Happy Valentine’s Day! The Gold Dome was awash today with lots of hearts and flowers, but lawmakers were focused on the people’s business with much of the day spent on the State’s budget. One of the bigger initiatives this session, proposed changes to Georgia’s Certificate of Need program that regulates healthcare services, was again in committee late this afternoon. Governor Kemp also announced My GCAL, the new suicide prevention app geared toward teens that be run by the Georgia Crisis and Access Line (“GCAL”) and the Department of Behavioral Health and Developmental Disabilities. This new technology will save lives, and today’s launch reflect a continued emphasis in the Governor’s Office on child and adolescent mental health. Catch up on the rest of today’s news from downtown in this issue of the #GoldDomeReport.

In this Report:

• Governor Kemp Debuts “Patients First Act”, My GCAL Teen Suicide App
• House Committee Reviews, Hears Testimony on CON Bill
• Committee Updates
• New Legislation
• Rules Calendars for Legislative Day 16

Governor Kemp Debuts “Patients First Act”, My GCAL Teen Suicide App

Amidst the clamor of legislative committee action, Governor Kemp has made two major announcements over the past two days. First, on Wednesday, Kemp announced his Patients First Act, a follow-on to his spending proposal for Medicaid waiver planning that would empower the executive branch to actually seek waivers from the federal government. The legislation, SB 106, would amend Title 33 to allow the Governor to apply to the federal government for a Section 1332 waiver from the Patient Protection and Affordable Care Act. It would also amend Title 45 to allow the Department of Community Health to apply for a Section 1115 Medicaid waiver that “may include an increase in the income threshold up to a maximum of 100 percent of the federal poverty level.” State law expressly prohibits the State from seeking the waivers without statutory authority from the General Assembly, and the Patients First Act would grant broad authority to the Governor and DCH to craft the waiver applications. It is yet to be seen whether the legislature will be willing to grant such wide discretion. The Governor’s press release is available here.

Today, Governor Kemp narrowed the focus to mental health, announcing the launch of My GCAL, the suicide prevention app geared toward teens and funded by the General Assembly last session. Legislators allocated $1.4M for the development of the app, which is a collaboration between the Georgia Crisis and Access Line (“GCAL”) and the Department of Behavioral Health and Developmental Disabilities. After today’s debut, Governor Kemp tweeted: “I applaud the hard work of Commissioner Fitzgerald and the Department of Behavioral Health & Developmental Disabilities to build this resource for our state and lend a helping hand to those in need.” The app is available for download in the App Store and Google Play, and the Governor press release is available here.

House Committee Reviews, Hears Testimony on CON Bill

Yesterday, Rep. Matt Hatchett (R-Dublin) and Rep. Terry England (R-Auburn) presented a substitute to HB 198, the House version of the revamp of Georgia’s Certificate of Need program found in Title 31, to a packed convening of the House Special Committee on Access to Quality Health Care. Much of the content of the legislation was discussed in meetings of the House Rural Development Council that has met over the last couple of years throughout the state. This meeting was chaired by Rep. Richard Smith (R-Columbus), who was appointed by Speaker David Ralston (R-Blue Ridge) to this newly created Committee. There was no public comment at this hearing, and no vote was taken on the initiative. Reps. Hatchett and England explained the proposal and fielded a few questions from the committee.  One portion of the proposal that Chairman Smith indicated he liked was in regards to the “transparency” on financials that hospitals would be required to make available.

The Committee met again today to hear testimony from supporters and opponents:

