Dr. Nikki Stone and mobile dental team in Hazard have helped cut tooth decay in the region 20 percent in a decade of operation

By Ann Blackford
University of Kentucky

When Dr. Daria "Nikki" Stone, associate professor at the University of Kentucky College of Dentistry, became the director of the Ronald McDonald Care Mobile program in Hazard, she realized she was finally in the right place at the right time, where her piece of the puzzle fit in the big picture.

Growing up in Blackey, in Letcher County about 30 minutes from Hazard, she didn't know she wanted to be a dentist. She was always a good student and loved science classes in school but her passion had always been art. At her father's coaxing, she entered college as a pre-med major, and discovered through the UK Health Careers Opportunities Program that dentistry was a profession that merged her love of art and science.

Dr. Daria "Nikki" Stone (University of Kentucky photos)

"Now, I have a passion and love for what I do, preventing tooth decay in children in elementary schools, preschools and Head Start centers in Eastern Kentucky and advocating for underserved children," Stone said.

Stone married her high school sweetheart, Mark, and they have two children; Ana and Ian, 16 and 13. Her early career included part-time teaching and covering clinics in Prestonsburg and Hazard as a stay-at-home mom and working in New Mexico for the National Health Service Corps to retire a school loan. She got a transfer to be closer to family, and her last year with NHSC was just across the Kentucky border in Virginia.

She had been practicing dentistry for 10 years when UK hired her to head the Mobile Care program, coming full circle to the place she holds most dear.

"I love that I've been able to come home to Appalachia, there is no more beautiful place or more wonderful culture," she said. "I love the way my people talk and hug and laugh, and I love that we are a deeply spiritual people who are deeply connected to one another. My children are 10th generation Appalachians and I wouldn't want to raise them anywhere else."

UK's North Fork Valley Community Health Center's mobile dental outreach program celebrated 10 years of serving children in 2015. Stone has directed the program since its inception. She and several dental hygienists and assistants provide preventive dental care twice a year to 2,400 Head Start children in Perry, Knott, Letcher and Leslie counties and once a year to all public elementary schools in Perry and Knott counties. Children receive dental exams, cleanings, fluoride treatments, sealants and both classroom-based and individualized educational sessions. Dental education is also available to parents and teachers at various community events.

"Teaching is actually one of my favorite parts of my job," Stone said. "I also love the practical, day-to-day side of being with children, and I also love the philosophical aspect of why we're doing what we're doing. . . . Children are truly a blessing to work with; they are so very honest and keep us laughing all day. I love that we are preventing tooth decay before it starts and lowering the tooth decay rates in Eastern Kentucky, which has some of the highest rates of tooth decay in the nation."

Stone and patient Wyatt "Bebo" Goins at
Roy G. Eversole Preschool in Hazard

Tooth-decay rates in the center's service area have decreased nearly 20 percentage points, urgent dental needs have been cut in half, and treatment-completion rates for Head Start children with urgent dental needs have increased dramatically, from 8 percent to more than 60 percent.

"When the UK dental outreach team started seeing children in local schools and Head Start centers in 2006, over half the children in Perry County had untreated cavities and 20 percent had painful abscessed teeth," Stone recalled.

Stone said she has found her place in the world. "I once had a very spunky little girl come on the mobile unit and she was very excited to be there," she recalled. "She couldn’t stop talking and she spoke really fast, going from one topic to another without transition. She jumped up in the dental chair and asked me this question, 'Did you wish upon a star to be a dentist?' It really caught me off guard and I had to stop and think about it for a couple of seconds. I realized I probably had not ever wished upon a star to be a dentist, but for some reason God chose to bless me with the opportunity to be a dentist to this beautiful little girl anyway, and to provide preventive dental care services to over 10,000 children just like her who have come on the mobile unit in the past 10 years. And maybe some of them will wish upon a star to become dentists someday."

Nominations are being sought for award recognizing lifetime contribution to rural health in Kentucky; deadline is June 17

In June of 2003, the Kentucky Rural Health Association began an award honoring a lifetime contribution to rural health in Kentucky. The first recipient was Dr. Dan Martin of the Trover Foundation in Madisonville. The annual award now bears his name and is given each year to an individual who has provided many years of service to rural Kentuckians. Last year’s recipient was Joseph E. Smith of the Kentucky Primary Care Association.

