Sunday, September 24, 2017

Author of Dreamland says opioid epidemic is making people talk about addiction, a first step in finding solutions

By Melissa Patrick
Kentucky Health News

Since Dreamland: The True Tale of America's Opiate Epidemic was published in 2015, the author says the nation has seen both positive and negative changes in the epidemic that is sweeping Kentucky and other states.

"The negative changes are pretty dramatic," Sam Quinones said in a telephone interview with Kentucky Health News. "The number of people who are dying from this is every year more, and there doesn't seem to be an end in sight. . . . It's a very scary time."

On the other hand, individuals and families have "come out of the shadows" and are now telling their stories of addiction, which he said will help lead to solutions.

Quinones came to Kentucky to speak at the Foundation for a Healthy Kentucky's annual Howard Bost Memorial Health Policy Forum, Monday, Sept. 25 in Lexington. It sold out.

He said in the interview that it's hard for him to talk about positive reactions to the epidemic, given the torment it has caused so many families. But he's glad there is talk.

"And that's what happened with AIDS. When people came out of the shadows, we found solutions to AIDS," he said. "With more awareness, more people are working together on this . . . and I definitely believe that is a crucial part of this whole response."

He added, "You have a lot more political action, you've got a lot more budgetary action, you've got media paying far, far greater attention to this than even a few years ago -- and so all of that is for the positive."

He also said the epidemic has caused people to question old dogma and re-think how the nation, the state and communities have treated addiction and its victims.

“In Kentucky, I would say one of the most radical ideas that has been tried – I would give it enormous applause – is you have two dozen counties at least that are now transforming part of their jails, pods that are within their jails, to full-time rehabilitation clinics," he said. "I think that is magnificent."

Dreamland, named for a huge, old swimming pool in Portsmouth, Ohio, a town ravaged by the opioid epidemic, is a collection of stories that traces the origins and effects of the epidemic, which started 20 years ago.

It tells the story of  a society that wants to be pain-free, both physically and emotionally; an extremely addictive prescription painkiller and its aggressive marketing campaign; the subsequent shift in how the medical community viewed pain, and how it became the fifth vital sign; and how a heroin trafficking operation out of Mexico, using a customer-service business model, forever changed how illicit drugs are delivered in America.

Sam Quinones
Quinones emphasized that he left his "politics at the door" when he wrote Dreamland and encouraged others to do the same when they read it, and not "cherry-pick" aspects of the book that suit their point of view, which he said sometimes happens.

"It's a big picture," he said. "It's a mosaic of things that went into this and you need to consider them all."

He said it will take a variety of responses to deal with the epidemic, including individual and humane care for patients who are addicted to prescription opioids, instead of just cutting them off; appropriate use of medication-assisted therapies, along with supportive group therapies; and a shift in the way we view pain, both physically and emotionally.

Quinones said the epidemic seems to be calling into question parenting practices that aim to protect children from all pain, such as the practice of giving all kids in an event a participation trophy; to question whether or not possessions actually lead to happiness; and to examine the role of personal responsibility related to diet and exercise as ways to approach issues of physical pain.

"I think there are a lot of ways in which this epidemic is calling us to question how we've been living."

Trump seeks Paul's vote for last-ditch bill to repeal and replace Obamacare, which would cost Kentucky billions in future funds

By Al Cross
Kentucky Health News

Kentucky would be a big financial loser under Senate Republicans' last-ditch plan to repeal and replace the Patient Protection and Affordable Care Act. Sen. Rand Paul says he opposes the bill, but not for that reason; he says that it would "keep Obamacare," which he has vowed to repeal, and that a more limited reform he favors is on the way from President Trump.

It remains to be seen whether Kentucky's senior senator, Majority Leader Mitch McConnell, will bring the Graham-Cassidy bill up for a vote by Saturday, Sept. 30, the deadline to pass it with a simple majority under budget-reconciliation rules. He has said he intends to, but that was before Arizona Sen. John McCain said Friday afternoon that he wouldn't vote for the bill, making its passage unlikely.

Friday morning, Trump had pressured Paul, tweeting “Rand Paul, or whoever votes against Hcare bill, will forever (future political campaigns) be known as ‘the Republican who saved ObamaCare.’”  Paul replied on Twitter, “Calling a bill that KEEPS most of Obamacare ‘repeal’ doesn’t make it true. That’s what the swamp does. I won’t be bribed or bullied.”

