Tuesday, June 25, 2019

Tick-borne disease in Ky. is relatively rare, but does occur; best defense against these tiny disease-carrying vectors is prevention

Top three tick posters from a contest held by the Kentucky Department of Public Health and Northern Kentucky Health Department, which attracted more than 700 entries (Click on it for a larger version.)
By Melissa Patrick
Kentucky Health News

Ticks and summertime go hand-in-glove, but that doesn't mean you can't enjoy outdoor summer activities; you just have to take extra precautions. Tick season in Kentucky runs through August.

“Spring and early summer are peak times for tick bites, which coincide with people venturing outdoors in the warmer weather,” Dr. Jeff D. Howard, commissioner of the state Department for Public Health, said in a news release. “It's important that people take preventive measures against tick bites and also check for ticks after visiting affected areas.”

Ticks are most likely to be hanging out in wooded areas; the boundaries between woods and fields; low-hanging tree limbs; under leaves, plants and ground cover; and around stone walls and woodpiles that are home to mice and other small mammals that carry ticks.

The health department recommends that Kentuckians remember four steps when it comes to protecting themselves from ticks: Protect; Check; Remove; and Watch.

Protect: To protect yourself from tick bites, avoid tick-prone areas, but if you are going to be in those areas use a tick repellent that has 20 percent DEET, picardin, IR3535 or lemon eucalyptus. Wear light-colored, long-sleeved shirts and pants tucked into socks. Use permethrin-based clothing sprays, unless you have cats, to which permethrin is toxic.

Check: After you've spent time outdoors, do a head-to-toe check for ticks using a hand-held or full-length mirror. Parents should check children. Common places to find ticks are behind the knees, around the waist, under arms, and on the neck and head. It is also important to check your gear and pets for ticks. If possible, change your clothes and shower after going outdoors. To kill ticks on dry clothes, put them in a dryer on high heat for 10 minutes. If clothes require washing, use hot water.

CDC illustration
Remove: Remove an embedded tick as soon as possible by grasping it as close to the skin as possible with tweezers and pulling straight out with gentle, even pressure. Do not jerk or twist the tick. Wash your hands with soap and water after the tick is removed. Apply an antiseptic to the bite site. Do not use alcohol, matches, liquid soap or petroleum jelly to remove a tick. Dispose of the tick by submerging it in alcohol, placing it in a sealed bag or container, wrapping it tightly in tape, or flushing it down the toilet. Never crush a tick with your fingers. Don't delay; remove a tick as soon as it is detected, because the longer it is attached, the higher the risk that it may transmit disease.

Watch: Watch for symptoms of tick-borne illness, including sudden fever and rash, severe headache, muscle or joint aches, nausea, vomiting, and diarrhea. Symptoms can arise within several weeks of removing a tick. Contact your health-care provider if symptoms occur.

Tick types and diseases in Kentucky

Overall, the incidences of tick-borne disease remains low in Kentucky, but that doesn't mean you shouldn't take precautions to protect yourself.

The lone star tick and the American dog tick are the most common ticks in Kentucky. And though bites from these ticks typically just cause local irritation and itching, a small percentage of them carry disease.

In particular, the adult female lone star tick, which has a white spot on its back and is about the size of a pencil eraser, can carry erlichiosis, a disease that can cause fever, headache, chills, muscle pain and in some cases a rash. Symptoms generally occur within one to two weeks of a bite. The first line of treatment is an antibiotic; if not treated properly, it can be fatal.

The CDC reports that Kentucky has one of the highest rates for cases of this disease, 9.7 per 1 million people. The lone star tick can also cause some people to become allergic to red meat.

The American dog tick is reddish-brown with mottled white markings on the back and is about the size of a pencil eraser. It can carry Rocky Mountain spotted fever, which usually begins with a sudden onset of fever and headache two to 14 days after being bitten by an infected tick.

Kentucky had 249 probable cases of Rocky Mountain spotted fever and one confirmed case in 2017, according to the state health department. Though rare, the bacterial disease can be deadly if not treated with the right antibiotics, with children under 10 making up most of the deaths, the CDC says.

Earlier this month, a 2-year-old Kentucky boy came down with a case of Rocky Mountain spotted fever that caused him to be unconscious for nearly a week, Lindsey Bever reports for The Washington Post. Kayla Oblisk told Bever that her son, Jackson, was bitten by a tick and they had just pulled it off and thrown it away without much worry. Within three days, he developed a dangerous high fever and developed a light pink rash all over his body. She said he was first diagnosed with a viral infection, but was eventually admitted to the hospital where he was diagnosed and treated for this rare but potentially fatal disease.

Both the American dog tick and the lone star tick can carry tularemia, a disease that infects animals and people and is often spread by rabbits. Symptoms of tularemia vary depending on how long the bacteria have been in the body and where the person contracted the disease. All forms of the disease are accompanied by fever. It can be life-threatening, but most infections can be treated successfully with antibiotics. In 2017, Kentucky had two cases of tularemia, according to the CDC.

A much smaller tick that is becoming more common in Kentucky is the blacklegged tick, also known as the deer tick. It carries Lyme disease, symptoms of which can range from mild to severe, including fever, headache, fatigue and a skin rash that looks like a bull's-eye, although not everyone gets the rash. This tick can also carry ehrilichiosis, which can weaken the immune system.

In 2017, Kentucky had six confirmed cases of Lyme disease and 14 probable cases, the CDC says.

Veterinarians in Kentucky now have access to a new program sponsored by the health department and the University of Kentucky that allows them to submit ticks for identification and testing. For more information about the program contact the program manager at tori.amburgey@ky.gov or the state public health veterinarian: kelly.giesbrecht@ky.gov.

A deeper dive

Elemental, a Medium publication for health-and-wellness journalism supported by science, has produced a multi-part special report about ticks called "Tickpocalypse" that explores in great detail the exploding tick population and the growing number of diseases that come with it.

The introduction to the series alarmingly refers to Lyme disease as a pandemic, a word that is only assigned to diseases that occur over a wide geographic area and affects an exceptionally high proportion of the population.

"It's estimated that 300,000 people contract Lyme each year in the U.S.," with victims found in all 50 states and Washington, D.C., it says. Further, it notes that Lyme is also on the rise in Europe, Africa and Asia.

Lyme disease is so bad that Mary Beth Pfeiffer, author of Lyme: The First Epidemic of Climate Change, calls for a "huge national and concerted international effort to bring it under control," Alex Bhattachari reports in one of the stories, "Lyme Disease Cases Are Exploding. And It's Only Going to Get Worse."

Bhattachari writes, "A public health crisis is hiding in plain sight, with tick-borne diseases creating millions of sick people at an economic cost running into the billions, and little has been done so far to mount a meaningful defense."

Other stories in the series are titled: "What It's Like to Have Lyme Disease Forever"; "Worrying About, Worrying About Lyme Disease"; "When Lyme Kills"; "What It's Like to be a Creepy-Crawler Field Researcher"; "Know Your Enemy: The Blacklegged Tick"; "When That Tick Bites"; "Lyme Prevention 101"; and "The Mouse Cure."

