Kentuckians tell pollsters they are concerned about air quality, but don't seem to put their concern into action

A recent poll shows that more than half of Kentucky adults, especially women, are concerned about air quality in their community, but only 48 percent say they change their behavior when an air quality alert is issued.

Perhaps they have never heard of an air quality alert, which is issued by a local or state air-pollution authority to protect the public's health from air pollution. The U.S. Environmental Protection Agency monitors air quality and uses an Air Quality Index to warn the public when the amount of particle pollution or ozone in the air may harm their health.

When pollution gets to a level of concern, alerts or action days are issued in participating areas, which in Kentucky are Louisville, Lexington and the Mammoth Cave area (primarily Edmonson County). This could explain why almost 30 percent of poll respondents from Louisville said they were very concerned about air quality in their community, and only 13 percent of respondents from Appalachia indicated this level of concern.

Almost 60 percent of Appalachians said they are not concerned at all about the air quality in their community, compared to 26 percent of Louisville respondents that aren't at all concerned. Few Eastern Kentucky counties are part of an air-quality monitoring program. In addition to the areas monitoring for alerts or action days, 37 Kentucky counties (colored in the map) participate in the monitoring program. Click here to compare counties.

Counties covered by an air-quality monitoring program are colored.

The poll indicated that just 20 percent of Kentucky adults said they change or limit their activities a lot when air quality alerts are issued, and about 30 percent said they change their behavior a little.  Respondents from the Louisville region were most likely to change or limit their activities, while those in the Lexington area were the most likely to not change or limit their behavior at all. 

When air quality is at an unhealthy level, people can protect themselves by limiting outdoor activities or avoiding heavy exertion.  These protective measures are even more important for those sensitive to air pollution, such as people with heart or lung disease, the elderly and children.

“The quality of our air impacts all of us, but is particularly important for sensitive groups, such as children with asthma. When an air quality alert is issued, we can protect ourselves and our families by avoiding heavy exertion and limiting outdoor activities,” said Dr. Susan Zepeda, president and CEO of the Foundation for a Healthy Kentucky, which co-sponsored the poll. “We can also do our part to limit emissions and protect our neighbors by turning off our car’s engine while we are waiting.” 

Almost 30 percent of Kentucky adults and 40 percent of Western Kentucky adults said they never turn their car’s engine off when waiting in their car and not moving, as in a traffic jam, train crossing or drive-through. Including those who never turn off their cars, more 60 percent said they wait at least four minutes before turning off their car’s engine when waiting in the car and not moving. Experts recommend turning off a waiting car’s engine after just ten seconds in order to save gas and limit emissions.

The poll was funded by the foundation and the Health Foundation of Greater Cincinnati and was conducted last year from Sept. 20 to Oct. 14 by the Institute for Policy Research at the University of Cincinnati. A random sample of 1,680 adults from throughout Kentucky was interviewed by telephone, including landlines and cell phones and the poll has a margin of error of plus or minus 2.5 percentage points.

Public Health Week theme: It's a good investment, saving lives and money

April 1-7 is National Public Health Week, and the Kentucky Department for Public Health is working to raise awareness and help people live longer, healthier lives by promoting the 2013 week's theme: the return on investment of public-health services.

Everyone likes sound, stable and high-return investments, and research shows that investing just $10 per person each year in proven, community-based public health efforts can save the nation more than $16 billion within five years. That’s a $5.60 return for every $1 invested.

“Our nation and community simply cannot sustain the current trajectory of health care spending and chronic disease Dr. Stephanie Mayfield, the state health commissioner, said in a Cabinet for Health and Family Services release. “Fortunately, we know that investing in prevention and public health can make an enormous difference and it’s the right direction for Kentucky to move in to address poor health outcomes.”

Supporting public health approaches to better health outcomes does reap life-saving returns, said Mayfield. For example, research shows that each 10 percent increase in local public health spending contributes to a nearly 7 percent decrease in infant deaths, a 3.2 percent decrease in cardiovascular deaths and a 1.4 percent decrease in diabetes-related deaths.

“In some way, public health touches everyone, every day in Kentucky. We are dedicated to making our infrastructure even stronger, including ongoing work to become nationally accredited in 2014, finding opportunities for improvement within our programs, and focusing on overall prevention for the health and well-being of Kentuckians,” said Mayfield.

Since 1995, communities nationwide have celebrated National Public Health Week each April to draw attention to the need to help protect and improve the nation’s health and to educate the public, policymakers and practitioners.

“We hope this week will serve as an opportunity for the public to learn more about the vital role of public health in Kentucky,” said Mayfield. (Click to learn more about the Kentucky Department for Public Health or National Public Health Week)

Will Kentucky expand Medicaid, and if so, how?

By Molly Burchett
Kentucky Health News

Kentucky is one of the last states to decide whether to expand Medicaid under federal health reform, and now that the General Assembly has gone home, Democratic Gov. Steve Beshear can turn his attention to the many questions that linger. Some Republican legislators think he will expand the program, but they worry about the cost when the state would have to start helping cover the new expenses, beginning in 2017.

Republican Gov. Bill Haslam of Tennessee decided Wednesday that he will not pursue Medicaid expansion, saying that it could put hospitals in financial jeopardy by giving them more patients on which they lose money, reports Michelle Kaske of Bloomberg. If he is right and the same logic applies to Kentucky, Medicaid expansion in the state could harm the rural hospitals and providers -- some of whom are already squeezed by the issues with the new managed-care system.

Along with Kentucky, 10 other states are undecided about Medicaid expansion: Alaska, Indiana, Kansas, Nebraska, New York, Oregon, Utah, Virginia, West Virginia and Wyoming. The map by The Advisory Board Company shows the lay of the land; for an interactive picture that outlines the research behind the map, click here.

Red=Not participating; Pink=Leaning toward not participating;
Gray=Undecided; Blue=Participating; Light Blue=Leaning toward participating

Only three states with Democratic governors are undecided; 18 Republican governors have rejected expansion. Kentucky is shown as leaning for it because Beshear has repeatedly said that he will expand Medicaid if the state can afford it. He has also mentioned that the state can reserve the right to pull out of the deal in 2017, when it must paying 3 percent of the cost of covering the newly insured, reaching 10 percent in 2020. Still, the questions about cost and affordability remain, and Beshear could be considering another option.

Tennessee has joined Ohio and Arkansas in negotiating with the Obama administration over plans to use federal Medicaid money to purchase private insurance for those who can't afford it but don't qualify for Medicaid now. However, Haslam's plan has been held up because the administration placed too many conditions on the money, writes Kaske. Republicans in other states, including Florida, Louisiana, Pennsylvania and Texas, have expressed interest in this option since Gov. Mike Beebe of Arkansas, a Democrat, ignited the wildfire of creating a hybrid of the two alternatives, reports Robert Pear of The New York Times.

The idea of privatizing Medicaid expansion appeals to many doctors and hospitals because they typically receive higher payments from commercial insurance than from Medicaid. However, many Kentucky hospitals and providers are concerned about the managed-care program that is run by three private organizations, and are calling for immediate action. Beshear has not said whether he will sign or veto a bill that would subject the managed-care firms to the prompt-payments and dispute-resolution rules of the state Department of Insurance.

