Lexington Herald-Leader wins grant for reporter to cover health and social services, monitor big state agency that handles them

The Lexington Herald-Leader has won a grant to hire a reporter to cover health and social services in Kentucky, with special attention to the state agency "that wields enormous power over Kentucky’s most vulnerable citizens with frighteningly little scrutiny and transparency," the newspaper says.

The grant comes from Report for America, which places talented emerging journalists in local newsrooms to report on under-covered topics and communities. It is the latest initiative of the Ground Truth Project, a nonprofit funded by several foundations and other phuilanthropies. Last year it funded an Eastern Kentucky reporter for the Herald-Leader, and has renewed that grant.

Read more here: https://www.kentucky.com/news/state/kentucky/article224586210.html#storylink=cpy

The new grant is also for a year, and is renewable. The newspaper will take applications for the job through Feb. 8, and plans to put the reporter on the payroll June 1.

John Stamper, the paper's accountability and engagement editor, writes that the reporter "will focus on the region’s health problems, expose flaws in Kentucky’s social-services programs, give voice to people struggling to care for themselves and their loved ones, and offer potential solutions to problems that have plagued the area for a century.

"In particular, this reporter will serve as a watchdog of the Kentucky Cabinet for Health and Family Services," which gets relatively little journalistic attention because of the decline in the number of newspaper reporters, especially in Frankfort. The reporter will spend much in the state capital, especially during sessions of the legislature, and also report from Eastern Kentucky.

Appalachians die sooner than 20 years ago, and region has a higher infant-death rate than U.S.; both attributed to smoking

By Melissa Patrick
Kentucky Health News

People who live in Appalachia are dying sooner than two decades ago, and the region has a higher infant death rate compared to the rest of the nation. A new study blames both largely on the region's high smoking rate, as well as its other bad health habits.

“What this report shows is the extreme damage that tobacco is causing our people, and how we are getting hammered by it worse than any other place in this country," said Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky.

Click on map to view or download larger version

The study, published in the academic journal Health Affairs, compared infant mortality and life expectancy disparities in Appalachia to the rest of the United States between 1990 and 2013, using national vital statistics data.

It found that Appalachia and the rest of the nation had similar rates for infant morality and life expectancy in the 1990s, but by 2013 infant mortality was 16 percent higher in Appalachia, and adults in the region were living 2.4 fewer years than people who lived in the rest of the country: 76.9 and 79.3 years, respectively.

The study attributes these widening gaps to "persistent or increasing disparities in general living standards and health-risk behaviors such as adult smoking, smoking during pregnancy, obesity, physical inactivity, and heavy consumption of alcohol."

Heart disease, lung cancer and other respiratory diseases were among the leading causes of death in the Appalachian region during the study period, all conditions that can be caused by smoking.

"We are the cancer-mortality capital of the nation right now, and we just cannot let that stand," Chandler said. "If we truly want to change Kentucky’s health statistics, the single most effective thing we can do is to reduce our smoking rates."

Kentucky has the highest smoking rate in the nation, 26 percent of adults. But smoking affects children, even those who don't smoke. Smoking during pregnancy is a risk factor for both birth defects and SIDS, according to the federal Centers for Disease Control and Prevention.

While the number of Kentucky mothers who smoked during pregnancy dropped from 26 percent in 2006 to almost 20 percent in 2015, this is still significantly higher than the national rate of 8 percent. Overall smoking rates and pregnancy smoking rates are highest in the state's Appalachian counties.

The report says the higher rates of birth defects and Sudden Infant Death Syndrome deaths in Appalachia accounted for 60 percent of the difference in infant mortality between the region and the rest of the country in 2009-13. Other contributors included diabetes, kidney diseases, suicide, unintentional injuries (such as traffic accidents) and drug overdoses.

There could be other causes for the increasing disparity. The researchers said it is possible that more affluent, healthier Appalachian residents may have migrated to more urban and affluent areas of the U.S., thus increasing the health and economic inequalities between the region and the rest of the nation.

They called for policies that address the region's high smoking rates, high unemployment rates, low education levels, poor access to health care, high obesity rates, transportation and housing issues, and try to increase access to healthy foods, to decrease the current gaps in health outcomes.

“Given the national gains in life expectancy, seeing the increasing disparity between Appalachia and the rest of the United States should serve as a wake-up call,” Rebecca Slifkin, co-author of the study said in a news release. “Many of the reasons for the disparities we observe are due to differences in social determinants of health. We really need new investments to ensure that health is not determined by where one lives. As a society, we invest huge sums in medical care to extend an individual’s life; imagine the gains we could make if similar resources were devoted to public health.”