Sunday, June 23, 2019

Study: Medicaid work rules caused coverage losses, no job gains in Arkansas; argument continues about what would happen in Ky.


By Melissa Patrick
Kentucky Health News

A study led by experts at Harvard University found that work requirements in Medicaid, like those proposed in Kentucky, resulted in thousands of people in Arkansas losing health coverage, with no evidence that they got jobs.

The study, published in the New England Journal of Medicine, brought predictable contrasting reactions from a health policy analyst and a Kentucky health official when asked if Kentucky can expect the the same results if the courts allow the rules.

"I don't see how Kentucky could expect any different outcome for its Medicaid program if it were allowed to go through," said Jason Dunn, policy analyst for Kentucky Voices for Health.

 Kristi Putnam, deputy secretary of the state Cabinet for Health and Family Services, disagreed. "We do not expect the same results," she said, adding that the study "does not tell the whole story."

Putnam manages the state's new Medicaid program, which wants the federal government to waive traditional Medicaid rules so the state can require, among other things, "community engagement" by most of the "able-bodied" individuals who gained coverage through the expansion of Medicaid to people who earn up to 138 percent of the federal poverty level. That means they would have to work, attend school or take job training 80 hours a month, or participate in drug treatment.

U.S. District Judge James Boasberg of Washington, D.C., has ruled twice against the waiver, as well as a similar one for Arkansas, after concluding that federal officials failed to show how work requirements would serve the objective of the 1965 Medicaid Act, which is to provide people with medical coverage. The administration of President Donald Trump has appealed the ruling.

Putnam said she doesn't think Kentucky would see the same results found in the Arkansas study,  largely because of the state's aggressive outreach campaign and its commitment to be flexible and proactive in its effort to improve the health of Kentuckians.

She said Kentucky''s roll-out period has been longer than the one in Arkansas, giving more preparation time; Kentucky is working with strategic partners who are committed to the program's success, like the Foundation for a Healthy Kentucky, the Kentucky Hospital Association, Kentucky Youth Advocates and all of the state's federally qualified health centers; employers and regional workforce development boards in the state are "excited and engaged" in the process; and the state continues to hold forums to inform stakeholders about the new requirements.

Communication is key

A big issue found in the Arkansas study was a lack of awareness and confusion about requirements that Medicaid beneficiaries report their work and community engagement activities. It found that one-third of the targeted adults had heard nothing about the policy, and that 44 percent were unsure whether it applied to them. Among those the state had told to report, only 49% were doing so regularly.

Putnam acknowledged that this is a "very legitimate concern," but said Kentucky is working hard to avoid the problem. She said field interviews with Medicaid beneficiaries in doctor's offices and health centers "found that a lot were not" aware of the rules. "And that kind of changed our approach in how we were communicating."

Putnam said the state plans to do more interviews, but has added more text messaging, increased its social-media presence, and is engaging with its strategic partners to get the information out, rather than relying on phone calls and mailed notices that are often not answered or read.

On the other side of the argument, Dunn said he expects the same outcomes as Arkansas because Kentucky has many of the same reporting hurdles, and that is what led to many in Arkansas to lose their coverage.  He noted that the study found that 95% of the people who lost their coverage in Arkansas shouldn't have because they were already working or would have qualified as exempt.

Putnam said that shouldn't be a problem here because Kentucky's technology is different. She said the state has gone to great lengths to assure that all reporting can be done from mobile devices, has worked to make sure the screens are easy to navigate and understand, and has designed the computer program to automatically exempt most people who qualify for an exemption.

Dunn disagreed. He said Kentucky Voices for Health has heard "a lot of complaints about the system" being difficult to sign up on, and difficult to use. The system is the same one people who are on the Supplemental Nutrition Assistance Program (formerly food stamps) use to report their work hours.

Dunn said recent reductions in Kentucky's SNAP rolls, due to failure to meet similar reporting requirements, indicate there would be similar drops in Medicaid coverage. "We've discontinued over 20,000 people through March of 2019, in about a one-year period," he said.

Putnam argued that the two programs offer different benefits and should not be compared. She said that because American health benefits are typically tied to hours worked, it is important to help Kentuckians learn how to work within that system. "The hope is that we can prepare people for the fact that this is part of our reality," she said.

Putnam added that Kentucky has the ability to be flexible and to react if it sees people dropping off the Medicaid rolls, which it will monitor "pretty much on a daily basis."

What's the objective?

Supporters of work and community engagement requirements have long argued that work requirements will spur employment and improve health.

In Arkansas, that didn't pan out. The researchers found no significant increase in employment, which fell from 42.4% to 38.9% among the targeted population. It also did not see a significant increase in the number of hours worked, or overall rates of job training or community service.

Putnam pointed to research that shows a connection between a person's overall economic well-being and their overall health well-being.

“We're more concerned with seeing improvements in health outcomes and people's well-being, but we believe that is very correlated to community engagement and improving your circumstances when you are able to," Putnam said.

Gov. Matt Bevin, a Republican who talked about the waiver in his 2015 campaign and is seeking re-election, has stated broader goals.

Bevin told Judy Woodruff on PBS News Hour last year that he would like to see all of the state's "able-bodied" people working or in some kind of community engagement, and asked, "Why should somebody have to go to work every day and pay taxes to provide something to someone who could do the same thing, but chooses not to? That's very un-American."

Dunn, of Kentucky Voices for Health, agreed that economic well-being is often tied to better health outcomes, but said it shouldn't be tied to any kind of eligibility.

“We like the idea of a service that provides linkages to educational opportunities and employment opportunities, we think as an overall effort in addressing social determinants of health that that is a good aspect of that – but not tying that kind of activity to eligibility. That is the part that is wrong," Dunn said. “I think what we'd like to see from this study is a better understanding that these kinds of policies do nothing but to serve to create new barriers to coverage. That they don't produce the results that people hypothesized and instead they lead to what a lot of researchers said was going to happen, and that is people lose their coverage."

Questions about the study

Putnam cautioned that the information gathered in the survey was self-reported and did not include any information about Arkansas' outreach efforts, nor any information from the Bureau of Labor Statistics, a federal agency that tracks employment. She added, "It does not tell the whole story of the individuals who are no longer getting Medicaid services."

Arkansas officials have said the study is not a "meaningful or thorough" evaluation, partly because it is based on less than a year's worth of data, Politico reports. They also said it did not address why most individuals who lost coverage did not re-enroll this year when they were again eligible.

Of the 18,000 who lost coverage, as of mid-May, roughly 4,300 had re-joined, Politico reports.

The study was led by the Harvard T.H. Chan School of Public Health. It looked at Arkansas' Medicaid work and community engagement requirements to see how insurance coverage and employment were affected. Arkansas was the first state to implement such requirements and prior to it being vacated by Judge Boasberg in March, the program resulted in 18,000 people losing coverage.

