H_PHC_2016A 01/08/2016 Committee Summary

09:08 AM -- Introductory Comments



Representative McCann called the meeting to order. A copy of the meeting agenda was distributed (Attachment A). She announced that the Joint Health Committee would meet on Thursday, January 14, 2016, and Thursday, January 21, 2016, and agendas for those meetings were distributed (Attachment B). Representative McCann stated that she would be allowing public testimony on the Consumer-directed Attendant Support Services Performance Audit during the afternoon portion of the meeting.



160108 AttachA.pdf160108 AttachB.pdf



09:09 AM -- Presentation by the Commission on Affordable Health Care



Bill Lindsay, Colorado Commission on Affordable Health Care (CCAHC) Chair, introduced himself and provided a presentation handout (Attachment C). He highlighted the legislative charge of the CCAHC and the commissioners who serve on the CCAHC. He referenced newspaper articles concerning high health care costs that are referred to in the handout. He outlined the phases of work for the CCAHC, and stated that the CCAHC is now in the evaluation phase. Mr. Lindsay reviewed the framework for the CCAHC outlined on page 8 of the handout.



160108 AttachC.pdf



09:15 AM



Cindy Sovine-Miller, CCAHC Co-chair, discussed the importance of transparency and informing customers about the quality and cost of health care. She reviewed the information on page 10 of the handout about health care spending. She discussed the shortage of primary care providers in Colorado. Ms. Sovine-Miller reviewed the health insurance coverage data provided on page 11 of the handout. She reviewed the work plan and timeline for the CCAHC.



09:22 AM



Representative Primavera discussed the physical rehabilitation study that was conducted by the CCAHC. Mr. Lindsay answered questions about the study. There was discussion about establishing a pilot program to provide additional data about potential cost savings that could be provided by physical rehabilitation and other therapies.



09:31 AM



Representative Joshi asked Mr. Lindsay about administrative costs related to health care. Discussion continued about increases in public health insurance enrollment, increased health insurance rates, and pharmaceutical costs. Ms. Sovine-Miller and Mr. Lindsay answered questions about the funding for the CCAHC. Discussion about health care costs ensued. Senator Lundberg referenced medical cost-sharing programs.



09:44 AM



In response to a question, Mr. Lindsay discussed the charge of the CCAHC and whether the CCAHC would be analyzing the underlying costs of health care. He discussed providing patients with options on care to make informed health care decisions. Discussion ensued about prescription drug costs and access. Ms. Sovine-Miller answered questions about whether the CCAHC partners with the Colorado Department of Labor and Employment to access data related to employer-sponsored health insurance. In response to a question, Mr. Lindsay discussed aspects of the federal Patient Protection and Affordable Care Act.



10:00 AM



Mr. Lindsay answered questions about the funding for the CCAHC. Dialogue about the CCAHC ensued.





10:07 AM -- SMART Government Act Briefing for CDPHE



Dr. Larry Wolk, Executive Director of the Colorado Department of Public Health and Environment (CDPHE), introduced himself and provided a presentation handout (Attachment D). Additionally, a copy of the CDPHE FY 2015-16 Implementation Plan (Attachment E) and 2016 CDPHE Regulatory Agenda (Attachment F) were distributed to the committee. Dr. Wolk referenced the FY 2014-15 Annual Report and the Governor's Health Plan. He highlighted the department's efforts to address oral health and obesity. Dr. Wolk discussed the department's efforts related to substance abuse and mental health, including the work of the Office of Suicide Prevention, and the department's work related to prescribing and dispensing of opioids. He outlined the department's work related to environment permitting, inspection, and monitoring.



