Monday, February 17, 2020

KET to air 'Undiagnosed: The Diabetes Epidemic' followed by a panel discussion about the disease on Monday, Feb. 24

Nearly half of Kentucky adults have diabetes or pre-diabetes -- and many of them don't know they have it.

To shine a light on this issue, Kentucky Educational Television is airing "Undiagnosed: The Diabetes Epidemic," a documentary that looks at the rising rates of diabetes and pre-diabetes in Kentucky, with a focus on what Kentuckians across the state are doing to reduce those rates.

More than one in eight Kentucky adults have been diagnosed with diabetes, according to the 2017 Kentucky Behavioral Risk Factor Survey. And 1.2 million, or 35.5 percent of the adult population, has pre-diabetes, a condition where blood glucose levels are higher than normal, but not yet high enough to be diagnosed as diabetes, according to the American Diabetes Association.


The 30-minute documentary will air Monday, Feb. 24 at 9 p.m., followed by a town-hall discussion with a panel of health and community officials, hosted by Dr. Wayne Tuckson of KET's "Kentucky Health."

Panelist include Dr. Connie White, deputy commissioner for clinical services with the state Department for Public Health; Dr. Fred Williams, a Louisville endocrinologist and a past president of the Kentucky Medical Association; Rev. Donald K. Gillett II, senior pastor at East Second Street Christian Church and the executive director of the Kentucky Council of Churches; and Richard Heine, co-facilitator with the Kentucky County Diabetes Coalition. 

The panel hits on a wide range of topics, including the importance of early screenings and interventions, the rise in diabetes rates among young people, the importance of communities to address this issue, and stigma about diabetes.

New federal policy means fewer life-saving liver transplants in Ky., say top medical officials at major universities, who are fighting it

By Mark Newman, Tom Miller and Kelly McMasters

A rushed proposal that became federal policy across the country this month will increase the cost and decrease access to life-saving care for patients in dire need of a liver transplant across much of the South and Midwest.

The result: People in Kentucky and largely rural areas of the country will be more likely to die because they won’t receive the care they need or would have had access to before this month.

As health care professionals and leaders of the state’s two academic medical centers, we are doing everything we can to delay or reverse this detrimental policy. Here’s what is happening and what is at stake for Kentucky:

On Feb. 4, the Organ Procurement and Transplantation Network, based on a recommendation from the United Network for Organ Sharing, implemented a new policy for how livers are allocated around the country for potential transplant. The OPTN sets transplantation policy at the direction of the U.S. Department of Health and Human Services.

The basic framework of this policy would mean more organs in rural states, like Kentucky, would be sent to larger inner-city medical centers that have higher populations. The idea was to create a policy that ensured more critically ill patients (within 500 nautical miles) received access to livers, rather than the patients in closer proximity.

While the transplant policy is well-intentioned, the fact is the governing board creating and directing the policy is dominated by officials from large urban, coastal areas. The resulting policy benefits those areas.

The process creating this program was rushed and the policy is deeply flawed.Even the framers of it concede there will be nearly a 30 percent drop in liver transplant volume in Kentucky as a result of this policy. We believe the drop will be even more significant, on the order of 40%.

Kentucky, as so many of us know, has a higher mortality rate for chronic liver disease such as cirrhosis than the national average. In rural areas of our state, the rate is even higher as access to care is more limited.

Several things -- all negative -- will occur in Kentucky and other rural areas of the country:
•This new policy will decrease access to livers for transplant even further.
•It will increase costs, the result of a more inefficient system because of rising costs for flights, fuel and transportation for Kentuckians and others who will have to travel farther to receive transplantation services.
•It will result in longer waiting periods and poorer health outcomes for Kentuckians and others who have to wait longer for donated livers.
•Others, who have to wait and who don’t have time, will be more likely to die.

We stand with a network of academic medical centers throughout the South and Midwest, including Emory University, the University of Michigan, Vanderbilt University and the University of Virginia, that have filed a lawsuit, asking to prohibit the federal government from implementing the policy. Although the federal court in Atlanta declined to stop the government from implementing the policy on Feb. 4, the fight is far from over.

We are continuing to ask the court to order the federal government to seek additional input. Ultimately, the federal government must craft something more equitable for everyone in America, not just those in larger cities or on the coasts.

We have received support from many federal policymakers, led by Senate Majority Leader Mitch McConnell. However, we continue to appeal to others to do what they can, with the voices and power they have, to prevent or reverse implementation of this ill-advised and biased approach to transplantation care.

We need, and respectfully ask, those in power to listen and act. For so many people, time is running out.

Mark Newman is chief executive of UK HealthCare; Tom Miller is chief executive officer of UofL Health; Kelly McMasters is chair of UofL's surgery department.

Saturday, February 15, 2020

Bills to help health departments with pensions pass House; some counties will have to increase their public-health taxes

By Melissa Patrick
Kentucky Health News

Two bills that were presented as part of a "three-phase approach" to create a sustainable solution to local health departments' pension crisis passed the state House Feb. 13. The third part of the plan involves the state budget.

The budget committee chair, Republican Rep. Steven Rudy of Paducah, cautioned House members that passage of the bills and the House's version of the budget, which will include funding for the bills, didn't mean the pension woes were over, because all of it must also be approved in the Senate.

"Our friends down the hallway will have a bite of this apple," he said. "So to put everybody's mind at ease, it's still a serious issue. We still don't have the permanent fix. But without Phase 1 and Phase 2, we can't get to phase three."

The first bill that passed would completely change the way health departments, regional universities and quasi-governmental agencies pay for their pension liabilities. It passed without dissent.

Rep. DuPlessis explains HB 171. (LRC Public Information photo) 
House Bill 171, sponsored by Rep. Jim DuPlessis, R-Elizabethtown, would move these entities away from the current "percentage of pay" formula, to a model that requires them to pay only what they owe the pension system, divided evenly over the next 27 years. This is often called "level dollar funding."

"This bill assigns their actual liability where they pay no more and no less that what they already owe," DuPlessis told Kentucky Health News in an interview.

The plan is also designed to keep employees in the system; many health departments have shifted to contract labor to reduce their pension payments. It would require all new employees to have a pension obligation of 10.35%, which is dubbed the "normal cost." So, in essence, the departments would get two pension bills to cover their pension costs, one for the unfunded liability for current and past employees and the other for new employees.

DuPlessis said these structural changes to the program will stabilize it. "If we don't take the bull by the horns and fix this, it's going to get to a point where nobody can make their payments," he said.

This proposal stems from a law that was passed during a special legislative session last summer, giving health departments, regional universities and quasi-governmental agencies the choice of staying in the Kentucky Retirement System and paying the full obligations or leaving the system, either by paying a lump sum or buying their way out over time. Those that choose to leave would need to move employees to a 401(k)-type plan.

The departments have said none of these choices are viable, and none have left KRS. The state Department for Public Health has said that without some relief from their pension obligations, dozens of health departments are at risk of closing.

Action is needed. The legislature has frozen health departments' pension contributions at 49.47 percent for the past two years, but on July 1, the day the next two-year budget starts, this is set to jump to 93%, a level many say would force them to close. Gov. Andy Beshear has proposed funding to make the effective rate 67%.

Rep. Joe Graviss, D-Versailles, one of the legislation's three sponsors, told House members that he was "extremely grateful" for the funding, "and I hope that we can keep and add to the money that the governor has allocated to help these organizations -- because they are going to need it. Let's not mince words, it is true, they will need some support."

An actuarial report shows that 14 of the 60 district and county health departments in KRS will owe more money under the 27-year schedule; the rest will owe less.

Randy Gooch, director of the Jessamine County Public Health Department, told Kentucky Health News Feb. 9 that about six departments would need state assistance to help pay pension obligations. He cautioned that this analysis has many moving parts.

DuPlessis told House members that while the original bill had language in it for a subsidy pool to help the entities that needed it, that language has been removed and that help will now be managed in the budget. "There will be a line item for every one of those entities and how much money they will receive," he said.

DuPlessis confirmed that the current plan is to help health departments that aren't able to meet their pension obligations, but in order for them to get that help, their counties must have a health tax of at least 8 cents per $100 assessed property value.

"So if you are below the 8 cents, you're going to have to raise your local taxes if you can't make your payments," he said. "That's fair because the local taxes will pay for the local service -- health departments are a local service."