KRHA is seeking nominations for this year's award. The nominee’s contributions might be in direct patient care, health professions education, health administration, health promotion or public advocacy. To nominate someone, please download the nomination form here and e-mail it directly to linda.asher@uky.edu or to her at the Office of Rural and Community Health, 2195 Harrodsburg Rd., Suite 125, Room 1213, Lexington KY 40504-3504, or fax to (859)323-1043. The deadline for nominations is Friday, June 17.

The award committee ranks the candidates using established criteria and makes a recommendation to the KRHA Executive Committee, which selects the honoree, if someone is deemed appropriate. The award will be presented at the KRHA annual conference Aug. 25-26 in Bowling Green. Any KRHA member who would like to serve on the Dan Martin Award Committee should email linda.asher@uky.edu. "There are many dedicated, compassionate people at work in rural health in Kentucky and we look forward to being able to give them some well-deserved recognition," Asher says. "Now is your chance to help us thank someone that you think deserves recognition. We need and appreciate your input."

Exercise can help prevent or slow cancer, study suggests

Exercise may keep you from getting cancer and slow the growth of a tumor if you get one, according to a mouse-based study published in the journal Cell Metabolism by researchers at the University of Copenhagen in Denmark.

They report that training mice regularly on a wheel (the mouse version of a treadmill) decreased the growth of multiple types of tumors, including skin, liver, and lung cancers. Also, mice that exercised regularly had a smaller chance of developing cancer in the first place, and less cancer-associated weight loss.

The researchers linked the anti-cancer effects to the release of adrenaline (also called epinephrine), a hormone central to the mammalian “fight-or-flight” response. Exercise stimulates the production of adrenaline, which mobilizes immune cells, including one called a "natural killer." NK cells are recruited to the site of the tumor by the protein IL-6, which is secreted by active muscles. NK cells can then infiltrate the tumor, slowing or completely preventing its growth.

The researchers pointed out that injecting the mice with adrenaline or IL-6 without the exercise was not sufficient to inhibit cancer development, showing that regular exercise was needed to activate the hormone and the protein.

Flu remains widespread in Kentucky; vaccinations still advisable

This year's round of influenza hit Kentucky later than usual, and that probably means this year's flu season could run past May, its usual end, the state Department of Public Health said in an alert April 6.

The flu is “widespread” in Kentucky for the ninth straight week, the health department said. "That means there’s increased flu-like activity or flu outbreaks in at least half of the regions of the state," Darla Carter reports for The Courier-Journal.

The department still recommends a flu vaccination, if you haven't had one for the current season, “particularly children 6 months and older and those people at high risk for complications related to the flu, to check with doctors’ offices, local health departments, pharmacies or other providers about getting the vaccine,” said Dr. Kraig Humbaugh, senior deputy commissioner.

The agency recommends other precautions:

• Avoid close contact with sick people.
• If you have the flu, limit your contact with other people.
• Stay home for at least 24 hours after your fever is gone. Your fever should be gone for 24 hours without the use of a fever-reducing drug.
• Cover your nose and mouth with a tissue when you cough or sneeze, then put the tissue in the trash.
• Wash your hands often with soap and water. If they are not available, use an alcohol-based rub.
• Avoid touching your eyes, nose and mouth.
• Clean and disinfect surfaces and objects that might be contaminated with flu and other germs.

Bevin administration is working to fix Benefind's technical glitches; 51,000 Kynect clients blocked from working with Kynectors

Update: 4/8/16 This story has been updated with comments from the Cabinet for Health and Family Services. 

By Melissa Patrick
Kentucky Health News

On Feb. 29, Gov. Matt Bevin's administration launched a new one-stop-shopping website for state benefits that was designed to make life easier for the one-fourth of Kentuckians eligible to use it. Instead, it caused an unprecedented disruptions of services after thousands received erroneous letters notifying them they would no longer receive their benefits.

Deborah Yetter of The Courier-Journal has reported extensively on the problem, with stories of Kentuckians who have lost their benefits and found it nearly impossible to get help because of hours-long waits in the state benefits offices and a phone system that tells them to call back later.

