Joint Sunset Committee



Joint Sunset Committee

Tuesday, January 31, 2012, 5:30 p.m.

JFC Hearing Room, Legislative Hall, Ground Floor

JSC Public Hearing – Delaware Health Care Commission

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JSC and Staff: Rep. John A. Kowalko, Jr., Chair; Sen. George H. Bunting, Jr., Vice Chair; Rep. John C. Atkins; Rep. E. Bradford Bennett; Rep. Michael Ramone; Rep. Daniel B. Short; Sen. Michael S. Katz; Sen. Liane M. Sorenson; Sarah Wootten, Joint Sunset Committee Analyst; and Judi Abbott, Legislative Council staff.

Absent: Sen. David G. Lawson; Sen. Robert I. Marshall

In attendance: Jim Lafferty, Mental Health Assoc; Bob Byrd, Byrd Group; Barbara DeBastiani, Mid Atlantic Assoc. of Community Health Centers; Linda Johnson, DHSS/DHCC; Robin Lawrence, DHSS/DHCC; Marlyn Marvel, DHSS/DHCC; Fred Townsend, DHCC; Judith Chaconas, DPH; Nick Moriello, Health Insurance Assoc.; Mack Thompson, Medical Society of DE; JoAnn Fields, Local MD; Ray Sukumer, CPS; Rich Heffron, DSCC; Brian Posey, AARP; Veronica Lempushiski, UD/DHRB; Tom Cook, Secretary of Finance; Rita Landgraf, Secretary of Health & Social Services; Karen Weldin Stewart, Insurance Commissioner.

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Agenda:

I. Welcome; Approval of JSC Meeting Minutes dated January 17, 2012

II. Delaware Manufactured Home Relocation Authority

a. Rescind vote to review Delaware Manufactured Home Relocation Authority

III. Overview of the Sunset Process

IV. Opening Comments by Delaware Health Care Commission

V. Points for Consideration/Question and Answer with JSC

VI. Public Comments

VII. Concluding Remarks

VIII. Adjournment

Representative Kowalko called the meeting to order at 5:33 p.m.

I. Welcome; Approval of JSC Meeting Minutes dated January 17, 2012

Representative Kowalko welcomed everyone and thanked them for attending. The other members of the Joint Sunset Committee introduced themselves.

Rep. Kowalko: Just a note. Senator Katz will be leaving shortly but will be rejoining us by conference call. I believe Rep. Atkins is on the way, and Sen. Lawson may or may not be joining us. He had another situation that developed also.

Motion made and second to approve the January 17, 2012 JSC minutes. Vote: Yes -7 (Rep. Kowalko, Sen. Bunting, Rep. Bennett, Rep. Ramone, Rep. Short, Sen. Katz, Sen. Sorenson). Motion carried.

II. Delaware Manufactured Home Relocation Authority

a. Rescind vote to review Delaware Manufactured Home Relocation Authority

Rep. Kowalko: The first order of business is that there has been a request for the Delaware Manufactured Relocation Authority, one of the agencies we were going to review, to rescind the vote to review the Manufactured Relocation Authority.

Reasons for the Delaware Manufactured Home Relocation Authority not to be reviewed in 2012 are as follows:

➢ Pursuant to the enactment of HB 62, which was signed into law on 7/13/2011, the composition of the board of directors governing the authority has significantly changed.

➢ The board of directors decreased from 9 to 5 members; all previous appointments were made by the Governor. Currently appointments are made by the Governor, the Pro Tem and the Speaker. Also, the amended board has a non-voting member representing the Consumer Protection Division in the Department of Justice, who previously did not have an official position on the board.

➢ Appointments to the board of directors were made in the late fall. 4 out of the 5 voting members are new to their positions on the board.

➢ The newly appointed members of the board of directors have met one time, on November 29, 2011, and are not scheduled to meet again until February 15, 2012.

➢ The board of directors is in the process of changing the by-laws and various procedures under which they operate.

➢ Additionally, Lydia Prigg, Director of Boards and Commissions in the Governor’s office, is currently working with the Council on Manufactured Housing and other various stakeholders on possible legislation that if enacted, may further impact and/or amend the Delaware Manufactured Home Relocation Authority.

➢ Per email correspondence received 1/27/12 from the new chairman of the board of directors, Anthony Testa, on behalf of all the members of the board, they respectfully request postponing a full sunset review for the reasons previously stated. While recognizing there is a need to review the Authority at some point in the near future, it may be more productive to allow time for the new board of directors to reorganize and formulate a path moving forward on their own.

I was tuned into this because at one time there was a request to review an agency that had just become an agency, SEU (Sustainable Energy Utility). I felt it would be premature to have an agency which either has dramatic changes or just comes into being from looking at it and getting the results that we need to get out of this committee. I've talked to some of my colleagues and I will allow one of my colleagues who has some questions about this to have the floor now.

Rep. Short: Thank you, Mr. Chairman. I guess the concern that I have with the DE Manufactured Home Relocation Authority is that part of the revision that has just occurred and just for the record, I believe you mentioned a law assigned in 2012, signed last July so it has now been 7 months and they have only met once. Part of the issue I have with this is the fact that in reading the minutes and the detail of that group, they were not meeting, and they were not able to obtain a quorum, never able to carry on with the business of that group and still assessing both the home owners and the park owners that they have now agreed to accumulate almost $6 million and in the last couple of years, there has been no relocations that have occurred. I did learn today that there is a limitation of the money that can be accumulated which is $10 million, and having talked with a couple of folks, I'm going to agree with your assessment that we ought to let them be sunset at a later date.

I do believe we need to keep the pressure on, and by that I mean I would like to make a motion that we sunset them for this year, but have them on the list for next year because I believe we need to give them a little bit of a chance because we now have 80% new members on that board down from 9 to 5, but give them a chance to recover from what they couldn't do in the past.

I am serious about the fact that I am concerned about the accumulation of money where we are assessing people to accumulate that money and the group is not doing what was intended to be done, but with the new group in place, and maybe some new energy and enthusiasm to get the job done.

I would like to make that motion that we relieve them in this period and put them back on the agenda for next calendar year. Seconded by Sen. Bunting.

Motion made and second to rescind the vote to review Delaware Manufactured Home Relocation Authority. Vote: Yes -8 (Rep. Kowalko, Sen. Bunting, Rep. Atkins, Rep. Bennett, Rep. Ramone, Rep. Short, Sen. Katz, Sen. Sorenson). Motion carried.

Rep. Kowalko: I just want to make one comment, I will direct if this motion passes that our analyst also give them a list of expectations that we hold for them as they come on line with the new board, especially in the area of the concerns you expressed. If you could sit and talk with Ms. Wootten, that would be appropriate and I do appreciate that.

III. Overview of the Sunset Process

I certainly want to welcome the people here. Tonight is the Sunset Committee public hearing for the Delaware Health Care Commission. I'm State Representative John Kowalko, serving as the Chair this year. My co-chair, Vice-Chair is Senator George Bunting and will be chair next year, and for many years to come, we will be switching seats.

I would like to introduce Rep. Atkins who just arrived.

The sunset process involves a periodic review of an agency, board, or commission within our state government. It is a part of our government that needs to be very open and it needs to involve the public and it needs to involve the legislature as well as the board, commission, or agency that is being reviewed.

As background to this process leading to this evening, each May, the Joint Sunset Committee decides who we are going to review the next legislative year, which usually includes 4 to 6 agencies, boards, or commissions. We then contact that entity under review, sending them a questionnaire to be filled out and returned. There is a communication line of correspondence back and forth that is presented to the Committee in a draft report prepared by our Joint Sunset Committee Analyst, Sarah Wootten.

As we start to collect the data, the agency, board, or commission preparing their responses to the questionnaire starts to realize that this is a healthy process. It is not supposed to be an inquisition or being called before the principal, or anything like that. Upon completion of the draft report by staff, a public hearing is held for the agency, board, or commission at which time that entity prepares a 15 minute presentation for the Committee.

Following tonight's presentation by the Delaware Health Care Commission, the Joint Sunset Committee will review and comment on the Points of Consideration prepared by the Joint Sunset Committee analyst. At that time, there will also be a question and answer period for the Committee members and representatives from the Delaware Health Care Commission regarding the information contained in the draft report and their opening comments.

Concluding that discussion, our audience will have an opportunity to comment on how well this entity is serving the interest of the public health, safety, and welfare in this state.

There is a 3 minute limit for each person from the public to address the Committee this evening or a 5 minute limit if you represent the entity. In the effort to ensure that all persons who wish to speak during the public comment portion of the public hearing are able to do so, we respectfully request you keep your remarks within these time limitations. If that amount of time is not sufficient for your comments, we do allow for written correspondence to be submitted to the Committee.

I would also encourage all persons who plan to speak during the public comment portion of the meeting to please consider submitting written comments as well to the JSC members. Any comment offered this evening is part of our public record; however, it is helpful for future meetings if the Committee members have something in a person’s or organization’s own words to review when considering recommendations for the Delaware Health Care Commission. If you do not have a prepared written statement tonight, you are welcome to submit your statement or comments at a later date to our staff.