The next day, after McCain's announcement, Trump tweeted, “I know Rand Paul and I think he may find a way to get there for the good of the Party!” At a speech in Alabama that night, he said, “I haven't given up on him because I think he may come around.”

On NBC's "Meet the Press" Sunday, Paul said, “I’ve always been a ‘yes’ for repeal,” but said he opposes the bill because it keeps “almost all of the spending, and just re-shuffles it and block grants it to the states. . . . You’re keeping all the money we’ve been spending through Obamacare, most of it, re-shuffling it, taking the money from Democrat states and giving it to Republican states. I think what it sets up is a perpetual food fight over the formula.”

U.S. Senator Rand Paul, R-Ky. (file photo)
Paul had made the money-shuffling argument before, and it sounded weak to editors at National Review. The old-line conservative magazine went after him Wednesday, Sept. 20, implying in an editorial that Paul, a Bowling Green ophthalmologist, secretly doesn't want to change the Obamacare system that has provided free Medicaid for 470,000 Kentuckians and subsidized private insurance for 81,000.

"The senator’s objections to the bill amount to a case for improving it, perhaps in a conference committee after it passes the Senate," the editorial said. "They do not amount to a case for voting it down. The bill goes farther in the right direction than the 'skinny repeal' bill for which Paul voted earlier this summer. That bill abolished only the individual and employer mandates. . . . Graham-Cassidy is still much better than Obamacare. It abolishes the individual and employer mandates, caps per capita spending on Medicaid, blocks federal funds from going to insurance plans that cover abortion, and lets interested states attain freedom from some of Obamacare’s regulations."

The editorial concluded, "There has been widespread speculation that Paul is playing a game on Obamacare: that he does not really wish to see major changes to it and will find libertarian-sounding objections to any Republican bill that has a chance of passage. This speculation may be unfair. But Paul’s arguments for a no vote make so little sense, and are so hard to square with his previous votes, that it is getting harder to dismiss."

"Meet the Press" host Chuck Todd told Paul that the editorial implied "that you don’t really want to change the Kentucky system. There’s a lot of people in Kentucky that like the system. But you can’t get caught ever saying that."

Paul replied, "That is a personal insult to my character," calling the magazine "a bunch of neocons who don't like libertarians." Earlier, he said, "I started my political career campaigning against Obamacare," pledging repeatedly to repeal it. "I can't in good conscience vote to keep it . . . Once we do, the Republican name is on health care, and thsi isn't going to work."

National Review blogger Theodore Kupfer wrote Sept. 22 that Paul's money-shuffling argument is "not quite accurate. Three analyses of the bill, from the [liberal-leaning] Center on Budget and Policy Priorities, [consulting firm] Avalere, and the [federal] Centers for Medicare and Medicaid Services, have found that the change in federal health-care funding would be negative for states that expanded Medicaid under the Affordable Care Act. Among those states are Republican strongholds Arizona, Louisiana, Arkansas, Ohio, and Kentucky."

Other analyses predict Kentucky would be one of the big losers, because it was one of the states that expanded Medicaid in 2014 under then-Gov. Steve Beshear. The Kaiser Family Foundation estimates that Kentucky would get 19 percent less money in 2020-26, $5.4 billion, than current law provides. That would be the 10th largest percentage loss among the states. The New York Times produced a chart showing that in funding per person, Kentucky would be the eighth biggest loser among the 50 states and the 35 expansion states.
The charts show the estimated differences in what states would get under the bill compared to what they are projected to get under current law. In its overall chart, the Times colored orange the states represented by senators that voted against at least one version of Obamacare repeal bills in July, as Paul did.
The bill is being revised to attract votes from holdouts, but Paul remains opposed, The Washington Post reports. If Paul remains opposed, the bill seems unlikely to pass, since Republicans need 50 votes and hold 52 Senate seats. The bill has drawn widespread opposition from lobbying groups. "A bipartisan group of governors and several influential interest groups came out against the proposal," the Post noted. The Post's Elise Viebeck writes that the hurry-up process for the bill is "unusually chaotic."

Paul has sent Trump a list "of what it would take to get him from no to yes," Jonathan Swan of Axios reports. "It's hard to see how they'd stop at least half a dozen moderate Republican senators dropping their support" for the bill. The list includes "a significant reassessment of this trillion-dollar spending machine," making Obamacare rules optional for states, and expanding association health plans, something that can't be done under budget-reconciliation rules -- but maybe by Trump alone.

