Monday, September 24, 2018

McCreary and Wayne counties win Health Policy Champion award from Foundation for a Healthy Ky. for being 'bright spots'

Foundation for a Healthy Kentucky CEO Ben Chandler announced the award as nominees listened.
By Al Cross
Kentucky Health News

Wayne and McCreary counties won the first overall Health Policy Champion award presented by the Foundation for a Healthy Kentucky, for being "bright spots" of progress on health issues in Appalachian Kentucky.

"We have a tie," Foundation President and CEO Ben Chandler said as he announced the award at the foundation's annual Howard L. Bost Memorial Health Policy Forum in Lexington on Monday.

The adjoining counties on the Tennessee border were two of eight nominees for the award, which spotlights "those folks who are advocating the policy changes that will make Kentucky healthier," Chandler said. The $5,000 award was divided equally between the McCreary County Health Coalition and the Wayne County Health Council.

"They show us there' s always somewhere to start when it comes to working to improve health," Chandler said.

The two counties were among nine in Kentucky and 42 in Appalachia that the Appalachian Regional Commission and the Robert Wood Johnson Foundation named "bright spots" because they had better than expected health outcomes given their resources and health indicators.

McCreary and Wayne were among 10 counties in a case study that took a deeper dive into what they were doing to improve the health of their citizens, despite their many challenges.

The Lake Cumberland district, with Wayne and
McCreary outlined. Taylor is not in Appalachia.
The other "bright spots" in Kentucky were Green, Adair, Russell, Wayne, McCreary, Pulaski and Lincoln counties, like McCreary and Wayne part of the Lake Cumberland District Health Department, and Lewis and Morgan counties.

The other Health Policy Champion award nominees were Dr. Van Breeding of Whitesburg, for fighting substance abuse; and Murray Mayor Jack Rose, Paducah cardiologist Pat Withrow, Paducah Mayor Brandi Harless, the Casey County Youth Coalition and, jointly, Lexington Mayor Jim Gray and Lexington Legends owner Andy Shea, all for efforts against tobacco use.

Sunday, September 23, 2018

Appalachian health researchers discuss work, with three sessions on drugs, and are urged to engage more closely with communities

By Melissa Patrick
Kentucky Health News

A big step toward improving health in Appalachia would be closer relationships between residents of the region and researchers -- who often drop in, gather data and leave.

That's what researchers were told last week as they gathered in Lexington to talk about their work in Appalachia, ranging from opioid disposal programs to air and water quality.
Joyce Bells-Berry of the Mayo Clinic, keynote at the
Appalachian Translational Research Network Summit

Joyce Bells-Berry of the Mayo Clinic said at the eighth annual Appalachian Translational Research Network Summit that it was time for Appalachian researchers to stop "helicopter" research and truly engage with communities in the region.

"Community engagement allows us to get to the why so that we can answer our research questions in a way that is pivotal for changing the lives of those around us, in a way that builds partnerships and mutual respect, while taking into consideration the needs of those around us, not just our needs as the academics," said Bells-Berry, a professor of epidemiology.

Scott Lockard, director of the Kentucky River Health Department, who is collaborating on a syringe-exchange project with the University of Kentucky, said he agreed.

"We don't like helicopter researchers," said Lockard, a native of Wolfe County. "We've been studied enough."

Lockard said Appalachian Kentucky is "ripe for collaboration" with researchers who will come to the region to work with residents and help communities find their own solutions to health issues, and be prepared to answer this question: "At the end of the day, does our research improve the lives of everyday Kentuckians?"

And, for that matter, all Appalachians. The Appalachian Translational Research Network is nine institutions in the major Appalachian states (Kentucky, Ohio, Pennsylvania, North Carolina and Tennessee) that collaborate to strengthen research and training efforts in the region. Its stated mission is to "catalyze translational research among partnering institutions serving Appalachian communities to synergistically improve the health of these communities."

Drug disposal programs questioned

One of the many presentations at the summit, held Sept. 20-21, involved researchers from UK and Wake Forest University who are working on finding ways to improve prescription-drug disposal programs in Appalachia. These programs include drop boxes, organized take-back events and drug-deactivation products that can be used at home.

Mark Wolfson, co-director of Wake Forest's Center for Research on Substance Abuse and Addiction, told the group that "best estimates" show that only 30 percent of all medications with abuse potential are used as prescribed, leaving 70 percent either unused or inappropriately used.

Kentucky has embraced organized drug-disposal programs as part of its strategy to curb the opioid epidemic. The state Office of Drug Control Policy says Kentucky has 198 drop boxes in 116 counties, with sites being added daily; many locations participate in twice-yearly national take-back days for prescription drugs, with the next one on Oct. 27.

A new state law requires pharmacists to tell customers how to safely dispose of controlled substances, and either provide or offer to sell them a product designed to neutralize drugs for disposal -- or provide on-site disposal. Kentucky is participating in a pilot program to provide drug deactivation pouches in Floyd, Henderson, McCracken and Perry counties.

But research indicates that the program is not effective. Wolfson said a study by East Carolina University, using Kentucky data, found that less than 1 percent of controlled medications that were unused were being collected in drop boxes.

Donald Helme, professor in the UK College of Communication and Information, is working with Wolfson. He has found through focus groups, moderated discussions of a few people, that hardly anyone knows about the drop boxes -- and even if they do, there is great skepticism about handing over drugs to government agencies, which house most of the drop boxes. 

"One of the main things that came up" in the focus groups, Helme said, is "Do not use law enforcement, do not use EMS, do not use the fire department to promote this, because they don't trust them."

