyone seeking an abortion.

Fiscal impact - The Department of Health & Welfare is currently in the process of updating the printed information that is required by existing law. The only additional expense to this legislation is the cost to design a web site, which is estimated to be approximately $25,000.00. Also, there may be a copyright fee to publish certain photographs on the internet. This cost is estimated to be approximately $7000.00. There is a provision in the legislation that the Department of Health & Welfare may charge a reasonable fee to help offset these costs.

MOTION: A motion was made by Senator Bailey to Print RS13954. The motion was seconded by Senator Stegner. A roll call vote was requested.
Senator Kennedy voted Aye Senator Burkett was absent

Senator Bailey voted Aye Senator Sweet voted Aye

Senator Stegner voted Aye Senator Ingram voted Aye

Senator Darrington voted Aye Senator Compton voted Aye

Senator Brandt voted Aye

The motion was carried by a vote of 8 Ayes and 1 Absent and excused.

RS13662C1 RS 13662C1, relating to Mental Health Services, was presented by Senator Joe Stegner.

The purpose of this bill is to revise the membership of the current regional mental health advisory boards and provide for additional powers and duties for the new boards which will increase their function beyond the advisory level.

The legislation will require the county commission chairs, and the Department of Health and Welfare program manager and the regional director in each region to appoint the members of the boards with

representation specified in the legislation. Once appointed, a list will be sent to the Department of Health and Welfare.

The legislation requires the collaboration, cooperation, and communication between the regional mental health boards, the regional substance abuse authorities and the regional children's mental health councils in order to increase efficiency and avoid duplication of efforts and services.

The new boards, once established, may develop a service plan component for their region that will address unmet needs within the region. Once developed, the service plan component will be submitted to the state mental health authority for their review and approval, and upon approval will be subject to appropriations made for that purpose.

Fiscal impact - There is no fiscal impact on the state general fund or any political subdivision, subject to future appropriations by the legislature or local governmental entities. This does not prevent each regional board from soliciting or acquiring funds from other sources for purposes that they may deem necessary or appropriate.

MOTION: A motion was made by Senator Ingram to Print RS13662C1. The motion was seconded by Senator Kennedy, and the motion was carried by a voice vote.
RS13458 RS13458, relating to the Board of Dentistry, was presented by the Board of Dentistry Executive Director Mike Sheeley.

The purpose of this proposed legislation is to define the term "extended access oral health care program" and to create a new dental hygienist's license endorsement that would provide for a dental hygienist who satisfied the applicable qualifications to be issued an "extended access dental hygiene endorsement" which would authorize the holder of the endorsement to provide dental hygiene services under a dentist's general supervision through an extended access oral health care program. An extended access oral health care program would include dental hygiene services provided through local, state and federal programs, hospitals, schools, community health centers and through such other nonprofit or charitable dental hygiene programs which are annually approved by the Board of Dentistry and which provide free or low-cost dental hygiene services to persons who, due to age, infirmity, handicap, indigence or disability, are unable to receive regular dental hygiene care in a private dental office. The proposed legislation deletes the requirement that a dentist issue written orders to a dental hygienist working under general supervision. The dentist must now diagnose and determine the treatment to be provided by the dental hygienist or authorize the dental hygienist to perform prescribed treatment.

Fiscal impact - Additional Board of Dentistry staff time will be required to process applications for the new dental hygienist license endorsement. The Board of Dentistry has not, as yet, determined whether an additional endorsement fee will be imposed in connection with the new dental hygienist license endorsement. As such, there is a possible fiscal impact on licensees.

MOTION: A motion was made by Senator Kennedy to Print RS13458. The motion was seconded by Senator Ingram, and the motion was carried by a voice vote.
RS13459CC1 RS13459, relating to the Idaho Dental Practice Act, was presented by the Board of Dentistry Executive Director Mike Sheeley.

The purpose of this proposed legislation is to amend the Idaho Dental Practice Act (Chapter 9, Title 54, Idaho Code) by the addition of a new Section 54-935 that would provide for a retired dentist who satisfied the applicable licensure qualifications to be issued a "volunteer's license." A volunteer's license would authorize (and limit the holder to provide dental services on a volunteer basis (no expectation/receipt of remuneration above the amount of actual expenses incurred) while practicing under the auspices of specifically approved extended access oral health care programs. A holder of a volunteer's license could not practice outside the permissible scope of the license and could not convert the license to another status (i.e., active, inactive, provisional or special status). A licensee practicing within the permissible scope of a volunteer's license would be entitled to immunity from civil liability so long as not practicing negligently. The purpose of the proposed legislation is to increase access to dental care among underserved members of the public.

Fiscal impact - The proposed statute provides that there will be no fees imposed in connection with the volunteer dentist's license. As such, there will be no fiscal impact on licensees.

MOTION: A motion was made by Senator Compton to Print RS13459C1. The motion was seconded by Senator Darrington, and the motion was carried by a voice vote.
RS13454C1 RS13454C1, relating to the Board of Dentistry, was presented by The Board of Dentistry Executive Director Mike Sheeley.

The purpose of this proposed legislation is to amend the Idaho Dental Practice Act (Chapter 9, Title 54, Idaho Code) by the deletion of the restriction in the existing definition of "dental assistant" found at Idaho Code 54-903(3) which only authorized dental assistants to practice under the direct supervision of a dentist and to include the term "dental assistant" in the definitions of the terms "general supervision" and "indirect supervision" presently found at Idaho Code 54-903(8) and (9). At present, the Dental Practice Act only authorizes a dental assistant to practice under the "direct supervision" of a dentist. Direct supervision requires that the dentist be personally present in the dental practice and that the dentist reviews the treatment provided by the dental assistant before the patient leaves the practice. Indirect supervision and general supervision require less stringent levels of supervision of an auxiliary's work by the dentist. The Board of Dentistry has determined that at some point in the near future it will be warranted and necessary to allow a dental assistant to indirect levels of supervision. The proposed revision will provide the necessary, statutory authority for the Board of Dentistry to promulgate administrative rules authorizing dental assistants to perform permissible functions under varying levels of supervision.

Fiscal impact - There is no fiscal impact on either dental assistants or the Board of Dentistry by reason of this proposed statutory amendment.

MOTION: A motion was made by Senator Stegner to Print RS13545C1. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
RS13528C2 RS13528C2, relating to the creation of the Idaho Conrad J-1 Visa Waiver Program, was presented by Laura Rowan from the Division of Health, Department of Health and Welfare.

The Conrad or State J-l visa Waiver Program would authorize the State of Idaho Department of Health and Welfare to recommend up to 30 (thirty) foreign trained physicians per federal fiscal year to locate in communities that are federally designated as having a health workforce shortage. Final approval of J-l Visa Waiver requests are made by the U.S. Department of State and the Bureau of Citizenship and Immigration Services. Under this proposed program, rural and underserved communities in Idaho would be able to apply for the placement of a foreign trained physician after demonstrating that they are unable to recruit an American physician, and all other recruitment/placement possibilities have proven to be inaccessible.

Fiscal impact - The administration of a Conrad/J-l Visa Waiver Program in Idaho will be funded by receipts generated from levying a processing fee for each application received. The fee amount will be $1,000.00 per application, and may be revised at the beginning of each state fiscal year by the Director of the Department based on costs to administer the program. The number of applications processed cannot exceed 30. Fiscal Impact to communities seeking this resource is estimated at $2,000 for FY 2005. The processing fee will support the time of a Program Specialist, clerical support, and travel expenses associated with processing the application, providing technical assistance, monitoring and program evaluation. Other than the obligatory fee, there are no federal or state funds to support this program. There is no impact to the General Fund.

Ms. Rowan's explained, the program proposed by RS 13528C2 would give the Idaho Department of Health and Welfare the authority to administer a J-1 Visa Waiver Program for the State of Idaho.

This program would allow the Department to recommend the placement of foreign trained physicians in rural and underserved communities across the state.

  • These are qualified physicians; the foreign trained physicians would have to successfully complete an American residency program, and achieve a license to practice in the State of Idaho.


  • Our communities would initiate the request for these placements.


  • This is an option of last resort for communities that face dire recruitment challenges; they must first show that every effort to hire an American physician was tried and exhausted.


The Department of Health and Welfare would make a recommendation from a qualifying applicant to the U.S. Department of State. The final approval comes from the U.S. Department of State and the Immigration Agency. In exchange for this placement, the physician is obligated to serve in areas that are federally designated as having a shortage of health professionals for a minimum of three years.

MOTION: A motion was made by Senator Ingram to Print RS13528C2. The motion was seconded by Senator Bailey, and motion was carried by a voice vote.
RS13525 RS13525, relating to Recovery of Medical Assistance (transfer of assets), was presented by the Division of Medicaid Deputy Administrator Kathleen Allyn.

Under federal and state law, the state is authorized to set aside transfers of assets owned by recipients of Medicaid where the transfer is made without adequate consideration and those assets could have been used to pay for the medical assistance provided through Medicaid. In a recent decision, a state district court ruled that the state's action was barred by a four-year statute of limitations which ran from the date of the transfer even though the circumstances of the transfer were not reasonably discovered by the state until after the four years had elapsed. The proposed legislation adds language to Idaho Code Section 56-218 that would prevent the statute of limitations from running until such time as the state discovers, or reasonably could have discovered, that the asset transfer was without adequate consideration. "Discovers" or "reasonably could have discovered" as used in proposed subsection 56-218 (8) is intended to have the same meaning as "discovery," as interpreted by the courts, in subsection 5-218(4), Idaho Code.

The proposed legislation also makes a technical correction to Idaho Code 56-218 to clarify that the non-Medicaid spouse of a Medicaid recipient need not survive the Medicaid recipient in order for the department to file a claim against the community property of the non-Medicaid spouse's estate.

Fiscal impact - Additional Medicaid recovery is difficult to estimate because details of transfers have been concealed from the state. For purposes of this legislation, additional recovery is estimated as follows:

SFY 2005: $100,000

SFY 2006: $100,000

SFY 2007: $100,000

SFY 2008: $100,000

SFY 2009: $100,000

Ms. Allyn explained, under state and federal law, the state can recover the cost of Medicaid services from the estate of a deceased Medicaid client. This includes property essentially given away by Medicaid clients prior to death - but the state's right to recover transferred property is only for a limited period of time - four (4) years.

This bill amends existing law to specify when that time period to recover transferred property begins.

The bill results from a court decision that the 4-year period to reverse a property giveaway had begun at the date of the transfer, even though the transfer was concealed from the department. The department did not find out about the transfer until well after four (4) years after the fact.

What this bill says is that the f-year period for recovering the property starts only when the department discovers or reasonably could have discovered the transfer.

The bill also makes a technical correction to clarify that the department can file a claim against community property in the estate of a spouse of a Medicaid recipient, even though the spouse predeceases the Medicaid recipient.

MOTION: A motion was made by Senator Ingram to Print RS13525. The motion was seconded by Senator Stegner, and the motion was carried by a voice vote.
RS13526C1 RS13526C1, relating to Residential or Assisted Living Facilities, was presented by Division of Medicaid Administrator David Rogers.

There has been disagreement between the Department of Health and Welfare and some residential or assisted living facility and certified family home operators about how to interpret the statutory basis for revoking or denying a license found in Idaho Code Sections 39-3345, 39-3375, 39-3545, and 39-3565 or certificate and the related definition of "substantial compliance" found in Idaho Code Section 39-3302(33) and Section 39-3502(32). Arguably, the language of these statutory provisions, when read together, can give rise to more than one interpretation.

After careful consideration, the Department has adopted a more narrow

interpretation of the law to provide that the serious action of denying or

revoking a license or certificate can only be taken by the Department when there is evidence that the health or safety of a resident is in danger. However, the failure of a licensee or certificate holder or license or certificate applicant to cooperate with reasonable requests of the Department during, or in connection with, a facility or home inspection will constitute resident endangerment.

Specifically, the proposed legislation amends Idaho Code Section 39-3345 and Idaho Code Section 39-3545 to provide that a license or certificate can be revoked or denied if the Department is persuaded by a preponderance of the evidence that the health or safety of any resident is in danger. Language is added to specify that the failure of a licensee or certificate holder or license or certificate applicant to cooperate with reasonable requests of the Department during, or in connection with, a facility or home inspection is presumed to endanger the health or safety of any resident. The definition of "substantial compliance" in Idaho Code Section 39-3302(33) and Section 39-3502(32), which is no longer referenced or relevant, is deleted.

These amendments do not affect the corrective actions available to the Department, or the circumstances when they can be applied, provided in Idaho Code Sections 39-3357, 39-3358, 39-3557 and 39-3558.

Fiscal impact - This legislation is expected to avoid some litigation costs. Based on an average hearing cost of $1,600 per hearing, and assuming that the equivalent of five hearings are avoided each year because of the language clarification, the legislation is estimated to result in the following cost avoidance:

Year 1: $8,000; Year 2: $8,000; Year 3: $8,000; Year 4: $8,000; and, Year 5: $8,000.

Mr. Rogers explained that the Department of Health and Welfare has decided that this proposed legislation does not provide the level of clarity that is needed. The department and others will work on the issues during the summer; therefore, he respectfully requested RS13526C1 be held.

MOTION: A motion was made by Senator Bailey to return RS13526C1 to the sponsor. The motion was seconded by Senator Ingram, and the motion was carried by a voice vote.
Announcement: Chairman Brandt informed the committee members about an invitation from U.S. Senator Larry E. Craig, relating to "The Road to Better Health Care: Medicare and Beyond," on February 17 at the Boise Centre on the Grove. If the committee's February 17, workload allows, he would like for the members to attend the conference.
ADJOURNED: There being no further business, the committee adjourned at 9:37 a.m.




DATE: Tuesday, February 10, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Sweet, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

Senator Stegner
GUEST: See the attached sign-in sheet
MINUTES: A motion was made by Senator Bailey to approve the minutes of Friday, February 6, 2004, as written. The motion was seconded by Senator Compton, and the motion was carried by a voice vote.
RS13731C1 This proposed legislation RS13731C1, relating to immunity for the use of defibrillators and amends Section 5-337, Idaho Code, to enumerate which persons to whom limited legal immunity apply in using a defibrillator, was presented by Representative Chuck Cuddy.

The purpose of this legislation is to clarify that the Medical Professional Training Defibrillator Operator is released from all liability due to providing the necessary training and prescription to the operator.

This legislation will give the Training Professional the same lawful protection now granted to the Operator.

There is no fiscal impact.

Fred Riggers, from Nez Perce, Idaho, testified to support RS13731C1. He reported he was one of the first people in Idaho to take the EMS (Emergency Medical Services) test, and being an EMS is very hard. He requested the committee support the legislation.

MOTION: A motion was made by Senator Ingram to send RS13731C1 to Print. The motion was seconded by Senator Bailey, and the motion was carried by a voice vote.
Gubernatorial Appointment: On Friday, February 6, 2004, the committee met with Jay F. Kunze, of Pocatello, who had been reappointed to the Hazardous Waste Facility Siting License Application Review Panel for a term expiring on March 6, 2006.
MOTION: A motion was made by Senator Compton to approve the confirmation of the reappointment of Jay F. Kunze to the Hazardous Waste Facility Siting License Application Review Panel for a term expiring March 6, 2006. The motion was seconded by Senator Sweet, and the motion was carried by a voice vote. Senator Bert Marley will sponsor Mr. Kunze.
Chairman's Conference: On January 28, 2004, the committee discussed a memorandum they had received from the Idaho Legislature's Joint Finance-Appropriations Committee (JFAC) co-chairs, dated January 14, 2004, seeking the committee's help in focusing on cost containment goals concerning the Department of Health and Welfare's Medicaid program. The JFAC memorandum read:

Over the past several years, the Legislature has enacted a number of cost reduction initiatives intended to curb Medicaid costs. Attached is a list of some of the more recent examples. Despite these initiatives, anticipated savings have not been realized, and expenditures continue to rise, surpassing appropriations in fiscal years 2001, 2003 and 2004.

One weakness in the Medicaid program that has hindered the budgeting process is that the agency has not routinely provided the Legislature with information on the extent to which it has achieved the cost savings anticipated by cost reductions. Such reporting is necessary to keep the Legislature informed of the impact of its policy decisions and to assist the Joint Finance -Appropriations Committee in identifying budget needs. JFAC will be directing the Department of Health and Welfare this year to respond to those questions this year.

Another challenge to cost containment efforts by the Legislature are the sometimes inconsistent intentions which develop between three committees JFAC and the House and Senate germane committees. In some instances, there is not a consensus to support the necessary changes in rules and regulations that are required to implement cost reduction measures that were intended in the appropriation bill from the previous year, which essentially takes the department off the hook, or at a minimum places the Department of Health and Welfare in an awkward position.

We need your help this year in focusing on clear cost containment goals in the budget process. For the past twenty years the average increase in the General Fund Medicaid budget has been nearly 14%. We are no different than other states in seeing a disproportionate amount of our resources chasing significant caseload and health care cost increases year in and year out. We also know the choices are difficult.

As you know we set aside time at the close of the budget hearing process for the germane committee chairs to address JFAC. We would like to enlist the help of your committees in examining what cost control policies would be most appropriate for reigning in the spiraling costs of Medicaid. Specifically, we would appreciate an actual committee vote on potential cost control measures, then have you present those results during your JFAC presentation the second week of February. Some of the issues could include, among others:

1. Reducing or freezing provider rates

2. Reducing or restricting eligibility

3. Reducing or eliminating certain Medicaid benefits

4. Implementing a co-payment system

5. Identifying long-term care reduction strategies

6. Continue efforts to shift other relevant state programs to Medicaid

7. Implement some form of provider fees.

Chairman Brandt explained that he must meet with JFAC on Wednesday, February 11, and the JFAC is seeking methods to control the increases in providing health care services. The committee reviewed and discussed JFAC's seven (7) issues as listed above.

The committee members did not believe they have enough detail information and knowledge about the Department's FY2005 budget request to make a determination of what items can or could be reduced.

The committee was informed on January 27, by the Department of Health and Welfare (DHW), that the DHW's FY2005 budget request is the same as what Governor Dirk Kempthorn requested in his State-of-the-State and Budget address to the Legislature.

The committee members had numerous questions about the DHW budget, such as:

  • What cost savings the DHW had during the last budget year (FY04), from the changes implemented as recommended by the committee last session?
  • What cuts were implemented?
  • Is the DHW "heavy" in upper management and salaries?
  • If reductions were implemented in the number of line-staff, were reductions also made in the number of managers to equal those cuts in staff?
  • What would provider fee reductions entail?
  • What would the impacts be if a scale-back on the number of people eligible for Medicaid services, or a reduction in provided services?
  • What would be the impacts of reducing or deleting some program services?
  • The impact of freezing salaries of upper management?
  • If the committee does propose cuts to the Health and Welfare budget, should one of the seven cost savings methods (listed above) be recommended, or should they review the DHW budget and then determine where the recommended cuts be made?
  • What DHW systems are being implemented to increase efficiency and improve services to provide quality health care?
  • Should the committee look for specific reductions in specific programs or specific areas of eligibility requirements?
  • Committee members agreed the Department of Health and Welfare has hard working, professional individuals, who do a good job.
  • Is DHW providing the best service for the best use of dollars?
  • Should DHW reduce administrative costs - not Medicaid services?
  • Long-term care - does the DHW have a dedicated staff in charge of long-term health care planning?
  • What is the DHW's long-term health care plan?


The committee members agreed that Idaho cannot afford to maintain the current services and eligibility for Medicaid services. Idaho simply does not have the funds to maintain this current status.

After discussion, and at this time, no recommendations were made to the JFAC seven reduction selections listed in the letter. The committee members requested the Department of Health and Welfare meet with them and present a detailed budget outline.

MEDICAID BUY-IN PROGRAM: Kelly Buckland, executive director of the Idaho Independent Living Association, outlined the Medicaid Buy-In for Idahoans with Disabilities Program. He encouraged the committee to recommend to the JFAC to finance the $400,000 needed to implement the program.

He explained, the Buy-in program is for Idahoans with disabilities wanting to work themselves off the system and are trapped by the all-or-nothing nature of the Medicaid program, i.e., if a person's income is below a certain level, he or she receives full Medicaid benefits; if a person makes one dollar more, he or she receives nothing.

People with disabilities have to make decisions based on financial reality. Should they consider returning to work, facing the risk of losing vital Medicaid benefits? As a result, they are compelled not to work and find themselves trapped into poverty. We should not be discouraging people with disabilities from working, earning a regular paycheck, paying taxes and moving off public assistance. A Medicaid buy-in program would enable Medicaid participants with disabilities to contribute to society.

In year 2003, the Blue Ribbon 2020 Task Force recommended that the state implement a Medicaid Buy-In Program so that individuals with disabilities could continue to receive Medicaid benefits and share in the cost of those benefits after obtaining employment.

Written comments were received from Steve Rodolets, Idaho Benefits Planning Assistance and Outreach Program. His comments, in summary, "The Medicaid Buy-In can simply remove the governmental order to not earn a living for ourselves and our families if people require medical attention to stay alive. Earned income can be achieved, even it won't cure what ails us. Then we might join you all in complaining about our taxes and the weather."

Mr. Buckland, again encouraged the committee to ask JAFC to finance this program.

ADJOURNED: The committee adjourned at 9:55 a.m.




DATE: Wednesday, February 11, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Sweet, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

Senator Stegner
GUESTS: See the attached sign-in sheets
Vice Chairman Compton conducted the meeting as Chairman Brandt was meeting with the Joint Finance-Appropriations Committee.
RS 13985 This legislation, RS13895, stating findings of the Legislature and rejecting certain rules of the Department of Health and Welfare, relating to the Medical Assistance Program, IDAPA 16.03.09, Section 204 and 210, Docket 16-0309-0308, Medicaid Fraud and Investigations Unit, was explained by Vice Chairman Compton.

This concurrent resolution would reject certain pending rules of the Department of Health and Welfare relating to the medical assistance program. The effect of this resolution, if adopted by both houses, would be to prevent the agency rules from going into effect.

On Friday, January 30, 2004, the committee held a second hearing concerning the Department of Health and Welfare's rules governing the Bureau of Fraud and Investigations. The committee rejected two sections of Docket 16-0309-0308, Sections 204 and 210.

MOTION: A motion was made by Senator Sweet to send RS13985 to Print. The motion was seconded by Senator Ingram. A roll call vote was requested.

Senators Kennedy, Sweet, Ingram and Compton voted Aye.

Senators Bailey and Darrington voted Nay.

Senators Burkett, Stegner, and Brandt were absent and excused.

The motion to send RS13985 to Print was carried by 4 Ayes, 2 Nays, and 3 absent and excused.

RS 13838 This proposed legislation, rs13838, relating to medical indigency, was presented by Tony Poinelli, a representative of the Idaho association of counties.

He explained the purpose of this bill is to close a loophole that exists in the law dealing with the 180-day delayed application process. The original intent of the 180-day delayed application was to encourage a provider or applicant to seek other resources that the individual may legitimately qualify for.

Generally, the process for applying to the county requires an application be submitted within 31-days after a person receives services. However, the provider may choose to file a delayed county assistance application, if it is determined that the applicant may qualify for one of the six (6) resources listed in the law. Because counties are the payers of last resort, that resource should be applied for before seeking property tax assistance. The other resources are limited to: medicaid, medicare, social security, crime victims, workers' comp, 3rd party insurance.

After determining that an individual may legitimately qualify for one of these, the provider or applicant can then file a county indigent application up to 180-days after the service is rendered by the provider. During that time frame, hopefully, one of the resources would have paid or otherwise notified the applicant or provider they ha ve been denied, thereby enabling them to file with the county.

The problem that has occurred, primarily in the north with out-of-state providers, is that the law is vague and seems to enable a provider to file for the 180-day delay if they just missed the 31-day filing window, and the person cannot qualify for another resource.

The counties are bound to comply with the time-lines outlined in the

Idaho code. The changes made to the 180 days delayed process simply

clarify those time-lines and qualifications for filing a delayed application for those providers who ha ve misused the time-lines allowed by law.

The counties originally were going to seek repeal of the section, but after investigating it further determined that it would have caused a significant impact on some counties. Also, it does work as many of the providers work with the counties. The language changes clarify the intent of this section.

The other two (2) changes are only clarity. One says that Medicaid

co-payments and deductibles would not be considered as a necessary medical service, and the other deletes the uniform county guidelines on indigent eligibility.

He discussed, Section 3, that Section 31-A3504, Idaho Code, be, and the same is hereby amended to read as follows:

35-A3504. ADVISORY DECISIONS OF PANEL. The general responsibility of the advisory panel will be to consider the eligibility of applicants on claims referred to them and render written opinions regarding such eligibility of applicants as based upon review of analysis of the resources available to the applicant, as defined in the Uniform County Guidelines on Indigent Eligibility referred to in section 31-3503 section 31-3502(17), Idaho Code. Following proceedings on each claim, the advisory panel shall provide the affected parties with its comments and observations with respect to the claim. They shall indicated in such comments whether the applicant appears to have resources available to him or her sufficient to pay for necessary medical services; does not have adequate resources; or any comments or observations which may be relevant and appropriate. The findings of the advisory panel may be used by affected parties in resolving contested claims in a manner consistent with the findings presented. However, such findings will be advisory in nature only and not binding on any of the affected parties.

There is no fiscal impact on the State of Idaho or any political subdivision.

MOTION: A motion was made by Senator Darrington to send RS13838 to Print. The motion was seconded by Senator Sweet, and the motion was carried by a voice vote.
SB 1291 This legislation, Senate Bill 1291, relating to the creation of the Idaho Conrad J-1 Visa Waiver Program, was presented by Laura Rowen from the Division of Health, Department of Health and Welfare.

The program proposed by Senate Bill Number 1291 would give the Idaho

Department of Health and Welfare the authority to administer a J-1 Visa Waiver Program for the State of Idaho.

This program would be discretionary and voluntary on the part of the Department. It would allow the Department to recommend the placement of up to thirty foreign trained physicians in rural and underserved communities across the state per federal fiscal year.

  • These are qualified physicians; the foreign trained physicians would have to successfully complete an American residency program, and achieve a license to practice in the State of Idaho.


  • The application will require a signed employment contract between the community and the physician. The physicians must agree to provide direct patient care full time for a minimum of three years in family medicine, internal medicine, pediatrics, obstetrics and gynecology or psychiatry, and they must serve Medicaid and Medicare patients, and provide a sliding payment scale for those who are compromised in their ability to pay for care.


  • Our communities would initiate the request for these placements; not the Department, and not the foreign physician. In addition to being in a workforce shortage area, facilities that provide primary medical or mental health services and are financially viable may apply.


  • This is an option of last resort for communities that face dire recruitment challenges; they must first show that every effort to hire an American physician was tried and exhausted. Evidence of active recruitment over a minimum of six months has to be shown.


  • The Department has monitoring and reporting obligations; if the terms and conditions for approval and placement are not met or cease to be fulfilled by the physician or the hiring facility, the physician may face deportation. The Department may deny future participation in the program if an applicant does not satisfy the reporting requirements, if the physician does not serve the community or population that he was committed to, the physician does not remain employed by the applicant for the full three years of employment, or if the applicant or physician is out of compliance with these or federal terms.


The Department will collect an administrative and processing fee of $1000 per application. The amount may be adjusted by the director to satisfy actual costs, should it be determined that it is in excess of $1000. There is broad community support for this fee.

The application process is as follows:

  • A qualifying facility submits a complete application to the Department for consideration after recruiting, screening, and agreeing to hire a physician holding a J-1 Visa.


  • If favorable and if all terms are met, the Department may then make a recommendation to the U.S. Department of State, that a waiver be granted to the J-1 physician.


  • The U.S. Department of State reviews the application and recommendation received from the State of Idaho, and takes action along with the Immigration Agency. If a Waiver is awarded, the physician is notified directly. The physician then must seek and H1-B Visa - which is essentially a work permit for someone with non immigration status. Their work contract with the community becomes binding.


In the past, Idaho communities have had access to similar, federally administered programs. The criteria for the federally administered program have become so stringent that very few Idaho communities would have access to it, though their level of need remains the same. The handout that is offered with this presentation shows areas of the state that would be eligible to request a primary care physician under this proposed state-administered program (in yellow). The facilities on the map are the few entities which might be eligible to participate in the federally administered program. (See Attachments #1 and #2)

Dr. James Scheel, Idaho Medical Association, testified the IMA supports this legislation.

Leslie Phelps, chief executive officer, of the Glenns Ferry Health Center, an Idaho Community Health Center, testified on behalf of Idaho's eight corporate Community Health Centers and the Idaho Primary Care Association.

She shared the strengths and benefits on how the creation of an Idaho Conrad J-1 Visa Waiver Program would assist us in providing primary health care services throughout Idaho.

  • This program would expand the physician recruitment options to recruiting highly qualified physicians into many rural areas.


  • Idaho is the only state without a Conrad J-1 Visa Waiver Program to help in assisting health centers and others recruit physicians.


  • This program will help address some of the difficulties we face in recruiting physicians into rural areas. Idaho has recently fallen to 50th in the Nation in the number of health care practitioners to population adding to our dilemma and need of recruiting options.


  • The Conrad Program would assist Idaho rural communities that have been unable to recruit an American physician for six months or more.


  • In addition, it provides an opportunity to hire a highly qualified foreign physician who has received residency training by an accredited residency program in the United States.


As previously mentioned, the Conrad J-1 Visa Waiver Program requires the foreign physician to practice in a Health Professional Shortage Area (IPSA) or medically undeserved area for three years. As you can see, this would assure us not only that health care services are being delivered, but also provide continuity of care over a period of time. Generally, the physicians extend their contracts for longer than the three (3) year requirements.

Glenns Ferry Health Center over the last three (3) years lost the ability to recruit four highly qualified J-1 Waiver physicians adding to our cost of providing services because we were forced to contract with locum tenen physicians approximately every three to four months to maintain coverage. This was a tremendous challenge since many physicians lack the skills necessary to meet the needs of the health centers delivery model.

Located in a rural area we need family practice physicians who are highly trained, possess obstetrical/delivery, and C-section skills as well as the medical skills to meet the growing health care needs.

  • The foreign physicians are the brightest, most highly skilled and knowledgeable physicians from their countries.


  • The foreign physician has the skill level required to meet the many demands of the primary health services provided by health centers.


Recently, Glenns Ferry Health Center was able to hire a J-1 Waiver physician through the Health and Human Services J-1 Visa Waiver Program. A state Conrad J-1 Visa Waiver Program would add to our ability to recruit qualified physicians in a more timely, effective and efficient manner than other options.

The fiscal impact for the implementation of such a program to the Department of Health and Welfare will be minimal. An application fee amount, as stated in 39-6113, will be no less than $1,000 and may be revised at the beginning of each state fiscal year. Receipts generated from levying a processing fee for each application will fund the program.

The State J-I Visa Waiver requirements for a health center corporation or other entity and physician are many. The fact that the physician is required to be licensed by the Idaho State Board of Medicine prior to applying for the J-1 Visa Waiver Program assures that very strict standards are met.

In closing I would like to urge your support for a State J-1 Visa Waiver Program. It would provide a positive avenue to help address the physician recruitment needs to assure continued and improved quality health care access for all Idahoans.

MOTION: A motion was made by Senator Bailey to send SB1291 to the Floor with a do pass recommendation. The motion was seconded by Senator Darrington, and the motion was carried by a voice vote.

Senator Bailey agreed to be the Floor sponsor for SB1291.

ADJOURNED: The committee adjourned at 9:12 a.m.




DATE: Thursday, February 12, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

Senators Stegner and Sweet
GUESTS: See the attached sign-in sheets
SB 1278 Bill Jerrel, from the Department of Environmental Quality (DEQ) presented SB1278, relating to the DEQ to provide that the Department may use a limited portion of interest revenue from wastewater and drinking water loans for operation of the loan programs subject to annual appropriation.

This legislation allows the Department of Environmental Quality to use a portion of the interest revenue from wastewater (CWSRF) and drinking water (DWSRF) loans for operating the programs.

Currently, the programs are funded for 4% of the annual federal contributions (approximately $13.8 million per year). This level of federal contribution is expected to decrease and will not provide sufficient resources for DEQ to manage the programs as the total funds managed have increased to more than $150 million. This funding mechanism will allow the programs to be self supporting.

There is no fiscal impact to the General Fund. A reduction in the SRF funds available for future loans would be in the amount of the funds used to administer the program. DEQ envisions no increased cost to borrowers. The current "at or below" market interest rates will continue.

Mr. Jerrel presented two handouts. Attachment #1 - Funding State Revolving Fund (SRF) administrative costs, and Attachment #2 - Operator Certification Improvements for Drinking Water and Wastewater Professionals. The federal EPA requires an annual audit be done on the programs.

Don Munkers, Idaho Rural Water Association, testified IRWA supports this legislation and requested the committee to send SB1278 to the floor with a do pass recommendation.

MOTION: A motion was made by Senator Compton to send SB1278 to the Floor with a do pass recommendation. The motion was seconded by Senator Kennedy, and the morion was carried by a voice vote. Senator Compton agreed to sponsor SB1278 on the Senate Floor.
SB 1279 This legislation, SB1279, relating to drinking water and wastewater, was presented by Toni Hardesty from the Department of Environmental Quality.

Protection of public health requires the use of licensed professionals for operating water and wastewater utilities, and testing backflow assemblies. This legislation provides for the transfer of licensure responsibilities for Drinking Water and Wastewater Professionals from the Department of Environmental Quality to the Bureau of Occupational Licenses (IBOL).

It set forth the policy, title, required license and definitions. Additionally, it provides for a board, to be appointed by the Governor, with qualifications, number, terms of office, removal from office, procedures, powers and duties. The Department of Environmental Quality will hold a position on this board.

The legislation states finances, fees, providing for the issuance of licenses with an annual renewal. It provides for the revocation or suspension of licenses, violations, and penalties. It establishes that an emergency exists and that this act shall be in full force and effect on and after its passage and approval. The IBOL will provide administrative, legal and financial services to the board.

After discussion, the Department of Environmental Quality Director Steve Allred, requested the committee to send SB1279 to the 14th Order for amendment and clarification.

MOTION: A motion was made by Senator Ingram to send SB1279 to the Floor with a do pass recommendation. The motion was seconded by Senator Compton.
SUBSTITUTE MOTION: A substitute motion was made by Senator Darrington to send SB1279 to the 14th Order for amendment. The motion was seconded by Senator Bailey.

Discussion:

Dick Rush, Idaho Association of Commerce and Industry, testified that IACI strongly supports SB1279.

Molly Steckel, a representative for the Idaho Chapter of the American Council of Engineering Companies (ACEC), testified to support SB1279, but ACEC does have an issue with Page 2, Line 1, of SB1279, "Operating personnel shall include every person making system control or system integrity decisions about water quantity or water quality that may affect public health."

She testified, the issue is the phrase "system integrity decisions" could be construed as an engineering function that we perform. The members of the ACEC are responsible for the design of the public drinking water systems and public wastewater systems. The ACEC performs studies, design the systems, write the manual that governs the system and do the initial printing. The ACEC recognizes that the intent of SB1279 is not to preclude the ACEC from doing the engineering they are qualified to do, however, it could be interpreted that way. And, if that were the case, engineers would be prohibited from performing the functions they are required to perform, or they would need to go get the other license.

The ACEC has suggested different language for SB 1279, and requested time to meet with DEQ and draft amendment language that everyone would be comfortable with.

A call for the vote on the substitute motion to send SB1279 to the 14th Order was made.

The substitute motion to send SB1279 to the 14th Order was carried by a voice vote.

HB 551 This legislation, HB551, relating to licensure by the Board of Psychologist Examiners, was presented by the Bureau of Occupational License Bureau Chief Rayola Jacobsen.

This legislation amends Section 54-2309, Idaho Code, to clarify conditions for non-issuance and revocation of licenses. It adds language making a violation of the Board rules and grounds for a disciplinary action against a licensee.

There is no fiscal impact on general or dedicated funds.

MOTION: A motion was made by Senator Darrington to send HB551 to the Floor with a do pass recommendation. The motion was seconded by Senator Bailey, and the motion was carried by a voice vote.
HB 553 This legislation, HB553, relating to the Board of Social Work Examiners, and amending Section 54-3203, Idaho Code, to increase the number of Board members by one to include a lay member of the public, was also presented by Bureau Chief Rayola Jacobsen.

This proposal responds to requests from the public to broaden representation of the Board.

The impact on dedicated funds would be the travel expenses for three board meetings a year for one board member. This board does not receive honorariums.

MOTION: A motion was made by Senator Darrington to send HB553 to the Floor with a do pass recommendation. The motion was seconded by Senator Bailey, and the motion was carried by a voice vote. Senator Brandt agreed to be the sponsor on the Senate Floor for HB553.
ADJOURNED: The committee adjourned at 9:25 a.m.




DATE: Friday, February 13, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Sweet, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

Senators Stegner and Ingram
GUESTS: Senator Williams, Representatives Henbest and McGeachin. Also, see the attached sign-in sheets
RS 13841C1 This proposed legislation, RS13841C1, relating to the Practice of Podiatry; amending Section 39-1305, Idaho Code, to remove certain medical staff membership requirements, was presented by Senator Stan Williams.

This legislation removes language in Idaho Code that requires

patients admitted to an Idaho hospital on the recommendation of a

licensed podiatrist, to have their required history and physical performed by a physician licensed pursuant to Chapter 18, Title 54, Idaho Code. Podiatrists are trained, qualified and licensed under Idaho Code to perform this routine examination.

There is no fiscal impact.

MOTION: A motion was made by Senator Compton to send RS13841C1 to Print. The motion was seconded by Senator Darrington, and the motion was carried by a voice vote.
RS 13992 Proposed legislation, RS13992, relating to Family Planning; amending Chapter 2, Title 56, Idaho Code, by the addition of a new Section 56-209(m) to provide that the Director of the Department of Health and Welfare shall apply for a Family Planning demonstration waiver, was presented by Representative Margaret Henbest.

This legislation would expand family planning services in Idaho to women of childbearing age with incomes up to 133% of the Federal Poverty Level. Family Planning services are limited to counseling and medical services prescribed or performed by an independent licensed physician or a qualified certified nurse practitioner or physician's assistant and includes diagnosis, treatment, contraceptive supplies, related counseling, and restricted sterilization. Contraceptive supplies include condoms, foams, creams, jellies, prescription diaphragms, intrauterine devices and oral contraceptives.

