460,000 Kentuckians on expanded Medicaid have lost their dental and vision benefits; officials blame judge's ruling against new plan

By Melissa Patrick and Al Cross
Kentucky Health News

One of the major objections to Gov. Matt Bevin's changes in Medicaid was that people who are covered by the program's 2014 expansion would have to participate in certain self-improvement activities to get dental and vision benefits that they had enjoyed for free, starting this week.

A federal judge vacated the plan Friday, but on Sunday those 460,000 Kentuckians lost their dental and vision benefits, because the self-improvement "rewards" program was part of the plan -- and state officials had acted separately to end the dental and vision benefits for those in the expansion.

Family Health Centers in Louisville built a dental clinic after

Medicaid expanded. (Angela Shoemaker, Courier-Journal)

When the plan "was struck down by the court, the My Rewards Account program was invalidated, meaning there is no longer a legal mechanism in place to pay for dental and vision coverage for about 460,000 beneficiaries who have been placed in the Alternative Benefit Plan," said Doug Hogan, a spokesman for the state Cabinet for Health and Family Services.

Hogan said the cabinet "made it clear" that dental and vision benefits were dependent on the plan taking effect, and that without it, "immediate benefit reductions would be required to compensate for the increasing costs of expanded Medicaid. This is an unfortunate consequence of the judge's ruling. Once we ultimately prevail in this legal challenge . . . beneficiaries will have access to these optional services."

The state is expected to appeal the decision of U.S. District Judge James Boasberg of Washington, D.C. Bevin has said the issue will ultimately be decided by the Supreme Court.

Kentucky Voices for Health said the state can't eliminate dental and vision benefits without having the change approved by the federal Centers for Medicare and Medicaid Services, "followed by filing a revised state regulation, holding a public comment period, and providing notice to affected Medicaid members."

Hogan disputed KVH's assertion that the changes are illegal. He said the state posted the changes in April and notified the affected members. The state has long had the authority to make dental and vision coverage optional in Medicaid.

KVH, an organization of lobbying groups, said people affected by the changes have the right to appeal, and suggested that they call their local legal-aid office for assistance and tell KVH about it.

Health Secretary Adam Meier told legislators June 20 that dental and vision benefits would be cut for some people if the court blocked the overall plan. He also said the state would consider cuts to the prescription-drug program, and consider rolling back the expansion, implemented by Bevin's Democratic predecessor, Steve Beshear, which covers people with incomes up to 138 percent of the federal poverty level.

Bevin, a Republican, has said Kentucky will end the expansion if courts block his plan, and has issued an executive order putting the termination into effect six months after the final judgment.

Under the vacated plan, people covered by the expansion were to earn credits for dental and vision care by participating in certain activities, such as passing a GED exam, completing job training, or completing wellness activities such as stop-smoking classes, weight-loss programs or diabetes education. They could also earn credits by working; most on the expansion work.

Critics of making vision benefits optional have said it is unwise because Kentucky has one of the highest diabetes rates in the nation, and the disease is often discovered through eye examinations.

Pregnant women, children, those who have been deemed medically frail, former foster youth up to age 26, and people covered by Medicaid before the expansion will get to keep their dental and vision benefits.

Bevin's plan, called Kentucky HEALTH for "Helping to Engage and Achieve Long Term Health," included, requirements for work, volunteering, job training or drug treatment; monthly reporting; lock-out periods for failure to comply; and premiums and co-payments based on income.

Hogan noted that Medicaid still "offers support and resources for those interested in improving their incomes and health. This ruling does not threaten the opportunities Kentucky HEALTH has already created. We look forward to offering these new resources to Kentuckians on a voluntary basis. You can log on to CitizenConnect.ky.gov to take free online courses about health skills, life skills, and work skills. You can also visit KCC.ky.gov to find a career center near you, where a coach can help you find training, education, and job opportunities in your area."

For most of the 1.4 million Kentuckians on Medicaid, the program remains the same for now -- no premiums or co-payments, no deductibles, no reporting requirements and no requirements for work or other "community engagement." Managed care organizations will be charging co-payments for services, according to a state document issued to call-centers and front-line staff. 

If you are one of the 300 or so Kentuckians on Medicaid who had already paid their premiums, the Kentucky HEALTH website says your managed-care organization will provide you further information about what to do.

County totals of people on Medicaid, the expansion and other categories is at http://www.uky.edu/comminfostudies/irjci/MedicaidenrollmentbycountyJune%202017.xlsx.

Optometry bill delivered to the governor after Senate changes

By Melissa Patrick
Kentucky Health News

A bill to regulate online eye exams has been delivered to Gov. Matt Bevin after getting final passage from the state House.

On an 88-0 vote, the House agreed with the changes the Senate made to House Bill 191 to remove the original bill's requirement for "simultaneous" consultation between online, Kentucky-licensed eye-care providers and their patients, which critics said would have limited access to eye care and tele-health technologies going forward.

The Senate passed the bill 36-0 March 14 with an amendment that changed the word "simultaneous" to either "synchronous or asynchronous." The bill's sponsor, Rep. Jim Gooch, R-Providence, said the change represented a compromise between all sides of the issue.

The bill requires that a person to be 18 to use the online services, that a medical history be obtained, that the person must have had an in-person eye exam withing two years of the online exam, and that a patient is not allowed to get contacts for the first time during an online exam.

This is the first time regulations have been placed on the online eye-care industry in Kentucky. It was supported by optometrists, who have a strong lobbying and campaign-finance presence in the legislature, and opposed by ophthalmologists, who do not.

Optometrists' bill to require online eye exams to be in 'real time' with an eye-care provider clears Senate health committee 6-4

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- A bill to require a portion of an online eye exam to be in "real time" with an eye-care provider went to the Senate floor amid warnings it would restrict access to eye care and conflict directly with a tele-health bill that recently passed the Senate.

Rep. Jim Gooch

The Senate Health and Welfare Committee voted 6-4 on March 7 for House Bill 191, sponsored by Rep. Jim Gooch, R-Providence, after lengthy debate. As amended by the panel, the bill would require a "simultaneous interaction between the patient and the Kentucky-licensed optometrist, osteopath, or physician" for an eye exam or prescription online.

