Agreement signed to help Kentuckians with severe mental illness transition out of institutional care to community housing

The state has reached an agreement with an independent agency that advocates for people with disabilities that should allow more people with severe mental illness to get out of institutional care an into community housing.

The agreement allows the Cabinet for Health and Family Services and Kentucky Protection and Advocacy to address many of the concerns identified in a 2012 P&A report about personal-care homes, which are long-term facilities that provide care for people who don't need full-time nursing care, but need some assistance.

The disability advocates have long argued that personal-care homes run counter to the Americans with Disabilities Act and a court decision saying that disabled patients should live in the "most integrated setting." That is defined as one "that enables individuals with disabilities to interact with non-disabled persons to the fullest extent possible," Kentucky Health News reported in 2012.

“The latest agreement shows that the cabinet recognizes that recovery is possible and that the best place for recovery to occur is in the community,” Jeff Edwards, director of P&A, said in the state news release. “The expectation is for Kentuckians with mental illness to receive services and supports that allow them to live fully included lives.”

The news release notes that P&A was prepared to file a federal lawsuit to ensure compliance with the Americans with Disabilities Act and other court decisions in August 2013, but instead, along with the health cabinet, made an agreement to address the many issues found in the 2012 P&A report. An amended agreement was signed in 2015.

And while the "full vision" of both of these earlier agreements has not been met, the release says that both agencies have agreed to renegotiate terms "that represent more objective, measurable goals for meeting the needs of these individuals."

"Today, more than 925 individuals with a serious mental illness are living successfully in the community with full tenancy rights, having received supported housing assistance and other supports and services from the cabinet under the terms of the prior agreements," says the release.

London doctor convicted of implanting unneeded pacemakers sentenced to 3½ years, fined $50,000, told to repay $257,515

Image from MGN Online via WKYT-TV

A Kentucky doctor convicted of "implanting pacemakers that weren’t medically necessary in order to make money" was sentenced Oct. 30 to three years and six months in prison, fined $50,000 and ordered to repay insurance companies and taxpayer-funded health programs $257,515, Bill Estep reports for the Lexington Herald-Leader.

Dr. Anis Chalhoub, 60, is expected to appeal his April conviction and ask U.S. District Judge Gregory F. Van Tatenhove to allow him to remain free while appealing. At sentencing in London, the judge told Chalhoub, “You’ve engaged in conduct that has harmed our community.”

Chalhoub was charged with implanted pacemakers into patients who didn’t need them between March 2007 and July 2011. He implanted about 230 pacemakers at the St. Joseph London hospital during that period, U.S. Attorney Robert M. Duncan Jr. said in a news release.

The unneeded pacemakers “will adversely impact these patients’ lives as they age and may compromise their ability to seek certain medical treatments in the future,” Asst. U.S. Attys. Andrew E. Smith and Paul C. McCaffrey said in a sentencing memorandum.

"Former coal miner Mark Meadows, for instance, told Van Tatenhove the experience had helped doom his marriage of 30 years and eroded his trust in doctors," Estep reports, quoting him: “It’s a dirty low-down rotten shame.”

Chalhoub practiced at the hospital "during a period when the hospital and doctors there allegedly took part in performing hundreds of unnecessary heart procedures," Estep notes. "Saint Joseph Health Systems agreed in January 2014 to pay $16.5 million to settle allegations that it engaged in a scheme to pump up revenue by billing federally-funded health programs for unnecessary procedures from January 2008 to August 2011. That was before the company merged with two others in 2012 to form KentuckyOne Health."

UK students say they're becoming addicted to Juul electronic cigarettes; expert says company has perfected nicotine delivery

Liz Donohoe puffs from a Juul while posing at UK's School of Art & Visual Studies. (Photo by Quinn Foster)

The nation's most popular brand of electronic cigarettes is creating addiction on the University of Kentucky campus, Jacob Eads reports for the Kentucky Kernel, the campus newspaper:

"If you’ve ever seen a cloud of smoke go up in the middle of a lecture, you’re probably familiar with the Juul. The popular brand of discreet and sleek e-cigarettes has become a habit in the hands of thousands of college students across the country, and UK students have bought into the trend. But in the haste of keeping up with the Juul’s rise to stardom, did anyone bother to read the box?"

E-cigs "are marketed as a nicotine alternative for adults who are trying to quit smoking, but some public health professionals are waging a war" against them, "in an attempt to study potentially adverse health effects they might have," Eads reports. "Some say it’s becoming increasingly impossible to cut ties with their nagging Juuls."

“I think it was kind of a fad to start out. Everyone got one, and now everyone is just super addicted,” junior marketing major Evan Dilbeck told Eads. “I’ve tried to quit several times because it’s $16 for a pack of pods, but it’s impossible when everyone around you has one.”

Juuls are addictive and successful because their maker, Juul Labs, “has figured out how to deliver more nicotine effectively,” said tobacco treatment specialist and nursing professor Audrey Darville told the Kernel. “I don’t think people really, truly appreciate how addictive nicotine is. That’s the hook… Once you become dependent on nicotine, it can be challenging to get off of it.”

The company says one disposable Juul pod, has about the same amount of nicotine as an entire pack of cigarettes, Eads reports: "Unlike other e-cigarettes, Juuls pack a punch comparable to traditional cigarettes. A hit from a Juul gives the body a jolt of nicotine at similar speeds to that of a cigarette, according to Darville. She said this almost-instantaneous rush is what makes the Juul so appealing."

Eads notes that the U.S. Food and Drug Administration recently mounted an assault on e-cigarettes because of the “epidemic proportion” of minors who are becoming addicted. "This came after FDA compliance checks uncovered 40 violations for illegal sales of Juul products to youth, one of which came from a local Lexington gas station."

Juul Labs CEO Kevin Burns said in a press release, “We are committed to preventing underage use.” The company "has also pledged to establish its own youth prevention campaign with the help of a $30 million investment intended fund youth education and independent research," Eads reports. "But while the gesture of a $30 million investment sounds promising, some public health officials say they’re still not buying it."

“That’s pocket change to them,” Darville said, “but they make it sound so wonderful.”

KET will air three hours of programs on youth mental health in November; first one airs Monday, Nov. 5 at 9 p.m. ET

Kentucky Educational Television will broadcst a six-part series called "You Are Not Alone," aimed at raising awareness of the issues regarding the mental health of Kentucky youth.

Topics will include depression, anxiety, stigma, suicide prevention, trauma, toxic stress, parental concerns and challenges, the role of schools, youth advocacy and promising strategies.

The six 30-minute programs, hosted by Renee Shaw, will air back-to-back on three consecutive Mondays in November. The first two, "Youth Speak Out" and "Help for Families and Caregivers" will air Nov. 5; "Whole Child, Whole School" and "Depression and Anxiety" will air Nov. 12; and "Trauma and Toxic Stress" and "Suicide Prevention/ Teaching Hope" will air Nov. 19.  All will begin at 9 p.m. ET.

Reporter writes about beating breast cancer, but perhaps most importantly, about first finding it: 'scheduling the mammogram'

One day each year, many newspapers go pink -- with pink ink or pink paper -- to increase awareness of breast cancer and support research to find a cure. This year, the Lexington Herald-Leader led its front page with a very personal a gripping story by staff writer Cheryl Truman about her breast cancer diagnosis, surgery and chemotherapy, and her struggle to get her life back and deal with troubling parts of the health-care system. The story is 1,928 words, and the most important may be at the end:

"Sometimes I will stop a moment and touch a flower, look for an extra few seconds at the farm view from my deck, brag about how the kids turned out. I am here to do that, and it has made all the difference," Truman writes. "Part of it is medicine, part luck. The first part was scheduling the mammogram."

