THE COUNCIL OF STATE GOVERNMENTS 2012 National Conference HEALTH POLICY TASK FORCE

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1


THE COUNCIL OF STATE GOVERNMENTS

20
12 National Conference


HEALTH

POLICY TASK FORCE


2:30
-
4:30 p.m.

Saturday,
December 1, 2012

Austin, Texas


POLICY & BUSINESS SESSION


Presiding:

Co
-
Chair:
Senator Kim Gillan, Montana


I.



Welcome and Member
Introductions



Senator Kim Gillan, Co
-
Chair


II.


Policy Session: Balancing Costs, Benefits of Medicaid Programs



Dr. Joseph Thompson, Arkansas Surgeon General



Dr. Kyle Janek
,

Executive Commissioner, Texas Health and Human
Services



April Alexander,
Regional

Director, State Affairs, Molina Healthcare


III.


Policy Session: Program Integrity Efforts by States



Matt McKillop,

Senior Associate, Research, Sta
te Health Care
Spending Project, Pew Charitable Trusts


IV
.


Business Items



Policy Resolutions

o

Task Force

members will have the

opportunity to submit,
discus

and vote on policy resolutions. T
hose resolutions
passed by the Task F
orce are forwarded for further
consideration and adoption by the Inter
governmental Affairs
Committee
and then the Executive Committe
e.

o

Resolution on Chronic Care Coordination,
Representative
Bob Godfrey, CT, Sponsor

o

Resolution Supporting Criminal Background Checks for
Nurses Applying for State Licensure,

Katherine A. Thomas,
Executive Director, Texas Board of Nursing


V.


Response
Items



CSG Policy Initiatives
, Debra Miller, CSG Director of Health Policy



Round Table Discussion:
Pressing Issues and State Solutions


VI
.


Adjourn

2


Speaker Biographies



Joseph W. Thompson, MD, MPH,
Arkansas Surgeon General and Director, Arkansas
Center f
or Health Improvement


Dr. Joe Thompson’s work is centered at the intersection of clinical care, public health
and health policy. He is responsible for developing health policy, research activities
and collaborative programs that promote better health and health care in Arkansas
. Dr.
Thompson works closely with the governor’s office, the Arkansas legislature and
public and private organizations across the state on relevant health policy topics.

Dr. Thompson has led vanguard efforts in planning and implementing health care financ
ing reform,
tobacco
-

and obesity
-
related health promotion and disease prevention programs. He was the lead architect
of the Tobacco Settlement Act of 2000 and instituted the Arkansas Health Insurance Roundtable. Under
his leadership, ACHI helped pass the C
lean Indoor Air Act of 2006, documented the state’s success in
halting progress of the childhood obesity epidemic, and helped implement ARHealthNetworks,
Arkansas’s health care benefits waiver for low
-
income workers.

Dr. Thompson has been at the forefront

of both Arkansas’s leading
-
edge efforts against childhood obesity
and in national efforts to reverse childhood obesity as the former Director of the Robert Wood Johnson
Foundation (RWJF) Center to Prevent Childhood Obesity.

He currently serves on the Ark
ansas Board of Health and is past president of the Arkansas Chapter of the
American Academy of Pediatrics. Nationally, Dr. Thompson serves on the board of the Campaign to End
Obesity and of AcademyHealth, as well as serving on Institute of Medicine’s stand
ing committee on
childhood obesity.

He is author of numerous articles and publications that reflect his research interests in
the areas of health and health care including access, quality and finance.

Dr. Thompson earned his medical degree from the Unive
rsity of Arkansas for Medical Sciences and
Master of Public Health from the University of North Carolina at Chapel Hill. He served as the RWJF
Clinical Scholar at the University of North Carolina at Chapel Hill, the Luther Terry Fellow in Preventive
Medici
ne advising the U.S. assistant secretary of Health in Washington, D.C., and the assistant vice
president and director of research at the National Committee for Quality Assurance in Washington,
D.C.

In 1997, he served as the First Child and Adolescent Heal
th Scholar of the U.S. Agency for
Healthcare Research and Quality (then the U.S. Agency for Health Care Policy and Research) before
returning to Arkansas.


Kyle Janek, MD,

Executive Commissioner, Texas Department of Health and Human
Services


A lifelong
Texan, Kyle Janek was born and raised in Galveston. After serving eight
years in the Texas House of Representatives, he was elected to the State Senate for an
additional 13 years. In September 2012, he was appointed by Governor Rick Perry to be
Executive C
ommissioner of the Texas Health and Human Services Department, a $16
billion operation that oversees health and human services, including Medicaid.


