Friday, February 23, 2018

Advocates urge lawmakers to raise cigarette tax to raise revenue, cut cancer rates; 1/3 of Ky. cancer cases are caused by smoking

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- At a Feb. 22 rally in the state Capitol, more than 100 advocates from the American Cancer Society Cancer Action Network asked Kentucky lawmakers to implement a policy measure proven to decrease smoking rates -- raising the state's cigarette tax. The ask if for an increase of $1 per pack, to $1.60.

Dr. Jason Chesney, surrounded by seven Kentuckians
holding pictures of loved ones who died from smoking-
related cancers, says it's time for Kentucky to increase its
per-pack cigarette tax by $1 to save lives and raise revenue.
Dr. Jason Chesney, director of the University of Louisville's James Graham Brown Cancer Center, told the advocates that Kentucky leads the nation in the number of people with cancer and deaths from it, and that one-third of all cancers in the state are caused by smoking.

"This is a health crisis in this state, like no other state in the country, and we have to stop this vicious cycle today." he said "This is the time."

Chesney pointed out that Kentucky has some of the highest smoking rates in the nation, with 25 percent of its adults and 16 percent of its teens smoking. The Cancer Society says that raising the cigarette tax by $1 would keep more than 23,000 Kentucky teens from ever smoking and would result in over 29,000 adults quitting.

Chesney said fewer teens smoking would eventually mean fewer adults smoking, making for a healthier Kentucky and huge savings to the state. He said smoking costs the state $1.9 billion in annual health-care costs, with more than $500 million of that in the federal-state Medicaid program. "On average, this means that a typical household has to pay an extra $1,100 in annual taxes per year," he said.

He added, "I strongly believe that this initiative will have a greater impact on the health and welfare of Kentuckians than anything that I can do in my lifetime and anything any of my colleagues at the University of Louisville or the University of Kentucky could do in their lifetimes." he said.

Dr. Mark Evers, director of UK's Markey Cancer Center, also said the "time is right" to pass this cigarette tax, noting that Kentucky has one of the lowest cigarette taxes in the nation. "Right now in Kentucky, with the highest rates of lung cancer and smoking, our cigarette excise tax is 60 cents," he said. The national average is $1.72 per pack.

Angela Criswell, the senior manager of medical outreach for the Lung Cancer Alliance, said smoking causes at least 12 kinds of cancer, and that nearly one in five deaths is attributable to it.

"Tobacco use is the leading preventable cause of cancer death and cause of death in the U.S.," she said. She added that raising the cigarette tax by $1 in Kentucky would also help the 60 percent of adults who say they want to quit do so.

Sixth-graders from Corbin Intermediate School (L-R) Bailyn
Scent, who told advocates her great-grandfather had died
from lung cancer; Andrew Collins, and Grayson Maggard.
(Foundation for a Healthy Kentucky photo)
Roger Cline, a cancer society volunteer who lost his wife to lung cancer, though she never smoked in her 59 years, said that while it was too late to help his wife, he called on Kentucky legislators to raise the cigarette tax by $1 to keep 23,000 young Kentuckians from ever smoking. Students from Corbin Intermediate School were at the rally in support of the tax.

Pam Pilgrim, who is the cancer society's lead volunteer in Kentucky, noted the estimated $266 million in annual revenue from the higher tax and said, "The bottom line is plain and simple. We need to save more lives in Kentucky and the state needs more revenue. A tobacco tax increase could go a long way toward solving both of these problems."

The rally was the fifth in a series sponsored by the Coalition for a Smoke-Free Tomorrow, which comprises nearly 150 organizations that support efforts to decrease smoking in the state, including the tax hike. The other rallies have focused on smoking and pregnancy, teenagers, behavioral health and heart health. The coalition is headed by the Foundation for a Healthy Kentucky, which funds Kentucky Health News but has no editorial control of it.

Thursday, February 22, 2018

Lobbying on cigarette tax ramps up, with foundation's ads and tobacco firm's use of farmers, retailers and paid media report

By Al Cross
Kentucky Health News

FRANKFORT, Ky. -- If activity by lobbying interests is any indication, the idea of raising the state cigarette tax $1 a pack is an active idea among members of the Kentucky General Assembly.

The main group advocating the tax increase, the Foundation for a Healthy Kentucky, reported spending more than any other lobby during the first month of the session. Its total of $100,240 was not far ahead of collective spending by tobacco companies that oppose the tax hike, which totaled $95,218.