Effective family planning healthcare reduces the number of unintended pregnancies and therefore the number of abortions. Planned pregnancies also result in healthier women, healthier babies, and healthier families.

Fiscal impact - The preliminary estimates indicate that 39,195 women would be eligible. Research data suggest that 25% of these women would be likely to enroll, and use these family planning services. Without increased access to family planning services, the state could anticipate spending 1.5 million on pregnancy and child health care costs for this population. The cost to the state for these additional enrollees for family planning is estimated to be approximately $500,000. The cost avoidance realized by the state will be around $1.0 million. This family planning expansion is possible through a 1115 demonstration waiver in which the Federal Government funds 90% of the cost. The state of Idaho

funds 10% of the cost. In 2003 an independent study was funded

by the Center for Medicaid and Medicare, which found that the six (6)

states included in the study all achieved budget neutrality after operating under the waiver.

Representative Henbest is a member of the House Health and Welfare Committee. She was questioned about why this proposed legislation was presented to the Senate Health and Welfare Committee and not to the House Health and Welfare Committee and Chairman Sali. She answered "no" when questioned about Chairman Sali being aware of the legislation, and explained this was not intentional.

Whenever a proposed House legislation is placed on a Senate Committee agenda, that does not mean the Senate Committee supports

the proposed legislation.

MOTION: A motion was made by Senator Compton to return RS13992 to the sponsor. The motion was seconded by Senator Sweet.

Discussion: Protocol and curtsey; legislation belongs in the House Health and Welfare Committee and should go before the Chairman as that is the appropriate place for the legislation; neither sponsor from the Senate is present to speak for the bill; legislation sponsored by a Senator and going before a House Committee; the right of a House representative to bring forth legislation to a Senate committee, and the prerogative of the chairman to accept or deny proposed legislation; and committee shopping by members of both the Senate and the House.

Senator Sorenson and Senator Keogh are cosponsors of RS13992, but did not discuss the legislation with the committee chairman and did not attend today's hearing.

After the discussion, Senator Compton withdrew his original motion.

SUBSTITUTE MOTION: A substitute motion was made by Senator Kennedy to send RS13992 to Print. The motion was seconded by Senator Burkett.
AMENDED SUBSTITUTE MOTION: An amended substitute motion was made by Senator Sweet to send RS13992 back to the sponsor. The motion died for lack of a second.
A roll call vote was taken on the substitute motion made by Senator Kennedy to send RS13992 to Print.

Senators Kennedy, Burkett, Darrington, and Compton voted Aye.

Senators Bailey, Sweet, and Brandt voted Nay.

Senators Steiner and Ingram were absent and excused.

The substitute motion to Print RS13992 carried with 4 ayes, 3 nays, 2 absent and excused.

RS 141013 This legislation, RS141013, relating to abortion a "Woman's Right to Know" was presented by Representative Janice McGeachin.

The purpose of this legislation is to help ensure that a woman receives information about fetal development, and the possible effects of an abortion on her health. To provide procedures when abortions may be performed and to provide for certain information to be made available to anyone seeking an abortion.

Fiscal impact - The Department of Health & Welfare is currently in the process of updating the printed information that is required by existing law. The only additional expense to this legislation is the cost to design a web site, which is estimated to be approximately $25,000.00. Also, there may be a copyright fee to publish certain photographs on the internet. This cost is estimated to be approximately $7000.00.

Senator Brandt explained he is also a sponsor of RS141013, and that is why the legislation was before the Senate Committee and not the House Health and Welfare Committee. He could have presented RS141013, but requested Representative McGeachin to be the presenter. He also informed the committee members that SB1294 will remain in the committee as this proposed legislation replaces the bill.

This proposed legislation changes the previous SB1294, and changes are as follows:

  • Page 1, line 24 - Retain "informed consent" basic definition from previous statute.


  • Page 3, line 8 - Change "any pregnant patient or immediate family member" to "any person." This makes the language identical to the language in the "parental consent" statute.


  • Page 3, line 11 - Addition of language making it clear that retention of the signed verification is primia facia evidence of the physician's compliance with the requirements of 18-609. This was added at the suggestion of Representative Ring who expressed concerns that the bill had taken out all reference to protection of the physician who was in compliance with the provisions of the law.


  • Page 3, line 32 - Addition of language making it clear that the patient may secure the written materials from the abortion provider or his agent. In order to assure a broad availability of this vital information, however, the woman may also secure the materials from many other sources (including health clinics, Planned Parenthood office. . . .) But that at the very least these materials will be available from district health offices and regional offices of the Department of Health and Welfare.


  • Page 5, line 20 - Clerical revision changing the language from "on or after" to "on and after" so as not to allow a delay in the requirement that the materials be provided.


  • Page 5, line 22 - Remove the requirement that the department charge a fee for the materials. This will allow that the materials be available in a broad range of outlets allowing for a true flow of information. This section also adds language requiring that the materials be made available in "easily accessible locations." This will assure the most accessible dissemination of the information to assure availability.


  • Page 6, line 31 - Changes the word "prepare" to "provide" making it clear that the director shall have available for use by abortion providers the forms required in order to comply with the provisions of this statute.
MOTION: A motion was made by Senator Kennedy to Print RS141013. The motion was seconded by Senator Compton, and motion was carried by a voice vote.
RS 14042 This legislation, RS14042, relating to Emergency Medical Services Personnel, was presented by Ken McClure, a representative of the Idaho Medical Association.

He explained, Health care organizations maintain a formal peer review process in order to reduce the occurrence of illness and death and to

enforce and improve standards of medical practice. This process enables research, discipline, and medical study to improve quality of care. Records used in peer review are confidential and privileged and generally are not subject to subpoena or discovery. This confidentiality allows open and honest communication which is critical for the peer review process to work.

Idaho's peer review statutes only apply to peer review of care provided in hospitals and other health care organizations. Emergency medical services (EMS) personnel provide care to patients before they arrive in the hospital setting. The quality of care EMS personnel provide is of critical importance to all Idahoans. Their current attempts at peer review are severely curtailed because they are not covered by these statutes.

This legislation would include EMS personnel within Idaho's peer

review statutes and thereby encourage their participation in this most important quality improvement tool.

Fiscal Impact - This bill will have no fiscal impact on state or local funds.

MOTION: A motion was made by Senator Compton to Print RS14042. The motion was seconded by Senator Sweet, and the motion was carried by a voice vote.
RS 13837 RS13837 relates to Emergency Services and provides an exception to jurisdiction of the sheriff, was presented by Senator Brandt.

The purpose of this legislation is to amend Section 46-1007, Idaho Code, to clarify jurisdiction of licensed emergency medical service agencies; and amending Section 46-1009, Idaho Code, to provide an exception to jurisdiction of the sheriff.

The jurisdiction and authority of police and fire departments is protected in 46-1007(3) but not that of emergency medical services. Approximately 85% of the ambulance services in Idaho are not affiliated with a fire department or law enforcement agency. This change will provide the same clarity about chain of command for EMS agencies as for fire agencies. Sheriffs are generally not trained or equipped to command medical incidents, and some local EMS agencies are frequently not affiliated with a sheriff's department, though they may frequently work together and cooperate with law enforcement. This legislation is in the best interest of public safety in our communities.

Fiscal impact - There is no fiscal impact to the General Fund.

MOTION: A motion was made by Senator Bailey to send RS13837 to Print. The motion was seconded by Senator Sweet, and the motion was carried by a voice vote.
RS 13641 This legislation RS13641, relating to the Department of Health and Welfare; stating findings of the Legislature and providing that the name of the Department of Health and Welfare shall be changed to the Department of Health and Social Services, was presented by Senator Brandt.

The Department has been known as Health and Welfare for many years and the name no longer makes sense. It does not reflect the widespread and critically important roles we play in local communities in every corner of the state. It is time to change the name. The old name suggests that "welfare" is half of what we do, and nothing could be further from the truth.

Very little of what is done today can be considered "welfare" as most people define it. Welfare goes back to the days when the Department gave out cash assistance without expecting anything in return. Today, that is no longer true.

I propose "social services" because that far more accurately explains the services the Department provides communities. By providing health and social services, we invest in people - some of them in need, some of them in crisis. By doing so, the Department also invests in local communities, local businesses, and local jobs.

That is not welfare. That is investment in our communities, and investment made through social services, not welfare.

Fiscal impact - $30,000 for replacement of signs at Department facilities and telephone book changes. Implementation is set for July 1, 2004.

MOTION: A motion was made by Senator Kennedy to send RS13641 to Print. The motion was seconded by Senator Bailey, and the motion was carried by a voice vote.
ADJOURNED: The committee adjourned at 9:25 a.m.




DATE: Monday, February 16, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Stegner, Sweet, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

None
GUESTS: See the attached sign-in sheet
RS 13846C1 This legislation, RS13846C1, relating to the Prohibition of the Practice of Dental Hygiene, was withdrawn by the sponsor, Brad Hoaglun, a representative of the Idaho Dental Hygienists Association. There were problems with the proposed legislation; therefore, no hearing was held.
RS 13849C1 RS13849C1, relating to Dentistry and amending Sections 54-906, 907, 908, and 911, Idaho Code, was presented by Brad Hoaglun, representing the Idaho Dental Hygienists Association.

This legislation updates the practice act for dental hygiene. It raises the fines for the unlawful practice of dental hygiene to a minimum of $500 to not more than $1,000. The bill also changes the number on the State Board of Dentistry by one with the addition of a dental hygiene member. Under this proposal the board would have five dentists, three dental hygienists and one consumer member. The additional hygiene member would be appointed on an at-large basis. The legislation will also allow for the selection of the licensing board chair to be either a dentist or dental hygienist and it would require that a quorum consist of at least one dental hygienist.

Fiscal Impact - The cost of the additional dental hygienist on the board is approximately $6,000. Presently the funds are available in the licensing board's account to pay for the cost of the new position. The board's funding domes from the licensure and renewal of licensure of dentists and dental hygienists. There is no impact to the General Fund.

Mike Sheeley, executive director of the Idaho Board of Dentistry, testified the board had not seen this proposed legislation. The board just met, and Mr. Hoaglun did not inform the board about this proposal. The Board of Dentistry is not scheduled to reconvene until April 2004. Mr. Sheeley could not support RS13849C1 at this time.

Jerry Davis, executive director of the Idaho State Dental Association, agreed with the statement of Mr. Sheeley. The Idaho Dental Association has not reviewed this legislation.

MOTION: A motion was made by Senator Ingram to return RS13849C1 to the sponsor. The motion was seconded by Senator Darrington.

Discussion: The Chairman directed the parties involved to meet in good faith soon, and try to resolve the issues.

SUBSTITUTE MOTION: A substitute motion was made by Senator Burkett to send RS13849C1 to Print. The substitute motion died for lack of a second to the motion.
The original motion, made by Senator Ingram and seconded by Senator Darrington, to return RS13849C1 to the sponsor was carried by a voice vote. Senator Burkett voted No.
RS 13852C1 This legislation, RS13852C1, relating to Dentistry and amending Sections 54-912, 915, and 916A, Idaho Code, to provide for programs accredited by the American Dental Association's Commission on Dental Accreditation or its successor specialty accrediting agency, was also presented by Brad Hoaglun, from the Idaho Dental Hygienists Association.

The legislation puts into statutes the requirement that any school, college or other program teaching dentistry or dental hygiene must be accredited by the American Dental Association's Commission on Dental Accreditation. Additional changes require accreditation for dental hygiene programs through regional accrediting agencies recognized by the U.S. Department of Education. It also requires that the program for dental hygiene be conducted for a minimum of two (2) academic years.

Fiscal Impact - There is no fiscal impact.

Senator Kennedy asked Mr. Hoaglun about any discussions, particularly the two-year educational requirements, with the Dental Association. Mr. Hoaglun reported there have been no formal discussions. Previously, there has been a discussion about the two-year educational requirements in rule vs. statute.

Idaho Code reads: 54-915(3) - Shall, for dental hygiene, have successfully completed the course of study in dental hygiene, and received a degree from a dental hygiene school accepted or college whose dental hygiene program is accredited by the American dental association's commission on dental accreditation or its successor specialty accrediting agency and is approved by the board. Such school or college must be accredited by a regional accrediting agency for colleges, universities, or institutions of higher education which is recognized by the United States department of and must conduct a curriculum consisting of not less that two (2) academic years for dental hygiene graduation with courses at the appropriate level to enable matriculation into a more advanced academic degree program;

Jennifer Kelly, president of the Idaho Dental Hygienists Association, explained that Idaho has two accreditation programs. She supports this legislation.

Mike Sheeley, explained that currently the Board of Dentistry does require graduation from a dental hygiene program accredited by the American Dental Association. That requirement is in currently in rule. He has not seen the proposed legislation and cannot support it as he has real concerns about the bill.

Jerry Davis reported he agrees with the statement of Mr. Sheeley.

MOTION: A motion was made by Senator Ingram to return RS13852 to the sponsor. The motion was seconded by Senator Darrington, and the motion was carried by a voice vote.
ACT TEAM Ken Deibert, the administrator of the Division of Family and Community Services (FACS), Department of Health and Welfare, outlined the ACT Teams who deal with the mental health services.

Senator Stegner explained he had to leave, but encouraged committee members to seriously consider funding both of these programs, the ACT Team and Community Resource Development. Both are areas where we can make a significant impact on families and individuals in delivery of those services. He believes it is very appropriate for the committee to request the Joint Finance-Appropriations Committee to provide funds for these programs as they both are vital to Idahoans.

Mr. Deibert explained, during 1993 the Department of Health and Welfare began a study of a model community-based system started in the state of Wisconsin. We asked for and received funding from the Legislature to incorporate Assertive Community Treatment and Psychosocial Rehabilitation ACT Teams in Idaho. We made the commitment because of the positive clinical outcomes.

Act Teams work focuses on people with serious and persistent mental illness, such as schizophrenia. The purpose of the program is to minimize rehospitalization and enable consumers to live successful and productive lives in their communities. There were significant reductions in hospitalization or incarceration for individuals with serious and persistent mental illnesses, who were involved with the ACT team treatment service. There is a marked increase in cost to provide service to this population. ACT Teams provide services every 24-hours, 7-days per week.

In 1993, the Department received $890,000 to fund our initial network. Again in 1995, the Legislature approved and additional $600,000 for ACT Teams which allowed the Department to expand partial ACT Teams to all seven (7) regions in Idaho. There are two types of ACT Teams, Urban and Rural Teams.

The current general fund ACT Team appropriation is $1.8 million. Mr. Deibert distributed a chart outlining the current ACT costs, full-time employees (FTEs) and budgets per region. Current ACT Teams are not staffed to National standards. An additional 55.75 staff and additional psychiatric time are needed to meet the National Urban Maximum team size, or additional staff plus psychiatric time to meet the Minimum Urban team size. The chart outlines the cost for seven (7) full ACT Teams, total cost for one new ACT Team, and the total cost for seven (7) full ACT Teams. (See Attachment #1)

COMMUNITY RESOURCES FOR FAMILIES Ken Deibert also explained the Community Resources for Families (CRFF) Program. This is a school-based child welfare partnership with the Department of Health and Welfare (DHW) and independent school districts throughout Idaho. The CRFF is a prevention program to address emergency conditions that threaten to disrupt families and negatively impact children.

CRFF is an elementary aged program that serves children in grades K through 6 with overall program goals being; to strengthen families to prevent child abuse and neglect, increase school readiness of children and increase the self-reliance of families through utilization of community resources.

The Department provides local school districts with program coordination and funding to hire Community Resource Workers (CRW) to work with school staff to identify children who are underperforming in school due to unmet physical or emotional needs in their home environment. The CRW meets with the families, assesses their strengths and needs, and links them with existing community resources.

The CRFF Program provides two levels of services, Emergency Assistance Services (EA) and Assessment and Referral Services (A&R). Family participation is voluntary. All families who choose to participate in the program receive up to 30 days of home-based supportive services (A&R). Within this 30-day period, some families may require more comprehensive planning and services. These families may be eligible for emergency assistance services.

  • The program began in 1994 in Boise as a partnership between the Boise School District and the Department of Health and Welfare.


  • In 1996 the program was replicated in Region 1.


  • CRFF expanded in 1997 with the replacement of Aid to Families with Dependent Children, (Title IV-A, AFDC) with Temporary Assistance to Needy Families (TANF). States were encouraged to use their welfare reform savings to maintain or expand child welfare and family self-reliance services. The Department, recognizing the success of the two established pilot sites, used welfare reform as an opportunity to expand the CRFF Program statewide, and enter into partnerships with 90 school districts throughout Idaho.


  • Two levels of services were provided to families which included Assessment and Referral (A&R) services up to 30 days and Emergency Assistance (EA), 90 day intensive in-home family services.


  • From 1999 to 2001, 11,546 families were referred to the program and of those 2,173 families received EA service, 7,103 received A&R. The remaining families either declined or were not eligible for services.


  • In school year 2001-2002, with shrinking TANF dollars, the funding source for the program changed.


  • The 2001 legislative session resulted in legislative intent language which directed $2,000,000 in TANF funds to be used to provide a 2-to-1 match between the school district and the Department. The school districts could use their discretionary dollars, and for every $2 contributed from the schools the Department provides $1.


  • 2000-2001 School Year - 93 school districts participated with 110 CRW's.
  • 2001-2002 School Year - 29 participating districts and 32 CRW's.
  • 2002-2003 School Year - 22 participating districts and 30 CRW's.
  • 2003-2004 School Year - 18 participating districts and 26 CRW's.


The Department has committed $2,000,000 for the 2003-2004 school year. The program continues the same as in the past year with the Department contributing $1 for every $2 spent by the school districts.

Three additional handouts relating to the Community Resource Program were distributed. (See Attachments #2 , #3 and #4)

ADJOURNED: Due to being called to the Senate Floor, the committee adjourned at 10:00 a.m.





DATE: Wednesday, February 18, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Sweet, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

Senator Stegner
GUESTS: Health and Welfare Director Karl Kurtz, Deputy Director Joyce McRoberts, Division of Medicaid Administrator David Rogers and Deputy Administrator Randy May, Division of Financial Management Administrator David Butler, and Senior Information Officer Bill Walker. Also, see the attached sign-in sheets.
MINUTES: A motion was made by Senator Compton for the committee to accept the minutes of Wednesday, February 11, 2004, as written. The motion was seconded by Senator Bailey, and the motion was carried by a voice vote.
A motion was made by Senator Ingram for the committee to accept the minutes of Tuesday, February 10, 2004, as written. The motion was seconded by Senator Bailey, and the motion was carried by a voice vote.
A motion was made by Senator Bailey for the committee to accept the minutes of February 12 and February 13, 2004, as written. The motion was seconded by Senator Ingram, and the motion was carried by a voice vote.
Health and Welfare Programs and Budget Chairman Brandt explained the committee had previously received a letter from the Joint Finance-Appropriations Committee (JFAC), with a request for the Senate Health and Welfare Committee to review seven (7) items relating to the cost of health care provided by the Department of Health and Welfare.

He explained the JFAC letter requested the committee to consider the seven areas for reducing or freezing Medicaid eligibility as well as provider rates. The budget is out of control for health care services, and JFAC is exploring ways to reduce or control costs. We are trying to get a grip on how to handle the growth and increased health care costs in the future.

The Department of Health and Welfare Director Karl Kurtz explained he wanted to discuss the Department's FY2005 budget, and to address some of the committee's concerns and questions. Mr. Kurtz had previously presented to the Joint Finance-Appropriations Committee the Department's maintenance budget request for FY2005. Mr. Kurtz also distributed a ten (10) page handout titled Workforce Comparison - Department of Health and Welfare vs. State. (See attachment #1)

The Department is made up not only of Medicaid, which is the largest expenditure category, but is also included in most of the other social programs such as Aged, Blind and Disabled, Community Mental Health, Adult and Children's Mental Health, the three (3) state institutions, and all the population health-based programs from immunizations to adolescent pregnancy programs.

This morning, at the request of the Chairman, Mr. Kurtz talked about the Department's biggest cost, the Medicaid budget. Medicaid expenditure is a little more than 70 percent of the total budgets. Of that 70 percent, about 97 percent of that budget goes to the payments of providers for services.

Senator Brandt asked, "is the 70 percent general fund appropriations or 70 percent of the entire budget?" Mr. Kurtz explained it is 70 percent of the entire budget. The total FY2005 budget request is about $1.4 billion. That includes the state general fund which is about $365 million, dedicated funds and/or receipts are close to $70 million, and the rest are federal funds. Idaho will receive about $1 billion in federal funds this year for the Department's budget.

Specifically in Medicaid, up until June 30, 2003 there was a split sharing between the state and the federal participation. Federal participation was about 74 percent and 26 percent by the state. That was called the Enhanced F Map, and on July 1, 2004 that will revert back to where it was, close to 71 percent federal and 29 percent state. That has had an impact on the amount the Department has requested from the Legislature to fund Medicaid. As he explained, about 97 percent of that budget goes to provider payments. So, as we try to get a handle on Medicaid, it has an impact on providers and the way providers deliver care services.

The Department has reviewed the JFAC letter the committee received, and tried to determine how do we get a handle on Medicaid costs. Nationwide, Medicaid and health care costs are up from 10 percent to 18 percent. It is a combination of inflation, new technology both in procedure and equipment, and pharmaceutical costs.

There are four (4) ways, on a policy level, to look at how do we get a handle on Medicaid; how can we reduce the growth of Medicaid.

1) ELIGIBILITY: Eligibility is delivered in terms of the federal poverty level (FPL). Medicaid is primarily for the aged, blind and the disabled, and for pregnant women and children.

  • In 1997, the state took advantage of a new federal program called the Children's Health Insurance Program (CHIP).


  • Eligibility for most of the women with children is 100 percent of the federal poverty level. The Pregnant Women with Children program has a high enrollment, and eligibility is set at 133 percent of the FPL.


  • In 1997-1998, we extended eligibility from 133 percent up to 150 percent for children ages zero to 19. Most children, ages zero to six, are under the children's insurance program. Older children are covered under CHIP from 133 percent up to 150 percent FPL.
  • Eligibility is one area where the eligibility factor, used by the Department, for Medicaid and CHIP is the federal minimal eligibility requirements. There are different eligibility requirements used for nursing home care which is based on Social Security income.


  • For the general broad category, eligibilities are the federal minimal level. Where the Department does have some flexibility and can adjust the eligibility requirements is for the aged as it relates to qualifying for nursing home and long-term care programs.


2) SCOPE OF SERVICES: Another area we have opportunities to look at for savings or adjustments to the Medicaid program is in the scope of services. Federal requirements have some minimum requirements on the types of services we must have in the Medicaid program. Many times the Department has shared with the committee members what is called the "Christmas Tree" sheet (see attachment #1, page 8).

  • The federally required programs account for about 45 percent of the Medicaid budget, the other 55 percent is at the option of the state. Those programs have grown in the past ten (10) years as we have added more optional services to the Medicaid program. Some of the larger expenditure categories are the ICF/MR facilities, the Aged and Disabled waiver to try to keep people in their homes, rather than in nursing homes. Nursing home care is a federally mandated program. The biggest item in the state option category is prescription drugs, and that was brought into the Medicaid program during the late 1980s. Prior to that, all prescription drugs were handled at the county level, and paid for 100 percent by local and state funds. So that is the second area that could be looked at. How do you want to control some optional services, what could we do away with? One service we tried to do away with a couple of years ago, was the emergency adult dental service. It is a challenge, how do you limit the scope of services?


3) LEVEL OF PAYMENT TO PROVIDERS: Idaho does have some control over the growth of a program, is the level of payment we pay to providers for services. There are some providers that get increases that are in either federal requirements and/or they are in state code. That includes nursing home payments - a very complex formula. Hospitals are cost reimbursed, and large hospitals (more than 50 beds) are reimbursed at 81.5 percent of costs. Smaller hospitals are reimbursed at 96.5 percent of their costs. There is an automatic payment mechanism to reimburse them their costs.

4) HOW DO WE MANAGE SERVICES AND WHAT WE PAY FOR?

  • Medicaid is an insurance system, so how do we transform the health care system?
  • How do we get control of health care cost?
  • How do we manage services and provide the right care at the right price?
  • How do we provide care management for the developmental disable population successfully?
  • How do we provide pharmaceutical costs to provide the right drug, at the right time, to the right people?
  • How do we keep people in their home instead of a nursing home?


All of the above is part of care management. Care management provides the right service, at the right time, and at the right price. The care management program for adults and developmental disabled has been very successful. Mr. Kurtz reported, we are now implementing some of the other care management areas as it relates to pharmaceutical, and we are also looking at hospital stays.

Mr. Kurtz explained these four (4) ways are how we address Medicaid health care.

A discussion was held regarding the seven (7) questions listed in the JFAC letter; the Health Connection program; Women with Children services; CHIP at 150 percent of the federal poverty level; eligibility for nursing home care; Social Security insurance, and the Kathy Beckett program.

The committee members also asked Mr. Kurtz about the role and authorities of the Idaho Board of Health and Welfare. Does the Department use the board members in an advisory capacity?

The committee and Mr. Kurtz also discuss numerous other areas, such as:

  • Co-payments for hospital services, drugs, and doctor fees. Are co-pays successful or do they just create additional paper work?
  • Would a delay in either the CHIP B program and/or the Access Card affect both programs? Mr. Kurtz answered, yes, a delay would affect both programs.
  • Most patients in Idaho's nursing homes are on Medicare.
  • Veterans' homes are now eligible for Medicaid.
  • Give the Department the tools to provide managed care services.
  • Adult Mental Health - ensure that population is getting the proper services.
  • Suicide prevention.
  • Long-term care plans for the Department.
  • Transition health care services from counties into the Department of Health and Welfare.


The committee expressed its deep appreciation for the educational and informative presentation given by Mr. Kurtz today. The Chairman will draft a letter to the JFAC and members will be given a copy.

The ten (10) page attachment distributed by Mr. Kurtz outlines the following:

Page 1 - Workforce Comparison - Authorized positions in the Department.

Page 2 & 3 - Full-time equivalent positions overview - fiscal years 2003-2004.

Page 4 & 5 - Medical Assistance Program - provider payment cost analysis.

Page 6 - Medicaid cost reduction initiatives - state fiscal years 2002-2003.

Page 7 - Medical Assistance Program - federally required vs optional Medicaid services.

Page 8 - Medical Assistance Program - federally required and optional Medicaid Services by service category.

Page 9 - Medical Assistance Program - Medicaid provider payments by type of service.

Page 10 - Federal poverty guidelines - 2003.

ADJOURNED: The committee adjourned at 10:22 a.m. to convene on the Senate Floor.




DATE: Thursday, February 19, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Ingram, Bailey and Burkett
MEMBERS ABSENT/

EXCUSED:

Senators Stegner, Darrington, Sweet, and Kennedy
GUESTS: See the attached sign-in sheet
MINUTES: A motion was made by Senator Bailey for the committee to accept the minutes of Friday, February 16, 2004, as written. The motion was seconded by Senator Ingram, and the motion was carried by a voice vote.
MEDICAID BUY-IN The Department of Health and Welfare, Division of Medicaid Administrator David Rogers explained the Medicaid Buy-In for Workers with Disabilities program.

The purpose of Idaho's Medicaid Buy-In program is to develop options for Idahoans with disabilities so they will have the opportunity to achieve self-reliance, be employed, and qualify for Medicaid coverage.

The medicaid buy-in option allows states to establish new Medicaid eligibility categories for working people with disabilities whose income or resources would otherwise make them ineligible for Medicaid. The buy-in provision, first established in 1997, was further broadened through the Ticket to Work and Work Incentives Improvement Act of 1999.

Mr. Rogers reported four (4) milestones for this program:

  • 2001 - Idaho receives Medicaid Infrastructure Grant to develop a Buy-In program.


  • 2001 - Program proposal developed by Buy-In Steering Committee.


  • 2003 - Blue Ribbon Task Force recommends Buy-In program.


  • 2004 - Governor Kempthorne calls for removal of Medicaid penalties for earned income. (Current Medicaid penalty for work is $576 per month.)


The Steering Committee's proposal has an income limit of 250 percent of the federal poverty level (FPL) - $1,871/month for a family size of one. The income disregards earned income up to 250 percent FPL. Resource allowance is the value of life insurance policy, retirement accounts, and $10,000 in assets. The committee's recommended cost sharing is no premium up to 250 percent FPL, and 7.5 percent premium more than 250 percent of the federal poverty level.

The current proposal has an income limit of 77 percent of the FPL, $576/month (current Medicaid eligibility standards), with resource allowance of $1,500 value of life insurance, qualified retirement accounts of $2,000 in assets.

Disability-related income assistance for Social Security Disability Insurance (SSDI) pays benefits of insured persons. This means individuals have worked long enough and paid Social Security taxes.

Supplemental Security Income (SSI) pays benefits based on financial need. SSI is a Federal income supplement program funded by general tax revenues, not Social Security taxes.

Mr. Rogers explained two (2) implementation options: 1) Establish an optional eligibility group through Medicaid State Plan Amendment; and 2) Limit eligibility to existing participants through Section 1115 Medicaid waiver.

It is estimated to implement the Steering Committee's recommendations would cost approximately $400,000.

In Governor Kempthorn's State-of-the-State address, he reported that many Medicaid recipients are penalized if they have a job. He recommended the removal of the penalty to enable Medicaid recipients to work without losing health care benefits and services that help the disabled remain independent. All Medicaid recipients can lose coverage if they get a different job or earn more money. If persons on Medicaid earn more than the federal poverty rate, they no longer qualify. For people with disabilities, eligibility can depend on a number of factors, including whether the federal government considers you eligible for Social Security disability payments.

A few years ago, the federal government created the Medicaid Buy-In program, which would allow states to revise the Medicaid eligibility guidelines for individuals with disabilities who need Medicaid for all their health care needs.

Kelly Buckland, director of the Idaho Independent Living Council, explained that Idahoans with disabilities want to work themselves off the system, but are trapped by the all-or-nothing nature of the Medicaid program, i.e., if a person's income is below a certain level, he or she receives full Medicaid benefits; if a person makes one dollar more, he or she receives nothing.

People with disabilities have to make decisions based on financial reality. Should they consider returning to work, the risk of losing vital Medicaid benefits often becomes too threatening to their future stability. As a result, they are compelled not to work and find themselves trapped into poverty.

Mr. Buckland explained we should not be discouraging people with disabilities from working, earning a regular paycheck, paying taxes and moving off public assistance. In 1995, a telephone poll of adult residents of Idaho indicated strong public support (79.3 percent) for funding medical benefits so that people with disabilities could enter the work force. A Medicaid Buy-In program would integrate skilled recipients with disabilities into the work force and transition them off Medicaid. The program would enable Medicaid participants with disabilities to contribute to society as they pay taxes and reduce or eliminate their need for public assistance.

There is a marriage penalty, i.e., a wife's income is more than $576 per month, that makes the disabled person ineligible for Medicaid benefits. That problem can cause divorce or persons to have their marriage annulled.

There are 31 recognized organizations that support Medicaid Buy-In, such as, the AARP, Area III Agency on Aging, and many others.

Mr. Buckland requested the Senate Health and Welfare Committee to support the Medicaid Buy-In program, and ask the Joint Finance-Appropriations Committee to fund the initial $400,000 to implement the program.

JFAC Letter After a lengthy discussion, the committee prioritized the items they considered to be in the JFAC letter of recommendations for the FY2005 Health and Welfare budget.

1. Appropriate $400,000 in general funds to provide implementation of the Medicaid Buy-In for Workers with Disabilities.

2. Appropriate $2,204,250 to the Mental Health Assertive Community Treatment Teams (ACT) to expand services in collaboration with Regional Mental Health Boards, as part of the development of service component plans identified in Senate Bill 1293 of the 2004 Legislative Session.

3. Appropriate $3,295,200 in general funds to the Community Resource for Families program to serve elementary aged children in grades K-6 with overall program goals being to strengthen families to prevent child abuse and neglect, increase school readiness of children, and increase the self-reliance of families through utilization of community resources.

ADJOURNED: The committee adjourned at 9:50 a.m.




DATE: Friday, February 20, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Ingram, Stegner, Sweet, Bailey, Burkett, Kennedy
MEMBERS ABSENT/

EXCUSED:

Senator Darrington
GUESTS: See the attached sign-in sheets
SB 1318 This legislation, SB1318, relating to the Practice of Podiatry, and amending Section 39-1395, Idaho Code, to remove certain medical staff membership requirements, was presented by Senator J. Stanley Williams.

This legislation removes language in Idaho Code that requires patients admitted to an Idaho hospital, on the recommendation of a licensed podiatrist, to have their required history and physical performed by a physician licensed pursuant to Chapter 18, Title 54, Idaho Code. Podiatrists are trained, qualified, and licensed under Idaho Code to perform this routine examination.

Idaho Code, Section 39-1395, is to be amended as shown:

Lines 29-37 - A podiatrist with medical staff privileges may initiate admission, but the admission is not complete until the history and physical is performed and signed by a physician licensed pursuant to chapter 18, title 54, Idaho Code. A member of the medical staff licensed pursuant to chapter 18, title 54, Idaho Code, shall have responsibility for the overall medical care of the patient while in the hospital. Arrangements for the services of a member of the medical staff licensed pursuant to chapter 18, title 54, Idaho Code, for the purposes of this section shall be the sole responsibility of the admitting podiatrist and not that of the hospital or any other member of the medical staff.

There is no fiscal impact.



Larry Benton, a representative for the Idaho Association of Podiatric Medicine, testified to support SB1318. He presented three (3) written comments, dated February 19, 2004, for the record:

F. Mark Owsley, M.D., Medical Director of Northwest Specialty Hospital in Coeur d'Alene, Idaho, wrote:

"I am writing in regards to podiatric physicians performing their own history and physical. I have worked with podiatrists in the past, especially Dr. Drager in Coeur d'Alene, and have not ever come across any problems with this. I have found Dr. Drager to be a competent physician who manages his inpatients and outpatients appropriately. As the Chief of Staff of Northwest Specialty Hospital in Past Falls, Idaho, I would welcome the opportunity for the podiatrists to perform their own history and physical. I have always found the local podiatrist to bring in consultations when needed."

Bret A. Dirks, M.D., North Idaho Neurosurgery and Spine, wrote:

"I have been asked by Michael Drager, DPM, to write regarding the competency of podiatric physicians to perform a history and physical. I have worked with Dr. Drager closely over the last 10 years and currently share an office with him. I hold no reservations and highly recommend that podiatrists perform their own history and physical for both inpatient and outpatient admissions. The podiatrists in our area take care of the overwhelming majority of foot problems, and continuity of care in an inpatient setting seems very appropriate."

Douglas R. Stafford, M.D., MIS Northwest, Minimally Invasive Surgery, Coeur d'Alene, Idaho, wrote:

"I am writing on behalf of our local podiatrist Michael Drager. Apparently there has been legislation introduced to allow podiatric physicians to perform their own history and physical for the admission of hospital inpatients. I have worked with Dr. Drager over the last several years. We have worked together on several cases usually involving lower extremity infections or peripheral vascular disease. I have not had any problems with podiatrist performing their own history and physicals and have actually found it helpful for the admitting process. Like any other physician, I have always found Dr. Drager to consult the appropriate primary care physician or a specialist when required."

James Scheel, M.D., a representative for the Idaho Medical Association, testified in opposition to SB1318. He explained the need for a licensed medical physician to perform the history and physical checks on patients, determining if the patient is using any high-risk drugs such as blood pressure medications, blood thinners, EKG, or has heart problems. Dr. Scheel does not believe podiatrists are trained or skilled in areas to perform medical history check and physical examinations for patients in a hospital setting.
Senator Robert L. Geddes, from District 31 in Soda Spring, Idaho, testified to support SB1318. He believes the number of years of schooling and internship in a hospital setting does qualify a podiatrist to perform a medical history and physical examination.
Gary Millword, DPM, a past president of the Idaho Podiatry Association, testified to support SB1318.

David Blackmer, DPM, testified to support SB1318, and presented written comments from Randal Wraalstad, DPM, a practicing podiatrist in Twin Falls, Burley, and Hailey, Idaho, to support SB1318. Dr. Wraalstad's written comments, dated February 19, 2004, read:

My name is Randal Wraalstad, DPM, and I am a practicing podiatrist in Twin Falls, Burley, and Hailey. I urge you to support S1318 and eliminate the requirement of a MD/DO to perform the routine History and Physical examination on patients admitted to Idaho hospitals. I have several reasons for my request:

1) This is an outdated statute. Most podiatrists trained in the last 10-15 years have had residency training that incorporated adequate exposure to, and experience with, performing these routine H & P's. I completed my residency in 1996 and had rotations in Internal Medicine, Anesthesia, Rheumatology, General Surgery, Orthopedic Surgery, Vascular Surgery, Emergency Room, Plastic Surgery, and Podiatric Surgery. All of these rotations required the routine performance of History and Physical examinations. These examinations were supervised by attending MDs, DOs, and DPMs, and were usually done side-by-side with allopathic residents.

2) The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has stated in December 2000 that, "it is consistent with MS.6.2.2 for qualified, credentialed, and privileged doctors of podiatric medicine to perform all or part of the inpatient admission medical history and physical examination independently, subject to applicable state law and the determination by the medical staff that high-risk patients require confirmation or endorsement of the history and physical by a qualified physician." JCAHO currently accredits most of the hospitals in Idaho.

3) This bill doesn't limit any hospital in their credentialing process. The hospitals and their governing bodies still have the authority to limit podiatry privileges based on each individual podiatrist's training and experience. If the medical staff determines that a podiatrist requires additional training in History and Physical examination, they are within their rights to limit that privilege. However, it also allows the individual podiatrist to either prove their competence or gain additional training in order to be granted admitting privileges.

4) Several hospitals have already discontinued the requirement of MD/DO history and physicals on podiatric patients, especially in the case of outpatient surgical procedures, or otherwise healthy patients that may require short hospital stays. Two of the hospitals that I perform surgery at, Cassia Regional Medical Center in Burley and Minidoka Memorial Hospital in Rupert, do not have this requirement.

