Louisville hospital merger probably means poor women won't get their tubes tied at University Hospital any more

Women who deliver through Caesarean sections at the University of Louisville Hospital may no longer be able to get their fallopian tubes tied at the same time, Patrick Howington of the The Courier-Journal reports. This rule may be one of many the hospital plans to adopt if the proposed merger with Catholic Health Initiatives, parent company of Lexington-based St. Joseph Health System, goes through.

The hospital has agreed to honor the Roman Catholic Church's rules against sterilization as a part of the merger agreement. University "President James Ramsey said reproductive procedures that can't be done at University Hospital will be performed at U of L's outpatient center on Chestnut Street, which isn't part of the merger," Howington writes. This would require an additional surgery for women seeking tubal ligations since the outpatient center does not deliver babies. "That's really inappropriate," said Dr. Marcello Pietrantoni, a Louisville obstetrician who specializes in high-risk pregnancies. "You're going through a second procedure, and the risks of complications . . . are doubled." (Read more)

Medical risks and additional costs are not the only concerns Louisville residents and neighbors have about the proposed merger. An editorial in today's Courier-Journal reminds readers of the hospital's missions to provide care for indigents in the city and train doctors, and questions the level of care from a public hospital guided by a religious organization. To read the editorial, click here.

Access to healthy food: A local angle is available on a national event tomorrow, and here's a Kentucky example

Update, July 21: First Lady Michelle Obama announced Wal-Mart and other retailers plan to open or expand 1,500 stores in the next five years in areas that do not have access to fresh fruit, vegetables and other healthy foods. "Make no mistake about it. This is a big deal. It is a really big deal," Obama said. Nearly 24 million people, including 6.5 million children, live in these areas, which have been coined food deserts. Wal-Mart plans to open 275 to 300 stores in urban and rural areas by 2016 and expand "food options in more than 700 food deserts," The Huffington Post reports.

The White House says First Lady Michelle Obama will make a major announcement tomorrow afternoon about her Task Force on Childhood Obesity's recommendations to make healthy, affordable food more accessible to all Americans. Using the U.S. Department of Agriculture's Food Desert Locator, community journalists can localize this story.

A food desert is a low-income census tract where a substantial number or share of residents have low access to a supermarket or large grocery store. Many rural areas are considered food deserts, and the USDA locator not only has data that can inform a story, but maps that can illustrate it. Reporter Tonya S. Grace of the Todd County Standard used it to localize the Healthy Food Initiative, a partnership between the U.S. Treasury, the USDA and the U.S. Department of Health and Human Services. To read her article, click here.

Website helps journalists, community planners, other Kentuckians in search of county-specific health data

A treasure trove of health data about every county in Kentucky is available to journalists and community planners looking to draw a statistical picture of their area. That was the message of a webinar hosted by the Foundation for a Healthy Kentucky Wednesday.

"We really hope the information we have on kentuckyhealthfacts.org will start a conversation," said Sarah Walsh of the foundation's "Local Data for Local Action" Initiative.

The website features a map of the state that is broken down by county. By clicking on a county, a plethora of information pops up, including information on a county's:

• demographics, such as graduation rates and per capita personal income;

• social and behavioral indicators, such as lack of physical activity and prevalence of smoking and obesity;

• health outcomes, such as infectious disease rates, motor vehicle deaths and premature death rates;

• access to care, such as flu vaccination rates, and number of available health care providers and physicians;

• maternal and child health, such as infant mortality, teen birth rates and low birthweight rates;
• senior health, such as the percentage of the senior population in a community.

The data can be compared to the rest of the state, the rest of the country or other counties, and users can create tables, bar graphs, line graphs or maps suitable for publication. "There's a lot of information here," Walsh said. (Graph created online shows obesity declining in Laurel and Pulaski counties after three years of increase, but still rising in Knox County and holding steadier in Rockcastle County. Up to six counties can be placed in one such graphic.)

