Meth is top drug problem in West Ky.; Paducah Sun story also gives essential information about drug abuse and treatment

"In Western Kentucky and Southern Illinois, law enforcement and rehabilitators see methamphetamine as the drug of choice, responsible for a large majority of substance-related arrests," Dave Thompson reports for The Paducah Sun. "The drug is cheaper than many others on the street. It's made with ephedrine or pseudoephedrine, common in some decongestants, along with other chemicals depending on the method the cook uses."

The National Institute on Drug Abuse says meth gives the brain significantly higher levels of dopamine, a chemical associated with pleasure, desire and motivation, than cocaine, and remains in the body longer, Thomspon notes.

The story tracks a young man identified only as Cody, who used the drug for six years before getting treatment at Four Rivers Behavioral Health through the McCracken County Drug Court. "Alienated from his family, with no one to rely on and facing felony charges, Cody finally decided he'd had enough," Thompson reports.

"I'd been through enough to where I was ready to sober up," he told Thompson. "I was definitely going to die . . . I took anything from anybody. I've dropped out of college twice over meth. I've totaled people's cars and left them in the roads. . . . I'm 27 and I've been to jail probably 20 times."

Thompson's story includes information that helps educate readers about drug abuse and its treatment: "Drug addiction is a disease. That's the prevailing opinion among many drug treatment programs like Four Rivers. Those who work in the field call it substance use disorder. That term is both an attempt to de-stigmatize those who use drugs and to understand that the issue is more complex and requiring of deeper treatment than simply telling someone to choose not to be addicted."

"Meth doesn't have the same extended withdrawal symptoms as drugs like opiates," Thompson writes, but "a person needs to learn how to deal with the cravings that might still linger. . . . A post-meth life can include lasting mental and physical effects, including psychosis, years after a person's last dose, Fleming said."

Study finds that maintaining five healthy habits could add a decade to your life, but only 8 percent of Americans follow all five

Harvard T.H. Chan School of Public Health photo

Americans could add about a decade to their lives, on average, if they maintained five healthy habits: not smoking, eating healthy, exercising regularly, maintaining a healthy weight and drinking in moderation, according to a new study.

It may sound easy enough, but the study also found that fewer people are adhering to these healthy habits: 8 percent between 2001 to 2006, down from 15 percent between 1988 to 1992. Researchers say the decline is "driven primarily by the increasing prevalence of obesity."

Americans also have a shorter average life expectancy than almost all other wealthy nations, ranking 31st in the world for life expectancy in 2015, says a news release about the study.

At this time, 50-year-old American women can expect to live another 33 years and men another 30 years. The study predicts those numbers would jump to 43 years for men and 38 years for women who maintained all five healthy habits.It predicted the additional life expectancy of those who didn't adopt any of the habits would be 29 and 25.5, respectively.

"In other words, women who maintained all five healthy habits gained, on average, 14 years of life, and men who did so gained 12 years, compared with those who didn’t maintain healthy habits," the release says.

The study at the Harvard T.H. Chan School of Public Health, published in the journal Circulation, looked at 34 years of data from 78,865 women in the Nurses’ Health Study and 27 years of data from 44,354 men in the Health Professionals Follow-up Study.

The researchers found that those who had the five healthy habits were 74 percent less likely to die during the study period, compared to those who didn't follow any of the healthy habits -- and 82 percent were less likely to die from heart disease or stroke, and 65 percent less likely to die from cancer.

The study defined "regular" exercise as moderate or vigorous activity for at least 30 minutes a day. Moderate drinking was defined as no more than one alcoholic drink per day for women, and no more than two per day for men. And a "healthy" diet was scored by giving points to those who ate vegetables, fruits, whole grains, beans, fish and poultry and "good" fats. It also gave points to those with diets low in sugar, sodium and red meat.

The study found that adopting any one of the healthy lifestyles resulted in an increase in life expectancy, and that adopting all five produced the most additional years of life. (Click on chart for larger version.)

"This study underscores the importance of following healthy lifestyle habits for improving longevity in the U.S. population,” senior author Frank Hu, chair of nutrition at the Chan School, said in the release. “However, adherence to healthy lifestyle habits is very low. Therefore, public policies should put more emphasis on creating healthy food, built, and social environments to support and promote healthy diet and lifestyles.”

Bevin lawyers defend Medicaid changes, say beneficiaries who sued lack standing; brief makes a sort of Catch-22 argument

The Trump and Bevin administrations, defending the latter's forthcoming work requirements for Kentuckians on Medicaid, say the 16 beneficiaries who challenged them in federal court in Washington lack the legal standing to do so.

The governments asked District Judge James Boasberg to uphold the Centers for Medicare and Medicaid Services' recent approval of a waiver that lets the state charge premiums and co-payments and "require some beneficiaries to work 80 hours a month, go to school, enroll in job training or participate in similar activities," James Romoser reports for Inside Health Policy. "The new rules apply primarily to beneficiaries who received coverage through the Affordable Care Act’s expanded eligibility."

The government lawyers argue that the beneficiaries lack standing to sue because they have yet to lose any coverage. "For instance, the beneficiaries may receive exemptions from the work requirements or other coverage restrictions under the program scheduled to take effect July 1, the lawyers said. Kentucky added that, even if the beneficiaries were subject to the program’s restrictions, Boasberg cannot provide them with any favorable relief because, if the beneficiaries prevail, Gov. Matt Bevin has promised to eliminate the state’s Medicaid expansion," Romoser reports.

In an argument reminiscent of the conundrum described in the Joseph Heller novel Catch-22, the state's brief argues, “Plaintiffs have not established that prevailing here likely will redress their alleged injuries. To the contrary, if plaintiffs win, they no longer will receive Medicaid.”

Romoser reports, "The Trump administration said it is appropriate to test whether work requirements will serve that goal and promote overall health and well-being among the beneficiaries who will be subject to the program." Its brief says, “The requirement is not about penalizing Medicaid beneficiaries, as plaintiffs suggest. It is about promoting public health by encouraging members of the expansion population to engage in behaviors associated with healthy outcomes.”

Girl, 13, tells crowd of 100 about dealing with mental-health issues and their stigma; Paducah Sun reports 'remarkable' story

A 13-year-old eighth grader with a long list of mental-health issues told nearly 100 attendees at the third annual West Kentucky Health and Wellness Summit about dealing with her condition and the stigma that surrounds it, including her experiences with being bullied.

Julia Burkhart, a student at Lone Oak Middle School, has been diagnosed with schizophrenia, bipolar disorder, general anxiety disorder and attention deficit hyperactivity disorder, better known as ADHD, David B. Snow reports for The Paducah Sun.

"When she walks down the hall, you wouldn't know her from any other student," Snow writes. "There are no identifying marks or signs on her to indicate she has mental illness. The problem is the signs placed on her by other people."

At the health and wellness meeting in Paducah, Julia told about being bullied in kindergarten, which she said got worse as she got older. In fifth grade, she said a student who she thought was her best friend started bullying her and that rumors started spreading that something was "wrong" with her -- and the attacks escalated on social media. Snow writes that Julia started cutting herself.

"No one knew how much I was hurting," she said. "I would refuse to go to school just because it was unbearable to step foot in that school."

Julia said school counselors tried to help, but it wasn't until she was diagnosed with manic bipolar disorder at age 11 and entered an outpatient treatment program and changed schools that things started getting better. She relapsed in seventh grade, which led to eating disorders and taking pills "to escape," she said. She was diagnosed with schizophrenia in April 2017 and went back into the outpatient program at the beginning of the 2017 school year, Snow reports.