• Legacy Sports led off the testimony supporting HB 198, stating in part that “competition” was good. The proposed legislation will allow the state to build a world class facility in the state.
• Ray Williams presented on behalf of Cancer Treatment Centers of America (“CTCA”). He thanked the sponsors and rose in support of the bill. The proposal allows his destination cancer hospital to convert to an acute care hospitals and eliminates the 65% out-of-state patient, 35% in-state patient restriction. The proposal also eliminates the 50-bed limit.  Mr. Williams reported that CTCA has turned away 211 Georgians from care. If the legislation passes, CTCA would operate as a general hospital, the way it does in four other states. It would also provide indigent and charity care and, according to Williams, those numbers have increased year over year. The hospital community states they owe penalties and fines, but Mr. Williams noted that CTCA has not been found non-compliant by DCH. Each of the two CON applications they applied for have been granted. According to Mr. Williams, CTCA has followed instructions provided by DCH on how they are to operate in Georgia. He also quoted Monty Veazey, that zip code should not determine access to healthcare.
• Ethan James and Keri Conley spoke on behalf of the Georgia Hospital Association (“GHA”).  GHA opposes HB 198 but does have a compromise proposal. GHA assembled a work group that looked at CON, trying to see where it could be modernized in the exploring the CON program. The Health Strategies Council (“HSC”) was previously used to update the need formulas to determine if a service was needed and also looked at quality.  The HSC ended in 2005, and in 2008 the General Assembly recommended its reformation. In 2012, all to the HSC were removed from statute. GHA asked for inclusion in the process to talk about CON, but noted that HB 198 is not a compromise and will damage the state’s hospitals and draw funding away from rural facilities. Mr. James noted that this legislation will only worsen the problems. 

Keri Conley talked about concerns, noting that healthcare is not a free market and elimination of CON for services does not make it a free market. Healthcare is only industry required to treat folks regardless of their ability to pay. As contractors, they get paid less than costs – unlike road builders, military base builders, etc.  Ms. Conley highlighted three detrimental parts of the proposal:

• It allows freestanding imaging centers without licensure or quality review;
• It allows freestanding cardiac cath labs to be put in place anywhere and currently hospitals now are required to meet a lengthy list of safety/quality measures; and
• it allows multi-specialty ASCs regardless of impact to the community’s access to emergency care/services.

According to Ms. Conley, hospitals subsidize emergency services now, and the state must decide if it needs 24/7 healthcare providers or if it is more important to have a choice where to get an MRI. Physicians can open ASCs now in rural counties, and it has not impacted CON. No one believes the CON program is perfect, and the need methodologies have not been updated in 20 years. The state health plan has not been modernized. Ms. Conley urged lawmakers to look at how to improve the program before throwing out the CON program.

Dr. Jonathan Lewin of Emory University spoke to the bill. He thanked the committee to look critically at the issue and create a forum for discussion. He wants to find areas where they could agree. Dr. Lewin noted that not all not-for-profit facilities are the same.  Emory is a research facility and a planning process is critical so as to teach, research new treatment/cures and provide the tertiary care needed. Emory provides more than half of the residency positions in Georgia. 

Many parties spoke for an against the bill. Virtually all hospitals who had concerns about restructuring the CON program favored the basic transparency provisions of the bill. The hospitals and health systems all invited a negotiation session with proponents and lawmakers to discuss the current CON program and proposed reforms. The following entities spoke to the bill:

• Supporting the Bill
  
  
  • CTCA
  • Legacy Sports
  • Americans for Prosperity -- Georgia Chapter
  • Georgia Society of Ophthalmology
  • Georgia Society of Ambulatory Surgery Centers
  • Hometown Health
  • Columbus Cardiology
• Reservations About the Bill
  
  
  • GHA
  • Georgia Alliance of Community Hospitals
  • Navicent Health
  • Stratus Health
  • St. Joseph’s / Candler Hospital
  • Northside Hospital (open records issues)
  • Wellstar Health System
  • Northeast Georgia Health System

Committee Updates

House Education Committee

The House Education Committee, chaired by Rep. Rick Jasperse (R-Jasper), to consider three propositions:

• HB 59, authored by Rep. Dave Belton (R-Buckhead), amends Title 20 to allow children of active duty military personnel to register in a local school district based on the parent's official military orders rather than requiring the family to establish residency. Chairman Jasperse asked about how far in advance military personnel get orders, to which Rep. Belton responded about six months. Rep. Todd Jones (R-South Forsyth) asked about how the bill and early enrolling would affect QBE funding, to which Rep. Belton responded the children would be treated like any other child enrolling mid-year. The Committee unanimously recommended the bill DO PASS and be sent to the Rules Committee.
• HB 69, authored by Rep. Scot Turner (R-Holly Springs), amends Title 20 to revise the prior school year requirement for the Special Needs Scholarship Program. Specifically, the bill removes the prior year attendance requirement if the applicant has previously qualified for the scholarship. The Committee unanimously recommended the bill DO PASS and be sent to the Rules Committee.
• HB 130, authored by Rep. Randy Nix (R-LaGrange), amends Title 20 to authorize the Georgia Foundation for Public Education to apply for recognition as a 501(c)(3) not-for-profit organization. The Foundation raised funds through education license plate sales and other sources, but 501(c)(3) status would allow for “exponential increases” in fundraising and grants. Reps. Doreen Carter (D-Lithonia) and Brenda Lopez Romero (D-Norcross) had several questions regarding the nonprofit entity structures. The Committee unanimously recommended the bill DO PASS and be sent to the Rules Committee.