"Action is needed to address the problems that patients and hospitals are experiencing with Medicaid managed care and to make the system work properly," wrote Harold "Bud" Warman, chair of the Kentucky Hospital Association, and Charles Lovell, chair-elect of the association, in a recent Herald-Leader article that laid out the various problems with the system. "And with the possibility that Medicaid will be expanded in Kentucky to include an additional 350,000 people, it is critical that these issues be addressed right away to avoid even greater problems in the future."

Either using federal dollars to buy private insurance in order to cover newly qualified individuals (the hybrid plan) under the health law's expansion  or expanding in the "traditional" way will not change the current managed care structure of Medicaid in Kentucky. Yet, it would mean that 350,000 more Kentuckians would be covered under managed care; Medicaid would cover those earning up to 138 percent of the federal poverty level, currently up to $15,856 a year for an individual.

The money that the federal government offers for expansion is very tempting. The question then may be, how will it be used?

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Senate sends bill for prompt payment by managed-care firms to Beshear, who won't say whether he will sign or veto it

A bill aimed at resolving payment disputes between medical providers and Medicaid managed-care companies passed unanimously Monday in the Senate, and has been sent to Gov. Steve Beshear for his consideration.

House Bill 5, sponsored by House Speaker Greg Stumbo, D-Prestonsburg, would apply existing prompt-payment laws to managed-care firms and would set up an appeal process in the Department of Insurance to handle disputes between them and medical providers. Those claims are now handled by the Cabinet for Health and Family Services, which administers Medicaid and has had some problems with the bill.

Hospitals, doctors and other health-care providers have complained that the cabinet is not resolving their payment disputes with managed-care firms, putting many rural hospitals, clinics and health departments in serious financial binds.  Mental health centers have also reported cutting back services.

Asked last night what he would do with the bill, Beshear said the cabinet "has worked with the managed-care organizations and health-care providers to reduce problems during the change, and many concerns have been addressed.  However, I recognize that some issues persist.  I will review this bill carefully.”

Beshear has 10 days, excluding Sundays, to decide whether to veto the bill, sign it into law or allow it to become law without his signature. Stumbo said that if bill is vetoed it would likely be House Bill 1 in the 2014 session, reports Jessie Halladay of The Courier-Journal. The bill is a top priority for many health-care providers.

State Auditor Edelen says state must fix managed-care issues that have put rural hospitals and providers on brink of survival

State Auditor Adam Edelen said last week that shoring up the financial base for rural hospitals in Kentucky is the number one challenge to the state's Medicaid managed-care system.

The managed-care system has left rural hospitals at a tipping point that determines whether or not they will survive, which is deeply disconcerting when considering access to quality health care for Kentuckians in rural areas, Edelen said in a cn|2 "Pure Politics" interview. The state has a significant rural population, and "you can't overstate the importance of these rural hospitals," he said.

Hiring private companies to manage Medicaid has helped Kentucky slow cost increases in the $6 billion program, but the system has serious structural issues, and hospitals, doctors, dentists and other providers say the managed-care organizations (MCOs) are not paying them for treating Medicaid patients, Jacqueline Pitts of cn|2 reported.

There are many stories "about providers who have submitted claims and all of sudden, these MCOs change the rules, and so these claims are deemed unclear or improper and they are sent back," House Speaker Greg Stumbo said.

Edelen said the problem is that there is no consistent oversight in the claims process from the cabinet, and there is no opportunity for the provider to respond. "Right now we have our providers up against such a wall that the choice is to do one of two things," he said. "It's either to opt out of Medicaid, which is not something we want to do considering we have one of the largest percentage of population on Medicaid anywhere in the country, or go to the courts," which is inefficient and expensive.

“You have good people in the cabinet trying to manage it, you’ve got providers that are just trying to provide services to people, but we’ve got to have a better system of oversight and accountability because if that happen and we begin to lose hospitals in rural Kentucky then we have significantly reduced the level of quality of life for the people of Kentucky,” Edelen said.

Fixing the system for those hospitals and doctors is what is so important to the state as a whole, he said. He said the state and MCOs have had enough time to work out glitches with doctors and hospitals, and they must make some substantial changes before medical care for Kentucky’s neediest suffers any more.

Managed care, pension payments causing problems for community mental health centers; Edelen, C-J call for changes

"Kentucky mental health centers are cutting back services and struggling to assist patients the first time they’re admitted because of ongoing struggles with Medicaid managed care," Don Weber reports for cn|2. "At the same time, they’re losing out on federal grants because of red flags caused by their administration costs being inflated by increasing contributions to the public pension system."

NorthKey Community Care Mental Health Center in Northern Kentucky, which serves eight counties, had to close its adult day-treatment programs for the seriously mentally ill. Dr. Owen Nichols, the president and CEO, told Weber, “I get calls periodically from elderly parents in the community wanting help with their adult child that suffers from schizophrenia because they’re now wandering the streets, having some difficulties with local authorities.”

A recent editorial in The Courier-Journal addresses Kentucky's need for better mental health treatment, saying that Kentucky has "an underfunded, fragmented and now —thanks mostly to Medicaid managed care —hopelessly complicated system of mental health care."

The editorial notes last week's C-J articles in which reporters Laura Ungar and Chris Kenning uncovered the problems families face when navigating a fragmented mental-health system while trying to provide appropriate treatment for a loved one suffering form a severe mental illness, in addition to the "F" grade Kentucky received for its poor mental-health funding.

The editorial also describes how structural issues with managed care, which began in November 2011, have complicated the state's mental-health system. It notes the community mental-health centers asked to be left out of managed care, "pointing out they already operate efficiently and amount to only about 3 percent of the state’s $6 billion a year Medicaid program."

In addition, the editorial notes, "State Auditor Adam Edelen recommended the Cabinet for Health and Family Services take mental health out of managed care and let the state resume running it." Against his advice and the requests of community mental-health centers, the state expanded managed care of mental health. Now some haven’t been paid for Medicaid services since January, when managed care took effect, the editorial says.

"The nightmare needs to end for the many Kentuckians who need basic mental health services," says the editorial. "It’s time for the state to fully explore this system and, if folks are serious about improving it, fix the problems and find the money to fund it." (Read more)

Newly formed Kentucky Health Cooperative gets OK to offer plans in state's health insurance exchange

The new Kentucky Health Cooperative's health-insurance plans have received approval from the state Department of Insurance and will be available on Kentucky's insurance exchange market when it opens in October.

“This is a red-letter day for Kentuckians,” Janie Miller, CEO of the cooperative, said in a news release. “Although health-care cooperatives have offered quality care and lower overhead expenses to members since the 1930s, they’re the ‘newest kid’ on Kentucky’s health insurance block. Efforts are underway to help the public become familiar with the cooperative concept.” The cooperative was formed with a mixture of private capital and federal loans.

Miller, a former secretary of the state Cabinet for Health and Family Services, said the cooperative is like member-owned and member-operated credit unions, rural electric cooperatives and food co-ops. “Think agriculture cooperative extension offices, and consider the impact such organizations have made,” she said. “Doing so makes it easy to imagine the potential, similar value to the citizens of our Commonwealth offered by a health cooperative.”

Joe Smith, chair of the cooperative's board of directors, said “A gateway has been opened to individuals and small businesses seeking more affordable, consumer-friendly, quality-driven health insurance options.”