5) Patient safety is not compromised, but patient convenience is enhanced. The vast majority of the people that will be affected by this bill will be healthy, Anesthesia Class I or II patients that require some type of outpatient podiatric procedure. These people have routinely had to schedule additional physician appointments, sometimes with lengthy delays and certainly with additional cost, solely for the purpose of a MD or DO physician to state that they were healthy enough to undergo a local or IV anesthetic. I have had numerous patients and several physicians wonder why this is currently necessary. I believe it isn't, and here's a chance to correct the situation.

Again, thank you for your time and attention to this important matter. I appreciate your careful consideration and hope for your favorable support of this bill (S1318).

Steve Millard, president of the Idaho Hospital Association, testified in opposition to SB1318. He emphasized patient safety and quality care, and stated this is not a "turf" issue, it is a safety issue.

The committee held a lengthy review and discussion relating to SB1318, inpatient and outpatient care, surgeries at a surgery center vs. hospital surgeries, and the educational training and skill requirements for podiatrists.

MOTION: A motion was made by Senator Ingram to send SB1318 to the Senate Floor with a Do Pass recommendation. The motion was seconded by Senators Sweet and Bailey. A roll call vote was requested by Chairman Brandt.

Senator Kennedy voted Nay.

Senator Darrington was absent and excused.

Senators Burkett, Bailey, Sweet, Stegner, Ingram, Compton, and Brandt voted Aye.

The motion was carried by 7 Ayes, 1 Nay, and 1 absent and excused.

SB1299 This legislation, SB1299, relating to immunity for the use of defibrillators, and amending Section 5-337, Idaho Code, to enumerate which persons to whom limited legal immunity applies in using a defibrillator, was presented by Representative Charles Cuddy.

The purpose of this legislation is to clarify that the medical professional training defibulator operator is released from all liability due to providing the necessary training and prescription to the operator. This legislation will give the training professional the same lawful protection now granted to the operator.

There is no fiscal impact.

MOTION: A motion was made by Senator Compton to send SB1299 to the Senate Floor with a Do Pass recommendation. The motion was seconded by Senator Bailey, and the motion was carried by a voice vote.
SB 1316 The bill, S1316, relating to the Department of Health and Welfare, stating findings of the Legislature and providing that the name of the Department of Health and Welfare shall be changed to the Department of Health and Social Services, was explained by Senator Skip Brandt.

The Department has been known as Health and Welfare for many years and the name no longer makes sense. It does not reflect the widespread and critically important roles we plan in local communities in every corner of the state. It is time to change the name. The old name suggests that welfare is half of what we do, and nothing could be further from the truth.

Very little of what id done today can be considered "welfare" as most people define it. Welfare goes back to the days when the Department gave out cash assistance without expecting anything in return. Today, that is no longer true.

I propose social services because that far more accurately explains the services the Department provides communities. By providing health and social services, we invest in people - some of them in need, some of them in crisis. By doing so, the Department also invests in local communities, local businesses, and local jobs.

That is not welfare. That is investment in our communities, and investment made through social services, not welfare.

Fiscal Impact - $30,000 for replacement of signs at Department facilities and telephone book changes. Implementation is set for July 1, 2004.

MOTION: A motion was made by Senator Kennedy to send SB1316 to the Senate Floor with a Do Pass recommendation. The motion was seconded by Senator Compton, and the motion was carried by a voice vote.
SB 1317 This legislation, SB1317, relating to Emergency Services; and amending Sections 46-1007 and 46-1009, Idaho Code, to clarify jurisdiction of licensed emergency medical service agencies, to provide an exception to jurisdiction of the sheriff, was presented by Senator Brandt.

The jurisdiction and authority of police and fire departments are protected in 46-1007(3) but not that of emergency medical services. Approximately 85 percent of the ambulance services in Idaho are no affiliated with a fire department or law enforcement agency. This change will provide the same clarity about chain of command for EMS agencies as for fire agencies. Sheriffs are generally not trained or equipped to command medical incidents, and some local EMS agencies are frequently not affiliated with a sheriff's department, though they may frequently work together and cooperate with law enforcement. This legislation is in the best interest of public safety in our communities.

Fiscal Impact - There is no fiscal impact to the General Fund.

Micahel Kane, a representative for the Idaho Sheriff Association, testified to support SB1317, but did request an amendment to Section 2(10). Senator Brandt is in agreement with the amendment and requested the committee to send SB1317 to the 14th Order.

MOTION: A motion was made by Senator Stegner to send SB1317 to the Amending Order. The motion was seconded by Senator Compton, and the motion was carried by a voice vote.
JFAC 2004 Senator Brandt informed committee members about the letter prepared and sent to the Joint Finance-Appropriations Committee, regarding the recommendations the Senate Health and Welfare Committee had made about the FY2005 budget for the Department of Health and Welfare. A copy of the letter was given to each committee member.
The committee welcomed the new Page, Marhett McKnight, from Liberty Charter School in Nampa. The current Page, Alex Johnston, also from Nampa, will return to school next week.
ADJOURNED: The committee adjourned at 10:00 a.m. to convene on the Senate Floor.




DATE: Tuesday, February 24, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Ingram, Stegner, Darrington, Bailey, Burkett, Kennedy
MEMBERS

EXCUSED:

Senator Sweet
MINUTES: A motion was made by Senator Bailey to approve the Minutes as written for the Committee meeting held on February 20, 2004. Senator Ingram seconded the motion. The motion passed by a voice vote.

A motion was made by Senator Ingram to approve the Minutes as written for the Committee meeting held on February 19, 2004. Senator Bailey seconded the motion. The motion passed by a voice vote.

GUESTS: See the attached sign-in sheet.
H 605 Roger Hales, Bureau of Occupational Licenses, presented H 605 relating to the Board of Social Work Examiners. H 605 amends Section 54-3209, Idaho Code, to clarify that the application fee includes the original license fee.

Senator Stegner asked what the current fee is. Roger stated it was $60.00.

MOTION Senator Stegner made a motion to report out H 605 with a Do Pass Recommendation. The motion was seconded by Senator Compton. The motion carried by a voice vote.
American Ecology Corporation

presentation

Roy Eiguren, representing the American Ecology Corporation, provided an overview of the company operations (PowerPoint presentation, see attached). Steve Romano, CEO of American Ecology Corporation, reported on Owyhee County "tipping" fees, and a contract with DEQ to manage abandoned waste at cost. He also commented on the Homedale airport pesticide clean-up and the grants made supporting the local communities. He reported on the indoor waste treatment building, the Simco road rail transfer station, and the investment of $4.5 million in a new disposal cell.
H 611 Roy Eiguren presented H 611 relating to commercial hazardous waste disposal fees; amends Section 39-4427, Idaho Code, to revise fees for certain manifested Remediation wastes, revise fees for disposal of certain hazardous wastes. Roy stated in July 2003 the Oregon legislature reduced fees for certain hazardous waste categories. The legislation is needed to maintain a level playing field for the Idaho company to compete in the region, and the legislation is revenue neutral. The key changes reduce fees for large environmental cleanup projects, and reduce fees for cleanup waste considered hazardous by other states. The changes are revenue neutral, and the changes maintain parity with Oregon and preserve the ability to compete.

A copy of a letter dated February 2, 2004, from Paul Slyman, Oregon Department of Environmental Quality, to Stephen Allred, Director of the Idaho Department of Environmental Quality was presented in conjunction with the presentation. The letter states Mr. Slyman reviewed the legislation which modifies Idaho's hazardous waste disposal fees, and stated, "the changes proposed in the bill will make your state's fees the same as Oregon's and ensure that state fees do not give either facility a competitive advantage."

Discussion Senator Brandt asked about the distance from the rail station to the facility. Mr. Romano stated it was 35 miles.

Senator Compton asked for explanation on how the legislation could be revenue neutral if it called for a reduction in fees. Mr. Eiguren stated the increase in the volume and a reduction in the fee would neutralize the issue. Senator Darrington stated the effect of the reduction in fees has historically stabilized revenue.

Senator Kennedy asked about the remediation waste from superfund cleanup. Mr. Eiguren stated they are substances considered to be hazardous and in most circumstances it can't be converted.

Senator Kennedy asked about the amount of additional tonage waste that would be brought into the site because of the new fee. Mr. Eiguren stated it would be a small amount. Mr. Romano stated he is not aware of any projects as of now, but the opportunity to bid, as bids become available will allow American Ecology the chance to compete.

Senator Kennedy asked about the protection of the Snake River Aquifer. Mr. Romano stated the facility is not over the aquifer. The site has a dry climate and natural clay, with little rain, and he views the management by private companies to be more rigorous than the federal program.

Senator Stegner asked if Owyhee County collects a fee in addition to property tax and whether this legislation affects the county. Mr. Eiguren stated the county collects a fee and taxes, but the legislation does not impact them.

Senator Stegner asked about the legislation allowing Idaho to compete with Oregon and it seemed like a race to the bottom. If Oregon lowered its rates to compete with California, then Idaho lowers their rates to compete with Oregon, where does it stop. Mr. Eiguren stated the fee has been amended five times since 1984. The fees peaked in 1990s at $4 million. The net effect over the long-term is to stabilize the fees coming into the account. Projections are to remain constant.

Senator Bailey asked if anyone from Owyhee County was at the meeting. Mr. Eiguren stated he met with the County Commissioners and they support the legislation.

Senator Compton asked why the market doesn't regulate the fees. Mr. Eiguren stated there is no legal, constitutional way to set a fee or tax on market conditions. And in a way they are dealing with market conditions in dealing with their colleagues and the legislature.

Senator Compton commented on how nice it is to see the CEO of American Ecology at the meeting and the example of a good corporate citizen.

MOTION Senator Compton made a motion to report out H 611 with a Do Pass Recommendation. Senator Bailey seconded it.

Discussion on the motion included questioning of Brain Munson, Hazardous Waste Manager for Department of Environmental Quality (DEQ). Mr. Munson stated the Snake River aquifer is 2000 ft. below the site, the site is under permit, and is monitored by inspectors who come weekly to monitor new loads. He stated that DEQ is satisfied there is no damage to the soil or air.

The motion carried by a voice vote.

Briefing State of Idaho, Department of Health and Welfare briefing relating to investigational and experimental health procedures.

David Rogers, Department of Health & Welfare, Director of Medicaid, was given the floor. Mr. Rogers stated the Medicaid program in Idaho is currently designed not to cover investigational, experimental procedures, these procedures are outside the standard of care for which there is an absence of evidence suggesting the effectiveness of those procedures. It is not an uncommon request. Sixteen requests were made for this type of therapy over the past year. He stated they have not looked into the fiscal impact of covering the requests of these procedures. He commented on the importance of trying to help the little girl today, and the difficulty of the situation. He stated he welcomed any guidance in regards to Idaho's Medicaid program structure in relation to benefits and services and individual circumstances.

Chairman Brandt stated they were up against federal rules, and there is a procedure to take into a consideration, asking for a waiver of those rules, has the state ever received authority to go ahead with experimental procedures? Mr. Rogers stated he was not aware of the state ever requesting a waiver for such a procedure. He clarified that the federal law and regulation in regards to experimental, investigational services in Medicaid, is fairly open. He stated he was not aware of any specific prohibition in federal law or rule against coverage of investigational therapeutic procedures. Under federal law, the Medicaid program in each state is required to submit a state plan that defines those benefits that are covered by that particular State's Medicaid program. The current plan in Idaho limits the coverage. And Idaho Department of Health & Welfare Rules are a reflection of how the State plan is structured.

Senator Burkett stated he also reached the consensus there was no prohibition in federal law. IDAPA 16.03.09.065 does not include experimental procedures. There is no definition of experimental procedures. How is it determined what is investigational, experimental when there is no definition in the Idaho plan? Mr. Rogers stated IDHW has a contract with Qualis Health (Qualis), and Qualis functions as the peer review organization, or quality improvement organization. The IDHW has a contract with Qualis that requires that Qualis review specific types of requests such as experimental, investigational procedures. Qualis has a variety of physicians, and specialists with different areas of expertise. The actual criteria used in making the determinations is done by looking through available peer review medical literature, and evidence that exists, that suggests the effectiveness of that procedure, and whether that procedure is within the standard of care for a given condition or diagnosis. The difficulty in a condition that is extremely rare is the absence of the type of peer review literature that specifically addresses the effectiveness of procedures.

Senator Burkett asked if Qualis develops the standards or does the State of Idaho provide anything to Qualis in writing that tells the standard it wants to use? Mr. Rogers stated it is the standard that Qualis uses as developed in the contractual agreement between the State of Idaho and Qualis. He believes it is the same standard used by other Medicaid programs that are certified by Qualis as well. Across the healthcare industry there is some variety of the definition or criteria applied to investigational, experimental services.

Senator Burkett stated his research led him to look into the fiscal impact to the State of Idaho in providing this procedure as opposed to the Medicaid costs for care for the next fifteen years of this little girl if she doesn't get the procedure, ie. fiscal advantage of the state of Idaho. He reported on Idaho Code 56-209b, see attached. He asked Mr. Rogers if Qualis has a copy of the statute, is this part of what they are operating under when they make these kinds of determinations? Mr. Rogers stated he wasn't sure whether Qualis has this statute. He stated he hasn't ever heard of this being used on an individual level. He also reported that Qualis does not undertake a cost-benefit analysis take on the requests that come in.

Senator Bailey asked how many requests were made last year for experimental, investigational procedures. Mr. Rogers stated 16 requests were made from February 2003 to January 2004.

Senator Ingram asked about the types of procedures that make up the 16 requests. Mr. Rogers stated the requests were for all types of procedures where there was not peer review evidence that suggests that the procedure was the standard of care for that specific condition.

Senator Ingram asked for clarification on the term "peer review" and more detail on Qualis Health. Mr. Rogers stated peer review is a quality improvement organization, it is Qualis for Medicaid and Medicare for the State of Idaho. Contracted to have medical professionals, particularly physicians, with a broad array of experience, to review coverage procedures, and to conduct quality improvement studies within.

Senator Ingram asked about the cost of hemophiliac cases, and over $1 million was spent in one year on blood transfusions, and how did the peer review pass on these people and not on other ones. Mr. Rogers did not know of the specific history in Idaho, but peer can be very expensive to quite expensive. The distinction is whether or not the course of treatment in that case, regardless of its expense, was within the standard of care, and evidence of its effectiveness in treating that condition in that case. Medicaid does not take into account cost when it looks at experimental, investigational treatment.

Senator Ingram commented on Idaho's Aids victims and a cap or limit on only 70 individuals, and their incredibly expensive treatments. And the Dialysis program that has a separate appropriation, limited to a certain amount. Mr. Rogers stated he did not know about Dialysis. HIV/AIDS program is outside the Medicaid program, it is funded partly by federal funds (Federal Ryan White Act) and general funds. If Medicaid elects to cover an eligibility group for individual services under Federal Medicaid law, the State has to provide that service comparably to all eligible persons. So the IDHW wouldn't have the ability to develop those sort of limits under Title 19 without going back and making a specific request from the federal government to waive current federal Medicaid regulations.

Mr. Rogers commented on the contract with Qualis who had an established definition in regard to medical necessity and in regard to experimental, investigational treatment that had been used more broadly, and the IDHW accepted that.

Senator Kennedy referenced a letter from the Director of Pediatric Stem Cell Transplant program at the hospital involved in the little girl's case. As rare as the disease is and the amount of money involved in treating this condition, isn't it extremely unlikely this would ever be called anything other than an experimental procedure? Or is it looked at as there will be so few of these and there is so much money involved in them that we might as well tell you that if any child gets this disorder there isn't going to be any Medicaid coverage ever? If IDHW follows the existing rule under the State of Idaho? Mr. Rogers stated this was not far from the mark. It is one of the questions he asked when looking at this situation. Given the fact it is a rare condition, how can it ever get to a point to perform trials to determine the effectiveness of it. He is not fully satisfied with the response that he was given and there are ways to do it with a limited population, but this is an extremely rare disease. It would be very difficult to undertake a process to evaluate to that level of rigor how effective this particular procedure is.

Senator Kennedy read from the letter stating the best success comes from performing the procedure in children under the age of 2 years. Is this being considered experimental, investigational because it costs so much money, not because they aren't having success in treating the condition with the cases they're being confronted with? Mr. Rogers stated this is not an issue solely about the dollars. It is as much an issue about IDHW coverage policy and the absence of coverage for investigational, experimental treatment and how it is defined.

Senator Brandt asked if any other states consider this not experimental. Mr. Rogers stated that in working with the hospital they were referenced to three State Medicaid programs that had covered the procedure, or a related procedure.

Senator Burkett stated the Sanfilippo Syndrome is one of eleven subtypes of mucopolysaccharidoses. Some of those states have covered one of the eleven subtypes. And most require the same type of treatment. He stated that in Idaho Code 56-209b he thought Mr. Rogers answered that it had been applied to procedures, but the section talks about persons. Senator Burkett requested that Qualis be provided the statute, to look at it person by person, not procedure by procedure. Mr. Rogers clarified that his response was that the Idaho Code had been applied to eligibility coverage, not procedure coverage, but again those types of optional eligibility groups that the State has elected to meet its Medicaid program such as low income children, frail, elderly, disabled.

Senator Burkett asked if the procedures, talking about for Annabelle Green, aren't they provided by some medical insurance carriers. He stated the rules developed for Medicaid should follow the same standards of people who have coverage. Otherwise, there are two classes of coverage in the State. He stated he did not think this was the intent of Medicaid, the intent is to provide insurance similar to what insurance carriers provide. Mr. Rogers stated that through the information he received from the hospital it seems this procedure is covered by some carriers. There is some variation in what is considered experimental, investigational procedures.

Chairman Brandt asked Senator Burkett to stay on the issue, but in the interest of time, it was necessary to move onto the next item on the agenda.

Senator Burkett requested that Majorie Reedy be given a few minutes to address the Committee.

Testimony Marjorie Reedy, advocate for Annabelle Green, asked Senator Burkett to direct her and she would not give her full presentation.

Senator Burkett asked about the costs for the procedure.

Ms. Reedy stated Annabelle has a rare genetic disease that is progressive. She stated Duke University has done a lot of transplants. She stated the difference in this transplant is that the cells come from an umbilical cord that is donated to a Cord Blood bank when a live birth happens. She stated over 500 procedures have been performed with 60-70 on children every year. Duke University is willing to negotiate the cost of the procedure. They talked with the family about a figure of $400,000 to $1 million dollars, which will cover the before care, the procedure and the after care, and the costs are dependent on the age of the child and the amount of damage the child has already suffered. The other cost to consider is if Annabelle isn't treated. She reported on an MPIII type case of a 14 year old girl, and her care is paid partly by Idaho, about $70,000 by Medicaid, this girl also has coverage that pays for her other care (including surgeries and procedures).

Discussion Chairman Brandt brought attention to the appropriation budget in regards to JFAC's action last week. They did not take into consideration the Committee's letter, because it came in at the eleventh hour. However, he informed them in his testimony before JFAC he told them a letter with suggestions would be forthcoming. He heard it was not given much attention because it was just asking for more money which he disputes. It did ask for some up-front money, but long-term funding issues would be positively impacted by the Senate Health & Welfare Committee suggestions. He referenced the last page of the handout regarding intent language. He stated his problem was that JFAC sets the policy of the IDHW without bringing it before the Senate Health & Welfare Committee. The issue is before the Committee now about how to proceed.

Senator Bailey stated he has a problem with $50,000 being used to change the name when it could be used elsewhere.

Senator Burkett commented on the intent language that puts limits on the CHIP program, a 1000 enrollee limit on CHIP B, and a 6% limit on CHIP A.

Mr. David Rogers stated a response is anticipated from the Center Medicaid Services within a few weeks.

Senator Compton commented on the enrollment limitations in CHIP A and CHIP B. He asked if the IDHW would comment on the intent language.

Joyce McRoberts, Deputy Director, IDHW stated the IDHW would not comment at this time. The Department Administrators would answer any questions the Committee had.

Chairman Brandt stated the Committee would resume discussion at another date because the Senate was scheduled to convene at 10:15 a.m.

ADJOURNMENT Chairman Brandt adjourned the meeting at 10:12 a.m.




DATE: Wednesday, February 25, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Stegner, Sweet, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

None
MINUTES: A motion was made by Senator Bailey for the committee to accept the minutes of Wednesday, February 18, 2004, as written. The motion was seconded by Senator Kennedy, and the motion was carried by a voice vote.
Board of Dentistry The Idaho State Board of Dentistry proposed three (3) bills for consideration by the 2004 Idaho Legislature. Those bills were the following: SB1288 regarding extended access oral health care programs; SB1289 regarding a volunteer's license for retired dentists; and SB1292 regarding a change to the definition of a dental assistant. Michael Sheeley, executive director of the Idaho Board of Dentistry, presented the legislation.
SB 1288 The purpose of SB 1288 is to accomplish the following: clarify and specifically define those locations where a licensed dental hygienist can practice outside of a private dental office under general supervision; general supervision requires that a dentist authorize the procedure to be performed by a dental hygienist, but does not require that a dentist be in the dental office when the procedure is performed, Idaho Code 54-903(8); discontinue the requirement for written orders in a private dental office or in an extended access oral health care program; and require that a dental hygienist obtain a license endorsement in order to practice in an extended access oral health care program. The primary purpose of SB 1288 is accomplished by the addition of a new definition for an "extended access oral health care program" at Idaho Code § 54-903(8).

In summary, an extended access oral health care program includes those public programs (city, county, state or federal) that provide dental and dental hygiene treatment to members of the public and other specifically approved public or private charitable programs that provide free or reduced fee dental or dental hygiene services to members of the public. SB 1288 authorizes a dental hygienist to practice under general supervision in an "extended access oral health care program" so long as the dental hygienist obtains a required license endorsement. In order to obtain the license endorsement, the dental hygienist's license must be in good standing and the dental hygienist must have practiced for a total of one thousand (1,000) hours in the two (2) immediately prior years.

The need for this proposal originated from the Board of Dentistry's participation in the Idaho Oral Health Summit and from additional discussions it had with representatives and members of the Idaho State Dental Association (ISDA) and the Idaho Dental Hygienists' Association (IDHA) beginning in the spring of 2002. In July of 2002, three (3) initial draft versions of this proposal were provided by the Board of Dentistry to the ISDA and the IDHA. In January of 2003, the ISDA and the IDHA were provided with an amended draft of the proposal and requested to provide comments to the Board of Dentistry. In May of 2003, all dentists and dental hygienists licensed by the Board of Dentistry were provided with a newsletter containing the Board of Dentistry's draft proposal and further comments were solicited.

In response to its requests, the Board of Dentistry received written comments from approximately seventy (70) dentists, dental hygienists and organizations. As a direct result of those comments (which were overwhelmingly in support of this proposal), the Board of Dentistry made additional revisions to this proposal. The written comments received included extensive communications from the Idaho Dental Hygienists' Association, the Public Health Districts, and the Dental Hygiene Program at Idaho State University. This proposal was also discussed at additional meetings of the Idaho Oral Health Summit in June of 2003 and January of 2004. Members of the Board of Dentistry engaged in continuing discussions regarding this proposal with representatives of the ISDA and eventually attended all seven (7) of the ISDA's regional component meetings during the Fall of 2003 in order to discuss this proposal with the ISDA's membership.

The final draft of this proposal, as well as all other legislative proposals of the Board of Dentistry, was published in a newsletter and disseminated to all dentist and dental hygienist licensees in December of 2003.

In discussing this legislative proposal with interested parties, the Board of Dentistry was frequently asked the following questions.

I. Why is the Board of Dentistry proposing these revisions? The proposed revisions are an attempt to achieve or accomplish a number of objectives as follows: to clarify those locations where a dental hygienist can practice outside of a private dental office under general supervision; to bring existing standards regarding written orders by dentists into line with current dental practice; and to attempt to facilitate access to care for Idaho citizens who do not typically obtain dental treatment in a private dental office.

2. What is the purpose of the extended access dental hygiene license endorsement? The purpose of the extended access endorsement is to allow dental hygienists qualified by means of experience to provide treatment within the permissible scope of practice under general supervision, and within the auspices of specified or approved programs at locations other than private dental offices. General supervision by a dentist is required for a dental hygienist providing services through an extended access dental hygiene program. The Board of Dentistry is hopeful that the extended access endorsement will facilitate the delivery of dental hygiene services to persons who would not otherwise receive them.

3. Does the extended access dental hygiene license endorsement create some form of independent practice for dental hygienists? No. Dental hygienists issued an extended access license endorsement are limited as to the type of programs and locations where services can be

provided and must practice under general supervision. A supervising dentist must determine the dental hygiene treatment to be provided by a dental hygienist.

4. Who determines a dental hygienist's or dental assistant's scope of practice in a dental office? At present and under the proposed revisions; the Idaho Dental Practice Act and the related administrative rules establish the parameters of the permissible scope of practice for

dental hygienists and dental assistants. However, the dentist in a private dental office or the supervising dentist in an extended access oral health program will continue to determine what specific permissible procedures a dental hygienist or dental assistant will provide to patients.

5. Why are additional qualifications required for a dental hygienist's license endorsement? The dental hygiene license endorsement proposed is the extended access dental hygienist endorsement. Within the context of that endorsement, the Board of Dentistry believed that

additional experience requirements are necessary to ensure the health, safety and welfare of the public.

SUMMARY OF PROPOSED CHANGES TO THE IDAHO DENTAL

PRACTICE ACT RESULTING FROM SENATE BILL 1288:

  • Private Office - Eliminates requirement of written orders for dental hygienists providing services under general supervision.


  • Extended Access Oral Health Care Program - Eliminates requirement of written orders for dental hygienists providing services under general supervision and requires a supervising dentist to authorize dental hygiene treatment to be provided.


  • Extended Access Oral Health Care Program - Eliminates use of word "institution" and substitutes term "extended access oral health care program" which is defined to include all public and certain other specifically approved oral health programs that provide services to persons who due to age, infirmity, handicap, indigence or disability, are unable to receive regular dental or dental hygiene treatment.


  • Extended Access Dental Hygiene Endorsement - Creates an optional "extended access dental hygiene endorsement" for actively licensed dental hygienists who are in good standing and who possess the required amount of dental hygiene practice experience. A dental hygienist must hold an extended access endorsement to provide dental hygiene services in an extended access oral health care program.
Brad Hoaglun, a representative for the Idaho Dental Hygienist Association, proposed two amendments for SB 1288.

1) Page 2, beginning on line 21 strike the language "holding a license with an extended access dental hygiene endorsement."

2) That Chapter 9, Title 54, Idaho Code, be and the same is hereby amended by the addition thereto of a New Section, to be known and designated as Section 54-904A, Idaho Code, and to read as follows:

54-904A. AUTHORIZATION FOR PROCEDURES PERFORMED UNDER AN EXTENDED ACCESS PERMIT BY DENTAL HYGIENISTS.

(1) In a private office or an extended access oral health care program, a dental hygienist holding an extended access permit may determine and provide preventative and therapeutic dental hygiene services.

Mr. Hoaglun requested that SB1288 be amended.

Jennifer Andrews-Kelly, a licensed dental hygienist and president of the Idaho Dental Hygienists' Association, testified and requested that Senate Bill 1288 be amended. She also presented written comments as follows:

The Idaho Dental Hygienists' Association (IDHA) is a professional organization of dental hygienists with the primary mission of promoting the highest standards of the dental hygiene profession. Promoting public awareness by providing quality oral health care to individuals in private and alternative practice settings, including underserved populations, is one of the visions of IDHA.

The Idaho Dental Hygienists' Association appreciates the time and efforts the Idaho State Board of Dentistry (ISBOD) has put forth in developing this legislation. IDHA has also spent plenty of time on this issue and in fact, IDHA has been working diligently on improving access to dental care for over four years and it has been a topic of discussion within our association for much longer. However, the proposed changes to the dental practice act are not sufficient to make a positive impact on access to oral health care for the underprivileged and underserved populations of Idaho. IDHA has tried to communicate our goals of expanding access to care by reducing the supervision requirements for dental hygienists. However, our visions for expanded access dental hygiene care have not been fully understood and are not part of this legislation. That is why I am here today to present two amendments to SB 1288 that will make a positive impact on access to dental care for the citizens of Idaho.

As prevention specialists, dental hygienists understand that recognizing the oral and total health care connection can prevent diseases, and that treating problems while they are treatable conserves critical health care dollars. All Idahoans can enjoy good oral health because the oral diseases such as caries ( cavities ), gingivitis (gum disease ), and periodontitis (bone disease) are preventable with regular provisions of oral health care services provided by dental hygienists. Regrettably, the experience, education and expertise of dental hygienists in Idaho are dramatically underutilized.

Increased utilization of dental hygienists in non-traditional settings such as schools, medical clinics, after school programs and nursing homes, etc., would promote increased use of dental services among low-income persons. The treating dental hygienist can serve as a pipeline for referring patients to dentists and other oral health care specialists. Increased utilization of dental hygiene services is critical to addressing the nations, and Idaho's, crisis in access to oral health care. The profession of dental hygiene, founded in 1923, was first a school-based profession; however, today dental hygiene services are tied to delivery in a private dental office. A blend of delivery of care by dental hygienists in private and public sectors as well as for those in underserved areas would benefit all citizens of Idaho. New alternative routes for accessing preventive oral health care services need to be discussed and implemented.

State practice acts for dental hygiene practice are different yet similar from state to state. For instance, all practice acts list what dental hygienists can and cannot do; however, dental hygienists in the Western part of the U.S. are educated to perform many services that those in other states are not taught to perform. Subsequently, dental hygienists in the West are licensed to practice many services that some other states do not teach or permit dental hygienists to do. An example is local anesthesia where in Idaho dental hygienists can administer local anesthesia and in other states they cannot. Another example is that in 11 other states dental hygienists can place and/or carve fillings; however, in Idaho dental hygienists are educated, at one of our teaching institutions, to place and carve fillings, but the practice act does not permit dental hygienists to provide this care for Idaho citizens.

Currently, dental hygienists assess medical histories and relate oral health to general health, perform oral cancer screening, and interpret charting of periodontal and other conditions. Dental hygienists also provide oral prophylaxis, a preventive procedure in which hard and soft deposits are removed from the teeth both above and below the gum line. Hygienists can also provide nonsurgical periodontal therapy which is a technique used to treat and maintain gum disease by removing hard deposits and bacteria from deep below the gum line along with smoothing the root surfaces of teeth. Nonsurgical periodontal therapy is often accompanied by local anesthetic and sometimes nitrous oxide to enhance patient comfort. Dental hygienists can also place pit and fissure sealants to the biting surface of teeth to prevent tooth decay in children and young adults. During all of these procedures, the hygienist evaluates the current oral health status of the individual and demonstrates or recommends ways to improve their oral self-care.

In March 2003, IDHA sent a detailed letter to the ISBOD explaining our

views and asking questions about the extended access oral health programs and the endorsements. Although some of the suggestions originally made in the IDHA letter were incorporated within the proposed revisions and this bill; they, unfortunately, were taken out of context and some suggestions or questions were not addressed. The major issue is that of supervision. Dental hygienists have worked under general supervision in the state of Idaho for nearly 20 years. Now the bill before you further defines what type of institutions dental hygienists can provide care in and this bill is proposing that dental hygienists be required to have an extended access endorsement to practice in this manner.

The endorsement is a licensing category that requires dental hygienists to have additional hours of practice experience, additional continuing

education, etc. Why is this necessary after all these years of practicing under general supervision without an endorsement? There, to IDHA's knowledge, have been no complaints against dental hygienists in our state related to this supervision issue. By increasing the restrictions, the access to care issue, which is paramount for dental hygienists, is not being addressed. Instead, increased restrictions and in some ways supervision is being requested by this bill. Therefore, amendment number one requests deleting the endorsement because it is not needed for general supervision.

IDHA has requested, in writing, to the ISBOD that we be permitted to

practice by being able to initiate care based on our assessment of needs, then develop a care plan, and subsequently provide care within our scope of practice because we are licensed to do so. Also, referral to a dentist would occur during and/or after dental hygiene care was provided. We asked why we needed to be authorized under general supervision and what authorization meant? We have, to date, not received an answer.

Another issue is that of liability. The Board is charged with protecting Idaho citizen's safety and; therefore, if an unsafe issue did arise with patient care, who would be liable as this bill is written? Dentists and dental hygienists would both be responsible, while the dentist(s) would not be present. Does this make any sense? Why not permit dental hygienists to work without authorization and be responsible for their own actions? Dental hygienists are licensed, have liability insurance and are educated to practice in this manner. Would a dentist be willing to grant authorization to a group of dental hygienists to provide a community service such as fluoride varnish or pit and fissure sealants for young children if he/she does not know or have professional experience with all the licensed dental hygienists involved in this project? Finding a dentist to provide written orders under the current practice act has already provided challenges and in some cases dead ends for those desiring to provide preventive projects on a volunteer basis. Is this issue about control and supervision, or access to care? Dental hygienists see it from an access to care stance and desire to provide care to underserved rural area citizens as well as those who are homebound, institutionalized, in schools, prisons etc.

This bill only addresses institutions and those citizens of Idaho related to the institutions (schools, public health) and not citizens in underserved rural areas. There are designated manpower shortage areas in our state without ample dentists or dental hygienists. Provisions of preventive and therapeutic dental hygiene care would be a great asset to these individuals. Currently, dental hygienists must practice supervised by a dentist which means in these localities dentists need to be present to have a dental hygienist work and dentists are not always available or present. In fact, the number of dentists nationwide is sharply decreasing, while the number of dental hygienists is increasing. In Idaho there are approximately 921 dentists and 871 dental hygienists that are actively licensed.

IDHA has a list of educational, practice, and safety requirements that would be placed in the rules section of the practice act to qualify a dental hygienist to practice without prior authorization and, thus, earn a permit licensing category above and beyond the typical license. These requirements are only appropriate if dental hygienists are permitted to practice without "authorization" of some form prior to initiating dental hygiene care. It relieves the dentist of the burden to have to diagnosis and authorize a dental hygienist to care for a patient; thereby, enhancing access to care. This type of less restrictive practice is what IDHA has been requesting vocally for over four years and less vocally prior to this time. Thus, amendment number two is included for your review, consideration and support.

In a recent research study performed by the Center for Workforce Studies, the Dental Hygiene Professional Index that measures regulation, supervision, tasks permitted and reimbursement issues, ranked Idaho as "Satisfactory". Other states identified as "Excellent" included Colorado, Washington, Oregon, California, and New Mexico. "Favorable" states were Connecticut, Missouri, Nevada, Minnesota, Maine, Utah and New York. While satisfactory does not sound so bad, many other Western states are ranked higher and this ranking correlates to enhancing the access to care issues in each state. Notice many states ranked higher than Idaho are listed in the 17 states that have less restrictive supervision laws mentioned on the fact sheet.

Where do we to go for expansion of dental hygiene practice? That is why we are here today. We request your support, for the two amendments, to bill SB 1288 to improve the oral health for the citizens you represent.

Jack Klure, DDS, president of the Idaho Dental Association, testified to support SB 1288. He expressed great concerns about the proposed amendments.
Jerry Davis, DDS, executive director of the Idaho Dental Association, testified to support SB 1288 without the amendments. He explained that providing care must be on the highest level of care.
James C. Wilson, executive director of Idaho Head Start Association,

testified: I am in support of this legislation because it will improve access to dental care not only by children participating in the Head Start program, but other low-income children and adults across the state.

Nearly all children participating in Head Start come from families whose income is below the federal poverty level. Indeed, unless the child is disabled, its family's income must be below that level in order for the Head Start grantee to receive federal funding. It is low income individuals who would benefit the most from the concept of an "extended access oral health care program."

I believe many of you may recently have seen television public service

advertisements featuring Representative Mike Simpson, himself a dentist who practiced in Idaho for over 22 years in a rural Idaho community. In it he names poor dental health the most prevalent chronic health problem among children. Establishing "extended access oral health care programs," particularly in rural areas will make preventive dental care more accessible and help avoid a good deal of unnecessary suffering among Idaho's children. I think you can agree, there are very few things that are more painful than a chronic toothache!

My brother is a practicing dentist. He has a sign in his waiting room. It says: "you don't have to floss all of your teeth -only the ones you want to keep." Flossing and brushing teeth are important dental hygiene procedures that can be taught at an early age. There are many relatively new preventive dental procedures which are effective and don't require the skills of a licensed dentist to perform, and which would be provided in extended access facilities.

Senate Bill 1288 recognizes that we are in a new era of dentistry. I urge you to send it out of this committee with a do pass recommendation.

Sally Kane, a dental hygienist who has worked in alternative practice settings with autonomy in collaboration with community dentists for more than 17 years, testified and distributed four (4) handouts pertaining to dental care and oral health. (See Attachments 1, 2, 3, and 4). She explained, most oral diseases being preventable, underprivileged children, the disabled and the elderly in long-term care facilities are experiencing crises levels of oral disease. According to the 2001 Idaho Smile Survey, 30% of all second graders have untreated tooth decay. If we look at Hispanic children 51% have treatment needs.

These are some pictures of students I served last week at Snake River Elementary School in Nampa. Unfortunately the children who need care the most are often the least likely to get it. In fact 80% of all tooth decay is concentrated in 25% of our children. Thanks to my assessment skills and the good hearts of Southwest Idaho Dentists these children will receive needed restorative care on Give a Smile Day. But hundreds like them may not be as lucky. For example Idaho data for 2002 shows that 55,341 children age birth to 5 years were enrolled in Medicaid/CHIP, but only 10 percent received a dental service and only 6 percent enrolled received a preventive dental service.

This is appalling to me since we must start early to prevent tooth decay. If we do we will see drastic reductions in tooth decay.

Dental Hygienists can help. Dental hygienists are licensed prevention specialist and most hygienists in Idaho hold a bachelor degree. Most dentists in Idaho want to keep us chained up to the traditional model of care, where preventive care is provided in private dental offices but if we are to make an impact on the oral health of Idaho's underserved we

must be unchained and allowed to practice in schools, rural communities, physicians offices and long term care facilities. Much like nurse practitioners practice as midlevel medical providers, it's time Idaho taps into the valuable resource it has in dental hygienists and permit them the same autonomy NP's have.

