State fines Caremark, top pharmacy benefit manager, $1.5 million for violations including 'inaccurate and inconsistent' information

By Melissa Patrick
Kentucky Health News

The state Department of Insurance has issued a $1.5 million fine to a subsidiary of CVS Caremark -- a pharmacy benefit manager for all but one of the Medicaid management companies in Kentucky -- for hundreds of reimbursement violations involving individual pharmacies, and for giving the department "inaccurate or inconsistent" information. The department put Caremark PCS Health on probation for one year.

Pharmacy benefit managers are middlemen between insurance and drug companies. They not only determine what drugs are offered, but how much an individual pays for the drug and how much pharmacists are paid for them.

The "order of civil penalty and probation" cited 454 violations regarding denials of reimbursement claims and 38 violations where Caremark provided "inaccurate or inconsistent information," the department said in a news release.

“The Department simply does not issue penalties of this nature lightly,” Patrick D. O’Connor II, deputy commissioner for policy, said in the release. “However, we have to ensure companies fully comply with our laws to protect consumers and other businesses.”

Rosemary Smith, a co-owner of Jordan Drug pharmacies in Eastern Kentucky and founding member of the Kentucky Independent Pharmacist Alliance, said the department's order was a "vindication of what we've been saying all along," and that she was pleased that state agencies are "now seeing what we've been seeing for a number of years." But she also said the issue hasn't been resolved because independent pharmacists are still being under-payed for their drugs.

"We still are having the same issues now, so we are going to be sending more of those [complaints] to the Department of Insurance," she said.

A spokeswoman for CVS Caremark, the parent firm of the pharmacy benefit manager, said it disagrees with the order and is "exploring our options."

"We are currently reviewing the terms of the Kentucky Department of Insurance’s order," Christine Cramer said in an e-mail. "However, we respectfully disagree that we have not complied with applicable requirements. . . . It should also be noted that states such as Kentucky currently have the necessary tools to ensure that there is appropriate oversight of pharmacy benefit managers’ compliance with applicable laws and regulations."

Cramer added, "CVS Caremark is committed to fairly reimbursing the pharmacies in our network while providing a cost-effective benefit for our PBM clients. For example, we reimburse independent pharmacies at a higher rate on average than we reimburse chain pharmacies, including CVS Pharmacy," a sister company that is a major drugstore chain. Cramer is senior director of corporate communications for CVS Health, the overall company.

Kentucky passed a law in 2016 that allows the Insurance Department to regulate PBMs much like insurance companies are regulated, and to provide an appeal mechanism to resolve pricing disputes between pharmacies and PBMs. The news release says this law allowed the state to investigate the many complaints filed by pharmacists and issue the order.

Sen. Max Wise, R-Campbellsville, who sponsored the bill, called the order a "huge win" for the more than 500 independent pharmacists who have been "telling and pleading their story for years now" that PBMs weren't paying them fairly for their prescriptions. He said he thought the probation period would prompt the managed-care companies to "start looking at other PBMs to work with."

This year, Wise won passage of Senate Bill 5, which put the state Department of Medicaid Services in charge of setting pharmacists' reimbursement rates, rather than the managed-care companies. It also allows the department to regulate contracts between the companies, PBMs and pharmacists; requires more transparency in how the PBMs spend the $1.7 billion a year they get for processing prescriptions; and gives the state authority to penalize the companies and PBMs for noncompliance.

"Senate Bill 5 is what will be the whammy that will end up doing even more damage to the PBMs," Wise said. "I think this is just the scratch of the surface. I think we're going to find more and when it comes to that, I think that truly the taxpayers are going to see the amount of profits that were reaped off of this that should have been going out to those independent pharmacists for a number of years."

Analysis finds nursing homes under-reported their staffing levels; 18 in Kentucky listed as 'much below average' on interactive map

New York Times map; click on the image to enlarge it. See the interactive version here.

"Most nursing homes had fewer nurses and caretaking staff than they had reported to the government for years, according to new federal data, bolstering the long-held suspicions of many families that staffing levels were often inadequate," Jordan Rau reports for The New York Times. The data show 18 Kentucky nursing homes with staff ratings "much below average."

The daily payroll records, gathered by the Centers for Medicare and Medicaid Services and analyzed by Kaiser Health News, show for the first time "frequent and significant fluctuations in day-to-day staffing, with particularly large shortfalls on weekends. On the worst staffed days at an average facility, the new data show, on-duty personnel cared for nearly twice as many residents as they did when the staffing roster was fullest," Rau reports.

But nursing homes often exaggerated staffing levels and rarely revealed these common periods of low staffing. The Times created an interactive, searchable nationwide map of more than 14,000 nursing homes and how their staffing levels stack up. To look up any nursing home's staffing data, go to https://www.nytimes.com/interactive/2018/07/07/health/nursing-home-map.html. Here's a list of Kentucky nursing homes that show up in dark red on the map, meaning their staffing rating is "much below average," by county in alphabetical order:

• Florence Park Care Center in Boone County
• Providence Gallatin in Gallatin County
• Landmark of Lancaster Rehabilitation and Nursing Center in Garrard County
• Kindred Hospital-Louisville in Jefferson County
• Landmark of Louisville Rehabilitation and Nursing in Jefferson County
• Oaklawn Health and Rehabilitation Center in Jefferson County
• Regency Center in Jefferson County
• Westport Care Center in Jefferson County
• The Pavilion at Kenton in Kenton County
• Vanceburg Rehabilitation and Care in Lewis County
• Salyersville Nursing and Rehabilitation Center in Magoffin County
• Calvert City Convalescent Center in Marshall County
• Signature Healthcare at Colonial Rehabilitation and Wellness in Nelson County
• Beaver Dam Nursing and Rehabilitation Center in Ohio County
• Friendship Health and Rehabilitation in Oldham County
• Providence Richwood in Oldham County
• Bowling Green Nursing and Rehabilitation Center in Warren County
• Corbin Health and Rehabilitation Center in Whitley County

Resurrecting old model for individual health-insurance market may limit who gets covered and how well, columnist says

Editor's note: U.S. Sen. Rand Paul of Kentucky has been one of the leading advocates of association health plans.