Details about the cooperative plans offered to individuals and businesses with 50 or fewer employees on the nw state insurance exchange will be announced in the coming months. (Read more at the KYHC website)

State Health Department gets diabetes prevention funding; will focus on prediabetes detection and lifestyle changes

The state Department for Public Health has been awarded a $134,380 federal grant to help reduce high rates of prediabetes and Type 2 diabetes in Kentucky.

“Diabetes is a tremendous public health concern that is both horrific for the individual, if unmanaged, and costly in terms of medications, various complications and long-term hospitalizations that are so often associated with the disease,” Audrey Haynes, secretary of the Cabinet for Health and Family Services, said in a press release.

In 2009, Kentucky's rate for diagnosed diabetes was the fourth highest in the nation at 11.4 percent of the population, compared to a national median of 8.3 percent. The rate means an estimated 366,000 adults in Kentucky have diabetes. An additional 266,000 Kentuckians are estimated to have prediabetes, according to the CFHS website.

Prediabetes often leads to Type 2 diabetes, the most common type, within a few years, but lifestyle changes promoted by the federal Diabetes Prevention Program can decrease the risk of developing diabetes by almost 60 percent, according to a recent study published in the Journal of Preventive Medicine.

“We must act now to begin reversing the devastating impact of diabetes on our state,” Haynes said. “We are excited to continue our work with the Diabetes Prevention Program to help more Kentuckians start making healthier lifestyle choices so they can avoid developing diabetes and lead longer, healthier lives.”

The DPP specifically targets individuals with prediabetes and works with them to reduce their risk of developing Type 2 diabetes. The risk factors for both are: being older than 45, being overweight or obese, physical inactivity, having a family history of diabetes, ever having gestational diabetes, high blood pressure, abnormal cholesterol, having a history of cardiovascular disease and being African-American, Hispanic/Latino, Native American, Asian American or Pacific Islander. Click here to take the diabetes risk test.

The federal Centers for Disease Control estimates that national efforts to prevent Type 2 diabetes could save $5.7 billion in health care costs by preventing 885,000 cases in the next 25 years. Kentucky will focus on three diabetes prevention strategies that involve raising awareness among health care providers to improve detection and treatment of prediabetes and encouraging both state/local government and business to add lifestyle change programs to the list of covered services under health plans, says the news release. (Read more about diabetes and prevention in Kentucky).

New health ranking of counties places Oldham at top for second straight year; some counties had big jumps and drops

By Molly Burchett
Kentucky Health News

A new report of the national county health rankings shows several Kentucky counties have improved in the last two years while others have gotten significantly worse.

For the second year in a row, Oldham County ranked best in health outcomes, and Floyd County ranked worst this year, but the statistical differences among closely ranked counties are so small that they are subject to error margins. The rankings recognize that by placing the counties into quartiles, or fourths, of the state's 120 counties.

Ranks in quartiles: white, 1st-30th; gray, 31st to 60th; light green, 61st to 90th; dark green, 91st to 120th.

The results were released Wednesday in the fourth annual County Health Rankings by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, and are available at www.countryhealthrankings.org. Detailed, county-by-county health data are available at KentuckyHealthFacts.org.

Morgan County jumped two quartiles over the past year, improving its rank by 40 notches, from 69th to 29th. Another strongly positive change from last year was Mercer's County's improvement from 61st to 40th.

On the other hand, other county rankings worsened: McLean went down two quartiles and 36 steps, from 57th to 93rd. Bourbon went from 42nd to 68th, Gallatin went from 71st to 94th and Hickman County 31st to 61st.

These Eastern Kentucky counties have been listed in the bottom quartile (91st to 120th) for the past three years: Lawrence, Johnson, Martin Powell, Wolfe, Magoffin, Floyd, Pike, Breathitt, Knott, Jackson, Owsley, Perry, Letcher, Clay, Leslie, Knox, Bell and Whitley.

The rankings are based on a model of population health that emphasizes the many factors that, if improved, can help make Kentucky communities healthier places to live: health behaviors, such as diet, exercise and alcohol use; clinical care, including access to care and quality of care; social and economic factors, such as education, employment and income; and the environmental quality of the physical environment.

Other factors considered in the rankings include the rate of people dying before age 75, high-school graduation rates, unemployment, access to healthy foods, air and water quality, income, and rates of smoking, obesity and teenage pregnancy.

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Study suggesting that coal is a cause of health problems in E. Ky. is disputed by industry and politicians, defended by researcher

By Molly Burchett
Kentucky Health News

A heated debate centers on new research showing that residents in Floyd County, where coal is stripped from the tops of mountains and ridges, report more health problems than those in two nearby communities without such mines, Elliott and Rowan.

The study, published in the online Journal of Rural Health, is the latest by Dr. Michael Hendryx of West Virginia University to suggest that residents of mining areas have poorer health conditions and experience more serious illness. It is available to readers of Kentucky Health News by clicking here.

Unlike some of his West Virginia research, Hendryx does not say there is a correlation between mining and poorer health outcomes in Eastern Kentucky. He does suggest the possibility of a connection by showing residents' self-reported health problems like asthma, chronic obstructive pulmonary disorder and hypertension are more common in mining areas. And in an interview, he said he believes there is a connection.

Stonecrest Golf Course at Prestonsburg in Floyd County,
built on a reclaimed mountaintop-removal coal mine.

The study and its critics highlight the challenges and pitfalls of discussing and reporting such research. The study's underlying motives and methodology are contested. The president of the Kentucky Coal Association, Bill Bissett, said Hendryx has reached a conclusion and is seeking evidence to support it.

"Bissett's accusation is completely false," Hendryx replied. "On the contrary, he is obviously the one with the biased perspective and has a strong financial motivation to try to discredit this work."

Bissett questions the study's use of self-reported health measures that did not consider medical history. Self-reporting is susceptible to bias, which can be reduced by using other sources of data/. This study only included data collected from interviews conducted by volunteers, which may have introduced more bias, Bissett said.

Hendryx replied, "We used undergraduate students from Christian colleges who were trained to be fair and objective in the survey procedures, and to use the same procedures in both the mining and non-mining communities." He said Peter Illyn, who runs the Christian organization Restoring Eden, approached him to do the survey because Illyn "wanted to give the students this experience, and he wanted to replicate the survey that we had done the previous year in West Virginia, this time in Kentucky."

The volunteers interviewed 544 participants lived in Floyd County and 351 in Rowan and Elliot counties, where coal is not mined. It used standard statistical devices to control for factors that might influence health status: age, sex, education, marital status, work as a coal miner, weight and tobacco habits. However, there was no consideration of health behaviors such as drug and alcohol use, wellness measures, exercise or other healthy lifestyle habits that could have positive influences.

"The survey had to be brief with the time and resources we had," said Hendryx. "We did measure overweight and obesity, which is a reflection of diet and exercise. We measured tobacco use. We did not measure alcohol use in this survey but in other studies we have found that heavy alcohol use is not common and is not an explanation for the findings."

Kentucky House Speaker Greg Stumbo, who is from Floyd County, said he disagreed with the use of Rowan County, home of Morehead State University, as a control group due to the higher rates of education attainment and per capita income, reported Ronnie Ellis of Community Newspaper Holdings Inc.