I am a living example of a hygienist who has been permitted to practice in this manner because I am employed in Public Health. With the current budget crises Idaho faces, it cannot afford to hire more dental hygienists. The State doesn't have to. Hygienists can improve access to care simply by making the practice act less restrictive. The citizens of Idaho can feel confident they will receive safe professional care by virtue of the hygienists, education, and successful completion of the National written exam, State clinical proficiency exam and accountability to the governing Board of Dentistry.

I know you think we are supposed resolves supervision issues with the Board of Dentistry before we approach you but unfortunately the system is not perfect and the Board is comprised of dentists who are not sensitive to the new vision of dental hygiene. The Board chooses to ignore recommendations put forth by several organizations that participated in the Idaho Oral Health Summit who are in favor of service delivery by dental hygienists. In fact I wrote the Board of Dentistry on two separate occasions about the practice act and my letters were never acknowledged.

I am not here to criticize but I am frustrated when I know how much that dental hygienists can help the underserved but forbidden the opportunity. I worked for Terry Reilly Health services in the late 1980's and implemented a preventive dental program for MSFW's and pregnant women in rural Idaho communities. I set up preventive dental clinics in Nampa, Homedale, Payette and Caldwell. I provided clinical care, taught patients oral self care, how to be a good dental consumer and facilitated referrals to area dentists. There was no dentist at any of the sites but I had several I could call on for questions. To me this is an example of collaborative practice. To meet BOD regulations, I had one dentist who

provided standing written orders, he is the one who permitted me to practice as I did. I never let him down or the thousands of people I served. I do not think this type of situation is ideal for the dentist and leaves the dentist open for liable in the unlikely possibility of an incident. Hygienists are capable of conducting themselves autonomously

in collaboration with dentists. They hold their own liability insurance.

Another area hygienists should be utilized is in long term care facilities. Oral care for people in long term care facilities is woefully neglected. In the late 1980's and early 90's, I visited nursing homes and shelters and taught oral care classes to health aids, screened the residents, and cleaned dentures. I can't tell you how horrible it is for the people who still

have their teeth. Few nurses aids provide the needed daily oral care the elderly need. I could see the residents cared about their teeth when they were healthy based on all the restorations I would see, but then due to infirmity when they could no longer do their self care. ..well some mouths looked like they had cottager cheese stuck on their teeth and gums. There are dental hygienists in Idaho today who would like to practice in these long-term care facilities but can't due to the overly restrictive practice act. I know I would feel a lot better if I had to admit a family member to a long-term care facility if they not only had an exercise room and beauty parlor but also a dental hygiene clinic in the facility!

For 10 years I have delivered and set up portable dental equipment in Snake River Elementary School to conduct a school based dental sealant project. For years I have provided care safely without incident. This is and example of how Dental Hygienists can be risk managers and target preventive programs to areas of greatest need.

I am currently working with the Idaho residency program to integrate oral health with well baby and child check ups. I see a future where dental hygienist could work for or in physician's offices to address oral health matters, just like there are social workers, nutritionists, phlebotomists and x-ray technicians. But today that is not possible because of the overly restrictive practice act.

Fluoride varnish is a new delivery system safe for infants and toddlers. It's like tree sap and sticks ta the teeth for hours to deliver low doses of fluoride to the teeth. Studies show 40-70percent reduction in tooth decay with twice a year applications. Did you know nearly 10 percent of Idaho WIC children have ECC?

Xylitol gum is a new preventive aid. Chewing Xylitol gum lowers the concentration of decay causing bacteria and actually helps repair (remineralize) existing decay. In fact, pregnant women who chew this gum will have children who develop fewer cavities. One study following Finish children to age 5 showed 70% reduction in tooth decay among

children whose mothers chewed 3-5 pieces of Xylitol gum.

Most caries are caused by S. Mutan and the mother is the one who passes this bad germ off to their children through kissing and feeding. Xylitol prevents the s.mutans from adhering to the teeth and promotes the colonization of more tooth friendly bacteria. When mom has fewer tooth decay causing germs, she won't infect her children.

I have accomplished much in my career but I could do more. I was taught how to restore, teeth 25 years ago but have never been allowed to do it because of an overly restrictive Dental Board. Hundreds of RDH's have restorative dental skills they can never use unless they move to Washington. It's a shame.

Tooth decay isn't just about a brown hole in a tooth, it's the most chronic disease effecting Idaho children today.

This great state of Idaho needs to recognize hygienists for the competent professionals they are. Today is the day we can make changes to realize the potential of hygienists and permit them to practice according to their education, with autonomy in collaboration with dentists. The result will be more people getting the needed oral health care they deserve, safely.

Ms. Kane opposed SB 1288 as it is too restrictive.

Katy Barbourn, a representative of Lucrary Dental Clinic, a non-profit dental clinic, testified to support SB 1288. She explained children with tooth decay is the single most common chronic childhood disease. More than 51 million school hours are lost each year to dental-related illness. Poor children suffer nearly 12 times more restricted-activity days than children from higher-income families.

There are 271,387 children in Idaho (ages 5-17 years). Of these children, 24 percent are eligible and enrolled in Medicaid; 7,072 children (2.6%) are eligible and enrolled in CHIP. In 2001, only 28.8 percent of children enrolled in CHIP received any kind of dental care.

Both dental and systemic disease can profoundly affect appetite and the ability to eat, and hence can compromise overall health and well-being. Because chronic illness and medications increase in aging population, these effects may be particularly evident among the frail elderly. In Idaho, more than 25 percent of the population age 65 and older have lost all of their teeth. More than 79 percent of seniors in Idaho do not have dental insurance. Seniors are also more likely to have acute dental needs.

Mid-to low-income residents in Idaho without insurance is 44.9 percent. For every adult without medical insurance, there are three without dental insurance.

In Idaho, 172,095 residents live below the national poverty rate­a number that has increased slightly over the last few years (Census 2000). Approximately 69.7 percent of those earning less than $15,000 annually do not have any dental coverage. Of those earning between $15,000 and $24,999, 63.5 percent do not have dental insurance. Put another way, you are only 6.2 percent more likely to have dental insurance at 300 percent of Federal Poverty Guidelines than if you are at 200 percent of Federal Poverty Guidelines­the income level where most clinics limit their sliding fee scale services.

Elizabeth Criner, from the Primary Care Association, testified she supports SB 1288.

Kelly Wright briefly testified she supports SB 1288.

MOTION: A motion was made by Senator Compton to send SB 1288 to the Floor with a Do Pass recommendation. The motion was seconded by Senator Stegner, and the motion was carried by a voice vote.

Senator Burkett was recorded as voting No.

Senator Compton was assigned as Senate Floor sponsor for SB 1288.

ADJOURNED: Chairman Brandt explained the committee must convene on the Senate Floor at 9:30 a.m.; therefore, SB1289, SB1292, and SB1290 will be rescheduled. The committee adjourned at 9:37 a.m.




DATE: Thursday, February 26, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Sweet, Bailey, and Kennedy
MEMBERS ABSENT/

EXCUSED:

Senator Stegner and Senator Burkett
MINUTES: A motion was made by Senator Bailey to accept the committee's minutes for Wednesday, February 25, 2004, as written. The motion was seconded by Senator Kennedy, and the motion was carried by a voice vote.
GUESTS: See the attached sign-in sheets
Docket No.

16-0219-0301 &

16-0219-0302

The Department of Health and Welfare's Division of Health Administrator Richard Schultz explained these two rules governing food safety and sanitation standards for food establishments were reviewed by the committee in January 2004. The House Health and Welfare Committee also reviewed the rules and had concerns about several sections of the rules.

It was determined the rules did not meet the needs of the Department of Health and Welfare or the state of Idaho; therefore, Mr. Schultz requested both the House and the Senate to reject Dockets 16-0219-0301 and 16-0219-0302. This would allow him to reconvene the group that helped draft the rules, add to that group those that have expressed concerns and, hopefully, come back during the 2005 legislative session with new proposed rules for consideration.

A House Concurrent Resolution 51, to reject these rules has been drafted. The current food safety and sanitation standards will continue being used throughout the year 2004, or until new rules are presented and approved in the year 2005.

Senator Kennedy asked what is the primary reason for asking the rules be rejected. Who is concern the rule would not be an improvement that we now have? Mr. Schultz explained the Independent Living Association is one group who has concerns.

The concerns are in two areas, such as the staffing requirement that says there shall be an individual in charge and present during those hours of food preparation, and the knowledge that person has to have.

The school districts have also expressed concerns like those expressed earlier by the Sheriff's Association about the staffing impact.

MOTION: A motion was made by Senator Darrington to send out HCR 51 with a Do Pass recommendation. The motion was seconded by Senator Compton, and the motion was carried by a voice vote.
SB 1320 This legislation, SB 1320, relating to Emergency Medical Services personnel and peer review, was presented by Ken McClure, an attorney for the Idaho Medical Association. He explained this legislation has been approved by the Idaho Hospital Association.

Health care organizations maintain a formal peer review process in order to reduce the occurrence of illness and death and to enforce and improve standards of medical practice. This process enables research, discipline, and medical study to improve quality of care. Records used in peer review are confidential and privileged and generally are not subject to subpoena or discovery. This confidentiality allows open and honest communication which is critical for the peer review process to work.

Idaho's peer review statutes only apply to peer review of care provided in hospitals and other health care organizations. Emergency medical services (EMS) personnel provide care to patients before they arrive in the hospital setting. The quality of care EMS personnel provide is of critical importance to all Idahoans. Their current attempts at peer review are severely curtailed because they are not covered by these statutes.

This legislation would include EMS personnel within Idaho's peer review statutes and thereby encourage their participation in this most important quality improvement tool.

Fiscal Impact - This bill will have no fiscal impact on state or local funds.

David Kim, M.D., an emergency room physician at the Saint Alphonsus Regional Medical Center and the Medical Director of the Saint Alphonsus Life Flight program, testified to support SB 1320.

Life Fligh Units provide advanced medical care and rapid medical transport to critically ill and injured patients. The units have highly experienced crews trained to handle virtually any medical emergency and respond to rescues in Idaho's challenging terrain.

Life Flight EMS personnel are trained in the technology advancements in treatments for the hear. They are trained and supported by the Saint Alphonsus Trauma Center knows for its comprehensive medical expertises in neuroscience, surgery, orthopaedic, newborn, and heart and vascular services. This is the only medical transport program in Idaho and is among 35 percent in the nation to achieve accreditation by the Commission on Accreditation of Medical Transport Systems.

Peer review is done internally by quality review units both in urban and rural systems. It is a volunteer, quality control review system.

MOTION: A motion was made by Senator Compton to Send SB 1320 to the Floor with a Do Pass recommendation. The motion was seconded by Senator Kennedy, and the motion was carried by a voice vote.

Senator Bailey voted Nay. Senator Compton was assigned as sponsor and Senator Brandt as cosponsor.

Idaho Office on Aging Sarah Scott, program operations unit manager for the Idaho Office on Aging presented an outline about the functions and operations of the agency.

Adult Protection provides timely, comprehensive and professional assistance to help protect vulnerable adults who may be abused, neglected, self=neglecting, or exploited. Help may come in the form of referral to law enforcement for criminal investigation or referral to supportive services provided by community resources.

Adult Protection helps the at-risk adult maintain a high level of personal independence, self expression, dignity and respect. Adult Protection seeks to preserve individual rights in the least restrictive manner while helping to obtain protection from further harm and solutions to problems.

Competent adults retain the right to refuse services. An adult is presumed competent unless adjudicated incompetent by a court of law, Section 39-5301, Idaho Code.

The Adult Protection Service is responsible for investigating allegations of abuse, neglect and exploitation against Idaho's "vulnerable" disabled and senior populations and working with other agencies toward resolution.

A vulnerable adult is more than 18 years of age or older; unable to protect himself due to a physical or mental impairment; judgement or behavior is affected to the point the person is unable to make, communicate, or implement decisions in his best interest.

The Aging Office deals with emergency cases such as exigent circumstance(those requiring immediate aid or action), and those in imminent danger, death or severe bodily injury could be reasonably expected to occur without intervention. The Office works closely with Law Enforcement and with the Bureau of Facility Standards in the Department of Health and Welfare's Medicaid division.

Abuse - Intentional, negligent, physical pain or injury by kicking, slapping, punching, pinching or biting. There is also psychological abuse (threats).

Neglect - Neglect is the failure of the caretaker to provide to a vulnerable adult food,. Clothing, shelter, medical care or necessary medications. Self-neglect is the failure of a vulnerable adult to provide such needs for himself.

A caretaker - An individual or institution that is responsible by relationship, contract, or court order to provide food, shelter, clothing, medical care or other life sustaining necessities.

Exploitation - The misuse of a vulnerable adult's funds, property or resources by another person for profit or advantage.

Adult Protection coordinates with individuals and their families, medical staff and care providers, law enforcement, and the courts and other community agencies.

What to report to Adult Protection:

  • Physical or mental abuse, unexplained bruises, falls, scratches, lacerations, or contusions.
  • Neglect such as malnourishment, inadequate hygiene, unkempt appearance, inappropriate housing.
  • Self-neglect is social isolation, confusion, malnourishment, failure to obtain medical care.
  • Exploitation as unusual accounts activity, unpaid bills, and any inappropriate legal documents.


Reports to Adult Protection:

  • Mandatory immediate reporting.
  • Anyone who believes a vulnerable adult is in danger of abuse, neglect, self-neglect or exploitation.
  • Reporting to the Bureau of Facility Standards (Medicaid).
  • Reporting to resident-to-resident incidents.


Information the Adult Protection Service will need:

  • Name and address of a vulnerable adult.
  • Names and addresses of care givers or others who care for the person.
  • Information about the health and mental status of the vulnerable adult.
  • Allegations of abuse, neglect or exploitation.
  • Name and address of alleged perpetrators.


What Adult Protection Service can do:

  • Investigate the situation.
  • Request assistance of Law Enforcement to remove vulnerable adults from immediate, life-threatening harm.
  • Refer substantiated cases to law enforcement, Bureau of Facility Standards, and other agencies for further investigation and corrective action.
  • Assist in arranging supportive services for vulnerable adults.
  • Refer cases involving clients who appear to be incapacitated to local boards of community guardians for possible guardianship proceedings.


Adult Protection response time for emergency exigent circumstance where vulnerable adult is placed in imminent danger and death or severe bodily injury could reasonablely be expected to occur without intervention, is immediate initiation of investigation. Non-emergency cases are investigated within 72 hours.

Ms. Scott explained the Adult Protection Service can be contacted at the following:

  • Idaho Commission on Aging, 334-3833;
  • Area I Agency on Aging in Coeur d'Alene, 667-3179;
  • Area II Agency on Aging in Lewiston, 743-5580;
  • Area III Agency on Aging in Boise, 322-7033;
  • Area IV Agency on Aging in Twin Falls, 736-2122;
  • Area V Agency on Aging in Pocatello, 233-4032; and
  • Area VI Agency on Aging in Idaho Falls, 522-5391.
Facility Standards The Division of Medicaid's Bureau of Facility Standards Bureau Chief Debby Ransom, RN, briefly outlined the services provided by the bureau.

The Bureau is responsible for licensing and certification of health care facilities. As part of that role, the Bureau of Facility Standards responds to complaints from a number of sources, such as complaints from residents, family and friends, employees, and other agencies such as home health, hospice, and case managers. Complaints are also received from Adult Protection, Ombudsman, and federal and state legislators.

Medicare and Medicaid certified providers and suppliers include the following:

Hospitals - Acute care, 48; psychiatric, 7; rehabilitation, 5; and critical access, 24; Nursing facilities - 48; Home Health Agencies - 60; Rural Health Clinics, 41; Ambulatory Surgery Centers, 41; OPT/SP, 26; Hospice, 28; End Stage Renal Disease (dialysis) 7; and Intermediate Care Facilities for the Mentally Retarded (ICF/MRs), 66.

There are 264 residential care assisted living facilities (RALFs) enrolled in the Medicaid program.

The 2003 recertification survey activity involved 31 home health agencies; 147 nursing home facilities; 53 certification programs, 126 ICF/MRs, and 289 residential or assisted living facilities.

During 2003, the Bureau conducted investigations on complaints from two (2) home health agencies; 137 nursing facilities; 45 certification programs; 16 ICF/MRs, and 152 residential or assisted living facilities.

During 2003, the Bureau had two (2) license revocations, and both were residential or assisted living facilities. The action took effect when the provider failed to exercise their appeal rights.

Ms. Ransom explained that legislators or anyone with a complaint or a need for adult protections services could contact her at 208-334-6626.

Due to the Senate Health and Welfare Committee members being called to the Senate Floor, both Ms. Scott and Ms. Ransom had to confine their presentations to meet the Senate's time lines.

Senator Ingram requested Chairman Brandt to have both presenters meet with the committee during the 2004 interim, to have a more detailed study pertaining to adult protection of Idaho's vulnerable adults.

ADJOURNED: The committee adjourned at 9:30 a.m.




DATE: Friday, February 27, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Stegner, Bailey, Burkett, and Kennedy.
MEMBERS ABSENT/

EXCUSED:

Senator Sweet
GUESTS: See the attached sign-in sheets
SB 1301 This bill, SB 1301 relating to Medical Indigency, will amend Sections 31-3502 and 31-3505, Idaho Code, was presented by Teresa Wolf, Social Services director for Nez Perce County.

The purpose of this bill is to close a loophole that exists in the current law dealing with the 180-day delayed application process. The original intent of the 180 day delayed application w as to encourage a provider or applicant to seek other resources that the individual may legitimately qualify for.

Generally, the process for applying to the county requires an application be submitted within 31 days after a person receives emergency services. However, the provider may choose to file a delayed county assistance application, if it is determined that the Applicant may qualify for one of 6 resources. The resources listed in the la w are: medicaid, medicare, social security, crime victims, worker's comp, and 3rd party insurance. Because counties are the payers of last resort that resource should be applied for before seeking property tax assistance. After determining that an individual may qualify for one of the listed resources, the provider or applicant can then file a county indigent application up to 180 days after the service is rendered by the provider. Hopefully, some time within the 180 days one of the resources may become available to the applicant or notify the applicant or provider they have been approved, thereby making it unnecessary to file with the county.

The problem that has occurred, primarily in the north without state providers, is that the law is vague in its description of the intended processes. Some providers have admitted that they use the section if they miss the 31-day filing window. Training has been provided by both the counties and the Idaho Hospital association to our out-of-state providers, but the practice still Continues.

The counties originally agreed to seek repeal of the section, but after further investigation it was determined that it would have caused a significant impact on some of our larger counties. The 180 day delayed application process does work when used properly and many of the providers comply with the intent. The change in the language clearly outlines the process for filing for other resources and what is expected of the applicant. Currently, the language makes it is only necessary to file for one of the six listed resources even if the applicant had no chance of qualifying. The unnecessary filings have at times caused an additional burden to be placed upon the Department of Health and Welfare due to these frivolous filings.

The other two changes are simply housekeeping issues. One addition is to add: Medicaid co-payments and deductibles would not be considered as a necessary medical service. The code currently only states Medicare and should have included Medicaid. The other deletes the term "uniform county guidelines" which have not been used for many years, and is no longer mentioned in the code.

Tony Poinelli, the deputy director of the Idaho Association of Counties, testified and requested the committee to support SB1301, with the following proposed amendments:

  • First amendment, Page 3, line 37- makes' it clear that counties will add appropriate documentation until the end of the investigative process (45 days).


  • Second amendment, Line 49 - clarifies that the information the provider has available at the time the resource is filed for can be accepted as long as the person would reasonably be expected to meet the criteria for the resource.


  • Third amendment, Line 53 - deletes "all."


  • Fourth amendment, Page 4 - adds language to a new subsection that this clarifies that those bills not covered by the resource being applied for may be denied by the Board.


  • A final amendment only changes the subsection numbering.


The Idaho Hospital Association President Steve Millard, testified to support the amended version of SB1301.

SB1301 provides guidelines that clearly state when, how and who should be considered when filing a delayed application for medically indigent assistance. The original intent of the 180 day delayed application process was to encourage providers to pursue other legitimate avenues of payment before filing an application for county medical indigent assistance, so that fewer applications would be received requesting taxpayer assistance with an indigent's medical bills. This has worked well when the spirit as well as the law has been properly followed.

In some areas of the State, the purpose of the existing law has been thwarted by those who have begun using the delayed application process as a method of obtaining more time to file a request for assistance. When this occurs the indigent has sometimes dissipated assets that could have provided reimbursement to the property taxpayers for the assistance provided. Reliance on the property taxpayers should remain a last resort.

This technical correction seeks to close the loophole in the process being exploited in some parts of the State while still meeting the original intent of the legislature to allow a delayed application to be filed when there is a demonstrated active pursuit of other sources of payment before a request for assistance from the property taxpayers is made.

Fiscal Impact - There is no fiscal impact on the State of Idaho or any political subdivision.

MOTION: A motion was made by Senator Stegner to send SB1301 to the Amending Order. The motion was seconded by Senator Bailey, and the motion was carried by a voice vote. Senator Compton was assigned as sponsor for SB1301.
SB 1293 This legislation, SB 1293, relating to Mental Health Services; amending Sections 39-3129, 39-3130, 39-3131, and 39-3132, Idaho Code; amends Chapter 31, Title 39, by the addition of a new Section 39-3134A, Idaho Code, was presented by Senator Joe Stegner.

The purpose of this bill is to revise the membership of the current regional mental health advisory boards and provide for additional powers and duties for the new boards which will increase their function beyond the advisory level.

The legislation will require the county commission chairs, and the Department of Health and Welfare program manager and the regional director in each region to appoint the members of the boards with representation specified in the legislation. Once appointed, a list will be sent to the Department of Health and Welfare.

The legislation requires the collaboration, cooperation, and communication between the regional mental health boards, the regional substance abuse authorities and the regional children's mental health councils in order to increase efficiency and avoid duplication of efforts and services.

The new boards, once established, may develop a service plan component for their region that will address unmet needs within the region. Once developed, the service plan component will be submitted to the state mental health authority for their review and approval, and upon approval will be subject to appropriations made for that purpose.

Fiscal Impact - There is no fiscal impact on the state general fund or any political subdivision, subject to future appropriations by the legislature or local governmental entities. This does not prevent each regional board from soliciting or acquiring funds from other sources for purposes that they may deem necessary or appropriate.

Tony Poinelli, deputy director of the Idaho Association of Counties, testified to support SB1293. He emphasized the importance of giving more responsibility and authority to local regions; keeping things at a regional level, to have more local control, and not at a State level.

He also submitted written comments as follows:

A letter dated January 19, 2004 to Rick Huber, Chairman of the Region V Mental Health Advisory Board in Rupert, Idaho, from Mr. Poinelli, was submitted for the record.

Dear Mr. Huber:

Thank you for your letter concerning the proposed legislation regarding the make up and the role of the regional mental health boards. I will take this time to try and address your concerns and

comments by summarizing them and responding.

I. Two meetings per year seems inadequate. The two meetings per year were intended to be the minimum they would meet but it was felt that each region needed to make the decision on how often they wanted to meet.

2. Two consumers of family member positions are not enough. I think the Workgroup would consider adding another person to the make- up of the board but also remember that there is a representative from the Regional Children's Mental Health Council which could also be a consumer. This board also has the potential to be a policymaking board and policy makers are also required.

3. The term "behavioral" causes concerns. This was another good point and we have been hearing about this concern. The name will likely be changed back to mental health or mental health and substance abuse. I am a little surprised that this was not mentioned by any member of the workgroup, which does have representatives from the Stakeholders and NAML As a Workgroup we have only dealt with mental health and substance abuse.

4. Why haven't those who would be given power shown more interest in existing boards? If you are talking about county commissioners, I do not believe they have ever been invited to attend meetings. The courts have assigned more financial responsibility to the counties. Very few counties are involved as I understand but those individuals are usually the welfare directors and not policy makers. It has been the feeling of those county representatives on the Workgroup that this is a growing area and more county involvement is needed. County commissioners should be involved since they represent all taxpayers in the county. County commissioners only makes up three (3) members of the fourteen (14) member board. We feel that everyone mentioned in the legislation is an integral component to the success within each region.

5. How would this improve the lives of people with mental illnesses? The primary purpose of the legislation is to provide more open communication, cooperation and coordination of services between agencies, consumers and providers on a regional basis so that those issues can be brought before governmental entities that can assist in making changes to the system. Currently, the existing structure (advisory board) does not communicate much with counties.

6. County Commissioners do not mental health issues and would be influenced more by fiscal concerns than human needs. You are correct that many county commissioners are not well versing about mental health issues but some of the county welfare directors are, and they have been able to appraise their commissioners on those issues. It was the feeling of the Workgroup that the individuals selected by the appointing authority (county commission chairs and regional Health and Welfare persons) would be the people in the regions that have shown an interest, knowledge and a willingness to serve.

To add further, these issues are not only mental health issues but major public policy issues as well. The health and welfare of local citizens in each county also fall back on the counties not just the state. We would hope that this is the beginning of providing better service in a more efficient manner. By all parties working together this can be achieved. If there is concern about county involvement, and if the current system seems to be working so well, it may be better if the counties were removed from any responsibility and let the state Department of health and Welfare provide the services.

I hope I have answered your questions. Our Workgroup consists of representatives from counties, providers, Health and Welfare, NAMI, Stakeholders, Legislators and others that have shown an interest. We have been meeting for about 4.5 years on this issue.

I will also be forwarding all comments and questions raised to Workgroup members and will include your letter.

A letter, received by the Idaho Association of Counties on January 12, 2004, from Rick Huber, Chairman of the Region V Mental Health Advisory Board in Rupert, Idaho, was submitted for the record.

I am the chair of the Region V Mental Health Advisory Board, and have been asked to write a letter on behalf of the Board. At the December meeting we discussed the proposed legislation to change the makeup and roll of regional boards. As a board we have concerns we wish to share with you.

1. Two meetings a year seem inadequate, given the complexity of mental health.

2. The members of the Board feel that two consumers or family member positions on these proposed boards is inadequate, given that the "Presidents New Freedom Initiative's" calls for increased involvement of these stake holders in the decision making process.

3. Where mental illnesses are not behavioral in nature, changing the title of the boards appears to ignore the biological nature of these ailments, and focus on symptoms of many, but not all those with these illnesses.

4. Why have not those who would be given power by this bill, shown more interest in existing advisory boards?

5. How would this bill, if passed, improve the lives of people with mental illnesses in Idaho?

6. We are unaware that county commissioners are well versed in mental health issues, and fear the control this bill would give them, would be influenced more by fiscal concerns rather than human needs.

As it stands now, the Region V Mental Health Advisory Board has voted to remain neutral on this bill, but if these concerns are not adequately addressed we would not lend our support to this proposal.

Mr. Poinelli also submitted several correspondences during January 2004 between himself and James R. Baugh from the Comprehensive Advocacy, Inc. (See Attachments #1, 2, and 3)

Madeline Wyatt, I am a mother of a 21 yr old son, a registered

nurse, RN, for 21 yrs, also a Bachelor or Arts of Management degree, member of the Mental Health and Substance Abuse Committee, member of the Stakeholder Committee, and lastly a consumer of mental illness.

I bring a message of a "Silent CRY" for the Mentally III of Idaho, those too "weak" to make the Plea for themselves, to support the Senate Bill 1293. This bill's purpose is to encourage the management of Mental Health needs at the local level and to uphold accountability that those needs are being met. This will require collaboration, communication, and cooperation between regional mental health boards and regional councils in order to increase efficiency and avoid duplication of efforts and services.

The new Regional Mental Health Board Members will be given additional powers and duties with broadened diversity which individual regions are allowed to design a program to meet the specific needs of the consumers and providers in their regions. This will be done on a voluntary basis. Region 7 is an example where consumers, providers and local participation are effectively working.

There are concerns of lack of participation in local support groups, thus causing consumers to have repeated exacerbations and hospitalizations. Last year LAMP (Life Alternatives for Mutual Progress) and Michigan House were forced to close their doors due to state funding cuts. The individuals that participated in these programs were returning to the community from exacerbated states of illness and/or severe conditions requiring further long-term support. Where will these people go for support?

I attempted to compile data about how often the police become involved in interventions of mental illness in communities. The data is compiled at the county level but not available at a statewide database. Please refer to the Idaho Resident Deaths Due to Intentional Self-Harm (Suicide) graph. (See Attachment #4). This information was provided by the Bureau of Health Policy and Vital Statistics. Note the alarming climb in suicide in the years 2001 and 2002. The over all year statistic for male suicide in 2002 was 177 as compared to the female rate of 26. The highest group of suicide was in the male age 45 to 54 the rate more than doubled from 20's and 30's to 43 in 2002. In 2001 teen suicides climbed to 47 compared to prior years of 20's and 30 ranges. These numbers were calculated per 100,000. This points to an overwhelming need for education for mental illness in the school systems and in homes. Helping youth and children to learn effective ways to communicate their feelings and allow them better ways to obtain what they need. These findings point to the fact, "The Existing System is NOT Working!"

What do we do to help improve on it, begin by passing Bill 1293, it is designed with a future goal in mind to facilitate "Single Stream Funding!" Ultimately wherever a mentally ill client enters the system there will be resources available in a well-designed regional plan to meet the client's needs. This will avert many individuals from mental institutions and the penal system, thus saving the state thousands of dollars supporting them in hospitals, jails and prisons. Providing education about mental illness in our communities should be a priority now so that the children of tomorrow will inherit a kinder, more humane and compassionate way to manage life disorders such as mental illness. Many families' lives are affected by mental illness. Everyday is a Choice for me when I wake up, to take good care of myself, eat well, exercise, and sleep well and above all have HOPE. I have walked through the DARKNESS and I have survived, and sometimes I thrive. I do love life, and there was a time when I could not say that. Please, oh please, hear the SILENT CRY of those TOO WEAK to utter a PLEA for "HELP" for the Mentally III of the Great State of Idaho!

I wish to thank you Mr. Chairman and members of the committee for allowing me the opportunity to speak to you today. I would like to open the floor for any questions at this time.

Teresa Wolf, a social services manager, testified to support SB1293. She explained, I have been a member of the Region II Mental Health Advisory Board for the last seven years. We meet one hour each month to listen to reports from Health and Welfare on how well they are doing their job. The board members, however, have questioned what exactly is our purpose other than the board exists by law. We don't see any real results from our meetings and are frustrated with the outcomes that are few and far between. In 2002, we had 15 members. As of January 2004, we are down to 11 members.

We really do not need anymore reports. What we need is coordinated service provision in our communities. What we are getting is a shifting of responsibility from agency to agency. This is not the type of help we, as a community, should be promoting to the population that we are to be assisting.

To better accomplish our responsibilities we need all parties involved in providing mental health services in the community to come to the table. We can then coordinate our efforts to accomplish the same goals that we all ultimately want to make, which is to provide direct services to those individuals suffering from mental illness.

Senate bill 1293 changes the membership of the existing boards and entrusts those members with the task of identifying the gaps in services, and developing a plan to meet the needs of the community. This is a step in the right direction.

James Baugh, executive director of Comprehensive Advocacy, Inc., a private nonprofit cooperation receiving federal funding for the purpose of providing advocacy for people with disabilities, and particularly those with mental illnesses in the state of Idaho.

He supports SB1293 except for one point he does not support. He objects to the appointments to the regional boards. He asked that the legislation amended so consumer members could be selected by the county commissioners, if necessary, but they should be selected from a slate of nominees made by mental health consumer organizations and family member organizations.

Mr. Baugh requested the legislation be sent to the amending order to insert a sentence within the paragraph that would require that consumers and family members be selected from a list of nominees of the local area. He also expressed his concern about the system to move mentally ill people out of the local area and into a state hospital so care will be paid for out of general funds.

Nez Perce County Commissioner J.R. Van Tassel, testified to support SB1293. He outlined the process of how this legislation was developed, and that counties want to work cooperatively with the Department of Health and Welfare and others to provide the best regional community-based services for the mentally ill population. He does not support amendments to SB1293.

Kathy Tidwell, a clinical social worker, testified to support SB1293.

Phil Bush, M.Ed., testified that this bill is the right idea and on the right track, yet the future board members need to be determined by a broader-based representation than the bill in its present state mandates. If the present bill cannot be amended to provide such a broad base, then it needs to not be so loaded with primarily county commissioners. Their concerns will be well represented by having three members on the board. If broader representation cannot be written into the bill, it could be changed by changing the wording of Section 2, page 2, line 9, to read: "the chairperson of the board of county commissioners of two (2) of the counties in the region."

Dr. Bush proposed changes because:

1. This Board will have board powers toward determining service delivery for mental health consumers.

2. Service components need to focus on best practice services that are the right services, at the right time and at the right price.

3. Such as, the contingency of the board needs to be a broad base of individuals, who have a significant education and experience in such service delivery, so they will be able to make good decisions and provide an effective resource base.

4. As presently written, the region's county commissioners will be determining the board's composition.

5. County commissioners usually have a very limited education and experience in the area of providing comprehensive mental health services.

6. In Region IV, they have demonstrated their lack of commitment to this process by withdrawing their representation of the board, even after the board whole heartedly backed the drug rehabilitation center that representation promoted. I do not know the representation and commitment county officials have demonstrated in other regions to their mental health regional boards. If you would like, I can find out in a timely manner.

Victoria Paulson, a representative of the Idaho Medical Association, testified to support SB1293.

The Idaho Independent Living Association Executive Director Kelly Buckland, testified to support SB1293. He also supports the proposed amendment to the legislation.

Senator Stegner explained his reluctance, as sponsor of the legislation, to put the proposed amendment into Idaho statutes, he does not want to be that specific in the statute. He does not feel it necessary to amend SB1293, at this time. He explained it is not only county commissioners on the appointing board, additionally the regional mental health program manager from the Department of Health and Welfare, and the regional director of the Department of Health and Welfare is also on the committee.

Senator Stegner thanked the county representatives who are present today, and the county organizations, the Department of Health and Welfare and others who worked so diligently to develop this legislation.

MOTION: A motion was made by Senator Stegner to send SB1293 to the Floor with a Do Pass recommendation. The motion was seconded by Senator Bailey.

Discussion: A general discussion was held about appointments to the board, such as fourteen members being appointed to the board without naming any specific advocacy who would have the authority, under this legislation, to submit recommendations to the appointing authority. This would be a small way to assure the involvement of these advocacy groups.

SUBSTITUTE MOTION: A substitute motion was made by Senator Kennedy to send SB1293 to the 14th Order for amendment, substantially in accordance with that suggested by Mr. Baugh. The substitute motion was seconded by Senator Burkett.

A Roll Call vote was requested for the substitute morion.

Senators Kennedy, Burkett, and Ingram voted Aye.

Senators Bailey, Stegner, Darrington, Compton, and Brandt voted Nay. Senator Sweet was absent and excused.

The substitute motion failed - 3 Ayes, 5 Nays, and 1 absent.

ORIGINAL MOTION: A vote was taken on the original motion made by Senator Stegner and seconded by Senator Bailey to send SB1293 to the Floor with a Do Pass recommendation. The motion was carried by a voice vote.
ADJOURNED: The committee adjourned at 9:50 a.m. as members were due to convene on the Senate Floor at 9:30 a.m.




DATE: Tuesday, March 2, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Acting Vice Chairman Duncan, Senators Darrington, Ingram, Stegner, Sweet, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

Acting Senator Freeman Duncan was appointed to serve on the Health and Welfare Committee during the excused absence of Senator Compton
GUESTS: See the attached sign-in sheets
MINUTES: A motion was made by Senator Bailey that he had reviewed the minutes of Thursday, February 26, and Friday, February 27, 2004, and recommended they be approved as written. The motion was seconded by Senator Kennedy, and the motion was carried by a voice vote.

A motion was made by Senator Ingram to accept the minutes of Tuesday, February 24, 2004, as written. The motion was seconded by Senator Bailey, and the motion was carried by a voice vote.

SB 1300 This legislation, SB1300, relating to naturopathic medicine, was presented by Senator Robert L. Geddes.

There are a significantly growing number of residents of the State of Idaho who choose natural health care. Naturopathic medicine is a distinct health care profession. The purpose of this legislation is to provide standards of practice and education, a code of ethics for practitioners, state administrative supervision, licensure, regulation and disciplinary procedures for every person providing naturopathic medical services in the state.

There is no fiscal impact to the general fund.

Boyd Landry, executive director of the Coalition for Natural Health, testified to oppose SB1300. He explained his opposition to licensing of naturopathic physicians. The Coalition for Natural Health is headquartered in the District of Columbia with a regional office in San Diego.

The Coalition for Natural Health (CNH) is a non-profit organization representing over 2,500 individuals nationwide who share a common goal: to promote the holistic approach to health and to ensure that natural health alternatives remain widely accessible to the public. The mission of the Coalition for Natural Health is:

  • to educate the public as to the true meaning and benefits of traditional naturopathy;
  • to educate legislators on the efficacy of traditional naturopathy; and
  • to prevent legislation that would prohibit traditional naturopaths from practicing now and in the future.


Before addressing the specific reasons for our opposition, I would like to address the proponents' true need to pass this legislation. As opposed to their stated need, the "naturopathic physician's" true agenda for this legislation is economic protection. The proponents need this bill because a new law creating a new medical profession is necessary to allow them to perform the range of medical services they want to perform and because some of these services would be interpreted as the practice of medicine. In other words, it is all about money and self-interest. Dr. Rena Bloom, a Denver "naturopathic physician" was quoted in the Colorado Daily (Exhibit 1) on Monday, January 18, 1999, as stating "We need this bill because at this point, we're illegal ­ we're practicing medicine without a license."

REQUIREMENTS OF LICENSURE - There are several contentious parts to SB1300: 1) Qualifications for Licensure; 2) Scope of Practice; and, 3) Title Protection. The proponents of this legislation will argue that twelve states have passed licensing legislation, of this type, and that Idaho should follow suit. However, since 1996, twenty states (Rhode Island, Massachusetts, North Carolina, West Virginia, Pennsylvania, New York, Florida, Texas, Minnesota, Kentucky, Iowa, Kansas, Missouri, Oklahoma, Louisiana, Arkansas, New Mexico, Colorado, Ohio, and Idaho) have rejected licensing legislation and twelve of these (Minnesota, Pennsylvania, Ohio, Oklahoma, Missouri, Idaho, Colorado, Massachusetts, New York, Florida, Rhode Island and Texas) rejected it more than once. In total, it has been rejected on over 50 different occasions in the past seven years.