Study predicts number of Kentuckians who drop off Medicaid will double if work and 'community engagement' rules are approved

By Melissa Patrick
Kentucky Health News

The federal-state Medicaid program provides health coverage to about 1.4 million Kentuckians, or about one in three. The exact number fluctuates, because Medicaid and other social programs have a substantial "churn," people coming onto the program as others come off.

WKYT-TV image

If work requirements are approved for Kentucky Medicaid, the number of people "churning off" of the program in the state would double over a two-year period, going from an estimated 108,000 adults to 216,000, estimates The Commonwealth Fund, a New York-based foundation that supports independent research on health policy reform.

The report says it "should be of concern to policymakers" because research shows that people with gaps in health insurance coverage "report problems getting health care or paying medical bills at rates nearly as high" as those who go without insurance at all.

To predict how work requirements would affect the insurance coverage of Medicaid enrollees, the researchers first analyzed data from federal polling to determine coverage patterns among non-disabled -- or "able-bodied"-- adults on Medicaid, and then applied those findings to a similar group of Kentucky adults.

In Kentucky, most people in this category are those who gained health insurance under the  expansion of Medicaid to those who earn up to 138 percent of the federal poverty level (about $16,000 for a single person). The expansion, under the Patient Protection and Affordable Care Act, added about 500,000 Kentuckians to the Medicaid rolls, most of whom work.

To determine the potential "churn," the study looked at national Medicaid enrollment in 2014 and 2015, when 9 million Americans were on the program and 3 million people churned off it. The researchers found that 37 percent of them remained uninsured, 28 percent regained Medicaid coverage and 35 percent got another source of coverage.

What about Kentucky?

The researchers then applied those findings to Kentucky, where Gov. Matt Bevin wants to require 80 hours a month of "community engagement" -- work, schooling or drug treatment -- for people on Medicaid who are not disabled, medically frail or primary caregivers. A federal judge in Washington, D.C., vacated the plan and the Centers for Medicare and Medicaid Services is still reviewing the issue.

District Judge James Boasberg said federal officials had not sufficiently considered public comments about the state's new plan, which were overwhelmingly against it, nor had they adequately considered the state's estimate that in five years its Medicaid rolls would have 95,000 fewer people with the plan than without it -- largely for non-compliance with its engagement or reporting requirements.

Based on federal Medicaid data for Kentucky, which showed about 325,000 non-disabled adults under 65 in the program in 2016-17, the researchers estimated that over two years, about 108,000 Kentucky enrollees would churn off of Medicaid if the program remained unchanged.

With the work requirements, the number leaving the program over two years would double, to 216,000, the researchers estimated.

"Depending on people's ability to regain Medicaid or gain private coverage with work requirements in place, the number of adults who would remain uninsured at the end of the two-year period ranges from 77,500 to 117,400," the report says.

The researchers add that they probably underestimated the number of people who will become uninsured as a result of work requirements, because the study only examined adults who had coverage at the beginning of the study period and didn't consider those who might have become eligible for Medicaid during those two years -- those who might not enroll under the proposed plan because of the administrative barrier created by the work requirement.

Over 8,000 kicked off Medicaid in Arkansas; advisory panel seeks a pause

Arkansas introduced its work and community-engagement requirements in June and has already kicked more than 8,000 people off of its Medicaid program for noncompliance -- with another 4,841 set to be kicked off in November if they don't comply with the new rules before then, according to a state report. Beneficiaries in Arkansas are kicked off if they fail to report sufficient work hours for three months in a given calendar year. They will be allowed to reapply in January.

A pending lawsuit seeks to invalidate the Arkansas program, and because of its similarities to Kentucky's case, Boasberg is handling the case.

Members of the Medicaid and CHIP Payment and Access Commission plan to ask the Trump administration to hold off on approving Medicaid work requirements, Victoria Pelham reports for Health Care on Bloomberg Law, a subscription-only newsletter.

Fourteen states have either gained approval for or have submitted applications to require able-bodied adults to have to work or participate in approved activities, like looking for a job or job training, in exchange for their Medicaid coverage, says the report,  concluding: "Adding new enrollment barriers such as work requirements will accelerate churn in the states that pursue them and leave hundreds of thousands without access to health care."

What do other studies say?

Other studies indicate work requirements undermine Medicaid enrollment.

A Center on Budget and Policy Priorities analysis estimates that between 45,000 and 103,000 Kentucky Medicaid enrollees could lose coverage because they won't meet new eligibility or paperwork requirements if the state is allowed to implement its new work requirements. This report adds that there is no evidence that beneficiaries who have lost their coverage will move to jobs with affordable private coverage and they will likely become uninsured.

The Bevin administration says a major goal of its plan, called Kentucky HEALTH for "Helping to Engage and Achieve Long Term Health." is to move Medicaid beneficiaries to private insurance. An Urban Institute analysis found that Medicaid beneficiaries tend to work in part-time, low-paying jobs and are unlikely to gain employer-sponsored insurance, since only 13.3 percent of part-time private-sector employees in Kentucky were eligible for such insurance.

Speaking only to these two analyses, Cabinet for Health and Family Services spokesman Doug Hogan said in an e-mail:

"Gaining access to employer-sponsored insurance (ESI) is just one potential path. It was never expected that a large percentage of the Kentucky HEALTH population would immediately see access to ESI. Some would see eligibility for subsidies on the ACA exchanges after graduating Medicaid eligibility. Some would have to upskill or increase educational attainment before finding employment that could move them up the income scale. . . . There are numerous studies that show that engagement and employment are linked to health, and that community engagement requirements are effective in driving participation."

Only syringe exchange in Lincoln Trail health district is a point of pride for Nelson County, Bardstown newspaper says in editorial

This editorial appeared in The Kentucky Standard, Bardstown, on Oct. 25.

Nelson County should take pride in its syringe exchange.

That might sound strange, at first. After all, a community sets up an exchange when it has a problem with substance abuse.

But the truth of the matter is that Kentucky has a substance abuse problem throughout the state. It can be hard for an idyllic historical town such as Bardstown or as bucolic a county as Nelson to admit that such a modern problem as intravenous drug abuse is just under the surface.

But that is just what Nelson County did when it authorized the needle exchange with the Lincoln Trail Health Department, the only one in the eight-county region.

Photo illustration by The Kentucky Enquirer

Staff from the health department and the exchange visited Nelson County Fiscal Court recently to provide an update following its first annual report.

One number on that report had caught some attention — the return rate of syringes, which was only 36 percent. That means that for every almost three syringes given out, only one was exchanged. At first blush, that does not come off as good.

But, part of that reason is simple math, as Sara Jo Best, the department’s director, explained to the magistrates.

Only a little more than half of the 96 people who sought out services last year ever came back for a second visit. And the vast majority of substance abusers don’t show up the first time with used needles.

The simple fact is that collecting used syringes is not the primary mission of the exchange. Syringe exchanges are about controlling communicable diseases among a population that is highly susceptible to them. And protecting intravenous substance abusers against hepatitis, HIV and other diseases also shields the wider population, because these diseases are not only transmitted through needles. Part of preventing the spread is taking dirty needles off the streets and out of homes, but that is just one part, and arguably not the most important.

One of the biggest advantages of having a syringe exchange is the ability of public health workers to reach a population that can be hard to find.

And these substance abusers are some of the ones where there lies the most potential to make a difference.