Senator Janek received a Bachelor of A&M University in 1980. He went back to his hometown to attend
medica
l school at the University of Texas Medical Branch. Upon receiving his Doctor of Medicine
3


degree, he took a residency in anesthesiology at UTMBi. He served as a Chief Resident his final year. A
board
-
certified anesthesiologist, Dr. Janek was in private pra
ctice at Lakeway Regional Medical Center
near Austin before accepting Gov. Perry’s appointment.



Dr. Janek has been a sponsor of medical missions to Central America. He is an active sponsor of

local little league teams and a member of both the Greater
Southwest Houston and the Fort Bend

Chambers of Commerce





April Alexander,

Regional Director, State Affairs, Molina Healthcare


April Alexander serves as Regional Director of State Affairs at Molina Healthcare in
Sacramento, California, where she manag
es the legislative affairs for the western
region Molina states.


In this role, she works with the Washington, California, Utah
and New Mexico Molina health plans to develop and implement legislative,
regulatory and political strategy.




Before Molina, s
he served as the Director of Legal and Regulatory Affairs for the
California Association of Health Plans,


where she was responsible for regulatory advocacy on behalf of
the health plans that participate in California’s state health programs and for provid
ing legal and policy
support on a variety of Medicaid and CHIP legislative issues.


Before entering the private sector, she
served as licensing counsel at the California Department of Managed Health Care.




April holds a J.D. from University of the Pacific


McGeorge School of Law and a Bachelor’s degree in
Political Science from Cal State, Chico.






Matt McKillop,

Senior Associate, Research, State Health Care Spending Project ,
Pew Charitable Trusts


Matt

McKillop is a senior associate for Pew’s States’ Health Care Spending
project, a joint initiative with The John D. and Catherine T. MacArthur
Foundation, that analyzes health care spending across the 50 states over the past
decade, delves into the factors

driving up costs, and examines the effectiveness of
cost
-
containment efforts. McKillop coordinates the project’s research on cost
-
containment strategies.


Previously, he conducted research on other state fiscal issues, such as pension and retiree health
care
benefits and states’ budget balancing measures. He also helped lead a cross
-
cutting communications team
within the Pew Center on the States. Prior to Pew, he led advocacy and community organizing campaigns
for So Others Might Eat, a nonprofit organiza
tion that serves poor and homeless residents of the District
of Columbia.


McKillop holds his master’s degree in public policy from The George Washington University and a
bachelor’s degree in political science from Kalamazoo College.




4


THE COUNCIL OF
STATE GOVERNMENTS

RESOLUTION ON CHRONIC CARE COORDINATION


Resolution Summary


Seven in ten deaths in the United States are caused by chronic disease, a total of 1.7 million deaths each
year.
1

The chronic diseases include heart disease, cancer, stroke, res
piratory diseases and diabetes. Most
importantly there is considerable evidence about how to prevent, postpone and treat these diseases.
2


There is little doubt that the level of health care spending in the U.S. is defining the current debate about
health
care. The most common chronic diseases cost the U.S. more than $1 trillion per year. In just 4
decades, by 2050, that cost will increase by a factor of six to $6 trillion per year.
3


Implementing evidence
-
based prevention strategies can reduce health care
costs borne by states for its
employees, state retirees and its low
-
income and disabled populations enrolled in Medicaid. For example,
8 out of 10 of the top 1 percent of Medicaid utilizers have at least three chronic conditions and 6 out of 10
have five o
r more chronic conditions.
4

The issue is even more prevalent in the dual eligible population


those are elderly or disabled persons eligible for both federal Medicare and state Medicaid


which
accounts for 38 percent of Medicaid spending overall and have

an average of 4.2 conditions, 5 physicians
and 5.6 prescribers.
5

One estimate is that 83 cents of every Medicaid dollar is spent on preventable and
highly manageable chronic diseases, including diabetes, asthma and hypertension.
6


Care coordination supports information
-
sharing across providers and involves consumers in their own
health care. The goal of care coordination is to ensure that patients’ needs and preferences are achieved
and that care is efficient and of high quality.



Additional Resources




Centers for Disease Control and Prevention


http://www.cdc.gov/chronicdisease/index.htm



CDC Chronic Diseases and Health Promotion


http://www.cdc.gov/chronicdisease/overview/index.htm




CDC Chronic Disease Statistics and Tracking


http://www.cdc.gov/chronicdisease/stats/index.htm




CDC Chroni
c Disease State Profiles


http://www.cdc.gov/chronicdisease/states/index.htm




1

http://www.cdc.gov/chronicdisease/index.htm, accessed on October 16, 2012
.