The study conducted telephone interviews with 30- to 49-year-olds, who were subject to the new requirements, compared with adults who were not subject to them. It also looked at outcomes for adults in three comparison states that have not implemented any work requirements: Kentucky, Louisiana and Texas (which, unlike the other two, has not expanded Medicaid).

In addition to finding a significant drop in insurance coverage among the 30- to 49-year-olds, from 70.5% to 63.7%, the researchers also found that the uninsured rate for this same group increased from 10.5% in 2016 to 14.5% in 2018, with smaller or no changes in the other groups.

The researchers found no significant increase in employment, which fell from 42.4% to 38.9% among the targeted population. It also did not see a significant increase in the number of hours worked, or overall rates of job training or community service.

The researchers concluded that the 18,000 people who fell off the Medicaid rolls in Arkansas after the work requirements were implemented neither secured jobs or other insurance coverage.

The most common reason (40.4%) for not reporting was a belief that they were not meeting the requirement, even though their responses indicated that they were meeting the requirement. Other reasons for not reporting were lack of internet access (32.3%) and confusion about reporting (17.8%).

"Lack of awareness and confusion about the reporting requirements were common, which may explain why thousands of persons lost coverage even though 95% of the target population appeared to meet the requirements or qualify for an exemption," the study report says.

The Trump administration has approved similar plans in nine states and seven more states have pending applications to add work requirements, according to the Kaiser Family Foundation.

New Hampshire's work requirements took effect this month. Jason Moon at New Hampshire Public Radio talked with health officials there and reports that "early signs are pointing to a bumpy road ahead." The issues described seem similar to those in Arkansas: confusion, lack of awareness, and difficulty with reporting requirements. This program is also being challenged in court.

The Commonwealth Fund estimates that if Medicaid work requirements are fully implemented in the nine states that have received federal approval, between 600,000 and 800,000 people could lose their coverage after 12 months. It is estimated that between 86,000 and 136,000 would lose coverage in Kentucky alone.

The state has estimated that after five years, Kentucky's Medicaid rolls would have 95,000 fewer people under the program than without it, in large measure for failure to meet reporting requirements.

Saturday, June 22, 2019

Ky. children among least vaccinated for cancer causing human papillomavirus; state has highest rate of HPV-related cancers

Did you know there's a vaccine that can prevent certain types of cancer? Many Kentuckians don't know. As part of a statewide effort to educate them, a Bardstown woman told her story to a group in Louisville about being told at age 30 that she would have to have her uterus removed because she had cancer of the cervix, Darla Carter reports for Insider Louisville.

Jessica Saxe, a Kentucky mother who was diagnosed with
cervical cancer at age 30, promotes the HPV vaccine.
(Saxe provided this family photo to Insider Louisville.)
Jessica Saxe told those attending the Louisville event that her son, Charlie, was 9 months old at the time of her diagnosis. She recalled thinking, “I don’t know if I’m going to live to see him walk. … I don’t know if he will remember me,” her voice breaking. “That was the hardest part as a mother, knowing that I might not be able to be there for my son.”

Charlie is now 6. Carter reports that Saxe has since become an advocate for encouraging others to get vaccinated against the sexually transmitted human papillomavirus, often referred to as HPV.

She was speaking at an event sponsored by the American Cancer Society, along with the Kentucky Department for Public Health and others, to promote HPV vaccines, which are effective in preventing cervical cancer and genital warts. They will be traveling around the state over the next few months to promote the life-saving vaccine.

HPV is one of the most common sexually transmitted diseases, and Kentucky's children are among the least vaccinated for it. HPV can cause cancers in the cervix, vagina, vulva, penis, anus, rectum and the back of the tongue and throat. Among these cancers caused by HPV, more than 90 percent could be prevented by the vaccine, according to the Centers for Disease Control and Prevention.

“Kentucky has the highest cancer burden for HPV-related cancers in the nation, so morally we have to” take action, Elizabeth Holtsclaw, the state and primary-care systems manager for ACS, said at the event. She said the goal of their outreach is to increase vaccine rates by 8% in the next 12 months.

In 2017, about 38% of Kentucky youths 13 to 17 were up-to-date on HPV vaccinations, meaning they’d received the full series of doses, according to the CDC, which is providing funding for the meetings. That was up from 34% in 2016 but well below the U.S. rate of nearly 49%.

The HPV vaccine is recommended for girls and women starting around age 11 until 26. For boys, it’s recommended starting at age 13 until 21. Until 12, children receive two doses of the vaccine at least six months apart. Those 15 and older get three doses. The earlier the vaccine is given, the better the immune response. It is important to note that the vaccine is the only one known to prevent any form of cancer.

The vaccine is proven to be a safe and effective way to protect against the HPV virus, but can be a tricky sell to parents, Carter reports. “Part of it is nobody wants to admit that this 12-year-old is ever going to have sex, which is a fantasy,” Connie White, senior deputy commissioner of the health department, said at the event.

Another contributor to the state's low HPV vaccination rate is that health-care providers don't seem to be promoting it strongly enough, Carter reports. Studies show a "clear, same-day recommendation" from a physician to a parent is the most important factor in whether a child gets vaccinated or not. That also means doctors must carry the vaccine in their offices, but many don't. The vaccine is not on the list that must be administered to incoming students or sixth graders.

“Somehow, we are treating the HPV vaccine as an ‘other’,” Holtsclaw said at the event. “Whether it’s because it’s not mandatory, we don’t know. But other states are doing all right without a mandate. … The doctor needs to feel comfortable and confident making that strong recommendation.”

Another reason for getting the vaccine when young is that it is supposed to be given before exposure to HPV, so ideally, before the person becomes sexually active, according to the CDC. “It’s a cancer vaccine; it’s not a sex vaccine,” Saxe said.

Saxe, who recently had a second child with the help of a surrogate, told the group that it’s critical for cancer survivors to share their stories to help persuade more people to get their children vaccinated and prevent other women from getting cervical cancer, Carter reports.

“We can stop this, but we can’t do it alone,” she said. “We need the doctors and the nurses and the pharmacists. We need the people in public health. We need policymakers. We need you guys to stand with us on this. We need you to make this a priority.”

Friday, June 21, 2019

Bevin joins appeal of court ruling that blocked new association health plans; AG Beshear says they threaten health coverage

By Melissa Patrick
Kentucky Health News

Would association health plans, a type of insurance that makes it easier for small employers to band together, free of many of the requirements of the Patient Protection and Affordable Care Act, provide enough protections to consumers?

Business Management Daily graphic
Gov. Matt Bevin's health secretary says they would. Attorney General Andy Beshear, who is running against Bevin, says they wouldn't.

Bevin and officials from 15 other states, filed a court brief June 7 urging the U.S. Court of Appeals for the District of Columbia to reverse a lower court's decision against expanded access to association health plans.

The brief prompted a verbal tussle between Beshear, one of the original plaintiffs in the lawsuit, and Health Secretary Adam Meier, who released his statement from the governor's office, where he was deputy chief of staff, instead of the Cabinet for Health and Family Services, which he leads.

