Obama joins Rogers at National Rx Drug Abuse and Heroin Summit, says it's time to focus on treatment over incarceration

By Melissa Patrick
Kentucky Health News

The fifth annual national summit on prescription drug abuse, started by U.S. Rep. Hal Rogers of Kentucky, was the largest, broadest and highest-profile yet.

A non-prescription drug was added to the title of the four-day event, making it the National Rx Drug Abuse and Heroin Summit. It drew more than 1,900 to Atlanta, including President Barack Obama, who joined an hour-long panel to talk about new ways to deal with a growing opioid and heroin epidemic.

U.S. Rep. Hal Rogers

"The rapid growth of this summit is truly a testament to the power of unity. Everyone here has one common goal - to save lives from the dark clenches of drug abuse," Rogers, a Republican from Somerset, said in a news release.

The summit was hosted by Operation UNITE, a Kentucky non-profit created by Rogers that leads education, treatment and law enforcement initiatives in 32 counties in Southern and Eastern Kentucky. The acronym stands for Unlawful Narcotics Investigations, Treatment and Education.

According to the federal Centers for Disease Control and Prevention, in the U.S. someone dies every 20 minutes from an opioid overdose and Kentucky has one of the nation's highest rates, with more than 1,000 deaths a year from it.

(On Monday, April 4, KET's "Kentucky Tonight" will have a report on the summit and a look back at the network's coverage of drug addiction issues. For a preview from host Bill Goodman, click here.)

The University of Kentucky and UK HealthCare, which helped sponsor the summit, sent a delegation of executive, clinical and research leaders, including President Eli Capilouto as one of the keynote presenters, according to a UK news release.

“Too many Kentucky families are too often confronted by the dark and painful scourge of prescription drug abuse and opioid addiction," Capilouto said. "It’s an epidemic that penetrates communities across the nation, both urban and rural, but has especially intractable roots in Appalachia and the regions served by the University of Kentucky.”

Obama opened his remarks on the panel by thanking Rogers,who is also co-chair of the Congressional Caucus on Prescription Drug Abuse, and UNITE, "the organization that has been carrying the laboring oar on this issue for many years now. We are very grateful to them."

Obama focused some of his comments on broadening access to medication-assisted treatments for addiction, most successfully with counseling and behavior therapy.

"What we do know is that there are steps that can be taken that will help people battle through addiction and get onto the other side, and right now that's under-resourced," the president said.

Obama's administration recently proposed doubling the number of patients a health-care provider can treat with buprenorphine, one of the drugs used to fight addiction, to 200 from 100.

He said the opioid and heroin epidemic is a public-health issue and not just a criminal-justice problem, which is the only way to reduce demand. "In this global economy of ours that the most important thing we can do is to reduce demand for drugs," he said.

Because the opioid and heroin epidemic is touching everybody and not just poor people and minorities, there is now more emphasis on treatment over incarceration, Obama said: "This is not something that's just restricted to a small set of communities. This is affecting everybody -- young, old, men, women, children, rural, urban, suburban."

The president also noted that there has been a significantly increase in opioid abuse in rural areas, which often suffer from an under-resourcing of treatment facilities and mental health services.

"And that's why, for all the good work that Congress is doing, it's not enough just to provide the architecture and the structure for more treatment. There has to be actual funding for the treatment," he said.

The president has proposed $1.1 billion in his upcoming fiscal year 2017 budget request to fund drug-treatment programs in counties all across the country.

Agriculture Secretary Tom Vilsack announced two rural initiatives at the summit: town hall meetings in rural areas hit hardest by drug abuse, including Appalachia, "to raise awareness of the issue and discuss possible solutions," and an extension of the Rural Health and Safety Education competitive grant program to include $1.4 million in grants that will now be available to rural communities to fight heroin and painkiller abuse, according to a press release.

The president also announced several other new initiatives: establishing a Mental Health and Substance Disorder Parity Task Force; implementing mental health and substance use disorder parity in Medicaid; releasing $11 million for the purchase and distribution of the opioid-overdose reversal drug, naloxone; expanding an initiative that improves local partnerships between law enforcement and public health; a $7 million investment for community policing to address heroin; and providing guidelines for the use of federal funds to implement or expand needle-exchange programs.

Kenton County's approval of a needle exchange inches Northern Kentucky, hit the hardest by heroin, toward getting one

The Kenton County Fiscal Court unanimously approved a mobile needle exchange program March 29, which moves the City of Covington's needle exchange program one step closer to fruition, Terry DeMio reports for the Cincinnati Enquirer.

The Fiscal Court's approval was one of several conditions required by the City of Covington to allow its exchange to move forward. Covington's plan also requires two other counties in the Northern Kentucky Health District to adopt exchanges (only Grant County has); limits access to only resident's of the district's four counties; and would move the exchange to St. Elizabeth Healthcare hospital.

In addition, it requires a one-for-one needle exchange and a mandate that all participants must be tested for hepatitis C, hepatitis B, HIV, and, where applicable, pregnancy. This condition is likely not legal and is being investigated by the Northern Kentucky's Health Board's legal counsel, DeMio reports.

Kenton County's plan differs from Covington's in that it mandates only the offering of these tests, DeMio reports.

Both plans will require the Kenton County Board of Health's approval.

Needle-exchange programs were authorized by the state anti-heroin law passed in 2015, and require both local approval and funding. They are meant to slow the spread of HIV and hepatitis C, which are commonly spread by the sharing of needles among intravenous drug users. Northern Kentucky has been hit the hardest in the state by heroin and its hepatitis C rates have been reported at 19 times the national rate.

The needle exchange would be funded by $250,000 from the R.C. Durr Foundation, and the health department would use its staff and already available testing to further pay for the exchange, DeMio reports.

The Fiscal Court also approved exploring the idea of building a community-wide addiction treatment center on the county jail grounds; putting $25,000 toward a heroin helpline; and approved a resolution to encourage the Northern Kentucky Board of Health to create a high-quality prevention and education program for the community.

The Northern Kentucky Area Development District has already put out proposals for the heroin helpline, DeMio notes. And County Judge-Executive Kris Knochelmann told him that Boone and Campbell counties were willing to consider putting $25,000 each toward it, and that St. Elizabeth had promised $75,000 toward its operation.

The other needle exchanges in the state that are either operating or have been approved are in Louisville and Lexington and in the counties of Pendleton, Carter, Elliott, Franklin, Grant and Jessamine.

Officials hope reduction in Ky. colon cancer deaths via screening can be replicated with lung cancer, in which state is No. 1

Health officials in Kentucky, especially in the eastern part of the state, hope to increase lung-cancer screenings by following a successful colon-cancer screening initiative, Jackie Judd reports for PBS NewsHour. (Centers for Disease Control and Prevention graphic: Colon-cancer screenings are up)

In rural Eastern Kentucky, smoking and lung cancer rates are double the national average, while the state is second in adult smoking rates and leads the nation in lung cancer and rates of death from it. That is "fueled by a toxic combination of poverty, medical illiteracy, limited access to care, lifestyle choices like smoking, and a fatalism that says knowing you have cancer won’t save you."

Another challenge is that local bans of smoking in public places have left two-thirds of residents living in areas with no such bans, and a statewide ban seems unlikely because it failed to pass the state House this year after narrowly passing last year. New Republican Gov. Matt Bevin opposes a statewide ban.

Fifteen years ago Kentucky led the nation in "both the highest incidence and mortality rates for colorectal cancer," Allison Perry reports for University of Kentucky News. Rural residents didn't seek care, partly because of a lack of facilities and partly because of a refusal to schedule an appointment. If local residents wouldn't seek care, health officials decided to bring care to local residents.