The public comment period remains open until we set recommendation meetings for each entity. We will come back to consider the suggestions of the entity as well as the suggestions of the public to set those recommendations.

I would now like to offer the floor to the Bettina Riveros, Chair of the Health Care Commission for opening comments at this time. For any person who is giving comments or addressing the Committee, we ask that you to identify yourself for the record. This ensures that the meeting minutes we prepare as part of this process are accurate and complete.

IV. Opening Comments by the Delaware Health Care Commission

Ms. Riveros: Good evening, everyone. Thank you, Representative Kowalko, and Senator Bunting, and members of the Committee. I am Bettina Riveros, chair of the Delaware Health Care Commission. It is my pleasure to present and respond to the Joint Sunset Committee this evening. We do see this as a healthy process and seek to continually improve as we serve our mission and serve all Delawareans by meeting that mission.

I would like to introduce the executive director of the Health Care Commission, Jill Rogers to my right. And also members of the staff, Marlyn Marvel, Robin Lawrence and Linda Johnson. I would also like to welcome fellow Commission members who have joined us here this evening. Secretary Rita Landgraf, from Health and Social Services, Dennis Ratford, President of the Ameritime Exchange for the DRVA, Insurance Commissioner Karen Weldin Stewart, Dean Kathleen Matt, Dean of the College of Health Sciences and head of the Delaware Health Science Alliance, Fred Townsend, with Schmittinger and Rodriguez, and Tom Cook, Secretary of Finance. Thank you all for joining us this evening.

PowerPoint Presentation follows with comments from Ms. Riveros and Ms. Rogers:

The Health Care Landscape

• Unsustainable increases in cost

• Inconsistent health outcomes

• Inadequate prevention and health promotion

• Will ultimately affect Delaware’s ability to compete

[As a purchaser, the state alone is responsible for $1.7 billion in health care costs, between the state employees and retirees, and our Medicaid spending. These costs as we all are well aware, take funds away from other initiatives and our unsustainable. Yet our outcomes in the health arena are not what they need to be. We do spend twice as much as other developed countries on health care and we don't have the outcomes to prove out that value. We are seeking to improve prevention and health promotion activities. We have had some wins and we will talk about some of those, but we need to do more around prevention and health promotion. All of these challenges that we face in the health care arena will affect our ability to compete. Our ability to invest in other areas, such as education and infrastructure. Our ability to have a strong and health population, something that we all want for all Delawareans for us to have a productive workforce, and for us to have affordable and high quality health care, a health care system which will not only serve all Delawareans, but also serve to promote Delaware to other businesses and to support existing businesses, and help them provide health insurance and health care to all of their employees.]

Charge of the Health Care Commission

• Access

- Promote access to health care for all Delawareans.

• Quality

- Promote a comprehensive health care system assuring quality care for all Delawareans.

• Cost

- Promote a regulatory and financial framework to manage the affordability of health care.

[As I noted, this is a very challenging time and now it is even more critical than ever for us to address these challenges around health care access, quality and cost. The Health Care Commission serves as an umbrella integrator, really as an integration point for health care policy and strategy across the state bringing together state agencies and the work that the different state agencies are doing around health care, bringing together private partners, and private providers, physicians, the Medical Society, the Health Care Association, and other organizations and providers such as that and other private organizations, and the non-profit community. So we provide, not only an umbrella organization to integrate those ideas and that strategy, but also as a key public venue to bring together and share those ideas. On this point, I really want to stress in my recent appointment as chair in September of 2010, I have focused tremendously on having a very open process at our Commission hearings to invite the public in and to encourage strong participation. I think we've been successful at encouraging that and in fact having that very open dialogue because we really see our role as we don't have all the answers. We see our role as bringing together and getting as much information as we can and serving that role to the community and serving that role to the legislature and to other branches of government to really fill that need to best serve Delaware.

So with respect to access, we've worked to promote access to health care to all Delawareans and insure a strong quality. Now on the cost front, to have a framework that supports affordable health care and affordable health care insurance for all Delawareans.]

Strategies

• Systems of Care

• Health Professional Workforce

• Research and Policy

• Information Technology

• Specific Health Care Issues

[I will just touch on the strategies. Really, the 5-prong strategies that we are using to address this. In the last year, we have been very focused on 3 main initiatives, which have been around the requirements with respect to Affordable Care Act and implementation of insurance exchange, and the work we need to understand what that would mean for Delaware, work force development and then how we deliver care. Those fold into these 5 main areas.]

Systems of Care

• Patient-Centered Medical Homes (PCMH)

-- Convene stakeholders and those conducting pilots

-- Create a shared understanding of goals, benefits and components of PCMH

-- Assist with data, research and evaluation

-- Serve as a forum for best practices

[Our Systems of care, such as the Patient-Centered Medical Homes, and how those delivery systems can adapt to where we are now and what we need to do moving forward.]

Health Professional Workforce

• Administration of

– Delaware Institute of Medical Education and Research (DIMER)

– Delaware Institute for Dental Education and Research (DIDER)

– Delaware State Loan Repayment Program for Physicians and Dentists (SLRP)

• Convening stakeholders to identify short and long-term strategies

• Focus on building capacity and access to care

[What our workforce is now, what it looks like now, and the workforce that we will need moving forward. We have 100,000 uninsureds in Delaware who need better access to care, and we have 900,000 people in Delaware, many in the lower part of the state who have limited access to care. How can we make sure we have a workforce in place in Delaware to meeting those needs, to provide primary care services, the physicians, the mid-level professionals, and the mental health services that we need up and down this state.]

Research and Policy Development

– Affordable Care Act (ACA) Planning and Implementation

– Center for Health Care Innovation

– Health Fund Advisory Committee

– Health Resources Board

[We have been very focused on Research and Policy development and providing that as health care strategy and as a research arm for the legislature, for our other partners in the community, and just as we look at the specific initiatives.]

Information Technology

• Health Benefits Exchanges

• Delaware Health Information Network (DHIN)

• Cost and Claims Database

[We have historically focused on Information Technology. That was a strong focus as we worked on the Delaware Health Information Network which is now independent as you are all well aware, but we are not looking at what else we can do to build out our ability to better understand our costs, claims, how we are utilizing care, and how we can better insure quality and reduce those costs.]

Special Health Care Issues

• Specialty-tier medications

• Access to dental care for patients with developmental disabilities

• Resource for implementation of health care recommendations

[We look at specific health care issues such as, tomorrow morning, in fact, we have hearing on specialty-tiered drug pricing. The legislature asked us in SB #137, I believe that is the correct number, that we are to look at the impact of potential for a 4th tier of drugs – to go into a 4th tier, where Delawareans would have to pay a percentage of the cost of the drugs, rather than a co-pay. We had our first hearing on it, and we are having a second hearing tomorrow, and we will be reporting back to the legislature in March on the potential impact of that kind of pricing structure, which has happened in other states.

We really have tried to focus our efforts into these 5 main areas, and Jill Rogers is our Executive Director, and she will be addressing each one in more detail. But if I can take any of your questions at this point, I am certainly happy to pause and do so.]

Rep. Kowalko: Before we move to questions, I want to acknowledge the work of your predecessor, Ms. Roy. She ran a very efficient department. We don't forget the ones that have gotten us to the stage right now. Are there any questions?

Sen. Bunting: We are working diligently for the last few months, Lt. Governor Denn and I, on a task force in the Senate in regards to mental health access for Kent and Sussex counties, and hopefully we will be finishing that up in March and we finalize our report, I would ask of you to digest that because there are a number of things that are coming out of that. Some very diligent people who have been working with stakeholders in the health care system in Kent and Sussex, particularly, in how to go forward with that.

The other thing, I was reading in some of my material, and I think one of recommendations being made is possibly for the attendance, not asking directly every time that the Secretary be there. I wholly support that. With the busy schedule the different Secretary's have, as long as they send a designee, a qualified one, and I would support maybe for us to do something with that moving forward. Thank you.

Ms. Riveros: May I respond to that? The second recommendation we fully support and that would actually be very helpful. I know some of the Secretary's serve on dozens of commissions, so that would certainly be helpful. And with respect to the first, I have discussed this with the Lt. Governor. In fact, we talked today. We do have some specific ideas with how we can take advantage of some of the state loan repayment, federal funds that are expiring, and how we can target them to some of the specific needs that will be noted in that report that is coming out. I will be happy to discuss with you in further detail in the future.

Sen. Bunting: I think with part of the report is focused in on, is the clearinghouse has sent…guardian, has a child and needs psychiatric help. School systems now are coming into play in this as well. They are saying…they pick it up usually the elementary…but their counselors don't have enough expertise to go further than that. There is a waiting list with behavioral issues and that is what we are trying to address. Maybe we have the agencies in a lot of cases that have the expertise and now how to get those people to those agencies, I think is part of the issue, I think.

Ms. Riveros: We will be happy to provide whatever support and I will continue to discuss that with the Lt. Governor. Thank you, Senator.

