Trump order aims to reduce suicide among new veterans

Trump before signing the executive order Tuesday
(Associated Press photo by Evan Vucci)

President Trump signed an executive order Jan. 9 to expand mental health care for veterans who are transitioning from military to civilian life in an effort to reduce suicides in that group.

"The order will take effect March 9 and is expected to provide all new veterans with mental-health care for at least a year after they leave the military," Dan Lamothe reports for The Washington Post. "Trump gave the Defense Department, the Department of Homeland Security and the Department of Veterans Affairs 60 days to iron out details and develop a joint plan, Veterans Affairs Secretary David Shulkin said in phone call with reporters."

New veterans are particularly at risk of suicide, and 60 percent of the 265,000 service members who transition out of the military each year don't qualify for care until the government establishes that a medical issue is related to their military service. Shulkin told Lamothe that people who have been out of military service for less than a year are 1 1/2 to two times more likely to commit suicide than any other age group. About 20 veterans a day commit suicide.

The full details of the plan aren't yet clear, but will likely include making peer-group therapy sessions available at all VA Whole Health facilities; such sessions are now only available at 18 of the facilities. An anonymous source told Lamothe that the Defense Department will expand the services of its Military OneSource program to allow veterans to access its counseling and 24-hour call line services for a full year after leaving the military instead of the current 180 days. The source said that the Pentagon will look for ways to start the transition process for service members while they are still in uniform.

Shulkin said the program is expected to cost a few hundred million dollars a year from the Defense and VA budgets, but will be paid for with existing money.

Two campaigns encourage smokers to keep trying to kick the habit; one emphasizes the importance of Mondays

Many New Year's resolutions have already been abandoned, but a new campaign says when it comes to kicking the smoking habit, every Monday offers the 25 percent of Kentuckians who smoke a new opportunity to try again -- giving you 52 chances a year to succeed.

The Monday Campaigns, a nonprofit public health organization associated with Johns Hopkins, Columbia and Syracuse universities, promotes the idea of using Monday as a day to commit to healthy behaviors.

“Studies show that Mondays are a natural opportunity to engage smokers and reduce their likelihood of relapse. It’s the January of the week, the day that smokers are looking for help," Joanna Cohen, director of Johns Hopkins' Institute for Global Tobacco Control, said in a news release.

A review of the research on the "Quit and Stay Quit Monday" website shows that Monday is the day smokers are most likely to choose as a quit date; people seek cessation services and information more on Mondays than other days; people are more engaged with online quit programs on Monday, and choosing Monday as a quit day increases confidence and success rates for quitters.

To be part of the "Quit and Stay Quit Monday" movement, the campaign suggests these steps: Quit on Monday; make a quit plan; connect with others; do a Monday check-in; celebrate progress; and quit again if you relapse until you are finally smoke-free. Its website also offers free resources and tips to help smokers quit.

Approximately two of three adult smokers, more than 22 million Americans, say they would like to quit. However, in 2015, of the 55 percent of adult smokers who made a quit attempt, only 7 percent were successful, according to the "Every Try Counts" campaign, also created to help people quit smoking.

The campaign is a two-year Food and Drug Administration initiative in 35 counties, including Kenton in Kentucky, to encourage cigarette smokers to quit through messaging that emphasizes the health benefits of quitting. The messages are being placed in and around gas stations and convenience stores, places that typically feature cigarette advertisements.

“The ‘Every Try Counts’ campaign encourages smokers to rethink their next pack of cigarettes at the most critical of places — the point of sale,” FDA Commissioner Dr. Scott Gottlieb said in the news release. “Tobacco companies have long used advertisements at convenience stores and gas stations to promote their products, and we plan to use that same space to embolden smokers to quit instead.”

The news release says, "Research shows those who have tried quitting before are more likely to try again, and those who have tried to quit multiple times have a higher likelihood of quitting for good."

As part of the initiative, the FDA partnered with the National Cancer Institute to create a website that provides smokers with resources and tools to help them quit, including a free text message program that sends tips and encouraging messages, a mobile app to track smoking triggers, access to trained coaches, information on FDA-approved smoking cessation products and information on the risk of smoking. These tools are available to everyone.

Additional resources for Kentuckians can be found at www.quitnowkentucky.org and www.smokefreetomorrow.org. Kentucky's Tobacco Quitline is 1-800-QUIT-NOW (1-800-784-8669). Also, many local health departments offer smoking cessation classes. Kentucky has also passed a law that requires insurance companies to cover smoking-cessation treatments and counseling without imposing barriers.

Weekly kicked off new year with front page all about health

The week or two after Christmas is a slack time for weekly newspapers; some still take a week off. But the Adair County Community Voice took the period as an opportunity to spotlight personal stories about local residents' efforts to improve their health.

"We try to be prepared for slow weeks during the holidays by making sure we have options, but it really would have taken something pretty massive to kick these stories off the front," Editor-Publisher Sharon Burton said in an email to Kentucky Health News.

"A lot of people refocus on their health during the new year, so we knew these articles would be timely and draw interest," Burton wrote. "My assistant editor made a major healthy lifestyle change in his life several years ago and is passionate about this topic. I think it shows in these articles."

To read the stories, click here. For the "jump page" where the articles are continued, click here. For an editorial by Burton that was also a good way to begin the year, with her sharing some philosophies of life, click here.