160108 AttachD.pdf160108 AttachE.pdf160108 AttachF.pdf



10:18 AM



Dr. Wolk discussed the Healthy Eating Active Living Program and the strategies of the program related to diabetes prevention. He discussed the department's strategies for addressing mental health and substance abuse. He referenced the Prescription Drug Monitoring Program. Dr. Wolk discussed the efforts of CDPHE and the Suicide Prevention Commission to address suicide prevention. He reviewed the department's efforts related to healthier air and clean air. He discussed the department's business technology team. He explained how the department is working to promote health equity and environmental justice, including providing language services. Dr. Wolk discussed the department's performance management system and the data that is tracked through the system.



10:30 AM



Dr. Wolk outlined the department's legislative priorities, which include addressing radon risks and uranium mill tailings. He discussed the evidential breath alcohol testing. Dr. Wolk referenced potential legislation related to marijuana edibles, air ambulances, and immunization reporting.



10:35 AM



Dr. Wolk provided an update on the implementation of House Bill 14-1360, concerning the continuation of regulation of home care agencies by CDPHE. He highlighted the upcoming rule changes related to home care agencies.





10:37 AM



Dr. Wolk answered questions about pesticides used on marijuana. He discussed health information exchanges in response to a question about electronic access to medical records. Mr. Wolk answered questions about the long-acting reversible contraceptive program.





10:49 AM



Dr. Wolk addressed questions about the ability of the CDPHE to provide assistance in setting up a lactation room at the Capitol. Representative Primavera discussed the Legislative Cancer Caucus and the Colorado Cancer Plan. Committee discussion with Dr. Work ensued.



11:04 AM



Dr. Wolk answered questions about non-tobacco nicotine products, health information exchanges, emissions testing for hybrid vehicles, and the federal Clean Power Plan. He answered questions about the potential immunization-related legislation, fetal tissue regulation, and the Colorado Medication Take-Back Program. Dr. Wolk responded to questions about waste tires and the paint care program.





11:20 AM



Shannon Breitzman, CDPHE, and Dr. Wolk provided information about the Colorado Medication Take-Back Program. Discussion ensued about prescription drug abuse, heroin use, and marijuana edibles. Dr. Wolk responded to a questions about Krabbe Disease, oil and gas inspections, and radon mitigation. In response to questions, Dr. Wolk further discussed the Colorado Medication Take-Back Program, Prescription Drug Monitoring Program, and marijuana edibles.



11:54 AM -- Public Testimony



Josh Winkler, Colorado Cross-Disability Coalition, testified on the Consumer-directed Attendant Support Services Performance Audit. He provided an informational packet (Attachment G). Representative McCann asked Mr. Winkler to further explain his position on the audit findings. He expressed his concerns that the staff of the Office of the State Auditor only interviewed two clients when conducting the audit. He discussed the Consumer-Directed Attendant Support Services Program and responded to questions from the committee.



12:01 PM -- Presentation by the Statewide Child Fatality Review Team



Dr. Scott Harpin, Colorado Child Fatality Prevention System State Review Team Co-chair, introduced himself. He provided a presentation handout (Attachment H) and the 2015 Child Fatality Prevention System Annual Legislative Report (Attachment I). He reviewed the mission of the Colorado Child Fatality Prevention System (CFPS). He referenced the state laws concerning the review of child fatalities. Dr. Harpin provided a history of the CFPS and explained how the local review teams and the state review team work together.



160108 AttachH.pdf160108 AttachI.pdf



12:05 PM



Laurie Andrews, Colorado Child Fatality Prevention System State Review Team Co-chair, discussed child fatality review teams and the data collected through the CFPS.



12:08 PM



Dr. Harpin reviewed the progress on the 2014 CFPS recommendations and outlined the 2015 CFPS recommendations. In response to a question, Dr. Harpin said that county-specific child fatality data is available, upon request.



12:18 PM



Colleen Kapsimalis, Colorado Department of Public Health and Environment (CDPHE), answered questions about the Infant Safe Sleep Partnership training. Senator Newell discussed the Sources of Strength Program, which is a suicide prevention program for youth. Dr. Harpin and Ms. Kapsimalis answered questions about child fatality data.