The site is especially valuable to journalists, said Al Cross, director of the Institute for Rural Journalism and Community Issues at the University of Kentucky. "These are the hard facts that local news media need to report as they hold up a mirror to their communities and help them address community problems," Cross said. "In most Kentucky counties, one or more facets of health are a community problem. They need more attention." Kentucky Health News is a service of the institute, funded by the foundation.

Much of the data come from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance Survey, a nationwide, random telephone poll that is conducted each year. Because there may not be enough survey responses from residents in some counties, much of the data on the site have been developed by looking at three or four counties that are near each other and demographically similar, which Walsh said makes the data more "stable and robust." Statisticians have reconfigured the data so that they are all based on a population of 100,000 people, enough to have confidence in the percentages.

While encouraging community planners to use the site, Walsh said the Kentucky Cancer Registry website is "one of the best in the nation" and has cancer-specific data that may not be available on kentuckyhealthfacts.org. She also pointed listeners to the Kids Count website, an Annie E. Casey Foundation-funded project that has statewide data specific to children.

What surfers won't find, however, are Kentucky numbers on the childhood obesity or childhood diabetes. "Different school districts and communities are collecting data but in different ways and at different ages," she said, adding those disparities make comparison analysis difficult. A bill to make schools collect and report body-mass-index data failed in the last session of the General Assembly.

The goal of Wednesday's webinar was to disseminate information so community planners can identify and address health needs in their area. "At the foundation we take a lot of inspiration from the words of Arthur Ashe, 'Start where you are. Use what you have. Do what you can'," Walsh said. "We believe communities can do a lot to change their health status." The webinar was part of the foundation's "Health for a Change: Ignite — Unite — Act" initiative and was the first in an ongoing series. The next session, July 27, will focus on how to plan a community health needs assessment. For more information about the series, click here.

Defenders of small, rural hospitals take issue with study that found poor patient outcomes

A recent study that concluded small, rural "critical access hospitals" have poorer patient outcomes and lower quality of care is making waves in the medical community. A federally funded monitoring team from three universities issued a response noting certain weaknesses of the study, which was published in the Journal of the American Medical Association earlier this month.

It's not news that critical-access hospitals "have room for improvement," the team wrote. "What the JAMA authors fail to report is how much CAH scores on the process of care measures have improved over time," it writes. "Our most recent trend analysis, for example, shows that CAH scores on each of the pneumonia measures increased between 9 and 22 percentage points between 2005 and 2009."

The analysis in question was performed by researchers at the Harvard School of Public Health. It focused on nearly 1,300 critical access hospitals and looked at the outcomes of Medicare patients who have congestive heart failure, heart attacks and pneumonia. For all three conditions, CAHs performed at a lower standard. Patients at CAHs were more likely to die, and the facilities were behind in implementing electronic health records. It also found CAHs had a smaller number of specialists like cardiologists working at them than at non-CAHs. "That doesn't sound like news to us, either," said Al Cross, director of the Institiute for Rural Journalism and Community Issues.

"Issues such as the limited supply of primary care providers, home health and hospice services, rather than the supply of specialists, should be the focus of interventions to improve rural health quality," said the Flex Monitoring Team, named after its assignment, to evaluate the Medicare Rural Hospital Flexibility Grant Program. The team is made up of researchers from the University of Southern Maine, the University of Minnesota and the University of North Carolina-Chapel Hill. (Read more)

Writing for the Daily Yonder, Dr. Robert C. Bowman, family-medicine professor at the A.T. Still University School of Osteopathic Medicine in Arizona, also took issue with the study, in part because its findings ran counter to an article that was also published in JAMA last year. That article concluded that "greater proportions of underinsured, minority, and non-English-speaking patients were associated with lower quality rankings for primary-care physicians," Bowman quotes.

"Now JAMA has an article this year claiming lower quality of care in certain types of rural hospitals that are completely different in location, population, funding, and workforce," Bowman writes. "So what happened between last year, when patients made the difference in quality, and this year when it was location of the hospital? ... Why do sophisticated researchers, reviewers, and editors maximize the context of care sometimes (in 2010) and minimize it at other times (in 2011)?"