The state has established a minimum health tax of 1.8 cents per $100 worth of property, with a cap of 10 cents per $100. Several public-health directors have said they have been told that only one county in a district health department would need to levy the 8-cent tax to qualify the district for state help.

A floor amendment was added to the bill that says any health department leaving its district would be responsible for its portion of the pension liability.

A spreadsheet of health departments and taxes that support each of them is at www.uky.edu/comminfostudies/irjci/Kylocalhealthtaxes.xlsx.

The second bill would overhaul the state's public-health system, including how health departments are funded and how they would prioritize their resources.

Rep. Moser presents HB 129.
(Photo by LRC Public Information)
House Bill 129, sponsored by Rep. Kim Moser, R-Taylor Mill, passed with a committee substitute on an 88-1 vote, with Rep. Chad McCoy, R-Bardstown, voting against the measure. It is meant to work concurrently with HB 171 and is called the Public Health Transformation Plan.

"Primarily, this creates sustainability of our health departments," Moser said. "It controls the cost and it relieves the instability that we are seeing now in the current system."

The current system funds each health department with the same formula, regardless of its ability to generate local funds. The new formula would take that into account, making it more equitable. In other words, departments that have more resources would get less state funding under this model.

The bill also identifies "core public health" services, which every health department would be required to provide and requires departments to perform community health assessments, which many of them already do, to determine their local public health priorities beyond the core requirements. These local priorities would have to meet certain criteria for the department to address them, and would need to be funded separately.

"This public health transformation initiative will result in a more simplified and a very focused public health model," Moser said. "It will prevent duplication of services. It encourages shared resources and it creates an expertise to really create that economy of scale or that fair and equitable system that we need across the state. This proposal will also increase accountability and transparency at both the state and the local levels within the system."

The bill codifies the existing 1.8 cents per $100 property tax as the floor, with a cap of 10 cents per $100. It also gives health departments one year to increase their environmental fees by up to 25% before the current 5% yearly cap is put back in place. This would allow health departments to bring those fees in line with what the service actually costs.

spreadsheet prepared by the Kentucky Health Department Association estimates that 14 of the 61 health departments would get less state funding, and the rest would get more, using a formula based on a county's population, its ability to support its health department with its current taxing authority, how many employees the county would need to provide only the health services required by law, and an estimated increase in environmental fees.

Moser said it is estimated that health departments' pension-liability contribution deficit could be as high as $38.5 million, and that "18 of our local health departments, which represent 41 counties, will face fiscal insolvency during the fiscal year 2020 without significant financial and operational changes."

Ky. flu cases creep up for the third week in a row; nine more Kentuckians have died from flu; it's not too late to get a flu shot

CDCP poster; for a larger version, click on it.
Kentucky Health News

Amid all the headlines about the novel coronavirus, health experts warn that there is a much more prevalent and potentially deadly virus killing people in Kentucky: influenza. Through the week ended Feb. 8, Kentucky had reported 17,203 cases of flu this season, with 50 deaths from it, four of them people under 18, according to the state Department for Public Health.

In an op-ed for the Lexington Herald-Leader, Dr. Brent Wright, president of the Kentucky Medical Association, and Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, reminded Kentuckians that it's not too late to get a flu shot to protect themselves from the virus.

They also noted that even if you get the flu, the vaccine helps decrease your symptoms. The annual shot is recommended for all over 6 months of age. They offered some practical advice to protect yourself and others:

"If you think you have the flu, consult with your physician as soon as possible, as there are antiviral medications available that can help. The flu is spread mainly through tiny air droplets, so be sure to wash your hands thoroughly, cover your mouth and nose when you sneeze and cough and avoid contact with others while you are sick."

The week ended Feb. 8 was the third in a row that flu cases have inched up in Kentucky, after dropping for three weeks in January.

The latest weekly report shows that Kentucky counted 2,101 new cases, a slight increase from the 1,815 reported the previous week and the 1,739 the week before that. The actual number of cases is higher because not all flu cases are counted; flu does not have to be reported, and five counties did not contribute to the latest report.

The state saw nine more deaths from the flu in the week ended Feb. 8; one victim was under 18. That brought the season total to 50.

Last year at this time, there were 9,263 cases of the flu reported in Kentucky and 25 deaths from it, including one under the age of 18.

Hotspots continue around the state, and while Perry County saw a bit of a reprieve in the Feb. 1 report, its numbers jumped up again during the week ended Feb. 8. It saw 76 new cases, for a total of 900. Pike and Barren counties continue to be hit hard; Pike added 152 new cases, for a total of 960; Barren added 188, for a total of 927. Bullitt County has added more than 100 cases at least two weeks in a row; most recently it added 105, for a total of 754.

Other hotspots: Allen added 39, for a total of 301; Garrard added 41, for a total of 120; Greenup added 59, for a total of 211; Hardin added 67, for a total of 221; Hart added 30, for a total of 179; Knott added 35, for a total of 267; Knox added 38, for a total of 85; Leslie added 39, for a total of 330; and Warren added 56, for a total of 640.
MMWR = Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention

Friday, February 14, 2020

As state works to secure Medicaid managed-care contracts, Senate passes bill to only allow three of them, down from five

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- Only three firms would get multi-billion-dollar contracts to manage Medicaid in Kentucky under a bill that passed the state Senate Feb. 12.

Five managed-care organization now oversee care for most Medicaid beneficiaries, and seven have submitted bids for the contracts that will be awarded later this year.

Sen. Stephen Meredith presents SB 30 to limit Medicaid managed-
care contracts to three.
(Photo from Legislative Public Information Office)
Senate Bill 30, sponsored by Sen. Stephen Meredith, R-Leitchfield, would limit the number of MCO contracts to three. The bill went to the House on a 29-7 vote after Meredith argued it is needed to reduce administrative burdens for health-care providers.

"Let's reduce the bureaucracy," said Meredith, a retired hospital administrator. "We don't need five managed-care organizations; they bring no value to the system whatsoever. All they do is deny and delay payment."

The bill has an emergency clause to make it take effect immediately if passed into law. That would keep the administration of Democratic Gov. Andy Beshear, which is working to secure its MCO contracts, from signing more than three.

Those contracts have already been offered once. Just days before Beshear took office, then-Gov. Matt Bevin's administration awarded the $8 billion in contracts to five insurance companies that excluded two companies with current contracts, Passport Health of Louisville and Anthem Inc., the state's largest health insurer. Both had said they would appeal the the awards. Beshear has since cancelled the contracts and reopened the bidding process.

Meredith has long lamented the burdens of manged care, particularly on rural hospitals, because they have such tight budgets. He said the United States spends 30 cents of every health-care dollar on administrative fees, five times what other industrialized nations spend.

And to those who would say, just fix the existing problems, Meredith pointed to a 2018 law that was supposed to improve the MCO credentialing and enrollment process, along with requiring monthly reports that showed claims, denials, and grievances. All those issues still exist, he said.

Minority Leader Morgan McGarvey, D-Louisville, voted against the measure and said that while he understands providers' ongoing frustrations, "My fear is that this bill wont' fix those problems."  He also did not like that this bill ties the hands of the executive branch.

Sen. Danny Carroll, R-Paducah, speaking for the bill, said that as someone who runs a small organization for children with disabilities, he battles with MCOs "every day" over wrongly denied claims and delays in payments. He said it would be helpful to only have to deal with three sets of rules, instead of five.

"It will make it less complicated. It will save money," Carroll said. "At a time when Medicaid reimbursements are so low, I think we owe it to providers at every level to allow them to save money wherever they can, and reducing administrative cost by limiting these numbers ... will allow money to be saved."   

Medical marijuana bill expected to pass House; Senate uncertain

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- A medical-marijuana bill described by supporters as one of the tightest in the nation is out of committee and is expected to pass the state House. The Senate is another matter.

Reps. Jason Nemes and John Sims Jr. presented the medical
marijuana bill, HB 136, in the House Judiciary Committee.
(Photo from Legislative Public Information Office)
"This is a question for the Senate," Rep. Jason Nemes, R-Louisville, told reporters after the House Judiciary Committee approved the bill. "It's going to pass the House; I have no doubt about it."

