Journal of Rural Health commentary says rural hospitals should regionalize adult care, like they do with maternity and infant care

As rural hospitals seek new ways to survive, a commentary in The Journal of Rural Health suggests that one new model could regionalize adult health care in much the same way it has been regionalized for perinatal care, the care given before and after the birth of a child.

Image from WFPL

"Regionalization of health care is not a new approach," note the authors of the commentary, which could spark debate about ways to save rural hospitals.

The survival of rural hospitals is a real concern. Four Kentucky hospitals have closed since 2010, and several are at risk of closing. In that time period, 113 rural hospitals in the U.S. have closed, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina.

Mosby's Medical Dictionary defines health-care regionalization as "the organization of a system for the delivery of health care within a region to avoid costly duplication of services and to ensure the availability of essential services."

"It may be a critical tool for the survival of rural community hospitals," write the commentary authors, Catherine Clary and Dr. William Kanto of Augusta University in Georgia, and Nikki King and and Tim Putnam of Margaret Mary Health in Batesville, Ind., 40 miles west of Cincinnati.

They explain that perinatal regionalization, which designates hospitals according to their ability to care for mothers and infants and uses those levels to determine where they should be best cared for, has resulted in "the decline of neonatal mortality and improving other perinatal statistics."

"Just as not all perinatal services could be provided in every community hospital, today there are specialized life-saving services (such as stroke, cardiovascular and trauma) available that cannot be fully supported by every rural hospital," they write. "However in an organized system of care, treatment can be initiated in the rural hospital and patients appropriately transferred, insuring universal access to these services and improved patient outcomes."

They also argue that specialized regionalization of adult care could free rural hospitals to expand some services, allow "vibrant telehealth" consultations that could allow patients to stay in their home facility with continuing support; and, if the partnership is with an academic medical center, provide opportunities for strong continuing-education programs.

They say such a model would include systems and protocols developed by the hospitals, and a strong telemedicine component; result in a growing respect and trust among the providers in the region that would lead to improved care and patient satisfaction; and make sure transferred patients would be returned back to their local hospital as soon as medically possible. That way, "The patient’s family incurs less expense and travel time," they write.

Also, prompt transfer demonstrates the specialty hospital's confidence in the rural hospital and providers, increases the patient and clinical volume of the rural hospital, and allows for post-discharge care to be conducted by local providers, they write:"The local hospital is the nexus for the continuing care for the patient; local providers are available to answer questions about medications, rehabilitation, and follow-up care, reducing the chance for error and confusion."

They add that being able to return a patient to their home facility is easier if the rural hospital has a "swing bed program," which allows a hospital bed to be used as an acute-care bed or a skilled-nursing bed, like in an advanced nursing home.

The authors conclude, "The survival of rural hospitals is an essential component in providing health care to a rural community, and rural hospitals are integral to the economic development and future growth of the community. With adult regionalization, patients receive required tertiary care, but the community hospital is supported through its use for rehabilitation and continued wellness."

State health officials ask health-care providers to report cases of any lung problems related to e-cigarettes; they plan to investigate

State health officials will be working closely with health-care providers, local health departments and federal health officials to gather information and investigate any cases of severe pulmonary disease related to use of electronic cigarettes and related products, primarily among teens and young adults.

As of Aug. 27, 215 cases of severe respiratory disease, possibly associated with electronic cigarette use, had been reported in 25 states. One patient in Illinois (no more specific location given) with a history of recent e-cigarette use was hospitalized with severe pulmonary disease and died Aug. 20.

Leafly photo

“While there have [been] no reported cases of severe respiratory illness related to e-cigarette or vaping in Kentucky so far, we remain vigilant in alerting health care providers to be on the lookout for patients with severe respiratory symptoms who report using electronic cigarettes or other vaping devices before they got sick,” Dr. Doug Thoroughman, acting state epidemiologist for the state Department for Public Health, said in a news release.

The announcement was made the same day the Centers for Disease Control and Prevention  issued an official health advisory asking providers to report cases of severe pulmonary disease of unclear cause and a history of e-cigarette product use within the past 90 days to the state and local health department.

The advisory says, "All patients have reported using e-cigarette products, and the symptom onset has ranged from a few days to several weeks after e-cigarette use. Within two states, recent inhalation of cannabinoid products, THC or cannabidiol, have been reported in many of the patients. To date, no single substance or e-cigarette product has been consistently associated with illness."

Thoroughman said Kentucky health officials will send out public-health alerts to clinicians early next week with a plan to collect information and investigate any cases reported for common factors on products that may be the source of the illness.

Patients have had symptoms including cough, shortness of breath and fatigue, with symptoms growing worse over a period of days or weeks before admission to the hospital. Other symptoms may include fever, chest pain, nausea, abdominal pain and diarrhea. Most of the cases reported are among adolescents and young adults, according to the state news release.

If you are experiencing any of these symptoms, state health officials ask that you refrain from further use of electronic cigarettes but keep the device for possible further investigation. The FDA encourages the public to submit detailed reports of any unexpected health issues related to tobacco or e-cigarettes to the U.S. Food and Drug Administration via its online Safety Reporting Portal.

Crusade for Children grants help 3 CHI St. Joseph hospitals

The WHAS Crusade for Children has given the Saint Joseph London Foundation $100,000 to establish a Level II neonatal intensive care unit at Saint Joseph London hospital. The unit will be one of only two Level II NICUs in southeastern Kentucky.

The unit “will be equipped to continue providing the best care to infants affected by premature birth, neonatal abstinence syndrome, fetal anomaly and respiratory disease,” said Leslie Buddeke Smart, president of the foundation.

The crusade also gave the foundation $36,000 to enhance patient care in the NICU and birthing center at the Women’s Hospital at Saint Joseph East in Louisville, and $35,000 to the Flaget Memorial Hospital Foundation to make its emergency department and operating rooms at Flaget Memorial Hospital more accommodating for young children. The Bardstown hospital gets more than 4,000 visits from children each year, CHI St. Joseph Health said in a news release.

People in the most rural areas are more likely to die from colon cancer even though they are less likely to get it in the first place

Patients who live in remote or very small rural communities are a bit more likely to show up at their doctor's office with late-stage colon cancer than other Americans, which could help explain why patients who live in these areas have such poor colorectal cancer outcomes, a new study says.

Johns Hopkins Medicine image

The study, published in The Journal of Rural Health, looked at the relationship between late-stage colorectal cancer at diagnosis and county-level characteristics, including the level of rurality (how rural a place is), patient characteristics, and factors such as persistent poverty, low education, and low employment.

The study notes that cancer outcomes are often worse for rural patients, with various studies finding they have an 8 to 15 percent greater chance of dying from colon cancer.

