EMS staffing shortages are at crisis level, says Kentucky EMS board chair

Centers for Disease Control and Prevention photo

By Melissa Patrick
Kentucky Health News

Kentucky's Emergency Medical Services are facing severe staffing shortages, with low pay, "abysmal" reimbursement rates and high turnover identified as the key reasons for the problem.

"We lose more paramedics every year than we gain, unfortunately. . . . We're hemorrhaging providers, we're losing more paramedics than we can replace,"  Kentucky Board of Emergency Medical Services Chairman John Holder told lawmakers at the July 30 Interim Joint Committee on Health Services.

Holder said Kentucky has an attrition rate of 21%, which means two out of 10 of their emergency medical technicians, commonly known as EMTs, will not return or certify again next year. Further, he said only 40% of their EMTs work with an EMS service. 

"That means that less than half of those who are certified are actually going to work on an ambulance and treat members of their community," he said. 

Holder said that even with new rules that allow only one paramedic per service, regardless of the size of the service, some EMS services can't even manage that level of staffing

“We're receiving regular calls from EMS services who are saying gentlemen were having to self-report that we cannot meet the staffing requirement as set by regulation, which means they don't have enough paramedics to staff their ambulances,” Holder said. “It truly is a crisis. I mean, we have services that are going to shut down if we can't find a solution to this problem.”

EMS staffing challenges have been ongoing, while the need for services increase. According to Holder's presentation, there were "31,006 more requests for ambulance transport annually than five years previous." 

One of the key challenges is poor compensation, which Holder said is directly related to "abysmal reimbursement."

 

"These EMS services are losing money when they make ambulance runs, which is hard," he said. "So a lot of folks will tell you, 'Oh, well just pay them more. We wish we could. And we would if we could, but with reimbursement the way it is, the pot is just not big enough to draw any more funds out of." 

Another challenge, he said, is poor access to education. 

"So especially in our in our rural parts of the state, our providers are having to travel hours, multiple times a week to try to find this education and they're either unwilling or unable to do it in a lot of cases because they're needed at home," he said. 

Holder said that while there have been efforts to address the workforce shortage, such as decreasing the initial requirements for EMS educators, removing licensing fees for newly certified providers, allowing reciprocity for providers from other states and decreasing the number of providers required for coverage, it hasn't been enough to fix the problem. 

What they need, he said, is increased reimbursement for services in order to increase wages and to secure funding for additional training sites and student scholarships. 

Kentucky's first emergency psychiatric unit opens in Lexington

The unit has a separate entrance. (UK photo by Hilary Brown)

By Allison Perry
University of Kentucky

State officials, community leaders and UK HealthCare officials celebrated Tuesday's opening of a new emergency unit in Lexington dedicated to the treatment of patients experiencing a mental health crisis.

The EmPATH (Emergency Psychiatric Assessment, Treatment and Healing) Unit is the first of its kind in Kentucky. It will open at 7 p.m. Tuesday, July 30, on the campus of Eastern State Hospital.

“The EmPATH model is a game-changer for mental-health care, and we are so proud to be the first in the state to open this unit,” said Robert S. DiPaola, UK's co-executive vice president for health affairs. “For many, seeking care for a mental-health issue can be difficult, frustrating and even frightening. With EmPATH, we’re using a proven, evidence-based approach that allows our behavioral health team to provide fast, appropriate evaluation and care that’s easier for patients to access in an environment conducive to healing.”

The U.S. has about 30 EmPATH units. UK HealthCare and New Vista, a mental-health care provider in 17 counties in the Lexington area, have collaborated with leadership from the state Cabinet for Health and Family Services to bring this new model of emergency behavioral health care to Kentucky.

Pioneered by DR. Scott Zeller, an internationally known emergency psychiatry expert , EmPATH units are carefully designed physical environments that help patients experiencing an acute mental health issue receive immediate support. Instead of individual treatment rooms, the units are wide open spaces with comfortable seating. Upon arrival, individuals will interact with supportive health care providers including psychiatrists, nurses, social workers, and even peer support specialists and can stay in the unit for up to 23 hours.

Eastern State Chief Administrative Officer and psychologist Lindsey Jasinski says peer support is one of the main factors that has made the model so successful. Patients will have the chance to speak to others who have deal with taking medication, receiving therapy, and participating in different programs.

“We have those folks here in the unit to say, ‘Can I share my experience with you?’” Jasinski said. “It can be helpful to hear from someone who has been in a difficult place and been able to successfully navigate that. It provides hope, and that’s what the EmPATH model is all about.”

At roughly 11,000 square feet, the EmPATH unit has room for up to 12 patients. Providers and support staff will regularly assess the individual’s symptoms and develop a care plan, which could include a treatment plan and discharge home with connection to appropriate outpatient services, or admission as an inpatient for round-the-clock care.

Studies show that 60 to 70 percent of individuals who come to an EmPATH unit are stabilized and back home within 24 hours; patients treated in these units are also far more likely to continue their care. A study published in Academic Emergency Medicine showed that 60% of individuals in rural areas with suicidal thoughts or ideation sought follow-up care after their initial treatment in an EmPATH unit.

In addition to providing faster, more appropriate care for psychiatric patients, the EmPATH unit will help reduce the load on traditional emergency departments. A 2020 study of emergency-room visits related to mental health showed an increase from 6.6% to 10.9% from 2007 to 2016. Zeller and the physician-owned partnership Vituity, which helps hospitals develop their own EmPATH units, estimate that 12 to 15% of ER visits are related to behavioral health.

While ERs can provide critical care to acute injuries, illnesses, and traumas, they often do not have the resources or staffing to effectively treat individuals in a mental health crisis. Because ERs must prioritize patients with life-threatening issues, those coming to an ER for mental-health care are likely to experience long wait times in an environment that isn’t conducive to helping these individuals.

“Our emergency departments give amazing care and save countless lives every day,” said Dr. Andrew Cooley, a UK HealthCare psychiatrist who has served as chief medical officer for Eastern State Hospital since 2013. “But we know that patients who come in with a life-threatening injury will need to take priority, and patients experiencing a behavioral health crisis will be further down the list to receive treatment. EmPATH is the alternative to that – a patient shows up here, and we immediately greet them and begin care.”

The EmPATH unit is open to adults age 18 and over experiencing a behavioral health crisis, which has a broad definition: any mental-health problem that impairs their ability to perform normal daily functions, take care of themselves, and keep themselves safe. That could include those seeking help for a substance use disorder, those experiencing depression and anxiety, someone who is thinking about self-harm or suicide, and more. Patients may be brought in through emergency medical services, or may self-refer and bring themselves in.

“The patient defines the crisis. We’re very open-door,” said Marc Woods, Eastern State's chief nursing officer. “We immediately try to assess what their needs are – not only for behavioral health, but also their basic needs. It allows our clinicians to say, ‘Are you hungry? Would you like a Coke?’ We’re quickly building a relationship so we can help address not only a mental health issue, but also get them connected to other services to improve their overall health and wellness.”

The EmPATH unit is part of UK HealthCare and will have its own entrance at Eastern State's campus, on Bull Lea Road in Lexington. The entire hospital is owned by the state Department for Behavioral Health, Developmental and Intellectual Disabilities and is managed by UK HealthCare. It operates 195 acute-care beds and provides critical, recovery-focused psychiatric care for adults from a 50-county region of the state.

Drug to reverse opioid overdoses is more available than it used to be; health official says stigma still exist around carrying it

By Shepherd Snyder, WEKU

The annual Kentucky Drug Overdose Fatality Report says overdose deaths in 2023 dropped by 9.8 percent from the year prior; 2022’s report showed a 5 percent decrease compared to 2021.