"I graduated in February from outpatient, and I've been continuing to better myself," Julia said. "And here I am now, speaking about my problems. I take pride in my recovery every day, and I am proud to have gone through this. It's made me realize what's really important."

Snow writes that Julia's experience is similar to what others with mental illness go through.

I think one of the biggest limitations for mental-health access is our own viewpoint of what a mental-health issue is," Dr. Laurie Ballew, a psychiatrist who is medical director of behavioral health at Lourdes Hospital, told Snow. "People have this negative thought process about mental health, not realizing that our brain is the organ that controls our body."

Snow writes, "Ballew said that mental illness is a brain illness, and symptoms generally are seen through changes in mood, appetite, activity or suddenly failing classwork or failure at one's job. Several mental illnesses are caused by having a chemical imbalance, and many are treatable like any other disease."

Al Cross, director of the University of Kentucky's Institute for Rural Journalism and Community Issues and publisher of Kentucky Health News, called the Sun article a "remarkable example" of how news outlets can help individuals tell their stories about stigma and mental health.

"More news outlets need to report stories like this to help reduce the stigma that still surrounds issues of mental health, behavioral health and drug addiction," Cross said.

43% of Ky. medical-school students become primary-care physicians; nationwide, the figure is only 20 percent

Kentucky seems to be dealing with the shortage of primary care physicians more effectively than the rest of the nation, but it's still uncertain if the state's efforts will be enough.

The problem is that fewer medical students are choosing to go into primary care. With the average medical student graduating with $200,000 or more in debt, many opt for higher-paying specialties, Sam Dick reports for Lexington's WKYT-TV. To make matters worse, older family physicians are retiring or dying and more patients are getting older and sicker.

In the next seven years, the United States will need 52,000 more family doctors and Kentucky will need about 1,400 more -- mostly in rural areas, Dick reports.

"You know, we're seeing a lot of health-care providers that are just burned out," Lexington Clinic physician recruiter Robert Bratton told Dick. "They're being asked to do more and more, in less and less amounts of time, and it's very difficult. . . . It's staggering. It really is. "

Dr. Hoellein, associate dean for student affairs at the University of Kentucky College of Medicine, told Dick that Kentucky is bucking this trend. He said that nationally 20 percent of medical school students choose primary care, but in Kentucky that number is up to 43 percent.

Toward that end, the UK medical school is expanding across the state. A two-year school is open at St. Claire Medical Center in Morehead, UK's Bowling Green campus opens this summer, and next summer UK Northern Kentucky will start taking medical students. The hope is that new, primary care doctors will train in those areas of the state and then remain in them to practice medicine.

Dick notes that physician assistants are helping to pick up some of the patient load, but Dr. Michael Eden, an "older family doctor," said, "Even at this point with them helping us out, we struggle some days to get everyone in."

Hepatitis A outbreak prompts warning in Ind. about travel to Ky., where state health commissioner pushes back; drugs play a role

The increasing number of hepatitis A cases in Kentucky has prompted the state health commissioner to do a video saying it's safe to visit the state, and has focused new attention on the role of drug abuse in the outbreak.

Kentucky officials have confirmed almost 400 cases of the liver disease since they declared an outbreak last summer. The annual average is about 20 cases.

Indiana health officials "told Hoosiers heading to Kentucky to get a hep-A vaccine," prompting acting Commissioner for Public Health Jeffrey Howard to push back. “Let me say that it IS safe to travel to Kentucky, and it IS safe to attend the Kentucky Derby,” Howard said in a YouTube video.

"What had looked like an isolated rash of cases in a few Kentucky counties has now become a multi-state, regional outbreak, with nearly 500 cases in four states and the numbers rising daily," Mary Meehan reports for Ohio Valley ReSource. "As with recent clusters of cases of HIV and elevated risk of Hepatitis C, this latest outbreak of hep A is also closely linked to the region’s addiction crisis."

That is unusual, Meehan reports: "Usually, Hep A outbreaks are caused by ingesting food contaminated with fecal matter. That often means the food is contaminated where it is grown or that a food service worker unwittingly passes on the disease through a restaurant."

West Virginia Health Commissioner Rahul Gupta told Meehan, “Individuals who may have substance use disorder and may be using illicit drugs may also not be able to keep up personal hygiene,” he said, “which puts them at higher risk for being infected with Hepatitis A.”

Howard said, "The biggest challenge we face is when outbreaks cross state lines,” noting a cluster of HIV cases in Northern Kentucky and Cincinnati linked to intravenous drug use. “For the first time in the history of Kentucky, we had HIV transmission with the most common risk factor being intravenous drug use,” he said. “We will see more and more outbreaks in the upcoming months and years.”

Death from hepatitis A is relatively rare, but the illness can be severe and last several weeks, Meehan reports: "Symptoms include``fever, fatigue, nausea, vomiting, dark urine, jaundice, clay-colored bowel movements and joint pain. . . . The best prevention is a good hand wash with soap and water."

Ohio Valley ReSource map

As Senate committee OKs package to fight opioid epidemic, McConnell files bill to relieve its impact on workers and employers

As the U.S. Senate's health committee sent the chamber a bipartisan bill aimed at the nation's opioid epidemic, Senate Majority Leader Mitch McConnell introduced a bill to provide relief to employers and employees in Kentucky and other states suffering most from the epidemic.

The commitee's bill incorporates another one filed by McConnell, calling on the federal Centers for Disease Control and Prevention to develop educational materials on pain management for doctors and pregnant women, and authorizing an increase in funding for grants that help organizations address the problem of prenatal opioid exposure.

Health, Education, Labor and Pensions Committee Chairman Lamar Alexander (R-Tenn.) and ranking Democrat Patty Murray (D-Wash.) sponsor the Opioid Crisis Response Act of 2018 (S.2680). “The challenge before us has sometimes been described as needing a moonshot,” Alexander said during the panel's markup of the bill.

“I believe that solving the opioid crisis might require the energy of a moonshot, but ultimately, it’s not something that can be solved by an agency in Washington, D.C.,” Alexander said. “I wish we could have a single blockbuster idea that an agency here could deal with and solve the problem: What we can do is take a number of steps to create an environment so that everyone … can succeed in fighting the crisis community by community.”

The bill includes more than 40 proposals from 38 different senators, Alexander said. "Specifically, it includes measures attempting to make it easier to prescribe smaller packs of opioids for limited durations, spur the development of nonaddictive painkillers and bolster the detection of illegal drugs at the border," Medscape reports.

The bill "seeks to boost scientific research related to pain, to aid medical and law enforcement efforts to prevent and track misuse of prescription drugs, and to provide assistance for communities already struggling with its consequences," The Hill reports.

Alexander said he expects other committees will also have ideas on how to combat the opioid epidemic, “but if we can present our framework to Senator McConnell, maybe this is something the Senate can move on this summer.” A subcommittee of the House Energy and Commerce Committee held a hearing Wednesday on a large number of opioid proposals; its chairman, Rep. Greg Walden(R-Ore.), told The Hill that he hopes to send legislation to the House floor by Memorial Day.

McConnell's new bill "would bring targeted relief to the states most devastated by substance abuse," said a press release from his office. "The state-based pilot program established under this legislation would encourage local businesses and treatment groups to form partnerships to help individuals in recovery find and maintain employment. The legislation encourages expanding transitional housing options for recovering addicts until they secure permanent arrangements. Further, it gives states more flexibility to spend federal career services and training funds to support individuals transitioning from treatment to the workforce."