"In the seven years following this new focus on colorectal cancer, the screenings rates nearly doubled, from 34.7 percent of the age-eligible population receiving screenings to 63.7 percent," Perry writes. "This raised Kentucky’s rank from 49th in the country to 23rd compared to other states. No other state has had such a dramatic increase in colorectal screenings in such a short period of time. As a result, the lives of many Kentuckians have been saved: the incidence rate for colorectal cancer is down nearly 25 percent, and the mortality rate has dropped 30 percent. Through colorectal screenings, doctors can find precancerous lesions and remove them before they become cancer. Screenings also allow physicians to find these cancers at an earlier stages, when they are more likely to respond to treatment."

The number of cancer screenings jumped in 2014 and 2015, as the state expanded eligibility for the Medicaid program under federal health reform, making many more people eligible for free screenings. Bevin is seeking change the state's program in ways that could require co-payments, premiums and deductibles.

In Kentucky "the challenge is to not only encourage certain lifelong smokers to get screened, but to get them to quit, and for others to never start," especially because of the addictive nature of smoking, Judd reports. "It will be even more difficult than changing the profile of colon cancer, because smoking involves addiction. The hope of public health officials is that the model used to bring down colon cancer deaths can be used to the same effect, not only for lung cancer, but for other diseases plaguing this depressed swath of America."

Ky. Republicans like Indiana Medicaid plan, but head of Medicaid directors' group says Ind. isn't far enough along to be a model

Gov. Matt Bevin and other Republicans have said they want to make Kentucky's version of Medicaid look like Indiana's, but a leading Medicaid official says that Indiana's program hasn't proven itself to save money or improve health, so it's unlikely other states will be allowed to use it as a model, Phil Galewitz reports for Kaiser Health News and The Washington Post.

Matt Salo, executive director of the National Association of Medicaid Directors, told Galewitz, “Other states have looked at it, but the Obama administration has made it pretty clear that Indiana is going to be a test case and much evaluation will need to be done before they approve any more like it.”

Now Bevin's office says it is looking at other states, too, as it negotiates with the U.S. Department of Health and Human Services, trying to come up with a revised program to save money, perhaps by August.

"The Indiana model is just one of many models that we are looking at for influence in crafting a plan that is specifically tailored for the needs of Kentucky," Bevin spokeswoman Jessica Ditto said in an e-mail. "We are working closely, and in good faith, with HHS as this process moves forward and have confidence that what we offer for their consideration will be a thoughtful, deliberate and unique plan that will improve health outcomes in a sustainable manner."

Under federal health reform, then-Gov. Steve Beshear expanded Medicaid to those in the state with incomes up to 138 percent of the federal poverty level, adding 400,000 people. The federal government pays for this expanded population through this year, but then the state will be responsible for 5 percent of the expansion, rising to the reform law's limit of 10 percent in 2020.

Bevin has said that Kentucky's revised program should require its members to have "skin in the game," and that the state cannot continue to pay for the health insurance of "able-bodied adults."

Healthy Indiana Plan

That sounds like Indiana, which has monthly fees and co-payments and refers its participants to a work program.

Even if it is just a dollar, everyone on Medicaid in Indiana pays something, whether it's through a monthly fee or through co-payments.

The Healthy Indiana Plan has two levels, HIP Plus and HIP Basic. Both plans offer incentives for using preventive services, but HIP Plus, which requires a monthly fee, also includes dental and vision services.

Those fees go into an account that is like a health savings account and is used for the first $2,500 of medical expenses each year. The state of Indiana pays the bulk of the $2,500 and if the participant's health-care expenses exceed this amount, the state will pay for the additional care at no cost to the individual.

HIP Plus is considered the best value and is available to everyone in the state with income below 138 percent of the federal poverty level. The consequences for not paying the required monthly fee vary by income level.

Those in HIP plus who make at or below the poverty level and fail to pay the fee are moved down to HIP Basic plan, which requires co-payments of up to $8 per service and $75 for each inpatient hospital stay. Both plans have a co-payment for using the emergency room for non-emergency reasons, $8 the first time and then $25 per visit thereafter.

HIP Basic members who make more than the poverty level are locked out of coverage for six months if they fail to make their monthly payment.

"No other program has been allowed to require health spending accounts, much less threaten to yank coverage for a person not paying in," Galewitz writes, paraphrasing Salo.

HIP members who are unemployed or work less than 20 hours a week are referred to available employment, work search and job training programs to help them gain employment or find better employment. This is a free and voluntary program and does not affect the receipt of benefits.

All members of HIP Plus must pay something. About half of Indiana Medicaid members have annual incomes below $600; they must pay a $1 monthly premium.

The monthly fee adjusts with income and family size. For example, a single person who makes $16,242, the maximum for expanded Medicaid, pays $27.07 per month to get HIP Plus, or $324.85 per year. A family of two could make as much as $21,983 and would pay $36.64 or $439.68 per year; and a family of four could make $33,465 and would pay $55.78, or $669.36 per year. Information comes from the eligibility calculator on the Healthy Indiana Plan website.

Is Indiana's plan working?

Indiana health officials told Galewitz that 94 percent of those who have signed up for HIP Plus continue to pay their fees.

Michelle Stoughton, senior director of government relations for Indianapolis-based Anthem Insurance Cos., called that a success. She said nearly 75 percent of Anthem's members on this HIP Plus have visited a dentist, and 65 percent sought vision care in the first three months of coverage. Anthem is one of three private insurers providing coverage under the Healthy Indiana Plan.

“What we heard for years . . . is that these people won’t pay and don’t have the ability to pay,” Stoughton told Galewitz. “But this has turned those arguments around and been able to show that people do want to be engaged.”

Indiana's hospitals and doctors support the Healthy Indiana Plan, mostly because the state increased their Medicaid rates, hospitals by an average of 20 percent and doctors' reimbursements by an average of 25 percent, Galewitz reports.

"As a result, Medicaid has gained more than 5,300 providers in the past year, and patients report few problems getting care," he writes. But he also noted that about 2,200 members have lost coverage since it began in May 2015 because they didn't pay their monthly fees.

Critics of Indiana's plan worry that the monthly payments and complicated structure will keep the poor from getting care. which goes against the core goal of Medicaid expansion, Galewitz writes. In addition, some conservative groups say the program may be more expensive than traditional Medicaid, because it provides dental and vision care and pays providers more. Others say that the red tape in the plan exceeds that of any state's Medicaid expansion.

The state had also hoped third parties would step up and help the poor pay for their monthly contributions, but this hasn't happened, Joan Alker, executive director of the Georgetown University Center for Children and Families, told Galewitz. She said, “It’s premature for Indiana to take a victory lap.”

Survey of Cincy-area students, including some in Kenton County, finds pot and vaping more popular than cigs; drug use down

Students in Greater Cincinnati, including Northern Kentucky, are more likely to use marijuana and electronic vapor products than cigarettes, according to a drug-use survey of students in the region.

Graph from PreventionFirst report

The survey found that students in the area were most likely to use alcohol (16.3 percent) within the past 30 days, followed by marijuana (11.7 percent), electronic vapor products (13.4 percent), tobacco (8.2 percent) and non-prescribed prescription drugs (4.6 percent).

This was the first year a question was included about electronic vapor products in the biennial surveys by PreventionFirst (formerly the Coalition for a Drug-Free Greater Cincinnati), a comprehensive effort to reduce adolescent alcohol and drug use.

The good news is that most students are not using alcohol, tobacco or other drugs, says the report.