“People who come to a syringe exchange program are fundamentally different than those who are not,” Kentucky Commissioner for Public Health Dr. Jeffrey Howard told The Standard recently. “If you are a substance abuser and you say, ‘I’m going to go to a syringe exchange program and get clean syringes,’ then you have acknowledged there’s something negative to what you’re doing and you’re going to take an action about that negative aspect. So in the psychology of that person, they are further along the addiction recovery pathway than someone who is not. We really need to take advantage of that.”

That’s why Howard said he wants to rebrand “syringe exchanges” into “harm reduction” centers, where substance abusers are linked to services such as testing and health screening and addiction recovery programs.

Best told Fiscal Court that is the approach the local exchange is looking to take. She acknowledged they had identified needed areas for improvement, and had already made some changes. One was finding a disease screening that returned faster results. In its first year, 34 percent of clients were tested for Hep C, but staff hope the faster results will improve that rate.

The number of participants could also improve, especially on the returns. Part of that is building trust with the participants, and some of that will involve time. It also means outreach, as Best said, so that those who need the services know where to find them.

Syringe exchanges in this state are new. While exchanges have been around in more densely populated areas for many years, operating one in a smaller and more rural area brings a host of new issues as well as insights.

But too often, fear of failure or the unknown stops organizations or agencies from trying something new. Those fears could be partly to blame for surrounding counties’ refusal to start their own. But if they think turning a blind eye will make the problem go away, they are wrong.

At least here in Nelson, we have acknowledged the problem, and after a year we understand it better. That goes a long way toward dealing with it.

Local outbreak of hepatitis A declared in Madison County, calling for vaccinations; heavy demand for vaccine in Whitley County

Madison County health officials have declared a local outbreak of hepatitis A and called on all local residents to get vaccinated for the liver disease that lives on poor hygiene.

"There are now 24 hepatitis A cases in Madison County related to the statewide outbreak that produced more than 2,050 across Kentucky," reports Mike Stunson of the Lexington Herald-Leader, citing the county health department. "It reported 13 cases on Oct. 6."

The department recommended hepatitis A vaccinations for all residents.

In Whitley County, where 99 cases have been reported, "Pharmacies are struggling to keep up with the demand for vaccines," reports Phil Pendleton of Lexington's WKYT and Hazard's WYMT.

"Rick Loudermelt at Whitley Pharmacy in Williamsburg says they have given out numerous vaccines since May of this year," Pendleton reports. "He says it's been hard to keep up with the demand, administering between 15 and 20 a week."

Madison County Public Health Director Nancy Crewe said vaccinations “should have a mitigating effect on the severity of the outbreak. We certainly don’t think there is any need for panic, but it is important that we get the word out to our citizens and encourage them to get the vaccine.”

The state Department for Public Health says more than 1,100 people have been hospitalized, and 14 died, in the statewide outbreak since November 2017.

Hepatitis A is usually spread when someone eats or drinks something contaminated by small amounts of stool from an infected person, according to the health department.

Symptoms include fever, fatigue, loss of appetite, nausea, abdominal discomfort, dark urine and yellowing of the skin and eyes. People can become ill 15 to 50 days after being exposed to the virus.

"Aside from the vaccination, good hand-washing is also recommended to help control the spread of hepatitis A," Stunson notes.

Feds form strike force to fight opioid abuse in Appalachia

The U.S. Department of Justice is forming a strike force to fight opioid abuse in Appalachia.

"Assistant Attorney General Brian A. Benczkowski says the Appalachian Regional Prescription Opioid Strike Force will investigate health-care fraud schemes and prosecute medical professionals and others involved in the illegal distribution of opioids," The Associated Press reports.

The department said the strike force will include extra prosecutors, the FBI, the Drug Enforcement Administration and the Department of Health and Human Services Office of the Inspector General.

Benczkowski said suffering caused by opioid abuse is "particularly staggering" in Appalachia. He says the problem is "more reprehensible when unscrupulous physicians and pharmacies" contribute to the epidemic by illegally supplying prescription painkillers.

Seniors can save lots of money by shopping around for Medicare drug plans, but few do; here are tips

Chart shows average premiums for most popular stand-alone Medicare prescription drug plans.

Seniors could save millions of dollars by shopping around for Medicare drug plans, but few do, Trudy Lieberman writes for Rural Health News Service: "With drug costs climbing for seniors, careful shopping is important this open-enrollment season," which for Medicare runs through Dec. 7.

“It’s not easy to compare options, but differences do matter,” Tricia Neuman, senior vice president of the Kaiser Family Foundation, told Lieberman.

And it can matter to a lot more people than it did before. "More than one million beneficiaries with drug benefits had spending above the threshold in 2015, more than twice the number in 2007," Lieberman reports.

Still, few "shop and compare Part D plans, even though this year the average Medicare beneficiary has a choice of 27 stand-alone Part D plans," for people in traditional Medicare, and 24 Medicare Advantage plans that include the drug benefit. Medicare.gov has a drug-plan finder to compare plans, but "Many people remain skeptical they can get a better deal, and may lack computer skills to find the best choice." Also, a third of Medicare beneficiaries have cognitive impairments, Lieberman notes.

Lieberman offers tips for Medicare drug shopping:

• Check for your regular drug(s) in the insurance plan’s tiers, preferred or non-preferred. A drug might be in one plan's non-preferred tier but in another's preferred tier, making it cheaper. Some drugs in the non-preferred tiers may require you to pay 50 percent of the cost. Specialty drugs have their own tier, usually with 33 percent consumer payment for non-preferred drugs.
• "Generic drugs might not be cheaper," Lieberman writes. "A generic in the non-preferred tier might be more expensive than a brand-name drug in a plan’s preferred tier."
• Does the plan requires “step therapy,” which means you must first try lower-priced drugs? Is preauthorization for services required? A Kaiser found that 80 percent of beneficiaries were in plans that required preauthorization for any service -- including Part B drugs administered in a doctor’s office. "Many consumers find preauthorization a real hassle," Lieberman notes.
• Talk with your health-care provider about cheaper alternatives. Maybe there is one in a plan’s preferred category. Prescribers "are often not knowledgeable about the ins and outs of drug plans, and may not have a patient’s financial wherewithal in mind when they write the prescription," Lieberman writes.

Average premiums on most popular Obamacare plan in U.S. will drop 1.5% in 2019; go up 9% in Ky.; state still lower than average

Chart from Insider Louisville

The average premium for the most popular health insurance policy on the federal exchange, called the "silver plan," will drop by 1.5 percent next year -- but not in Kentucky, where the rate for that same plan will increase by 9 percent.

A Centers for Medicare and Medicaid Services news release notes that 2019 will be the first year the national average has dropped since full implementation of the Patient Protection and Affordable Care Act in 2014. This year the average premium for these benchmark "Obamacare" plans increased by an average of 37 percent, and by 25 percent the prior year.

Nationally, CMS says a 27-year-old, single non-smoker who gets insurance through the exchange, HealthCare.gov, will pay an average annual premium of $4,872, down from $4,944. In Kentucky, that will rise to $4,524, from $4,152.

Healthcare.gov customers in 17 of the 39 states will see declines, three will see no change and customers in Kentucky and 19 other states will see an increase in their premiums in 2019, Boris Ladwig reports for Insider Louisville.  

Ladwig adds that despite the 9 percent increase in Kentucky, the state's rates for 2019 remain in the lowest third among the 39 state in the exchange. In Kentucky, about 90,000 people signed up for an Obamacare plan during the 2018 open enrollment. Nationally, that number was around 12 million.

