Sunday, July 15, 2018

Medicaid dental and vision cuts worry patients and health-care providers; Democrats want answers, restoration of benefits

Kentucky Health News

Kentucky is in the third week without dental, vision or non-emergency transportation benefits for 460,000 Kentucky adults on Medicaid, and Democratic lawmakers, health advocates and dentists are continuing to voice their concerns, prompting the state health cabinet to respond online, including a Facebook video that cites "misinformation that is circulating in the media."

The 460,000 who lost their benefits are people covered by the state's 2014 expansion of Medicaid, under the 2010 Patient Protection and Affordable Care Act, to those who earn up to 138 percent of the federal poverty level.

Under a Medicaid plan that was vacated by a federal judge in Washington, this expansion group was supposed to move to a "My Rewards" program that allowed them to earn dental and vision benefits by participating in certain activities, like self-improvement classes or wellness activities or passing a GED exam. But when the plan was vacated two days before it was to take effect, the state says this left this group without any way to earn these benefits.

The abrupt removal of benefits created confusion among providers and beneficiaries, and prompted Democrats to hold news conferences questioning the reasons for the action and its legality.

Jessica Clark-Boyd, manager of the Healthy Smiles clinic in
Prestonsburg, told the Lexington Herald-Leader that half its
appointments were canceled after the state limited coverage
for some on Medicaid. (Photo by Silas Walker, Lexington Herald-Leader)
Will Wright reported for the Lexington Herald-Leader July 10 that the schedule of a Prestonsburg dentist showed five and a half hours of vacancies because more than half of her patients had lost their dental benefits.

Misty Clark, the dentist and owner of Healthy Smiles Family and Cosmetic Dentistry, told Wright that she normally has three patients per hour. The office manager, Jessica Clark-Boyd, told Wright that they have rescheduled dozens for appointments next month, hoping their insurance will be restored by then. "If not, Healthy Smiles could be in big financial trouble," he writes.

Wright also tells the story of Lynda Joseph of Pikeville, a Healthy Smiles patient who was scheduled to get a tooth pulled this month, but is one of those who lost dental benefits. Joseph wondered why the Bevin administration would cut benefits to people who are so close to the poverty level.

Joseph, who works part-time at Walmart, told Wright that she doesn't know when she'll be able to get the extraction. "I don’t mind paying the premium," she said. "Even if the premiums became higher, I wouldn’t mind that. The question is, am I going to be able to pay for it out-of-pocket?"

Democratic legislators from Eastern Kentucky, and a few others, held a news conference July 10 to "criticize both the moral and economic impacts" of these cuts, and called on Republican Gov. Matt Bevin to reinstate the benefits. The lawmakers said the cut "unnecessarily strips health-care benefits from working families and could hurt the state economy, particularly in Eastern Kentucky," Wright reports.

He adds that a report from the left-leaning Kentucky Center for Economic Policy found that the Medicaid expansion "has pumped billions of dollars into the economy and created thousands of jobs -- half of the net job growth in Kentucky since December 2007 came from the health care sector."

At a time coal has declined, "The industry that we have seen in our region that has actually been able to grow some, to be able to invest in its infrastructure, to be able to provide quality health care throughout our region, has been the health-care industry because of the expansion of Medicaid," House Minority Floor Leader Rocky Adkins said at the news conference in Pikeville.

Rep. Chris Harris of Forest Hills and other Eastern Kentucky
lawmakers, and former state auditor Adam Edelen, left, spoke
at a news conference against the cut of dental and vision cuts
to those on expanded Medicaid. (Image from WYMT-TV)
Rep. Angie Hatton of Whitesburg said, "We can't stand to lose more jobs, and our health- care industry will lose jobs because of this," reports Christina Bates of Hazard's WYMT-TV.

Bates also tells the story of Cory McCauley, who said she was one who lost her dental and vision benefits, and that she had learned about it on the news. "We got no notification in the mail whatsoever," she said. McCauley told Bates that she and her husband have relied on the program while he is in medical school.

"I actually had an appointment because I have a cavity . . . so now I can't keep that appointment because I'll have to pay for it out of pocket, which is just not realistic for us right now with no income," said Bates.

Kentucky Voices for Health has a video of the news conference, and a blog post about the recent changes, by KVH policy analyst Jason Dunn.

William E. Collins, a dentist in Pike County, wrote an opinion piece for the KVH blog that says the cuts are so harmful to "the working poor." He notes the hundreds of appointments he and his colleagues had to cancel last week because the online benefit system listed patients' benefits as "no current coverage" or "alternative benefits." But he also says that through a team effort between providers and the state, part of the eligibility issues were resolved.

"This is not about politics. This is about humanity," Collins wrote. "Placing blame seems to be necessary for some, but finding and correcting the problem is what the enrollees need."

All 37 members of the state House Democratic Caucus sent a letter July 10 to Health Secretary Adam Meier asking him to answer a long list of questions about the process used to remove the benefits; how the new benefit structure is affecting recipients and providers; the expected impact of removing the benefits; and how premiums already collected will be returned.

Democratic U.S. Rep. John Yarmuth of Louisville sent a letter to Alex Azar, secretary of the U.S. Department of Health and Human Services, that also included a list of pointed questions that asked for "clarification regarding these changes."