Beshear issued a statement saying, “I disagree with the governor’s new action because it threatens health care coverage for Kentuckians, including people with pre-existing health conditions. While Matt Bevin continues his work to strip vital coverage away from our families, I am fighting to make sure all Kentuckians get the health care they need and can afford it.”

In response, Meier called on Beshear to retract his "false and outrageous claim" and linked to official guidance from the U.S. Department of Labor that says association health plans "may not charge higher premiums or deny coverage to people because of pre-existing conditions."

“The Department of Labor has been very clear that association health plans cannot deny coverage to individuals based on pre-existing conditions,” Meier said. “To state otherwise is false and shows a complete lack of understanding of the intent of the Department of Labor rule, which is to provide workers and small businesses with greater access to affordable health insurance options. AHPs are a great way for sole proprietors and small businesses to have the same kind of health coverage that big corporations offer their employees.”

Technically, Meier is correct. But critics of the AHP rule say that while they recognize that the guidance says AHPs can't deny coverage based on pre-existing conditions, the rest of the policy is set up to allow them to easily do so by simply denying coverage for conditions they don't want to cover, such as not covering insulin for diabetics or not covering mental-health care.

The American Medical Association sides with Beshear on this issue. In a 2018 friend-of-the-court brief, the AMA laid out a list of concerns.

 "There is a significant risk that AHPs could disproportionately impact individuals with pre-existing conditions," the AMA said. "To be sure, on its face, the regulation states that it protects coverage of pre-existing conditions. But in reality, AHPs can easily evade that crucial legal requirement by using proxies for health status."

For example, AMA wrote that AHPs "can charge premiums based on factors that are not explicitly defined in terms of health or medical conditions, but that closely track those forbidden factors."

Further, it notes that the AHP rule allows them to charge different premiums based on age, gender, industry or geography. "But each of those seemingly neutral characteristics can be used to disguise differential treatment based on health status or one's likelihood of suffering from particular pre-existing conditions."

The AMA argued, "Denying patients coverage based on seemingly neutral characteristics that the insurance industry knows, in reality, are associated with higher medical costs or pre-existing conditions would leave patients with lower quality care, greater out-of-pocket expenses, and overall poorer health outcomes. Those consequences subvert the object and design of the ACA."

In addition to its concerns that AHPs will undermine the consumer protections in the ACA, the AMA said they would destabilize ACA exchanges by pulling healthy individuals out of ACA plans.

Citing examples, the AMA also noted that AHPs  have a "long history of fraud and abuse" and adds  that the AHP rule itself recognizes this when it says, "The Department anticipates that the increased flexibility afforded AHPs under this rule will introduce increased opportunities for mismanagement or abuse, in turn increasing oversight demands on the Department and state regulators."

What's it all about? 

President Donald Trump signed an executive order in 2017 to expand access to association health plans, stating that expanding access to such plans would "allow more small businesses to avoid many of the [Patient Protection and Affordable Care Act's] costly requirements."

In June of last year, the Department of Labor did just that, by expanding the types of groups that could ban together to offer coverage under an AHP.

The department also loosened association requirements so that more of them could be classified as large-employer coverage, which would exempt them from having to cover the 10 essential health benefits required by the ACA, like covering mental health or prescriptions. Nor, under the new rule, would they be required to pay the tax that large -group market insurers have to pay when they choose to not cover them. As previously noted,  association insurers can set premium rates based on age, gender, industry or geography.

In March 2019, the policy was struck down in federal court following a lawsuit filed by 11 attorneys general, including Kentucky's Beshear.

In his ruling, Judge John D. Bates, of the U.S. District Court for the District of Columbia, who was appointed by President George W. Bush, concluded that the labor department "unreasonably expands the definition of "employers" to include groups without any real commonality of interest" and that it had  misinterpreted the Employee Retirement Income Security Act's definition of an employer when it allowed working owners without employees to be covered by the AHPs. Bates added that the policy "was intended and designed to end run the requirements for the ACA."

This month, Bevin, along with 15 other states, filed a court brief urging the federal appeals court to reverse the district court's ruling. Bevin's involvement put Kentucky on both sides of the issue.

"By broadening the definition of a qualifying employer, more small businesses can take advantage of that purchasing leverage," says the brief. "Thus "a substantial number of uninsured people will enroll in AHPs because the Department [of Labor] expects the coverage will be more affordable than what would otherwise be available to them.""

AHPs in Kentucky?

The 2019 Kentucky General Assembly overwhelmingly passed House Bill 396 to update the Kentucky insurance code to adopt the Department of Labor's final rule and expansion of AHPs. Bevin signed it into law March 26.

Kentucky already has some association health plans that are fully insured and industry specific for employer groups, but has not approved any under the new policy, said Susan West, spokeswoman for the Public Protection Cabinet, which includes the Kentucky Department of Insurance.

West said in an email that the state was "on the cusp" of approving a fully insured AHP under the new rules that would have gone into effect June 27, but it has since been put on hold because of the federal court ruling and subsequent appeal. 

"Given the recent federal ruling and discussion among regulators at the recent [National Association of Insurance Commissioners] meeting, in which Kentucky participated, the DOI is waiting on the federal [Department of Labor] to determine their course of action and appellate options before moving forward with approving specific plans and registering associations," West said.

Thursday, June 20, 2019

Rural hospitals continue to be at risk of closing; Medicare won't pay hospital rates for drastically scaled-down services


Rural hospital closures are a growing trend, and federal policies don't support a model that would include a scaled-back version of services. But that's what many rural hospitals need to do in order to ensure their future, Mary Meehan reports for Ohio Valley ReSource, a public-radio partnership that covers Kentucky, Ohio and West Virginia, especially their Appalachian areas.

“The reality is that many rural communities can’t really support a full-fledged hospital. They may need primary care and perhaps emergency department services, let’s say a primary care clinic attached to an emergency department," Ty Borders, director of the Rural and Underserved Health Research Center at the University of Kentucky, told Meehan.

But federal policy complicates that simplified model for care, Borders said: “Medicare won’t pay for that. Medicare will only pay for hospital or emergency department services that are in a hospital. And in most rural communities, that’s a critical-access hospital,” which limits its beds, services and patient stays in return for slightly larger federal reimbursements.

"Which are the hospitals that are closing," Meehan reports as she details the struggles and closures of several rural hospitals, starting with the Owen County Hospital in Owenton, which closed in 2016.

County Judge-Executive Casey Ellis told Meehan that over the years the hospital had operated for profit, not for profit, under a private owner and even under the support of a community foundation. It closed in 2016, but its emergency room continued operation under new management for 18 months.

“I have always seen it struggle,” Ellis said. “I grew up seeing it struggle.”

Such closures are part of a growing trend across the Ohio Valley and across the nation, Meehan notes. So far 107 rural hospitals have closed since 2010, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, and research shows the trend is accelerating. Four hospitals have closed in Kentucky since 2010, and several others are at risk of closing.

Meehan also writes about the Bell County seat of Pineville, where citizens ate "scrambling for options to save their hospital, even holding community prayer services."