"While rural communities overall have lower incidence of cancers compared to urban populations, they have higher cancer-related mortality rates," says the report. In other words, people in the most rural areas are more likely to die from colon cancer even though they are less likely to get it in the first place.

The researchers identified 132,777 patients in Kentucky and nine other states who had colorectal cancer in 2010-14. After placing patients in five rural-to-urban categories, the study found that the adjusted percentages of stage 4 colon-cancer patients by county geography were: metropolitan areas, 19.3 percent; micropolitan areas (with a city of 10,000 to 50,000) adjacent to a metro area, 20.4%; non-adjacent micropolitan areas, 19.2%; small rural places, 20.2%; and remote rural places, 22.7%.

"Patients living in remote, small counties were significantly more likely to present with stage 4 colorectal cancer than patients living in other counties," the study report says.

The data came from cancer registries in California, Connecticut, Georgia, Hawaii, Iowa, Kentucky, Louisiana, New Mexico, Utah and Washington. The registries included 352 rural and 235 urban counties, representing 18% and 20% of all rural and urban U.S. counties, respectively.

Among the 10 states studied, "Patients in Kentucky had the lowest adjusted rate (18.2%) of stage 4 diagnosis," the report says.

Kentucky's rate of colon cancer is the nation's highest, but the state has been nationally recognized for getting its citizens screened for it. A University of Kentucky news release in March said the Kentucky Cancer Consortium received an award for its efforts to increase screening. The release said that between 1999 and 2016 screening rates in Kentucky rose from 35% to 70%, improving more than any other state in the country and moving the state from a ranking of 49th to 17th.

Breakdown of study; click on image for a larger version

The study found that younger patients, black patients and single or widowed patients were more likely to present with late-stage colorectal cancer. The researchers note that these findings are consistent with decades of data and suggest that little or no improvement has been made in addressing these disparities.

It also found that a lack of insurance was the most significant predictor of late-stage diagnosis, which was also consistent with other research.

"Patient medical insurance categories had the greatest effects on the rate of stage 4 colorectal cancer at diagnosis. The rate was highest among uninsured patients (28.6%) compared to patients with any type of Medicaid insurance (24.4%) and other insured patients (18.4%)."

In addition to a known lack of screening services in rural areas, "the high cost of colonoscopy, access to specialty referral networks, lack of transportation, and lower health literacy may all play a role in these findings," says the report.

The American Cancer Society recommends colorectal screening for average risk individuals to begin at the age of 45, instead of 50. Those with a family history of colon or rectal cancer should check with their doctor about getting screened earlier. Colon cancer is 90 percent curable when detected early.

September is National Recovery Month; recovering addict Rex Chapman slated to attend event in Paintsville Sept. 21

Every September, the Substance Abuse and Mental Health Services Administration sponsors National Recovery Month to increase awareness and understanding of substance-use and mental disorders and to celebrate the people who recover.

"This observance celebrates the millions of Americans who are in recovery from mental and substance-use disorders, reminding us that treatment is effective and that people can and do recover," says a National Recovery Month report that discusses common disorders and misused substances.

This year's new logo features a typewriter "r" for recovery.

The 2019 theme is "Join the Voices for Recovery: Together We Are Stronger," which SAMHSA says emphasizes the need to share resources and build networks across the country that support recovery in all its forms. This is the 30th anniversary of the event.

This year's focus is on the various groups that support recovery in our society, including community members, first responders, the health-care community, youth and emerging leaders.

Mental and substance-use disorders are quite prevalent in the United States, with 46.6 million adults 18 or older having any mental illness in the past year and in 2017, an estimated 30.5 million Americans aged 12 and older currently using illicit drugs or used an illicit drug in the past month, says the National Recovery Month report.

"The observance reinforces the positive message that behavioral health is essential to overall heath, prevention works, treatment is effective, and people can and do recover," says The Association for Addiction Professionals on its website.

Only one event is listed for Kentucky on the National Recovery Month webpage. The Kentucky Addiction Center is partnering with the Rex Chapman Foundation to sponsor the "Recovery Out Loud" event. It will be held at Paintsville Lake State Park in Staffordsville from 8 a.m. to 8 p.m. Sept. 21. The event will include a full day of food, music and activities, including a 5K run, stories of success and a chance to meet former University of Kentucky basketball star Rex Chapman, who played 12 years in the NBA, and to hear his story of addiction and recovery.

SAMHSA offers a Recovery Month Toolkit for individuals and organizations to use to increase awareness about recovery. It includes tips and resources for planning Recovery Month events and for distributing information in communities.

86 percent of Kentucky's school districts have already adopted tobacco-free polices, ahead of state law with opt-out provision

Only 24 of Kentucky's 172 school districts, or 14 percent, have not passed a tobacco-free policy that mirrors a new state law that will take effect next July 1, according to the Foundation for a Healthy Kentucky, which says more districts are expected to enact the policy soon.

The law gives districts the ability to opt out of the law during its first three years, but it seems to have prompted them to opt in. Half of the districts with the policy have enacted it since Gov. Matt Bevin signed the law April 9, the foundation's Bonnie Hackbarth said. When it was signed, only 74 of the state's 172 school districts, or 42 percent, were fully tobacco-free.

Many of the adopters since Aug. 9 were in a swath of counties in the Pennyroyal regions of Southern Kentucky, from Taylor and Cumberland in the east to Lyon in the west; tobacco production remains common in the region, and there is a smokeless tobacco plant in Hopkinsville, the seat of Christian County, which has not adopted the policy. Here are maps showing the increase since April:

Dr. Angela Tackett Dearinger, UK physician, appointed commissioner of the Kentucky Department for Public Health

By Melissa Patrick
Kentucky Health News

The state Cabinet for Health and Family Services has named Dr. Angela Tackett Dearinger commissioner of its Department for Public Health.

Dr. Angela Tackett Dearinger

Dearinger, 43, is board-certified in internal medicine, pediatrics, public health and general preventive medicine. She is an associate professor at the University of Kentucky and is its College of Medicine's assistant dean for accreditation of graduate medical education. She has also been  associate chief of staff for education for the U.S. Department of Veterans Affairs hospitals in Lexington.

One of Dearinger's mentors, Dr. F. Douglas Scutchfield, the Peter P. Bosomworth Professor Emeritus in the UK College of Public Health, called her a "superlative" choice.

"What she'll bring to this role is a broad knowledge of what current public health is about," Scutchfield said. "She understands from an academic perspective and from her relationships with the practice community at local and state levels how you can intervene on a population basis to improve health status." He later added, "I think she will do a marvelous job. I'm just delighted."

Dearinger and Scutchfield created the Kentucky Public Health Research Network, the first practice-based research network for public health in Kentucky. Last year Gov. Matt Bevin appointed her to the Kentucky Board of Medical Licensure.