Section 54-5102(1) provides as follows for all would-be licensees to be graduates from approved naturopathic colleges:

1) "Approved naturopathic medical program" means:

(a) A course of study from a college or university granting the degree of doctor of naturopathy or doctor of naturopathic medicine accredited by an accrediting agency recognized by the state or federal government; or

(b ) A college or university granting the degree of doctor of naturopathy, or doctor of naturopathic medicine that has the status of candidate for accreditation with the accrediting agency; or

( c ) A postgraduate degree granting college or university of the healing arts approved by the examining board and state or federal accrediting agency. Such college or university shall require a minimum of sixty (60) semester units for admission and a minimum of four thousand (4,000) hours in basic and clinical sciences, naturopathic philosophy, naturopathic modalities, and naturopathic medicine, of which not less than two thousand (2,000) hours shall be academic instruction and not less than two thousand (2,000) hours shall be school or college approved supervised clinical training. The college or university shall provide adequate instruction to maintain naturopathic medicine as a separate and distinct healing art."

A close look at "naturopathic medical" schools reveals inherent problems with this type of education. The faculty of Bastyr University (Exhibit 2), the only fully "accredited school" highlights the limitations of the "medical" education claimed by graduates of these schools. Recent information from www.bastyr.edu shows a total of 46 faculty members in the "naturopathic medicine" program with 43 of those listing degree of "N.D." as their primary qualification. Of the three "non-N.D." degreed professionals, there is only one M.D.! Thirty-nine of Bastyr's faculty, forty-six members hold N.D. degrees from Bastyr as their primary qualification. Seventeen of the thirty-nine have had their degrees for five years or less. Three hold N.D.'s from National College of Naturopathic Medicine in Portland.

Southwest College of Naturopathic Medicine (SCNM) located in Tempe, Arizona, is the newest "candidate" for accreditation. However, SCNM has an extensive list of problems. Initially, for the majority of time in SCNM's existence, the school could only attain candidacy status for accreditation with the Council on Naturopathic Medical Education (CNME). SCNM was only able to reach full accreditation with CNME after the CNME violated its own policies to accredit the school. Incredibly, CNME granted full accreditation less than 90 days after SCNM suspended operations to address severe financial problems in the summer of 1999. These egregious violations of its own policies resulted in the revocation of CNME' s recognition as an accrediting agency by the United States Department of Education.

In addition, The Arizona Republic (Exhibit 3) reported hazardous environmental conditions at SCNM in a September 12, 2001 article which stated, "Several students have alleged that the school, one of four of its kind in the country, has made them sick because of improper ventilation of its cadaver lab, among other things."

The Auditor General for the State of Arizona in a June 2000 (Exhibit 4) report to the Legislature reported that at least 19 individuals received a license to practice naturopathic medicine without properly passing the required examination given by the Arizona Board of Naturopathic Medicine. The report stated, "Everyone passed the February 1999 exam, but without scoring adjustments, no one would have passed." In fact, the auditor herself who had absolutely no training in naturopathic medicine took the exam and passed after using the same scoring adjustments. What does that say?

In the past, proponents of this bill have provided legislators with a chart that compares the three "naturopathic medical" schools to top medical schools such as Johns Hopkins, Yale, and Stanford. This chart compares course hours, and implies that these "naturopathic medical" schools are academically on par with, or better than, the best medical schools in the United States. However, these schools have practically no medical doctors on staff, and the first of these schools to be accredited (Bastyr) was not accredited until the late 1980s. National College and SCNM only have candidacy status. Most of the instructors at these schools are "naturopathic physicians," which means that most instructors either graduated from unaccredited schools or are relatively new to practice. I ask you to closely examine the faculty at National College in Exhibit 5 where you will find that 24 (60%) of the 40 faculty members with National College degrees received their degree prior to National receiving candidacy status. In fact, the faculty member who teaches oncology and gynecology lists National College as her only credential. Moreover, National College has had three different presidents in the past two-years, which is cause for additional concern.

The truth is "naturopathic medical" education and training mimics medical education and training in form, but not in content! Conventional medical students start clinical work under physician supervision in their third and fourth years, and are assigned to work in major teaching hospitals and clinics. Even after four years of medical school, graduates are ineligible for full medical licenses but must enter residency programs which last between three and eight years. It is clear that "naturopathic medical" colleges in the United States do not provide the equivalent of a medical education. Dr. Richard Roberts, Board Chairman of the American Academy of Family Physicians summed it up best in The Wall Street Journal, August 22, 2002, when he said, "Naturopaths should not be the coordinator of care. There's a world of difference [compared with M.D.s] in terms of the training, the ongoing education, and the day-to-day work. It is like having the flight attendants fly the plane."

The Council on Naturopathic Medical Education (CNME), the accreditation board that recently accredited naturopathic medical institutions and programs, had its recognition withdrawn in 2001 by the United States Department of Education (Exhibit 6) because it demonstrated "pervasive non-compliance" in "not following its own standards." If they are willing to cut corners with their accrediting agency, who is to say that they would not cut corners on the Advisory Committee on Naturopathic Medicine? History does have a way of repeating itself.

NATUROPATHY VS. NATUROPATHIC MEDICINE - A person who feels ill and sees an allopathic physician will typically be given a diagnosis to name the disease and then a prescription for medication to kill the germs that cause the illness. Once the symptoms have disappeared, the person is considered healthy. The allopathic approach to healing is to find the agent of disease-that is, bacteria or virus--and then to kill it.

Vis medicatrix naturae, or the healing power of nature, is central to traditional naturopathic philosophy. This philosophy holds that disease occurs when toxins that have accumulated internally­usually due to incorrect lifestyle, a poor diet, and improper care of the body which weakens the body. Bacteria and viruses, which are always present, seldom cause problems in a healthy body. While allopathic methods of treatment may get rid of symptoms, these treatments alone do not bring healing. The human body is designed to heal itself. Traditional naturopathic modalities stimulate the body's inner forces to get rid of accumulated toxins and thereby allow intrinsic healing to take place. Rather than trying to attack specific diseases, traditional naturopaths focus on cleansing and strengthening the body.

Traditional naturopaths avoid procedures that are common to medical care-diagnosing disease, treating disease, prescribing drugs and pharmaceuticals, and performing invasive procedures. Instead, traditional naturopaths focus on health and education, teaching their clients how to create internal and external environments that are conducive to good health. This is how naturopathy was meant to be practiced as described by Benedict Lust's obituary reported in The New York Times, "The members of the American Naturopathic Association do not believe in ...drug treatments, medicinal remedies or vivisection. " (Exhibit 7)

Traditional naturopathy is simply not the practice of medicine. Diagnosing and treating disease, prescribing drugs and pharmaceuticals, performing major and minor surgery, giving injections and drawing blood, and performing other invasive procedures are medical practices that are outside the scope of traditional naturopathy. Anyone who performs these procedures without a license is illegally practicing medicine and, under existing laws, can be and should be prosecuted for doing so without a license.

While self-styled "naturopathic physicians" seek to claim the same core philosophy as traditional naturopaths, in practice, they move into territory long held by allopathic physicians. "Naturopathic physicians" seek to have laws enacted that would authorize them to perform minor surgery, practice obstetrics including episiotomies, prescribe certain drugs including some synthetic antibiotics, and use many allopathic diagnostic procedures including X-rays, electrocardiograms, ultrasound, and clinical laboratory tests. These procedures move "naturopathic medicine" far from the realm of traditional naturopathy and into the practice of medicine. This is why, "naturopathic physicians" are seeking to be licensed; otherwise, in conducting their desired scope of practice they would be illegally practicing medicine.

FISCAL IMPACT - A close look at Senate Bill 1300 reveals that the potential licensees will not support the cost of regulation through fees. Given the fact that the program has no way to support itself, it is inappropriate for Idaho to create a new program for which only eleven (11) individuals will be eligible, especially a program Idaho would have to subsidize. There is no need for a new medical profession and certainly no legitimize basis for Idaho to subsidize it! Furthermore, if a person needs any surgery or prescription drugs there are already licensed medical doctors to fill this need. Practically and fiscally speaking there is simply no demonstrated need for this hybrid profession.

SCOPE OF PRACTICE - If "naturopathic physicians" are allowed by Idaho to "diagnose and treat" disease, prescribe medications, and perform surgery , a "new medical profession" will be created and they will be elevated to the status of primary care physicians. This promotion is high on their agenda because of the status and the money associated with it. Thomas Kruzel, Chief Medical Officer at Southwest College of Naturopathic Medicine and former President of the American Association of Naturopathic Physicians, was quoted in the Spring 1994 edition of The Naturopathic Phvsician (Exhibit 8) as saying, "Naturopathic physicians are primary care, family practice physicians, and as such are gate keepers to the medical system, along with family practice MDs and DOs." By licensing "naturopathic physicians" Idaho would be equating "naturopathic physicians" with MDs and DOs, because "naturopathic physicians" will inform their "patients" that there is no need to continue to see a regular medical physician, as they have consistently done in states where they are licensed. These "patients" assume "naturopathic physicians" have an education from legitimate medical schools approved by the Liaison Committee on Medical Education. The lack of a need for a "new medical profession" is one of the primary reasons licensing efforts like this one have been rejected on over 50 separate occasions in the last seven years.

In a sworn deposition (Exhibit 9) Mr. Kruzel defined minor surgery in this way:" . . . generally it means that you do not enter a body cavity." The Oregon "naturopathic medicine" licensing law defines minor surgery as "the use of electrical or other methods for the surgical repair and care incident thereto of superficial lacerations and abrasions, benign superficial lesions, and the removal of foreign bodies located in the superficial structures; and the use of antiseptics and local anesthetics in connection therewith." It is difficult to reconcile Kruzel's definition of minor surgery with the actual wording of the Oregon law.

Furthermore, Kruzel has given the following sworn testimony regarding his qualifications to perform vasectomies:

Q: You mentioned that you could do vasectomies on male gonads; is that correct? A: That's correct...Q: You don't consider that to be an invasive procedure? A: Certainly it's an invasive procedure, but it doesn't invade a body cavity, the scrotum is considered an appendix. Q: And is this procedure taught at National College? A: I don't know if it is or not. ..I'm saying that it's within the scope of naturopathic medical practice, and I believe that it probably is taught in school. ..Q: How many vasectomy operations did you do in school? ...A: I did no vasectomies. Q: Do you feel that the fact that you did no vasectomies in school qualifies you to do them in the scope of practice out here with the public? A: Yes. It's a relatively simple procedure to do. Q: Could you learn this procedure by a video tape? A: Possibly.

The Washington Association of Naturopathic Physicians (WANP) exposed their real agenda of displacing medical doctors as justification to expand prescriptive rights for "naturopathic physicians" to include Schedule II drugs. In a 1998 report to the Washington legislature, the WANP stated, "The primary reason for this language change is to ensure that patients seeking naturopathic care will not unnecessarily be burdened with seeking a second office visit by another licensed practitioner (i.e. a real medical doctor) in order to get, for example, codeine cough syrup or an antibiotic which is not currently in the list of legend drugs that a naturopathic physician can prescribe."

Fortunately, the Washington legislature exposed the ruse and did not grant additional scope.

UNIVERSITY OF CALIFORNIA. SAN FRANCISCO -CENTER FOR HEALTH PROFESSIONS - The Center for Health Professions at the University of California, San Francisco, released a study funded by The Arkay Foundation in September of 200 I titled, "Profiling the Professions: A Model for Evaluating Emerging Health Professions" and an accompanying profile titled, "Profile of a Profession: Naturopathic Practice." The study recognized the right of professions to not seek state regulation choosing to allow market forces and consumer choice to protect the public. It stated, ". ..professions have declined regulation, basing their decision on the low potential risk of harm to the public, evidence that regulation can negatively affect access to care, and the capacity of the market to weed out the lower qualified members of the profession."

The study also spoke to the true reason that groups seek state regulation-POWER -when it stated that:

" Although regulation is the legislatures' decision, legislatures virtually never seek to regulate a profession on their own. When it is enacted, it is almost always after long and contentious battles between competing or would-be competing professions. Therefore, though informative, the existence of regulation mayor may not mean much more beyond the capacity of the would-be regulated profession to gamer sufficient political power ."

WHITE HOUSE COMMISSION ON COMPLEMENTARY AND ALTERNATIVE MEDICINE POLICY (WHCCAMP) - By Executive Order 13147, the White House Commission on Complementary and Alternative Medicine Policy was created in March of 2000 and completed its work in March 2003 with the submission of its report, http://www.whccamp.hhs.gov/finalreport.html, to the Office of the President. The Commission was comprised of 20 members, and the Commission held 10 meetings in Washington, DC, and four town hall meetings around the United States. It is important to recognize that a study of this magnitude will have a number of divergent opinions on a wide variety of topics. The proponents sometimes represent that the Commission recommended that every state should license "naturopathic physicians." However, an accurate reading of the report reveals such representations are untrue. In the section titled " Access and Delivery," the commission provided guidance to Idaho when it stated, "Now is the time to look at policy options for the future and to design strategies for addressing potential issues of access and safety .Beyond these basic concerns, protecting the public, maintaining free competition in the provision of CAM services, and maintaining the consumer's freedom to choose appropriate health professionals are issues to be considered when developing strategies and policies."

Secondly, the Commission made it clear that concern exists in the CAM community over appropriate regulatory frameworks for CAM, especially frameworks designed using current regulatory models. The report stated, "Some CAM professionals believe that to reorganize CAM on the conventional professional model, with the kind of licensure, registration, or exemption procedures that this implies, will damage the fundamental character of much of CAM. Some believe that in the past, legislation to "protect the public" was often used to restrict competition in the provision of services."

Thirdly, a well-respected physician and a member of the Commission, Dr. Tieraona Low Dog, teamed up with another member of the Commission to send a letter to the Secretary of Health and Human Services to address a number of issues included in the report. One issue related to equating CAM practitioners with designated primary care specialties. They stated:

"While we endorse demonstration projects that seek to identify what, if any, value "CAM" providers add to established primary care teams, we want to go on record noting that we do not believe that CAM providers are fungible with the primary care providers enumerated in Title VII. Further, "Efforts (such as Senate Bill 1039) to equate their degree of training, or the scientific basis of their practice, with that of the designated primary care specialties puts the public at risk of receiving unvalidated and non-evidence based primary care."

CONCLUSION - The reasons set forth above demonstrate why licensure for this new "medical profession" should not be considered. It is clear that the education of "naturopathic physicians" does not meet the standards one would expect from primary care providers who diagnose and treat disease, prescribe medications, deliver babies, and perform surgery, and this is a role already being filled by medical doctors. If licensure is granted, those so-called "naturopathic physicians" will be so elevated in stature that they will be perceived by the public as equal to the far more extensively- trained allopathic physicians, thus creating the potential for confusion and providing of improper medical care.

If licensure is not granted, "naturopathic physicians" may continue to practice in the same manner that is legal today- without making diagnoses, without prescribing medications, and without performing invasive procedures. Those who perform these procedures without a license will be practicing medicine without a license and will be breaking the law. Legal procedures are already in place for addressing this problem, at no added cost to the state.

There has been no change in Idaho since last year that would establish a need for this legislation. There is absolutely no demonstrated need to create a new medical profession by licensing "naturopathic physicians." In the over 50 different occasions state legislatures have looked at this question in 1997, 1998,1999, 2000, 2001,2002, 2003, and thus far in 2004, they concluded that there is no need to create a new medical profession styled as "naturopathic medicine."

Since the public is not crying out for the licensure of "naturopathic physicians," then who is? The cry for licensure is coming from eleven (11) "naturopathic physicians" in the State and their trade organization, the American Association of Naturopathic Physicians. This is not about public protection. This is about trying to obtain legislative economic protection, status, and power. These three "naturopathic physicians" gambled on going to school for a profession that is not licensed in 38 of the 50 states, and they now expect Idaho to bail them out! Nancy Aagenes, Past-President of the American Association of Naturopathic Physicians, stated in 1996 and it is still true today, "Nonetheless a student coming out of our schools, uncertain and anxious anyway often simply will not practice in an unlicenced state. If enough of us default on our loans, a major source of income for our schools is cut off."

The State does not need to create a new medical profession known as "naturopathic medicine." Idaho needs to reject the position of the AANP as the nineteen states that considered this type of legislation in 1997, 1998, 1999, 2000, 2001, 2002, 2003, and thus far in 2004, rejected such licensing.

This legislation is nothing but a self-serving attempt by a minuscule special interest group to legitimize their alternative approach to the practice of medicine by mandating the creation of their own licensing process and to steal by legislative action the titles that have been used by registrants for over twenty years.

The attached above mentioned exhibits during this testimony, and also a CD-R containing a copy of the Arizona Office of the Auditor General Performance Audit, Arizona Naturopathic Physicians Board of Examiners - June 2000 report were presented. (See Attachments #1 and #2).

Lucy Pierson, represented herself, and testified to support SB1300. Her medical insurance does not pay for a naturopathic physician because Idaho does not require them to be licenced; therefore, insurance will not pay and a person must pay for their own medical care. Lincesure would require insurance companies to pay for medical care.
Donna Mussell, representing herself, testified to oppose SB1300. She explained she has operated a business in Boise for 15 years, and naturopathic medicine is a very established form of medical care. She does not want the law to the enforced licensing law in Idaho. She seeks natural health and wants the freedom of choice, wants to freely practice health care.
Michele S. Morgan, M.H., PhD, president of the Idaho Coalition for Natural Health, testified to oppose SB1300. On February 24, 2004, she submitted written testimony to oppose SB1300, as shown:

I am president of the Idaho Coalition for Natural Health. I am an Ordained Inter-faith Minister and a Holistic, Herbal and Homeopathic Practitioner. I have been in practice for more than 25 years and am now residing and maintaining an active alternative health care practice in Boise.

It is my understanding that a small but determined group of Naturopathic Physicians are once again attempting to gamer support for their bill, SB 1300, that would require licensing. This bill, not sponsored by all Naturopaths and alternative practitioners who are practicing in Idaho at this time, will have serious opposition.

This bill as it is written, does not represent the views of a majority of Naturopaths and alternative practitioners, but rather a small segment who are seeking to have the same legal rights as medical doctors to perform treatments and prescribe drugs without the benefit of a full medical education.

It is my intent to share with you both my own concerns and the concerns of the ICNH board and all the ICNH members across the state. We believe that licensing is unnecessary and would serve to eliminate alternative health care options. In our minds this is a slippery slope that will u1timately 1imit, not expand alternative health care for people in need.

The ICNH board and members will be attending the hearing of SB1300 on March 2, 2004. We trust that our statement of opposition and concern will be heard and taken very seriously by the committee. SB1300 asks to license Naturopaths under the guise of protecting the public but in reality this bill will only serve to compromise health freedom in Idaho. Thank you for consideration in this matter.

Today, Dr. Morgan testified opposing SB1300. She explained, I have a Ph.D. in the Health Science of Botanical Medicine specializing in Homeopathy and Herbal medicine from Union University in Los Angeles, California. I have been in private practice for 25 years.

I am here today to tell you of my experience with naturopathic lincesure in Montana in the year 2000.

In 1993, before the licensing law, I worked with two Naturopathic Physicians in Helena. They were my friends. I shared office space with one of them. We referred clients to one another and taught classes together .

In 1996, I was severely injured in a car accident and had to leave Montana for medical treatment. I handed over my client base to these two trusted friends. After a 3-year rehabilitation, I returned home to Helena to re-open my practice.

I placed ads in the newspaper, on cable TV and radio, had a web site built and printed thousands of new brochures. Within 3 days, after my advertising began, I received a call from my Naturopathic Physician friend informing me I could no longer advertise or practice homeopathy and herbal medicine in Montana because I was not an "N.D."

Her words to me were, and I quote, 'cease and desist or we'll find a way to take you out.' She stated she knew I was a respected, trusted practitioner with more years in the profession than either one of them, but that they had worked too hard for this law for me to be an exception.

I called my attorney for advice. After reading the law he informed me that there was no provision for me and that my education, degrees, experience, reputation...none of it mattered.

Soon, I received a letter from the Montana Medical Review Board informing me that the screening panel was considering prosecution for "practicing medicine without a license" and "holding myself out as a doctor without a license". If found guilty , I would face a $1,000 fine and 6 months in jail. My attorney replied that since being out of state, I was not informed of the licensing law and was innocent of all charges. The response was, if I agreed to maintain a silent practice, stop the ads, shut down the web site and destroy the brochures within 48 hours, the inquiry would be dropped.

I was in shock; heartbroken. My clients were enraged that their health freedom was being denied and begged me to fight it. But, truly, I couldn't face jail time or court fees. Ultimately, I was forced to leave the state I called home. I came to Idaho to practice under its current Health Freedom Law.

In my mind, SB 1300, as it is written, is the beginning of this story allover again­ for myself and all of Idaho's non-licensed practitioners, AND their clients­present and future. Please vote no on SB1300.

Laurence Smith, testified to oppose SB1300. He explained he is not a doctor, he is an herbalist and owner of a health food store. He had a heart attack and traditional medication did not work. He looked for a teacher and has studied herbal medicine for 19 years. He stated, I teach empower. He wants people to have the knowledge and power to change and improve their lives.

Laws should solve problems, so what is the problem? If there is a problem, is this the best solution? In the proposed law there is a list of things naturopaths do, but in the exclusions many of these items have been omitted. We have a good law.

Joan Haynes, ND, a naturopathic physician who is licensed in the state of Oregon, testified to support SB1300. She believes that due to the Idaho not requiring licensing it limits her abilities to operate.
Lyn Darrington testified to oppose SB1300, and that the Idaho Association of Health Plans , Regence Blue Shield of Idaho, does not support this legislation.
Mark Michaud, M.D., testified to support SB1300. He outlined the importance of having accountability and standards, and how important it is to know when to refer to a medical physician.
Debbie Dalrymple, testified to oppose SB1300. She believes people should have the right to choose to die with dignity. She asked what is wrong with the current law? Why spend money to fix something that is not broken?

Dr. Todd Schlapfer testified to support SB1300. He represented the Idaho Association of Naturopathic Physicians and testified, I am a practicing naturopathic physician in Coeur d'Alen. I received my doctorate in naturopathic medicine from the National College of Naturopathic Medicine, and hold a license to practice naturopathic medicine in our neighboring state of Montana. I am in favor of SB 1300.

Naturopathic medicine is a distinct, comprehensive system of natural health care based upon a thorough grounding in biomedical science. What conventional medicine and naturopathic medicine have in common is education in biomedical science. What is different and distinguishes our professions is our education in unconventional medical science and therapeutic modalities. It would never be possible to merge the two professions into an indistinguishable singularity. As an ND, if l wanted to become an MD, I would have to go to an MD school with the privilege of bypassing most of the already traversed medical science. If an MD wanted to become a naturopathic physician, one would have to do the same through an ND school. Unfortunately, because some states, like Idaho, do not yet license naturopathic physicians, this distinction is murky. For example, there's nothing stopping an MD or any citizen from claiming to be an instantaneous ND. No standard of education or accountability required. This has become a growing problem for an increasing number of states.

The established standard for a physician-level practitioner of health care is licensure. Educational qualifications are central to that determination. Accredited education is required for all licensed health care professions. SB 1300 is no exception. In the same way the Liaison Committee for Medical Education accredits medical schools, the Council on Naturopathic Education accredits naturopathic medical schools. Both are established at the federal level under the Department of Education. There is no higher educational standard.

POINTS OF CLARIFICATION - Contrary to the eloquently stated assertion, we do not "deliver babies, cut on people and hand out drugs."

Under 54-5108(2) it is clearly stated that one cannot do any OB without complying with established Idaho Code 54-1404, pertaining to the Idaho board of nursing. SB1300 establishes no exception to this statute.

Minor office procedures are limited to the repair and care of superficial abrasions and lesions, e.g., a wart or splinter. We are prohibited from using general or spinal anaesthesia, inducing or performing an abortion, procedures involving the eye, ear, tendon, nerves veins, or arteries extending beyond superficial tissue. We cannot treat any lesion suspected of malignancy unless in collaboration with an MD or DO. Two references: 54-5102 (3), and 54-5105 (4-9).

Prescriptive privileges is limited strictly to those prescription substances that are consistent with naturopathic education, training and board examination. These are natural-source medicines, e.g. thyroid, bio-identical hormones, and natural source antibiotics. This bill does not determine a formulary. SB1300 sets up a formulary council, an entity separate from and not under the authority of the board. There will be 5 members; 2 naturopathic physicians, 2 pharmacists nominated by the State Board of Pharmacy, and one MD or DO nominated by the State Board of Medicine. See 54-5109.

SB1300 provides for a restricted license. This applies to practitioners who have been practicing in Idaho for at least the past 5 years and who can demonstrate a minimum of 4000 hours of academic and clinically supervised naturopathic training. This allows established practitioner to continue to practice as they have, without diagnostic imaging privileges, minor surgery privileges or prescriptive privileges. Restricted licenses will be granted once. This provision closes after six months. See 54-5112

Estimated numbers of licenses granted for the first year is significantly larger than you were told yesterday by opposing testimony. The range somewhere between 120-150.

SB1300 provides no mandate for insurance coverage.

Testimony has been given that may have been misleading.

Florida is seriously considering a licensure bill for naturopathic physicians. A House bill will soon be introduced by Representative Bower. A number has already been assigned.

California is on course to establish rules and regulations for its licensees.

At the same time as our hearing, Washington D.C. voted 13-0 in favor of licensure for naturopathic physicians. It now is being prepared for signature by the mayor.

Laurence Hicks, a physician and surgeon from Rupert, Idaho, testified he is also a naturopathic physician, and was testifying to support SB1300. He explained the issue is on using the title doctor. He wants the public to understand the different levels of education required to be a medical physician. He believes this legislation was very carefully crafted and does support SB1300.
Written testimony was received from Townsend D. Wolfe from Boise, in opposition to SB1300, as follows: Empowering a few individuals with responsibility for which they are not fully trained (medical procedures and prescriptions) while at the same time taking away hundreds of jobs from individuals who serve others with SAFE and natural remedies is not a responsible position to take, and I strongly ask that you oppose this bill.

No only will this bill restrict free enterprise from hundreds of people, but it will severely limit the ability of Idahoans to take responsibility for their health care choices.

Written testimony was received from Terry Durst to oppose SB1300 in the strongest terms. In summary he reported: This licensing effort is another effort of the American Association of Naturopathic Physicians and has been around for several years now. In the Senate in 1998 and in the House in different iterations, as the proponents try to make it palatable to the Senate and House. Similar legislation did not get out of the Health and Welfare chairman's office last term in the House. Not getting out of your office would be a great service to the citizens of Idaho.

This is an organization that comprises the graduates of three Naturopathic Colleges in this country who are seeking exclusive use of the term "Naturopath." They are seeking primary care physician status without having the necessary education, internships, residencies, etc. This group advocates and has authorization in the few states where they have held sway to prescribe prescription drugs for which they are not qualified. Former Senator "Moon" Wheeler, a former pharmacist was against this effort because of the pharmaceutical qualifications issue.

The AANP also advocates minor surgeries. Minor surgery is defined as any surgery that does not penetrate the abdominal cavity. They also advocate episiotomies in "Natural childbirth." I'm sorry but that is NOT natural childbirth. The brand of Naturopathy or Natural Health practiced by the members of this association practice is a strange form of naturopathy. Traditional naturopathy uses no toxic substances and does no invasive procedures. Traditional naturopathy works with the natural order and in harmony with the body, while most allopathic and some of the methods of the members of AANP work against the body's natural rhythm.

The AANP seeks exclusive use of the term "naturopath" which would mean that should this ill advised bill pass, many good natural health practitioners who cause no harm to society by our modalities and methods, such as myself, would not be permitted to use the name I have become accustomed to in the last ten years. I worked very hard for about four years of structured study to earn my Doctor of Naturopathy degree, preceded by 25 years self-study, and living by those principles and now 10 years of private. The Idaho State Constitution give Idaho citizens the right to treat their health as they see fit, and that practitioners may ply their skills amongst the populace without fear of State involvement so long as they do not overstep their abilities the proscribed boundaries.

I urge you to oppose SB1300 in the strongest possible terms. The AANP has tried several times and will continue into the future to gain the exclusive use of the term Naturopath. They seek exclusive authority to practice what any traditional Naturopathy would shun like a bad habit. "Naturopathic heresy" is another term that could be used to describe this group which comprises only ten or eleven AANP backed and sanctioned Naturopaths. These NDs in Oregon have the title NMD. This is Naturopathic Medical Doctor. They seek primary care status and are MD wannabes. They are not qualified for such a title. It would be most unfair for all the wonderful Naturopaths and Natural Health Practitioners in this State to be thrown into limbo or worse, so that these eleven people may ply their trade as a very exclusive clique.

I have no personal animosity to any member of this organization. I'm sure every member of the AANP is a very nice person and is only practicing what they have been taught. My opposition is to the "only the eleven of us" attitude and the above stated procedures and practices they advocate.

I urge you to vote NAY when the time comes, and preserve the status quo in Idaho that serves its citizens very well. Do not throw many very good and well-meaning practitioners into limbo, or worse. Do not throw citizens who seek natural methods of health and healing into limbo. Many have been with particular health practitioners for years, and if that care giver doesn't meet the standards of the AANP or the State and must cease and desist, that client who may have great trust in their "natural doctor" will be searching for one of those NMDs (only eleven at this time).

This is a classic case of a special interest group, a very small special interest group that is not in the best interest of all the people in the state of Idaho. Please help keep health care decisions and those who practice natural health free, at least the freedom to choose for ones' self.

Written comments were received from Briana Werner. In summary, she reported: I am all for the naturopathic medicine. I have used a naturopathic physician in line with the regular doctors. I have avoided going to the regular doctor with sinus, menopause, cholesterol issues, sleeping, stress, and aches and pain problems.

I am glad we have Naturopaths because it is nice to use non-chemical remedies with the help of a naturopath. They keep you from using the wrong kind of remedies and they know which ones won't be bad with other medications you might be on.

We need someone to consult for all the vitamins, herbs and natural remedies that are out there. We really need to have the Naturopaths working side-by-side with regular doctors. I have met lots of people who are allergic to some chemicals, but can take natural remedies. It would be crazy to not have these two professionals working together. Yale has started to have them work side-by-side and so has Oregon, and some other states.

Please allow the Naturopaths to be licensed in Idaho. Let us have a choice, after all, isn't that what America stands for? Chiropractors and physical therapists are a form of natural remedy, and they are licensed.

Written comments were received from Jennifer Rizzuti, from Boise, to oppose SB1300. She wrote: As a citizen of Idaho, I would like to voice my concern over the pending Naturopath licensing bill, SB1300.

In reviewing SB1300, I fail to understand the problem this bill is trying to address. It appears there is a small number of Naturopathic physicians trained in a limited number of four year degreed, on-campus universities trying to exclude traditional Naturopaths and herbalists.

I am particularly disturbed by the freedom this bill provides to Naturopathic practitioners to diagnose, treat and prescribe. In addition, there appears to be no accountability to AMA-approved governing medical body.

SB1300 may be presented as protection for the Idaho public, but the question to answer is, "who is currently falling ill or dying at the hands of Naturopaths in this state?" In fact, many consumers are currently receiving exceptionally good care.

The existing health freedom law, Title 54-1804, continues to serve us very well to protect the natural health care community and consumers of those services in Idaho. Please vote "No" on SB1300.

The committee members asked numerous questions of persons testifying, both for and against SB1300, and conducted an in-depth review of the legislation.

Chairman Brandt announced the committee members must convene on the Senate Floor; therefore, he would continue hearing testimonies on Wednesday, March 3, 2004.

ADJOURNED: The meeting adjourned at 9:55 a.m.




DATE: Wednesday, March 3, 2004
TIME: 8:00 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Acting Vice Chairman Duncan, Senators Darrington, Ingram, Sweet, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

Senator Stegner and Vice Chairman Compton
GUESTS: See the attached sign-in sheets
SB 1418 This legislation, SB1418 relating to the Department of Health and Welfare, was presented by the Intergovernmental and Fiscal Division Chief Bill von Tagen.

This legislation is to amend the statutory language to broaden the use of "do not resuscitate orders" and DNR protocols beyond emergency medical services personnel and to clarify the Department of Health and Welfare's role and rule making authority in the section.

The bill will have no fiscal impact.

MOTION: A motion was made by Senator Sweet to send SB1418 to the Floor with a Do Pass recommendation. The motion was seconded by Senator Bailey, and the motion was carried by a voice vote. Senator Bunderson will be the Floor sponsor.
SB 1300 SB1300 was introduced by Senator Robert Geddes on Tuesday, March 2, 2004, and the hearing was continued today.

Chairman Brandt announced he would call those persons to testify who registered on the sign-in sheets of March 2, and did not get a chance to present their testimony.

Dr. Todd Schlapfer, from Coeur d'Alene, continued his testimony from March 2, 2004, to support SB1300.

Historically, naturopathic medicine is one of the oldest continuously licensed health care professions in the U.S. Its origins can be traced back to late nineteenth-century European physicians, who wanted to re-orient medicine toward healthful living and therapies. It was brought to the U .S. and Canada in the 1890's and was adopted by physicians who established schools to educate and train physicians of natural medicine. I have a letter dated 1922 signed by Dr. Benedict Lust, one of most well known pioneers of naturopathic medicine, showing that education and training then was at least 3 years, which was customary for physicians at the time. Matriculation included medical science ( as it was known then), surgery, OB and prescriptive medicines. But the emphasis of therapeutics was on nature-based modalities, e.g., hydrotherapy, diet, exercise, homeopathy, etc.

In the middle years of the twentieth century , the development of miracle drugs such as antibiotics, and the large scale funding that became available from pharmaceutical companies, combined to create a near monopoly of heath care by conventional medicine. That stage lasted until the mid-1970's and resulted in the suppression of many alternatives to the mainstream system.

Over the past 25 years, the American public has become increasingly aware of the costs and consequences of relying primarily on drugs and surgery for health care. There began a large and growing demand that natural medicine alternatives be accessible in a consistent, effective way. The result has been the re-emergence of modern naturopathic medicine.

This is a bill for licensure of those who have met the respected and

conventional standards for physician level education and training to practice naturopathic medicine in the State of Idaho.

Why do we need this legislation?

I. To provide for full and legal access to what naturopathic physicians can provide. The public increasingly seeks access to naturopathic physicians, but find it untenable that they cannot receive the full benefit of naturopathic services. The current situation restricts the trade of our profession in Idaho.

2. To distinguish between physician-level practitioners of naturopathic medicine and natural health care providers that do not require licensure.

3. To create an environment of free choice and collaboration between naturopathic physicians and all variety of health care for the citizens of Idaho.

4. To create appropriate standards of education and practice for those using the title "Naturopathic Physician", or "Naturopathic Doctor."

In the United States Department of Labor, Dictionary of Occupational Titles, you will find Naturopathic Doctor defined: It's fairly long, so I'll summarize. Diagnoses, treats, and care for patients, using a system of practice that bases treatment of physiological functions and abnormal conditions on natural laws governing the human body. . . .It goes on to describe modalities, which include botanical, nutritional, food, mechanical, minor surgery , and prescriptive medicines compatible to body processes. SB1300 is precisely consistent with this definition.

In the American health care system, a doctor means someone who diagnoses and treats, and has met an established standard of education, training and board examination in order to accept this responsibility .Making a diagnosis requires a comprehensive understanding of human function, chemistry, anatomy, physiology,

pathology and disease processes, examination, etc. Unlicenced practitioners do not practice an established form of health care requiring a license. As such, practitioners not requiring a license to practice, e.g. "naturopaths", "traditional naturopaths", "natural health consultants", "herbalists", etc are not required to study the detail of human function, pathophysiology, and diagnostic evaluations for determining a diagnosis. Subsequently they agree, according to a recent publication from the Coalition for Natural Health,". ..not to diagnose and treat disease. . . ." This is consistent with not practicing as a doctor. To put oneself out as a doctor without physician-level training is completely inconsistent with responsible health care.

Those practicing as unlicenced practitioners do not seek licensure or regulation. Their literature and the laws under which they are allowed to practice specifically provides, among other limitations, that they do not diagnose, do not claim or make themselves out to be doctors. There is no established standard of education and practice for unlicenced practitioners. There is an established standard of education and practice for naturopathic physicians.

In order to resolve public confusion and ensure public safety , any reference to a practitioner using naturopathic modalities who does not have physician level education and training that meets an established standard to diagnose and treat, should not use any title referencing themselves as a doctor. The White House Commission on Complimentary and Alternative Medicine Policy along with the Center for the Health Care Professions at the University of California have been very clear about the fact that unlicenced practitioners are not doctors. They recommend titles, e.g., naturopath, traditional naturopath, natural health consultant, etc.

Both science and the people have found that health care is best delivered when we can integrate our varied professional expertise and help each other be successful in caring for our patients. Naturopathic medicine has entered the mainstream. For the same reason MDs, dentists or nurses are licensed, licensure of qualified naturopathic physicians is necessary.

I hope that you will carry this message to the people of Idaho by supporting the passage of SB'300, the Naturopathic Physicians Licensing Act.

Chuck Lempesis, an attorney and a representative of the Coalition of Health, testified in opposition to SB1300. He explained this issue has been ongoing for years. He wants to encourage natural health care in Idaho. He requested the committee to not adopt SB1300.

Dennis Davis, ND, briefly testified to support SB1300.
Gay Doman, briefly testified in opposition to SB1300.
Ken McClure, an attorney for the Idaho Medical Association (IMA), testified the IMA does not want to get involved in the scope of practice and does not see SB1300 as affecting public health. The IMA does not support or oppose SB1300.
Senator Geddes explained SB1300 does not put anyone out of business. He believes SB1300 is good legislation.
Larry Benton, a representative of the Idaho Association of Naturopathic Physicians, explained that a lot of effort and months of time was involved to develop SB1300. This legislation does not restrict persons from conducting their business, but that it does restricts the use of the term "doctor."

He presented an eight (8) page review of SB1300 with details relating to specific areas of change. (See Attachment #1).

He also presented a Bastyr University report relating to the Naturopathic Medicine Program of 2003-2004. (See Attachment #2)

Mr. Benton requested the committee to send SB1300, to the amending order.