CMS has said the reduction is a result of the Trump administration's efforts to stabilize the individual market, but the Kaiser Family Foundation, and other health experts, say it is a result of insurers overcompensating their rates in 2018 after the administration lowered the subsidies it paid to insurers and also because insurance companies that offer Obamacare plans are making a profit.

In Kentucky, Anthem Health Plans of Kentucky and CareSource will offer federally subsidized plans on Healthcare.gov, with rate increases of 4.3 percent and 19.4 percent, respectively. Anthem will expand its coverage area into 34 counties it once served, to cover a total of 93. CareSource will cover 61 of the state's 120 counties.

The Kentucky market president for CareSource, Michael Tayler, told Kentucky Health News in an e-mail that its premium increases for 2019 result from a number of factors.

"The elimination of the individual mandate that relieved the consumer tax penalty, and inflation related to medical and prescription drug costs, both impacted our rate decisions," he said. "It’s these factors and other federal policy changes related to short-term limited duration and association plans that will most likely cause consumers with the greatest health care needs to enroll. These changes may create a gap in marketplace participation and ultimately a greater risk for insurers."

The Kentucky Department of Insurance and Anthem did not respond to requests for comment.

Open enrollment on HealthCare.gov begins Nov. 1 and will run through Dec. 15.

Analysts tell health advocates that Medicaid budget 'shortfall' described by state officials is premature

By Melissa Patrick
Kentucky Health News

The warning from the administration of Republican Gov. Matt Bevin that some Medicaid benefits may need to be cut because of a budget shortfall over the next two fiscal years has caused unnecessary alarm, a research and policy analyst for the Kentucky Center for Economic Policy, said at the Kentucky Voices for Health annual meeting in Lexington Oct. 19.

Analysts Jason Dunn and Dustin Pugel
gave an update on health policy at the
Kentucky Voices for Health meeting.

Dustin Pugel referred to a presentation the Cabinet for Health and Family Services made in August to the legislature's Budget Review Subcommittee on Human Resources, predicting that over the next two fiscal years the state will be $300 million short in what it needs to pay for Medicaid.

"There's some problems with their math," Pugel said.

He said the cabinet based its estimate on its initial forecast of expenses, though there is almost always a gap between what an agency requests and what the legislature puts in the budget.

"To call that a shortfall is strange," Pugel said. "And if, in fact, you add up all of the agency requests in the entire budget versus what was enacted, then we would say that we have a $2 billion shortfall in the general fund, which of course we don't." He said the projected "shortfall" would be only 1 percent of the state's total budget.

Medicaid is a joint state and federal health insurance program that spends about $11.5 billion a year to cover 1.4 million Kentuckians, nearly one in three. Before its expansion under the Patient Protection and Affordable Care Act in 2014, by Democratic Gov. Steve Beshear, the program was mainly limited to very poor pregnant women and children, disabled people and low-income elderly in nursing homes.

Asked in September to respond to the KCEP report on this topic, cabinet spokesman Doug Hogan said cabinet officials explained to the legislators that their overall concern is about a shortfall in the state's General Fund because the state must have money in the fund to get federal matching money.

"The state General Fund shortfall is 6.61 percent in FY19 and 5.61 percent in FY20," Hogan said in an e-mail. "This is significantly more than 1 percent, and not easy to adapt to, since Medicaid spending is primarily driven by two things: (1) the number of eligibles and (2) benefits costs, much of which are mandatorily required under federal law."

Pugel said the cabinet's own data shows that benefit costs and Medicaid enrollment are declining, which "should indicate that Medicaid expenditures will come in under the initial expectation."

Pugel told the roomful of health advocates that the cabinet's proposed solution to this "shortfall" is to eliminate dental, vision and pharmacy benefits to those on Medicaid, or even to end the expansion of the program to those who earn up to 138 percent of the federal poverty level. The expansion added about 500,000 people to the Medicaid rolls.

"Even if it were true, we have a lot of time," Pugel said. "We've got a fiscal year and a half to be able to figure this out and there's really not a lot of cause for alarm -- and alarm in this case would be threatening to remove very important benefits."

The center's report adds that the cabinet failed to explain the context for the projected shortfall and ignored additional resources that were already appropriated to deal with some of the costs.

For example, the report says the cabinet's shortfall spreadsheet includes higher fees for dispensing drugs and increases in the Supports for Community Living and Traumatic Brain Injury programs without showing that $91 million was appropriated to offset those costs.

Hogan said the cabinet did not "ignore" those resources. He wrote, "This demonstrates that KCEP does not understand or chooses to ignore CHFS testimony about how the shortfall was projected, which was to take the Consensus Forecast Group projection, add additional costs not anticipated by CFG that occurred after CFG made projection, and then look at the difference in the enacted budget amount."

Asked about this, Pugel held to his center's claim. "To add those as additional costs without any indication that they are also paid for is erroneous," Pugel said in an e-mail. He added that the financial director tried to make this point clear at one point in the meeting, "but it was a short explanation and the point didn't come across to the lawmakers."

Hogan wrote, "KCEP is an agenda driven left leaning organization that inaccurately interprets data to support its narrative. KCEP lives in a fictional land where money and resources are unlimited and solutions typically involve simply throwing more money at whatever issue they are looking at that particular day, while ignoring that the money must come from somewhere else."

UK gets $15 million grant to treat 900 drug users with hepatitis C in Hazard area to examine concept of 'treatment as prevention'

By Melissa Patrick
Kentucky Health News

The University of Kentucky has received a five year, $15 million grant along with a $50 million donation in drugs, to treat hepatitis C in Hazard and Perry County in order to examine the concept of "treatment as prevention."

Hepatitis C is a contagious liver disease caused by a virus that is primarily spread by injection drug users when they share needles or other equipment. Left untreated, it can lead to cirrhosis or liver cancer.

Jennifer Havens

The Kentucky Viral Hepatitis Treatment Project, led by Jennifer Havens at the UK Center on Drug and Alcohol Research, will provide treatment to 900 Perry County drug users who have hepatitis C. They have already been identified through Havens' previous work in the county around drug addiction.

Havens told the UK Board of Trustees, at a day-long meeting devoted to the issues of opioid abuse, that it's important to treat people who test positive for hepatitis C in drug-using networks as a way to prevent its transmission.

"Once they are cured, they are no longer transmitting," she said Thursday. "So it makes a whole lot of sense to use this treatment-as-prevention approach. It lowers the community viral load."

Havens said the project's goal is to increase access to hepatitis C treatment in rural Appalachia by removing the barriers to care, such as cost, insurance restrictions and poor access to specialists.

The project will also cover the cost of substance-use disorder treatment for each of the participants and a case manager to help with any additional barriers to care, such as transportation. It will also cover the cost of the Perry County Health Department's syringe exchange during the study period.

Havens said the treatment will reduce the future health-care burden in a region that already has such vast health disparities. Ultimately, she said she plans to use the evidence gathered from the research to build new models of hepatitis C care across the nation.

Funding for the project comes from the National Cancer Institute and the National Institute on Drug Abuse. Also, Gilead Sciences Inc. will donate 900 doses of the costly hepatitis C anti-viral drug, valued at $50 million.

As the FDA plans to approve sale of a super-strong painkiller, a Kentucky doctor with authority in the field objects

By Al Cross
Kentucky Health News

A Kentucky doctor with expertise in the field is objecting to the Food and Drug Administration's plan to approve for sale a painkiller stronger than fentanyl, an opioid that is deadly even in very small doses.