She graduated from Transylvania University and the UK College of Medicine. She completed her residency in internal medicine and pediatrics at the University of Alabama at Birmingham then earned Master of Public Health degree at UK.

In a news release, state Health Secretary Adam Meier called Dearinger a "proven leader with outstanding qualifications and a thorough understanding of Kentucky's public health system."

"The Kentucky Department of Public Health is at a pivotal point in its history, working to address many population-health issues in fiscally challenging times," Meier said in the release. "Successfully navigating through these complex issues will require great leadership, and to that end I am excited to have Dr. Angela Dearinger join DPH as the public health commissioner."

Dearinger is the third health commissioner under Bevin, who is running for a second four-year term this fall. She replaces Dr. Jeffrey Howard, who left in August to become a White House fellow, a year-long job as a full-time assistant to senior White House staff, cabinet secretaries or other major federal officials.

Howard became acting commissioner in November 2017, replacing Dr. Hiram Polk, who had brought him into the department and was forced out. Howard was named commissioner in June 2018, despite criticism that he made an inadequate response to a hepatitis A outbreak that began about the time Polk left. The outbreak became the nation's largest, and has killed 61 people.

Like Howard, Dearinger is from Eastern Kentucky. A Paintsville native, she lives in Versailles with her husband and three children. She said in the news release, "I am honored to have the opportunity to serve as the public health commissioner, and excited to collaborate with public health partners from across the commonwealth to address our shared health-care needs and challenges."

After 2018 tax hike, cigarette sales in Ky. dropped 10%, more than the national decline; bill would tax e-cigs, sales of which are rising

The tax hike made cigarettes noticeably more expensive in Kentucky than in Indiana and Tennessee, and narrowed price differentials with Ohio and West Virginia; that may have reduced Kentucky sales.

By Melissa Patrick
Kentucky Health News

The year after Kentucky increased its cigarette tax by 50 cents, to $1.10 per pack, 36 million fewer packs were sold in the state. That was a decrease of about 10 percent, more than the national decline of 6.1%.

According to an Aug. 9 report from the state budget director, in fiscal year 2019, which ended June 30, 321.1 million packs of cigarettes were sold in Kentucky, down from 357.1 million in fiscal 2018.

The report notes that from calendar year 2016 to 2017, cigarette sales in the state dropped 3.5%.

That's a "big deal." said Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, which lobbied for the tax increase and is now pushing for a tax on electronic cigarettes.

"It is pretty clear to us that a lot of these packs of cigarettes were not purchased as a result of the rise of the cigarette tax," Chandler said. "You can never completely prove it, but the fact that we had such a decrease . . . the size of the decrease was unusual right after the cigarette tax went into effect."

The last Kentucky Health Issues Poll, taken Aug. 24-Oct. 21, 2018, found that half of Kentucky smokers said they smoked less, or considered or tried to quit smoking, following the tax hike; 39% of Kentucky smokers said they reduced their smoking, 33% considered quitting, and 26 % tried to quit.

Chandler called those results "pretty good data that would suggest that the price increase does affect people's behavior."

Some critics of cigarette-tax increases argue that governments shouldn't rely on revenue sources that are declining. Chandler said that any loss in revenue from fewer tobacco sales will result in a significant long-term savings to the state's health budget. He said the state Medicaid program pays $600 million a year in smoking-related costs.

Chandler said he thought a proposed tax on electronic cigarettes would have a similar effect on teenagers' use of the products.

"I think particularly among young people, the tax will have a profound effect," he said. "One thing this information shows you is that when you raise the price, consumption does go down. And we believe that the people who are more likely to be susceptible to a price increase are kids because they don't have a whole lot of disposable income."

Kentucky lawmakers have pre-filed legislation (Bill Request 32) for the 2020 legislative session to tax electronic cigarettes like other tobacco products, as a way to curb surging youth use of the devices.

Map by Stateline, a service of the Pew Charitable Trusts, shows in
green states that tax e- cigarettes. (Click on map for a larger version)

Use of e-cigarettes nearly doubled among Kentucky youth from 2016 to 2018, with more than one in four high-school seniors reporting last year they they had used e-cigs, and experts say that is part of a national epidemic.

At a July news conference, state Rep. Jerry Miller, a Louisville Republican and House State Government Committee chair, announced a bipartisan proposal to levy an excise tax of 27.5% on electronic cigarettes.

E-cigarettes are the only tobacco product not subject to a state excise tax in Kentucky. The bill would also raise the excise tax on tobacco products such as snuff and chewing tobacco to equal the tax on cigarettes.

In its 2014 report, "The Health Consequences of Smoking: 50 Years of Progress," the surgeon general said increasing prices is "one of the most powerful tobacco control interventions" because price hikes are proven to reduce smoking, especially among teenagers.

An e-cigarette tax was in the 2018 bill that raised the cigarette tax, but was removed in the Senate, just before final passage and after lobbying by Altria Group, the largest tobacco company and 35% owner of Juul Labs, the largest e-cig company. Altria outspent all other lobbying interests in the 2018 legislative session, spending about $380,000 to influence legislators.

Between Jan. 1 and April 30 of this year, Juul Labs has spent around $43,000 for lobbying the General Assembly, according to a report from the Kentucky Legislative Ethics Commission.

Stateline reports that 17 states and the District of Columbia have specific taxes on e-cigarette products, with half of those taxes implemented in 2019, according to the Public Health Law Center at the Mitchell Hamline School of Law in St. Paul, Minnesota.

Cigarette sales decrease as Juul sales increase

A graph on the Juul Labs website shows that since the end of 2017 the quarterly decline in cigarette sales has steadily accelerated, going from 3.5% to 7.2%, while Juul sales surged, with the quarterly increases rising from 1% to 6.3%. The Juul analysis notes that a 1% annual decline in cigarette sales represents about 125 million fewer packs of combustible cigarettes.

"These changes in the U.S. tobacco market are a testament to the success of Juul products in switching adult smokers off combustible cigarettes," Juul CEO Kevin Burns said in the report.

Chandler pushed back on that assertion, saying that research does not show that adults who switch to an e-cigarette product are more likely to quit -- and that it also shows that those who use e-cigarettes often use both products. He added that the U.S. Food and Drug Administration has not approved e-cigarettes as a smoking cessation device.

He said research shows that teenagers who would never have smoked a traditional cigarette are using e-cigarettes at alarming rates. Other studies show that those who use e-cigarettes end up smoking traditional cigarettes at about the same rate as teens who first start with traditional smokes.

"I don't buy into the notion that Juul suggests, that the e-cigarettes have been central in cutting down smoking," Chandler said. "What I see is young people taking up e-cigarettes who would have never smoked otherwise."