“Given that the federal government covers 94 percent of all Medicaid expansion costs in Kentucky, the dysfunction Gov. Bevin has brought to this critical health care system should be of great concern to you and your agency," Yarmuth wrote. "Health care coverage for the people of Kentucky is too important to be jeopardized by politics and dysfunction."

Meanwhile, the Poor People's Campaign protesters, who were finally allowed entry into the Capitol July 10 for the first time since a judge ruled police broke the law by denying them entry, delivered toothbrushes to the governor's office in protest of the dental and vision cuts, WKYT reports.

In a July 6 letter to the Centers for Medicare and Medicaid Services, three advocacy groups asked the agency to disapprove the withdrawal of dental and vision benefits, saying the state failed to comply with procedural requirements, including an appropriate public-notice period or a 30-day public comment period required by federal law. They also cite that the judge's intent was that the program remain status quo until after Azar's further review of the plan, called Kentucky HEALTH for "Helping to Engage and Achieve Long Term Health."

In a July 10 Facebook video, Kristi Putnam, deputy secretary for the health cabinet, says there has been a "good deal of confusion and misinformation" about Kentucky HEALTH since the federal judge "temporarily stopped its implementation."

Putnam who is also the program manager for Kentucky HEALTH, asks "media partners" to call the cabinet if they learn about beneficiaries or providers who are having issues, explaining that the Pikeville dentist who spoke to the Louisville Courier Journal last week had his problems resolved within two hours, but this wasn't reported in the article. "Please let us help," she said.

Putnam added that Medicaid systems have been checked and are running properly, and that eligibility was in place for pregnant women, children and foster children up to the age of 26. She said the kentuckyhealth.ky.gov website has been updated with new resource pages and the computer screens used by providers have been improved to allow for better understanding of who qualifies for dental and vision benefits and who doesn't.

Saturday, July 14, 2018

New oral-health plan includes expanded role for hygienists, soft-drink tax to fund loans to get more dentists in under-served areas

The plan was completed in December 2017 but just released.
By Melissa Patrick
Kentucky Health News

Kentucky's new plan for oral health calls for the state to expand the role of public-health hygienists, find other ways to expand the dental workforce in under-served areas, and raise dentists' Medicaid fees. And to pay for part of the plan, it calls for a tax on soft drinks that cause tooth decay.

The challenge is that all of these suggestions require action by the Kentucky General Assembly.

The Strategic Plan on Oral Health was assembled after more than 120 stakeholders and oral-health advocates attended a two-day summit and small-group meetings to set the state's oral health priorities. The last plan was released in 2006.

One key strategy would require lawmakers to expand the scope of practice for public-health dental hygienists in Kentucky.

Current law says public-health hygienists have to be employed or contracted by a public health department. The state has only 18 hygenists, working in 10 programs in 33 counties. They largely provide preventive care, patient assessment and referrals for under-served children in public schools.

The plan calls for the hygienists to be allowed to practice in more settings, such as nursing homes, group homes, juvenile justice facilities and some correctional facilities, and to let them apply silver diamine fluoride, a liquid that stops tooth decay and reduces pain until the patient can see a dentist.

Map shows share of third- and sixth-graders with untreated dental cavities, by region;
Appalachian Kentucky is colored light purple. (Lexington Herald-Leader map)
The proposals are aimed at the widespread tooth decay in Kentucky children. A 2016 study by Delta Dental and Kentucky Youth Advocates found that two out of five Kentucky third and sixth graders have untreated cavities, and the problem is "significantly greater" in Appalachian Kentucky, where more than half of the children in the study had untreated cavities.

The plan also calls for allowing public-health hygienists to use tele-dentistry, which would allow them to see more patients in a more timely fashion.

“To expand the ‘scope of practice’ would allow public-health hygienists to assist in arresting disease and pain, while still focusing on getting them care by a dentist," Julie Watts McKee, dental director for the state Department of Public Health, said in an email. "It improves access. And access improves health."

Expanding the scope of practice for public-health hygienists was widely supported at the two oral health summits, but a survey before the events found that only 24 percent of the dentists in the poll supported expanding hygenists' scope of practice, compared to 97 percent of hygienists. The poll surveyed 64 dentists and 67 hygenists among 474 people defined as interested in Kentucky's oral health.

Another goal of the plan is to find ways to entice dentists to practice in Kentucky's under-served areas, such as tax incentives, educational debt reimbursement and increasing Medicaid fees.

The plan stresses that better data collection is needed to support its goals. It says one dentist who is listed as taking Medicaid patients made only 14 Medicaid claims in one year, indicating that the need for access to dental care is greater than is being reported. "Data drives good policy," McKee said at an October health committee meeting about the report.

Kentucky offers the Kentucky State Loan Repayment Program, which is funded though the National Health Service Corps and administered by the Kentucky Office of Rural Health. However, such loans are offered to only a dozen or so Kentuckians each year, and are available to not only dentists, but to other health-care providers willing to work two years at an "eligible site."

The strategic plan calls for a state-funded repayment program for new dentists who agree to practice in limited-access or under-served areas, a budget decision for the General Assembly. The report points out that Kentucky likely has enough dentists overall, but instead has a "maldistribution" problem: not enough of them in too many places.

Richard Whitehouse, executive director of the Kentucky Dental Association, said in an email that KDA supports the debt-relief proposal, and has lobbied the federal government for such funding, but "This is a difficult sell at this time."