The study used the 2008 Appalachian Regional Commission definition of Appalachia, which covers 428 counties in 13 states, 54 in Kentucky.

Post's chief fact-checker gives McConnell an upside-down Pinocchio for a flip-flop the senator won't acknowledge

"It has become a regular feature of the U.S. political system that the politicians in the minority accuse the politicians in power of cutting deals behind closed doors to advance controversial legislation — only to engage in similar tactics once they regain power," writes Glenn Kessler, who runs The Fact Checker column for The Washington Post.

And so it goes with Senate Majority Leader Mitch McConnell and Senate Republicans' health bill, says Kessler as he compares McConnell's recent remarks with those he made in 2009 and 2010 as Democrats were passing the Patient Protection and Affordable Care Act, better known as Obamacare. Kessler, a Cincinnati native, normally gives politicians one to four Pinocchios, depending on how far they stray from the truth; in this case, he gives the Kentuckian one upside-down Pinocchio "for statements that represent a clear but unacknowledged 'flip-flop' from a previously-held position." Here's a video version:

Kentuckians on public insurance such as Medicaid used ERs more often after full implementation of the Affordable Care Act

Use of emergency rooms was expected to decrease after the implementation of the Patient Protection and Affordable Care Act, but it rose among people with public insurance such as Medicaid, according to a report for the Foundation for a Healthy Kentucky.

One in four Kentuckians in 2015 said they had visited an ER in the past year, about the same proportion as before the ACA was implemented in 2014. The 25.5 percent rate was "significantly higher" than the national rate of 18.3 percent, said the report by the State Health Access Data Assistance Center at the University of Minnesota.

Among people with public insurance, the ER usage rate rose to 41.3 percent from 34.5 percent. Among those with private insurance, it fell to 15.2 percent from 17.4 percent.

Supporters of the law said that as more people became insured, the more likely it would be that they would find a medical home to meet their health-care needs. "One of the benefits supporters hoped would result from the ACA was reduced use of ERs, where treatment is a lot more expensive," Foundation CEO Ben Chandler said in a news release. "What we found is that ER visits declined for several months after the ACA first went into effect, but then they rose again."

The study found that since the implementation of the ACA in 2014, the total number of ER visits dropped during the first three quarters of 2014 and then rose to a level in 2016 that was 4.5 percent higher than in 2012.

The survey asked Kentuckians why they went to the ER. Nearly three in 10 said they went because of a medical emergency. About the same number said they went because no other facilities were open when they needed care. Only 3 percent used the ER because they didn't have a regular doctor; another 3 percent said they used the ER because it was close by. Seven percent said they went because their doctor told them to, and 3 percent said they were taken by an ambulance.

"The explanations are multifaceted, but it turns out Kentuckians had some very rational reasons for heading to the ER," Chandler said. "The bottom line is that many of the benefits of having insurance coverage for the first time in life will take a while to play out, and that's certainly the case with ER use."

For hospitals, the difference is that they are being paid for many ER visits because more patients have insurance. Kentucky has had the largest drop in the number of uninsured in the nation since the ACA, dropping from 20.4 percent in 2013 to 7.8 percent in 2016, according to Gallup.

The study found that the proportion of ER visits that hospitals reported as charity care or self-pay dropped from 23 percent in 2012 to less than 6 percent by the third quarter of 2016. Meanwhile, visits covered by Medicaid rose from almost one-third in 2012 to almost half in 2015 and 2016.

"Hospitals have benefited from the ACA because they're having to eat less of the cost of caring for uninsured Kentuckians," Chandler said. "That's especially important for smaller, rural hospitals."

The report, "Emergency Department Utilization in Kentucky," is part of the foundation's ongoing study of the impact of the ACA in Kentucky.

Bill for panels to review lawsuits against health-care providers passes Senate, gets off House fast track but still headed for law

Editors: This story has been updated to reflect action that took place after its initial publication.

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – A bill to require a panel of three physicians to determine if lawsuits against health-care providers have merit before being filed in court has passed the Senate will likely become law next month.

Sen. Ralph Alvarado

Senate Bill 4, sponsored by Republican Sen. Ralph Alvarado, a Winchester physician, cleared the Senate Health and Family Services Committee on an 8-3 vote Jan. 3 and passed the full Senate 23-13 on Thursday, Jan. 5.