McConnell said many Kentucky employers cite substance abuse as an obstacle to maintaining a full workforce. "One study attributed roughly 25 percent of the decline in workforce participation between 1999 and 2015 to aspects of the opioid crisis," the release said.

Meanwhile, on the illegal side of the drug landscape, McConnell announced that the Drug Enforcement Administration had granted his request to open an office in Paducah like the one it already has in Madisonville. He said in a release that DEA was responding to local officials' call for such an office, and a "tremendous upsurge in the amount of methamphetamine and synthetic cannabinoids imported and distributed in Western Kentucky."

FDA cracks down on sale of e-cigarettes to youth, sends 40 warning letters about Juul devices that look like big flash drives

Smoke-shop manager Cathleen McCarthy demonstrates the

Juul device. (Photo by Suzanne Kreiter, The Boston Globe)

"The Food and Drug Administration on Tuesday announced a nationwide undercover 'blitz' to crack down on the sale of e-cigarettes — particularly the hugely popular Juul products — to children and teenagers by regular and online retailers," reports Laurie McGinley of The Washington Post.

The crackdown will continue through April. So far it has found dozens of violations of the laws and has issued 40 warning letter related to Juul sales. Juul (branded JUUL) is a highly popular vaping device that packs a powerful nicotine punch, with dozens of flavors like mango and creme brulee that attract teenagers.

Because the device is small and looks like a USB drive, teens find it easy to hide them from parents and teachers. Other vaping devices like myblu and KandyPens are similar. And because teen smoking rates have dropped dramatically in the past 20 years, vaping makes up the lion's share of adolescent nicotine use. In 2015, the national rate for high-school e-cig use was 24.1 percent, compared to 10.8 percent for cigarettes.

At 23.4 percent, Kentucky high school e-cig use was similar to the national average in 2015, but the 2017 Youth Risk Behavior Survey showed a drop in the student's e-cig rate to 14.1 percent. The 2017 national numbers haven't been released. About the same number of Kentucky teens smoke cigarettes -- 14.3 percent -- as e-cigs, down from 47 percent in 1997.

About 45 percent of Kentucky's high-school students said said they had ever used an electronic vapor product, compared to about 41 percent who had ever tried smoking cigarettes.

And although many consider vaping safer than smoking traditional cigarettes, the vapor contains other dangerous chemicals.

 "The announcement about the crackdown came a week after health organizations and lawmakers urged the FDA to be more aggressive in discouraging e-cigarette use among minors, The Campaign for Tobacco-Free Kids, Truth Initiative, American Academy of Pediatrics, American Cancer Society Cancer Action Network, American Heart Association and American Lung Association sent a letter to [FDA Commissioner Scott] Gottlieb warning that progress against smoking is 'at serious risk of being reversed' because of the agency's failure to take action against products that appeal to youth," McGinley reports.

Juul Labs said in a statement that selling its products to minors was "unacceptable" and it already has programs in place to prevent and act on violators, but promised to announce extra measures soon.

Most Kentucky adults believe addiction is a disease but a fourth of them think it is not

It is widely understood by health professionals that addiction is a disease, and a recent poll found that most Kentucky adults believe that, too. But one in four think it is not.

The Kentucky Health Issues Poll, taken Oct. 24 through Dec. 2, found that 70 percent of Kentucky adults believe addiction is a disease, with no discernible difference between those who knew someone with an addiction and those who didn't. The poll also found that 26 percent of Kentucky adults believe that addiction is not a disease, while 4 percent said they didn't know.

"Treating addiction as a disease, and then working together to magnify the treatment programs that are working, is the only way we are going to move from our substance use crisis to long-term recovery - both for individuals, and for the Commonwealth," Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, which co-sponsors the poll, said in a news release.

Responses to the question varied by location, with those living in large urban areas more likely to believe that addiction is a disease than those in largely rural areas.

Kentucky adults in the Lexington region, at 76 percent, are most likely to believe that addiction is a disease. In Eastern Kentucky the figure is 62 percent. Those figures, and those for other regions, are subject to error margins of plus or minus 5.2 to 5.6 percentage points; the margin of error for statewide results is 2.4 percentage points.

Among Kentucky adults who recognized addiction as a disease, 81 percent said they believed it to be both a physical and psychological disease, which is correct; 17 percent said it was psychological, and 1 percent said it was a physical disease only.

Chandler noted that Kentucky is one of the hardest-hit states when it comes to opioid and other substance-use disorders, noting that the state's number of drug overdose deaths jumped 12 percent between 2015 and 2016. The 2015 Behavioral Health Barometer for Kentucky found that, in a single-day count in 2015, 23,565 Kentuckians were enrolled in substance-use treatment, compared to 20,481 in 2011, a 15 percent jump.

To that end, Kentucky lawmakers recently passed a law to require the Cabinet for Health and Family Services to conduct a comprehensive review of all state substance-use disorder programs and services, and to only pay for and license those that follow nationally recognized, evidence-based protocols, subject to available funding.

The National Institute on Drug Abuse describes addiction as a "chronic disease characterized by drug seeking and use, despite harmful consequences" that can be affected by the biology, environment and development of an individual. This shift in thinking, based on scientific research and evidence, has changed the way substance-use disorders (once simply called substance abuse) are perceived and subsequently treated.

Dr. Mina "Mike" Kalfas, a certified addiction expert in Northern Kentucky, told Terry DeMio of the Cincinnati Enquirer that this shift in thinking has been necessary to provide effective treatment.

"Every facet of our mission -- from using Narcan to medication-assisted treatment to syringe exchange -- relies on general consensus recognizing this as a disease," he told DeMio.

In the same news release, the foundation also announced that this year's annual Howard L. Bost Memorial Health Policy Forum, to be held Sept. 24 in Lexington, will explore the state's substance use epidemic and examine the latest solutions. Registration for the conference will open soon.

The poll was funded by the foundation and Interact for Health, a Cincinnati-area foundation. It surveyed a random sample of 1,692 Kentucky adults vial landlines and cell phones.

More large to medium Kentucky hospitals rated low for patient safety

By Melissa Patrick
Kentucky Health News

A nonprofit group that rates hospitals has released its latest patient-safety grades, once again giving most Kentucky hospitals a B or C. Kentucky's overall ranking of 34th remained the same as the fall of 2017 report.

The Leapfrog Group, a nonprofit based in Washington, D.C., evaluated about 2,500 hospitals nationwide, including 46 in Kentucky. Most of Kentucky's 129 hospitals were not rated because critical-access hospitals in rural areas don't have to report their quality measures.

The Leapfrog Group Hospital Safety Grade website is
easy to use and offers information on 46 Ky. hospitals.

The grades are calculated using 27 performance measures of patient safety that indicate how well hospitals protect patients from preventable medical errors, infections and injuries. The study uses data from the Centers for Medicare and Medicaid Services, the annual Leapfrog Hospital Survey and the American Hospital Association's annual survey.

Leapfrog gave an A to 10 Kentucky hospitals, or nearly 22 percent of those graded, lower than the national average of 30 percent. It gave Bs to 17, Cs to 13 and Ds to six -- two more than the fall report. None got a failing grade.

Taylor Regional Hospital in Campbellsville and Highlands Regional Medical Center in Prestonsburg got their first Ds on the biannual ranking. Taylor had received Cs as far back as the spring of 2015 and Highlands had gotten Cs as far back as the fall of 2015; Lourdes Hospital in Paducah got its second D in a row.

The three Louisville hospitals that are consistent low scorers did so again, with Jewish Hospital, Sts. Mary & Elizabeth Hospital and the University of Louisville Hospital getting Ds again.