Photo from Wikimedia Commons

That comes as access to naloxone has improved, in part because of state and federal programs that support local health departments and emergency services.
Holly Buchenroth, an assistant professor in Eastern Kentucky University’s Emergency Medical Care Program, says requesting access to naloxone has become an easy process.

“Any first-responder agency can get access to this naloxone if they qualify and are in a rural county that's eligible, and all they have to do is complete a training, make a request and document the usage or distribution,” Buchenroth said.

Naloxone is a nasal spray medicine that reverses opioid overdoses with no negative side effects. It’s also sold under the brand names Narcan and Evzio.

Kentucky got $800,000 last year from the federal government to dispense Narcan to first responders in rural counties. Last year, more than 160,000 units of the medicine were distributed across the state.

Scott Lockard, public health director of the Kentucky River District Health Department, says the added resources have been a big help. The health department serves Knott, Lee, Leslie, Letcher, Owsley, Perry and Wolfe Counties. 

“A couple years ago, Narcan was much harder to access, and we've seen much more awareness around harm reduction and the importance of getting Narcan, naloxone out there,” Lockard said. “So pretty much there's no excuse now.”

Other agencies, like the Pike County Health Department have fared similarly. Director Tammy Riley says in 2021, the agency wasn’t able to distribute any naloxone kits to individual community members, with just 82 Narcan kits distributed to the county in total.

They’ve since been able to turn that around.

“Compare that to our 2023 data, 3,500 Naloxone kits were distributed through the harm reduction program, 25 Naloxone kits through first responder and community organizations and 240 Naloxone kits to individual community members,” Riley said.

Riley says they’ve also focused on education. For every box of Narcan they give out, they inform its receiver on how to use it.

“When you see those numbers of distribution, every box that's distributed to an individual is provided with about a five to 10 minute education session,” Riley said. “We don't just hand naloxone to an individual and say, ‘Good luck.’”

The life-saving drug is also getting cheaper. Buchenroth says that’s in part because of its availability over-the-counter at chain pharmacies.

“You can pick up a generic two pack now for about $35, so the price has come down,” Buchenroth said.

But access in rural areas could still improve. Riley says in places like Pike County, where the health department covers a large area, it’s harder to follow up with those in recovery compared to urban areas like Lexington or Louisville.

“We need a Quick Response Team in Pike County, so when those individuals do refuse those 911, first responder services, we could deploy a Quick Response Team to find that individual in the throes of reversal when they're most likely to seek treatment,” Riley said.

Other officials, like Lockard, say getting rid of the stigma that carrying Narcan involves is also an issue.

“Although the resource of the service may be here, they're still reluctant to make themselves available to the resources that they can access,” Lockard said. “So how do we reduce the stigma? How do we do more training in the communities?”

Maria Slone is a social worker with Lexington’s community paramedicine program and works with a quick-response team. She says there’s a simple way to bridge that gap: community involvement.

“They're not going to have as many resources as we have, but how much buy-in is in their community members and their law enforcement and their courts and EMS providers?” Slone asked. “What does that look like for them to have that buy-in?”

Most recently, the state has launched a website that shows a map of all the locations naloxone is available, both for free and for purchase. It’s available at findnaloxone.ky.gov.

Learning CPR for children and infants could help save a little life

(Photo from Prostock-Studio, via iStock/Getty Images Plus)

By Dr. Callie L. Rzasa

University of Kentucky

More than 23,000 children in the United States suffer an out-of-hospital cardiac arrest annually. Although the reported number of infant out-of-hospital cardiac arrests varies widely, only 6.5% for children less than 1 year old who experience an out-of-hospital cardiac arrest survive to hospital discharge.

According to the National Center for Injury Prevention and Control, unintentional choking and suffocation are a leading cause of all injury deaths for infants less than a year old. Nearly 3,500 infants die each year in the U.S. from sleep-related infant deaths such as suffocation, entrapment, strangulation and sudden infant death syndrome.

Make safety a habit at home by implementing safe sleep practices, such as making sure babies sleep in their own crib or bassinet on a firm, flat surface without potential suffocation hazards such as blankets, stuffed animals or crib bumpers.

New parents, grandparents, babysitters and caregivers should take the time to learn infant- and child-specific CPR (cardiopulmonary resuscitation). It’s important to remember if the child is unresponsive, not breathing or only gasping, call 911 and start CPR immediately.

For a child 1 or older:

• Push on the middle of the chest 30 times at a depth of 2 inches with one or two hands at a rate of 100 to 120 compressions per minute.
• Provide 30 compressions and then give two rescue breaths.
• Repeat cycles.

For an infant younger than 1:

• Push on the middle of the chest 30 times at a depth of 1½ inches with two fingers at a rate of 100 to 120 compressions per minute.
• Provide 30 compressions and then give two rescue breaths.
• Repeat cycles.

If you have access to an automated external defibrillator, use it as soon as possible. Most AEDs are equipped with child- and infant-sized pads. They can help guide CPR and provide treatment for certain heart arrhythmias. Continue compressions until emergency services arrives.

For more information about CPR for adults, children and infants, find a class or training center near you.

Callie L. Rzasa, M.D., is medical director of Kentucky Children's Hospital Congenital Heart Clinic and American Heart Association board president in Central and Eastern Kentucky.

Seven mobile crisis-response grants aim for 'better treatment, a lot quicker' for people undergoing mental-health crises

Kentucky Health News

Seven local-government organizations are getting grants to start community crisis co-response programs, which form partnerships between behavioral-health professionals, law enforcement or other first responders and local governments in order to lower the distress of individuals in crisis and avoid unnecessary hospitalizations and incarcerations while extending crisis services to communities.

The money comes through a state Cabinet for Health and Family Services grant. The recipients are Boyle County, Christian County, the Cynthiana Police Department, the Lexington Fayette Urban County Government, the Maysville Police Department, the Perry County Ambulance Authority and the Warren County sheriff, in Bowling Green.

Perry County EMT Scott Helle (Image from WYMT) 

Perry County EMT Scott Helle told Hazard's WYMT that in a mental-health crisis, taking a patient to a hospital can be a burden on hospital staff and adding “wait time for their patients to be able to see a mental-health provider.” The grant will allow the ambulance service to add a community paramedic, peer support specialist or case manager to its staff.

Helle said “It will give us the opportunity to give them better treatment, a lot quicker,” and the pilot grants will help other communities create similar teams.

Mike Rogers, director of Boyle County Emergency Medical Services, said in a state news release that the grant “will ease the burden on our law enforcement, hospital, judicial system and emergency services.”

Robert Peak, assistant police chief in Cynthiana, said This will be an invaluable resource to the most vulnerable members of our citizenry. Realizing that mental health and chemical dependency cannot be fully addressed by traditional police strategies is key to implementing programs such as this.”

Warren County Sheriff Brett Hightower said, “Having qualified professionals working alongside our team of law enforcement will help expedite and assess the needed care for those in crisis, which better serves our community.”

Several recipients sent the state videos about what they hope the funding will do in their communities. To see the video provided by Maysville police, click here. To see a video from Boyle County, click here. To see Helle's video, go here.

Rural trauma deaths could be reduced if ambulances could bill insurance companies for delivering blood en route to the hospital

Kentucky Hospital Association chart, adapted by Kentucky Health News

Kentucky Health News

In 2020, a traumatic injury killed an American every 31½ minutes, and such injuries are the top killer of children and adults under 45. Those statistics could be better if more ambulances carried blood, Lauren Caruba of the Dallas Morning News reports in a package with the San Antonio Express-News.