Whitehouse wrote, "A properly run program of debt forgiveness or loan repayment would greatly expand access to care. I have heard of studies suggesting that if a provider establishes a practice for at least three years, they are likely to remain. So, this investment could have a lasting effect on improving access to care and oral health outcomes."

The plan notes that Kentucky Medicaid's low reimbursement for dental services is a huge challenge in getting dentist to work in under-served areas. The plan calls for the state to compare current Medicaid fees to the regional "usual and customary rates" and adjust them accordingly, a suggestion made by a Medicaid official at the summit.

Whitehouse said Medicaid usually pays 30 to 40 percent of what is considered a "usual and customary rate." He added that a practice can break even if its Medicaid patient base is below 25 percent of its total, but above that, "the dentist is actually losing money and the practice begins to suffer." He added, "This accounts for why it is difficult to encourage new dentists with $250,000 of student debt to start a practice in areas of greatest need."

Figures are as of May 2017; map is from state Oral Health Plan. For a larger version, click on the map.
The report says slightly more than a third of dentists in Kentucky do not accept Medicaid, and one in five report that fewer than a third of their patients are covered by Medicaid. Ten Kentucky counties, mostly in Western Kentucky, have no dentist who cares for Medicaid patients.

To help fund the loan-repayment program, the plan calls for the state to implement a soft-drink tax. This idea was referred to the nongovernmental Kentucky Oral Health Coalition, which said in an email that its members would discuss the proposal and determine if it's a priority they want to tackle.

Whitehouse said KDA is in full support of a soft-drink tax, and has found a lot of stakeholder interest in it, but no support in Frankfort for it.

"Because of the correlation between soda and oral decay, this seems an appropriate response in order to improving oral health in Kentucky," he said. "Earmarking the revenue from such a tax to loan repayment or increasing Medicaid reimbursement would also expand access to care. We believe, if we can get off the bottom of national rankings relating to oral health, this will also have an economic benefit in terms of our workforce and tax base."

The report also calls for the Kentucky Oral Health Coalition to lead the effort in finding ways to improve the oral health literacy of non-dental health professionals, the general population and especially policy makers.

Friday, July 13, 2018

Justice Department sends Ky. another prosecutor to fight fentanyl, orders charges to be brought regardless of quantity

Attorney General Jeff Sessions announced moves Thursday to
fight the spread of fentanyl. (Photo by Jonathan Ernst, Reuters)
Kentucky is one of the states that will get an extra federal prosecutor to fight the spread of fentanyl, a powerful opioid blamed for an increasing number of overdoses.

As part of the fight, Attorney General Jeff Sessions ordered Justice Department prosecutors in Kentucky and other areas "that have been especially hard-hit by overdose deaths from fentanyl to bring drug charges against anyone suspected of dealing the synthetic opioid, regardless of quantity," reports Sari Horwitz of The Washington Post.

Horwitz notes, "According to the Centers for Disease Control and Prevention, more than 42,000 Americans died of opioid overdoses in 2016, a figure driven by a dramatic surge in deaths from fentanyl and other synthetic opioids." In Kentucky that year, almost half (623) of the 1,404 overdose deaths involved fentanyl, which "is often mixed into heroin or cocaine," Horwitz notes. "It is 50 times more powerful than heroin, 100 times more powerful than morphine and can kill a user almost instantly. Dealers also press fentanyl into counterfeit pills sold on the street. Most illicit fentanyl comes into the United States through the mail or express shipping systems or is brought across the southwest border, according to the Justice Department."

All Kellogg's Honey Smacks cereal has been recalled, so throw it away or get a refund; CDC says, 'Do not eat this cereal'

All Honey Smacks cereal has been recalled after a multi-state salmonilla outbreak has been linked to the cereal, infecting 100 people in 33 states. Two have been infected in Kentucky.

The Kellogg Co. first recalled the product mid-June, but the U.S. Food and Drug Administration says the cereal is still being offered for sale in some places.

"Retailers cannot legally offer the cereal for sale and consumers should not purchase Kellogg's Honey Smacks cereal," says the FDA.

The federal Centers For Disease Control and Prevention warns: "Do not eat Kellog's Honey Smacks cereal of any size package or with any "best if used by date." In a tweet, the CDC said, "Do not eat this cereal."

While the official recall notice is for all Honey Smacks cereal products dated between June 14, 2018 through June 14, 2019, the FDA says you need to get rid of all of it, because Honey Smacks products with earlier dates might be contaminated.

The CDC warns that even if some of the cereal has been eaten and no one got sick, you still need to throw the rest of it away or return it for a refund. And if you have stored a cereal that looks like Honey Smacks, but can't remember the brand -- throw that away too and thoroughly wash the container with warm, soapy water before using it again. Click here for Kellogg's consumer website, or call 1-800-962-1413.

Symptoms of salmonella are diarrhea, fever, and abdominal cramps, with most infections lasting four to seven days. Symptoms usually start 12 to 72 hours after being infected. Most people recover without treatment, but some must be hospitalized. Young children, the elderly and those with weakened immune systems are at most risk of a serious or fatal infection.

The CDC says salmonella is responsible for about 1.2 million illnesses, 23,000 hospitalizations and 450 deaths in the U.S. in an average year. Most of the infections come from food.