The study surveyed nearly 40,000 students in grades seven through 12 from 88 public and private schools in several counties in Greater Cincinnati and Kentucky's Kenton County. They were asked whether they'd used any of 21 drugs.

The survey found that use of alcohol, tobacco and marijuana have declined significantly since 2000: alcohol down 46 percent, tobacco down 61 percent and marijuana declining 22 percent. Since 2012, non-prescribed prescription drug use has declined 29 percent.

It found that students' perception of the harm that alcohol can do has increased, while they were less concerned about marijuana.

With marijuana, as students get older "their perception of harm decreases, and use increases," said PreventionFirst CEO Mary Haag told Terry DeMio  of the Cincinnati Enquirer.

"Marijuana has become very prevalent and it's becoming more so," Hamilton County Commissioner Dennis Deters, who chairs the Hamilton County Heroin Coalition, told DeMio. "It's dangerous to our children and it enhances their risk when they become adults for serious addiction."

The report calls age 13 a "pivotal age" because this is when first drug use often occurs in students.

The report also finds that peer and parental disapproval rates are at an all-time high.

"We know how important friends and parents are in a young person's life," Haag said in the news release. "Students whose peers and family express disapproval are more likely to make the healthy choice to not use drugs and alcohol."

Boyd, Clark counties approve needle exchanges; Boyd's is a limited, one-for one; Covington's proposed limits draw objections

By Melissa Patrick
Kentucky Health News

Clark and Boyd counties are the ninth and 10th Kentucky counties to approve a needle-exchange program, and Madison and Anderson counties are talking about it. Meanwhile, the city of Covington has approved an exchange with conditions that don't match its health department's plan, and one of the conditions might not even be legal.

Needle exchanges were approved under the state's anti-heroin law passed in 2015, and require both local approval and funding. They are meant to slow the spread of HIV and the hepatitis C virus (HCV), which are commonly spread by the sharing of needles among intravenous drug users.

Clark County Health Director Scott Lockard noted that the federal Centers for Disease Control and Prevention has "identified 54 counties in Kentucky as being vulnerable to rapid dissemination of HIV or HCV infection among persons who inject drugs. Of the top 25 most vulnerable counties in the nation 16 of them are in our state."

Clark County

On March 23, the Clark County Fiscal Court approved on a 4-2 vote a needle exchange that will start on or before June 1, but the program will need re-authorization in January, Greg Kocher reports for the Lexington Herald-Leader.

"Both the Fiscal Court and the [Winchester] City Commission inserted a sunset clause in the orders requiring the health department to present data on our program in January 2017 in order to get re-authorization for a longer time period," Lockard told Kentucky Health News in an e-mail.

He noted that the CDC identified nearby Wolfe County as the most vulnerable county in the nation to rapid dissemination of HIV and HCV among drug users, with adjoining Powell and Estill counties 15th and 25th, respectively.

"Residents from all three of these counties frequently come to Clark County for medical services from our provider community and the health department," he said. "More must be done in the area of prevention if we are to avoid a situation similar to what Scott County, Indiana, encountered."

That county, about 30 miles north of Louisville, has drawn national attention for its high rates of HIV and hepatitis C, mostly caused by intravenous drug users who share needles. According to published reports, "from November 2014 to mid-June 2015, the Indiana county of 24,200 reported 170 HIV cases. It reported 130 new cases of hepatitis C in 2014," noted Bill Robinson of The Richmond Register.

According to Lockard, Clark County's program will use a patient negotiation model, which does not require a one-to-one needle exchange, during the initial visit, but will try to get close to a one-for-one model on subsequent visits.

"We will educate participants that they need to return needles to get needles," he said.

Boyd County

The Boyd County Fiscal Court voted 4-1 March 15 to approve a one-to-one needle exchange for one year, Lana Bellamy reports for The Daily Independent. 

The Ashland City Commission had already given its approval for the exchange, which may begin as early as July. Bellamy reports that the program will be paid for by special taxing districts, and all of the fiscal court members voiced concerns about the sustainability of the funding.

Ashland-Boyd County Health Department Director Maria Hardy told the court that syringes typically cost about 97 cents each, but the health department will be able to buy needles from a distributor for 9 cents each, Bellamy writes.

The Boyd County program will assign tracking numbers to its participants to protect their identities and allow a maximum of 40 needles to be exchanged each week.

County Commissioner John Greer, the only member to vote against the resolution, said he was concerned the program would encourage drug abuse and Sheriff Bobby Jack Woods agreed, Bellamy reports. This is a common concern among opponents of needle exchange programs, though evidence-based studies have proven otherwise.

Covington

During the same week, the City of Covington approved a needle-exchange program, but with conditions that could kill the program, Terry DeMio reports for The Cincinnati Enquirer.

The conditions are that all participants be tested for hepatitis C, hepatitis B, HIV, and, where applicable, pregnancy. That could be illegal, DeMio reports.

A Northern Kentucky Health Board spokeswoman told DeMio that they believe that they cannot require anyone to undergo any medical procedures, but said they were checking with legal counsel. Other health and harm-reduction officials told DeMio that this requirement is not legal, and that such a condition would likely prevent a program from getting off the ground.

"The Covington commission's resolution includes other conditions that differ from the health board's model program, too, and would require passage from the Kenton County Fiscal Court and the Board of Health before it's approved," DeMio writes.

These conditions include a requirement that two other counties in the Northern Kentucky Health District also adopt a needle-exchange program (only Grant County has); restrict use of the program residents of the district's four counties; and moving the exchange to St. Elizabeth Healthcare hospital.

The city also wants a one-for-one exchange, Michael Monks reports for The River City News.

The health department says its plan is "need-based," not one-for-one, because studies show that is the best way to reduce the risk of community exposure and spread of HIV and HCV. This is the main goal of the program, although needle-exchange programs also provide HIV and HCV testing and access to drug treatment.

The health department's plan is to initially provide clients with the number of syringes they would use in a week, along with a safe container for their return with instruction to return the used needles for new ones. Participants who don't return dirty needles after three trips would not receive new syringes, DeMio reports.

The department has been trying to establish needle-exchange programs in the district since the law passed one year ago. The Kenton County Fiscal Court is expected to discuss a needle exchange plan March 29, DeMio reports.

Dr. Lynne Saddler, the health department's director, told the Enquirer "that the Covington resolution was a start and that more discussion is planned by the health department."

Other counties

Madison County Health Department officials are also worried about becoming another Scott County, Indiana, as they face an epidemic of heroin use in their county, Bill Robinson reports for The Richmond Register.

Thus they have begun the process of educating their public officials, Robinson writes. Public Health Director Nancy Crewe presented her detailed findings to support a needle exchange at a quarterly joint meeting of the county Fiscal Court, Richmond City Commission and Berea City Council, noting that they were just beginning the long process of educating the public.

A needle exchange program was also brought up at the March meeting of the Anderson County Fiscal Court meeting, and was met with some disparaging remarks, Ben Carson reports for The Anderson News.

"What jackass thought of that idea?" asked Magistrate David Montgomery. "We might as well give them the dope, too."

Despite these comments, Montgomery did volunteer to be on a committee to explore a needle exchange program along with members of the health board, Lawrenceburg City Council, law enforcement, EMS and county jailer.

Robinson also reports that the Bourbon County Fiscal Court has voted to reject an exchange.

The other needle exchanges in the state that are either operating or have been approved are in Louisville and Lexington and in the counties of Pendleton, Carter, Elliott, Franklin, Grant, and Jessamine.

At top legislative Republican's invitation, Democrats embrace Obamacare, or at least Kynect and Beshear's Medicaid expansion

By Melissa Patrick
Kentucky Health News

With a verve for Obamacare most had not publicly demonstrated, state House Democrats passed bills March 22 to preserve the Kynect health insurance exchange and the state's expansion of the federal-state Medicaid program.