Tobacco-settlement funds will subsidize summer meal programs' purchase of Kentucky fruits and vegetables

The state Department of Agriculture is offering a subsidy for summer meal programs in Kentucky to buy fruit and vegetables produced in the state. The program is funded by $185,000 in tobacco-settlement money awarded by the state Agricultural Development Board and administered by the Kentucky Association of Food Banks. 

"The program is the first of its kind in the nation," the department said in a news release about the Kentucky-grown Fruit and Vegetable Incentive Program, which it calls K-VIP.

“When we started the Kentucky Hunger Initiative two years ago, we began a conversation about how to combat the unfortunate reality that one in five Kentucky school children are food-insecure,” Agriculture Commissioner Ryan Quarles said Jan. 8 at the Kentucky Fruit and Vegetable Conference in Lexington. “The K-VIP program gives summer feeding programs an added incentive to provide fresh, locally grown fruit and vegetables for hungry kids in the summer months while expanding market access for Kentucky farmers.”

Warren Beeler, executive director of the Governor’s Office of Agricultural Policy, said the ag-development board “jumped at the chance to expand market access for farmers and feed hungry kids at the same time.” The board spends half the money from the states' 1998 settlement with cigarette manufacturers, with the goal of broadening the state's agricultural base.

Tamara Sandberg, executive director of the food-banks group, said in the release, “The summer meals program helps ensure children receive the nutritious food they need to thrive during the summer months when school is out. K-VIP will help increase the portion of local Kentucky produce served through summer meals.”

Meal programs served 2.8 million Kentucky children last summer. The U.S. Department of Agriculture "reimburses summer site sponsors for meals served at feeding sites, and claims for reimbursement are processed by the Kentucky Department of Education," the release said. "For every lunch served, the summer feeding site sponsor receives reimbursement from USDA of $3.83."

To participate in K-VIP, sponsors must be approved by the Education Department to serve as summer meal site sponsors and submit an enrollment application to the food-banks association at www.kykidseat.org/kvip by April 15. Contact Cathy Gallagher (cathy.gallagher@education.ky.gov) at the Kentucky Department of Education to become an approved summer feeding site sponsor.

Enrolled sponsors will be eligible for reimbursement for up to one-third of their spending on Kentucky-grown produce. "Due to the limited number of funds, there is no guarantee of reimbursement," the release says. "K-VIP payments will be capped at 10 cents times the total number of meals reimbursed by USDA."

Kentucky growers may contact Tina Garland (tina.garland@ky.gov) at the state Agriculture Department to connect with summer feeding site sponsors in their area.

Substance abuse about as common in rural areas as urban, but rural drug users are less likely to get treatment, UK studies find

By Melissa Patrick
Kentucky Health News

In some ways, substance abuse is worse in urban areas, but rural drug users are less likely to get treatment, according to two studies recently released by the Rural and Underserved Health Research Center at the University of Kentucky.

The studies looked at the last 10 years, which included several significant developments in the field. In 2008-2010 came the first parity laws, which ensure equal coverage of treatment for mental illness and addiction in most group health plans, including Medicaid; 2011-13 saw the early expansion of insurance under the Patient Protection and Affordable Care Act; and 2014-15 saw clarification of the parity laws and further insurance expansions, including Medicaid.

Click on the chart to view a larger version of it.

The first study, "Illicit Drug and Opioid Use Disorders among Non-Metropolitan Residents," found that the percentage of adults with substance-use disorders was about the same in rural areas as in metropolitan areas. However, research authors Tyrone Borders and Hefei Wen note that there are some "statistically significant" differences that indicate more serious problems in urban areas.

For example, the share of urban adults with an illicit drug-use disorder in the previous year, 3.33 percent, was significantly higher than the rural rate of 2.86 percent. Also, the share of urban adults with any type of drug-use disorder in 2014-15 was significantly higher than in 2011-13, when it was 3.07 percent.

Heroin more common in cities, prescription painkillers in rural areas

The number of adults with heroin-use disorders in the past year was "significantly higher" in metropolitan areas than rural areas, the researchers report. The most recent data show that 0.31 percent of urban residents had a heroin-use disorder in the previous year, half again as high as the 0.20 percent in rural areas.

Disorders involving the use of prescription pain relievers were more common in rural areas, involving 1 percent of the population in rural areas and 0.87 percent in metropolitan areas. Overall opioid-use disorders were virtually the same in urban and rural areas, 1.07 percent and 1.09 percent respectively, and those rates have been stable over time, the researchers report.

The researchers say they are particularly concerned about recent increases in heroin use disorders. "Heroin is more frequently injected than prescription pain relievers and is associated with hepatitis C and HIV transmission," they note. "Moreover, because the compounds contained in heroin are often unknown, it is associated with a higher risk of overdose mortality than prescription pain reliever use." Heroin is increasingly laced with painkillers that are much more powerful.

The report concludes: "Additional policies and interventions are arguably warranted to further promote access to treatment and reduce the prevalence of drug use disorders in the U.S."

Rates in 2014-15 of perceived need for treatment, and use of treatment,
among rural Americans with drug use disorders in the previous year.

The second study, "Perceived Treatment Need and Utilization for Illicit Drug and Opioid Use Disorders in Non-Metropolitan Areas," looked at the perceived need for treatment of substance-use disorders, compared to the actual use of treatment.