By Trudy Lieberman, Rural Health News Service

A new health insurance option awaits consumers this fall. Proponents say it will offer lower premiums and relief from increasingly expensive Obamacare policies sold in the so-called individual market. That’s where people who don’t have employer or government-sponsored insurance go when they need coverage.

It’s no secret that rising premiums have hurt people in that market if they are among those whom the law considers too wealthy for subsidies to help them out. For example, families of four with incomes above $100,400, and single people whose incomes exceed $48,560.

So the Trump administration has approved the return of association health plans, called AHPs for short. Fraternal or professional organizations can sponsor one. A single proprietor or sole owner of a business can also set up one of these new arrangements.

These “new” arrangements are not new. They were around for years before the Affordable Care Act was passed in 2010, and they’ve been resurrected to provide a low-cost option for a small slice of the insurance marketplace. Labor Secretary Alexander Acosta offers this rationale: “Many of our laws, particularly Obamacare, make health care more expensive for small businesses than large companies. AHPs are about more choice, more access and more coverage.”

Once again the individual market may become the Wild, Wild West of insurance, as sellers pick and choose what benefits to offer. They can present a shopping nightmare for consumers who try to slog through the market and understand what they’re buying. Many of the protections offered by the ACA are gone, and shoppers are on their own to sort through the fine print that may or may not disclose what they are buying.

For example, the Affordable Care Act outlawed the practice of considering a person’s pre-existing health conditions before issuing a policy, one of the most important protections it provided. Under the government’s rules for AHPs, a person’s health still cannot be factored into the decision to issue a policy. But insurers may find a way around this limitation, says Sabrina Corlette, a research professor at Georgetown University’s Center for Health Insurance Reforms. “The way benefits are designed can make a policy very unattractive to certain groups of sick people,” she told me.

For example, if an insurance group doesn’t want to cover a lot of people with HIV/AIDS, it could create a network that includes almost no doctors who treat people with that condition.

AHPs must still cover the ACA’s preventive services, such as mammograms and diabetes screening. But other ACA protections are gone. Fewer benefits, and less comprehensive benefits, are the trade-offs for cheaper policies. “AHPs will have more flexibility in how they vary premiums and what benefits are covered,” says Cori Uccello, senior health fellow at the American Academy of Actuaries.

Here’s where the shopping task gets tricky. AHPs won’t be required to cover any of the ACA’s package of essential benefits: things like mental health, maternity, and prescription drugs. It’s also possible their benefits could come with limitations on hospital stays and doctor visits. Comparing policies with these different combinations of benefits will take some effort.

There are other changes, too, that would-be shoppers should be aware of. The “flexibility” touted by the labor secretary means that AHPs will now be able to use gender in deciding how much to charge. Women could be forced to pay more than men because insurers say that, especially at younger ages, women have more claims.

On the Health Affairs blog, Katie Keith of Keith Health Policy Solutions showed what could happen when gender is factored into pricing. Keith pointed to a Blue Cross Blue Shield comment letter that suggested AHPs could charge young men more than 40 percent less than traditional insurers could, while charging young women 30 percent more, or higher.

Occupations could also matter. The AHPs could charge engineers 9 percent less than traditional insurers but charge taxi drivers 15 percent more. Engineers apparently file fewer claims than taxi drivers.

That may be the biggest change, that AHPs will be able to consider people’s jobs in the decision to insure them. The ACA had outlawed the practice of occupational underwriting, which had meant that waiters, musicians, models, beauty operators, fry cooks, even doctors and lawyers sometimes couldn’t obtain insurance because insurance stats showed people in those occupations filed more claims. Will people in those occupations be turned down now?

Association health plans might look like a panacea for the country’s health-care woes. But questionable practices are likely to resurface, and it’s not clear state insurance departments, which had a tough time keeping tabs on fraud and abuse years ago, are up to the job of policing them.

AHPs may well throw the individual market into a big mess without addressing the fundamental problem they purport to solve: the underlying high price of American medical care.

What would you choose: lower premiums or skimpier benefits? Write to Trudy at trudy.lieberman@gmail.com.

Perseverance is often needed to set up syringe exchanges, since local politicians have the say-so, and it's a local election year

It took two years, but Campbell and Kenton counties will finally launch their syringe exchange programs the week of July 23.

The new mobile exchanges will be run by the Northern Kentucky Health Department at locations of St. Elizabeth Healthcare. The Newport location will begin July 24 and the Covington location will start July 26, reports The River City News.

It took perseverance for the counties to establish the exchanges, overcoming social and political obstacles, like many other Kentucky counties that are still trying to create their own exchanges.