House Bill 136 , with a committee substitute, passed Feb. 12 by a vote of 17-1-1, with Rep. Joseph Fisher, R-Fort Thomas, passing. Fisher had expressed concern about people driving under the influence of marijuana and how this would be effectively managed.

Rep. Kim Moser, R-Taylor Mill, was the lone no vote. Moser, who has consistently said she would like to see more evidence-based research on medical marijuana that includes guidelines for prescribing, called the medical-marijuana laws in other states a "popular national social experiment."

Senate President Robert Stivers, who has long been the key obstacle to the bill in the Senate, reiterated Feb. 12 that he thought there could be a "path forward" for this bill in the Senate, though he said they haven't talked about this bill yet. (Later in the day, Nemes said he had a long, encouraging conversation with Senate Majority Floor Leader Damon Thayer.)

Stivers said that while he recognized that there are some real medical benefits to it, he said he wished the federal government would conduct a three-tier, double-blind study so that people would know how it really needs to be used.

House Concurrent Resolution 5, sponsored by Rep. Danny Bentley, R-Russell, asks the federal government to expedite research on the safety and efficacy of medical marijuana. It has passed out of the House and has been assigned to the Senate Health and Welfare Committee.

"It's a balancing test of: Do the goods outweigh the bads?" Stivers said.

Kentucky would be the 34th state, plus the District of Columbia, with legalized medical marijuana. So far, only 11 states and D.C. have legalized it for recreational use. A recent poll shows that 90 percent of Kentucky adults favor legalizing medical marijuana, or cannabis.

The latest version of the bill removed a list of conditions that could be treated with cannabis or its psychoactive ingredient, THC, and says any list of conditions will be determined by a panel of doctors and advisers established under the state health department.

Dr. Jeffrey Block, an anesthesiologist with the University of Miami, offered a short list of conditions for which there is conclusive or substantial evidence that THC is an effective treatment, including intolerable nausea or vomiting, intractable epilepsy, intractable chronic pain and intolerable muscle spasm, particularly from multiple sclerosis.

The bill wouldn't allow patients to smoke marijuana. Nemes said this concession was necessary to get votes, even though smoking is usually the quickest and most efficient way to get the drug into the system. It also does not allow colorful packaging or formulations that would be attractive to children.

Nemes said 13.5 percent of the money that comes in from the program would be used to help those who can't afford it get medical marijuana, since insurance won't cover it. Another 13.5% would go to law enforcement. The bill also includes an opt-in or opt-out provision for local governments.

Eric Crawford, an advocate for medical marijuana, told the group that an automobile accident in 1994 had left him paralyzed, and he used marijuana instead of opioids for his constant pain and muscle spasms.

"Narcotics make me out of my mind. They make me high and unable to function at all," he said. "Cannabis allows me to get out of bed and make the most of my life."

Crawford said if HB 136 became law, "I would not be a criminal. I would not have to live in fear. I would not have to lay awake at night worrying about law enforcement coming to my home. I would not have to stress about going to jail, or losing my home, work or freedom."

Joe Trigg, a 30-year veteran with 15 deployments, said, "Thousands of other veterans and myself would benefit from this bill." But he also said, "House Bill 136 can do better and should do better."

First, he said because it is written so tightly, it will likely result in higher prices and a larger black market. He also suggested that the rules against smoking and limiting growing are a result of lobbying, and said that rules on how it can be grown do not benefit Kentucky farmers.

Kent Ostrander of the Family Foundation of Kentucky, urged caution and called for more evidence-based research, saying, "We cannot use anecdotal based assumptions" when it comes to medications.

The bill would make marijuana legal medicine in Kentucky on Jan. 1, 2021.

Federal appeals court strikes down Medicaid work requirements

Gov. Matt Bevin announced his plan in 2016. (WFPL photo)
A federal appeals court ruled Friday against the work requirements that then-Gov. Matt Bevin tried to impose on Medicaid enrollees who were not "medically frail" and had no dependents.

The Trump administration was arbitrary and capricious when it approved Bevin's plan and one in Arkansas, a three-judge panel of the U.S. Court of Appeals for the District of Columbia Circuit ruled unanimously.

The U.S. Department for Health and Human Services essentially ignored the main purpose of Medicaid, which “was to provide health-care coverage to populations that otherwise could not afford it,” wrote Senior Judge David Sentelle, who was appointed to the court by Ronald Reagan.  The Trump administration is expected to ask the Supreme Court to hear the case.

The ruling upheld several by a judge in the D.C. District Court, which scuttled a program Arkansas had started and kept Kentucky's from taking effect. Democratic Gov. Andy Beshear, who defeated Bevin in the November election, rescinded Kentucky's plan soon after taking office in December. Republicans control the state legislature but have shown no interest in enacting Bevin's plan.

The plan had been challenged by 16 Medicaid beneficiaries in the state, who noted the Bevin administration's initial forecast that Kentucky Medicaid rolls would have 95,000 fewer people in five years than without the plan, in large measure because of noncompliance with the requirements to work, attend school or perform community service 80 hours a month and report monthly.

Bill to cap insulin co-pays in some health plans to $100 per month per prescription moves to full House with 74 sponsors

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- A bill to limit the cost-sharing requirements for insulin prescriptions has passed out of committee and is before the full House.

Charlotte Whittaker, Rep. Danny Bentley and Mary Beth Lacey
 present HB 12. (Twitter photo by Lawrence Smith, WDRB-TV)  
House Bill 12, sponsored by Rep. Danny Bentley, R-Russell, would require state-regulated health-insurance plans to cap a patient's cost for a 30-day supply of each insulin prescription drug at $100 "regardless of the amount or type of insulin needed to meet the covered person's insulin needs." The bill does not include Medicaid, Medicare or self-insured government plans.

Insulin is a hormone that regulates the amount of glucose in the blood, and a lack of it causes diabetes. People with Type I diabetes can't make any insulin so they must inject it to control their blood sugar -- and to stay alive. People with Type II diabetes, which is more common, can produce some insulin, but not enough. Type II is usually treated with diet, exercise and oral medications.

More than one in eight Kentucky adults have been diagnosed with diabetes, according to the 2017 Kentucky Behavioral Risk Factor Survey. In that year, diabetes was the fifth leading cause of death in Kentucky, according to the federal Centers for Disease Control and Prevention.

Bentley, who is a pharmacist with Type I diabetes, said HB 12 is supported by the American Association of Retired Persons, the American Diabetes Association, the Kentucky Medical Association, the Kentucky Pharmacy Association and Insulin4All.

Holding up a $290 box of insulin, Bentley said it's not uncommon for a person to use up to five boxes a month, which could end up costing about $1,200 monthly without insurance. The woman who loaned him the box said she paid about $300 a month for her monthly supply or about $3,600 a year, with help from insurance. But that does not include all the other supplies and equipment she needs to treat her diabetes, which also comes at a great, ongoing cost.

Bentley said in the last 14 years, the cost of insulin has gone up 550 percent.

In a detailed blog post about how this cap would help many thousands of Kentuckians with diabetes, Dustin Pugel of the Kentucky Center for Economic Policy reports that from 2012 to 2016, insulin prices at point of sale more than doubled in Kentucky, growing from $352 to $721 for a 30-day supply.

He adds that nearly one in three Kentucky adults with health insurance have plans with large cost-sharing requirements, whether it's in the form of a high deductible, large co-payment or a plan that covers only a fixed percentage of the cost through co-insurance.

The bill passed unanimously out of the House Health and Family Services Committee Feb. 13 with a committee substitute. Including Bentley, the bipartisan bill has 74 sponsors. If passed into law, it would go into effect Jan. 1, 2021.

Charlotte Whittaker, volunteer state president of AARP Kentucky, said older Americans with diabetes are hit especially hard with these growing cost, noting that Medicare Part D enrollees take an average of four to five prescriptions per month, with an annual income of about $26,000.

"Prescription drugs don't work if you can't afford them -- that's the bottom line," she said, later adding, "No Kentuckian should be forced to choose between putting food on the table or buying a lifesaving medication."

Mary Beth Lacey of the American Diabetes Association reminded the panel that people who need insulin need it to live and to avoid devastating complications, like blindness, kidney failure, lower limb amputation, heart attack, stroke and even death

Lacey, who described herself as a 43-year survivor of Type I diabetes, showed the committee a device that allows her to constantly monitor her insulin level through her cell phone. She stressed that such technology should be available to everyone, but isn't when people with diabetes are still simply trying to figure out how to pay for their insulin.