The website, called Benefind, can be used to apply for Medicaid, the Kentucky Children's Health Insurance Program (KCHIP), the Supplemental Nutrition Assistance Program (SNAP, once known as food stamps) and Kentucky Transitional Assistance Program (KTAP).

The problem goes beyond those programs. The 500 paid Kynectors, who help Kentuckians use the Kynect health-insurance exchange, have not been able to help because federal regulations require participants who use multiple services to first go though the Department of Community Based Services, the state agency that manages Benefind. As of now, Kynectors can only help Kentuckians who have never received other state benefits.

Health advocates have called the launch of Benefind a "disaster." At a March 31 news conference, Bevin, along with health officials from the Cabinet for Health and Family Services and a Deloitte Consulting official, acknowledged the widespread problems and said they were working tirelessly to correct them.

“Our primary focus is to ensure that we deliver, as seamlessly as possible, as safely as possible, as expediently as possible all the benefits that folks expect and need from the Commonwealth of Kentucky," Bevin said.

State officials at the news conference said they had worked with federal officials to extend benefits through April, so that no one should be cut off from Medicaid or SNAP if they qualified for those benefits in March. The state has also stopped automatic letters generated by Benefind.

In addition, they have updated websites and changed the phone message to better explain what is going on; extended the re-certification time frame for SNAP benefits from six months to 12 months, allowing those cases to continue with a simple review instead of a client interview; hired an additional 185 people to help with the deluge of telephone calls and visits to the local state benefit offices; and Deloitte has assigned trainers to every county to help the DCBS staff.

Officials have encouraged the public to log on to the Benefind self-service portal at https://benefind.ky.gov/ to ease the burden on processing centers.

So, what happened?

Deloitte built Benefind under the administration of Gov. Steve Beshear at a cost of $101.5 million to replace an outdated eligibility system. Deborah Sills of Deloitte said at the news conference that they believed the system was ready to launch at the end of February, but "there were some issues that didn't present themselves until after the system went live."

However, Ryland Barton of Louisville's WFPL reported that on Feb. 25, a 27-page "Worker Portal Defect Workaround Guide" was distributed to DCBS staff showing that the administration knew there would be problems with the rollout.

But the cabinet says a guide like this is standard procedure.

"Deloitte says a guide like that is standard operating procedure when you’re dealing with a huge system rollout like this," Doug Hogan, spokesman for the cabinet said in an e-mail. "It’s a new system and (this was) a guide to help staff navigate the system better and help them work though issues they might encounter. Additionally, there were these same types of documents for the original rollout of Kynect."

Bevin's administration explained that the problem has been caused by an automatic review of cases where information from Kynect and the old eligibility system didn't match.

“Cases where information between the Kynect case and legacy case did not match (for example, household composition or income) are required to be managed by a state agent before they can be acted upon by agents or Kynectors,” Jessica Ditto, Bevin’s communications director, told WFPL in an e-mail. “This constraint has been placed to protect program and data integrity — plus, this is required by federal law.”

Ditto told Barton about 51,000 cases are under review, and noted that once the conflicting data has been reconciled, "the cases will become open for Kynectors and agents again, just as before.”

Sills told reporters that Benefind had not been altered in any way from its original 2014 design and affirmed Bevin's stance that the move to Benefind had nothing to do with his administrations decision to close Kynect and move to the federal exchange.

"None of these issues are caused by any changes the current administration has made to the system's purpose or design," Sills said.

However, Beshear said in a news release that Kynect and Benefind were meant to work together, not for Benefind to take over signing people up for Medicaid.

"The Benefind program was developed to complement Kynect, the state-run exchange," Beshear said in the release. "Although he attempts to blame the 'prior administration,' Governor Bevin’s administration mismanaged the launch of this new system, and in doing so, created a disastrous situation for thousands of families in Kentucky."

Bevin and Deloitte say the system was always designed to support Medicaid enrollees. "Benefind is Kynect, Kynect is Benefind," Bevin said at the news conference.

Not really, says Kentucky Voices for Health, a coalition of groups supporting Kynect,  "For people needing Medicaid coverage and other social benefits right now, there is no right door for access, let alone 'one door'," the group said in a press release Wednesday. "Kynect was built to provide access to health insurance and Medicaid enrollment; and Benefind was built to enhance Kynect with additional social services benefits. While they’re part of the same system, they provide different essential functions."