Bowman, founder of the Rural Medical Educators Group of the National Rural Health Association, took a jab at the researchers. "Do Harvard University researchers associated with hospitals with the most sources of income and the highest reimbursement rates even have the perspective to write about hospitals with the least lines of funding and the lowest reimbursement in each line?"

Though he takes issue with the article, Bowman said the topic "about high and lower quality critical access hospitals" is worthy of research. "Perhaps one of the problems with attempting such research is that there is little variation across rural hospitals. Perhaps that's because the system is designed to spend uniformly less on health care across rural America. . . . The end result is less care and less economic impact from health care in 30,000 zip codes with 65 percent of the U.S. population. And more care delivered in 3,400 zip codes in 4 percent of the land area." (Read more)

All students at many Kentucky schools will get free lunches, regardless of household income

All students in as many as 102 of Kentucky's 174 school districts will get a free lunch every day starting next month. Kentucky is one of three states to be chosen for the U.S. Department of Agriculture's Universal Meal Service pilot program, which is to run for the next four years.

To be in the program, a school must have at least 40 percent of its students eligible for free or reduced-price lunch through regular USDA programs, based on household income. Schools must also be certified with the Supplemental Nutrition Assistance Program (SNAP) and Kentucky Transitional Assistance Program (KTAP), the successor of welfare. Districts containing eligible schools must notify the Kentucky Department of Education's Division of School and Community Nutrition of their intent to participate by July 29. Parents "don't have to do anything to make this happen," said Lisa Gross, spokeswoman for KDE.

"Really what this program is designed to do is cut down on the bureaucracy," Gross said." "If a school is identified as eligible, that takes care of a lot of reporting. It's designed to cut down on the red tape." Tennessee and Illinois are the other two states chosen to participate. By 2014, all states will be eligible for it, under requirements of the Healthy, Hunger-Free Kids Act.

The Covington and Owsley County school districts have the highest percentage of students — 88 percent — eligible for free or reduced-priced lunch. Magoffin County has the second highest with 86 percent followed by Newport (85%); Bell County (83%); and West Point Independent in Hardin County (81%). To see a list of all 102 eligible districts, click here.

Small, rural hospitals with 'critical access' designation have poorer patient outcomes and lower quality of care, study finds

A study has found that small, rural hospitals with the "critical access" designation have poorer patient outcomes and lower quality of care.

The analysis, performed by researchers at the Harvard School of Public Health, focused on nearly 1,300 critical access hospitals, a designation is given to facilities that have 25 or fewer acute-care beds and are more than 35 miles away from another hospital. In return for such concessions as limiting patient stays, CAHs get extra Medicare and Medicaid reimbursements. The Rural Assistance Center reports there are 30 CAHs in Kentucky.

The study looked at the outcomes of Medicare patients who have congestive heart failure, heart attacks and pneumonia. For all three conditions, CAHs performed at a lower standard. For patients treated for heart attacks, CAHs provided care in keeping with Hospital Quality Alliance standards 91 percent of the time, compared to 98 percent at other hospitals. The difference was even larger for patients with congestive heart failure patients (80.6 percent vs. 93.5 percent) and smaller "but still significant" for pneumonia (89.3 percent vs. 93.7 percent), the report says.

Patients at CAHs were also more likely to die. They had higher 30-day risk-adjusted mortality rates for all three conditions than patients admitted to other hospitals. The study also found CAHs behind in the implementation of electronic health records, 6.5 percent to nearly 14 percent.

"Despite more than a decade of concerted policy efforts to improve rural health care, our findings suggest that substantial challenges remain," the study authors write. "Although CAHs provide much-needed access to care for many of the nation's rural citizens, we found that these hospitals, with their fewer clinical and technological resources, less often provided care consistent with standard quality metrics and generally had worse outcomes than non-CAHs." (Read more)

Overweight people tend to cluster with those who are likewise

The adage "birds of a feather flock together" seems to apply when it comes to the obesity, with a study concluding that overweight people tend to befriend others who are overweight. Obesity also tends to run in families, with obese parents raising obese children, research-reporting service Newswise reports.

