Tuesday, August 20, 2019

Health foundation offers new public-service announcements about dangers of teen e-cigarette use; free to anyone

The Foundation for a Healthy Kentucky has released four new public service announcements to show the dangers young people subject themselves to by using electronic cigarettes. The spots are part of the foundation's "I Just Didn't Know" campaign and feature Kentucky teens.

The new PSAs include two 30-second videos for television and a 30-second and 60-second audio PSA for radio. Additionally, the campaign provides PSAs that were released in April.The campaign materials are free to anyone who would like to use them.

In one of the PSAs, Hayley from Grant County says, "A lot of people don't know that one little pod of this e-cigarette is equal to a whole pack of cigarettes."

Research shows that public health campaigns can play a crucial role in reducing tobacco use among teens.

A study, published in the American Journal of Preventive Medicine, of the U.S. Food and Drug Administration's national tobacco public education campaign found that between Feb. 2014 and Nov. 2016, "The Real Cost" campaign prevented up to 587,000 youth from trying traditional cigarettes, half of whom might have gone on to become adult smokers, according to a FDA statement. This will result in a savings of more than $53 billion in future smoking-related costs like medical care, lost wages, lower productivity and increased disability, says the release.

"The Real Cost" campaign expanded to educate teens on the dangers of e-cigarette use in Sept. 2018.

"Over and over, we hear that teens -- and sometimes even their parents -- just don't understand the significant health risks of kids using these highly addictive tobacco products," Ben Chandler, president and CEO of the foundation, said in a news release about the four new PSAs. "We're doing all we can to help pass laws that restrict youth access, but we know that most kids are going to be making the final decision themselves. When someone leans over and urges them to buy an e-cig, we want to make sure they have a clear, factual understanding of all the reasons to avoid becoming a pawn of the tobacco industry."

A 2018 federal report said one in five high-school students and one in 20 middle-school students used e-cigarettes, a 78 percent jump for high schoolers over 2017 and a 48% jump for middle schoolers.

In Kentucky, a 2018 state poll found that 27% of high-school seniors reported using e-cigarettes, up from 12% in 2016.

E-cigarettes do not release harmless vapors, but instead contain substances such as: ultrafine particles, which can be inhaled deep into the lungs; flavorings such as diacetyl, a chemical linked to serious, irreversible lung disease; volatile organic compounds, which are known to be carcinogenic; other cancer-causing chemicals; and heavy metals, including nickel, tin and lead, according to the Centers for Disease Control and Prevention.

E-cigs also contain high levels of nicotine, which is highly addictive and can harm young people's brain development and reduce attention span and impulse control. Nicotine use in adolescence can also prime the brain for future addiction to other drugs, says the CDC.

One of the most popular e-cigarette brands with teens is the Juul, largely because they look like an oversized computer flash drive, are easy to conceal and come with flavorings. One Juul pod contains as much nicotine as a pack of 20 regular cigarettes.

"We regularly hear stories of kids using several e-cig juice pods a day, which means they inhale multiple packs of cigarettes worth of nicotine," Chandler said. "No wonder the FDA is investigating incidences of seizures associated with youth e-cig use."

On Aug. 7, the FDA announced that it was investigating 127 reports of seizures, tremors, fainting or other neurological symptoms that may be related to electronic cigarettes, and have asked anyone who has experienced such symptoms to report them.

All the PSAs can be found at www.ijustdidntknow.org. Contact Alexa Kerley at 877-326-2583 or akerley@healthy-ky.org for broadcast-quality copies.

Drug Free Lexington has also recently released PSAs aimed at educating e-cig users about their harmful effects are also free for all to use.

Sunday, August 18, 2019

Rural coroner made the tough calls on his town's opioid epidemic

Coroner Steve Talbott, in his funeral home
(Photo by Michael S. Williamson, The Washington Post)
How many rural coroners, witnessing death after death from opioid overdoses, would call police in an effort to see how their county was being inundated by the misused prescription drugs? We don't know the answer to that question, but we do know what funeral director Steve Talbott, the elected coroner of Clinton County for the last 25 years, did. He made the calls, and one result was the conviction of a local physician who shared a building with the pharmacy that dispensed more opioids per person per county in 2006-12 than any in the U.S.