The bill also requires a person to be 18 to use the online services, that a medical history be obtained, that the person must have had an in-person eye exam within two years of the online exam, and that a patient is not allowed to get contacts for the first time during an online exam.

Gooch told the committee that his bill doesn't keep technology out of Kentucky, but does set reasonable standards that ensure patient safety, and also "supports our local eye-care providers." Independent optometrists are one of the most powerful lobbies of the legislature.

Dr. Ben Gaddy, an optometrist and lobbyist for the Kentucky Optometric Association, told the committee that HB 191 simply establishes "safeguards on technology" for an online eye exam that the consumer takes on their own, with no interaction with a provider. "It does not limit where a consumer can purchase contact lenses or glasses -- it's the same as it is today. And it does not interfere with fair trade," he said.

Gaddy said 25 percent of diabetes cases, a real problem in Kentucky, are diagnosed during an in-person eye exam, and a "simultaneous interaction" with an eye-care provider during an online exam would be the only way diabetes and other health conditions could be caught. He added that his association is also concerned that individuals think they have had an eye health exam when they use these online services, when they haven't.

Much of the committee's debate was around that word "simultaneous," which means "at the same time," and the word "asynchronous," which means "not at the same time."

Sen. Ralph Alvarado, R-Winchester, argued that the bill is in direct conflict with his tele-health bill, SB 112, which passed the Senate Feb. 26. It says a requirement for a face-to-face encounter "is satisfied with the use of asynchronous telecommunications technologies" if the provider has access to the client's medical history prior to the encounter.

Alvarado, a physician, said the House bill includes safeguards needed to let eye-care providers participate in an asynchronous interaction, and said the word "simultaneous" must be removed not only because of this conflict, but because it limits technologies going forward and limits care to "a lot of people."

Gaddy replied, "Simultaneous doesn't always mean real-time-to-the-second interaction, but it means that there is more than just the issuance of a prescription."

Sen. David Givens, R-Greensburg, said it is legislators' responsibility to define what "simultaneous" means, or courts would, and they wouldn't be looking at the law's intent, but would "take a strict interpretation." But he voted for the bill.

Sen. Reggie Thomas

Sen. Reginald Thomas, D-Lexington, voted no, saying, "Simultaneous means simultaneous. Words do matter, and what this bill will do in effect is eliminate the ability of people to get glasses or contacts, when they've already gone to a physician and they've already gone to a followup exam,  from using those resources at a much cheaper rate without any risk of having their eyes damaged."

Sen. Julian Carroll, D-Frankfort, originally voted yes but changed his mind. "We are creating an enormous problem for our courts to decide this issue if we don't decide it legislatively," said Carroll, a former governor. "I feel a responsibility as a legislator to avoid a fight in the court over something that is so obvious. We passed one bill that provides for asynchronous and another that provides for synchronous, and that's irresponsible on us as legislators. Now we need to change one of them."

Sen. Danny Carroll, R-Paducah, also voted against the bill, as did Alvarado.

Earlier, Alvarado, referring to Gaddy's suggestion that a simultaneous visit is needed because a health or eye condition could otherwise be missed, called that "a silly example." He described a scenario where a tele-health patient calls in because they have a cough or a cold. "Could they have lung cancer?" he asked rhetorically. "They could," he said. " But we're not going to say you're not going to be able to have a telemedicine visit because we might miss a lung cancer, so you've got to come in and be checked."

Dr. Carl Baker, president of Kentucky Academy of Eye Physicians and Surgeons, spoke in opposition to the bill. He reminded the committee that it would affect more than just glasses and contact-lens prescriptions. He said it also affects how eye-care providers can assess and treat eye diseases.

Baker, a retina specialist practicing in Paducah, said the House bill would limit new technologies that allow for asynchronous, in-home assessments for diseases like diabetes, macular degeneration and glaucoma.

He said the bill would make it illegal for him to continue working for an insurance company that hires him to assess patients for "diabetic retinopathy" by looking at pictures of their retina that were taken by a technician in the patient's home. He said all his patients are given a recommendation to get an eye exam within the next 12 months, but those with a positive diagnosis for the disease are encouraged to see their provider immediately, and receive frequent follow-ups.

"We are enhancing the access to care," Baker said, "and I will tell you that the way this bill is written, that is not possible."

Baker said the bill would also affect specialists who do remote glaucoma screenings and the use of iPads to monitor macular degeneration remotely. "This technology would be illegal under this bill," he said.

Earlier, Gaddy said the bill differentiates between "doctor-directed tele-health" and "consumer-initiated telehealth," and said the procedures described by Baker were doctor-driven, and therefore not affected. "This bill only addresses consumer-driven technology," he said.

Peter Horkan, who represents Opternative, an online company where consumers get a renewed prescription for contacts or glasses, said current safeguards are working. He said 33 percent of people who sign up for the test aren't allowed to take it: “Thirty-three either hear from either an ophthalmologist or a representative of an ophthalmologist that they need to go and have a comprehensive eye exam.”

He said about 15 percent of their patients are "denied for deviation" because there is such a difference between their old and new prescription.

With legislative session more than half over, most health-related bills are still on the table; here's a roundup

For KHN's complete chart of health bills, click here.

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- Most health-related bills in the legislative session appear to be driven by the state's opioid epidemic, tort reform and issues of health-care providers, but only a bill that addresses organ donation has gone to the governor, and the session is more than half over.

If signed, House Bill 84, sponsored by Republican Rep. Lynn Bechler of Marion, would require coroners and medical examiners to contact the Kentucky Organ Donor Affiliates if they know that a decedent wishes to be an organ donor. The current law only requires hospitals to contact KODA when an organ donor dies.

The bill, called "Courtney's Law," is named for Courtney Flear of Princeton, an organ donor who was killed in an automobile accident in 2015, but because of the wording of the current law her organs were not donated despite her wishes, according to Bechler's legislative update.

The opioid epidemic in Kentucky rages on, prompting lawmakers to push for bills to curb it.

