Tuesday, June 18, 2019

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

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

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

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

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

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

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

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

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

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

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

Monday, June 17, 2019

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

By Melissa Patrick
Kentucky Health News

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Saturday, June 15, 2019

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Kentucky's rankings

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

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

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

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

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

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

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

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

Friday, June 14, 2019

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

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

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

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

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

Thursday, June 13, 2019

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Wednesday, June 12, 2019

U of L can't find a partner to buy Jewish Hospital, but will continue professional partnership on education, transplants etc. 'for now'

Jewish Hospital and its Rudd Heart and Lung Center
Failing to find the partner it says it must have, the University of Louisville has suspended efforts to buy Jewish Hospital and the other Louisville-area assets of Catholic Health Initiatives, operated as KentuckyOne Health. The failure leaves in limbo the future of a major Kentucky hospital and its affiliated health-care facilities.

“U of L officials were not willing to put the university at financial risk by taking on the acquisition alone,” the university said in a news release. “We regret ending our talks with CHI but we must do what is fiscally responsible for the University of Louisville,” U of L President Neeli Bendapudi said in the release. “Without a viable partner, we do not have the resources necessary to make the acquisition a reality.”

"KentuckyOne and U of L will continue their professional partnership for now, including the academic affiliation agreement that ensures undergraduate and graduate/resident medical education programs continue at Jewish Hospital and Frazier Rehab Institute," report Morgan Watkins and David Harten of the Louisville Courier Journal. "If the programs cannot be continued at those facilities, CHI will assign those residencies to another facility requested by the university, according to U of L’s statement Wednesday."

University spokesman John Karman "said U of L is continuing to make progress on contingency plans that it has been working on since last year concerning the transition of its service lines from Jewish Hospital to other health care facilities," the newspaper reports. "More than 1,000 employees work at the hospital. Jewish also serves as the only adult organ transplant center in the city, and all of the physicians who perform lung, kidney, liver, pancreas, heart and dual organ transplants at Jewish are employed by U of L."

KentuckyOne's assets have been for sale for more than two years. Besides Jewish and Frazier Rehab, they include Sts. Mary and Elizabeth Hospital, four outpatient centers, Our Lady of Peace psychiatric hospital and Jewish Hospital Shelbyville.

UK nurse creates Farm Dinner Theater as a way to remind farmers of safe practices; has some unexpected benefits

Deborah Reed (UK photo by
Mark Cornelison)
A University of Kentucky nursing professor has come up with a novel way to remind farmers about farm safety: dinner theater.

At Farm Dinner Theater, farmers watch each other perform funny skits with a serious message. At a recent show at the Lincoln County Extension Office in Stanford, Thelma Blair asked her husband Jack if he remembered to wear ear plugs before working on his loud farm machinery. The audience laughed as Jack yelled, "WHAT?" in response. "While they delight in Jack's feigned deafness, it serves as a reminder to use ear protection when working with machines, Hilary Brown reports for UK Now. The Blairs are respected farmers in their community, and were excited to participate in the program when their extension agent asked.

The skits may fill a need because health and safety standards don't apply to small family farms. Lectures aren't effective, and pamphlets are easy to ignore, so Reed, who grew up on a nearby farm, wanted to find another way to help farmers recognize farming hazards and practice safety measures, Brown reports.

"Based on our research, we found that farmers learned best from watching each other and stories based on real situations," Reed told Brown. "They like humor. From observing farmers and how they choose their work behavior we know they learn from an apprentice model where role modeling is so important." And a free dinner doesn't hurt.

Reed says the program has helped in ways she didn't expect, such as "how the farmers would come together and work out issues among themselves," Brown reports. "At one event, a farmer mentioned how his father, who was grappling with Alzheimer's, kept trying to get the keys to the family tractor. Their solution was to move the tractor out sight. Once they did that, he stopped trying to drive it."

Another unexpected benefit: Attendees say the program has helped relieve their stress. Farmers are under a lot of stress these days because of bad weather, the trade war, low crop prices and more, and depression and suicide among farmers has increased greatly in recent years. Farm Dinner Theater "gives farmers the opportunity to come together, discuss their situations, and to support each other," Reed told Brown. "Non-farm people in the community come to these events and have a better understanding of the stressors that farmers face and can support them better."