Jenn Abelson, Andrew Ba Tran, Beth Reinhard and Aaron C. Davis of The Washington Post reported the story last week, following the Post's publication of other stories drawing on the Drug Enforcement Administration database for those years. Their story is a look at the opioid epidemic from the bottom up, in Albany, Paintsville and Booneville; Kanab, Utah; and Carthage, Tenn., where pharmacies were funnels for large volumes of painkillers.

When Talbott responded as coroner to an overdose death, the Post reports, "Friends and relatives of the dead rarely had answers to Talbott’s questions: What kind of pills did they take and where did they come from? A toxicology report often answered the first question. It was the second one that typically eluded Talbott. As overdose deaths soared, Talbott repeatedly called the state police, hoping they could identify the source of opioids poisoning his community."

Clinton County (Wikipedia map)
Since 2006, 41 people have died of prescription opioid overdoses in the county of 10,000. Talbott told the Post that law enforcement took far too long to pay attention. "The federal investigation began in 2015 after Talbott noticed multiple overdose deaths involving patients of a local physician, Michael L. Cummings, and the Kentucky Board of Medical Licensure expert found Cummings’s treatment of several patients fell below minimum standards of care, court records show," the Post reports. "In 2017, Cummings was charged in federal court with the illegal distribution of controlled substances, which resulted in the deaths of three patients." He pleaded guilty in March to 13 counts of illegally prescribing controlled substances, and was sentenced July 24 to 30 months in prison and fined $400,000. Cummings had his medical practice in the same building as Shearer Drug, operated by Kent Shearer, who declined to comment.

The Post reports, "The 6.8 million opioid pills bought by Shearer Drug from 2006 through 2012 accounted for 66 percent of the total ordered by the county’s five pharmacies, according to The Post’s analysis." When Talbott heard those figures from the Post, he told the newspaper: “It’s a lot of pain medication for this little town.”

"Talbott, who said he grew up with Shearer and attended the same school, hasn’t talked to the pharmacist in a few months," the Post reports. "Talbott said the overdose deaths have waned since Cummings was indicted in 2017, but the epidemic is far from over." He told the paper, “There were just too many people dying from these drugs in such a small place. I hate these drugs. They are awful.”

Saturday, August 17, 2019

State denies Planned Parenthood abortion-clinic permit

Republican Gov. Matt Bevin's administration has denied an abortion-clinic license to Planned Parenthood in Louisville, saying it performed abortions without proper authorization from the previous administration, as Democrat Steve Beshear was leaving the governor's office.

Health Secretary Adam Meier told Planned Parenthood in a letter Friday that the 23 abortions it did in December 2015 and January 2016 were a "substantial failure" to comply with state law. Planned Parenthood said it would "continue to fight this decision."

"The decision comes amid an ongoing federal court battle in which Planned Parenthood alleges state officials, under Bevin, an anti-abortion Republican, are deliberately obstructing its efforts to get a license for abortion services," report Deborah Yetter and David Harten of the Courier Journal.

"Planned Parenthood officials produced documentation from state officials directing them to open the clinic and begin providing all services, including abortions, so it could be inspected and granted a license. But the license had not been issued when Bevin took office in December 2015. His administration ordered Planned Parenthood to stop, saying such abortions were not authorized without a license. Planned Parenthood immediately stopped providing abortions as it continued with its license application."

The application languished, and in June U.S. District Judge Greg Stivers in ordered the state to expedite its review "and report back to him no later than Aug. 19 with a decision," the CJ notes. On Friday, Bevin's office told Stivers that he has "no jurisdiction over the state licensing process."

The administration first refused to grant Planned Parenthood a license on grounds that it lacked adequate agreements with other health-care providers. Meanwhile, it tried to revoke the license of Kentucky's only operating abortion clinic, EMW Women's Surgical Center in Louisville, claiming its transfer and transport agreements were deficient. Stivers ruled that the law requiring such agreements is unconstitutional; his ruling is on appeal.

Friday, August 16, 2019

Rural hospitals are likely to be hurt by limit on payments to those with large shares of Medicaid and uninsured patients

Many if not most rural hospitals are likely to take a hit from an Aug. 13 decision of the U.S. Court of Appeals for the District of Columbia Circuit.