2

Ibid.


3

DeVol, Ross,
et al
.

An Unhealthy America: The economic burden of chronic disease.


The Milken Institute. October 2007
.



4

http://knowledgecenter.csg.org/drupal/system/
files/filearea/medicaid/day_two.dematteis.pdf

5

http://knowledgecenter.csg.org/drupal/system/files/filearea/medicaid/day_two.dematteis.pdf

6

Partnership To Fight Chronic Disease. (2011). “Medicaid in a New Era: Proven Solutions to Enhance Quality and Reduce

Costs.”
http://www.fightchronicdisease.org/events/medicaid
-
new
-
era
-
proven
-
solutions
-
enhance
-
quality
-
and
-
reduce
-
costs
,
accessed on Nov. 7, 2012
.

5




CSG Knowledge Center, The Diabetes Crisis: Today and Future Trends


http://knowledgecenter.csg.org/drupal/content/diabetes
-
crisis
-
today
-
and
-
future
-
trends



CSG Knowledge Center, Alzheimer’s Disease and Caregiving


http://knowledgecenter.csg.org/drupal/content/Capitol
-
Research
-
alzheimers
-
disease
-
and
-
cargiving



CSG Knowledge Center, Removing barriers to coordinated care

seen as key to better patient
outcomes, lower health costs


http://knowledgecenter.csg.org/drupal/content
/removing
-
barriers
-
coordinated
-
care
-
seen
-
key
-
better
-
patient
-
outcomes
-
lower
-
health
-
costs





CSG Knowledge Center, Medicaid Policy Academy, June 27
-
29, 2012


http://knowledgecenter.csg.org/drupal/content/medicaid
-
policy
-
academy
-
june
-
27
-
29
-
2012



Partnership to Fight Chronic Disease


http://www.fightchronicdisease.org/






CSG Management Directives




Managemen
t Directive #1:

Copies of this resolution will be sent to the Secretary of the United States
Department of Health and Human Services (HHS), the Director of the federal Centers for Disease
Control and Prevention (CDC), the Association of State and Territori
al Health Officials (ASTHO),
the National Association of County and City Health Officials (NACCHO), appropriate legislative
leaders throughout the country and the nation’s governors.




Management Directive #2:

CSG staff will post approved resolution on
CSG’s Web site and make it
available through CSG’s regular communication venues at the state and local level to ensure its
distribution to the state government and policy community.




















6


RESOLUTION ON CHRONIC CARE COORDINATION


WHEREAS,

chronic disease is recognized as the leading cause of disability and death in the United
States; and accounts for 1.7 million deaths or 70% of all deaths in the U.S. each year; and

WHEREAS,

chronic diseases


such as heart disease, stroke, cancer, respir
atory diseases and diabetes


are among the most prevalent, costly, and preventable of all health problems; and

WHEREAS,

implementing prevention programs around multiple chronic conditions can help states
reduce the overall financial burden of chronic ill
ness within public programs such as Medicaid and
Medicare, as well as state employees’ health insurance; and

WHEREAS,

the inefficient coordination of care for people with chronic conditions has led not only to
higher costs, but poorer health outcomes for
the most vulnerable populations within states. For example, 8
out of 10 of the top 1 percent of Medicaid utilizers have at least three chronic conditions and 6 out of 10
have five or more chronic conditions. The issue is even more prevalent in the dual eli
gible population
which accounts for 38 percent of Medicaid spending overall and have an average of 4.2 conditions, 5
physicians and 5.6 prescribers; and

WHEREAS,

preventing and treating chronic disease is an important public health initiative that will
im
prove the quality of life for state residents affected by these conditions and will reduce Medicaid costs
to the states;

NOW, THEREFORE BE IT RESOLVED,

that The Council of State Governments encourages states to
consider the feasibility of implementing an assessment and review of all chronic disease management
programs in states by:



Considering the creation of a Chronic Disease Legislative Caucus to ident
ify best practices in
chronic care coordination and to make recommendations to the Governor, Legislature,
Department of Health and other relevant state agencies in an effort to take steps to reduce the
burden of multiple chronic conditions on the state and

its residents.




Considering the development of a state plan to meet the health care needs of residents with
multiple chronic conditions.


Adopted this 3
rd

Day of December, 2012, at CSG’s 2012 National Conference in Austin, Texas.
