The Arizona State University study didn't conclude why obese people tend to "cluster," but did provide "some important information about trends in obesity and the public health implications," said Dian and Tom Grisel, who wrote TurboCharged: Accelerate Your Fat Burning Metabolism, Get Lean Fast and Leave Diet and Exercise Rules in the Dust.

"Obese families and friends usually have two things in common: food choices and activity levels or more accurately, lack of activity. Obese parents tend to raise obese children. Obese family and friends hang out and eat the same kinds of detrimental foods and participate in the same kinds of detrimental habits," the Griesels said.

That has serious implications for Kentucky, which has the sixth highest obesity rate in the country. More than 67 percent of adult Kentuckians are either obese or overweight and Kentucky was one of just six states whose obesity rate has increased two years in a row, the recently-release report "F as in Fat" found.

Though people may tend to find others who are like-minded when it comes to food, that doesn't mean they want to be overweight. "Study participants revealed that if given the choice, they would select some pretty serious diseases like alcoholism, depression or herpes instead. In fact, 25.4 percent preferred sever depression and 14.5 percent actually preferring total blindness over obesity," Newswise reports. (Read more)

Kentucky 6th in obesity; state rate rises for 2nd consecutive year

"It's official: Kentucky is a mecca for blubber," The Courier-Journal's Darla Carter reports. The state has the sixth highest rate of obese adults, is one of just six states whose obesity rate has risen for the second year in a row, and is one of a dozen states with above 30 percent. The findings are in the 2011 "F as in Fat" report released by the Trust for America's Health and the Robert Wood Johnson Foundation.

Kentucky's obesity rate is 31.5 percent. Mississippi had the highest rate with 34.4 percent and Colorado was lowest with 19.8 percent. The problem is biggest in the South, which has nine of the 10 fattest states; Michigan also ranks. Fifteen years ago, no state had an obesity rate of more than 15 percent, the report notes. "Today, the state with the lowest obesity rate would have had the highest rate in 1995," said Jeff Levi, executive director of the Trust for America's Health. "There was a clear tipping point in our national weight gain over the last 20 years, and we can't afford to ignore the impact obesity has on our health and corresponding health care spending."

The problem is largest for racial and ethnic minority adults — the obesity rate for blacks in Kentucky is over 43 percent — and for those with less education and lower incomes. Almost 33 percent of adults who didn't graduate from high school are obese, compared to 21.5 percent of people who have college or technical college degrees. More than 33 percent of adults who earn less than $15,000 per year were obese, compared to nearly 1 in 4 adults who earn at least $50,000 each year.

The obesity epidemic is having an effect on people's health. Since 1995, diabetes rates have doubled in eight states, including Kentucky. In 1995, Kentucky had a diabetes rate of 4.2 percent. Now it is 10.5 percent. The hypertension rate 15 years ago was 22.2 percent. Now it is 31.6 percent. (Read more)

The rates only reflect adults who are defined as obese, not overweight. Taking both figures into account means 67.1 percent of Kentucky adults are either obese or overweight. For county-by-county data, from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System and Kentucky Health Facts, click here.

Louisville's University Hospital limits care for non-local patients

University Hospital in Louisville has been forced to stop providing some free or deeply discounted care to patients who live outside Jefferson County. The number of low-income patients coming to the hospital from surrounding counties created a $20 million shortfall last year, "jeopardizing University's primary obligation to treat Louisville's poor," The Courier-Journal's Patrick Howington reports.

Out-of-town patients who want elective procedures such as colonoscopies now have to pay up to 70 percent of the charge. They also must show that they tried to get care in their home county first and may have a longer wait than Jefferson County patients. The changes do not affect patients who come seeking care for trauma, high-risk pregnancies, strokes or cancer care.