This research by the same authors found that overall, the rates of perceived need for treatment and actual use of treatment were low among rural residents with drug-use disorders, and have changed little since 2008, despite the implementation of policies to increase access to treatment.

"Perceived need for treatment" was defined as persons recognizing they have a drug problem and thinking that formal treatment could be beneficial. "Perceiving a need for treatment is considered an essential first step in the treatment-seeking process and has been shown to be strongly associated with treatment utilization," the authors write.

They found that the rates of perceived need for treatment for use of illicit drugs was about the same in urban and rural areas, and those perceptions haven't changed much in the last decade. For rural residents, this rate ranged from a high of 11.3 percent in 2011-13 to a low of 6.7 percent in 2014-15.

Among people with opioid-use disorders, the rural and urban rates were also about the same, but the perceived need for treatment in rural areas more than doubled between 2008-10 and 2011-13, from 7.8 percent to 18.5 percent. The rate declined to 13.4 percent in 2014-15.

The study found that 26.7 percent of urban adults with an opioid-use disorder got treatment during the study period, significantly higher than the 17.9 percent among rural adults. However, the gap almost disappeared in 2014-15, when the urban and rural rates were 24.3 and 24.1 percent, respectively.

The difference was even greater in treatment for heroin use, 48.6 percent for urban adults and 25.7 percent for rural ones. There was little difference in treatment rates for abuse of prescription painkillers: 19.5 percent for urban adults and 20.6 percent for rural.

However, the perceived need for treatment of disorders related to prescription painkillers was significantly higher in rural areas, 13.2 percent, than the urban rate of 8.1 percent. Among those with a heroin-use disorder, the rural rate was higher, but the difference wasn't statistically significant.

The researchers suggest several overlapping policy issues to consider: a need for improved insurance reimbursements for screening and treatment in rural primary care; a need to address the limited access to behavioral-health and substance-abuse treatment in rural areas; the need for targeted substance-abuse treatment, needle exchanges, and safe-sex education programs in areas with rising heroin use; and issues around the limits on the number of patients that can receive medication assisted treatment for opioid use.

They also say that stimulating positive perceptions about treatment among illicit drug users and their families and friends could encourage them to get treatment.

The studies used data from the National Survey on Drug Use and Health for the years 2008-2015. The data were combined to create adequate sample sizes and to reflect different substance-use treatment policies during the study period. The results were adjusted for demographic, social and economic factors as well as whether the person had health insurance.

Sen. Rand Paul cites President Trump's action on Paul's health-insurance idea as an example of the president's competence

Republican U.S. Sen. Rand Paul of Kentucky vouched for President Trump's competence on CBS's "Face the Nation" Sunday morning, using Trump's embrace of Paul's idea for health insurance as an example.

Host John Dickerson asked Paul, a physician, why Trump has responded to the new book, Fire and Fury, "by talking about his mental stability . . . when, instead, he could say, 'Forget this book. We've passed tax cuts, we're defeating ISIS, we've nominated a bunch of judges.' Why do you think he did that?"

Paul said he didn't know, but "I've been around the president quite a bit; I've been in the White House quite a bit with him. I can give you one example that I think really shows his great insight and ability to cut through to the chase and do things that ordinary politicians don't do. And that's when I took him the idea of letting individuals join together to buy insurance across state lines. Every politician, Republican and bureaucrat in Washington, said we couldn't do it, and they hadn't done it in 30 years."

Paul said Trump told administration lawyers to look at the relevant law "and see if the interpretation of these previous government attorneys have been correct. And he had the wherewithal just to say, no, we're going to let individuals join these groups so they can get cheaper insurance and perhaps better insurance as well and perhaps get insurance for people who don't have insurance. But he did that because he's different than any other politician. And now we have all these wise-acres out there wanting to criticize and be presumptuous about trying to judge someone's intelligence. I can tell you, he's got the wherewithal to do things that no politician's been able to do and in a good way."

Paul's appearance was his first on national television since he was injured in an attack by one of his neighbors in a gated subdivision in Bowling Green. Asked how he was feeling, he said, "A little bit better each day. It was sort of I guess a living hell for the first four or five weeks. Couldn't get out of bed without assistance, six broken ribs, damage to my lungs, two bouts of pneumonia. It was really a tough go of it. But each day I feel a little bit better. This last month I've been doing better."

Paul avoided a question about whether he thought the neighbor's attack was politically motivated. "We usually don't ask if someone's raped or mugged or whatever why the person did it. We want punishment and deterrents," he said. "And I guess that's what I'm mostly about. I just don't think of any kind of motivation or justification, whether it's political or personal, to attack someone who's unaware from behind in their own yard."

Ky. leads nation in overuse of antibiotics, one reason for rise of drug-resistant bacteria; here's how to avoid serious infections

Dr. Kevin Kavanagh
(Lexington Herald-Leader photo)

An infection-control activist offers a dire warning about drug-resistant bacteria and offers tips on how to protect yourself from these deadly super-bugs in an op-ed piece for the Lexington Herald-Leader.

"There is a war going on, reminiscent of a zombie apocalypse," writes Dr. Kevin Kavanagh, who is also the board chairman of Health Watch USA. "The insidious agent is spread easily between people; a bite is not required. It does not turn its captors into mindless killing drones but instead, when they least expect it, they are slowly eaten from the inside out.The apocalypse is called drug-resistant bacteria, and so far, modern medicine is failing miserably at stopping it."