Campbell County approved an exchange in 2016, but state law requires approval from the city in which the exchange will operate, as well as the board of health and the county government, and Newport did not approve the exchange until February of this year.

Newport's decision came after a cluster of HIV cases were identified in the region, as well as a high number of hepatitis C cases. From Jan. 1, 2017, to March 16 of this year, the NKHD had diagnosed 45 cases of HIV, 21 of them intravenous drug users. From 2009 to 2016, zero to five such cases were reported each year, department spokeswoman Emily Gresham-Wherle told Terry DeMio of the Cincinnati Enquirer. The region also has a high rate of hepatitis C infections, typically carried by sharing of needles.

Kenton County and Covington had also approved a syringe exchange in 2016, but with a requirement that it could not start until two other Northern Kentucky counties in the NKHD district had operational exchanges. Campbell County's exchange allows the Kenton County program to go forward; NKHD has operated one in Grant County for three years.

The new mobile units will provide clean needles, Naloxone overdose-reversal kits, offer HIV tests, and provide referrals for other health services, including addiction treatment. What they won't do is provide condoms -- which are also known to fight infectious diseases and commonly distributed in these programs -- because the mobile exchanges will be located on the grounds of Catholic hospitals, DeMio reports.

Nevertheless, it appears that health officials in the area are grateful to St. Elizabeth for providing a site for the exchanges. Hospital spokesman Guy Karrick told DeMio that while the hospital couldn't countenance the distribution of contraceptives, it wanted to get the exchange going as quickly as possible. He added that the exchange might be better situated on health department property.

Despite the many challenges that face largely rural, conservative Kentucky counties to support opening these programs, Kentucky leads the nation in the number of counties with local syringe exchange programs (perhaps in part because it ranks third in the number of counties). As of June, 47 45 of Kentucky's 120 counties have approved syringe-exchange programs at more than 50 sites.

However, the federal Centers for Disease Control and Prevention says 54 Kentucky counties are among 220 in the nation with the highest risk of an HIV or hepatitis C outbreak among IV drug users, and half of those 54 counties still haven't approved exchanges.

One of the 27 high-risk holdouts, Clinton County, narrowly approved an exchange in March but backed out eight days later after complaints that it would encourage drug use. In the Republican primary election in May, the Fiscal Court magistrate most vocally opposed to the exchange defeated the county judge-executive, who favored it. The CDC says the county has the 11th greatest risk of any county in the nation for an HIV or hep-C outbreak among drug users.

Lawrence County, ranked 39th on the list, has also struggled with the issue. The county health board approved the proposal in September 2016, and the Louisa City Council followed suit in July 2017, the Fiscal Court unanimously rejected the proposal in March, WYMT-TV reported.

County Judge-Executive John Osborne told a packed house at the meeting that while he worries about HIV and hepatitis C, he worries about needles more, WYMT reported. "If you give out 40 needles at a time, you're probably are going to see a lot more needles on the ground," Osborne said. “It does bring a lot of people not from this area and that could cause a lot more problems.”

Public Health Director Debbie Miller told WYMT that she was disappointed but not surprised with the result. “I feel like the Fiscal Court is telling us that they’re not concerned with the fact that Lawrence County has been deemed one of the most vulnerable counties in the U.S. for an HIV or hepatitis C outbreak," she said. "The bottom line is, no matter how uncomfortable these syringe exchange programs make us all feel, and they do all make us somewhat uncomfortable, they are proven to save lives."

On the other hand, five Eastern Kentucky counties on the CDC list have started syringe exchanges in the last few months.

Perry, Letcher and Wolfe counties added exchanges in April "thanks to the expanded initiative by the Kentucky River District Heath Department," Will Puckett reported for WYMT in April. That came a few months after after Lee and Owsley counties approved theirs.

Scott Lockard, the department's public health director, told Puckett that the price of bringing in used needles and exchanging them for clean ones is small compared to the cost of treating diseases: $80,000 for a case of hepatitis C, "and the cost for someone who contracts HIV can cost over half a million dollars."

Getting county officials to accept a syringe exchange program often depends on public education and perseverance, as evidence by another county that took two and one half years to get its exchange.

In March, Mary Meehan reported for Ohio Valley ReSource that it took Bourbon County two and a half years, and two failed votes, to get an exchange. It finally passed on a 6-2 Fiscal Court vote, and opened its doors in May.

Bourbon County is not on the CDC list, but the concerns there reflect those voiced across the state. People worry that the drug users will just take the needles and sell them; some say drug users are just looking for a handout; others say it is enabling their misbehavior, and others worry that it will draw addicts from surrounding counties that don't have exchanges.

Research shows that syringe-exchange programs do not encourage the initiation of drug use, nor do they increase crime or the frequency of drug use among current users. They do reduce the spread of infectious diseases like HIV and hepatitis C; increase community safety; and connect people to treatment, according to the state Cabinet for Health and Family Services.

Meehan writes, "The health facts run up against deeply help opinions about the moral aspects of drug use and the notion that a needle exchange enables drug addicts to continue harmful behavior." She reported that Bourbon County Judge-Executive Mike Williams encouraged other community leaders to persevere. "It took us three times," he said. "Don't give up, and keep presenting the facts."

The State Journal in Frankfort recently said in an editorial that syringe exchanges are part of a holistic approach to fight the opioid epidemic, noting that the Franklin County's exchange had provided more than 115,000 clean syringes to users, and collected more than 82,000 used ones.