Jewish and Sts. Mary & Elizabeth are owned by KentuckyOne Health. The university hospital separated from KentuckyOne July 1 and is now operated by U of L. KentuckyOne Health is working to sell both Jewish and Sts. Mary & Elizabeth.

U of L Interim President Greg Postel told Chris Otts of WDRB that the New York private equity firm BlueMountai Capital Management will decide "within a month or less" whether to purchase Jewish Hospital (and the Frazier Rehabilitation Institute).

Pikeville Medical Center in Eastern Kentucky dropped to a C after getting As since the spring of 2015.

Baptist Health Lexington got its A grade back, having last received an A in the fall of 2015 and getting mostly Bs with one C in-between.

Jackson Purchase Medical Center in Mayfield got an A again, having gradually worked itself up to its first A ever in the last report, up from its two initial D grades, received in the fall of 2014 and spring of 2015.

Lake Cumberland Regional Hospital in Somerset got a B after receiving mostly Cs since the spring of 2015, and one D in the spring of 2016.

Norton Brownsboro Hospital got a B for the first time since the spring of 2015, having received only Cs since that time. Owensboro Health also got a B after getting straight Cs since the spring of 2015.

St. Joseph Hospital in Lexington kept its B for the second Leapfrog grading period in a row, after getting Cs and Ds since the spring of 2015.

The two University of Kentucky hospitals once again got a B.

The Leapfrog Group says its bi-annual analysis was developed under the guidance of the nation's leading patient-safety experts and is peer-reviewed. Click here to see all of Kentucky hospital's Leapfrog hospital safety grades. Click here for Leapfrog recommendations on how to use the grades.

As new Medicaid plan nears, various sources offer ways to find out more about it and how you could be affected

Kentucky will start phasing in its new Medicaid program in July, so the state and other stakeholders have created tools and "explainers" to help Medicaid enrollees and others understand the changes and deal with them. The program is expected to be fully implemented by the end of the year.

The state's new Medicaid plan, called Kentucky HEALTH for "Helping to Engage and Achieve Long Term Health," includes, among other things: work or training requirements, reporting changes in status, lock-out periods for failure to comply, and premiums and co-payments. The changes will largely impact "able-bodied" Kentuckians who have gained Medicaid coverage through the expansion, which covers people with incomes up to 138 percent of the federal poverty level.

A county-by-county spreadsheet of enrollment in Medicaid, as of January 2018, is at http://www.uky.edu/comminfostudies/irjci/MedicaidbycountyJan2018.xlsx.

An interactive tool the state doesn't like

WFPL, a public radio station in Louisville, has created an interactive tool called "Kentucky Medicaid Waiver Calculator," to help Medicaid enrollees and others figure out how it will affect them, based on family size, income and other factors.

Screenshot of WFPL's Kentucky Medicaid Waiver Calculator

"It breaks down the changes for people in various situations in a straight-forward way, arming Medicaid enrollees with more information before the changes kick in on July 1," Lisa Gillespie and Alexandra Kanik, who jointly created the calculator, report for WFPL.

After consulting several health policy experts to assure the accuracy of the tool, Gillespie and Kanik write that they reached out to the Cabinet for Health and Family Services, but cabinet spokesman Doug Hogan declined and threw cold water on the whole thing: “Any tool created outside of this system would most certainly provide inaccurate information to current and potential beneficiaries."

The interactive tool will be updated as more is learned about the affected populations, Gillespie and Kanik report. They add that "the best way to get information on eligibility and current benefits is through Benefind," the state's online portal.

Stakeholder Advisory Forums

Officials have announced 10 public "stakeholder advisory forums" to help ease the transition to the new plan. The next one will be held at 1 p.m. May 3 at the Transportation Cabinet auditorium on Mero Street in Frankfort.

The state has published a Kentucky HEALTH overview that includes answers to frequently asked questions; it is online at https://kentuckyhealth.ky.gov/SiteCollectionDocuments/Kentucky%20HEALTH%20General%20Information%20Quick%20Print.pdf.

The state has also recently sent postcards to eligible Kentucky HEALTH adults to inform them on how to start earning money into their My Rewards account, which allows beneficiaries to earn "virtual reward dollars" by doing preventive screenings, health classes, volunteering, job training and other activities that can be used to "buy" services like dental and vision care, among other things.

Kentucky Voices for Health, an advocacy coalition that has voiced concern about the changes, has created two "explainers" on Kentucky HEALTH, one in two pages and a more detailed version in four pages.

Insurers are also gearing up

The state is offering provider forums for Medicaid managed-care organizations, and two of the five MCOs, Passport Health Plan and Wellcare Health Plans, are offering workshops for health-care providers on the changes.

Wellcare President Bill Jones said in a news release that his firm has been working closely with the state to prepare for the changes, including efforts to be able to connect Kentuckians with the job training or volunteer opportunities they will need under the new program.

"From revamping our website, so people can easily check whether they’re meeting the requirements of Kentucky HEALTH, to enhancing the training of the people taking questions by phone, we are working to ensure a seamless experience for our members," Jones said.

Humana continues move away from fee-for-service model, toward paying for a whole case and incentivizing better outcomes

Health insurer Humana Inc. "has reached an agreement to pay five maternity-care providers, including three near Louisville, based at least in part on patient outcomes, rather than the number of health-care services they provide," reports Boris Ladwig of Insider Louisville.

The deals show how Humana is "moving away from the traditional fee-for-service model, in which health-care providers are paid for each individual care procedure, and toward so-called bundled care or capitation models, in which providers are paid for entire health episode or per patient," Ladwig writes. "Humana and the maternity care providers expect that their cooperation, which will target low-to-moderate risk pregnancies, will reduce readmissions and complications, thanks in part to data analysis."

If the clinics can reduce costs of a pregnancy below a target set in the contract, they can get part of the savings as a bonus — if patient outcomes improve. "For example, if the providers reduce costs, but quality declines — based on measures including the share of patients who make it to full term and the share of patients who require a C-section — the providers will not eligible for the bonus," Ladwig reports.

Brent Stice, director of value-based strategies for Humana, told Ladwig, “We don’t just want them to reduce cost if it doesn’t increase quality.”

Maternity-care providers who are participating in the plan are Ob/Gyn Associates of Southern Indiana, in New Albany; TriHealth and Seven Hills Women’s Health Centers, both of Cincinnati; and two providers in Kansas and Texas.

The Centers for Medicare and Medicaid Services has said bundled payments “may lead to higher quality and more coordinated care at a lower cost to Medicare,” Ladwig notes. "Government agencies and insurers are moving away from the fee-for-service model because they say it incentivizes providers to see as many patients and perform as many procedures as possible without focusing on health outcomes, which increases health-care costs both in the short and long terms. However, they say bundled payment and capitation models incentivize providers to perform as few procedures as necessary and to focus more on long-term health outcomes, which benefits patients and lowers costs."

Humana is making bundled payments to 40 orthopedic practices in 13 states for Medicare Advantage customers who get total hip or knee replacement, Ladwig reports: "Stice said the company is in conversations with other medical providers about such agreements, and he expects Humana’s push away from the fee-for-service model will continue."

Rural family physicians in practices that follow model for comprehensive, coordinated care expand patients' access to care

By Melissa Patrick
Kentucky Health News

Rural family physicians who work in patient-centered medical homes generally provide more services and procedures than those in non-PCMH practices, according to a recent study at the University of Kentucky. A PCMH is not just a place, but "a model of the organization of primary care," says the federal Agency for Health Research and Quality.