The federal Centers for Disease Control and Prevention reports that at least 2 million Americans are infected with a drug-resistant bacterium every year, and at least 23,000 of them die from it. There are signs that the problem will only get worse.

Kavanagh reports that some projections of the annual death toll from drug-resistant infections will reach tens of millions worldwide, surpassing cancer and heart disease as the leading cause of death. This has been widely written about, including stories from CBS News, BBC, Scientific America and STAT, to name a few.

Antibiotic resistance has been linked to the over-prescription of antibiotics; patients not finishing their entire antibiotic course; overuse of antibiotics in livestock and fish farming; poor infection control in health-care settings; poor hygiene and sanitation; and the absence of new antibiotics being discovered, Andrew Duong reports for InfectionControl.tips.

The overuse and over-prescription of antibiotics is a real problem in Kentucky. Kavanagh writes that Kentucky's antibiotic use is more than double the usage in other states and that the fluoroquinolone (Cipro, Floxin) class of antibiotics is prescribed at one of the highest rates, often inappropriately.

Centers for Medicare and Medicaid Services map shows  ZIP-code-level rates for antibiotics prescribed per 1,000 fee-for-service Part D Medicare beneficiaries in 2016. Dr. Kevin Kavanagh of Health Watch USA calls Kentucky the "bulls-eye of antibiotic overuse."

He adds that health-care providers have a responsibility to be the "gatekeeper[s] of antibiotic usage," but all too often "succumb to patient pressure."

"For most common illnesses, antibiotics are not effective," Kavanagh writes. "They will not work on viruses that cause the common cold nor on the flu. They will also not work on most 'sinus' infections."

Kavanagh adds details on how misuse of antibiotics can lead to a dangerous gastrointestinal infection caused c. diff (clostridium difficile), which is "almost impossible to get rid of" since it is not only resistant to many antibiotics but can transform into a spore that can remain inactive for years, only to reemerge when the body is in a weakened state.

"You know this is a bad actor when severe cases are being cured (and to a very high degree) by using a tube to place someone else’s feces into the patient’s GI tract," he writes. "Even the mention of this a decade ago would have been meet with ridicule and disbelief but 'desperate times call for desperate measures.' Lucky this one works."

Kavanagh offers these tips to protect yourself:

• Avoid the use of antibiotics whenever possible.
• Stay healthy, maintain good hygiene and get your vaccinations.
• When seeking health care, ask about a facility's MRSA (methicillin-resistant staphylococcus aureus) and c. diff rates, and any recent outbreaks of other dangerous bacteria.
• Check Hospital Compare, which offers information about the quality of care at over 4,000 Medicare-certified hospitals, to determine the facility’s track record on these measures.
• Kavanagh warns that a hospital's ability to handle these infections doesn't mean they are good at preventing them. He advocates for a "seek-and-destroy" methodology, similar to the one used by the Veterans Administration and England's National Health Service.
• If you are going for surgery and are not offered a test to see if you are a MRSA carrier, ask for one. If you are told it is not cost effective, he writes, "Remember it is a $10 preoperative test."
• Kavanagh notes that there is "solid evidence that MRSA preoperative screening is needed for most major surgeries" to determine which preoperative antibiotics are needed or if intervention is needed to prevent an infection, called decolonization.

Another study finds teens who use non-cigarette tobacco products, like e-cigarettes, are more likely to try cigarettes

By Melissa Patrick
Kentucky Health News

Teens who use electronic cigarettes and other non-cigarette tobacco products are twice as likely to start smoking cigarettes a year later than teens who have never used those products, according to recently completed research.

Dr. Ellen Hahn

Ellen Hahn, a University of Kentucky nursing professor, said in an e-mail that the study adds to a growing body of research that youth who use e-cigarettes and/or other non-cigarette products, like cigars, hookah or smokeless tobacco, are more likely to smoke conventional cigarettes one year later.

"This is a serious concern, given that most adult smokers start when they are young, setting them up for a lifetime of suffering from addiction, chronic disease, and premature death," she said.

Hahn also runs the nursing college's BREATHE (Bridging Research Efforts and Advocacy Toward Healthy Environments) program and its Kentucky Center for Smoke-Free Policy.

The study was done at the University of California, San Francisco , where researchers noted that smoking as few as one cigarette per month in adolescence is associated with future daily smoking and smoking in adulthood, and that 90 percent of adult smokers tried their first cigarette before the age of 18.

Kentucky high-school students already have one of the highest smoking rates in the nation at 14.3 percent, according to the 2017 Kentucky Youth Risk Behavior Survey. The national rate is 8 percent.

The Population Assessment of Tobacco and Health study surveyed more than 10,000 youth between the ages of 12 and 17 across the U.S. who said they had never smoked. The participants were also asked if they had used electronic cigarettes, hookahs, non-cigarette combustible tobacco or smokeless tobacco. A year later, they were asked again about their tobacco use. The research was conducted between 2013 and 2015.

graphic: centeronaddiction.org

The study, published in the Journal of the American Medical Association Pediatrics, found that teens who had used e-cigarettes, hookahs, or non-cigarette tobacco products were twice as likely to have smoked cigarettes a year later, compared to those who hadn't used a non-cigarette tobacco product.