"Hospitals that care for a large share of Medicaid, low-income and uninsured patients stand to receive less funding from the federal government after the D.C. Circuit reconsidered how Medicaid disproportionate-share hospital reimbursement is calculated," Alex Kacik reports for Modern Healthcare. "A three-judge panel . . . reversed a lower court and reinstated a 2017 rule establishing that payments by Medicare and private insurers are to be included in calculating a hospital's DSH limit, ultimately lowering its maximum reimbursement."

Hospitals qualify for disproportionate-share payments if they get a significant portion of their revenue from Medicaid, which usually doesn't cover the cost of care. And rural hospitals are more likely than others to fall into that category.

The Centers for Medicare and Medicaid Services issued a rule in 2017 rule saying Medicare and private-insurance payments must be included when calculating the maximum disproportionate-share payment, part;y "to prevent hospitals from double-dipping by collecting DSH payments to cover costs that had already been reimbursed," Kacik reports. "Previous cases also revealed that some states have made DSH payments to state psychiatric or university hospitals that exceed the net costs, or even total costs, of operating the facilities."

Four children's hospitals in Minnesota, Virginia and Washington, along with eight children's hospitals in Texas, filed suit to challenge the rule, saying CMS had overstepped its authority. The next step in the case could be an appeal to the Supreme Court or a hearing by all the judges on the appeals court, either of which could be denied without further hearings.

'Juul-alikes' fill niche left when firm stopped selling some flavors; Drug Free Lexington releases videos aimed at e-cig users

New York Times photo by Brittainy Newman
Pressed by the chief of the Food and Drug Administration last fall, Juul Labs "stopped selling most of its hugely popular flavored nicotine pods in stores last fall," but now other companies are "trumpeting their own fruity and candy-flavored pods as compatible with Juul devices," Sheila Kaplan reports for The New York Times. That illustrates "just how entrenched the youth vaping problem has become, and that voluntary measures are unlikely to solve it."

Chris Bostic, deputy director for policy of Action on Smoking & Health, told Kaplan that the FDA “needs to step in,” but the agency's willingness to do that has been unclear since Scott Gottlieb left the commissioner's office. He had proposed requiring that stores put flavored electronic cigarettes, except menthol, mint and tobacco flavors, "to areas off limits to minors," Kaplan notes. "But the details of the proposal were vague, and with Dr. Gottlieb’s departure, it’s unclear how federal policy might change." Acting Commissioner Norman E. Sharpless has said he is working on the plan.

The company has filed lawsuits and international-trade complaints against other companies’ "Juul-alikes" but "says it still has the legal right, under FDA rules, to bring back dozens of its own sweet flavors that it once sold in very limited release. They include varieties of watermelon, strawberry and melon, which competitors are already selling, as well as specially designed concoctions: Coconut Bourbon, Elderflower Fizz, Mimosa and Thai Tea, and others," Kaplan writes. "In April, Juul told Congress it had no intention of bringing those flavors back in the United States."

A poll last year showed that 27 percent of Kentucky high-school seniors reported using electronic cigarettes, up from 12 percent in 2016.

Meanwhile, Drug Free Lexington has released three "public service announcements" about Juuls. "These fast-paced, fact-based PSAs, designed to target parents, teachers, administrators and other working with youth, are free for all to use," the Foundation for a Healthy Kentucky reports. "These short ads provide insight into the chemicals in Juul and their harmful effects, the rising popularity of Juul, why youth may be more susceptible to e-cigarette use and addiction, and why e-cigarettes are especially damaging for teens including negative health costs and long-term adverse health effects."

Thursday, August 15, 2019

FDA proposes new, graphic warnings for cigarette packs and ads

A Food and Drug Administration photo illustration shows three  of the 13 proposed warnings.
The Food and Drug Administration has again published a proposed rule to "require color graphics depicting the negative health consequences of smoking be added to cigarette packages and in cigarette advertisements," Inside Health Policy's Beth Wang reports.

The warnings would be the first update to cigarette package warnings in more than 30 years. They were authorized by a 2009 law, but a tobacco-company lawsuit blocked FDA's first attempt.

Wang describes the proposed warnings:

Tobacco smoke can harm your children,” with an image that shows the head and shoulders of a boy 8 to 10 years old, wearing a hospital gown and receiving a nebulizer treatment for chronic asthma.

Tobacco smoke causes fatal lung disease in nonsmokers,” with an image showing gloved hands holding a pair of diseased lungs containing cancerous lesions.