12:25 PM



Ms. Kapsimalis answered questions about whether legislation would becoming forth based on the 2015 CFPS recommendations. She responded to questions about the interaction between the CDPHE and the Colorado Department of Human Services child fatality review teams. Discussion about the child fatalities ensued.



12:31 PM



The committee recessed.



01:35 PM -- Presentation of the Consumer-Directed Attendant Support Serv. Audit



Trey Standley, Office of the State Auditor (OSA), gave an overview of the OSA's role related to the SMART Act. He explained that the OSA is required to annually conduct audits on one or more specific programs or services in at least two departments. He described the analysis that the Office uses when auditing the programs. He discussed the audit report of the Consumer-Directed Attendant Support Services (CDASS) program in the Colorado Department of Health Care Policy and Financing (HCPF), and provided an OSA briefing document to the committee (Attachment J). Mr. Standley gave background information on the CDASS program and reported that the program served 3,124 clients and cost $82.3 million for FY 2014.



160108 AttachJ.pdf



01:40 PM



Mr. Standley reported on the program's performance plan. He told the committee that there were no performance measures in HCPF's FY 2015 Performance Plan that directly related to CDASS; however, it did include measures related to the Home- and Community-Based Service (HCBS) waivers. He described the performance measures for HCBS waiver programs set by HCPF. He stated that the audit found that the measures generally comply with SMART Act requirements; however, the audit recommends that HCPF do more to measure the cost effectiveness of the CDASS program. Mr. Standley discussed a HCPF 2013 study that compared the costs and outcomes of clients enrolled in CDASS to the costs and outcomes of clients who receive services through alternative delivery options. He stated that the study did not accurately reflect the cost effectiveness of the program. Overall, the program complies with client flexibility intended by statute and is line with program goals.



01:46 PM



Mr. Standley responded to legislator concerns about the small sample size of clients used for the audit. He noted that audits do not typically focus on clients or members of the public, but rather the focus is on case management and administration of the program. He told the committee that a client survey was ruled out due to the nature of the sensitive information, and that 30 client files were examined during the audit. He stated that two clients were interviewed for the audit due to their involvement with many aspects of the program and could speak generally.



01:55 PM



In response to legislator questions, Mr. Standley discussed the different cost comparisons for the programs. Mr. Standley explained that the savings from lower hourly rates for attendants in the program is recouped in other area of the program.



02:02 PM -- Jose Torres-Vega, Colorado Cross-Disability Coalition, testified in support of CDASS. He noted that the program requires a large amount of funding and expressed concern over the limited number of clients that were interviewed for the audit. He told the committee that he received training on how to manage funds he receives through CDASS. He also suggested that quality of life analysis to be included in the audit.



02:05 PM -- Christina Johnson,, stated that she has been in the CDASS program since 2008 and explained that she prefers CDASS to the agency home program due to quality of life issues. She expressed concern that the audit did not take into account the experiences of the clients. Ms. Johnson responded to questions from committee members.



02:10 PM -- Katherine Carol, self, explained that she is the mother of a child with a disability, and expressed support of the program. She told the committee that home health care was not a good experience for her and her daughter. She noted that her daughter has a social life and is able to work using CDASS. She stated that the program liberates individuals and families.



02:13 PM -- Angela Nevin, self, told the committee about her experiences as a care attendant employed by CDASS and expressed support for the program.



02:16 PM -- Linda Andre, self, testified in support of the program. She told the committee that she has been in the CDASS since the program inception. She explained that due to the services she receives through CDASS, she is able to have a job.



02:21 PM -- Debbie Miller, self. testified in support of the bill and discussed her families experience with the program. She noted that her son is in the program. She testified in support of the program, and explained negative experiences with agencies in the past.



02:27 PM -- Julie Farrar, self, testified in support of the CDASS program. She explained the Centers for Medicare and Medicaid Services requirements for long-term care, and talked about Colorado's long-term care system. Ms. Farrar responded to questions from members. She noted that CDASS client allocation is based on the needs of the individual.



