Wednesday, November 13, 2019

More action needed to protect patients from antibiotic-resistant infections, which kill an American every 15 minutes, CDC says

Cover of CDC report; to download it, click here.
More action is needed to protect Americans from antibiotic-resistant infections, 2.8 million of which occur in the U.S. each year, killing more than 35,000 people, one about every 15 minutes, says the federal Centers for Disease Control and Prevention.

On top of that, 12,800 people died from an infection that is not drug-resistant but is "caused by the same factors that drive antibiotic resistance—antibiotic use and the spread of germs," the CDC said in its report, Antibiotic Resistance Threats in the United States, 2019. "The number of people facing antibiotic resistance is still too high. More action is needed to fully protect people."

Hospitals are a main battleground in the fight. The word "hospital" appears 188 times in the 148-page report, which was issued days after the Leapfrog Group's latest rankings of patient safety at hospitals nationwide, including 50 in Kentucky. The most common grade, on an A-to-F scale, was a C, and the report showed that many hospitals had difficulty dealing with resistant infections.
The University of Louisville Hospital got a D overall in the Leapfrog Group's patient-safety ratings and was rated poorly in dealing with one of the major antibiotic-resistant infections, Methicillin-resistant staphlycoccus areus (MRSA), and C. diff, an infection related to the use of antibiotics. Click to enlarge.
The report's foreword, by CDC Director Robert Redfield, sums up the history of antibiotics in personal terms: "In March 1942, Mrs. Anne Miller of New Haven, Connecticut, was near death. Infectious germs had made their way into her bloodstream. Desperate to save her, doctors administered an experimental drug: penicillin, which Alexander Fleming discovered 14 years earlier. In just hours, she recovered, becoming the first person in the world to be saved by an antibiotic. Rather than dying in her thirties, Mrs. Miller lived to be 90 years old.

"Today, decades later, germs like the one that infected Mrs. Miller are becoming resistant to antibiotics. You could have one in or on your body right now—a resistant germ that, in the right circumstances, could also infect you. But—unlike the bacteria that threatened Mrs. Miller—the bacteria may be able to avoid the effects of the antibiotics designed to kill them. Unfortunately, like nearly 3 million people across the United States, you or a loved one may face an antibiotic-resistant infection."

The use of antibiotics has a self-defeating element: the growth of genetically different bacteria and fungi that have mutated into forms that are resistant to the antibiotics or picked up resistance traits from other germs through mobile genetic elements. Also, antibiotic use encourages development of Clostridioides difficile, or C. diff., a bacterium "that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon," says the Mayo Clinic. The CDC report says 223,900 cases of C. diff. occurred in 2017, killing at least 12,800 Americans.

"Dedicated prevention and infection control efforts in the U.S. are working to reduce the number of infections and deaths caused by antibiotic-resistant germs, but . . . CDC is concerned about rising resistant infections in the community, which can put more people at risk, make spread more difficult to identify and contain, and threaten the progress made to protect patients," the CDC said in announcing the report. "The emergence and spread of new forms of resistance remains a concern."

What is to be done? "Public-health prevention programs targeting resistant germs can and have worked to slow spread and save lives, but more needs to be done," the report says. "The U.S. and global community must scale up these effective strategies and develop new strategies to prevent infections and save lives. In the United States, infection prevention activities have proven effective in slowing the spread of resistant germs. This includes:
  • Strategies to decrease spread within healthcare settings (e.g., implementing hand hygiene)
  • Vaccinations
  • Implementing biosecurity measures on farms
  • Responding rapidly to unusual genes and germs when they first appear, keeping new threats from spreading

Monday, November 11, 2019

Rural weekly reports on increasing tick-borne allergy to red meat

Map shows cases entered by site users and is not verified. For a larger version of the map, click on it.
A tick-borne allergy to red meat is becoming more common, the Adair County Community Voice reported Oct. 31, in a pair of front-page stories: one on the main front and the other leading its occasional Health and Wellness section.

The allergy is caused by a sugar molecule called alpha-gal. Anna Buckman writes, "Dr. Kourtney Gentry Gardner, an allergist-immunologist in Bowling Green, diagnoses about five people a month with the alpha-gal allergy, and it’s becoming increasingly more common, she says."

Close-up of the Lone Star tick, which
is much larger when it is full of blood.
People who are bitten by the Lone Star tick, especially those bitten repeatedly, are at risk of "having allergic reactions to the molecule, which is found in most mammalian or red meat," Buckman notes. "It is relatively new to the allergy world," having been identified in scientific literature only 10 years ago.

Buckman deals with the science but brings the story home by writing about some local victims, illustrating the varying manifestations of the allergy:

"Tiffany Bean can no longer hang out at summer gatherings where friends grill burgers because, following a tick bite, she developed a food allergy so severe that she even has reaction being around the fumes of cooked beef. . . . Rick Wilson is also allergic to red meat but can eat dairy products. He only had occasional reactions when he was still consuming red meat."

Joshua Wethington (Adair Co. Community Voice photo)
"Five-year-old Joshua Wethington doesn’t like dairy-free pizza, but that’s the only kind he can have. Because of a tick bite at some point in his short life, he is so allergic to red meat that allergists recommended removing dairy from his diet because it is a byproduct of cows." Joshua’s mom, Dana Wethington, told Buckman, “I’m having a hard time getting him to eat things because it doesn’t taste the same to him.”

Other differences: "Bean went from just having an itchy tick bite to having a stomach illness for hours or breaking out into a rash if she consumed anything with alpha-gal. She has lost 40 pounds due to the allergy," Buckman reports. "Joshua got hives all over his body every day that he consumed red meat. Wilson experienced severe itching and nearly passed out during one of his few reactions. Speak to three people with alpha-gal and you’ll discover one thing is certain: it’s complicated. The only similar experiences that Bean, Wilson and the Wethingtons have are the difficulty of living with the allergy and dealing with its affects when they go out publicly."