Two bills are aimed at early intervention and prevention in schools. HB 55, sponsored by Rep. James Tipton, R-Taylorsville, calls for the creation of an age-appropriate curriculum on drug abuse and prevention that would be taught in every school. HB 3, sponsored by Majority Floor Leader Jonathan Shell, R-Lancaster, would require drug education as part of an "essential skills" program. Both have passed the House and are in the Senate Education Committee.

HB 246, sponsored by Rep. Danny Bentley, R-Russell, would expand access to medication-assisted therapies for treatment of substance-abuse disorders by bringing a grant-funded pilot program to the state that allows pharmacists to administer non-controlled MATs. This bill awaits a floor vote in the House.

Rep. Addia Wuchner, R-Florence, has several bills that address the opioid epidemic. HB 364 would require all pregnant women to be tested for hepatitis C, with the results added to the child's records. It also recommends that the child be tested at 24 months if the mother tests positive. Hepatitis C can be transmitted from mother to baby during childbirth. Most new cases of hepatitis C are a result of illegal intravenous drug use. This bill awaits a floor vote in the House.

Wuchner is also the sponsor of HB 148, which shifts ownership of controlled substances from a deceased hospice patient to the hospice program for disposal. Currently these drugs belong to the estate. This bill has passed the House and is in the Senate Health and Welfare Committee.

Another Wuchner bill, HB 124, calls for a comprehensive review of all state substance use disorder programs and services, and would require the state to only pay for and licence ones that follow nationally recognized evidence based protocols.

Bills for tort reform are also moving in the Republican-led legislature, with votes largely split along party lines.

HB 4, sponsored by Wuchner, would keep doctors' reviews of other doctors from being used in medical-malpractice lawsuits. It has passed the House and a Senate committee and awaits a vote in the full Senate.

Senate Bill 2, sponsored by Sen. Ralph Alvarado, R-Winchester, would limit the amount of non-economic damages that could be awarded in personal-injury and wrongful-death lawsuits. the bill is a proposed constitutional amendment, requiring a three-fifths vote in each chamber and approval by a majority of voters in a statewide referendum at the November election. It is awaiting a vote on the Senate floor, but has been passed over seven times since Feb. 14.

SB 20, also sponsored by Alvarado, would do several things, including limiting attorney fees in malpractice cases, add a requirement for a sworn statement from a doctor saying that a lawsuit has merit before it could proceed, and keep apologies or expressions of regret made by a provider from being used in a lawsuit. This bill also awaits a Senate floor vote.

Insurance and provider-issue bills are also quite prevalent, as usual.

SB 5, sponsored by Sen. Max Wise, R-Campbellsville, which would put the state back in charge of its Medicaid drug program, came about because he said pharmacy-benefit managers hired by the state's Medicaid managed-care organizations, are not paying Kentucky's independent pharmacies a fair price for their drugs -- which is putting them at risk of closing. It also calls for more transparency. This bill has passed out of committee and awaits a vote on the Senate floor.

Other states are also dealing with this issue. The Arkansas Pharmacist Association held a news conference Feb. 21 and revealed that CVS Caremark paid their CVS locations an average of $60 more per prescription than they paid their local independent pharmacies. CVS Caremark is the pharmacy benefit manager for four of Kentucky's five managed-care organization.

A bill in the Senate that is getting some pushback from consumer groups is HB 191, which would restrict the growing practice of online eye examinations. This bill, sponsored by Rep. Jim Gooch, R-Providence, is in the Senate Health and Welfare Committee.

Other bills in this category would improve telehealth access and payment to providers; update state guardianship laws; increase access to autism benefits; improve some of the administrative challenges around managed-care organizations; change how hospitals are paid for charity care; and require ambulance providers to disclose fees, among other things.

HB 64, sponsored by Rep. Stan Lee, R-Lexington, would allow eligible veterans to use hyperbaric oxygen treatment for treatment of traumatic brain injuries. This treatment is currently not covered by insurance, and the bill would not require insurance to cover it. It awaits a vote in the full Senate.

Children's health: Several of the health-related bills are aimed at improving the health of the state's children.

HB 318, sponsored by Rep. Kim Moser, R-Taylor Mill, and and SB 51, sponsored by Alvarado, would require school properties and school events to be tobacco-free. Both are sitting in their respective education committees. Alvarado has said the House needs to pass its bill first, since the Senate passed a similar bill last year but the House didn't take it up. A recent Kentucky Health Issues Poll found that 87 percent of Kentucky adults support such a law.

In the wake of a 2016 Kentucky Incentives for Prevention survey that found one in 12 of Kentucky's high-school sophomores said they had attempted suicide, HB 30, sponsored by Rep. Regina Huff, R-Williamsburg, would require educators to have two hours of in-person suicide prevention training every other school year. Current law requires a minimum of two hours of self-study every year. This bill unanimously passed the House and is in the Senate Education Committee.

Other education-related bills would require abstinence until marriage to be taught in sex-education classes, set guidelines around training for seizure disorders; and require automated external defibrillators in every school with three trained employees. Another youth-safety bill would require children under the age of 12 to wear a bicycle helmet.

Taxes and budget: In addition to the many health-related bills on the table, the Coalition for a Smoke-free Tomorrow, comprising nearly 150 organizations trying to decrease smoking in the state, is lobbying hard to raise the cigarette tax by $1, to $1.60. They say this proven tactic would not only decrease the number of teen smokers by more than 23,000, but would also cause 29,000 adults to quit smoking. Smoking is the leading cause of lung cancer in Kentucky and is also responsible for one-third of all cancers in the state.

Advocates of the tax also say it would ease the state's revenue shortage. The House is expected to release this week its version of the proposed budget for the next two fiscal years. Republican Gov. Matt Bevin proposed to eliminate funding for more than 70 programs, including five for cancer screenings and research, and local health departments are warning that adding $38.5 million to their pension liability will result in significant cuts to their programs and overall staffing if they don't get any relief.

House passes optometrists' bill to thwart online eye exams by requiring 'real time' consultation with an eye doctor

The state House has passed a bill to restrict the growing practice of online eye examinations, a threat to one of the most powerful lobbies of the legislature: independent optometrists. The Senate may give it a closer exam.