It would establish panels of three medical experts, two chosen by each side and the third chosen by the other two, to review suits against health-care providers to determine if the case has merit before the lawsuit can proceed. Panel findings would be admissible in court, but not legally binding.

Such legislation has passed the Senate before, but died in the House, which was controlled by Democrats. The bill was on a fast track to pass the House Saturday, with other priority bills of the new Republican majority, but freshman Rep. Jason Nemes, R-Louisville, said on Facebook that at his request, action on it was delayed until legislators return in February.

Last year's Senate committee debate on the legislation took about two hours. This year's consumed about 20 minutes.

"These review panels are a reasonable, common-sense approach that protects caregivers and their patients," he said. "It does not limit, delay or deny a plaintiff's access to courts, any claim can still proceed. It does not create additional cost for a patient or their family to sue a health care provider. It does not bind a jury from determining findings of fact and conclusions of law. It does not create an additional layer between the citizen and the courts. It does add a layer of accountability for health-care providers and personal injury lawyers."

Such lawyers are represented at the legislature by the Kentucky Justice Association. Liz Shepherd, president of the group, said it recognizes that the political environment has changed but still wants "a seat at the table" to protect citizens' rights under the Seventh Amendment to the U.S. Constitution.

"We want to be part of the solution, but at the same time protect a client's right to trial by jury," Shepherd said. "There are a lot of public reports that show a small percent of doctors cause most of the medical negligence claims, and what we are concerned about is that there will be a wholesale change with unintended consequences that is really there to address the problems of a very few doctors and very few attorneys."

In support of the bill, David Adkisson, president and CEO of the Kentucky Chamber of Commerce, pointed out that all of the states bordering Kentucky have some kind of tort reform. "In the business community, we think it's time for Kentucky to catch up and make this a better place for medical providers to operate and for consumers to purchase health services," he said.

Alvarado said the panels are expected to issue an opinion on the claim within six months of the panel's selection. He said that under the current process, cases can take up to four years to litigate.

Sen. Reginald Thomas, D-Lexington, said testimony in previous years said such panels in other states take up to two years to issue an opinion, thus delaying the time it takes plaintiffs to get their claims heard.

“I vote no, because I believe every person who is a citizen of the state should have access to the courthouse door," Thomas said. "I believe in justice. I believe in everyone having their day in court. Everyone has a right to be heard.”

Alvarado disputed Thomas's assertions, saying that his research from Indiana's program found that the review process is timely and "works very well." He also said if both parties want to bypass the review panel, the bill allows for that.

Sen. Tom Buford, R-Nicholasville, voted for the bill, but said he had some concerns that the review panel is made up entirely of medical professionals, which he said, "I think is a mistake for the justice of the individual."

Struggling Tenn. hospital takes care of Kentuckians, who get better care than Tennesseans thanks to expanded Medicaid

Jellico Community Hospital, just across the Kentucky border in Tennessee along Interstate 75, was taken over by Community Hospital Corp. last May, but that's not a guarantee it will survive, especially since Tennessee refuses to expand Medicaid to its poorest citizens, as Kentucky has, Harris Meyer reports for Modern Healthcare.

Meyer notes that one of the contributing factors to the hospital's struggle is the Tennessee Legislature's refusal to expand Medicaid under health reform to those who make up to 138 percent of the federal poverty level. That would decrease the hospital's level of uncompensated care.

About half the hospital's patients come from Kentucky, and its administrators, doctors and nurses all told Meyer that it is easier to get testing and specialty care for Kentucky Medicaid patients than for uninsured Tennessee patients who would qualify for expanded Medicaid.

“We're able to do more for Kentucky patients,” Christy Elliott, the hospital's case management supervisor, told Meyer. “For Tennessee patients, it's a struggle. If you don't have insurance, you don't get services.”

One such patient was Rebecca Jarboe, a mother of three from Kentucky. She told Meyer that she went into a "difficult" labor during a snowstorm on Valentine's Day. Because of the weather and her condition, she said she and her husband decided to travel 14 miles from their home to Jellico to have the baby, instead of making the 70-mile-journey down I-75 to the University of Tennessee Medical Center in Knoxville, 20 miles of which would have been over snow-covered Pine Mountain (known locally as Jellico Mountain).