"But troubles are of the earthly kind," she adds, noting that a declining population, old buildings and spending more on care than being reimbursed for it adds to the growing problem.

Meehan says research shows people are still getting the most critical care, but Ayla Ellison, managing editor of Becker's Hospital Review, told her that it can get more costly as caregivers become distant and must be transported farther to the nearest hospital, sometimes by helicopter.

Hosptials are often the largest employer in a county and are critical to its economy. Ellis told Meehan that about 50 people lost jobs when the Owen hospital closes, that it's hard to recruit jobs to a town with no hospital, and that as citizens age, they often move to communities nearer a hospital.

Ellis said the county has done what it can to help its 11,000 people across roughly 350 square miles, including developing 18 helicopter landing sites and by conducting a "huge campaign" on when and when not to call 911. The county has two ambulances to serve the entire county, Meehan reports.

“We can’t send a paramedic 20 minutes down the road to go see Miss Joe to change her bandage (and) talk about her medications” if that means risking a situation where no ambulance is available in a crisis, Dan Brenyo, the county's emergency-services administrator, told Meehan.

In the same week Meehan's story appeared, the rural hospital in Fentress County, Tennessee, 20 miles south of the Kentucky border, closed "following months of financial turmoil," Jacob E. Rosenbaum reports for the Fentress County Courier.

Jamestown Regional Medical Center, which had a staff of about 150, closed after it stopped receiving Medicare and Medicaid payments for new patients, Juan Buitrago reports for the Nashville Tennessean. County Executive Jimmy Johnson said the hospital missed a liability-insurance payment, worrying employees. CEO Michael Alexander told Buitrago that he hopes the hospital will be able to reopen. The next closest hospital, in Albany, Ky., is nearly 40 minutes away.

Rural hospitals are at a greater risk of closing in states that did not expand Medicaid under the Patient Protection and Affordable Care Act. Tennessee is one of the 14 states that have not done so; Kentucky did. According to the North Carolina research program, 12 rural hospitals have closed in Tennessee since 2010, three in 2019. A separate report shows that Tennessee has 15 rural hospitals at high risk of financial distress, and Kentucky has eight. The researchers' list is not public.

Wednesday, June 19, 2019

U of L's pass on buying Jewish Hospital raises fears about the hospital's future, including its large number of low-income patients

University of Louisville President Neeli Bendapudi says there is no immediate risk of Jewish Hospital closing, in the wake of the university's decision not to buy the money-losing but medically significant facility. But there is much worry in the Louisville region about its future.

Courier Journal photo
CommonSpirit Health, formerly known as Catholic Health Initiatives, have been trying to sell Jewish and eight other facilities under the KentuckyOne Health brand for two and a half years. U of L said it could not find a suitable partner to help fund the acquisition and couldn't afford to do it alone.

Bendapudi said June 13 that there is also no immediate plan to reduce the services that the university provides through Jewish, including a wide range of care provided by U of L physicians, including its cardiology and transplant services, and training of residents from the university's medical school. She added that the university must receive at least 90 days' notice before its contracts with KentuckyOne can be terminated.

KentuckyOne spokeswoman Lannette VandeToil said there were no current plans to close Jewish or any other facilities, adding that two other organizations have been in ongoing talks with KentuckyOne Health about a possible deal: hedge fund BlueMountain Capital Management an anonymous entity, Morgan Watkins reports for the Louisville Courier Journal. 

Despite all of these assurances, local health experts worry about the future of Jewish Hospital and the tens of thousands of patients that it cares for,  Boris Ladwig reports for Insider Louisville.

Ladwig reports that Jewish and Sts. Mary & Elizabeth hospitals have been incurring operating losses of more than $1 million per week.

Dr. Peter Hasselbacher, emeritus professor of medicine at U of L, told Ladwig that he was disappointed in the university's decision to walk away, but not surprised. He added that he didn't see "any signs that instill confidence in the facility's future," Ladwig writes.

"All I see are warning signs that the community should be prepared to take up the slack to take up the medical needs of urban Louisville," he told Ladwig. "I'd love to be more optimistic, but I can't be. I see us slowly circling the [drain]."

Hasselbacher also expressed his concern about what would happen to the tens of thousands of patients that Jewish Hospital cares for if it were to close or reduce its services, many of them without insurance or covered by the federal government, which Ladwig notes generally pays hospitals less than it costs to provide the care. Hasselbacher notes that the financial issues that come with taking care of this population will follow them to other hospitals in the area if Jewish were to close.

"I'm seeing challenges . . . to the city and state that they are going to be very reluctant to" address, Hasselbacher told Ladwig, who reports: "According to recent filings, Jewish and Sts. Mary & Elizabeth hospitals have a combined 78,000 annual emergency-room visits, compared to 65,000 at nearby University Hospital. Bendapudi said University is “at capacity” and Norton Healthcare’s downtown hospital, too, sometimes has to divert patients to other facilities."

Tuesday, June 18, 2019

As the tobacco industry transitions into e-cigarettes, McConnell transitions from tobacco advocate into health advocate

Sen. Mitch McConnell, right, endorsed making 21 the legal age
for tobacco products at the Foundation for a Healthy Kentucky
on April 18 with CEO Ben Chandler, state Rep. Kim Moser of
Taylor Mill and state Sen. Julie Raque Adams of Louisville, left
Senate Majority Leader Mitch McConnell of Kentucky is sponsoring a bill to raise from 18 to 21 the legal age for buying tobacco products, a move he says is one of "my highest priorities." The "T-21" bill is also a priority of the tobacco industry, which is moving into electronic cigarettes and wants a higher legal age to reduce pressure for youth-oriented regulations, such as limits on flavorings of vapor products.

In researching a package of reports on the senator, National Public Radio looked into his long relationship with the industry and found that he "repeatedly cast doubt on the health consequences of smoking, repeated industry talking points word-for-word, attacked federal regulators at the industry's request and opposed bipartisan tobacco regulations going back decades," NPR producer Tom Dreisbach reports.

That contrasts with McConnell's recent announcement of his T-21 bill, in which he said, "Our state once grew tobacco like none other, and now we're being hit by the health consequences of tobacco use like none other." He noted, "I might seem like an unusual candidate to lead this charge."

Driesbach adds that the industry "has provided McConnell with millions of dollars in speaking fees, personal gifts, campaign contributions and charitable donations to the McConnell Center [at the University of Louisville], which is home to his personal and professional archives."

Another sort of of archive is the primary source for the NPR report. "The disclosure of millions of once-secret tobacco industry documents — which are now readily searchable online — has opened a window into McConnell's interactions with tobacco executives and lobbyists," Driesbach notes. "Many of the records were first reported by the Lexington Herald-Leader, as part of a yearlong investigation into McConnell" in 2006 by reporter John Cheves.

The American Lung Association and the American Cancer Society Action Network favor McConnell's bill, but other groups object to a provision requiring each state to raise its legal tobacco age to 21 in order to keep getting federal grants for substance-abuse prevention. "It is highly likely that this provision will be used by the tobacco companies to pass laws that weaken state and local efforts to reduce tobacco use," says the Campaign For Tobacco-Free Kids.