Study finds it takes longer than previously thought for a heavy smokers' risk of heart disease to be the same as a non-smoker

Quitting smoking has immediate benefits to the heart, but it takes longer than previously thought for a former smoker's risk of heart disease to return to the level of someone who has never smoked, Lisa Gillespie reports for Louisville's WFPL.

Medical News Today photo

“The conventional wisdom is that within five years of smoking cessation, your cardiovascular risk goes back to that of someone who has never smoked, [but] we found that it could take longer,” lead study author Meredith Duncan, of the Vanderbilt University Medical Center, told Gillespie.

The study, published in the Journal of the American Medical Association, found that among heavy smokers, within five years after quitting, a person's risk of heart disease is significantly lower than that of a person who continues to smoke, but it takes 10 to 15 years, and as much as 25 years, before their risk is the same as a person who has never smoked. A heavy smoker is someone who has smoked a pack a day for 20 years.

“Even among these really heavy smokers, we found that there’s a huge benefit of quitting, and that they experienced a 39 percent reduced risk of cardiovascular disease within five years of smoking cessation relative to people who continue to smoke,” Duncan told Gillespie.

"The upper estimate of this time course is a decade longer than that of the Nurses' Health Study results for coronary heart disease and cardiovascular death and more than 20 years longer than in some prior reports for coronary heart disease and stroke," says the study report.

Most concern about smoking is related to cancer, with little thought to how it affects the heart, Gillespie writes. She notes that cigarette smoking is linked to about 80% to 90% of lung cancer deaths, according to the Centers for Disease Control and Prevention, but smoking is a major risk factor for heart disease and is responsible for 20% of all deaths from heart disease, the study says.

Duncan told Gillespie that doctors and other health-care providers should consider the study when treating patients who have quit smoking.

“Physicians really want to err on the side of caution,” she said. “They may want to say, ‘For up to 10 years, we’re going to consider you to be at higher risk’.”

Data for the study came from the nearly 8,800 men and women who took part in the Framingham Heart Study, a long-term, ongoing study of factors that contribute to heart disease. Duncan cautioned that the Framingham study is predominantly made up of white people who live in a community outside Boston, so it is not certain if these findings extends to other races or ethnicities.

Duncan told Gillespie that she and her team will now experiment with the existing heart risk calculator, a tool that is used for those who have not had a prior heart event, to predict their risk of a heart attack or stroke. She said they are adding questions about the time since a person quit and how heavily they smoked.

The researchers' hypothesis is that those additions might line up the risk calculations with her study results. “We want to see if … adding just those two variables to the calculator helps in aiding risk prediction among former smokers,” Duncan said.

Skyrocketing cost of insulin examined by legislative committee and research showing cost makes patients ration the hormone

Advocates called on state lawmakers to find a way to make insulin more affordable, with several of them telling an all-too-common story of how they must ration their supplies because the hormone is too expensive, or of being forced to use a different product than their provider recommends because that's the only one their health insurance will cover.

Angela Summers, 48, of Louisville, told the Interim Joint Committee on Banking and Insurance Aug. 21 that she  struggled to pay for her insulin after moving back to Kentucky from New York in 2009, when the cost, with insurance, jumped from $35 a month to over $400 a month. She said that resulted in years of rationing that led to diabetes-related health issues that resulted in the amputation of her lower right leg in 2013.

"I could keep my lights on or I could pay for my insulin," she said in a prepared statement for the committee. She said she often bargained with herself, saying, "I'll make one month's worth of insulin last three months . . . or I'll just get it next month, which turns into six months."

Summers told the group that she is now taking what she called an "outdated" and "inferior" type of insulin that she can buy at Walmart for about $25 a vial. She said this isn't the type of insulin that her provider recommends, but is what her insurance will cover. "I use inferior insulin; because my insurance covers it, because I can afford it and because I'm not ready to die," she said.

Gary Dougherty, chief state lobbyist for the American Diabetes Association, told the committee that Summers isn't alone in her struggle, Jim Hannah reports for the Legislative Research Commission.

“Using less than the prescribed amount of insulin can result in uncontrolled glucose levels which can lead to damage to one’s eyes, kidneys and heart,” Dougherty said. “Ultimately, without enough insulin, diabetic ketoacidosis can occur. If untreated, it can lead to diabetic coma – or even death.”

Angela Laudner of Northern Kentucky, who uses three vials of insulin a month, told the committee that she bought a vial of her insulin in Canada for $22, while that same vial's over-the counter retail price was $300 at the Costco in Newport, Tom Latek reports for Kentucky Today.

Dougherty gave the committee a list of facts about diabetes and insulin in Kentucky: 567,000 residents, or just over 15 percent of the state’s adult population, have diabetes; of those, an estimated 108,000 don’t know it. Another 1.16 million, or 35 percent of the adult population, have pre-diabetes. Each year, an estimated 130,000 Kentuckians are newly diagnosed with diabetes.

People with diabetes spend about 2.3 times more on health care than those who don't, Dougherty said. In Kentucky, the total direct medical expense for diagnosed diabetes in 2017 was estimated at $3.6 billion. An estimated $1.6 billion was spent on indirect costs from lost productivity due to diabetes.

The Diabetes Association's key legislative recommendations were to require transparency throughout the insulin supply chain; to lower or remove patient cost-sharing for insulin, such as capping co-pays for insulin or exempting it from the deductible; and to ensure that the value of co-pay assistance programs would apply toward a patient's deductible.

Rep. Danny Bentley, R-Russell, introduced a bill during the last legislative session to address the rising cost of insulin that called for increased price transparency from drug manufacturers and pharmacy benefit managers. It didn't make it out of committee.

Bentley pre-filed legislation in June, Bill Request 105, that would cap the insulin co-pay at $100 per month. It would not instruct the state attorney general to investigate insulin pricing, as a similar bill that recently passed in Colorado does. Several legislators said the legislature should give the attorney general power to investigate prices, Latek reports.

Attorney General Andy Beshear launched an investigation in March to find out whether pharmacy benefit managers have overcharged the state and discriminated against independent pharmacies. In July, he asked for more legal help to further this investigation. He has also filed lawsuits against three of the nation's largest insulin makers to address the skyrocketing drug prices.

Pharmacy benefit managers are the middlemen between insurance and drug companies. They determine which drugs are offered, their prices and the payments to pharmacists.

Research shows cost makes patients ration insulin

A study released this month by the Centers for Disease Control and Prevention that looked at strategies adults with diabetes use to reduce their prescription drug costs. It found that in 2017 and 2018, nearly 18% of working-age adults with diabetes rationed their insulin by taking smaller doses, waiting to fill prescriptions, or skipping their insulin altogether.

The study found that among working-age adults, 36% of those without insurance said they were not filling a prescription because they did not have the money. Even among those with private insurance and Medicaid, respectively, 14% and 17.8%, said likewise.