Brown reports, "The results of these events have been remarkable. Fifty percent of the farmers who attended reported to have incorporated changes in their habits and on their farms within two weeks. Sixty percent made changes within two months. The program was so successful, Reed, who has won numerous awards for the program and was named by Oprah Magazine as "One of Five Nurses Who Might Just Save the World", was appointed UK's first agricultural nurse, the first at a land-grant university. Her position is funded by UK's College of Agriculture, Food and Environment, and marks the beginning of a unique partnership" with the College of Nursing.

The project is funded with a grant from the National Institute for Occupational Safety and Health.

Tuesday, June 11, 2019

Foundation says its 6-year, 7-county effort to help communities tackle health issues can be a model for the rest of the state

Foundation for a Healthy Kentucky map of recently finished "Investing in Kentucky's Future" program
If more Kentucky communities tackled their health issues as communities, the overall health of the state could be improved. That's one lesson of a six-year program that the Foundation for a Healthy Kentucky recently completed in seven counties.

The "Investing in Kentucky's Future" initiative focused on children. It "improved student eating habits, increased youth physical activity, trained teachers to support students experiencing trauma, and increased youth resilience," the foundation said in a report on the program, which reached nearly 13,000 students in 28 participating schools.

It said the initiative "strengthened cross-sector coalitions" in the seven counties and "led to the adoption of 38 local ordinances and policies to help sustain the improvements and promote health equity long-term." Looking ahead, it "has prompted the foundation to expand its work in obesity prevention and childhood trauma interventions."

For example, in May, the foundation announced a $200,000 grant in Russell and surrounding counties to address childhood trauma in a rural setting, building on lessons from a Jefferson County program that was part of the initiative.

The overall goal of the $2.4 million initiative was to reduce school-aged children's risk of developing chronic diseases later in life. The communities contributed $1.7 million in matching funds, as well as countless volunteer hours by local citizens.

"Health is something that people don't typically recognize as a community undertaking, and this initiative aimed to transform that thinking and set in motion a series of changes that will lead to healthier, more productive adults throughout each participating Kentucky county," foundation president and CEO Ben Chandler said. "We're sharing what's been learned so other Kentucky communities can replicate these achievements."

An event of the Clinton County Healthy Hometown Coalition
Six of the participating communities (Breathitt, Clinton, Grant, McLean, McCracken and Perry counties) chose childhood obesity prevention as their issue. Jefferson County focused on adverse childhood experiences (ACEs) and building resilience in children who have faced trauma.

Both issues are complex, and influenced by a variety of factors, so they require involvement by various sectors of the community, working in a coalition, the foundation said. With its report, the foundation released videos on obesity prevention and ACEs to help other Kentucky communities.

"Participants told us that identifying a local champion and engaging the school system were critical to success in each of the counties," Chandler said. "But by far the most decisive factor was ensuring that the local health coalition includes multiple members from a broad range of community organizations: schools, hospitals, elected officials, youth groups, and businesses. It takes more time to get everyone aligned but the resulting collaboration makes all the difference in creating long-term change to improve health."

The grant "gave us an opportunity to do something big and to really make an impact and we've done that," Marsha Bach, a member of the Grant County coalition, Fitness for Life Around Grant County (FFLAG) and a health promotion manager with the Northern Kentucky Health Department, says in the obesity video.

Each grant included a one-year planning phase in which the foundation provided training and technical assistance for development of a business plan. This made the program more accessible to small communities with fewer resources, said Amalia Mendoza, senior program officer at the foundation, who developed and oversaw the program.

Among the successes the foundation listed were:
  • New policies expand physical education in middle school, require future streets to be usable by walkers and cyclers, allow school fitness equipment to be used by the community after school, and make healthier foods available in schools and park concession stands.
  • New facilities include parks, fitness equipment, sidewalks and walking paths, playgrounds, filtered drinking water fountains, community trails and standing desks in schools.
  • Many communities leveraged the Foundation grant to secure additional funding. For example, the Purchase Area Health Connections-Paducah Chapter secured another $400,000 Rotary Club grant to build a playground at the health park developed with foundation funding, and then another $500,000 donation to build a second phase of the park; sidewalks to school in Grant County will be part of trail system funded by a follow-up grant from another foundation.
  • More than 90 percent of students had increased physical activity and improved nutrition, from such measures as classroom movement activities and standing desks; events such as fun runs, walking and biking programs, and the Annual Nutrition Fair created by the Partnership for a Healthy McLean County; a "Fitness Buddies" program of the Clinton County Healthy Hometown Coalition, in which high-school students helped third and fourth graders with intense physical activity; elimination of deep fryers in school cafeterias; installation of filtered drinking water fountains; and work with farmers to get more fresh produce to students.
  • All six coalitions began or expanded student food programs over the weekends or the summers. Most students reported that school was the only place they got fruits and vegetables. Offering fresh produce at snack time "appears to be a successful strategy" to increase consumption, the report found.