Paul repeated on NBC what he told Kentucky interviewers last week, that the Trump administration will act "in the next couple of weeks" to start implementing his plan for a national-association health plan, in which anyone could enroll. That could create a group with great bargaining power, but the plan would also be exempt from most Obamacare rules, allowing people to buy thinner, cheaper coverage and taking them out of the Obamacare markets, perhaps weakening them.

Kentucky's other senator was asked Sept. 20 why he would support a bill that would cost the state billions in federal funding. McConnell spokesman Robert Steurer cited Gov. Matt Bevin's support of the bill with 14 other Republican governors, and quoted McConnell as saying:

Mitch McConnell (Reuters photo)
“The men and women we represent have suffered a lot under Obamacare. Skyrocketing costs. Plummeting choices. Collapsing markets. Many of us thought our constituents deserved better. That’s why we did as we promised and voted to repeal this failed law so we could replace it with something better. The forces of the status quo went all out to defeat our every effort to improve health care. Thus far, they have succeeded. Thus far, they have yet to offer truly serious solutions of their own. The Graham/Cassidy bill would repeal the pillars of Obamacare and replace that failed law’s failed approach with a new one: allowing states and governors to actually implement better health-care ideas by taking more decision-making power out of Washington. Governors and state legislators of both parties would have both the opportunity and the responsibility to help make quality and affordable healthcare available to their citizens in a way that works for their own particular states. It’s an intriguing idea and one that has a great deal of support.”

Jennifer Haberkorn of Politico writes, "If successful, Graham and Cassidy would accomplish what McConnell couldn’t: Make good on the GOP’s pledge to undo Obamacare and transform Medicaid from an open-ended entitlement into a capped program. Critics say the result would be draconian cuts that would throw millions off of their health coverage and endanger the most vulnerable Americans."

McConnell is taking a political risk with Graham-Cassidy, after failing to get a repeal bill through the Senate in early August and strongly backing appointed Sen. Luther Strange in an Alabama primary against defrocked judge Roy Moore, who has made McConnell's leadership an issue. Moore is favored to win the Sept. 26 runoff primary.

"McConnell may figure he has nothing left to lose," write Burgess Everett and John Bresnahan of Politico. "He’s already taken a huge political hit for failing to repeal Obamacare. And Republicans say privately that if McConnell didn't take one final stab, he'd be lashed by Trump for giving up. . . . McConnell clearly sees an upside in showing Trump and the GOP base that Republicans haven't abandoned repeal. After weeks of declining to endorse the latest health-care bill, McConnell has embraced Graham and Cassidy’s bill as the Sept. 30 deadline approaches, endorsing it on the floor and playing up the bill on social media."

Saturday, September 23, 2017

Public-health nurses from Ky. return after hurricane relief work

“The Kentucky Angels,” a group of public health nurses from Kentucky, returned to the state Friday after helping victims of Hurricane Irma in Florida, Tom Latek reports for Kentucky Today, published by the Kentucky Baptist Convention.

"The team, which consisted of 10 nurses and two administrative staff members, spent more than a week helping displaced residents in the Orlando and Naples areas," Latek reports. "The Florida Department for Public Health and the residents they assisted gave them the nickname of 'Kentucky Angels'."

The nurses work for health departments in Louisville, Franklin County and Northern Kentucky. They "were the first team from Kentucky to respond to a request for help from another state in the wake of a natural disaster," Latek reports. "They were originally expected to be deployed for 15 days, but their deployment ended up lasting eight days.

The Cabinet for Health and Family Services produced a news release and a video story about the Angels, which can be viewed at

Friday, September 22, 2017

SAVE THE DATE: Friday, Nov. 10 for Covering Health: A News Workshop, in Madisonville; free of charge to all journalists

On Friday, Nov. 10 in Madisonville, the Institute for Rural Journalism and Community Issues and the Foundation for a Healthy Kentucky will present the latest in their series of workshops to help local journalists cover health care and health in Kentucky.

The presenters will include Al Cross, director of the institute and editor-publisher of Kentucky Health News; KHN reporter Melissa Patrick, a former nurse; Dr. Ellen Hahn of the University of Kentucky College of Nursing, who directs the Bridging Research Efforts and Advocacy Toward Health Environments (BREATHE) program; and Wayne Meriwether, CEO of Twin Lakes Regional Medical Center in Leitchfield, a leader of the Population Health Committee in Grayson County.

"Covering Health: A News Workshop" will run from mid-morning to mid-afternoon at the Ballard Convention Center, near the KY 70 interchange with Interstate 69 (formerly the Pennyrile Parkway). Lunch will be served, and the event will be free of charge, thanks to support from the foundation.