Bean told Buckman, “People don’t seem to take it seriously. You tell people that you have it and that you could die from it, and people are like, ‘Oh no, you can’t die from eating a hamburger or bacon.’ Well, yeah, you can.”

Alpha-gal victims use technology to help each other, including a smartphone app ("Is it Vegan?"), a Facebook groups (“The AlphaGal Kitchen” and “Alpha-Gal Support Kentucky”) and an interactive map that locates cases (above).

"Recommended by a member on a Facebook support group, the Munfordville Pool Hall and Grill is a relief to alpha-gal sufferers and also sets a great example for other restaurants for being allergy-friendly in general," Buckman writes. "The pool hall has designated one fryer where no red meat or cheese is prepared. They have designated skillets to cook foods for separate consumption because people with alpha-gal allergy can have a negative reaction from even the residue from a mammal product.

Pool-hall employee Justin Minton told Buckman that employees acted after notiing that several people in the community have the allergy. “Speaking from experience, going to Subway is pretty much the only place my grandpa can go,” Minton told Buckman.

Even though "people with alpha-gal are helping one another with useful information, Kandace Webster, an advance-practice registered nurse at T.J. Health Columbia Primary Care, "urges sufferers to seek professional guidance," Buckman reports.

Sunday, November 10, 2019

Gov.-elect Beshear says he'll quickly rescind Gov. Bevin's Medicaid plan; Republicans are wary of legislating it back to life

Beshear claims victory (Reuters photo by Harrison McClary)
By Melissa Patrick
Kentucky Health News

Governor-elect Andy Beshear says he will rescind Republican Gov. Matt Bevin's Medicaid plan, which includes, among other things, highly controversial requirements for work and other "community engagement," and key Republicans in the General Assembly seem wary of trying to legislate such requirements over the Democrat's likely veto.

Beshear said in claiming victory Tuesday night, "In my first week in office I am going to rescind this governor's Medicaid waiver," the federal term for such plans. "Health care is a basic human right and my administration will treat it as such."

But the Republican-controlled legislature could pass the plan on its own, and override a Beshear veto. State Sen. Ralph Alvarado, a Winchester physician who was Bevin's running mate for lieutenant governor, didn't completely dismiss the possibility of legislating work requirements.

"All options are on the table, but it has only been three days since the election," Alvarado said in an e-mail Friday. "Legislative intervention would require significant coordination and consensus from legislators. It is also important to remember that Medicaid expansion, itself, was achieved through executive order and not through legislative approval."

Other Republican lawmakers were quicker to say that their super-majorities in the House and Senate shouldn't try to institute the waiver legislatively.

Meredith (WKYT-TV image)
"It's not a matter you want to spend your political capital on," because it wouldn't get that much return for the effort expended, said Sen. Stephen Meredith of Leitchfield, co-chair of the Medicaid Oversight and Advisory Committee and a former hospital administrator.

House Majority Floor Leader John "Bam" Carney of Campbellsville was likewise skeptical, but said GOP legislators would need to discuss it. "Even lots of Republicans have different opinions about Medicaid, with so many of their constituents on it," he said.

Under Bevin's proposal, most able-bodied Medicaid recipients would have had to work, volunteer, attend school or take job training at least 80 hours a month, and make monthly reports, in order to keep their benefits. Those who are primary caregivers or medically frail would be excluded.

The plan was aimed at those who gained coverage through the expansion of Medicaid to households with incomes earn up to 138 percent of the federal poverty line. It was approved through an executive order under then-Gov. Steve Beshear, the governor-elect's father, under the Patient Protection and Affordable Care Act, which will pay 90% of the expanded costs in 2020.

Steve Beshear could expand Medicaid without the involvement of the legislature because of a 1966 state law that requires the state to "take advantage of all federal funds that may be available" for the program, which began in 1965.

The law was the subject of legislation this year that would have given the secretary of the Cabinet for Health and Family Services full control over Medicaid funding, and the ability do do away with the expansion, Jason Dunn, policy analyst for Kentucky Voices for Health, said in an e-mail.

Republican lawmakers proposed to codify the work and community engagement requirements this year in House Bill 3, sponsored by House Speaker David Osborne of Prospect and Speaker Pro Tem David Meade of Stanford. It was introduced late in the session and failed to make it out of the House Health and Family Services committee, chaired by Rep. Kimberly Moser, R-Taylor Mill.

Moser, like Alvarado, did not dismiss the possibility of legislating the work and community engagement requirements. "We are still reviewing the options," she said in an e-mail. "We need to continue to improve health care delivery for the citizens of our Commonwealth."

HB 3 would have also placed restrictions on other public benefits. It spurred creation of a legislative panel called the Public Assistance Reform Task Force, which has been discussing such programs.

Health advocates argue that work and community engagement requirements, along with co-payments and premiums, would create barriers to care that would lead to large reductions in enrollment. Arkansas was the first state to implement such rules; before its plan was vacated by the same federal judge who blocked Bevin's plan, 18,000 people lost coverage, often from failure to report.

The first version of Bevin's plan estimated that after five years, Medicaid would have 95,000 fewer members than it would without it—largely because of noncompliance, including lack of reporting. "This is paperwork and it is intended to tear health care away from people," Beshear, the state attorney general, said in a debate with Bevin.

The governor argued that "able-bodied" Medicaid beneficiaries need some "skin in the game" and that it is a form of "bigotry" to assume that able-bodied people should be "babied." He claimed that hundreds of thousands of people in the expansion choose not to work.

Studies have indicated that most people who would be affected by the community-engagement rules are already meeting them. One study, based on polling, found that 97% were already meeting the requirements; another, based on claims data, showed that 64% were.