“The care here is excellent,” a tired-looking Jarboe told Meyer while lying in her hospital bed cradling 2-day-old Silas and surrounded by her family. “Whatever you need, they are right at the door, and everyone is really friendly.”

The 31 states that have expanded Medicaid have been able to "shore up finances" in many of their rural hospitals, Meyer writes, but others have not fared so well. Nationwide, more than 50 rural hospitals have closed in the past six years, and nearly 300 more are in deep financial trouble, according to the National Rural Health Association.

A state report by then-Auditor Adam Edelen last year found that one in three of Kentucky's rural hospitals were in poor financial condition. Since the release of the report, several Kentucky rural hospitals have merged with larger hospital groups to make ends meet and rural hospitals in Nicholas and Fulton counties have closed.

Meyer also notes that Jellico hospital's problems go deeper than just not expanding Medicaid. In its service area good-paying jobs with health benefits have dwindled, only 10 percent of the population has private health insurance, residents have higher-than-average rates of disease, and there is rampant obesity and drug abuse. A similar story could be told about many rural Kentucky communities.

In addition to providing health care, the 54-bed hospital with its staff of 232 is the community's largest employer, as is often the case. The mayor of nearby Williamsburg, where the hospital has a clinic, noted that new businesses will often not consider moving to a community without a hospital.

“A lot depends on economic development in these communities,” Alison Davis, a professor of agricultural economics who studies rural healthcare at the University of Kentucky, told Meyer. “What are they going to do to create jobs? It's the No. 1 issue besides substance abuse they are facing. It's a struggle, and not every community will make it through.”

Adventist Health System, out of Florida, announced in May 2014 that it wanted to get rid of the hospital because it was losing "millions a year." A year later, CHC, a Texas-based not-for-profit with a mission to preserve access to healthcare in rural communities, took over the hospital and its clinic. CHC owns, manages and provides support to 21 community hospitals nationwide, according to a news release.

CHC told Meyer that it is optimistic the hospital will survive because of the medical staff's commitment to keeping quality healthcare in their community. It has also implemented cost-saving measures, like decreasing staff and installing a less costly electronic health record system, and is exploring ways to further save money, while increasing its client base.

But several local business leaders told Meyer they weren't so sure the hospital will survive.

“There have been so many layoffs that they don't have enough people to do lab work or X-rays, and you have to wait and wait,” Elsie Crawford, business manager of the Wilkens Medical Group in Jellico and a member of the City Council, told Meyer. “You can't draw more patients if you don't have enough people to take care of them.”

Dr. Charles Wilkens, who helped establish and maintain the hospital, told Meyer, “People would die for lack of health care if we didn't have a hospital in this community.”

Medicare starts to overhaul the way it pays providers, rewarding them for quality, penalizing them for shortcomings

By Molly Burchett
Kentucky Health News

The Obama administration on Monday set a timeline for historic changes in how it pays doctors, hospitals and other health providers under Medicare, shifting away from the program's traditional fee-for-service model and towards a model that rewards care quality.

Rather than give the usual yearly fee increases to Medicare doctors for every procedure or service, the Department of Health and Human Services will tie 30 percent of traditional, fee-for-service payments to models like "accountable care organizations," which base payments (and penalties) on patients' health outcomes. The goal is for half of all Medicare payments to be handled this way by 2018, reports Jason Millman of The Washington Post.

"Today's announcement is about improving the quality of care we receive when we are sick, while at the same time spending our health-care dollars more wisely," said HHS Secretary Sylvia Burwell. "We believe these goals can drive transformative change, help us manage and track progress and create accountability for measurable improvement."

Medicare is the country's largest payer for health-care services, so these payment changes will affect doctors' offices and hospitals across the country. Many experts have viewed this broader shift to rewarding care quality as long overdue, but it's still uncertain how well the approach will work.

"We still know very little about how best to design and implement [value-based payment] programs to achieve stated goals and what constitutes a successful program," concluded a 2014 Rand Corp. study funded by HHS, Millman reports.

Some health-care professionals said Medicare is just aligning with what is already working in the private sector by moving away from fee-for-service, reports Alex Wayne of Bloomberg Businessweek.  “The private sector is further ahead than Medicare right now,” said Justine Handelman, vice president for legislative and regulatory policy at the Blue Cross and Blue Shield Association.

Since Medicare is already limiting payments as part of the 2010 health-reform law, the government must “ensure that only reforms proven to be efficient and effective are put in place,” Chip Kahn, CEO of the Federation of American Hospitals, told Wayne. “Further cuts would undermine our ability to invest in delivery system innovations needed to continue this trend.”

