Wednesday, July 31, 2013

Critics say new Medicare rate-setting board has too much power; former budget chief says new system requires it

Critics as diverse as Republican state Rep. Addia Wuchner and former national Democratic chairman and Vermont governor Howard Dean, a physician, are criticizing the Independent Payment Advisory Board, a panel created by the federal health-care reform law to hold down health-care costs. But a finance executive who helped create the board says the critics are off base.

Dean wrote recently in The Wall street Journal that the board "is essentially a health-care rationing body," and Wuchner said in an op-ed piece in several Kentucky newspapers that the board's recommendations "will result in reduced care access" and "would intrude and erode the physician-patient relationship."

Despite Dean's assertion, the law "specifically states that the board is not allowed to make any recommendations that would ration care," Peter Orszag wrote for Bloomberg View. Orszag is vice chairman of corporate and investment banking at Citigroup, and was President Obama's budget director after running the bipartisan Congressional Budget Office.

Orszag says Congress already sets Medicare rates, and the board is designed to "be more facile and dynamic" as the law changes the medical funding system from the current fee-for-service" model "toward paying for value in health care." He says that is already happening faster than expected, because the CBO says Medicare's net costs have risen only 2.7 percent in the current fiscal year, which ends Sept. 30. "Redesigning the payment system is a fundamentally different approach to containing costs," which requires "a process for tweaking our evolving payment system in response to incoming data and experience," Orszag argues.

Wuchner, a registered nurse bioethicist from Florence, says the board has too much power. She notes, "Unlike typical advisory-board recommendations that have to be accepted or rejected by Congress, IPAB’s recommendations become law unless Congress passes its own plan with a three-fifths majority in the Senate in relatively short order that brings comparable savings."

Tuesday, July 30, 2013

Obama and allies tout preventive-services and drug benefits of health-reform law to Medicare beneficiaries in Ky.

The federal health-reform law has made drugs more affordable for seniors, broadened coverage for preventive services and made Medicare more solvent, the Obama administration and its allies are pointing out today, the 48th anniversary of the enactment of the Medicare program.

According to the Department of Health and Human Services, Medicare beneficiaries in Kentucky have saved nearly $141 million on prescription drugs because of the Patient Protection and Affordable Care Act. Last year, 72,391 Kentuckians saved more than $51 million, or an average of $703 each, on prescriptions because those in the “donut hole” of Medicare Part D got a 50 percent discount on covered brand-name drugs and a 14 percent discount on generic drugs. The law will keep expanding coverage for both types of drugs until it closes the donut hole, the gap in coverage between modest and huge prescription needs.

The law also eliminated deductibles and co-payments for screening and other preventive services for seniors and people with disabilities. Last year, 485,843 Kentuckians with traditional Medicare used one or more free preventive service.

"The health care law extends the life of the Medicare Trust Fund by 10 years," said a news release from U.S. Rep. John Yarmuth, D-Louisville. From 2010 to 2012, Medicare spending per beneficiary grew 1.7 percent a year, much more slowly "than the per capita rate of growth in the economy," the release said. "And the health care law helps stop fraud with tougher screening procedures, stronger penalties, and new technology."

Earlier, the administration noted that Americans received $504 million in rebates from insurance companies because of the law's requirement that a certain percentage of premiums paid must be used for health care. In Kentucky, the rebates totaled $14.4 million to 206,771 consumers (slightly more than half, totaling almost $11 million, in the individual market) and averaged $100 per family. For other data on the effects of the law in Kentucky, click here.

Monday, July 29, 2013

Nominees sought for award honoring lifetime in rural health

The Kentucky Rural Health Association seeks nominations for an award honoring a lifetime contribution to rural health in Kentucky, named for Dr. Dan Martin of the Trover Foundation in Madisonville. A nominee's contributions might be in areas of direct patient care, health professions education, health administration, health promotion or public advocacy. To nominate someone, please complete the form, available here and e-mail it to Linda Asher at; or to the Office of Rural and Community Health, K320 Kentucky Clinic, Lexington, KY 40536-0284; or fax it to (859)323-1043.

Newspapers large and small inform readers (and even non-subscribers) about the complexities of health-care reform

By Al Cross
Kentucky Health News, Institute for Rural Journalism and Community Issues

In about two months, states and the federal government will open online marketplaces for health insurance, which will also offer subsidies based on income and the opportunity for the poor to enroll in the Medicaid program in states that have expanded it above the poverty level. By March 31, almost all Americans will be required to have health insurance or pay a penalty.

These steps will implement the health-reform law that Congress passed in 2010 and that even the White House calls Obamacare. It will be one of the most complex and challenging changes in American society since World War II, and newspapers are starting to help their readers get ready for it. Sunday's Lexington Herald-Leader had a story by Mary Meehan titled "What you need to know about Kentucky's health-reform plan."

But such reporting is not, and should not be, solely the province of metropolitan newspapers. Last week the Adair County Community Voice in Columbia published a 10-page special section on health-care reform. The front page had an overall story on the Patient Protection and Affordable Care Act, based on information gathered at a Kentucky Chamber of Commerce informational meeting, and a sidebar on the penalties and subsidies, with a box on each. Inside were several other stories, mainly from Kentucky Health News, and lots of ads from health-care providers.

The really special thing about the special section was that Editor and Publisher Sharon Burton sent the edition containing it to every household in Adair County, using the postal regulation that allows newspapers to send 10 percent of their annual circulation to non-subscribers at subscriber rates. At the Institute for Rural Journalism and Community Issues, we have long urged local newspapers to do this with their health sections, because we think there is a big overlap among people who most need such information and people who do not subscribe to their local newspaper. Newspapers can sell enough ads to cover the extra printing and postage costs, or even sell a sponsorship for the additional circulation.

"Information about health care reform has come in bits and pieces and most of us probably really don't understand it with any depth," Burton told us in an email. "I jumped at the opportunity to attend the Kentucky Chamber of Commerce Health Care Reform Summit because the agenda looked excellent and it has been difficult to get a good overview of how health care reform will impact our local businesses and individuals. We originally planned a total-market issue in June but had to delay it until July. We decided to delay the health care reform section as well so that it could go to everyone. We've had numerous compliments from readers who had said it was the best compilation of information they have seen in one place."

To download the Community Voice's health-care reform section, as a PDF of approximately 10 MB, click here.

Sunday, July 28, 2013

Rural doctors need to support recruitment of more colleagues, former Leitchfield hospital administrator writes

With Kentucky's doctor shortage about to be exacerbated by expansion of the Medicaid program and federally subsidized health insurance, there will be more competition than ever to recruit physicians, especially to rural communities. Some doctors resist such recruitment, but they are short-sighted, writes Stephen Meredith, former chief executive officer of Twin Lakes Regional Medical Center in Leitchfield.

Twin Lakes Regional Medical Center
"When I became CEO of TLRMC in 1983 our local hospital had seven doctors on its medical staff, so the first order of business was the recruitment of additional physicians, or so I thought. When this idea was presented to the collective medical staff it with was met with a resounding 'NO.' The medical staff’s concern was recruitment would hurt them financially by further 'dividing the pie' of a finite number of patients," Meredith writes for The Record in Leitchfield.

But many more doctors were recruited (now more than 30), and the old doctors realized it was a good thing, Meredith writes: "Two of the more vocal physicians against recruitment later acknowledged the addition of more physicians, especially specialists, made their own practices even busier than before. In defense of these men, they were so busy seeing patients in their practices, they had to believe they were seeing everyone who possibly needed medical care. However, they had no idea how many people were leaving our community for health care because of the shortage of physicians."