The almost entirely party-line votes were a response to Republican Senate President Robert Stivers, who had challenged the House to act on the bills so the public will know where legislators stand on health reform.

The Senate is not expected to pass House Bills 5 and 6, but may use them as a device for debate of an issue on which Republicans seem to think they have had the upper hand. Democrats appear to think otherwise.

"This is a political issue, we all know that," House Speaker Greg Stumbo said. "The president of the Senate wanted to challenge us to talk about it, so I think we ought to talk about it because . . . Kynect is working."

(The debate begins four minutes into the following KET video. The continuation of the debate can be seen here.)

Kynect, where Kentuckians can sign up for Medicaid or buy federally subsidized health insurance, was established under executive order with federal grant money by then-Gov. Steve Beshear, a Democrat. It is paid for by a 1 percent assessment on all insurance policies sold in the state. The fee formerly funded a pool for high-risk insurance, which health reform made unnecessary.

Gov. Matt Bevin and other Republicans say Kynect is not necessary because the federal exchange, used by most states, does the same thing. "We will still be providing Kentuckians with access to care," said Rep. Addia Wuchner, R-Florence. "It will be as easy as going to a different website."

Democrats say using the federal exchange will leave Kentuckians without enough of the assistance needed by people who are unfamiliar with health insurance. More than 400,000 Kentuckians have used Kynect to sign up for Medicaid and about 100,000 have used it to get health insurance, many with the help of Kynect-paid "Kynectors."

Rep. Darryl Owens, D-Louisville, the bills' sponsor, said many people in Kentucky don't have access to the Internet and that many who do are not "tech savvy." He said that a decrease in the number of helpers, who are available to meet clients after hours and at convenient locations, will create additional barriers to access for many Kentuckians.

Rep. Kelly Flood, D-Lexington, told the House about one of her constituents who learned in the middle of a family medical crisis that they had been dropped from Medicaid. Flood said the woman told her she could not "reach that wonderful Kynector who used to tell me what was going on."

The Kynector later told her that "she had been swamped with others like her who wanted to know what was happening to the stability of their health care that they had just secured," Flood said. "It is so much more complicated than just going to a new website. I am wanting us to understand the people whose lives are on the line."

The state, completing a plan put in place by the Beshear administration, recently shifted Medicaid users of Kynect to a new system called Benefind that handles most public-assistance programs.

Emily Beauregard, executive director for Kentucky Voices for Health, told Greg Stotelmyer of Public News Service that the wait times on Benefind are two hours and 6,000 to 7,000 calls are going unanswered each day. Advocates have said that the average wait time on Kynect is two minutes.

Cabinet for Health and Family Services spokesman Doug Hogan told Stotlemyre that there had been "difficulties" with the transition and the cabinet is "working diligently with the contractor to correct problems and make the system perform as was intended."

The House voted on the bills separately but the main debate touched on both Kynect and Beshear's expansion of Medicaid to people with incomes up to 138 percent of the federal poverty level. The federal government is paying for the expansion until next year, when states will begin paying 5 percent, rising to the law's limit of 10 percent in 2020.

Bevin and other Republicans say that is not sustainable, and he is negotiating with federal officials to change Medicaid to save money and add more personal responsibility, such as premiums, co-payments and deductibles.

Rep. Joni Jenkins, D-Louisville, chair of the House Budget Subcommittee on Human Services, said most Kentuckians who get insurance through Kynect and expanded Medicaid work in low-income jobs and without the program cannot afford insurance.

"With all of this great news -- more people covered, profitable hospitals, more jobs, better health care and wellness -- I believe the evidence is overwhelming that Kentucky must keep Kynect and expanded Medicaid," Jenkins said.

At times the debate was more about federal health reform in general than about the specifics of Kynect or Medicaid expansion.

Rep. Jim Gooch, a Providence insurance agent who recently became a Republican, said many Kentuckians have been helped by Obamacare, others have been hurt. He said many can't afford their co-payments and deductibles, and he said President Obama lied when he said people could keep their old health plans and doctors if they wanted after the reform law passed in 2010.

Another insurance agent, Rep. Jeff Greer, D-Brandenburg, argued the other side. He said the Patient Protection and Affordable Care Act had brought many people their first affordable health insurance, especially those with pre-existing conditions, and relieved many farmers of the need to to work another job to get insurance.

"What I see is that we have something that is working, and I'm in a field where I see it work and yet we want to dismantle it and go to something that we're not sure is gong to work or not, Greer said. "I just don't get it."

House Minority Leader Jeff Hoover, R-Jamestown, said using the federal exchange "will not cause a single policy to be canceled or a single person to lose coverage." He said 36 other states now use the federal exchange "seamlessly."

Hoover and other Republicans said the debate was overdue, referring to Beshear's executive actions that the legislature was unable to block.

The Kynect bill passed 52-46, followed by a 54-44 vote for the Medicaid expansion, with Republican Reps. Jim DuPlessis of Elizabethtown and Jim Stewart of Flat Lick joining the Democrats. Reps. Gerald Watkins, D-Paducah, and David Floyd, R-Bardstown, did not vote on either bill.

All House seats are on the November ballot. House Democratic Caucus Chair and state party Chair Sannie Overly was asked how a vote for Obamacare might affect the election. "I think that House Bill 5 and 6 are simply a message to others that we stand by our commitment to providing access to healthcare to all Kentuckians," she said. "We've seen that our constituents support making sure that their friends and neighbors and relatives have access to health care."

To the same question, Rep. Robert Benvenuti, R-Lexington, said, "I think the voters have already thoughtfully evaluated that and cast a strong vote for Gov. Bevin, so I do think it will come up again in these November elections."

Full House has Senate bill to regulate how druggists dispense 'biosimilar' medication that hasn't even been approved by FDA

Update: SB 134 passed the state House 96-0 March 23 with a floor amendment that allows communication by fax, telephone, electronic transmissions or other prevailing means by the pharmacist to the provider to suffice as notice. The bill now awaits concurrence.  

Brand-name drugs called "biologics," because they are made from living tissues, have no competition from "interchangeable biosimilar" products in the U.S. because no interchangeable products have been approved by the U.S. Food and Drug Administration. But that hasn't stopped the drug industry and Kentucky lawmakers from moving a bill to regulate how pharmacists could dispense these drugs if and when they are approved.

"This bill allows Kentucky pharmacists the ability to dispense safe and less expensive biological medications by allowing substitution of interchangeable biosimilars," Sen. Ralph Alvarado, R-Winchester, told the House Health and Welfare committee, which approved it March 17.

Current law does not allow these substitutions without advanced approval from the prescriber, Alvarado said. "This bill removes that hurdle."

The most contentious part of Senate Bill 134 has been its requirement that pharmacists must notify prescribers when they make this substitution, which advocates say is necessary because there are slight variations between the drugs.

Alvarado, also a physician, said the notification comes down to a "safety mandate," noting that if the patient had a "bad outcome" while on one of these medications, it is important for the provider to know exactly what medication the patient is taking.

Democratic Rep. David Watkins, a retired physician from Henderson, voted for the bill and supported the provider notification requirement.

"We're not talking about generics where you have exactly ideal medications, you are talking about biosimilars . . . which would be in some instances different molecules and have some different aspects," Watkins said. " I think that not notifying my office would be a gross disservice to my patients."

But the pharmacists disagree, and want substitution of interchangeable biosimilars to be handled the same way as generic medications, with the prescriber able to place a note on the prescription that says "do not substitute," said Bob Oakley, chairman of the Kentucky Pharmacists Association.