The leading pro-tobacco spender, at $44,643, was Altria Client Services, a subsidiary of Altria Group, which includes Philip Morris USA, the nation's largest manufacturer of tobacco products.

This month, Altria spent an as-yet-undisclosed sum with Commonwealth Radio Reports of Louisville, which distributed a 45-second audio report to Kentucky radio stations about tobacco farmers and retailers lobbying legislators against the tax increase. The report did not say who sponsored or produced it.

Richard Farmer, the reporter and company owner, told Kentucky Health News that Altria brings tobacco farmers to Frankfort every session, but this year added retailers. That indicates the stakes are higher; in addition to the foundation's campaign, the state faces serious revenue problems.

The foundation is also using paid media. It has laid out more than $98,500 for an advertising campaign set to begin Monday, Feb. 26, Marcus Green reports for Louisville's WDRB. The foundation is staffing the Coalition for a Smoke-Free Tomorrow, comprising more than 150 groups and individuals.

“It will be a multimedia campaign,” Bonnie Hackbarth, spokeswoman for the foundation and the coalition, told Green. “We will be using billboards, cable TV, digital, and we will be focusing on the health benefits that can be achieved through a $1 or more increase on the tax on cigarettes.”

Hackbarth told Green that the campaign will focus on the health benefits of quitting smoking. Kentucky's smoking rate of 25 percent "trails only neighboring West Virginia," Green notes.

"Hackbarth said the coalition, whose members include health, business and other groups, does not expect that a standalone bill raising the cigarette tax will pass during the current session," Green reports. "But she said it’s possible the measure could be added during budget negotiations or approved in a special session on tax reform. Advocates estimate a $1-per-pack cigarette tax could generate more than $266 million for the state each year while also reducing smoking-related illnesses."

Hackbarth said of the ad buy, “This is the first wave and we will continue until we will be able to win.”

In his report, Farmer said, "Opponents say the tax hike would unfairly burden those least able to pay, the nearly 48 percent of low-income Kentuckians who smoke, and it would hurt the family farm, according to Christian County farmer Robert Gray," who said tobacco prices are stable, unlike those for other farm products.

Altria's allies also argue the hike would be "counterproductive," Farmer reported, because "60 percent of states recently increasing cigarette taxes failed to meet revenue projections. Growers pointed out that higher taxes would drive smokers across borders to buy cigarettes, harming Kentucky convenience stores, which derive more than a third of their sales from cigarettes."

Raising the tax $1 a pack would make it $1.60, the same as in Ohio but much higher than the 99.5 cents in Indiana, the other state that shares a major metropolitan area with Kentucky. The rates in other bordering states are $1.98 in Illinois, $1.20 in West Virginia, 62 cents in Tennessee, 30 cents in Virginia and 17 cents in Missouri; the last two are the lowest in the nation.

Foundation President and CEO Ben Chandler said in an email that tobacco manufacturers are “hiding behind farmers,” who “get about 3 cents per pack of cigarettes for their tobacco. Yet the health-related costs are about $35 per pack. And every household in Kentucky pays about $1,200 in extra taxes each year to cover those health costs. We’re grateful that lawmakers are beginning to understand this message, and will keep working until we can announce we’ve kept our promise to make Kentucky healthier by reducing smoking and exposure to secondhand smoke.”

Wednesday, February 21, 2018

Fewer Kentuckians are worried about losing health insurance, though fewer say they are on employer-sponsored plans

By Melissa Patrick
Kentucky Health News

Nearly one in four Kentucky adults with health insurance worry that they could lose their health coverage -- less than last year, when almost one in five said they were concerned, according to the latest Kentucky Health Issues Poll.

The survey, taken by telephone Oct. 24 to Dec. 2, found that the share of Kentuckians with public insurance (such as Medicaid, Medicare or veterans' benefits) in 2017 moved back up to its 2015 rate of 35 percent. It had dropped to 29 percent in 2016.

The share of Kentuckians with employer-provided insurance dropped to 39 percent, continuing a bumpy decline that began in 2014, when the rate was 50 percent. About 11 percent of Kentucky adults reported they bought health insurance on their own or through a parental plan.

The decline in employer-sponsored insurance could be significant, because part of Gov. Matt Bevin's strategy in adding work rules to Medicaid is to encourage those on the program to find jobs that offer insurance. Most of those who will be affected by the work rules already work, but many at low-paying jobs that don't offer insurance.

