If his bill passes, Chloe’s Law would be named for a little girl in Cass County who almost died from congestive heart failure because doctors didn’t realize she had oxygen toxicity. Representative Rick Brattin says the state should make testing mandatory.

Brattin says some hospitals in the Kansas City area have already started requiring the screening be done before newborns are released, and it’s already common practice for adults.

He says a pulse oximentry screening is done with a light … there’s no blood drawn and every hospital already has the devices to perform the screening, so there’s no cost incurred. Adults undergoing surgery are routinely checked for blood oxygen levels.

No one opposed the measure; The American Heart Association spoke in favor of the bill.

U.S. Health and Human Services Director Kathleen Sebelius made the recommendation last fall that all states require a pulse oximetry reading on newborns to detect congenital heart diseases, the number one cause of death for newborns.

Jay Nixon began by highlighting Missouri’s response to the disasters in the state last year. He keyed on the inspirational words of one Joplin tornado survivor, “always take that extra step.”

Missouri Governor Jay Nixon presents his State of the State Address to a joint session of the state legislature. Picture courtesy, Tim Bommel, Missouri House of Representatives.

Nixon touted that the state has not raised taxes and has reduced the size of government. With his proposed budget, he says, he reduces the state’s payroll by 4,100 positions. A total of 816 reductions are included in the new proposal. He notes the state’s workforce is the smallest its been in 15 years.

The address did not include the specifics of his proposed $106 million cut from the state’s 4-year and community colleges, but he did allude to it.

“To balance our budget in a way that protects our scholarships and academic programs I’m calling on our colleges and universities to continue to look for more ways to cut overhead and administrative costs and run smarter, more efficient operations.”

He said colleges and universities will have to change their business models. An example he offered is the “Innovation Campus” program at the University of Central Missouri.

“Students will enroll in college courses while still in high school and then participate in high-impact apprenticeships throughout the college curriculum.” he says. “Corporate partners will underwrite tuition scholarships and faculty and employees will partner to guide each student.”

Nixon encouraged the state’s institutions to develop similar programs.

The Governor stressed budget priorities, including education.

“For the past three years, even in challenging budget times, we’ve maintained level funding for our K-12 classrooms,” Nixon says. “This year we’re gonna take the next step. The budget I present tonight provides record funding for our K-12 classrooms because it’s the right thing to do.”

Some of Nixon’s calls to the legislature were familiar. In his only chide of the night he said, “For the past three years I’ve called for comprehensive tax credit reform. Some of you in this room stood with me on that issue, others did not.”

Nixon says over the past four years more than $2 billion in state tax credits have been redeemed. He re-iterated the call to pass legislation to retool and reform tax credits. He also urges legislators to create bills on charter school accountability and to increase the number of professionals working with autistic children.

Another priority that carries over is that of campaign finance limits. Nixon told the joint session, “When one person with an axe to grind can make an unlimited contritbution to advance a narrow agenda, when lobbyists for powerful interests can tip the balance in an election, the very foundations of our democracy are at risk.

AUDIO: Listen to Governor Jay Nixon’s 2012 State of the State Address (54 mins.)

AUDIO: Mike Lear reports (1 min.)

Rolla veterinarian Dan Brown is a state senator who wants a law enacted requiring all dog and cat owners to make sure the animals are vaccinated against rabies.  His bill says anyone who feeds or shelters an animal for three or more days would commit a misdemeanor if the animals don’t get their shots.

He says rabies most often is in wild animals.  But domesticated animals are the usual link between the rabid wild animals and humans. 

Some critics read his bill to mean farmers would have to inoculate their barn cats and people feeding feral cats in their neighborhoods would have to have them vaccinated.

St. Louis lawyer Dave Roland is the one who thinks the proposal is overkill. He cites numbers from the Bureau of Communicable Disease and Prevention for the last decade that there have been only about ten cases of domestic animal rabies  in the last ten years.  And he says Missouri has had only two rabies fatalities in the last 53 years. 

Brown says most communities already have rabies vaccination ordinances.  His bill targets rural areas. The Senate Agriculture Committee is studying it.

AUDIO: Listen to the committee hearing 47:45 

Director of the Department of Social Services' Family Services Division Alyson Campbell conducted a recent meeting with Medicaid stakeholders to discuss how the spend down is applied.

Family Support Division Director Alyson Campbell says it was discovered that some of the Division’s staff were allowing costs paid by Medicare or private insurance to count toward patients’ spend down amounts, which by federal guidelines is incorrect. When it began those staff members, individually, to amend that practice, the patients they worked with were impacted.

Division staff have held one meeting with providers and other stakeholders to discuss the situation. Campbell says the goal is to help people understand how the spend down must be applied and to look for other ways patients’ needs can be met within that structure.