The FDA reports that 30 people have been hospitalized from the outbreak, and no deaths have been reported. The agency reports that it initiated an inspection at the third-party manufacturer that produces the cereal and that the samples taken at the site matched the outbreak strain, as had the ones taken by state officials. "As of June 12, 2018, the manufacturing facility is no longer producing product," says the FDA.

"The recall effort follows other prominent salmonella outbreaks, including one linked to pre-cut melon from a facility in Indianapolis that sickened 70 people and another connected to eggs from a single North Carolina producer where 45 people were made sick. Earlier this year, 210 people were infected by an E. coli outbreak that killed five people linked to romaine lettuce that had been grown in Arizona," Eli Rosenberg reports in The Washington Post.

Attorney General Andy Beshear sues another drug company, accusing it of worsening Kentucky's opioid epidemic

Attorney General Andy Beshear filed suit July 12 against Mallinckrodt Pharmaceuticals, charging the firm with knowingly misrepresenting the addictive nature of its drugs.

The lawsuit in Madison Circuit Court alleges that the company claimed the drugs "could be taken in higher doses without disclosing the greater risks of potential addiction," a Beshear press release said. "Beshear said this action allowed the company to grow its market in Kentucky while contributing to the state’s drug epidemic."

The case is the seventh opioid-related lawsuit Beshear has filed, the release noted, adding that Franklin Circuit Judge Thomas Wingate recently refused to dismiss Beshear’s 2016 lawsuit against Endo Pharmaceuticals regarding its drug Opana ER. The suit alleges that Endo, which sought the dismissal, violated state law and directly contributed to opioid-related deaths and overdoses in Kentucky.

The Mallinckrodt suit alleges that the company had “front groups” promote opioid use and resist efforts to restrict opioid prescribing and failed to report suspicious shipments of opioid supplies into Kentucky. “While an agreement with the DEA currently prevents us from releasing a total number of doses sent to Kentucky,” Beshear said in the release, “I can tell you that number is egregious and large enough to potentially cause addiction in every man, woman and child in this state.”

The release said that in 2017, Mallinckrodt agreed to pay the federal government $35 million for violating federal reporting laws and entered into an accountability agreement with the DEA. Beshear’s lawsuit claims Mallinckrodt willfully violated Kentucky law by failing to report suspicious orders.

Thursday, July 12, 2018

'Stay cool, stay hydrated and stay informed' to avoid heat-related illnesses in summer, which CDC says kill over 600 a year

Summer is a time to head outdoors and enjoy the hot weather, but it's important to remember that those warm days we love so much can also be dangerous, especially for older people.

More than 600 people a year die from heat-related illnesses, and most of them are seniors, the federal Centers for Disease Control and Prevention reports.

The CDC says most of those deaths and heat-related illnesses are preventable if you "take measures to stay cool, remain hydrated and stay informed."

Heat-related illnesses happen when the body isn't able to properly cool itself, and can range from milder conditions (fainting, dizziness, heat rashes and cramps) to heat exhaustion. The most serious heat-related illness is heat stroke.

The CDC says one of the main things that affects a person's ability to cool down during hot weather is high humidity. When the humidity is high, sweat doesn't evaporate as quickly as it normally does, and it's the evaporation that keeps us cool.

Other factors that put a person at risk of heat-related illnesses are age, obesity, fever, dehydration, heart disease, mental illness, poor circulation, sunburn, and prescription drug and alcohol use.

Older adults, the very young, and people with mental illness and chronic diseases are at the highest risk, which are often groups that depend on others for their care.

The National Institutes of Health adds that seniors are particularly at risk for heat-related illnesses because they often have age-related changes their skin, such as poor blood circulation and inefficient sweat glands. In addition, seniors with heart, lung and kidney diseases are at increased risk, as are those with high blood pressure. NIH also notes that seniors who take diuretics, sedatives and tranquilizers, as well as multiple medications are at increased risk of getting a heat-related illnesses.

The CDC suggests checking on people in high-risk groups at least twice a day when it's hot outside, and to make sure you ask these four questions: Are they drinking enough water? Do they have access to air conditioning? Do they know how to keep cool? and Do they show any signs of heat stress?

The most common signs and symptoms of heat exhaustion are excessive sweating; cold, pale and clammy skin; a fast, but weak pulse; nausea or vomiting; muscle cramps; tiredness or weakness; dizziness, headache and fainting.

The signs and symptoms of heat stroke -- which requires immediate medical attention -- are high body temperature (103 degrees Fahrenheit or higher); hot red, dry or damp skin; a fast, strong pulse; headache, dizziness, nausea, confusion, and passing out.

The CDC offers tips for everyone to follow to avoid heat-related death or illness, as well as some just for seniors and those in those high risk groups.

Tips for everyone:
  • Stay in air-conditioned locations as much as possible
  • Limit outdoor activity, especially during midday when the sun is hottest
  • Pace activity, start slow and gradually pick up the pace
  • Drink more water than usual, and don't wait until you are thirsty to drink
  • Wear loose, lightweight, light-colored clothing
  • Take cool showers or baths to cool down
  • Wear and reapply sunscreen as needed
  • Check the local news for health and safety updates
Additional tips for those most at risk:
  • If you don't have air conditioning in your home, contact your local health department or locate an air-conditioned shelter in your area. Public facilities, like malls and libraries, are also available, as is the air-conditioning in vehicles.
  • Do not rely on a fan as your primary cooling device during an extreme heat event
  • If your doctor limits your fluids, or has you on water pills, ask them how much you should drink during hot weather.
  • Check on friends and neighbors, and have someone do the same for you
  • Don't use the stove or oven to cook, it only makes your house hotter.
  • Do not engage in very strenuous activities and get plenty of rest
It's also important to never leave children or pets in cars. As of July 3 in the U.S., 21 children had died of vehicular heatstroke this year, according to a KidsandCars.org.