In 2014, when then-Gov. Steve Beshear expanded Medicaid to those who earn up to 138 percent of the federal poverty level, the share of Kentuckians without health insurance dropped from 25 percent to 12 percent. The rate rose to 15 percent in the latest poll, after two years at 13 percent, but those numbers were within the poll's error margin of plus or minus 2.4 percentage points.

The survey also found that an additional 6 percent of Kentucky adults who had health insurance at the time they were polled were without it at some time during the prior 12 months.

"Health insurance and good health go hand in hand," said Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, which co-sponsors the poll with Interact for Health, a Cincinnati foundation. "Preventive care and wellness checks are as necessary as treatment for chronic illness, and too many Kentucky adults are still going without the care they need due to lack of insurance."

Tuesday, February 20, 2018

In county with 75% on Medicaid and 12.4% unemployed, Salyersville mayor ponders Medicaid's new work rules

Kentucky's new Medicaid plan requires some of its recipients to work or volunteer will be phased in, with poor areas last, but some are worried that finding work there won't be easy, and that enforcing the new requirement will cause some to lose their coverage.

"I would not be truthful if I didn't say it's a big challenge," Kristi Putnam, the Medicaid waiver program manager for the state, told Miranda Combs of Lexington's WKYT-TV.  "It's a big project. There are a lot of moving parts and lots of partnerships."

Kentucky was the first state the federal government allowed to require some of its Medicaid recipients to work, volunteer or get job training 80 hours a month to keep their health insurance. This requirement will largely affect those who gained coverage through the expansion of the program, under federal health reform, to those with incomes up to 138 percent of the federal poverty level.

Combs compared unemployment and Medicaid numbers and found that "the latest unemployment rate numbers were above the state average in each of the 10 counties with the highest percentages of Medicaid recipients," making many wonder where these people are going to work.

Screenshot of WKYT interactive map with percentage of population on Medicaid 
The top 10 Medicaid counties have between 58 percent to 82 percent of their population on the program, and have unemployment ranging from 5.2 percent to 12.4 percent. The statewide unemployment rate is 4.4 percent.

Combs talked to Salyersville Mayor Pete Shepherd about how 75 percent of the people in Magoffin County ended up on Medicaid.

"We got here because the federal government decided in the 1960s to give food stamps and welfare to everybody that was under a certain threshold," Shepherd said, adding that the loss of coal jobs added others to the rolls.

"We had a lot of people that went off good-paying jobs to nothing," Shepherd said. "It's not their fault, and a lot of them would work if there were jobs available."

Shepherd, who said he needed more guidance from the state on the program, also voiced his concern about the new work rules, saying, " You can't make jobs if there's nothing there to have for jobs."

Putnam told Combs that the state will help people meet the  new requirements, which won't be rolled out in Magoffin County until November.

Putnam estimated that about 239,000 people in Kentucky will have the "community engagement requirement," and that half of them already meet it. "It's really intended to help connect people to resources so that they aren't in the multi-generational poverty situation where they depend on benefits," she said.

Opponents of the plan are concerned that the lock-out periods for failure to meet work requirements, pay premiums, or report changes or renew coverage in a timely manner will result in Kentuckians losing their health coverage. The Bevin administration recognizes that many will lose their coverage, estimating that there will be 95,000 fewer Kentuckians on Medicaid in five years than without the program, partly because of "non-compliance."

Three nonprofit groups representing 16 Kentuckians have sued the federal government to block Kentucky's Medicaid waiver. The Trump administration and Gov. Matt Bevin want the case to be heard in federal court in Frankfort.

Attorney general sues Cardinal Health for distributing large volumes of opioids to state, alleges wrongdoing

Attorney General Andy Beshear filed suit Feb. 19 against Ohio-based Cardinal Health, saying the company has practiced unfair, misleading and deceptive business practices while flooding the state with highly addictive opioid painkillers.

The lawsuit, filed in Jefferson Circuit Court, alleges that Cardinal failed to report "suspiciously large volumes" of opioid shipments, particularly in Eastern Kentucky, to state and federal authorities.

“Kentucky has lost so much,” Beshear said. “But a better future is possible. The companies that made billions have a duty to help us create a future. They have a duty to fully fund treatment, prevention, recovery and enforcement efforts.”