Governo
r Luis Fortuño, PR



Senate Majority Leader Jay Scott Emler, KS

CSG National President



CSG National Chair




7


Resolution Supporting Criminal Background Checks for Nurses Applying for State
Licensure

The role of state boards of nursing is to protect the
public against unsafe practitioners and ensure that
those who are licensed are safe to practice.

These state boards license approximately 3.2 million nurses,
including licensed practical/vocational nurses, registered nurses, and advanced practice registere
d nurses.
Most states have one licensing board for all nurses in the state. Four states have separate licensing boards
for licensed practical/vocational nurses (California, West Virginia, Louisiana, and Georgia). Nebraska
has a separate licensing board
for advanced practice registered nurses.


A significant number of applicants for nurse licensure have criminal histories. Out of the first 11,846
fingerprints processed in Kansas, nearly 15% of licensee applicants had criminal histories
7
. Many of
these t
ransgressions may be relatively innocuous. However, there are a significant number of instances in
which a nurse with a criminal history violated public trust and jeopardized the safety of patients. For
example,
a nursing school graduate in Kansas submit
ted an application for licensure
8
.
The background
check revealed that the applicant had five drug and alcohol convictions
9
. The name on the convictions
did not match the name the graduate put on the licensure application
10
.
Only a fingerprint based
backg
round check could have revealed these convictions. In another example from Texas, the Board of
Nursing granted restricted licensure to a nurse with a known non
-
violent criminal history
11
. Several
months later, the state’s Rap Back program automatically
alerted the Board to the fact that authorities
recently arrested the nurse for the aggravated sexual assault of two patients
12
. Upon learning of these
arrests, the Board immediately suspended the nurse’s license to make certain no other patients could be
e
ndangered
13
. Boards of nursing need criminal history information to ensure that a nurse is unlikely to
harm patients. Those most at risk of harm include the young, disabled, and elderly populations.

Criminal background checks (CBCs) are an effective tool t
o ensure public safety because criminal
histories often indicate potential for future criminal behavior. Statistics from the U.S. Department of
Justice confirmed that over two
-
thirds of released prisoners are rearrested within three years
14
. Results
from
the Federal Background Check Pilot Program for Long
-
Term Care Workers (2008) showed that over
the course of the study, conducting CBCs prevented more than 9,500 applicants with a history of
substantiated abuse or a violent criminal record from working with

and preying upon frail elders and
individuals with disabilities
15
.




7

Blubaugh, MSN, RN, Mary. (2012). Using Electronic Fingerprinting for Criminal Background Checks.
Journal of
Nursin
g Regulation
, Volume 2 (Issue 4), 50
-
52.

8

Blubaugh (2012).

9

Blubaugh (2012).

10

Blubaugh (2012).

11

Based on conversations with
the Texas Board of Nursing.

12

Based on conversations with
the Texas Board of Nursing.

13

Based on conversations with
the Texas

Board of Nursing.

14

Langan, PhD, Patrick A, & Levin, PhD, David J. (2002). Recidivism of Prisoners Released in 1994.
Bureau of
Justice Statistics Special Report,
June 2002, NCJ 193427. See:
http://bjs.ojp.usdoj.gov/content/reentry/recidivism.cfm

15

Senate Special Committee on Aging. (2008.) Building on Success: Lessons learned from the federal background
check pilot program
for long term care workers. See:
http://aging.senate.gov/letters/bcreportexecsummary.pdf

8


While nearly all jurisdictions ask applicants to self report any criminal history upon application for
licensure, data reflect that many nurses with criminal histories fail to self report.

In Kansas, 29% of
nurses with criminal histories seeking initial licensure failed to disclose a criminal history during the
initial period of implementation
16
. Prior to enactment of CBCs, the Texas Board of Nursing identified 35
applicants who failed to
disclose criminal background information on their applications
17
. After
instituting CBCs, the Board identified 262 applicants who failed to disclose a criminal history
18
. This
demonstrates that CBCs more effectively uncover the identity of nurses with crim
inal histories, many of
which would not otherwise disclose offenses if simply asked to self report.

The implementation process is simple. Applicants can go directly to the board of nursing for
fingerprinting or any other facility designated by the board.

Fingerprints can be obtained via live scan or
paper and ink. Once collected, the fingerprints are sent to the FBI. The FBI conducts the background
search and sends this information to the board. Then, the board decides how to process this information.

Every jurisdiction currently conducting criminal background checks places the cost of the service on the
applicant.