Dustin Pugel, an analyst for the Kentucky Center for Economic Policy, said what this comes down to is that federal law and the courts have said Medicaid is a program that is designed to provide medical assistance, and after Beshear withdraws the waiver, "that is exactly what we'll have."

"We're talking about hundreds of thousands of people who can take a deep sigh of relief after this is over because now they're going to be able to get to a doctor when they need to without barriers," Pugel said.

Bevin is 5,189 votes behind Beshear in unofficial returns. He has refused to concede and has asked for a recanvass of the vote, which is scheduled for Thursday, Nov. 14. A recanvass is a re-tabulation of numbers gleaned from precincts and absentee votes.

50 Kentucky hospitals get semi-annual ratings on how well they protect patients from infections, injuries and other safety issues

More Kentucky hospitals are doing better at protecting patients from infections, injuries and other in-hospital threats, according to the latest national rankings, on an A-to-F scale. The ratings improved slightly from the spring; two additional hospitals got As, and fewer got Cs and Ds.

However, two of the University of Kentucky's hospitals dropped to a D, as did Sts. Mary & Elizabeth Hospital in Louisville, which is being renamed U of L Health – Mary & Elizabeth Hospital after its purchase by the University of Louisville.

Louisville's Jewish Hospital, which will also get a U of L prefix as part of the university's purchase of some KentuckyOneHealth units, got an F on patient safety in the latest rankings by the Leapfrog Group, a nonprofit watchdog organization.

Other Kentucky hospitals with Ds were the Hazard ARH Regional Medical Center and Highlands Regional Medical Center in Prestonsburg.

Methodist Hospital of Henderson, which got an F in the spring, got a C, the most common grade for the 50 Kentucky hospitals rated. Most of Kentucky's 125 hospitals were not rated, since rural hospitals with "critical access" status don't have to report quality measures to the federal government.

Leapfrog bases its grades on data about "infections; surgery and safety problems; error-prevention practices; and metrics on doctors, nurses and staff to determine its rankings and grades twice a year," the Lexington Herald-Leader notes. Leapfrog says its data come from the Centers for Medicare & Medicaid Services (CMS), its own surveys and other sources.

One tab rating The Medical Center at Bowling Green,
which got a C overall, breaks down how it did on infections.
(For a larger version of the chart, click on the image.)
The Leapfrog site offers details on each of the measures under headings titled infections, problems with surgery, practices to prevent errors, safety problems, doctors, nurses & hospital staff. It also includes an easy-to-read, color-coded scale that indicates how the hospital is performing.

UK's Albert B. Chandler Hospital and Good Samaritan Hospital got Ds this fall after Cs in the spring. "In other rankings, UK does very well," the Herald-Leader notes. "Chandler Hospital was ranked as the No. 1 regional facility in Kentucky by U.S. News and World Report and has been for four years.

Dr. Mark Newman, UK’s executive vice president for health affairs, told the Herald-Leader, “Like many academic medical centers, UK HealthCare serves a disproportionate number of patients with complex medical needs, which is not accurately represented by Leapfrog. . . .The quality of care and safety of our patients is of utmost importance at UK HealthCare and we continue to invest in substantial resources to continually improve in these areas.”

Chandler Hospital's rating cited surgery problems such as objects left in patients' bodies; surgical wounds that split open; death from serious treatable complications; collapsed lungs; serious breathing problems; and dangerous blood clots. It also got lower marks for antibiotic-resistant infections and surgical-site infection after colon surgery. "Dangerous bedsores and patient falls/injuries also were issues," the Herald-Leader notes. "Good Samaritan received below-average scores in many of the same areas."

The Centers for Disease Control and Prevention reports that the U.S. has about 35,000 deaths a year from drug-resistant infections. That's one about every 15 minutes, CNN notes.

Jewish Hospital also had problems with infections, surgery, bedsores patient falls and injuries, and communication with patients. U of L Health told the Courier Journal that the ratings of some of its hospitals (U of L Hospital got a D, as usual) didn't reflect "the complex nature of the patient cases they handled or the high-risk population they serve," CJ reporter Morgan Watkins writes.

U of L "noted that some of the information Leapfrog took into account dates back to early 2016," when its hospital was managed by KentuckyOne Health. "The university resumed control of U of L Hospital in mid-2017 and officially acquired Jewish and other Louisville-based KentuckyOne facilities on Nov. 1."

Chief Medical Officer Jason Smith said, "Since 2018, U of L Hospital has reported almost perfect compliance with the Leapfrog Safe Practices. We have reviewed our publicly reported data since July 2017, and utilizing the Leapfrog Group’s own calculator for scoring with that data, our calculated grade would have been a C."
On the positive side, two Kentucky hospitals earned As for the first time: Flaget Memorial Hospital near Bardstown and Jewish Hospital-Shelbyville. The other As went to Baptist Health Lexington, Clark Regional Medical Center in Winchester, Georgetown Community Hospital, Cynthiana's Harrison Memorial Hospital, Louisville's four Norton Healthcare hospitals, and the St. Elizabeth Healthcare hospitals in Edgewood, Florence and Fort Thomas.

The most common grade was a C, given to 20 hospitals. The 10 with B grades are Owensboro Health, Glasgow's T.J. Samson Community Hospital, the three CHI Saint Joseph Health hospitals in Lexington and London, Baptist Health Paducah and Mercy Health Lourdes in Paducah, and Whitesburg ARH Hospital.

Community forum in Louisville addresses teen use of e-cigs

By Melissa Patrick
Kentucky Health News

Kentucky students led a community forum about the epidemic of electronic cigarette use among teens at DuPont Manual High School in Louisville Nov. 6.

Claire Ramsey of Henry County led the discussion at Manual.
"Many students and their parents think that e-cigs or vapes are safe, but they are not, especially for students and young adults. And there just isn't enough research yet to know whether they're safer than cigarettes for adults," said Claire Ramsey, a Henry County seventh-grader who led the discussion.