A letter, dated February 18, 2004, from the Bingham County Commissioners to Senator Geddes, was submitted. The letter stated, as follows:

We, the Bingham County Commissioners, applaud your introduction and encourage your support of SB1300. This legislation will provide for the health and safety of the citizens of Idaho who seek health care from qualified naturopathic physicians.

As you may be aware, problems with unqualified practitioners led the Bingham County Commissioners to adopt Bingham County Ordinance 98-10. This Ordinance assures Bingham County citizens that practitioners are, in fact, qualified naturopathic physicians. Please find the Ordinance attached for your reference.

In as much as the legislation will provide the same assurance to the citizens of Idaho statewide, and upon passage of SB1300, the County will sunset Ordinance 98-10, which will then be replaced by the higher standards of this bill.

Also submitted was a letter, dated September 10, 2003, from Rod Page, the Secretary of Education in Washington D.C., addressed to Robert Lofft, the executive director of the Council on Naturopathic Medical Education in Eugene, Oregon. The letter reported, as follows:

At its June 9-10, 2003 meeting, the National Advisory Committee on Institutional Quality and Integrity recommended that I grant initial recognition for a period of two years to the Council on Naturopathic Medical Education as a nationally recognized accrediting agency. This recommendation was made under Sections 114 and 496 of the Higher Education Act of 1965 (HEA), as amended, and pursuant to relevant statutory and regulatory provisions.

I concur with the recommendation of the National Advisory Committee. I am satisfied that accreditation by the Council is a required element in enabling students and graduates of the programs the agency accredits or pre-accredits to participate in Federal programs administered by other Federal agencies. These other Federal programs include the Academic Research Enhancement Awards and the Loan Repayment Program administered by the National Institutes of Health's National Center for Complementary Alternative Medicine. Accordingly, For a period of two years from the date of this letter, I grant initial recognition to the Council on Naturopathic Medical Education as a nationally recognized accrediting agency for the accreditation and pre-accreditation throughout the United States of graduate-level, four-year naturopathic medical education programs leading to the Doctor of Naturopathic Medicine (N.M.D.) Or Doctor of Naturopathy (N.D.) Degree.

Please convey my best wishes to the members of the Council. I appreciate their continuing efforts to improve the quality of postsecondary education in the United States.

A letter, dated February 4, 2004, from Don Warren, B.SC.,N.D., to all Representatives and Senators of the Idaho State Legislature, relating to the confirmation of USDE Recognition Faculty Credentials of N.D. Programs, was submitted and reads as follows:

At the June 9-10, 2003 meeting, the National Advisory Committee on Institutional Quality and Integrity (NACIQI) recommended that the USDE grant initial recognition for a period of two years to the Council on Naturopathic Medical Education as a national accrediting agency. The Council will apply for continued recognition in the spring of 2005. The CNME will continue to remain in full compliance with USDE regulations and so anticipate this recognition being renewed.

It is also important to note that each of the programs that the CNME accredits in the U.S. are regionally accredited or pre-accredited by recognized regional accreditors.

The CNME recognizes that the quality and effectiveness of a naturopathic medicine program in fulfilling its mission and objectives depend largely on the competence and performance of its faculty. The first standard in Section IV, p.37, of the Handbook of Accreditation for Naturopathic Medicine Programs requires that:

Members of the faculty are appropriately qualified by education and experience for their teaching positions in the naturopathic medicine program. Advance or professional degrees, and other evidence of competence to teach at the doctoral level in a subject area are required.

A copy of the CNME's Handbook of Accreditation may be obtained by sending a request to cnme@bellsouth.net It is also available electronically in pdf format.

The committee members and the chairman conducted a second lengthy review of SB1300, and questioned and explored many areas of concerns.
MOTION: A motion was made by Senator Bailey to send SB1300 to the 14th Order. The motion was seconded by Senator Kennedy.

Discussion: Term of "doctor" implies a high degree of education; x-rays; treatments of superficial injuries; prescribed drugs and drug therapy and how they relate to people's health; this type legislation should not be formulated by the Senate on the amending order; Section 6, page 4, exemptions be removed from the bill. Further questions were asked and considered.

SUBSTITUTE MOTION: A substitute motion was made by Senator Burkett to Hold SB1300 in Committee until next year. The motion was seconded by Senator Darrington. A roll call vote was requested by Chairman Brandt.

Senators Burkett, Sweet, Darrington and Duncan voted AYE.

Senators Kennedy, Bailey, Ingram, and Brandt voted NAY.

Senator Stegner was absent and excused.

The substitute motion failed with a vote of 4 Ayes, 4 Nays, 1 absent.

ORIGINAL MOTION: A roll call vote was taken on the original motion made by Senator Bailey and seconded by Senator Kennedy to send SB1300 to the Amending Order.

Senators Kennedy, Bailey, Ingram, and Brandt voted Aye.

Senators Burkett, Sweet, Darrington, and Duncan voted Nay.

Senator Stegner was absent and excused.

The original motion failed with a vote of 4 Ayes, 4 Nays, 1 absent.

SB 1383 This legislation, SB1383, relating to purchasing and public works contracts by the state of Idaho, to provide for health insurance requirements for vendors and public works contractors, was presented by Senator Clint Stennett.

Recognizing that the cost of health care for individuals without health insurance coverage is passed on to the taxpayer; and businesses that do not provide health insurance coverage have a competitive advantage over those who do. This measure attempts to level the playing field and slow the growth in Medicaid and health insurance costs by requiring that all businesses with 25 or more employees provide health insurance for 80 percent of their full and part-time employees as a condition of doing business with the state of Idaho.

By providing that more Idahoans are covered by health insurance, there should be a savings in catastrophic health care fund, Medicaid and health insurance rates.

An in-depth review of this legislation was held by committee members questioning such areas as:

  • Workman's comp insurance coverage
  • 25 or more employees requiring insurance
  • Creating a level-field for employers and employees
  • Health insurance and workman's comp being two separate items
  • The taxpayer is ultimately the payer for medical coverage for persons without medical insurance
  • Social responsibilities of employers
  • Free market and costs for medical insurance
  • Co-payers, prescription drug costs
  • Some employers do not provide medical insurance as they simply cannot afford medical insurance costs
  • This is a good "first step" towards providing insurance for Idahoans.
MOTION: A motion was made by Senator Burkett to send SB 1383 to the Floor with a Do Pass recommendation. The motion was seconded by Senator Kennedy. A roll call vote was taken.

Senators Kennedy, Burkett, and Ingram voted Aye.

Senators Bailey, Sweet, Darrington, Duncan, and Brandt voted Nay.

Senator Stegner was absent and excused.

The motion failed with a vote of 5 Ayes, 3 Nays, and 1 absent.

SB 1289 This bill, SB1289, relating to the Idaho Dental Practice Act to provide a volunteer's licenses to specify qualifications, was presented by Executive Director of the Idaho Board of Dentistry Mike Sheeley.

The purpose of this proposed legislation is to amend the Idaho Dental Practice Act (Chapter 9, Title 54, Idaho code) by the addition of a new Section 54-935 that would provide for a retired dentist who satisfied the applicable licensure qualifications to be issued a "volunteer's license." A volunteer's license would authorize (and limit) the holder to provide dental services on a volunteer basis (no expectation/receipt of remuneration above the amount of actual expenses incurred) while practicing under the auspices of specifically approved extended access oral health care programs.

A holder of a volunteer's license could not practice outside the permissible scope of the license and could not convert the license to another status (i.e., active, inactive, provisional or special status). A licensee practicing within the permissible scope of a volunteer's license would be entitled to immunity from civil liability so long as not practicing negligently. The purpose of the proposed legislation is to increase access to dental care among underserved members of the public.

The proposed statute provides that there will be no fees imposed in connection with the volunteer dentist's license. As such, there will be no fiscal impact on licensees.

MOTION: A motion was made by Senator Ingram to send SB1289 to the Floor with a Do Pass recommendation. The motion was seconded by Senator Sweet, and the motion was carried by a voice vote.
ADJOURNED: Chairman Brandt announce that SB 1292 will be heard on Thursday, March 4, 2004. The committee adjourned at 10:04 a.m. to convene on the Senate Floor.




DATE: Thursday, March 4, 2004
TIME: 8:00 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Acting Vice Chairman Duncan, Senators Darrington, Ingram, Stegner, Sweet, Bailey, and Kennedy
MEMBERS ABSENT/

EXCUSED:

Vice Chairman Compton and Senator Burkett
GUESTS: See the attached sign-in sheets
SB 1292 This bill, SB1292, relating to the Board of Dentistry, to provide that a dental assistant may work under the direct, indirect or general supervision of a dentist, was presented by Mike Sheeley.

The purpose of this proposed legislation is to amend the Idaho Dental Practice Act (Chapter 9, Title 54, Idaho Code, by the deletion of the restriction in the existing definition of "dental assistant" found at Idaho Code 54-903(3) which only authorized dental assistants to practice under the direct supervision of a dentist and to include the term "dental assistant" in the definitions of the terms "general supervision" and "indirect supervision" presently found at Idaho Code 54-903(8) and (9).

At present, the Dental Practice Act only authorizes a dental assistant to practice under the "direct supervision" of a dentist. Direct supervision requires that the dentist be personally present in the dental practice and that the dentist reviews the treatment provided by the dental assistant before the patient leaves the practice. Indirect supervision and general supervision require less stringent levels of supervision of an auxiliary's work by the dentist.

The Dental Practice Act currently authorizes a dental hygienist to perform various permissible functions under the general, indirect and direct supervision of a dentist.

The Board of Dentistry has determined that at some point in the near future it will be warranted and necessary to allow a dental assistant to perform some permissible functions under either general or indirect levels of supervision. The proposed revision will provide the necessary statutory authority for the Board of Dentistry to promulgate administrative rules authorizing dental assistants to perform permissible functions under varying levels of supervision.

There is no fiscal impact on either dental assistants or the Board of Dentistry by reason of this proposed statutory amendment.

Mr. Sheeley emphasized that simply changing these definitions now causes no immediate change to occur to dental assistants. Everything that they have been allow to do remains the same.

Jean Boyles, from Boise, retired and representing herself, briefly testified and informed the committee that she is against the bill before you. I am concerned that the people who have an interest in this legislation have contributed $3,800 to the 2002-2003 campaigns of members of this committee. You are good people caught in a bad system. Thank you for your time and I am asking that you not be influenced by money that may be on either side of this legislative decision.

She reported, a Boise State University poll found that 64 percent of Idahoans believe that campaign money influences legislative decisions. She stated she is against all legislation, but does not want to shut-down the government. She wants to eliminate money contributions made to elected officials, and presented a list of donations made to the committee members.

She does opposed SB1292, but admitted it will have no effect to her standard of care by her dentist.

Jeanette Bullock, a dental hygienist representing the Idaho Dental Hygienist Association, testified to oppose SB1292. She read a letter, dated February 21, 2004, from Luann Spain to Senator Brandt. A copy of this letter was given to each committee member. Ms. Bullock read:

My name is Luann Spain and I have been a dental assistant for almost 30 years. I have completed education in expanded functions for dental assistants and I teach "Fundamentals of Dental Assisting" and "Expanded Functions Dental Assisting" at the Idaho State University School of Applied Technology. I am writing in regards to an upcoming bill related to expanding the level of supervision for dental assistants in Idaho (Bill #S1292).

I am concerned about having dental assistants working under general supervision when no dentist is present in the office. Even with my years of experience, I would not feel comfortable providing patient care without the dentist being present in the office. Dental assistants in Idaho are not required by law to be certified and/or monitored by the Idaho State Board of Dentistry, and are not required to have any emergency training. I have CPR certification, but if an emergency should occur in the dental office, many dental assistants would not feel comfortable or qualified to handle the situation. I also find it interesting that none of the dental assisting educators in the state were informed of this proposed rule change.

I support having formalized education, certification and/or registration and monitoring of dental assistants by the Idaho State Board of Dentistry. I also support having recognition of dental assistants who have completed comprehensive educational courses in basic fundamentals and expanded functions. I think that dental assistants who have completed this additional level of training and education should be recognized for their accomplishments and then be held accountable for their actions. Until this happens, dental assistants should remain under the direct supervision of a licensed professional.

By voting NO to the bill, you will be serving the citizens of Idaho well. From a dental assisting standpoint, I will be assured that safety will be your number one priority. Also, perhaps by voting no, discussion could begin between dental assistants, all licensed dental professionals and the Idaho State Board of Dentistry regarding the necessity of formalized education, certification and monitoring of dental assistants.

Thank you for your time and attention to this matter. If you vote in support of bill S1292, you may be jeopardizing the safety of the citizens of Idaho. I encourage you to vote NO to this bill S1292.

Kelly Reich, a member of the state Board of Dentistry and also a dental hygienist, testified to support SB1292. She explained, I am a member of the Idaho State Board of Dentistry and one of the two dental hygiene members on the board. I am also a long-standing member of the American Dental Hygiene Association and the Idaho Dental Hygiene Association.

I come before you today as a representative of the Board of Dentistry, and to speak in support of SB1292. As Mr. Sheeley has previously stated, this bill will not impact or change the current level of supervision of dental assistants. Currently, dental assistants cannot perform any functions in the dental office without the dentist being present in the office. This definition of direct supervision is outlined in the information that you were given by Mr. Sheeley defining SB1292.

As a member on the Board of Dentistry, one of my duties is to assure the health, safety and welfare of the citizens in Idaho by licensure and regulation of dentists and dental hygienists. The Board feels strongly that education and training is necessary when performing specific dental procedures especially for dental assistants. Dental assistants can become certified dental assistants by attending an accredited dental assisting program and successfully passing a national examination. In Idaho, dental assistants do not have to be certified but in order to perform certain duties they must successfully complete specific Board approved Expanded Functions courses.

The Expanded function courses are a method by which the dental assistant can receive the didactic and clinical experience to perform specific duties and the Board of Dentistry can assure the safety of the public. The Board of Dentistry understands the importance of the supervisory role of the dentist and the necessity of that supervision.

I am assuming that each one of you has had some type of dental treatment by a dentist and dental hygienist. The dental assistant is an adjunct member of the dental team who works in conjunction with the dentist and dental hygienist. In this role, some of the duties that a dental assistant can perform are: taking and developing x-rays, taking impressions of the teeth, charting and recording restorations in the mouth, and expanded functions such as the placement of sealants on children's teeth, fabricating and cementing temporary crowns, polishing of the teeth after the completion of a dental cleaning by a dentist or dental hygienist, and monitoring nitrous oxide.

Passage of SB1292 will allow the Board of Dentistry to further define, by rule, duties which can safely be performed by dental assistants in a dental office setting under general supervision. As you are aware, any rule changes will again be subject to public input and the legislative process. Contrary to the opposing testimony you have heard, I feel that this bill is a non-threatening, logical approach by the State Board of Dentistry, and provides an initial step for future legislation. I believe this bill deserves your support.

Brad Hoaglun, a lobbyist for the Idaho Dental Hygienist Association, testified to oppose SB1292, as written. He believes this legislation puts the cart before the horse.

He presented information from Jennifer Andrews-Kelly, president of the Idaho Dental Hygienists' Association. The information related to the 2002 survey of the Idaho Dental Hygienists' Association (IDHA). She wrote:

As requested, I am providing copies of the 2002 survey IDHA conducted. I think you will find the results interesting and I have highlighted some of the most important points. Items highlighted in pink relate to expanding dental hygiene practice and access to care. Items highlighted in yellow refer to dental assisting issues.

The survey indicates that 91 percent of dental hygienists are in favor of expanding dental hygiene practice. Dental hygienists are overwhelmingly in favor of unsupervised dental hygiene practice in all settings, including alternative practice settings.

I would also like to point out that a statistic from the survey was inaccurately quoted during the committee hearing on February 25, 2004. A member of the Idaho State Board of Dentistry (ISBOD) said that 94 percent of the respondents supported additional education for practice in alternative settings under general supervision. However, the survey states, "Dental hygiene respondents reported that having experience in supervised settings before providing care unsupervised was necessary.

In addition, the survey indicates that a substantial amount of illegal practice by dental assistants occurs. This indicates that the practice of dental assisting needs to be monitored by the ISBOD. The Idaho Dental Hygienists' Association (IDHA) believes that dental assistants should be certified by completing formalized education. Certification should be renewed annually with continuing education requirements and training in medical emergencies. The safety of the public will be ensured when mandatory dental assisting standards are part of dental practice act, and dental assistants will no longer be trained "off the street" to provide care.

Please let me know if I can provide any additional information or answer any questions that you may have. (See Attachment #1).

Mr. Hoaglun requested the committee to hold SB1292 in committee. This would allow the Board of Dentistry, the Idaho Dental Association, and the Idaho Dental Hygienists' Association to meet and come back next year, 2005, with new legislation.

Jerry Davis, executive director of the Idaho Dental Association, testified to support SB1292. He explained this legislation can enhance the dental practice and provide more efficience in this field. Regardless, anything that goes bad in a dentist's office, the dentist is ultimately responsible and liable.
Elizabeth Criner, a lobbyist for the Idaho Primary Care Association, testified to support SB1292. She explained this legislation is a step forward and more cost effective.
Kathy Barbour, a representative of Lucrary Dental Clinic, a non-profit dental clinic, testified to support SB1292. She requested the committee to pass SB1292.
Written comments were received from Jan Simpson to oppose SB1292. She wrote: I am a registered dental hygienist and licensed in Idaho. I am also a registered voter from District 28 (Bingham County). I am writing you in opposition to bill#S1292. This bill would change the practice act for dental assistants. It would allow them to work under general supervision, which means a dentist should not have to be present in the office.

My concern is that dental assistants in Idaho are not required to have formalized education or certification. They can be trained on the job, and many of them are. They are not held accountable or liable for their actions by any agency and they are not required to know CPR. I am concerned for the safety of Idahoans that may be treated by these persons without the proper supervision. Dental assistants need to be directly supervised by a licensed dental professional.

Please vote no to bill #S1292 (granting general supervision to dental assistants) to ensure the safety of the citizens of Idaho.

Written comments were received from Shari Williams of Coeur d'Alene, who wrote: I am e-mailing to voice my opposition to SB1292, proposing to change the supervision requirements. I am writing to you as a former dental assistant, a current dental hygienist and as a dental hygiene educator and member of IDHA.

In my opinion, lessening the supervision requirements for dental assistants performing tasks on the general public is frightening. Although there are some duties that many dental assistants can do very well with or without the dentist being there, there are hundreds of dental assistants who lack even the minimal certification to perform these services.

If dental assistants are to be allowed indirect and general supervision then they should be licensed by the State of Idaho to do so. This is the standard for dental hygienists and dentists. Currently, a certificate of completion is the only verification dental assistants need to perform such potentially damaging (to the patients) services as polishing teeth and fillings. Many assistants don't even have that. They are trained in the office by their employer to perform the rote memory tasks without knowing (in many cases) the potential damage to the patient's oral health. Many dental assistants, at the direction of their employer's perform duties far beyond the scope of certification.

If this bill passes, the public's oral and overall health care will suffer. If the dental assistants are to have general supervision, they need a standard of formal education and licensure just as do the dental hygienists and dentists in our great state.

Written comments were received from Kristin Calley, a licensed dental hygienist who was an on-the-job-trained dental assistant for nine years before entering the dental hygiene profession, to oppose SB1292. She wrote:

I am concerned about the proposed statute change presented by the Idaho State Board of Dentistry that would allow dental assistants to work under general supervision when a dentist is not present in the office. Dental assistants in Idaho are not required by law to be certified and are not monitored by the Idaho State Board of Dentistry. Unfortunately, when I was a dental assistant, I thought I was very knowledgeable about my assisting abilities and providing patient care. However, it wasn't until I entered dental hygiene school and received a quality education that I realized as an on-the-job-trained dental assistant, I didn't know what I didn't know. That realization made me aware of how important it is for any person who assists a dentist or provides care to a patient must be educated and have accountability.

Dental assistants must work under direct supervision of a dentist or dental hygienist because they are on-the-job-trained, and do not have an educational background to understand basic dental theory, treatment risks or outcomes, medical emergencies, or infection control. As a matter of fact, any person could walk into a dental office and begin working as a dental assistant. How safe is that for the citizens of Idaho? Dental assistants are not required to complete any formalized education in Idaho.

In Idaho, dental assistants are not required to have cardiopulmonary certification (CPR), so if they were working when the dentist was not in the office, what would happen if there was a medical emergency with a patient? Dental assistants are not required to complete any continuing education courses on an annual basis; therefore, staying up to date with current theory is a problem. Many consumers who I have spoken with are not aware that dental assistants are on-the-job-trained. They assume that everyone who works in a dental office has completed a certain amount of education. They become upset knowing that dental assistants might be completing services that are billed out to the patient. Patients are only willing to pay for services that are provided by an academically educated and licensed health care provider.

I question why the Idaho State Board of Dentistry is even trying to change the level of supervision for dental assistants. They are no submitted rules that accompany this proposed change, so knowing how the dentists are planning to utilize dental assistants under general supervision is of great concern. If the Idaho State Board of Dentistry indicates they are planning to have certification and monitoring for dental assistants in the future, I day do not put the cart before the horse. Implement the monitoring and certification process first, then revisit changing the level of supervision if the safety concerns can be addressed.

The ultimate role and responsibility of the Idaho State Board of Dentistry is to assure the safety and welfare of the citizens of Idaho. Allowing non-licensed and non-educated personnel to work with patients when the dentist professional is not in the office is a violation of this role and mission.

By voting NO to the bill, you will be serving the citizens of Idaho well. From a licensed oral health care provider standpoint, I will be assured that safety will be your number one priority. Thanks you for your time and attention to this matter. If you vote in support of bill S1292, you may be jeopardizing the safety of the citizens of Idaho. I encourage you to vote NO to bill #S1292.

Other written comments for opposition to the proposed changes to supervision requirement for dental assistants were received from Jennifer Andrews-Kelly. She wrote:

I am a licensed dental hygienist and president of the Idaho Dental Hygienists' Association (IDHA). IDHA is a professional organization comprised of dental hygienists with a vision of representing the highest standards of practice, to maintain the integrity of the dental professions.

IDHA appreciated the efforts of the Idaho State Board of Dentistry (ISBOD) to update the practice act. However, IDHA does not support Senate Bill 1292 suggesting a reduction in the supervision requirements for dental assistants in Idaho. IDHA believes this bill will jeopardize the safety of the public and do nothing to increase access to oral health care.

  • Dental assistants must work under direct supervision because they are trained on the job and are not required by the ISBOD to complete formalized academic education, training, subsequent certification with monitoring or take continuing education courses.


  • Dental assistants are not required by the ISBOD to hold a CPR certification or receive any other emergency medical training.


  • In fact, anyone here today could be employed as a dental assistant. Do you know how to safely provide dental care? Would you know how to care for a patient who is having a medical emergency?


  • There is no penalty or accountability for dental assistants who practice outside the legal parameters of practice or compromise patient safety. Dental assistants are not required to complete any jurisprudence certification to work, so they are not held accountable to know the laws and administrative rules of the ISBOD.


  • In a statewide survey conducted by IDHA in 2002, respondents showed that dental assistants are providing services beyond the legal scope of practice. (See Attachment #1)


  • Forty-eight states either have direct or indirect supervision for dental assistants not general supervision. Furthermore, the American Dental Association supports direct supervision of dental assistants.


  • If consumers understood that dental assistants were providing services when they are not formally educated, registered or certified with monitoring, they would be concerned. Therefore, dental assistants need to be directly supervised by licensed dental professionals to protect the public.


  • Efforts to increase access to oral health care should not reduce the quality of care or put the public in harms way. The citizens of Idaho deserve to have oral health care provided by persons with the appropriate education, knowledge and certification to assure safe and quality oriented care.


  • On behalf of the Idaho Dental Hygienists' Association, I urge you to vote NO on Senate Bill 1292.
The committee conducted an in-depth review of SB1292 and discussed areas such as education and requirements should be fully defined, scope of services defined, certification, why the needed changes proposed in SB1292.
MOTION: A motion was made by Senator Stegner to send SB1292 to the Floor with a Do Pass recommendation. The motion was seconded by Senator Sweet.
SUBSTITUTE MOTION: A substitute motion was made by Senator Kennedy to hold SB1292 in committee.

The substitute motion died for lack of a second.

ORIGINAL MOTION: The original motion made by Senator Stegner and seconded by Senator Sweet was carried by a voice vote. Senator Kennedy was recorded as voting Nay.
HB 627 This bill, HB 627, relating to Welfare to strike a sunset clause to maintain authorization to the director of the Department of Health and Welfare to provide welfare assistance to drug dependent persons upon certain circumstances, was presented by Representative Donna Boe, District 30.

The purpose of this legislation is to reinstate legislation which was scheduled to sunset June 30, 2003. The legislation makes it possible to provide Food Stamps and Temporary Cash Assistance to persons convicted of a drug related felony occurring after August 22, 1996 (date of approval of the Federal Welfare Reform Act, Personal Responsibility and Work Opportunity Reconciliation Act), provided they are in compliance with probation and parole.

Representative Boe explained this program is for women with children. Of those, 75 percent have substance abuse problems, and need help to transition from incarceration into communities. She requested the committee to give HB 627 a do pass recommendation.

There would be no additional impact to the General Fund. When this legislation expired, Health and Welfare made a determination to continue services until the legislation could be re-instated. Federal funds pay for 100 percent of food stamps and 70 percent of TAFI cash benefits and supportive services. Idaho's match for this program is an average of $8500 total per year. The Department of Health and Welfare reports that approximately ninety households are served in the program and projects that this number will remain constant.

Chairman Brandt requested Representative Boe to obtain the number and percentage of these women who return to prison. Committee members expressed concerns about giving substance abusers money. Representative Boe explained this is only $309 per month on a Debit Card and the Department of Health and Welfare tracks the cards.

MOTION: A motion was made by Senator Duncan to send HB627 to the Floor with a Do Pass recommendation. The motion was seconded by Senator Darrington, and the motion was carried by a voice vote.
Chairman Brandt announced that HB693 and HB697 would be heard on Friday, March 5, 2004 at 8:00 a.m
ADJOURNED: The meeting adjourned at 9:33 a.m.




DATE: Friday, March 5, 2004
TIME: 8:00 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Senators Darrington, Ingram, Stegner, Sweet, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

Vice Chairman Compton (Acting Senator Duncan did not attend the meeting)
GUESTS: See the attached sign-in sheets
HB 693 This legislation, HB693, relating to anatomical gifts to include a statement that the organs, tissues or parts may or may not be retrieved, was presented by Representative Margaret Henbest, District 16.

This legislation requires that the Idaho document of gift for making an anatomical gift by a living donor include a statement that the gift may or may not be retrieved by a for profit entity. Information about for profit use must also be provided to persons who may make this gift on behalf of a family member who has not provided a document of gift.

There is no fiscal impact on the general fund.

Representative Henbest proposed two (2) amendments to HB693, and requested HB693 be sent to the amending order. Her proposed amendments are as shown:

On Page 1 of the bill, line 23, after "That" delete "the organs."

On Page 2 of the bill, line 21, after "that" delete "organs."

Representative Henbest distributed two forms for review. They are: "Idaho Donor Document of Gift" and a copy of Utah's "Anatomical Gift Form."

Written comments, dated March 4, 2004, from Tracy Schmidt, executive director of the Intermountain Donor Services, wrote to Representative Henbest to support HB693. Her written comments are:

Thank you for the opportunity to visit with you today regarding HB693. Based on making the few changes that we discussed, the Organ Recovery Agencies that serve Idaho are supportive of moving this bill forward.

As the nonprofit organ recovery agencies serving Idaho, it is critical that any language in this bill does not create a misunderstanding to the public that organ donation is a part of any for-profit system.

MOTION: A motion was made by Senator Ingram to send HB693 to the 14th Order for amendment. The motion was seconded by Senator Darrington, and the motion was carried by a voice vote. Senator Burkett will be the sponsor.
HB 697 This bill, HB697, relating to Rules of the Board of Health and Welfare, to provide for the adoption of rules and standards concerning criteria for the use of Air Medical Services by certified EMS personnel at emergency scenes, was presented by Representative Margaret Henbest, District 16.

This legislation will amend Section 56-1017, Idaho Code, to provide for the adoption of rules and standards concerning criteria for the use of air medical services by certified EMS personnel at emergency scenes.

There is no fiscal impact on the general fund.

She reported that HB697, when heard in the House, had no opposition testimony.

Dia Gainor, bureau chief of the state Emergency Medical Services Bureau in the Division of Health testified and supports HB697.

She reported, the proposed language would add a new dimension of rulemaking authority to the current responsibilities of the EMS Bureau to promulgate rules related to patients at emergency scenes who may need transportation by helicopter.

Severely injured trauma victims and patients experiencing extreme medical emergencies in Idaho need to get to definitive care at a hospital. Essential factors that benefit these patients are how quickly they can be transported and the clinical sophistication of medical care while enroute.

The criteria for use of a helicopter for a patient is not part of the curriculum in initial training programs for EMTs, and is unaddressed in the majority of EMS agencies standing orders from their medical director.

Such protocols would identify the common expectations for certain scenarios or clinical conditions where use of a flight service should be considered.

Protocols do not override EMS agencies' autonomous decision-making. It is essential that critical patients are treated similarly.

Within the last year and a half, the National Association of EMS Physicians, the Air Medical Physicians Association, and the Association of Air Medical Services have all endorsed the need for criteria to guide local EMS providers' decision-making about flying critical patients.

The EMS Bureau is committed to negotiated rule making to assure that the most extensive involvement of affected agencies occurs.

Roy Eiguren, a representative for Saint Alphonsus Regional Medical Center testified and reported Saint Alphonsus strongly supports HB 697.
MOTION: A motion was made by Senator Stegner to send HB697 to the Floor with a Do Pass recommendation. The motion was seconded by Senator Darrington, and the motion was carried by a voice vote. Senator Burkett will sponsor HB697.
HCR 40 This legislation, HCR 40, stating findings of the Legislature and encouraging Idaho citizens to reduce, reuse and recycle household hazardous waste and electronic waste, was presented by Senator Bert Marley, District 29.

According to the EPA (Environmental Protection Agency) 3.2 million tons of electronic waste in up in U.S. landfills each and every year. About 250 million computers will become obsolete within the next five (5) years. By the year 2006, about 165,000 computers and televisions will become obsolete every day in the United States. We are facing a problem with these things that contain toxic metals such as mercury, lead, and other toxic chemicals, threatening our landfills and reaching into our aquifers.

It is estimated that 1.4 billion pounds of lead are in landfills, and electronic waste makes up approximately 40 percent of that amount. Along with that, the growth of electronic waste is far outstripping the normal mainstream processing.

The purpose of this resolution is to articulate the support of the Legislature of the State of Idaho to encourage all citizens of Idaho to reduce, reuse and recycle household hazardous and electronic waste. This is a first-step to recommend that we pay more attention to deciding how we are going to deal with this problem in the future.

He requested the committee to support HCR40. There is no impact on the general fund.

Mark Miller, Environmental Health and Safety Specialist at Hewlett Packard (HP) and reported that HP supports HCR40.
Roger Seiber, a lobbyist for Waste Management testified to support HCR40. He reports recycling sites and disposal of this type of waste requires us to work together to seek ways to handle the problem.
Dean Ehlert, a solid waste program coordinator for the Department of Environmental Quality, and we think this is a good step helping make the awareness of these issues. The Department continues getting calls about household hazardous waste and electronic waste on what is the best way to manage it. The Department of Environmental Quality supports HCR40. It is a good opportunity to help bring up the awareness and discussions going how to handle this stuff properly.
MOTION: A motion was made by Senator Bailey to send HCR40 to the Floor with a Do Pass recommendation. The motion was seconded by Senator Stegner, and the motion was carried by a voice vote.
Written comments were received from Justin Hayes, program director, Idaho Conservation League. His comments included the following:

RE: Support for HCR #40 - encouraging Idahoans to recycle household hazardous waste

Due to a scheduling conflict I will not be able to attend your Friday, March 5, hearing on HCR40. I am submitting this letter as written testimony on this issue. Thank you for your consideration.

The Idaho Conservation League enthusiastically supports House Concurrent Resolution #40; stating the findings of the Legislature and encouraging Idaho citizens to reduce, reuse and recycle household hazardous and electronic waste.

The inappropriate disposal of hazardous household substances and electronic, or e-waste, poises a significant and growing threat to Idaho's drinking water. Each day untold numbers of well-meaning Idahoans dispose of hazardous items in a manner that will come back to haunt us all. Why do they do it? Why do they put hazardous chemicals out with the trash? Why do they send the toxic inner workings of spent computers to the local landfill? Why? Because they do not know any better and they don't know what else to do with this stuff.

The average person simply has no idea that so many of the items that we use on a daily basis­in our homes, in our places of work or at play­contain toxic or hazardous substances.

Did you know that "picture tubes" used in televisions and computer monitors typically contain about 4 pounds of lead? Many of these also contain panel glass that contains high levels of barium, a toxic substance that can affect breathing, blood pressure and internal organ function. Mercury, cadmium, zinc, chromium and many, many other dangerous compounds are in electronic components. What happens to all this stuff when it gets buried or burned? Eventually, it gets into our water.

By 1998, twenty million personal computers in the U.S. became obsolete. The vast majority of these were simply tossed into landfills, where, over time they will release their toxic contents into seeping water, contributing to groundwater and surface water contamination.

Each year, amazing leaps in technology makes more and more computers and other types of electronic equipment obsolete. The e-waste stream is quickly turning into an e-waste river. Collectively we need to address this issue before the e-waste river turns into an e-waste tidal wave.

How can the Legislature help? For starters, the Legislature can begin the public discussion of this pressing matter here in Idaho. Your committee has taken the first step, this hearing, a hearing on a non-binding Resolution that merely presents the findings of the Legislature and encourages people to recycle is the first step.

I urge you to take the next step and send this Resolution to the full Senate with a "do pass" recommendation.

Truly addressing this issue will take a long-term effort to educate the public about the impacts that improper disposal can have and about the options that they have to correctly recycle and dispose of these items. These matters are simply not on the public's radar screen. With your help we can start this dialog.

The wise use, and reuse, of our precious natural resources is a win-win for all of us. Whether it is the recycling and reuse of the compounds or the prevention of a contaminated aquifer, we all benefit.

Thank you very much for your consideration of this important matter.

HB 658 and HJM 17 HB658, relating to Medicaid eligibility, amending Title 56, Idaho Code, by the addition of a new Chapter 12, Title 56, Idaho Code, and HJM 17 relating to the Senate and House of Representatives of the United States in Congress, was presented by Representative Janice McGeachin.

The purpose of this legislation is to establish the Idaho Long-term Care Partnership Program. It is an effort to control the spiraling costs of long-term care on the Medicaid budget, and to provide an incentive for people to purchase their own long-term care insurance. This legislation would become effective immediately upon repeal of restrictions to asset protection contained in the 1993 Omnibus Budget Reconciliation Act. The Department of Health and Welfare shall count insurance benefits paid under a private policy toward asset disregard to the extent the payments are for covered services under the long-term care partnership program.

This program will be administered by the Idaho Department of Health and Welfare and the Idaho Department of Insurance. The Department of Health and Welfare has indicated that various start up costs cannot be accurately estimated at this time. However, as an indication of a potential start up costs, the four states that successfully implemented partnership programs spent an average of $2.7 million per state in grant funds to develop their programs. The Department of Insurance currently provides marketing and counseling services for long-term care through a grant it receives from the federal government. Based on estimations, it would cost less that $100,000 per year and require 1.5 additional FTE (full time employees) to administer this program through the self-funded Department of Insurance. The Governor's Office has estimated that for each long-term care policy, there is an associated savings of approximately $5,000 to the Medicaid program, and $1,600 to the Medicare program. With 11,000 active policies in Idaho, that translates to more than $70 million cost avoidance to our publicly financed health care programs.



The purpose of the House Joint Memorial 17 is to encourage the U.S. Congress to amend Section 1917(b)(1)(C) of the Social Security Act by deleting May 14, 1993 as the deadline for approval by states of long-term care partnership plans. This will allow all states the right to participate in long-term, care partnership plans. There is no fiscal impact to the general fund for HJM17.

Representative McGeachin distributed a 9-page handout relating to the Medical Assistance Program by type of service, the growing expense of long-term care, the intent of the Medicaid program, the long-term care partnership solution, what is a partnership program, important points about partnerships, current long-term care partnership programs for New York, California, Connecticut and Indiana, why only four states, and states that want to move forward (passed enabling legislation). (See Attachment #1)

Kathleen Allyn, deputy administrator of the Division of Medicaid, explained she wanted to be more helpful in the fiscal impact costs. It is difficult at this time to estimate the costs to be involved with this legislation.

This legislation, HB658, approach is called a dollar-for-dollar approach. This model allows consumers to purchase a valid long-term care insurance coverage depending on the amount of assets they are wanting to protect.

Long-term insurance programs began in the early 1990s so estimates are several years (10 to 20 years) away to determine any savings. She does not deal with eligibility, but is aware the homestead is not counted. She also explained the average long-term stay is about two (2) years. She is to present SB1290 next week to the committee, and that legislation deals with estate recovery by Medicaid.

Idaho would seek any grants possible.

Kelly Buckland, executive director of the Idaho State Independent Living Council (SILC), explained eligibility exceptions such as a home, a car, and $2,000 are exempted until death.

This legislation allows disabled people to keep their home. As a disabled person, he cannot purchase long-term health care insurance - regardless of the cost, but an employer could purchase a group long-term insurance plan, and he could then participate in the program. He strongly supports HB658.

As executive director of the Idaho State Independent Living Council Mr. Buckland had sent Representative McGeachin a letter, dated February 23, 2004. His written comments were presented:

The State Independent Living Council aspires to promote a philosophy of independent living, including a philosophy of consumer control, peer-support, self-help, self-determination, equal access, and individual and system advocacy, in order to maximize opportunities for individuals with disabilities, and the integration and full inclusion of individuals with disabilities into the mainstream of society.

I am writing in support of HB658, long-term care insurance, and HJM 17, long-term care partnerships. Both bills are innovated approaches to help solve long-term issues.