Rep. Kowalko: Any more questions? Ok, let's proceed with the presentation.

Ms. Rogers: Thank you, Bettina. Thank you, Representative Kowalko, and Senator Bunting, and members of the Committee. Building on what Bettina began with, I want to provide a little bit, briefly, detail about the specific areas that we are working on the strategies, and then of course, I will be happy to answer any questions that you might have.

As Bettina said as she led off, one of the primary areas that we focus on in the Heath Care Commission is in assuring that the health care systems that exist in Delaware are supporting both of the patients and of the public, and there are a couple of specific initiatives that we have under way to address systems of care, one being an effort around patient –centered medical homes, which is an emerging concept and we hear more about those almost every day. There are different models, different versions and different definitions and what we find is that over the last several months, as many as 10 different types of pilot projects for medical homes in Delaware are emerging, all with creative ideas, all with intent to serve the public and to make care more efficient and better quality. We want to make sure that each is taking advantage of the knowledge and experiences of the others, and so that the Health Care Commission is seeking to serve as sort of a clearinghouse itself and a convener so that when pilot projects get under way around patient centered medical homes, they benefit from the knowledge and experience of others around the table, so we are planning a forum in the next month or 2 to assure that those projects are well-coordinated and they end up resulting in better care for the public.

In addition, we work, as Bettina said, around health professional workforce, making sure we have the right workforce delivering the right care in the right places throughout the state. As you know, we administer the DIMER and DIDER programs for medical and dental education and also the state loan repayment program. But in addition to those, we have taken on the role of convening stakeholders around workforce development as well, making sure that schools of nursing, and the work that we do around DIMER and DIDER are really reaping the fullest benefit possible for the citizens of Delaware. We look forward to convening a subcommittee and a working group of our Health Care Commission over the next several months to address that.

Under Research and Policy Development, obviously the Affordable Care Act has a significant impact on us. Some of it known, some of it yet unknown, and our role at the Health Care Commission, we feel is to understand what needs to be done in order to implement it and really make the most effective use of the resources we are already devoting here in Delaware. Even as we begin to understand what is going to come with health benefit exchanges and other aspects from the federal level, there are several programs within the state for the uninsured and really understanding what they provide and how they need to be coordinated with each other, and what comes next, is going to be a major function of the Health Care Commission as well.

The Center for Health Care Innovation is another example around Research and Policy development. That is a new concept that emerged from conversation convened by the Delaware Public Policy Institute. Recently they recommended that the Health Care Commission build a state-wide culture of … innovative approaches to delivering care. Again, building on the fact that the costs that Bettina referenced are skyrocketing and our outcomes are not always what we would like them to be. Innovation is going to be key for us to really understand what works and what doesn't work, so we are looking forward to convening that group, the kinds of discussions that they may have are around accountable care organizations, again, patient centered medical homes, and making sure that whatever is implemented, the outcomes are tracked and we understand what is really working and what may or may not be working.

In addition, the Health Fund Advisory Committee is a board that is a body that this group, the Health Care Commission, sits on. Bettina is a member of that group, as are 2 of our commissioners, and provide guidance and advice to what kinds of programs should be funded with the Health Fund Tobacco Settlement money.

Finally, in this area, the Health Resources Board, which is – it's role itself is evolving over the last several years and the Health Care Commission sees great opportunity with alignment with that board and to point us in the same direction that the broader health care policy that exists and assures coordination in that area.

Bettina also referenced Information Technology and of course, the Delaware Health Information Network was, and is now independent. There are opportunities to develop the health benefits exchanges as well as the cost and claims database for Delaware that will inform the health care decisions that we make both individually and collectively. The goals around Information Technology, I think that we all share, are to maintain privacy when it comes to our own individual medical information, but to increase transparency when it comes to our health care system. Our goals in this area are to put information in the hands of Delawareans and policy makers, and health care providers so that we can align our resources, and make sure that the services we provide are efficient and will result in the outcome that we are looking for.

In addition, as Bettina referenced, we from time to time take on special health care issues. She referenced the specialty-tier medications that we are currently working on. There is also guidance to the Health Care Commission to develop a plan to assure that dental care is available to persons with disabilities in Delaware and we are undertaking that project as well. And then, in addition, we really seek to be a resource for recommendations around implementation of health care systems that might be made by other bodies, for example, the Delaware Cancer Consortium, the Governor's Council on Health Promotion and Disease Prevention. Many of those recommendations recently issued by those bodies referenced the health care system and in order to make sure that we align both our goals and our activities, we need to play a central role in the implementation of recommendations.

In summary:

Going Forward

• Reaffirm importance of research, data collection and evaluation

• Provide leadership and build consensus in a changing health care environment

• Serve as a source of information and expertise across stakeholders

[We feel strongly that the Health Care Commission can provide leadership and serve as a consensus builder as it has done in the past. We can continue to fulfill that role, also serve as a source of information and expertise across stakeholder groups, and we hope to reaffirm the importance of research and data as we approach the health care changes that are going to result from health care reform and from the changing health care landscape here in Delaware. One of the things that the Health Care Commission has done less of recently has been research and data collection and quantifying both the problem and the solutions and we hope to return to that as well.

So we are happy to answer any questions? Thank you]

Rep. Kowalko: I have a few questions if my colleagues don't mind, I'll start the questions. On the first point, patient-centered medical homes – those are strictly physical medical homes, or are they –

Ms. Rogers: No, it is more of a concept. And the idea is that the patient and family are at the center of the care that is provided, so it may be that the primary care provider is seeing the patient day to day, but they have additional needs, and that may not always be – all those needs may not always be fulfilled by a medical provider.

Rep. Kowalko: Is there any licensing board or oversight – conducting pilot programs, or are they just doing that?

Ms. Riveros: Let me just clarify. They are not a physical home. It is more of a different way for some of the providers to practice. They can be certified under the federal certification process for an existing physician practice to be certified as a medical home and then they are eligible for enhanced Medicare payments. So there is that process. We are really working, and the Medical Society has really come strongly to the table to provide a pilot where they are working with different providers to enhance reimbursement rates and also to provide a broader T-based approach to care. So you can do more prevention and more chronic disease management. And manage the patients in a different way but it is more of a …way of practicing rather than a physical home.

Rep. Kowalko: I appreciate that. I know it is not within your purview or your authority to regulate that. But a general question, I am not intimately aware of the medical home…and if they aren't doing it, certainly justifiably to get an enhanced reimbursement rate and provide more services. I don't want to just leave that out there without any control. That is not the purpose of this committee, certainly, we are not reviewing them. But you understand the concerns I have that when we have something that is intended to be funded by federal or state funding, that there is no oversight on such a thing. What are legitimate ones. What if someone comes out with an illegitimate – do you know what I'm saying? I don't expect that - the Health Care Commission would have any place in that discussion. I would like you to look into that a little bit.

Ms. Riveros: We would be happy to provide you with further information about this.

Rep. Kowalko: I would appreciate that, thank you. Now, the administration of the Delaware Institute for Dental Education and Research, I know that there have been some question about whether or not we have an adequate number of dentists in this state – it was raised I think in a Medicaid report. I don't know - I'm not bringing it to you, but I know there is legislation floating around and may come forth. I don't know how this affects your position with this group, but it is to allow their, disallow their tests as being the only qualification test for dentists. I don't know if you are aware of it, but it was one of the proposals of the Medicaid Review Commission that if we had more dentists here, there would be more people taking care of the Medicaid patients, and therefore the costs would be lower and is an obstruction to it by the severity of the local dentists tests as opposed to National Certification. I don't know if that has anything to do with the Health Care Commission either, but I would say you should keep attention for it, if you can, because I don't know how this is going to shake down.

Ms. Riveros: We have heard, certainly, of those concerns around shortages, and we are happy to review that legislation as requested to, or as needed, and to provide whatever insights we can. We certainly want to be a good resource for you and for others on any issues like that.

Rep. Kowalko: And now, your research and policy development of the Affordable Care Act. This is something that is sitting out there – the elephant in the room and I don't know how much you can do about it now, but I would caution that in 2014 we are going to have a mandate, a captive clientele so to speak - mandated coverage, which the cost is going to have to be borne somewhere and it probably is going to be a…so in the absence of a public option, alternative, for a previous control regulatory capacity where we can limit premium increases. We are looking at 2014 in a desperate situation for any state, with the Affordable Care Act. I agree we should have it, but I want to make sure that the Health Care Commission especially is prepared for suggestions and does the research beforehand. How much is this going to cost us – give me a ballpark estimate. I am not ordering to do that. I just think it is a good place for us to get some sort of a number that we can deal with. Rather than 2014 arrives and nothing – everybody thinks that there is going to be stages so that in 2014, we will be able to be – it won't be doomsday. I'm not that optimistic. I see things - I don' know if it is a non- presidential election year – so who knows what will happen in the context of elections. But I would just urge that the Commission keep your eye on that before it bounces out of control.