And those who had used more than one of the non-cigarette tobacco products were nearly four times as likely to try cigarettes a year later. The results were adjusted for socio-demographic, behavioral and environmental smoking risk.

At one-year follow-up, 4.6 percent of youth who hadn't smoked previously had tried a cigarette, and 2.1 percent had smoked one within the past 30 days. Cigarette ever use at follow-up ranged from 18.8 percent to 19.2 percent for youths who had reported using a non-cigarette tobacco product during the initial assessment.

"In light of these observed associations between non-cigarette tobacco use and future smoking, novel tobacco products have the potential to undermine public health gains in combating the smoking epidemic," the study authors wrote.

They were likely referring to the significant drops in teen smoking over the past 20 years. For example, the youth survey shows that in Kentucky, the teen smoking rate dropped from 47 percent in 1997 to its current rate of 14.3 percent. Nationwide, it dropped from 36 percent in 1997 to 8 percent in 2016.

And though e-cigarette and smoking rates are about the same in Kentucky (14.1 percent and 14.3 percent respectively), the 2017 "Monitoring the Future" survey found that nationwide more teens are vaping than smoking cigarettes. For example, it found that 9.7 percent of high-school seniors nationwide reported smoking tobacco, compared to 16.6 percent of them using electronic cigarettes.

The researchers called for policies that discourage teen use of all of these products, including pack size requirements and flavor restrictions.

"In policy terms, the findings provide a rationale to treat alternative cigarette products as a group and potentially extend policies that work for one product to the others (such as a ban on flavoring)," the authors concluded. "Even if youths do not progress to smoking cigarettes, any tobacco use is harmful. The estimated health risks of non-cigarette tobacco products should include the additional health consequences of future cigarette use."

Hahn said the most effective way to prevent youth from smoking is to raise the price of cigarettes and non-cigarette products, one of the main goals of the the newly formed Coalition for a Smoke-Free Tomorrow, of which the Kentucky Center for Smoke-Free Policy is a member.

She said, "It is estimated that 23,200 fewer youth in Kentucky would start to smoke if we raise the per pack tax by at least $1 as well as raise the tax accordingly on non-cigarette products."

Republican state Sen. Stephen Meredith of Leitchfield has filed a bill to raise Kentucky's cigarette tax by $1, with parallel increases in other tobacco taxes. The idea is supported by Kentuckians, with a recent poll showing 73 percent of the state's voters supporting the $1 tax increase on cigarettes. The current 60-cent tax is about a third of the national average of $1.71 per pack.

Anthem Blue Cross Blue Shield has become less likely to pay your ER bill if it concludes your visit wasn't an emergency

Anthem Blue Cross Blue Shield, which has most of Kentucky's private insurance market, has a new policy that allows it to decide whether to pay a claim for emergency treatment -- after it sees the final diagnosis, Miranda Combs reports for Lexington's WKYT-TV.

"That says they're going to look at the final diagnosis when you come to the emergency department and use that to determine if they refuse it saying it was a non-emergent event," Dr. Ryan Stanton, an emergency physician for 12 years, told Combs. "The biggest concern I have is that people are going to use this as a reason not to go to the emergency room for true emergencies or when they think they have an emergency."

Alison Wrenne has first hand experience of this new policy. Wrenne told Combs she was at home when the pain in her abdomen became so severe, she fell to the floor. After waiting for a while to see if it would subside, she went to the emergency room on the advice of a friend who is a physician assistant. At the ER, Wrenne had an ultrasound to confirm it was an ovarian cyst that had ruptured, which was not life-threatening, but her doctor told her there was no way for her to know that, she said.

"A couple of months later, I got a bill from the hospital and a letter from Anthem saying they had rejected my claim and that I should have . . . visited my local practitioner," Wrenne said. The bill was for more than $4,000.

Stanton, a regular medical contributor to WKYT, told Combs, "This policy flies in the face of the 'prudent layperson standard'," part of the "Patient's Bill of Rights" in the 2010 Patient Protection and Affordable Care Act. The standard "says that if you feel like you have an emergency, then you have the right to go to the emergency room and you have the right for that to be covered by your insurance company."

Stanton said Kentucky is one of just a few states where Anthem is enforcing the new policy. Anthem says the policy has been in place since 2015, but Stanton said he just started seeing Anthem refuse payments in his ER last summer.

Anthem told WKYT, “Anthem’s goal is to ensure the broadest access to high quality, affordable health care, and one of the ways to help achieve that goal is to encourage our members to receive care in the most appropriate setting.”

It added, “Emergency rooms treat life- and limb- threatening situations, and if a member feels he or she has an emergency, they should always call 911 or go to the ER. But for non-emergency ailments, ERs are an expensive and time-consuming place to receive care. Primary-care physicians should always be the first medical professional members see with non-emergency medical concerns, with urgent care, telemedicine, retail clinics and Anthem’s free 24-7 nurse lines available to assist members in after-hours situations.”

Combs reports, "Anthem goes on to say they will continue coverage to anyone that is directed to the emergency room by another medical provider and if a patient thinks they are in an emergency situation Anthem says they still highly suggest going to the hospital or calling 911. Anthem says they will cover services if they were provided to a child under the age 14, if there isn’t an urgent care or retail clinic within 15 miles or if the visit occurs between 8 p.m. Saturday and 8 a.m. Monday or on a major holiday. They say all visits will be reviewed by the hospitals layperson before the insurance company makes a decision on the coverage of the visit."