Sunday, June 9, 2019

Six Kentucky nursing homes are on a formerly unpublished list of 400 poor performers around the nation

Of the six Kentucky facilities on the poor-performers list, only
Twin Rivers Nursing and Rehabilitation Center in Owensboro
is getting additional oversight. (Photo from Owensboro Times)
By Melissa Patrick
Kentucky Health News

The U.S. senators from Pennsylvania have released a report that includes the names of nearly 400 nursing homes with a "persistent record of poor care" that had not previously been publicly available.

Six are in Kentucky: Klondike Center and Springhurst Health and Rehab in Louisville; River Haven Nursing and Rehabilitation Center in Paducah; Woodcrest Nursing and Rehabilitation Center in Elsmere; Mountain Manor of Paintsville; and Twin Rivers Nursing and Rehabilitation Center in Owensboro.

Some issues listed in the report specific to the Kentucky nursing homes were failure to provide prescribed medication and treatments, failure to inform providers when the treatments were missed, and failure to provide appropriate burn-wound care, which resulted in a state inspector finding the individual "lying in bed with a large amount of green drainage on dressing and a pool of green drainage on the bed sheets."

Pennsylvania's senators, Democrat Bob Casey and Republican Pat Toomey, released the list after questioning why the federal government only shares a list of about 80 failing nursing homes that get special oversight until their issues are resolved, and not the list of nearly 400, which also qualify for the oversight program, but aren't included because of "limited resources."

The 80 nursing homes that get the additional oversight are "special focus facilities" and are identified on the federal Nursing Home Compare website with a small yellow triangle. Those on the list of 400 are candidates for this special program, but are not identified in any way on the website as nursing homes that provide persistently poor care.

The senators' report says, "Despite being indistinguishable from participants in terms of their qualifications for enhanced oversight, candidates are not publicly disclosed. As a result, individuals and families making decisions about nursing home care for themselves or for a loved one are unlikely to be aware of these candidates."

Owensboro's Twin Rivers Nursing and Rehabilitation Center is the Kentucky's only "special focus facility" on the list. The report says that the only parties who have known if a nursing home is a candidate to be a special-focus facility are the Centers for Medicaid and Medicare Services, the government of the state in which the nursing home is based, and the facility itself.

The report says CMS has not consistently updated these nursing homes' data on Nursing Home Compare; it says nine are listed as having perfect scores for staffing and quality of care.

Further, it says that the nursing homes that are considered special-focus candidates do not face additional oversight, are not surveyed more frequently, nor are they "subject to more rigorous enforcement actions, additional disclosure or reporting requirements."

“There is no information on Nursing Home Compare explaining the reason for a facility’s participation in the program, the length of time it has been in the program or whether it has improved,” the report said.

About 1.3 million Americans live in 15,600 nursing homes, according to CMS.

Courier Journal has answers to many questions about CBD oil

CBD products for sale at Rainbow Blossom in Louisville
Photo by Michael Clevenger, Louisville Courier Journal
As cannabidiol, better known as CBD oil, becomes readily available in Kentucky and is touted as a cure-all for a host of medical problems, from arthritis to anxiety, Laurel Deppen of the Louisville Courier Journal reports on its safety and legality.

Much of the concern about the safety and legality of CBD oil comes from its association with marijuana, since both come from the cannabis plant, Deppen notes. Here is her guide to answer many of those concerns.

What is CBD oil? CBD oil is made by extracting CBD from the cannabis plant, then diluting it with a carrier oil, such as coconut or hempseed oil, according to healthline.com.