"We should not be struggling to stay alive, we should be thriving," she said, "Without insulin, people with diabetes die, and scaling back on insulin can lead to costly and sometimes deadly complications."

Research shows that about one in seven adults under 65 diagnosed with diabetes skipped doses, took less of their medicine or delayed filling a prescription to save money. Lacey said research shows that for one in four insulin users say cost has affected their use of it.

Lacey said 1.7 million Kentuckians either have or are at risk of having diabetes. The ADA estimates that the cost of caring for diabetes in Kentucky based on 2017 data was greater than 6.1 billion a year. 

"By keeping insulin affordable, we can help keep people with diabetes out of the ER and the hospital and away from expensive and potentially disabling or deadly complications," she said.

She added that the ADA would like to see a $100 a month collective cap, rather than a $100 per month per prescription cap.

Rep. Robert Goforth, R-East Bernstadt, said he would like to see assistance for people who have no insurance, which Bentley said was not addressed in this bill. Bentley said HB 423, sponsored by Rep. Steve Sheldon, R-Bowling Green, also addresses the cost of insulin and would help the cash customer. He added that House Bills 398, 399, 400 and 423 also deal with the price of insulin.

Sheldon, a co-sponsor of HB 12, called it a great first step.

"Drug pricing all across this nation has gotten completely out of hand," he said. "Until we get away from the way we price all drugs, it's going to be difficult and insulin is probably the most extreme example."

The bill's fiscal note estimates that capping the co-pay for insulin to $100 each month will increase premiums for health plans, excluding Medicaid and the state employee plan, 7 to 24 cents per member per month.

Asked who would absorb this, Sheldon said because insulin prices are so inflated and because so many groups have "their hands in the cookie jar," the industry "will find a way to eat that 24 cents for sure."

Saint Joseph Hospital listed as one of America's 250 best

Saint Joseph Hospital of Lexington announced Feb. 13 that it was the only facility in Kentucky to be included in the lost of "America’s 250 Best Hospitals" list by Healthgrades 2020 for the second consecutive year. "The distinction places Saint Joseph Hospital in the top 5 percent of nearly 4,500 hospitals assessed nationwide for its superior clinical performance as measured by Healthgrades, the leading resource that connects consumers, physicians and health systems," the hospital said in a news release.

“This is an honor for our highly experienced and dedicated physicians and employees, who make awards like this possible,” hospital President Bruce Tassin said. “We are committed to providing our patients with quality care and services, and to be recognized among top 5 percent of hospitals in the country to receive this award is exciting for us all. We cannot thank our team enough for their hard work and dedication. As Lexington’s first hospital since 1877, we are honored to continue serving this community more than a century later.”

From 2016 through 2018, Medicare patients in hospitals receiving the 250 Best Hospitals award averaged a 26.6 percent lower risk of dying than if they were treated in hospitals that did not receive the award, as measured across 19 conditions and procedures for which death is the outcome.

In addition to being named one of America’s 250 Best Hospitals, Saint Joseph also was ranked in the best 100 hospitals, the top 2 percent, for pulmonary and cardiac care. Its sister hospital, Saint Joseph East in Lexington, won a pulmonary care award for the last two years.

Thursday, February 13, 2020

Bills aimed at reducing youth 'vaping' pass first hurdles

By Melissa Patrick
Kentucky Heath News

FRANKFORT, Ky. -- Two House bills aimed at reducing teen use of electronic cigarettes have cleared committee and are before the full House. One would place a 25 percent tax on the products, which is projected to bring in nearly $50 million in the next two-year state budget; the other adds regulations aimed at making it harder for teens to obtain e-cigarettes.

Abby Piper, with Jefferson County Public Schools; state
Rep. Jerry Miller; and Bonnie Hackbarth, of the Foundation
 for a Healthy Kentucky, presented HB 69 in committee.
The sponsor of both bills, Rep. Jerry Miller, R-Louisville, says both bills are needed, to protect independent "vape" shops. House Bill 32 has the tax and HB 69 the regulations.

"These are two pieces of a whole," he said. "While 32 may hurt independent vape shops, HB 69 will help independent vape shops."

HB 69 would require makers and retailers of "enhanced vapor products" with flavorings, other than tobacco or menthol, to register with the state Department of Alcoholic Beverage Control and pay a registration fee of $210 per location annually.

The bill refers to e-cigarettes as "enhanced vapor products," but they actually produce an aerosol that contains volatile organic compounds, ultrafine particles, heavy metals and potential cancer-causing agents, not a vapor.

HB 69 would also prohibit registered retailers or manufacturers of e-cigarettes from selling them online, through catalog sales or by phone; prohibit home delivery by outside vendors; require real-time age verification for purchase through an electronic third-party source no later than Jan. 1, 2021; require flavored products other than tobacco and menthol, and those with more than 4% nicotine content to only be sold in "vape" shops; and authorize fines on any person under 21 who tries to purchase e-,cigarettes or related products.

Miller added that the bill also allows the state to track purchases back to the store that sold them as a way to thwart those who might buy them in bulk and then sell them to minors.

"This bill simply seeks to regulate a product which adults should be able to use, but is such that it is very prone to abuse by underage people," Miller said. "We have a crisis of youth using these nicotine products, and that's what this bill is about."

Data from Kentucky Incentives for Prevention survey, graphic from
from Sept. 18 Department for Public Health PowerPoint presentation
The Kentucky Incentives Prevention Survey found that from 2016 to 2018, Kentucky teens nearly doubled their e-cig use, with more than one in four high-school seniors and one in seven eighth-graders reporting use in 2018.

The House Committee on Licencing, Occupations and Administrative Regulations Committee approved HB 69 Feb. 12 with no dissent.

Kentucky Smoke-Free Association Board Chair Tony LeBlanc defended the industry, which he said is considered "evil" in the U.S., but promoted in the United Kingdom as 95% safer than cigarettes, and a way to quit smoking, citing a 2013 British study that he acknowledged some have disputed.

"We're doing everything we can to keep these out of teen hands, but I'm telling you right now, this is a device that is saving lives. It's saving lives and people are trying to tax it and ban it and smear it through the mud. I don't understand," he said.

The British study was debunked in a recent American Journal of Public Health article, which included an appendix of research to back up its conclusions. It said, "The evidence-lacking estimate derived in 2013 cannot be valid today and should not be relied upon further."

After the meeting, Bonnie Hackbarth, vice-president of external affairs at the Foundation for a Healthy Kentucky, pointed out that it is illegal in the U.S. to advertise e-cigarettes as a smoking-cessation device, citing the recent 700-page U.S. Department of Health and Human Services report that says more research is needed before it can be concluded that e-cigs help people stop smoking.

E-cigarette tax 

The day before HB 69 passed, HB 32 passed out of the House Appropriations and Revenue Committee with a committee substitute that would impose a 25% wholesale tax on e-cigarettes, instead of the 27.5% it first proposed.

The bill would also raise the wholesale tax for "other tobacco products," such as cigars, to 25% from the current 15%, and add e-cigarettes to that list. It would also double the per-unit tax on non-smokeable and chewable products, as was proposed in Democratic Gov. Andy Beshear's budget.

Miller said the aim of the bill is to decrease youth e-cigarette use. "The most effective way to attack use by those under 21 is through raising the price," he said.

Representatives from the Kentucky Smoke Free Association, which represents about 400 independent vape shops statewide, told the panel that while they support the added regulations in HB 69 because they address teen access issues, they do not support the tax because it would hurt their businesses, while doing little to hurt leading e-cig maker Juul Labs or grocery and gas-station chains, which will still be allowed to sell e-cigs with tobacco and menthol.

"It's going to do nothing but hurt them and increase the [money in the] pockets of companies like Juul, who can absorb a 25% tax easily," said LeBlanc, who spoke at both meetings.

(Juul is not happy with the bills; recently it sent a message to its customers asking them to reach out to their legislators in opposition of the bills. The website includes a link to a message that states opposition to the bills.)

The opponents said their goal is to help people quit smoking cigarettes, and argued that the tax would discourage adults who want to use them as a smoking-cessation device. Further, they said it will push teens into purchasing their products online.