Ramsey gave the audience a short lesson about the different e-cigarette products and accessories on the market, including a special hoodie designed to hide the device and allow the person to inhale the aerosol through what appeared to be the hoodie draw-string.

A panel of experts presented a range of e-cigarette topics as they related to youth, including some that addressed the specific health dangers to youth, marketing tactics that target youth, an update on vaping-related lung disease, and policies to decrease youth use of e-cigs.

Dr. Aruni Bhatnagar of the University of Louisville told the group of about 70 that nicotine is especially harmful to teens and young adults because it can harm developing brains. He said it is associated with a decrease in impulse control, affects attention and learning capacity, changes the chemistry of their brains and can prime adolescent brains for addiction to other drugs. Research also shows, he said, that teens who use e-cigs are more likely to start smoking regular cigarettes.

E-cigarette use among Kentucky's teens nearly doubled between 2016 and 2018, with more than one in four high school seniors and one in seven 8th graders reporting use in 2018, according to the Kentucky Incentives for Prevention study.

One Juul Labs pod has as much nicotine as a whole pack of cigarettes and many teens go through several pods a day. Juul is one of the most popular brands of e-cigarettes among teens.

Ben Chandler, CEO of the Foundation for a Healthy Kentucky, which hosted the event, listed several policy measures that it will support in the legislative session that begins in January, including taxing e-cigarettes just like cigarettes; raising the age to buy tobacco products and e-cigs to 21; and increasing state funding for smoking prevention and cessation to $10 million, up from $3.8 million.

Asked about cessation products for teens, the panelists said there are no validated cessation programs and protocols for teens who are using e-cigarettes, and a great need for them.

Some resources for teens who are looking to quit include:
Dr. Sara Moyer, Louisville's director of health, noted that the Louisville health department has no age restrictions on its smoking-cessation classes.

Vitamin E acetate may be the culprit

The Centers for Disease Control and Prevention said Nov. 8 that vitamin E acetate, an additive sometimes used in e-cig products, may be to blame for the national outbreak of related lung injuries.

The CDC found vitamin E acetate in all of the samples taken from 29 patients who were sickened by e-cigs in 10 states. THC, or tetrahydrocannabinol, the psychoactive ingredient in marijuana, was detected in 82% of the samples, and nicotine was detected in 62% of the samples.

"This is the first time that we have detected a potential chemical of concern in biological samples from patients with these lung injuries," says the CDC. "These findings provide direct evidence of vitamin E acetate at the primary site of injury within the lungs."

Several other studies have linked cases of EVALI, which stands for "E-cigarette or Vaping product-use Associated Lung Injury," to vitamin E acetate in products containing THC.

That said, the CDC says it's not able to attribute all of the cases of the lung injuries to one compound or ingredient, and there may be more than one cause of the outbreak.

"While it appears that vitamin E acetate is associated with EVALI," CDC said, "evidence is not yet sufficient to rule out contribution of other chemicals of concern to EVALI."

As of Nov. 5, 2,051 cases of lung injury related to electronic cigarettes had been reported to the CDC, and 39 deaths had been confirmed in 24 states.

Of the 1,364 patients on which the CDC has age data, 14 percent were under 18 years old; 40% were aged 18 to 24; 25% were 25-34; and 21% were 35 and older.

The CDC reports that among 867 patients who reported e-cigarette use in the previous 30 days, 86% reported using products with THC; 34% reported exclusive use of THC-containing products; 64% reported using products with nicotine; and 11% said they used only nicotine-containing products.

In Kentucky, 33 cases are under investigation, with three of them confirmed and 11 of them considered probable. Seven reported cases have been ruled out.

The CDC recommends that for now at least, no one should use electronic cigarettes or products containing THC; no one should buy any e-cigarette products off the street, particularly those with THC; and no one should modify or add any substances to e-cig products that are not intended by the manufacturer. It also says that because the cause or causes of these lung injuries is unknown, the only way to assure that you are not at risk is to refrain from use of all e-cigarette or "vaping" products.

Saturday, November 9, 2019

Kentucky doctors and hospitals are changing the culture of opioid prescribing, acknowledging their role in spurring the epidemic

Dr. Philip Overall in the emergency room at St. Claire Hospital in Morehead, which has cut the unit's opioid-prescription rates by half. (Photo by John Flavell for the Lexington Herald-Leader)
Acknowledging their role in causing the opioid epidemic, some Kentucky doctors have mounted an effort with hospitals to reduce prescriptions of painkillers.

The effort began at St. Claire Hospital in Morehead, which has stopped using opioids as its first response to pain. It has been adopted by the University of Kentucky and endorsed by the state health cabinet and the Kentucky Hospital Association.

This is "the first coordinated push . . . to stifle traditional opioid prescribing practices" in Kentucky, reports Alex Acquisto of the Lexington Herald-Leader. "Progress has mostly been a result of independent gumption on the part of providers," like Dr. Philip Overall, emergency-room director at St. Claire, and Dr. Phillip Chang, chief medical officer for UK HealthCare.

Dr. Phillip Chang (H-L
photo by Alex Slitz)
Chang came up with the Kentucky Statewide Opioid Stewardship program, or Kentucky SOS. He and other doctors, mostly from Central Kentucky, have formalized its philosophy "into an actionable plan for others," which has been accepted by "all but nine of the state’s 125 hospitals," including all acute-care and critical-access hospitals, Acquisto reports. "For its statewide scale and applicability across hospital departments, KY SOS is the first of its kind in the country, Chang said."

The hospitals are collecting prescription data for Chang and his team, who will use it to develop appropriate reduction benchmarks hospitals should aim for, Acquisto reports.

The doctors' idea came from experiences with patients.