Dr. Raeford Brown

Dr. Raeford Brown, a professor of anesthesiology and pediatrics at the University of Kentucky, is the longtime chair of the FDA’s Anesthetic and Analgesic Drug Products Advisory Committee. The panel voted 10-3 on Oct. 12 to support approval of a form of sufentanil branded as Dsuvia. Brown said he was unable to attend that meeting, but sent the panel a statement saying why sufentanil "represents a danger to the general public health and will make our job of protecting Americans more difficult." He explained the reasons for his opinion:

"Once the FDA approves an opioid compound, there are no safeguards as to the population that will be exposed, the post-marketing analysis of prescribing behavior, or the ongoing analysis of the risks of the drug to the general population relative to its benefit to the public health. Briefly stated, for all of the opioids that have been marketed in the last 10 years, there has not been sufficient demonstration of safety, nor has there been post-marketing assessment of who is taking the drug, how often prescribing is inappropriate, and whether there was ever a reason to risk the health of the general population by having one more opioid on the market."

Because sufentanil is so potent, it is given in "quite small" doses and easy to divert to illegal use, Brown warned. "I predict that we will encounter diversion, abuse, and death within the early months of its availability on the market." Sufentanil is 500 times stronger than morphine.

The FDA says it can require the drug to be used only in "closely controlled settings," Brown wrote, but "In order to have this happen, the education of all prescribers would need to be guaranteed. This has not been demonstrated with any other opioid, and, given the lack of teeth in the current risk evaluation and mitigation strategies for opioids, there is currently no educational nor regulatory scheme that will guarantee that this drug will be used only as described in the label."

Brown's statement was part of a letter from the nonprofit public-interest group Public Citizen that criticized the FDA for not having its full Drug Safety and Risk Management Advisory Committee participate in the meeting of his committee, "predictably increasing the odds of a vote favoring FDA approval." The letter also said the FDA made "an unrealistic and dangerous decision . . . that the two major safety problems causing the agency to reject sublingual sufentanil tablets in 2017 were no longer a barrier to its approval and that the benefits thereby outweigh the risks."

Dsuvia’s manufacturer, AcelRx Pharmaceuticals Inc., says its 30-microgram tablets are no stronger than any other opioid already available in the U.S. It says the design makes it easier for use on a battlefield, "and could help elderly or obese patients, for whom an intravenous opioid can be difficult and oral opioids take some time to start working," Emma Court of Marketwatch reports.

Medicare open enrollment runs through Dec. 7; here's more advice, including a book by a former Kentucky business editor

"For those approaching Medicare or already covered by it, now is a critical time of year to review health benefits," Sally Squires writes for The Washington Post. "Several changes are coming in 2019, including to Medicare Part D drug coverage insurance and to some Medicare Advantage plans, which are offered by private insurance companies and are known as Medicare Part C."

So, it seems "more important than ever for Medicare recipients — and anyone approaching age 65 — to begin looking at all the details right now, during Medicare’s open enrollment period, which began Oct. 15 and ends Dec. 7," Squires writes. "This is the prime time of year when changes can be made in a plan without penalty. There are a lot of different plans that can work better or worse depending on your health status and finances. Experts say you should choose a plan that will not just take care of your health needs today but also what they could be in 10 years."

One such expert is Philip Moeller, a former business editor of the Louisville Courier Journal, who is the author of a popular book, Get What’s Yours for Medicare: Maximize Your Coverage, Minimize Your Costs, which Squires notes.

Squires details some important elements of Medicare, such as Part A, "which covers inpatient hospital care, short-term care in a skilled nursing facility, hospice care and some in-home care." Most people pay no Part A premiums because they Medicare taxes have been deducted from their paychecks for at least 10. "Part B premiums range from about $134 per person per month to $429 per month for those earning about $160,000 as an individual or more than $320,000 for a joint tax return," Squires notes. "The cost of Part C Medicare Advantage plans varies by the company offering the plans and benefits covered." And look carefully at those plans, beyond premiums to deductibles and co-payments, advises Trudy Lieberman of the Rural Health News Service.

Also, it's important to remember that "Medicare covers most, but not all, costs," Squires writes. "For 2018, the Part A deductible that a patient must cover is $1,340 for each hospital admission during the year. For extended hospitals stays beyond 61 days, there are additional costs of at least $335 per day that recipients pay."

Parent firm of KentuckyOne Health gets conditional approval from Catholic Church to merge with San Francisco's Dignity Health

The parent firm of most Catholic-owned hospitals in Kentucky, Catholic Health Initiatives, has received conditional approval from church officials to merge with Dignity Health, a not-for-profit chain based in San Francisco.

The deal "would create the nation's largest not-for-profit hospital company by revenue," Harris Meyer and Tara Bannow report for Modern Healthcare. CHI's Kentucky facilities, operating under the name KentuckyOne Health, include Louisville's Jewish Hospital and its affiliates; St. Joseph Hospital in Lexington, London, Martin, Mount Sterling and Nicholasville; Flaget Memorial Hospital in Bardstown, Our Lady of Peace in Louisville; and Sts. Mary and Elizabeth Hospital in Louisville.

After the church's Congregation for the Doctrine of Faith deferred to local bishops, Denver Archbishop Samuel Aquila told CHI "that as long as his five moral conditions for the deal continue to be met, he had no moral objections to the merger going forward," as long as the merged chain had a recognizably Catholic name and other relatively minor conditions, Modern Healthcare reports.

"While the archbishops of Denver and San Francisco, where CHI and Dignity, respectively, are headquartered, previously had signed off on the so-called ministry alignment agreement, their approval was dependent on Vatican approval, which was uncertain," Meyer and Bannow report. "That left a cloud over the plan, initially announced in 2016, to create a combined system with 139 hospitals in 28 states with total annual revenue of nearly $30 billion."

The National Catholic Bioethics Center had given the merger "an unfavorable moral analysis . . . which added to the uncertainty about the Vatican's decision. CHI and Dignity then sought additional moral analyses from three other ethicists, who gave favorable opinions," the reporters write. "The merger still needs approval from state regulators in California, Arizona and Colorado, CHI's chief financial officer, Dean Swindle, said on an Oct. 11 call with investors."

California Attorney General Xavier Becerra is facing pressure "to ensure that the deal does not limit reproductive health services, care for LGBTQ patients, or services for low-income and under-served communities," Meyer and Barrow report. "Fifteen of Dignity's 39 hospitals are historically non-Catholic and provide services that are prohibited under Catholic doctrine, forcing the dealmakers to craft a merger model that worked around the directives." It would allow Dignity's non-Catholic hospitals to keep doing services the church considers immoral, such as tubal ligations after deliveries.

UPDATE, Nov. 23: Becerra approved the deal with conditions, including continuation of emergency services and women's health-care services at the California hospitals for 10 years. The merged firm will be CommonSpirit Health, Modern Healthcare reports.

McConnell says Senate may again target Obamacare

https://www.washingtonpost.com/politics/mcconnell-gop-may-take-another-shot-at-repealing-obamacare-after-the-midterms/2018/10/17/7a0e7c70-d23c-11e8-8c22-fa2ef74bd6d6_story.html?utm_term=.fd0ac6f59baa

UK Rural and Underserved Health Research Center symposium Nov. 12; topics include opioids, vaccines, hospitals, miners' health

The Rural and Underserved Health Research Center is holding a free half-day symposium to discuss research in a wide range of topics, including: rural opioid misuse and suicide, pneumonia-vaccine disparities, the impact of rural hospital closures on emergency services, and health-care utilization among coal miners with black lung and other respiratory diseases.