Ms. Riveros: Absolutely, in fact, last year and into this year, we have had dozens of outreach events in the community to understand our concerns and needs and views with respect to some of the provisions of the Affordable Care Act. So we have taken in a lot of input. We do have approximately 100,000 uninsureds in Delaware, some portion of that population will be eligible for Medicaid, moving forward, so we will certainly take that as a charge as we look at what will happen in 2014 and the potential cost to the state.

Rep. Kowalko: The last thing before we go to the points for consideration, or other questions, your access to dental care for patients with developmental disabilities, I would just – is that supposed to be a problem and expense, then I would suggest Practice without Pressure is an organization that can share the wealth of their expertise with the Health Care Commission. Again, for the record, I just want to note that Deb Jastrebski, the founder…one of ten recipients nationwide – and there are only 10 each year of about 400 nominations to receive the Robert Wood Johnson Foundation award for volunteer service, and that is a pretty monumental achievement. It is the first time in Delaware. It is also such a uniquely effective process in dental care – cost effective process, also, I might add since it belies…a lot of cases for sedation or active restraints and things like that.

Ms. Riveros: Yes, Practice without Pressure – that's a great asset for us to have in our community. Thank you.

Rep. Bennett: Getting out to the outreach portion, it has been my understanding that you have done work with some small businesses and also constituents in New Castle County, and I'm down here in Kent County. I haven't been aware of anything down here, or maybe I just didn't hear about it. But is there a possibility to continue those in Kent and Sussex County?

Ms. Riveros: We have been in Kent and Sussex but we are happy to do more, so we are always available and if you would like us to provide an update in Kent County, we would certainly be happy to do so. I know we were in Lewes several times with the small business community there, and we were in Kent I would say probably in the 3rd quarter of last year. But we will be happy to return.

Rep. Bennett: Maybe a yearly update, or something would be helpful. Thank you.

Ms. Riveros: Absolutely, we will be happy to do that. Thank you.

Sen. Bunting: Yes, my classmate, Sherman Townsend, he has served on the DIMER board for a number of years, and Sherman, periodically we are talking back and forth, and last year I think it was a funding issue as well with DIMER. I really just think it is extremely important on this Mental Health Resolution, we had a young psychiatrist who came in front of us in the Lewes area. She is facing $200,000 in debt for her education coming out in practice, and that is a steep thing to write out as a new practice.

The other thing I have, and I'm being parochial here for Sussex, but in talking with a number of my general practitioners, these folks have got great educations, most of them don't net what a high school principal makes. They don't have – they have to create their own retirements, on and on they have to by a…when they leave the practice, and I'm really fearful across our country, not just Delaware, that we are pushing these folks out of business. I don't know – the bigger issue for this Committee, I'm sure, and maybe even the Health Care Commission, but it is an issue and we are losing potentially some really bright people walking away from their practices, basically, or they find it necessary that they can't independent practice anymore and they have to go with one of the hospitals in order to - not only computerization is one element, but that, as young people come out of college, there is going to be less and less of an element I think. But those that have been in the practice for a long time, it is a big deal. When you've got to put up $90,000 or more to get your practice digitalized and so forth. Thank you.

Sen. Sorenson: I kind of had the same question. I also had a conversation with Sherman Townsend. I just wondered about the funding for DIMER, is the funding adequate.

Ms. Riveros: The funding – at the present time, we have agreements with Jefferson and Temple and Philadelphia College of Osteopathic Medicine to tender to them a certain dollar amount and then they reserve slots. At Jefferson, it is 20 slots, and 5 at the other 2 schools. That has been a very effective way to get Delawareans to attend. And in fact, we have seen a strong return of those Delawareans to practice. Whether that is sufficient or not, it has been sufficient to this point. It is always challenging. I think people would always like to receive more money, and so that is difficult. I know Sherman Townsend, who has done an amazing job and has dedicated endless hours to DIMER. It is a fabulous program, DIMER and DIDER. I know he would like to see an increase in funding.

Rep. Short: Just a comment. I don't know if you have explored this or not. The trend in the medical community now is moving away from physicians in practices to hospital based and hospital employee relationships. Have you thought more about the possibility of creating this educational process that brings them back to home of residency somewhere here in Delaware versus allowing them to be, once that is completed, to be able to venture wherever they are. I just wonder if you have gotten into that discussion yet. That is where I understand the trend is going is because of the concerns of cost as a physician in practice that we now have a whole host of hospital based physicians that used to be in private practice.

Ms. Riveros: With respect to the trend there is I would say a fairly significant trend for the hospitals to acquire some of those practices but there is also a very strong interest to preserve those independent in private practices as well. I know the Medical Society has taken strong steps to try to support those private practitioners as well. I know with the DIMER and DIDER program, we do try to create close connections and rather court some of those residents. We have many of them coming to do residencies. I know Dr. Nevin talks quite a bit, all the residents that are at Christiana Care, and they are also at A I DuPont Hospital for Children, and so we do try to bring them back and we have found that medical students tend to practice within 50 miles of where they do their residency. So that is a key element for us to bring these DIMER and DIDER students back and having residencies here.

Right now we actually have 11 third year students who are doing their entire year in Delaware. That is a great new trend that we are seeing, in trying to build this community connections.

Ms. Rogers: We do need more here and we absolutely need more down state, and we are actually looking at things we can do, and down state in other high need areas, in Kent and Sussex and parts of New Castle County, we have shortage areas and we need to see how we can best use the limited dollars that we have in the DIMER and DIDER programs to direct those physicians and other professionals in the mental health areas as well, to those areas of need, so we are really trying to focus them and get them to those areas.

Rep. Kowalko: Let me ask Rep. Short, are you concerned with the assimilations of private practices into the group practices, such as the Christiana Care? I know the purpose of that is to cut the cost –

Rep. Short: I was looking for a more innovative process where we utilize the assets that we have to get those physicians back in Sussex County, where we have a vast shortage of primary care physicians, which has created a concern. If you don't have the driving force in the primary, then you don't have the specialties because you've missed that one loop which is that you can't get to the specialist without going to the primary to begin with, so as I didn't get to ask the other question, I imagine all these residencies are in New Castle County, are they not?

Ms. Riveros: I would say the majority. There was a program several years ago to have them downstate as well.

Rep. Short: We have a shortage of nurses in some parts of the state…concentration of the population, so I think – I'm…an insurance agent – and I've been an advocate which is pretty dangerous in the insurance business advocating regional concept for selling insurance and I think we ought to move to a regional concept of physician practices that allow us to use what is on the outlying portion of the peninsula to enhance that part of the state. I think that relationship…a regional medical center and some other folks would pay great dividends for us. That was what I was looking at that you might go beyond the norm and kind of say, ok, we are going to explore some of the avenues of approach that we might expand this program and maybe there is more money that was allocated which we heard everybody say might be important, and then we foster some of that to some areas where we have a great intensive need in the southern part of the state, not just in the mental health area, but in the primary care area. If we do what we always have done, we are going to get what we've always gotten, and I was looking for a little bit more innovation I guess.

Ms. Riveros: And that is why we have committed to report back to the Health Care Commission from our workforce development work group in May or early June, on the current gaps up and down the state and what our needs are now and what we expect our needs to be in the future.

Another point I think is critical to share, is our state loan repayment program which is part of the funding under the DIMER has successfully added 78 individuals to practice in Delaware. The way that works, it can apply to primary care and mid-level professionals, and we can offer to repay part of their loans if they are practicing in a non-profit setting. That has been a very effective way for us to bring others into the state and we can actually get federal matched dollars as well. We do have some federal dollars that have gone unmatched because we didn't have the state funds to match them, but we are working to take advantage of private funds that are available through some recent developments in the insurance market, I'll put it that way, where we are working with some private donors to match those federal funds and really target some of the highest need areas with additional services. So we are working to be innovative, but we will be reporting back on our workforce needs and we will be happy to share that with all of you.

Rep. Short: One closing comment, and the reason why I think this is so important. My district, which was the nylon capitol of the world is no longer the nylon capitol of the world, and now it's major employer is the Nanticoke Health Services, so there has been this huge transition from what is important in the Seaford western corridor has now become health care to make sure it fosters and grows and prospers. If it wasn't for this body here, in the legislature in the state, the Nanticoke hospital would be in a whole different condition than it is in now, so I think that is why this plays into a real puzzle with all the pieces together to make this a lot more successful in the economic driver that this provides as well, so I just thought I would bring this up.

Ms. Riveros: Absolutely. I couldn't agree more.

Rep. Kowalko: I agree. I think that we don't have adequate medical professionals in these downstate counties, and I think it is absolutely imperative that we use every dollar of our federal match for loan repayments. That is the only way we are going to grow new physicians and incentivize people to not take on that crushing burden of loans. If the Health Care Commission can come up with an exact number of what is left on the table, I think that is a good starting point for some of us as legislators outside the purview of this committee to look at how we can urge matching monies so that we don't let anything go – I'm not a big fan of DELDOT projects saying we are lose a billion here so we've got to come up with the $300,000,000 and we are going to borrow it to match that. But in the case of this, we are talking about need for physicians, need for health care providers, and need for a resurgence in the growth of that profession, and so it is a different animal here. I'm willing to let health care federal dollars go wanting if they are not necessary or going to become a burden, but in this case, every dollar we lose, is a dollar that will be well-spent and will be returned many dollars on the investment, so I do appreciate you working in that area.