Is CBD oil legal in Kentucky? As long as CBD is derived from industrial hemp, it is legal. The 2018 Farm Bill allowed “the production and marketing of hemp” and other derivatives of cannabis with less than 0.3 percent THC, or tetrahydrocannabinol, the plant's psychoactive ingredient.

Can you get high off CBD oil? No, because it doesn't have enough THC.

Can you grow hemp in Kentucky? With a license. The Kentucky Department of Agriculture also requires anyone handling or processing plants, seeds, leaf or floral materials derived from hemp to be licensed. Without a license, growers could face the same penalties as those for growing marijuana.

Can you manufacture CBD oil in Kentucky? Yes, with a license, which is also issued by the Department of Agriculture.

Is CBD oil safe? Is it addictive? Deppen reports that it is not addictive, but adds that "a lot of facts remain unknown" about its safety. Medical experts recommend that you speak to a doctor before taking any medication or supplement, especially if you have a pre-existing condition.

Will CBD oil help or hurt my anxiety? Bottom line, more research is needed. Deppen reports that there haven't been any confirmed studies on whether it hurts or helps anxiety. However, she writes that "Some patients have reported less anxiety or depression after use, including more restful sleep."

How will CBD oil affect my heart? Will it affect my medications? In a previous Courier Journal article, James Patrick Murphy, former president of the Greater Louisville Medical Society, warned that CBD treatment may not be for everyone, including those with heart conditions or those who take blood thinners. Deppen explains that CBD can inhibit liver enzymes that metabolize drugs.

Does CBD oil show up on a drug test? "If a drug screening only tests 'positive or negative' for THC and not the amount, there's a chance your CBD oil intake could cause you to fail the drug test," Deppen reports.

Where can I find it? Most CBD oil has largely been sold in local, independent stores, "but as the demand for CBD products rises, you're more likely to find it on a store shelf where you'd least expect it," Deppen writes.

Walgreens started selling CBD products in almost 1,500 stores earlier this year, and CVS began selling them in in 800 stores. Both chains will sell the products in Kentucky. Deppen reports that Target and Walmart have started having "initial discussions" with CBD manufacturers, according to the New York Post.

Saturday, June 8, 2019

Study: Private insurance pays hospitals 241% more than Medicare (186% in Kentucky); suggests shift to a Medicare model

By Melissa Patrick
Kentucky Health News

As health-care costs continue to rise for both employers and employees, one group of researchers says private insurers should move away from how they pay for hospital services, which requires them to pay a percentage of billed charges, and start paying the way Medicare does, based on a fixed-price agreements that are transparent to all. The American Hospital Association says that would not be sustainable, because Medicare doesn't pay hospitals enough.

The Rand Corp., a global research firm, made this recommendation based on its a study that found private health plans in the U.S. paid hospitals 241 percent more than what Medicare would have paid them in 2017, up from 236% in 2015.

Kentucky's private plans paid 186% more than Medicare in 2017, the fourth smallest difference among those in the 25 states surveyed. For inpatient treatment, the state's costs were second lowest of the 25, but its outpatient costs were above average.
All but five Kentucky hospitals in the study had a rate greater than 200% of what Medicare pays for outpatient services, with nearly 19 greater than 300% for that same measure. There was a bigger difference in prices for outpatient care than for inpatient care. In Kentucky those rates were 245% and 142%, respectively; nationally, they were 293% and 204%.

“The widely varying prices among hospitals suggests that employers have opportunities to redesign their health plans to better align hospital prices with the value of care provided,” Chapin White, the study's lead author and a policy researcher at Rand, said in a news release. “Employers can exert pressure on their health plans and hospitals to shift from current pricing system to one that is based on a multiple of Medicare or another similar benchmark.”

The report says the data is also important because it allows employers to create networks that move their employees away from the higher-priced hospitals to the lower-priced ones.

The study reported on the relative price of private insurance to Medicare by dividing the amount allowed for private insurance by the amount allowed for Medicare for the same service, in the same facility. The researchers used data from about 4 million patients in 1,589 hospitals in 25 states.

The researchers used claims data from self-insured employers, two state all payer claims databases and records from health insurance plans that chose to participate. For each private claim, they re-priced the service using Medicare's grouping and pricing formulas.

Prices varied greatly by state and hospital. Of the 36 Kentucky hospitals in the study, private health-plan prices for outpatient services ranged from 85% of Medicare at Jane Todd Crawford Hospital in Greensburg to 526% at TJ Samson Community Hospital in Glasgow.