The problem is worst in the sparsely populated West, but "parts of the South performed worse compared with the coasts," Caruba reports. The package focuses on western Colorado and has an interactive map showing how far every location in the 48 contiguous states is from a trauma center. The part of the map centered on Kentucky shows that from most of the state, Level I and II trauma centers are more than half an hour, when deaths from bleeding peak.

Section of Dallas Morning News interactive map, selected by Kentucky Health News

"The solution is straightforward: If paramedics widely carried blood, as military medics have done for years, tens of thousands of lives could be spared annually. But the country’s fragmented health-care system does not allow for an easy fix. . . . Despite repeated pleas from specialists, the federal government has not prioritized or properly invested in the plight of injured Americans."

The Defense Department has greatly improved combat death rates with faster evacuation, "increased tourniquet use and administered blood on the way to the hospital," Caruba notes. "No such overhaul has happened in U.S. health care, and efforts have not been made to broadly adopt the military’s best practices, particularly before patients reach a hospital."

In 2019, fewer that 1% of trauma patients "received blood products of any kind on the way to the hospital, even when they displayed clear warning signs of bleeding out," Caruba reports, citing research by the University of Alabama-Birmingham. She notes that there is relatively little research into trauma deaths, and that the federal government doesn't even track them. But a federal report in 2016 estimated that over the previous decade, 200,000 to 300,000 trauma deaths were potentially avoidable.

The U.S. has more than 23,000 emergency medical services, "but only about 100 ground ambulance services have blood on hand, trauma advocates have found in recent surveys. While most air ambulance companies carry blood products, they treat only a small fraction of injured patients," Caruba reports. "Blood is a costly, limited resource, and most emergency medical providers lack relationships with blood banks. They also face regulatory and logistical hurdles, like maintaining blood refrigeration temperatures in the field and creating a system where unused units do not go to waste."

The Prehospital Blood Transfusion Initiative Coalition is focusing on the servcies' "inability to bill insurers for the cost of the blood and the rules in some states that prevent paramedics from starting transfusions," Caruba reports. "The group hopes to present recommendations to Congress and the National Association of State EMS Officials next year. Their goal is that every patient with major bleeding — including the injured and those hemorrhaging from medical complications — will receive blood if they need it."

More than 1 in 10 minors ambulanced to ERs have behavioral issues, but EMS lacks guidelines in Ky. and most other states

Photo illustration by Maga Doctor News

Kentucky Health News

Here's another indication that the country has a youth mental-health crisis: More than 1 in 10 minors who were brought to the hospital by ambulance in 2019-20 had a behavioral-health emergency, and 85 percent were between 11 and 18 years old, says a study in the journal Academic Emergency Medicine.

“Our study found that pediatric behavioral-health emergencies requiring an ambulance were much too frequent,” said the study's senior author, Dr. Jennifer Hoffmann, emergency-medicine physician at Ann & Robert H. Lurie Children’s Hospital of Chicago and assistant professor at Northwestern University Feinberg School of Medicine.

But there are no national guidelines for emergency medical servcies to manage such patients, Hoffmann said in a news release: “We found considerable variation in the use of sedative medications and restraints across different parts of the country. There is a great need for standardized EMS protocols for pediatric behavioral health emergencies. Currently only four states have these available.” Those are Maryland, Michigan, Rhode Island and Utah.

Among children 6 through 11, the study found that children with developmental, communication and physical disabilities were three times more likely to be restrained than children without these disabilities.

“EMS personnel are likely less comfortable with weight-based dosing of sedative medications, and EMS agencies in most states don’t have pediatric-specific sedative protocols, which might contribute to the increased use of physical restraints for younger children while in the ambulance,” said Julia Wnorowska, a Northwestern medical student who was first author on the study.

“Also, protocols for EMS personnel are needed to help manage children with autism spectrum disorders and other neurodevelopmental disabilities. Specific interventions could be developed to prevent and reduce agitation in this population, such as personalized emergency information forms that delineate patient-specific triggers and de-escalation techniques.”

Hoffman said, “Future research should determine whether the use of restrictive interventions can be reduced, while simultaneously promoting staff safety, through strategies such as education and adoption of pediatric-specific protocols.”

Spending reports by health-care lobbying interests reflect their success at having their way in the Kentucky General Assembly

The legislature meets in the Capitol. (State photo)

Kentucky Health News

Seven of the top eight spenders on lobbying the General Assembly last year had health-care issues in play. Most of the seven were mainly focused on health issues, and most of them were successful.

Lobbying reports to the Kentucky Legislative Ethics Commission showed the Kentucky Chamber of Commerce, which lobbies on some health issues, ranked first by spending $408,301, mainly for the 16 lobbyists it employs. The Kentucky Hospital Association was second at $304,707.

"Included in the hospital advocacy group's spending was $23,000 on digital advertising for its priority legislation that passed into law after stops and starts, loosening requirements on ambulance services to improve slow response times," notes Joe Sonka of the Louisville Courier Journal. "KHA also successfully lobbied for two bills providing incentives to attract and retain nurses and health care workers and one to expand hospitals' remote access to pharmacy databases."

The third-place spender, at $269,685, was tobacco company Altria, parent of Philip Morris USA. Altria "successfully lobbied to block a bill raising taxes on cigarettes and vaping products and another that would give local governments the ability to add extra regulations on the display of tobacco and vaping products," Sonka reports.

The fourth-ranking spender was the ACLU of Kentucky, at $195,489. Among other things, it lobbied unsuccessfully against bills to restrict abortion.

The main lobbying group for doctors, the Kentucky Medical Association, ranked fifth at $157,416. KMA spent $30,000 "for polling it commissioned late in the year to craft messaging for one of its top legislative priorities" in the session that begam Jan. 3 and will resume Feb. 5. "The KMA has a website promoting a "physician-led, team-based care model," urging people to contact legislators and oppose legislation to lift limits on services that can be provided by nurse practitioners," Sonka rpeorts.

Hospital firm HCA Healthcare, which has hospitals in Bowling Green and Frankfort, was seventh in lobbying spending at $146,548. LifePoint Health, which has hospitals in Flemingsburg, Georgetown, Lebanon, Mayfield, Maysville, Paris, Somerset, Versailles and Winchester, reported spending $110,002, ranking it 17th. 

The Pharmaceutical Care Management Association ranked eighth, at $142,257. The group represents pharmacy benefit managers, who are middlemen between drug manufacturers and insurance companies; the managers have come under much legislative scrutiny in recent years. The group successfully oppposed a bill to rein in in pharmacy benefit managers; House Bill 457 "breezed through the House by an 88-3 vote but then ground to a halt in the Senate without any readings or committee hearings — all while the association spent more than $52,000 on advertisements urging legislators to defeat the bill," Sonka writes. "Senate President Robert Stivers said the bill stalled after his caucus began to hear concerns from the business sector about the measure increasing the costs of health plans, mirroring the association's messaging."

The other lobbying group in the top eight was the Kentucky League of Cities, which ranked sixth at $151,308. Its main legislative interest, a constitutional amendment to give cities more taxing options, including sales taxes, was defeated by the No. 9 group, the Kentucky Retail Federation, which reported spending $142,237. Overall lobbying expenses hit a record $24.3 million in 2022.

Parents in 21 more counties get CPR kits for infants, for total of 32; hundreds still available, with money from health insurers

The CPR Anytime® training kits are given to parents.