House Bill 191, which passed the House 90-7 on Feb. 13, would require a visit with an eye doctor in "real time" for an eye exam or prescription online. Its sponsor, Rep. Jim Gooch, R-Providence, said in a news release that it aims to keep patients safe. "Companies like Opternative already have doctors sign off on the results and prescription, but not in real time," notes Garrett Wymer of Lexington's WKYT-TV.

Dr. William "Chip" Richardson, a Georgetown ophthalmologist and secretary-treasurer of the Kentucky Academy of Eye Physicians and Surgeons, testified against the bill in committee, saying online assessments can reach people with eye problems that may otherwise go undiagnosed.

"While allowing those online options may hurt his financial bottom line (particularly with his sales of glasses and contacts), the bottom line, he says, is they improve access to care," Wymer reports. "Richardson said he is afraid the bill would essentially run those online options out of Kentucky and hurt some patients' access to eye care."

"The bill also requires someone wanting an online eye exam or prescription to have had an in-person exam in the last two years," Wymer notes. "Richardson said that part of the bill could be helpful."

Gooch told Wymer that his bill does not ban "safe technology," but improves it by requiring real-time interaction between a person and a doctor. On the House floor, he noted that online exams are unregulated in Kentucky.

Rep. Kim Moser, R-Taylor Mill, unsuccessfully tried to amend the bill. She said it would be "burdensome, especially to those with disabilities This effectively shuts down e-commerce."
The other six House members who voted against the bill were Republicans Robert Benvenuti of Lexington, Brian Linder of Dry Ridge, Sal Santoro of Florence, Diane St. Onge of Fort Wright and Scott Wells of West Liberty, and Democrat Susan Westrom of Lexington.

The bill is now in the Senate Health and Welfare Committee. "South Carolina's legislature passed a similar bill two years ago," Wymer reports. "The governor vetoed the bill, but it was overridden. Just last month a judge threw out a lawsuit challenging the law."

At Pikeville building dedication, national optometry leader says new college will be a national leader in training of optometrists

UPike Health Professions Education Building

The University of Pikeville dedicated its newest facility, the Health Professions Education Building, Oct. 27. The building houses the school's new Kentucky College of Optometry, the only such college in Kentucky, and UPike’s growing nursing program.

“Our nursing students are enjoying their new space in the HPEB,” said Karen Damron, Ph.D., dean of the Elliott School of Nursing. “They utilize study areas that were not available prior to moving in the facility. In addition, the faculty offices are highly professional and conducive to meeting with current and prospective students. This new building will be key in the continued expansion of our nursing program.”

U.S. Rep. Harold “Hal” Rogers told more than 600 people at the dedication that UPike is helping close the gap on health disparities in Central Appalachia. “Today Central Appalachia has the highest rates of preventable blindness in the nation,” he said. “So what does UPike do? They build a state-of-the-art facility with the very best equipment, cutting-edge technology and a first-class team.”

The $72 million for the building came from grants by the U.S. Economic Development Administration and the Appalachian Regional Commission, and a low-interest stimulus loan from the Department of Agriculture’s Rural Development Administration, according to a university news release.

ARC Federal Co-Chair Earl Gohl said, “It’s a beautiful day in Appalachia because this building and school are going to help support and move forward the culture of health in Appalachia.”

The news release noted that Kentucky is one of only three states in the nation in which optometrists have the ability to perform laser and minor surgical procedures. That is a broad scope of practice authorized by those states' legislatures after lobbying from optometrists.

William T. Reynolds, secretary-treasurer of the American Optometric Association, said the college is developing a national model for access to vision care in rural communities.

“They will be the drivers of optometric education for years to come,” he said. “This school will be showing the entire nation how to properly educate and train students in this new frontier of our profession.”

The college emphasizes rural optometry and projects that more than 30 percent of its graduates will practice in medically under-served areas of Appalachia. It operates rural clinics that will serve an estimated 18,000 unique patients annually, the university said.

Proposed changes in Medicaid, especially making beneficiaries earn dental and vision benefits, alarm them and health advocates

Family Health Centers in Louisville built a dental clinic after Medicaid
expanded; under proposed changes people in the expansion would
have to engage in self-improvement activities to get dental or vision
benefits. (Angela Shoemaker photo, special to The Courier-Journal)

Gov. Matt Bevin's plans to change Kentucky Medicaid alarm people who are on the federal-state program, reports Deborah Yetter of The Courier-Journal.

The first example is Louisville construction worker David Thompson, who was able to get his first heath coverage in years through then-Gov. Steve Beshear's expansion of Medicaid under the Patient Protection and Affordable Care Act in 2014. "Thompson is hurrying to schedule dental and eye exams — care he said he urgently needs but realizes could be eliminated," Yetter reports.

Bevin's changes would initially eliminate basic dental and vision benefits for "able-bodied" adults in the expansion, which covers people with household incomes up to 138 percent of the federal poverty level. That makes a family of four with annual income of as much as $33,400 eligible for Medicaid.

For the first three years of the expansion, the federal government paid the full cost. Now states are paying 5 percent, and by 2020 that share will rise in annual steps to 10 percent, the ACA's limit — unless the ACA is changed, which also seems likely.

Bevin says the state can't afford the cost and expects the Trump administration to let him make changes that his aides say will leave Kentucky Medicaid with 85,000 fewer people on its rolls in five years than it would have without the changes. About 1.3 million Kentuckians are on Medicaid.

The governor and other state officials say the changes aren't just about saving money. Doug Hogan, a spokesman for the Kentucky Cabinet for Health and Family Services, said the plan will "better engage members in their own health, wellness, education and employability," as well as improving Kentuckians' health outcomes.

The plan would charge small, income-based premiums and co-payments for Medicaid coverage of people with incomes above the poverty line, and would require able-bodied people on the program to work, look for work or take job training unless they are a primary caregiver. They could earn rewards points to get dental or vision benefits by "passing a GED exam, completing job training or completing wellness activities such as stop-smoking classes.," Yetter notes.

"Advocates and public-health officials are increasingly concerned about what they believe will be an adverse effect on Kentuckians," Yetter reports. "Advocates worry consumers won't understand the complex changes to the program and, as a result, will lose coverage."