The following bills were assigned to Subcommittee:

• HB 68 -- Academic Innovation
• HB 83 -- Academic Achievement
• HB 86 -- Academic Achievement
• HB 169 -- Academic Innovation

Senate Health and Human Services

Yesterday, Chairman Ben Watson, MD (R-Savannah) and his Committee heard the legislation, SB 18, by Sen. Kay Kirkpatrick (R-Marietta) which would enact the “Direct Primary Care Act.” The legislation allows physicians and patients to enter into agreements for patients to receive care and clarifies that such agreements are not forms of insurance and are exempt from regulation by the Commissioner of Insurance in O.C.G.A. 33-7-21.  25 states have passed similar legislation. The Committee raised some questions regarding how an individual, who was a party to such agreement, might terminate the contract and after discussion amended the proposal so that the agreements could be terminated by either party and the patient would be entitled to any unused portion of the money paid at the point of entry into the contract within 30 days of termination.  It does allow either party to the agreement to terminate.  The Committee gave the bill a DO PASS by Committee substitute and it now moves to the Senate Rules Committee.

House Appropriations Committee — Health Subcommittee

The Health Subcommittee of the House Appropriations Committee, chaired by Rep. Butch Parrish (R-Swainsboro), met yesterday and today to hear testimony on the FY 2020 Budget.

Commissioner Frank Berry of the Department of Community Health indicated the department will prioritize departmental reorganization and efficiency improvements in the upcoming fiscal year. These changes will consist of the establishment of a project management department specializing in strategic planning. He also indicated that Governor Kemp has expressed his desire for less administrative burden across the department, resulting in DCH conducting continuous program improvement to fix deficiencies. The department’s largest budget line items for FY 2020 include:

• Background checks: $737,635
• Third party liability: $1,803,250
• CHIP eFMAP adjustments: $3,708,763
• Utilization of existing funds to expand Medicaid asset verification system: $609,091

Specific items for the departments aged, blind, and disabled programs include:

• Benefits growth: $88,885,270
• Medicare part B: $6,839,224
• Gene therapy: $5,926,010
• FMAP: $92,022,626
• IPPS Phase 3: $9,275,234
• Long Term Acute Care: $3,168,093
• Health insurer fee moratorium: Decrease of $34,439,780
• Hospital provider fee payment: $10,410,506

LaSharn Hughes, executive director of the Georgia Board for Physician Workforce gave an overview of the Board’s efforts to expand the number of physicians in rural areas via grants to undergraduate medical school programs. These grants will receive no increase and will continue into FY 2020 at the same level of FY 2019. Ms. Hughes also touched on medical school debt in Georgia, which is higher than the national average. Chairman Parrish asked why the Georgia average is higher to which Ms. Hughes explained that typically the largest medical school debt is incurred during the residency matching process but did not explain why this puts Georgia above the national average. Rep. Pat Gardner (D-Atlanta) discussed the funding for Mercer and Morehouse and noted that their funding is usually at similar levels. She asked if this funding parity will continue considering Mercer’s planned expansion. Ms. Hughes expressed that the Board always supports expansion into rural areas.

J. Patrick O’Neal, Commissioner of the Department of Public Health, outlined the issues DPH has been working on; including PDMP, maternal mortality, and the burden of alzheimer’s. Additionally Commissioner O’Neal discussed the potential of telehealth expansion to provide better healthcare outcomes. Rep. Carolyn Hugley (D-Columbus) asked about the disparity of maternal mortality for African American mothers and what DPH is doing to bridge that gap. Commissioner O’Neal explained that this disparity occurs across socioeconomic levels and the  current working theory considers unique stressors for African American females during pregnancy to be a leading cause of maternal mortality, which DPH is currently studying.