Three times as many Kentucky counties will get cardiopulmonary resuscitation kits for infants, funded by the Kentucky Association of Health Plans, representing health-insurance companies in the state.

The American Heart Association is delivering the life-saving CPR kits to health-care facilities to give to new parents. Each kit includes an inflatable mannikin and video that teaches infant CPR in as little as 20 minutes.
 
The initiative, launched in May 2022, has provided 3,000 kits to neonatal intensive-care units in 11 counties. A $150,000 grant from KAHP is funding 4,350 more kits, nearly 2,500 of which have been distributed in 21 counties: Bath, Bell, Boyd, Casey, Clark, Estill, Floyd, Garrard, Harlan, Hyden, Jackson, Johnson, Madison, Montgomery, Nicholas, Perry, Pike, Powell, Rockcastle, Rowan, and Warren.

“Rural communities often face a critical shortage of health-care professionals,” said Ashley Sokoler, AHA's Kentuckiana director. “That’s why it’s so important to make CPR training available to new parents in rural areas and provide the healthcare facilities they visit with the resources needed to implement training without causing additional strain on their staff.”

Hospitals, clinics, and other healthcare providers interested in requesting kits can contact AHA Kentuckiana Community Impact Director Tracy Monks at tracy.monks@heart.org for information.

Two Kentucky hospitals, in Lexington and Prestonsburg, each lose $2.4 million in very different lawsuits over 'patient dumping'

Baptist Health Lexington (Photo for The Courier Journal by Jack Weaver)

Highlands ARH Medical Center, Prestonsburg

Two Kentucky hospitals have recently lost lawsuits that charged them with “patient dumping,” generally defined as discharging patients who are uninsured or unable to pay – or refusing to admit them in the first place, reports Andrew Wolfson of the Louisville Courier Journal.

The judgments were virtually the same, but the cases were very different.

On Aug. 31, a Floyd County jury awarded $2.4 million to Ashley Shepherd, "who claimed Highlands ARH Medical Center retaliated against her after she refused to go along with an alleged scheme to boot out suicidal, psychotic and homicidal patents when their insurance coverage expired, usually after three days," Wolfson reports. "Shepherd, a behavioral therapist, said she was directed by supervisors at the hospital in Prestonsburg to persuade patients they were no longer psychotic, suicidal or homicidal so they could be discharged when they could no longer pay or their insurance coverage ran out."

Shepherd, a 36-year-old single mother, testified in a deposition, “I was told this is not a hotel.” ARH denied the charges, but the jury said it should pay $2 million in punitive damages.

On Sept. 13, a federal jury in Louisville "awarded $2,395,000 to tow-truck operator William “Tully” Williams, 65, whom Baptist Hospital Lexington turned away when he was transported there by EMS suffering from a dangerous type of heart attack" on Final Four weekend in April 2015, Wolfson reports. "The hospital said it had to 'divert' heart-attack patients because it didn’t have any cardiothoracic surgeons on call. . . . He had to be loaded back into an ambulance and taken to another hospital down the road. . . . His lawyer, Hans Poppe, said the hospital committed a 'reckless comedy of errors,' including failing to advise local ambulance services of its plans."

Williams sued Baptist Health after the federal government found that the hospital violated the Emergency Medical Treatment and Labor Act by failing to screen and stabilize Williams before sending him to the University of Kentucky hospital a mile away, Wolfson reports. The law allows fines of up to $100,000, or lets patients sue for more.

Baptist Health attorneys argued that the delay was "only a few minutes, but its own medical expert conceded it didn’t meet the standard of care," Wolfson reports. The jury's verdict included $1.85 million in punitive damages, which are designed to discourage similar conduct by the defendant and others. The case was tried by District Judge Claria Horn Boom.

Shepherd's attorney, Jerry Patton of Prestonsburg, told Wolfson that his client's award “sends a message to health-care providers who bear tremendous responsibility for the treatment and care of psychiatric patients that the law must be followed, and above all patient safety and care is paramount to any and all other considerations, including profit.”

Appalachian Regional Healthcare's chief legal officer, Cristi R. Lee, gave Wolfson a statement: “Patient care is always the top priority in all ARH locations, regardless of that patient's ability to pay. Additionally, processes are in place to encourage all staff to make their voices heard should they want to suggest opportunities for improvement or have any concerns while working in our facilities.”

"She noted the case, tried before Judge Thomas Smith, involved one claim related solely to Shepherd’s employment and there were no claims of medical negligence," Wolfson reports. "She said ARH was disappointed with how the law was applied and has asked Smith to overturn the verdict."

In the other case, Baptist Health spokeswoman Kit Fullenlove Barry told Wolfson that the diversion of Williams said was a “rare and unusual occurrence. . . . While we are surprised and disappointed with the verdict, we are pleased that Mr. Williams received the care he needed and is doing well.” Baptist "said it later hired a consultant to train employees how to comply with the law," Wolfson reports.

Carter County student goes to hospital with adverse vape reaction

A Carter County ambulance (Carter County Times photo)

An ambulance took a student from East Carter High School in Grayson to Kings Daughters Medical Center in Ashland Thursday after the student had an adverse reaction to an electronic cigarette, Carter County school officials said. They said the student was being treated for non-life threatening symptoms, and school administrators and law enforcement were investigating the incident while students were being asked to stay in their classrooms, the Lexington Herald-Leader reported.

The student lost consciousness but "didn't appear to suffer any lasting harm," reports Jeremy Wells of the Carter County Times, paraphrasing Supt. Paul Green. He told the Times that vaping “is a huge issue, not just for Carter County Schools, but schools all across the state. . . . What they don’t understand is that while there are perhaps some of these  aren’t as harmful as others – though they’re all harmful – but a lot of times kids don’t know what’s in these.”

Wells reports, "That became an issue on Thursday when the students who had the vape got rid of it, fearing punishment, and medical personnel had to wait on toxicology reports to determine what the student was in fact reacting to."

Green said, “The first thing they [the first responders] want to know is what was in it. Because they don’t know how to treat a student, or anybody, if they don’t know what they’ve actually consumed or inhaled. So, it’s a scary situation where we’re glad that today didn’t end in anything worse, but we want to make sure we continue to work hard with everybody to prevent this from happening in the future. . . . We’re still trying to find out exactly what caused that adverse reaction.”

The school district issued a statement saying, “The safety of our students is of the utmost importance across the district. We ask that parents and guardians discuss the dangers of vaping with their children.”

After changes to appease county governments, the bill to address ambulance transfer times is raring to go for its final dispatch

Dwayne Oliver and Doug Byers of Lee County's ambulance service
refit one after a run. (Photo by Ryan C. Hermens, Lexington Herald-Leader)

UPDATE: March 29, The Senate passed HB 777 with a committee substitute 34-2. The House concurred in the Senate changes, giving the bill final passage. 

By Melissa Patrick

Kentucky Health News

After yet another round of negotiations, a House bill aimed at improving ambulance transfer times nears a vote on the Senate consent calendar, used to pass bills without further discussion.

"All parties came to the table and I think we all agree," Rep. Ken Fleming, R-Louisville, the bill's sponsor, told Kentucky Health News. "We know it's not perfect. We do have a lot of work ahead of us in the task force, and then we're gonna really peel this whole issue back even further to make sure that we deliver the best quality of care for patients." 

Fleming told the Senate Health and Welfare Committee March 16 about a friend's sister who died while waiting on transport, and of organs that had barely made it to the hospital on time to save a life.

The Kentucky Association of Counties objected to parts of House Bill 777 and Chairman Ralph Alvarado asked them to go back to the negotiating table to work our their differences.