They especially worry about the "loss of dental benefits in a state with poor overall dental health," Yetter writes. She quotes Muriel Harris, associate professor of public health at the University of Louisville and board chair of Family Health Centers: "We're all very, very concerned. Those who have made the decisions are not considering the population we serve. It's just undermining any gains we have made in the past."

As for vision benefits, Yetter reports, "Kentucky optometrists have argued routine eye exams often uncover other serious health problems including diabetes, high blood pressure and eye disease that can result in blindness."

Yetter writes, "Collecting premiums and co-payments, tracking work or volunteer activity and managing the rewards accounts all will involve major technology systems changes and likely, hiring of outside vendors to manage such systems, advocates say. That adds to expense and potential complications, they said. . . . Kentucky is proposing monthly premiums of $1 to $37.50 per month, based on income and length of time enrolled in Medicaid. The longer people remain in Medicaid, the more it will cost, since Bevin's plan is aimed at pushing people to move to the commercial insurance market through employer coverage when available."

Most private employers in Kentucky don't offer health insurance to employees. The Kentucky Health Issues Poll has found that the percentage of Kentuckians on employer-provided insurance rose from 37 percent to 50 percent in 2014, but fell to 41 percent in 2015 and rose to 45 percent last year.

Kentucky rises to No. 3 in diabetes, increasing concern about removing dental and vision coverage from basic Medicaid

Gov. Matt Bevin's plan for Medicaid "would have a profound effect in a state with the nation's third-highest rate of diabetes," The Courier-Journal reports, because it would remove dental and vision care from the regular package of benefits.

Reporter Deborah Yetter cites a Louisville optometrist who often discovers diabetes during routine eye exams, and an Eastern Kentucky dentist who "is seeing many more patients thanks to Kentucky's 2014 expansion of Medicaid that added coverage for those he describes as the 'working poor'."

"Dr. Bill Collins, a dentist and president of the Kentucky Dental Association, sees many patients with diabetes, which can worsen oral health," Yetter writes. "Some patients are in such bad shape they must have all of their teeth extracted" because, he said, they have gone "so many years without care and without insurance."

Kentucky had the nation's sixth highest diabetes rate until Friday, when the federal Centers for Disease Control and Prevention issued figures for 2015 and ranked the state third.

"The percentage of adults with diabetes went from 11 in 2014 to 12 in 2015, the statistics show, as the state continued to struggle with the disabling and potentially fatal disease. Only Mississippi (14) and West Virginia (13) had higher percentages," Yetter reports. "Moreover, diabetes rates among those on Medicaid are nearly double that of the rest of the population, according to a 2015 state report" based on 2013 figures.

Dentists and optometrists asked Bevin not to remove dental and vision coverage from basic Medicaid, "arguing visits to the dentist and eye doctor are often the first step in identifying more serious health conditions, including diabetes," Yetter notes. "But the administration made only slight changes to its proposal, allowing dental and vision benefits only for the first three months of Medicaid coverage." Afterward, dental and vision benefits would be optional, "available only through a 'rewards' program where Medicaid members can earn points to pay for them through activities such as work or volunteering."

Cabinet for Health and Family Services spokesman Doug Hogan told Yetter there would be several "easy ways" for Medicaid members to gain dental and vision coverage, including weight-loss programs and classes about diabetes.

Hogan "said Bevin's proposal was designed to mirror commercial health plans, which do not typically include dental and vision benefits," Yetter writes. "And Medicaid does not require dental and vision benefits to be included."

Bevin's proposal to the federal government "also promotes moving many people off Medicaid to commercial insurance through their employers," Yetter notes. "Collins said the problem with the governor's plan is that many of the adults added through the expansion work at low-wage jobs that don't offer health insurance."

"I don't think they understand who they are trying to take off," Collins told Yetter. "These are the working poor. You're taking off working people who are trying to make a living."

Yetter writes, "Collins said diabetes is especially problematic for people with poor oral health because it makes them more susceptible to infection, tooth decay and other oral diseases. Such patients require careful monitoring and access to regular dental care, Collins said. Without it, he worries Kentucky will never drag itself up from its low rankings in tooth decay and its high rate of toothless adults - for many a barrier to jobs or well-paying jobs."

"I know something has to be done to address the Medicaid funding," he told Yetter. "But we need to find ways to fund it."

The 2014 expansion made anyone in a household with income up to 138 percent of the federal poverty level eligible for Medicaid. Before that, Yetter notes, "Medicaid was limited to very poor pregnant women and children, disabled people and low-income elderly in nursing homes."

The federal government is paying the full cost of the expansion through Dec. 31. On Jan. 1, the state will begin paying 5 percent, rising in annual steps to the federal health-reform law's limit of 10 percent in 2020. Bevin says the state can't afford the cost.

Young diabetes coalition coordinator forms partnerships to uncover and fight the disease in five Eastern Kentucky counties

By Mallory Powell
University of Kentucky

Growing up in Hazard, Brittany Martin was familiar with diabetes. Many of her older relatives had been diagnosed with the chronic condition, and her younger family members were starting to develop it as well. In a state with one of the highest rates of diabetes — 11.3 percent of adults had a diagnosis in 2014 —Martin’s family wasn’t out of the ordinary, but she found the status quo unacceptable.

Since she graduated from the University of Kentucky in 2014 with a dual degree in biology and sociology, Martin’s family history and her interest in health have converged in her current role as coordinator of the Big Sandy Diabetes Coalition, where she serves as an AmeriCorps Vista volunteer.

Brittany Martin administers a diabetes screening. (UK photo)

The coalition, based at Big Sandy Health Care in Prestonsburg, aims to improve detection, prevention and treatment of diabetes through screening and connection with local resources; it serves Floyd, Johnson, Magoffin, Martin and Pike counties, the Big Sandy Area Development District.

Diabetes is especially prevalent in the region, with 13 percent of adults diagnosed with it. In Pike County, the rate is at least 16 percent.

The rates are based on surveys that ask people if they have been diagnosed with the disease. An estimated 138,000 Kentuckians are thought to be living with undiagnosed diabetes.