However, Hogan noted  in the e-mail that page 15 of a training document for Kynectors originally posted November 2015 "clearly shows that Benefind was intended to process all Medicaid plans, even Qualified Health Plans...it was truly designed to process all benefits."

Beshear and his advocacy group, Save Kentucky Healthcare, have also released a one-minute video entitled "If It Ain't Broke Don't Fix It" criticizing the Bevin administration's rollout of the system.

10 common misconceptions about cancer and the environment

With the advent of the internet, people are swamped with information about cancer and some of it is not based on "sound scientific evidence" or is "at best, anecdotal," which can "hamper efforts to prevent and treat" it, reports Curt DellaValle, a cancer epidemiologist and senior scientist at Environmental Working Group. He writes about some of the most common misconceptions about cancer:

Misconception #1: Getting cancer is almost completely out of your control: DellaValle recognizes that some cancers are caused by genetics and "bad luck" and notes that the World Health Organization reports that 20 percent of cancers are thought to be caused by environmental factors such as pollution, infections and radiation, but he also says "as many as half of cancers may be preventable," noting that smoking, poor diet and lack of exercise are major contributors.

Misconception #2: “Everything” causes cancer: "Not all chemicals, pollutants or guilty pleasures will lead to cancer," DellaValle writes, while also noting that the amount of exposure to the carcinogen plays a role. "The International Agency for Research on Cancer, a research arm of the WHO, has looked into nearly a thousand suspected causes of cancer. Of those suspicious substances and activities, they have concluded that just about half are known or potentially carcinogenic.

Misconception #3: Exposure to a known carcinogen will give you cancer: "Known carcinogens" are substances that have strong evidence that they can cause cancer, but  it is important to recognize that the risk between them differs. "A person exposed to a known carcinogen is not 100 percent certain to develop cancer, not by a long shot," DellaValle writes. For example, he writes that  there is a difference between asbestos exposure, a potent carcinogen, and eating processed meats, which is also a known carcinogen, but one that only modestly increases your chances of getting cancer.

Misconception #4: Natural products are safe and synthetic products are harmful: DellaValle writes that "arsenic, asbestos, formaldehyde, radiation and tobacco occur naturally and are known carcinogens." His advice is to "arm yourself with information" and "know what you're buying and don't assume everything that says 'natural' is harmless."

Misconception #5: Chemicals that the body absorbs and retains for a long time are more dangerous than those that are quickly excreted or metabolized: "The hazard of a substance is determined not just by the degree of exposure but also how it interacts with the body," he writes. For example, nitrates and nitrites in food and water can change into compounds that cause cancer in the body, while chemicals that are excreted quickly, like pesticides and heavy metals, can also cause cancer.

Misconception #6: The cancer risk you accumulate is irreversible: DellaValle writes that certain harmful exposures, like to radiation, does not allow full recovery, but damage from many environmental exposures can be partly reversed with elimination or significantly reducing the exposure. "The Surgeon General’s report on tobacco concluded that quitting smoking at any age reduces a smoker’s risk of cancer by up to 50 percent in just five to 10 years," he writes.

Misconception  #7: Mammograms cause breast cancer: "The risk with the very small amount of radiation emitted during a mammogram is minuscule for most patients," he writes. However, "women who are pregnant should avoid mammograms and X-rays that their doctors don’t consider necessary. Radiation could harm the developing fetus."

Misconception #8: Cell phones, wi-fi, microwaves, power lines and airport X-ray machines will cause cancer: DellaValle writes that cell phones, wi-fi, microwaves and power lines "emit non-ionizing radiation" and is less invasive than "ionizing radiation" that comes from  X-rays, sunlight and uranium. The WHO considers cell phone radiation a possible carcinogen "based on a suspected association between cell phone use and brain cancer,: DellaValle recommends holing your  phones a few millimeters away from your body to "drastically reduce exposure" or use hands-free devices and texting. He does say that it is a good idea to keep wireless routers a few feet from places where people spend long periods of time, though he notes that there is little or no evidence to support that wi-fi signals cause cancer. He also notes that it would take about 1,000 trips through an airport X-ray scanner to equal the radiation exposure from one medical chest X-ray.