Senate President Pro Tem David Givens, R-Greensburg, was touted as being instrumental in finding consensus. He said KACo still does not support the bill, "but I sense that their opposition has now been moved to a place of neutrality." The bill is being pushed by the Kentucky Hospital Association.

Fleming said one change would require the Cabinet for Health and Family Services to send a notice to all cities and counties that a hospital has proposed to establish an ambulance service. The legislative bodies of the affected cities and counties would have 30 days to respond, and lack of response will be deemed support.

Another change would "sunset" the new rules in 2026, while allowing "all actions taken by cities, counties and hospitals, exemptions from obtaining a certificate of need and any certificate of need" granted under these new rules to remain in effect on and after this date.

A certificate of need is, in effect, a license to operate a health-related service. "Kentucky and Hawaii are the only states that regulate ambulance services under a certificate-of-need provision," notes Alex Acquisto of the Lexington Herald-Leader. And Kentucky does that with an independent Kentucky Board of Emergency Medical Services, comprised of EMS personnel.

The bill would make the board an independent agency of the state government, which would investigate all complaints about ambulance services, while leaving discipline to the board, and create a task force to do a thorough review of "the need, or lack thereof, for the certificate-of-need process for ambulance services."

Fleming said that will be one of the task force's biggest assignments. "There are 48 states that do not have certificate of need when it comes to ambulances," he said, "so we've got to figure out why are we an outlier."

Rep. Ken Fleming

The task force was a way to scale back the original version of the bill by deferring action on some points. "We're going to have to roll up our sleeves," Fleming said. "It's just going to be good, healthy discussions." He said it will be important for the task force to look at EMS workforce issues because that is a challenge that keeps coming up. 

Among other things, the bill would reform the certification requirements to allow cities, counties and hospitals to transport patients under certain conditions; make it easier for patients to register complaints; and exempts organ-procurement organizations from speed limits and traffic-flow patterns while transporting a human tissue in an emergency.

Stories of ambulance delays abound.

Acquisto's story begins with the story of an emergency patient at the St. Claire Regional Medical Center in Morehead with a ruptured blood vessel in his esophagus who waited five and a half hours for an ambulance (helicopters were not available because of rain) and was finally transported to Lexington in an ambulance from Ohio, which hospital CEO Donald Lloyd told her is "not permitted."

Acquisto reports that a survey done by the hospital association found that the average wait time for patients to be transported was seven to eight hours, with 90% of those requests to transfer a patient to a higher level of care, according to Nancy Galvagni, president of the association.

House hopes third bill is the charm as it sends the Senate compromise legislation to address ambulance delays

Update 3/16/22: House Bill 777 was heard in the Senate Health & Welfare committee today, but was delayed after the Kentucky Association of Counties objected to parts of it. Chairman Sen. Ralph Alvarado asked the stakeholders to go back to the negotiating table and try to work out their differences before they vote on it. 

By Melissa Patrick
Kentucky Health News

The House has passed and sent the Senate a bill aimed at improving ambulances' response times, for both emergent and non-emergent transfers.

Rep. Ken Fleming, R-Louisville

The bill, sponsored by Rep. Ken Fleming, R-Louisville, is the third measure on the topic this year, after 13 stakeholders put in more than 1,000 hours of work to reach a compromise. 

"House Bill 777 has been a wild and wooly ride," Fleming said while presenting the bill Monday on the House floor, where it passed 77-15 after little debate.

The Kentucky Hospital Association initiated the legislation, citing a statewide poll that found Kentuckians offered broad support for measures to increase the number of ambulance services in the state.

Fleming commended the work of stakeholders' efforts to find solutions that were in in the best interest of the patients and their quality of care, while also addressing the needs of the industry. 

"This bill basically comes down to this: transporting patients from one point to another," he said, later adding, " "We've got a problem, and 777 is trying to address those timing issues." 

Fleming said he had heard from individuals who waited eight hours to several days for a transfer, and he said a friend's sister died because she was not transported in a timely manner.

Co-sponsor Rep. Kim Moser, R-Taylor Mill, said "This is about strengthening our system, our emergency services in Kentucky. This is not and it should never be about revenue. . . . Our job is to ensure quality patient care."

A key provision in HB 777 would establish a task force to meet between legislative sessions to study emergency medical services and make recommendations to the next General Assembly. It would require the Kentucky Board of Emergency Medical Services to create a special committee to study issues defined in the bill, such as needs of patients with behavioral-health issues.

The bill would also change the certificate-of-need requirements to allow cities, counties and hospitals to transport patients under certain conditions without obtaining a certificate, effectively a license. For example, a hospital could create an ambulance service limited to transporting patients from that hospital.

Rep. Jim DuPlessis, R-Elizabethtown, said picking and choosing groups for different certificate-of-need rules opens the door for others, noting that birthing centers have been asking for this for years. 

HB 777 would also:

• Require the state health cabinet to investigate and hold hearings regarding complaints related to ambulance services, while leaving disciplinary enforcement to KBEMS;
• Make it easier for patients to register complaints;
• Give the cabinet complete and immediate access to all data and records of KBEMS and its contractors;
• Make KBEMS an independent agency of state government, rather than part of the Kentucky Community and Technical College System;
• Add KBEMS to the list of boards and commissions for which the Public Protection Cabinet provides administrative services, technical assistance and advice;
• Exempt organ-procurement organization vehicles from speed limits and traffic-flow patterns while transporting a human organ or tissue in an emergency situation; and
• Create a Technical Advisory Committee on Emergency Medical Services to advise regarding Medicaid EMS issues.

Compromise bill to address hospitals' issues with ambulance services passes first hurdle; aimed at delays in transfers

Update 3/16/22: House Bill 777 was heard in the Senate Health & Welfare committee today, but was delayed after the Kentucky Association of Counties objected to parts of it. Chairman Sen. Ralph Alvarado asked the stakeholders to go back to the negotiating table and try to work out their differences before they vote on it. 

By Melissa Patrick
Kentucky Health News

With input from 13 stakeholders, a compromise version of a bill to improve ambulance responses to both emergent and non-emergent transfers is headed to the full House for consideration. 

Rep. Ken Fleming, R-Louisville

Sponsor Ken Fleming, R-Louisville, told the House Health and Family Services Committee that it had taken more than 1,000 hours of work to produce House Bill 777, with input from a range of lobbying interests. This is the third numbered version of the legislation to be filed, which is unusual.

Previous versions included things like response time requirements, putting regulatory authority in the Cabinet for Health and Family Services and eliminating of the need for any new emergency medical service to get a certificate of need from the state. All those provisions caused an uproar among EMS workers and some of their allied associations, but HB 777 appears to be more palatable, with only a few concerns voiced to the committee Thursday. 

"This bill has not been an easy task," Fleming said. "It reflects the stakeholders . . . being open-minded, and their willingness to serve patients, and their determination to do the right thing." 

Fleming said the bill "moves the ball forward" in dealing with issues of transportation between health-care facilities, the main impetus for the bill. 

"I have many examples where patients were not transferred from one facility to another from either eight hours or several days," he said. 

The bill was the brainchild of the Kentucky Hospital Association. Its president, Nancy Galvagni, spoke of long delays that hospitals experience when trying to get patients to the level of care that they need, especially in rural areas. In an earlier interview with Kentucky Health News she told of patients who had died waiting on a patient transfer and psychiatric patients who were being refused transport. 

"The problem we're seeking to address isn't a hospital problem. It's not an ambulance problem. It's not a local government problem. It's a patient problem," she said. "And I think we all understand that we just can't do things the way we've always done when people's lives and their health is in the balance."