The phenomenon extends to other lines of work, Meredith notes: "What occurred within our medical community was recognized and theorized by John Nash as the theory of economic equilibrium for which he won the 1994 Nobel Prize in economics. His theory, in essence, is when we all work together for everyone’s mutual benefit rather than just our own, in the long-run, everyone benefits by expanding the 'size of the pie.' No one wins when it comes at the expense of others, but everyone wins when we take a broader view of our community and purposefully commit to pursuing initiatives which leave no one behind. After all, we are all in this together." (Read more)

Minorities need to ignore myths and sign up for organ donation, writes African American columnist for Herald-Leader

Christian program resumes operation, paying medical bills for churchgoers who vow not to smoke, drink or have extramarital sex

Harlan County Schools look for school-nurse help after county health department, which had done it for free, asks for $10,000

Friday, July 26, 2013

Beshear, Stumbo credit law for reducing prescription-drug deaths, but reduction was far outnumbered by rise in heroin fatalities

UPDATE: Final, revised data show that prescription-drug deaths in Kentucky actually increased slightly, from 1,022 in 2011 to 1,031 in 2,012, according to the Kentucky Injury Prevention and Research Center. Heroin-related deaths rose from 42 in 2011 to 129 in 2012, a smaller increase than preliminary data showed but still a rise of 307 percent.

Deaths from prescription-drug abuse in Kentucky declined last year for the first time in a decade, and top state officials are crediting a law passed by that year's General Assembly.

However, passage of the law has prompted many drug users to switch to heroin, and the increase in heroin deaths (121) was much larger than the decline in prescription-drug fatalities (19).

"Autopsied overdose deaths attributed to the use of heroin increased 550 percent over the previous year, from 22 in 2011 to 143 cases in 2012," a release from Gov. Steve Beshear's office said. The decline in prescription-drug deaths was 1.9 percent, from 1,023 to 1,004, but the release said nothing else about the new problem and did not link it to the 2012 law that cracked down on abuse of prescription drugs.

“The impact of this bill can’t be measured just in the numbers of pills we’ve kept off the streets,” Beshear said in the release. “This bill, I believe, has literally saved lives in Kentucky.”

House Speaker Greg Stumbo, D-Prestonsburg, said, “I’m proud of the results, and the fact that other states are following our lead. Our goal now is to build on these gains and to improve access to treatment, so that abusers can truly escape this deadly cycle once and for all.”

The first quote in John Cheves' Lexington Herald-Leader story came from Van Ingram, executive director of the state Office of Drug Control Policy, which the new law required to begin publishing annual reports on drug overdose fatalities in the state: "There's no great victories here. I'm glad that we're at least seeing a leveling off and some small decline. I've been in this job for nine years and have watched a steady rise in numbers that whole time."

Top counties: Leslie, Clinton, Clay, Estill, Floyd, Nicholas, Perry, Whitley, Monroe (Herald-Leader)
The law, known as House Bill 1 before Beshear signed it, required pain-management clinics to be owned by a licensed medical provider, required all drug prescribers to register with a state monitoring system, and reduced the number of prescriptions for heavily abused controlled substances, a release from the governor's office said.

"Since the law was passed, 20 non-physician-owned pain management facilities have closed," the release said. The "Cabinet for Health and Family Services has issued cease-and-desist letters to another four pain management facilities operating outside the scope of state regulations."

"Of the 1,004 overdose fatalities in 2012, 888 were found to be unintentional, 59 were suicides and 57 remain undetermined," the release said. "Alprazolam (Xanax) remained the most-detected controlled substance in overdose deaths, present in 41 percent of all autopsied cases. Morphine was found in 32 percent of autopsies, followed by hydrocodone at 26 percent and oxycodone at 24 percent."

"Autopsies often found more than one drug present," Cheves notes. "The youngest overdose fatality was 16; the oldest was 72. Slightly more than half of the victims were men. Leslie County (population 11,170) reported the state's top per-capita rate of an annualized 85 fatal overdoses for every 100,000 people. The county had 11 overdose deaths in 2012, up from eight the previous year. In descending order, the other leading counties were Clinton, Clay, Estill, Floyd, Nicholas, Perry, Whitley, Monroe and Magoffin." (Read more)

Read more here:

New survey shows physicians feel need to limit health-care costs but make that secondary to the interests of their patients

A new survey about health-care costs reveals that 85 percent of U.S. physicians feel a responsibility to address costs but say other professionals have more of a responsibility to do that, because physicians' obligation toward patients' interests is more important than cost reductions.

While 36 percent of physicians said they have a "major responsibility" to reduce costs, other major players in health care, such as lawyers, insurance companies, hospitals and drug companies, bear that major responsibility, says the study published in this week’s Journal of the American Medical Association.

“Physicians feel stuck in a difficult position,” lead author Dr. Jon Tilburt says in a Mayo Clinic release. “Despite their sense of responsibility to address health care costs, physicians consistently express a commitment to the best interests of patients even when it is expensive. Given this finding, we recommend that cost-containment strategies aimed at physician behavior should focus on innovations that not only promote savings but also preserve physicians’ commitment to individual patients.”

Physicians expressed general agreement with quality initiatives that may also reduce health costs, but were less enthusiastic about cost-containment measures involving changes to payment models, says an American Medical Association release. For example, physicians opposed the idea of cuts in Medicare fees for hospital readmissions and eliminating fee-for-service models.

A strong majority of physicians (69 percent) were enthusiastic about promoting chronic disease care coordination and limiting corporate influence on physician behavior (63 percent). The survey also found that 76 percent of physicians are aware of the costs of tests or treatments they recommend, says the Mayo release.

Physicians said costs can be reduced by improving quality, efficiency and continuity of of care through evidence-based initiatives and cost transparency, says the AMA release. Results of the random survey of 2,500 U.S. physicians indicate ways in which policymakers can collaborate with physicians to address rising health care costs.

“Moving toward cost-conscious care in the current environment in which physicians practice starts with strategies for which there is widespread physician support might create momentum for such efforts...," writes the study's authors in the journal article. Tilburt says physicians want to do the right thing, but when push comes to shove, they will do what's best for patients. Let's start with win win strategies that physicians support and that will cut costs and improve care, he said in a MedPage Today video interview. Click here to watch that video.

Health Watch USA hosts chief medical director of Center for Medicare and Medicaid Services in Lexington and online July 31

Dr. Patrick Conway, chief medical director of the federal Center for Medicare and Medicaid Services, will be presenting to Kentucky-based Health Watch USA on July 31 at 5 p.m., and with a few clicks on the computer, you can attend virtually.

Conway will be discussing CMS goals and the results of its value-based quality improvement programs, physician fee schedule quality proposals and future opportunities for CMS collaboration aimed to drive health-care quality.

Using your computer, you can attend and participate in the discussion through an online chat while listening to Conway's presentation and viewing the slides. Just click here to log into the conference's webpage and Adobe Connect will download to your computer free of charge.

The online login will be active 15 minutes before the presentation on July 31, and the presentation slides will be available to download as a PDF from the conference page. You can also attend the presentation at the Northside Library in Lexington. Click here for more information.

Health Watch USA, based in Somerset, was founded by Dr. Kevin Kavanagh to promote health care transparency and patient advocacy, says its website.

Tuesday, July 23, 2013

Hospital and insurance chiefs say health reform will improve Ky.'s health care and its health, after bumps in road

By Al Cross
Kentucky Health News

The federal health-reform law will improve health care and help make Kentuckians healthier, though some will be inconvenienced, officials of Kentucky's leading hospitals and the Humana Inc. insurance company said Tuesday at the Kentucky Chamber of Commerce's annual Business Summit.

"We have the ability to move the needle, and we will move the needle," Kentucky One Health CEO Ruth Brinkley said after citing the state's dismal health statistics. She was one of four hospital chiefs on a panel that concluded the meeting in Louisville.

Dr. Michael Karpf, head of UK HealthCare, said "More people will be insured, we'll do things better and we'll focus on the right things. . . .You've just got to buckle up for the ride."