University Hospital is generally the facility of last resort for low-income patients in the region. The training hospital for the University of Louisville, it receives extra state funding to help pay for patients who can't pay for themselves. Last year, the university got nearly $69 million to cover indigent care, but that care cost it $89 million. The $20 million shortfall is five times higher than 2005's shortfall of $3.7 million.

Last year, University gave treatment to 767 Hardin County patients, compared to 441 five years ago; 221 Warren County patients compared to 134 in 2005; and 200 Hart County patients, almost twice the number from 2005. (Photo of patient DeEdra King and physical therapist Cathy Gerrish by Aaron Borton) The economy is likely to blame, Howington reports. "The economic downtown cost many people their jobs, and thus their health insurance, and contributed to a surge in uncompensated care at many Kentucky hospitals." (Read more)

Medicaid matters, and makes people healthier, study finds, contradicting argument that it's worse than no coverage

Though the overhaul of Kentucky's Medicaid program has its critics and could potentially be confusing to patients, the program itself is very important, acording to a new study. It found that people on Medicaid, compared to those with no insurance, "had better access to and used more health care; they were less likely to experience unpaid medical bills; they were more likely to report being in good health; and they were less likely to report feeling depressed," National Public Radio's Julie Rovner reports.

"What we found in a nutshell is that having Medicaid makes a big difference in people's lives," said Amy Finkelstein, a Massachusetts Institute of Technology economist and one of the study's main researchers. "We report almost a one-third increase in the probability that you report yourself as being happy."

The study also concluded that Medicaid recipients got outpatient care 35 percent more often than those who don't have insurance. They also responded their had own doctor 55 percent more often and a regular office or clinic they went to 70 percent more often than people without Medicaid coverage.

The findings run counter to arguments by critics of Medicaid, including Scott Gottlieb, who wrote an opinion piece in the Wall Street Journal headlined, "Medicaid Is Worse Than No Coverage At All."

While conservatives have long been critical of the program and liberals supportive of it, the study, being published as a working paper by the National Bureau of Economic Research, seems above political gaming; one of its researchers was an economic advisor to President George W. Bush and another an advisor to the Obama administration. (Read more)

State awards Medicaid managed-care contracts to 4 firms, including Passport; networks to be established by Oct. 1

In an effort to save $1 billion in the next three years, and fill a hole in the current state budget, Gov. Steve Beshear announced Thursday that Kentucky's Medicaid program will be run by four companies, including the beleaguered Passport Health Plan. (Associated Press photo by Ed Reinke)

The move will affect 815,000 Kentuckians who qualify for Medicaid, a program for the poor and disabled. Despite the changes, they will not see a cut in services, and the moves are expected to create nearly 550 jobs, Beshear said. For his press release, click here. For audio of his press conference, go here. He plans to fly around the state Friday to get the word out about the changes, the Lexington Herald-Leader reports.

The companies are Coventry Health Care, based in Bethesda, Md.; WellCare Health Plans of Illinois; and Centene Corp. of St. Louis. As it has been doing already, Passport will serve Jefferson and 15 neighboring counties, but its contract was renewed for only one year. The other companies were awarded three-year contracts. Passport was the subject of a scathing audit earlier this year by state auditor Crit Luallen, who uncovered unnecessary spending. The other organizations operate in at least seven states each.

Now that the contracts have been awarded, the companies will start establishing provider networks, which they have until Oct. 1 to do, Jill Midkiff, spokeswoman for the Kentucky Cabinet for Health and Family Services, told Kentucky Health News. Initially, Medicaid recipients will be matched with a company based on what network their doctor is part of. "But if they don't want to stay with that company, they can change immediately or change after they've been with them for a little while," Midkiff said.

Unlike with Passport, Midkiff said, Coventry, WellCare and Centene will not be responsible for a specific number of counties; they will simply serve their in-network doctors, wherever they happen to be. "Which doctors are in which networks in which counties is not a question I can answer," Midkiff said. "It will be something the companies will be working to establish."