A key provision in HB 777 would establish a task force to meet between legislative sessions to study emergency medical services and make recommendations to the General Assembly. It would require the Kentucky Board of Emergency Medical Services to create a special committee to study a list of specific issues defined in the bill, such as response times and needs of patients with behavioral-health issues. 

Both lawmakers and stakeholders praised the idea of the task force, which was not included in previous versions of the legislation.

The director of KBEMS, Mike Poynter, told Kentucky Health News in a statement that it was unfortunate that the agency had been mentioned as part of each of the three bills filed on this issue. In an earlier interview, Poynter told KHN that while there is always room for improvement, "I don't think KBES is broken and I have the statistics that can back that up."

"We do believe that House Bill 777 is the best compromise we can come to at this time," Poynter said in a statement. "We wish that KBEMS and other EMS professionals would have been brought to the table before any of this legislation took draft. . . . We would welcome more time to sit at the table with all affected stakeholders to create a more pro-active plan, rather than be forced into a reflex, expedited reaction."

Poynter also spoke to the resiliency, passion and expertise of EMS workers. "Like we always do, the EMS family adapts and will find solutions to problems no matter what. EMS professionals don’t do what they do because they have to, they do so because they feel called to do so."

The bill would also reform aspects of the certificate-of-need requirements to allow cities, counties and hospitals to transport patients under certain conditions without obtaining a certificate. For example, a hospital could create an ambulance service limited to transporting patients from that hospital.

Galvagni told Kentucky Health News that Kentucky is one of only two states that has a certificate-of-need process for ambulances, which she said creates a barrier to care. 

Conjuna Collier, senior vice president of risk management at Masonic Homes of Kentucky, told Kentucky Health News that the certificate-of-need portion of the bill is important due to the challenges ambulance services face in managing emergency calls and inter-facility transfers. 

Collier said that they have transfer issues "on a daily or weekly basis," including patients discharged from the hospital early in the morning but not arriving at the next facility until late in the evening to "way up in the middle of the night." She said they also struggle to get Covid-19 patients transferred and get patients to and from dialysis in a timely manner. 

"Of course, a heart attack is going to come before picking up a 90-year-old at a dialysis appointment, but then there still is that service that's not getting provided for that resident," she said, later adding, "There just needs to be more of them." 

Dr. Walt Lubbers, an EMS physician, medical adviser for the Kentucky Board of EMS and a representative of the Kentucky EMS Association, said the bill offered a "reasonable compromise on a whole lot of things."  

"It provides good stability for letting the folks that know about EMS continue to regulate EMS, as well as a reasonable change to the complaint process," Lubbers said. "And it recognizes that we don't think we're done and that we can't walk away with this being the only EMS bill that any of us ever think of."

Harlan County Judge-Executive Dan Mosley said he wasn't at the meeting to support or oppose the bill, but to voice concerns and to ask that they "look at it further" and "slow it down."  

He said he gets many calls from people who can't get transported from Harlan Appalachian Regional Healthcare Hospital to UK HealthCare in Lexington or that an ambulance did not make it to their home. "This happens more often, more times than it should," he said. 

Mosley said his concern is around the shortage of personnel in emergency medical services, and what would happen if more services are allowed to open that could further dilute their workforce and services.

"The goal has to be what we can effectively do that improves the service to our citizens, not only those that are in the hospital, but those that are at home that need to call 911 and expect and deserve that that ambulance gets there to help them," Mosley said. "Until we address the human shortage element in this industry. I'm afraid efforts like this will have unintended consequences." 

Kevin Pharis, director of Grayson County EMS, told Kentucky Health News that removing all of the certificate-of-need requirements, as proposed in the previous bill, would not fix the problem because "We do not have the personnel to staff ambulances that we already have." He said paramedics are leaving for better pay better pay and working conditions in hospitals, and the cost to become a paramedic versus what they are paid is a problem.

The bill doesn't deal with staffing, but that is part of budget discussions because sponsors recognize that staffing is an issue, said Rep. Kim Moser, R-Taylor Mill, a recent co-sponsor of the bill and chair of the committee. 

The hospitals' Galvagni said, "House Bill 777 does not give all parties what they desire, but we feel it's an important first step to addressing the needs of our patients. . . . We're very proud that we were able to work out a solution to move this issue forward." 

HB 777 would also: 

• Require the health cabinet to investigate and hold hearings regarding complaints related to ambulance services, while leaving disciplinary enforcement to KBEMS;
• Make it easier for patients to register complaints;
• Give the cabinet complete and immediate access to all data and records of KBEMS and its contractors;
• Make KBEMS an independent agency of state government, rather than part of the Kentucky Community and Technical College System;
• Add KBEMS to the list of boards and commissions for which the Department of Professional Licensing in the Public Protection Cabinet provides administrative services, technical assistance and advice;
• Exempt organ-procurement organization vehicles from speed limits and traffic-flow patterns while transporting a human organ or tissue in an emergency situation; and
• Create a Technical Advisory Committee on Emergency Medical Services to advise regarding Medicaid EMS issues.

Other organizations involved in crafting the bill are the Kentucky League of Cities, the Kentucky Association of Firefighters the Kentucky Psychological Association and Advocacy Network; the Kentucky Association of Counties; the Kentucky Association of Healthcare Facilities;, the nursing-home lobby; the Kentucky Center of Assisted Living; the Kentucky Ambulance Providers Association; the Kentucky Association of Public-Safety Communications Officials; and the Kentucky Emergency Number Association.

Estill County paramedic and EMS trainer is recognized as one of the nation's 50 'Community Stars' on National Rural Health Day

Sheila Wise (Photo courtesy of Sheila Wise)

Shelia Wise, a paramedic and training major at Estill County EMS in Irvine, has been recognized today by the National Organization of State Offices of Rural Health  as a “Community Star” for her community education efforts and her work in helping to shape her hometown EMS service into what she considers one of the best in the state.

Wise, who began a career in accounting before switching  to EMS in the 1990s, holds just about every instructor certification available in the field (and others outside of it), and she puts them to use — not just in training first responders, but also staff at the local hospital, other clinics, health departments, schools, churches, other community organizations and students in a nearby university-based paramedic program.

She’s been involved in efforts to combat substance use disorder, including serving as a member of the region’s Overdose Task Force. She also serves as a medical liaison to the county coroner’s office.

And Wise has been instrumental — along with her husband, Jimmie, the director of the EMS service — in developing the close relationship that exists between the service and Mercy Health-Marcum & Wallace Hospital, the critical-access hospital that is the service’s next-door neighbor.

“I can tell you I am so honored to have received this recognition. I don't feel that I do anything special,” Shelia Wise said. “I just do a job that I love in a community that I grew up in, where I know most everyone. A lot of my patients have watched me grow up. So, when I am working in this community, I am caring for not just patients — but truly my friends and family.”

She added: “Jimmie and I have worked with EMS for a very long time. We eat, sleep and drink emergency services and would not have it any other way.”

As part of the Community Star recognition, Wise is featured in an electronic book released on National Rural Health Day, Nov. 18. The publication, on the powerofrural.org website, features stories of 50 Community Stars from across the country. The book is also available for purchase in print.

“Shelia Wise is one of those health care professionals who really gets it — she understands what it means to work in a rural community, that those communities often face limited resources, but that the residents living there deserve the highest level of care possible,” said Ernie Scott, the director of the Kentucky Office of Rural Health. “Rural Kentucky is where she’s from. Rural Kentucky is where she works. Rural Kentucky is who she is. And, rural Kentucky is where her heart is. The Irvine community, Estill County and all of Kentucky are lucky to have her here.”