"We hope many reporters and editors who cover Western Kentucky will spend a few hours with us to learn how their reporting can help their readers, listeners and viewers live healthier lives and better understand the health-policy debates going on in Frankfort and Washington," Cross said. "We also invite their suggestions for the program."

The program will be announced soon. For a report on last year's workshop, in Eastern Kentucky, click here.

192-bed Prestonsburg hospital will become 12th in ARH system

The hospital will become Highlands ARH Regional Medical Center.
Continuing the trend of hospital consolidation, Prestonsburg-based Highlands Health System will become part of Appalachian Regional Healthcare, the hospital firms announced Friday. They said they hope to complete the merger early next year.

"It has been very important to us to identify a strong organization that can continue to provide the same level of advanced healthcare services our patients have come to expect from Highlands as well as position the hospital for continued growth in the future," Highlands President Harold C. Warman said. "Appalachian Regional Healthcare has been the leading provider of care in Eastern Kentucky for more than 60 years and in that time the health system has been consistently recognized for its quality and commitment to excellent patient care."

The 192-bed Highlands Regional Medical Center "will become the 12th hospital in the ARH system," a news release said. "All other Highlands outpatient services and facilities in Floyd, Johnson, Martin and Magoffin counties are also included in the merger."

Education and updates on substance-use disorders, treatment and policy scheduled at University of Pikeville Tuesday, Oct. 3

Shaping Our Appalachian Region's Healthy Communities program and the University of Pikeville will host a substance-use disorder education event Tuesday, Oct. 3 from 11 a.m. to 5 p.m. at the university's Kentucky College of Optometry (Health Professionals Education Building). The meeting is for "health professionals and stakeholders who share the vision of reducing the scope and impact of substance use disorder and related consequences through education, awareness, prevention, and access to services," SOAR said in a news release. The event is free, but space is limited, so registration is required.

Speakers at the event will provide guidelines based on evidence, "discuss how to integrate prevention and management into practice in a rural setting, and provide resources and tools to help current and future providers in Appalachia turn the tide on the substance use epidemic," the release says. 

The special circumstances of addiction in pregnant women and their children will be discussed by Dr. Connie White, deputy director of the state Department for Public Health; Dr. Allen Brenzel of the Department for Behavioral Health, Development and Intellectual Disabilities; and Jill Martin, of the Hazard Primary Care Centers and Mountain Comprehensive Care Clinic.
The event will include personal stories of addiction and recovery from former basketball star Rex Chapman and others. The audience will hear legislative and regulatory updates from UK HealthCare officials Mark Birdwhistell, Douglas Oyler and Dr. John O’Brien Jr.

“We are facing an opioid crisis in Eastern Kentucky that is threatening our livelihood and way of life,” said Dr. Joshua Crum, associate dean of clinical affairs at the university's Kentucky College of Osteopathic Medicine. “KYCOM is meeting the challenge put forth by Governor Bevin to fight this epidemic through an inter-professional and collaborative approach known as the Kentucky Addiction Prevention Education program. Partners include the University of Kentucky and the University of Louisville Schools of Medicine and Dentistry.”

SOAR was created to advance the economy of Appalachian Kentucky, but it and the federal Centers for Disease Control and Prevention "have partnered for more than two years to build a more connected network of health-focused organizations, institutions, federal partners, and individuals in Appalachia," the release notes.

“Substance-use disorder is a real issue in every community in the SOAR region,” said Jared Arnett, the group's executive director. “This epidemic has touched every single person in our region in some way, shape, or form. A groundswell of meaningful solutions and best practices has evolved from the work of countless individuals and organizations that are passionate about treating those battling substance-use disorder.”

Thursday, September 21, 2017

State changes Medicaid reporting procedures to reduce burdens for providers, get better data for comparisons

The state Department for Medicaid Services is trying to "streamline reporting procedures for healthcare providers across the state" and "reduce administrative burdens for physicians and provide more uniform data for comparisons," it said in a news release.
“Quality measures are critical as we become more data-driven in our efforts to address outcomes and improve patient care,” Health Secretary Vickie Yates Brown Glisson said in the release. “This is the first step toward applying a greater level of consistency among reporting so that everyone is collecting the same data, requirements are less burdensome for the health-care community and ultimately we have a clearer picture of what is going on in our state’s health-care landscape.”
Medicaid officials say they have worked closely with health-care interests to create a "quality measure set," unveiled Thursday at the annual Kentucky Medicaid Group Management Association conference in Louisville.
"Every insurer and government program defines quality in their own way," Kentucky Medical Association Executive Director Patrick Padgett said in the release. "They require different information to be submitted by physicians, which increases administrative burdens and costs, while confusing patients about how the healthcare system defines quality,”  
Joe Smith, CEO of the Kentucky Primary Care Association, said in the release, “The partnership between DMS and the provider groups across the state is a positive step in improving the health of the Medicaid members. KPCA member clinics are pleased with the leadership at DMS for providing a Kentucky driven direction on health care quality measurement."