"The idea of a patient-centered medical home is that you organize your services in a way to better meet the needs of the patient, and that should include being able to do more for the patient," Dr. Lars E. Peterson, lead author of the study, said in an interview. "We've shown that there is evidence that if you are in a patient centered medical home practice, if you structure your care that way, you can actually provide even more services."

Peterson is the director of research at the American Board of Family Medicine and an associate professor of family and community medicine at UK. 

The study, published by UK's Rural & Underserved Health Research Center, used data from more than 3,000 rural family physicians and compared the results according to rurality, measured by population: "large rural" (20,000-250,000), "small" rural (2,500-19,999), and "frontier" (less than 2,500).

Considering a list of 21 clinical services, the study found that rural family physicians in both the large and small rural areas who practiced at PCMHs provided more services than those who did not work in a PCMH. It didn't find much difference in services provided by in the sparsely populated areas.

The other exceptions to the overall finding were inpatient hospital care, major surgery, and nursing home care. They were provided at about the same rate in both the large and small rural areas regardless of PCMH status. Also, physicians in "small" rural areas provided home visits at about the same rate as non-PCMH physicians.

Family physicians in the "large rural" areas didn't show any real differences in obstetrical and prenatal care, but those who practiced in a PCMH in "small" rural areas provided more obstetrical and prenatal care their non-PCMH counterparts.

The study found two areas in which "frontier" PCMH family physicians out-performed their non-PCMH counterparts: chronic disease management and preventive services. All of the frontier PCMH family physicians provided chronic disease management, and 98.3 percent provided preventive care; among non-PCMH physicians, the percentages were 89.3 and 87.4, respectively.

Peterson said it's important for rural communities to find ways to increase access to care, especially in the areas of women's health and mental health, which is often lacking. He added that even with the passage of the Patient Protection and Affordable Care Act and the expansion of Medicaid to people who earn up to 138 percent of the federal poverty line, many still struggle to find health care.

"This is just another way of expanding access to patients," he said. "Within rural areas, physicians who work in practices that have a patient-centered medical home designation tend to be able to do more for their patients than physicians who are not in practices that are organized in that way."

Comparing medical procedures, researchers found that while PCMH family physicians in "large rural" areas had higher rates for eight of 18 procedures, the only two that showed a significant dfference over their non-PCMH counterparts were for in-office skin procedures (92.6 percent and 80.4 percent, respectively) and neonatal circumcisions (33.3 percent and 22.1 percent).

"Consistent with family physicians in rural PCMHs being less likely to provide inpatient care, they were also less likely to provide hospital-based procedures . . . than family physicians in rural non-PCMHs," the study report said.

The PCMH physicians in the "small" rural areas had a higher rate for 12 of the 18 procedures, but only showed significant differences over their non-PCMH counterparts for four of them.

"Family physicians practicing in PCMHs in small rural areas reported over 10 percent higher rates of providing IUD insertion, endometrial biopsies, neonatal circumcision, and office skin procedures than those practicing in non-PCMHs," the report said.

In the sparsely populated "frontier" areas, PCMH physicians had higher rates only for cosmetic procedures, though that rate was not significantly different when compared to the non-PCMH family physicians in such areas.

The report points out that while rural health-care providers tend to offer a broader range of services than their urban counterparts because of their limited health care resources, they often lack the financial and provider infrastructure needed to offer the PCMH model of care.

To that end, the report stresses the importance of creating programs to help rural practices shift to this model of care and in finding financial incentives to encourage rural family physicians already working within the PCMH model to broaden their scope of practice.

"Supporting rural practices that wish to transform to the PCMH model to improve care and access will be essential to meeting patient needs," said the report. "With strong evidence that overall health care costs and hospitalization rates are lower when physicians have a broader scope of practice, including inpatient care, determining how to best structure care by rural family physicians in all care settings will be essential."

Regional oral-health coalitions getting $1 million in grants from Delta Dental to develop and implement programs

In response to a 2016 study of the oral health of Kentucky's children, Delta Dental of Kentucky has given $1 million to launch five regional oral-health coalitions, formed in partnership with Kentucky Youth Advocates. Four of the five regions have announced what they plan to do with their money.

Findings from Delta Dental of Kentucky and Kentucky Youth Advocates study
(Lexington Herald-Leader map)

The 2016 study, "Making Smiles Happen" found that the number of third and sixth graders in need of early or urgent dental care has increased since the last study, completed in 2001; that 40 percent of them have untreated cavities; that more than half do not have sealants; and that their oral health was largely determined by their socioeconomic status.

The Appalachian region's initiative, called "Oral Health of Eastern Kentucky," or OAK, received a $200,000 grant to promote continuous data collection, and implement community projects and outreach programs to educate the region on predominant oral health concerns and solutions.

The Louisville region’s initiative, called "United for Kids’ Smiles," received $200,000 to help improve oral health in children through age 6, by bridging the gap between medical and dental providers, education on preventive care, and expanding use of fluoride varnish in primary-care clinics.

The Northern Region Oral Partnership received nearly $150,000 to help improve the oral health of under-served or at-risk children in the area, through improving oral-health literacy, providing education on preventive care, and aiding in access to oral-health services.

The Western Regional Oral Health Coalition got $200,000 to improve oral health in children by training and educating dental providers, increasing the use of tele-dentistry, and investing in dental care for uninsured children.

The Central Kentucky Oral Health Coalition is still working on its proposed initiative and funding will be available to them once it is completed and approved, according to Kentucky Youth Advocates.

Click here for a full scope of work for each region's project, along with a video.

Oldham County adds e-cigarettes to smoking ban, partly at the behest of students, and drops exemptions, including break rooms

Oldham County has expanded its anti-smoking ordinance that it passed in 2006, the second jurisdiction to do so this month.

The Oldham County Fiscal Court voted 7 to 1 on April 17 to add electronic cigarettes to the ban and to remove exemptions that had left some workers unprotected from second-hand smoke, Kentucky Youth Advocates reports. On April 10, Paducah expanded its ban to electronic cigarettes and private places of employment.

The county's new ordinance removed exemptions to independently ventilated rooms in hospitals, hospice or nursing homes, facilities operated by private organizations, designated hotel and motel rooms, retail tobacco stores and designated indoor smoking areas.

The change was prompted partly by Youth Linking Oldham County, "a new collective of high-schoolers advocating for healthier lifestyles and a shift in social norms," Oldham Era Editor Amanda Manning reported in March, when the ordinance had first reading. "They said that the JUUL, a vaping device that looks similar to a flash drive, is popular among students."

Smoke-shop manager Cathleen McCarthy demonstrates the

JUUL device. (Photo by Suzanne Kreiter, The Boston Globe)

“It’s becoming a really big thing in our high school,” student Ava Schumacher said. “They were originally made to get people to stop smoking, but kids our age find them appealing because they come in different flavors.”

"The new ordinance also removes an exemption that allowed for smoking breakrooms in the workplace," Manning reports. Liz Burrows, health educator at the Oldham County Health Department, told the Fiscal Court, “We know based on science that those break rooms are not effective.”

The statewide Coalition for a Smoke-Free Tomorrow praised the Fiscal Court, health department and advocates who led the effort for the stronger protections.

"Strengthening this law -- by removing exemptions that left some workers unprotected and by including e-cigarettes -- recognizes that everyone has the right to breathe clean air," the coalition said in a statement. "Doing so recognizes that comprehensive smoke-free workplace ordinances improve health, and save health care dollars.And it recognizes that no one should have to choose between their lives, and their livelihood.

"Including e-cigarettes among the tobacco products that must be taken outside will keep the air in indoor public spaces and enclosed workplaces free of the toxic aerosol and pollution emitted by these devices. Oldham County is one of 21 Kentucky jurisdictions that has protected workers from these emissions, which can cause lung cancer and contribute to heart disease."