"It's a Jedi mind trick," Sharon Eubanks told Driesbach. Eubanks "led the Justice Department's landmark racketeering case against the industry," he notes. "E-cigarette companies want to avoid liability for the youth vaping epidemic, says Eubanks."

McConnell is "covering for them," said Dr. David Kessler, who as commissioner of the Food and Drug Administration in the mid-1990s tried to regulate nicotine as a drug, "Still, whatever the motivation, Kessler says he welcomes increasing the tobacco age to 21," Driesbach reports.

Georgeanna Sullivan, a deputy press secretary for McConnell, told NPR, "No one has done more to help transition Kentucky and our nation past tobacco culture than Senator McConnell." She noted that McConnell helped engineer the repeal of federal production limits and price supports for tobacco in 2004, which led to a huge decrease in tobacco farmers' numbers and political clout.

In an interview for the package of reports, McConnell said the industry got much help from both Republicans and Democrats in Kentucky. "There was nobody not fighting for tobacco in Kentucky in that era," he said. "Nobody."

UPDATE, June 19: In an editorial, The Winchester Sun says McConnell's bill doesn't do enough:

"What the T-21 legislation represents is an opening bid in a negotiation — a negotiation over how much leeway tobacco and e-cigarette companies should be given to market their drugs and turn profits off people addicted to their products. No good negotiator takes the first offer put on the table. The first offer is always the other side’s dream scenario — a maximum benefit for them, a minimum benefit for you.

"Public outcry over companies making money by selling flavored addiction juice to kids has forced those companies and their supporters to the table. National T-21 legislation is their dream scenario.  The legal age to buy e-cigarette products is already 18, so the law extends that prohibition by three years. In exchange for those three years, they want to be free to make their products as addictive and enticing as possible, including in ways that might appeal to minors."

The editorial concludes, "changing the legal age by itself is a mostly empty gesture that will have limited real-world impact. In the worst case, it would provide cover for companies in the business of marketing addiction to kids. Health advocates should applaud McConnell for bringing up the issue and being willing to pass national legislation. But they shouldn’t fall for the gimmick of the initial offer."

Monday, June 17, 2019

Ky. 34th in overall well-being of children in Kids Count; best rank is in health, worst is in 'family and community,' cause of many ills

By Melissa Patrick
Kentucky Health News

The 30th annual Kids Count Data Book on children's well-being, released Monday by the Annie E. Casey Foundation and Kentucky Youth Advocates, ranks Kentucky 34th in the overall well-being of its children, where it has hovered since 2012. Nearly one in four Kentuckians are children.

Kentucky's highest rank, 25th, was in health. One of the state's bright spots is that it has so few children without health insurance, 4%, under the national average of 5%.

Kids Count charts; for larger versions, click on each image.
The state also continues to make progress in the areas of economic well-being and teen births; but the report also shows that more than one in five Kentucky children live in poverty, and 10 percent of them live in families where the head of the household doesn't have a high-school diploma.

Growing up in such a family matters, because research shows that children who grow up in these households not only have "fewer socioeconomic advantages, but also are more likely to be born with a low birth weight, have other health problems, enter school unprepared and have limited educational and employment opportunities as adults," the report says.

“The challenge of the Data Book — or any quality piece of research — lies in the answer to the question, ‘So what?’” Terry Brooks, executive director of Kentucky Youth Advocates, said in a news release. “This national report card on kids can become a catalyst for informed and thoughtful policy innovation for Kentucky’s children. Possibly even more critical given the environment in which we find ourselves today, the ‘So what?’ of the Data Book can provide a common ground for progress as we enter a highly contested and polarized campaign season.”

Kids Count measures 16 indicators to determine children's overall well-being. The latest data are for 2017, and are compared with data from 2010. The report focuses on four major domains: health, economic security, education, and family and community.

Economic well-being: As the national and state economy improved, so did Kentucky and the rest of the nation on all four indicators for economic well-being. Kentucky ranked 37th in this domain, up three slots from 2018.

Between 2010 and 2017, the percentage of Kentucky children living in poverty dropped from 26% to 22%; children whose parents lacked secure employment dropped from 37% to 31%; and teens who were not in school and not working dropped from 11% to 7%.

The biggest improvement in economic well-being was a reduction in the number of children living in households with high housing costs. That share dropped from 32% in 2010 to 23% in 2017. Such a household is defined as one where more than 30% of monthly household pre-tax income is spent on housing-related expenses, including rent, mortgage payments, taxes and insurance.

This is good news because "paying too much for housing limits the resources families have for other necessities such as child care, food, health care and transportation, as well as their ability to save and achieve financial stability," says the report.

As with many indicators, racial and ethnic disparities persist. In 2017, 38% of African-American children in Kentucky lived in households with high housing cost compared to 21% of white children.

Education: Kentucky ranked 27th, up two spots from last year. The good news is that 90% of Kentucky high-schoolers graduate on time, ranking the state second in the nation, says KYA.

That said, this indicator also displays racial and ethnic disparities; 16% of the state's Hispanic and Latino children and 23% of the state's African-American children did not graduate on time in 2017, compared to 9 percent of the state's white children.

The bad news in the education domain is that there was no significant progress from 2009 to 2017 in fourth-grade reading and eighth-grade math proficiency. The report shows that 62% of Kentucky fourth-graders are not proficient in reading and 71% of eighth-graders are not proficient in math.

Also, 59% of the state's young children are not attending pre-school -- and this figure worsened by nearly 4% from 2009-11 to 2015-17.

Family and community: This domain produced Kentucky's worst ranking: 43rd, a drop of four slots from last year.

The best news coming out of this domain is that Kentucky continues to show a steady decline in its teen birth rate, which dropped to 29 births per 1,000 females ages 15 to 19 in 2017. That was a 37% drop from 46 per 1,000 in 2010. But it still remains 53% above the national average of 19 per 1,000.

Several family and community indicators have changed little since 2010, such as: 35% of Kentucky's children live in single-parent families, and 16% live in high-poverty areas, defined as neighborhoods where more than 30% of the households are in poverty.

The report says that along with higher levels of financial instability, "Residents of these neighborhoods contend with poorer health, higher rates of crime and violence, poor-performing schools due to inadequate funding and limited access to support networks and job opportunities."

Kentucky Youth Advocates encourages policymakers to prioritize policies and programs that would expand opportunities for children, including a refundable earned-income tax credit, expanded child-care supports, paid family leave, more outreach for the Children's Health Insurance Program, raising the legal age to purchase tobacco products to 21, not changing the Medicaid program in ways that would decrease coverage for parents, and investing in early literacy and quality child care.

Further, KYA points out the importance of making sure every child in Kentucky is counted in the upcoming 2020 census, noting that the 2010 census is estimated to have missed 12,500 of them.