Stumbo told Ellis, “Everybody in the world knows that you can take a population that is less well educated and that has a lower per capita income and you’ll see their health habits are (worse) and hence their rates of diseases are attributable to those two things.” Rowan has a much better health status than surrounding counties, according to the latest national County Health Rankings.

Hendryx defended his research controls and the process of relying on self-reported medical histories. He said the health problems may be caused by tiny particles of dust from coal mining, which have been linked to health problems, can penetrate the lungs to cause health impacts, reported James Bruggers of The Courier-Journal. Hendryx said there are also concerns about polluted water and soil.

The study's data only hint at a connection between surface coal mining and poor health. Hendryx said he can’t prove that mountaintop removal is causing people to get sick, but he believes it is. What is needed, he told Bruggers, is a more thorough and expensive “gold standard” study of air and water quality near residences, and samples of blood, hair and toenails that can reveal exposure to pollutants.

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Most Kentucky adults don't know that drug overdose is the leading cause of death in the state, but those in the east do

Drug overdoses, driven largely by prescription drug abuse, overtook motor vehicle accidents as the leading cause of unintentional deaths in Kentucky back in 2010 and remain the state's leading cause of death. From 2000 to 2010, the number of drug-overdose deaths in Kentucky rose a staggering 296 percent, highlighting the state's drug abuse epidemic that now kills more than 1,000 Kentuckians a year. But a recent poll suggests many Kentuckians are not fully aware of the state's drug problem.

In an effort to gauge awareness of the problem, the Kentucky Health Issues Poll asked Kentucky adults whether traffic accidents, falls, firearms or unintentional drug overdoses resulted in the highest dumber of deaths in the state each year. Only 44 percent of Kentucky adults correctly indicated that drug overdose is the leading cause of unintentional Kentucky deaths; 43 percent incorrectly identified traffic accidents as the leading cause.

Respondents from Eastern Kentucky, where the problem is most prevalent  were more likely to correctly identify it as the leading cause of death, at 69 percent. However, only 29 percent of Louisville-area respondents did.

“Experts have reported significant prescription pain reliever abuse in eastern Kentucky,” said Susan Zepeda, presient of the Foundation for a Healthy Kentucky, which co-sponsored the poll.  “It is no surprise that the Kentuckians most aware of this issue are those who are living in this region.  Awareness is the first step towards curbing this trend – it is up to all of us to get involved and take action to reduce the toll of this health crisis.”

The poll was conducted for the foundation and The Health Foundation of Greater Cincinnati from Sept. 20 through Oct. 14 by the Institute for Policy Research at the University of Cincinnati. A random sample of 1,680 adults throughout Kentucky was interviewed by land line and cell telephones, and the poll's margin of error is plus or minus 2.5 percentage points.

Legislature eases physician assistant rules; nurse practitioners' prescription power, Medicaid prompt-payment bills, others linger

By Molly Burchett and Al Cross
Kentucky Health News

The Kentucky General Assembly has joined other states in easing the restrictions on physician assistants’ medical practice, but has held up a similar move for advanced registered nurse practitioners. Both issues relate to the shortage of medical practitioners in many Kentucky counties, and the quality of medical care.

The Senate added the physician assistant language of Senate Bill 43 to House Bill 104, an art-therapy bill, in order to preserve an agreement between the Kentucky Medical Association and the Kentucky Academy of Physician Assistants. It will repeal the law that bans PAs from practicing for their first 18 months unless a physician is on site; one will still have to be available by telephone. The amended bill has been sent to Gov. Steve Beshear for his signature or veto.

The amendment was used because the House had tacked onto SB 43 an amendment from advance practice registered nurses that would have repealed the need for them to have a collaborative agreement with a physicians to prescribe non-narcotic drugs. The KMA opposes that idea.

"It's looking like the doctors win," said Sen. Julie Denton, R-Louisville, who favors the repeal. "I'm not hopeful" it can pass, she said, but added that some physicians also favor it: "With Obamacare coming in, we're going to need all the front-line physicians we can get." Leading opponents of the measure, Republicans Katie Stine of Fort Thomas and Carroll Gibson of Leitchfield, didn't return a call seeking comment.

Nurse practitioners say that SB 43 is necessary to allow them to fill health-care gaps in rural Kentucky and address the state's shortage of primary-care providers. The Kentucky Coalition of Nurse Practitioners and Nurse Midwives says in an article prepared for Kentucky newspapers that NPs have never been required to practice under physician supervision and 17 states allow full prescribing authority for non-scheduled medications.

The Medicaid prompt-payment bill, HB 5, went to a conference committee after the House refused to go along with Senate changes, and may be considered when the legislature returns later this month, ostensibly to consider any bills Beshear vetoes. The bill would apply prompt-payment laws to managed-care organizations and would move Medicaid late-payment complaints to the insurance department; those are now handled by the Cabinet for Health and Family Services, which administers Medicaid.

In the final crunch to pass legislation before the veto recess, lawmakers attached seven health care-related bills to HB 366, which had focused on identifying congenital heart disease in newborns. It had 10 additional measures "hung on it like a Christmas tree before the free conference committee of House and Senate members," reports Ryan Alessi of cn|2's "Pure Politics."

The bills still hanging on the measure, dubbed the "healthy Christmas tree," are:

• HB 187, addressing a free prescription-drug program for under-insured Kentuckians.
• HB 79, which would exempt licensed health care providers from being disciplined for prescribing naloxone in the event of an overdose.
• HB 387, which aims to provide nutritional supplements for low-birth-weight newborns.
• SB 201, which addresses licensed diabetes educators.
• SB 38, to require Medicaid to accept provider credentialing by a Medicaid managed-care organization.
• SB 108, relating to managed-care contracts with the IMPACT Plus program, a behavioral health program for children.

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Kentucky families struggle to care for violent, mentally ill children, and say their plight has been made worse by managed-care firms

Kentucky families struggle to care for violent, mentally ill children, and say their plight has been made worse by managed-care companies that fragment mental-health care and make it harder to find appropriate, stable treatment, which ultimately places the larger public at risk, Laura Ungar reports for The Courier-Journal.

Ungar writes that the lives of these Kentucky families resemble in part the one that lead to a devastating outcome in Newtown, Conn., where 20-year-old Adam Lanza, who had poor mental health and was under his mother’s care, went on a shooting rampage in an elementary school and killed 20 students and six staff members.

To represent the Kentucky families fighting, this battle, Ungar tells the story of the Davies family, who battle to keep themselves safe from the violent rage of their 14-year-old daughter, Lucy, while struggling to find the help she needs. Lucy has threatened to kill her 16-year-old sister, Katie, and herself, she’s tried to throw Katie and her father Dan down the basement stairs, and she’s been abusive to her mother.

Lucy suffers from a long list of disorders: neurological problems from fetal alcohol spectrum disorder, a mood disorder, post-traumatic stress disorder, and cognitive difficulties, Ungar reports. "Since Lucy was adopted at age 9, she’s received fragmented treatment in more than six facilities and doctors’ offices, none of which have been able to stop her violent outbursts," Ungar writes. Now, her Medicaid managed-care insurer, Coventry Cares, won’t cover her treatment in an Illinois facility called NeuroRestorative, which Ungar says offers her the best chance at improvement.