Among adults of all ages in the study, 13% reported they didn't take their medications as prescribed in order to cut cost.

A Yale University study shows that one in four patients with diabetes have reported using less insulin than prescribed due to its high cost, and that over a third of those patients said they had never discussed this reality with a health-care provider.

And the price of insulin keeps going up, with the average cost of an insulin prescription doubling between 2012 and 2016, according to the Health Care Cost Institute. Kentucky data from that report shows that the average point of sale price per prescription was $352 in 2012, rising to $721 in 2016. The report found the average national price increased from $344 in 2012 to $666 in 2016.

The CDC study concludes: "In 2018, medications to treat diabetes ranked sixth out of the top 20 therapeutic classes of dispensed prescriptions, accounting for 214 million prescriptions. In 2017, the annual per capita expense for outpatient medication for those with diagnosed diabetes was almost $5,000. . . . The burden associated with high prescription drug costs remains a public health concern for adults with diagnosed diabetes."

State approves lower overall rates and expanded area for one Obamacare insurer, lowers rate-hike request of the other one

Insurance Department maps, adapted by Kentucky Health News; click on either for a larger version.

Federally subsidized health insurance in Kentucky next year will cost more or less than this year, depending on the insurer and the type of plan. And many consumers will have more choices.

Policies offered on the federal insurance exchange by Anthem Health Plans of Kentucky will go up an average of 9.7 percent, which 2.3 percentage points less than the 12 percent Anthem asked of the state Department of Insurance.

The department approved proposals by CareSource Kentucky Co. that will be 4.5 percent less than this year, on average. CareSource will serve an expanded area, covering 83 counties. That means 56 of the state's 120 counties will have more than one insurer to choose from on the exchange.

"The actual rates charged will vary based on individual plan selection and factors," the Insurance Department noted in a news release. Detailed rate filings are at http://insurance.ky.gov/ratefil.

“The department has reviewed some rate decreases for individual health insurance plans,” Insurance Commissioner Nancy G. Atkins said. “For the first time in years, Kentuckians purchasing health insurance on the exchange could see rate decreases.”

CareSource will offer 12 individual plans on the federal exchange, which must be used to get the tax credits for premiums. "These plans vary in levels from catastrophic to gold, and include nine different silver and bronze options," the release said. Silver and bronze plans are in the middle range for premiums and deductibles under the 2010 Patient Protection and Affordable Care Act.

Anthem will offer 13 individual plans on the Exchange, under different network and service area options. "The Anthem Pathway HMO service area includes seven approved plans. These plans, with a broad provider network, will be offered in 77 counties," the release said. "The second option is the narrower Anthem Pathway Transition HMO, and includes six different plans available in 17 counties." The areas overlap only in Hardin County.

Open enrollment for individual plans opens Nov. 1 and ends Dec. 15. The Insurance Department says that before enrollment opens, consumers should work with an agent, do their own research or contact the department to understand their options. “It is critical to review the details for each plan to minimize the potential for surprises later on,” Adkins said, “and ensure individuals purchase the plan that best suits their individual needs.”

U of L moves to maintain heart transplants at Jewish Hospital

Doctors perform a heart transplant. (Photo from WBUR, Boston)

The heart-transplant program at Jewish Hospital in Louisville may continue after all, now that the University of Louisville plans to take over the facility on Nov. 1.

KentuckyOne Health, which is selling the hospital and other facilities to the university, is asking the national organ-donor network to disregard its July 18 request that the program be put on long-term inactivation, Kentucky One and the university announced Friday. Letting the program go inactive could have required recertification by the Centers for Medicare and Medicaid Services, which would take more than a year and cost millions of dollars.

The university has collaborated for 35 years on the program, which is linked to its medical school.  “The heart-transplant program is simply too important for our university, our community and the patients who are depending on this life-saving procedure,” U of L President Neeli Bendapudi said in a news release. “We thank KentuckyOne for working with us to maintain the program. We are taking steps to shore up our efforts, and very soon we will have a plan in place to ensure the viability of the program for the future.” 

The release noted, "The first heart transplant in Kentucky took place on Aug. 24, 1984, at Jewish Hospital. Last year KentuckyOne and UofL celebrated a major milestone after the 500th heart was transplanted."  However, the number of transplants at the hospital has declined greatly; KentuckyOne blamed a change in how hearts are allocated by the United Network for Organ Sharing.

Jewish Hospital also performs lung, liver, kidney and pancreas transplants, "making it one of a select group of hospitals transplanting all five solid organs," the release said. However, kidney and liver transplants at the hospital have also become less frequent.

Tobacco-free-schools law for 2020 prompts 57 more districts to adopt policy, making a strong majority; newbies can get free signs

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- A statewide smoking ban in Kentucky schools is still almost a year away, but passage of it appears to have prompted most school districts to go ahead and adopt tobacco-free policies. And they're getting some help in telling students, teachers and campus visitors about it.

The law passed this year prohibits the use of all tobacco products, including electronic cigarettes, on school-owned property and school-sponsored events in all Kentucky schools, effective July 1, 2020. School boards have three years to opt out of the ban, but the law appears to be making them opt in.

When the bill became law, only 72 of the state's 172 school districts, or 42 percent, were fully tobacco-free. As of Aug. 9, that number was up to 129, about 75% of the districts and 79% of students, with more to be added soon.

The law also requires schools to post signs, but provides no funding for signage. The Kentucky Medical Association, the Kentucky Foundation for Medical Care and the Foundation for a Healthy Kentucky have created signs in consultation with the Kentucky School Boards Association. and are offering them to districts that adopted tobacco-free policies after the law passed.

"We know that placing readily recognizable tobacco-free signs on campuses across this state will remind students, staff and entire communities that tobacco use has no place anytime or anywhere at school," Ben Chandler, president and CEO of the health foundation, said at a Frankfort news conference.

Chandler said districts that adopted tobacco-free policies after April 9, when the bill became law, can get the indoor, outdoor and vehicle signs on a first-come, first-serve basis.

In January 2020, if supplies remain, the signage will be offered to all school districts, including those that had previously passed tobacco-free school policies.

The focus of concern about students and tobacco has shifted from traditional cigarettes to electronic cigarettes. More than one in four high-school seniors in Kentucky reported last year that they had used e-cigarettes, and experts say that is part of a national epidemic.

Testimony from students during the legislative session helped persuade many of the lawmakers about the need for a tobacco-free school law, and two students reiterated that at the news conference.

"This is a very real problem," said Abbi Stratton, a senior at Graves County High School in far Western Kentucky. "It has definitely increased over the course of my freshman to my senior year."

Stratton and another senior, Kendall Tubbs, said Graves County passed its tobacco-free school policy after Aug. 9, making it the 130th district to do so.