Norton Healthcare President and CEO Stephen Williams said Kentucky has some of the best health care in a nation that has the best health care in the world, but the state's health status is low and the U.S. ranks only in the middle among industrialized nations, though it pays more for health care than any other country. A fundamental reason for the state's poor health, he said, is lack of access to health care.

At an earlier session, in response to a question about the Patient Protection and Affordable Care Act, Humana President and CEO Michael Broussard said, "Having access and people covered is the right thing to do. When people have the ability to go get health care, they're going to be healthier."

Brinkley there are some things in the law that she does not like, but she didn't name them, and said her organization was "very encouraged" by Gov. Steve Beshear's expansion of Medicaid to people with incomes up to 138 percent of the federal poverty level. "It will offer an accessible system to the people who need it most," she said, adding, "None of us will do well if the vulnerable remain vulnerable."

While no one on the panel or the audience raised the prospect that the law would be repealed, as House Republicans have voted to do dozens of times, there were no suggestions that repeal is a possibility. Broussard said of the law, "It's here to stay."

Earlier, he said implementation of the law "will create some disruptions" but also "some really neat changes," as the country changes to a true "health care" system, from the current "sick care."

The reform law is making hospitals change their approach from a fee-for-service system, which rewards them for more and longer admissions and procedures, "to something that rewards outcomes," Karpf said.

"We are paid to do the wrong things," Williams said. The current system "basically rewards more volume, whether it's needed or not. . . .We're volume-based rather than value-based," which the new system is supposed to be.

Hospitals have not been at the forefront of helping people be healthier and avoid hospital stays, but need to do more of that, said Steve Hanson, CEO of Baptist Health. "It's the right thing to do." He said one his company's stated missions is to enhance health, "which we don't talk nearly enough about, and we do even less."

Brinkley said she worries that there won't be enough health-care providers to handle the people who are joining the health-care system, but she said the law will decrease use of hospital emergency rooms, and "that will be good for all of us."

"We have got to keep people out of our emergency departments," said Hanson, whose company owns or manages 10 Kentucky hospitals. "That's the most expensive place . . . and it's still not the best care."

Hanson said President Obama's delay of the employer mandate (actually the requirement for employers to report on their health insurance to the Internal Revenue Service) would not be the last delay in the implementation process, because the law is so complex. Brinkley said she would not be surprised to see other parts delayed.

Among patients, "There will be some disappointments and concerns," Karpf predicted, noting that some won't be able to keep their doctor if he or she is not in the network of the health plan they choose, contrary to promises made by the law's advocates. "Once you sign up for a plan you may not have much of a choice of a doctor."

Also, Karpf said, the process of buying insurance through the online exchanges may be daunting for people who have never bought a health-insurance policy. For example, he said, they may not realize that they are buying a policy with high deductibles.

And, agreeing with some of the law's critics, Karpf said many people may lose their employer-provided insurance because their employers will choose to drop coverage for employees and pay the relatively modest penalty for not insuring them.

Broussard said the implementation problems will work themselves out, but "We'll be talking about this for the next decade."

As prescription painkillers become harder to get and abuse, heroin replaces them in Eastern and Southern Kentucky

Heroin use, which has been a problem in Northern and then Central Kentucky after the state began cracking down on prescription painkillers last year, has been spreading to the Southern and Eastern parts of the state. Heroin is becoming more popular throughout Kentucky because it is cheaper and easier to get than prescription painkillers, specifically opioid medications, reports Valarie Honeycutt Spears of the Lexington Herald-Leader.

While an 80-milligram OxyContin costs between $60 to $100 a pill on the black market, heroin costs $45 to $60 for a multiple-dose supply, reports The Partnership at  With national and state efforts to curb prescription drug abuse, including the reformulation of OxyContin that makes the drug more difficult to crush and snort, heroin can also be easier to obtain and abuse.

As drug users turn from prescription drugs to heroin to get their high, Northern Kentucky and major cities like Lexington and Louisville are struggling to address the problem, says an Operation UNITE press release. Operation UNITE is a regional anti-drug coalition fighting substance abuse in Southern and Eastern Kentucky counties (map).

Most Southern and Eastern Kentucky counties are just beginning to see the signs of heroin use, says the release. Dan Smoot, CEO of Operation Unite, told Spears that heroin’s spread throughout Kentucky was inevitable. “We knew it was coming. We just didn’t know when it would hit,” he said.

Rowan County was hit before most Eastern Kentucky counties, said Smoot; the most recent example of increased heroin use occurred July 9, when Operation UNITE agents arrested a known prescription drug trafficker attempting to bring a large quantity of heroin into Beattyville, says the release.

Uncertainty about what heroin users are actually getting makes the drug especially dangerous, says Paul Hays, law-enforcement director for Operation UNITE. “You don’t know the purity of the heroin,” he said in the release. “Dealers will often ‘cut’ the drug with other substances in order to boost their profits. There’s no way the public knows what they’re shooting up.”

This increased risk can be deadly, and although there's no evidence of an increase in heroin overdose deaths in Eastern Kentucky, a task force has been created to address this fatal problem in Lexington. There have been 29 heroin overdose deaths in Fayette County so far this year, seven more than the amount of overdose deaths in all opf 2012, Fayette Coroner Gary Ginn told the newspaper.

Read more here:

Monday, July 22, 2013

School boards across Ky. realign school-nurse programs, squeezed by budget cuts and Medicaid payment issues

School districts in Kentucky have long relied on county health departments for school nurses, but state budget cuts and problems with Medicaid reimbursements have squeezed the health agencies, and they in turn have put the squeeze on the schools for more money and other measures.

Despite some concerns, the Russell County Schools board voted to approve a contract with the Lake Cumberland District Health Department to provide school nursing services. Corbin Independent Schools did not continue its normal contract with the Whitley County Health Department for these services, and has employed its own nurses this year instead. Fayette County Schools will coordinate a hybrid, scaled-back program with the Lexington-Fayette County Health Department, rather than relying solely on the department for services.

The Russell County board had tabled its contract with the Lake Cumberland department last month due to concerns about a lack of provisions allowing for reimbursement if the nurse ever had to take time off, reports John Thompson of The Times Journal in Russell Springs. Superintendent Michael Ford said the health department was unwilling at this time to accept such provisions, but that it has not been a problem in the past.

Ford also said the district would get the same services if it hired its own school nurse. So, in the face of concerns from many members, the board voted last week to continue providing school-nurse services through the department, Thompson reports.

On the other hand, Corbin is hiring its own nurses. Its health-department contract ended in May because the department went months without receiving Medicaid reimbursements for school-nursing services, and the department had no financial resources to continue them, reports Jeff Noble of The Times Tribune.

Citing cuts in federal funding, Fayette County Schools has scaled back its school-nurse program. The joint program between the school system and the local health department will go from having 30 registered nurses for school services to operating with 13 registered nurses and 14 licensed practical nurses, reports Jim Warren of the Lexington Herald-Leader.

Fayette Superintendent Tom Shelton said last week that the plan is to supplement the nurses with other health care providers or additional help from the department; school personnel will also help by administering some medication.

This is a temporary solution to meet school nursing needs to give the schools time to develop a permanent solution, Shelton told Warren. Shelton said he wants to develop a completely new model for providing nursing services after next year.

Sunday, July 21, 2013

Kentucky, insurance companies are applying lessons learned in state's hurried transition to managed-care Medicaid

By Molly Burchett
Kentucky Health News

Gov. Steve Beshear rushed to transplant Medicaid into a new bed called managed care, hoping the new medium would save money and improve health, but his administration didn't take time to condition the soil, fertilize the ground or oil the machinery in 2011. This month, managed-care company Kentucky Spirit proved to be the self-plucking bad weed, fleeing the state as it cited unbearable costs.

Kentucky’s hurried transition to Medicaid managed care has been anything but smooth for many doctors, hospitals and other health-care providers. They have complained about late payments and burdensome reimbursement processes.