She says the greatest impact regards the use of what she calls “wraparound services,” including transportation and homecare. “People are receiving those services today, and with the changes, or with the correction of the policy that we’re trying to implement, it’s possible that those services…they would not qualify for those services because the Medicaid coverage wouldn’t kick in as early in the month as it did previously.”

Campbell says right now the discussion is centered on what other options are available within federal guidelines.

The Division will host another meeting from 10:00 a.m. until noon January 5 in Room 400 of the Harry S. Truman Building in Jefferson City.

Margaret Donnelly says since September 2 when DHSS began handling those assessments it has acted on over 13,150 individual cases, and with faster service and shorter wait times than Syncare. She says that includes all the cases that were part of the so-called “backlog” left by that company.

Department of Health and Senior Services Director Margaret Donnelly

The Department continues to handle all new cases that have come in for assessment, re-assessment and care plan changes. She puts that at over 200 cases every day.

Donnelly says it is costing less for DHSS to handle those assessments than it would have to have operated under the Syncare contract. She wants to see the Department continue in the role through the end of the fiscal year.

Getting the state’s money back

In October DHSS referred the matter to the Attorney General’s Office. Since then, Donnelly says the state has recovered all of a $670,000 performance bond. The Attorney General’s office is still working to recover money from Syncare, who she says was paid a little over $1 million on a $5.5 million contract.

Donnelly says assessment of the Department’s performance is ongoing. “We are continuing to meet regularly and frequently with the stakeholders including the provider groups and advocates and legislators to discuss how services should be provided over the long term.” She says the chief concern for providers has been that clients needs are met in a timely, efficient manner. “And of course, all of us have the goal of making sure that is done in the most cost-effective way.”

The Department is also looking at other states that have systems in which providers take an active role in care plan development after assessments are completed. “It will take a while for us to develop the technology in that system, but we are in active discussions with the providers about increasing that role.”

What has changed since September

Donnelly is glad the situation has developed as it has. “I’m just really happy that we were able to get staff hired on a very tight timeline and get people the services that they need.” To those who experienced delays while Syncare was under contract, and after, she says, “I am very happy that the staff has come forward and we have had people just working long hours to be sure that we get the situation where it is today, which is that we are now moving forward with all new assessments and care plan changes being handled in a timely way, and that the cases which came to us from Syncare have all had action taken upon them.”

Lieutenant Governor Peter Kinder in October called on the Nixon Administration to allow the state’s healthcare providers to conduct assessments to clear the backlog left by Syncare as quickly as possible.

In response to Director Donnelly’s update on the situation, his office released this statement:

“Missouri law dictates these in-home healthcare assessments are to be completed within two weeks from when they are requested, yet it’s taken DHSS more than three months merely to get caught up with the backlog. In the meantime, how many new cases have been set aside? How many seniors and disabled Missourians have been denied assessments while DHSS has slowly whittled away at this backlog that shouldn’t have existed in the first place? What assurances do we have that DHSS will be able to prevent future backlogs?

“I will continue to work closely with seniors, senior advocates and in-home healthcare providers to make sure these assessments are being done on a timely basis and that those who need care and qualify for care are getting it. The Legislature also will address this through legislation in the coming session, and I will work with lawmakers, as well, to make sure we come up with a solution to keep this travesty from occurring again.”

Hinson’s planned approach is to put before voters a flat fee on cell phones statewide, though he is not sure yet what the amount will be. “Right now I’m looking at somewhere around 75 cents proposing to put on the ballot.”

In those counties that have a fee on landline phones to support 911, Hinson says his plan would repeal those and replace it with his cell phone fee. Part of the fee paid by each user would go back to the county he or she lives in. The rest would go into a fund to support statewide 911 system upgrades and mapping.

Other details to be worked out might deal with issues related to consolidating 911 centers across the state. Hinson hopes to have a bill ready soon after the session begins.

AUDIO:  Mike Lear reports – 1:00

Director Margaret Donnelly says the inspections and food trace-back investigation by federal agencies were extensive, but did not reveal a definitive source. She says a grower in California was suspected of being connected but records were “insufficient to complete the picture.”

She told the House Appropriations Committee on Health, Mental Health and Social Services it is not unusual for a source to go unidentified. “The food which caused the outbreak is identified in less than 50 percent of food bourne outbreaks, and the reason for that is because of the amount of time that passes from when the person is exposed to the pathogen until the public health receives a report. This incubation period can be up to ten days. In addition, after that period of time, food products are often no longer available for analysis.”

The outbreak cost the Department 25 thousand dollars in lab costs that Donnelly says were absorbed by its normal appropriation. 60 people were infected in 10 states; 37 of those were Missourians.