Dr. Jacob Perry, a St. Claire surgeon, "performed an emergency laparoscopic surgery to remove a patient’s gallbladder — an invasive procedure that pretty much guaranteed an opioid prescription to deal with post-operation pain," Acquisto writes. "Instead of taking the painkillers his patient had been given, she managed her pain with Advil, and two days later, she returned to work. Perry recalled being flummoxed, and then determined: If all she needed was an over-the-counter pain pill, could others manage their pain the same way?"

Perry started asking patients to whom he had prescribed opioid how many pills they had taken, and “The vast majority were like, 1, 2, 3, maybe four,” he said. SO, "He began lowering some of his prescription doses, from 30 to 20," Acquisto reports.

Perry was mentored by Chang when he was at UK. Chang’s inspiration came in 2013, when he was UK's chief of trauma and critical care, Acquisto writes: "A male patient in his 20s kept visiting Chang’s clinic for a few weeks after being treated for a trauma injury. Each time he visited he complained of pain, and each time Chang refilled his opioid prescription."

“I had this epiphany: We’re prescribing too much,” Chang told a group of health-care providers at the Hazard hospital last month. “We’re creating addicts. Seventy-five percent of addiction stemmed from health care. We are responsible.”

When the patient came back for a third refill, Chang looked up his prescription history and found that "In just four weeks, he and a few other area doctors had prescribed this patient more than 1,000 pills," Acquisto reports.

“People ask why we’re not after meth or cocaine,” Chang said. “Because three out of four heroin users started with prescription opioids, meaning something we wrote. This is the only addiction crisis that started with hospitals and physicians. This is the only thing we caused. This we’re responsible for.”

The Morehead hospital urges its staff are urged to maximize alternatives to opioids, "like ice, heat, and over-the-counter painkillers such as acetaminophen," Acquisto reports. "Ibuprofen, muscle relaxers, and other non-steroidal anti-inflammatory drugs (NSAIDs). If opioids are necessary, “prescribe the lowest effective dose and quantity,” or a dose that lasts no longer than three days, the hospital says.

Friday, November 8, 2019

First Ky. Senior Hunger Summit brings awareness to issue, seeks solutions; nearly 3,000 Ky. seniors on waiting list for home meals

By Melissa Patrick
Kentucky Health News

One in six Kentuckians older than 60 have faced the threat of hunger in the past year, prompting state officials to hold the first-ever Kentucky Senior Hunger Summit Oct. 30 in Frankfort to raise awareness of the issue and to help connect people in communities to find solutions.

Shannon Gadd, commissioner of the Department for Aging and Independent Living, told Kentucky Health News that while the government can't fully fund or supply all of the resources needed to help all of these hungry seniors, it can act as a connector and catalyst to raise awareness of the issue and to marshal resources.

"To tackle food insecurity, it will require a grassroots, community-led effort. I believe that many resources already exist and there is much great work happening," Gadd said in an e-mail. "The first step to addressing the issue is bringing everyone to the table to discover that good work and how we can work together to tackle the problem. The summit was a kickoff and there will be more to come."

In Kentucky, 16.6 percent of those 60 and older suffer from food insecurity, a 10% increase over the last four years. Kentucky ranks 39th for food insecurity and 46th for home-delivered meals, according to the United Health Foundation's annual America's Health Rankings.

Gadd said there were 2,917 Kentucky seniors on a waiting list for home-delivered meals on June 30, the end of the 2018-19 fiscal year.

She said the need for such services is great in Kentucky because "we have a very high number of adults ages 60 and older with independent-living difficulty, which translates to a higher need for home-delivered meals and other supportive services."

Kentucky seniors rank 49th in physical inactivity and 45th in the percentage of seniors who are "able-bodied," according to the rankings.

Gadd said other factors to consider "include supporting an increasing 60-plus population while sustaining a decrease in funds, a previous practice of funding only hot meals rather than frozen or shelf-stable meals, and the use of multiple food providers across the state, rather than a single state contract."

Who's at risk and health consequences

James Ziliak, founding director of the Center for Poverty Research at the University of Kentucky, pointed out that because most seniors live on a fixed income, any increase in their out-of-pocket spending puts them at risk of becoming food-insecure.

James Ziliak
Ziliak, who has done research on food insecurity for more than a decade, noted that poverty is a substantial factor in whether a senior is food-insecure. For example, he said seniors with incomes under the federal poverty line ($12,490 for an individual and $16,910 for a couple) are 30% more likely to have food insecurity.

The risk of food insecurity is at least twice as high for minorities, Ziliak said. After controlling for age, income and race, the risk also increases for those with less education, those who have a disability, those who are divorced or separated, those who have a grandchild living in the home. In addition, he said that seniors who self-report as socially isolated have a 50% greater risk of food insecurity.

Ziliak also presented his and Craig Gunderson's research on the health consequences of senior hunger. Gunderson is from the University of Illinois at Urbana-Champaign.

They found that food-insecure seniors, compared to those who were food-secure, had a 60% higher risk for depression; 40% higher risk for congestive heart failure; 22% greater risk for coronary heart disease; 53% greater risk for a heart attack, and 37% greater risk for chest pain. They were also 52% more likely to report they had asthma, and 20% more likely to report fair or poor health.

"The health consequences are real," Ziliak said. "Feeding people feeds their soul, it feeds their mental health, it feeds their physical health. We need to make sure we are doing our job."

Feeding people can also help them live longer. A study co-authored by Ziliak and published in Health Affairs found that people in the Supplemental Nuitrition Assistance Program (SNAP, formerly known as food stamps) have 1 to 2 percentage points less risk of mortality.

Ziliak noted that Kentucky leads the nation for the number of people between the ages of 50 and 59 who are food insecure, and said this is something that Kentucky should be paying attention to.