It's also not been smooth for the state or the managed-care firms, which are subsidiaries of insurance companies. There have been court battles, tension-filled negotiations, dropped contracts, allegations of a contract breach and now the departure of Kentucky Spirit, pushing its 125,000 clients to one of the other two companies operating outside the Louisville region.

Most important, patients have suffered from the rapid switch and ensuing wrangles.  They complain that prescriptions previously covered by the old "fee for service" system are now denied as not being"medically necessary" by managed-care firms, which the state pays a set fee per person. Patients in rural areas complain because they must drive long distances to find providers in their Medicaid company's network.

But there have been improvements in delivery of health care, particularly in the areas of vaccinations and other preventive services, says the state Cabinet for Health and Family Services. Those include a 33 percent increase in flu vaccinations and an increase in immunizations for children, more well-child visits, increased smoking-cessation consultation, and more than a 50 percent increase in diabetes testing, cabinet spokeswoman Jill Midkiff said.

State and companies made some missteps

Amid those encouraging signs for the future, most of the news about managed care in the past 10 months has been about Kentucky Spirit's potential departure  which occurred July 6. The cabinet is preparing legal action to seek damages from Kentucky Spirit for abandoning its contract; the company, a subsidiary of St. Louis-based Centene Corp., says it didn't break the contract and took every step possible to make a smooth and orderly transition. The state Court of Appeals ruled that Kentucky Spirit could end its contract without a two-month transition period for patients because the state had plenty of time to make arrangements for the company's departure.

It's not clear that the state can recoup damages, or lost taxpayer money, from Kentucky Spirit, though it is having to pay the other two companies more because Kentucky Spirit was initially the low bidder for a managed-care contract. CoventryCares and WellCare of Kentucky are paid an average of about $100 more per month per Medicaid patient.

When Kentucky Spirit first threatened to leave in October 2012, it said it was losing money due to "faulty data" the state provided during the bid process. The two other companies received the same information.

"There were no flaws in the state's data book," CoventryCares CEO Michael Murphy told Kentucky Health News. But he said the companies miscalculated because the data book didn't refer to retroactive payments. That led to a loss of $50 million for Coventry in the first quarter of 2012, he said. Now, he added, the company has a greater understanding of the system.

WellCare, asked if the state provided faulty data, did not answer as definitively. "Medicaid programs are expansive and complex, and it is not unusual for any state to provide data during a RFP [request for proposals] process that may have anomalies or other issues that could negatively impact rates if left unaddressed over time," said Mike Minor, president of the firm.

Schedule seemed politically influenced

Both companies said the state's transition to managed care was rapid and taught difficult lessons. That raises questions about whether haste made waste. Kentucky Spirit blames the state for its losses, and providers blame managed care companies for reimbursement issues, but evidence continues to clearly indicate two problems: too little time and money.

The state has been using managed care in the Louisville region through the not-for-profit Passport Health Plan since the late 1990s, and had long considered expanding it to other parts or all of the state to save money as Medicaid costs burgeoned, especially during the Great Recession.

Gov. Steve Beshear proposed statewide managed care in the budget he gave the General Assembly in early 2011, called a special legislative session to authorize it in March 2011, and signed the legislation on March 25 of that year. The state requested proposals from managed-care companies two weeks later, and bids were due less than two months later.

Contracts were finalized July 8 but implementation was not scheduled until Oct. 1. It was delayed until Nov. 1 "at the insistence of the Kentucky Hospital Association," which "asserted more time was needed for hospitals to negotiate contracts with plans," says University of Kentucky report published last year and funded by the Foundation for a Healthy Kentucky.

"Several informants told us that they believed that the upcoming election for Kentucky’s race for governor was a primary contributing factor in the rapid implementation timeline," the report says. "Beshear’s office saw the closing of this gap as a major issue that needed to be addressed before the November election," which was held Nov. 8. That effectively delayed most publicity about complaints regarding implementation until after the election.

"There is no doubt that the commonwealth’s rapid transition from a Medicaid fee-for-service program to a managed-care program raised a number of unforeseen challenges," said Minor, of WellCare.

"Certainly, the short timeframe . . . made for a difficult transition," said Midkiff. "Despite the negative portrayal of the managed-care companies, much progress has been made . . . and we expect that progress will continue."

Implementation timeline from UK's Medicaid managed care report
In October 2012, the managed-care companies continued to be dissatisfied with their fees, claiming they were inadequate to provide quality care, says the UK report. In January 2013, the state gave CoventryCares and WellCare 3 to 5 percent rate increases.; Kentucky Spirit asked for 21 percent, Murphy said, but got only 1 percent.

Murphy said the state had reduced rates below those established by the federal Centers for Medicare and Medicaid Services. "We want to establish base rates for primary care services that we hope the state will continue," he said.

Minor said, "While there were legitimate prompt-pay issues during the first six months of implementation of Medicaid managed care, we are now well past those issues."

Looking ahead

Murphy said some of CoventryCares' initial failures were due to the company's lack of understanding, and it has found Health and Family Services Secretary Audrey Haynes and her actuaries very cooperative and transparent, helping improve the system. "CoventryCares had to first figure out the problems going on with providers and payments. We had to understand the risks we had, and things have settled down quite a bit, especially regarding the pre-authorization process," he said. "We've stopped the bleeding."

Murphy said health-care providers will bear the burden of Kentucky Spirit's departure. To resolve issues faced by providers even before that, the cabinet has held regional forums across the state. Reception at the forums has been positive, and providers have been grateful for the opportunity to address any problems or complaints they have with the cabinet and Medicaid staff, said Midkiff.

Some providers still complain, saying that they should not have to meet with managed-care and state officials to receive payment for services already provided to Medicaid patients.

Starting in January 2013, primary care providers were supposed to be paid Medicare rates for Medicaid services over a two-year period, but some providers have yet to see that rate increase. Murphy said Coventry is planning to pay the increased rates as soon as the state's application is approved by federal officials.

Murphy said managed care should not be about the money, but about the member. He said primary care is at the core of improved health outcomes. Minor said WellCare has also made it a goal to establish relationships with primary-care providers.

But for those primary-care providers facing financial difficulties in wake of payment cuts, it is about the money because they need it to keep their practices open.

One of providers' latest complaints is CoventryCares' recent limit on dispensing certain prescription pain killers, to a 15-day supply. The move was made "to curb the manipulations going on with opioid painkillers," said Russell Harper, the company's director of government relations.

Murphy said, "It's not everybody, but there are physicians that don't want to engage in health care." He acknowledged that the prior-authorization process between doctors and pharmacists can be a hassle, but it's just another facet of managing the health care of Medicaid patients. That, and saving money, are what managed care is all about.

Thursday, July 18, 2013

Seven Ky. communities get grants to reduce risks for chronic diseases among children and 'Invest in Kentucky's Future'

Seven diverse Kentucky communities are getting money to reduce the risk of chronic disease among Kentucky's youth. The initial grants announced Thursday are part of the Foundation for a Healthy Kentucky's new Investing in Kentucky’s Future initiative, a five-year, $3 million program.

“The health of our next generation is at stake,” said Susan Zepeda, CEO and president of the foundation. “Our goal is to help communities make positive changes in policies and service access that will help our children grow into healthy, productive adults. Regardless of the challenges, we want to help communities find new pathways to positive solutions.”

Community groups will use their initial grants to collect and analyze local health data. That analysis will guide development of innovative strategies for effective, sustainable measures to improve children's health. Those communities chosen for the initiative are:

Clinton County School District, Albany: initial grant of $27,755 for the Clinton County Healthy Hometown Coalition. “We are thrilled that our community was chosen to participate in this important initiative,” Asst. Supt. Paula Little said. “The members of the Healthy Hometown Coalition are committed to helping children grow up in a physical, social, and cultural environment that supports good health habits. With help from the foundation, we can develop our capacity to make a lasting, positive change in our community.”