In Ky., four people a day die of drug overdoses; lawmakers learn about prevention, treatment, recovery efforts in day-long meeting

By Melissa Patrick
Kentucky Health News

"Recovery is possible. Treatment works."

That was the one consistent message of hope for those with an opioid addiction Sept. 20, as a stream of experts told Kentucky lawmakers that opioids have become a "public health catastrophe" in the state, as one put it.

"Today, there is not a lot of good news," Van Ingram, executive director of the Office of Drug Control Policy, told the members of the Interim Joint Committee on Health and Welfare and Family Services and Medicaid Oversight and Advisory Committee at a joint, all-day meeting in Frankfort.

"When the clock strikes midnight tonight, four Kentuckians will have died of a drug overdose," Ingram said. "When the clock strikes midnight tonight, 140 Americans will have died from a drug overdose. These are all preventable deaths that don't have to happen."

Kentucky saw a 7.4 percent increase in overdose fatalities in 2016, and more than half of the 1,404 deaths involved fentanyl, a synthetic opioid that is up to 50 times more potent than heroin, according to Ingram's office. One-third of the deaths involved heroin. Ingram noted that this trend continues, with fentanyl being present in 53 percent of overdose deaths in the first half of this year.

Throughout the day, more than 20 experts talked about the impact of opioids in the state, including prevention and treatment strategies.

Kentucky Chamber of Commerce President and CEO Dave Adkisson said the epidemic has taken a toll on the state's economic growth and development, especially participation in the labor force.

“The businesses I’ve talked with throughout the state say drug abuse is a key contributor to the problem,” Adkisson said. “Many people actively looking for work cannot pass the drug tests required for employment and many of those who do have jobs are exiting the workforce due to untreated, or undertreated, addictions.”

Dr. Gil Liu, the medical director of the Department for Medicaid Services, said that over the past two years, Kentucky has doubled its behavioral health spending and quadrupled its substance use treatment spending.

He warned that Kentucky has the nation's highest rate of newly diagnosed hepatitis C, which is largely spread when intravenous drug users share needles.

He said the state is working to relax some of its "stringent" rules around who can or cannot be treated for the disease, but warned that the treatment, which can cure the disease, is costly. His PowerPoint presentation said it would cost the state $2.4 billion if all hepatitis C diagnosed recipients received treatment. Now, the state pays around $70 million.

"Those who have entered into treatment and that we have information on represent the tip of the iceberg," he said. "We have a large caseload that has yet to enter into treatment."

Dr. Allen Brenzel, clinical director of the Department of Behavioral Health, Development and Intellectual Disabilities, said addressing children's adverse childhood experiences must be part of the solution to "break the cycle" of addiction. He said 50 percent of drug use and 78 percent of intravenous drug use in adults may be attributed to ACEs.

ACEs are potentially traumatic events in a child's life, like physical abuse or substance misuse in the home, that can have negative, lasting effects on their health and well-being. Kentucky's children have "significantly higher" ACE scores than the rest of the nation.

"If we want healthy adults, we've got to screen for ACEs. we've got to identify them, we've got to address them," he said.

Brenzel and others talked about the importance of medication-assisted treatment for substance abuse.

“If this is something that the individual requires to lead a healthy lifestyle, to work, to have insurance, to raise their kids, then we have to end this stigma that somehow if you’re not off your medication that you’re not in recovery, and I do think we’re progress in that,” Brenzel said.

 “We’ve had a long battle, in my opinion, over the last 10 to 15 years about abstinence-only versus medication-assisted treatment. It’s not versus. It’s that individual assessment that leads to the individual, most appropriate treatment for that person.”

Dr. Molly Rutherford, vice-president of the Kentucky Academy of Family Physicians, said it's time to move beyond the stigma of addiction and the stigma of treating people with MAT.