The newspaper said there are still many in Franklin County who object to the exchange, but "We’d ask whether it’s better for a user to share needles and potentially infect others or be infected or to use clean needles and reduce or eliminate the chance of infection."

Groups that blocked Medicaid plan ask feds to restore related dental, vision cuts; cabinet addresses service-denial claims

By Melissa Patrick
Kentucky Health News

Three advocacy groups have asked the Centers for Medicare and Medicaid Services to reject recent changes to Kentucky's Medicaid program that took dental, vision and non-emergency medical transportation benefits from 460,000 Kentuckians.

In a letter to CMS, the National Health Law Program, a public-interest law firm; the Kentucky Equal Justice Center, and the Southern Poverty Law Center say the state failed to comply with procedural requirements, including an appropriate public-notice period or a 30-day public comment period required by federal law.

The letter also says the state's official request to remove these services, called a state plan amendment (SPA), was never approved, noting that it is not on CMS's online list of approved SPAs, so "We have concluded that CMS has not approved this SPA."

The 460,000 people are covered by the state's 2014 expansion of Medicaid, under the 2010 Patient Protection and Affordable Care Act, to those who earn up to 138 percent of the federal poverty level. Under a state Medicaid plan that was vacated by a federal judge, those covered by the expansion could "earn" dental and vision benefits by participating in certain self-improvement activities, such as passing a GED exam, completing job training, or completing wellness activities such as stop-smoking classes, weight-loss programs or diabetes education. They could also earn credits by working; most on the expansion work.

When U.S. District Judge James Boasberg of Washington, D.C., vacated the state's new overall plan for Medicaid, that left the 460,000 people without a way to earn the benefits. The three groups, which filed the lawsuit, argue in their letter to CMS that the state's denial of benefits violates Boasberg's order because "The court expressly intended to maintain the status quo." The letter urges CMS to "act quickly" to reject these changes," which they say "are causing great confusion and harm."

As an example, the letter says an employee of a Kentucky Medicaid managed-care organization said one of its members had been told they couldn't have a "medically necessary" surgery until some of her teeth were pulled, but her dental benefits had been denied because of the cutback.

Cabinet blames reported denials of service on providers

Deborah Yetter of the Louisville Courier Journal reported "widespread concern and confusion about the cuts," including patients showing up at dental clinics who should have been covered, like children and pregnant women, but were showing up in the state's system as having no coverage. The Kentucky Oral Health Coalition has also reported similar denials to eligible children and pregnant women.

Doug Hogan, a spokesman for the Cabinet for Health and Family Services, told Yetter that it was the Courier Journal and the advocacy groups who were perpetuating confusion, noting that pregnant women and children are exempt from the cuts.  He also blamed health-care providers who "have misinterpreted computer-screen eligibility information and turned away some patients."

Hogan told Kentucky Health News that the office of a Floyd County dentist who had told Yetter he had turned away about 10 children had, it turned out. misread information on a computer screen. "Our records show that the concerns were sent to the cabinet at 12:45 p.m. on Tuesday, and by 2:45 p.m. Tuesday we had confirmed their eligibility for full dental and vision services."

Hogan also wrote, "We have identified examples where providers have misinterpreted computer-screen eligibility information and turned away some patients, despite them having active coverage. To eliminate any further confusion, we have created several documents aimed at educating Medicaid recipients about their benefits and outlining for providers the beneficiaries who have routine vision and dental coverage. Over the last few months, numerous provider trainings were held."

Hogan concluded, "We appreciate everyone’s help in making sure our beneficiaries are receiving the services and support they need. If you think you have been incorrectly identified in a different eligibility group, you can call 800-635-2570 for assistance." Hogan supplied an emendated computer-screen grab as an example of problems and the cabinet's action:

Click on the image to view a larger version

The Kentucky Equal Justice Center has filed an open records request seeking more information on the state plan amendment that was submitted to CMS in April. Hogan said in an e-mail, “We are still reviewing the letter, but we have been in contact with CMS throughout the state plan amendment process going all the way back to April and will continue to work with them through the approval process.”

The vacated plan, called Kentucky HEALTH for "Helping to Engage and Achieve Long Term Health," was set to launch July 1. It included requirements for work, volunteering, job training or drug treatment; monthly reporting; lock-out periods for failure to comply; and small premiums based on income.

On June 29, Boasberg sent the plan back to the U.S. Department of Health and Human Services for review, ruling that Secretary Alex Azar had not fully considered the state's projection that in five years the Medicaid rolls would have 95,000 fewer people with the plan than without it.

Ky. ranks next to last in exercise, which should include both aerobics and strength training; 'closest thing to a wonder drug'

By Melissa Patrick
Kentucky Health News

Kentucky adults rank next to last for getting the recommended amount of exercise, followed only by Mississippi, according to a recently released Centers for Disease Control and Prevention study, based on CDC polling that asks people about their exercise habits and health.

The poll found that only 14.6 percent of Kentucky adults reported getting the amount of exercise that experts say is needed, well below the national figure of 22.9 percent.

Among Kentucky men, 17.9 percent reported getting that amount of  exercise; the national figure for men is 27.2 percent.

Among Kentucky women, 11.4 percent reported getting enough exercise; nationally, 18.7 percent of women said they did.