• Fitness for Life Around Grant County, Williamstown: initial grant of $21,643 for FFLAG and the Northern Kentucky Health Department. “We are pleased and excited to be given the opportunity to work with the Foundation for a Healthy Kentucky,” FFLAG Chairman Jeff Walters said. “We are a small group that has been working on improving the health of our community and we believe we’ve had a positive impact thus far. This grant will accelerate the process and the work that’s been started.”

Foundation for Appalachian Kentucky, Hazard: initial grant of $32,558 for Perry County Wellness Coalition. “We’ve been working for several years to improve the menu and encourage better eating habits in and out of school,” said Linda Campbell, nutrition director at Perry County Schools. “It’s not as easy as changing a menu or just buying whole wheat bread. We’re changing a culture, and that’s not a simple thing. Working together, as a community, we can really start to make a difference. This grant from the Foundation for a Healthy Kentucky allows us to take the next steps toward helping our kids to become healthier.”

Green River Area Development District, Owensboro: initial grant of $40,483 for Partnership for a Healthy McLean County. “The Partnership for a Healthy McLean County realizes the impact community organizations, schools, work sites and health care have on the health of families,” said Jiten Shah, executive director of the district. "Obesity is a major factor for many chronic diseases which can begin in childhood and continue into adulthood. "

Kentucky Heart Foundation Inc., Ashland: initial grant of $19,245 for Healthy Kids, Healthy Communities in Ashland. “Investing in Kentucky’s Future is a perfect fit for the work of the Healthy Kids Coalition and gives us the opportunity to continue to work on policy, system and environmental changes to improve the health of children in Boyd and Greenup counties,” said Laura Patrick, coordinator of Healthy Kids, Healthy communities. “We know that this approach will help sustain change for years to come and what is great about it is that it is sustainable.”

Kentucky River Community Care, Inc., Jackson: initial grant of $34,156. “This foundation grant will help Breathitt County plan more opportunities for youth and families to participate in healthy lifestyle activities,” said Bridget Turner, KRCC director of clinical services. “We need to develop a strategic plan to specifically address the many barriers that face our children and threaten their future. Education, prevention, behavioral health, physical health, nutrition, employment, substance abuse are a few of the issues that we are trying to deal with in our county.”

Louisville Metro Department of Public Health and Wellness: initial grant of $34,160. “If we are ever going to realize a healthier future for our citizens, we must improve the health of our young people,” said Dr. LaQuandra Nesbitt, director of the department. “These funds from the Foundation for a Healthy Kentucky will facilitate a coordinated, systemic approach to overcome the health barriers that many of our youth face. The grant will allow us to formulate policies and strategies to improve health that are based on accurate data with buy-in from stakeholders across the community.”

Reducing chronic diseases to improve Kentuckians' health
Chronic diseases such as cancer, diabetes and heart disease, are those that last over time, decrease quality of life, increase the risk of early death and occur at higher rates in Kentucky than in surrounding states; substance abuse and some mental illnesses are also chronic diseases.

Kentucky’s children are at greater risk than most for chronic diseases, including high rates of obesity and smoking. When children grow up, they are at an increased risk for heart disease, cancer or stroke, and Kentucky is above the national average in deaths from these diseases.

The Investing in Kentucky's Future initiative will help Kentucky communities confront this cycle of problems. The foundation is encouraging local leaders to identify how best to engage the community in order to have the biggest impact.

“This is the first step in our multi-year approach, which will lead to implementation of permanent solutions for healthier communities,” said Zepeda. “We believe that by working together on the local level, civic leaders with vision can develop innovative strategies to improve the health of our children.”

More than 50 interested organizations responded to the foundation’s request for proposals in October last year, and 22 were invited to submit a full proposal. The foundation’s board of directors approved funding for seven as part of the initiative. Click here to read more about the foundation.

Study shows talking with college students about binge drinking makes them think about it

College students who hear warnings about binge drinking from family or friends are more likely to be concerned about their own alcohol use, compared to those who don't hear this advice, a new study indicates.

The study found that students who were not distressed about their binge drinking had not heard concern expressed to them about their alcohol consumption.

“On the other hand, when a friend or family member expressed concerns to a student about her or his excessive drinking, it can help the student reflect on their alcohol consumption and begin to take steps to reduce it,” said lead researcher Jeffrey Hayes, professor of counseling psychology in Penn State's College of Education, in a news release.

Despite the negative consequences of binge drinking, about 80 percent of college students drink alcohol, and about half of those who drink engage in binge drinking, says the National Institute on Alcohol Abuse and Alcoholism. Hayes said more than half of college students who sought counseling reported drinking alcohol at a level considered to be “hazardous” by the World Health Organization.

As a psychologist, Hayes often hears about the negative effects of binge drinking on students' academic performance and emotional and physical well-being. "I am aware of and concerned about the ingrained culture of binge drinking among adolescents," he said in the release.

Results of this study can help inform professionals who work with college students to encourage student engagement through outreach programs, and it also raises awareness for family and friends of those who may abuse alcohol, said Hayes. (Read more)

Wednesday, July 17, 2013

U.S. News gives Kosair Children's Hospital a national ranking; 11 other Kentucky hospitals make 'high-performing' list

Each year, U.S. News and World Report publishes its "Best Hospitals" guide for people seeking a high level of specialty care. The only Kentucky hospital to be nationally ranked in the report for 2014 is Kosair Children's Hospital in Louisville. It received national rank in these areas of specialty care: heart, lung, neurology, cancer, orthopedics and urology.

While no Kentucky hospitals were nationally ranked in adult specialty categories, 11 Kentucky hospitals made the cut for meeting standards of strong performance within the state:
     1. St. Elizabeth Edgewood - 11 high-performing specialties
     2. Baptist Health Louisville - 10 high-performing specialties
     2. University of Kentucky Albert B. Chandler Hospital - 10
         high-performing specialities
     4. Baptist Health Lexington - 9 high-performing specialties
     5. Jewish Hospital in Louisville - 7 high-performing specialties
     6. Norton Hospital in Louisville  - 5 high-performing specialties
     7. University of Louisville Hospital - 2 high-performing specialties
     8. King’s Daughters Medical Center in Ashland - 1 high-performing specialty
     8. St. Elizabeth Florence - 1 high-performing specialty
     8. St. Elizabeth Fort Thomas- 1 high- performing specialty
     8. St. Joseph East- 1 high-performing specialty

To read more about specialty rankings for each hospital, click here for an article in The Lane Report or here for the U.S. News report.

Kentucky among states selected to study, address expensive problem of 'superusers' of emergency rooms

Kentucky is one of a few states teaming up with the National Governors Association to address the expensive problem of uninsured or Medicaid-covered "superusers" who over-use hospital emergency rooms or other costly health services instead of lower-cost alternatives like primary care.

“I’m proud Kentucky has been chosen to participate in this important program,” Gov. Steve Beshear said in a news release. “Across the nation, an understanding has been growing that we must focus our efforts on providing the best in coordinated care, helping to direct individuals who may be using more expensive, less effective services to more cost-efficient preventive services that provide better health outcomes in the long run. It’s by achieving these outcomes that we will build a healthier future for Kentucky.”

Kentucky, Alaska, Colorado, Kentucky, New Mexico, Puerto Rico and West Virginia will participate in a policy academy designed to help them create systems for these "superusers", enabling state officials to confront rising Medicaid expenditures while improving quality of care and health, says an NGA release.

These "superusers," sometimes called "super-utilizers" or "frequent flyers," often go to a hospital or emergency room for recurring health issues that can be treated more effectively and less expensively in other ways. Kentucky Medicaid spent more than $219 million on emergency-room use in 2012, and 4,400 Medicaid recipients used ERs 10 or more times during that year, says Beshear's release.

“There’s a handful of people who drive most of our spending,” Dan Crippen, the executive director of the governors’ association, told Kelsey Miller of Kaiser Health News. While the median ER visit cost $615 in 2009, an office-based visit with a physician cost $361, according to the federal Medical Expenditure Panel Survey.