Ms. Riveros: May I add, and thanks to the work of one of our commission members and the Insurance Commissioner, Karen Weldin Stewart, and others on the commission, we have worked with Blue Cross and Blue Shield of Delaware who has designated some funds for…development, and what we have considered doing it taking advantage of those funds and provide a match to federal dollars so that we don't lose that money and we can then apply that to our highest need areas and that is actually a key initiative that we have been working on and to get that really moving quickly. We will certainly report back on any other gap that we have, too.

Rep. Kowalko: And that is ok to use those funds and convey them as a matching state fund – although they – ok, I am getting a nod yes.

Rep. Short: Did I hear you clearly that all that money is going to Kent and Sussex County?

Ms. Riveros: That remains undetermined, but we are very open.

Rep. Kowalko: If there are no further questions, I want to move on to the points for consideration. We will bring them up to you and you can answer them or at least understand what we are going to expect back as a sort of fulfilling of these things.

V. Points for Consideration/Question and Answer with JSC

• Legislation was never introduced to amend DHCC’s governing statute to include evaluating Health Fund programs and for making recommendations to the HFAC regarding the best use of tobacco settlement dollars. Funding for an additional staff person was also not provided for this purpose. (Joint Sunset Committee Review History)

Ms. Wootten: I was just noting that a previous Joint Sunset Recommendation was never fulfilled. However, they do have representation, - they have an agreement with the Health Fund Advisory Committee but it just not enumerated in the statute.

Rep. Kowalko: Ok. So that's something that this committee should require ourselves to enumerate that in the statute. That is an historical cleanup.

Ms. Riveros: And I have served on the Health Fund Advisory Committee for the last 2 years, and participated.

• Including the appointments made by the President Pro Tempore and the Speaker in the geographical and political affiliation balance criteria places greater limitations on those individuals they are able to appoint. For example, currently the President Pro Tempore and/or the Speaker would be restricted to appointing Republicans or Independents should a vacancy occur for one of the positions they appoint. Additionally, the President Pro Tempore would be restricted to appointing a Republican or Independent from Kent County in order to ensure that both the geographical and political affiliation criteria are met. (Composition of the Health Care Commission)

Rep. Kowalko: This is always an ongoing situation with commissions and boards. It has become an antiquated policy to allow a political labor link, and a discussion I had with Ms. Wootten…more in tune with the reality of things. I suggested that maybe we should have some kind of an a-political appointment. We did that with some other authorities and Ms. Wootten suggested that when it comes to money, the things that deal with money, you don't want to step into that treacherous area of not meeting the expectations of the political parties. Rather than risk that, I think that we are going to continue that discussion with some concerns expressed.

Ms. Wootten: You can certainly implement a change here upon the expiration of the current members’ terms.

Sen. Bunting: I agree with that. I think we are too small a state, and my own personal philosophy, I've never asked a person what their politics are, but I think we try to pick the best people to fill those positions. I know that Lydia Prigg and others who have been involved in that – we get so frustrated trying to find people, because you've got to try and find a label to fit a person and so forth. I'm like John, that time has gone by.

Ms. Riveros: We have been blessed with very strong commission members, and they have served very well, and I couldn't be more privileged then to have the commission members that we have on there.

Rep. Kowalko: And I have no doubt that they are maintaining an a-political stance on everything. Moving forward, and that will probably be something that we will work on that there will no longer be that requirement for a political party label. How popular that will be with our body out there that is going to pass these laws, I don't know. This committee, I think, has been a tremendous advocate for separating the politics from, - this committee itself, and we could separate the politics from the reality of that, that it is not required to be here and the people that we do pick are of a quality of character that they are not going to let that affect them anyway. We will have to deal with that in the political world – and would certainly be within the constraints of future appointments.

Rep. Ramone: As a point of reference, I'm listening to how wonderful you all are doing and how great everything is, so who verbalized this as an issue, I don't remember it coming up. Obviously somebody did the research to say that the Speaker…appointing one Republican or Independent should a vacancy occur. In addition, the President Pro Temps would be restricted – who did all that research – who brought this up as an issue?

Rep. Kowalko: The analyst does that under my direction to see whether or not we have existing structures that have become antiquated.

Rep. Ramone: So there was a request to see if there was a political balance.

Rep. Kowalko: No, the request was, what kind of rules do we have in making these appointments.

Rep. Ramone: And that was your request of –

Rep. Kowalko: Yes, and one of the answers was that this is of the attitude that there has be a balance.

Rep. Ramone: I just wasn't sure where this came from – I've got it.

• Remove or amend the find and declare clauses enumerated in 16 Del. C. § 9901, as they relate back specifically to the 1990 Indigent Health Care Task Force and are no longer applicable. (Mission)

Rep. Kowalko: I am going to move to our analyst to explain bullet point 3.

Ms. Wootten: Section 9901 really would be a lot like the WHEREAS clauses at the beginning of a bill. These were defined and laid out in the actual statute, so there was a recommendation, I believe, during one of the annual retreat meetings of the Health Care Commission to have those removed as they no longer apply. They relate back to the Indigent Health Care Task Force recommendations.

Rep. Kowalko: We don't vote on that, now (Ms. Wootten: No.) – we are enumerating the things we will be voting on at the next meeting. In other words, the first bullet point, putting into Code what is missing, and in this bullet point, taking out Code what is not applicable anymore. I don't want anybody getting all uptight if we ask a lot of questions about these things, and this is not the place where we are going to agree to do or not to release things. Certainly we want the feedback of the public as we go through these things and you can see interpreting 16 DEL. C. §9902 is not something that the public or ourselves are going to be that familiar with, but we have to address each one, one by one.

• Determine if DHCC is still constituted an independent public instrumentality, pursuant to 16 Del. C. § 9902 upon its transition under the Office of the Secretary, DHSS. (Organization)

Rep. Kowalko: That is an organizational point.

Ms. Wootten: I thought it would be helpful for the committee members for this to be clarified that it is still an independent public instrumentality even though it was moved under the Office of the Secretary.

Ms. Riveros: Yes, we do operate as an independent entity operationally and for fiscal oversight it is within the Delaware Department of Health and Social Services. And that has been advantageous to support in a fiscal issue to make sure that this is managed and with operational support for the staff, but the commission is an independent authority.

• Revise the duties, authority and functions outlined in 16 Del. C. § 9903, so the statutory language is broad enough and will not become outdated as circumstances change. Also included in the revisions should be language with respect to refocusing efforts on policy analysis and developing a comprehensive plan to prepare for federal health care reform implementation. (Duties, Authority and Functions)

Rep. Kowalko: We discussed that briefly – there is a stampeding herd coming toward our coffers and we certainly are going to be very dependent on the Health Care Commission to be in tune with recommendations, anything that has to happen that should be recommended, that should be pursued. When we talk about outdated as circumstances change, we will be reviewing things, - statutory language, just to make sure we have that in the language where we have the flexibility. Having language in place that would compromise our opportunities to react as quickly as we are going to have to react – or innovatively, I think is a better word, that you have to react, is paramount upon us to have that in place.

Ms. Riveros: That is a very positive suggestion.

Rep. Kowalko: Thank you.

• There is currently one vacant position on the Health Care Commission staff, for the Director of Planning and Policy. (Health Care Commission Staff)

Rep. Kowalko: That is true.

Sen. Katz: …by telecom - (was excused – telecom disconnected)

Rep. Kowalko: Ok, Sir, thank you for joining us.

Ms. Riveros: Thank you, Senator.

Yes, there is a vacancy. With Jill Rogers now as Executive Director , I have asked her to assess her staff and their current responsibilities and needs and she will be doing that in the months to come.

Rep. Kowalko: Ok, and I certainly would never step into the intimacy of what your needs are – again, with the looming health care reform, probably planning a policy is a position you want some stability in, let's put it that way.

• Evaluate whether to continue publishing both “The Total Cost of Health Care in Delaware” and “Delawareans Without Health Insurance” reports annually. (Research and Policy Development)

Ms. Wootten: Those were 2 reports that were published on an annual basis until 2008. There was some discussion in the meeting minutes to continue publishing those, however that has not come to pass in recent years.

Rep. Kowalko: Do you think that the Commission wants to continue publishing those and if not, is it a cost motivation.

Ms. Riveros: It is certainly a cost issue, and I would ask that Jill consider that as she looks at staffing as well. We haven't tried to really take advantage of federal dollars that we have to support our planning efforts under the Affordable Care Act to look at our market – some of our needs, our uninsured, so what I would suggest that we look at the work that has been done on that front to see how much of a gap that fills, so that we can, to the extent we have to, or we want to continue these studies, we spend fewer state dollars in order to do that – just being good stewards of the taxpayer dollar.