The announcement marks the first time that goals have been set to fundamentally change the way Medicare pays for health care, giving providers incentives to reduce unnecessary services.

Dr. Douglas Henley, CEO of the American Academy of Family Physicians, told CNBC: "We're all partners in this effort focused on a shared goal. Ultimately, this is about improving the health of each person by making the best use of our resources for patient good. We're on board, and we're committed to changing how we pay for and deliver care to achieve better health."

Speakers at conference discuss impacts and possible solutions for deadly mistakes and near misses in hospitals

By Melissa Patrick
Kentucky Health News

Medical mistakes made in hospitals cause 98,000 deaths per year. Or four times that many?

That is the widely accepted number based on a 1999 Institute of Medicine report, but a study published in the Journal of Patient Safety says that as many as 210,000 to 440,000 Americans die each year in the hospital because of a preventable harm, Marshall Allen of ProPublica reports on NPR. But the current culture in health care does not support the reporting of mistakes or near misses, said speakers at the Health Watch USA 2013 Conference on Nov. 1 in Lexington.

Keith Widmeier, training officer for the Wayne County Emergency Medical Service, talked about the importance of reporting medical errors: "How are we supposed to fix things if we don't address the near misses?" he asked. "We must look at patterns and address them, learn from the data. Reliable data helps promote systemic change. The current system creates a system of not reporting."

Helen Haskell, president of the grassroots patient-safety organization Mothers Against Medical Error, said there are many contributing factors to this culture, and suggested that there is much to be learned from patient stories.

She told story after tragic story of young patients who had died because of medical error, including the story of her son, Lewis Blackman.

Lewis was a healthy 15-year-old who developed severe upper abdominal pain while on a non-steroidal anti-inflammatory drug and a narcotic following an elective surgery. Nurses and residents failed to act upon increasing signs of instability, including 24 hours with no urine output and four hours with no blood pressure. Haskell asked repeatedly for an attending physician. Four days after the operation, her son died. The autopsy showed a giant duodenal ulcer and 2.8 liters of blood and gastric secretions in the peritoneal cavity. He had been bleeding internally.

It is the responsibility of our health care system to become more transparent, listen to people's stories and put systems in place to decrease the chance of medical errors, Haskell said. Health care must improve in the areas that errors most commonly occur, she said, such as true informed consent, unnecessary surgeries, medication and diagnostic error, failure to rescue, and communication errors.

To decrease medical errors, Haskell suggested that the system use technology as the driver of improvement, providing continuous feedback between everyone involved in the care of a patient and involve the community and government.

Nurse burnout and job dissatisfaction also lead to medical error in hospitals.

"We cannot expect high quality health care with burnout," said Jeannie Cimiotte, a Ph.D., RN and associate professor at the Rutgers University College of Nursing and executive director of the New Jersey Collaborating Center for Nursing.
Cimiotte cited a Pennsylvania study that found the implications of increases in nurse workload are burnout and job dissatisfaction, missing important changes in patient conditions and failing to report important patient information at shift change. She said the study also found high nurse burnout appears to be a possible explanation for the association between nurse staffing and infection, jeopardizing patient safety resulting in hospital-acquired conditions and poor health care outcomes.

A culture of change and transparency has been implemented and is working at the Department of Veterans Affairs hospitals in Lexington since 1987, said Dr. Steve Kraman, who was chief of staff and chairman of the Risk Management Committee of the hospitals from 1986 to 2003. They not only require the reporting of medical errors and near misses, but provide full disclosure to patients who have been injured because of accidents or medical negligence, and offer fair compensation for injuries, Kraman said.

The VA has used this model since 1987 and has had "encouragingly moderate liability payments," said Kraman. In 2010, the University of Michigan reported remarkable decreases in suits, costs, trials and time to resolution. They also linked the openness of such a program with patient safety benefits due to reduced need for secrecy surrounding errors. The University of Illinois reports no increase in either number or suits or payouts since participating in this model of care, according to Kraman.

Kraman asked the participants: Is full accountability and transparency the way we should do health care? The answer was a resounding yes.

"This is a decision based on how we behave in society.  We should behave in a stand-up manner," Kraman said.

Health Watch USA, based in Somerset, was founded by Dr. Kevin Kavanagh to promote health care transparency and patient advocacy, says its website.