“Kentucky has too long lagged behind in health rankings, and now is the time for us to begin truly moving the needle in the right direction,” said Cabinet for Health and Family Services Secretary Audrey Tayse Haynes. “By participating in this national effort, we can learn what has worked for other states and share Kentucky’s experiences as well.”

State leaders will first meet as a group with consultants from various health-care sectors, then officials will spend 18 months implementing the plans in their communities, says Miller. Funding for the effort is provided by the Robert Wood Johnson Foundation and the Atlantic Philanthropies.

Tuesday, July 16, 2013

Online health-insurance exchange will differ in several ways from those in other states; scheduled to go online Oct. 1

Kentucky is one of 17 states setting up its own online health-insurance exchange under the Patient Protection and Affordable Care Act. A new report provides a limited update about the process, and reminds us that Kentucky doesn't have a long-term plan to pay for the Kentucky Health Benefits Exchange, branded Kynect and scheduled to go online Oct.1.

The state is writing regulations to govern the operations of the exchange, and "developing IT systems that house and execute the eligibility determination rules for exchange coverage, federal premium tax credits and cost-sharing subsidies, Medicaid, and the Children’s Health Insurance program" says the Georgetown University report, prepared for the Commonwealth Fund, which calls itself "a private foundation that aims to promote a high-performing health care system."

Most states are involving their legislatures in decisions about exchanges, says the report. This is not the case in Kentucky, perhaps because Republicans control the state Senate. Tea party activist David Adams has filed suit, challenging the legality of Gov. Steve Beshear's decision to implement the exchange without legislative approval. So far, a judge has denied the governor's request to dismiss it.

Even the exchanges with their own rulemaking authority like Kentucky have worked with the legislatures for other decisions, "such as the exchange's long-term financing mechanisms," says the report. The federal funding Kentucky is using to establish the exchange will be gone by 2015, but as of May 31, Kentucky and seven other states had no plans for a long-term revenue source.  Other states have either assessed insurers offering coverage on the exchanges or they are assessing taxes to cover the cost, says the report. Kentucky officials have indicated they will use assessments, but some Republicans have said that would be a tax, which only the General Assembly can impose.

The report also highlights the various approaches states have taken to toward selection of exchange plans. Kentucky is called a "market organizer," meaning that it "manages plan choices through limits on the number or type of plans that an insurer can offer but does not selectively contract with insurers," says the report. As required by the health-reform law, the Kentucky exchange will require participating insurers to offer at least "silver" and "gold" plans, and it is also requiring them to offer catastrophic coverage outside the metal-labeled tiers (which could have included "bronze").

Kentucky opted for no more than four plans per metal tier. Officials say limiting the number of plans will help consumers avoid being overwhelmed while giving insurers flexibility. Although the employer mandate to provide health insurance was delayed until 2015, Kentucky's exchange is still expected to offer multiple tiers through multiple insurers for employers to buy insurance, says the report.

On the advice of a 19-member board Beshear appointed to oversee the exchange, Executive Director Carrie Banahan has decided to not require plans to display quality metrics, as 10 other states plan to do, the report says. The board is chaired by Sharon Clark, commissioner of the Kentucky Department of Insurance.

The board and Banahan have gone against the grain on some other decisions. Most states are deferring to existing rules governing insurance agents; Kentucky is the only state requiring all agents to represent at least two insurers participating in the exchange.

In June, the state Cabinet for Health and Family Services issued a request for "Kynectors" to help Kentuckians shop for health insurance on the exchange. These employees and volunteers will help individuals and small businesses in determine their health-plan needs and help them choose plans to meet those needs, the cabinet said. To view the solicitation for Kynectors, click here.
The state is currently looking for exchange "kynectors"
Information for the report was gathered from minutes of the board.  Click here for a list of board members and here to view board meeting materials. Minutes of the May meeting will be posted after the board's next meeting on July 15, Midkiff said.

Dr. Hernandez, dead at 84, remembered as public-health leader, especially for women

Funeral services were held Tuesday, July 16, for Dr. Calixto “Carlos” Hernandez, a Cuban refugee who was a leader in Kentucky's public-health system and commissioner of the state health department from 1984 to 1992. He died Saturday, July 13, at the age of 84, of abdominal cancer.

Hernandez' s obituary said he was to have been the "head of all health resources" for Fidel Castro until he saw in 1957 that Castro's revolution would not be what he thought it would be. "The revolution turned out to be the biggest, bitterest disappointment of his life,” his widow, Jacqueline Hernandez, told Kevin Wheatley of The State Journal in Frankfort.

After an internship and residency in Louisville, he ran the Hardin County Health Department, became an American citizen, earned a master’s degree in public health from the University of California, Berkley, and joined the state health department. He was named its commissioner by Gov. Martha Layne Collins and kept the job under Gov. Wallace Wilkinson.

Wheatley reports, "Among his proudest achievements was a program providing mammograms to disadvantaged women, his wife said. Dudley Conner, who worked as a division director . . . said Carlos Hernandez was interested in women’s health initiatives and also launched programs focused on cervical cancer, preventive medicine and children’s immunizations, to name a few." Conner said, "He was very compassionate, kind-hearted, would help you do anything that needed to be done. He always was concerned about people and their public health."

Hernandez never fully retired, working as a medical consultant on Social Security disability cases, his widow told Wheatley. He is also survived by a daughter, Elena Hernandez Page; a son, Carlos Hernandez; and four grandchildren. (Read more)

Community-based solutions to childhood obesity show signs of progress elsewhere; will Kentucky pick up on them?

By Molly Burchett
Kentucky Health News

For decades, researchers reported with alarm the increasing trend of overweight children in America, with one in three kids on the way to developing Type 2 diabetes. Across the country, action has been taken to address this problematic trend, and now some preliminary, scattered results indicate that obesity rates have plateaued or dropped in some areas. Is Kentucky part of this success, and if not, will it learn from it?

The first set of positive signs came last year, with falling child obesity rates in New York City and Philadelphia, reports Lydia DePillis of The Washington Post. And, a recent Robert Wood Johnson Foundation brief shows similar progress in states with a large rural population as well:
  • Mississippi posted a decrease from 43.9 percent of kids being overweight and obese in 2005 to 40.9 percent in 2011, three years after passage of the Mississippi Healthy Students Act. 
  • In North Carolina, Vance and Granville counties saw significant declines after implementing healthy living programs based on the Centers for Disease Control’s community guide.
  • Kids in Kearney, Neb., in grades one through five saw a 13.5 percent decline in obesity rates between 2005 and 2011.
  • West Virginia fifth graders posted a 8.6 reduction in obesity rates over a six-year period.
Overall, progress was made through community-based solutions, including changes to make healthy foods available in schools while eliminating fried foods and working to integrate physical activity into people's daily lives while educating them about the importance of doing that, says the brief.

Kentucky, which suffers from one of the highest childhood obesity rates in the country, could learn from these successful programs. The state ties Mississippi for the highest percentage of youth in grades 9 to 12 that are obese (18 percent) and has the third highest percentage of children ages 10 to 17 who are obese (21 percent), compared to 16.4 percent nationally, says a report by Kentucky's Task Force on Childhood Obesity.

The Kentucky General Assembly has not enacted legislation regarding healthy eating and physical activity like many other states, notes a National Conference of State Legislatures report, but established a task force that made various recommendations to the legislature in September for strategies that address the problem of childhood obesity and that encourage better nutrition and increased physical activity among Kentucky children.

Some of the task force's recommendations include: requiring schools to improve nutritional content of school food, including promoting the use of school gardens, adopting a statewide standard for physical activity initiatives and nutrition education in schools and encouraging physical activity through a coordinated school health program. To view that report, click here.