Dennis Troughton of the Georgia Drugs and Narcotics Agency explained how the agency enforces regulations for pharmacies. His department’s budget requests consisted of an upgraded database to allow the agency to better streamline their investigations along with more agents to actually conduct ground level enforcement and investigations. He noted that because all agents are pharmacists, they must take significant pay cut to work for the agency, making recruitment very challenging.

The Subcommittee heard public testimony this morning, which included:

• Donna Davidson of the Easterseals Coalition requesting a $513,000 addition to the FY 2020 budget to serve additional kids through the Champions for Children program.
• Matt Caseman of the Georgia Nurses Association requesting funding in the FY 2020 budget to expand the Georgia Nurses Foundation Peer Assistance Program. The funds would be used to increase case manager services.
• Rusty Paul of the Georgia chapter of the Home Care Association of America requesting a 10% rate increase for personal care services under CCSP and SOURCE waivers (approximately $11M in state dollars). Mr. Paul noted the additional costs associated with mandatory fingerprinting and federal pay rules in recent years and stated that a rate increase would allow for wage increases for caregivers. Rep. Carolyn Hugley (D-Columbus) asked how much wages would increase, to which a representative of Caremaster noted that average wages of $9.70 per hour would likely go to $10.50 or $11 per hour.
• Nancy Paris of the Georgia Center for Oncology Research and Education requesting $887,500 to be shared among the state’s regional cancer coalitions to continue implementation of screening and education programs, as well as $1M in funding to expand distribution of education and best practices for cancer care and research around the state. Chairman Parrish and Rep. Pat Gardner (D-Atlanta) both expressed appreciation for the unified effort in requesting funding.
• Bryan Ginn of PCOM Georgia expressing appreciation for the Subcommittee’s support through capitation funding and startup funding last year and invited a continued partnership. In response to a question from Rep. Darlene Taylor (R-Thomasville), Mr. Ginn noted that PCOM’s South Georgia campus in Moultrie will welcome its first students in August 2019, and PCOM is committed to growing programs on that campus going forward.
• Elise Blasingame of Healthy Mothers Healthy Babies Coalition of Georgia requesting funds for six Mother-Baby satellite clinics in six counties with the poorest outcomes.
• Russel Carlson of the Georgia Health Care Association requesting assistance with a “more current funding mechanism” for caregivers in skilled nursing facilities. According to Mr. Carlson, 73% of Georgia’s skilled nursing residents are enrolled in Medicaid. Rep. Jesse Petrea (R-Savannah) asked about the impact of last year’s fingerprinting law on skilled nursing facilities, which Mr. Carlson estimated at $660,000 in state funds and $2M total. Jenny Helms of Leading Edge Georgia also spoke in favor of GHCA’s proposal.
• Sally Buchanan of Creative Community Services requesting re-establishment of therapeutic foster care, which was previously eliminated in Georgia, by re-bundling Medicaid funds for providing foster care and therapy services. Ms. Buchanan also requested a Medicaid waiver, state plan amendment, or pilot program to provide for housing and supervision for youth aging out of foster care who have IQs between 70 and 85 and do not qualify for a current developmental disability waiver. She also noted and reiterated that as much as 19% of our unemployed population may be former foster children. Rep. Petrea inquired why the youth aging out of foster care cannot be served by DBHDD or other public behavioral health services, as well as whether foster care rate increases over the past few years have had an impact. Ms. Buchanan responded that they had helped, but much more is needed given the services required by the kids.
• Micah Whitfield of Postpartum Support International requesting funds for implementation of a maternal mental health initiative. Kalarin Mackey of Emory expressed support of the proposal.
• Michael Brooks of Georgia Primary Care Association expressing appreciation for the Subcommittee’s prior support and requesting assistance in marketing and expanding their services.
• Emily Jones of the March of Dimes requesting a $2.3M allocation to support the the addition of four conditions to the state’s newborn screening program, $200,000 to fund two additional nurse abstractors for the Maternal Mortality Review Committee, and $500,000 for the Morehouse School of Medicine to establish a maternal mortality center of excellence.
• Daniel Thompson of the Georgia OB/GYN Society requesting a $200,000 for the Maternal Mortality Review Committee (same request as March of Dimes), $865,000 to fund all existing OB/GYN residency slots in Georgia, and funding for the perinatal telepsychology program proposed by Postpartum Support International.  
• Teresa Heard of Easterseals Southern Georgia requesting additional support serve additional children through the Champions for Children program.
• Cristy Carey of PSA Healthcare requesting additional rate increase funding for services they provide under the GAPP Medicaid Waiver (children birth to 21). Steve Neff of Bayada Home Health Care also spoke in support of rate increases.
• Michael Cortez of the American Heart Association requesting support for accreditation and designation of hospitals as stroke centers. He reminded the Subcommittee that stroke is the fourth leading cause of death.