Based on Cardinal's 20.7 percent share of the Kentucky market, Beshear's office attributes 63.6 million of the 307.2 million doses of prescription opioids filled by Kentucky pharmacies between 2016 through 2017 to the company, "which breaks down to 69 doses for every man, woman and child in Kentucky."

Further, Beshear's office says this breaks down to 302 doses for every citizen in Floyd County; 245 doses for each citizen in Clay County; and 222 doses per citizen in Bell County, but only 1.5 per citizen in Jefferson County.

Since November 2017, Beshear's office has also filed opioid lawsuits against two other drug companies, McKesson Corp., making similar claims as the Cardinal suit, and Endo Pharmaceuticals and Endo Health Solutions for violating state law and directly contributing to opioid-related deaths and overdoses from the drug Opana.

Monday, February 19, 2018

Bevin sues in federal court at Frankfort to get lawsuit over Medicaid changes heard in Kentucky, not Washington

By Al Cross
Kentucky Health News

The legal maneuvering over changes to Medicaid in Kentucky escalated Monday, as Gov. Matt Bevin sued the national groups and Kentuckians who had sued the Trump administration over its approval of the changes Bevin wanted.

The first suit was filed in federal court in Washington. It did not name Bevin or his subordinates as plaintiffs, apparently because he has said a court ruling against his changes would result in his ending the 2014 Medicaid expansion that covers 480,000 Kentuckians.

Bevin's suit was filed in federal court at Frankfort. He wants the case decided in Kentucky, and "seeks to ensure that, as the architect and administrator of the waiver, the Commonwealth's voice is heard," his office said in a press release, adding that the case would ensure that his administration's arguments "are fully considered."

The release noted that the Trump administration's Department for Health and Human Services "recently moved to transfer the case to Kentucky, further confirming the necessity of having a Kentucky court resolve this dispute."

"We cannot sit idly by while the Commonwealth’s plan is debated in an out-of-state courtroom,” Steve Pitt, Bevin's chief lawyer, said in the release. "A Kentucky court, with the full participation of the Commonwealth, should decide this vital issue."

The first suit was filed Jan. 24, 12 days after the Trump administration approved Bevin's proposal that many if not most people covered by the Medicaid expansion be required to work, volunteer or take job training. The plan also includes small, income-based premiums for Medicaid beneficiaries.

The suit, filed on behalf of 16 beneficiaries in Kentucky, alleges that the work rules violate federal law. Kentucky was the first state to win approval of such rules, and Indiana has followed suit; other states' requests are pending.

Bevin's suit seeks a declaratory judgment that his plan complies with the same laws that the first suit says the plan violates. The first suit also says the plan violates the Constitution, which requires that presidents "take care that the laws be faithfully executed." Bevin's suit seeks a judgment that the claim can't be decided by a court, or that the approval of Bevin's plan didn't violate the clause.

Claims made in filing a lawsuit give only one side of a case.

Sunday, February 18, 2018

Anthem makes several exceptions to its controversial policy of denying payment for ER visits it deems non-emergency

Responding to complaints from legislators and health-care providers, Anthem Blue Cross Blue Shield has added several exceptions to its recently established policy of not paying for emergency-room visits if it determines there was no emergency. The policy first took effect in Kentucky, Missouri and Georgia; "Ohio, Indiana and New Hampshire were added to the program in January, after the new exceptions were already in place," Leslie Small reports for FierceHealthcare.

The exceptions include patients who:
  • are sent to the ER by another provider, including an ambulance
  • visit an ER between 8 p.m. Saturday and 8 a.m. Monday, or on a major holiday
  • are younger than 15
  • live more than 15 miles from an urgent care center
  • are traveling out of state
  • receive any kind of surgery
  • get intravenous fluids or IV medications, or an MRI or CT scan
  • have an ER visit associated with an outpatient or inpatient admission
"Anthem said the changes went into effect Jan. 1," Shelby Livingston reports for Modern Healthcare. "It will apply the exceptions to any previously denied claims."

The company said in a prepared statement, “Anthem stands by our belief that emergency rooms are an expensive place to receive routine care. The costs of treating non-emergency ailments in the ER has an impact on the cost of healthcare for consumers, employers and the health care system as a whole.”