"Stop arguing over the right treatment," she said. "The right treatment is different for every individual and is the treatment that prevents his or her death."

Dr. Lana Davenport, medical director of The Infinity Center in Ashland, said medication-assisted treatment is probably the best treatment for rural people with substance-use disorders, because abstinence-only programs require ancillary services, such as Alcoholics Anonymous or Narcotics Anonymous, and they often don't exist in rural areas.

Several groups shared how their programs help pregnant women with substance-use disorders and their infants, who are often born with neonatal abstinence syndrome. In Kentucky, one out of every 50 newborns has NAS.

Jennifer Hancock, president of the Volunteers of America chapter in Louisville, which runs Freedom House, a program that serves pregnant women with an addiction for up to two years after the child's birth, said the average cost of an NAS case is about $100,000. She said every 10 healthy babies represents a $1 million savings to the state, because most of the cost of these babies falls to the Medicaid program. She called the state's opioid problem "a public-health catastrophe."

Brenzel wrapped up the meeting by noting that Kentucky received $10.5 million from the federal 21st Century CURES Act, and will spend this money on a combination of evidence-based projects that focus on prevention, treatment and harm reduction.

One of the projects will create "bridge clinics" at the University of Kentucky, the University of Louisville and the Saint Elizabeth hospitals in Northern Kentucky that will allow them to become the first point of treatment for people with addictions.

The hospitals' emergency rooms will be staffed with a peer-support specialist who, with permission, will connect with the patient in the emergency room and then will regularly follow up with them after discharge. If the patient wants to start treatment immediately, the emergency rooms will have a protocol to assess the patient and do that, if appropriate.

The hope is to increase those getting treatment from 10 percent to upwards of 70 percent, Brenzel said.

Ingram said, "We're going to beat this. It's just going to take time."

Wednesday, September 20, 2017

Dr. Mark Newman, Owensboro native, taking over at UK HealthCare from Dr. Michael Karpf, who will remain an adviser

Dr. Mark Newman
The University of Kentucky has a new hospital leader. Dr. Mark Newman succeeds Dr. Michael Karpf as executive vice president for health affairs.

Newman, an anesthesiologist, has been president of Private Diagnostic Clinic, the physician practice plan for Duke University’s Medical Center, since 2014. A native of Owensboro, he has been at Duke since 1992.

"Newman grew up in Kentucky as part of a farm family with a strong focus on education," a UK news release said. "He stayed close to home to attend Western Kentucky University to help his family while his father was ill, and began running the family farm after his father passed away." Getting an Air Force scholarship to the University of Louisville medical school, he completed a residency in the Air Force and a fellowship at Duke University Medical Center before returning to active duty. He was deployed for the invasions of Panama, Kuwait and Iraq.

“I will be helping lead one of the nation’s renowned institutions of higher learning, research and clinical care as well as returning to my home state,” Newman said in the release. “The last decade has seen UK HealthCare evolve into a system with the focus and the flexibility to grow and build on its reputation while advancing the health- and patient-care opportunities for people throughout the commonwealth, and I look forward to being part of its continued success.”

Karpf "will continue making his $900,000 salary for the next year as he advises UK President Eli Capilouto on state and federal health care issues," Linda Blackford reports for the Lexington Herald-Leader. "Under Karpf’s 13 years of leadership, UK HealthCare invested almost $2 billion in new facilities, faculty, programs and technology, as well as forging new partnerships with regional health care institutions and expanding the College of Medicine to satellite locations around the state. Capilouto has frequently said Karpf oversaw the greatest success story in academic health center history, a statement he repeated at the UK Board of Trustees meeting Friday," Sept. 15.

"After Karpf’s year of advising concludes, he will make $200,000 a year as a part-time faculty member in the College of Medicine, conducting policy research," Blackford reports. "Karpf’s eventual part-time salary was calculated by taking 50 percent of the salary earned by medical professors who are at the 75th percentile of pay in the Association of American Medical Colleges survey."

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Obamacare boosted Ky. hospitals, but bad debts are rising again due to high-deductible plans, and the law's future is uncertain

Baptist Health Richmond is among hospitals featured in the story.
Kentucky's expansion of Medicaid under the Patient Protection and Affordable Care Act turned out better for the state's hospitals than they expected, but they worry about its future, Josh Shepherd writes for The Lane Report, a Lexington-based business magazine.