Jason Underwood, a lobbyist for the group, cited a study by the National Bureau of Economic Research that found higher e-cigarette taxes could lead to increased cigarette smoking. The study looked at Minnesota data, which imposed a 95% tax on e-cigs, much higher than proposed here.

Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, endorsed the 25% tax.

"We know that raising the price of tobacco products is one of the most effective measures for reducing tobacco use," he said, adding later, "An excise tax of 25 percent of the wholesale price is close enough to the current tax on cigarettes and would lead to a substantial enough price increase to create a considerable reduction in youth vaping."

Rep. Lynn Bechler, R-Marion, who cast the only vote against the tax bill, said he didn't think this "sin tax" was warranted because people are already taxed enough. He added that he had taken the testimony of the "vape" shop representatives to heart.

"I don't want to put those people out of work," he said. "So if we're putting people out of work and the epidemic isn't going to lessen, I don't understand the reason to do it."

Beshear's budget recommends a small increase in the existing tax on cigarettes and other tobacco products and a 10-cent-per-milliliter tax on vaping liquids. These hikes are projected to raise $57 million over the next two years.

E-cigarettes are subject to the state's 6 percent sales tax, but that's all; they are the only tobacco product in Kentucky that does not have an excise tax.

State health department issues caution regarding flooding

With polluted floodwaters rising in Kentucky, the state Department for Public Health is reminding residents of how to deal with it in healthful ways.

“We urge Kentuckians to use caution in flooded areas, and once floodwaters recede and the clean-up begins, to keep yourself and your family safe,” said Rebecca Gillis, director of the Division of Public Health Protection and Safety. “Taking the time to follow safety guidelines related to food safety, mold removal and other issues helps prevent unnecessary injury and illness.”

The guidelines include:

Flood Waters
  • Flood cleanup poses risks of wounds, so cleanup workers should be sure that they are up-to-date with tetanus vaccinations, ideally before starting cleanup activities. Adults need a tetanus booster shot every 10 years. Td or Tdap can be used; getting the Tdap instead of Td for one tetanus booster during adulthood is recommended to maintain protection against pertussis (whooping cough). Being up-to-date for tetanus vaccine can greatly simplify wound treatment.
  • Flood-related drowning can occur when people become trapped by rising flood waters or when voluntarily enter flooded areas. Never enter flood waters unless you are escaping immediate danger. Do not attempt to drive a vehicle through flood waters, even if they appear shallow. Monitor the weather conditions and water levels to avoid becoming surrounded by water.
  • Floods can damage utilities, leading to downed power lines and a risk of electrocution. Stay clear of damaged power lines. Natural gas and propane systems can produce dangerous gas leaks. If you smell gas, open doors and windows and evacuate the area.
Home Clean-up and Mold Removal
  • Wear proper safety equipment, such as work gloves, boots, helmets, eye and ear protection, and chainsaw chaps when operating power tools or machinery.
  • Ensure that all electrical tools are properly grounded and use ground-fault interrupters if available. Never use electrically powered tools in or near standing water.
  • Homeowners whose homes sustained water damage are urged to follow recommendations to limit mold growth. Mold fungi can be found both indoors and outside, and can accumulate in homes affected by water damage.
  • Signs of mold include discolored walls, possibly showing water damage, or green or black spots on walls. Mold also has a musty, earthy smell or a foul stench. Allergy sufferers tend to be most affected by it.
  • If mold is growing in your home, you will need to clean it up and fix the moisture problem. Mold can be removed from hard surfaces with commercial products, soap and water, or a bleach solution of no more than 1 cup of bleach in 1 gallon of water. Severe mold cases may require an expert.
  • Doors and windows should be open while cleaning affected areas. Use protective glasses or goggles, rubber boots and waterproof gloves, and wash clothing afterwards. If there is heavy mold growth, use a respirator or suitable mask to prevent breathing the mold. Remove all wet items that have been wet for more than 48 hours and cannot be cleaned and dried.
Food Safety
  • Think about food safety if you have been affected by power outages. Keep freezers closed to maintain proper temperature for frozen foods. A freezer will hold its appropriate temperature for approximately 48 hours when full, and for 24 hours when half full. If you have power outages, it is best to keep freezers closed to help keep frozen food from going bad.
  • Refrigerated foods should be safe as long as power is out for no more than four hours. Throw away any perishable food in your refrigerator, such as meat, poultry, lunch meats, fish, dairy products, eggs and any prepared or cooked foods that have been above 40 degrees Fahrenheit for two hours.
For more on health issues and flooding, visit https://www.cdc.gov/disasters/floods/index.html or
https://healthalerts.ky.gov/Pages/FloodSafety.aspx.

List of top 100 rural hospitals by health-care analytics firm's rural-health center includes those in Cynthiana and Winchester

Clark Regional Medical Center in Winchester and Harrison Memorial Hospital in Cynthiana were named on a list of top 100 rural and community hospitals for 2020.

The Chartis Center for Rural Health, owned by health-care analytics consultancy The Chartis Group, announced the list today at the Rural Health Policy Institute's annual conference. The RHPI is part of the National Rural Health Association.

The hospitals on each list are grouped by state, but not ranked, so there is no single "best" hospital. The rankings are based on Chartis' Hospital Strength Index, which considers performance based on 50 rural-relevant factors in eight broad market-, value-, and finance-based categories.

At the RHPI's annual Rural Health Conference in May, Chartis will recognize the top 20 rural and community hospitals on the list.

McConnell throws cold water on bills to control drug prices, rein in surprise medical billing

Senate Majority Leader Mitch McConnell says divisions within his Republican caucus are keeping the Senate from taking up bills to control drug prices and surprise medical billing.

The Kentuckian spoke "hours after Sen. Chuck Grassley (R-Iowa) said he is gathering GOP support for his bill (S. 2543), and Senate Minority Leader Chuck Schumer (D-N.Y.) insisted that senators also get a chance to vote on House Democrats’ Medicare drug-price negotiation plan if the Senate takes up-drug pricing legislation," John Wilkerson reports for Inside Health Policy.

McConnell said, “We have internal divisions within my party in the Senate on both the Grassley bill and the bill that came out of the HELP committee on surprise billing,” referring to the Health, Education, Labor and Pensions Committee.

Wilkerson reports, "Legislation to control drug prices and curb surprise billing are supposed to help pay for renewing a group of popular health care programs called the 'extenders,' and McConnell said the Memorial Day deadline for funding those programs will 'generate another discussion' on both policies. However, he said the division within the Republican party and between the two parties makes it difficult to get a deal on drug pricing."

The House has passed a bill to let Medicare negotiate drug prices using international prices as a reference, and Senate Democrats support it. "The House bill is more aggressive than the Senate Finance bill, which would let drug companies continue setting launch prices but would make companies pay the government back when prices rise faster than inflation," Wilkerson reports.

“We’ve also told Leader McConnell that if he wants to bring any drug pricing proposal to the floor for a vote, we will demand a vote on H.R. 3,” Schumer said.

During the markup of the Senate drug pricing bill (S. 2543), Finance Committee Ranking Democrat Ron Wyden (OR) said Democrats planned to tie a vote on drug pricing legislation to a vote on letting Medicare negotiate drug prices. Democrats also insisted Senate Majority Leader Mitch McConnell (R-KY) allow a vote on preexisting conditions legislation prior to a floor debate on drug pricing. -- John Wilkerson

Wednesday, February 12, 2020

To thwart coronavirus, an undisclosed number of Centre College students are quarantined after returning from China

The building called Old Centre (A-M photo by Ben Kleppinger)
Several Centre College students who recently returned to the Danville campus from China have been quarantined as a precaution against the fast-spreading and sometimes deadly coronavirus, reports Robin Hart of the Danville Advocate-Messenger. 

Centre officials said in the first week of February that they were “keeping a watchful eye” on the students, as well as other students who studied abroad during the school's winter break, Hart reports. “On Saturday we received a recommendation from the Kentucky Department for Public Health, in consultation with the Centers for Disease Control, asking that those with recent travel history from China be isolated for a period of 14 days after their arrival,” Centre spokesman Michael Strysick said Feb. 12. President John Roush told students and staff Feb. 9, “This is 14 days from an individual’s time of arrival, not 14 days from today. . . . I want to be very clear that no one has the coronavirus or even shows any symptoms.