Medical professionals push back

Patrick Padgett, executive vice president of the Kentucky Medical Association, writes in an op-ed for the Lexington Herald-Leader that Anthem controls nearly 60 percent of Kentucky's commercial health-insurance market, "so the policies they adopt have an enormous impact on the delivery of health care in our state."

He said a failed merger between Anthem and Cigna has left Anthem facing a lawsuit with a possible $1 billion payment to Cigna, "and these new policies send the clear message that in the desperate scramble for profit, your comfort and convenience as a patient are secondary."

He offered examples of policies on emergency-room payments, a requirement that clients only use a MRI provider of the company's choosing, and denial of authorization for procedures done the same day as an examination.

"Comfort and convenience should be essential parts of the health care system," Padgett writes. "They should not be sacrificed at the altar of disastrous business decisions."

The American Medical Association asked Anthem to immediately rescind the emergency-room policy in states where it has been put into effect and halt implementation in all other states.

“Patients and caregivers should never second-guess their instincts that emergency care is needed, nor should they be expected to self-diagnose to determine whether, for example, chest pain is a heart attack or indigestion,” AMA Executive Vice President and CEO Dr. James L. Madara told Anthem President and CEO Joseph Swedish in a letter on June 29. “Anthem’s policy requires that they diagnose their acute symptoms at a critical and emotional moment, when time could be of the essence. The impact of this policy is that very ill and vulnerable patients will not seek needed emergency medical care while, bluntly, their conditions worsen or they die.”

The American College of Emergency Physicians, which was instrumental in getting Congress to pass the "prudent layperson" standard, said in October that Anthem has developed a "secret list of diagnoses that they will not pay for, such as "chest pain on breathing" and blood in the urine, even if the patient thought it was a medical emergency." The organization commissioned a poll from Morning Consult that found among other things, 67 percent of Americans oppose this policy to deny coverage for emergency care.

Poll finds 69 percent of Kentucky voters support increasing the state cigarette tax by $1 a pack, to $1.60

By Melissa Patrick
Kentucky Health News

Seven of 10 Kentucky voters favor raising the state's cigarette tax by $1 a pack, according to a new poll released by the Coalition for a Smoke-Free Tomorrow, which favors the measure.

The poll, conducted Dec. 13-18 by Mason-Dixon Polling & Research, found that 69 percent of registered voters surveyed supported a $1 cigarette-tax increase. The current 60-cent tax is about one-third of the national average of $1.71 per pack.

Support for a $1-a-pack increase rose to 73 percent when voters were told that the tax would raise about $250 million for the state, prevent about 20,000 young people from becoming smokers, and eventually save Kentuckians about $1 billion over the long-term in health-care costs as smoking rates declined over the next several years.

Ben Chandler

"The thing that is compelling about this kind of a levy is that it has this extra benefit that you don't get with other levies . . . it improves the health of the people of Kentucky," Ben Chandler, chair of the coalition, said in a telephone interview. "And in a state where you have the highest cancer rate in the nation, levying a further tax on tobacco and cigarettes is just that much more compelling."

The coalition says 34 percent of Kentucky's cancer deaths are related to smoking, nearly 9,000 Kentuckians die every year from smoking-related diseases, and if we don't reduce the rate of youth smoking, 119,000 of Kentucky children now younger than 18 will die prematurely.

Kentucky legislators entered the 2018 legislative session that opened Jan. 2 with a budget deficit of more than $150 million, and a need to find even more money to address the crisis in government pensions.

The poll asked about different ways the legislature could raise money to address the state's budget crisis; 52 percent of those polled favored increasing the cigarette tax, while only 19 percent supported increasing the sales tax to 7 percent from 6 percent.

"That is such a huge gap that it becomes very clear what voters want the legislature to do," said Chandler, who is also the president and CEO of the Foundation for Healthy Kentucky, which staffs the coalition. It made a grant to the American Heart Association to pay for the poll.

The poll also found 80 percent support for raising the tax on other tobacco products if the cigarette tax is raised. Among less popular taxes, 9 percent supported raising taxes on services, such as dry cleaning and car repair, and 4 percent supported applying the sales tax on groceries; 16 percent said they were not sure what taxes to raise.

"It is clear that voters – underline voters – feel that the way forward to dealing with the health issues in Kentucky and the revenue problem in Kentucky is a cigarette/tobacco tax," said Chandler, who was elected state auditor and attorney general and 6th District congressman.

The cigarette tax was overwhelmingly supported across party lines, with the differences falling within the poll's error margin of plus or minus 3.9 percentage points. Republicans, at 71 percent, supported raising the cigarette tax by $1 at a slightly higher rate than Democrats (67 percent) or independents (66 percent).

The Louisville metropolitan area (74 percent), the Bluegrass (77 percent) and Northern Kentucky (72 percent) showed the highest support for the tax, followed by Eastern Kentucky (64 percent) and Western Kentucky (61 percent).

Sen. Stephen Meredith

Sen. Stephen Meredith, R-Leitchfield, filed a bill Jan. 2 that would create a $1 "health care reimbursement assessment" on every pack of cigarettes sold in Kentucky. The bill calls for 90 percent of the money to go to a reimbursement fund for Medicaid treatment of tobacco-related illnesses. The remaining 10 percent would fund tobacco-cessation programs in counties that have comprehensive smoke-free ordinances.