Michael Bouton, a certified long-term care specialist who provided personal care to his father, testified to support HB658.
April Howard, owner and agent of Howard Insurance Agency and Agency of Choice, a past state president and member of the Idaho Association of Insurance and Financial Advisors, past local president and member of the Boise Association of Insurance and Financial Advisors, and a member of the Idaho Association of Health Underwriters and Treasure Valley Health Underwriters, testified to support HB658. She has been in the insurance business since November 1984 in Boise.

She explained, this is the first great step in protecting our great state of Idaho from bankruptcy due to the over use of our Medicaid (Welfare) system by citizens who could easily afford to purchase long-term care protection. We need to give them an incentive of 100 percent of deductibility of their long-term care premium, and by using a State Partnership system with long-term care I can see that this will encourage them to protect their estate, stay in control, and stay off of Medicaid.

Other advantages are:

  • Savings for the State by not paying for every citizen's long-term care.
  • Leaving Medicaid dollars for the truly poor citizens.
  • Makes families more responsible.
  • Discourage attorney Medicaid trust plans.


A partnership plan that is successful, is the Indiana Partnership Program. This is a great step to protect the state of Idaho for when the baby-boomers enter the age of needing long-term care, and could easily bankrupt our state. Now is the time to plan for the future, and not wait until the damage is done.

MOTION: A motion was made by Senator Bailey to send HB658 and HJM17 to the Floor with a Do Pass recommendation. The motion was seconded by Senator Ingram, and the motion was carried by a voice vote. Senator Bailey will be the sponsor of HB658 and HJM17.
ADJOURNED: The committee adjourned at 9:25 a.m.




DATE: Monday, March 8, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Senators Darrington, Ingram, Stegner, Sweet, Bailey, Burkett, Kennedy
MEMBERS ABSENT/

EXCUSED:

Vice Chairman Compton and Senator Kennedy
GUESTS: See the attached sign-in sheets
MINUTES: A motion was made by Senator Bailey to accept the committee's minutes for Tuesday, March 4, 2004, as written. The motion was seconded by Senator Darrington, and the motion was carried by a voice vote.
HCR 49 This legislation, HCR49, stating findings of the Legislature concerning oversight processes in assisted living facilities and directing the Department of Health and Welfare to undertake changes necessary to accomplish goals stated, was presented by Michelle Glasgow. She is a representative of the Idaho Assisted Living Association, an association that represents 70 percent of the assisted living residences in Idaho

The purpose of this Resolution is to encourage the development of and propose statute and rule changes that allow an oversight process in assisted living that uses new methodologies, and increased efficiencies to assure that facilities have appropriate and timely surveys,

without dramatic increases to the state general funds.

Present Statute and Rule require that assisted living residence be surveyed by the oversight agency at least once annually. However, some assisted living residences have gone as long as five (5) years without a full survey. Lack of surveys has consequences to both residents and providers. Complaints are up. Providers are concerned that they may or may not be in compliance, and they have no benchmark. Many insurance companies are refusing to issue liability insurance, because they have no outside assurances that an assisted living residence is operating within the bounds of compliance.

The Idaho Assisted Living Association has been concerned with this growing trend, and has recommended to the Department of Health and Welfare that they look at ways to adapt the survey process, sometimes through statute and rule change, to build efficiencies into the system that would allow the department to survey assisted living residences in a timely manner. The Division of Medicaid has recently agreed to work together with providers and advocates to develop an efficient oversight process. This new survey process will allow for personal centered care. Care, driven primarily by the resident rather than prescriptive rule in order to adjust to the unique care setting of assisted living, be built on objective outcome-based standards, rather than subjective interpretation of statute and rule.

The Division of Medicaid has committed to work with us in starting this process. However, this kind of dramatic change will take a strong commitment, and just plain hard-work to continue from all the parties involved. Many dramatic differences in attitude need to be overcome. A commitment from the Legislature, backing this process, provides the impetus to take this process to the end. We ask for this resolution, HCR49, because we want this process to succeed.

Randy May from the Division of Medicaid reported about the Residential or Assisted Living Facilities survey and licensure restructuring project (RALF), a restructuring task force. He explained, the Department of Health and Welfare has put together a task force and they have held four meetings. The team is working well together and the Department has spent $25,000 in start-up costs.

There are 265 facilities in Idaho, and Medicaid would need additional staff in order to inspect those facilities as often as needed. The Department is committed to this project for the long-haul. The Department will work through this process, and bring the results to the Senate Health and Welfare Committee during one of the summer interim meetings.

The task force has established a web site and it will be updated weekly. The web site is located at:

http://www2.state.id.us/dhw/FacilStandards/RALF_restructure/

meetings.htm.

Mr. May also outlined what the task force is doing, its objectives, and the participant stakeholders.

OBJECTIVES:

  • Ensure the right health outcomes for the client in the right setting.
  • Ensure sound processes and procedures are in place to deliver the right health outcomes for clients residing in RALFs. Those right health outcomes should be the product of a designed process, not just left to chance.
  • Ensure client choice and person centered planning are key components of the RALF program.
  • Develop a shared vision among the Department, providers, professional associations, the Ombudsman, and stakeholders of the proper role, scope and purpose of the RALF, and of the survey and licensure process.
  • Develop a more streamlined, commonsense process that supports sound business practices.
  • p

  • Partner with the industry to develop tools to help drive the right health outcomes in the right setting.
  • Get the right stakeholders to the table to redesign the processes to ensure:

o the right health outcomes happen and. . . .

o there is a commonsense business approach and. . . .

o there is a partnership rather than an adversarial relationship.

PARTICIPANT STAKEHOLDERS::

  • Department Representative (Project Manager) - Virginia Loper
  • Department Representative (a RALF survey expert) - Debby Ransom
  • Department Representative (a policy expert) - Chris Baylis
  • IDALA Representative (Developmental Disabilities/Mental illness expert) - Sharon Ashcraft
  • IDALA Representative (Small facility expert) - Jerry Shriner
  • IDALA Representative (Large facility expert) - Linda Simon
  • IDALA Representative (At-large expert) - Jerry Mitchell
  • IHCA Representative (At-large expert) - Robert Vande Merwe
  • Non-affiliated industry representative (At-large expert) - Debra Corbin
  • An ombudsman (or Area Council on Aging representatives) - Cathy Hart
  • COAD Representative (Consumer Advocacy expert) - Corrina Wolfe
  • At-large expert (Alzheimer's/Dementia clients/practicing RN) - Angela Browning


The team meets weekly on Friday mornings, 9:00 a.m. to 12:00 noon, at the Division of Medicaid, located at 3232 Elder Street in Boise.

The Senate Health and Welfare Committee members are very supportive of this project, and appreciated this update. Some members were confused about the need for this legislation, a Concurrent Resolution, when the Department of Health and Welfare could do this without legislation. Mr. May explained that was correct, in fact, the Department of Health and Welfare had started this project prior to the Concurrent Resolution (HCR49) action. He stated the Department will remain committed, for the long-haul, on this project.

Michelle Glasgow yielded to the committee's question - why do we even need this legislation? She explained, the reason this project was put into a Resolution was that the Idaho Assisted Living Association actually had a bill, written in Legislative Services, to move the survey process from the Bureau of Facility Standards to the Bureau of Occupational Licenses. The Association had become frustrated in their efforts to get the Department of Health and Welfare to change the survey process, and make it more efficient. Because the Association was so concerned about the survey process, they decided to propose that the survey process be moved from the Bureau of Facility Standards to the Bureau of Occupational Licenses. During the course of the summer, many persons including legislators, were interested in moving the process to the Bureau of Occupational Licenses. The Idaho Assisted Living Association gained the support of most of its members to move the survey process to the Bureau of Occupational Licenses.

This fall, the Medicaid Division proposed exploring the process of changing the survey process within the Department of Health and Welfare. Many members of the Idaho Assisted Living Association wanted to move the survey to the Bureau of Occupational Licensing, because they had lost faith in the Department of Health and Welfare. The Association believed we needed a Concurrent Resolution to show that the Legislature is behind this process, and not just Health and Welfare, so members would be acceptable to the process of changing the survey within the Department of Health and Welfare.

The Idaho Assisted Living Association has put that trust level into the process. Our providers, and the legislators who were actually interested, needed this reassurance that the process would be taken seriously. The Bureau of Occupational License could sign-off on a real, good-faith, effort that this was going to happen.

Because there was so much information around the state, we still wanted to move the survey process. We have so many providers, statewide, who are really concerned with working with the Department of Health and Welfare, and to increase everyone's trust level with this process, we believed it best to put this issue into legislation.

MOTION: A motion was made by Senator Bailey to send HCR49 to the Floor with a Do Pass recommendation. The motion was seconder by Senator Sweet, and the motion was carried by a voice vote. Senator Stegner is recorded as voting Nay.
HB 696aa This bill, H696 as amended, relating to Medicaid; amending Chapter 2, Title 56, Idaho Code, by the addition of a new Section 56-209m, was presented by Representative Margaret Henbest, District 16.

This bill directs the Department of Health and Welfare to apply for a waiver from the Center for Medicare and Medicaid Services, to conduct a pilot project to determine the effectiveness of priority reimbursement for weight control therapies for Medicaid clients.

She explained that obesity is a growing health care problem which leads to an increase in diabetes, heart disease, and other health problems. Many of these people are becoming a financial burden on our Medicaid system, and we need to develop strategies that are effective to help this very challenging population. The problem needs to be addressed as we face increasing higher health care cost, we need to intervene now.

Preliminary estimates to start up a pilot project that would affect 100 Medicaid persons would cost about $1,500 per client. The pilot would be capped at 100 clients for a period of three (3) years. This would be a new Medicaid program. Idaho's share of the start-up cost would be approximately $45,000. The pilot would not go forward unless funding was available.

Representative Henbest yielded to several questions relating to good current health care programs that the Legislature cannot afford to finance as much as needed, such as the infant and children's programs. Also, will a three-year study prove the costs and successes? Would the project be handled by care managers? Assurance that this pilot project would not provide memberships to an exercise gym. Who will be the gatekeeper, monitoring and reporting procedures? The responsibilities of providing education about obesity, nutrition, foods and diet? If the private diet industry could find a way to bill the state, would they be interested? What would be the impact on the medical insurance industry? Anorexia and drugs, and would diet drugs be involved? Possible safety concerns, i.e., anorexia. The possibility of a sliding fee scale for pregnant women, and trying the pilot for 3-years only, then determine and test the results and successes.

The Division of Medicaid Deputy Administrator Kathleen Allyn explained that obesity is a growing concern nationwide, and if left unattended will continue growing. She was uncertain about what role the Healthy Connection program would play in the initial pilot. She explained there may be grants that would help a state have such a program to conduct a pilot study on obesity. She assured the committee the grant would not pay for a membership at a exercise gym. The obesity pilot would not be a mandatory part of the Medicaid program.
Sharlean Green, who lives in Idaho, but works in Washington, works with the obese population. She is glad to learn Idaho is considering such a program. She supports HB696.
MOTION: A motion was made by Senator Ingram to send HB696 to the Floor with a Do Pass recommendation. The motion was seconded by Senator Stegner.

Discussion: Using the pilot only as a test mode, and killing the pilot if results not successful.

On a roll call vote:

Voting Aye - Senators Burkett, Stegner, Ingram, Darrington, Brandt.

Voting Nay - Senators Bailey and Sweet.

Senator Compton was absent.

The motion was carried by a vote of 5 Ayes, 2 Nays, 1 absent.

Senator Ingram agreed to be the Floor sponsor.

ADJOURNED: The committee adjourned at 9:24 a.m. to convene on the Senate Floor.




DATE: Tuesday, March 9, 2004
TIME: 8:00 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Stegner, Sweet, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

None
GUESTS: See the attached sign-in sheets
MINUTES: A motion was made by Senator Bailey that the committee accept the minutes of Thursday, March 4, 2004, and Wednesday, March 5, 2004, as written. The motion was seconded by Senator Sweet, and the motion was carried by a voice vote.
SB 1290 The Division of Medicaid Deputy Administrator Kathleen Allyn and Corey Cartwright, a deputy attorney for the Department of Health and Welfare, presented SB1290 relating to the recovery of Medical Assistance, and amending Section 56-218, Idaho Code.

The purpose of this legislation is to clarify the state's responsibility in Medicaid estate recovery, and to decrease litigation costs.

Under state and federal law, the state must attempt to recover the cost of Medicaid Services from the estate of a deceased Medicaid client. This includes property essentially given away by Medicaid clients prior to death - but the state's right to recover transferred property is only for a limited period of time - four (4) years.

This bill, S1290, amends existing law to specify when that time period to recover transferred property begins.

The bill results from a court decision that interpreted current law to say the four-year period to reverse a property giveaway begins at the date of the transfer, even when the transfer is concealed from the Department. The Department does not find out about the transfer until more than four years after the fact, at which time the Department is precluded from reversing the transfer.

What this bill says is that the four-year period for recovering the property starts only when the Department discovers or reasonably could have discovered the transfer.

The bill also makes a technical correction to clarify that the Department can file a claim against community property in the estate of a spouse of a Medicaid recipient, even though the spouse predeceases or dies before the Medicaid recipient.

Fiscal Impact - Additional Medicaid recovery is difficult to estimate because details of transfers have been concealed from the state. For purposes of this legislation, additional recovery is estimated at as follows: $100,000 each for SFY2005,SFY2006, SFY2007, SFY2008, and SFY2009.

Ms. Allyn distributed a chart about Medicaid estate recovery. The chart below was derived from a North Carolina Department of Health and Human Services survey. The survey was done in 1997- 1998 by intern Beth Kidder under the direction of Susan Harmuth. The chart lists states, type of estate recovery, assets subject to recovery, use of TEFRA liens, surviving spouse dependent in home, undue hardship criteria, and the amount collected as percent of total 1997 Medicaid expenditures. (See Attachment #1)

NOTES TO CHART- Attachment #1:

1) Type of Estate Recovery

Probate=State restricts recovery to property defined in probate code

expanded=State goes after assets in addition to probate

none=State had no recovery program as of 1997

NR=State did not respond to this portion of the survey.

(2) Assets Subject to Recovery--Assets the States, who have an expanded definition of probate, go after.

l = cash (the $2,000 retainable spendown or burial money not used)

2 = other personal property of recipient that might have avoided probate

3 = property transferred under joint tenancy with rights of survivorship

4 = property in which recipient had a life estate interest (might be a trust)

5 = trust (usually inter vivos)

6 = annuity

7 = all allowed by OBRA 93

8 = other not defined

NR = not reported or no recovery program.

(3) Use of TEFRA Liens

yes = State uses TEFRA liens

no = State does not use TEFRA liens

NR = not reported or no recovery program.

(4) Surviving Spouse Dependent in Home--State's procedure in going after a home when the surviving spouse lives there.

I = State may waive its right to go after the home when the surviving spouse dies

2 = State may defer recovery to death of surviving spouse

3 = State negotiates amount of waiver or recovery

4 = State uses some method other than above

NR = not reported or no recovery program.

(5) Undue Hardship Criteria--Related to (4) above but these are State procedures towards going after all assets when it may cause undue hardship.

I = State may waive recovery

2 = State may defer recovery until death of eligible exempt dependents

3 = State may negotiate amount of recovery

4 = State may use some method other than above

NR = not reported or no recovery program.

In summary, some major points of SB1290 and Section 56-218, Idaho Code, are:

  • This legislation is to clarify the state's responsibility in Medicaid estate recovery and to decrease litigation costs.
  • Under state and federal law, the state must attempt to recover the cost of Medicaid services from the estate of a deceased Medicaid client.
  • This includes property fraudulently transferred by Medicaid clients prior to death - but the state's right to recover the transferred property is only for a limited period of time ­­ four years.
  • This bill amends existing law to specify when that time period to recover transferred property begins.
  • This bill applies only to situations where property is being transferred with the intent of making a person eligible for Medicaid. The bill is also limited only to transfers that take place within 36 months of when someone applies for Medicaid eligibility.
  • The bill results from a court decision that interpreted current law to say the 4-year period to reverse a property giveaway begins at the date of the transfer, even when the transfer is fraudulently concealed from the Department of Health & Welfare.
  • The Department may not find out about a fraudulent transfer until more than 4 years after the fact, at which time the Department is precluded from reversing the transfer.
  • What this bill says is that the 4-year period for recovering the property starts only when the Department discovers or reasonably could have discovered the transfer.
  • This "discovery" standard for starting the 4-year period is commonly applied by the courts in relation to other statutory time limits and serves to place reasonable limits on the time within which the Department can reverse a transfer of property.
  • In addition, the time limits in the probate code for filing claims against an estate still apply.
  • The bill also makes a technical correction to clarify that the Department can file a claim against community property in the estate of a spouse of a Medicaid recipient, even though the spouse predeceases or dies before the Medicaid recipient.
  • At the same time, the Department may not recover against the property until both the Medicaid recipient and the spouse are dead.
Susan Graham, an attorney in Boise, testified in opposition to SB1290. She explained this bill allows unlimited time for Idaho to recover assets, and, if passed, will create confusion.

Ms. Graham objected to Section 56-218(8) which states:

(8) The cause of action to void a transfer without adequate consideration established in this section shall not be deemed to have accrued until the department discovers, or reasonable could have discovered, the facts constituting the transfer without adequate consideration.

Robert Aldridge, an attorney who has practiced law in Idaho for 34 years, and for many years a large part of his practice has been in the area of Medicaid. He supports SB1290. He outlined the process used in developing this proposed legislation. He explained that many professionals (the cottage industry) advise clients to make transfers and wait out the three-year time period, and then go and receive Medicaid.

Medicaid is a "needs-based" poverty program. It is a program where people have essentially spent their dollars to take care of themselves and are now down to the limits established by law where society has said we will take care of you subject to terms and limitations.

The first part of the statute makes it that the state can recover regardless of the order of death, that is fair. This bill makes it clear when to do recovery.

Paragraph (8) is exactly how the existing language is used by the courts in this state anytime there is a fraudulent conveyance done in a manner of set-aside. After death, the state should be paid.

A brief discussion was held about relying on federal law as federal laws always overrides state laws.

Mr. Aldridge explained the system is not simple, it is very complex, but this statute gives the state clear guidance to follow for estate recovery.

MOTION: A motion was made by Senator Sweet to send SB1290 to the Floor with a Do Pass recommendation. The motion was seconded by Senator Burkett, and the motion was carried by a voice vote.
HB 579aa This legislation, HB579 as amended, was presented by James Baugh, executive director of Comprehensive Advocacy (Co-AD) Inc. This bill relates to the protection of the mentally ill. Mr. Baugh distributed a handout explaining the protection and advocacy system, what would the proposed changes do, federal law requirements, and HB579 - access to protection and advocacy staff. (See Attachment #2)

HB579aa would add language to Idaho Code, Title 66 Chapter 3, which would give patients who are subject to involuntary commitment the right to contact and communicate with representatives of the state protection and advocacy (P&A) system. This agency is designated by the governor under federal laws (42 U.S.C. Section 6042, and 42 U.S.C. Section 10801. To receive federal funds for the purpose of protecting the rights of people with disabilities. The P&A system must have authority to communicate with people who reside in treatment facilities, to investigate allegations of abuse, neglect, and other rights violations. This bill clarifies in state law the rights of people who are involuntarily committed to the custody of the state to communicate with representatives of the Idaho P&A.

The bill also clarifies that the person's right to communicate with their attorney includes the right to communicate with their attorney includes the right to communicate with employees of their attorney's firm.

The language is parallel to the language in the Idaho Children's Mental Health Services Act (Idaho Code 16-2425(14).

HB579 was amended on page 2 of the printed bill, in line 36, delete "6042" and insert "15043."

There will be no impact to the general fund.

Kelly Buckland, executive director of the Idaho Assisted Living Association, briefly testified he supports HB579aa.
MOTION: A motion was made by Senator Compton to send HB579aa to the Consent Calendar with a Do Pass recommendation. The motion was seconded by Senator Kennedy, and the motion was carried by a voice vote.
HB659a HB659, as amended, relating to the Idaho Board of Nursing and amending existing law to remove physician supervision requirements applicable to certified nurse midwives, clinical nurse specialists and nurse practitioners, and to require peer review for renewal of license, was presented by Representative Margaret Henbest.

This legislation more clearly clarifies the current relationship between advanced practice professional nurses (APPNs) and physicians. She explained, supervision implies direct contact and oversight of every patient encountered, and that is nighter practical nor possible in rural and remote practices. What is practical and possible is collaboration through the appropriate members of the health care community in order to deliver good patient care.

Representative Henbest discussed sidebars and Idaho Statutes, Title 54 Chapter 14. She distributed a copy of Title 54, Chapter 14, Nurses. (See Attachment #3)

Debra Casdorf, MFP, a nurse practitioner with 35 years of experience and 10 years of college. She has her own business in Emmett, Idaho, and has more than 6,000 patients. She carries her own liability insurance and peer reviews. Removing the word "supervision" will be cost effective and reduce the amount of required paperwork. She testified to support H659.
Patricia Berglund, a physician assistant who works with supervising physicians, and is mutual on HB659.
Patrice Burgess, MD, briefly testified in opposition to HB659.
Dave Foss, he is an advance practical nurse in Parma, Idaho, working in a small rural clinic. He has been a nurse for 11 years and a nurse practitioner for the last six years. He has a supervising physician available for three hours twice a month. The cost to the clinic for those six hours of supervision is $9,000 per year. He believes HB659 will reduce costs for the clinic where he is employed. He testified to support HB659.
Sharon Stephen, RN,GNP,PhD, who is a professor of nursing at the Northwest Nazarene University, testified to support HB659.

This bill that amends existing law to remove physician supervision requirements applicable to advanced practice nurses (certified nurse midwives, clinical nurse specialist, and nurse practitioners). The bill was amended to add a section about collaboration and a requirement for peer review of practice for renewal of license to address the concerns of the Idaho Medical Association. HB659a brings Idaho in-line with 43 other states and reflects actual practice.

Advanced practice nurses, like myself, a gerontological nurse practitioner, have the education and experience to provide health and limited medical care to Idahoans. Collaboration is a reflex of all nurses, especially advanced practice nurses. The standard for professions is self-regulations. The regulation by the Boards of Nursing and Medicine as currently exists, is confusing and subject to varied interpretations. Please allow HB659a to advance to the Senate Floor.

Marvin Sparrel, briefly testified he is natural about HB659. He is happy with the practice as it is currently.
Written comments were received from Nancy Kerr, executive director of the Idaho Board of Medicine. She wrote, the bill removes the requirement for physician supervision of Certified Nurse Midwives, Clinical Nurse Specialists, Nurse Practitioners, and Registered Nurse Anesthetists. As another state regulatory agency, the Board of Medicine takes no position on this bill.

The Board of Medicine is not aware of any patient safety concerns that initiated the request for change in supervising status nor is it aware of any potential adverse safety outcomes if the proposed change is enacted.

Written comments were received from Darryl Beehler, DO, president of the American Osteopathic Association in Chicago, Illinois, who wrote the following:

The American Osteopathic Association (AOA) is the national organization representing over 52,000 D.O.s in this country. As I am sure you are aware, there are two types of "complete" physicians eligible for medical licensure for unlimited practice of medicine in the United States - D.O.s (osteopathic physicians) and M.D.s (allopathic physicians).

It has come to the AOA's attention that HB659, which passed out of the House of Representatives on February 26th, is now under consideration in the Senate Health and Welfare Committee. If enacted, HB659 would remove the physician supervision requirement for nurse practitioners and simply require nurse practitioners to collaborate with an undefined health care professional. The AOA respectfully voices its strong opposition to this bill.

Physicians and nurses need to work together for the best interests of the patient, with physicians as the "leader" of the health care team. The AOA supports the intent of the amendments to HB659, requiring certified nurse-midwives and clinical nurse specialists to collaborate with other health professionals when providing care. However, the language must go further to require supervision by a physician.

As you are aware, the education, training, and examination, required to obtain a license as a nurse practitioner drastically differs from those required by a physician licensed for the unlimited practice of medicine. Physician supervision of nurse practitioners is necessary to ensure patient safety.

Thank you in advance for your consideration of our comments regarding HB659.

ADJOURNED: Chairman Brandt announced the hearing for HB659aa would be continued on Thursday, March 11, at 8:00 a.m., and HB694 was also rescheduled for hearing on March 11, 2004. The committee adjourned at 9:40 a.m. as they were due to convene on the Senate Floor at 9:30 a.m.




DATE: Wednesday, March 10, 2004
TIME: 8:00 a.m.
PLACE: Room 437
MEMBERS PRESENT: Vice Chairman Compton, Senators Darrington, Ingram, Stegner, Sweet, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

Senator Brandt
GUESTS: See the attached sign-in sheets
Vice Chairman Compton conducted the meeting today.
MINUTES: A motion was made by Senator Bailey to accept the committee's minutes for Friday, March 5, 2004, as written. The motion was seconded by Senator Kennedy, and the motion was carried by a voice vote.
HB676aa This legislation, HB676, as amended, relating to hazardous waste and amending Section 49-2202, Idaho Code, to increase the fees applicable to the transportation of hazardous waste, was presented by Representative Elaine Smith, District 30, and Representative Wayne Meyer, District 3.

This bill increases the fees from $20 to $70 for a single trip permit, and increases the fees from $250 to $500 for an annual permit for the transportation of hazardous wastes. The Hazardous Material/Hazardous Waste Transportation Enforcement Fund for the Idaho State Police will receive these additional funds. The total revenue increase estimate is $92,200.

Most states charge more fees than Idaho for permits and annual fees for the transportation of spent fuel, high-level radioactive waste and highway route­controlled quantities of radioactive materials, such as:

California - Per company annual fee (unless otherwise noted) Highway Patrol License required for all motor carrier hazmat in excess of 500 lbs., $100; $75 for renewal

Colorado - For nuclear materials--$500, plus $200 per trip; all hazmat­annual fees based on number of vehicles ranging from $10 to $400, single trip $25

Connecticut - $25

Georgia - All hazmat, $100 annual or $25 per trip

Connecticut - All hazmat-- Annual fees based on # of vehicles ranging

from $10 to $400, single trip $25

Idaho - "Vehicle registration endorsement" $3 if purchased at registration or renewal, $5 all other times, $5 for single trip endorsement

Indiana - "Notice" required, no permit, $1,000 per cask

Illinois - Fee only, $2,500 per truck shipment, $4,500 per cask for rail shipments, $3,000 for each additional cask. Truck shipments over 250 miles in Illinois pay $25/mile surcharges for each mile over 250 for each truck in the shipment

Iowa - Fee only, $1750 per highway cask, single cask truck shipments subject to $15/mile surcharges for every mile over 250. $1250 first rail cask, $100 for each additional cask

Kentucky - $25, plus full cost of an escort across Kentucky

Maine - Not specified

Minnesota - All hazmat, $50 registration fee, $15 per apportioned vehicle; Public Safety Dept. "Notice" required, no permit, $1,000 per vehicle

Mississippi - $2,500

Nebraska - Fee only, $2000 per cask, truck or rail (LB 165, 2003)

Nevada - All hazmat, $500 plus $125 per truck, plus actual cost for additional assessment required of motor carriers of radioactive waste

New Hampshire - Fee to be established

New Jersey - Fee not specified. Up to $250 fine for first offense, up to $500 for subsequent offenses

New Mexico - All hazmat, no fee

Ohio - All hazmat, $50 registration fee; apportioned per truck fee, $600 permit fee

Oregon - $500 annual or $70 per shipment, whichever is less

Pennsylvania - Fee only, $1,000 per shipment, Penn. State Police assess escort fees. All hazmat, $20 for first card, $10 each additional card

Rhode Island - No fee

South Carolina - $75 or $750, based on volume and level of radioactivity

Tennessee - Fee only, $1,000 per cask for truck shipments; $2,000 per cask for rail shipments; Dept. Env. & Conserv "License for delivery" required. fee depends on category

Utah - $400 per trip

Vermont - "Approval to transport," $1000

West Virginia - All hazmat, $50 registration fee, permit required-no additional fee

Wisconsin - Registration for all hazmat, $25 annual, $20 one day permit

Wyoming - $200 per package

IN Idaho, fees are collected by the Department of Transportation, and fees are used for services and training provided by law enforcement officers.

Captain Lamont Johnson, Idaho Law Enforcement, testified to support HB676. If legislation is passed, the fees collected will be used for additional training of law enforcement officer to inspect and handle hazardous and radioactive waste shipments on Idaho's highways. All loads of waste leaving Idaho must also be inspected.
Allen Frew, manager, Port of Entry for the Idaho Transportation Department, testified to support HB676aa.
There was a lengthy discussion relating to the fiscal statement of $92,200, low-level waste shipment to Hanford, increase fees prior to amendments, fees pertaining only to carriers with hazardous waste, escort services provided by law enforcement, nuclear waste escort service, the need for additional officers to be trained for hazardous waste inspections, and carriers filing travel plans when crossing the state.
MOTION: A motion was made by Senator Burkett to send HB676 to the amending order, until we get a new fiscal statement. The motion was seconded by Senator Kennedy.
SUBSTITUTE MOTION: A substitute motion was made by Senator Darrington to send HB676aa, to the Floor with a Do Pass recommendation. The motion was seconded by Senator Bailey.

A roll call vote was taken on the substitute motion.

Voting AYE - Senators Darrington, Sweet, and Bailey

Voting NAY - Senators Compton, Ingram, Stegner, Burkett, and

Kennedy

Absent and excused - Senator Brandt

The substitute motion failed with 3 Ayes, 5 Nay, 1 absent.

ORIGINAL MOTION: The original motion to send HB676 to the amending order was carried by a voice vote. Senator Ingram was recorded as voting NAY. HB676 was transferred to the Amending Order. Senator Burkett agreed to sponsor HB676.
HB656 This bill, H656, relating to licensed pastoral counselors and amending Section 54-2303, Idaho Code, was presented by Representative William Sali, District 21.

This bill will repeal the licensing of Pastoral Counselors. There has been only one such licensed counselor since the law was enacted.

The Board of Professional Counselors will lose one license fee, but will be free of the administration of rules and consideration of applications and renewal of licenses for pastoral counselors.

MOTION: A motion was made by Senator Darrington to send HB656 to the Consent Calendar with a Do Pass recommendation. The motion was seconded by Senator Sweet, and the motion was carried by a voice vote. Senator Darrington will be the Floor sponsor HB656.
HB748 This legislation, HB748, relating to residential care for the elderly, and amending Chapter 35, Title 39, Idaho Code, was presented by Representative William Sali, District 21.

Veterans, railroad retirees and some insurance companies will only provide medication benefits if the medication is purchased in bottles.

The purpose of this bill is to continue to allow registered nurses, in assisted living facilities, to distribute medication from bulk bottles to medisets or unit dose blister packaging. The bill will, thereby, aid residents in self-administration of medication, and reduce the possibility of medication errors and contamination. This has been the standard procedure for nearly 10 years; however, due to conflicting rules this legislation is necessary for consistency.

This bill will have no adverse impact on the general fund. If this legislation is not passed, it could cost veterans and railroad retirees up to $900,000 a year.

From 2000-2003 The Rules Governing Residential Care and Assisted Living Facilities specifically stated that nurses could fill medisets, a practice that in actuality has been used for years as the practice dramatically reduces medication errors in assisted living.

Both Arizona and Washington provide specific direction, allowing nurses to fill medisets. It is an assumed practice in most states and is regularly referred to in many state's medication assistance training.

The FDA has provided guidance concerning this rule, stating that the FDA usually defers to the state in such matters In Rules Governing Certified Family Homes, there is a "mirror" rule allowing nurses to fill

medisets in CHF settings. For whatever reason, the Bureau of Facility Standards has chosen to leave this rule in place. The authorization form refers to requiring medisets.

The $900,000 impact refers to the costs to Veterans and railroad retirees if they must start purchasing their drugs in unit dose blister pack cards instead of taking advantage of their prescription benefits given in bulk containers. In 2003, while considering the option of proposing legislation to allow for the return of unopened, unused medication, the Idaho Assisted Living Association conducted a statewide, statistical analysis of the use of medications in assisted living, including the medications arriving in facilities in bulk containers from Veterans and railroad retirees.

Though the Bureau of Facility Standards stated in testimony that no one opposed this rule, the Idaho Assisted Living Association told the Bureau of Facility Standards in July of 2003 that it would oppose this rule change. In ignorance of proper procedure, we may not have conveyed our objections through the appropriate formalities. A number of nurses have also contacted both Facility Standards and the Board of Nursing in opposition to this rule change. In meetings in August 2003, we informed Medicaid that we would oppose the proposed rule. We notified Senator Skipper Brandt and Representative Bill Sali, in September 2003, that we were opposed to this temporary rule, and explained why we had issues with it. We informed both Bureau Chief Debra Ransom and Deputy Administrator Randy May, in a meeting just prior to the 2004 legislative session, that we intended to propose legislation in opposition to the rule change.

Representative Sali explained, the Arizona State Board of Nursing. In 1990 reported it is within the scope of practice for a Licensed Nurse to prepare a medication device for the purpose of facilitating the ultimate user's self administration or subsequent taking of the medication if the following requirements are met.

1. General Requirements

A. Written policy and procedure are maintained by the agency/employer.

B. A physician has prescribed the medication which has been properly compounded, packaged, labeled and delivered to the ultimate user.

Rational - Ensure the ultimate user's independence and compliance with prescribed treatment modality.

Representative Sali emphasized this legislation does no t violate any FDA (Food and Drug Administration) regulations. He distributed three (3) handouts.

Attachment # 1 - Letter dated June 2003, from Patricia Lashway, director of Residential Care Services, Aging and Disability Services Administration.

Attachment #2 - A e-mail from the Division of Drug Information in Rockville, Maryland.

Attachment #3 - A copy of the Idaho Administrative Code IDAPA 16.03.19 - Rules Governing Health and Welfare/Division of Welfare Certified Family Homes.

Attachment #4 - Medicaid authorization form relating to moving into a Certified Family Home.

Richard Markuson, R.Ph., executive director of the Idaho State Board of Pharmacy, testified in opposition to HB749. He explained the Board was not made privy to HB748 prior to its introduction in the House. However, in the short time available for review of the proposed new section, we have noted several inconsistencies with current state and federal law.

The bill requires assisted living facilities to create a policy for repackaging medications previously packaged, labeled, and dispensed by a licensed pharmacist. The bill is unclear in many respects, but appears to require only a minimal amount of labeling information. The labeling requirements are insufficient to meet current federal and state labeling requirements. Attached hereto are copies of the CPG (Compliance Policy Guideline) from the Department of Health and Human Services which sets out the federal law issues. Also attached are copies of Pharmacy Rule 159.02 and Idaho Code Section 54-1732(a)2 which outline state labeling requirements. (See Attachments #5).

Labeling of repackaged pharmaceuticals is within the definition of the practice of pharmacy under Idaho Code Section 54-1704. Additionally, repackaging of pharmaceuticals is included within the definition of manufacturers (Idaho Code Section 54-1705(18) and manufacturers must be registered with the Board of Pharmacy. Idaho Code Section 52-1729.

Lastly, the fiscal not of the bill indicates that: "If this legislation is not passed, it could cost veterans and railroad retirees up to $900,000 a year." This is apparently a concern over whether assisted living facilities will have the authority to receive medications from VA and railroad pharmacies. However, this is not the case. Under existing law, bulk medications can be received in their original packaging where authorized by Health and Welfare. HB748 is not necessary to allow this to continue.

The Board of Pharmacy and its staff are ready, willing and able to sit and discuss any problems the assisted living facilities have with the current law. However, this should be done in an orderly fashion with all interested parties when there is time available for a full analysis of all of the issues. HB748 should be set aside until this occurs.

Mr. Markuson also presented a copy of a e-mail, dated February 24, 2004, from Joseph Steiner, dean and professor, Idaho State University, College of Pharmacy. Mr. Steiner wrote:

You asked me to comment on the fax you sent about House Bill No. 748. The only health care professional with the knowledge and training to assure proper repackaging of prescription medications is the pharmacist. There is more to filling individual dose systems than just transferring the drug dosage. These include assuring that the integrity of the medication is maintained, storage considerations, correct labeling, and maintenance of proper records. The bill allows any licensed nurse (which includes LPNs) to perform a task without the proper knowledge or skills.

When the nurse acts as dispenser and administrator of the medication, it bypasses the double-checked system we have to prevent medication errors. I see this bill as detrimental to the public health by allowing for greater potential for medication errors to occur, and greater liability.

The Bill also includes the phrase "to maintain security of medication received from a pharmacist in accordance with pharmacy standards." Since repackaging by anyone other than a pharmacist or a pharmacy technician under the supervision of a pharmacist violates pharmacy standards, the security of the medication cannot be maintained.

The Division of Medicaid Administrator David Rogers explained HB748 relates to House Concurrent Resolution 55. He agreed with the Board of Pharmacy comments. The Department of Health and Welfare was not brought into the circle in developing this legislation.
Andrew Doman, an attorney for the Idaho Assisted Living Association, testified and distributed a two-page handout relating to IDAPA 16.03.22, IDAPA 23.01.01 and Title 54 Chapter 17. (See Attachment# 6).
The Committee recommended that members of the Idaho Assisted Living Association sit down with members of the Department of Health and Welfare, the Board of Pharmacy, and the Board of Nursing to discuss this problem.
Written comments were received from Scott Burpee, chief executive officer of Valley Vista Care Services. He explained, he could not come to testify on HB748, however, this bill is premature and is being advanced in contradiction of several agreements made between Health and Welfare, the Board and Care Council, and a special committee formed to work on Pharmacy issues last year. At no time was this legislation discussed, and in fact, IDALA never objected to the new rules relating to this. This bill is much broader in scope than what the statement of purpose claims, and would allow unlicenced pharmacies in assisted living facilities. The end run the Assisted Living Association did to avoid close examination of this issue should be exposed, and this issue referred for closer review by other providers, consumers, and state agency personnel.

Currently, nursing homes have to be licensed as an institutional pharmacy to process meds now, and they cannot package meds. They are inspected annually. HB748 allows assisted living facilities to package meds without any license, no inspections, and no oversight and allows a practice in excess of what more tightly regulated facilities do now. It is hard to see how this can be a safe situation when the nurse does not actually administer the medication, and there is really no provision for oversight. Since these prescriptions may be mail-order, there is probably no pharmacist review of all the medications to catch medication contradictions.