The study looked at three Kentucky hospital systems, including Baptist Health, Catholic Health Initiatives and Norton Healthcare. It found a decrease in relative pricing in each of the systems since 2015, with Baptist Health billing private insurers 168% more than Medicare in 2017, down from 203% in 2015; CHI billing 187% more in 2017, compared to 236% in 2015; and Norton Healthcare billing 185% more in 2017, compared to 205% in 2015.

Overall, the study found a wide variance among hospital systems, ranging from 150% of Medicare rates at the low end and more than 400% at the high end. "In general," the report says, "prices paid by private health plans are much higher than Medicare, and there is a wide variation."

The researchers found that if employers and health plans participating in the study reduced their hospital payments to Medicare rates, it would have resulted in $7.7 billion in savings for employers in 2015-17. It said reducing prices from the 75th to the 25th percentile would have reduced employer spending by $1.4 billion, about 40% of the employers' and plans' spending on hospitals in 2017.

The analysts offered two different interpretations for this variation. One is the "cost shifting story," which argues that Medicare severely underpays hospitals, compelling them to charge privately insured patients more. The other is "the leverage story," which says hospitals have used their leveraging power to extract unreasonable price deals from health plans, which in turn makes Medicare prices "look woefully inadequate by comparison."

The challenge is that while employers are looking for ways to decrease health-care costs, hospitals depend on cash flow generated by private insurance plans to upgrade and expand their services. "Lower private prices would require hospital managers to find ways to increase revenues to reduce costs to maintain current margins," says the report.

The American Hospital Association released a statement that took issue with the small sample size, which it described as less than 5% of all covered persons in about half of all states, and just 2% of the 181 million Americans with employer-sponsored insurance nationally.

It also took issue with the usage of Medicare payment rates as the benchmark for hospital prices, stating that in 2017, hospitals received payment for only 87 cents for every dollar they spent caring for Medicare patients.

"Simply shifting to prices based on artificially low Medicare payment rates would strip vital resources from already strapped communities, seriously impeding access to care," AHA General Counsel Melinda Hatton said. "Hospitals would not have the resources needed to keep our doors open, innovate to adapt to a rapidly changing field and maintain the services communities need and expect."

All that said, many think something has to give. Employers have increasingly shifted to high-deductible plans to help offset some of their costs, but this has created a situation where employees have become "under-insured" because they can't afford the cost burden that comes with such plans.

Further, according to an analysis by The Commonwealth Fund, the cost of employer health-insurance premiums and deductibles continues to outpace wages. The analysis found that Kentucky families covered through work spent, on average, 13% of their income for health coverage in 2017.

The study recognizes that it only used data for about one-third of U.S. hospitals, and that for many of those hospitals, only outpatient prices could be reported; and that it only includes facility claims and not claims for treatment by physicians or claims for prescription drugs.

The report offers detailed suggestions on how employers can use this data to seek lower prices for their health plans. It also includes suggestions for policymakers, including placing limits on payments for out-of-network hospital care or allowing employers to buy into Medicare or another public option that pays providers based on a multiple of Medicare rates.

The research was funded by the Robert Wood Johnson Foundation, the National Institute for Health Care Reform, and the Health Foundation of Greater Indianapolis and participating self-insured employers.

Friday, June 7, 2019

1 in 5 hospital patients need care after discharge, but can have limited choices unless they know their options, columnist advises

Health columnist Trudy Lieberman
"One in five patients across the country needs further care after discharge from a hospital," Rural Health News Service columnist Trudy Lieberman writes. "Many times their families don’t know where to turn for help." The hospital can be a weak link, she warns: "Discharge planning is deficient, can be harmful, and sometimes results in a patient’s decline."

Discharging hospitals can limit patients' options, Lieberman writes: "If hospitals are hitting the limits of what Medicare will pay for a patient’s care, they have a great incentive for moving people out. To them it doesn’t matter if a patient is moved to another state, as I was, or to another town. Either one can make it difficult for family to visit and keep an eye on the care, which is all-important."