"It's a tidal wave coming, people," he said. "One in five of Kentuckians between the ages of 50 and 59 are food insecure. That's astounding. We lead the nation."

A recent report by the Kentucky Center for Economic Policy, "SNAP is Good for Kentuckians' Health," cited research showing that food-insecure seniors had roughly the same quality of life as someone 14 years older -- and that SNAP participation leads to a 30% reduction in the likelihood that seniors will cut back on needed medications. It also cited a 2018 study of older adults, which concluded that getting SNAP benefits was associated with a 14% reduction in hospitalization and a 10% reduction in emergency-room use.

"SNAP is a really important tool, not only in our anti-poverty, anti-hunger toolbox, but also in our public health toolbox. And I think we would do well to start thinking of that more as a public health program," Dustin Pugel, author of the report, told Kentucky Health News.

A 2018 federal report shows food-insecure households spend about 45% more ($6,100) on medical care in a year than people in food-secure households ($4,200). And currently, the health-care costs for food insecurity in Kentucky are more than $854 million.

What can be done?

Ziliak suggested several solutions, including making sure that the 65% of seniors who are eligible for SNAP but don't use it get signed up; making it easier for them to sign up for the program and stay on it; changing federal regulations to give seniors more SNAP benefits; and changing the rules so mobility-challenged seniors can use SNAP to buy prepared food, not just in grocery stores.

In Kentucky, SNAP recipients over 65 must re-certify every two years, but those under 65 must do so annually. In 2017, 63,000 Kentuckians over 60 years old participated in SNAP, according to KCEP.

Pugel noted that the U.S. Department of Agriculture wants to restrict people with modest savings from getting SNAP, which would result in fewer seniors qualifying for the program. "If what we're trying to do is reduce food insecurity and improve health, especially among seniors, then that is a harmful policy; that is counterproductive to those goals," he said.

Roger McCann, executive director at Community Action Kentucky, said he hopes society is moving to a time when people recognize that food insecurity and other social determinants, like transportation and housing, play a significant role in a person's health and that addressing those determinants should be part of a person's medical care. He said this holistic approach would result in better health outcomes for everyone.

For example, he said, just like a person gets a prescription for a test or a drug, patients should also get prescriptions to have healthy meals delivered to them as they recover from a procedure if they live alone. "If you don't eat, your're not healthy," he said. "It is as simple as that."

Others spoke at the conference about innovative ways to address seniors' food insecurity, including a university program in Ohio that has a congregate meal program on its campus, and a hospital in Owensboro that donates its extra food to create frozen home-delivery meals. Gadd spoke about the need to work across state agencies to find solutions and the need to consolidate resources and to create a centralized database to help people.

State Agriculture Commissioner Ryan Quarles told the crowd that he has been working on this issue for several years through his Kentucky Hunger Initiative, a first-of-its-kind program that involves farmers, charitable organizations, faith groups, community leaders and government entities. "It affects every county, every city and every community in Kentucky," he said.

The Aging and Disability Resource Center provides information and resources about aging and disability issues.
The home-delivered meal program was titled C2 by the Older Americans Act. This table shows the breakdown of federal and state funds for each area development district for fiscal 2019-20. The numbers do not reflect state administrative costs. The program is overseen by the state Department for Aging and Independent Living, which provided the table. (Click on it for a larger version.)

Kentucky schools can tap federal money to provide more school-based health services for students enrolled in Medicaid

Kentucky school districts can now use federal Medicaid funding to expand school-based health services, the state announced Friday.

“The Medicaid state plan amendment will allow school districts to use federal funding to expand access to qualifying physical- and mental-health services for students enrolled in Medicaid,” Kristi Putnam, deputy secretary of the Kentucky Cabinet for Health and Family Services, said in the news release.

Examples of services that could now be covered include physical and behavioral health screenings, immunizations, dental care, speech therapy supports, and mental health counseling, says the release.

Historically, schools could only bill Medicaid for students who were disabled or met other limited criteria. The Centers for Medicare and Medicaid Services changed that in December 2014 to let states provide school-based health services to any student enrolled in Medicaid, and get federal reimbursement for it.

More than two in five Kentucky children are covered by Medicaid, but the state just recently decided to seek the money, a decision that seems largely driven by an increase in behavioral-health issues in schools.

“Approval of this amendment is a game-changer,” Health Secretary Adam Meier said in the release. “This will provide additional resources to support increased access to mental health services for students using money already being spend by school districts."

Putnam pointed out that the additional funding will help support the School Safety and Resiliency Act, or Senate Bill 1, that calls for one trained school resource officer in every school and one guidance counselor for every 250 students by July 1, 2021, or as funds and qualified personnel become available. School-based mental-health providers fall under a subsection of the guidance-counselor requirements and are listed as optional. The bill has no funding attached to it.

It's important to note that Medicaid will only pay for licensed mental-health providers, not guidance counselors, unless they have a special certification, which most of them don't, Eva Stone, district health coordinator for the Jefferson County Public Schoolstold Kentucky Health News in April.

Terry Brooks, executive director of Kentucky Youth Advocates, applauded the decision to take advantage of this previously untapped funding, especially for the purposes of funding SB 1.

"The importance of preventive health and behavioral health services is undeniable as is the insight to provide them in schools to maximize students access," Brooks said in a prepared statement. "Ensuring children have these services not only positively impacts health, it is a catalyst to better academic achievement and even better school environment."

Being able to treat children in schools will also reduce many of  the barriers parents have to get their children health care, such as lack of transportation, non-flexible work schedules, or finding a provider who accepts Medicaid, the state news release says.

The release says the change to Medicaid will be phased in, and approval for reimbursements to school districts is retroactive to August 1, 2019.

Thursday, November 7, 2019

WVLK Radio will focus on the opioid epidemic from 9 a.m. to 6 p.m. Wednesday, Nov. 13, with 'Enough: Opioid Awareness Day'

WVLK Radio in Lexington will host a day-long program to talk about the opioid epidemic on Nov. 13 titled, "Enough: Opioid Awareness Day."