Hart writes, "Because of medical privacy laws, Strysick said he could not say how many students were quarantined. However, he did say that students will be able to continue with their classes."

Monday, February 10, 2020

Poll finds Ky. adults overwhelmingly favor legalizing medical marijuana; bill expected to be called up in committee this week

By Melissa Patrick
Kentucky Health News

As lawmakers move close to legalizing medical marijuana in Kentucky, a new poll shows that an overwhelming number of Kentucky adults would support such a measure, and that a solid majority would approve legalizing the drug under any circumstance.

The latest Kentucky Health Issues Poll found that nine in 10 of adults in the state favor legalizing marijuana for medical purposes and nearly six in 10 say it should be legalized generally. But when asked if they favored legalizing it just for recreational purposes, that number dropped to 49 percent.

Support for medical marijuana has increased since 2012, when 78% supported it for medicinal purposes, 38% supported it under any circumstances, and 26% supported it for recreational purposes.

Jennifer Chubisnki, vice-president of research and evaluation at Interact for Health, which co-sponsors the poll, said it was important to remember that the policy landscape around marijuana has shifted since 2012.

"In 2012, 18 states and the District of Columbia had legalized medical marijuana, compared to 33 states and the District of Columbia today," she said in a news release. "Further, in 2012, the first policies to legalize recreational marijuana were passed in Colorado and Washington state. Today, recreational use is legal in 11 states and the District of Columbia.”

The poll is timely since House Bill 136, the medical marijuana bill, is expected to be heard in the House Judiciary Committee on Wednesday, Feb. 12. Of the 100 members in the House, 50 are co-sponsors.

Rep. Jason Nemes
Republican Rep. Jason Nemes of Louisville, the bill's primary sponsor, said on Kentucky Educational Television Monday night that he thinks this is the year it will pass.

A medical-marijuana bill passed the House Judiciary Committee 16-1 last year, but with only five days left in the legislative session and opposition in the Senate, it did not get a vote in the full House.

Senate President Robert Stivers has said he wouldn't support a medical-marijuana bill without medical studies to back it up. He told reporters last month that there could be a "narrow path" forward for Nemes' bill, but it will be a balancing act to weigh the good and bad of passing such a law.

A companion bill has been filed in the Senate, Senate Bill 107, with 11 of the Senate's 38 members signed on as co-sponsors; its primary sponsor is Sen. Stephen West, R-Paris.

The poll found that support for legalizing marijuana was strong across party lines. Support for medical marijuana was the highest in each group, with 95% of Democrats supporting it, 92% of independents and 90% of Republicans.

Those numbers dropped in each of the groups when asked if they supported it under any circumstance, with 68% of Democrats, 59% of independents and 51% of Republicans saying they would favor allowing residents to buy and use marijuana under any circumstances.

Only 60% of Democrats, 54% of independents and 38% of Republicans said they would support legalizing marijuana for recreational use.

The poll's margin of error for the statewide results is plus or minus 2.5 percentage points. It surveyed a random sample of 1,559 Kentucky adults via landlines and cell phones Oct. 16 through Dec. 6,.

Four in 10 Kentucky adults said they knew someone who regularly used marijuana. This was the first time this question has been asked.

Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, which co-sponsors the poll, said the results were consistent with what the foundation learned at its annual forum in September, which focused on the public-health impacts of legalizing medical marijuana.

"What we heard at the forum, and what this poll confirms, is that support for medical marijuana is very strong, but we also learned that it's well ahead of the science showing that marijuana is safe and effective for most of the medical conditions claimed by pro-legalization advocates," Chandler said in a news release.

He added, "Despite the continuing lack of evidence, dozens of states have legalized medical marijuana. If Kentucky follows suit, our goal must be to put in place measures to protect the public health going forward."

He also cautioned that if such a law were to pass in Kentucky, safeguards must be in place to protect the state's youth, since legalizing marijuana, even for medical purposes, makes it more available and socially acceptable.

About 16 percent of Kentucky high school students use marijuana monthly, according to the 2019 Youth Risk Behavior Survey. That's down from nearly 29 percent in 1997, but the rate has held fairly steady over the past 15 years.

Nemes and others have suggested that medical marijuana could help decrease the use of opioids in the state.

Rep. Scott Lewis, R-Hartford, told Jacob Mulliken of the Owensboro Messenger-Inquirer, "I have had people that I trust tell me that there are a lot of medical benefits to it, and with the opioid crisis that we have -- if that can be prescribed instead, it would sure make a lot of sense. I intend on voting on it," he said.

Sens. Matt Castlen, R-Owensboro, and Robby Mills, R-Henderson, told Mulliken they did not see themselves voting in favor of the bill. Mills called it "poor public policy" and said, "I'm opposed to that bill and I still think that there are a lot of questions as far as legalization in any form."

Castlen told Mulliken he couldn't vote for the current form of the bill, and said it needs more research. "There is no doubt that this plant has benefits, but I need entrusted sources and would like to see our universities have the opportunity to do trials," he said. "No one has brought any university studies to my office and I need facts to make a decision. I couldn't support it as written."

One study suggests the number of opioid prescriptions declines when medical marijuana is legalized, but Shanna Babalonis, a nationally recognized researcher who spoke at the foundation's conference, cautioned that the study only shows a correlation, not causation.

The American Marijuana study compared the states' opioid-prescribing rate one year before legalization and one year after legalization. It found that out of 19 states, 15 showed a fall of opioid prescribing rate one year after legalization, and only four increased their usage.

"It just says that if you live in a state with medical marijuana, there are more/less opioids prescribed," Babalonis said in an e-mail. "We have no idea if this has anything to do with medical marijuana or opioid policy, physician training, addiction awareness, patients being worried about becoming addicted, etc."

At the September conference, Babalonis called for more randomized, well-controlled, well-executed, placebo-controlled research on the medical benefits on marijuana, stating that at this time, "There is no evidence that suggests cannabis can help with any aspect of the opiod crisis."

Babalonis is an assistant professor at the University of Kentucky medical school, in its Center on Drug and Alcohol Research. She has a doctorate in behavioral neuroscience and psychopharmacology.

Sunday, February 9, 2020

Pension bill has winners and losers among health departments; some counties may be asked to increase taxes to get state help

By Melissa Patrick
Kentucky Health News

Under a new pension funding proposal pending before the Kentucky General Assembly, some counties could be asked to increase their public-health taxes to help pay for their health departments' pension liability.

Reps. Graviss and DuPlessis tout their bill. (Photo by Melissa Patrick)
"Because we've been giving a free ride to some of these guys, they haven't had to go to their communities and ask for a tax increase," said Rep. Jim DuPlessis, R-Elizabethtown. "That needs to stop."

DuPlessis spoke Feb. 6 after the House State Government Committee unanimously approved his bipartisan bill to completely change the way health departments, regional universities and quasi-governmental agencies pay for their pensions.

The legislature has frozen health departments' pension contributions at 49.47 percent for the past two years, but on July 1, the day the next two-year budget starts, this is set to jump to 93%, a level many say would force them to close. Gov. Andy Beshear has proposed funding to make the effective rate 67%.

DuPlessis's House Bill 171 would move these entities away from the current "percentage of pay" formula and move them to a model that requires them to pay only what they owe the pension system, divided evenly over the next 27 years. This is often called "level dollar funding." "You pay what you owe, no more, no less," DuPlessis explained.

The plan is also designed to keep employees in the system; many health departments have shifted to contract labor to reduce their pension payments. It would require all new employees to have a pension obligation of 10.35%, which is dubbed the "normal cost." So, in essence, the departments would get two pension bills to cover their pension costs, one for the unfunded liability for current and past employees and the other for new employees.

Rep. Joe Graviss, D-Versailles, one of the legislation's three sponsors, said it will have winners and losers.

Randy Gooch, director of the Jessamine County Public Health Department, said under the proposed 27-year amortization schedule, about 45 of the 60 health departments in the Kentucky Retirement System would owe less money and about 15 would owe more -- and about six of them would need state assistance to help pay their pension obligation.

Gooch cautioned that his analysis involves "a lot of moving targets" and that it's important to keep an eye for the actuarial report on the bill, which wasn't available last week.