Patients and their families may not be aware of just what sub-acute-care facilities, home-care agencies or rehabilitation centers can do, and may not even know about a relatively new type of hospital, the long-term acute care facility (LTAC), which "treats sicker patients for an average of at least 25 days for recovery," Lieberman writes. "Neither had I, when I found myself transferred to one early in 2018 after a long hospital stay."

Kentucky has one freestanding LTAC, Kindred Hospital in Louisville, and eight that are inside or adjacent to another hospital: in the Baptist Health hospitals in Corbin, Madisonville and Paducah; St. Joseph Hospital in Lexington; UK HealthCare in Lexington; St. Elizabeth Fort Thomas; a Kindred facility in Jewish Hospital in Louisville; and the Commonwealth Regional Specialty Hospital in The Medical Center at Bowling Green.

The 32-bed ContinueCARE facility in the 273-bed Corbin hospital recently won a Respiratory Center of Excellence designation from the Center for Improvement in Healthcare Quality, making it "the first facility in the country to receive this specific CIHQ designation for respiratory therapy," Baptist Health said in a news release.

Lieberman has suggestions for dealing with care after discharge: "Medicare requires a discharge notice, which sets out a patient’s appeal rights and procedures, to be given no later than two days after a person is admitted to a hospital. Some are given at admission, usually a time of confusion, and the explanation of rights is likely to be overlooked. Be aware of it, though, and read it carefully. You may need to rely on it if you think a relative needs to stay longer in the hospital. And for all families who need more care after a hospital stay, the website of the Center for Medicare Advocacy has loads of information."

For Lieberman's full column, and her previous columns, click here.

Thursday, June 6, 2019

Valerie Horn of Whitesburg is latest Healthy Ky. Policy Champion, for increasing access to healthy foods in Letcher County

The Foundation for a Healthy Kentucky has named Valerie Horn, a retired school counselor from Whitesburg who helps low-income residents in Letcher County gain access to healthier foods, as the latest Healthy Kentucky Policy Champion.

Horn chairs the Whitesburg/Letcher County Farmers Market and directs the local Grow Appalachia program for the Cowan Community Action Group.

She has also served as county director for Appal-TREE (Appalachians Together Restoring the Eating Environment), a Community Farm Alliance program that includes a summer food service for area children, classes in healthy cooking, and a campaign that encourages middle- and high-school students to choose water over sugary drinks.

Horn was nominated by Mike Caudill, the CEO of Mountain Comprehensive Health Corp. in Whitesburg. He said Horn was the inspiration for the clinic's "Farmacy" program, which allows doctors to prescribe fresh fruits and vegetables to the clinic's patients so that they can get them at the farmers' market for free.

"The Farmacy program has directly benefited several thousand people in our area and has contributed over $500,000 to the local economy," Caudill said in a news release. "Thanks to Mrs. Horn's hard work and passion, this program has continued to be a success and has even been replicated in other communities and is a best practice."

Jared Arnett, executive director of Shaping Our Appalachian Region, which promotes economic development in Appalachian Kentucky, also praised Horn's efforts.

"Mrs. Horn understands the impact food has on the culture of a community, and strives to bring healthy food into people's homes," Arnett said in the release. "She is not afraid of a challenge and works hard to meet people where they are, so that she can help meet the needs of her community."

The award was presented by foundation CEO Ben Chandler at a regional community health forum at Community Agricultural and Nutritional Enterprises in Whitesburg.

"The policy changes that Valerie Horn has championed and helped implement are giving the people of her home community the opportunity to eat and live healthier," Chandler said. "She is also working to bring together people representing various sectors: farmers, community health-care and cultural organizations and schools, to ensure that Letcher County residents can bring home and use fresh produce and other healthy foods. These cross-sector coalitions are key to improving health in a community."

Horn is now eligible for the Gil Friedell Policy Champion Award, which comes with a $5,000 grant from the foundation to a Kentucky-based nonprofit of the winner's choice. The winner will be announced at the foundation's annual health policy forum Sept. 23 in Lexington.

State's sixth annual Viral Hepatitis Conference to be held July 31

Kentucky will hold its sixth annual conference on viral hepatitis on July 31 in Lexington, three days after World Hepatitis Day.

"Hepatitis in Kentucky: The Role of Professionals in Hepatitis Elimination" will be hosted by the Kentucky Rural Health Association and run from 7:30 a.m. to 5 p.m. at the Griffin Gate Marriott Resort in Lexington.