Helme and Wolfson will design and test a drug-disposal messaging campaign for the five counties in the study, in hopes of justifying a bigger campaign in the future. It is being conducted in conjunction with health departments in Bell, Whitley and Floyd counties in Kentucky and Burke and Wilkes counties in North Carolina.

Environmental health issues explored

Along the theme of community-engaged research, Ellen Hahn, deputy director and community-engagement core leader at UK's Center for Appalachian Research in Environmental Sciences, or UK-CARES, talked about her efforts to "match-make" researchers who are working on air and water quality issues with Appalachian communities.

Hahn, a nursing professor and director of BREATHE (Bridging Research Efforts and Advocacy Toward Healthy Environments), said part of their efforts involve citizen science projects. As an example, she pointed to an air-quality project conducted by students and teachers at Perry County Central High School and UK, described in a video:



Keeping pre-diabetes from becoming diabetes

Dr. James Keck, assistant professor in UK's Department of Family & Community Medicine, talked about his research around increasing access to the Diabetes Prevention Program, an evidence-based lifestyle program that helps people with pre-diabetes to keep the disease from progressing.

Keck said that like the rest of the nation, about one in three Kentuckians have pre-diabetes, a condition that increases the likelihood that a person will eventually be diagnosed with diabetes without preventive intervention.

He said the one-year prevention program has been hamstrung by a general lack of knowledge about it by both patients and clinicians, as well as its cost, which runs about $700 a year. But he added that more and more insurance plans, including UK health insurance and Medicare, now pay for it.

Recognizing the challenges of bringing such a program to rural Kentucky, Keck said his next project will be to to determine if a free, six-week diabetes program offered by Kentucky Homeplace community health workers is as effective as his year-long program.

Studying syringe exchanges

Hilary Surratt, associate professor at UK's College of Medicine, is researching syringe-exchange programs in Appalachian Kentucky.

In collaboration with the Clark, Knox and Pike county health departments, Surratt's research includes  injection-drug users who use the exchanges as well as those who don't. It will also include interviews with community stakeholders, who are both for and against the exchanges. The goal of the research is to understand the many barriers to access and to identify strategies to increase uptake.

Surratt found that among 175 exchange participants, 46 percent said their primary drug of injection was crystal methamphetamine; 27 percent said buprenorphine ( a drug typically used to combat drug addiction), and 17 percent said heroin.

Of particular concern was that more than one in three said they had shared needles and syringes with other injection-drug users in the past three months. And the average number of times they said they had injected in the past month was 80, while the median number of syringes they reported getting was only 50.

One of the main purposes of a syringe-exchange program is to prevent the spread of HIV and hepatitis C, which are commonly spread by the sharing of needles among injection-drug users.

Surratt also found that nearly 40 percent of the exchange participants said they had a personal history of overdose, but only 14 percent said they had access to Narcan, an anti-overdose drug.

She showed a map with the ZIP codes of the interviewees, representing 10 counties, illustrating the great distances drug users must travel to get clean needles.

"When I see something like this, it says to me that we need to think of innovative kinds of solutions to keep engaging people," she said. "Because we know over time that distance is a barrier to consistent use of these programs."

Members of the Appalachian Translational Research Network are UK, Wake Forest, East Tennessee State University, The Pennsylvania State University, The Ohio State University, Ohio University, the University of Cincinnati and Marshall University in Huntington, W.Va.

Saturday, September 22, 2018

65 kids a day are abused or neglected in Ky., third in nation; officials urge safe sleep practices, care about who provides care

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – When it comes to keeping babies safe, three of the most important things are safe sleep practices, recognizing that bruising in non-mobile infants is not normal, and choosing an appropriate caregiver.

So said members of the state's Child Fatality and Near Fatality External Review Panel, who told legislators at the Sept. 19 joint health committee meeting that three-fourths of cases they reviewed in 2017 were "potentially preventable."

They lawmakers also heard the executive director of Prevent Child Abuse Kentucky say the state ranked No. 3 for "child maltreatment" in 2016. Jill Seyfred added that 23,827 Kentucky children were confirmed victims of child abuse or neglect in 2017, about 65 a day.

The ABCs – and D – of safe sleep

Dr. Jaime Pittenger, a review-panel member and the president of Prevent Child Abuse Kentucky, told the committee that 39 percent of the deaths the panel reviewed in 2017 involved sudden unexpected deaths in infancy, or SUDI, a broad term that covers both sudden infant death syndrome and other fatal sleeping accidents. That number is "on the rise this year," she warned.

Pittenger, who heads the pediatric residency program at the University of Kentucky, stressed the importance of following the ABC's of safe sleep to prevent injury or infant deaths – Alone, on their Back, and in a Clean, Clear Crib.
Safe Sleep Kentucky website graphic; for a larger version, click on it
And because so many of the fatalities or near-fatalities are connected to substance abuse, Kentucky has added a D to that list to point out the Danger of sharing a bed with a child, especially when under the influence of alcohol or other drugs.

Almost two-thirds of last year's SUDI cases in Kentucky involved an impaired caregiver who slept with their baby and the baby died from suffocation or asphyxiation, the review panel found.

Pittenger pointed out that many Kentucky infants don't have a safe place to sleep: "We can make it sound like everybody has a bassinet, a crib, but they don't."

Rep. Joni Jenkins, D-Louisville, suggested that the state look into providing children who don't have a crib with a "baby box" with instructions on safe sleep, as some other states and countries do.

"Some years ago we decided that every child that left the hospital ought to have the appropriate car seat," Jenkins said. "It seems to me that a logical [solution] is that every child that leaves the hospital after birth should have an appropriate place to sleep as well."

CDC photo
"Those who don't cruise, don't bruise": Pittenger offered this rhyme as a way to remember that bruising in infants not old enough to be mobile "is not normal." She was quick to point out that bruising doesn't always mean abuse, but "should raise a red flag to make you ask questions."