Oldham County is the fifth county in the state to pass a comprehensive smoke-free ordinance, the Oldham Era reports.

The coalition comprises more than 155 groups who support efforts to decrease smoking in the state. Kentucky's smoking rate is second only to West Virginia's, and tobacco is the broadest cause of Kentucky's most serious health problems.

McConnell files bill to better inform doctors and pregnant women about alternatives to opioids, boost grant money for it

Senate Majority Leader Mitch McConnell of Kentucky introduced a bill Thursday to require the Centers for Disease Control and Prevention to develop educational materials to give doctors and expecting mothers better information about alternatives to opioids, and to authorize more money for a competitive federal grant to help organizations address that aspect of the opioid epidemic.

The Louisville Republican said in a floor speech that the would-be Protecting Moms and Infants Act “continues our years-long efforts to protect the most vulnerable. . . . Medical professionals, law enforcement officials and many others across Kentucky are working every day to bring an end to the misery of the opioid epidemic. This legislation will continue that fight.” 

McConnell said Second District U.S. Rep. Brett Guthrie, R-Bowling Green, is sponsoring companion legislation in the House.

Poll: 24% of Kentucky adults know someone with a pill problem and 16 percent know someone with a heroin or meth problem

By Melissa Patrick
Kentucky Health News

Whether it's the misuse of prescription pain relievers, heroin or methamphetamine, the latest Kentucky Health Issues Poll findings indicate that many Kentuckians have a drug problem.

The poll, conducted Oct. 24 to Dec. 2, found that nearly one in four Kentucky adults, or 24 percent, said they knew someone who had experienced problems as a result of prescription pain relievers. That number has remained largely the same since 2013, but it indicates the depth of the problem.

"Misuse of opioids such as OxyContin, Vicodin, Percocet and codeine remains a critical public health and safety issue for Kentucky," Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, which co-sponsors the poll, said in a news release. "Not only are we losing more than 1,600 lives a year to overdoses, we are facing incredible losses in quality of life, workplace productivity, and business competitiveness."

The good news: Kentuckians said they are being prescribed pain relievers less often. In 2011, the poll found that 55 percent of Kentucky adults said they had been prescribed a pain reliever in the past five years; in the latest poll, the number dropped to 34 percent.

"Perhaps all of the education that's being done about the dangers of over-prescribing narcotic pain relievers is starting to make a difference, both in the number of people getting prescriptions and the amount of the pain medication they receive," Chandler said.

Seven percent of those polled said they weren't prescribed enough pills to control their pain; 21 percent said they were prescribed the right amount; and 6 percent said they were prescribed more than needed.

The poll also found regional differences in prescribing. The highest percentage of Kentucky adults who said they had been prescribed a pain reliever in the past five years was in the Louisville area (41 percent) and Northern Kentucky (40 percent). In was 37 percent and 36 percent in Lexington and Western Kentucky, respectively. The lowest share, 26 percent, was in Eastern Kentucky. That is the region where problems with drug addiction and overdoses are greatest, so the numbers could indicate that users are using illegal drugs or getting prescription medicines from illegal sources.

Click on any chart to view a larger version of it.

The poll found that 16 percent of Kentucky adults said they knew someone who had problems as a result of using methamphetamine or heroin. Both numbers were unchanged from the prior poll.

The poll shows that problems with heroin increased steadily between 2013 and 2016, but remained steady over the last year. Meth problems have remained steady since 2013.

Responses to these questions also varied by region with the percentage of adults who said they knew someone with problems due to heroin highest in Northern Kentucky (29 percent) and lowest in Western Kentucky (11 percent). The percentage of adults who said they knew someone with problems due to methamphetamine was highest in Eastern Kentucky (22 percent) and lowest in the Lexington area (13 percent).

Since 2013, the percentage of Kentucky adults who said they knew someone with a heroin problem has remained about the same in Northern Kentucky, which is often called ground-zero for this issue. However, this number has risen significantly in Louisville (from 8 percent in 2013 to 23 percent in 2017), Lexington (from 9 percent to 18 percent) and Eastern Kentucky (from 8 percent to 14 percent), with a lesser increase in Western Kentucky (from 7 percent to 11 percent).

Since 2013, Kentucky adults reporting they knew someone with a meth problem increased in Louisville (from 6 percent in 2013 to 16 percent in 2017) and Northern Kentucky (11 percent to 17 percent) and declined in the Lexington area (19 percent to 13 percent). The numbers remained about the same in Eastern and Western Kentucky.

"This poll is yet another piece of evidence that Kentucky's focus on resolving the drug abuse crisis must continue," Chandler said. "And it must involve multiple sectors of our society working together to engage all individuals struggling with addiction."

The news release about the poll notes that a National Vital Statistics Report shows meth use may be rising to problematic levels similar to heroin use; the National Institute on Drug Abuse reports that Kentucky had the fifth highest death rate due to drug overdose in 2016; and a CDC report found opioids, including prescription drugs, are the most common cause of overdose deaths.

Kentucky passed a law last year that generally limits painkiller prescriptions to a three-day supply if prescribed for acute pain, which lines up with the Centers for Disease Control and Prevention's guidelines for prescribing opioids. The limit does not apply to prescriptions for chronic pain.

This year the legislature passed a law to require pharmacists to tell patients how to safely dispose of unused opioids and other controlled substances, and either provide or offer to sell them a product designed to neutralize the drugs for disposal, or provide on-site disposal. Nearly 80 percent of Americans using heroin, including those in treatment, reported misusing prescription opioids first, according to the National Institute on Drug Abuse.

The poll was funded by the foundation and Interact for Health, a Cincinnati-area foundation. It surveyed a random sample of 1,692 Kentucky adults via landlines and cell phone. The poll's margin of error for each statewide result is plus or minus 2.4 percentage points.

Index of readiness for disasters and health emergencies has Ky. about same as U.S.; slips in environmental, occupational health

By Melissa Patrick
Kentucky Health News

Is Kentucky ready to manage a natural disaster or a health emergency? Just as much as the nation as a whole is, according to a recently released Robert Wood Johnson Foundation report.

The annual report, called the 2018 National Health Security Preparedness Index, gives Kentucky an score of 7.1 on a 10-point scale for preparedness, the same as the national average. The state and nation saw a slight improvement from the previous year's score, following continuous improvements since 2013.

"Five years of continuous gains in health security nationally is remarkable progress," Glen Mays, who leads researchers at the University of Kentucky who develop the index, said in a news release. "But achieving equal protection across the U.S. population remains a critical unmet priority."

Kentucky was one of 11 states more or less at the national average. Those below average were largely in the Deep South, Southwest and Mountain West regions. Maryland had the top score of 8.0 and Alaska and Nevada shared the bottom number of 6.4.

Such numbers are becoming more important. "The United States experienced the most active and expensive year on record for disasters and emergency events in 2017, with total economic damages exceeding $300 billion," the report begins, adding that the "uneven pace" of improvement for health security across the U.S. is "leaving large and growing segments of the American population under-protected."

The index analyzes 140 measures, such as the number of pediatricians, flu-vaccination rates, bridge safety and food and water safety, to calculate a composite score of health security for each state and the nation as a whole.

The measures are then grouped into six larger categories including, health security surveillance; community planning and engagement; information and incident management; health-care delivery; countermeasure management; and environmental and occupational health.