Smoking causes head and neck cancer,” with an image showing the head and neck of a woman 50 to 60 years old who has a tumor protruding from the right side of her neck, just below her jawline.

Smoking causes bladder cancer, which can lead to bloody urine,” with an image of a gloved hand holding a specimen cup with bloody urine.

Smoking during pregnancy stunts fetal growth,” with an image of an infant on a medical scale with a digital display reading 4 pounds.

Smoking can cause heart disease and strokes by clogging arteries,” with an image of a 60- to 70-year-old man with a large, recently sutured incision in his chest as he undergoes monitoring.

Smoking causes COPD, a lung disease that can be fatal.” There are two versions of the COPD warning. One will have an image of gloved hands holding a pair of diseased, darkened lungs removed from a smoker; the other will have an image of the head and neck of a 50- to 60-year-old man who has a nasal canula under his nose supplying oxygen, with the oxygen tank behind him.

Smoking reduces blood flow, which can cause erectile dysfunction,” with an image of a 50- to 60-year-old man sitting on the edge of a bed and leaning forward with one elbow resting on each knee. The man’s head is tilted down with his forehead pressed into the knuckles of his right hand while his female partner sits behind him on the bed, looking in another direction.

Smoking reduces blood flow to the limbs, which can require amputation,” with an image of feet with several toes amputated due to damage resulting from peripheral vascular disease caused by smoking.

Smoking causes type 2 diabetes, which raises blood sugar,” with n image of a personal glucometer device showing a high blood sugar level.

Smoking causes age-related macular degeneration, which can lead to blindness,” with the image of a senior man getting an injection in his right eye to prevent additional macular degeneration.

Smoking causes cataracts, which can lead to blindness,” with the image of a man who is at least 65 years old who has a cataract covering his right pupil.

A lawsuit by public-health and anti-smoking advocates prompted FDA to issue the proposal, Wang notes: "The proposed warnings are required by law to be displayed on half the front and rear panels of cigarette packages, and on the top 20% of the area at the top of advertisements.

"This marks the second time FDA has issued a proposed rule to require graphic warnings on cigarette labels and advertisements," Wang notes. "The first rule was blocked in 2012 by the U.S. Court of Appeals for the District of Columbia in R.J. Reynolds Tobacco Company v. FDA, which argued the proposed rule violated the First Amendment by not justifying why there is a need to issue regulation on commercial speech. In March, however, a federal court ordered FDA to issue the proposed rule by Aug. 15, and a final rule by March 15, 2020."

The Family Smoking Prevention and Tobacco Control Act of 2009 "required nine new health warning statements to be included on cigarette packages and in cigarette advertisements, and it directed FDA to develop color graphics depicting the negative health consequences of smoking to accompany warnings," Wang notes. "After having their initial proposed rule rejected by the court in 2012, FDA undertook a research and development process to consider whether the TCA’s textual warning statements would promote greater public understanding of the risks associated with smoking. Through that process, FDA determined there was support to propose adjusting some of the TCA statements. FDA ended up with 16 statement-and-image pairings to test in a final quantitative consumer research study, which resulted in the 13 cigarette graphic health warnings listed in the proposed rule."

The poorer the household, the more likely its kids are to inhale secondhand smoke; Ky. is poor and has 2nd highest smoking rate

Study charts show less exposure among older youth, who tend to spend more time outside the home.
Children who live in poverty are nearly three and a half times more likely to be exposed to secondhand cigarette smoke than their counterparts in high-income households, a new study says.

The National Health and Nutrition Examination study, released by the National Center for Health Statistics, found that from 2013 to 2016, nearly 55 percent of children aged 3 to 17 whose families are below the federal poverty level were exposed to secondhand smoke. That was the case for only 16 percent of those living in well-to-do households, those with incomes at or above 400% of the poverty level, which for a family of four is income of $103,000 a year.

Secondhand smoke exposure is defined by the presence of a metabolite of nicotine, in blood, urine or saliva. African American youth, at all income levels, had the highest levels of exposure; overall, 62% were exposed. After declining for decades following the 1980s, these percentages have remained steady in recent years; Kentucky has the nation's second-highest adult-smoking rate, 26%, and its household-poverty rate of 17.2% is the fifth highest among the states.