"Usage has become a social norm," he said. "Even when class is going on, kids are always vaping."

"Vaping" is a term popularized by the electronic-cigarette industry. Actually, e-cigarettes produce an aerosol, which is a suspension of particles in a gas; a vapor is "a substance in the gaseous state as distinguished from the liquid or solid state," the Merriam-Webster dictionary says.

Kendall Tubbs, Abbi Stratton and Ben Chandler spoke
about a program to provide free signage to schools that
adopted tobacco-free policies after passage of the law.

"E-cigs are chock-full of nicotine and poisons that are addicting and sickening our kids," Chandler said. "So let's call them what they are -- tobacco products -- and let's keep them away from our kids."

KMA President Bruce Scott said the surge of e-cigarette use among Kentucky's teens is creating a new generation of nicotine addicts.

"When you consider the fact that 90 percent of adult smokers started smoking before age 18, we have an imperative to make sure that we stop smoking and convince every high school student never to pick up a cigarette or tobacco product in the first place," he said.

An order form and information about the signage can be found on the Tobacco-Free for Students website, www.tobaccofreestudents.org.

Youth who use electronic cigarettes are much more likely to use marijuana; connection has increased with refillable e-cig pods

By Melissa Patrick
Kentucky Health News

Youth who use electronic cigarettes are more likely to use marijuana, and the odds are even greater for those who start using e-cigarettes early, according to newly published research.

HealthDay photo

The analysis of 21 separate studies, published in JAMA Pediatrics, found that the odds of marijuana use were 3½ times higher among youth who used electronic cigarettes, than among those who didn't; that risk was higher among those between the ages of 12 to 17, compared to young adults aged 18 to 25.

The researchers are concerned about the link between e-cigarette use and marijuana.

"Studies have shown that marijuana use during adolescence is associated with reduced cognitive abilities, motivation, satisfaction with life, and life achievement, as well as significantly greater rates of mental health disorders, such as depression, anxiety and schizophrenia," the summary of the studies says.

Teen use of e-cigarettes in Kentucky doubled from 2016 to 2018, according to a state survey. It found that 26.7% of high-school seniors reported using e-cigs in the month before they were surveyed, up from 12.2% in 2016.

Among 10th graders, use increased to 23.2% from 11.3%. Among eighth graders, it rose to 14.2% from 7.3%. Sixth-graders' use went to 4.2% from 2.3%.

A national study found that use of e-cigarettes increased nearly 80% among high schoolers and 50% among middle schoolers from 2017 to 2018.

The study, involving data from more than 128,000 participants aged 10-24, found that the association with marijuana was stronger in younger youth and those who used both e-cigarettes and other tobacco products, such as traditional cigarettes.

"The findings of increased marijuana use with [e-cigarette] use in younger vs. older youths is consistent with developmental assumptions that a younger, less-developed brain is more vulnerable to substance use and addiction," says the report.

E-cigarettes have high levels of nicotine, which has been proven to be harmful to the developing brains of teens and may "increase [the] risk for future addiction to other drugs," according to the Centers for Disease Control and Prevention. The brain develops until about age 25.

The study also found that the association with marijuana was stronger in the studies published in 2017 or after. The reason is unclear, but the researchers point to the rise in refillable cartridges and pod-like devices, which have high levels of nicotine.

The report concludes, "These findings highlight the importance of addressing the rapid increases in e-cigarette use among youths as a means to help limit marijuana use in this population."

UK Extension Service teaches life skills such as nutrition in drug-treatment facilities; 10 counties have grants for gardens

By Katie Pratt
University of Kentucky

CAMPBELLSVILLE, Ky. -- Program assistants and agents with the University of Kentucky's Cooperative Extension Service are teaching life skills to help individuals recovering from drug and alcohol addiction live healthier lives once they leave treatment facilities.

In January, the UK College of Agriculture, Food and Environment hired recovering heroin addict and doctoral student Alex Elswick as extension specialist for substance-use prevention and recovery. He has started a program with agents in three counties; two other programs with agents in four other counties are to start next month. Elswick is co-founder of the UK Collegiate Recovery Community.

In Taylor County, program assistant Angie Freeman offers nutrition-education programs to clients at The Healing Place, an addiction recovery center in Campbellsville. She has led programs at the all-male treatment facility since 2013, presenting topics such as meal planning, MyPlate, food budgeting and food safety.

The education programs are funded by the federal Supplemental Nutrition Assistance Program, which includes what were once known as food stamps. This part of the program is known as "SNAP-Ed."

“Our eight-week class series is geared toward trying to have a healthy family and a healthy lifestyle on an economical level,” Freeman said. “Hopefully, they will take the things we have talked about and go home and actually meal plan using the weekly grocery ads, so they can make a really good shopping list and eat on a more economical basis.”

Freeman discusses ways clients and families can eat healthier.
(Photo by Steve Patton, UK Agricultural Communications)

The Healing Place staff report that the eight-week class greatly helped participants, so they now require all of their clients to complete the class before leaving the treatment facility.

Steve Croghan of Columbia has been a client at the center for six months, recovering from an addiction to suboxone and methamphetamine. When interviewed, he was days away from graduating from the program's first phase. He said Freeman’s class gave him information that will help him as he moves forward with his life.

“Angie and Kara have been tremendously helpful for us,” he said. “Angie actually takes the time with us to make us understand what is going on and gives us a lot of good nutritional values. It helps us live out there healthier.”

In addition to nutrition education, Freeman’s class tends a small, raised-bed garden on the property. Taylor is one of 10 counties that have grants from SNAP-Ed to install and help manage gardens at addiction recovery centers. 

Extension agents and program assistants in Jefferson, Pendleton, Daviess, Martin, Lawrence, Pulaski, Boyd and Madison counties have received funding to partner with local addiction recovery centers to install gardens at the facilities.

Christopher Browning is a Healing Place client from New Haven, recovering from a heroin addiction. Even though he was raised in rural Kentucky, he said the gardening classes have been eye-opening. He enjoys tending the garden.

“It’s something different to do in a place like this,” he said. “It makes us not so sheltered in. We get to get out and do some things that we might enjoy doing on the outside.”

The Healing Place started out with one raised-bed garden in 2018, with their clients raising cool- and warm-season salad ingredients. They added another bed this year and plan to add another in 2020.

“I really hope they gain basic knowledge about how to grow their own fruits and vegetables,” Back said. “Some of them have never really done this before, and it’s just a way for them to see it firsthand. Maybe later on down the road in their life, they may be interested in growing some on their own.” 

Recently, 17 men graduated from Freeman’s series of classes. Two of them were Croghan and Browning, who were excited about their accomplishment.