The changes did not satisfy the American College of Emergency Physicians. "This is still a fundamentally flawed policy,” Laura Wooster, the group's associate executive director of public affairs for the American College of Emergency Physicians, told Small. “Making fixes around the edges doesn’t end this dangerous policy that’s really going to scare patients away from going to the ER or even considering going to the ER.”

Wes Brewer, former president of ACEP's Kentucky chapter, told Lisa Gillespie of Louisville's WFPL, “We have hundreds of cases where people with conditions, where I don’t know in what universe you wouldn’t think they’re emergencies, have been denied.”

Small reports, "Anthem’s program was meant to deter members from using the emergency room for illnesses or injuries that aren’t life-threatening. But critics say patients shouldn’t be forced to self-diagnose, warning that the new policies will encourage people to avoid seeking care for serious medical conditions out of fear that their claim will be denied."

Shannon Muchmore reports for HealthcareDive, "Anthem has said its program denies a small percentage of claims, but the change in policy signals the payer may be worried about the backlash, including from patients who have gone public with denied claims.

Saturday, February 17, 2018

Older people and those in poor health most likely to lose Medicaid due to work rules, study says; state's numbers differ

The Kentuckians most likely to lose their Medicaid coverage because of new work requirements "are older and in poor health while those most likely to keep their insurance are younger and in better condition," according to an Urban Institute analysis, reports Adam Beam of The Associated Press.

Based on census data, the institute figures that 357,000 Kentucky Medicaid beneficiaries won't qualify for one of the exemptions from the new rules, which will be phased in starting July 1. "Of those, 188,000 are not working and most at risk of losing coverage," Beam writes. "Their average age is 45, with 48 percent of them older than 50." He adds that 76 percent lack a car, household access to the internet or a high-school diploma; have serious health limitations; or live with someone who does.

State officials' estimates differ. They say 224,000 people will be covered by the work rules and 100,000 to 130,000 people will qualify for exemptions, such as being a full-time student or a primary caregiver. The study estimates the exempt number at 174,000 and says their average age is 34, and 85 percent are high-school graduates, reflecting those two major exemptions. "About 20 percent report one or more serious health limitations," Beam notes.

The different estimates may be driven by limitation of the study, which was funded by the Robert Wood Johnson Foundation. "The rules for work requirements apply to full-time students, but the data does not distinguish between full-time and part-time, so the study counted all students as exempt. That's likely an overestimate," Beam writes, "The work requirements also exempt pregnant women, a population not counted in the data."

Also, the work rules exempt the 'medically frail,' which the study could not count. "Kentucky's application to the federal government said this could include people with active cancer, aplastic anemia, blood clotting disorders, chronic alcohol or drug abuse, and mental illness," Beam reports. "But it's unclear how those rules will be applied. It's possible a number of people the study identified as not exempt from the work requirement would fall into one of those categories."

Beam adds, "The study also identified another group: about 169,000 people who would not be exempt from the work requirements but who already have a job. It would be easier for them to meet the requirements and not lose coverage. Of those, 36 percent reported they worked less than the required 80 hours per month. But working isn't the only way to fulfill the requirements. People can also participate in community service, attend school or take job training classes.

All three groups are short of access to high-speed internet, Beam notes: "That could make it difficult to document their compliance with the work requirement, since state officials want people to use a mobile-friendly website to track that data. But people can also log their hours by mailing in printed forms or by visiting county offices of the Department of Community Based Services."

30 more Kentuckians die from flu, raising season total to 128

Thirty more people died from influenza in Kentucky during the week ended Feb. 10, the last one for which figures have been compiled. That was 10 more deaths than the previous week, and nine more than the highest weekly toll of 21, recorded in two consecutive weeks in January. The flu is now known to have killed 128 people in Kentucky during the current flu season, four of them children.

Kentucky had 1,023 new laboratory-confirmed flu cases from Feb. 4 through 10, a big increase from the 660 confirmed cases in the previous week. The total for the season is 6,287. Of that number, 5,125 have been Type A and 1,144 have been Type B.

All regions of the state except Lexington and Lake Cumberland reported increased flu activity during the week. Here is the state's detailed weekly report:

Friday, February 16, 2018

Bill to de-privatize Medicaid drug benefits and help independent pharmacists is moving, despite cost; some seek transparency

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky.  –  A bill to put the state back in charge of its Medicaid drug program is heading to the full Senate, but likely faces a "winding road" to its final passage, its sponsor says. The main obstacle appears to be cost, but that is countered by desires to open up the shadowy process in which a few companies make millions handling Medicaid prescriptions.