"These children and teens are sicker, they miss more days of school, and they're at higher risk for heart disease, stroke and lung cancer as adults," said Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky. "One of the most important health benefits of Kentucky's new tobacco-free schools law is that it reduces kids' exposure to secondhand smoke where they spend a significant chunk of their time, both during the school day and at after-school events. We urge every Kentucky school district to move quickly to adopt and implement a tobacco-free policy in compliance with the new law." The law takes effect statewide in August 2020, except in school districts that opt out of it.

Federal grant will let former Gov. Fletcher start treatment and housing for addicts in 101 rural counties in 8 states, 47 in Ky.

Dr. Ernie Fletcher spoke in Owensboro last year about
his plan to take the Recovery Kentucky concept beyond
Kentucky. (Photo by Alan Warren, Messenger-Inquirer)
An organization headed by former Kentucky governor Ernie Fletcher will get $6.6 million in federal funds "to establish a center of excellence for substance-abuse disorder and . . . provide treatment and housing options for low-income and high-risk individuals in 47 Kentucky counties," Senate Majority Leader Mitch McConnell of Kentucky said in a press release Aug. 15.

The money comes from the Rural Communities Opioid Response Program of the Department of Health and Human Services. It will go to the Fletcher Group, "which has partnered with the University of Kentucky to establish an opioid response program and will maintain its headquarters in rural Kentucky, the release said. "Its work will target 101 rural counties in eight states."

The group's chair and chief medical officer is Fletcher, a physician and Republican who was governor in 2003-07. He said in the release, “Leader McConnell has been a tireless champion fighting against the opioid crisis facing Kentucky and many other parts of the country. His support for this new funding opportunity will enable the Fletcher Group to establish a Rural Center of Excellence on Substance Use Disorder to continue to spread the successful Recovery Kentucky model to other parts of the commonwealth and beyond. The center will provide technical assistance to rural communities seeking to establish evidence-based treatment and recovery housing options for at-risk populations.” Fletcher, as governor, helped start Recovery Kentucky.

The Kentucky counties to be served are mainly in Appalachia: Adair, Bath, Bell, Breathitt, Carter, Casey, Clay, Clinton, Cumberland, Elliott, Estill, Floyd, Garrard, Green, Harlan, Johnson, Knott, Knox, Laurel, Lawrence, Lee, Leslie, Letcher, Lewis, Lincoln, McCreary, Magoffin, Martin, Menifee, Monroe, Owsley, Perry, Pike, Powell, Robertson, Rockcastle, Russell, Wayne, Whitley and Wolfe.

The non-Appalachian Kentucky counties to be served are Boyle, Breckinridge, Carroll, Grayson, Hickman, Mercer and Taylor.

Baby born fine after mother monitors fetal heartbeat for doctors, to make sure he doesn't develop deadly disease in the womb

Tim and Greta Wright and family (UK photo by Hilary Brown)
By Hilary Brown
University of Kentucky

In 2018, Greta Wright and her husband Tim, of Lexington, received two surprises. The first surprise was finding out she was pregnant with their second child. The second, less joyous surprise was that Greta had a rare auto-immune disease called Sjorgren's Syndrome, and it could be fatal to her unborn son.

"Needless to say, we were frightened and felt completely defenseless," she said.

Sjorgren's Syndrome is an autoimmune disease that attacks the glands that make tears and saliva. It's a rare disease, affecting somewhere between five and 40 people out of 100,000. During pregnancy, certain proteins in the mother's blood can cross the placenta and damage certain organs in the fetus, and the heart is especially susceptible. In a condition known as fetal heart block, the baby's heartbeat can slow to a dangerously low rate or even stop completely.

"The fetal heart is at risk to be affected, especially the nerve wiring system, which might lead to fetal heart block," said Dr. Majd Makhoul, pediatric cardiologist in the Kentucky Children's Hospital Congenital Heart Clinic. "If this happens, the heart top and lower chambers don’t communicate with each other and that leads to decreased cardiac function and heart failure. This can lead to serious fetal complications and sometimes fetal death."

"One to three percent of women with Sjorgren's will have babies affected with this electrical condition," said Dr. Wendy Hansen, an obstetrician in UK HealthCare's Department of Maternal-Fetal Medicine and chair of the Department of Obstetrics and Gynecology. "Although Sjorgren’s was a new diagnosis, she could have had when she was pregnant with her first child, and she simply didn’t know."