Misconception #9: Artificial turf sports fields cause cancer: The jury is out on this one. DellaValle says, "No data exists at this time to say that artificial turf causes cancer, but scientists are just beginning to explore the question. In the meantime, you should play on artificial turf in well-ventilated areas, avoid hand-to-mouth contact while playing and limit direct contact between turf and skin."

Misconception #10: Residential pesticides are safe: DellaValle writes that many of the pesticides suspected to cause cancer in farm workers are being sold for residential use and notes that some evidence exists that they increase the risk of cancer. While recognizing that  homes would use these products less often and at a lower dose, he did caution to not use them around children or pregnant women. He noted that studies have found that children exposed to pesticides while in the womb and in infancy face an increased risk of childhood cancers like leukemia and brain tumors.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Legislature's many health bills include some with life-saving potential, better prevention, greater access and help for children

By Melissa Patrick
Kentucky Health News

One paragraph in this story was incorrect and has been stricken.

FRANKFORT, Ky. -- Kentucky legislators have all but ended their regular session without agreeing on a budget, but were able to pass a wide range of health bills that await Gov. Matt Bevin's signature or veto.

Legislators can still pass more bills, including a budget, when they return for one day, April 12, and reconsider any bills the governor vetoes (except the budget, if one passes that day).

Many of the health bills deal with regulation, such as which agency oversees home medical equipment and licensing rules for physicians. Others, like SB 211, sponsored by Sen. Alice Forgy Kerr, R-Lexington, establish a special day to encourage research for amytrophic lateral sclerosis by officially naming Feb. 21 "ALS Awareness Day."

But several others will impact the daily lives of Kentuckians, directly or indirectly. Some have the potential to save lives.

Senate Bill 33, sponsored by Sen. Max Wise, R-Campbellsville, requires every Kentucky high-school student to receive compression-only CPR training. "Each year nearly 424,000 people have sudden cardiac arrest outside of the hospital and only 10 percent of those victims survive," Wise said at a Jan. 13 Senate Health and Welfare Committee meeting. "Yet when a CPR trained bystander is near, they can double or triple these victims survival rate."

Another bill with life-saving potential would let Kentuckians take time off work to be "living donors" or donate bone marrow without the risk of losing jobs or income. House Bill 19, sponsored by Rep. Ron Crimm, R-Louisville, requires paid leave of absence for such reasons, and offsets this cost to the employer with tax credits.

(An amendment to this bill, illustrating how legislation gets passed in unusual ways during the closing days, would allow Lexington to impose an additional 2.5 percent hotel-room tax to improve its convention center.)

A minor housekeeping bill had an important health amendment attached to it that mandates assisted-living communities to provide residents with educational information about the flu by Sept 1 of each year. SB 22 is sponsored by Sen. Ralph Alvarado, R-Winchester. The CDC estimates that between 80 and 90 percent of seasonal flu-related deaths occur in people over 65.

Colon cancer, which kills more than 850 Kentuckians a year, remained in the spotlight with passage of HB115, sponsored by Rep. Tom Burch, D-Louisville. It would expand eligibility for screenings to age-eligible, under-insured Kentuckians, or uninsured persons deemed at high risk for the disease. This bill is aimed at the 7 percent of Kentuckians who have remained uninsured since the state expanded Medicaid under federal health reform, and those who have insurance but can't afford deductibles or co-payments.

Other bills intended to create better access to care for Kentuckians would expand the duties of advanced practice registered nurses (SB114); decrease the oversight of physician's assistants (SB154); create a pilot program to study telehealth and how it's paid for (HB 95); and better define who can perform administrative duties in pharmacies (HB 527).

Children: "Noah's Law," or SB 193, sponsored by Alvarado, mandates the coverage of amino-acid-based formulas for eosinophilic esophagitis and other digestive disorders. It will have an impact on more than 200 Kentucky families. It is called "Noah's Law" after 9-year-old Noah Greenhill of Pike County who suffers from the disease, which requires him to get this formula through a feeding tube four times a day because of severe food allergies, at a daily cost of more than $40. This bill has already been signed by the governor and took effect immediately.

HB148, sponsored by Rep. Linda Belcher, D-Shepherdsville, allows day-care centers to be able to obtain and store epinephrine auto-injectors for emergency use. This bill was amended to include "participating places of worship" as a location that newborns up to 30 days old can be left without threat of prosecution to the parent or family member who leaves them there.