Lexington restaurant gives people with addictions second chance

A Lexington restaurant was recently profiled in The New York Times for its efforts in giving people in treatment for drug and alcohol addiction a second chance.

DV8 Kitchen opened last September and not only hires people in treatment for an addiction, "but also focuses its entire business model on recovery, using the restaurant setting as a tool for rehabilitation," the Times' Priya Krishna reports.

Diane Perez and Rob Perez (Photo by
Pablo Alcala, Lexington Herald-Leader)
"The name is a play on the word “deviate” — a reference to the employees’ aim to detour from their pasts and rebuild their lives," Krishna writes. The restaurant is owned by Rob and Diane Perez, who also own Saul Good Restaurant & Pub.

The owners told the Times that over the course of 10 years in the restaurant business, they had lost 13 employees to addiction, and half of the cases were related to opioids. “They were not fired,” Mr. Perez told Krishna. “They were dead.”

Krishna writes that the restaurant culture is conducive to alcohol and drug use, with late nights, free shift drinks and tips paid in cash, "the common medium for drug transactions."

“There are more late nights than early mornings, and it’s acceptable to have a hangover,” said Rob Perez, a recovering alcoholic who told Krishna he had been sober since 1990. “You think all this is fun and normal, because everyone else has that lifestyle.”

In 2016, Kentucky had 1,419 drug-overdose deaths, about four per day. Lt. Jessica Bowman, a public information officer for the Lexington Fire Department, told Krishna that paramedics in Lexington have administered Narcan, the overdose-reversal drug, to at least one person every day since July 2016.

The Perezes told the Times that they hold their employees to "exacting standards" and that by hiring from and working directly with treatment centers, this adds an extra layer of accountability.

Janet Patton of the Lexington Herald-Leader writes, "The Perezes focus on training people on baking cinnamon rolls as well as on life skills such as living in recovery. To help employees make evening support meetings, DV8 Kitchen only serves breakfast and lunch most days, focusing on breads and rolls."

“We are not certified experts on this, nor do we claim to be,” Diane Perez told the Times. “We are just providing the piece of the puzzle that is giving people a job right away when they are getting clean.”

Fifth annual Viral Hepatitis Conference in Lexington July 31

Kentucky will hold its fifth annual viral hepatitis conference, "Kentucky's Hepatitis Epidemic: The Role of Professionals in Hepatitis Elimination" July 31 in Lexington, three days after World Hepatitis Day.

The meeting is hosted by the Kentucky Rural Health Association, the state Department for Public Health's Adult Viral Hepatitis Prevention Program and the Kentucky Immunization Program. It will run from 8 a.m. to 5 p.m. at the Griffin Gate Marriott Resort & Spa in Lexington and will offer continuing education credits for medical professionals. Space is limited; click here for more information and to register.

Kentucky leads the nation in the rate of new hepatitis C infections, with the highest rates occurring in the Appalachian region and Northern Kentucky, where injection drug use is most prevalent. Hepatitis C is often spread through the sharing of needles among intravenous drug users.

Laura Ungar of the Louisville Courier Journal reported in March that one in 56 Kentucky births in 2014-16 were to mothers with a history of hepatitis C, and that those births more than quadrupled between 2010 and 2016, from 260 to 1,057. The national rate in 2015 was one in 308.  Hepatitis C can be transmitted from mother to baby during childbirth. Kentucky passed a law this year that requires all pregnant women to be tested for the disease, with the results added to the child's records. It also recommends that the child be tested at 24 months if the mother tests positive.

Kentucky is also experiencing an outbreak of hepatitis A, reported by the state health commissioner as "the worst on record across the nation and in Kentucky." As of June 30, Kentucky has had 1,034  cases of hepatitis A since the outbreak began almost one year ago in August, 603 hospitalizations and seven deaths. Most of Kentucky's cases have been among the homeless and drug users.

Topics for the conference will include the national hepatitis action plan; hepatitis infections related to the growing opioid epidemic; Kentucky's opioid response efforts; best practices for screening, diagnosing and linking patients to care; innovative interventions to address hepatitis outbreaks; perinatal transmission of hepatitis; Medicaid and hepatitis treatment in Kentucky; and a session on mobilizing community action. The draft agenda and a biography of each speaker can be found on the registration website.

Wednesday, July 11, 2018

State fines Caremark, top pharmacy benefit manager, $1.5 million for violations including 'inaccurate and inconsistent' information

By Melissa Patrick
Kentucky Health News

The state Department of Insurance has issued a $1.5 million fine to a subsidiary of CVS Caremark -- a pharmacy benefit manager for all but one of the Medicaid management companies in Kentucky -- for hundreds of reimbursement violations involving individual pharmacies, and for giving the department "inaccurate or inconsistent" information. The department put Caremark PCS Health on probation for one year.