While two Kentucky hospitals closed soon after the expansion began in 2014, "Elizabeth Cobb, vice president for health policy at the Kentucky Hospital Association, points out that there have been no hospital closures in the past several years and revenue from Medicaid expansion has stabilized several community hospitals that were considered financially at risk in 2014," Shepherd reports.

Cobb told Shepherd that Kentucky's health-care industry is much more stable now than it was earlier in this decade. "Medicaid expansion is partially responsible because residents who gained insurance coverage sought care and created a revenue surge," Shepherd writes. "More importantly, she said, provider systems have shifted away from over-reliance on inpatient hospitalization to generate income."

When Kentucky expanded Medicaid, "Hospital administrators worried that expanding eligibility to families with incomes up to 138 percent above federal poverty guidelines would negatively affect their payer mix by shifting patients from commercial insurance to Medicaid, which pays less reimbursement for services," Shepherd notes. But KHA found that the 103 percent increase in the Medicaid population was mostly from people who didn't have insurance and would have otherwise been treated as charity cases. Hospitals reported significant decreases in bad debt.

"The increase in Medicaid enrollment has produced a significant net gain in most hospital revenues across the commonwealth," Shepherd writes. "According to the Kentucky Hospital Association, rural hospitals have been helped tremendously by providing a federal payer where there once was just mounting bad debt owed by private payers." However, more individual patients now have high-deductible plans that are putting them in debt to hospitals, Shepherd reports.

The Medicaid expansion is in doubt because of a last-ditch attempt by Republicans in Congress to repeal the reform law. Even if that fails, federal officials are expected to approve Gov. Matt Bevin's request for a waiver of rules allowing changes that would tamp down enrollment and introduce "deductibles for recipients as an incentive to 'avoid unnecessary care'," Shepherd notes.

Friday, September 15, 2017

Kentucky's share of people with health insurance goes up again, giving state most-improved status, but future remains uncertain

By Melissa Patrick
Kentucky Health News

In the third full year since the Patient Protection and Affordable Care Act was implemented, the percentage of Kentuckians without health insurance continued to shrink, giving the Bluegrass State a larger drop in its uninsured rate than any other state.  So says a new report from the U.S. Census Bureau, with data from its year-round American Community Survey.

Census Bureau map; click on it to view a larger version
Kentucky's uninsured rate dropped to 5.1 percent in 2016, down from 6.1 percent in 2015 and 8.1 percent in 2014. In 2013, the year before the ACA was implemented, the rate was 14.3 percent.

Put another way, 95 percent of Kentuckians had health insurance in 2016, compared to 86 percent in 2013.

That gain came mainly because then-Gov. Steve Beshear expanded Medicaid under the ACA to those who earn up to 138 percent of the federal poverty line, adding about 470,000 Kentuckians to the free health-insurance program.

“It’s clear beyond a shadow of a doubt the Affordable Care Act is working. It has helped Kentuckians get the care they need to improve their health, work and take care of their families. It has created jobs in our state and kept many more Kentuckians from being an illness or accident away from financial ruin,” Kenny Colston, communications director for the liberal-leaning Kentucky Center for Economic Policy, said in a news release.

The survey also found that 96.7 percent of Kentucky's children had health insurance in 2016, up from 93.6 percent in 2013. Kentucky Youth Advocates estimates this represented an increase of 37,000 children. Children are covered by the Children's Health Insurance Program, a program similar to Medicaid in which the federal government pays most of the cost. Kentucky calls its part of the program K-CHIP.

Medicaid and K-CHIP funding uncertain 

The recent gains aren't guaranteed to continue, with changes looming on both the state and federal level for both the adult and children's insurance programs.

Gov. Matt Bevin has submitted a proposal to overhaul the state's Medicaid program that largely targets "able-bodied" adults without dependents who qualify for Medicaid under the expansion. Bevin says the state can't afford to pay for this expanded population; the state's share is 5 percent this year, rising in annual steps to the ACA's 10 percent limit in 2020.

Bevin's plan is designed to encourage participants to have a higher level of involvement in their care through premiums and work or volunteer requirements. If approved, the state estimates that 95,000 fewer Kentuckians will be on Medicaid in five years than if the proposal is not accepted by federal officials. They are expected to approve Bevin's request, and perhaps allow other changes.

The Bevin administration has said that the goal is for these able-bodied adults without dependents to move to higher-paying jobs that offer employer-provided health insurance. Opponents of the plan say these higher-paying jobs are scarce in Kentucky, and note that many in this group already work at low-paying jobs that don't offer health insurance -- or if it's offered, it's not affordable.