The latest Centers for Disease Control and Prevention study found that one in 68 of the nation's children have autism, and Kentucky legislators passed two bills this session to address their needs. SB 185, sponsored by Sen. Julie Raque Adams, R-Louisville, creates the Office of Autism and guidelines for an Advisory Council on Autism Spectrum Disorders. This bill has already been signed by the governor. HB 100, sponsored by House Minority Leader Rep. Jeff Hoover, R-Jamestown, requires insurers to maintain a website to provide information for filing claims on autism coverage and make autism-benefit liaisons available to facilitate communications with policyholders.

Big bills: One of the high-profile health bills that passed this session is SB20, sponsored by Alvarado, which creates a third-party appeals process for providers to appeal denied Medicaid claims. Alvarado has said that 20 percent of Medicaid claims are denied, compared to the national average of around 6 percent. He suggest that bringing this bill will help bring these numbers more in line with each other and thus will encourage more providers to participate in Medicaid.

A bill that will eventually increase accessibility to drugs made from living tissues that are very expensive, but also very effective, also passed. SB 134, sponsored by Alvarado, would allow pharmacists to substitute a less-expensive "interchangeable biosimilar" drug for its name-brand "biologic" one, even though the U.S. Food and Drug Administration hasn't approved these interchangeables yet. Humira and Remicade for arthritis, and Enbrel for psoriasis, are a few of the most common biologics on the market.

Another bill is aimed to help small-town pharmacies stay competitive with chains. SB 117, sponsored by Wise, allows the state Insurance Department to regulate pharmacy benefit managers, like Express Scripts, much like insurance companies. It would also provide an appeal mechanism to resolve pricing disputes between pharmacies and PBMs. The state has more than 500 independent pharmacists that will be affected by this law.

Bigger issues: Health officials say the single most important thing that Kentucky can do to improve the state's health at no cost is to pass a statewide smoking ban for workplaces. Rep. Susan Westrom, D-Lexington, filed a smoke-free bill late in the session that didn't even get a hearing in committee, despite having passed the House last year. Bevin opposes a statewide ban.

Adams and Alvarado filed a bill to require insurance companies to pay for all evidence-based smoking cessation treatments in hopes of decreasing the state's smoking rate, but it was filed late in the session and only brought up for discussion.

Democratic Rep. David Watkins, a retired physician from Henderson, filed three bills to decrease smoking in the state: one to increase the cigarette tax, one to raise the legal age for buying tobacco products to to 21, and one to require retail outlets to conceal tobacco products until a customer requests them. All were to no avail.

Rep. Darryl Owens, D-Louisville, filed bills to continue the Kynect health-insurance exchange and the state's current expansion of the federal-state Medicaid program. The bills passed mostly among party lines in the House, but the Senate has not voted on them as Senate President Robert Stivers said he would if the House did.

U of L dental school's general-dentistry and oral-medicine chair elected president of American Academy of Oral Medicine

Wendy S. Hupp

Wendy S. Hupp, associate professor and interim chair of the Department of General Dentistry and Oral Medicine of the University of Louisville School of Dentistry, will be the next president of the American Academy of Oral Medicine.

Hupp joined the U of L dental school in 2007 and is a diplomate of the American Board of Oral Medicine. She lectures nationally on the treatment of medically complex patients, pharmacology, HIV/AIDS, clinical oral pathology, and women’s health. She is widely published.

She is a graduate of the University of Pennsylvania and practiced general dentistry in Wayne, Pa., for nearly six years. She completed residency training in oral diagnosis, oral medicine, and oral and maxillofacial radiology at the Naval Postgraduate Dental School.

Oral medicine specialists are qualified to treat patients for such health conditions as TMJ, burning mouth, sensory disorders and many other oral complications. Hupp said in the news release that she plans to increase awareness of this specialty during her time as president.

Bevin gets bill to create third-party appeals process for denied Medicaid claims, which sponsor says are all too common

By Melissa Patrick
Kentucky Health News

A bill to create an independent process for Kentucky health-care providers to appeal claims denied by Medicaid managed-care organizations is on its way to the governor's desk for his signature.