The symposium will be held at the University of Kentucky Gatton Student Center, Senate Chamber A268, from 9 a.m. to 11 a.m. Nov. 12. The event is free, but registration is required before Nov. 5. Click here to register. Click here to see the full agenda.

The RUHRC is a grant-funded program that focuses its research on access to healthcare and substance abuse treatment in underserved rural areas of the United States, including Appalachia. The research is meant to better inform health policy makers "with the ultimate goal of reducing inequities in care and improving population health in rural communities," says its website.

Ky. Rural Health Association's annual conference to be held in Bowling Green Nov. 15-16; registration prices go up Nov. 2

The 20th annual conference of the Kentucky Rural Health Association will be held in Bowling Green Nov. 15-16 at Western Kentucky University's Knicely Conference Center, 2355 Nashville Rd. Through Thursday, Nov. 1, the registration fee is $125 for KRHA members and $175 for non-members. After Nov. 1, the fees are $175 and $225, respectively. Student rates are $45 and $55, respectively. For detailed registration information, click here. For a copy the agenda and other information, click here.

E-cig conference in Louisville Dec. 10; FDA says crackdown on teen sales may impede usage by adults who want to quit smoking

Amid growing concerns that electronic cigarettes will undermine the progress made in reducing tobacco-related disease in Kentucky, the Coalition for a Smoke-Free Tomorrow will host a half-day conference Dec. 10 in Louisville to explore the latest evidence about the health effects of e-cigarettes.

Getty Images

The Foundation for a Healthy Kentucky and Kentucky Youth Advocates will also release a new focus group report that day about Kentucky youth attitudes and perceptions about e-cigs.

"E-cigarette use among youth is at now at epidemic levels, escalating dramatically since the introduction of flavored pod e-cigarettes such as Juul and copycat products," Ben Chandler, chair of the coalition and CEO of the foundation, said in a news release. "Kentucky lawmakers and health advocates need to know what the research says about these products, and how they're impacting future tobacco use and health. We'll also examine the policies that should be enacted to turn back this alarming new trajectory."

Speakers at the conference, titled "Next Generation Tobacco: The Impact of E-Cigarettes on Kentucky's Future Health," will discuss who's using e-cigarettes and other electronic nicotine delivery systems in Kentucky, and potential policies for preventing associated disease and illness.

Speakers will focus on the role of flavors in encouraging underage vaping; the extent to which e-cigarettes and other vaping devices actually help people quit smoking; what's in vaping products; whether they are a safer alternative to combustible cigarettes; and the evidence that e-cigs are a gateway to smoking for youth and young adults.

The conference will be held Monday, Dec. 10, from 8:30 a.m. to 12:15 p.m. at the foundation office, 1640 Lyndon Farm Court, in Louisville. Remote viewing sites will be announced later this month. The conference is free, but registration is required. Click here to register and to see the full agenda.

The announcement of the conference is timely.

On Oct. 12, the U.S. Food and Drug Administration sent warning letters to 21 e-cigarette companies seeking information about whether more than 40 products, including some flavored e-cig products, are being illegally marketed or are outside the agency's compliance policies, according to an agency news release.

This is the FDA's latest effort to stop the illegal sale of e-cigs to youth and decrease the "kid-friendly marketing and appeal of these products," it notes. In recent months, the agency has sent more than 1,300 warning letters and fines to retailers for illegally selling e-cigs to minors; given major e-cig makers 60 days to submit plans to address youth access and use; adjusted compliance policies; and launched a new anti-vaping advertising campaign aimed at teens called "The Real Cost."

"The FDA remains committed to the potential opportunity for e-cigarettes to help adult smokers transition away from combustible cigarettes. But we cannot allow that opportunity to come at the expense of addicting a whole new generation of kids to nicotine," Dr. Scott Gottlieb, the FDA commissioner, said in the release.

He added, "We’ll take forceful steps to stem the youth use, even if our actions have the unwelcome effect of impeding some opportunities for adults. These are the hard tradeoffs we now need to make."

Flu season is here, and Kentucky has already seen one death from it; health officials urge all 6 months and older to get a shot

By Melissa Patrick
Kentucky Health News

The 2018-19 flu season has barely started, but Kentucky has already reported its first flu-related death -- in Lexington, according to the Lexington-Fayette County Health Department. The flu killed 325 people in Kentucky in the last flu season.

Flu is a very contagious disease caused by the influenza virus that spreads from person to person. Symptoms include fever, headache, cough, sore throat, runny nose, sneezing and body aches.

An antiviral drug can shorten the course of the illness or reduce its severity if given within two days of a person getting the flu, but there is no real treatment for the disease, and that's why health officials encourage everyone six months and older to get a flu shot.

"There's no treatment for the flu," Dr. Ryan Stanton, a Lexington emergency-room physician, told WKYT-TV. "Our only fight against this is prevention."

KHN Editor Al Cross's bandage after
his flu shot. (Photo by Patti Cross)

Concern that the state will experience another flu epidemic like last season has prompted a statewide "Focus on Flu" campaign to encourage Kentuckians to get their flu shot. The campaign is being led by doctors, health agencies and the Foundation for a Healthy Kentucky. Their message: "Get your shot! Consult your doc! Stop the spread!"

And it's a message for sharing. Kentucky ranks 33rd in the nation for the number of people who get a flu shot, and at the campaign's kick-off rally in September, it was reported that only 40 percent of Kentuckians got a flu shot last flu season.

And while a flu shot won't guarantee that a person won't get infected, the U.S. Centers for Disease Control and Prevention says it will reduce the risk of infection by 40 to 60 percent, and it has been shown to reduce the severity of illness in people who get vaccinated but still get sick.

Experts also recommend that people get the shot early, because it takes about two weeks after the vaccination for the recipient to develop immunity.

Contrary to a pervasive myth, the flu vaccine cannot give you the flu.

The CDC says "flu vaccines cannot cause flu illness" because the vaccine is made from flu viruses that have been "inactivated" or "killed" and thus are not infectious, or from a single gene from a flu virus, as opposed to the full virus, which allows a person to produce an immune response without getting the infection.

The CDC recommends that everyone over six months of age get a flu vaccination every year, and especially people who may be at higher risk for complications or negative consequences. They include:

• Children age six months through 59 months;
• Women who are or will be pregnant during the flu season;
• Persons 50 years of age or older;
• Persons with extreme obesity (body-mass index of 40 or greater);
• Persons aged six months and older with chronic health problems;
• Residents of nursing homes and other long-term care facilities;
• Household contacts and caregivers of children younger than 5 and adults 50 and older.
• Household contacts and caregivers or people who live with a person at high-risk for complications from the flu; and
• Health care workers, including physicians, nurses, medical emergency-response workers, employees of nursing home and long-term care facilities who have contact with patients or residents, and students in these professions who will have contact with patients.

And don't forget to use common-sense practices: wash your hands frequently, cover your mouth when you cough or sneeze and stay home when you are sick to stop the spread of infection.

If you're looking for a place to get your flu shot, the CDC offers an interactive "flu vaccine finder" that allows you to type in your zip-code to find nearby locations that offer flu shots. Local health departments also offer the vaccine.

Providers didn't give reason for prescribing opioids 1/3 of the time; study says better documentation could decrease prescribing

An analysis of medical records from 2006 to 2015 found that doctors didn't record a diagnosis for opioid prescriptions almost one-third of the time.

"The findings help support criticism by the Centers for Disease Control and Prevention, the Food and Drug Administration and others that say inappropriate prescribing practices have helped drive the opioid crisis," Maggie Fox reports for NBC News.

Nearly 50,000 Americans died from opioids in 2017, 1,565 of them in Kentucky.