Pharmacy benefit managers are middlemen between insurance and drug companies. They not only determine what drugs are offered, but how much an individual pays for the drug and how much pharmacists are paid for them.

The "order of civil penalty and probation" cited 454 violations regarding denials of reimbursement claims and 38 violations where Caremark provided "inaccurate or inconsistent information," the department said in a news release.

“The Department simply does not issue penalties of this nature lightly,” Patrick D. O’Connor II, deputy commissioner for policy, said in the release. “However, we have to ensure companies fully comply with our laws to protect consumers and other businesses.”

Rosemary Smith, a co-owner of Jordan Drug pharmacies in Eastern Kentucky and founding member of the Kentucky Independent Pharmacist Alliance, said the department's order was a "vindication of what we've been saying all along," and that she was pleased that state agencies are "now seeing what we've been seeing for a number of years." But she also said the issue hasn't been resolved because independent pharmacists are still being under-payed for their drugs.

"We still are having the same issues now, so we are going to be sending more of those [complaints] to the Department of Insurance," she said.

A spokeswoman for CVS Caremark, the parent firm of the pharmacy benefit manager, said it disagrees with the order and is "exploring our options."

"We are currently reviewing the terms of the Kentucky Department of Insurance’s order," Christine Cramer said in an e-mail. "However, we respectfully disagree that we have not complied with applicable requirements. . . . It should also be noted that states such as Kentucky currently have the necessary tools to ensure that there is appropriate oversight of pharmacy benefit managers’ compliance with applicable laws and regulations."

Cramer added, "CVS Caremark is committed to fairly reimbursing the pharmacies in our network while providing a cost-effective benefit for our PBM clients. For example, we reimburse independent pharmacies at a higher rate on average than we reimburse chain pharmacies, including CVS Pharmacy," a sister company that is a major drugstore chain. Cramer is senior director of corporate communications for CVS Health, the overall company.

Kentucky passed a law in 2016 that allows the Insurance Department to regulate PBMs much like insurance companies are regulated, and to provide an appeal mechanism to resolve pricing disputes between pharmacies and PBMs. The news release says this law allowed the state to investigate the many complaints filed by pharmacists and issue the order.

Sen. Max Wise, R-Campbellsville, who sponsored the bill, called the order a "huge win" for the more than 500 independent pharmacists who have been "telling and pleading their story for years now" that PBMs weren't paying them fairly for their prescriptions. He said he thought the probation period would prompt the managed-care companies to "start looking at other PBMs to work with."

This year, Wise won passage of Senate Bill 5, which put the state Department of Medicaid Services in charge of setting pharmacists' reimbursement rates, rather than the managed-care companies. It also allows the department to regulate contracts between the companies, PBMs and pharmacists; requires more transparency in how the PBMs spend the $1.7 billion a year they get for processing prescriptions; and gives the state authority to penalize the companies and PBMs for noncompliance.

"Senate Bill 5 is what will be the whammy that will end up doing even more damage to the PBMs," Wise said. "I think this is just the scratch of the surface. I think we're going to find more and when it comes to that, I think that truly the taxpayers are going to see the amount of profits that were reaped off of this that should have been going out to those independent pharmacists for a number of years."

Tuesday, July 10, 2018

Analysis finds nursing homes under-reported their staffing levels; 18 in Kentucky listed as 'much below average' on interactive map

New York Times map; click on the image to enlarge it. See the interactive version here.
"Most nursing homes had fewer nurses and caretaking staff than they had reported to the government for years, according to new federal data, bolstering the long-held suspicions of many families that staffing levels were often inadequate," Jordan Rau reports for The New York Times. The data show 18 Kentucky nursing homes with staff ratings "much below average."

The daily payroll records, gathered by the Centers for Medicare and Medicaid Services and analyzed by Kaiser Health News, show for the first time "frequent and significant fluctuations in day-to-day staffing, with particularly large shortfalls on weekends. On the worst staffed days at an average facility, the new data show, on-duty personnel cared for nearly twice as many residents as they did when the staffing roster was fullest," Rau reports.

But nursing homes often exaggerated staffing levels and rarely revealed these common periods of low staffing. The Times created an interactive, searchable nationwide map of more than 14,000 nursing homes and how their staffing levels stack up. To look up any nursing home's staffing data, go to https://www.nytimes.com/interactive/2018/07/07/health/nursing-home-map.html. Here's a list of Kentucky nursing homes that show up in dark red on the map, meaning their staffing rating is "much below average," by county in alphabetical order:
  • Florence Park Care Center in Boone County
  • Providence Gallatin in Gallatin County
  • Landmark of Lancaster Rehabilitation and Nursing Center in Garrard County
  • Kindred Hospital-Louisville in Jefferson County
  • Landmark of Louisville Rehabilitation and Nursing in Jefferson County
  • Oaklawn Health and Rehabilitation Center in Jefferson County
  • Regency Center in Jefferson County
  • Westport Care Center in Jefferson County
  • The Pavilion at Kenton in Kenton County
  • Vanceburg Rehabilitation and Care in Lewis County
  • Salyersville Nursing and Rehabilitation Center in Magoffin County
  • Calvert City Convalescent Center in Marshall County
  • Signature Healthcare at Colonial Rehabilitation and Wellness in Nelson County
  • Beaver Dam Nursing and Rehabilitation Center in Ohio County
  • Friendship Health and Rehabilitation in Oldham County
  • Providence Richwood in Oldham County
  • Bowling Green Nursing and Rehabilitation Center in Warren County
  • Corbin Health and Rehabilitation Center in Whitley County

Monday, July 9, 2018

Resurrecting old model for individual health-insurance market may limit who gets covered and how well, columnist says

Editor's note: U.S. Sen. Rand Paul of Kentucky has been one of the leading advocates of association health plans.