Sen. Ralph Alvarado

The only appeals process for providers now is through the MCOs themselves, and the only recourse for denied claims is through the courts.

"We are looking at almost 20 percent of the claims that are out there through Medicaid being denied to providers," the bill's sponsor, Republican Sen. Ralph Alvarado of Winchester, told Kentucky Health News. "So with that there are millions of dollars that all of those providers are losing out on. This finally gives them an opportunity to keep the MCOs accountable."

WellCare of Kentucky, one of the MCOs Alvarado targeted last year while trying to get a similar bill passed, denied that it has so many disputed claims, but says it will work with the Cabinet for Health and Family Services if Senate Bill 20 is enacted.

"WellCare of Kentucky rarely disputes claims for medical necessity, with only 1 percent of claims being denied for this reason," spokesperson Charles Talbert said in an e-mail. "We are supportive of initiatives that help to ensure our members get the right care, at the right time, in the right setting."

Another MCO that Alvarado targeted last year as having a high rate of denied claims, Aetna Better Health of Kentucky, formerly CoventryCares, said in an e-mail, "We work tirelessly, along with our network of providers to improve access to and quality of care for our Medicaid members and we are committed to continuing these valuable collaborations."

CareSource, another MCO, declined to comment.

Kentucky implemented managed care in 2011 mainly as a way to save money. In managed care, an MCO gets a lump sum per patient, a system that encourages them to limit payments to providers. Providers have complained about denied claims and slow payments, causing some to suggest that managed care creates an incentive to deny care.

"Kentucky Medicaid MCOs have a denial rate that is four times the national average," Alvarado said in an e-mail. "These MCOs, in general, are garnering massive profits on the backs of our providers by simply not paying for services; and then claiming that they are 'managing care'."

MCOs serve about 1.1 million Kentuckians and account for about 69 percent of the state's Medicaid budget, according to a state news release.

Last year the state renegotiated all MCO contracts in hopes of decreasing the number of disputes over rejected claims, but health-care providers told the Senate Health and Welfare Committee Jan. 13 that this is still an ongoing problem, especially with behavioral health.

Nina Eisner, CEO of The Ridge Behavioral Health Systems, told the committee that there are examples all over the state of patients with homicidal thoughts unable to get their care paid for by MCOs.

Senate Bill 20 says that after providers exhaust an MCO's internal appeals process for denied claims and a final decision has been made, the provider can then seek a third-party review from an administrative hearing tribunal in the cabinet. The appeals process would apply to all contracts or master agreements entered into or renewed on or after July 1, 2016.

Alvarado said the proposed appeals structure is very similar to the one for commercial insurance appeals at the Department of Insurance. He noted that Kentucky's commercial denial rates are around 6 percent, which are close to the national average, and said he hopes this independent appeals process will bring the MCO denial rates more in line with this.

"If we go from 20 percent to 6 percent, I think most providers will accept that," he said. "This is fair. It is fundamentally American to have an appeals process and it is needed."

Alvarado sponsored a similar bill last year, but it died in the House. A similar bill passed both chambers in 2013, but then-Gov. Steve Beshear vetoed it. Alvarado said he is confident Gov. Matt Bevin will sign this year's version.

Alvarado said that once this "fractured relationship between providers and Medicaid" has been mended "it might actually open up the door for more providers to participate with Medicaid."

Sheila Schuster, a Louisville mental-health advocate, agreed, and said that while Medicaid reimbursement rates are "not great," not being paid at all for services rendered is not acceptable and has been a deterrent for providers to participate.

She said the Kentucky Mental Health Coalition and the National Alliance on Mental Illness support SB 20 because "they want providers to be fairly treated and to be able to provide the services that they need."

Dr. Rice Leach, outspoken leader in public health at the local, state and national levels, dies at 75

RICE LEACH, M.D. (Lexington Herald-Leader photo)

Lexington Health Commissioner Rice Leach, a national, state and local leader in public health, died Friday of lymphoma. He was nine days short of his 76th birthday.

Lexington Mayor Jim Gray called Leach "a great man in every way: compassionate, committed, determined."