Rep. Kowalko: I would posit that since we are not talking about just publishing it, or are we talking about actually conducting these studies in those areas.

Rep. Ramone: Can I get clarity on that, because I'm not sure that is – is that what you are saying, or not what you are saying? Are you saying that you are still conducting the research, but you are not publishing? Or are you not conducting?

Ms. Riveros: We have not done these studies, these specific studies, because we haven't had the funding to do it. However, under the Affordable Care Act, we have exchange planning funds, and we have done a lot of work looking at the insurance landscape and the uninsured landscape in Delaware, and what I would suggest is let us take this back as an action item and say, how far do we get in what these reports did in the work that has been done that has been paid for already, and where do we still have gaps and when do we want to pick this up again, depending on the availability of funds to support it, if that is reasonable.

Rep. Ramone: I wasn't suggesting that you should or shouldn't, I just didn't quite read it correctly. It sounded like you were still doing it, just not filing.

Ms. Riveros: I'm sorry if I wasn't clear.

Rep. Kowalko: You were clear. I picked up that you weren't doing the study. I just want to caution that if we do have an opportunity to have federal funds, these are very important knowledge tools. If we don't have them gathered somewhere else, I would suggest from a personal standpoint that we as legislators, need to know the total cost of health care in Delaware. Moving up to 2014, we have to know the total cost now. We have to also know the total cost of health care in Delaware in order to craft any kind of alternative plan to control that cost, and we no longer have room, unless some other agency provides these kinds of numbers, I don't want to walk into a room and say, we have to cure this because it costs us $10 billion dollars – where did you get that number – well I guessed it, you know what I mean? I think it is very important and Delaware is without health insurance, too, as we ride the wave of Medicaid costs and things like that where we are talking about without health insurance, and we are talking about the hidden costs of that, and if they end up in the emergency room, or when someone doesn't match a qualification standard for Medicaid. I have a personal friend who is gainfully employed, and is like a $1000 under the requirement for Medicaid, so, her health has suffered and I have advised her to go to clinics. We have to have a number on that, and so I would say that if you can use federal money, to accumulate that kind of information, I would ask that you continue to do that. That would be very beneficial. Some of the ideas I see proffered around Legislative Hall for moving quickly to avert a crisis, you have to have the facts. Nothing has a better argument than the facts.

Ms. Riveros: We will continue to do so. In fact, last year we had an environmental scan conducted by the University of Delaware of the landscape, so that actually helps to provide us some of the data, and we have other reports as well. But we will continue to do that work and try to take advantage of those federal funds.

Rep. Kowalko: Excellent.

Rep. Ramone: Just a point of clarity. Maybe for our points for consideration, shouldn't this better be read as: Evaluate whether to continue researching and/or publishing?

• Evaluate whether to continue researching and/or publishing both “The Total Cost of Health Care in Delaware” and “Delawareans Without Health Insurance” reports annually. (Research and Policy Development)

Rep. Kowalko: We can do that, certainly. That will be the point for consideration that we will consider.

• Limited budget resources constrain DHCC’s ability to produce the research and expertise that would add to the body of knowledge about health reform and health policy to the extent it once did. (Challenges)

Rep. Kowalko: It is a challenge that you are facing.

Ms. Wootten: It was a challenge that was identified in the questionnaire that they submitted.

Ms. Riveros: Yes, I think that is generally with respect to research and policy, however, the action that we've taken to address that is taking advantage of these federal grants to bring in assets to support our research and policy development. I think we've been very effective in doing that and I would be more than happy to share any of the reports and research and data that has been generated under that process.

Rep. Kowalko: Is there a danger that the federal grants, the federal money has a finite end date or expiration date on that, and then once we get dependent on it, and have a well-oiled information gathering and policy research and expertise policy body in place, all of a sudden we can't afford it anymore.

Ms. Riveros: I would say it is certainly a temporary measure that we've taken advantage of – the federal funds are available through 2014. So it is a temporary measure.

Rep. Kowalko: Ok, then I would suggest that either you have taken action on that to meet this challenge and that you prepare for a future without the money, whether that means you establish a well, self-sustaining thing that lowers the cost of health care that once the federal money runs out, we can afford as a state to support that. That is going to be more of a challenge than just the challenge enumerated here.

Ms. Riveros: I would say we have a short term solution.

Rep. Kowalko: Ok.

• Recently, DHCC has not undertaken or supported statewide research which would measure the impact of programs, track key health policy indicators such as the number of uninsured as well as barriers to purchasing insurance by employers, and other issues that will undoubtedly be identified either through the Affordable Care Act or the future demands of delivering health care to Delawareans in the years ahead. Returning to these activities could better position the Commission to support activities needed to meet the increasing demands on Delaware’s health care system. (Opportunities for Improvement)

Rep. Kowalko: I think that reflects on the discussion we just had about identifying costs, identifying necessary things that we have to do to prepare and any progress that we have done up to that 2008, or whatever, imbedded in this type of need, that we re-continue those as opposed to waiting for the inevitable. That is certainly listed under an Opportunity for Improvement that was suggested and in your answers, you will give us a little more dissertation on that.

Ms. Riveros: Yes, and we would be and forgive me, I don't recall the date, but I know there are specific efforts to gather barriers for small employers to purchase insurance, and I know that was earlier in 2006. Although we haven't specifically undertaken a formal study, we have gathered a lot of input from that small business community and continue to do so as we look for input with respect for the best ways to implement our requirements under the Affordable Care Act, so we have very good numbers on 106,000 uninsureds. How many are in the group market, how many are in self insured…plans, how many are – I mean, we have very good data on that and certainly would be willing to share that with the committee if you are interested in that. And we have of the 106,000, we have 12,000 that are a part of the CHAP program and have access to care there. So I think we have, although it may not be as formalized as perhaps it was in the past, we have taken advantage of some of our planning dollars from the federal government to get at some of those issues, and certainly, we will continue to do so.

Rep. Kowalko: I think that is laudable, because if we have that information, again, the way to win a debate or to carry the day to ask for legitimate requests, for anything, whether it be from our taxpayers, our finance committee, or from ourselves within ourselves, is to have those identifiable needs and costs and find a way – it is never going to be effective if we say we have unbearable costs, put a number on it, so we can construct a bearable match for that cost – that revenue of some sort – however we arrive at that. I think that in my opinion of what the Health Care Commission has accomplished is one of your foremost tasks, responsibilities, but also capabilities to execute that and I understand that you are doing that, and again, if we have a finite amount of revenue to support that, or a temporary revenue, I want to make sure we are prepared for the future so that we can continue that. Whatever happens in 2014 is not going to be the end because there are going to be adjustments made on that and if we aren't at the top of our game, then we can anticipate those things, those needs and move forward.

• DHCC has struggled over the years with effective means of communicating with appropriate and concerned parties. (Opportunities for Improvement)

Ms. Wootten: Again, that came from their from Joint Sunset Committee questionnaire. They indicated that was an area that they can improve on.

Ms. Riveros: I think one area that we saw an opportunity for improvement and we have since reached out as I noted operationally we work within the Health and Social Services and I've reached out to Secretary Landgraf to see if we can take advantage of her efforts to improve communication through web-based interfaces, social media, and other things, and she has graciously offered the support of her office to support the Health Care Commission in that initiative. We do try to – as I noted in my opening remarks, we have monthly meetings, we do a lot of outreach, we have a lot of people attend every meeting, and keep it actually very interactive throughout the meeting. We do have many members of the private organizations, provider community, Medical Society, Health Care Association, and others and non-profit community who regularly attend, so within that core group I would say our communications have been very good for reaching individual health consumers, I think that is an area where we can take advantage of some of those other methods and I appreciate Secretary Landgraf's support in that area, and that is something that we brought up at the last Health Care Commission that we want to move forward on.

Rep. Kowalko: I really appreciate that because there are sometimes struggles to communicate with parties outside of the very vested interests parties and the consumer falls into that. They have a vested interest – it is their lives – their unaffordability of health care. But it is hard to just have a communication device that someone can just pick up a phone and say, ok, here is what I know – I'm a consumer. So I do appreciate and Secretary Landgraf has had set up where we have adequate communication. But we can never fulfill I don't think the curiosity of the average consumer to know what we are doing by limiting ourselves to just website. That is a step in the right direction, but when we have these kind of Google communications, things we also need to figure out ways to get that message out there regularly and, not in an informal basis, but regularly so that people can be aware of that. We've had that with other agencies that communicate and it looks like they are doing it adequately, but that is because…education is everything. The most interested people are going there and getting the information but seeking it out is not the norm for a consumer. It is very difficult to know how to do it, how to find out the information, so I appreciate your efforts to improve that.

Rep. Bennett: It may be helpful also to give the legislators updates periodically. We get questions all the time form constituents – that is another good way for us to get the word out to them for individuals that you may not be able to reach.

Ms. Riveros: We would be very happy to do that whenever you would like.

Rep. Bennett: Whether it is through emails, or whatever, periodically, a newsletter, or an email – once in a while because we do get constituents that are concerned about it, especially the implementation of the Affordable Care Act.