Each Community Star was nominated for recognition by someone familiar with their rural health work and contributions. A selection committee reviewed and evaluated nominations and made recommendations on which stories to include in this year’s publication.

Past nominees have included physicians, nurses, allied health providers, hospital administrators, board members, volunteers, community health workers and first responders. Other nominees have included coalitions and collaborators working together on initiatives that address a specific health crisis or need, or drive large-scale health and wellness programs.

The Community Stars initiative, begun in 2015, shines a spotlight each year on individuals and organizations who work every day to close gaps, open doors, address challenges and develop solutions through collaboration, education, innovation and communication.

Short staffing of Kentucky ambulance services leads to deaths

Dwayne Oliver of Lee County ends a hospital run. (Photo by Ryan C. Hermens, Lexington Herald-Leader)

Kentuckians are dying because their local emergency medical services can't find enough employees to staff the ambulances.

That's the upshot of a detailed story by Bill Estep in the Lexington Herald-Leader, which begins with the story of a Magoffin County man who died while waiting for an ambulance that took 45 minutes to arrive.

Lifeguard Emergency Medical Services spokesman Terence Ramotar blamed the delay on a staff shortage. Estep reports, "That is a problem in many parts of Kentucky and the nation, and it’s causing longer response times for some calls, according to EMS officials."

The ambulance had to come from another county because Magoffin has only two and both were on runs. "It’s not unusual for a rural county in Kentucky to have two ambulances on duty but for both to be tied up, forcing dispatchers to call for an ambulance from another county under mutual-aid agreements, adding to the time needed to respond," Estep reports.

"Without measures to get more people to train as EMTs and paramedics and stay in the field, the EMS system in Kentucky 'is in danger of collapsing,' Keith Sanders, head of the ambulance service in Edmonson County, told Kentucky lawmakers at a committee hearing in August."

The services "have struggled to recruit and keep workers, especially paramedics. There are a number of reasons," Estep reports. "The job can involve long hours and high stress, and the coronavirus pandemic of the last 18 months has made that worse, raising worries among EMS workers about getting sick or carrying Covid-19 home to family members, and forcing some to quarantine after being exposed."

Also, Estep writes, "The pandemic reduced the number of training classes in 2020, meaning fewer people in the pipeline. It can take up to two years to become a paramedic. Many rural services can’t afford to pay as well as urban ambulance services or hospitals, making it harder to keep paramedics.

"Ambulance providers said another factor is that Medicaid and Medicare, two primary payment sources for ambulance services in much of rural Kentucky, pay less for many runs than it costs to treat and transport patients. That affects their ability to pay paramedics and emergency medical technicians. . . . The shortfall is being met by ambulance crew members working extra shifts, sometimes 80 hours or more a week and often at more than one service, according to directors around the state."

Estep's story focuses partly on the performance of Lifeguard, a subsidiary of Global Medical Response, the world's largest medical transport firm. It also operates in Floyd, Pike, Knott, Leslie and Harlan counties. "Prestonsburg Mayor Les Stapleton, a retired state police officer, said Lifeguard has good professional staffers, but hasn’t had ambulances readily available in Floyd County at times," Estep reports, quoting him: “I’ve got people that have literally died.”

State officials have dealt with staffing issues by "allowing people with less emergency medical training to drive ambulances and waiving the recertification fee for trained EMS workers who had allowed credentials to lapse," Estep reports. But Michael E. Poynter, director of the Kentucky Board of Emergency Medical Services, told him that the pay issue needs fixing.

"Sanders, the Edmonson County EMS director, said many ambulance services can only afford to start EMTs at $11 or $12 an hour — less than some restaurants are offering these days." He asked at the Aug. 26 legislative hearing, “Why would you spend a thousand dollars to take a class to make $11 an hour when you can go serve fast food and make $15?” Ramotar told Estep that Lifeguard starts EMTs at $10 to $11.44 an hour and paramedics at $16 to $17.44 an hour.

Another financial issue is low Medicare and Medicaid reimbursements. Sanders said the average cost of a run for his ambulance service in Edmonson County is $880, while the average reimbursement from Medicare and Medicaid is $386, and the difference comes from taxpayer dollars.

Legislation to fix surprise medical billing won't apply to ground ambulances, but may produce data that will spur their inclusion

The new law will apply to air ambulances of Lifeguard Emergency Services of Eastern Kentucky and those of other U.S. ambulance services, but not to their ground ambulances. (Lifeguard photo)

The congressional fix for surprise medical bills, contained in the legislation to keep the government open, provide pandemic relief and do many other things, does not apply to ground ambulances, which "have the highest out-of-network billing rate of any medical specialty," The New York Times reports.

Congress "had little data on the actual costs of ambulance trips, and worried about tussling with the local governments that often oversee these services — especially those whose budgets have been battered by the economic downturn," Sarah Kliff and Margot Sanger-Katz report for the Times.

Research by Dr. Karan Chhabra of Boston's Brigham and Women’s Hospital found 71 percent of ambulance rides "have the potential to generate a surprise bill, with an average cost to the patient of $450," the Times reports. "Whether an ambulance company chooses to pursue this bill is something his research cannot determine, which is why it is merely potential." An earlier study found most ambulance rides "resulted in an out-of-network bill, a substantially higher rate than the medical specialties that the new legislation covers."

In the world of surprise medical bills, $450 is relatively small, and many ambulance services write off unpaid out-of-network bills as bad debts. But the new Congress could extend the new law — which President Trump signed Sunday night and will take effect in 2022 — to include ground ambulances.

"Medicare, which pays ambulances set rates and bans surprise billing for the patients it covers, is reviewing its payment rates," the Times reports. "As part of that process, the government is collecting detailed data from ambulance companies about their costs and prices. And the surprise-billing legislation passed this week establishes a commission to study the problem of ground ambulance bills, another way for lawmakers to learn more about how things are currently working."

McConnell puts fix for 'surprise billing' problem in must-pass bill

McConnell on Dec. 15 (Pool photo by Rod Lamkey via AP)

The massive bill to keep the government open and provide $900 billion in pandemic relief also includes a compromise solution to the nagging problem of "surprise billing" in health care, key members in both parties said Sunday night.

Senate Majority Leader Mitch McConnell, who was pulled in opposite directions on the issue and had remained mum about it, made the final call, Susannah Luthi of Politico reports.

"While the health-care industry agreed that patients should be held harmless in emergency situations, hospital and physician groups and insurers fought vigorously over who would pick up the tab," Luthi reports. "The compromise deal congressional committees struck earlier this month was considered largely a win for hospitals and doctors —and tweaks made in the final legislation are even friendlier to providers, according to a summary obtained by Politico." 

The key change is in the negotiation procedure for health-care providers and insurance companies to resolve billing disputes or take them to a mediator. "The bill would forbid arbiters from taking into account Medicare and Medicaid rates, which are typically much lower than what commercial coverage pays," Luthi writes. "That is a loss for insurers, employers who fund a major chunk of private coverage, and patient advocates who thought including those public rates as a barometer could help curb health-care prices. As a guardrail, the measure also bars arbiters from considering providers' billed charges, which are usually well out of line with what insurers or patients end up paying."

Surprise billing usually happens when a patient is treated by a provider, or transported by an emergency medical service, that is not in the network called for by the patient's insurance. Contracted emergency-room physicians are a common case; as many as one in five ER visits can result in a surprise bill. "Some private-equity firms have turned this kind of billing into a robust business model, buying emergency room doctor groups and moving the providers out of network so they could bill larger fees," The New York Times reports.