House Appropriations Committee -- Human Resources Subcommittee

The Human Resources Subcommittee of the House Appropriations Committee, chaired by Rep. Katie Dempsey (R-Rome), met again today to hear from two more agencies along with public comments.

The Department of Veterans Services’ Commissioner Mike Roby gave an overview of the Department and highlighted that a little over half of their funding comes from state coffers.

Judy Fitzgerald, Commissioner of the Department of Behavioral Health and Developmental Disabilities (“DBHDD”), presented DBHDD’s FY 2020 requests along with a look into the Department’s priorities beyond the next year. The priorities of DBHDD remain rooted in:

• Crisis services
• IDD waivers
• Addictive disease beds
• Administrative Services Organization
• Hospital services
• Forensic services
• Core services

Their budget requests fall into two major categories. The annualization of funds from the FY 2019 budget include:

• BHCC funding: $8,263,770
• 125 NOW and COMP waivers $3,666,672
• C&A MH commission and supported employment for 500 youth and young adults: $1,530,000
• Medicaid loss offset: $7,054,652
• ASO funding: $9,547,164

The Department’s request for their largest priorities in FY 2020 includes:

• Forensic Coordinator (8): $627,344
• Forensic Evaluator (5) $782,480
• Forensic Community integration home (6 beds) $433,080
• 125 new NOW and COMP waivers $4,249,798
• MH supportive housing vouchers (700 new individuals) $2,488,254
• Crisis bed infrastructure (21 BHCC/CSU): $10,212,349
• AD residential beds (144 beds) $4,939,920

Rep. Tommy Benton (R-Jefferson) asked which areas are in the greatest need of Behavioral Health Crisis Centers to which Commissioner Fitzgerald responded with Gainesville, Northwest Georgia, and Metro Atlanta (specifically Fulton County). Rep. Benton continued by asking if the average of the total funds fo the eight Forensic Coordinators would constitute their individual salaries along with why their salaries are less than the Evaluator position. Commissioner Fitzgerald explained that the line items for both of these positions would encompass their salaries and benefits. She further explained that the Evaluator position requires licensed psychiatrists and, thus, is a higher paying position. Rep. Benton then asked about the specific allotment of NOW and COMP waivers to which Commissioner Fitzgerald explained there are 75 NOW and 50 COMP waivers and that there are currently about 6,000 individuals on the waiver planning list.

A representative from United Cerebral Palsy of Georgia spoke to the subcommittee about the organization’s work. She also requested a budgetary addition of $2.6 million. This money would be used to cover 5% rate increase to identify specific NOW and COMP waiver services. Currently the organization has seen an increase in the turnover rate of caregivers in the state.

Shelly Simmons from the Statewide Independent Living Council thanked the subcommittee for its work last year in appropriating funds to the organization. She is asking for $800,000 to build five new satellite offices in the state in areas currently not served by the organization.

Rep. Emory Dunahoo (R-Gainesville) asked how many people are expected to be employed at each new office. Ms. Simmons said that the number of employees will vary by how much work the individual offices conduct, but the average is expected to be about two or three employees.   