02:36 PM -- Mark Simon, self, testified in support of the CDASS program. He explained that the program was created with the input of the clients. He noted difficulties with receiving agency care in his rural area, and explained how he receives services with CDASS. He explained the process of receiving allocations for CDASS and noted that he does not always use his full client allocation. He talked about the lack of fraud allegations for the CDASS program.



02:45 PM



Mr. Standley returned to the table. He responded to additional questions from members. He reiterated that collecting the data to compare CDASS to other programs would be very labor intensive. He confirmed that the content of the audit is typical for an OSA performance audit. Mr. Standley noted that HCPF agrees with all recommendations expect the cost effectiveness analysis, to which it partially agreed. It was noted that the program exists in other states.



02:52 PM -- Presentation of the Medicaid Prescription Drugs Performance Audit



Jenny Page, OSA, reported on the Medicaid Prescription Drugs Performance Audit. She referenced the report that was provided to the committee (Attachment K). Ms. Page explained that the the audit resulted from a legislative request over concerns about spending on Medicaid drugs, and focused on HCPF's efforts to control the the cost of outpatient prescription drugs in 2012 and 2013. She explained that federal regulations require HCPF to monitor use and prescribing of Medicaid drugs. Ms. Page explained the total fiscal year cost of prescription medications.



160108 AttachK.pdf



02:56 PM



Ms. Page went over the strategies and goals of the department related to Medicaid drug cost containment. She stated that the audit found that HCPF is attempting to reduce cost of prescription drugs through changes in payment to pharmacies, requiring pharmacies to provide generic drugs instead of brand name, annually monitoring prescription drug claims, and issuing reliable reports. Ms. Page explained that he audit found that HCPF is generally meeting legislative requirements and described key findings from the audit report. She reviewed audit recommendations and pointed out that HCPF generally agreed with the recommendations and will issue a status report to the Legislative Audit Committee.



03:01 PM



Ms. Page responded to questions from members. She explained further about the partially agreed to recommendations. Ms. Page explained that the preferred drug list is update at least annually. Ms. Page clarified the outpatient drug costs for the year. Ms. Page concluded the presentation.



03:08 PM -- Presentation of Annual Report: Status of Outstanding Audit Recommendations



Jenny Page, OSA, reported on the Status of Outstanding Audit Recommendations. She referenced a report that was distributed to the committee (Attachment L). The report gives a summary of outstanding audit recommendations that had not been implemented by departments as of June 30, 2015. Ms. Page explained the layout of the report. She told the committee that the report covers recommendations made to agencies from July 2009 to June 2014 and includes about 2,800 recommendations. 99 percent od the recommendations were agreed to at least partially by the departments. Ms. Page explained that departments set their own implementation date and noted that 96 percent of all recommendations have been implemented on time. 107 audit recommendations were still outstanding. Some recommendation are outstanding due to lateness or high priority.



160108 AttachL.pdf



03:12 PM



Pooja Tulsian, OSA, explained the outstanding audit recommendations for HCPF. She started with the eight outstanding financial recommendations, and explained the two high priority recommendations. She told the committee that there are no IT or performance recommendations outstanding. Ms. Tulsian responded to legislator questions. Ms. Tulsian noted that there is risk of federal sanction with the outstanding recommendations.



03:15 PM



Ms. Tulsian explained the outstanding audit recommendations for the Colorado Department of Human Services. She started with the 17 outstanding financial recommendations, and explained the two high priority recommendations. She explained that there are also IT and performance recommendations, but none outstanding. In response to a question, Ms. Tulsian explained that the recommendations are monitored annually for status until they are fully implemented.



03:19 PM



Kerri Hunter, OSA, explained the federal government's involvement in some of the audit recommendations. She noted that the report was created to alert the legislators of outstanding recommendations. Members expressed concern over the timing of outstanding and partially implemented recommendations.