By Trudy Lieberman, Rural Health News Service

A new health insurance option awaits consumers this fall. Proponents say it will offer lower premiums and relief from increasingly expensive Obamacare policies sold in the so-called individual market. That’s where people who don’t have employer or government-sponsored insurance go when they need coverage.

It’s no secret that rising premiums have hurt people in that market if they are among those whom the law considers too wealthy for subsidies to help them out. For example, families of four with incomes above $100,400, and single people whose incomes exceed $48,560.

So the Trump administration has approved the return of association health plans, called AHPs for short. Fraternal or professional organizations can sponsor one. A single proprietor or sole owner of a business can also set up one of these new arrangements.

These “new” arrangements are not new. They were around for years before the Affordable Care Act was passed in 2010, and they’ve been resurrected to provide a low-cost option for a small slice of the insurance marketplace. Labor Secretary Alexander Acosta offers this rationale: “Many of our laws, particularly Obamacare, make health care more expensive for small businesses than large companies. AHPs are about more choice, more access and more coverage.”

Once again the individual market may become the Wild, Wild West of insurance, as sellers pick and choose what benefits to offer. They can present a shopping nightmare for consumers who try to slog through the market and understand what they’re buying. Many of the protections offered by the ACA are gone, and shoppers are on their own to sort through the fine print that may or may not disclose what they are buying.

For example, the Affordable Care Act outlawed the practice of considering a person’s pre-existing health conditions before issuing a policy, one of the most important protections it provided. Under the government’s rules for AHPs, a person’s health still cannot be factored into the decision to issue a policy. But insurers may find a way around this limitation, says Sabrina Corlette, a research professor at Georgetown University’s Center for Health Insurance Reforms. “The way benefits are designed can make a policy very unattractive to certain groups of sick people,” she told me.

For example, if an insurance group doesn’t want to cover a lot of people with HIV/AIDS, it could create a network that includes almost no doctors who treat people with that condition.

AHPs must still cover the ACA’s preventive services, such as mammograms and diabetes screening. But other ACA protections are gone. Fewer benefits, and less comprehensive benefits, are the trade-offs for cheaper policies. “AHPs will have more flexibility in how they vary premiums and what benefits are covered,” says Cori Uccello, senior health fellow at the American Academy of Actuaries.

Here’s where the shopping task gets tricky. AHPs won’t be required to cover any of the ACA’s package of essential benefits: things like mental health, maternity, and prescription drugs. It’s also possible their benefits could come with limitations on hospital stays and doctor visits. Comparing policies with these different combinations of benefits will take some effort.

There are other changes, too, that would-be shoppers should be aware of. The “flexibility” touted by the labor secretary means that AHPs will now be able to use gender in deciding how much to charge. Women could be forced to pay more than men because insurers say that, especially at younger ages, women have more claims.

On the Health Affairs blog, Katie Keith of Keith Health Policy Solutions showed what could happen when gender is factored into pricing. Keith pointed to a Blue Cross Blue Shield comment letter that suggested AHPs could charge young men more than 40 percent less than traditional insurers could, while charging young women 30 percent more, or higher.

Occupations could also matter. The AHPs could charge engineers 9 percent less than traditional insurers but charge taxi drivers 15 percent more. Engineers apparently file fewer claims than taxi drivers.

That may be the biggest change, that AHPs will be able to consider people’s jobs in the decision to insure them. The ACA had outlawed the practice of occupational underwriting, which had meant that waiters, musicians, models, beauty operators, fry cooks, even doctors and lawyers sometimes couldn’t obtain insurance because insurance stats showed people in those occupations filed more claims. Will people in those occupations be turned down now?

Association health plans might look like a panacea for the country’s health-care woes. But questionable practices are likely to resurface, and it’s not clear state insurance departments, which had a tough time keeping tabs on fraud and abuse years ago, are up to the job of policing them.

AHPs may well throw the individual market into a big mess without addressing the fundamental problem they purport to solve: the underlying high price of American medical care.

What would you choose: lower premiums or skimpier benefits? Write to Trudy at trudy.lieberman@gmail.com.

Sunday, July 8, 2018

Perseverance is often needed to set up syringe exchanges, since local politicians have the say-so, and it's a local election year

It took two years, but Campbell and Kenton counties will finally launch their syringe exchange programs the week of July 23.

The new mobile exchanges will be run by the Northern Kentucky Health Department at locations of St. Elizabeth Healthcare. The Newport location will begin July 24 and the Covington location will start July 26, reports The River City News.

It took perseverance for the counties to establish the exchanges, overcoming social and political obstacles, like many other Kentucky counties that are still trying to create their own exchanges.

Campbell County approved an exchange in 2016, but state law requires approval from the city in which the exchange will operate, as well as the board of health and the county government, and Newport did not approve the exchange until February of this year.