State Sen. Max Wise
"While it feels like every lobbyist in Frankfort has been hired to work against Senate Bill 5, local communities have stepped up their support," Republican Sen. Max Wise of Campbellsville told the Senate health committee Feb. 14, adding that community leaders all over the state have sent letters of support for the bill and its main lobby, independent pharmacies.

Wise said the problem is that pharmacy benefit managers, or PBMs, hired by Medicaid managed-care organizations, aren't fairly reimbursing independent pharmacies, putting them at risk of closing.

In addition to not paying a fair price for drugs, Wise said the PBMs are only paying independent pharmacists a "professional dispensing fee" of 85 cents per prescription, despite recommendations from the Centers for Medicare and Medicaid Services that says the fee should be around $10.64.

Rosemary Smith, a Beattyville pharmacist who co-owns six drug stores in Eastern Kentucky called Jordan Drug, said in a telephone interview that the low payments from the PBMs are "simply not sustainable."

"We have claims that we aren't even getting the cost of the drug, let alone any professional dispensing fee that would keep our stores in business," Smith said. "We've seen the reimbursement go down and down and now a lot of our prescriptions are being reimbursed at a low cost, with a 35 cent fee."

One of six pharmacies Rosemary and Luther Smith own (website photo)
Smith is co-founder of the Kentucky Independent Pharmacist Alliance, which represents the more than 500 independent pharmacies in the state. She said all they are asking for is a "level playing field."

"It's not Ace Hardware versus Walmart," she said. "We're not selling hammers. We're not selling nails. We are taking care of patients."

For example, she sees a conflict of interest with CVS Caremark, a PBM that is part of a company that operates a chain of pharmacies. CVS has contracts with four of the five Medicaid managed-care organizations in Kentucky.

"They are our competition and they are setting our prices," she said. "And what they are doing is, we call it a 'squeeze and buy' -- they are trying to squeeze us so we either go out of business or we have to sell to them."

CVS disagreed, saying in an e-mail that it is committed to providing its PBM members with a broad network of pharmacies that includes local, independent pharmacies.

"We reimburse our participating network pharmacies, including the many independent pharmacies that are valued participants in our network, at competitive rates that balance the need to fairly compensate pharmacies while providing a cost-effective benefit for our clients," said Christine Cramer, the senior director of corporate communications for CVS Health. "We also have a well-established appeals process for network pharmacies regarding reimbursement, and our responses to those appeals comply with all applicable laws."

Wise said at the Feb. 14 committee meeting that Medicaid in Kentucky spent $1.68 billion on pharmacy benefits last year, with about $1 billion of that going to pharmacies. He said the difference in the amounts went to pharmacy benefit managers, which have no obligation to report how they spent the money.

"PBMs currently set all the rules with little to no government oversight whatsoever," Wise said. "As a state senator, taxpayer, I don't think that's right." He said he has asked the Cabinet for Health and Family Services, which houses the Department for Medicaid Services, how that $1.68 billion is being spent, but has been unable to get an answer.

From left, Deputy Medicaid Commissioner Anne-Tyler Morgan, Chief of
Staff Eric Clark and Commissioner Stephen Miller address the committee.
Medicaid Commissioner Stephen Miller warned that if Wise's bill passes, it would cost Kentucky taxpayers an additional $36 million a year. That was his agency's official estimate of the bill's cost, attached to it as a "fiscal note."

Wise said the bill shouldn't cost the state any money, and asked Miller, "If the Department of Medicaid Services can't tell me how much PBMs are receiving, how can they come up with a fiscal note?"

Sen. Ralph Alvarado, R-Winchester, brought up a separate study by Optum that says the state would have a potential savings of up to $348 million if Wise's bill becomes law. A physican, Alvarado said that knowing what he knows, "I tend to believe this more."

After some back and forth with several committee members about the fiscal note, Miller said, "We still stand by our numbers."

Miller explained that because managed-care organizations are required to spend 90 percent of their monies on direct patient services, leaving 10 percent for administrative fees and profit, they haven't been concerned about the PBMs because the business model encourages MCOs to keep their costs low.