The agenda for the event has not been released. Click here for more information and to register. Continuing education credits will be offered to medical professionals.

The association also offers the Kentucky Hepatitis Academic Mentorship Program, or KHAMP, which is an in-depth training for providers to learn how to treat and test for hepatitis C.

The next KHAMP event will be held the day after the hepatitis conference, Aug. 1. Click here to register. The program is offered throughout the year in varying locations. The following one will be held on Oct. 8 in Benton.

To date, more than 100 providers have taken the training, resulting in over 300 consultations, according to Tina McCormick, executive director of the association.

For more information about the program, contact McCormick at KRHA@twc.com or KRHA.KHAMP@gmail.com.

Hepatitis, a serious liver disease, is a real problem in Kentucky.

The state identified an outbreak of hepatitis A in November 2017. According to the state's weekly report, 4,682 Kentuckians have been diagnosed with hepatitis A and 2,262, or 48 percent, have been hospitalized. Fifty-eight people in the state have died from it. The primary risk factors for getting the highly contagious disease remains illicit drug use and homelessness.

Kentucky also leads the nation in hepatitis C, which is commonly spread by the sharing of needles among intravenous drug users.

Wednesday, June 5, 2019

City of Pineville takes over troubled hospital, lays off half of staff, which wasn't being paid anyway; new owner being sought

Mayor Scott Madon spoke to the crowd at the Pineville hospital
while its new name was displayed. (MDN photo by Ray Welch)
The financially troubled hospital in the Bell County seat of Pineville remains open, barely, with a new name and a new operator: the City of Pineville, at least for the time being, while it seeks a new owner.

The hospital is now Pineville Community Healthcare, after two years as Southeastern Kentucky Medical Center. That was the name given it by Fort Lauderdale, Fla.-based Americore Health, which leased the facility from the Pineville Community Hospital Association, now in bankruptcy. "There are plans to change the name back once the litigation is over," reports Anthony Cloud of the Middlesboro Daily News.

"The local folks will now be making the decisions on this hospital," Pineville Mayor Scott Madon said to cheers on the hospital steps Monday afternoon. Madon "said that he and the community had taken the hospital for granted and they needed to support the hospital," Cloud reports.

The Centers for Medicare and Medicaid Services, which provide about 90 percent of the hospital's reimbursements, cut off payments May 24 after a state inspection found the hospital to be financially unstable and risking patient safety.

Madon said the city will seek reinstatement by CMS, but for now would operate with a skeleton staff. WYMT-TV in Hazard reports that 60 of the 120 employees were laid off, after eight weeks in which they had been paid only with gift cards, and "Only the emergency room is operational."

Tuesday, June 4, 2019

As health departments face crippling pension costs, unless lawmakers intervene, health boss promotes a new model for them

Without a reprieve from pension-contribution rules, 42 county health departments will close in the next year, and 22 more will the following year, says the Department of Public Health, which made this map.
By Melissa Patrick
Kentucky Health News

Under the gun of new pension rules, Kentucky's health commissioner wants local health departments to drastically cut services, but he says the departments need the legislature to give them one more reprieve from big pension bills that would put dozens of them out of business in the next 12 months.

Dr. Jeffrey Howard, the health commissioner, says his plan calls for a system that would assure the survival of public health in the state, and would ultimately improve the state's health outcomes.

Dr. Jeffrey Howard, health commissioner
Howard created this new model largely in response to the state's pension crisis, which on July 1 will require health departments to increase their pension obligation from 49.47 percent to 83.43 percent of payroll -- unless a special session of the General Assembly changes that.

In the regular session that ended in April, Gov. Matt Bevin vetoed a bill that would have offered some temporary relief to health departments. He has said he will call a special session to deal with the issue, but he and legislators have yet to secure the agreement and votes needed to pass a bill into law.

Without any relief from this added pension contribution and everything remaining the same, Howard's Department of Public Health says 42 health departments would close in the next 12 months, and 22 more would run out of reserves and be forced to close in the the next 24 months.

A taxing situation?

One of the departments most in danger, in Anderson County, recently raised its local property tax from 30 cents per $1,000 in assessed valuation to 52.5, cents to pay for its possible extra pension obligation, Ben Carlson reports for The Anderson News. Without relief from the added pension liability, the agency is slated to pay an extra $140,470 a year.