"The care tracking is just so fragmented, and we have managed-care companies that determine from afar what care people can get. They go from provider to provider. It’s a tragedy," said Louise Howell, president of Buckhorn Children and Family Services, where Lucy was treated briefly before becoming too violent for the staff. “This child is a perfect example of someone in need of a strong therapeutic community," Howell said. "And there’s so many of them."

Before going to Buckhorn, Lucy was at Rivendell Behavioral Health Services in Bowling Green, where she received brief treatment after threatening to kill her sister. From Buckhorn she got an emergency transfer to Our Lady of Peace in Louisville, which could handle her high level of violence. She was released when she moved from the Medicaid plan Kentucky Spirit, which plans to break its contract with the state, to Coventry Cares, with which Our Lady of Peace had severed ties.

Lucy's mother told Ungar that every switch of caregiver and facility increases the trauma to her daughter, who desperately needs stable care. Lucy’s parents say she would have such stability at NeuroRestorative, where her fetal alcohol syndrome could be addressed on a long-term basis. But two doctors working for Coventry, who have never examined Lucy, told her parents that Conventry "won’t cover the placement because there’s no evidence that inpatient care for brain trauma is medically necessary," Ungar reports.

Her eyes full of tears, Cynthia Davies told Ungar, “You cannot look into my daughter’s eyes and tell me she doesn’t deserve care. She’s a human being.” (Read more)

Kentucky receives an F grade for its low funding of mental-health services; supply falls short of demand

Kentucky's supply of mental-health services is much lower than demand for those services, in terms of state funding, and the state spends only 45 percent of the national average in mental-health funding per person.

In 2010, Kentucky dedicated about $232 million to mental-health services, according to the Kaiser Family Foundation, which is $54 per person, compared with a U.S. average of $121 that year. That ranks Kentucky among the bottom 10 states without including individual mental health reimbursements for Medicaid, reports Chris Kenning of The Courier-Journal.

The state's Medicaid rates for mental-health services haven't been raised substantially in years, and only a fraction of mental-health facilities offer residential treatments, reports Kenning. He also reports the most recent “Grading the States” report of the National Alliance on Mental Illness gave Kentucky an F in 2009. The group considered measures such as the number of programs using evidence-based practices and the number of psychiatric beds.

Kentucky officials cite new efforts to improve care, such as partnering with the University of Kentucky at a new Eastern State Hospital that will open soon, and pursuing a change to allow Medicaid funding of community outpatient teams, reports Kenning. Kentucky also funds 14 regional community mental-health centers, which served 160,000 people last year, and there are 179 mental-health facilities, which include 40 offering residential care, reports Kenning.

Yet, these efforts fall short of providing mental health services for those Kentuckians in need.  In 2011, a surprisingly high 42 percent of Kentucky adult females and 31 percent of Kentucky males reported having poor mental health. Experts estimate that one in four people will suffer from some form of mental illness in a given year, which is nearly 1.1 million people in Kentucky, Kenning reports. 

It is critical for Kentucky officials to examine this issue in light of the Department of Health and Human Services rule that included mental-health benefits and treatment of substance-abuse disorders as part of the 10 "essential health benefits" insurance plans must provide when federal health reform takes full effect next year. HHS estimates it will expand mental-health and substance-abuse treatment benefits to 62 million Americans, and there is already a shortage of such services in Kentucky.

Kentucky hospitals gave $1.96 billion to communities in 2011, including $576.7 million cover of Medicare, Medicaid shortfalls

In 2011, despite economic and financial obstacles, Kentucky hospitals' estimated value of benefits to their communities up 17 percent from the year before, to $1.96 billion. So says the Kentucky Hospital Associated 2011 Community Benefits Report, compiled by the Kentucky Hospital Association with data submitted by hospitals. (Chart gives a breakdown of hospitals' total community benefits and services expenditures in 2011.)

Kentucky hospitals say they absorbed $576.7 million in 2011 shortfalls from Medicaid and Medicare, which cover 19 and 55 percent of Kentucky hospital patients; those losses were 26 percent larger than 2010, and may nearly double under federal health reform, to an estimated $852 million by 2019.

Bridging gaps created by Medicaid and Medicare underpayment is only one example of how the 131 Kentucky hospitals demonstrate their commitment to local communities by investing in community needs, the report says. In addition to covering government shortfalls, community benefits include providing charity care, forgiving bad debt and supporting medical research.

In 2011, the reports says, Kentucky hospitals financed $451 million in charity care, which means they cared for the sick and injured even if those patients could not afford care.

In Glasgow, T.J. Sampson Community Hospital and Dr. Bharat Mody (left), a general surgeon, have teamed up to fulfill the unmet health care needs of low-income, working, uninsured or under-insured adults of Barren County through a charity program called Community Medical Care. The program provides assistance with basic coverage for those who qualify, in addition to helping cover the cost of medications, glasses or hearing aids.

In 2011, Kentucky hospitals absorbed $426.5 million in bad debts, losses due to patient non-payment that often occur in hospital emergency rooms. Dennis Manners, who had a $500,000 medical bill and sometimes visited the ER 25 times a month, is one patient out of the total 22 percent of University of Louisville patients who cannot afford care and often cannot even afford their $15 co-pay. Highlighting its efforts to give back to the community, the reports says U of L developed a new treatment plan for Manners, which included sending him to a treatment center outside of Cincinnati.

Many health-improvement services in Kentucky communities, such as health fairs, screening programs, immunization clinics, health needs assessments and community planning, are financed by Kentucky hospitals. According to the report, $43.7 million was spent by these hospitals on such outreach programs that serve all ages and a number of special needs populations. For example, Northern Kentucky's St. Elizabeth Healthcare is fighting against cardiovascular disease, diabetes and stroke with its Cardiovascular Mobile Health Unit that brings vascular services to the community for easy access, screenings, risk appraisals and education.

Hospitals also spend a lot of money, an estimated $127.5 million in 2011, to ensure health professionals are properly educated -- a great need in Kentucky, where 59 of the 120 counties are designated as health professional shortage areas. One effort, the Rural Physician Leadership Program on the campus of St. Claire Regional Medical Center in Morehead, addresses this shortage by training physicians to serve in rural areas of Kentucky and the nation.

Other community benefits include subsidized health services, estimated at $32.3 million, to support programs like Highlands Regional Medical Center's Highlands Center for Autism in Prestonsburg (left). The center is the first of its type in the state and was created in 2009 to address autism in Kentucky, which is estimated by the Center for Disease Control to be diagnosed in one out of every 88 children, says the report. Each child at the Highlands center has a customized treatments plan involving psychologists, educators, behavior analysts, speech pathologists, pediatricians and neurologists, who collaborate to help children with autism reach their full potential.

The annual KHA report reminds people what hospitals do for the state and provides education about ongoing efforts. A more recognizable contribution is that Kentucky hospitals had a combined spending of $6.4 billion in 2011 on staff salaries, purchases or supplies and services that create a‘ripple effect” in the overall economy to generate state businesses, jobs, and tax revenue. The reports says St. Joseph Mount Sterling, for example, provided 213 jobs and generated about $12 million in annual local payroll in 2011. Kentucky hospitals' compensation comprises 5.8 percent of all wages and salaries in the state.