DuPlessis said legislators want to help health departments that aren't able to meet their pension obligations, but in order for them to get that help, their counties must have a public health tax of at least 8 cents per $100 assessed property value.

The state has established a minimum public-health tax of 1.8 cents per $100 worth of property, with a cap of 10 cents per $100. Several public-health directors have said they have been told that only one county in a district health department would need to levy the 8-cent tax to qualify the district for state help.

"We're not going to let the health departments go out of business," DuPlessis said after the meeting. "They're an integral part of the state. They are a statutory requirement of the state, and we're not going to let that happen."

At the same time, he said, "It's not fair for the state to keep sending money to people who aren't taxing those who they are serving. This bill says you pay what you owe. And for health departments that can still tax, they need to take care of it because they're supporting their local communities."

The committee removed language that would create an assistance fund to help struggling health departments and certain other groups pay their employer contribution rates. Rep. James Tipton, R-Taylorsville, assured colleagues that he would work to make sure that assistance was added in the Appropriations and Revenue Committee, where it is expected to go and where he is a member.

He said it will be the working group's recommendation for the A&R Committee to maintain the $50 million that is in the current budget to assist these entities, and to add another $50 million, as Beshear has proposed.

Jason Bailey, founder and executive director of the Kentucky Center for Economic Policy, said in an e-mail that a funding component is essential for the bill to work, since the costs are significant to protect the "losers" from unaffordable contribution levels.

"It’s important to note that funding will not just need to be there for this biennium but for the next few decades," he said. "By itself, it helps some, but deepens the problem for others."

The Kentucky River District Health Department would be a loser. Its public health director also stressed the importance of financial help from the state.

Scott Lockard
"As long as the funding is included in 171, we are very much in favor of it because it recognizes we can't raise it locally," Director Scott Lockard said. "If there is not a funding component . . . [House Bill] 171 closes our doors."

HB 171 would increase Kentucky River's pension liability to about $4.6 million, up from $2.6 million in the current funding arrangement.

"So if I was to try to pay my liability without a new funding source, it would literally close my doors in less than six months, with this increased pension liability," Lockard said.

Still, two of the seven counties in the district, Lee and Letcher, already have an 8-cent public-health tax, so it would qualify for state help under the suggested plan for fund distribution.

Dr. Kraig Humbaugh, director of the Lexington-Fayette County Public Health Department, said that while level-dollar funding will raise costs for his department, its fixed monthly payment is appealing. "We never know what our contribution is year to year, making it very difficult to plan or strategize," he said.

HB 129, the Public Health Transformation bill, which changes the way public health departments are funded, as well as how they prioritize their resources, would make local governments levy a public-health tax rate of at least 1.8 cents per $100, or equivalent alternative funding, which would be allocated toward basic programs.

Public health directors say passage of both bills is imperative.

"It is crucial for health departments that 129 and 171 are both passed," Lockard said. "They go hand in glove. So if 171 is passed without 129, then that is going to cause more financial hardship, and vice-versa. If 129 is passed, but 171 is not passed, then you're going to see health departments that are just not going to be able to meet that 93 percent" percentage-of-payroll pension funding.

Lockard added, "This will allow us to keep employees in the retirement system and not to contract out our future staffing needs because going forward our normal cost will be 10.35% for any employee. So I would start hiring all those employees back again and putting them in the retirement system that I'm now contracting out to a staffing company."

He said the bills "will allow my agency a path forward financially where we can take care of pension obligations and get the funding we need to focus on providing the core public health services to the people of Kentucky River District."

Rural hospitals will get millions in settlement being negotiated with state, but range of possible amounts is wide; will feds help pay?

Most of Kentucky's rural hospitals are in line for millions of dollars of taxpayer money to settle an old lawsuit with the state, but just how many millions is uncertain. So is whether the federal government will foot part of the bill, reports John Cheves of the Lexington Herald-Leader.

The 58 hospitals "won a series of court rulings finding their Medicaid reimbursement rates unfairly low from 2007 to 2015," Cheves writes. "Last year, a unanimous three-judge panel of the Kentucky Court of Appeals sided with the hospitals. The Cabinet for Health and Family Services erred during the administration of then-Gov. Steve Beshear, the current governor’s father, the appeals court found."

The cabinet has appealed to the state Supreme Court, which hasn't decided whether to take the case and has given the two sides extra time to negotiate a settlement.
State Budget Director John Hicks

After losing to now-Gov. Andy Beshear in November, then-Gov. Matt Bevin sent the legislature a budget memorandum that estimated the cost of the settlement at $426 million. But the budget the Democratic governor proposed to the Republican-controlled legislature estimates it at $61.9 million.

“The 420 was a number that never should have been revealed,” Budget Director John Hicks told the Senate budget committee Feb. 4. “It was some forecast of the prospect of the loss to the Commonwealth, and current events are proving that’s not likely to take place to any extent to 420 million.”

Cheves reports, "An attorney for the majority of the hospitals suing the state said the $420 million estimate depends on whether the federal government, through the U.S. Centers for Medicare and Medicaid Services, agrees to share in the damages alongside the state of Kentucky." Medicaid paid 71 percent of Kentucky Medicaid costs from 2007 to 2015.

Politics could play a role. After Donald Trump was elected president, Bevin and CMS worked to make unrelated changes in the program, but their effort to require work from able-bodied Medicaid beneficiaries was blocked by the courts, and Beshear rescinded it.

Kentucky's rural hospitals began objecting in 2007 to changes in their Medicaid reimbursements. In 2010, the cabinet began holding individual dispute-resolution meetings with them. “Rather than issuing dispute-resolution decisions, the cabinet waited until May 31, 2013, to write the hospitals letters (saying) that they did not have appeal rights and dismissing the same without administrative evidentiary hearings or further due process,” the Court of Appeals said in its decision. “The hospitals requested administrative hearings from the cabinet’s dismissal letters within 30 days pursuant to [state administrative regulations]. The cabinet responded to those requests with letters stating no administrative hearings would be conducted.”

The same day it dismissed the hospitals' complaints, the cabinet sued them, seeking a ruling to uphold its Medicaid reimbursement formula. The hospitals counter-sued, leading to a Franklin Circuit Court ruling and the Court of Appeals decision. "In October 2015," Cheves notes, "the cabinet replaced the Medicaid reimbursement rate methodology that led to the litigation with a new one."

Saturday, February 8, 2020

Latest flu report: Cases inched up again in Ky., and 8 more adults in state died from it; many schools close; flu shot is best defense


Kentucky Health News

New cases of influenza inched up again in Kentucky during the week ended Feb. 1, and eight more adults in the state were reported dying from it. So far, 41 Kentuckians have died from the flu this season, three under the age of 18, according to the state Department for Public Health.

The latest weekly report shows in the week ending Feb. 1, Kentucky counted 1,815 new cases, a slight increase from the 1,739 reported the previous week. During this flu season, 15,102 cases have been reported in Kentucky. The actual number is higher because not all flu cases are counted; flu does not have to be reported, and six counties did not contribute to the latest report.

The latest numbers show that the flu is at least twice as bad as it was last year at this time, when there were 7,285 confirmed cases of the flu, and 21 deaths, one under the age of 18.

Health officials recommend that everyone over 6 months old get an annual flu vaccination. It is not too late, since the season usually runs through May.

Schools across the state continue to cancel due to "widespread illness" Last week, Fayette County, one of the largest school districts in the state, canceled school for two days.

Lexington's WLEX-TV reported Wednesday, Feb. 5 that these county school districts in its market would close Thursday and Friday: Breathitt, Casey, Clark, Fayette, Floyd, Harlan, Jackson, Jessamine, Johnson, Knox, Leslie, Lincoln, Montgomery, Nicholas, Rockcastle, Russell and Scott. Burgin Independent Schools and Bath and Pulaski counties have also canceled classes due to widespread illness.

Louisville's WDRB-TV reported Feb. 6 that Elizabethtown Independent Schools and county schools in Barren, Gallatin, Hardin, LaRue, Taylor and Washington counties would be closed due to illness. The Louisville Courier Journal added Meade County to the list.