"So they are going to pay the PBMs as little as possible to provide the services, and then the PBMs are going to squeeze out the independent pharmacies to maintain their profit margin," said Sen. Danny Carroll, R-Paducah. "When you get to the crux of it, that's what happening,"

Miller suggested that an alternative would be to renegotiate contracts with managed-care organizations to require PBMs to pay pharmacies a higher dispensing fee, but he cautioned that for  every $1 the state increases the fee, it would cost $6 million of state money.

It was also suggested that there needed to be more competition among PBMs.

The bill passed the health committee with two members casting a "pass" vote, including its chair, Sen. Julie Raque Adams, R-Louisville. "We have a 36-million-dollar fiscal note attached to this bill and that's significant to me," she said. "That plays a role in everything else that we do relative to budgetary decisions. Those are real dollars and they are going to impact real people."

Sen. David Givens, R-Greensburg, also passed, but told the cabinet officials, "We're not pleased with your inability to adjudicate fairness." He noted that the problem is a national issue. West Virginia recently decided to manage its own pharmacy benefits, and Ohio and Arkansas are considering it.

Casey Ross of Stat, the health-and-science service of The Boston Globewrites in an in-depth article that Washington lawmakers are also concerned about PBMs. The President's Council of Economic Advisers released a report on drug prices last week that raised alarms about PBM consolidation, and calls for policy changes to encourage competition.

"PBMs say they are saving money for insurers and their members, but their contracts with drug makers and other parties are secret, so no one knows how much of that money is being passed on to consumers," Ross writes. "Furthermore, their ability to extract higher payments creates an incentive for drug makers to further raise their list prices, which leaves many consumers, especially the uninsured, facing higher out-of pocket costs. . . . People who work in the pharmacy benefit business argue the only way to reform it is to eliminate the secret discounts that allow these middlemen to thrive."

Jim Waters, president and CEO of the Bluegrass Institute for Public Policy Solutions, a libertarian, free-market think tank, writes that Wise's bill is indicative of a "sledgehammer-to-ant syndrome." He calls for more transparency from PBMs, suggesting that they be required to reveal their reimbursement rates for prescriptions, including how much they pay manufacturers, insurers, employers and pharmacists.

"If such transparency reveals monopolistic-like conflicts of interest or unholy alliances between the PBMs and big pharmacies, then – like a policy MRI – perhaps it will be clear where surgery is needed. Even then, a scalpel will be much-more effective than a sledgehammer." Waters writes.

Wise said he is open to other solutions, but said the managed care organizations and PBMs weren't likely to offer them unless "we show we're serious about moving legislation forward."

"Don't let the MCOs and PBMs win by withholding that information from us," Wise told his colleagues. "Rather, let's send a strong message that this committee and the Senate is going to stand up for local pharmacies and for small businesses, to keep the pressure up on those groups to offer alternative solutions."

Other business: The committee also passed Senate Bill 112, sponsored by Alvarado, which develops policies around telehealth payments and the oversight of telehealth providers, and would require physicians to be licensed in the state to be reimbursed. This bill is expected to increase healthcare access and savings to the state.

Thursday, February 15, 2018

Advocates for heart health urge raising cigarette tax by $1 to reduce smoking, a major cause of heart disease

Representatives and volunteers with the American Heart
Association and the state chapter of the American College
of Cardiology rallied in Frankfort on Valentine's Day to urge
lawmakers to raise the cigarette tax by $1 for heart health.
By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- At a Feb. 14 rally in the state Capitol, advocates for heart health urged lawmakers to raise Kentucky's cigarette tax as a way to reduce smoking, a known cause of heart disease.

"We are here on Valentine's Day, the day which celebrates love, to ask our legislators and governor to do something that will have a profound and long lasting impact on the health of all of us Kentuckians," said Dr. Andy Henderson, president of the American Heart Association's Central Kentucky Board of Directors. "We are asking them to protect the hearts of all Kentuckians by raising the tax on cigarettes by at least $1 per pack."

Smoking kills about 9,000 Kentuckians every year, with about one-third of those deaths from heart disease caused by smoking or second-hand smoke, according to the AHA. It is also responsible for many other heart related diseases, including stroke and chronic obstructive pulmonary disease (COPD), of which Kentucky has the second highest rate in the nation.

Republican Sen. Ralph Alvarado, a Winchester physician, told the advocates that "the message is starting to soak in" with legislators, especially this budget year that is trying to address such a huge deficit. He noted that this tax, which would raise $266 million, could help to fill a half-billion-dollar gap.