As diabetes coalition coordinator, Martin juggles many responsibilities, from hosting community screenings to planning board meetings and writing a regular newsletter. It didn’t take her long to observe that irregular screenings, a lack of follow-up, and shortage of robust data inhibited diabetes prevention and care at both individual and community levels.

“We decided we wanted to set up more systematic screenings, instead of opportunistic screenings, and eventually set up a diabetes registry and keep track of participants,” Martin said.

She is now leading a project to determine whether regular community screenings and targeted follow-up can help to identify undiagnosed cases, measurably improve health, and reduce the emotional and economic burden of diabetes through connection with local resources.

"Brittany’s important work, receptivity to our input, and unparalleled enthusiasm have made her a stellar CLIK participant," said Nancy Schoenberg, co-director of community engagement and research for the CCTS. "She is an ambassador for UK, the CCTS and CLIK, sharing her expertise and her commitment to the health of residents of the commonwealth."

Martin, a registered phlebotomist, has personally screened 586 people since she began working with the coalition in August 2015. At each initial screening, she gathers baseline data and provides diabetes education. She then follows up with people who are diabetic or pre-diabetic to connect them with local resources and encourage them to come back for screening in six months.

Much of Martin's work has been supported by grants and training from the University of Kentucky Center for Clinical and Translational Science, which facilitates interdisciplinary and community-engaged health research with a focus on Appalachia. A CCTS community engagement grant provided funding for a pilot study of diabetes screening at a senior living center in Pike County.

Martin, 25, has since received further funding and research training through the CCTS Community Leadership Institute of Kentucky, which aims to enhance the capacity of local leaders to address health challenges.

Through CLIK, Martin received training on evidence-based interventions, data mining for research, and data collection and analysis — essential skills to assess the impact of a project. Equipped with this additional expertise, she is now researching the effectiveness of her diabetes screening system in Martin County.

The opportunity to work in several Appalachian counties, especially Kentucky's two easternmost, has enlightened even a native of the region about its diverse needs and challenges.

“People speak of Appalachia as a whole, but Martin County has so much less than Pike County,” she said. “Martin County doesn’t have a hospital. They have such a lack of access to care. They have one grocery store. It was very hard for me to find the resources to give them.”

Depending on the month, Martin hosts up to 10 community screenings across the five counties served by Big Sandy Health Care.

The results alarm her. “It’s actually kind of scary. Roughly 24 percent of people are pre-diabetic and 25 percent are diabetic. That’s roughly half of my sample in the red zone,” she said.

Martin sees particular challenges for individuals who face multiple health issues and dire socioeconomic circumstances. “Sometimes we’ll go do screenings in the homeless shelter. Imagine being homeless and diabetic. Sometimes people are also recovering from addiction. Really, can you imagine being homeless and diabetic and recovering from an addiction?”

At some of the community screenings, people have been surprised to learn that they’re diabetic or at immediate risk. In a screening at Big Sandy Community and Technical College, she said, many students “learned that they had pre-diabetes, and they were in their early 20s. It was scary for them. One person was diabetic and didn’t know it. At all ages we’ve screened, there’s been at least one person who’s said ‘Oh my god, I didn’t know, I didn’t know the signs.’”

However, the data she has gathered encourages her about the potential impact of systematic community screening with targeted follow-up.

Her initial screening study in Pike County found that 50 percent of people who received follow-up information and returned for their six-month screening had lower A1C levels, the essential measurement for a diagnosis of diabetes.

Martin's demonstrated success has also yielded nearly $20,000 in outside funding to pay for community screenings and upcoming educational classes. The Anthem, Aetna and Passport health plans have provided a total of $11,000 in sponsorships for screenings. It costs about $7 to screen one person.

Martin also recently received a $9,000 grant from Marshall University in West Virginia to support diabetes education classes in Big Sandy communities, with “gentle yoga” exercises for their clients in order to increase movement and activity, especially for individuals who are wheelchair-bound or have trouble exercising.

“There are a lot of positive health effects of gentle yoga,” she said. “We work with the aging population, and as they age we want to keep them moving. Safe, slow movements, even if someone is wheelchair-bound, can help keep away chronic effects of things like diabetes.”

Martin is developing yet another partnership to integrate retinopathy eye screenings at some community-outreach events. Over the course of nearly 600 diabetes screenings, Martin observed the a great need for eye care, and engaged both UK and the new Kentucky College of Optometry at the University of Pikeville to provide retinopathy screenings at some of her events.

When Martin isn’t busy with her full-time (and mostly unpaid) work as the diabetes coalition coordinator, she works at least 30 hours a week as a waitress. She is also studying for the Medical College Admission Test and the Optometry Admission Test, with plans to apply to medical and/or optometry school at Pikeville. Her ultimate goal is to become a practicing physician in a rural community.

She has a demanding portfolio of responsibilities, and says she sleeps about five hours a night but doesn’t tire of her work: “I’m right where I’m supposed to be.”

Kentucky College of Optometry about to open in Pikeville

Artist's rendering of Kentucky College of Optometry, Pikeville

The University of Pikeville says it is about to open the nation's largest optometric college in terms of floor space, the Kentucky College of Optometry.

"Dr. Andrew Buzzelli, vice president for optometric education and the college’s founding dean, said that, at 130,000 square feet, KYCO is the largest optometry college in the country," Josh Little reports for the Appalachian News-Express in Pikeville. "The cost to build the college is $55 million, plus $9 million for equipment."

Students at the college will perform optometric services for local residents, under the supervision of doctors of optometry. "Pikeville Medical Center will still continue to be the main provider in the area, but they only have two providers, so the care is in here," Buzzelli said. "In the other schools around the country, care is all around the city, that’s not true here. ... This will be for our specialty clinics, such as laser surgery." He said The college will offer electrophysiological tests, which now require residents to travel to Lexington or Huntington, W.Va.

The university is already home to the School of Osteopathic Medicine.

Kentucky College of Optometry at University of Pikeville is set to enroll its first class in fall 2016

The Kentucky College of Optometry, part of the University of Pikeville, has received preliminary accreditation, allowing it to recruit students for its first class next fall.