However, raising local taxes doesn't seem to be a popular option among the 113 counties that have a health tax.

Of the 23 counties that have reported their tax rates for the coming year, only five have proposed an increase, and minutes of the local health board meetings do not indicate that the increases are being driven by the need to cover higher pension costs, said Mike Tuggle, the state health department's assistant director for administration and financial management. He said in an email that the department will continue to receive tax resolutions through early October.

Using local tax dollars to fund public health would result in huge inequities, said Scott Lockard, director of the Kentucky River District Health Department, which covers some of the state's poorest and unhealthiest counties.

"Communities that need public-health services the most, that have the highest poverty rate, that have the poorest health outcomes, also have the least ability to raise local revenue," Lockard said. He added that when he was the health director in relatively wealthy Clark County, his tax base was about the same as it is for all seven counties in his district, which has about three times as many people.

"In Eastern Kentucky, we cannot raise enough local tax revenue to address this problem. And shifting the burden from the state to the locality is just not going to work for these poor communities," he said. He added that Howard's new plan is designed to address some of these inequities.

Crisis = Opportunity?

Howard says the crisis has created an opportunity.

He told a statewide board of health meeting in January that the state can take the opportunity to move away from a public-health system that is "an inch deep and a mile wide" and transform it in a way that will improve health outcomes across the state. "This is truly an opportunity to transform a system that has needed transforming for many decades," he said at the meeting, shown on YouTube.

Howard's plan calls for departments to scale back their services, and only be required to provide four "core public health" areas. He said it doesn't matter if the department implements these programs or if a community partner does, only that the department is committed to making sure they are in place.

The core areas include: foundational public health services, five areas that are required by law or regulation; the Women's, Infants and Children nutrition program; the HANDS program, which stands for Health Access Nurturing Development Services for child rearing; and harm reduction and substance-use disorder programs, including syringe exchanges.

The plan also requires health departments to perform community health assessments, which many of them already do, to determine their local public health priorities beyond those core requirements.

However, under Howard's new plan, before a department could implement a program to address a local need, such as diabetes management, it must first see if the need is already being addressed elsewhere, and if it is, they would be asked to work with that agency to either support or complement its program instead of creating a new one.

If the need is not being met in their community, a department would then have to present its proposed program to a newly formed advisory board, which would review the request to make sure it meets a list of five criteria, including whether it is data-driven, offers an evidence-based solution, is adequately funded, includes a performance and quality management plan; and has an exit strategy.

At the January meeting, Howard said the plan has the support of the Kentucky Health Departments Association, the Kentucky Association of Local Boards of Health, the Kentucky Public Health Association and the University of Kentucky's Center of Excellence in Rural Health. The health-department association has long promoted a similar model called "Public Health 3.0," on which Howard's plan is based.

Howard said the plan also has the support of his colleagues at the health department and Gov. Matt Bevin. He said it will be introduced to lawmakers during the 2020 session, noting that it will require "some overwhelming legislative buy-in." He also said he needs lawmakers to hold the pension rate at 49.47% for one more year to give him time to get this plan in place.

Scott Lockard
The new model has already been embraced at the Kentucky River department, which covers Knott, Lee, Leslie, Letcher, Owsley, Perry and Wolfe counties.

Why? "We are one of the most financially fragile health departments in the state," Lockard said. "We are redirecting our resources just to our foundational services, and basically we're going to be focusing on what we are statutorily mandated to do."

Under the higher pension rates, the Kentucky River department's extra pension obligation is about $1.3 million each year, and it has less than one year of unrestricted resources available before it would be forced to close, according to a spreadsheet provided by Tuggle. That makes it the fourth-worst-off department in the state.

Lockard said he has been working for the last year toward this "public health transformation" model. He said his agency has cut its payroll costs by $900,000, renegotiated contracts with pediatric therapists, is working toward referring all cancer screenings out of the department, and will be discontinuing all maternity services.

Bottom line, he said, if a program is not financially viable or is not statutorily mandated, it must go. And if somebody else can meet the need in the private sector, we need to let them do it.

He ended his interview with a warning: "I feel like we are facing truly a tipping point in public health, that if we do not make the right choices now and put a sustainable public-health funding model in place, the health outcomes for the people of this state are going to be impacted for generations."