The point of medication rules is to ensure that when a prescription is made, a pharmacist reviews all the medications in relation to each other, and catch conflicts that could be potentially fatal to a resident. By allowing mail-order and packaging, this is circumvented. The cost impact is doubtful as no actual study statewide was done (they didn't ask us). Before we reap the effects of unintended consequences, some effort should be made to see just how big a problem this is, and what alternatives are available before passing this bill.

On a final note, the industry was able to get the requirement to carry liability insurance removed, so if a mistake hurts a resident the facility may very likely not have insurance coverage in place.

MOTION: A motion was made by Senator Bailey to send HB748 to the Floor with a Do Pass recommendation. The motion was seconded by Senator Sweet, and the motion was carried by a voice vote.
HCR 55 HCR55 was also presented by Representative Sali. This concurrent resolution would reject certain pending administrative rule changes of the Department of Health and Welfare relating to licensed residential and assisted living facilities. The effect of this resolution, if adopted by both houses, would be to prevent the agency rules from going into effect.

This concurrent resolution has no fiscal impact.

MOTION: A motion was made by Senator Bailey to send HCR55 to the Floor with a Do Pass recommendation. The motion was seconded by Senator Sweet, and the motion was carried by a voice vote. Senator Stegner was recorded as voting No.
H 552aa This legislation, HB552, as amended in the House, relating to counselors and marriage and family therapists, was presented by Rayola Jacobsen, bureau chief of the Bureau of Occupational Licenses.

This bill will amend Section 54-3404, Idaho Code, to correct terminology, provide references to pastoral counselors, and allow the board to adopt rules requiring continuing education for renewal of license; amends 54-3405A, Idaho Code, to delete continuing education requirement for pastoral counselors; delete obsolete language; makes a grammatical change; and makes technical corrections. It will amend Section 54-3405C, Idaho Code, to delete certain continuing education requirements, and to delete obsolete language and to make technical corrections.

There is no fiscal impact to dedicated or the general fund.

MOTION: A motion was made by Senator Ingram to send HB552aa to the Floor with a Do Pass recommendation. The motion was seconded by Senator Darrington, and the motion was carried by a voice vote. Senator Ingram will be Floor Sponsor.
ADJOURNED: The meeting adjourned at 9:37 a.m.




DATE: Thursday, March 11, 2004
TIME: 8:00 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Stegner, Sweet, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

None
GUESTS: See the attached sign-in sheets
HB659aa This legislation, HB659 as amended, was first presented on Tuesday, March 9, 2004, but due to time limits the hearing was rescheduled for additional time today. This bill relates to the Idaho Board of Nursing, amends Sections 54-1402 and 54-1411, and clarifies the current relationship between advanced practice professional nurses and physicians. The bill was again presented by Representative Margaret Henbest, District 16. She outlined the proposed amendments to the Engrossed Bill.
Todd Swanson, MD, testified to support HB659. It is time to change the law. He explained the reasons' he supports the bill and they are liability concerns, access to care, cost, and professional respect.
Shelia Gifien, MD, testified in opposition to HB659. She explained that all parties operate with some supervision.
Dick Rant, he is neither a physician nor nurse practitioner, but he works with both of them as he works for St. Luke's Family Health. He testified to oppose HB659. He expressed his concerns about followup care of patients who enter the hospital. He believes supervision is needed.
Myrna Olsen-Fisher, a family nurse practitioner for 37 years, testified to support HB659, and wanted the term "supervision" taken out of legislation. She has a nurse practitioner business and has a physician on contract for two (2) hours, twice a week, and pays him $10,000. per year, and councils with him as needed. She is accountable to the Board of Nursing.
Sandra Evans, M.A.Ed., R.N., executive director of the Idaho Board of Nursing, testified to support HB659.

She explained, advanced practice professional nurses have been formally recognized in Idaho law since the early 1970's, first as nurse practitioners only and more recently as certified nurse midwives, clinical nurse specialists, nurse practitioners and registered nurse anesthetists. Since 1973, when Idaho became the first state in the country to recognize nurse practitioners, the definition of advanced practice nursing and the regulation of licensed advanced practice nurses in our state has been evolving to best meet the unique needs of Idaho's citizens.

In the initial years of advanced practice nursing, it was believed that physician supervision of these nurses was necessary for public protection. However, significant advances in the educational preparation of advanced practice nurses, more clearly defined standards of conduct and scopes of practice, and more than 30 years of documentation of the quality of care offered by these highly skilled providers have served to negate the need for this oversight.

When the Idaho Legislature granted full regulatory oversight of advanced practice nursing to the Board of Nursing, it charged the Board to provide for public protection through the establishment of strict criteria for licensure and relicensure; the clear definition of scopes of practice for each category and specialty of advanced practice nursing; and, thorough investigation of complaints and the imposition of appropriate disciplinary action where warranted. It is this regulatory oversight and these clearly defined standards of practice and conduct that serve to best protect the public, not the arbitrary imposition of physician supervision, which has been historically inconsistently applied.

Advanced practice nurses are fully educated, well-qualified providers. Most of them have not less than six years of professional nursing education as their preparation. Many of them hold related academic degrees in addition to their graduate and postgraduate nursing credentials. They provide primary health care service throughout Idaho in group and independent practices, and in both large and small communities, but always in concert with other health care providers, including physicians, pharmacists, social workers, dietitians, physical therapists and others. This professional collaboration is a clearly defined component of standards for practice adopted by the Board of Nursing for each category of advanced practice nursing. To assure that licensees practice in accordance with these adopted standards, the Board conducts biennial audits of their practice as part of the process of licensure renewal. Results of the most recent audit validate 100% compliance with all required criteria.

Data maintained by the Board of Nursing indicates those nurse practitioners, certified nurse midwives, clinical nurse specialists and registered nurse anesthetists have positive influences on quality and access to care, and that they practice with safety in a wide range of settings. In terms of quality of care, evidence is available to indicate that advanced practice nurses provide care that is of as high a quality as that of physicians, as long as their scopes of practice are well-defined, that they remain current in their knowledge of their advanced specialty, and that they remain in compliance with practice standards established by the Board. The requirement that these nurses be subject to supervision by physicians for activities that are well within their legal scopes of practice and for which they have been educated and have demonstrated competence is inconsistent with any argument for public protection. The public is best protected when standards for conduct and practice are clearly defined and consistently applied and when the appropriate licensing board maintains oversight. The requirement for physician supervision does little more than makes these nurses dependent on physicians for their practice and livelihood, serving to better protect the special interests of physicians rather than in any way enhancing public safety.

It will be argued that because advanced practice nurses perform medical functions, it is essential that physicians direct their practice. However, a 1977 Idaho Attorney General's opinion determined that the functions performed by these nurses do not constitute the practice of medicine, but rather, constitute the accepted practice of advanced practice nursing, as it is defined in law. The delivery of health care involves various licensed providers, many of whom perform functions that may overlap. Qualified providers legally and safely perform these overlapping functions within parameters defined by their respective professional licensing boards.

On behalf of the nine members of the Idaho Board of Nursing, I encourage your support of this legislation. HB 659 presents changes that are consistent with safe nursing practice and sound regulatory oversight. Removing the requirement for physician supervision of the practice of these competent providers in no way compromises' patient safety.

Randy Hudspeth, director of Advanced Practice Nursing at Saint Alphonsus Regional Medical Center in Boise, testified to support HB659a. He explained, I grew up in Idaho, graduated from Idaho State University and also hold graduate degrees from the University of Arizona as a nurse practitioner and from Syracuse University in New York as a cardiovascular clinical nurse specialist. I manage both NPs and CNSs at Saint Al's.

No one thinks they practice in a vacuum, and practice can place any restrictions they want on their setting. We all understand there are four categories of advanced practice nurses, but this is not solely a nurse practitioner issue. The first category, the registered nurse anesthetists had supervision removed from their section of the statute in 1994. Since that time, they have had a very successful track record of safe, high quality independent practice in Idaho. They work collaboratively with other health professionals and we have no reason to believe that other APN would not have that same experience. Their group is supportive of this bill.

Second, Certified Nurse Midwives­by the very nature of their national certification­indeed the only category that has the word certification in their section­are required to uphold their national standard and maintain physician backup and ongoing physician relationship to guide their practice. I have a written letter from Connie Wolcott, their state president who could not be here today from Shoshone, and they are supportive of this bill.

Third, Clinical Nurse Specialists­there is only 23 in Idaho and as far as we can count them all, they are employed at Saint Alphonsus, St. Luke's, the VA, two (2) in mental health and the others are faculty at either BSU or ISU. These people are primarily nurse educators. The ones in my department work to orient new nursing staff, teach procedures, quality assurance monitoring, and community case management, much in an expanded role of a regular registered nurse. None of these functions require physician supervision, and in talking with physicians at Saint Al's most have no involvement with CNS and really do not even know what they do. Truthfully, physician supervision for this group for the most part is totally ignored. We have CNS practice­teaching other nurses. This is truly only a paperwork exercise to meet the letter of the law and is totally meaningless for all practical purposes.

I have been recruiting a cardiovascular CNS for the past year. To date, we have spent $32,727 in recruitment costs for this position that pays 65,000 to $75,000 annually. St. Luke's is recruiting for the same position without success either. There is no CNS program in Idaho, so we have to recruit from out-of-state. We had one candidate, but when I went through the licensing and certification requirement, she was OK with that part, but the physician supervision piece was too much and her feeling that if a cardiac surgeon or cardiologist did not like her, and decided not to agree to supervise her, then she would be unable to legally work. She decided not to take the job. Chances are that would never happen, but it is a problem. This law is a problem and is costing my department in continued recruitment costs, and is causing the position to remain vacant. I need some help here to remedy this problem.

The problems our current people are having far outweigh any future threat by a new graduate that wants to be independent, and could be anyway under current law, if they can hire a doctor for a few hours a month.

At Saint Alphonsus, one of my department pays a physician more than $65,000 annually to supervise three (3) nurse practitioners. Under new limit laws, if this program expands to more than three nurse practitioners, I will need to hire an additional physician to supervise. This is a needless cost. If this law passes, then the current physicians can continue to supervise additional numbers, because in a hospital we do have organized supervised NP practice. We have just not been limited in numbers until the new restriction came in place.

Lastly, safety has not been an issue, and it is not proven in any research study that unsafe practice exists. Your fellow legislators in all of these other states, which have taken this step, did not legislate unsafe practice.

In closing, this should be considered an evolutionary step in the development of advanced practice.

Fourth category, Nurse Practitioner­There are 373 licensed nurse practitioners in Idaho. The majority of these work for physicians, in hospitals, health departments or teach in universities. Very few are in independent practice. We can count somewhere around 12 in the state. However, you must know that this law is not about independent practice. Today, under the current law, NPs can have independent practice if they want itl. Some have. There is nothing to stop them. How do they handle physician supervision­they hire a physician. You heard examples from Deb Casrorph, who hires a physician for $100 an hour to come in and peer review a sample of her charts. Myrna Fisher in Kuna has a physician who is paid $10,000 a year to provide this service. Lynne Kawhura in Idaho City, a town that has not had a physician in recent memory, and who is the only provider between Boise and Stanley, has a hired physician in Boise, who has never been to her clinic, and whom she brings selected charts into Boise for them to review. These are common scenarios.

We are concerned about inexperienced NP starting practice, but we do not seem to be able to hire experience. Why? Look at this map. (See Attachment #1). Every state around us­those where we would most commonly hire from­do not have physician supervision language­and NPs do not want to move from those states to Idaho. In Idaho, their livelihood is at risk. For example, Cyndy Rice is a NP in Pocatello. On Monday, she e-mailed me to use this example. She is part of a small group in practice with a large patient group. The physician with whom she contracts for supervision informed her on Monday that his malpractice insurance will no longer cover him to supervise a mid level who is off-site from where he practices. What does this mean for her­try to hire another doctor, close her office that employs three (3) people, practices illegally without this supervision relationship that is basically only for billing purposes. These people's livelihood is a risk the moment a physician says, "I can no longer supervise you."

Supervision wording is an issue that needs resolved. It impacts a great number of currently working, experienced NPs in Idaho­the group that previous people testifying did not seem to feel there was a problem.

Julie Taylor, director of Governmental Affairs for Blue Cross of Idaho, testified to oppose HB659. She explained, this legislation is in direct conflict with the Idaho Medical Practice Act.

  • Title 54, Chapter 19 of the Idaho Code is the Medical Practice Act. Its purpose is "to assure the public health, safety, and welfare in the state by the Licensure and regulation of physicians, and the exclusion of unlicenced persons from the practice of medicine."


  • As you read further into the Medical Practice Act, you find Section 14, "Grounds for Medical Discipline." The paragraph (17) states that physicians shall be disciplined if they fail "to supervise the activities of externs, interns, residents, nurse practitioners, certified nurse midwives, clinical nurse specialists, or physician assistant." This is the section of Title 54 that is in direct conflict withH659.


  • Further, the Board of Medicine could bring action against any physician found to be violating this provision of the Medical Practice Act and their license could be restricted, suspended, or revoked.


  • While I'm unsure if the board would bring action in cases like this, Blue Cross is extremely concerned about the fallout if this bill were to become law, because the contracts we have with physicians would be affected. Depending upon the Board of Medicine's findings, we could break off contracts with physicians who supervise these medical professionals.


I urge you to vote against H659 so that the physicians and the advanced practice nurses noted in the scop of this bill can work out their differences and agree on legislation.

James Scheel, MD, a representative of the Idaho Medical Association, testified and reported the IMA cannot support this bill, as written. He expressed numerous concerns to HB6./ He discuss out of hospital birth deliveries, peer reviews, ensure quality services, and supervision.
Written comments were received from Jim Gardner, MD, in opposition to HB659.

I am writing this is regards to the HB 659 regarding independent practice by licensed Idaho Nurse Practitioner. I do not support the bill in the current role, as I feel strongly that nurse practitioners, while trained for much of the roles we cover in primary care, they have a need for supervision in the setting of rural practice in particular. This is evident in a training situation I was involved with seven (7) years ago for a nurse practitioner student with the Idaho State University program. This person did their requirement to practice with a license in the confines of one year of training in Riggins. They saw an average of less than three (3) patients per day for that year of training. I came from a background in medicine of seeing 30-plus patients a day as a training physician, and more patients than that for three years of residency training. This is a level of experience that cannot be compared to a stand-alone practice without supervision. As you are aware in your home community, I do supervise a nurse practitioner in Kooskia, and the review and teaching in that setting is of an invaluable tool to help with maintained of quality education and care. I would clearly, in this setting, support a setup that allowed for finding a better database of physicians in Idaho to support and supervise nurse practitioners to allow for many underserved areas to have access to health care that medical doctors do not serve. I hope these comments are helpful in your consideration of this bill.

Written comments were received from Wayne Hollopeter, MD, who opposed HB659. He wrote, I am writing you to voice my opposition to nurse practitioners practicing independently. A nurse practitioner spends 2-4 years in nursing school and then another two years in nurse practitioner school, compared to a family physician who has spent 4-5 years in undergraduate school, four years of medical school, and then three years of residency. In this local area, I have already seen nurse practitioners make serious medical errors and yet they continue to bill the same as a medical doctor.

I do not think it is right to have somebody with half the education doing the same job as a medical doctor, and I believe the current system of working under the review of a medical doctor is working adequately in most cases. I am sure you are aware that Syringa General Hospital already has a nurse practitioner at a clinic in Kooskia, who is being sponsored by Drs. Gardners in Grangeville. Of course the doctors who are sponsoring nurse practitioners would sometimes prefer that the nurse practitioners would be able to practice independently, so they would not share the liability of any mistake that the nurse practitioner might make. This would allow more and more practitioners to begin practicing, however probably the malpractice insurance rates would be such that they would not be able to afford practicing in small areas, such as Kooskia. I would like for you to consider these points and please vote against House Bill 659.

Written comments were received from Larry Barker, chief operating officer for Clearwater Valley Hospital and Clinics in Orofino, Kooskia, and Pierce, to oppose HB659. He wrote, we urge you oppose the Nurse Practitioner bill to be voted on Thursday. Please vote no. We feel the Nurse Practitioners need oversight and supervision by a physician. The following Doctors urge you to vote no.

Dr. Kelly McGrath M.D.; Dr. Phillip Petersen M.D.; Dr. Michael Meza M.D. and Dr. Angela Thomas M.D.

Written comments were received from Theresa Uptmor, director of Clinic Operations, who wrote to oppose HB659. She wrote, on behalf of St. Mary's Hospital and Clinics and our physicians, I would like to state that we STRONGLY oppose HB659. We employ a Nurse Practitioner at this time, and it is our belief that although they have a wealth of knowledge and are an integral part of a physician team when seeing patients, that they need direction and supervision by a MD on a daily basis. As previously noted, a nurse practitioner's presence in rural area clinics is essential, but they are an extension in a physician practice and, as such, should not be practicing without physician oversight. Please oppose this bill when it reaches the Senate.

Ronald L. Sigler, MD; Andrew F. Jones, DO; Jeffrey K. Edwards, MD;

Jack Casteel Bruner, MD; A. Jackson Secrest, MD, and Haley Minnehan MD.

Written comments were received from Neeraj Soni, MD, Emergency Medicine of Idaho, to support HB659. He wrote, I currently have a thriving practice with nurse practitioners and that relationship will not change. However, supervision is a misnomer and I would say that we work more in a collaborative and consultative relationship rather than one of supervision.

I also believe that my liability is higher than it would be if I did not supervise a nurse practitioner. NPs should be legally responsible for their own practice, as physicians are. Having to supervise nurse practitioners also makes my malpractice insurance costs higher which is not a necessary cost as NPs already practice on their own license and currently carry their own malpractice insurance. Nurse practitioners in all states surrounding Idaho are not supervised and this is the standard in every state but four (4), including Idaho.

Protection of the public is not an effective argument as NPs have 30 plus years of successful practice in Idaho, which was the first state in the union to legally recognize nurse practitioners. Nurse practitioners have improved the accessibility and quality of health services especially in rural areas and have reduced health care costs as well.

Thank you for your time and efforts on behalf of Idaho citizens. I hop you will support this worthwhile legislation.

Written comments from Si Steinberg, MD, to support HB659. The comments are:

As I am an MD who supervises nurse practitioners, I am writing to you in support of the legislation to remove physician supervision from the law. I currently have a trriving practice with nurse practitioners and that relationship will not change. My experience with nurse practitioners is that they are 100 percent competent to evaluate and prescribe for psychiatric patients under their own recognizance. Furthermore, just as I, a psychiatrist, would contact a colleague for a consultative opinion on a particular case that I was uncertain about, my nurse practitioners consult me in the same manner. I believe this to be an indication and endorsement of ethics and compenance.

I also believe that my liability is high than it would be if I did not supervise a nurse practitioner. NPs should be legally responsible for their own practice, as physicians are. Having to supervise nurse practitioners also makes my malpractice insurance costs higher which is not a necessary cost as NPs already practice as their own license and currently carry their own malpractice insurance. Nurse practitioners in all states surrounding Idaho are not supervised and this is the standard in every state but four, including Idaho. Protection of the public is not an effective argument as NPs have thirty plus years of successful practice in Idaho, which was the first state in the union to legally recognize nurse practitioners. Nurse practitioners have improved the accessibility and quality of health services especially in rural areas and have reduced health care costs as well..

MOTION: A motion was made by Senator Stegner to send HB659aa to the Floor with a Do Pass recommendation. The motion was seconded by Senator Burkett. After discussion, a roll call vote was taken.

Voting AYE - Senators Brandt, Compton, Ingram, Stegner, Sweet,

Burkett, and Kennedy.

Voting NAY - Senators Darrington and Bailey

The motion was carried with 7 Ayes, 2 Nays, no absent members.

HB 694 This bill, HB6904, relating to the Idaho Board of Nursing, was presented by Sandra Evans, executive director of the Board of Nursing.

Ms. Evans explained, HB694 is necessary to assist the Board of Nursing in fulfilling its mission to protect the public. This bill amends the Idaho Nursing Practice Act to require applicants for initial nurse licensure and for reinstatement of licensure to submit to criminal background checks.

The Board of Nursing grants initial licensure to approximately 1,500 nurses a year. An additional 200-300 nurses seek reinstatement of lapsed licenses each year.

The Board believes that crimes that have a potential impact on the ability to practice safely should be a significant part of the decision to grant nursing licenses to these individuals.

A felony conviction is a significant event. The behavior underlying a misdemeanor conviction is also of significance, given the common use of plea bargains and reduced sentencing in today's criminal courts. Either of these occurrences should be carefully scrutinized in determining whether or not a candidate should be granted the authority to practice nursing in Idaho.

Currently, the Board includes questions related to criminal convictions and pleadings on the application for licensure. The Board then relies on information provided by the applicants in response to these questions for its decisions. This process, of course, results in the Board being dependent on the honesty and integrity of applicants to respond truthfully to the questions being posed.

In the last few years, the Board has become increasingly concerned about the risk posed by applicants that are less than candid or honest in their responses to key questions on the licensure application and could, as a result, slip through the otherwise close scrutiny of the Board.

HB694 allows the Board of Nursing to validate information provided by applicants, and in doing so, to provide greater protection to persons who are recipients of nursing care in this state.

Criminal background checks for new and reinstating licensees is a requirement that the Board of Nursing believes is critical to our responsibility to protect the public. Thank you for assisting the Board in its mission, by supporting HB694.

MOTION: A motion was made by Senator Burkett to send HB694 to the Consent Calendar with a Do Pass recommendation. The motion was seconded by Senator Sweet, and the motion was carried by a voice vote.
ADJOURNED: The Committee adjourned at 9:46 a.m. as they were due to convene on the Senate Floor at 9:30 a.m.




DATE: Friday, March 12, 2004
TIME: 8:00 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Darrington, Ingram, Stegner, Sweet, Bailey, Burkett, and Kennedy
MEMBERS ABSENT/

EXCUSED:

None
GUESTS: See the attached sign-in sheets
MINUTES: A motion was made by Senator Bailey to accept the committee's minutes for Monday, March 8, 2004, as written. The motion was seconded by Senator Stegner, and the motion was carried by a voice vote.
HB 815 This legislation, HB815, relating to the disclosure of controlled substance adulteration or misappropriation, and amending Chapter 1, Title 37, Idaho Code, was presented by former Attorney General Jim Jones.

This legislation will provide for reporting by employers of health care providers to licensing boards if the employee is terminated for the adulteration of a controlled substance. It also provides for the transmittal of this information from the board to a prospective employer.

There is no fiscal impact to the general fund. There will be an impact to the Board of Nursing dedicated fund. The Board of Nursing estimates this legislation will result in the need for an additional .5 FTE (full-time employee). A one time expense of $3,500, and ongoing expenses of $12,000 annually.

Section 37-117A was discussed and reviewed:

37-117A.(Lines 11- 20) REPORTING AND DISCLOSURE REQUIREMENTS FOR EMPLOYMENT RELATED ADULTERATION OR MISAPPROPRIATION OF CERTAIN DRUGS. (1) When the employment of a health care provider has been terminated, either voluntarily or involuntarily, for adulteration or misappropriation of controlled substances, as defined in chapter 27, title 37, Idaho Code, the employer shall, within thirty (30) days of the termination, furnish written notice of the termination, described herein as "notice of termination," to the health care provider's professional licensing board of the state of Idaho, which shall include a description of the controlled substance adulteration or misappropriation involved in the termination.

Mr. Jones discussed a case in Nampa where the employee had a drug problem while employed by Mercy Medical Hospital, but was only required to attend a three-day substance abuse class. Five (5) years later, Saint Alphonsus Medical Center hired this nurse and now, the result of a resident's death, the hospital is facing a lawsuit. The hospital would not have hired this nurse if they were aware of her drug problem.

The Idaho Hospital Association, the Idah0 Board of Medicine, the Board of Nursing and others were involved in drafting this legislation, HB815, and all agreed it is needed.

Roy Eiguren, an attorney for Saint Alphonsus Regional Medical Center, testified they were involved in developing the legislation and supports HB815.
Bonnie Haynes, from the Idaho Hospital Association, briefly testified to support HB815.
MOTION: A motion was made by Senator Ingram to send HB815 to the Floor with a Do Pass recommendation. The motion was seconded by Senator Bailey.

Discussion:

  • Most cases are disposed of by the employer.
  • Most cases end in resignation in lieu of firing.
  • Costly procedure to devote manpower from agencies to work with the prosecuting authorities to try and get cases prosecuted, to get these bad employees out of the system so they can get on with their programs.
  • People who are hiring these people who have resigned, such as hospitals and health care agencies, need to rely on information that is submitted, in good faith, to the respective boards of health that they operate under.
  • This legislation will get bad people out of the system. This legislation is needed and is good for Idaho.
  • If a person is wrongly terminated and that information is given to the board, there is no reason why the board cannot take action to qualify the information.


A roll call vote was requested.

Voting AYE - Senators Brandt, Compton, Darrington, Ingram, Sweet,

Bailey, Burkett, and Kennedy

Voting NAY - Senators Stegner and Burkett

The motion was carried by a vote of 7 Ayes and 2 NAY.

HB 646 This bill, HB646, relating to the Idaho Health Facilities Authority, and amending Section 39-1443, Idaho Code, was presented by Patrick V. Collins, an attorney with the law firm of Hawley Troxell Ennis & Hawley, LLP, who explained, I am here today representing the Idaho Health Facilities Authority.

The Idaho Health Facilities Authority (IHFA) is an independent public body of the state of Idaho, created by statute in 1972. The Idaho Health Facilities Authority was created to facilitate financing for Idaho public and nonprofit health institutions and otherwise promote the health and welfare of the people of Idaho. The Idaho Health Facilities Authority fulfills this duty by issuing bonds on behalf of healthcare institutions serving Idaho. These bonds are payable solely from the revenues of the hospital and are not obligations of the state of Idaho or the Idaho Health Facilities Authority.

The purpose of House Bill 646 is to make a small amendment to the definition of "health institution," to make it clear that hospitals operating health facilities in Idaho either directly, or indirectly through one or more affiliates, are entitled to borrow money from or issue bonds through the Idaho Health Facilities Authority. This amendment reflects the recent trend toward consolidation in the healthcare industry, whereby, some Idaho nonprofit hospitals have become members of corporate families. Such hospitals include St. Joseph's Hospital in Lewiston, St. Mary's Hospital in Cottonwood, St. Benedict's Hospital in Jerome, and St. Alphonsus Hospital in Boise.

Under the current code, the lawyers who serve as bond counsel in transactions for these hospitals have to create a fairly complicated set of agreements to enable the hospital to issue bonds through the IHFA. This bill would simplify those transactions and reduce some of the transaction cost for the hospital. It would not expand the powers of the IHFA or of the hospitals. It would just allow them to continue to access the debt markets in a more efficient and straightforward way.

This bill also has the support of the Idaho Hospital Association. On behalf of the Idaho Health Facilities Authority and Idaho's public and nonprofit health care institutions, I ask for your "do pass" recommendation for House Bill 646.

MOTION: A motion was made by Senator Compton to send HB646 to the Consent Calendar with a Do Pass recommendation. The motion was seconded by Senator Stegner, and the motion was carried by a voice vote.
SB 1419 This bill, SB1419, relating to the Idaho Prescription Drug Program, and amending Title 56, Idaho Code, was presented by Steve Tobiason,a representative for the AARP Idaho.

This legislation creates a prescription purchase program known as Idaho Rx. This program is available to Idaho residents, who do not qualify for Medicaid, and who have an income level equal to or less than 200 percent of federal poverty level. It does not apply to Idaho residents who are currently covered by a prescription drug benefit plan, or who have voluntarily terminated coverage from such a plan within 90 days of application for the Idaho Rx purchase card.

The applicant will be required to pay for prescription medications, but will be able to purchase the medications at a reduced price. This program should reduce the utilization of visits to the hospital emergency rooms, and utilization of other more costly health care resources for this part of Idaho's population.

This legislation would be implemented in two phases. The first phase would begin January 1, 2005 (fiscal year 2005). The second phase would begin July 1, 2005 (fiscal year 2006). The projected cost of the program for fiscal year 2005 would be $400,000. The projected cost for fiscal year 2006 would be $800,000.

The program cost for the first year ($400,000 - fiscal year 2005) would be offset by revenues from the application fees received in the projected sum of $225,000 (75,000 applications at $3 each equals $225,000). This would result in a net fiscal impact to the state of $175,000 for fiscal year 2005.

The cost of the program in fiscal year 2006 would be covered by the rebates recovered by the Department of Health and Welfare in the operation of the program. The fiscal impact is based upon the experience of similar prescription purchase programs in other states.

Mr. Tobison recommended SB1419 be sent to the 14th Order for amendments, as follows:

Page 2, Line 10 - Add "as set by the department for fiscal year 2003" after "price,".

Page 2, lines 18/19 - Strike through ", or another business licensed to dispense prescription drugs in Idaho,".

Page 2, Line 27 - Add "by the department to the participating retail pharmacy" after "fund".

JoAn Condie, CEO of the Idaho State Pharmacy Association, Inc., testified to support SB1419. She presented a letter, as shown below:

On behalf of the membership of the Idaho State Pharmacy Association (ISPA), this letter is in support of SB1419 with the proposed amendments. Many hours of discussion and work have brought us to an agreement on the amended legislation presented to you today.

We thank the AARP representatives for inviting the Idaho State Pharmacy Association to participate in the writing of this legislation, making it feasible for pharmacists to participate in a program that will benefit the uninsured citizens of Idaho.

William Roden, a representative of the Idaho Pharmaceutical Association, testified that no attempt was made to discuss this program with the pharmaceutical industry. He distributed a copy of a new article by Dan Gallagher, an Associated Press writer, about a new Internet Web site, located at, http://www.RxIdaho.org with information that consolidates access to 250 discount drug programs. (See Attachment #1)

Mr. Roden also presented a 17-page handout relating to prescription assistance in Idaho. (See Attachment #2)

More than a week ago, Mr. Roden requested a copy of the proposed amendments, but he has not seen any amendments to SB1419. With the new federal Medicare prescription program being implemented he believes additional time is needed to address this issue before legislation is considered.

Anthony Wisneski, an attorney, testified in opposition to SB 1419.
Clyde Dailey, state director of AARP Idaho, testified and presented a letter of supporters. The letter reported:

We the undersigned support Idaho Rx, SB1419, and request your vote in the affirmative for this important legislation. The passage of S1419 will provide necessary relief to low and middle income Idahoans who do not have health insurance, by establishing a program which will allow them to purchase their prescription medication at discounted prices.

The passage of Idaho RX, S1419, promotes healthy and productive Idahoans and is consistent with our objectives of quality medical care and access to all residents of Idaho. The National Multiple Sclerosis Society, Easter Seals­Goodwill, Area 3 Agency on Aging, Idaho Council on Developmental Disabilities, Idaho Community Action Network, Americans With Disabilities Task Force, Comprehensive Advocacy, Inc., Living Independence Network Corp., Idaho Health Care Association, the National Alliance for the Mentally Ill of Southeast Idaho, Idaho State Independent Living Council, the Center on Disabilities and Human Development, Policy Division, and Epilepsy Foundation of Idaho, are listed as supporters of SB1419.

Kathleen Allyn, deputy administrator of the Division of Medicaid for the Department of Health and Welfare, explained the Department is neutral on SB1419. She explained the Department's cost estimate for SB1419, the expenses, total cost, and cost to the state general fund.

  • 6 FTEs enrollment staffing, total cost $300,000 (all general fund)
  • EPICS, AIM, Fiscal, Smart PA system changes:

  • Programming, total cost $2,062,500 (all general fund)
  • Training, manuals, project management, total cost $687,500 (all general fund)
  • 2 FTEs pharmacy rebate, total cost $100,000 (all general fund)
  • 1 FTE pharmacy help desk, total cost $50,000 (all general fund)
  • 1 FTE project coordinator, Total cost $50,000 (all general fund)
  • Outreach, total cost $50,000 (all general fund)


The total cost to implement SB1419 would be $3,300,000 and all from the general fund.

This assumes six (6) staff could enroll up to 75,000 eligibles over a one-year period, with no eligibility verification (even automated), no ongoing case maintenance, and no Quality Assurance eligibility activity; temporary staff would be needed at peak times, with some delays in processing likely if a large number of applications are received in a short time period within the startup year. This assumes start-up period of one year.

The proposed legislation's sponsor maintains that the development and maintenance costs of the program can be funded through supplemental rebates (to be negotiated), and application fees (up to $225,000) generated by the program. However, any rebate and application fee revenues will not be available until after the program is operational.

Jeff Buell, a representative of Johnson and Johnson, testified to oppose SB1419. He explained that Idaho would need to spend millions of dollars to start-up this program. He distributed a copy of an Idaho Statesman news article dated March 3, 2004, about the state launching RxIdaho.org Web site for needy residents wanting low cost prescription drugs. (See Attachment # 3)

Mr. Buell also distributed a four-page handout with questions and answers about Idaho Rx.org, such as:

  • What is a patient assistance program?
  • Why were patient assistance programs created?
  • How long have assistance programs been in place?
  • How do pharmaceutical companies determine who qualifies?
  • How many patients have been helped by assistance programs?
  • What is the price tag for the millions of medications provided through assistance programs?
  • Where can people find more information about these programs?
  • How are you helping providers navigate patient medical privacy?

(See Attachment #4)

Written comments were received from the AARP Idaho, to support SB1419.

The Idaho Prescription Drug Purchase Card is a new card for low income and middle class Idahoans who are uninsured, or who lack prescription drug insurance.

The card enables qualified applicants to purchase their prescription medication at participating pharmacies at a discounted price. Savings are estimated at 15-60 percent off retail.

Discounted prices will be negotiated with prescription drug manufacturers by the Department of Health and Welfare.

Who is eligible?

An individual or family whose annual family income does not exceed 200 percent of the federal poverty level. The person or family must be an Idaho resident and be uninsured or lack prescription drug insurance.

Examples of income eligibility:

Individual with an annual income of $17,960 or less;

Family of two with an annual family income of $24,240 or less;

Family of four with an annual family income of $36,800 or less.

An individual or family who qualifies for the program may apply at any one of the Department of Health and Welfare's eligibility offices located throughout Idaho. The enrollment form may either be completed in person or be mailed to the Department of Health and Welfare.

Who will benefit?

It is estimated that 64 percent of uninsured children in Idaho will be eligible for the discount prescription drug card and 57 percent of adults.

Eligible Idahoans are estimated to save 15-60 percent off the retail price of drugs. Savings on prescription drugs that mean thousands of dollars to Idahoans.

MOTION: A motion was made by Senator Bailey to send SB1419 to the 14th Order. The motion was seconded by Senator Darrington, and the motion was carried by a voice vote.
HJM 25 Chairman Brandt explained that HJM 25, relating to skilled nursing facilities, would be routed on a buck slip. The proposed joint memorial did not arrive from the House Health and Welfare Committee in time for a hearing today.

Robert Vande Merwe, executive director of the Idaho Health Care Association, presented the following letter.

I am sorry that HJM25 is so late coming to you. The House did not hear it in time for you to consider it in today's meeting. We are asking that you approve a buck slip to allow HJM25 to go directly to the floor next week after you receive it.

This memorial is not opposed by the Health and Welfare, and is expected to easily pass the House.

It asks our Congressional Delegation to apply for a waiver to allow "deemed status" in skilled nursing facilities (SNFs). This means that if a facility is willing to pay for and is successful in acquiring accreditation by an approved national accrediting body, such as JCAHO, then the Department of Health and Welfare would not be required to complete a thorough compliance survey. They would be "deemed" to be in compliance with the regulations. Hospitals have "deemed status" while SNFs do not.

Not many facilities, 20 percent perhaps, would be willing or able in meeting the stringent standards of the accrediting body. Those that do, however, will be Idaho's finest SNFs. A thorough and expensive Federally mandated compliance survey conducted by Health and Welfare is unnecessary and wasteful for such a facility.

As the fiscal impact indicates: "Tens of thousands of dollars could be saved if the department is not required to inspect these exceptional, accredited Skilled Nursing Facilities.

Please accept our apologies for getting this to you so late, and please approve the forthcoming buck slip. Thank you very much.

ADJOURNED: The committee adjourned at 9:39 a.m.




DATE: Thursday, March 18, 2004
TIME: 8:30 a.m.
PLACE: Room 437
MEMBERS PRESENT: Chairman Brandt, Vice Chairman Compton, Senators Sweet, Bailey, Kennedy, Darrington
MEMBERS

EXCUSED:

Senators Ingram, Stegner, Burkett
GUESTS: See the attached sign-in sheet.
Introduction Senator Williams introduced Randy Young, Young's Septic Service, from District 28.
TESTIMONY Randy Young stated the nature of his business and the history of the property where he land applies sewage. In the 31 years of business Young's Septic Service had never received any complaints until Mr. Aaron Gepford took residence in a property adjoined by fence line to the land where Young's land applies sewage. Since then he has been denied permits because he did not meet the guidelines and setbacks according to Department of Environmental Quality (DEQ). He has submitted soil samples, and water samples as directed by DEQ. The results were acceptable readings of nitrates and metals. He stated he conducts his business in an environmentally safe manner. Mr. Young stated he never received 503 Rules until he was shut down. He stated DEQ's actions are related to Mr. Gepfords pressure.
TESTIMONY Aaron Gepford stated he has been sued by Young's three times. He stated Young's does not adhere to the regulations of land applying domestic septage. Mr. Gepford stated he supports DEQ and their actions. He stated there should be three C's: Clean Up, Containment, and Compensation. Clean up and testing should be required on every land application site after the site is closed. He stated containment is necessary, by the enforcement of current setbacks as established in 1994. He concluded by stating compensation should be required, every land application site should be required to be bonded or insured.
TESTIMONY Steve Allred, Director Department of Environmental Quality, stated Randy Young has appealed the decision of DEQ to deny his permit. The appeal hearing will be before the Board in May, 2004. He stated no citations have been issued in this matter. He stated the setbacks are in place for health safety.
Discussion Discussion on the subject included:
  • Does DEQ provide copies of the Rules when individuals apply for permits. Mr. Allred stated the rules are listed on the website, and they are readily available. He stated individuals are explained what the rules mean to them.
  • Mr. Allred stated land application is allowed only on specific sites.
ADJOURNMENT Chairman Brandt adjourned the meeting at 9:30 a.m.