Paula Sherlock, a retired Family Court judge, stressed the importance of reporting bruising in non-mobile infants: "We don't want to think that our kids are abusing our grandkids, so we believe things that we shouldn't believe."

"Don't leave your child with someone you wouldn't leave a puppy with": This was Sherlock's advice for choosing a caregiver. She added, "People who have violent tempers, who have histories of domestic violence, should not be left in a care-giving role with children who can't defend themselves or tell anybody what happened," she said. "The vast majority of the kids we see are under the age of 4 and a huge portion of them are under the age of 2."

Happiest Baby blog photo
Sherlock said 41 percent of Kentucky children determined to have abusive head trauma in 2017 were left with a caregiver to whom they were not related. "Typical of that is the boyfriend who is watching the baby while mom goes to work," she said. "Mom has no affordable daycare, she has no good support system and so a completely inappropriate person is left with the child, who is not his child. We see a really startling number of these cases."

Abusive head trauma is also called "shaken baby syndrome." It can be caused by a direct blow to the head, dropping or throwing a child, or shaking a child resulting in an injury to the child's brain.

Seyfred said the top risk for these children are substance abuse and family violence. "Substance abuse was documented as a risk factor in 65 percent of the reports, with family violence as a risk factor in 42 percent," she said.

There are other dangers. Pittenger said people who have a history of crime or mental illness have also been connected to the majority of these abused and neglected children. The panel report found that 85 percent of the 2017 cases reviewed had a prior history with child protective services.

What's Kentucky doing to protect its children?

Sherlock and others stressed the importance of the review panel, which she said works to identify gaps in the system and to find ways to fix them.

She also stressed the need to get quick, efficient, affordable and non-punitive help for Kentucky parents who are suffering from addiction.

"These parents need help," she said. "These kids are very vulnerable and if they are being born to drug-addicted parents and then going home to be cared for by these parents, that is a recipe for disaster." Sherlock said, "My experience in court: drug addicted parents did not by and large beat their children to death . . . but the neglect is so gross and so widespread that these children are not fed, they are not supervised."

Rep. Kim Moser, R-Taylor Mill, and Sen. Reginald Thomas, D-Lexington, praised the HANDS program as a tool to help at-risk families learn how to better care for children. HANDS, for Health Access Nurturing Development Services, is a home-visitation program for new and expectant parents that works toward healthy pregnancies and births, healthy child growth and development, safe homes and self-sufficient families.

Thomas said he thought every parent would benefit from this program, but especially those at high risk. "The reality is that children don't come with a how-to manual," he said.

Moser also praised the START program, which integrates addiction services and other wrap-around services to families with at least one child under 6 years of age who is in the child-welfare system and has a parent with a substance-use disorder that puts that child at risk. START stands for Sobriety Treatment and Recovery Team. Moser said she would love to see both of these programs expanded.

Seyfred told the panel that Prevent Child Abuse Kentucky had recently partnered with WellCare and the Kentucky Hospital Association to create a video focusing on safe sleep, abusive head trauma, and choosing an appropriate caregiver to show new parents before they leave the hospital.

Pittenger spoke to the importance of this education: "One of the saddest stories I ever heard was a dad who just didn't understand that shaking would hurt his child. He never knew, he never thought that what he was doing when he lost his temper would hurt the child. Some people just don't know."

Kentucky has also passed laws to require caregivers and professionals who serve children to receive training on pediatric abusive head trauma.

Sen. David Givens, R-Greensburg, charged everyone at the meeting to tell at least one person with a newborn or who is pregnant about what they had learned about the importance of safe-sleep practices and quality caregivers.

"We could save one child's life just through that conversation," he said. "So let's do that. Let's all leave here today charged in the course of the next two weeks to have that conversation with at least one person. We may make a difference."

To report suspected child abuse in Kentucky, call 877-KYSAFE1 (597-2331) or online at https://prd.chfs.ky.gov/ReportAbuse/OutofHours.aspx. The national abuse hotline can be reached at 1-800-422-4453.

Lexington has 100+ restaurants on probation for health violations; hepatitis A raises concern, but no cases have been related to food


Amid a nearly statewide outbreak of hepatitis A, the Lexington-Fayette County Health Department is monitoring more than 100 restaurants that it has placed on probation for violation of public-health standards, Janet Patton reports for the Lexington Herald-Leader.

"Spoiled food. Soiled equipment. Dirty floors, dirty walls. Live roaches and flies inside kitchens. Dead ducks hanging outside. Lexington’s restaurant inspectors have seen it all," Patton writes. "Since 2015, they’ve compiled a list of restaurants and other food service providers to target for heightened scrutiny."

The cleanliness of restaurants has taken on fresh importance since the hepatitis A outbreak started in about a year ago. The Lexington health department recently recommended that everyone in Fayette County be vaccinated against the liver disease because some food service workers had tested positive for the virus. No Kentucky cases of the disease have been attributed to food service.

A restaurant goes on probation if it has an inspection score below 85 or a critical violation that can’t be corrected immediately, including "employee hygiene practices such as a lack of hand washing, cold food being too hot or hot food being too cold, dishwashers not sanitizing properly, or evidence of rodents or insects," Patton reports. The most common violation is incompletely cleaned dishes and utensils, "either because the dishwasher isn’t dispensing sanitizer or the water isn’t hot enough to kill germs."

Kitchens at two Lexington hospitals are on probation. The one that serves patients and the cafeteria at UK Good Samaritan Hospital, went on probation when a May inspection "found live flies throughout the kitchen, and dirty walls, ceiling and equipment," Patton reports. UK spokeswoman Kristi Willett said the kitchen scored 98 in a follow-up inspection May 30. She said the hospital "has passed all other health department inspections in the past five years with a score of 98 or above.”