In order to ensure a safe pregnancy, the UK fetal-cardiology team applied for a grant from the National Institutes of Health to participate in a large-scale national study of fetal heart block. The study seeks better understanding of its risks and causes, and to find medical interventions that can reverse fetal heart block if caught early enough.

Traditionally, pregnant women with Sjorgren's have weekly appointments with fetal cardiologists to assess for fetal heart block during the critical period of pregnancy. However, a complete fetal heart block can develop in as little as 24 hours, and there is no effective treatment for it. Some medications can reverse it, but only in the early stages.

So, Hansen had Greta use a listening device two to three times a day to monitor the fetal heartbeat. Using sound clips of both normal and abnormal heartbeat as reference, she sent recordings to both Makhoul and Hansen if she had questions about the heartbeat's regularity. Once, an irregular heartbeat concerned Makhoul enough that he had Greta to come to the hospital, where she was proactively treated as if the fetus was being affected by the syndrome. Less than 12 hours later, the heartbeat stabilized and stayed normal throughout the rest of the pregnancy.

"Greta would come into each visit with a list of questions and articles she had read, makes me smile when I think about it," said Hansen. "Her and Tim's openness, sense of humor, positivity and great communication were their defining qualities."

In April, Greta and Tim's son Asa was born healthy with no complications. Makhoul attributes Asa's strong start to his dedicated and conscientious parents.

"Greta and Tim made our job easy by asking the right questions from early on and being deeply engaged at every step of the process," said Makhoul. "They were appropriately concerned and anxious at times but approached the situation with the right attitude and maximized their chance of having a healthy baby by adhering to our recommendations to the letter."

"Doctors Makhoul and Hansen made what could have been a horrible experience a great one," said Greta. "We felt like we were part of the UK family. We also knew that we didn’t have to worry about two separate teams of doctors – the Maternal-Fetal Medicine and the Pediatric Congenital Heart Clinic­­ – communicating with each other as we saw it happening proactively every day."

Wednesday, August 14, 2019

University of Louisville is buying Jewish Hospital after all, with the help of an unusual $50 million loan to be backed by Ky. taxpayers

The University of Louisville is buying Jewish Hospital and associated facilities after all, with help from the state and two foundations, to head off a threatened closure of the hospital, which is an important transplant center.

"U of L has searched for months for ways to save Jewish Hospital, which has been losing money for years but is also home to valuable clinical and research programs intertwined with U of L's academic mission," reports Grace Schneider of the Louisville Courier Journal.

KentuckyOne Health's "parent company, CommonSpirit Health, accelerated efforts by U of L and the state to save Jewish when the company's executives notified them early this month that they intended to shut down the facility in about two months – and to go public with the plans on Thursday, Aug. 15," Schneider reports. The school's trustees endorsed the deal Aug. 14.

U of L said in June that it had failed to find a necessary partner to buy the hospital. Now, instead of a partner, it has a friendly lender – the Commonwealth of Kentucky – and two philanthropic benefactors: a foundation controlled by CommonSpirit, and one created when the hospital was bought by the old Catholic Health Initiatives firm in 2012.

Because the hospital's main tower is estimated to have a life expectancy of only three years, U of L plans to merge Jewish with nearby University of Louisville Hospital. U of L will also own Sts. Mary and Elizabeth Hospital in south Louisville, Our Lady of Peace psychiatric hospital, Jewish Hospital Shelbyville, "four outpatient centers and a 740-employee medical group," the CJ reports. "The health system has operating losses of about $43 million a year in earnings before interest, taxes, depreciation and amortization."

"U of L will pay $10 million for the local KentuckyOne facilities and have CommonSpirit forgive a $19.7 million promissory note," Schneider reports. "The sellers, which include KentuckyOne and certain affiliates, are expected to provide $76.4 million in 'net working capital,' including accounts receivable," and the purchase price is to be adjusted if that amount is different, the CJ's Morgan Watkins reports in another story.

The two foundations "have committed a total match of $50 million toward the effort," Schneider reports. "The state is to loan U of L another $50 million," through an unusual loan from the Kentucky Economic Development Finance Authority.