The Accreditation Council on Optometric Education notified the university of the approval. ACOE will review the school annually during its first three academic years, and a request for full accreditation will be made by the university not less than 12 months prior to graduation of the program’s first class, the university said in a news release.

“We are the first school to receive such recognition under the new, more stringent accreditation standards, and in a record time of one year and three months from the time we initiated our self-study,” Founding Dean Andrew Buzzelli said in the release.

A recent state law allowing optometrists to perform selective laser and peri-ocular surgical procedures will allow the college to bring such treatments to medically under-served areas, the release said. "The approach to clinical care will also be unique," it said. "The college of optometry is partnering with local federally qualified health care centers and hospitals to create a new patient-centered model for the education of eye care providers and creating access to vision care for the citizens of Appalachia."

The college will be the 22nd in the nation and will admit 60 students per class, for a four-year total of 240. "With no other colleges of optometry in Kentucky, West Virginia, Virginia, North Carolina, South Carolina or Georgia, KYCO will be the most accessible college of optometry in the Southeastern portion of the country," the release said.

It noted that Central Appalachia "has the highest incidences of severe vision loss from other factors such as diabetes and hypertension," the release said, noting that Owsley County leads the nation with more than 18 percent.

UPike, as the university calls itself, also has a college of osteopathic medicine and a school of nursing.

Get a prescription before buying decorative contact lenses for Halloween, optometrists recommend

Many people incorporate decorative contact lenses into their Halloween costumes, and not all of them are purchased legally. They can be found on the Internet, beauty salons, convenience stores and some national retailers.  The Kentucky Optometric Association recommends that you never buy lenses from these sources.

Wearing decorative contact lenses purchased illegally and without a prescription can lead to serious health issues and potentially damage your eyesight, the association said in a news release.

The Food and Drug Administration classifies all contact lenses as medical devices, whether they correct vision or not. When considering decorative contact lenses as part of your costume, the optometrists say you should obtain a prescription from a doctor, who can also teach you how to properly care for your eyes while wearing contacts.

“Even though these are non-corrective lenses, they still pose the same potential health and safety risks as other contact lenses,” said Dr. Bill Reynolds, an optometrist in Richmond and a trustee of the American Optometric Association. “When purchased over the counter, decorative contact lenses can put people at risk for bacterial infections, allergic reactions or even significant damage to the eye’s ability to function with the potential for irreversible sight loss.”

Ensure children's eye safety during fall sports season

Children are back in school, playing sports, and parents can take precautions to ensure their children's eye safety as they compete.

Although many parents are unaware of the risks posed to their child's eye safety, about 40,000 eye injuries take place in the United States during sports or recreational activities each year, says Prevent Blindness America. Some sport-related eye injuries lead to vision loss, with almost one-third of them occurring in children between the ages of 5 and 14, says the Kentucky Optometric Association.

“Eye injuries are the leading cause of blindness in children in America, and most injuries occurring in school-aged children are sports-related,” Benton optometrist Dr. Laurel Van Horn said in a KOA release. “The results of an eye injury can range from temporary to permanent vision loss, so it’s important that parents take the proper steps when their children play sports.”

Almost 90 percent of these injuries are preventable with proper use of eye protection on the playing field, says Van Horn. To prevent such injuries, the KOA provides the following tips for eye and vision safety while playing sports: Always wear protective eyewear, do not rely on street eyewear for protection, and refer to the American Society for Testing and Materials standards when shopping for protective eyewear. Click here to learn more or find an optometrist in your area.

Itchy, watery eyes? Some tips to relieve spring allergy symptoms

The sunshine and bright colors of spring are here, but so are seasonal allergies from pollen, dander, smog or mold that can often lead to itchy, watery eyes. Eye irritation is the body's immune response to allergens, so when pollen comes in contact with eyes, for example, the body releases histamine, causing eye redness, burning and itching.

The Kentucky Optometric Association says discomfort from itchy, swollen or water eyes can be reduced with simple steps, such as maintaining a healthy diet full of anti-oxidants like spinach, broccoli, carrot discomfort that boost the immune system in addition to taking fish oil supplements that help reduce redness and irritation.

Other tips from the KOA include using preservative-free lubricating eye drops or re-wetting eyes with contact solution if you wear contact lenses. Applying a cold compress to eyes can also relieve itching and redness by constricting the histamine-releasing blood vessels. And remember: Do not touch or rub eyes, and be sure to wash hands with soap and water.

A local eye doctor can examine eye allergy symptoms to ensure the cause is properly identified, said Dr. Max Downey, an optometrist in Campbellsville. Optometrists' treatment could range from eye drops to prescription medicines, said Downey.

In addition to discussing allergy relief with your optometrist, the KOA recommends adults have yearly eye exams at the minimum, depending on the severity of allergies.

January is Glaucoma Awareness Month; disease is second leading cause of blindness

One million Americans will be diagnosed with glaucoma in the next 10 years, prompting Kentucky optometrists to raise awareness of the disease this month.

"People who do not visit their eye doctor on a regular basis are putting their vision and quality of life at risk," said Dr. Ben Gaddie, president of the Kentucky Optometric Association. "Glaucoma is often referred to as 'the sneak thief of sight' because it can strike without pain or other symptoms. Vision lost to glaucoma cannot be restored, so early detection and treatment are paramount."

Glaucoma is the second leading cause of blindness in the country. Data from the American Optometric Association show 50 percent of Americans incorrectly believe glaucoma is preventable and fewer than 20 percent of Americans are aware glaucoma causes deterioration of peripheral vision.

The Glaucoma Research Foundation has found African Americans ages 45 to 65 are 14 to 17 times more likely to go blind from the disease than Caucasians. People with a family history of glaucoma, those over the age of 60 or people who have experienced severe eye trauma are also more prone to the disease. (Read more)

Regulations allowing optometrists to use lasers pass; opponents may sue for violation of Open Meetings Act

Though ophthalmologists and the Kentucky Medical Association strongly objected, a legislative committee passed regulations Tuesday that will allow optometrists to perform some eye surgeries using lasers. In answer, opponents says "they might file legal action against the Kentucky Board of Optometric Examiners, which drafted the regulations, for failing to comply with the state's Open Meetings Act," reports Beth Musgrave of the Lexington Herald-Leader.