New Legislation

The following legislation of interest was introduced in the House today:

• HB 287, authored by Rep. Matt Dubnik (R-Gainesville), amends Title 48 to delete a tax exemption for community based faculty physicians. This bill was referred to the House Ways and Means Committee.
• HB 288, authored by Rep. Alan Powell (R-Hartwell), amends Title 15 to change the amount a court clerk can charge for the submission of documents related to real estate and personal property. This bill creates a flat fee of $25 for all documents instead of a per-page fee. This bill was referred to the House Judiciary Committee.
• HB 289, authored by Rep. Mary Margaret Oliver (D-Decatur), amends Title 16 to outlaw the possession and use of bump stocks in Georgia. This bill was referred to the House Public Safety and Homeland Security Committee.
• HB 290, authored by Rep. Sharon Cooper (R-Marietta), amends Title 31 to establish a pilot program to provide preexposure prophylaxis drug assistance to persons at risk of becoming infected with HIV. This bill was referred to the House Health and Human Services Committee.
• HB 292, authored by Rep. Tommy Benton (R-Jefferson), amends Title 47 to eliminate remittances required to be made by the University System of Georgia to the Teachers Retirement System of Georgia. This bill was referred to the House Retirement Committee.
• HB 300, authored by Rep. Vance Smith (R-Pine Mountain), amends Title 33 to redesignate continuing care retirement communities as life plan communities. This bill was referred to the house Human Relations and Aging Committee.
• HB 301, authored by Rep. Wes Cantrell (R-Woodstock), amends Title 20 to establish educational scholarship accounts for children whose family income is less than 200% of the federal poverty level, who have been adopted from foster care, who have an active duty military parent, who have individualized education programs, who have documented cases of having been bullied, or have simply been enrolled in a Georgia public school for the past year. The bill would allow parents of such children to take the public funds allocated for their children’s public education and place those funds in an account that could be used to pay for tuition, fees, and textbooks at private schools, as well as tutoring services, online education programs, and therapy services. The bill was assigned to the Ways & Means Committee.
• HR 214, authored by Rep. Sam Watson (R-Moultrie), reauthorizes the Rural Development Council. This resolution was referred to the House Economic Development Committee.

The following legislation of interest was introduced in the Senate today:

• SB 101, authored by Sen. Brandon Beach (R-Alpharetta), amends Title 31 to require volunteer coaches with youth athletic associations to undergo training to reduce the likelihood of injuries to youth athletes engaged in high risk athletics. This bill was referred to the Senate Education and Youth Committee.
• SB 102, authored by Sen. Emmanuel Jones (D-Decatur), amends Title 20 to provide for a pilot program to plan, implement, and improve sustainable community schools. This bill was referred to the Senate Education and Youth Committee.
• SB 104, authored by Sen. Chuck Payne (R-Dalton), amends Title 31 to revise the the parental requirement for consent for an order not to resuscitate for their child. This bill provides that a parent’s consent must be submitted orally or in written form. This bill was referred to the Senate Judiciary Committee.
• SB 106, authored by Sen. Blake Tillery (R-Videlia), amends Title 49 and Title 33 to authorize the Department of Community Health to submit a Section 1115 waiver to the United States Department of Health and Human Services. The bill states that the waiver may request an increase in the income threshold up to 100% of the poverty line. The bill also authorizes the Governor to submit a Section 1332 waiver request. This bill was referred to the Senate Health and Human Services Committee.
• SR 161, authored by Sen. Renee Unterman (R-Lawrenceville), commends the School Social Workers Association of Georgia and recognizes March 1, 2019 as School Social Workers Association of Georgia Day at the state capitol.

Rules Calendars for Legislative Day 16

The House will consider the following measures tomorrow for Legislative Day 16:

• HB 63 -- Insurance; health benefit plans to establish step therapy protocols; require (Ins-Cooper-43rd)
• HB 128 -- Insurance; insurers do not have to notify the Georgia Composite Medical Board of agreements to settle medical malpractice claims against physicians when the settlement resulted in the low payment under a high/low agreement; provide (Ins-Silcox-52nd)
• HB 166 -- Genetic Counselors Act; enact (Substitute)(H&HS-Silcox-52nd)

The Senate Rules Committee did not meet today, therefore there is no calendar set in the Senate for tomorrow.