The reports says hospitals are more important than ever to the overall economic health of Kentucky communities. This is the fourth year for the report, generated by the voluntary KHA survey and other data sources, including the annual survey by the American Hospital Association; Kentucky Hospital Statistics, 2013; and Kentucky Hospitals’ Economic Importance to Their Communities, 2011. The KHA report covers community benefit expenditures made in 2011, which is the most recent year for which statewide data is available.

Poll shows Kentucky health-care providers often fail to discuss HIV testing with patients

A new poll suggests that most Kentucky health-care providers follow guidelines for discussing HIV screening with their patients, despite the the importance of early treatment to prevent its progression to AIDS.

Although the Centers for Disease Control and Prevention recommends routine HIV screenings for most patients, just 32 percent of Kentucky adults aged 18 to 64 report discussing HIV testing with their medical provider, according to the Kentucky Health Issues Poll.

About 40 percent of Kentucky adults reported they had never been tested for HIV. It’s estimated that 4,500 Kentuckians are living with HIV infection and it is estimated nationally that one in five people who have HIV do not know they do.

“It made headlines earlier this month when a little girl - the second person in history - was cured of HIV. As exciting as this development was, for most people, HIV remains a life-long condition that must be managed through medication to keep it from progressing to AIDS. The CDC’s recommendations are meant to improve the overall population health by detecting HIV so treatment can begin,” said Dr. Susan Zepeda, president and CEO of the Foundation for a Healthy Kentucky, which co-sponsored the poll.

“It appears that Kentucky providers are either not adhering to the routine screening recommendations or not communicating this message clearly to patients,” she said.

The poll, co-sponsored by the Health Foundation of Greater Cincinnati, was taken Sept. 20 through Oct. 14 by the Institute for Policy Research at the University of Cincinnati. A random sample of 1,680 adults throughout Kentucky was interviewed by landline and cell telephones. The poll's margin of error is plus or minus 2.5 percentage points

Conway, other AGs ask FDA to require generic prescription pain pills to be abuse-resistant, tamper-resistant

Generic versions of popular pain relievers must be made harder to abuse, in order to curb prescription drug abuse that is epidemic in many states, Attorney General Jack Conway and 47 other attorneys general said in a letter sent to federal officials Monday.

The National Association of Attorneys General letter encourages the Food and Drug Administration to adopt standards requiring manufacturers and marketers of generic prescription painkillers to develop tamper- and abuse-resistant versions of their products, because the attorneys general are concerned that non-medical users are shifting to non-tamper-resistant formulations of generic opioids.

“Prescription drug abuse is an epidemic that kills more than 1,000 Kentuckians each year,” Conway, who co-chairs NAAG’s Substance Committee, said in a news release. “The development of tamper-resistant and abuse-deterrent opioid drug products is a valuable aid to the law enforcement, legislative and public awareness initiatives many of us have implemented in our states to combat prescription drug abuse.”

Prescription drugs can be deadly when abused, and fatal drug overdoses are now the leading cause of death due to unintentional injury in the United States and Kentucky, exceeding even motor vehicle deaths, according to the Centers for Disease Control and Prevention. Federal data show that U.S. drug overdose deaths totaled 38,329 in 2010, rising for the 11th straight year, and accidental deaths involving addictive prescription drugs overshadow deaths from illicit narcotics.

In Kentucky, the number of drug-overdose deaths in Kentucky rose a staggering 296 percent from 2000 to 2010, according to the Kentucky Injury Prevention and Research Center. Kentucky is one of the most medicated states in the country, and has the sixth highest overdose rate. Last year, 220 million doses of the highly addictive painkiller hydrocodone were dispensed in the state -- that’s 51 doses for every man, woman and child in the state, says the AG release.

The news release from Conway's office said he led the effort to reach out to the FDA, along with Attorneys General Luther Strange of Alabama, Pam Bondi of Florida and Roy Cooper of North Carolina. Click here to read the letter; for a news release, click here.

Bill encouraging schools to stock EpiPens to stop deadly allergic reactions will become law

A bill encouraging Kentucky schools to stock EpiPens, or epinephrine auto-injectors, to stop anaphylaxis, a life-threatening allergic reaction, has passed will soon be signed into law by Gov. Steve Beshear.

When someone has anaphylaxis, the sooner you use an EpiPen, the better the outcome can be, said Thomas Sternberg, an allergist at Graves-Gilbert Clinic in Bowling Green, told Alyssa Harvey of the Daily News.

Under House Bill 172, schools could keep at least two EpiPens in case of emergency, and school boards would develop and approve policies and procedures for managing a student’s life-threatening allergic reaction, reports Harvey.

The bill also helps schools receive or buy the auto-injectors through local health departments and directs the state Department for Public Health to develop clinical protocols for using the auto-injectors in schools. Harvey reports that EpiPens can be donated to schools, and the EpiPens for Schools Program will provide up to four free auto-injectors per school year; if more are needed, they can be purchased at a discounted rate.

"You don’t know when someone could have an anaphylactic reaction,” Rep. Addia Wuchner, R-Florence, who sponsored the bill, told the Daily News. She alluded to an incident in Virginia, where a 7-year-old student died last year after an anaphylactic reaction, and no medications were available at the school to treat her. "There could be a hero in the school who was able to reach for that epinephrine pen and save a child’s life and not a tragedy like in Virginia,” Wuchner said. She filed the bill late in the 2012 session, but the language has been revised for this year's session to encourage rather than mandate schools to stock EpiPens.

Amy Wallace, treasurer and former president of the Bowling Green area's Food Education Allergy Support Team, told Harvey she was disappointed schools will not be required to make necessary provisions, but said advocates of the bill are happy to see that the problem is being addressed. (Read more)

Feds letting Arkansas privatize Medicaid expansion; idea could spread like wildfire, as in Florida, but cost questions remain

Arkansas has turned heads nationally with its preliminary plan to expand Medicaid using the private insurance market, showing that the Obama administration is willing to give states more flexibility than expected in expanding the program.

Health and Human Services Secretary Kathleen Sebelius has agreed to a proposal by Arkansas Gov. Mike Beebe to reject the Medicaid expansion but use federal money to buy private health insurance for the 200,000 people who would have been covered under ordinary expansion, reports Sandhya Somashekhar of The Washington Post.

States that have come down on either sides of the Medicaid-expansion issue may reconsider their decision in light of the Arkansas proposal, said Sara Rosenbaum, a health law professor at George Washington University. "If Arkansas is allowed to do this, I expect it to spread like wildfire," Rosenbaum told the Post.

The first place could be Florida, where a state Senate committee rejected Republican Gov. Rick Scott's expansion plan and proposed a privatization plan like that in Arkansas. Last week, a House committee voted to reject any expansion of the program. Scott "made it clear he was not going to lobby the Legislature on Medicaid," preferring to emphasize other issues, The New York Times' Lizette Alvarez reports. For coverage from the Tampa Bay Times and The Miami Herald, click here.

Could the wildfire spread all the way up to Kentucky?

Gov. Steve Beshear has said he wants to expand Medicaid in Kentucky if the state can afford it, but many Republican lawmakers oppose the idea, saying it would not be fiscally responsible. On the national level, 26 states and the District of Columbia have expressed a desire to expand Medicaid, 17 have said they reject it and seven are undecided, according to the nonpartisan Kaiser Family Foundation.