Surprise billing is a problem in Kentucky. "A 2018 survey found that 32% of privately insured Kentucky adults reported receiving a medical bill that included an unexpected expense in the previous year," Butler County Republican Party Chair Matthew Embry wrote in a Dec. 2 piece for the Courier Journal. "To make matters worse, 70% of patients who were hit with surprise medical bills had no idea they were receiving treatment from a provider outside of their insurance network. . . . If the patient can’t afford to pay astronomical surprise bills, they can be harassed by collection agencies, threatened with legal action and even forced into bankruptcy."

The bill's passage is a big capstone for the political career of retiring Sen. Lamar Alexander, R-Tenn., a close friend of McConnell. But one of the majority leader's biggest business constituents is Humana Inc., the Louisville insurance firm. 

Insurers did appeared to get something in the final deal, Luthi reports: "Lawmakers appear to have watered down a measure that would have required them to disclose detailed information to employers about their drug costs and rebates through their contracts with middlemen known as pharmacy benefit managers, whose business practices have come under scrutiny in recent years for their role in high drug costs. Instead, the legislation calls for insurers to submit more general information on medical costs and prescription drug spending to relevant federal agencies, which would feed into a government report on drug pricing trends."

The U.S. Supreme Court recently ruled that states could regulate pharmacy benefit managers, which the Kentucky legislature recently decided to regulate, partly in an effort to help independent pharmacies deal with competition with pharmacy chains than operate PBMs. 

Data and health directors' observations suggest that pandemic lockdown increased overdoses, which declined as state reopened

Graph from Kentucky Injury Prevention Research Center, University of Kentucky

By Melissa Patrick

Kentucky Health News

Apparent overdoses reported by Kentucky hospitals and ambulance services shot up in the two months after Gov. Andy Beshear declared a state of emergency because of the covid-19 pandemic, and have been on a downward trend since the state started reopening in mid-May.

"I don't want to give false hope," Dana Quesinberry, research core director for the Kentucky Injury Prevention and Research Center, said as she explained the data on hospital emergency departments' and emergency medical services' reports of "overdose encounters," a term KIPRC uses because overdoses may be suspected but not necessarily confirmed.

"We are still at higher levels than we've ever been, but the fact that we are seeing that decline over the last few weeks is very important," Quesinberry said. "There is hope that we are making progress again, so whatever triggered the increase is being managed or mitigated in some way." 

She said the data coincides with preliminary reports that also shows an uptick in overdose deaths during April and May. Quesinberry said official 2020 overdose death numbers are not yet available, but "Preliminary data indicates that we have had increases in drug overdose deaths during covid." For April, "We are still looking at a monthly count that exceeds at least anything in the prior couple of years, in a month total." She added later, "We are seeing increases in May as well." 

Quesinberry, an assistant professor for the Department of Health Management and Policy at the University of Kentucky, said researchers will need to explore what triggered the peak in overdose encounters and then look at what slowed it down.  

"We know that there has been an impact on the opioid epidemic during covid and we are working very hard to understand what that impact has been," she said, adding later, "This is a time of tremendous uncertainty driven by the pandemic. It's important to understand that it has consequences beyond the spread of infectious disease."

Public health reports coincide

"Covid has had a huge impact on substance use because it has led to more isolation," John Moses, team leader for harm-reduction services at the Lexington-Fayette County Health Department. "I have a feeling that we are seeing a lot more people relapse and go back to using again. I think that people who maybe work full time and only did drugs on the weekend were laid off and now may be doing drugs seven days a week. We know that when people are isolated like that, there is a lot more depression and that always has an effect on drug use."

Moses said his county is on pace to equal the number of overdose deaths in 2017, which were the most ever. "Last year Lexington-Fayette County had a total of 122 overdose deaths; we are already at 107 for the year," he said. "Last year we did a really good job of getting the overdose rates down, but thanks to covid, I believe that we are seeing more overdose deaths." 

Moses also noted that anytime there is an interruption in the drug supply, which has been seen during the pandemic, more fentanyl comes into the community.  He said it is being mixed in with heroin, methamphetamine, cocaine and even THC vape cartiridges, and "This disruption in the drug supply has caused more fentanyl to be here, and more overdoses."

Christie Green, public-health director of the Manchester-based Cumberland Valley District Health Department, said she had heard anecdotally that there were several overdoses about three weeks ago related to a batch of pressed pills that were being sold as Xanax, but were mostly fentanyl -- a synthetic opioid that is much stronger than heroin. 

"This is the first time that I've gone through something that is socially stressful like covid . . . while working so closely with people who are active in substance-use disorder, and it's just been really hard on them," Green said. "A lot of their social supports are gone. I really worry about them, honestly."

Marcy Rein, public-health director of the Whitley County Health Department, said her health department signed up for a system called ODMap in May to track overdoses in the community, along with about 40 other counties and health departments in the state.

"The system allows us to look at the big picture, to look at the maps to see if we have hotspots in a particular area or not," she said. She said a rash of overdoses in May prompted them to join the system. 

Rein said preliminary data shows that the pandemic is having an impact on rates if suspected overdoses: "We're not saying that covid causes the increase in overdoses, but certainly some of the factors that go along with covid most certainly put people at higher risk, like the isolation and also the economic impact."

Andrea Brown, public-health director of the Bourbon County Health Department, said it saw an increase in overdoses in April, and started keeping track of those numbers more diligently in May after signing up for ODMap, which she said only records EMS-related encounters, at least for now.

She said the EMS-only data shows that from from May 5 to July 19, almost two and a half months, Bourbon County had 28 overdoses and five fatalities. Brown estimated that the county had 11 overdoses in April but wasn't sure how many died.

"We are still getting overdoses," she said. "I feel like last year we may have had 12 overdose deaths, something in that ballpark, so if we've already had five between May and July, then I think we are really, once the data actually comes out, we're probably going to see a much higher increase." 

Brown said the health department's harm-reduction syringe exchange has been giving out more Narcan, which can block the effects of an overdose, "so I think the word on the street is probably getting around that there has been an increase of overdoses in our community. The Narcan is definitely a hot ticket item right now."

Jamey Whaley, harm-reduction and-peer support specialist with the Maysville-based Buffalo Trace District Heath Department, said some of his syringe-exchange participants have reported an increase in overdoses where they have had to administer Narcan. He said he is also seeing people relapse and return to the program. 

"I don't know if that's because of the covid and the mental-health side of it that has made them decide to go back to using," he said. 

Scott Lockard, public health director at the Hazard-based Kentucky River District Health Department, said Eastern Kentucky has seen an influx of pressed tablets with fentanyl and carfentanyl, noting that Lee County saw a huge uptick in overdoses from a substance called "smurf dope" just a few weeks ago. WLEX-TV reported July 1 that smurf dope is a bright blue substance that is a mixture of methamphetamine or heroin and fentanyl. 

"I think any time you see a different substance than what people normally utilize, there is an adjustment period in how they use it and the strength, the purity level of it when it is a fentanyl or carfentanyl," Lockard said. "If somebody has been abusing Suboxone, which is a pharmaceutical-grade substance, and then now they are dealing with these pressed tablets, that's where I think it increased a lot of the issues that we were seeing with the increase in overdoses."

He said anecdotally, based on what he hears from EMS, law enforcement and harm-reduction people, there have been fewer overdoses near the end of June and in July.

For help in finding treatment for substance-use disorder for yourself, a friend, or loved one, the state has a website: findhelpnowky.org.