Kentucky improved or stayed about the same as the national averages in all but one of those broad areas -- environmental and occupational health, which measures state's ability to maintain the security and safety of water and food supplies, to test for hazards and contaminants in the environment, and to protect workers and emergency responders. Kentucky's score for this measure dropped about 5 percent from the prior year, to 6.0. The national score is 6.6.

Kentucky saw its greatest improvement in health security surveillance, which rose 13.2 percent between 2013 and 2017. This measure looks at the state's ability to monitor and detect health threats, and to identify where hazards start and spread so that they can be contained rapidly. Kentucky's score for this domain was 8.6, compared to the national average of 8.1.

The state's lowest score, 5.2, is in health-care delivery, but that is the same as the national average. This category measures a state's ability to ensure access to high-quality medical services across the continuum of care during and after disasters and emergencies.

Suggestions from the report to to improve health security include: improving data sources and metrics; strengthening networks and coalitions; improving workforce policies, like offering paid leave and health insurance; improving health care delivery preparedness; assuring a dedicated and adequately resourced health security emergency response is in place; assuring adequate funding for an established health security infrastructure; and allowing for flexibility in the existing health security funding mechanisms.

New Medicaid rules would lead to many more people losing coverage than Bevin administration has estimated, critics say

Changes in the state Medicaid program, to be phased in starting July 1, would lead to many more people losing health coverage than the state has estimated, 43 academic experts say in a friend-of-the-court brief filed in a lawsuit challenging federal officials' approval of the changes.

The experts argue that the changes are "likely to remove at least twice as many beneficiaries in the first year while barring initial enrollment for countless others," then go on to forecast much higher numbers. The Bevin administration disputes the projection.

The state has estimated that the changes will cause about 20,000 fewer people to have Medicaid coverage in the first year than would have been the case without the changes, rising to a total of 97,000 in the fifth year.

Critics of the changes say the numbers are likely to be higher, based on recent experience with work requirements in the Supplemental Nutrition Assistance Program that are similar to the new rules requiring work, job training or community service by adults who are not disabled, medically frail, pregnant, or primary caregivers.

SNAP, formerly known as food stamps, requires able-bodied adults 18 to 49 without dependents to work at least 20 hours a week or lose benefits after three months in any three-year period. The requirement was waived in most of the country from 2009 to 2015, due to high unemployment; some states have re-instituted it in some counties.

In their court brief, the academic experts cite examples in Georgia, Maine and Alabama, where SNAP participation fell from 62 to 85 percent in counties where work requirements were reinstated, and assert: "Viewed from that lens, of the 350,000 people subject to the work requirements in Kentucky, Medicaid losses will be much higher and faster than the Commonwealth predicted, between 175,000 and 297,500 losing coverage in the first year."

On the blog of Health Affairs, a policy journal, Erin Brantley and Leighton Ku cite the same data but add cautionary notes: "There are certain differences in the work requirements in SNAP and Medicaid," and "Improving economies might explain a small portion of the declines" in SNAP participation. "Impacts in other states and areas may differ. In some cases, the reports are unclear about which SNAP beneficiaries are included in the estimates of those subject to work requirements."

Still, the writers conclude that the data "suggest that Medicaid enrollment could plummet rapidly" in Kentucky due to the program's new requirements.

Gov. Matt Bevin's deputy chief of staff for policy, Adam Meier, said in an e-mail that while he couldn't speak for the methodologies used, the differences could be because the Medicaid benefit is so much higher than the SNAP benefit.

"The differences could be attributable to the fact that the state spends approximately $6,700 on average per Medicaid eligible individual—thus it is [a] much richer benefit than SNAP, so there is more incentive to participate," he said.  "Further, it may also be due to the broad spectrum of qualifying activities that can be done to satisfy Kentucky’s community engagement requirement, making it easier to satisfy than the basic SNAP employment and training requirements."

Meier said the SNAP enrollment declines cited weren't simply due to non-compliance, but also because many had improved their personal situation and no longer needed, or qualified, for the program.

"For example, in Kansas, SNAP able-bodied adults without dependents (ABAWDs) subject to the requirements experienced a 127 percent increase in their income within one year of leaving, the average income among those working were now above the poverty line, and enrollees’ average income more than doubled. In addition, nearly one-half of Kansas ABAWDs were employed within one quarter of leaving SNAP, and the amount of time ABAWDs spent enrolled in SNAP was cut in half," he said.

Meier also pointed out that Kentucky's new Medicaid plan does not make any changes to initial eligibility or application requirements, so no one will be barred from enrollment, as the court brief suggests.

Bevin's administration estimates that about half the estimated 350,000 people who will be subject to the work rules are already meeting them. It says an unspecified part of the enrollment decline will come from people failing to meet reporting requirements.

The rules will be phased in, beginning in areas with low unemployment, administration officials have said.

Legislature tosses health departments and mental-health centers a budget lifeline; bills on disposal of opioids become law

By Al Cross
Kentucky Health News

FRANKFORT, Ky. – As it wrapped up its business, the Kentucky General Assembly threw a financial lifeline to health departments and mental-health centers, passed a telehealth bill without an amendment favored by insurance companies, and overrode the governor's veto of a drug-disposal bill.

Budget: In a revision of the budget it passed earlier, the legislature froze for one year the pension contributions of health departments and 11 of the state's 14 community mental health centers, which were facing increases in pension payments of 49.5 to 83.4 percent, averaging 69 percent.

That would have been a double whammy with the 6.25 percent across-the-board cut proposed by Gov. Matt Bevin and included in the budget, which is likely to force cuts in personnel and services.

Bevin could veto the revision bill, but he suggested Friday evening that it was making the budget better. And he indicated that he would still have to make cuts because the budget will be unbalanced. Legislative leaders have disputed that.

Home care for the disabled: In a rare gain among programs, the budget adds $10.5 million to the General Fund to generate an extra $24.6 million in federal Medicaid money each fiscal year for the Supports for Community Living program, which enables developmentally and intellectually disabled Kentuckians to receive care in homes rather than health-care facilities.

The money will "raise reimbursement rates to SCL service providers who have not seen an increase since 2004, even as costs have risen 27 percent through inflation since that time," says the Kentucky Center for Economic Policy. "The stagnant payment rates have contributed to a 45 percent turnover rate among providers and a 41 percent decrease in services offered to intellectually and developmentally disabled Kentuckians."

Telehealth: By a vote of 65-20, he House gave final passage to SB 112, aimed at increasing access to health care and saving money by requiring the state to develop policies on health care by telecommunication –including a reimbursement model, with similar expectations for the public insurance market. The House did not consider an insurance-company floor amendment filed by Rep. Jim Gooch, R-Providence, that would have removed a key provision, requiring telehealth visits to be paid for at same level as regular visits unless otherwise negotiated. Bevin could still veto the bill.

Drug disposal: The legislature overrode Bevin's veto of House Bill 148, sponsored by Rep. Addia Wuchner, R-Florence, to shift ownership of controlled substances from deceased hospice patients to the hospice for disposal. Bevin's veto message said the bill was contrary to federal law and U.S. Drug Enforcement Agency policy, but Senate President Robert Stivers cited a DEA memo that cleared the way for the bill.

Bevin allowed to become law without his signature Senate Bill 6, sponsored by Sen. Alice Forgy Kerr, R-Lexington, to make pharmacists tell customers how to safely dispose of unused opioids and other controlled substances, and either provide or offer to sell them a product designed to neutralize drugs for disposal, or provide on-site disposal. More than 70 percent of all opioid addictions result from misuse of prescription drugs.