The loan will be for 20 years, "with no principal payments or interest accrued for the first five years," and "is contingent on gaining the after-the-fact authorization for an additional appropriation from the fiscal 2019-20 budget with a bill prefiled at the start of the General Assembly's 2020 session," Schneider reports.

The authorization is needed because the loan amount "far exceeds the agency's maximum of $500,000," as does the length of the loan, and KEDFA "usually doesn't provide financing up front," Schneider reports. "Not all Kentucky lawmakers are on board, despite the insistence of House Speaker David Osborne, R-Prospect, that the plans have gained broad bipartisan support."

Gov. Matt Bevin "said U of L's search for an industry partner to help buy KentuckyOne's facilities led to a dead end because the prospective companies took a 'buffet' approach," Schneider reports. "They wanted to pick and choose properties they'd like to own and leave others, and that wasn't going to work, the governor said. Bendapudi acknowledged that the university's board of trustees had similar concerns about taking on a money-losing venture and turning it around."

However, a combined hospital run as "a true non-profit, not subject to the whims of the markets, should [be] less costly to operate and less pressured to post large profits, she said."

The combined operation will be huge, and the deal is "fueled by an ambitious vision to create a top-notch academic medical center," Schneider writes. "KentuckyOne's payroll is 4,539 employees and there are more than 3,100 working at U of L Hospital, for a total of 7,639. KEDFA listed full-time Kentucky resident jobs for the combined venture at 6,736. That doesn't include Hoosiers and people from other states who work at the facilities. The state list shows that between the years 2025 and 2039, the combined health system should have at least 5,880 full-time Kentucky resident jobs to meet the wage and payroll requirements."

Rule expanding definition of 'public charge' criteria to Medicaid draws fire from hospitals and advocates for immigrant families

Acting Citizenship and Immigration Director Ken Cuccinelli
announced the final rule at a White House press conference.
Adult immigrants would find it harder to remain in the United States if they signed up for Medicaid benefits, under a rule that the Department of Homeland Security finalized Aug. 12.

The rule brought "outcry from stakeholders across the health-care industry who say the policy will drive up the number of uninsured patients and increase the cost of uncompensated care," reports James Romoser of Inside Health Policy. "Immigration advocates and the California attorney general have already indicated they intend to sue to stop the so-called public-charge rule, which is scheduled to take effect Oct. 15."

The rule "is in some respects not as harsh as the proposed rule released last fall," Romoser writes. "The administration backed off its proposal to penalize immigrants who receive Medicare Part D low-income subsidies, and it also decided not to penalize immigrants who receive Medicaid while they are pregnant or under the age of 21."

Still, six major hospital lobbies said in a joint statement, “This rule could undermine access to care for legal immigrants by discouraging the use of critical public programs like Medicaid. We are concerned that this could lead to delays in care that would negatively impact the health of the communities we serve. We ask the administration to withdraw this harmful rule.” The statement came from the American Hospital Association, America’s Essential Hospitals, the Association of American Medical Colleges, the Catholic Health Association of the United States, the Children’s Hospital Association and the Federation of American Hospitals.

"The Trump administration said the rule will better enforce provisions in immigration law meant to deny permanent legal residency to any immigrant likely to become a 'public charge,' a term used for people who depend on government assistance," Romoser reports. The term has been used as a criterion since Congress passed the first immigration law in 1882.

However, the term has historically "focused on cash welfare programs, Romoser notes. "The new rule broadly expands the definition to include food stamps, housing vouchers and Medicaid. Under the rule, even a short stint on Medicaid could doom an immigrant’s chance to remain in the country legally, immigration advocates say."

Sara Rosenbaum writes for The Commonwealth Fund, "Whereas before only nursing home care counted toward public-charge status, now a host of services, from preventive care to treatment of chronic conditions like diabetes, could render someone a public charge after 12 months."

Kaiser Family Foundation chart; click on it for a larger version
Other critics fear a chilling effect on immigrants with U.S.-born children, who are citizens. "Enrolling their children in Medicaid is not supposed to trigger any penalties," Romoser reports, "but widespread fear about the rule is already causing many immigrant families to avoid seeking Medicaid or any other government assistance even for children who are U.S. citizens, stakeholders say."