Kentucky has no requirements for physical activity in schools. About 65 percent of Kentucky's youth did not attend physical-education classes in 2010, and 80 percent did not attend such classes five days per week, says a 2011 Center for Disease Control and Prevention survey.

However, the state does have several programs to promote physical activity or healthy eating. They includes the Farm to School program, which has been adopted by 1,243 schools and 174 school districts and is a collaborative effort between federal and state agencies to bring local agricultural products to schools and to educate students about local food production, says the report.

Using the success of other state programs and existing Kentucky programs as a guide, Kentuckians and "the members of the Task Force on Childhood Obesity are encouraged to continue their advocacy efforts to address Kentucky’s health crisis in ways that have the greatest likelihood of preventing and reversing chronic diseases associated with childhood obesity," says the report.

Kids' excessive salty snacks are linked to obesity, high blood pressure; new limits on school vending items may help

As new research shows that America's child-obesity epidemic is linked to eating too many salty snacks,  new federal regulations could ensure that vending-machine snacks in Kentucky's schools are healthier and lower in sodium.

Spurred by children eating too much salt and being too fat, "blood pressure in America's kids and teens has gone sky-high," creating a young generation at risk for serious health problems, including heart disease, stroke, reports Brian Alexander of NBC News.

“Kids eat far too much sodium,” the study's co-author, Dr. Stephen Daniels told NBC. “And they aren’t adding it at the table, and their parents aren’t putting it into food; they’re getting it through processed foods.” The research, published Monday in the journal Hypertension, links this rising blood pressure to children's increasing bod- mass index and sodium intake.

The "Smart Snacks in Schools" nutrition standards, announced last month by the Department of Agriculture, require any food sold in public schools to meet calorie, fat, sugar and sodium limits. The changes shouldn't be very significant for Kentucky students because the state already prohibits vending machine sales during the school day. And, a few existing state regulations, like fat content, are tougher than the federal changes and will remain in place, Sue Bartenfield, nutrition program manager for the Kentucky Department of Educationtold Stu Johnson of the Kentucky Public Radio bureau in Frankfort. The new federal limits on calories and sodium are tighter, and the federal law will also keep vending machines shut down for a half-hour after school, Bartenfield told Johnson.

Kentucky picks up on federal Medicaid funding for inmates, which will expand when health reform takes full effect

Medicaid now covers care for inmates outside
prisons and jails, and health reform will extend
coverage to most former prisoners upon release.
By Molly Burchett
Kentucky Health News

Kentucky has missed out on millions of dollars from the federal government by not having it help pay for institutional health care of prison inmates outside prisons and jails. When the Affordable Care Act takes full effect Jan. 1, most Kentucky inmates will be eligible for expanded Medicaid coverage of hospitalizations and nursing-home stays, and the state is planning to have the feds pay almost all the cost. That should have benefits beyond saving state and local tax money.

Only a dozen states have taken advantage of the 16-year-old option to stick the federal government with 50 to 84 percent of such costs, and Kentucky is not among them, reports Christine Vestal of Stateline. The option stems from a 1997 ruling by the Department of Health and Human Services that Medicaid could cover care for Medicaid-eligible inmates who leave correctional facilities for at least 24 hours for treatment in qualified hospitals or nursing homes.

State and local governments have legal obligations to provide adequate health care to prisoners; those tapping the federal funds (Arkansas, California, Colorado, Delaware, Louisiana, Michigan, Mississippi, Nebraska, North Carolina, Oklahoma, Pennsylvania and Washington), and some scattered local governments use Medicaid to pay for hospital and nursing-home care for those prisoners qualifying for Medicaid, reports Vestal.

Kentucky has mostly been paying for such care out of the state's General Fund rather than utilizing its ability to spread the cost via Medicaid. For most states and localities, not bothering to seek Medicaid reimbursement for prisoners is an omission "that deprives them of millions of dollars in potential federal reimbursement," writes Vestal.

Fourteen years after the ruling, in September 2011, Kentucky's Cabinet for Health and Services began picking up on the deal, and Medicaid paid for the first hospital stay for a Kentucky prisoner. "Since then, improvements have been made in the processing and coordination with the State Department of Corrections," said Jill Midkiff, the cabinet's director of communications.

Expanded Medicaid makes most inmates eligible

Ever since the 1997 ruling, it has made fiscal sense to get inmates who needed outside medical attention enrolled in Medicaid, which has historically been used for inmates who are pregnant or disabled. Midkiff said Kentucky's program has mostly covered pregnant inmates.  “But in 2014 it really becomes a no-brainer,” Aaron Edwards, a legislative analyst in California who helped get the state’s program started, told Vestal.

That’s when the major elements of the Affordable Care Act take effect, and Medicaid expands in Kentucky to cover individuals at 138 percent of the poverty line -- now $15,856 for an individual or $32,499 for a family of four. Most prisoners will then qualify for Medicaid, said Midkiff. "As a result, all state prisoners requiring a hospital stay who meet requirements for Medicaid eligibility should be covered," she said.

The federal government will pay all the cost of newly eligible Medicaid patients from 2014 to 2017, when Kentucky will increasingly pick up part of the tab, rising to 10 percent by 2020. One of the big changes involves the process to enroll Medicaid eligible inmates, which wasn't standardized before, and the Kentucky Health Benefits Exchange will make that process easier.

The state has projected General Fund cost savings from Medicaid coverage of inmates at $7 million to $8.4 million a year. Local governments will save money, too; the cabinet says it is working to ensure Medicaid enrollment is part of a standardized processes for jails around the state. For county-specific data about Medicaid expansion, click here for information prepared by the cabinet, which includes information about the benefit for county jails.

Prisoners' enrollment in Medicaid impacts the community in other ways. The health law requires coverage of behavioral health services, such as substance-abuse treatment and mental-health services. Upon release from prison, most inmates will have Medicaid coverage and access to these services, and studies have shown that access to services like substance abuse and mental health treatment reduces an inmate’s chances for recidivism, reports Mary Flynn of the California Health Report.

Most prisoners don't have health insurance upon release from prison, and studies show they do not receive treatment for chronic conditions but use expensive emergency rooms instead of primary-care doctors. Now, most will be covered by Medicaid and will have access to preventive services, reports Michael Ollove of Stateline.

Monday, July 15, 2013

Rushed transition to managed care is cautionary tale for other states, especially those with large rural populations

Since Kentucky's abrupt change to a Medicaid managed-care system in 2011, problems have been widespread among patients and providers, highlighting the dangers for other states, and especially rural ones, about a rushed transition to this model without sufficient preparation or oversight. Such problems could spread as Kentucky and some other states expand Medicaid under Obamacare.

“The Kentucky case is a harbinger of what can happen when states don’t allow enough time and devote sufficient resources to strengthen the Medicaid agency’s oversight capacity and systems — or develop strong contracts and care-monitoring systems from scratch if they haven’t contracted with managed care plans before,” Debra Lipson, a senior researcher at Mathematica Policy Research, told Jenni Bergal of Kaiser Health News, writing for The Washington Post.

Kaden Stone and mother, Angelina Alcott (Photo by Julie Bergal)
Patients in Kentucky's managed-care system complain of being denied treatment or having to drive long distances to find doctor's within their plans network. That's especially true of people in rural areas, such as Darlene VanHoeve in southeastern Kentucky, Bergal writes. VanHoeve has a son who needs treatment for autism at a center an hour away, but managed-care firm WellCare of Kentucky wouldn't pay for these services despite a physician's order, saying the center wasn’t in its network. In Greensburg, 8-year-old Kaden Stone loves playing baseball and riding his bike, but as a result of congenital bowel problems that have required dozens of surgeries and procedures, he needs PediaSure, his mother told Bergal. Yet, managed-care firm Coventry Cares stopped paying for it last fall, saying it was not “medically necessary.”