Using data from the 2010-2015 National Health Interview Survey, the researchers looked at the percentage of adults between the ages of 18 and 64 who met the federal guidelines for both aerobic and muscle-strengthening activities during their free time. The polling did not consider any exercise done while on the job or during a commute.

The 2008 activity guidelines call for muscle-strengthening activities at least twice a week, with either moderate aerobic exercise for at least 150 minutes per week or vigorous aerobic exercise for at least 75 minutes per week, or an equivalent combination. 

Meeting the moderate exercise requirement involves about 20 minutes a day of activities like walking briskly, water aerobics, bicycling slower than 10 miles per hour, doubles tennis or general gardening. The vigorous aerobic requirement hurdle requires about 11 minutes a day of things like race-walking, jogging or running, swimming laps, singles tennis or jumping rope. And add to that two days of muscle-strengthening" exercises, like lifting weights, yoga, push-ups or sit-ups.

Exercise is known to reduce the risk of heart disease, high blood pressure, Type 2 diabetes and certain cancers -- all conditions in which Kentucky ranks in the top 10 states. It can also improve mental health, and Kentucky adults consistently report more poor mental health days than the rest of the nation: averaging 4.6 in the 30 days before they were polled, compared to 3.8 days nationally.

"Physical activity is the closest thing to a wonder drug," then-CDC director Thomas Frieden, told Kentuckians at the 2016 Shaping Our Appalachian Region Innovation Summit in Pikeville.

In general, the study found that adults residing in the Southeast were much less likely than adults in other regions to meet the activity guidelines; states in the West were consistently more likely to have a "significantly higher" rate of activity.

The bottom five states in percentage of adults who met the standard, were Arkansas: 15.7 percent; Indiana: 15.1; South Carolina: 14.8;  Kentucky: 14.6; and Mississippi: 13.5. The top five were Colorado, 32.5 percent;  Idaho,  31.4; New Hampshire, 30.7; Washington, D.C., 30.7; Vermont, 29.5; and Massachusetts: 29.5.

Patients confused, providers worried, Democrats and advocates upset over decision to limit Medicaid dental and vision benefits

The end of dental and vision benefits for 460,000 Kentuckians on Medicaid caused some pregnant women and children to be denied care because of a reported glitch in the system. It also prompted complaints from Democrats and others that the move violated federal law.

The Bevin administration blamed the cuts on a federal judge's ruling that vacated the state's new Medicaid program, which was to launch July 1. Judge James Boasberg of Washington, D.C. sent the plan back to the U.S. Department for Health and Human Services for review, ruling that Secretary Alex Azar had not fully considered the state's projection that in five years the Medicaid rolls would have 95,000 fewer people with the plan than without it.

The state's action mainly affects Kentuckians who gained access to Medicaid when then-Gov. Steve Beshear, a Democrat, expanded it in 2014 to those who earn up to 138 percent of the federal poverty level, under the 2010 Patient Protection and Affordable Care Act.

Deborah Yetter of the Louisville Courier Journal reports, "Dentists have been forced to turn away children and other patients who are mistakenly showing up in the state's computer system as having lost coverage," including pregnant women and disabled adults who are clearly exempt from the cutoffs.

Yetter offered examples, including a Floyd County dentist who said he turned away at least 10 children since Monday for lack of Medicaid coverage; another in Louisville who said her patients were coming in for appointments with no idea they had lost their coverage and couldn't pay the $30 required for those without insurance; and another in Pikeville who said he had had to cancel multiple appointments for people who had lost coverage but should have been exempt.

The Kentucky Oral Health Coalition says that they too have heard from multiple KOHC dental providers across the state that the state's changes to the dental program have resulted in the denial of routine dental care to eligible children and pregnant women. 

"Due to a shortage of dentists who accept Medicaid in Kentucky, particularly in rural areas, we know that some families travel several hours just to get to a dental appointment," KOHC writes in a statement, adding that summer vacation is typically a prime time for caregivers to schedule these visits. "This timing adds to the urgency. We cannot allow families to show up only to be turned away and miss their opportunity to access the dental care they need to stay healthy." 

Doug Hogan, spokesman for the state Cabinet for Health and Family Services, told Yetter that he needed more specifics to determine if people were being wrongly classified or if providers had gotten incorrect information. "According to system checks, eligibility is being correctly applied to children and pregnant women," he said, adding that those with concerns can call 1-800-635-2570.

Dental providers who serve the poor are worried

Jennifer Hasch, a dental hygienist at the Shawnee Christian Healthcare Center, which serves people regardless of income in west Louisville, at a July 2 news conference in Louisville with local Democrats, said that 70 percent of their patients were on Medicaid, with an estimated half of those in the expansion population, Joe Sonka reports for Insider Louisville.

Photo from Family Health Centers website

Hasch added that when poor people can't see a dentist, they go to the emergency room, which she said was at least three times as expensive as a normal dental visit. She later told Sonka that the abrupt end of dental benefits for so many had created much uncertainty about who did or did not still have dental coverage.

Bill Wagner, CEO of Family Health Centers, federally qualified clinics that treat patients regardless of income, told Louisville's Metro Council last month that the center feared 8,400 of their patients could lose Medicaid coverage over the next five years under the plan.

"Wagner added that with the dramatic increase in patients covered by Medicaid expansion over the last five years, the city has lowered its annual amount payments to the center for uncompensated care by roughly $1.1 million," Sonka reports.

While speaking at the news conference, Wagner  said that the clinics likely will have to start charging a basic fee of $30 per visit, an amount some can't afford, Yetter reports.