The spend down was created for Missourians with a disability or aged 65 or older whose income exceeds the limits of Medicaid eligibility. Those persons can qualify for Medicaid if they incur medical bills that exceed the difference between their net income and the eligibility limit. The amount that exceeds that limit is called the “spend down” amount.

Participants must meet the spend down monthly. One of the ways that is done is by having medical expenses that are not covered by a third party, such as Medicare or private insurance. At issue is that some providers have been allowing expenses that were covered by Medicaid or private insurance, which the Department says goes against the Federal policy for the plan.

Family Support Division Directory Alyson Campbell says the Department began correcting that practice. Providers who were allowing ineligible expenses were approached on an individual basis and told to follow Federal policy.

As those providers changed their practices, the recipients they dealt with had to stop using other supplemental services, like transportation to get to appointments and procedures.

Acting Director Brian Kincaid told the Committee the Department’s policy regarding the spend down has not changed. Rather, he says some of the Department’s workers were applying the program incorrectly.

The Committee also heard testimony from a man who says his mother was dealing with a provider who was asked to stop accepting some bills being covered by Medicare, toward the spend down. Michael Oliver’s mother has used a wheelchair since her leg was amputated and depends on dialysis. He says until the policy changed with her provider, she was transported to dialysis by a van with a wheelchair lift paid for by Medicaid. Now, he says she may have to move to a facility to receive treatment and be separated from her husband. He says going to such a facility or using other transportation sources will cost more than she makes in a month.

Kincaid says no more changes in application will be taking place for the time being. “Because of the confusion and the anxiety around the issue of…that’s what we tried to clarify earlier in the month by having our workers continue to do…however they were doing spindown, continue to do that so we keep an even keel.”

The Division is preparing to assemble a committee to try and explain the issue. Campbell says they will, “walk through what is ‘spend down,’ and to make sure that everyone understand that we are attempting to, and it’s our responsibility to follow the Federal law. So we want to have discussion with the people that will be impacted by this so that we can all get on the same page.” A meeting has been scheduled for December 14.

Campbell says an administrative rule will also be filed. “In my review of the situation, it’s very apparent that we need to be more specific in the regulation that governs the spend down program for Missouri. By doing that, we can also make sure that our policy is in line with the regulation in the federal law.’

Kincaid says providers, patients and patient advocates need to contact the Department with any issues.

The Committee has asked to have a representative present when that committee meets.

AUDIO:  Hear the testimony of Acting Director of the Department of Social Services, Brian Kincaid and Family Services Division Director Alyson Campbell before the House Appropriations Committee on Health, Mental Health and Social Services – 49:09

Doctor Steven Zweig, who passed the nation’s first certifying examination in geriatric medicine, has made it his focus throughout a career that has put him in charge of the family and community medicine department at the University of Missouri School of Medicine in Columbia.

His article in the October Journal of the American Medical Association says there is a growing need for doctors who can help the aging population get proper care and make end-of-life decisions.

He says there are few doctors who want to care for older patients and for a long time there had not been a way to teach resident specialists about elder care. “All of us, whether we do family medicine or internal medicine or geriatric medicine have to touch older patients and are responsible for doing a good job. Clearly those who practice orthopedic surgery, cardiology, ophthalmology,…are all involved in taking care of older patients. So there are a lot of basic principles that apply to the work that all of us do.,” he says.

The University of Missouri was one of the first medical school to start a cross-discipline training geriatrics program for its students. Zweig says about 40 of the nation’s 400 medical schools have followed suit.

Listen to Dr. Zweig’s interview 26:42 mp3　

Senator Jane Cunningham (R-Chesterfield)

Senator Jane Cunningham and other supporters of Proposition C originally wanted it to be a constitutional amendment, but that effort ended in the Senate. “We had to compromise to get it through the Senate and through a filibuster. So, we did that and got it in statute.”

With the result of last August’s vote in mind, the Senator says it’s time to go for the original goal. “I think legislators in Missouri saw how popular it was so my guess is, they would not be so reluctant to put it in the Constitution now.”

Cunningham plans to introduce almost the exact language of Proposition C, with one addition. She says she thought the language of the bill would protect insurance providers and carriers, making them separate from federal mandates. “Right now they have some dictates that they have no choice of whether or not they put in their plans. They put those mandates in and that raises premiums and we’re all required to pay those increased premiums.” She wants to add a separation for not only medical providers, individuals and businesses who buy health insurance but also carriers.

The U.S. Supreme Court is preparing to take up the health care act and consider the Constitutionality of its individual mandate. Senator Cunningham acknowledges, if the Court upholds the law Proposition C would be null and void, let alone any amendment to Missouri’s Constitution based on it.