The cafeteria at St. Joseph Hospital "has been on probation since June, when an inspection found live roaches in the kitchen in the reach-in cooler, as well as unclean floors, walls, soda and juice dispensers," Patton writes. Kentucky One Health spokeswoman Mary Branham said the inspection was “not reflective of the scores our food service typically receives,” and the follow-up score was 99.

Patton reports that several "high profile" restaurant operators said the label "probation" is misleading. “People don’t understand … that upon reinspection the score was good,” said Rob Ramsey, who operates several restaurants with his family name in Lexington. “As far as I’m aware of we’ve never had a food-safety hazard that has been passed to the public.”

Deal to sell Jewish Hospital may be falling apart, raising the possibility that it might be closed, with big ramifications

KentuckyOne Health photo
The future of Louisville's Jewish Hospital is in doubt. Its owner, KentuckyOne Health, "continues to lose money after months of negotiating to sell it and other local facilities to a hedge fund, according to a doctor who has written about the local health care industry."

So reports the Louisville Courier Journal, which interviewed Dr. Peter Hasselbacher, a retired University of Louisville medical professor. "I would not be surprised for Jewish Hospital to close its doors within a matter of months," he said. "I wish the best for them, but I think the odds are stacked against them."

"Hasselbacher's concerns are shared by five other doctors and five current KentuckyOne staff members in a variety of roles, as well as a former administrator with knowledge of the negotiations," the CJ's Grace Schneider and Morgan Watkins report. "They shared information with the Courier Journal on the condition of anonymity because they aren't authorized to discuss the matter and due to their employment with or other professional ties to KentuckyOne and the university," which has an organ-transplant program at Jewish.

The CJ's sources and Hasselbacher doubt that KentuckyOne will be able to sell Jewish to BlueMountain Capital Management, a New York hedge fund that has formed a hospital-management firm with a Los Angeles billionaire. Its first acquisition, of "a failing non-profit Catholic hospital chain in California, has failed – the hospital system has filed for bankruptcy," Hasselbacher reported on his Kentucky Health Policy Institute blog on Sept. 5. He said that is "casting a very dark curtain over this potential transaction in Louisville."

The deal was expected to include Jewish's several satellites, including one in Shelbyville, and their doctors' practices; Sts. Mary & Elizabeth Hospital in southwest Louisville; and Saint Joseph Martin, a small hospital in Eastern Kentucky's Floyd County. But St. Joseph was sold to Appalachian Regional Health in June, and "Our Lady of Peace Hospital, a profitable psychiatric hospital that KentuckyOne initially intended to keep, is now part of what's on the block with BlueMountain," the newspaper reports. "But the hedge fund now wants Jewish out of the bundle, according to the longtime doctor with ties to Jewish and U of L and a local health care executive."

The CJ notes, "KentuckyOne and BlueMountain announced in December that they were entering negotiations, but have set new deadlines for closing the transaction." KentuckyOne interim president and CEO Chuck Neumann said through a spokesman that "a complex due diligence and transaction process" has delayed the deal. A BlueMountain spokesman said negotiations are continuing.

"Neumann told employees Friday that executives have no plans to close Jewish, but added that they're making contingency plans in case they can't reach an agreement," the CJ reports. University President Neeli Bendapudi told the newspaper, "We really are trying to be prepared for everything." Jewish has 462 beds, so its closure would have serious ramifications..

"The remaining downtown hospitals (University Hospital and Norton Heathcare) will be swamped if not overwhelmed," Hasselbacher wrote. "Sharing with the outlying hospitals is not likely sufficient to take up much if any of the load. University Hospital is already full. Without a landing pad for transplant, rehab, cardiology, and other specialty services historically housed at Jewish, the University will lose access to those teaching services."

KentuckyOne's Denver parent, Catholic Health Initiatives, is heavily in debt. It said 16 months ago that it would sell its Louisville properties, "in a bid to shed facilities that were losing money," the CJ notes. "KentuckyOne and BlueMountain's announcement of negotiations in December allayed fears that the health system couldn't find a buyer. But several signs point to trouble for Jewish, which needs more than $200 million in upgrades. Worse, it's received D ratings in recent years from a nonprofit health care watchdog that evaluates patient safety."

UPDATE, Sept. 24: Insider Louisville reports, "Jewish Hospital for years has been losing money and until recently had been propped up financially by the profitable University Hospital, which KentuckyOne managed. However, the University Hospital’s management — and profit — have reverted to the University of Louisville, leaving Jewish in a more precarious financial situation and its owner with greater incentives to sell it."

Friday, September 21, 2018

Addict who writes column for Appalachian papers publishes book

Phillip Lee, a recovering drug addict who writes a column for newspapers in Appalachian Kentucky and Tennessee, has published a book, The Journey of an Addict.

"Through overdoses and many hospitalizations, through nursing homes and rehabilitation centers, through drug treatment programs and prisons, I survived through it all only by the grace of my higher power," Lee writes on Amazon. "This book is part of a complete dedication in my life to helping others reach recovery. Not being easy at all, I tell how it's the hardest thing I've ever done in life. I tell you about the personal rewards of recovery. The freedom and calm that is gained is second best to nothing. Looking back on some of the insane and dangerous situations, I can even laugh at some of the stories now."

Lee began writing a column for the weekly Clinton County News in his hometown of Albany in May 2017. For a while it bore the name of the book as well as the title "An Addict's Corner." Now only the book carries the name.