"Without an accurate count of all kids in 2020, Kentucky risks leaving real money on the table that could be used for health care, education, child care and other vital programs many young children in low-income families count on for a healthy and strong start in life," says the release.

The Kids Count Data Center provides current and trend data for 4,315 child well-being indicators related to each of the four domains in the report, at both a state and county level. It also offers a feature to create customized tables, maps, bar charts and graphs.

Saturday, June 15, 2019

Scorecard ranks Kentucky's health system 40th; bright spot is health insurance; biggest increasing problem is drug overdoses

Chart by The Commonwealth Fund, which explains: (a) The 2019 rankings generally reflect 2017 data.
(b) Comparisons are with a "baseline" period, which varies among the measured indicators. The report says, "There were generally four to five years between indicators’ baseline and current-year data."
By Melissa Patrick
Kentucky Health News

Kentucky remains in the bottom fourth of all states in the latest ranking of states' health systems, though it inched up in the rankings two spots to 40th overall. Its bright spot is access to health insurance; its biggest increasing problem is drug abuse, as measured by overdoses.

The Commonwealth Fund Scorecard on State Health System Performance evaluates states on 47 indicators of health in five areas: access and affordability, prevention and treatment, avoidable hospital use and hospital cost and healthy lives,which includes measures on premature death, health status and risky behaviors. This is the Commonwealth Fund's seventh scorecard, with the first one released in 2007.

The report found that suicide, alcohol and drug-overdose deaths have increased markedly in the past decade and that the prevalence of these "deaths of despair" vary by region. Kentucky is one of 13 states, all east of the Mississippi River, with more than 30 drug-overdose deaths per 100,000 people.

For every 100,000 Kentuckians, 37.2 died of overdoses in 2017. That was 57 percent more than in 2013, when the rate was 23.7 deaths per 100,000. In the same period, Kentucky alcohol deaths increased 45%, from 6.6 per 100,000 to 9.6. Deaths by suicide showed no real statistical difference from 2013 to 2017, when the numbers were 15.5 and 16.9 deaths per 100,000.

Nationally, from 2005 to 2017, the report shows that deaths from drug overdoses went up 115%, deaths from alcohol increased 37% and deaths from suicide increased 28%. In every state, deaths from those causes have risen at least 3 percent since 2005.

"Drug overdose mortality is disproportionately impacting states in the eastern part of the country and suicide and alcohol related deaths are occurring at higher rates in the west," David Radley, senior scientist at The Commonwealth Fund and lead author of the study, said during a press conference.
“What we're seeing is a regional epidemic when it comes to premature deaths from suicide, alcohol, and drugs," Dr. David Blumenthal, president of The Commonwealth Fund, said in the news release. "It's going to take solutions that meet local need, and greater cooperation across all sectors -- at both the federal and state level -- to end the crisis that is shortening life expectancy in the United States."

Sara Collins, vice-president of The Commonwealth Fund and co-author of the study, said one of the best things states could do to ensure that people with substance-use disorders have access to care is to expand Medicaid to people who earn up to 138% of the federal poverty line, as Kentucky has under the 2010 Patient Protection and Affordable Care Act, or "Obamacare."

The Commonwealth Fund's new data center lets users create
custom tables, graphs and maps. The uninsured rate in the
Southeast is 16%; in the U.S.12%; and in Kentucky it's 7%.
Kentucky's Medicaid expansion has given it one if its few bright spots when it comes to health care: the low number of people without health insurance.

In 2013, 21% of Kentuckians lacked health insurance. Medicaid expansion in 2014 has been the major factor in lowering that to 7%, which ranks Kentucky eighth best among states.

Despite these gains in coverage, the report notes that health insurance remains unaffordable for many, especially for those whose incomes are just over the eligibility threshold for the Obamacare marketplace subsidies. 

And at the same time, it says employer plans are growing at a faster rate than median incomes, "leaving many families paying more for their insurance, but getting less."

Kentuckians spent 7.3% of their median income on employee premiums for health insurance, slightly above the national average of 6.9%.

Kentucky's rankings

Compared to the baseline data on 45 measurements, Kentucky has improved on 18 indicators, shown little or no change on 18, and worsened on nine.

Kentucky's top rankings were in prevention and treatment (20th) and access and affordability (23rd), but it remained near the bottom for health disparities (40th), avoidable use and cost of hospitals (48th) and healthy lives (49th). It ranked 50th for its large numbers of adults who smoke, adults who report fair or poor health and children who are overweight or obese. (50th was not the worst ranking because the District of Columbia was counted as a state.)

Among the state's top indicators, Kentucky ranked fourth for its high percentage of adults who got an annual hemoglobin A1C test, an indicator of diabetes; and seventh for its low number of home-health patients who did not get better at walking or moving around.

Home-health patients' mobility was Kentucky's most improved measurement, other than the much lower uninsured rate; 22% did not improve their mobility in 2017, compared to 36% in 2013. Another big improvement was in adults who went without care because of cost, falling to 12% in 2017 from 19% in 2013.

Kentucky worsened in deaths caused by overdoses, listed above; preventable hospitalizations of people 18-64, which rose from 5.4 per 1,000 employer-insured enrollees in 2015 to 7.6 per 1,000 in 2016; and death within 30 days of hospital admission, which was 14.3% in 2014-17 and 13.3% in 2010-13.

Hospital 30-day mortality measures death rates for Medicare patients with a principal diagnosis of heart attack, heart failure, pneumonia or stroke within 30 days after admission, regardless of whether the patient dies while still in the hospital or after discharge.

The report also estimated what would happen if the state improved to the level of the best-performing state, which once again was Hawaii. Among other things, 108,982 more adults and children in the state would have health insurance; 136,534 fewer adults would skip needed care because of cost; and 174,435 more adults would receive age- and gender- appropriate screenings for cancer.

For the first time, the scorecard also includes regional comparisons. The Commonwealth Fund has a data center (datacenter.commonwealthfund.org) that allows users to explore state health system performance and policy data through custom tables, graphs and maps.

Friday, June 14, 2019

Former pharmacist in Williamsburg gets 6½ years in federal prison for illegally dispensing drugs

Kimberly Jones, pharmacist and owner of a Williamsburg drug store for the last decade or so, "has been sentenced to six and a half years in prison after being convicted of illegally dispensing drugs," Bill Estep reports for the Lexington Herald-Leader. U.S. District Judge Gregory F. Van Tatenhove also fined her $5,000 in federal court at London on June 11.

Kimberly Jones
"A jury acquitted Jones on most of the charges against her, but convicted her on seven charges related to illegally dispensing drugs," Estep writes. "In some cases, Jones gave drugs to people who didn’t have a prescription at the time."

In letters to the judge, people "described Jones as a hard-working, compassionate woman who supported local schools and adopted a little girl so that the child wouldn’t have to go into foster care," Estep reports. "One person said she’d seen Jones cry because a doctor prescribed a drug that an elderly person couldn’t afford. But a prosecutor argued that Jones ignored 'glaring red flags' that her pharmacy was contributing to the region’s drug problem."