"We just thought it was a singular issue where it was right to spend an entire day to try to find solutions and to discuss the intent of the problem," said Dave Krusenklaus, WVLK's program director.

Kruser, as he is called on the air, said the programming was inspired by state Senate President Robert Stivers of Manchester, who has said the opioid epidemic is not a problem in Kentucky, but is the problem in Kentucky, one that has touched everybody.

On Nov. 13, the station will offer a diverse day of programming about opioids from 9 a.m. to 6 p.m.

Guests will talk about the many aspects of the disease, and will include health-care providers and representatives of programs that treat opioid addiction, public-health officials, people who are recovering from opioid addiction, family members of those who have lost loved ones to addiction, lawmakers (including U.S. Reps. Hal Rogers and Andy Barr of the 5th and 6th Districts), law-enforcement officials, government and city officials working on this issue, and more.

"This is not a problem that you could necessarily legislate away," Krusenklaus said. "This is a human condition problem that we've got to solve ourselves. . . . This is an issue that you have to keep out in front of people."

State ends advisory against recreational use of Ohio River, maintains advisory for Briggs Lake Near Russellville

The state has ended the recreational public-health advisory it issued Sept. 26 due to harmful algal blooms in the Ohio River. "Results from recent water samples collected throughout the advisory area from the McAlpine Dam near Louisville to the Greenup Dam near Greenup are below the recreational advisory threshold for microcystin toxins," the Division of Water and the Department for Public Health said in a news release.

The advisory was issued when water samples indicated the presence of toxin-producing algal blooms. "Although the advisory is being removed, the DOW and DPH advise there are always risks associated with recreating in natural waters, especially with the incidental ingestion of water, and recommend avoiding contact with waters that have visible algal blooms," the release said.

An advisory remains in effect for Briggs Lake, off Duncan Chapel Road northeast of Russellville. The Division of Water has a webpage about harmful algal blooms in Kentucky. All current HAB advisories in Kentucky are at http://watermaps.ky.gov/HABs.

Wednesday, November 6, 2019

Medicaid program that pays employer-sponsored insurance premiums for employees has a new application process

By Melissa Patrick
Kentucky Health News

A program that will pay the premiums of working Medicaid members who have access to insurance through their employers has a "new and improved" application process, the state says.

The voluntary program, called the Kentucky Integrated Health Insurance Premium Payment program or KI-HIPP, allows Medicaid members to sign up for their employer-sponsored health insurance plan and have Medicaid pay their part of the premium.

Starting Nov. 4, KI-HIPP allows primary policyholders who are not on Medicaid to apply for the program if they have at least one Medicaid-eligible person on their policy. In addition, it allows families with anyone enrolled in a 1915(c) Medicaid Home and Community Based Services waiver.

“KI-HIPP is an excellent example of a government partnership that works with the employer-sponsored insurance market to expand insurance coverage options, particularly for families,” Medicaid Commissioner Carol Steckel said in a news release. “It allows Medicaid beneficiaries to choose a plan that meets their needs and empowers them to take control of their health. The added benefit is that this partnership saves the Medicaid program money.”

As of Oct. 30, the program had 220 members enrolled which would translate to a projected annual savings of nearly $800,000 for the Medicaid program, says the release.

Jason Dunn, a policy analyst for Kentucky Voices for Health, told Kentucky Health News that while KI-HIPP could be a great plan for some people and their families, he cautioned that it is important for consumers to carefully examine what he called the "risk" before making a switch, especially those with very low incomes.

For example, he pointed out that those who choose KI-HIPP will have more paperwork to manage, since participants are required to submit a copy of their paystub each pay period as proof of premium payment. It also requires the participant to submit annual re-certifications for both plans.

Dunn also noted that there is a risk that KI-HIPP participants could end up paying more out-of-pocket costs for their health care if they don't see providers who accept both the employer-sponsored insurance and fee-for-service Medicaid. If the provider only takes the employer's insurance, the KI-HIPP participant must pay all out-of-pocket costs, including co-pays, deductibles and co-insurance. "And that can be pretty pretty expensive," he said. "All that can be thousands of dollars a year."

Dunn added that individuals also need to explore what would happen if they were part of the KI-HIPP program, but then became no longer eligible for Medicaid, or were no longer able to meet the KI-HIPP requirements. In either case, the premium would no longer be reimbursed by Medicaid, and the employer could have to pick up the cost until the next open enrollment if they were not permitted to dis-enroll from the employer's plan.

Tens of thousands of Kentuckians go on and off Medicaid each month, for various reasons. As an example of that, the health cabinet confirmed that as of Nov. 4, 25 people had left the KI-HIPP program because their incomes rose above the Medicaid eligibility limit; by Nov. 6, the number of KI-HIPP participants had risen from 195 to 199.

To improve the application process, the system now includes a stand-alone application which is designed to make it easier for newly eligible Kentuckians to apply for KI-HIPP or to add it to an existing Medicaid case. "It's great to make it easier to apply, but we just want to make sure people know what they're applying for and what the risks are," Dunn said.

The release notes that Kentuckians enrolled in the existing Health Insurance Premium Payment (HIPP) program will move to KI-HIPP in December, and HIPP program members will get a letter in the mail with guidance on how to make this transition.

Sign up for KI-HIPP at benefind.ky.gov or call 855-459-6328. For more information see https://chfs.ky.gov/agencies/dms/member/pages/kihipp.aspx. Click here for a link to a Kentucky Voices for Health explainer about the program.

Sunday, November 3, 2019

Is Bevin 'trying to rip health care away from our families'? Is it true Beshear 'sold out Kentucky' in an opioid lawsuit? Here are facts.