"The Journey of an Addict is a series of stories and personal experiences I have gone through in active addiction, my experiences now, and what it takes to remain drug-free today," Lee writes. "I give all the credit to my higher power, who is Jesus Christ, whom without today I am nothing. As an addict, I know you will gain understanding of your own addiction through reading this book. As a family member of an addict, you will gain real world knowledge of what we as addicts go through on a constant basis."

Thursday, September 20, 2018

FDA goes to war against teenagers' 'epidemic' use of electronic cigarettes, says another generation is at risk of nicotine addiction

By Melissa Patrick
Kentucky Health News

The U.S. Food and Drug Administration is launching a new anti-vaping campaign aimed at teens.

The campaign, "The Real Cost," will target nearly 10.7 million students through hard-hitting advertising on digital and social media sites that are popular among teens, like You Tube and Instagram, and by placing ads at least 10,000 high-school bathrooms.

The ads will educate teens on the risk of nicotine addiction and the dangerous chemicals in the products; an estimated 80 percent of them don't see a great risk of harm from regular use of e-cigs, according to the latest "Monitoring the Future" survey, which tracks substance use by students in 12th, 10th and 8th grades.

In 2017, more than 2 million youth were current users of e-cigarettes. Kentucky's high-school students use traditional cigarettes and e-cigarettes at about the same rate, 14 percent, according to the 2017 Youth Risk Behavior Survey. However, the same report shows that more high school students have ever tried e-cigs, compared to ever trying the traditional ones: 45 percent and 40.5 percent, respectively.

FDA Commissioner Scott Gottlieb called teens' use of e-cigs "epidemic" and said it "jeopardizes the extraordinary public health gains we've made in reducing smoking rates in the nation."

“We have data to show that use of e-cigarettes, while potentially posing much less harm than combusting tobacco, is not benign. It causes its own health effects. And nicotine use by kids is dangerous. It causes direct effects on their health and their brains,” Gottlieb said in a written statement. "Not to mention the risk of lifelong addiction. There’s a large pool of nicotine users that’s being created among kids by these products. And some portion of them are at risk of transitioning to and risking addiction to cigarettes.”

Gottlieb stressed that while the FDA recognizes e-cigarettes can play a role in helping adults quit smoking, there is no reason for teens to use them.

“Even as we consider the potential benefits of innovative tobacco products and the role that some such products may play in reducing harm to current adult smokers, the FDA won’t tolerate a whole generation of young people becoming addicted to nicotine as a tradeoff for enabling adults to have unfettered access to these same products," he said.

The nearly $60 million campaign efforts will be funded by user fees collected from the tobacco industry, not by taxpayer dollars, says the news release.

The campaign comes just days after Gottlieb announced a major crackdown on e-cig sales to minors, including the issuance of more than 1,300 warning letters and civil money-penalty complaints to retailers who illegally sold e-cig products to minors; a request to the five top-selling e-cig companies (Juul, Vuse, MarkTen, blu e-cigarettes and Logic) to submit plans describing how they will address the widespread youth use of their products; and warning companies that have misleading labels and ads that resemble kid-friendly foods such as juice boxes, candy and cookies, that they must stop.

"Making sure e-cigs aren't being marketed to, sold to, or used by kids is a core priority and the guiding principle behind our efforts," Gottlieb said.

A federal judge in Boston has said these efforts haven't moved fast enough and has ordered the FDA to quickly finish writing a rule requiring graphic warnings on cigarette packages and advertisements, The Associated Press reports. On Sept. 5, Judge Indira Talwani gave the FDA until later this month to provide an expedited schedule for finalizing the graphic warnings rule.

An FDA spokesman told AP that the agency continues "to move forward on the work to support a new rulemaking," is analyzing the judge's decision, and will comply.

Tuesday, September 18, 2018

To defend against another flu epidemic in Kentucky: 'Get the shot. Consult your doc. Stop the spread," campaign says

Nurse practitioner Sara Wellman gives Ben Chandler his shot;
Health Commissioner Jeffrey Howard looks on.(Photo by Al Cross)
By Al Cross
Kentucky Health News

Influenza killed 325 people in Kentucky last flu season, when only 40 percent of Kentuckians got a flu shot. The state's doctors, health agencies and the Foundation for a Healthy Kentucky aim to keep such things from happening this season.

The foundation, the Cabinet for Health and Family Services and the Kentucky Medical Association staged an event in the state Capitol rotunda Tuesday to urge Kentuckians to get a flu shot on Wednesday, Sept. 26 or at least by the end of October.

Flu cases have already been reported, and "Last year was one of the worst years ever for the flu," which can be at lot worse than an inconvenience, said KMA President Bruce Scott said. He said he can't understand why some people still think you can get the flu from a flu shot, because "The virus is not live." He called it "a myth."

There is no guarantee that any one shot will prevent the flu in any one patient, because viruses, vaccines and patients vary. But every shot is likely to help reduce the effects of the flu. "Even if you get sick you’re going to have an easier time of it if you get your shot," Foundation CEO Ben Chandler said. "The sad thing is, Kentuckians who live on very low incomes are less likely to get the shot, but are more likely to have the kinds of chronic conditions that make them more vulnerable to serious flu complications."

The writer's bandage after his flu shot
Chandler said flu shots are inexpensive and "easy to get," and to illustrate the point, he, Scott and others got their shots during a break in the press conference. They got "Focus on Flu" bandages that carry the theme of the campaign. He and other speakers urged Kentuckians to post a selfie photo of their arm with the bandage on social media, writing #gotmyshot and #focusonflu.

Flu shots are not available to infants under 6 months and people with compromised immune systems, but the "herd immunity" created by vaccinations of their neighbors gives them some protection, said Dr. Brent Wright, associate dean for rural health innovation at the University of Louisville and a director of KMA's Kentucky Foundation for Medical Care, which is supporting the effort.