KYA Executive Director Terry Brooks said some of the recent changes in Bevin's proposal could create "very real barriers to coverage" for adults, which research shows could result in fewer children being covered. "We also know that kids are more likely to have health insurance when their parents do," he said in a prepared statement.

Bevin spokesman Woody Maglinger told The Associated Press, "It may be a fact of life in Terry Brooks' alternate universe, but it is not a fact in Kentucky," Maglinger said. He noted that Bevin's plan would not change Medicaid eligibility requirements for children.

Last-ditch ACA repeal pushed; Bevin favors, Paul opposes

In Congress, Republican Sens. Bill Cassidy of Louisiana and Lindsey Graham of South Carolina are pushing a last-ditch effort to repeal the ACA and redistribute its funding from states that expanded Medicaid to states that did not, Sarah Kliff of Vox reports.

The bill would block-grant Medicaid money but would not allow states to re-enroll people now covered by the Medicaid expansion, reports Ed Kilgore of New York magazine: "They’d have to cover them some other way, presumably via private insurance."

The bill would reduce federal funding of Medicaid in Kentucky by more than $3 billion over the next 10 years, but Graham told Fox News that Bevin has endorsed his bill.

Graham also said Senate Majority Leader Mitch McConnell "needs to be as committed to repealing Obamacare as [Democratic predecessor] Harry Reid was to passing Obamacare, and Harry Reid had us in on Christmas Eve on Obamacare passage. . . . We had a lot of time off in August when we should have been here, repealing and replacing Obamacare."

McConnell told Kentucky Health News that the bill will come to the floor if there are 50 votes for it, which would put Vice President Mike Pence in position to break the 50-50 tie and pass it. "There’s a lot of discussion, but the time is running on that," McConnell said Thursday afternoon. "It could well come up. If we have 50 votes, we’ll go to it." The deadline to pass the bill with 50 votes, under budget-reconciliation rules, is Sept. 30.

Cassidy told The Washington Post that the bill has "48 or 49" votes, but it has not been vetted for passage under reconciliation, and the Congressional Budget Office has not said how the bill would affect the federal budget or the insurance-coverage rate. McConnell has asked the CBO to "quickly score" the bill, the Washington Examiner reports.

The Examiner adds: "Sen. Rand Paul, R-Ky., announced he would not be in favor of the legislation, which he called 'Obamacare lite'." Graham said on Fox that he would tell Paul that he should trust Bevin to provide "state-run health care." Paul was among the 49 votes for McConnell's last repeal-and-replace bill.

Congress also faces a Sept. 30 deadline to extend funding for CHIP, which provides health coverage for roughly 9 million children. The Senate Finance Committee has agreed on a plan to extend the program for five years, but phase out federal funding in 2021.

Two flu cases reported in Kentucky; CDC recommends everyone over 6 months old get a flu vaccination

Two confirmed cases of influenza have been reported in Jefferson County, signaling the coming start of the flu season in Kentucky.

The federal Centers for Disease Control recommends that every American over six months of age get a flu vaccination, and especially encourages people who may be at higher risk for complications or negative consequences:

• Children aged six months through 59 months;
• Women who are or will be pregnant during the influenza season;
• Persons who are 50 years of age or older;
• Extremely obese persons, those with a Body Mass Index of 40 or greater;
• Persons with chronic health problems;
• Residents of nursing homes and other long-term care facilities;
• Household contacts (including children) and caregivers of children younger than 5, particularly contacts of children younger than 6 months and adults 50 or over;
• Household contacts and caregivers or people who live with a person at high-risk for
complications from the flu; and
• Health-care workers, including students who have contact with patients.

Adequate supplies of flu vaccine are expected to be available for this year’s flu season, the state Department for Public Health said in a news release. "Only injectable influenza vaccine formulations will be distributed in the United States," the release said. "Vaccination can be given any time during the flu season."

"Getting the flu can be debilitating and sometimes life-threatening. Vaccination is the best tool we have to prevent the flu," state Health Commissioner Hiram Polk said. “It’s also extremely important to take simple preventive steps to avoid the flu. You should also follow the advice your parents gave you to prevent flu and other illnesses that tend to circulate at this time of year – wash your hands frequently, cover your mouth when you cough or sneeze and stay home when you’re sick.”

The flu can be very contagious, and can cause fever, headache, cough, sore throat, runny nose, sneezing and body aches. For more information on influenza or the availability of flu vaccine, Kentuckians should contact their primary-care provider or local health department. Information is also available online at