Newport's decision came after a cluster of HIV cases were identified in the region, as well as a high number of hepatitis C cases. From Jan. 1, 2017, to March 16 of this year, the NKHD had diagnosed 45 cases of HIV, 21 of them intravenous drug users. From 2009 to 2016, zero to five such cases were reported each year, department spokeswoman Emily Gresham-Wherle told Terry DeMio of the Cincinnati Enquirer. The region also has a high rate of hepatitis C infections, typically carried by sharing of needles.

Kenton County and Covington had also approved a syringe exchange in 2016, but with a requirement that it could not start until two other Northern Kentucky counties in the NKHD district had operational exchanges. Campbell County's exchange allows the Kenton County program to go forward; NKHD has operated one in Grant County for three years.

The new mobile units will provide clean needles, Naloxone overdose-reversal kits, offer HIV tests, and provide referrals for other health services, including addiction treatment. What they won't do is provide condoms -- which are also known to fight infectious diseases and commonly distributed in these programs -- because the mobile exchanges will be located on the grounds of Catholic hospitals, DeMio reports.

Nevertheless, it appears that health officials in the area are grateful to St. Elizabeth for providing a site for the exchanges. Hospital spokesman Guy Karrick told DeMio that while the hospital couldn't countenance the distribution of contraceptives, it wanted to get the exchange going as quickly as possible. He added that the exchange might be better situated on health department property.
Despite the many challenges that face largely rural, conservative Kentucky counties to support opening these programs, Kentucky leads the nation in the number of counties with local syringe exchange programs (perhaps in part because it ranks third in the number of counties). As of June, 47 45 of Kentucky's 120 counties have approved syringe-exchange programs at more than 50 sites.

However, the federal Centers for Disease Control and Prevention says 54 Kentucky counties are among 220 in the nation with the highest risk of an HIV or hepatitis C outbreak among IV drug users, and half of those 54 counties still haven't approved exchanges.

One of the 27 high-risk holdouts, Clinton County, narrowly approved an exchange in March but backed out eight days later after complaints that it would encourage drug use. In the Republican primary election in May, the Fiscal Court magistrate most vocally opposed to the exchange defeated the county judge-executive, who favored it. The CDC says the county has the 11th greatest risk of any county in the nation for an HIV or hep-C outbreak among drug users.

Lawrence County, ranked 39th on the list, has also struggled with the issue. The county health board approved the proposal in September 2016, and the Louisa City Council followed suit in July 2017, the Fiscal Court unanimously rejected the proposal in March, WYMT-TV reported.

County Judge-Executive John Osborne told a packed house at the meeting that while he worries about HIV and hepatitis C, he worries about needles more, WYMT reported. "If you give out 40 needles at a time, you're probably are going to see a lot more needles on the ground," Osborne said. “It does bring a lot of people not from this area and that could cause a lot more problems.”

Public Health Director Debbie Miller told WYMT that she was disappointed but not surprised with the result. “I feel like the Fiscal Court is telling us that they’re not concerned with the fact that Lawrence County has been deemed one of the most vulnerable counties in the U.S. for an HIV or hepatitis C outbreak," she said. "The bottom line is, no matter how uncomfortable these syringe exchange programs make us all feel, and they do all make us somewhat uncomfortable, they are proven to save lives."

On the other hand, five Eastern Kentucky counties on the CDC list have started syringe exchanges in the last few months.

Perry, Letcher and Wolfe counties added exchanges in April "thanks to the expanded initiative by the Kentucky River District Heath Department," Will Puckett reported for WYMT in April. That came a few months after after Lee and Owsley counties approved theirs.

Scott Lockard, the department's public health director, told Puckett that the price of bringing in used needles and exchanging them for clean ones is small compared to the cost of treating diseases: $80,000 for a case of hepatitis C, "and the cost for someone who contracts HIV can cost over half a million dollars."

Getting county officials to accept a syringe exchange program often depends on public education and perseverance, as evidence by another county that took two and one half years to get its exchange.

In March, Mary Meehan reported for Ohio Valley ReSource that it took Bourbon County two and a half years, and two failed votes, to get an exchange. It finally passed on a 6-2 Fiscal Court vote, and opened its doors in May.

Bourbon County is not on the CDC list, but the concerns there reflect those voiced across the state. People worry that the drug users will just take the needles and sell them; some say drug users are just looking for a handout; others say it is enabling their misbehavior, and others worry that it will draw addicts from surrounding counties that don't have exchanges.

Research shows that syringe-exchange programs do not encourage the initiation of drug use, nor do they increase crime or the frequency of drug use among current users. They do reduce the spread of infectious diseases like HIV and hepatitis C; increase community safety; and connect people to treatment, according to the state Cabinet for Health and Family Services.

Meehan writes, "The health facts run up against deeply help opinions about the moral aspects of drug use and the notion that a needle exchange enables drug addicts to continue harmful behavior." She reported that Bourbon County Judge-Executive Mike Williams encouraged other community leaders to persevere. "It took us three times," he said. "Don't give up, and keep presenting the facts."

The State Journal in Frankfort recently said in an editorial that syringe exchanges are part of a holistic approach to fight the opioid epidemic, noting that the Franklin County's exchange had provided more than 115,000 clean syringes to users, and collected more than 82,000 used ones.

The newspaper said there are still many in Franklin County who object to the exchange, but "We’d ask whether it’s better for a user to share needles and potentially infect others or be infected or to use clean needles and reduce or eliminate the chance of infection."