Wright added that you can be a carrier of the flu virus and not get sick, but not if you get the shot.

Allison Adams, president of the Kentucky Health Departments Association, said the agencies will offer vaccinations and education campaigns. The "Focus on Flu" campaign includes public service announcements, education materials, social media messages, and partnerships to make flu shots. 

Speakers also noted measures to take if you think you have the flu. Studies show that flu antiviral drugs work best when they're started within two days of getting sick. 

And if you do have the flu, rest at home. "No need to be a stoic," Chandler said. "You’re just putting others at risk." People with flu should washing their hands frequently with soap and water, cover their mouth and nose when they cough or sneeze, and limiting contact with others.

The three points of the campaign are "Get the shot. Consult your doc. Stop the spread." For resources on the flu, see this blog post from the Association of Health Care Journalists.

U.S. Senate passes 70 opioid bills, two from McConnell; House-Senate compromise in works for final passage

The U.S. Senate passed a comprehensive, bipartisan opioid package Monday that focuses on prevention and treatment that includes two measures sponsored by U.S. Senate Majority Leader Mitch McConnell. A House-Senate compromise is in the works for final passage.

“The CAREER Act will help individuals in recovery find the housing and the job opportunities they need to rebuild lives of sobriety. And the Protecting Mothers and Infants Act will help the federal government do more to support pregnant women and protect unborn children from these drugs," McConnell said in a news release. "This landmark legislation is like a Swiss army knife that will help the federal government fight opioid addiction in many different ways."

The legislation, comprising 70 bills, passed on a 99-1 vote with Sen. Mike Lee, R-Utah, dissenting. The $8.4 billion package "creates, expands and renews programs across multiple agencies," including provisions to prevent the "deadly synthetic drug fentanyl from being shipped through the U.S. Postal Service as well as allowing doctors to prescribe more medication designed to wean addicts off opioids, such as buprenorphine," Colby Itkowitz reports for The Washington Post.

Opioids were responsible for nearly 50,000 deaths last year, 1,565 of them in Kentucky. President Donald Trump declared the opioid epidemic a public-health emergency in October.

While lawmakers say the bill is a "step in the right direction," many health advocates and experts say it's not enough because it doesn't provide enough money to "fully combat" the crisis, Itkowitz reports.

Sarah Wakeman,the medical director for Massachusetts General Hospital’s Substance Use Disorders Initiative, told the Post that “Really targeting the depth of the opioid epidemic would require an infusion of federal dollars on par with the more than $20 billion a year spent on HIV/AIDS. . . . We have historically not thought of addiction as a medical issue and so our health care and public health system are woefully unprepared to respond in a robust way.”

The House passed its opioids package in June. It included 58 opioid bills, with two of the measures sponsored by Rep. Hal Rogers, Republican from Eastern Kentucky's 5th Congressional District.

According to the Senate bill's author, Sen. Lamar Alexander, R-Tennessee, the Senate and House expect to work out their differences by Friday, Sept. 21, so they can vote on a final bill in the next two weeks, and present it to the president by early October, CBS News reports.

One key difference in the bills is a decades-old federal rule that prevents Medicaid for paying for care at inpatient treatment facilities with more than 16 beds, called the IMD exclusion.

"The House bill partially overturns the IMD exclusion for mental-health patients who also have an opioid use disorder, which the Congressional Budget Office says would cost nearly $1 billion over the next 10 years," the Post reports. "The Senate bill makes some changes to the IMD rule, including making sure pregnant and postpartum women continue receiving Medicaid-covered services administered outside such facilities, such as prenatal care. But it doesn’t allow Medicaid to pay for addiction treatment in bigger facilities."

Sunday, September 16, 2018

Arkansas drops thousands from Medicaid for non-compliance with work requirements; Ky. official says 'Kentucky is not Arkansas'

By Melissa Patrick
Kentucky Health News

Arkansas is the first state to implement work and community-engagement requirements for some of its "able-bodied" Medicaid beneficiaries, just like Kentucky is trying to do. Three months into the new rules, the state has kicked 4,353 people off Medicaid for noncompliance, and will likely kick thousands more off next month.

Opponents of Kentucky's new plan, called Kentucky HEALTH (for Helping to Engage and Achieve Long Term Health), have long said they expect the same thing to happen in Kentucky if it's allowed to proceed.

"Kentucky’s work requirement is far more complex [than Arkansas'] and will require more reporting from participants. It is likely, then, that many will fail to meet the requirements and lose their Medicaid coverage," Dustin Pugel of the Kentucky Center for Economic Policy wrote Aug. 16 in a paper as part of the latest federal comment period on Kentucky HEALTH.

Cabinet for Health and Family Services spokesman Doug Hogan said the cabinet doesn't expect the same thing to happen in Kentucky.

"Kentucky is not Arkansas," Hogan wrote. "Arkansas operationalized within a few months after getting approval, chose to utilize technology that was not geared toward reporting activity for Medicaid, and had some challenges getting communications out to beneficiaries about the changes. In contrast, Kentucky has worked over the course of more than 1½ years with providers, nonprofits, MCOs [managed-care organizations] and members to get information out, invest in a new IT system, conduct training across the state for all stakeholders, and research ways to better engage citizens."

Kentucky's plan would require "able-bodied" Kentuckians who are not primary caregivers to work, attend school, take job training or volunteer 80 hours a month, or, if appropriate, get into drug treatment. It also includes small, income-based premiums and lockout periods for noncompliance, among other things.

For an Excel file with numbers on expansion and other Medicaid enrollment in each Kentucky county, click here.
A federal judge in Washington, D.C., was worried enough about how many Kentuckians could lose coverage under the state's new plan that he sent it back for review.