03:23 PM



Ms. Tulsian explained that HCPF has not implemented the outstanding recommendations due to the computer system capacity, which will be resolved when system changes are implemented at the end of 2016. Ms. Page concluded the presentation.



03:25 PM -- Response from the Department of Health Care Policy and Financing



Susan Birch, Executive Director, HCPF, responded to the audit report presentation. She explained that HCPF understands the need for improvement and balance to the state budget. She discussed the CDASS audit, and explained the CDASS program concept. She confirmed that many other states have similar programs. She expressed department support for the client choice allowed by this program, and noted that fiscal accountability and transparency is also important. Director Birch noted that the department is on track with audit recommendations as of December 2015.



03:31 PM



Director Birch responded to questions from members. She explained that HCPF is committed to the CDASS program and ensuring its accountability. She noted that there will be small changes to the program, but there are no major changes planned. She noted that clients and stakeholders will be informed about potential changes within the program.



03:35 PM



Director Birch moved on the Medicaid drug audit. She reiterated the purpose and results of the audit. Most of the audit recommendations will be implemented with HCPF's updated pharmacy benefit management system (PBMS) later in 2016. HCPF will continue to monitor opiod drug over-utilization.



03:39 PM



In response to a question, Dr. Judy Zerzan, Chief Medical Officer, HCPF, explained Colorado's PBMS. The PBMS allows the department to track Colorado Medicaid money and volume quantity. Director Birch clarified that the Department of Regulatory Agencies, not HCPF, tracks prescription drug abuse. Dr. Zerzan explained that the new PBMS technology will monitor drugs more quickly and efficiently. Members expressed concern over the HCPF's access to information about prescription drug abuse.



03:44 PM



In response to a question, Dr. Zerzan explained that generic drugs make up about 85 percent of Medicaid prescriptions. The percentage has remained stable in the past few years, but may change due to new drugs. The legislators discussed a prescription drug monitoring bill. Members expressed concern over the abuse of prescription drugs by recipients and perscriptions provided by terminated Medicaid providers. Director Birch responded that scheduled upgrades to HCPF's IT systems will provide better oversight.



03:48 PM



In response to questions, Dr. Zerzan explained that the preferred drug list is evaluated each quarter and drug stability is considered when reviewing the list. Dr. Zerzan also explained that over-utilized recipients were found through the claims system. Dr. Zerzan explained the process for switching preferred drugs for chronic patients.



03:55 PM



Director Birch gave concluding remarks.



03:57 PM -- Presentation from Results First Regarding the Child Welfare System



Ann Renaud, Governor's Office of State Planning and Budgeting, presented on the Results First Initiative. She referenced a handout that was provided for the committee (Attachment M). She gave an overview of the Results First Initiative, its inception, employees, and program approach. She explained that under the Initiative, adult criminal justice, juvenile justice, and child welfare programs have been reviewed. She summarized the program inventories, and noted that 47 percent of programs reviewed use evidence based practices. These programs were modeled by the Initiative for cost-benefit. Ms. Renaud described the results of the cost-benefit model for each program area.



160108 AttachM.pdf



04:03 PM



Ms. Renaud responded to questions from the committee on the restorative justice program. She explained the return on investment formula and how it works for state run organizations and child welfare. She explained that the model is used as a cost avoidance tool. Ms. Renaud explained the child welfare programs analysis. She explained that the four programs analyzed have a positive return on investment.



04:11 PM



In response to a question, Ms. Renaud explained that the Pew Charitable Trust provides funding for the Initiative. The Initiative is looking to foundations and the General Assembly for future funding. Currently, the Initiative is working with departments to incorporate the model and build long term evaluation capacity in the state. Committee discussion followed about the negative impact programs identified by the Initiative. Ms. Renaud noted that the Department of Corrections has reviewed the analysis from the Initiative, and is working on improving programs that were analyzed. Ms. Renaud advised that more details on program analysis were available and full report is available on-line.



04:16 PM



Representative McCann adjourned the meeting.