Oakley told the committee that while pharmacists support automatic substitution of an interchangable biosimilar for the name-brand biologic, they do not support notification. "Therefore, we are here to ask that we just keep it simple and keep it seamless," he said.

Rep. Addia Wuchner, R-Florence, said the bill had accommodations to make notification manageable for pharmacists, and asked Oakley what their real problem was. He replied, "It just adds more work to . . . their busy day."

But the pharmacists' lobby has cited other reasons. KPhA Executive Director Bob McFalls told James McNair of the Kentucky Center for Investigative Reporting, "Prescriber notification requirements have shown to increase costs for the health-care system overall" since they cause more brand-name drugs to be dispensed.

SB 134 passed the Senate 36-1 March 2, with Republican Sen. Jimmy Higdon, the majority whip from Lebanon, the only one voting against it. Higdon had submitted several floor amendments to modify the notification requirements, but withdrew them before the final vote.

Higdon told McNair that he didn't understand the urgency to pass this bill, noting that its passage would have no immediate effect.

“It’s the kind of bill that should be discussed,” Higdon said. “This whole thing is very complicated and futuristic, and a lot of people are talking to us about passing this. I just want to err on the side of caution. It doesn’t need to be fast-tracked. We need to do it right.”

Higdon was referring to the many lobbyists hired by pharmaceutical manufacturers that have descended on Kentucky in support of this bill.

"At least nine drug companies and groups have stated an interest in the Senate bill, according to the Kentucky Legislative Ethics Commission, McNair reports. "The number of registered lobbyists hired by pharmaceuticals employers has nearly doubled, from 46 in 2011 to 83 today. Their annual spending has more than doubled, to $824,196 in 2015."

The bill now resides in the House. Speaker Pro Tem Jody Richards, D-Bowling Green, has filed a floor amendment to remove the notification requirements.

About biologics and biosimilars

While conventional medications are made from pure chemical substances and can be easily replicated, biologics are made from living tissues and each batch varies slightly from the last, according to the FDA. That's why these products can't be called generics, which are chemcially identical.

The most common biologics are Humira and Remicade for arthritis and Enbrel for psoriasis. They are very expensive and can cost thousands of dollars each month.

"Express Scripts, the pharmacy benefits manager, estimates that while biologics accounted for only 1 percent of all prescriptions in 2014, they accounted for 32 percent of all prescription-drug spending," McNair reports.

Biosimilars are medications that are "highly similar" to already FDA-approved biological products. To date, only one of these, Zarxio, used for certain cancer patients, has been approved by the FDA, but it was not designated as interchangeable. According to the Regulatory Affairs Professional Society, six biosimilars have applied for FDA approval.

Interchangeable biosimilars are expected to produce the same clinical results in any given patient as it's "highly similar" biologic. To date, no interchangeable biosimilar medications have been approved by the FDA. When appoved, Alvarado suggested that they will cost up to 40 percent less than the biologics.

Kentucky is home to the North American distribution hubs for Amgen, Genentech and Johnson and Johnson and is the primary distribution point for many of the biologics (and soon to be biosimilars) in the U.S., according to an e-mail from RunSwitch PR.

Legal clinic for cancer patients, families and caregivers in Louisville April 13 is free, but requests RSVP if you plan to attend

A free legal clinic for people facing cancer, and their families and caregivers, will be held in Louisville April 13. The Kentucky Cancer Program at the University of Louisville, the Louisville Bar Association and the Louisville Pro Bono Consortium are sponsoring the clinic at Gilda’s Club of Louisville, 633 Baxter Ave., from 5:30 to 7:30 p.m. Wednesday, April 13. Free parking is available behind the building and across the street from the club.

Attorneys will be available to offer help with life-planning documents under Medicare Part D, including wills, powers of attorney, health care surrogacy and living wills. They also will provide guidance on employee benefits during illness and government assistance that is available such as Medicaid, Medicare and Social Security disability insurance.

Admission is free, but RSVPs in advance are needed; call 502-852-6318. For additional information, contact the Kentucky Cancer Program at jlcaud02@louisville.edu or 502-852-6318.

Republicans accuse Beshear of holding down failed co-op's premiums to make Obamacare look good; he denies the charge

By Al Cross
Kentucky Health News

Did Kentucky's government-sponsored insurance company fail because then-Gov. Steve Beshear and federal officials kept its rates artificially low to make Beshear's embrace of federal health reform look better?

Sen. Ralph Alvarado

That's what Republican state Sen. Ralph Alvarado of Winchester, using documents provided by Gov. Matt Bevin's office, suggested or claimed March 14 in a Senate floor speech about the Kentucky Health Cooperative.

"It appears that rates for the co-op may have been purposely kept down for the sake of optics, to make the rollout of the ACA in Kentucky appear successful when it clearly was not," Alvarado said, citing "multiple meetings between the co-op, the governor's office and CMS," the federal Centers for Medicare and Medicaid Services, which oversees the state-based co-ops created under the reform law, in the fall of 2014.

"Somewhere along the way rates were kept down despite these actuarial recommendations," which said the money-losing cooperative should increase its rates 35 to 40 percent for the 2015 plan year, Alvarado said. The co-op's average increase, announced in late October 2014, was 15 percent. In November, CMS expanded the co-op's $47 million solvency loan to $125 million "to try to sustain this company," he said.

Beshear denied the charges through a spokeswoman, Hayley Prim. She said in an email, "Rates were set by the co-op, which was a privately run insurance plan. Like all other insurance plans, the rates must be certified by the Department of Insurance and actuarially sound. The state did not hold rates artificially lower to improve optics."

CMS officials encouraged co-ops "to price their plans low and grow as fast as they could," Adam Cancryn reported for SNL Financial in November 2015, in a long article that is widely regarded as the best written about the failure of the co-ops. Twelve of the 23 have closed or plan to.

The insurance co-op's offices are in eastern Jefferson County.

In December 2014, the Kentucky Health Cooperative reported a loss of $50 million, "with several hazardous financial conditions indicated," Alvarado said, but that year its chief executive officer, chief financial officer and member-services vice president got bonuses of $50,000, $40,000 and $40,000 on top of their salaries of $250,000, $179,000 and $131,000.

"This company had no money, was in deficit, and yet funds were being used clearly for bonuses," Alvarado said. Its CFO, Leonard Sherman, left the company in December 2014, according to a document filed by its liquidators.

Joe Smith of Frankfort, who was chair of the cooperative's now-dissolved board, said in an interview that the salaries and bonuses were "probably a little bit less" than typical in the insurance industry. He said bonuses were paid because the co-op enrolled many more customers than expected, but no bonuses were paid after the first year.

Smith blamed "the Republican Congress" for killing the co-op and those in many other states by limiting the "risk corridor" subsidies paid to insurance companies for covering sicker-than-average populations.

He acknowledged that the Obama administration largely abandoned the co-ops, making them "a sacrificial lamb," but he said they could not effectively compete with large insurance companies, mainly because the reform law prohibited them from advertising, as the big insurers wanted. The law created funding for the not-for-profit cooperatives as a way to provide competition with for-profit insurers and hold premiums down.

Janie Miller, who was Beshear's first health secretary, resigned as CEO of the Kentucky Health Cooperative in June 2015. That October, the co-op said it had largely eliminated its losses but would close because it was getting only a $9.7 million of a $77 million risk-corridor subsidy that it needed to stay afloat. It is now in liquidation, supervised by Franklin Circuit Court.

Alvarado said Miller and her successor, Glenn Jennings, refused to appear at a legislative budget subcommittee meeting in November. He said the Insurance Department "gave us very limited answers about what happened, [which] made me wonder if any wrongdoing was involved."