District Judge James Boasberg vacated the plan just days before it was set to kick in on July 1, in part because the U.S. Department of Health and Human Services had not sufficiently considered the state's estimate that in five years Kentucky's Medicaid rolls would have 95,000 fewer people with the plan than without it, largely for non-compliance with its requirements.

Medicaid provides coverage to about 1.4 million people in Kentucky, about half of them children and nearly 500,000 through the expansion of the program to those who earn up to 138 percent of the federal poverty level. It is this expansion population that will be most affected by Kentucky HEALTH if it is approved. Most who gained coverage through the expansion are already working.

The cabinet is proceeding as if it expects the Centers for Medicare and Medicaid Services to approve the plan. On Sept. 15, Associated Press Frankfort correspondent Adam Beam wrote on Twitter: "Update on Kentucky's Medicaid work requirements: Joint status report filed in federal court today. It says CMS continues to evaluate Kentucky's application and submitted comments. All parties will provide more info by Oct. 15."

A lawsuit is also pending that seeks to invalidate the Arkansas program and because of its similarities to Kentucky's case, Boasberg is handling that case as well as Kentucky's.

What's happening in Arkansas?

The new Medicaid program called Arkansas Works, which was approved under a waiver of the federal Medicaid rules, took effect in June. The program requires non-exempt enrollees to work or participate in qualifying activities, like job training, education or volunteering, 80 hours a month and report their hours electronically. It is being phased in and now affects only enrollees aged 30 to 49.

Kaiser Family Foundation graphic
The Kaiser Family Foundation reports that of the 60,012 Arkansans who were subject to the new requirements in August, 27 percent, or 16,357, did not report 80 hours of qualifying work activities and "nearly all" of those reported no work activities at all. However, they have three months to report such activities to be in compliance.

Arkansas data shows another 5,076 people are at risk of losing their coverage in October because they have had two months of non-compliance, and 6,174 have not been in compliance for one month.

According to a news release from Gov. Asa Hutchinson's office, the Arkansas Department of Human Services conducted "extensive outreach" from April to August to their beneficiaries to let them know about the new requirements. Hutchinson said some who did not comply may have found work, gained coverage elsewhere or moved out of state without notifying officials.

"Some simply chose not to comply. Those are the ones who will lose their Arkansas Works coverage for the remainder of 2018," Hutchinson said. "Personal responsibility is important. We will continue to do everything we can to ensure those who qualify for the program keep their coverage, but we will also make sure those who no longer qualify are removed.”

Arkansas estimates it will save $30 million by dis-enrolling 4,353 beneficiaries.

Within hours of the announcement, CMS Administrator Seema Verma, a champion of work requirements as a way to lift people out of poverty, said on Twitter: "“I’m excited by the partnerships that Arkansas has fostered to connect Medicaid beneficiaries to work and educational opportunities, and I look forward to our continued collaboration as we thoroughly evaluate the results of their innovative reforms.”

Advisory panel alarmed by Arkansas numbers

Members of a federal advisory panel, the Medicaid and CHIP Payment and Access Commission (MACPAC), "expressed dismay" Sept. 13 over the Arkansas numbers. Some  of the members said "the early numbers are so worrisome that the agency should force the state to put the work requirements on hold," James Romoser reports for Inside Health Policy. Romoser reports that Commissioner Alan Weil called the numbers "a serious red flag" that needed to be brought to CMS's attention as soon as possible, before policymakers adopt Medicaid work requirements in more states.

“This is very important information,” Weil said of the early Arkansas statistics. “These waivers were granted on the belief that they would yield an increase in work, and clearly it takes time to determine the validity of that hypothesis. But I’m not really comfortable with us just offering some sort of retrospective reporting on how many people lose coverage. It does seem to me -- even on the basis of this pretty preliminary information -- that, as of now, we don’t have any evidence of increased engagement with work-related activities, much less work, and we have significant evidence of a large number of people losing coverage.”

Weil added, “It feels to me as MACPAC we have an obligation to state that rapid implementation of large-scale change of this nature across multiple states is a really risky proposition.”

MACPAC Chair Penny Thompson said the commission will consider formally communicating concerns to CMS at its next meeting, which is scheduled for Oct. 25-26, Romoser reports.

CMS has also approved work requirements for Medicaid in Indiana and New Hampshire. Seven other states (Arizona, Kansas, Maine, Mississippi, Ohio, Utah and Wisconsin) have applied for permission to implement them.
Kaiser Family Foundation table; click here for more details; click on chart for a larger version.

Kentucky public-health nurses in N.C. helping deal with Florence

Commissioner Jeffrey Howard, far right, posed with the team headed to North Carolina. Back row, L-R: Nancy Hamilton (Department for Public Health), Sherita Hall (Louisville Metro Public Health and Wellness), Christopher Smith (Lexington-Fayette County Health Department), Angela Kik (Dept. for Public Health), Shelley Wood (Department of Insurance), Heather Toews (Lexington-Fayette County Health Dept.), Rachel Harrison (Bracken County Health Department), Sandra Glover (Dept. for Public Health). Front row, L-R:  Charlene Woodard (Louisville Metro Public Health and Wellness), Stephanie Carpenter (Lexington-Fayette County Health Dept.), Rebecca Hardin (Dept. for Public Health)
Several Kentucky public-health nurses are in areas of North Carolina devastated by Hurricane Florence to provide medical support to victims in medical-support shelters. They will be there for about two weeks, said the state Cabinet for Health and Family Services.