Meredith told Kentucky Health News that he wasn't surprised by the results of the poll, and that a good thing about increasing the cigarette tax by $1 would be that it doesn't increase the tax burden for every Kentuckian, but only for those who use tobacco products, with the additional revenue going toward paying for tobacco-related illnesses.

"I think everybody thinks there needs to be more accountability in the health care delivery system and that is what we are attempting to do," he said. " If you want to smoke that is certainly your right and privilege, but don't make me as a non-smoker have to pay for your smoking related illnesses in the future."

Meredith added that the $1 increase would offer a multitude of benefits, including an economic incentive for tobacco users to quit, which would result in a healthier population, decreased health costs to the state, improved worker productivity, healthier children and fewer kids smoking.

Chandler said the coalition had not taken a position on the bill, but he personally would like to see the money generated from the tax spent on health-related programs. "The coalition does not have a position on how the money should be spent," he said. "We are in agreement that the levy ought to be instituted."

Tips on how to avoid hypothermia and carbon monoxide poisoning, and how to keep your sleeping baby safe in the winter

With temperatures in Kentucky falling below freezing for days and several months of cold weather in front of us, the state Department for Public Health offers tips on protecting yourself from getting hypothermia, how to avoid carbon-monoxide poisoning, and also offers safe-sleep suggestions for families with babies that will also keep them warm.

Hypothermia

Hypothermia happens when your body loses heat faster than it can produce heat, causing a dangerously low body temperature. If left untreated, it can eventually affect the brain, making the victim unable to think clearly or move well. It can also lead to heart and lung failure, and even death.

Hypothermia is often caused by immersion in cold water, but can also be a result of exposure to extremely cold temperatures. The federal Centers for Disease Control and Prevention adds that it can also happen during cool temperatures (40 degrees) if a person is wet (from rain, sweat or cold water) and becomes chilled.

According to the CDC, older adults with inadequate provisions, babies sleeping in cold bedrooms, people who are outdoors for long periods of time, and people who drink alcohol or use illicit drugs are at the most risk of getting hypothermia.

Symptoms include shivering, an altered speech pattern, abnormally slow rate of breathing, cold pale skin and lethargy. In infants, the symptoms include bright red or cold skin and very low energy levels. The Department for Public Health advises that you seek medical attention if you or a loved one experiences the signs of hypothermia.

Here are the health department's tips tips to prevent hypothermia:

• Wear appropriate clothing, including layers of synthetic and wool fabrics, hats, coats, scarves and gloves. The best outerwear is water-resistant.
• Avoid consuming alcohol if outdoors, which can speed the loss of heat from the body.
• Avoid activities that cause excessive sweat, which leads to damp clothing, and chilling.
• Stay as dry as possible
• The CDC recommends making a car emergency kit that among other things includes extra hats,coats and mittens, blankets, a cell phone and portable charger, water, snacks and jumper cables.

Carbon Monoxide Poisoning

The department warns Kentuckians that portable generators, propane gas stoves, and ovens heated with gasoline, which have all been used as heat sources indoors, can lead to carbon-monoxide poisoning.

Carbon monoxide is an odorless, invisible gas produced when gasoline, natural gas, propane, kerosene and other fuels are not completely burned during use. Breathing in carbon monoxide fumes prevents the body from using oxygen normally and can result in death.

Consumer Reports graphic

The CDC reports that each year more than 400 Americans die from unintentional carbon monoxide poisoning, more than 20,000 visit the emergency room and more than 4,000 are hospitalized.

Early symptoms of carbon-monoxide poisoning include headache, nausea, vomiting and fatigue. If you are experiencing symptoms or if you have questions, call the Poison Control Hotline at (800) 222-1222.

Here are tips for avoidng carbon-monoxide poisoning:

• Install a battery-operated carbon-monoxide detector in your home and replace the battery when you change the time on your clocks each spring and fall. Replace the device every five years.
• Don’t use a generator, charcoal grill, camp stove or other gasoline or charcoal-burning device inside your home, basement or garage or near a window.
• Don’t run a car or truck inside a garage attached to your house, even if you leave the door open.
• Don’t burn anything in a stove or fireplace that isn’t properly vented. Have your chimney checked or cleaned yearly.
• Don’t heat your house with a gas oven.
• Seek immediate medical attention if you suspect carbon monoxide poisoning

Infant Safe Sleep

In general, parents and caregivers should follow the ABCs of safe sleep to prevent injury or infant deaths -- Alone, on their Back, and in a Clean Clear Crib.

schoolworkhelper.net

However, Department of Public Health officials warn that winter months present a different – but very serious – threat for babies when parents and caregivers resort to using unsafe sleep practices in an effort to keep babies warm.

The state health department offers these safe-sleep tips for babies in the winter months:

• For added warmth, dress baby in a one-piece pajama or wearable blanket, and layer with an undershirt of a onesie. They also offer a warning to make sure your baby doesn't get too hot.
• Keep the baby’s room at a comfortable temperature and don't overheat the room.
• Don't put a hat on your baby to sleep; there is a risk the hat could slip down, covering the baby’s face.
• If a blanket must be used to keep a baby warm, make sure the baby’s feet are at the bottom of the crib and the blanket is tucked in around the mattress. The blanket should be no higher than the baby’s chest with the baby’s arms out.
• Keep all portable heaters away from the baby and baby’s sleep area. The baby can overheat if too close to a heater, receive burns or become tangled up in cords of small electric heaters.