“It’s nice to actually complete something,” Browning said. “I have not done so well with that the last few years of my life, but I have actually had the patience and the time to do something productive.”

Health foundation offers new public-service announcements about dangers of teens' use of electronic cigarette use; free to anyone

The Foundation for a Healthy Kentucky has released four new public service announcements to show the dangers young people subject themselves to by using electronic cigarettes. The spots are part of the foundation's "I Just Didn't Know" campaign and feature Kentucky teens.

The new PSAs include two 30-second videos for television and a 30-second and 60-second audio PSA for radio. Additionally, the campaign provides PSAs that were released in April.The campaign materials are free to anyone who would like to use them.

In one of the PSAs, Hayley from Grant County says, "A lot of people don't know that one little pod of this e-cigarette is equal to a whole pack of cigarettes."

Research shows that public health campaigns can play a crucial role in reducing tobacco use among teens.

A study, published in the American Journal of Preventive Medicine, of the U.S. Food and Drug Administration's national tobacco public education campaign found that between Feb. 2014 and Nov. 2016, "The Real Cost" campaign prevented up to 587,000 youth from trying traditional cigarettes, half of whom might have gone on to become adult smokers, according to a FDA statement. This will result in a savings of more than $53 billion in future smoking-related costs like medical care, lost wages, lower productivity and increased disability, says the release.

"The Real Cost" campaign expanded to educate teens on the dangers of e-cigarette use in Sept. 2018.

"Over and over, we hear that teens -- and sometimes even their parents -- just don't understand the significant health risks of kids using these highly addictive tobacco products," Ben Chandler, president and CEO of the foundation, said in a news release about the four new PSAs. "We're doing all we can to help pass laws that restrict youth access, but we know that most kids are going to be making the final decision themselves. When someone leans over and urges them to buy an e-cig, we want to make sure they have a clear, factual understanding of all the reasons to avoid becoming a pawn of the tobacco industry."

A 2018 federal report said one in five high-school students and one in 20 middle-school students used e-cigarettes, a 78 percent jump for high schoolers over 2017 and a 48% jump for middle schoolers.

In Kentucky, a 2018 state poll found that 27% of high-school seniors reported using e-cigarettes, up from 12% in 2016.

E-cigarettes do not release harmless vapors, but instead contain substances such as: ultrafine particles, which can be inhaled deep into the lungs; flavorings such as diacetyl, a chemical linked to serious, irreversible lung disease; volatile organic compounds, which are known to be carcinogenic; other cancer-causing chemicals; and heavy metals, including nickel, tin and lead, according to the Centers for Disease Control and Prevention.

E-cigs also contain high levels of nicotine, which is highly addictive and can harm young people's brain development and reduce attention span and impulse control. Nicotine use in adolescence can also prime the brain for future addiction to other drugs, says the CDC.

One of the most popular e-cigarette brands with teens is the Juul, largely because they look like an oversized computer flash drive, are easy to conceal and come with flavorings. One Juul pod contains as much nicotine as a pack of 20 regular cigarettes.

"We regularly hear stories of kids using several e-cig juice pods a day, which means they inhale multiple packs of cigarettes worth of nicotine," Chandler said. "No wonder the FDA is investigating incidences of seizures associated with youth e-cig use."

On Aug. 7, the FDA announced that it was investigating 127 reports of seizures, tremors, fainting or other neurological symptoms that may be related to electronic cigarettes, and have asked anyone who has experienced such symptoms to report them.

All the PSAs can be found at www.ijustdidntknow.org. Contact Alexa Kerley at 877-326-2583 or akerley@healthy-ky.org for broadcast-quality copies.

Drug Free Lexington has also recently released PSAs aimed at educating e-cig users about their harmful effects are also free for all to use.

First man on moon may have died because he chose the wrong Cincinnati-area hospital for surgery; don't make the same mistake

By Trudy Lieberman
Rural Health News Service
    Last month The New York Times ran a cautionary tale about the heart surgery and care astronaut Neil Armstrong received and his death two weeks later at a community hospital in the Cincinnati suburb of Fairfield in 2012.
    The Times had received documents from an anonymous tipster who said he/she was “compelled to share this information” so “others can be saved as a result of the dissemination of this information to the public because this American hero did not have to die an untimely death.”  

    The hospital had made a secret $6 million settlement with the family, the Times reported, and consulted cardiac experts who pointed out numerous trouble spots in Armstrong’s care. One of those experts, Dr. Ashish Jha, a professor of medicine at Harvard University, told the paper, “It feels to me like his death was wholly preventable. It’s not completely clear to me he needed the cardiac surgery that he got.”

    The Times noted that the records did not say why Armstrong or his family chose a community hospital rather than the University of Cincinnati Medical Center, a larger academic institution that perhaps had more experience dealing with patients like Armstrong.
    That’s the takeaway for countless others considering surgeries and procedures, especially ones that are complex. You want your surgeries done at facilities by surgeons who have experience and expertise at doing them.
    Shortly before the Times published its stories, a Washington-based organization, The Leapfrog Group, released a report on minimum volume requirements for eight high-risk procedures.
    Leapfrog is one of many organizations that make public information about hospital safety. I believe it is one of the most credible. Its warnings about hospitals performing too few complicated procedures that carry a high risk of complications, even death, are to be taken seriously.
    Now Leapfrog has a new standard that sets minimum targets that both hospitals and individual surgeons should meet for patient safety. Previously they had standards only for hospitals.
    “Studies that have looked at correlation show you have a greater risk of dying when you’re at a lower volume hospital,” says Leah Binder, who heads the group.
    Her group does not believe it is safe for patients if their surgeons have not done a minimum number of eight complicated procedures. Those are surgeries, she said, where compelling evidence shows that volume is crucial to positive outcomes.
    The procedures are bariatric surgery for weight loss; carotid endarterectomy; esophageal resection for cancer; lung resection for cancer; mitral valve repair and replacement; open abdominal aortic aneurysm repair; pancreatic resection; and rectal cancer surgery.
    For example, for a cancer lung resection, only about 22 percent of hospitals and 17 percent of surgeons met Leapfrog’s standard for adequate experience with these procedures. Bariatric surgeries for weight loss had the best numbers, with about 68 percent of hospitals meeting the standard and 51.5 percent of the surgeons doing the same.
    Why? Binder said health insurers have imposed regulations for covering the procedure, and they may require preauthorization and other checks. “Because of that scrutiny, we think they are better.”
    In other words, insurance-company oversight may be a good thing, especially since three-quarters of hospitals overall had not established criteria to determine whether the other seven procedures on Leapfrog’s list were appropriate for the patient.
    Binder said rural hospitals were most likely to fall short of the volume requirements. They struggle because sparse populations in their areas mean they don’t perform the same procedure often enough to gain expertise.
    “The priority has to be not the hospital, but the people served by their hospital.”
    Patients must understand the level of risk they face if they choose to have complicated procedures done at a hospital with such low volume.
    “Some people may not want to drive to a facility that’s further away, but at least they should understand that the procedure is not that safe,” Binder warns.
    The hospital industry maintains that attributing surgical expertise only to the numbers of procedures performed ignores other safety improvement strategies.
    Binder says she can’t say performing 100 surgeries is better than 90, but “I do know that 100 is better than one, two, or three. “People in health care know it, and it’s time the rest of the people know that, too.”
What’s been your experience with hospitals or surgeons harming a loved one? Write to Trudy at trudy.lieberman@gmail.com.