The "strike team" is nine registered nurses and two staff members from health departments in Louisville, Lexington and Bracken County, the state Department of Insurance and the Department for Public Health. “I commend them and thank them for their compassionate service,” CHFS Secretary Adam Meier said in a news release.

People in medical-support shelters "have medical needs and are in relatively stable condition but have a chronic disease or condition such as diabetes or require oxygen or dialysis," the release said. "Nurses will be conducting history and physical exams, providing patient assessments, assisting with medicine administration and providing general nursing care and comfort." Their work can be followed on Twitter at https://twitter.com/chfsky.

The state health department is prepared to deploy environmental-health specialists and support personnel "if requested to address critical public-health issues, including food safety, food salvage and disposal, food and water-related illness, clean water sources, water sampling, solid waste water system analysis and mosquito control," said Health Commissioner Jeffrey Howard Jr., M.D.

Assistance requests are coordinated and authorized through a multi-state compact, under which the requesting state reimburses all associated costs incurred by the provider state, the release said.

Friday, September 14, 2018

State's high-school obesity rate goes up; hope is in pre-school numbers, which have dropped; adult obesity rate is 8th in U.S.

By Melissa Patrick
Kentucky Health News

Kentucky's high-school students have been getting fatter, but obesity among preschoolers in the Women, Infants and Children nutrition program has been dropping, according to the latest national State of Obesity report.

Kentucky's high schoolers ranked third among the 43 states that reported high-school obesity rates in 2017, at 20.2 percent, up from 18.5 percent in 2015. The higher states were Arkansas, at 21.7 percent, and Tennessee, at 20.5 percent.

The figures come from the Youth Risk Behavior Surveillance system, a continuing national survey of that age group. The report said last year was the first in which the poll found any state with a youth obesity rate over 20 percent.

Another survey, the National Survey of Children's Health, says one-third of Kentucky children between the ages of 10 and 17 were either overweight or obese in 2016.

The news was better among children aged 2 to 4. Using figures from the WIC program for low-income mothers and children in 2014, researchers found that 13 percent of Kentucky children in the program were obese, a significant drop from 18 percent in 2010. The 2014 rank was 32nd among the states.

Over the past five years, the Foundation for a Healthy Kentucky has worked with and funded efforts in six Kentucky communities to reduce childhood obesity.

"What we've learned through these grants is that it takes a coalition of partners committed to system-wide changes that make better nutrition and increased physical activity easier and more likely for everyone," Foundation President and CEO Ben Chandler said in a news release. "It's hard work and it takes long-term commitment, but it's imperative to getting Kentucky back on track to better health."

Preventing obesity in children can return long-term dividends. Research shows that children who are obese or overweight often grow up to become obese and overweight adults, and the number of obese adults in Kentucky is not getting any better.

"The obesity rate in the Commonwealth has been on a dangerous trajectory for nearly two decades, tracking a national trend that is costing the state billions in health care and lost productivity, and jeopardizing the health of 1.1 million Kentucky adults every year," Chandler said.

Source: The State of Obesity 2018 report
The percentage of obese Kentucky adults has been about the same since 2015, when the state made a big jump from 31.6 percent to 34.6 percent. (The rate was less than 13 percent in 1990.) In 2017, the rate was 34.3 percent, ranking the state eighth for adult obesity.

The only states with higher obesity rates than Kentucky are West Virginia, Mississippi, Alabama, Arkansas, Louisiana and Tennessee. The report says that seven states had adult obesity rates at or above 35 percent in 2017 and no state had a statistically significant improvement over the past year.

While the report primarily focuses on obesity, it also shows that the number of Kentucky adults who are either obese or overweight is much larger, 67.2 percent.

The figures come from the federal Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System, an ongoing poll. Adult obesity rates by county are available at KentuckyHealthFacts.org.

The national report, "The State of Obesity: Better Policies for a Healthier America" was done by the Trust for America's Health and the Robert Wood Johnson Foundation.

It says obesity among Kentuckians is most common between the ages of 26 and 64. The rate is 37.3 percent among those 26-44 and 38.2 percent among those 45-64.

African Americans in Kentucky are the most likely racial or ethnic group to be obese, at 40.2 percent, followed by 34.4 percent of whites and 28.5 percent of Latinos. More men in Kentucky were obese than women: 36 percent and 32.5 percent, respectively.

State ranks last in physical activity, and all this costs us

These numbers cost money, according to a report from the United Health Foundation, the American Public Health Association and Partnership for Prevention. It says that starting this year, Kentucky is expected to spend $6 billion annually in health care costs directly related to obesity.

The State of Obesity report looks at several of those obesity-related health issues.

It shows that Kentucky's diabetes rate has inched down a bit since it hit its highest rate ever in 2015, 13.4 percent, but at 12.9 percent, the state still ranks seventh in the nation. The researchers estimate that nearly 600,000 Kentuckians will have diabetes in 2030.

The state's rate of high blood pressure, at 39.4 percent, has remained about the same since 2013. Kentucky ranks fifth for hypertension and the report projects there will be nearly 1.2 million Kentuckians with it in 2030.

Given the above numbers, it is no surprise that Kentucky ranks first for the percentage of adults who are not physically active, 34.4 percent.

The report calls for widespread implementation of evidence-based programs, policies and practices to reverse the obesity trend, including efforts that take a multi-sector approach, approaches that make the healthy choice the easy choice and investment in programs that narrow health inequities. Toward this end, the researchers offer 40 specific recommendations for federal, state and local policymakers; the restaurant and food industries and the healthcare systems.

“The good news is that there is growing evidence that certain prevention programs can reverse these trends. But we won’t see meaningful declines in state and national obesity rates until they are implemented throughout the nation and receive sustained support," John Auerbach, president and CEO of Trust for America’s Health, said in a news release.