Alvarado said the legislature's Program Review and Investigations Committee should examine the co-op's finances and the Senate should issue a subpoena requiring Miller and Jennings to appear.

Then-Gov. Steve Beshear,
discussing health reform at the
Brookings Institution in D.C.

Prim, Beshear's spokeswoman, said, "While it is unfortunate the co-op did not succeed, an overwhelming majority of Kentuckians have a positive view of Kynect," the online exchange where Kentuckians can buy federally subsidized health-insurance policies. "It has succeeded by providing low-cost health insurance options and creating a competitive marketplace for private insurers that have kept rates low for everyone."

In his speech, Alvarado incorrectly referred to Kynect policies as Medicaid, the federal-state health plan for the poor and disabled. Beshear expanded Medicaid eligibility to Kentuckians in households with incomes up to 138 percent of the federal poverty level.

Alvarado declined to give Kentucky Health News the documents to which he referred in his speech, saying he got them from Bevin's office, which could be asked for them.

Bevin's office provided the liquidators' first report, filed Dec. 31; an actuarial report on small-group plans for 2016, submitted in July 2015; an actuarial report on individual plans for 2015, filed in August 2014; and a February 2015 letter from Miller responding to the Insurance Department's request for a "corrective action plan." None of the documents mention the meetings Alvarado said occurred among CMS, the co-op and the governor's office.

The August 2014 actuarial report said, "The financial viability of KHC is in question. . . . KHC's projections reflect very aggressive assumptions, albeit within a reasonable range, and may result in a very optimistic view of future experience."

The co-op's members used medical services more often than it expected. In the second quarter, there were 263 hospital patient days per 1,000 members, higher than the pricing assumption of 184 per 1,000 but a still a "significant decrease" from the first quarter, for which the report did not give a figure.

The co-op was also having trouble dealing with members and health-care providers. Its corrective plan filed in February 2015 addressed complaints about such things as slow payment standards, paid premiums not being posted to members' accounts, complaints from in-network providers about being processed as out-of-network, and long waits for customer service, with supervisors not being available.

The liquidators' report to the court estimated that the co-op still owes about $80 million in claims, and their financial analysis left unclear whether all those claims would be paid. The balance sheet in the liquidators' statement, dated June 30, said the co-op had $117 million in assets and $128 million in liabilities, and the liabilities included only $67.7 million in unpaid claims. However, the co-op's biggest federal loan, of $125 million, is "subordinate to policyholder obligations, claimant and beneficiary claims, operating expenses and state reserve and solvency requirements," the report said. CMS, the federal agency, has asked an independent actuary to provide its own estimate of unpaid claims.

Judge denies Bevin's bid to close Lexington abortion provider, citing difficulty that would create for Eastern Ky. women

UPDATE, June 15: A three-judge panel of the state Court of Appeals reversed the ruling.

A Lexington judge has rejected Gov. Matt Bevin's request to close the city's only abortion facility, saying that it is operating legally and that closing it would restrict access to abortions by residents of Eastern Kentucky.

Circuit Judge Ernesto Scorsone said Friday that he wouldn't issue an injunction to close EMW Women’s Clinic on Burt Road because the state failed to show that it is likely to win its lawsuit or that allowing it to stay open in the meantime would cause any irreparable injury.

“In addition to the evidence indicating that EMW is operating legally and in conformity with the most important regulations of a licensed abortion facility, closing the clinic is against the public interest,” Scorsone wrote. “EMW is the only physician’s office that routinely provides abortion services in the Eastern half of the state, and both parties agree that a right to an abortion during the first trimester of pregnancy is constitutionally protected. Closing EMW would have a severe, adverse impact on the women in the eastern part of the state.”

The clinic's attorney, Scott White, said it only performs first-trimester abortions and would reopen next week. It had closed in response to the lawsuit because of potential fines. Bevin spokeswoman Jessica Ditto said the administration would take the case to the state Court of Appeals.

The state claims the clinic needs to be licensed as an abortion clinic because that is all it does.

At a hearing Wednesday, "Clinic owner Ernest Marshall said the clinic used to do more regular gynecological health care, and is open to doing more, but he said that since his partner died a few years ago, the clinic’s primary work is abortions," Linda Blackford reports for the Lexington Herald-Leader. "On Feb. 17, state inspectors with the Cabinet for Health and Family Services visited the clinic, where they reported that employees told them the clinic only performs abortions. Inspectors also found dirty conditions and expired medicine."

Scorsone wrote that he was sure the clinic would address those issues, which typically do not lead to efforts to shut down medical facilities. He wrote, “The uncontroverted testimony presented at the hearing is that it is within the standard of care to perform first trimester abortions in a doctor’s office and that these procedures are less dangerous than others routinely performed in an office setting. The procedures used do not require sedation or the services of an anesthesiologist, factors that indicate EMW is a private physician’s office exempt from the licensing requirements for ambulatory surgical centers.”

"Scorsone said that the facility is already in compliance with the two most important requirements of an abortion clinic – that it has in place a transfer agreement with a hospital and a transportation agreement with an ambulance service in case there are complications with a procedure," Joseph Gerth reports for The Courier-Journal.

The clinic performed 411 of the 3,187 abortions reported to state officials last year. Most (2,773) were done by the EMW Women's Surgical Center in Louisville, which Marshall owns.

"The Bevin administration has targeted abortion clinics for regulatory action in the first months of his term," Gerth notes. "In February, he sought to block Planned Parenthood from offering abortions at a new clinic it opened in Louisville." That clinic has suspended abortions while the suit proceeds.

Bill for review of medical lawsuits dies from special elections

A bill that would create panels of experts to review lawsuits against health-care providers is going nowhere, again.

State Senate President Robert Stivers said Friday that he and other leaders of the Senate's Republican majority sent Senate Bill 6 back to committee because last week's special elections continued Democratic control of the House. They did likewise with a bill for a "right to work" law that would ban union membership or fees as a condition of employment.

“The reality is the House does not see as the majority party in this Senate does, that right-to-work would even be another tool that could increase and expand on job recruitment and retention,” Stivers said. “The other thing is we’ve had Senate Bill 6 sitting on the board for quite some time. But, because of the elections two weeks ago, the consequences are, they would pass this chamber but die in the House.”

Bills to preserve Kynect and Medicaid expansion head for votes in Democratic House despite a likely death in Republican Senate

By Melissa Patrick
Kentucky Health News

Bills to continue the Kynect health-insurance exchange and the state's current expansion of the federal-state Medicaid program passed out of the House Health and Welfare Committee March 17, starting a series of legislative votes on health reform that once seemed unlikely.

House Speaker Greg Stumbo said he expects the bills to pass the Democratic-majority chamber, even though Republicans in the fall elections could cast votes as support for "Obamacare," the federal reforms under which then-Gov. Steve Beshear created Kynect and expanded Medicaid.

“There’s never really been a debate on this issue,” Stumbo said. “There’s not been a true letting of the facts, if you will.”

Six days earlier, Senate President Robert Stivers had more or less dared Stumbo to move the bills, whose sponsor had said he did not expect them to pass the Republican-controlled Senate, in order to "have a full, fair debate on the issue" and see where legislators stand on it.

House Bill 5 would require the state to keep operating Kynect, which Gov. Matt Bevin is starting to dismantle or transform. In his campaign, Bevin vowed to abolish the exchange, saying it did nothing that the federal exchange does not. Recently his administration announced that it would continue operating a state-based exchange but use the federal exchange for enrollments.

"They're being pushed into what everyone calls Obamacare, and they don't want that," Stumbo told reporters.