The regulations, authorized by Senate Bill 110 in this year's General Assembly, now go to another legislative panel for final approval. The bill has been cause for controversy, in large part because it passed through the legislature in a swift 12 days. Oklahoma is the only other state that gives similar operating privileges to optometrists.

Ophtalmologists said Tuesday the optometric board "used a task force appointed by the state optometric association, a trade group, to develop the regulations, and those meetings were held in secret with no public input," Musgrave reports. Legislators and optometrists disagreed, saying public comment was allowed at an open meeting in July, and the regulations were altered after task force members took the comments into consideration.

Dr. Woodford Van Meter, president of the Kentucky Academy of Eye Physicians and Surgeons, said patient safety is at risk of optometrists are allowed to perform the procedures, in part because the bill states they only have to receive 32 hours of training and show they can do the procedure once before they can use lasers. By contrast, Van Meter said ophthalmologists have 17,000 hours of surgical training and perform surgeries hundreds of times before being allowed to do them on their own.

If the regulations pass, optometrists may be allowed to perform the surgeries by year's end. (Read more)

Optometrists, ophthalmologists renew battle over optometrists' ability to perform medical procedures

Ophthalmologists renewed their fight yesterday against new rules "that would allow optometrists to perform more complex procedures that critics say will endanger patients," Mike Wynn of The Courier-Journal reports. The Kentucky Board of Optometric Examiners held the hearing on regulations that would implement a law passed quickly by the General Assembly after a years-long lobbying effort by optometrists and their trade group's executive director, Darlene Eakin, left. (C-J photo by Pam Spaulding)

The law allows optometrists to do limited laser treatments, "injections of medicine and removal of benign lesions from eyelids," Wynn writes. The only other state that allows them to do so is Oklahoma, but critics say no problems have been reported in that state and have noted that only 41 Kentucky counties have ophthalmologists.

Ophthalmologists "charged that the rules are not stringent enough to ensure optometrists — who are not medically licensed — can perform the treatments without causing harm," Wynn writes. The rules would require optometrists who want to expand their practice to take classes on more than 20 medical topics, pass tests, get clinical experience and "demonstrate competency to a board-approved expert," Wynn notes. "Lexington ophthalmologist Ken Weaver said wording in the draft resembles 'vague ideas,' rather than medical standards, and could allow an optometrist to perform eye surgeries after a 16-hour course from an unqualified instructor." (Read more)

Watching 3-D movies may strain eyes but doesn't harm them and can help detect vision impairment, optometrists say

With summer blockbusters set to be released in the coming months, the Kentucky Optometric Association says watching 3-D movies is not harmful to eyes, but can cause eye strain and headaches.

To help with those conditions, the association recommends sitting farther back from the movie screen.

In some cases, some viewers won't be able to recognize 3-D pictures because they lack binocular vision. "Although this doesn't pose any problem viewing the screen, it serves as a vision screening that something is abnormal with the viewer's binocular vision," the association says in a news release used by the Journal-Enterprise of Providence.

"That means 3-D actually has a benefit," said Dr. Joe Ellis, an optometrist in Benton and president of the optometric association. "It can alert people to undetected vision disorders and eye diseases that, if caught early, are fully treatable."

Viewers might consider seeing an optometrist or ophthalmologist if they get headaches while watching 3-D, if they feel nauseous or dizzy after viewing or if it is difficult for their eyes to adjust back to normal after viewing. (Read more)

New Kentucky optometry law prompting legislators in other states to consider same or similar changes

Now that Kentucky lawmakers have allowed optometrists to expand their scope of care, legislators in Nebraska, South Carolina and Texas may follow suit. They are looking at legislation that would allow optometrists to perform minor surgeries that were previously only allowed to be done by ophthalmologists, who are medical doctors.

Despite objections from several physician organizations — who say optometrists lack the medical training to perform the surgeries or deal with the complications — The Better Access to Quality Eye Care law was signed by Gov. Steve Beshear this winter. It lets optometrists perform a range of new procedures, including post-cataract surgery and two types of glaucoma surgery, reports Carolyne Krupa of American Medical News. The bill caused controversy partly because of the amount of campaign contributions, totaling almost $400,000, that optometrists made to all but one legislator and Beshear in the past two years.

Bills being considered in Nebraska and Texas would allow optometrists to "remove skin lesions from eyelids" and perform the same eye surgeries now permitted in Kentucky. The bills in Nebraska, Texas and South Carolina would also let optometrists make injections in the eyelid.

In 1998, Oklahoma because the first state to allow optometrists to perform some eye surgeries. Earlier this year, Kentucky became the second state nationwide. (Read more)

Beshear signs first bill of session; optometrists will benefit

Gov. Steve Beshear has signed legislation that will significantly increase the scope of care optometrists can provide, making it the first bill to become law in this session of the General Assembly.

"Access to quality health care is a critical issue for families across the commonwealth," he said in a press release. "After careful consideration, along with meetings with many interested parties, today I signed Senate Bill 110 to give Kentuckians greater access to necessary eye care."

The bill made an unusually speedy passage through the General Assembly after being filed Feb. 7. The Courier-Journal reported earlier this month optometrists have given a total of $400,000 in campaign contributions to legislators, the only exception being one who is a physician. Beshear's re-election campaign has also received optometrists' money.

The law will allow optometrists, who do not attend medical school, to perform more types of procedures, most notably one that uses a laser to fix complications that can arise from cataract surgery. Only optometrists in Oklahoma are likewise allowed to use lasers while treating their patients; in every other state, only opthalmologists can. The law also allows optometrists to prescribe certain drugs and lets the state Board of Optometric Examiners define what procedures optometrists can legally perform.

"In order to ensure the highest degree of oversight, I will be meeting with the Board of Optometric Examiners to make sure that providers of these services undergo extensive training," Beshear said. "I believe this new law will mean more Kentuckians can get the eye care they need." Optometrists practice in 106 counties in Kentucky. Two-thirds of the state's counties do not have an ophtalmologist, and supporters of the bill sais it will make eye care more accessible and affordable in rural areas.