Northern Kentucky debate (Photo by Albert Cesare, Cincinnati Enquirer)
By Al Cross
Kentucky Health News

Health-related issues figure prominently in some of the final messages that the candidates for governor are delivering to voters as Tuesday's election approaches.

Democratic Attorney General Andy Beshear says of Republican Gov. Matt Bevin, "He has tried to rip health care away from our families."

A Republican TV commercial says Beshear is "so liberal, he wants to give taxpayer-funded health care to people who can work and choose not to."

And a Bevin TV ad says, "Beshear did profit from opioids" and "sold out Kentucky."

The three commercials have varying degrees of truth, and as usual for political ads, fall far short of telling the whole story. They obscure a fundamental difference between the candidates on an issue that affects hundreds of thousands of Kentuckians.

That is the expansion of the federal-state Medicaid program by Beshear's father, then-Gov. Steve Beshear. At last count, the expansion covered more than 450,000 people, paying their bills when they get health care.

Bevin's proposal

Bevin wants to require as many as half of those people (estimates vary) to work, volunteer, attend school or take job training at least 80 hours a month, and make monthly reports, in order to keep their benefits. Those who are medically frail or must care for children would not be included.

Studies indicate that most Kentuckians who would be affected by the "community engagement" rules are already meeting them. One study based on polling found that 97 percent already meet the requirements; another, based on claims data, showed that 64% are.

A federal judge in Washington, D.C., has blocked Bevin's plan, known as a waiver, and judges who heard an appeal last month sounded skeptical of it. Bevin has issued an order that would abolish the expansion six months after a final court decision against his plan. He has said the Supreme Court will decide the issue; the high court does not have to consider appeals.

The first version of Bevin's plan estimated that after five years, the state's Medicaid program would have 95,000 fewer people than it would without it—largely because of noncompliance, including lack of reporting. "This is paperwork and it is intended to tear health care away from people," Beshear said in a debate, pledging to do away with the plan "in my first week of office."

Bevin "has justified the idea both in terms of cost—because the state pays about 10% of the costs of the expansion—and values," Idrees Kahloon of The Economist magazine writes in a "Democracy in America" column about the governor's race after interviewing Bevin.

"When your correspondent asked him whether the point of the waiver was to save the state money, he flatly answered, 'No,' and then held up both his index fingers, one of which was more curved than the other, the result of having had to set it himself when he was young."

“I have scars on my body that we couldn’t afford to get stitched up so they’re as thick as a finger instead of thin as a string,” Bevin told Kahloon. “Every dollar we give to an able-bodied, working-age person with no disabilities and no dependents is a dollar we’re not able to provide … for those truly in need in our state.” Bevin often says he has empathy for the uninsured because he didn't have health insurance until he joined the Army.

Kahloon, a native of Morehead, notes, "Many of the counties in Kentucky most reliant on Medicaid—both for health coverage and to keep rural hospitals financially solvent—are also steadfastly Republican strongholds. To make inroads with them, Mr. Beshear must instill fear about the prospect of policy change. Whether he has done so is unclear."

State House Minority Leader Rocky Adkins, who ran second in the May primary, talked about Medicaid as he campaigned last week with Beshear in Democratic counties in Eastern Kentucky. In that region, he said, “The only growth we’ve seen here has been in the health-care industry.” Bevin has discounted estimates of the Medicaid expansion's creation of jobs.

Opioid epidemic

There has been less debate about the Medicaid expansion than about Beshear's record on the opioid epidemic. The Bevin ad's contention that Beshear "did profit from opioids" and "sold out Kentucky" are based on Beshear's partnership in the law firm of Stites & Harbison. It represented Purdue Pharma in the lawsuit filed against the maker of Oxycontin by then-Attorney General Greg Stumbo in the mid-2000s.

Stumbo's successor, Jack Conway, settled the case for a $24 million payment by Purdue Pharma shortly before Beshear became attorney general. Beshear has said he took no part in the matter, but has refused to say whether he shared as a partner in the fees the law firm earned from Purdue. After Beshear took office, he approved a retroactive $4 million contract for work on the case by a Louisville firm that later made Conway a partner.

Beshear said in 2017 that he did not "recall doing any work" on the case at Stites & Harbison. "I was there a long time," he said. "I don't want to suggest that no one asked me a question about what General Conway was like or not like, but I was not an active participant in that case."

This year Beshear wrote a memo that "says he stepped away from anything related to the state's litigation against Purdue when he took office," Phillip Bailey reports for the Louisville Courier Journal. "Why write that memo three years later? Beshear made multiple attempts to stiff-arm that question and others when I asked about the memo last week . . . Beshear said it was more appropriate to go through a campaign spokesman to schedule an interview, but he eventually relented."

Beshear told Bailey, "We had a policy from the beginning that I was not involved in any Purdue matter other than making a recommendation about where the settlement funds went," but wanted to document it because Purdue Pharma was rumored to be headed for bankruptcy.

Bevin's chief of staff, Blake Brickman, told Bailey, "The memo only raises further questions. Any competent and ethical attorney knows that recusal letters are put in the record immediately, not over three years after the alleged recusal occurred."

In 2017, Purdue Pharma got Pike Circuit Judge Steven Combs to seal the case file, including the only deposition from a member of the Sackler family that owns the company. Stat, the health-and-science publication of The Boston Globe, asked Combs to unseal the file, and Beshear's office took no position on the issue (after denying an open-records request for the deposition, citing Combs' order). Combs granted Stat's motion, but Purdue has appealed.

As attorney general, Beshear has sued nine opioid manufacturers and distributors, alleging that they caused or worsened the opioid epidemic, which has left thousands of Kentuckians dead from overdoses. He says no other attorney general in the nation has filed as many suits against opioid makers and distributors. Bevin has noted that none of the suits have resulted in settlements.