On Thursday, July 5, the Kentucky Rural Health Association sent out a list of codes from the state Department for Medicaid Services that are to be used for Medicaid members who are listed under the "Alternative Benefit Plan" created for the expansion population.

What's it all about?

Medicaid is a joint state and federal health insurance program that spends $11 billion a year to cover about 1.4 million Kentuckians, more than 600,000 of them children. Before the expansion, it was mainly limited to very poor pregnant women and children, disabled people and low-income elderly in nursing homes.

Bevin and his administration have long argued that any money spent on the "able-bodied" expansion population takes money away from those who are truly in need. Others, including Judge Boasberg, hold that "where Medicaid's fundamental purpose and statutory protections are concerned, expansion beneficiaries stand on equal footing with 'traditional' populations," Sara Rosenbaum writes for The Commonwealth Fund.

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

Under Kentucky HEALTH, people covered by the Medicaid expansion were to earn dental and vision benefits by participating in certain activities, such as accessing preventive-care services or participating in job training. (Most people on the expansion work.)

Separately, the state moved to end the free benefits for the expansion population starting July 1 because of Boasberg's ruling.  "There is no longer a funding mechanism in place to pay for dental and vision services," the health cabinet said in a statement. 

MaryBeth Musumeci, associate director for Medicaid and the uninsured at the Kaiser Family Foundation, told Lisa Gillespie of Louisville's WFPL that it’s perfectly legal for the state to limit dental and vision benefits, but that it could also restore them.

“The court’s decision is not prohibiting Kentucky from continuing to offer vision and dental as they have prior to the waiver,” Musumeci told Gillespie. “Those benefits continue to be optional and they could include them in the benefit package, or not.”

State officials said they limited the benefits to reduce expenses in Medicaid, but that was illogical, the Lexington Herald-Leader said in an editorial, "because emergency-room visits for dental problems will increase," and are three times as expensive as a dental visit. The editorial noted that administration "officials have said they can’t say how much eliminating the dental and vision benefits would save or cost and that fewer than 10 percent of Medicaid recipients use those benefits."

The elimination of vision and dental coverage does not apply to pregnant women, children, individuals who are considered medically frail, former foster youth up to age 26, and groups covered by Medicaid before the expansion, including parents who make below 28 percent of the federal poverty limit, Gillespie notes.

Louisville Democrats voice outrage over cuts

Democratic politicians gathered Monday at a news conference in Louisville to blast the Bevin administration's handing of the matter.

At a news conference, U.S. Rep John Yarmuth of Louisville called Kentucky HEALTH illegal, and said it was driven by Bevin's "ideological motivations," Sonka reports.

“Medicaid is not a work program," Yarmuth said. "It is not a program designed to familiarize people with commercial health insurance, as the governor has said. It is a program to provide medical coverage to the poor and working poor."

Rep. John Yarmuth and other Democrats spoke against the
Bevin administration's cuts to dental and vision benefits for
some on Medicaid. (Photo by Joe Sonka, Insider Louisville)

Yarmuth added that if Bevin ends the expansion, as he has said he would do if courts ultimately block the plan, it would cost the state an estimated $30 billion in economic activity for hospitals and providers over the next 10 years, while the state would pay only 10 percent of that, because the federal government covers the rest of the expansion costs, Sonka reports.

Yarmuth told Nick Storm that he had asked the Centers for Medicare and Medicaid Services on July 2 if Kentucky had cut off these dental and vision benefits legally, and they told him they didn't know.

Nick Storm of Spectrum News reports that former state auditor Adam Edelen, who is considering the 2019 race for governor, also spoke at the news conference, saying “What we need is leadership in Frankfort that understands it’s not that the poor are not working hard enough, it’s that the work they’re doing doesn’t pay enough.”

Rep. Joni Jenkins suggested that patients with unresolved dental pain created a "gateway to addiction," which is "like throwing gasoline on our opioid epidemic here in Kentucky."

Sen. Gerald Neal said that he and Sen. Morgan McGarvey plan to file a bill in next year’s legislative session to require that all Medicaid recipients in the state have dental and vision benefits.

So what's next?

While the state and federal governments have been expected to appeal the court decision, Rosenbaum reports that the Trump administration could also decide to rework Kentucky's plan, which she writes "would seem to be the prudent choice, since the decision leaves open the door to Medicaid work experiments, and since multiple state proposals are potentially waiting in the wings."

Eight other states with Republican governors (Arkansas, Arizona, Indiana, Kansas, Maine, New Hampshire, Utah and Wisconsin) and one state with a Democratic governor (North Carolina) have asked the Trump administration for the green light to enact similar requirements as had been requested in Kentucky HEALTH.

The Associated Press sums up the judge's fundamental question as this: "Are poverty programs meant to show tough love or to help the needy?"

Local coverage

Bobbie Curd of The Advocate Messenger in Danville offers an example of how to localize this story. She notes that Boyle County has 5,700 people on Medicaid, equal to 20 percent of the county's population. (County totals of people on Medicaid, the expansion and other categories are at http://www.uky.edu/comminfostudies/irjci/MedicaidenrollmentbycountyJune%202017.xlsx.)

The director of the Boyle County Health Department, Brent Blevins, told Curd that he, and many others weren't told of the limitation of dental and vision benefits.

“If we don’t have a good program or option for those people to pick up quickly, you’ll have people going without coverage for extensive lengths of time,” Blevins said.