Rural coroner made the tough calls on his town's opioid epidemic

Coroner Steve Talbott, in his funeral home
(Photo by Michael S. Williamson, The Washington Post)

How many rural coroners, witnessing death after death from opioid overdoses, would call police in an effort to see how their county was being inundated by the misused prescription drugs? We don't know the answer to that question, but we do know what funeral director Steve Talbott, the elected coroner of Clinton County for the last 25 years, did. He made the calls, and one result was the conviction of a local physician who shared a building with the pharmacy that dispensed more opioids per person per county in 2006-12 than any in the U.S.

Jenn Abelson, Andrew Ba Tran, Beth Reinhard and Aaron C. Davis of The Washington Post reported the story last week, following the Post's publication of other stories drawing on the Drug Enforcement Administration database for those years. Their story is a look at the opioid epidemic from the bottom up, in Albany, Paintsville and Booneville; Kanab, Utah; and Carthage, Tenn., where pharmacies were funnels for large volumes of painkillers.

When Talbott responded as coroner to an overdose death, the Post reports, "Friends and relatives of the dead rarely had answers to Talbott’s questions: What kind of pills did they take and where did they come from? A toxicology report often answered the first question. It was the second one that typically eluded Talbott. As overdose deaths soared, Talbott repeatedly called the state police, hoping they could identify the source of opioids poisoning his community."

Clinton County (Wikipedia map)

Since 2006, 41 people have died of prescription opioid overdoses in the county of 10,000. Talbott told the Post that law enforcement took far too long to pay attention. "The federal investigation began in 2015 after Talbott noticed multiple overdose deaths involving patients of a local physician, Michael L. Cummings, and the Kentucky Board of Medical Licensure expert found Cummings’s treatment of several patients fell below minimum standards of care, court records show," the Post reports. "In 2017, Cummings was charged in federal court with the illegal distribution of controlled substances, which resulted in the deaths of three patients." He pleaded guilty in March to 13 counts of illegally prescribing controlled substances, and was sentenced July 24 to 30 months in prison and fined $400,000. Cummings had his medical practice in the same building as Shearer Drug, operated by Kent Shearer, who declined to comment.

The Post reports, "The 6.8 million opioid pills bought by Shearer Drug from 2006 through 2012 accounted for 66 percent of the total ordered by the county’s five pharmacies, according to The Post’s analysis." When Talbott heard those figures from the Post, he told the newspaper: “It’s a lot of pain medication for this little town.”

"Talbott, who said he grew up with Shearer and attended the same school, hasn’t talked to the pharmacist in a few months," the Post reports. "Talbott said the overdose deaths have waned since Cummings was indicted in 2017, but the epidemic is far from over." He told the paper, “There were just too many people dying from these drugs in such a small place. I hate these drugs. They are awful.”

State denies Planned Parenthood abortion-clinic permit

Republican Gov. Matt Bevin's administration has denied an abortion-clinic license to Planned Parenthood in Louisville, saying it performed abortions without proper authorization from the previous administration, as Democrat Steve Beshear was leaving the governor's office.

Health Secretary Adam Meier told Planned Parenthood in a letter Friday that the 23 abortions it did in December 2015 and January 2016 were a "substantial failure" to comply with state law. Planned Parenthood said it would "continue to fight this decision."

"The decision comes amid an ongoing federal court battle in which Planned Parenthood alleges state officials, under Bevin, an anti-abortion Republican, are deliberately obstructing its efforts to get a license for abortion services," report Deborah Yetter and David Harten of the Courier Journal.

"Planned Parenthood officials produced documentation from state officials directing them to open the clinic and begin providing all services, including abortions, so it could be inspected and granted a license. But the license had not been issued when Bevin took office in December 2015. His administration ordered Planned Parenthood to stop, saying such abortions were not authorized without a license. Planned Parenthood immediately stopped providing abortions as it continued with its license application."

The application languished, and in June U.S. District Judge Greg Stivers in ordered the state to expedite its review "and report back to him no later than Aug. 19 with a decision," the CJ notes. On Friday, Bevin's office told Stivers that he has "no jurisdiction over the state licensing process."

The administration first refused to grant Planned Parenthood a license on grounds that it lacked adequate agreements with other health-care providers. Meanwhile, it tried to revoke the license of Kentucky's only operating abortion clinic, EMW Women's Surgical Center in Louisville, claiming its transfer and transport agreements were deficient. Stivers ruled that the law requiring such agreements is unconstitutional; his ruling is on appeal.

Rural hospitals are likely to be hurt by limit on payments to those with large shares of Medicaid and uninsured patients

Many if not most rural hospitals are likely to take a hit from an Aug. 13 decision of the U.S. Court of Appeals for the District of Columbia Circuit.

"Hospitals that care for a large share of Medicaid, low-income and uninsured patients stand to receive less funding from the federal government after the D.C. Circuit reconsidered how Medicaid disproportionate-share hospital reimbursement is calculated," Alex Kacik reports for Modern Healthcare. "A three-judge panel . . . reversed a lower court and reinstated a 2017 rule establishing that payments by Medicare and private insurers are to be included in calculating a hospital's DSH limit, ultimately lowering its maximum reimbursement."

Hospitals qualify for disproportionate-share payments if they get a significant portion of their revenue from Medicaid, which usually doesn't cover the cost of care. And rural hospitals are more likely than others to fall into that category.

The Centers for Medicare and Medicaid Services issued a rule in 2017 saying Medicare and private-insurance payments must be included when calculating the maximum disproportionate-share payment, partly "to prevent hospitals from double-dipping by collecting DSH payments to cover costs that had already been reimbursed," Kacik reports. "Previous cases also revealed that some states have made DSH payments to state psychiatric or university hospitals that exceed the net costs, or even total costs, of operating the facilities."

Four children's hospitals in Minnesota, Virginia and Washington, along with eight children's hospitals in Texas, filed suit to challenge the rule, saying CMS had overstepped its authority. The next step in the case could be an appeal to the Supreme Court or a hearing by all the judges on the appeals court, either of which could be denied without further hearings.