The Justice Department said Jones continued filling prescriptions from suspicious providers in other states even after the Drug Enforcement Administration warned her about specific doctors. Assistant U.S. Attorney Andrew E. Smith said in a sentencing memo, “Pharmacists should act as gatekeepers, not enablers. But too many professionals like Jones have been complicit in their patients’ addictions, and our district, like many others across the country, is now grappling with the consequences.”

Thursday, June 13, 2019

Medicare cuts 19 Kentucky hospitals 1% for patient-safety issues; two in Louisville have been been penalized five years straight

The federal government is penalizing 19 Kentucky hospitals, nine more than last year, for falling short on patient safety in the fiscal year that ended Sept. 30.

Centers for Disease Control and Prevention photo
Medicare imposed a 1 percent cut in payment to 800 U.S. hospitals this year that were found to have high numbers of patients with avoidable infections and complications, such as blood clots, urinary-tract and surgical-site infections, bed sores and falls, and infections related to antibiotic-resistant infections, like methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C.diff.).

This is the fifth year of the Hospital Acquired Conditions Reduction Program, which was created under the 2010 Patient Protection and Affordable Care Act. The program penalizes the worst 25% of hospitals on a list of patient-safety measures, even if their records have improved from the previous year, Jordan Rau reports for Kaiser Health News.

Critical-access hospitals and specialized hospitals that treat psychiatric patients, veterans and children are exempt from the penalties.

Since the program's inception, Rau reports, 110 hospitals have been punished all five times. Two of them are in Louisville: the University of Louisville Hospital and Jewish Hospital & St. Mary's Healthcare.

Ephraim McDowell Regional Medical Center in Danville and Jennie Stuart Medical Center in Hopkinsville are on the penalty list for the fourth straight year.

Norton Hospital / Norton Healthcare Pavilion in Louisville is being penalized for the third straight year, after being penalized the first year of the program but not the second.

Highlands Regional Medical Center in Prestonsburg, Jewish Hospital-Shelbyville, and St. Claire Regional Medical Center in Morehead were penalized last year and are also on the list this year.

Rockcastle Regional Hospital & Respiratory Care Center in Mount Vernon is also on the list for the second year in a row. It has only had one other penalty in the past five years, in 2016.

Owensboro Health Muhlenberg Community Hospital in Greenville is being penalized this year. In the past five years, the only other time it was not penalized was in 2017.

Officials at the Muhlenberg County hospital said the 1% reduction in Medicare reimbursements comes to about $50,000 a year, Renee Beasley Jones reports for the Messenger-Inquirer in Owensboro. Beasley reports in depth on the hospital's penalties and how the administration is working to improve its quality and patient safety scores.

Several hospitals are being penalized for the first time, including: T. J. Samson Community Hospital in Glasgow, Flaget Memorial Hospital in Bardstown, Saint Joseph Mount Sterling, The Medical Center at Albany, Baptist Health Louisville, Lake Cumberland Regional Hospital in Somerset, and Baptist Health La Grange.

Jackson Purchase Medical Center in Mayfield is also being penalized this year. The last time it was on the list was during the first year the penalties were implemented, in 2015.

University of Kentucky Hospital in Lexington has been on the penalty list every other year since the program's inception, including this year.

Click here for a Kaiser Health News tool that shows Medicare penalties for hospital readmissions and hospital-acquired conditions. The data can be broken down by year, state, hospital, and county.

The hospital industry has long protested these penalties, saying it is the wrong approach to encourage hospitals to improve quality and safety. A 2018 statement from the American Hospital Association cites research that shows only about 41% of the 768 hospitals penalized in 2017 had HAC scores that were significantly higher, statistically speaking, than hospitals not being penalized.

"In other words, the majority of hospitals receiving HAC penalty have performance indistinguishable from those that are not being penalized," it says.

Further, Rau reports that "hospitals also complain that the ones that do the best job testing for infections and other threats to patients appear to be among the worst based on statistics, while their more lackadaisical peers look better than they might be."

But supporters of the program argue that "the penalties are warranted in prodding hospitals to improve quality," he writes.

“The fact that everyone’s talking about it, from front-line nurses to boards of directors, is positioning patient safety where it should be, which is at the forefront of everyone’s minds,” Missy Danforth, the vice-president of health care ratings at the Leapfrog Group, told Rau.

Danforth also dismissed the hospital complaints that the penalties are not fairly applied. She told Rau, "There's a lot of really strong, good best practices to getting to zero on these infections."

Study finds young adults who recognize cartoons used in e-cigarette marketing are more likely to use e-cigs in the future

Label, copyright 2015 by Brian Allen
Electronic cigarette companies are using cartoon characters to market their products, and research shows that it's working, Jon-Patrick Allem writes on The Conversation.

Allem is an assistant professor at the University of Southern California and one of the researchers on a study that found young adults who recognize the cartoons used in the marketing of electronic cigarettes are more likely to use e-cigarettes in the future.

"In other words, among never-users, recognition of actual cartoon-based marketing images – but not recognition of non-cartoon-based marketing images – was associated with a greater likelihood of participants reporting susceptibility to use electronic cigarettes," Allem writes.

The study, published in the refereed journal Drug and Alcohol Dependence, examined whether a person's susceptibility to using e-cigarettes in the future increased as a result of their exposure to cartoon-based marketing from e-cig companies.

A prior study by Allem and his colleagues had already established that e-cigarette makers are using cartoons as a marketing strategy, and that many companies’ logos are cartoons. Cartoon marketing for e-cigs is unregulated, though restrictions on cartoon marketing for combustible cigarettes and chewing tobacco have been in place since 1999.

Using an online survey, the researchers presented the participants with 22 images of electronic cigarette products, 11 of them had a cartoon on the packaging and 11 of them did not.

The study found that 38% of the 802 participants recognized at least one cartoon-based marketing image. Among the 286 never-users, individuals who reported cartoon recognition were four times more likely to be susceptible to using e-cigarettes in the future compared to those not susceptible.

Susceptibility was measured by responses to a series of questions such as, “Do you think that you will try vaping soon?," Allem writes.

The researchers controlled for demographic characteristics and exposure to other types of marketing that may be associated with susceptibility to use electronic cigarettes, "allowing us to confidently claim that cartoon recognition is associated with susceptibility," Allem reports.

Further, he writes that these findings "are consistent with prior research that examined the impact of cartoon-based marketing on the purchase and use of a range of products from combustible cigarettes to sugary foods."

Allem says his study does not explain why cartoon recognition is associated with susceptibility to using electronic cigarettes in the future, but other research suggest it is because cartoons are a simple and fun way to communicate an idea that increases attention to a product, which ultimately leads to product recognition and altered attitudes.

He also recognized that the study only provides a correlation between cartoon marketing of electronic cigarettes and susceptibility to using them. He also notes that the study only included adults and that he plans to expand it to youth.

Allem writes, "We believe that our findings could motivate policies aimed at reducing cartoon-based electronic cigarette marketing similar to those for combustible cigarettes and chewing tobacco."