Hardin County Supt. Teresa Morgan said, “Student attendance numbers are not tremendously bad, but they certainly aren’t the best. Teacher attendance numbers are also below what we normally see. Other key members of our staff -- transportation, child nutrition, custodial, instructional assistants -- are also not able to come to school because of illness. We are hopeful that an additional day adjacent to the weekend will give everyone some extra time to get better."

Children between the ages of 1 and 10 have been hit the hardest, with nearly 6,000 of the state's 15,102 confirmed cases in this age group.

Hotspots continue around the state, but Perry County, which is one of the counties that has been hit hardest by the flu, saw a big drop in new cases during the week ended Feb. 1. It saw only 16 new cases, for a total of 824. Pike County is still being slammed, with 159 new cases for a total of 808. Barren and Warren counties continue to be hit hard; Barren had 144 new cases and Warren saw 82 new ones, for respective totals of 739 and 584.

Allen added 42, for a total of 262; Bullitt added 110, for a total of 649; Carter added 46, for a total of 88; Floyd added 46, for a total of 150; Greenup added 69, for a total of 152; Hardin added 46, for a total of 154; and Leslie added 36, for a total of 291.

MMWR = Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report

Friday, February 7, 2020

Most health departments support overhaul of their funding, though some would lose; spreadsheet lists estimated impact on all

The logo used by state and local health departments
By Melissa Patrick
Kentucky Health News

Driven by the state's pension crisis and a non-equitable funding model, Kentucky health departments warn that if the state doesn't change its requirements for how they prioritize available public health resources -- and how they are funded -- many of them will have to cut essential services, and half could close their doors.

Legislators and health-department officials are seeking a complete overhaul of the state's public health system, not only to help it survive in the face of a $40 million deficit in 2020, but also focus on core programs to improve the state's poor health outcomes.

"House Bill 129 codifies the prioritization of public health funding at every resource level -- state, local and federal -- to programs that provide the most significant opportunity to improve Kentucky's overall health," said Allison Adams, president of the Kentucky Health Department Association. "It also codifies the methodology in how that funding is distributed at the local level so that it is equitable at each county level."

The current system funds each health department with the same formula, regardless of its ability to generate local funds. The new formula would take that into account, making it more equitable, Adams said. In other words, departments that have more resources would get less state funding under this model.

A spreadsheet prepared by Adams' group estimates that 14 of the 61 county and district health departments would get less state funding, and the rest would get more, using a formula based on a county's population, its ability to support its health department with its current taxing authority, how many employees the county would need to provide only the health services required by law, and an estimated increase in environmental fees.

Several district health departments, which serve multiple counties, would get the largest annual increases. Barren River, which serves eight counties in Southern Kentucky, would gain $1,018,200; Lake Cumberland, which serves 10 counties to the east, would gain $1,377,842; and Elizabethtown-based Lincoln Trail would gain $1,054,679.

The 14 departments that would get less funding would be in Breathitt, Bullitt, Clark, Fayette, Franklin, Johnson, Knox, Madison, Marshall, Montgomery, Oldham, Whitley and Woodford counties, and the Wedco District Health Department, which serves Harrison, Nicholas and Scott counties. The losses range from $36,729  in Whitley County to a high of about $1 million for the Lexington-Fayette County Public Health Department.

Dr. Kraig Hambaugh, director of the Lexington agency, cautioned that the numbers in the spreadsheet are estimates, with many based on assumptions. He said that even with the predicted gains and losses, the model is designed to make sure every county's core public health needs can be met.

Humbaugh also stressed that the new model is just one part of the departments' funding puzzle, since it doesn't address their looming pension obligations. He said that if nothing changes before July 1, the beginning of the next fiscal year, the current pension obligation of 93 percent of payroll would make his department use about $6 million of its $17 million budget for retirement costs.

All that said, he recognized that his department would lose money under this new model, but said he still supported it.

"This shouldn't turn into an us-versus-them kind of game, one health department versus the other, because we're all part of one larger system that is designed to promote health in the commonwealth and to protect the public's health," he said.

He added that he felt HB 129 also shows legislators and the public that local health departments are willing to do their part to economize and use their resources wisely.

Adams said the association has been talking about this new funding methodology for about five years and that association members have had opportunity to vet it. Further, she said an over-whelming majority of the departments supported the new model during a roll-call vote.

"This is a funding methodology that provides equitable resources to all of our communities so that we can provide the most basic public health services at each county level," she said.

HB 129, sponsored by Rep. Kim Moser, R-Taylor Mill, passed the House Health and Family Services Committee, which she chairs, on Jan. 16. It is now in the Appropriations and Revenue Committee. The "Public Health Transformation" bill  has 20 bipartisian sponsors.

Pension woes

This new model has been in the works for several years, but gained momentum after health-department pension obligations were set to jump from 49.47% of payroll to 93%.

During a special session last summer, lawmakers gave health departments, regional universities and quasi-governmental agencies the choice of staying in the Kentucky Retirement System and paying the full obligations or leaving the system, either by paying a lump sum or buying their way out over time. Those that choose to leave would need to move employees to a 401(k)-type plan.

The departments say none of these choices are viable, and none have left KRS. The state Department for Public Health has said that without some relief from their pension obligations, dozens of health departments are at risk of closing.

Gov. Andy Beshear has proposed giving the departments about $16.5 million in each year of the budget as a way to freeze their employer contribution rate at 67.41% of payroll. The Democratic governor's proposal would have to be approved by the Republican-controlled legislature.

Lawmakers are working on another pension solution through HB 171, sponsored by Rep. Jim DuPlessis, R-Elizabethtown, which would change how health departments, regional universities and quasi-governmental agencies, pay for their pensions altogether. It would move away from the current  percentage-of-pay" formula and move to one that requires entities to pay what they owe the pension system over 27 years, which is often called "level dollar funding." It passed the House State Government Committee Feb. 6 and is expected to be sent to the Appropriations and Revenue panel.

What is Public Health Transformation?  

The new public health model calls for health departments to only be required to provide four "core public health" areas. They include services required by law or regulation; the federal Women's, Infants and Children nutrition program; the HANDS program, which stands for Health Access Nurturing Development Services for child rearing; and harm reduction and substance-use-disorder programs, including syringe exchanges.

"The programs that we've identified that are the most basic, which we call foundational services, are the programs that have been identified as comprehensive public-health systems," Adams said. "So if we provide those at every level, over time we should expect better health, better health outcomes and longer life expectancies."

The plan also requires departments to perform community health assessments, which many of them already do, to determine local public health priorities beyond the core requirements. Such priorities would have to meet certain criteria for the department to address them and would also need to be funded separately.

For example, a vaccination clinic run by the Todd County Health Department that serves only Amish and Mennonite families would be considered a local public health priority.

"It’s a niche need in Todd County that the public health department, because of strict state and federal funding guidelines, has struggled for years to fund," Alex Acquisto reports for the Lexington Herald-Leader. She notes that the program costs about $5,000 a year.

Photo by Silas Walker, Lexington Herald-Leader
The clinic serves about 3,000 people, or a fifth of the county's population, Acquisto reports, telling of  their monthly horse-and-buggy trips to the clinic to get vaccinations for their infants and toddlers, most of whom only speak Pennsylvania Dutch.

Until a decade ago, when the clinic started, virtually none of the Amish or Mennonites in the area were vaccinated. "If you have a fifth of your population who isn't vaccinated, then your whole public is at risk," Jennifer Harris, the health department's director, told Acquisto.

The bill would also allow health departments, for the first time, to refuse state program funding that their counties don't need in order to invest in the services they do need.

"Without passage of this bill, in Todd County, the Amish and Mennonite and public-school vaccination clinics would be some of the first services cleaved from the budget, because Harris can no longer afford them," Acquisto writes.

The bill also requires local governments to ensure a minimum public-health tax rate of at least 1.8 cents per $100 of assessed property value, or equivalent alternative funding, to be allocated toward foundational public-health programs.

And to help offset some of the added cost, health departments are asking for a one-year reprieve on a rule that restricts increasing environmental fees to no more than 5% each year. After that year is up, the statute would go back into place. This would allow health departments to bring those fees in line with what they actually costs, since they are currently subsidizing the difference.

At the committee meeting, Moser said, "The public health transformation initiative will result in a more simplified and a more focused public health model that prevents duplication, encourages shared responsibilities and resources and expertise to create economies of scale, a fairness across the state, and clearly defines the role throughout the system."