Hospitals and doctors have continuously voiced complaints about denied or delayed payments from managed care companies. Kentucky health officials admit there have been problems related to the speedy switch to managed care in 2011, writes Bergal, but they insist that claims are now being paid promptly. They also insist that providers meet with managed-care companies to claim outstanding payments and that care quality has improved in the state.

Advocates for the mentally ill argue that the care system for them has deteriorated, saying plans have denied patients' long-standing prescriptions, forcing some community mental health centers to limit or cancel programs, says Bergal. “The whole thing has been a mess,” Sheila Schuster, executive director of the Kentucky Mental Health Coalition, told Bergal.

As Medicaid rolls expand, those already in the program could be shut out of some of the key preventive services included in the new health law, says a recent study published in Health Affairs.

States that have phased in managed care more slowly have been more successful, so Kentucky's story is a cautionary tale for other states. “It was a significant challenge,” Michael Murphy, chief executive of Aetna-owned Coventry Cares, told Bergal. “Obviously, we learned a few lessons in Kentucky.” Perhaps this tale will keep other states from having to learn lessons too.

Eye exams are now required for children ages 3 to 6 when first starting public school or preschool

Add eye exams to your back-to-school checklist, because state law now requires children aged 3 through 6 who are entering a public school or preschool program for the first time to have a vision exam.

“Studies show that vision problems are a major factor in limiting children’s abilities to learn and succeed,” said Dr. Tonia Batts, a Mayfield optometrist, said in a news release from the Kentucky Optometric Association. “Having children’s eyes examined is one of the most important things parents can do to support their children’s education and good health. . . . Many problems may not be obvious to them or their children’s teachers.”

Early diagnosis and treatment can prevent loss of sight from amblyopia, which most people call "lazy eye." Half of amblyopia cases are not diagnosed until after age 5, when it is difficult to correct, Batts said. Amblyopia the leading cause of vision loss in people under age 40, more than injuries or any other disease, but if detected early, is 100 percent treatable.

Batts said an eye examination is particularly important if your child loses place while reading; avoids close work; tends to rub his or her eyes; complains of frequent headaches; squints to use only one eye or consistently performs below academic potential.

Eye exams are covered by many private insurance plans, Medicaid and the Kentucky Children's Health Insurance Plan. Private programs may also help families with eye exam expenses. The Kentucky Vision Project, sponsored by the Kentucky Optometric Association, has donated millions of dollars in vision care, says the group's news release. Sight for Students and the Lions Club have other programs that can help. To find an optometrist in your area, click here.

LaRue County High School collaborates with university and nursing home to offer nurse-aide training course

Fifteen students at LaRue County High School have signed up for a new nurse's aide class offered in coordination with Campbellsville University and a local nursing home through which students will earn a nurse certification. The class is being subsidized by the county school district.

The school board agreed on June 17 to pay $300 per student.  Although students accepted into the program will be expected to cover the remaining $200 of the course fee, grants are available to help them, and upon completion of the course, students will receive a certificate stating that they have completed some medical training, says Denise Skaggs, instructional supervisor for the school system.

"The course is titled as an SRNA (State Registered Nurse Aide) program; where students will learn skills involving senior personal care, mobility assistance, checking vitals (i.e. heart rate, blood pressure etc.) and minor medical equipment use and care," says Rebecca Roscoe of the LaRue County Herald-News.

Classes will be coordinated by Campbellsville University and held at the Brockman Center in Hodgenville and at the Sunrise Manor nursing home, where the course's required 16 clinical hours will take place, reports Roscoe. The hands-on clinical experience will be a great benefit, Skaggs said.

The idea for the course came from a survey in which 45 students expressed interest in a nursing program due to their interest in pursuing a medical career, Roscoe reports. Administrators talked to Taylor County school officials, who have implemented a similar program, to gain insight about launching their own program.  Thirty students applied and 15 students have been accepted by a review committee.

“I’m glad to see us offer something specific for our students that will help them achieve success in their future career,” Skaggs told Roscoe. “I think the program is a great addition because it speaks to our community … and now that we know the services that are available for us we want to take advantage of programs offered to benefit and increase our students success.” The program serves as a model for other public high schools to do the same.

Friday, July 12, 2013

As health care expands and more providers are needed, pressure grows to allow nurse practitioners more prescribing authority

By Molly Burchett
Kentucky Health News

As Kentucky expands Medicaid and implements the Affordable Care Act, more Kentuckians will have health coverage and access to care, worsening Kentucky's already existing shortage of physicians, particularly those providing primary care in rural areas. And, as the stakes get higher, so do tensions between physicians and nurse practitioners about how newly covered Kentuckians will receive their care.

Nurse practitioners say part of the solution involves removing their requirement to have a "collaborative agreement" with a doctor to write prescriptions. Nurse practitioners have been pushing for years to get rid of this requirement, saying they have the expertise to independently prescribe non-scheduled or routine drugs like cholesterol medications, reports Laura Ungar of The Courier-Journal in an article about the NPs' debate with physicians.

Doctors say collaborative agreements are necessary to protect patients, and call for a team-based approach to health care, writes Ungar. “My hope is the collaborative agreement will be strengthened,” Dr. Shawn Jones of Paducah, past president of the Kentucky Medical Association, told Ungar. “Certainly, physician manpower is an issue in Kentucky and in the U.S. ... but there’s not a great amount of evidence that collaborative agreements impair nurse practitioners from performing their duties.” But Ungar's story notes that NPs sometimes have trouble finding a collaborating physician.

Legislation to let NPs prescribe non-scheduled drugs without a doctor agreement passed the state House but failed in the Senate this year. The NPs aren't giving up, and many are working with state Sen. Paul Hornback, R-Shelbyville, on a similar bill for the next legislative session. Most agree that collaborative agreements are appropriate in the case of controlled substances, such as narcotic painkillers, but other wish to prescribe other drugs too, reports Ungar.

Seventeen states and the District of Columbia allow full prescribing authority for nonscheduled medications to nurse practitioners (see chart below), which means they do not require a signed agreement with a physician. Note that no Southern states allow nurse practitioners to work independently.

A recent report by Deloitte Consulting estimated that the state needs 3,790 more doctors just to meet current demand, which means this is what is needed even before considering the health law or Medicaid expansion. The report says that unlike the need for nurse practitioners, which is balanced between rural and urban populations, the state's doctor shortage occurs mostly in rural areas; the need was 61 percent rural in 2012 and is forecast to be 63 percent rural as Medicaid also expands.

The state needed 183 primary care physicians in 2012, and will need about 284 by 2017. The neediest counties are Bullitt and Spencer, which are close to Louisville. The need is heavily concentrated in the eight southwest border counties, and with Medicaid expansion, it will increase by 42 percent, says the report.

It's clear that large gaps appear in Kenucky's health-care workforce in Kentucky, particularly in rural areas, the Deloitte report says. A more detailed look at the county level is needed to determine the true workforce capacity issues, and can be done by provider type through an interactive tool the firm developed by clicking here.

The need for nurse practitioners in 2012 is relatively low compared to other groups -- 148, or 5 percent of the current supply, says the report. However, "If 6 percent of the current [NP] population were added to the current PCP [primary care provider] supply, the entire PCP gap could be addressed," the Deloitte report says. (NPs are generally referred to as advance practice registered nurses, or APRNs, as indicated on this map.)
To help address this overall provider shortage, Deloitte made 11 recommendations to the state, one of which included authority for nurse practitioners to prescribe less risky drugs without an agreement with a physician. This has been the issue debated by NPs and doctors at the legislature. The report says loosening collaborative agreements could do a lot to address the need for primary care. Giving nurse practitioners more authority has many benefits, including the fact that nurse practitioners who would be able to work more independently may be more likely to set up practice in rural areas.

Some other recommendations in the report include creating support programs for small practices in rural and under-served areas; considering limits on medical malpractice awards; expanding regional rural health tracks to get more new doctors to rural areas and keep them there; and increasing health-care degree and residency capacity across the state.