Blevins added that it "would be a significant issue in our community" if 1,000 or even 500 people in Danville lose their ability to afford dental and vision care.

Studies put numbers on what Eastern Kentucky employers know: High rates of opioid use make it hard to find employees

Herald-Leader chart (click on it to view a larger version)

"Kentucky's drug crisis has affected the workforce, causing higher turnover, bringing additional costs to train new employees and fueling employee thefts," Bill Estep reports for the Lexington Herald-Leader. Research shows that the problem is worst in Eastern Kentucky.

Economists for the Federal Reserve Bank of Cleveland, which covers the region, "estimated that participation in the labor force by men in their prime working years — ages 24 to 54 — was 4.6 percent less on average in counties with high rates of opioid prescribing than in counties with low prescribing rates," Estep writes.

“Poor labor market outcomes are highly correlated with prescription opioid availability,” Kyle Fee, a senior analyst for the bank, wrote in a report about the research. However, the study "did not parse out the reasons for the impact, such as whether people couldn’t hold a job because of addiction," Estep notes.

Read more here: https://www.kentucky.com/news/state/article213189309.html#storylink=cpy

Read more here: https://www.kentucky.com/news/state/article213189309.html#storylink=cpy

The phenomenon was greatest among men who had not gone to college. Among whites, the labor-force participation rate was 7.4 percent less in high-prescribing counties; among non-whites, it was 9.7 percent, the researchers concluded.

"Prescribing rates dropped significantly in Eastern Kentucky counties between 2011 and 2016, but remained well above the national rate," Estep notes. "The national rate in 2016 was 66.5 prescriptions for each 100 people. That compared to 251 in Owsley County, 249 in Bell, 239 in Whitley, 226 in Floyd, 220 in Pike, 219 in Johnson, and 209 in Perry, according to Fee’s report."

Estep also cites a recent study by the Organisation for Economic Co-Operation and Development that cited opioids as a factor in why the U.S. labor participation rate was then lowest in the 35 countries in the group, saying the correlation with low participation “in areas most beset by opioid addiction suggests that addiction ultimately impairs participation.” And he mentions an earlier study by Oak Ridge Associated Universities, which did focus groups in Appalachia for the Appalachian Regional Commission. “Participants gave examples of both small businesses and larger manufacturing firms that were unable to recruit workers who could pass drug screening,” the study report said.

Convenience-store operators told Estep likeiwse. Mike Bowling, who owns stores in London and Manchester and has been in business for 18 years, told the reporter, “This is the hardest I’ve ever seen getting workers and keeping workers.”

Blocked from starting new Medicaid plan, state comes up with a question-and-answer sheet to help providers and their patients

By Melissa Patrick
Kentucky Health News

As the Cabinet for Health and Family Services scrambles to deal with the fall-out from a court ruling that vacated the state's new Medicaid plan, which was set to go into place Sunday, July 1, its call centers and front-line staff are using a new question-and-answer document to help health-care providers advise their Medicaid clients.

The document says Kentucky HEALTH (for "Helping to Engage and Achieve Long Term Health") hasn't been cancelled, but instead has been "halted for further review" by the federal government.

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

The state has also posted a Kentucky HEALTH update on its website, and the question-and-answer document says the state will be sending additional information about the changes this week.

In the meantime, most of the 1.4 million Medicaid members' benefits will stay about the same as they have been for now -- no premiums, no deductibles, no reporting requirements and no requirements for work or other "community engagement." The Q&A says managed-care organizations that deal with Medicaid patients and providers will be charging co-payments for services.

The exceptions are the 460,000 members covered by expanded Medicaid, who had been moved to a My Rewards Account and have lost their dental and vision benefits.

"When Kentucky HEALTH was invalidated by the court, the My Rewards program was eliminated, and there is no longer a funding mechanism in place to pay for dental and vision services," the health cabinet said in a statement.

The Q&A says that while members cannot use the benefits that may have already earned in their My Rewards accounts, they can still continue to earn these "virtual" dollars for qualifying activities if they so choose.

The Q&A offers answers about many topics and concerns, including questions about whether a person on Medicaid can still go to the doctor; what to do about premiums and co-payments; and the status if the "community engagement" or work requirements that were struck down.

The answer to the questions of "Will I be reimbursed if I've already made a premium payment: Will you be sending a refund?" is that the state and manged-care firms are working on how to manage this, and hope to have an update soon to share with these members. At this time, no premiums are due.

The Q&A also says all managed-care firms will be required to charge a co-payment for medical services, saying, "The requirement to make co-payments was a state change that was separate from Kentucky HEALTH."

The document has a list of 18 services that require co-payments. A few examples include $3 for office visits, $1 for generic drugs, $4 for preferred brand-name drugs that don't have a generic equivalent; and $8 for emergency-room visits.

The cabinet continues to stress in this document that the supports and resources in Kentucky HEALTH to help Kentuckians improve their income and health are still available and that members can still log on to www.CitizenConnect.ky.gov to take free online courses about health, life and work skills. It also encourages interested Kentuckians to visit www.KCC.ky.gov to find their local career center.

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

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

By Melissa Patrick and Al Cross
Kentucky Health News

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

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

Family Health Centers in Louisville built a dental clinic after

Medicaid expanded. (Angela Shoemaker, Courier-Journal)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hepatitis A outbreak worst ever; Ky. leads the nation; state health commissioner advises Kentuckians to wash hands, get vaccinated

Image: WNDU

State health officials say the hepatitis A outbreak in Kentucky is the worst ever, and the crisis isn't over.