Moving to managed care is the Beshear's administration's answer to fill a $166 million hole in the Medicaid budget, created by a lack of expected federal funding. The federal government pays more than 70 percent of Medicaid costs, bringing the expected savings to $1.3 billion over three years.

Lawmakers vigorously butted heads over how to resolve the issue, making it the most contentious of this year's legislative sessions. The Democratic House sided with Beshear's plan, but the Republican-led Senate fought it, saying managed care would not save the money Beshear promised. They instead proposed making across-the-board cuts, even to the basic school-funding formula. The issue went to a special session, with Beshear warning that, without a compromise, Medicaid reimbursement to hospitals and providers would have to be cut 35 percent. When he promised House Democrats that he would line-item-veto the Senate's spending cuts, the House passed the bill and he made the vetoes.

The bill gave state officials had until July 1 to get contracts in place, a deadline they missed by almost a week. The plan must now be approved by the federal Centers for Medicare and Medicaid Services. The waiver was submitted to CMS June 11. CMS officials have 90 days to review and approve or disapprove the submission.

WHAT IS MANAGED CARE?

A managed care organization "in the broadest context is an organization that is responsible for managing patient care as opposed to just paying the bills that come in," explained Robert Slaton, who was executive vice president of University Healthcare, now known as Passport, from 1998 to 2006. In the traditional Medicaid setup, the doctor or hospital bills the state and the state pays the bills. "With an MCO, the doctor or hospital bills the managed care company and they have a lump sum from Medicaid and they pay the bills," Slaton explains.

Before the contracts were signed, Slaton said the MCOs likely studied Kentucky demographics carefully and came up with a lump sum they would like to be paid per patient based on the Medicaid members in the state. "Our experience was they had a very sophisticated information system and over time they were able to drill down to understand exactly where expenses were being incurred, more so than a total statewide system," Slaton said.

Because the lump sum it receives for each patient stays static, unlike in the fee-for-service model in which the state pays for whatever bills are incurred, there is incentive for the MCO to keep costs down. That can mean requiring more preventive care, like screenings or dental checkups, in order to save money in the long run; and analyzing care to prevent duplication of services. And it can involve sending case managers to visit repeatedly ill patients to help them get their health issues in check. "It's the kind of thing where it's doing the right thing and also, in the long run, saves money," Slaton said. "If someone who is a diabetic gets sick, you don't want to just pay for them to go to the doctor. You want somebody to help them figure out how to live a healthier lifestyle."

Because there is incentive for MCOs to keep costs down, does that also create incentive to deny care? Slaton said no. "It used to be probably true that there was too much emphasis on denying care," he said. "Now what they try to do is provide appropriate and necessary care, but eliminate duplication ... The old ways of cutting fees and denying care just won't fly. You'll have such a political backlash that you end up losing your contract."

Webinar next week will spotlight county-by-county health data

How can you find by-county health statistics and other other key health resources? That will be the focus of a July 13 webinar, hosted by the Foundation for a Healthy Kentucky.

The free webinar, which starts at 3 p.m. EST next Wednesday, will teach listeners how to navigate the Kentucky Health Facts website and point listeners to other resources like the Kentucky Cancer Registry.

It will be hosted by Sarah Walsh, the senior program officer at the foundation's Local Data for Local Action Initiative. The goal of the intiative is to provide access to key state and local health data to help decision making at the local level. "At the foundation, we take a lot of inspiration from the words of Arthur Ashe, 'Start where you are. Use what you have. Do what you can'," Walsh said. "I love that the data on our Kentucky Health Facts website can help local health advocates understand where they are starting from, so they can really do something to make their community a healthier place to live."

Under the moniker "Health for a Change: Ignite — Unite — Act," this is the first in a series of webinars hosted by the foundation. On July 27, Walsh will discuss how to plan a community health needs assessment. For more information about future webinars, click here.

To register for the webinar, click here.