A more flexibile arrangement could be a game changer because it makes expansion more appealing, especially for states where expanding Medicaid has been politically unpopular and polarizing. in Arkansas, which has a Democratic governor and a Republicna legislature, officials say that from an ideological standpoint, using private insurance appeals to lawmakers from both parties, reports Somashekhar. She reports that even Democratic-led states might prefer this arrangement because it gets rid of some bureaucratic hurdles.

However, there are questions about cost. The Congressional Budget Office estimates that private insurance plans cost $3,000 more per person than Medicaid, reports Somashekhar. On the other hand, Arkansas officials say the move could ultimately save money in administrative charges along with other cost-control measures.

Although the Arkansas proposal is not concrete, it provides proof that the Department for Health and Human Services encourages innovative, state-based approaches to promote expansion. Many states may develop a new route best suited to their specific needs, without having to leave federal money on the table. (Read more)

Deadly, recalled pills still circulating in Pennyrile Region

A pain reliever that has been recalled and declared dangerous by the Federal Drug Administration is still circulating around southern Kentucky.

The drug marketed under the name Reumofan Plus is being distributed in Elkton and the broader Pennyrile Region, despite being recalled, and a local doctor's office says patients on the drug have had dangerous side effects, reports Nick Tabor of the Kentucky New Era.

Dr. Keith Toms of Generations Primary Care told Tabor three of his patients have taken the drug and had bad side effects. One patient had dangerous elevations of liver enzymes, and two diabetic patients had dangerous spikes in blood sugar.

The Food and Drug Administration has received reports of deaths, strokes, severe internal bleeding, dizziness, insomnia, high blood sugar and other problems associated with the drug since June. The manufacturer, operating under the names Reumofan Plus USA, LLC and Reumofan USA, LLC, announced a voluntary product recall last month, reports Tabor.

According to the FDA, undeclared ingredients in the drug, which is used as a treatment for muscle pain, arthritis, osteoporosis, bone cancer and other conditions, could result in serious illness. Tabor reports a FDA laboratory analysis of Reumofan Plus found that it contains diclofenac sodium, a non-steroidal anti-inflammatory drug, and methocarbamol, a muscle relaxant.

Tabor reports the FDA has issued an alert telling consumers to stop taking the drug immediately and consult a health-care professional. The agency also said it may follow up on the Reumofan recall with warning letters, seizure, injunction requests or criminal charges. (Read more)

Survey finds employees pay greater share of health costs, and most large employers penalize them for using tobacco

As large employers respond to changes influenced by health care reform and rising costs of care, employees are paying a greater portion of their health-care costs. That trend that is likely to continue over the next few years, says a new report on employer-based health plans.

Although employers cover most costs of work-based plans, employees contribute 42 percent more for health coverage than they did five years ago, while employers paid 32 percent more, according to the study from the benefits consultant Towers Watson and the National Business Group on Health. Overall, costs went up 34.4 percent.

When employers were asked if they thought health plans would change by 2018, which is the year the excise tax on high-cost plans takes effect, 92 percent said plans would be different, and nearly half said they expect a significant or transformative change. Such change will increase both accountability and engagement for employees.

% of large employers saying they were "very confident" they would offer health benefits in 2022

Nearly two-thirds of employers surveyed offer employees financial rewards to encourage participation in health programs, according to the report, which said tying employee contributions to successful completion of specific tasks, such as health assessments and screenings, remains the most popular contribution strategy. Growth in the use of penalties to engage employees in health-program participation has slowed over the last two years, but the use of surcharges for tobacco use continues to grow. By 2014, 62 percent of surveyed companies are expected to apply tobacco-use surcharges.

"While U.S. employers remain committed to health care benefits for active employees over the next five years," the report says, "they are redifining their financial commitment in the short run and are more reluctant to commit to coverage for employees over a longer period."

The 18th annual Towers Watson/National Business Group on Health Employer Survey on Purchasing Value in Health Care tracks employers' strategies and practices. It was completed by 583 employers,between November 2012 and January 2013. The report says it identifies the actions of the best performing companies as well as current trends in health-care benefit programs of U.S. employers with at least 1,000 employees. Survey respondents collectively employ 11.3 million full-time employees and have 8.5 million employees enrolled in their health care programs. Download a report PDF by clicking here.

Louisville dental school to mark Women's History Month with women's art and oral-health fair and reception

The University of Louisville School of Dentistry will kick off its Women's History Month celebration March 18 with "Chew Art," an all-women's art and oral-health fair and reception.

In an effort to better engage with the community on issues related to oral health, increase oral health literacy and celebrate Women's History Month, the fair will focus on specific oral health care needs of women. The school will provide oral health information, and in some cases, limited screenings for women who live with diabetes, hypertension, who are pregnant or undergoing various treatments for cancer.

But the school says this event will not be like an ordinary trip to the dentist or health fair; it will be much more exciting! It is teaming up with Kristen Hughes, Arts in Healing manager at the Kentucky Center for the Performing Arts, to employ an innovative Arts in Health Care approach. Unlike the normal clinical environment, original works of art, created by a group of local female artists, will be on display at the fair.

The "Chew Art" event will take place Monday, March 18, from 5 to 7 p.m. on the second floor of the newly renovated dental building at 501 S. Preston St. and will feature tapas, wine, sangria and live music in addition to the art displays.  To RSVP, email Deborah Wade at D0wade01@louisville.edu.

Nightmare, drug-resistant superbugs, including one that kills half the people who get it, are a big threat

"Nightmare bacteria" leading to deadly infections that are difficult and sometimes impossible to treat are on the rise in American hospitals, and threaten to spread to otherwise healthy people outside of medical facilities, according to a federal Centers for Disease Control Vital Signs report published Tuesday.


These superbugs, carbapenem-resistant Enterobacteriaceae, or CRE, have become resistant to nearly all the antibiotics available today, including drugs of last resort. According to the report, CRE infections are caused by a family of germs that are a normal part of a person's healthy digestive system, but can cause infections when they get into the bladder, blood or other areas where they don't belong.

The report says almost all CRE infections are found in patients receiving serious medical care, and they kill up to half of patients who get bloodstream infections from them. In addition to spreading among people, CREs easily spread their antibiotic resistance to other kinds of germs, making those potentially untreatable as well.

Only 10 years ago, such resistance was hardly ever seen in this group of germs. Although these superbugs are uncommon, their prevalence has quadrupled in the past decade in medical facilities in 42 states, the CDC says.

The report calls for immediate action to stop the spread of these deadly infection; it is a critical time for U.S. doctors, nurses lab staff, medical facility leaders, health departments, states, policymakers and patients to help fight the spread through coordinated and consistent efforts.

The report asks patients to do three things: Tell your doctor if you have been hospitalized in another facility or country, take antibiotics only as prescribed, and insist that everyone wash their hands before touching you. For more details, click here for the Vital Signs report.

Commission says drastic changes to doctor pay and cuts to wasteful services can fix Medicare problem without tax hikes

A national advisory panel says “drastic changes” in how Medicare reimburses doctors and other providers are needed to shore up Medicare's finances, improve patient outcomes and rein in health care costs, and there is no need to seek more taxpayer money.