"It's the worst on record across the nation and in Kentucky," Dr. Jeff Howard, Kentucky Commissioner of Public Health, told Beth Warren of the Louisville Courier Journal.

Kentucky health officials have confirmed 969 cases and six deaths from the highly contagious liver disease. No other state has reported as many.

Warren notes that Louisville has been the hardest hit, with 480 cases and three deaths. The other deaths were in Ballard, Meade and Greenup counties. Kentucky normally only has about 20 hepatitis A cases a year.

The state Department for Public Health reports that most of the cases have been among the homeless and drug users. So far, there haven't been any food-related transfers of hepatitis A, but it's a major fear.

"Sharing a home, a cigarette, marijuana joint, a drink, or sex with someone who has the virus puts you at high risk," according to an advisory website in Louisville, Warren notes.

The health department's weekly hepatitis A outbreak report, which was last updated on June 16, shows that Bell, Breathitt, Butler, Edmonson, Johnson and Washington counties have identified their first cases since August of last year.

Health officials urge people who live in counties with an outbreak, and those who are in high-risk groups, to get vaccinated against hepatitis A. They also encourage people who work in food preparation and service to get immunized. Immunization requires two vaccines, six months apart.

Public schools across Kentucky require students to get the vaccine before starting school this year.

Besides Jefferson County, the 11 other counties reporting five or more cases are: Ballard, Grayson, Ohio, Rowan, Shelby, Whitley, Fayette, Powell, Lincoln, Grant and Bourbon.

Officials are also encouraging everyone to wash their hands for about 20 seconds with soap and water after using the bathroom, before they eat, and when they get home from being out in public, adding that hand gels are not an alternative because they don't kill the virus.

Warren tells the story of a Louisville woman who is one of the 10 percent of people in Louisville who got the virus but was not in a high-risk group.

Angela Glotzbach, a medical sales representative, told Warren that she was "baffled" by her diagnosis and described being sick for three months as "1,000 times worse than the flu."

"Dehydration from vomiting and diarrhea sent her to the hospital three times and she suffered tremors, joint and back pain, fatigue and trouble forming sentences," Warren writes.

The most common symptoms of hepatitis A are fatigue, low-grade fever, loss of appetite, joint pain, sudden nausea and vomiting, yellow eyes or skin, abdominal pain, pale stools and dark urine. A person with the virus is contagious for up to two weeks before showing symptoms and one week after. Symptoms usually last less than two months, but 10 percent to 15 percent of victims remain sick for up to six months.

Dr. Paul Schulz, infectious diseases specialist and system epidemiologist for Norton Healthcare, told Warren that it's unlikely that most adults got the vaccine as a child unless they traveled abroad or were in a high-risk population because it wasn't available until 1995, and wasn't added to the child immunization schedule until 1999. He added that a health care provider can perform a simple blood test to see if someone has been vaccinated or has immunity.

Kentucky's cigarette tax goes up 50 cents a pack, to $1.10; health advocates say it's a great time to quit smoking

Coalition for a Smoke-Free Tomorrow

Kentucky's cigarette tax just went up 83 percent, from 60 cents per pack to $1.10 a pack. Anti-smoking and health advocates hope the 50-cent increase, effective Sunday, will prompt smokers to kick the habit.

"Many more people are former smokers than current smokers today, which proves that quitting, though hard, can be done," Ben Chandler, chair of the Coalition for a Smoke-Free Tomorrow, said in a news release.

The coalition of 160 organizations and advocates had lobbied hard against the tobacco industry to get the tax raised by $1 a pack, arguing that anything less would have no real health impact on the state because the tobacco industry could afford to offset the lesser increases with coupons and discounts.

Kentucky adults have the second highest rate of smoking in the nation, 24.5 percent, and the state leads the nation in many of the diseases, including many cancers, caused from from it.

The federal Centers for Disease Control and Prevention reports that nearly seven in 10 adult smokers want to quit, and a similar percentage have tried to in the past year. And for those who are successful, the positive health effects are both immediate and long-term.

Research shows that within 20 minutes of quitting, a person's blood pressure and pulse drops and within just 24 hours, the chance of having a heart attack decreases and within one year, the chance of having a heart attack falls to half that of smokers, according to the coalition news release. Quitting also reduces the smokers risk of lung and other types of cancers, as well as lung disease and stroke.

Chandler, who is also the president and CEO of the Foundation for a Healthy Kentucky, reminded Kentucky smokers that it's never too late to quit and noted that while it often takes several attempts to be successful, there are many resources available to help.

"Medications and counseling are available, free of charge to most, to help you through the roughest times," he said.

For example, Kentucky law requires health insurance companies, Medicaid and its managed-care organizations to cover the cost of smoking-cessation treatments and counseling without imposing any barriers.

The state also offers the Kentucky Quitline program called Quit Now Kentucky, which can be found at www.quitnowkentucky.org or by calling 1-800-QUIT-NOW (1-800-784-8669). This program offers three different programs, a phone only program, and online program and a combined phone and online program. This program and nicotine replacement therapies are available to many free of cost.

Many employers, health organizations and local health departments offer free or low-cost smoking cessation programs. The American Lung Association also offers Freedom from Smoking clinics in several Kentucky locations.