Ms. Riveros: That is actually a wonderful idea. In fact, we had an issue come up recently about the…with respect to the Health Care Commission hearing, these forms, physician orders that actually take your advanced directives and put them in the form of a medical order, and it is something that Joann Hasse actually brought up as a concern that they weren't being followed. We had a presentation by Sheila Grant who participates on this committee and does a fabulous job, and it would be something to be great to share with legislators because your constituents would be very interested to know that we really need to get the word out that if you have an advanced directive you should also take the next step and get this order filled out so that people can follow that – a physician can actually follow your directive. That would be one example where I think it would be great to have that communication and share that with the legislators. Thank you, we will plan to do that.

Rep. Kowalko: That is not only a good idea, that is a very pertinent idea. Right now, the legislators have email listing of their constituency for an email blasting. It is very finite and limited. I would like to have every constituent on it because we can't afford – but it is a communication access point, that if you send us reports, we can duplicate that. We did that with the Attorney General’s Office in a foreclosure mediation. I said, send us everything and we will put it out on our email blast and then you have a world wide ranging capability of people to connect with. So necessary things, like the advanced directive, but also things that may not look necessary that someone can pick up, even if it is a date of a meeting, hearing, and/or consumer group sort of town meeting. That is a good idea. Thank you, Representative Bennett. I know that all of my colleagues would love to have that information to promote not only themselves, but the information to their constituency, which is foremost in their minds. It is very necessary and needed that we communicate to the average person.

Ms. Riveros: We will definitely move forward with that. Thank you.

• DHCC must form solid partnerships with other entities that share their concerns and agencies that will be impacted by the changes as a result of the implementation of the federal Affordable Care Act to forge the best possible path forward for Delaware. (Opportunities for Improvement)

Rep. Kowalko: Again, as you are working through this in your suggestions how you can improve, maybe identifying a list of other entities that you have so that we can facilitate, reach the skids that they understand the importance that you are trying to do, that you are not trying to interfere or intercede in their area, but you need them to be aware as we are making you aware, unfortunately as many times as I am making you aware, which I apologize for, of what is looming before us. As you follow your own opportunity for improvement and suggestions, you might want to consider that.

Any questions? Ok, we are going to go into the public comments.

VI. Public Comments

As a reminder, there is a 3 minute limit for each person from the public to address the Committee or a 5 minute limit if you represent the entity. Again, we won't stand up here with an egg timer and gong you when you get to 3 minutes, but we do hope you won't go longer than that.

Barbara DeBastiani, Mid-Atlantic Association of Community Health Centers: Members of the Joint Sunset Committee, Members of the Health Care Commission and the Public, my name is Barbara DeBastiani and I represent the Delaware members of the Mid Atlantic Association of Community Health Centers. I am here today to support the Delaware Health Care Commission in their continuing mission to develop a pathway to basic, affordable health care for all Delawareans.

Delaware's federally qualified Community Health Centers provide medical care, dental care, and mental health services to over 33,000 Delawareans — men, women, and children - most of whom are uninsured or under-insured. In 2010, that accounted for over 120,000 total visits. The health care services are supplemented by supportive services including care management, patient education, translation, and transportation. The Community Health Centers are located in each county to help assure convenient access.

During the over 20 years that the Delaware Health Care Commission has been in existence, it has been a strong partner with our Community Health Centers in many ways:

The Commission has recognized Delaware's health centers as key safety net providers for the uninsured and under-insured. It has maximized state and federal dollars by providing periodic development and expansion grants to health centers. These funds have enabled the health centers to leverage additional federal funds for ongoing service support.

Delaware's Health Centers employ over 262 FTE staff. Over 40 FTE of those staff are physicians, dentists, dental hygienists, nurse practitioners, nurse midwives, and physician assistants, all of whom are providing direct, hands on care. But we may not be so successful in attracting high quality care providers if it were not for DIMER and DIDER. Their relationships with Jefferson Medical College at Thomas Jefferson University, the Philadelphia College of Osteopathic Medicine and Maurice H. Kornberg School of Dentistry at Temple University assist Delaware students in achieving their goal of medical and dental education. The DIMER and DIDER loan repayment programs are an invaluable tool to assist health centers in recruiting and retaining health care professionals.

The CHAP or Community Healthcare Access Program provides access to primary care doctors, medical specialists, and other health resources including prescription programs, laboratory and radiology services for Delawareans who "The Voice of Communities In Need" are uninsured, not eligible for state medical assistance programs such as Medicaid, and who meet the program's financial eligibility guidelines. CHAP staff assist individuals in establishing a health home, scheduling appointments, and removing barriers to obtaining healthcare services. Community Health Centers along with physicians enrolled in the Medical Society of Delaware's Voluntary Initiative Program network are the primary providers of medical care to CHAP patients. The CHAP program which now resides within the Division of Public Health, was initiated by the Delaware Health Care Commission and funds outreach and enrollment staff at all Delaware Community Health Centers.

As we continue our progress toward health care reform, the Health Care Commission has taken a lead role in assuring that Delaware is prepared to meet the challenges and opportunities that come with universal health care. Delaware health centers were one of many business and consumer groups invited by the Commission to provide input on what a Health Insurance Exchange should look like for Delaware. With more insured people comes the challenge of assuring that there are sufficient healthcare providers to meet their needs, many of which have gone undiagnosed and untreated for years. The Commission is re-energizing their Workforce subcommittee to identify barriers and opportunities to meet our future workforce needs.

The Delaware Health Care Commission has a unique position in state government. This policy-setting body allows creative thinking outside the usual confines of conducting day-to-day state business. The Commission is authorized to conduct pilot projects to test methods that will help the state meet its health care needs. One need only point to the Delaware Health Information Network and the Community Healthcare Access Program as two highly successful projects to come from the Commission.

The Delaware Health Care Commission is too important a body to dismantle, especially as we work towards universal health care. The Mid Atlantic Association of Community Health Centers strongly supports the work of the Delaware Health Care Commission and urges you to vote for its continuation. Thank you.

Rep. Kowalko: I appreciate that. I think I can speak for the group – it is not the intention of this group to sunset such an important thing as the Delaware Health Care Commission. Unfortunately the title of our committee, Sunset Committee,…that is what they are there to do, and no, that is exactly the opposite of what we are here to do. What we are here to do is facilitate, advise, help, and recommend and provide necessary legislative services for commissions that are successful, like the Health Care Commission has been and will continue to be, and needed, as we approach that 2014. That is the last time I will talk about that, until next time. But I do appreciate your statements. If there are no questions, we are not going to – unless somebody has a question, but your remarks are well put and well taken. Thank you.

Dr. JoAnn Fields, primary care physician, Kent County: Thank you, Representative Kowalko, Senator Bunting. My name is JoAnn Fields. I speak in support of the Delaware Health Care Commission. I am a local primary care physician in Kent County, interested in health reform and improving access to medical services. I have attended the Delaware Health Care Commission's monthly meetings fairly regularly since about 2006. I believe the Health Care Commission has been a valuable source of objective, well researched information from multiple sources about what in our health care system works and what in our health care system needs to be improved. I hope they are given authorization to continue. I believe the Commission is a valuable resource for all of you and all your colleagues in the state legislature.

The Delaware Health Care Commission has worked with and collected information from all parts of our complex health care system - nurses, doctors, state public health, children's health advocates, hospitals, the Universities, demographers, insurance agents, insurance companies, federally qualified health centers, community organizations that work with the uninsured, the Community Healthcare Access Program CHAP, Screening for Life, people involved in workforce development, and information technology experts. The Commission has brought together all of these people over the years and is a wealth of knowledge on how our health care system works. They have worked on ways to eliminate health care disparities, ways to measure outcomes for the state's cancer screening programs, and ways to expand to use of information technology.

On the foundation of that strong fund of knowledge and experience, the Delaware Health Care Commission with direction from the Department of Health and Social Services has been the public face of the new Health Reform law, the Affordable Care Act. They hold open, monthly public meetings and allow public input into their discussions. Last summer they worked with the consultants from Public Consulting Group to hold public forums in communities all over the state where various stakeholder groups could come out and voice their ideas about the new Health Reform law. They held focus groups where leaders from various stakeholder groups could voice their input. They initiated plans to set up the Health Benefits Exchange which will be an online portal where people can access their insurance options and enroll in the Exchange beginning in 2014. They have plans for what the governing Board of the Exchange should look like and what the administrative entity that operates the Exchange might be. The U.S. Department of Health and Human Services has said that by January 2013 the states have to show sufficient progress toward creating an Exchange. So there is a lot more work that still needs to be done this year.

I believe the Delaware Health Care Commission is uniquely positioned to guide this project and provide input to you and all the state legislators on what is best for Delaware as we proceed to 1) authorize the creation of the Exchange, 2) appoint members to the governing Board of the Exchange, and 3) set guidelines for an essential benefits package to be offered on the Exchange. The job is large and complex and the Delaware Health Care Commission is an important partner. Thank you for the opportunity to speak.