Alvarado, who has sponsored several anti-tobacco bills, pointed out that support for raising the cigarette tax by $1 is backed by 70 percent of Kentuckians, the Kentucky Chamber of Commerce, medical groups and the education system.

"We've got to do something to help reduce our youth smoking [rates], which are the worse in the country, and adult smoking rates and this would help us get there," he said."Continue to be advocates, contact your legislators and let them know what your stance is, advise them on how they could use those funds to help us with the current budget crisis."

Henderson, who is also the CEO of Lexington Clinic, reminded the crowd that Kentucky has some of the highest smoking rates in the nation for both teens and adults. He said raising the cigarette tax by $1 a pack would not only keep teens from smoking, but would cause an estimated 2,900 smokers to quit, saving the state an estimated "millions and millions of dollars in health care costs year after year." The Campaign for Tobacco-Free Kids estimates that raising the tax by $1 would result in 23,200 fewer Kentucky teens smoking.

Henderson said that he primarily supported this measure for its many health benefits, but added that there was no denying it would bring new revenue to a state that sorely needs it.

Withrow wields cigarette (Melissa Patrick photos)
"I've heard our leaders say they don't want any new taxes. This is not a new tax and no-one is being forced to pay the tax. If you don't want to pay it, don't smoke. It's that simple," he said.

While holding a huge mock-up of a cigarette, Dr. Patrick Withrow of Paducah, the 2018 governor-elect of the Kentucky chapter of the American College of Cardiology, also called on the state's lawmakers to raise the tax, noting that at 60 cents a pack, Kentucky has one of the lowest cigarette taxes in the nation. The national average is $1.72 per pack.

"The cigarette smoking tax is a win-win-win," said Withrow, a long-time volunteer of the American Heart Association. "It will improve the health of Kentuckians. It will reduce tobacco use. It will lower health care cost and it will help businesses -- and it will improve the coffers."

The rally was the fourth in a series sponsored by the Coalition for a Smoke-Free Tomorrow, which comprises nearly 150 organizations that support efforts to decrease smoking in the state, including the tax hike. The other rallies have focused on smoking and pregnancy, teenagers and behavioral health. The next rally, set for 11 a.m. Feb. 21 in the Capitol rotunda, will focus on smoking and cancer.

House passes optometrists' bill to thwart online eye exams by requiring 'real time' consultation with an eye doctor

The state House has passed a bill to restrict the growing practice of online eye examinations, a threat to one of the most powerful lobbies of the legislature: independent optometrists. The Senate may give it a closer exam.

House Bill 191, which passed the House 90-7 on Feb. 13, would require a visit with an eye doctor in "real time" for an eye exam or prescription online. Its sponsor, Rep. Jim Gooch, R-Providence, said in a news release that it aims to keep patients safe. "Companies like Opternative already have doctors sign off on the results and prescription, but not in real time," notes Garrett Wymer of Lexington's WKYT-TV.

Dr. William "Chip" Richardson, a Georgetown ophthalmologist and secretary-treasurer of the Kentucky Academy of Eye Physicians and Surgeons, testified against the bill in committee, saying online assessments can reach people with eye problems that may otherwise go undiagnosed.

"While allowing those online options may hurt his financial bottom line (particularly with his sales of glasses and contacts), the bottom line, he says, is they improve access to care," Wymer reports. "Richardson said he is afraid the bill would essentially run those online options out of Kentucky and hurt some patients' access to eye care."

"The bill also requires someone wanting an online eye exam or prescription to have had an in-person exam in the last two years," Wymer notes. "Richardson said that part of the bill could be helpful."

Gooch told Wymer that his bill does not ban "safe technology," but improves it by requiring real-time interaction between a person and a doctor. On the House floor, he noted that online exams are unregulated in Kentucky.

Rep. Kim Moser, R-Taylor Mill, unsuccessfully tried to amend the bill. She said it would be "burdensome, especially to those with disabilities This effectively shuts down e-commerce."
The other six House members who voted against the bill were Republicans Robert Benvenuti of Lexington, Brian Linder of Dry Ridge, Sal Santoro of Florence, Diane St. Onge of Fort Wright and Scott Wells of West Liberty, and Democrat Susan Westrom of Lexington.

The bill is now in the Senate Health and Welfare Committee. "South Carolina's legislature passed a similar bill two years ago," Wymer reports. "The governor vetoed the bill, but it was overridden. Just last month a judge threw out a lawsuit challenging the law."