"Researchers at the Georgetown University Center for Children and Families said in a May report that fears in the immigrant community contributed to a 2.2% decline in children enrolled in Medicaid and CHIP last year," Romoser notes. "In an analysis of the proposed rule, the Kaiser Family Foundation estimated that between 2.1 million and 4.9 million Medicaid and CHIP enrollees living in a household with a noncitizen would disenroll from the insurance programs."

Ken Cuccinelli, acting director of U.S. Citizenship and Immigration Services, said at a White House announcement, “President Trump’s administration is re-enforcing the ideal of self-sufficiency and personal responsibility, ensuring that immigrants are able to support themselves and become successful in America.”

Tuesday, August 13, 2019

Interactive map of DEA database makes it easy to spot major sources of pain pills in 2006-12; Ky. had No. 1, and 18 of top 100

Screenshot of Post map shows how to get individual pharmacy data. Added to screenshot are Ky. towns with pharmacies in top 100 of pain pills per person per county in 2006-12. Click on it for larger version; click here for interactive version.
Last month The Washington Post published a story and interactive map about the Drug Enforcement Administration database that reveals the distribution patterns of opioid painkillers from 2006 through 2012, when the opioid epidemic was surging. The first map showed the number of pills by county; a new map makes them easily visible by store, and the Post did a story about the data, with a list of the pharmacies that handed out the most pills per person in its county.

Shearer Drug of Albany, Ky., ranked first in the nation, dispensing 6,778,550 pills, or enough to give every person in surrounding Clinton County 96 pills a year. No. 4 was Booneville Discount Drugs in Owsley County, with 2,850,040 pills, or 86 per person per year. No. 6 was Glenn's Apothecary of Marion, with 5,171,800 pills, 80 per year for each person in Crittenden County.

Other Kentucky pharmacies in the top 50, their total pills and the amount per year for each resident of the county were: No. 16, Value-Med of Paintsville, 10,449,480, the third largest number of pills in the country (64); No. 18, Capps Pharmacy of Burkesville, 3,106,950 (64); No. 21, Hometown Pharmacy of Hyden, 4,935,500 (61); No. 22, Three Forks Apothecary of Beattyville, 3,307,670 (61); No. 25, Prescription Center of Morgantown, 5,128,760 (57); No. 26, Medicine Cabinet Pharmacy, Paintsville, 9,183,940 (56); No. 38, Mount Vernon Drug in Rockcastle County, 5,848,170 (49); and No. 42, Lyon Drug Store, Eddyville, 2,835,670 (48).

Those in the second 50, ranked by pills per person in the county, were No. 57, PEJ Inc. of Jackson in Breathitt County, 4,317,280 (43); No. 67, Rice Drugs of Beaver Dam, 6,716,610 (40); No. 75, Campton Pharmacare, 1,983,500 (39); No. 84, Weathers Drugs of Elkton, 3,227,880 (38); No. 94, Beringer Drug Center of Warsaw, 2,144,650 (37); Community Drug of Manchester, 5,691,230 (36); and No. 100, Evans Drug Co. of Fulton, 1,751,200 (36).

"While the crisis makes it clear that many of the opioids were diverted to the black market, the DEA database obtained by the Post does not track the pills after they reach the pharmacies," the newspaper reports. "There are legitimate reasons small pharmacies can have outsize volumes, including proximity to surgical centers." In Albany, Shearer Drug is next door to the building that once housed the office of former physician Michael Cummimngs; he was sentenced July 24 to 30 months in prison and fined $400,000 after pleading guilty to 13 counts of illegally prescribing controlled substances, the Clinton County News reports.

In a separate story, the Post reports that journalists in more than 30 states have published more than 90 stories based on the data, and uses an example from Pikeville: "In Kentucky, where the flow of pain pills left behind a trail of deaths from opioids, the DEA data didn’t come as a surprise to Russ Cassady, regional editor of the Appalachian News-Express. But he was still shocked by the magnitude of the figures. From 2006 to 2012, there were 66,785,120 prescription pain pills supplied to Pike County — 146 pills per person per year." Maria Sanchez Diez quotes Cassady: “We knew the numbers were bad, but it definitely gives some perspective," Cassady said. “The epicenter of the map you guys posted, the deep red counties, that’s us.” The story also notes coverage by The News Journal of Corbin and Lexington's WKYT-TV, as well as The Paintsville Herald's Aaron Nelson, which was previously reported by Kentucky Health News.