CDC photo

The analysis, published in the Annals of Internal Medicine, used data from the National Ambulatory Medical Care Survey, an annual survey of doctor-office visits.

Because providers can enter up to three diagnosis codes per visit, the researchers limited their sample to visits with two or fewer codes to remove this as a possible reason for not listing pain as a diagnosis.

The study found that opioids were prescribed in nearly 32,000 visits, for cancer-related pain 5 percent of the time and for a non-cancer pain 66 percent of the time.

"No pain diagnosis was recorded at the remaining 28.5 percent of visits in which an opioid was prescribed," says the report. It adds later, "At visits with no pain diagnosis recorded, the most common diagnoses were hypertension, hyperlipidemia [high cholesterol], opioid dependence and ‘other follow-up examination'."

Kentucky has aggressively worked to crack down on prescription-drug abuse, including passing a law in 2017 that limits painkillers to a three-day supply for acute pain, in keeping with the CDC's recommendations. However, the law has a long list of exemptions, and allows a prescriber to override it by documenting a justification.

"Transparently and accurately documenting the justification for opioid therapy is essential to ensure appropriate, safe prescribing; yet, providers currently fall far short of this, particularly when renewing prescriptions," the researchers conclude. "Requiring more robust documentation to show the clinical necessity of opioids—which many insurers already do for novel, costly drugs—could prompt providers to more carefully consider the need for opioids while facilitating efforts to identify inappropriate prescribing."

U of L gets $16.4 million from National Institutes of Health to study impacts of the environment on diabetes and obesity

The University of Louisville has been awarded $16.4 million to study how the environment impacts diabetes and obesity, U of L announced.

"Officials said research will be conducted on how air pollution could be connected to diabetes, and whether the dietary supplement carnosine can protect people from air pollution," reports Lisa Gillespie of WFPL.

Aruni Bhatnagar, director of the U of L Diabetes and Obesity Center, told Gillespie that the funding will also be used to explore diabetes and obesity as it relates to cardiovascular issues.

“Diabetes and obesity are the leading cause of public health problems within the country as well as within the state,” Bhatnagar told Gillespie. “Heart disease is one of the main consequences of diabetes and obesity. In fact, people who have diabetes, about 70 percent of them die from heart disease.”

The National Institutes of Health grant will also fund research around the effects of pollution on stem cell health; how exercise can reduce inflammation; and how the heart talks to blood vessels to increase blood flow during exercise, the university says.

Free webinar Nov. 28 on why Ky. cities and counties can't pass local laws around the distribution, sale and regulation of tobacco

The Foundation for a Healthy Kentucky is offering a free webinar about how state laws prevent local governments from passing tobacco-control ordinances and other health policies in Kentucky.

The laws "pre-empt" local regulations on distribution, sale and regulation of tobacco products, so if a city or county in Kentucky wants to pass an ordinance to raise the legal age to purchase tobacco products, or ban tobacco flavors in electronic cigarettes that appeal to youth, they can't.

Presenters in the webinar will share their experiences with teh issue and discuss advocacy strategies for countering and repealing pre-emption laws.

They include Tonya Chang, vice president for advocacy with the American Heart Association Great Rivers Affiliate; Ellen J. Hahn, professor, University of Kentucky Colleges of Nursing and Public Health; Traci Kennedy, consultant to Americans for Nonsmokers' Rights; and Mark Pertschuk, director of Grassroots Change: Connecting for Better Health.

The free one-hour webinar is part of the foundation's Health for a Change training series. It will be held Wednesday, Nov. 28 from 1 p.m. to 2 p.m. Click here to register.

Louisville psychiatrist writes book about landmark research that gets to root of why people struggle in their relationships

Nov. 18, 2018: Story updated to reflect Living on Automatic: How Emotional Conditioning Shapes Our Lives and Relationsips was chosen by American Book Fest as a finalist for the "2018 Best Book Award" for best new non-fiction .

By Melissa Patrick
Kentucky Health News

In a world inundated with interpersonal conflicts, a Kentucky psychiatrist has written a groundbreaking new book that explains what lies at the root of these conflicts and offers a way to resolve them.

"It's a book that talks about why the things that go wrong in our relationships go wrong, and why we live on automatic pilot and do things that we sometimes don't even want to do, but we repeat them over and over again and we wish we could stop," Dr. Christine B.L. Adams, one of the book's authors, said in a telephone interview.

The book, Living on Automatic: How Emotional Conditioning Shapes Our Lives and Relationships, is a collaborative effort between Adams, a child psychiatrist in Louisville, and the late Dr. Homer B. Martin, her colleague and mentor. Adams said their landmark research around emotional conditioning is based on 80 combined years of psychotherapy with thousands of patients. It was recently chosen by American Book Fest as a finalist for the "2018 Best Book Award" for best new non-fiction.

The authors write that people are emotionally conditioned within the first two to three years of life by their parents or caretakers to fall into one of two roles that form the basis of their personalities.

The two roles are called omnipotent and impotent. An omnipotent is conditioned to please and do for others; an impotent is conditioned to need constant emotional care and attention from others. Each role is a matter of degree, the authors say; people fall on a continuum from mild to severe for each of these conditioned roles.

The result of this emotional conditioning, Adams says, is that people tend to seek relationships that meet their own needs, rather than relationships that recognize each other as individuals.

But this isn't working, she said, pointing to how interpersonal conflicts have resulted in such high rates of divorce and substance abuse and increasing conflicts between parents and their children.

"So this says to me that the way we've been doing it has not been very successful and perhaps there is a better way," Adams said.

That way, she says, is for people to re-learn how to interact with each other in ways that promote better relationships. She calls it deconditioning, and explains it in the final chapters of the book.

"What you learn to adopt when you try to shed your conditioning is a standard of reasonableness rather than a standard of automatic conditioned responding," she said. "You have to learn a technique of evaluating yourself and the other person simultaneously in every exchange you have with them."

She added that this technique helps a person determine what is called for in each situation.

"In this way you don't automatically respond just to the role of the other person," she said. "You respond according to what each person needs for the particular situation at that particular time."

Adams said people who have gone through this process "have much better lives, are able to manage their lives better and have better relationships," and when one person goes through the process it typically has a "ripple effect" throughout a family and others who are close to them.

Beyond romantic relationships, Adams said the book also has applications for young parents to help them raise "more well-balanced" children, as well as help for agencies that work with children.

She said the book is written for a general audience, in hopes of bringing awareness to this new concept of emotional conditioning, and how this causes us to act on automatic pilot most of the time when it comes to our relationships.

"This is a landmark study of what really happens in relationships," she said. "And when you impart information to people that they've not known before, then a lot of people start thinking about it in new ways and will apply it to themselves and their family and their friends."

Look beyond premium costs when choosing a Medicare plan; Medicare Advantage may not be an advantage for you

By Trudy Lieberman, Rural Health News Service

Making decisions about Medicare coverage has never been easy. Over the years the task has become more complicated as Congress has moved to privatize the system.

Open enrollment, the time for evaluating your coverage and making changes if you can, opens Oct. 15 and runs through Dec. 7 this year. This is the first of two columns that address decisions people about to become eligible for Medicare and those already on the program will have to make.

While some 57 million people are still in traditional Medicare, which remains a social insurance program, the number of beneficiaries in privatized Medicare known as Medicare Advantage has grown steadily. Today one-third of all beneficiaries have joined private plans, many of them responding to sales pitches - sometimes questionable ones - from insurance companies that now regard their Medicare Advantage business as a major profit center.