For more information about safe sleep practices, click here for the SafeSleep Kentucky website and for more information about hypothermia and carbon monoxide poisoning , click here for the Kentucky Health Alerts website.

Poor adults on Medicaid more likely to quit smoking in expansion states like Ky.; 26% of Ky. smokers use cessation benefit

Corrective Notice: This is a corrected version of a story published Dec. 22, revised to reflect that 26 percent of Kentucky's Medicaid smokers used the smoking cessation benefit during the 2016-17 fiscal year, and not 15 percent as originally reported. The original calculation did not take into account that of the 1.4 million Kentuckians on Medicaid, only about 800,000 of them are adults. If you are a publisher that has used this story, please replace it with this revised story or post a correction on the original. We regret the error. 

By Melissa Patrick
Kentucky Health News

Low-income adults who gained health insurance under the expansion of Medicaid like Kentucky and most other states were more likely to quit smoking than those in states that didn't expand the program.

So says a study by the University of Pittsburgh Graduate School of Public Health, published in the journal Medical Care. Researchers examined smoking-related responses from more than 36,000 low-income adults without dependent children using data from the federal Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance Survey for the years 2011 to 2015.

It found that in the 31 states that expanded Medicaid, 8.1 percent of those newly covered said they had quit smoking in the past year, compared with 6 percent of low-income adults in states that did not expand Medicaid. (This was after the researchers factored in the effects of smoking rates from demographics, differences in cigarette taxes and states' indoor-air smoking policies.)

“Smoking cessation is notoriously difficult to achieve,” Marian Jarlenski, senior author and assistant professor in Pitt's Department of Health Policy and Management, said in a news release. “The sizable increase we found in smoking cessation might lead to significant reductions in death and diseases caused by smoking, and the taxpayer-funded health care expenditures that come with treating them.”

The report notes that smoking is responsible for 9 percent of annual health-care spending in the U.S. The annual cost of smoking related health care costs to Kentucky is estimated to be $1.92 billion.

J. Wyatt Koma, a lead author of the study, said there are many ways that engaging with health-care services could motivate new Medicaid enrollees to stop smoking.

“During the Medicaid enrollment process, people are asked whether they smoke, so it’s possible that this question might prompt them to start contemplating smoking cessation," he said in the release. "After enrollment, they have access to primary-care visits, where their clinician is likely to counsel them about quitting. And studies have shown that people in states with Medicaid expansion are much more likely to get prescriptions for smoking-cessation medications, which are covered by Medicaid.”

The researchers say the study provides evidence that Medicaid coverage can help people stop smoking. Koma said the quit rate of 8.1 percent is low, especially compared to the almost 70 percent of adults who say they want to quit.

What about Kentucky?

About 30 percent of low-income adults in the United States are smokers, which is double the national average. That rate is even higher among Kentucky's Medicaid population -- almost 44 percent, according to a survey conducted by the federal Center for Medicare and Medicaid Services.

That means 349,840 of the approximately 800,000 Kentucky adults on Medicaid are smokers. In the 2016-17 fiscal year, 90,013 of them used the smoking-cessation benefit -- about 26 percent of the smokers.

Of those, 49,319 were on Medicaid due to the expansion, which covers about 480,000 people, and 40,694 were on traditional Medicaid, according to the state Department of Medicaid Services. The expansion took effect in 2014.

The figures shows only how many Medicaid beneficiaries used the smoking-cessation benefit and not how many of them were successful at quitting.

A similar look at Medicaid claims data from 2015 found that only 17.2 percent of Medicaid smokers used a smoking-cessation medication and a mere 1.4 percent received smoking-cessation counseling. The 2015 Cabinet for Health and Family Services report cited a much smaller number of Kentuckians on Medicaid dependent on tobacco, only 10 percent, but that data was based partly on records that were likely incomplete.

New law and advocacy could lead to higher participation

When the numbers for the current fiscal year are compiled, they could show increased use of the smoking-cessation benefit, because Kentucky passed a law in the 2017 legislative session to require all health insurers, including Medicaid managed-care companies, to remove barriers to coverage for all federally approved tobacco-cessation medications and programs. The law took effect June 29, the day before the fiscal year ended.

Why was the law needed, if the Patient Protection and Affordable Care Act requires all insurance policies to cover smoking-cessation treatments? Insurers erected several barriers to treatment, such as co-payments, prior-authorization requirements and limits on length of treatment.

One of the goals of the newly formed Coalition for a Smoke-Free Tomorrow, staffed by the Foundation for a Healthy Kentucky, is to educate the public and health-care providers about the new law.

“We are all working to educate physicians, community health workers and residents to ensure they know that counseling and nicotine-replacement therapies are available free of charge," said Ben Chandler, president and CEO of the foundation. "The starting points for smokers vary; it may be a talk with their doctor, or seeing one of the ads for the Kentucky QuitLine campaign. Our goal is to make sure that every Kentuckian who is addicted to nicotine knows where they can get the help they need to successfully kick the habit.”

Resources to help Kentuckians quit smoking can be found at www.quitnowkentucky.org and www.smokefreetomorrow.org. Kentucky's Tobacco Quitline is 1-800-QUIT-NOW (1-800-784-8669). Also, many local health departments offer smoking cessation classes.