Other health bills: In the days before the legislature reconvened to consider vetoed bills and pass others, Bevin signed several health-related bills into law, including:

SB 5, sponsored by Sen. Max Wise, R-Campbellsville, to put the Medicaid program in charge of reimbursement rates for pharmacists. Rates are now set by pharmacy benefit managers, firms hired by managed-care organizations (mainly insurance-company subsidiaries). The bill sets reporting requirements for PBMs and MCOs and the $1.7 billion a year they get from the state. It also would allow the Medicaid program to approve contracts and fees between MCOs, PBMs and pharmacists.

HB 463, sponsored by Rep. Michael Meredith, R-Brownsville, to prohibit PBMs from requiring clients to make a co-payment that is higher than a lesser cash-payment amount, and keep them from penalizing a pharmacy for telling patients if that option is available. It is called the "clawback" bill, because PBMs "claw back" the difference between the higher co-pay and the lower price of the drug.

SB 71, sponsored by Sen. Steve Meredith, R-Leitchfield, would require the inclusion of abstinence only education in any sex-ed classes taught in Kentucky. Kentucky has no comprehensive sexual health education standards; the state Department of Education is reviewing proposed rules.

Failed bills: Health-related bills that were poised for passage but did not make it included SB 95, sponsored by Kerr, to require health insurers to cover standard fertility preservation services for patients who have become infertile by means of surgery, radiation, chemotherapy or any other medical treatment affecting reproductive organs and processes; and SB 149, sponsored by Sen. Julie Raque Adams, R-Louisville, chair of the Senate Health and Welfare Committee, to establish an advisory council for palliative care, given to make patients with incurable illnesses more comfortable.

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

In 1990-2016, Ky. had 4th highest increase in risk of death, 2nd biggest rise in death risk from mental or substance-use disorders

By Al Cross
Kentucky Health News

Life expectancy in Kentucky increased from 1990 to 2016, but by only 1.4 years, while it increased 4.4 years nationwide, so the state fell from 42nd to 46th in life expectancy, according to "the most extensive state-by-state U.S. health study ever conducted," as described by the Institute for Health Metrics and Evaluation at the University of Washington. The institute conducted the study and published it in the Journal of the American Medical Association.

The lagging life expectancy is driven largely by premature deaths, between age 20 and 55. From 1990 to 2016, the risk of premature death rose more than 10 percent in five states: West Virginia, Oklahoma, New Mexico, Kentucky and Wyoming. Kentucky rose from 12th to seventh in the estimated years of life lost from premature death; states ranking ahead of it, in ascending order, were Arkansas, Oklahoma, Louisiana, Alabama, West Virginia and Mississippi.

The study compared the risk of death from various factors. The risk of death from mental and substance-use disorders increased more in Kentucky from 1990 to 2016 than any state but West Virginia, another indicator of the depth of the opioid epidemic in Central Appalachia. Ranked by years of life lost from various causes, opioid use rose nationally from 22nd in 1990 to to 15th in 2016. The age-standardized U.S. death rate from opioids rose 343 percent, far more than any other factor.

In overall life expectancy, several states fell much farther in the rankings than Kentucky did. Kansas fell to 30th, from 12th; Idaho dropped to 23rd from eighth; Indiana went to 42nd from 27th; and South Dakota fell to 25th from 11th.

The greatest gains in rank were by California, which moved up to second from 24th; New York, which rose to fifth from 39th; New Jersey, which moved to eighth from 26th; and Maryland, which is now 21st after being ranked 38th.

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

Legislature overrides vetoes to pass tax bill; tobacco advocate says cigarette tax will have 'very, very small' impact on growers

By Al Cross
Kentucky Health News

FRANKFORT, Ky. – Kentucky's cigarette tax is going up by 83 percent in July, to $1.10 a pack, but the impact on Kentucky tobacco farmers will be "very, very small." So said the legislature's leading tobacco advocate after Republican legislators overrode Republican Gov. Matt Bevin's vetoes of the omnibus tax bill and the budget it finances.

Sen. Paul Hornback

Republican Sen. Paul Hornback of Shelbyville, a longtime tobacco grower, was one of two senators who voted for the surprise tax measure on April 2 but voted against it on Friday, April 13. The other was Sen. Joe Bowen, R-Owensboro.

Hornback, asked afterward why he switched, recalled saying when he voted the first time that it was "a bad revenue bill" that weighed heavily on agriculture, particularly tobacco, "because the largest single tax it creates is the tobacco tax, the cigarette tax."

Challenged on whether the tax would have any impact on Kentucky's 4,000 or so tobacco farmers, Hornback smiled and said, "Well, it sounds good." He added, "It does have some. It's very, very small." Tobacco trades in a world market.

The tax may not have much effect on Kentucky's second-in-the-nation smoking rate, either. Anti-smoking advocates called for a $1-a-pack increase, saying that cigarette companies will keep smokers hooked by offering coupons and discounts when the tax hike hits, then gradually raise their prices.

Hornback said a more significant factor in his vote was that estimates of revenue from the higher tax were based on last year's sales and did not seem to take into account a likely loss in Kentucky sales to residents of states where the tax is or will be lower, such as Indiana. "I don't know what that number is, but it's a big number," he said.

Original map from Campaign for Tobacco-Free Kids, adapted by Kentucky Health News

Hornback said he also switched on the bill because it wasn't the comprehensive tax reform the state needs. He said some Republicans pushing for an override argued that the bill was just "one bite of the apple" and the politically touchy subject could be tackled again. He is skeptical.

"I don't think we have the will to go back and re-address this issue of comprehensive tax reform anytime in the foreseeable future," Hornback said. "That's my concern. If we're gonna do it, we should have done it. We ought to do it right, and we didn't do that."

Bowen said he switched to opposing the bill because "I had buyer's remorse from the time I cast an 'aye' vote, and I was glad to be able to go get a mulligan" -- a golfer's term for a replacement shot.

"Picking winners and losers has never worked for me, and that was a big-time picking winners and losers" measure, he said, due to its selective application of the sales tax to certain services. "It's the hardest-working people who are going to be hit the most with that; you know, people who drive an old car need the most repairs."

Democratic senators, none of whom voted for the bill, made that and similar points. Minority Leader Ray Jones of Pikeville called it "trickle-down economics at its finest."

Bowen said, "I was gonna get up and explain my vote but once Ray Jones made all my arguments, I wasn't going to reinforce what he had to say. It's a weird process, isn't it?"

The cigarette tax will fall more heavily on the poor because they are more likely to be smokers.

Bowen said he generally favors consumption taxes such as the sales tax over income taxes, "but we didn't take that far enough. We just cherry-picked it, and I had a lot of problems with it."

Bowen said he made his position known to other Republican senators in a conference call the night before. He said Republican leaders didn't ask him to reconsider.

Supporters of the tax bill had no votes to spare, since it had passed with a bare majority, but two other Republicans switched form opposing the bill April 2 to supporting it on the override vote.

Sen. C.B. Embry of Morgantown said in a floor speech that he is a former teacher and had been lobbied by teachers from Butler, Ohio, Muhlenberg and Hopkins counties, and "I'm going to stand with the teachers of the Sixth District."

The other senator who switched to support the bill was Wil Schroder of Wilder, who has a Democratic opponent for re-election. He said in an interiew that "I wasn't confident the first time" that the tax bill had gone through a proper deliberative process, but resolved those concerns and voted for it on substance.

The final and decisive vote to pass the bill into law was cast by Senate President Robert Stivers, R-Manchester, who had managed its initial passage. He said it will fill a funding gap that has been created by politicians in both parties over many years, and taxes many of the same services proposed by a commission appointed by the last governor, Democrat Steve Beshear.

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