Rep. Kowalko: Thank you, Dr. Fields.

Brian Posey, Associate State Director, AARP Delaware: Thank you, very much, Mr. Chair, and thank you to the members of the Committee. My name is Brian Posey from AARP Delaware. On behalf of more than 162,000 AARP members in Delaware, I am here to voice continued support for the Delaware Healthcare Commission.

The Healthcare Commission fills a valuable role in bettering healthcare in our state. I have attended the meetings for many years and have witnessed the serious efforts to address emerging healthcare needs that Delaware is facing. A few examples of discussions from recent meetings include:

• Strategies and concrete results in increasing Delaware's healthcare workforce. This is being accomplished through DIMER, DIDER, and through Delaware's school loan repayment program to increase provider access in underserved areas.

• Discussion of hospice and palliative care in Delaware — made more important by Delaware's increased aging population and the desire for individuals to remain in their homes as they age.

• A focus on the overall health delivery system in Delaware, including access to care, system of delivery, prevention and detection, and the role of technology in increasing the quality of care.

• And, as an ongoing effort, the Healthcare Commission's involvement in preparing Delaware for the full implementation of the Affordable Care Act. A major element of the healthcare reform law is for states to create a marketplace for commercial insurance. These "Health Benefit Exchanges" will provide consumers a vehicle to compare and enroll in insurance plans in an easy- to-understand, apples to apples fashion. This effort is hugely important to Delaware consumers — particularly the 100,000 or so who are currently uninsured. It is our view, AARP's view, that the Healthcare Commission is uniquely suited to make sure that Delaware is prepared for implementation in 2014.

Finally, the issues I just shared are not going away. Delaware's population is growing dramatically, particularly the older population, and healthcare costs continue to rise, and the need for more healthcare professionals is a perpetual challenge. The Delaware Healthcare Commission should be commended for its work, and AARP looks forward to helping Delaware, and the Commission, continue to improve the quality and access to care.Thank you.

Jim Lafferty, Mental Health Assoc.: Representative Kowalko, Senator Bunting, and members of the Committee, I appreciate the opportunity to speak to you this evening about the Health Care Commission. I am Jim Lafferty, the Executive Director of the Mental Health Association in Delaware.

As I see it, the Commission plays a critical role in the research and policy development in the health care system in the state of Delaware. Themes include access to care, system of delivery, the role of technology, utilizing data, etc. They are sort of the gathering point, if you will, or the focal point for health care activities in the state – the one organization that is able to look at and coordinate health care activities in the state.

As a result of the Health Care Commission subcommittee on mental health access of which I was a member, certain parts of the state were designated mental health shortage areas. Delaware has significant issues facing it in the health care arena, workforce development being a critical one in the state, and especially so in Sussex and Kent counties.

Among other health care professions, the lack of mental health professionals is striking. You've heard discussion about it and there have been questions and comments about the shortage of primary care physicians. There are other shortages. I am focusing on mental health this evening.

The population to psychiatrist rate in Sussex County that was developed as a result of a study that the University of Delaware did in 2006, was approximately one psychiatrist to 20,000 individuals in Sussex County. I believe that number today is 1 to 27,000 and continues to grow as the population in Sussex County continues to grow but the mental health professional workforce does not grow.

There was a particularly acute need for child psychiatrists. Psychiatry in general, child psychiatry in particular in both Kent and Sussex again, most acutely even Sussex County. Other mental health professionals trained in treating childhood emotional problems and working with children who have experienced adverse childhood events, such as physical and sexual abuse. That has been Lt. Governor Denn's focus with his committee has taken a really hard look at the mental health needs, if you will, folks in Sussex County. As you know, we have a number of children now who have been the victims, if you will, of sexual assault.

We understand, at least in the mental health arena, the impact of these adverse childhood events, particularly sexual abuse, physical abuse, on the developing brain of the child and science has gotten to the point where physical changes in the brain can be observed and the impact of abuse at various ages can actually be put into where it says to which part of the brain is affected and which behaviors are going to be affected as well from the trauma.

I just urge and I thank you for supporting the Health Care Commission, but I really urge the support of additional funds being directed toward Sussex County in particular in the areas of mental health care. We've got a number of folks to take care of now, and we are going to have an ongoing need for professionals in Sussex County.

As I view it, the Health Care Commission is a vital part of the coordination of health care activities in the state as well as assessing the outcomes of health care initiatives in this state and there were comments about understanding the outcomes of some of the initiatives that are being tried – some of the pilots.

I certainly support the Health Care Commission as an entity vital to the state of Delaware and I applaud the Health Care Commission for its work. And I want to thank you for supporting the Health Care Commission. You made my remarks pretty easy. Thank you very much.

VII. Concluding Remarks

Rep. Kowalko: Thank you, Sir. If there are any comments from the Committee members at this time?

Sen. Bunting: I would like to thank Mr. Lafferty for his testimony. Since we've, the Lt. Governor and I, have been working on this, I had a gentleman, who not only talks psychiatry, but he is a practicing psychiatrist who retired in Bethany, and he was at one of the major colleges, and he has volunteered – he has taken all my notes that I can give him, minutes, and so forth, and he sees the issue. He's got a little – he has some broader ideas that I think will help as well and anytime we get help like this, and once the public is aware of this, not only because of the Bradley case, but just issues in general, and we draw on people like this – these professionals that come up and say they want to volunteer their time. Thank you.

Rep. Kowalko: I also would like to thank you, sir, for being here, and I want to thank the Health Care Commission and I also want to point out that, not limiting it, the mental health children, to just a traumatic experience, but also appreciating that a lot of our education challenges is to providing an adequate mental counseling for some children. Every time you hear or read of a child of attempting or committing suicide, or a depressive state that keeps them from learning, and taking advantage of the opportunities of education, that is a scream that you can't cover your ears and it will pierce your hands and pierce your eardrums and it should. I applaud everybody that makes an effort in that area. I am hoping that we will continue investigating because that is a large landscape that we have to survey and it is a daunting challenge but it is necessary for future generations.

I appreciate everyone being here tonight and I will entertain a motion to adjourn.

Motion made and seconded. Vote: Yes -7 (Rep. Kowalko, Sen. Bunting, Rep. Bennett, Rep. Ramone, Rep. Short, Rep. Atkins, Sen. Sorenson). Motion carried.

Thank you everyone on the committee and thank you everyone in the public for being here. I really appreciate it very much.

VIII. Adjournment

The meeting adjourned at 7:15 p.m.

Notes:

A tentative date and time has been identified for the Health Care Commission’s recommendation meeting for Thursday, March 15th at 10am. We will continue to meet in the JFC Hearing Room, provided the Joint Finance Committee is not meeting at that time. A confirmed date, time and location will be posted on the General Assembly’s website in the coming weeks. Public comments will also continue to be received until the recommendation meeting.

A friendly reminder to all Committee members, our next public hearing is scheduled for next Wednesday, February 8th at 5:30pm for the Unemployment Insurance Appeal Board.

Summary of comments submitted prior to the January 31, 2012 Delaware Health Care Commission public hearing are as follows:

|Name/Organization |Delaware Health Care Commission |

|Contact Info |Outline of Public Comments Submitted to the Joint Sunset Committee |

| | |

|Joann Hasse |Mrs. Hasse believes DHCC serves a very useful purpose and should continue to exist. |

|Chair - Health Care | |

|DE League of Women Voters |Consider amending the statute to allow ex-officio members on the committee, if unavailable to attend |

|478-4096 |meetings, to send the Department’s chief deputy in their absence to participate and vote. |

|joannhasse@ | |

| |Chief deputy would have broad knowledge of functions and finances and some authority to speak for the |

|(memo received 1/23/12- |Department. |

|sent to JSC 1-30-12) | |

| |Frequently legislation is written specifying the Secretary “or a designee” to serve on various |

| |committees, allowing the appointment of almost anyone from the Department. In Mrs. Hasse’s opinion, this|

| |would be inadequate to serve the purposes of the DHCC and it would be better to leave the statute |

| |unchanged than to amend it in that fashion. |

| | |

|Sarah Noonan |Per Ms. Noonan, DHCC is an extremely valuable partner to Westside Family Healthcare, Delaware’s largest |

|Deputy Director |community health system and the safety-net provider for over 23,000 low-income uninsured and |

|Westside Family Healthcare |underinsured in the state. |

|656.8292 Ext-116 | |

|Sarah.Noonan@ |Westside faces significant challenges in recruiting medical and dental providers willing to practice in |

| |the underserved low-income communities that they serve. |

|(memo received 1/27/12- | |

|sent to JSC 1-30-12) |The state loan repayment program incentivizes providers to practice in the designated health |

| |professional shortage areas in Delaware for an extended period of time. |

| | |

| |This program also ensures that Delaware is competitive with other states that may have a similar program|

| |or no program at all. |

| | |

| |Westside has benefitted from the research conducted by the DHCC using the resources available to support|

| |needs assessments and strategic planning. |

The full comments submitted by Ms. Hasse and Ms. Noonan are on the following pages:

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