Currently the National Council of State Boards of Nursing (NCSBN) is conducting a major initiative to
assist boards in the adoption of sta
te and federal criminal background checks. Of the nation’s 55 boards
of nursing (excluding U.S. territories), 40 boards conduct state and federal CBCs. Fifteen states, Alabama,
Colorado, Connecticut, Hawaii Maine Massachusetts Minnesota, Montana, Nebrask
a, New York,
Pennsylvania, Vermont, Virginia, Washington, and Wisconsin do not. This disparity is disconcerting and
constituents in states involved in the Nurse Licensure Compact are put at risk. Nurses with criminal
licenses could take advantage of the
Compact by seeking licensure in a less restrictive state, bypassing
background check laws of more restrictive states, and freely practicing in any Compact state. The goal of
the NCSBN initiative is to have all states enact state and federal CBCs by 2015.


Additional Resource Information


National Council State Boards of Nursing Website: CBC Call to Action Initiative
--

https://www.ncsbn.org/2946.htm?the_url=&rdePwdDays=
9223372036854775807

Blubaugh, MSN, RN, Mary. (2012). Using Electronic Fingerprinting for Criminal Background Checks.
Journal of Nursing Regulation
, Volume 2 (Issue 4), 50
-
52.


Available at:
https://ww
w.ncsbn.org/CBC_article.pdf

Protecting the Public: State and federal Criminal Background Check Fact Sheet


Available at:
https://www.ncsbn.org/CBCs_General_October2012.pdf

NCSBN is willing

work with stakeholders by providing educational resources and expertise. Please feel
free to contact NCSBN with any questions about this initiative at:
policyandgovernmentrelations@ncsbn.org
.






16

Blubaugh (2012).

17

Based on conversations with
the Texas Board of Nursing.

18

Based on conver
sations with
the Texas Board of Nursing.

9


Nurses Criminal Background Check Management Directives



Management Directive #1:

The Council of State Governments will educate policymakers and other
stakeholders of the urgent need for criminal background checks for nursing licensure as a public safety
issue.



Management Directive #2:

The Council of State Governments’ Health Policy

Task Force will post
approved resolution on The Council of State Governments’ website.



Management Directive #3:

The Council of State Governments will distribute a copy of this resolution
to appropriate legislative leaders, government stakeholders, exte
rnal stakeholders, and state governors.



Management Directive #4:

Work with states considering the introduction of legislation related to
criminal background checks to identify needs and concerns. Prepare and disseminate relevant tools and
resources to
these states.





























10


THE COUNCIL OF STATE GOVERNMENTS

RESOLUTION SUPPORTING CRIMINAL BACKGROUND CHECKS FOR

NURSES APPLYING FOR STATE LICENSURE


WHEREAS
, nurses work with the sick, disabled, elderly and other vulnerable populations,
and
it is in the interest of public safety to review nurse licensure applicants’ past criminal behavior in
determining whether they should be granted a license to practice nursing in a state or territory;


WHEREAS
, criminal histories are indicative of futu
re criminal behavior, and data show that
two
-
thirds of paroles released commit a new offense or violate parole within two years of
release;


WHEREAS
, applicants for nurse licensure with criminal histories may not reveal a positive
criminal history on appl
ications, and fingerprint based background checks are an effective tool
to identify past criminal behavior and ensure ongoing patient safety;


WHEREAS
, of the nation’s 55 boards of nursing (excluding U.S. territories), 40 boards conduct
state and federal C
BCs. Fifteen boards do not. This progress has been significant, but we need
every state to conduct criminal background checks;


WHEREAS
, boards of nursing assure the security and confidentiality of the background
information and must comply with any state
or federal requirements to obtain access to state
criminal background checks, making this process fair to licensure applicants;


WHEREAS
, Public Law 92
-
544 provides funding to the Federal Bureau of Investigations (FBI)
for acquiring, collecting, classifyin
g, preserving and exchanging identification records with duly
authorized officials of the federal government, the states, boards of nursing, cities, and other

institutions;


BE IT NOW THEREFORE RESOLVED,
that the Council of State Governments urges states
t
o conduct fingerprint based criminal background checks on all nurse licensure applicants by
enacting a relevant provision in the jurisdiction’s Nurse Practice Act or relevant regulations;


BE IT FURTHER RESOLVED
, that The Council of State Governments reco
mmends that
states work with their boards of nursing in developing plans to conduct nurse licensure
comprehensive federal and state criminal background checks.


Adopted this 3
rd

Day of December, 2012, at CSG’s 2012 National Conference in Austin, Texas.
















Governor Luis Fortuño, PR



Senate Majority Leader Jay Scott Emler, KS

CSG National President



CSG National Chair