With a Medicare Advantage plan, generous payments from the federal government to private insurers allow them to provide a person’s Medicare benefits along with some extras like eyeglasses, limited dental care, and gym memberships. The government payments have been so rich they’ve also allowed the plans to entice people to join by offering coverage with no monthly premium or a very low one.

So the first basic choice is whether to select traditional Medicare -- and buy a supplement to fill in what Medicare doesn’t pay -- or to select a Medicare Advantage plan.

Increasingly, though, some people may not have a choice. More employers who fund part of their retirees’ health insurance are automatically enrolling their workers about to retire in Medicare Advantage plans, and those workers may not understand what they are getting, said Tricia Neuman, a senior vice president of the Kaiser Family Foundation: “Employers may see this as an attractive way to shift some of the risk to employees.”

A few years ago, I met a retiree of a computer firm in California who had developed Parkinson’s disease and was seeking help from the state’s insurance counseling program to switch out of the employer’s retiree Medicare Advantage plan. He was having trouble seeing the specialists he needed to treat his disease.

Counselors told him he had few options. He could easily drop his Medicare Advantage plan and return to traditional Medicare. But he was no longer eligible to buy a Medigap policy, which he sorely needed.

California, like almost every other state, says insurers offering Medigap policies may scrutinize senior applicants’ health status once those seniors have passed their initial eligibility period. That period is generally the first six months after they sign up for Medicare Part B, which pays for physician services and hospital outpatient care. After that, if you have a preexisting condition, you’re out of luck.

Only New York, Connecticut, Massachusetts, and Maine allow seniors to buy a Medigap policy anytime. A few other states allow seniors to buy them under certain conditions - like losing retiree coverage. Seniors living outside those states, though, could be making an irrevocable decision by choosing a Medicare Advantage plan or allowing themselves to be placed in one automatically.

Yet the allure of no monthly premium or a cheaper premium than a Medigap policy would require draws seniors to Medicare Advantage plans. A cheaper premium or no premium sounds good when you’re well, but what happens when you’re sick? That’s when many seniors find they want to go back to traditional Medicare.

“Premiums are not a good way to choose a plan. It’s important to look beyond the premium,” Neuman advises.

Still, not much is known about how seniors in Medicare Advantage plans fare when they have a really serious illness. But in late September the Office of the Inspector General reported that insurers offering Medicare Advantage plans may be inappropriately denying services to seniors and called on Medicare to step up its oversight of those plans.

The Office of the Inspector General found that Medicare Advantage plans overturned 75 percent of their denials between 2014 and 2016, raising questions about why seniors were denied in the first place.

“The high number of overturned denials raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided,” the report noted. “This is especially concerning because beneficiaries and providers rarely used the appeals process.” Seniors may be denied services but never register any complaints.

As with all insurance, you make a trade-off. Pay less upfront and more when you get sick, or minimize your risk by paying more in premiums to have better coverage when illness strikes. That is the great-unknown seniors must consider.

Traditional Medicare plus a good Medigap can become your best friends if you have a hospitalization for a serious illness as I had when an infection came out of the blue and kept me in the hospital for four months earlier this year. For doctor, hospital, and rehabilitation charges that totaled some $3.5 million, we paid only about $2,500 out of pocket.

My next column will address finding a good drug benefit.

What experience have you had with Medigap policies or Medicare Advantage plans? Write to Trudy at trudy.lieberman@gmail.com.

Need for improved staffing in nursing homes and hospitals was among timely topics at annual Health Watch USA conference

By Melissa Patrick
Kentucky Health News

Several speakers at the Oct. 4 Health Watch USA Healthcare Transparency and Patient Safety Conference in Lexington talked about the importance of adequate staffing in nursing homes and hospitals to maintain and improve safety for patients and staff.

Sherry Culp of the nonprofit Nursing Home Ombudsman Agency of the Bluegrass said that while regulations issued in 2016 by the Centers for Medicare and Medicaid Services have offered some positive changes, such as requirements for improved training and "appropriate competencies and skills," and better provisions for planning of care, it didn't do enough with staffing.

"The final rule really fell short on nursing staffing standards," she said. "We wanted there to be registered nurses in the building 24 hours a day. . . . We know that an RN level of nursing is the level that has the competence to deal with some of the significant changes in conditions that occur in this vulnerable population."

Culp said the rules only require an RN to be in the building eight hours a day, and that person is often "locked up in an office doing paperwork," while 90 percent of the care is provided by nurse aides, who have less than 100 hours of vocational training. Her agency monitors living conditions at nursing homes and informs residents of their legal rights.

Woodcrest Nursing and Rehabilitation Center in Elsmere has
a one-star rating. In 2016 a resident fell down the stairs in his
motorized wheelchair, died and went undiscovered for
nine hours. (Herald -Leader photo by Marcus Dorsey)

She said the agency gets calls from overwhelmed aides who tell her they have been put into impossible situations to care for as many as 40 people with little orientation and no help. "I think a lot of nurse aides are just thrown to the wolves," Culp said.

As part of a three-part, in-depth report on the dismal state of Kentucky's nursing homes, John Cheves of the Lexington Herald-Leader reports about the staffing issues in Kentucky's nursing homes, noting that collectively Kentucky's nursing homes rank as some of the worst in the country.

As of Aug. 7, he reported that Kentucky had 52 "one-star" nursing homes (18 percent of the state total), which are considered to be "much below average" and 71 "two-star" homes (25 percent), which are "below average." These ratings come from CMS's five-star rating system, which looks at a facility's staffing, health inspections and quality of resident care.

Hospitals have staffing issues, too

Staffing issues are also an issue in hospitals, said Christine Pontus, associate director of health and safety for the Massachusetts Nurses Association.

Pontus pointed out that registered nurses are vital to the care of patients because they are the front line person to recognize and react to a patient's ever-changing health status. She called this process "surveillance" and said that basically, "That's what nurses do."

She shared research to support the importance of nursing surveillance, which found that "greater nurse surveillance capacity was significantly associated with better quality of care and fewer adverse events," and the ability of nurses to provide appropriate surveillance is, among other things, largely dependent on adequate staffing.

Culp said RNs are needed 24 hours a day in nursing homes because it is imperative that someone with appropriate training be able to to determine if further care is needed when residents fall and hit their head. She said some of these fall victims have injuries that go unnoticed, "sometimes ever, or until their death or weeks later."

One study of staffing in hospitals, found that RNs who work in an environment that supports their physical and emotional safety are more able to provide better surveillance, which ultimately leads to improved patient outcomes, more positive patient experiences and higher RN engagement rates.

"National, peer reviewed studies show higher patient assignments are associated with more patient deaths, complications, medication errors and readmissions," Culp said.

Pontus noted that while Medicare requires "adequate" numbers of nurses at all levels, it doesn't define the term or who determines the numbers. Similarly, she said the Joint Commission that accredits hospitals calls for the "number, competency and skill mix of staff in relation to the provision of needed care and treatment," but does not clearly define or offer a formula to determine this mix.

"These ambiguous statements allow health care facilities to continue to operate at or below minimum [staffing] levels," she said. "Something is not working. Regardless of all the regulations and the Joint Commission, it's not working and we need to do something."

Jonathan Rosen, safety and health consultant for AJ Rosen & Associates LLC, cited another study that looked at nurse staffing and hospital deaths: "We estimate that the risk of death increased by 2 percent for each below-target shift and 4 percent for each high-turnover shift to which a patient was exposed."

So far, California is the only state to pass a nurse-to-patient ratio law. Rosen said a study found that since the requirements took effect, nurses' occupational injuries have dropped one-third.