Medicare needs $138 billion over the next decade to avoid steep cuts in physician pay, and avoiding those cuts has become an annual scramble in Congress known as "the doc fix."  A panel dominated by internal-medicine specialists, The National Commission on Physician Payment Reform, has concluded that reduction of wasteful medical services can help solve the problem and "our nation cannot control runaway medical spending without fundamentally changing how physicians are paid," it says in its report.

Source: Henry J. Kaiser Family Foundation and Congressional
Budget Office, Budget and Economic Outlook, January 2011

The U.S. spends nearly $3 trillion a year on health care, and that level of spending is unsustainable. The report says that as a proportion of the federal budget, the cost of Medicare has risen from 3.5 percent in 1975 to 15.1 percent in 2010 in 2010). In 2020, it is projected to consume 17 percent, or 4 percent of the U.S. gross domestic product.

Recognizing the way that physicians are paid contributes substantially to the high cost of health care, The Society of General Internal Medicine convened the commission in March 2012 to make recommendations for payment reform. According to the report, some of the factors that drive up health care expenditures are:

• Fee-for-service reimbursement
• Consolidation in the health-care industry
• Reliance on technology and expensive care
• Reliance on a high proportion of specialists
• Paying more for the same service or procedure when done in a hospital setting as opposed to an outpatient setting
• A disproportionate percentage of health care spending directed to a small number of people who are very sick and costly to treat
• High administrative costs
• Fear of malpractice lawsuits
• Fraud and abuse

The commission says increased taxes are not needed to fix the Medicare problem, and the Medicaid shortfall could be entirely found by reducing overuse of services within Medicare. See the chart to the right for a breakdown of those excess medical costs.

The commission developed 12 recommendations to reduce health costs, calling for drastic changes to the current fee-for-service payment system and a five-year transition to a physician payment system that rewards quality and value-based care and not the volume of care.

The 12 recommendations were based on the principles that payment reform should improve care quality and efficiency, encourage care for the medically disadvantaged, reduce marginal and ineffective services, increase transparency to the public and should reward patient-centered comprehensive care. (Click here to see those recommendations)

Study finds only counties in Appalachia, mostly in Kentucky, had increasing rates of death among both sexes as century turned

By Molly Burchett
Kentucky Health News

More than 40 percent of counties saw increases in female death rates as the 21st Century began, while the death rate for men rose in just 3 percent of counties, a study shows. Only Appalachian counties, mostly in Kentucky, had worsening rates for both sexes. (Click on a map for a larger version.)

Change In Male Mortality Rates From 1992–96 To 2002–06

Change In Female Mortality Rates From 1992–96 To 2002–06

On the Health Affairs maps above, blue counties showed substantial improvement, while those in aqua showed minimal improvement and worsening counties are in red.

The study identifies some shared characteristics among the 1,334 counties where more women are dying prematurely, but the main factors weren't medical or behavioral, according to David Kindig and Erika Cheng, authors of the study report.

Although counties with high rates of smoking and obesity had increased mortality rates, the report found socioeconomic factors in the Appalachian states of Kentucky and West Virginia, such as the percentage of a county’s population with a college education and the rate of children living in poverty, had more to do with increased mortality rates.

In Kentucky, Owsley County has been ranked last on health-related measures by the Population Health Institute. Areas like this in Appalachia suffered rising death rates in both sexes because college education is a rarity, child poverty is normal, recreational facilities are scarce, restaurants are mostly fast-food outlets, and adults lack social support, reports Geoffrey Cowley of msnbc.

The chart below shows how Kentucky compares to the national average in premature death and that Owsley County suffers from tremendously high rates.

County Health Rankings by University of Wisconsin's Population Health
Institute and the Robert Wood Johnson Foundation (countyhealthrankings.org)

These findings provide supporting evidence for the ever-increasing need for significant health improvement efforts in Appalachia. According to the report, efforts must extend beyond a focus on health care delivery and include stronger policies affecting health behaviors and the social and environmental determinants of health,with corresponding investments in those areas. (Read more)

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Smoking ban gets 'a good scrubbing' before Judiciary Committee

By Al Cross
Kentucky Health News

The bill for a statewide smoking ban is favored by three-fifths of Kentucky adults, but is dead for this session of the General Assembly. However, its supporters think they made some headway Monday as they laid groundwork for getting it through the state House a year from now.

The House Judiciary Committee held an informational hearing on House Bill 190 to "give it a good scrubbing" before a committee that is more skeptical of it than the Health and Welfare Committee, which approved it early in the session, the bill's sponsor, Rep, Susan Westrom, D-Lexington, said afterward.

Westrom said she was encouraged by the hearing because it exposed weaknesses in the bill that she will correct for the next regular session, beginning in January 2014. For example, she said, Rep. Steven Rudy, R-Paducah, argued that the bill's language would make it illegal to use smoke in barns to cure the dark tobacco grown in Western Kentucky, largely for smokeless consumption.

"This is about vetting," Westrom told Rudy. "You have a different mindset that I do sitting on the Health and Welfare Committee."

Rudy acknowledged that secondhand smoke is not beneficial, but asked, "Has there ever been a death certificate that secondhand smoke killed this person?"

Dr. Sylvia Cerel-Suhl, Central Kentucky president of the American Heart Association, replied that Lexington recorded a significant drop in acute heart attacks after enacting a smoking ban, and said "thousands of studies" of secondhand smoke have shown exposure to it can cause premature death.

"The evidence is absolutely overwhelming," she said, and asked if anyone else had any questions. No one did, but the committee was one member short of a quorum.

Advocates told the legislators that 37 jurisdictions, covering 34 percent of the state's population, limit smoking in some way. Mark Hayden, a trial lawyer and former Campbell County commissioner, said a statewide ban is needed because enacting ordinances, writing regulations and enforcing them is a burden for local officials.

The bill would give local health departments power to enforce the ban. Scott Lockard, president of the Kentucky Health Departments Association and the health director in Clark County, said his agency has issued no court charges, only warning citations, since its board passed a ban, and Woodford County has issued only three citations.

Others appearing at the hearing included Dr. Stephanie Mayfield, commissioner of the state Department of Public Health, and Lt. Gov. Jerry Abramson, who was invited by the Kentucky Smoke-Free Kentucky Coalition. He discussed enforcement of of the ban in Louisville, where he was mayor.

Rep. Tom Riner, D-Louisville, said the ban is "one of the most important pieces of legislation that has been brought before this body, because it literally affects every Kentuckian. . . perhaps the most important piece."

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Legislature sends fix of last year's pill-mill bill to Beshear

"After more than a year of debate, a bill that would revamp Kentucky’s prescription-drug law to more strictly focus on pill abuse and ease requirements on patients is heading to the governor’s desk," Mike Wynn reports for The Courier-Journal. On a 36-0 vote, the Senate sent House Bill 217 to Gov. Steve Beshear, who said he will sign it tomorrow.

The chief lobbyist for the Kentucky Medical Association said the physicians' group did not get all the changes it requested in last year's law but is satisfied with the bill. It "would exempt hospitals and long-term care facilities from many of the requirements that doctors must follow before prescribing drugs," Wynn writes. "It also creates a 14-day exemption for surgery patients and gives doctors more discretion in examining patients before a prescription is given." (Read more)