Leach had been Lexington’s health commissioner for five years, leading it to national accreditation, and medical director and executive director of the local health department’s primary-care center for six years before that. He was Kentucky commissioner of public health from 1992 to 2004, and before that chief of staff to the U.S. surgeon general. He spent 26 years with the U.S. Public Health Service, mostly with the Indian Health Service, but also worked in Bolivia, Panama and Guatemala.

Leach's outspoken nature endeared him to public-health officials who were not as disposed to strong public statements. His last campaign was for the establishment of needle exchanges to prevent the spread of hepatitis C and HIV through needle sharing by users of heroin and abusers of prescription drugs. Citing research, he stoutly rebuked elected officials who said the exchanges promote drug abuse.

"He was intrepid in another explosive landscape, the one where science and politics intersect," recalled Jamie Lucke of the Lexington Herald-Leader. "I was reminded of this by a recent report about states where propagandistic misinformation riddles the state-ordered briefing that women receive before an abortion. Kentucky is not one of them. I hesitate to publicize this because some politician will rush to change it. But our “informed consent” briefing is dispassionate, nonjudgmental and, above all, informative — much like Leach, who oversaw its drafting after the legislature enacted the mandate in 1998."

Lucke added, "As admirable as all of that is, none of it accounts for why the people who worked for and with him loved him so very much. That would be his kindness and unfailing sense of fun. . . Nowadays you hear that doctors are demoralized by the business demands of their profession. Perhaps Leach’s fascinating life and and profound legacy will serve as a beacon guiding them back to public health — it might be less lucrative but potentially more fun and rewarding."

Leach's last recognition was the 'hero" award from the Lexington-Fayette County Board of Health, which renamed it the Dr. Rice C. Leach Public Health Hero Award. The award is usually given during National Public Health Awareness Week, which this year is April 4-10, but was presented in March because of his medical condition.

Leach is survived by his wife of 50 years, Mireille, whom he met in Guatemala; two sons, George, of Louisville, and John, of Frankfort; two grandchildren, Nicolas Cowan Whitcomb and Alyse Marie Whitcomb; and a brother, George Brown Leach, Jr. He was preceded in death by a daughter, Mary, who died of cancer in 2007.

His Mass of Christian Burial will take place in the Good Shepherd Catholic Church in Frankfort at 1:30 p.m. Tuesday, April 5, with visitation beginning at 10:30 a.m., Rogers Funeral Home in charge. In lieu of flowers, contributions are suggested to the church, 72 Shepherd Way, Frankfort KY 40601.

Adults 62-85 are often taking combinations of drug or dietary supplements that could be deadly; risk nearly doubled in 5 years

Update: 4/4/16, This story has been updated to reflect that the study says the number of adults using at least five prescription drugs a day has increased and not the average older American is using at least five prescription drugs a day.

The number of older Americans at risk of potentially life-threatening drug interactions almost doubled between 2005 and 2011, according to a study from the University of Illinois at Chicago.

"One in six older adults now regularly use potentially deadly combinations of prescription and over-the-counter medications and dietary supplements, a two-fold increase over a five year period," says the release.

More than half the potentially deadly interactions involved a non-prescription medication or dietary supplement such as a vitamin. The study found that older adults have increased their use of vitamins and supplements, despite limited evidence of their clinical benefit.

The study, published in JAMA Internal Medicine, examined changes in medication use in more than 2,000 adults aged 62 to 85 between 2005 and 2011.

Fifteen potentially life-threatening drug combinations of the most commonly used medications and supplements were identified, and the study found nearly 15 percent of older adults in 2011 used at least one of these dangerous combinations, up from 8 percent in 2005.

The study found that older adults have grown more fond of non-prescription medications and supplements: 63.7 percent of older adults used them in 2011, up from 51.8 percent in 2005. Older adults using at least five prescription medications increased to 35.8 percent from 30.6 percent in the same time period.

The most common life-threatening interaction identified by the study was cholesterol-lowering drugs (statins), drugs used to prevent blood clots (anti-platelet drugs) and omega-3 fish oil supplements.

“Many older patients seeking to improve their cardiovascular health are also regularly using interacting drug combinations that may worsen cardiovascular risk,” one of the researchers said in a news release.

The researchers encourage health-care providers to carefully consider adverse effects of combining prescription and nonprescription medications when treating older adults, and to counsel patients about the risks. Older adults should also ask their pharmacists about potential drug interactions.