House Bill 6 would keep the current expansion of Medicaid to people with incomes up to 138 percent of the federal poverty level. Bevin is negotiating with federal officials to change the program, saying it will not be sustainable once the state has to start paying part of the cost.

Rep. Darryl Owens

The committee approved the bills along party lines. Their sponsor, Rep. Darryl Owens, D-Louisville, said he filed them because "It is important for people to understand that there are those of us in this legislature that want to continue expanded Medicaid, that want to continue Kynect."

The exchange is paid for by a 1 percent assessment on all insurance policies sold in the state. The fee formerly funded a pool for high-risk insurance, which reform made unecessary. Approximately 1.4 million Kentuckians use Kynect, all but about 100,000 of them on Medicaid.

Kynect was started with federal grants. Rep. Robert Benvenuti, R-Lexington, argued that the state must include that $273 million when considering its cost. "I think most people in this room, most people in Kentucky, pay federal taxes as well, so this whole notion that there is a great federal money tree in which we can go pick off of and build things is just not correct," he said.

Owens replied, "I'm not saying it's a money tree, I'm just saying it's a grant that the federal government gave the states if they wanted to develop their own system," Owens said. "And I think the thing we miss when we talk about that is we have a great system; we have the best system in the country."

Rep. Tim Moore, R-Elizabethtown, whittled the definition of Kynect down to a business that advertises and markets Medicaid and health insurance to Kentuckians, and asked, "How do you spend that kind of money to go out and build a marketplace for soliciting folks to do what would be in their own interest anyway?"

Cara Stewart of the Kentucky Equal Justice Center said the marketing has value because it has created a brand that Kentuckians recognize and trust, allowing them to know where to go to get health insurance. She said Kynect runs seamlessly to help Kentuckians shop and enroll in coverage for both Medicaid and federally subsidized insurance plans, unlike Bevin's approach.

She said later that it now takes two minutes to reach customer service on Kynect and two hours on Benefind, which is operated by the state Department of Community Based Services. "We are radically changing the quality of service to Kentuckians," she said.

Rep. Tim Moore

Moore said he was glad the bills would be voted on because Kynect and the Medicaid expansion had been created through "dictatorship," not "the will of the people." Beshear acted under a state law that requires the government to get as much federal money as possible for Medicaid, and he used his broad executive powers under the state constitution to transform the high-risk pool into Kynect.

Moore said Bevin's election showed public opinion on the issue. However, a poll in November, after the election, showed Kentuckians supported the Medicaid expansion by 3½ to 1 and keeping Kynect by 2 to 1.

Democratic Rep. David Watkins, a retired physician from Henderson who voted for both bills, said, "It is kind of sad that our citizens don't pay attention to what our politicians are saying because they do have consequences."

Democratic Rep. Joni Jenkins of Louisville, chair of the House Budget Subcommittee on Human Services, said her panel's hearings convinced her that the state needs to keep it. She said there is value in having one system for Kentuckians to access health insurance, and to have Kynectors, who not only help people access health insurance, but also help them access health services.

Emily Beauregard, executive director for Kentucky Voices For Health, said after the meeting that navigating health insurance is difficult, especially for those who have never had it. "We need to help connect people to a source of care and help them understand how to use their benefits and that's what we've been able to do through Kynect," she said. "Coverage alone is not going to solve Kentucky's health issues."

Benvenuti said after the meeting, "There are various ways to get people to health care and creating a huge governmental system that is duplicative of the federal system is simply not the best use of our dollars."

As for Medicaid, Benvenuti said, "We've got to create a system where everybody who gets health care through an expansion population, or however you want to define it, has skin in the game and is responsible ultimately for their own health care."

Patients may be liable for big bills from air ambulances; state House panel approves bill calling for study of companies' charges

Air ambulance services have enabled rural Kentuckians to get advanced emergency care more quickly, but there's a catch.

"Increasingly, the service also can mean the difference between getting well at a price you can afford or at a price that could push you over a financial cliff," Trudy Lieberman writes for Rural Health News Service. "Air ambulances have become the centerpiece of a nationwide dispute over balance billing, a practice that requires unsuspecting families, even those with good insurance, to pay a large part of the bill."

On Wednesday, March 16, the state House Banking and Insurance Committee approved a bill calling for a study of air-ambulance charges. House Bill 273 was sponsored by Rep. Tom McKee, D-Cynthiana, "after a constituent of McKee’s was transported to the hospital via air ambulance after a fall, but it was an unexpected bill for thousands of dollars not covered by insurance which really knocked him off his feet," Don Weber reports for cn|2's "Pure Politics."

Rep. Tom McKee

"McKee says having more information about emergency care transportation may have allowed the individual to avoid the high cost," Weber reports, quoting him: “I have learned in looking at it that certain air-ambulance companies provide a subscription service for perhaps as little as $50 a year, that you can have coverage to know if you need to be transported, the full cost would be paid. As we move forward, I think we’re going to learn a lot more to at least inform people.”

McKee said the charges, which can run well into five figures, may seem huge “but those air-ambulance companies have to keep people on duty and have to have a full crew ready to go at a moment’s notice. But, I think as citizens, we all need to know where we are in regard to being transported and things like we’ve learned, a subscription service could be available.”

Some committee members said they want to see if the charges are justified. “It’s nice to know what the cost is, $40,000, but if it only costs them $8,000 to do it,” said Rep. Steve Riggs, D-Louisville. “So we have to learn more than just what the average retail cost is, we have to also learn more about what the profit margin is.”

Lieberman reports that your air-ambulance bill may not be covered "because the provider is not in your insurer’s network," but "Sometimes it’s impossible to tell if a provider belongs to a network or not. When you are wheeled into the operating room, are you going to ask the anesthesiologist if he or she belongs to the hospital’s network? How many accident victims suffering from trauma are going to direct EMS workers to check if the air service is in or out of network before they’re lifted to a hospital? You can also get stuck even if the ambulance company is in the network. An insurance payment may not come close to covering the cost.

“Rates ambulance companies charge private patients are much more than they are charging to Medicare or Medicaid,” whose rates are too low to suit the companies. Consumers Union Programs Director Chuck Bell told Lieberman. “The air ambulance industry has grown rapidly, and prices have shot up a lot with some companies trying to make a quick buck.”

Annual County Health Rankings for Kentucky show many shifts in the middle echelons, not much at the top and bottom

By Melissa Patrick
Kentucky Health News

The sixth annual County Health Rankings report shows little change in Kentucky's top and bottom rankings, but there were a few surprises, with several counties showing up in the top 10 for the first time.

Marshall County was one, ranking 10th in both health outcomes and health factors, the rankings' two main measures. This is an improvement from last year's 26th in outcomes and 19th in factors. Bullitt County also moved into the top 10 for the first time this year, ranking sixth for outcomes, up from 27th.

Health outcomes include length and quality of life. Health factors contribute to outcomes and include four categories: health-related behaviors, clinical care, social and economic factors, and the county's physical environment. The rankings for each county are relative to other counties in the same state.

"Communities use the rankings to help identify issues and opportunities for local health improvement, as well as to garner support for initiatives among government agencies, healthcare providers, community organizations, business leaders, policy makers, and the public," says the report.

The County Health Rankings are a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute.

2016 Health Outcomes - Kentucky

The report is a general categorization of a county's health status. The rankings are arranged in quartiles, or four numerical classes, to de-emphasize the small statistical differences among closely ranked counties. Kentucky has 120 counties, in quartiles of 30.

The bottom quartile comprises almost entirely Appalachian counties, the only exception being Fulton, in the Mississippi Delta at the state's western tip.

Oldham and Boone counties continued to be the top two for health outcomes in the state, as they have been since the rankings began. Spencer County, ranked third, spent the last two years ranked 11th. Shelby and Scott counties are ranked fourth and fifth in outcomes. All are suburban, formerly rural, counties in the state's three major metropolitan areas.

The bottom 10 counties in health outcomes are all rural. They saw little change from last year, with Harlan (117) and Wolfe (119) being the only new additions. The bottom five counties in outcomes are Floyd, Harlan, Perry, Wolfe and Owsley (which has been ranked last for health outcomes every year, except 2013, when it ranked 102nd).

Counties that saw the greatest improvements in health outcomes were Livingston (LG on map), moving up from 70th to 35th; Trimble (TI), moving up from 56th to 27th; and Crittenden (CD), moving up from 64th to 38th. All these counties moved into a higher quartile with these ranking changes.

Morgan County, which for years had health outcomes far better than its health factors, saw the greatest decline in the outcome rankings, moving from 48th to 76th. It was followed by Russell, which fell from 61st to 88th; and Bracken, which dropped from 46th to 72nd. Russell County remained in the same quartile as last year, but the other two counties shifted to a lower one.

2016 Health Factors - Kentucky

The top five counties for health factors have all been in the top 10 before. They include Oldham, Boone, Spencer, Woodford and Campbell counties; Campbell had dropped last year to 12th.

The bottom five counties for health factors are Magoffin, Wolfe, McCreary, Breathitt and Bell, all in the Eastern Kentucky Coalfield.

Counties that saw the greatest improvement in health factors were Clark, moving from 53rd to 29th; Gallatin, going from 89th to 67th; and Crittenden, rising from 86th to 64th. Only Clark, just east of Lexington, moved into a higher quartile.

Counties that saw the greatest declines in health factors were Taylor , dropping from 30th to 58th; Butler, falling from 66th to 94th; and Union, dropping from 46th to 73rd. Each of these counties dropped into a lower quartile. Butler, Fulton and Carroll were the only non-Appalachian counties in the bottom quartile.

The report identifies "meaningful gaps" that exist between the best and worst Kentucky counties and suggests that policymakers look at these gaps as they search for ways to improve the counties' health, including: adult smoking, adult obesity, uninsured rates, preventable hospital stays, education levels, unemployment, children in poverty and income inequality.

The report says, "Every year, over 2,800 deaths in Kentucky could be avoided if all residents in the state had a fair chance to be healthy."

More Kentucky patients are recuperating in their local, rural hospitals after surgery in an urban hospital

By Melissa Patrick
Kentucky Health News

Rural residents are increasingly being transferred out of big urban hospitals to recuperate in rural hospitals, many of which are struggling financially and can use the business.

"We have seen trends of this around the state," said Elizabeth Cobb, vice president of health policy for the Kentucky Hospital Association, said in an interview.

Oregon's legislature voted recently to encourage the trend in that state, by appropriating $10 million for rural health-care improvements, with the largest part encouraging such transfers.

In Kentucky, Cobb said the transfers would have to make sense from procedural, convenience and financial perspectives, but when it works out it is great for both the urban and rural hospitals, and also for the families.

"Certainly when there is a treatment or procedure that will take a significant amount of recovery, it is a wonderful thing for rural Kentuckians to be able to transfer back to their community facility to finish off their recuperation," she said.

Oregon's program aims to create a more consistent patient population in its rural hospitals, which will help stabilize their funding. At the same time, the program will relieve pressure on strained urban hospitals, Chris Gray reports for The Lund Report.

Rural hospitals are struggling financially all over the country and often have inconsistent patient volumes, while urban hospitals struggle with reaching capacity, and often worry they might have to expand, Gray notes.

A state report by then-Auditor Adam Edelen last year found that one in three of Kentucky's rural hospitals were in poor financial condition and suggested that to survive, they might have to adapt to new business models, such as merging with larger hospitals or hiring them as managers, forming coalitions with other hospitals, or finding a health-care niche that hasn't been served, such as creating a partnership with urban hospitals to allow rural patients the ability to recuperate closer to home.

While it sounds like a "common-sense system," Gray reports that the program is costly to set up, between $4 and $7 million, but once it is up and running, and the hospitals learn how to coordinate, "it should be self-sustaining, since money from insurers, Medicaid and Medicare will follow the patient," according to an interim workgroup of rural health officials from Oregon.

A rural health physician told Gray that "local hospitals and healthcare access, along with good public schools, provide the backbone for a viable community when employers are looking to invest in a community," he writes.

Trying to stop overdose epidemic, CDC tells docs to limit most opioid prescriptions to 3-7 days, use low doses and warn patients

Graphic from CDC guideline brochure

Kentucky Health News

Doctors who prescribe highly addictive painkillers for chronic pain should stop and be much more careful to thwart "an epidemic of prescription opioid overdoses" that is "doctor-driven," the federal Centers for Disease Control and Prevention said Tuesday, March 15.

"This epidemic is devastating American lives, families, and communities," the CDC said. "The amount of opioids prescribed and sold in the U.S. quadrupled since 1999, but the overall amount of pain reported by Americans hasn’t changed."

Kentucky ranks very high in use of opioids and overdoses from them, and Louisville reported a big increase in overdoses this month, Insider Louisville reports.

The agency said doctors should limit the length of opioid prescriptions to three to seven days, use "the lowest possible effective dosage," monitor patients closely, and clearly tell them the risks of addiction.

It said most long-term use of opioids should be limited to cancer, palliative and end-of-life treatment, and that most chronic pain could be treated with non-prescription medications, physical therapy, exercise and/or cognitive behavioral therapy.

The guidelines are not binding on doctors, but Dr. Thomas Frieden, the CDC director, "said state agencies, private insurers and other groups might look to the recommendations in setting their own rules," the Los Angeles Times reported.

However, Modern Healthcare reported that the guidelines are unlikely to change physicians' practices. "One current hurdle to curbing the number of prescriptions is that it's much easier for a busy clinician to prescribe a 30-day supply of oxycodone or Percocet to treat a patient's chronic pain than it is to convince him or her to do physical therapy," Steven Ross Johnson writes. "The time constraints affecting physicians' practice has never been more acutely felt than in this era of health-care reform that emphasizes quality and value-based payment."

Money could be a key in making the guidelines effective. Sabrina Tavernise of The New York Times writes, "Some observers said doctors, fearing lawsuits, would reflexively follow them, and insurance companies could begin to us them to determine reimbursement." The federal Centers for Medicare and Medicaid Services could also play a role.

Johnson notes that physicians are trained to "reserve opioids for severe forms of pain . . . but in the 1990s, some specialists argued that doctors were under-treating common forms of pain that could benefit from opioids, such as backaches and joint pain. The message was amplified by multi-million-dollar promotional campaigns for new, long-acting drugs like OxyContin, which was promoted as less addictive."

Purdue Pharma, maker of OxyContin, agreed to pay $600 million in penalties to settle federal charges that it over-promoted the drug to doctors, prompting the epidemic, especially in Central Appalachia.

"When reports of painkiller abuse surfaced, many in the medical field blamed recreational abusers. In recent years, however, the focus has shifted to the role of doctors," Harriet Ryan and Soumya Karlamangla report for the Times, noting that a 2012 analysis "of 3,733 fatalities found that drugs prescribed by physicians to patients caused or contributed to nearly half the deaths."

Doctors, insurers, drug companies and government agencies "all share some of the blame, and they all must be part of a solution that will probably cost everyone money," Caitlin Owens writes for Morning Consult, which also notes prescribers' complaints and CDC's responses.