Adair County Community Voice fills several pages in sample-copy edition with stories about the opioid epidemic and its cost

Continuation of Page 1 story shows child with photo of his mother, who died from a fentanyl overdose.

Most rural newspapers shy away from reporting on the opioid epidemic, aside from its criminal-justice aspects, perhaps because they naturally avoid unpleasant news that isn't served up to them. Not the Adair County Community Voice in Columbia, Kentucky, which started a series about the issue in a big way last week, in a sample-copy edition sent to everyone in the county of 20,000.

The Voice filled its front page with three stories about drugs, introduced with a 72-point all-caps headline, "THE COST OF ADDICTION" and a blurb reading, "The cost of addiction runs high. It has affected every family and every aspect of our community," and inviting "anyone with a story to tell" to call Editor and Publisher Sharon Burton.

The front-page stories told of a 23-year-old mother's drug problems and her death from fentanyl; the failure of state social workers to prevent the death of a baby born with methamphetamine in its system; and the heavy pressure that drug cases are putting on local courts and jails. On the editorial page, Burton wrote, "We must come together as a community to battle this raging beast."

And that wasn't all. A Health and Medical section began with a story and photo illustration (a judge posed in his courtroom) explaining the new state law that allows involuntary treatment for someone suffering from alcohol or drug abuse. Below it were a story about a woman who forced her daughter to get treatment, and one about a statewide proposal to tax electronic cigarettes. On the back page was a story citing a database recently revealed by The Washington Post giving the number of pain pills per person shipped into the county from 2006 to 2012.

This isn't the first foray into the issue for the Voice, which is the smaller weekly in Adair County. In December it did a story about the local syringe exchange, which aims to prevent disease outbreaks among intravenous drug users and inadvertent injury from discarded needles, and found that most of the exchange's clients were from adjoining and more populous Taylor County, which doesn't have an exchange. Both are served by the Lake Cumberland District Health Department.

Pence, health secretary visit Manchester to announce grants to fight opioid epidemic and praise Gov. Matt Bevin for fighting it

Photo by Ryan Hermens, Lexington Herald-Leader

Vice President Mike Pence and Health and Human Services Secretary Alex Azar came to Clay County Aug. 8 to announce federal grants of $10 million to fight opioid abuse in Kentucky and boost Gov. Matt Bevin.

One grant is part of a $400 million program of the Department of Health and Human Services for rural areas, through community health centers, schools and universities to expand access to treatment.

"Kentucky’s portion will help fund roughly $750,000 in training programs through the University of Pikeville and payments of up to $167,000 for prevention and treatment services at Eastern Kentucky University, the faith-based Grace Community Health Center, as well as treatment facilities in Whitesburg, Hazard, Prestonsburg and Beattyville," Alex Acquisto reports for the Lexington Herald-Leader.

Pence heaped praise on Bevin, who is running for re-election and lost Clay and surrounding counties in the Republican primary election in May. He gave Bevin credit for the 15 percent reduction in deaths from opioid overdoses in Kentucky in 2018.

Bevin told the invitation-only crowd of about 200 at EKU's Manchester campus that mitigating the opioid epidemic “has been a focus of mine ... from the moment I was elected, I said, we’ve got to tackle this head on.”

U.S. Rep. Harold "Hal" Rogers of Somerset "credited the people of Manchester for their initial stand against the epidemic over 20 years ago," Nita Johnson reports for The Times Tribune in Corbin. (The Manchester Enterprise sent a photographer but no reporter after a dispute about credentials.)

3 SW Va. counties among many suing drug makers over opioids; Washington Post takes a look with text, pictures, audio: 'We was addicted to their pills, but they was addicted to the money'

L-R: Lee, Wise and Russell counties; City
of Norton is within Wise (Wikipedia map)

"Towns and cities across America are fighting back against the drug industry, seeking billions of dollars in damages to treat addiction and rebuild their communities," through a lawsuit in federal court in Cleveland, Joel Achenbach of The Washington Post reports, in a deep, multimedia story from Southwest Virginia -- where three counties, two of which border Kentucky, and the City of Norton are plaintiffs in the suit.

In photographs, audio, video and text, the story is told by a Post team and people who are in recovery, including some who relapse; a police officer who saw the epidemic coming but was largely ignored; pharmacists who refused to fill dodgy prescriptions; and the district director of the state health department. "People here are familiar with pain," Achenbach writes. "Coal miners tell stories of explosions they survived. Disability rates are high. This was a place where the purveyors of pain pills found a ready market."

Jason Boyd and daughter (Washington Post photo by Melina Mara)

The most compelling account comes from Jason Boyd, a recovering and relapsing father of four who makes a case that sounds like a good opening or closing argument in a trial: “We was addicted to their pills, but they was addicted to the money, because that’s what it is about. The definition of murder is when you sit and you plan about how killing somebody. Well that’s pretty much the definition of what they done. They sit back and say, ‘All right, this is addictive,’ but it’s same thing as just sitting there saying, ‘Well, we will murder a whole bunch people and make millions of dollars off of it.’ ”

Achenbach notes, "The drug companies issued broad defenses of their actions during the opioid epidemic. They have said previously that they were trying to sell legal painkillers to legitimate pain patients who had prescriptions. They have blamed the epidemic on over-prescribing by physicians and also on corrupt doctors and pharmacists who worked in 'pill mills' that handed out drugs with few questions asked. The companies also said they should not be held responsible for the actions of people who abused the drugs."

Those statements were made to The Post last month in response to its release of a Drug Enforcement Administration database that is central to the lawsuit, Achenbach writes. It "became public through legal action by The Washington Post and HD Media, owner of the Charleston Gazette-Mail in West Virginia. Over seven years, the database shows, drug companies shipped a combined 74 million opioid pills to the city of Norton and the three surrounding counties — enough for 106 pills per resident every year." The city and Lee and Dickenson counties are among the plaintiffs in a similar lawsuit in Virginia, The Coalfield Progress reports.

The Post reported that the database showed Norton, a town of 4,000, received more pain pills per person, 306, than any other place in America in 2006-12. That is misleading, City Manager Fred Ramey told the Progress, “since all demand is not local” and Norton “is a regional commercial hub and home to two hospitals, a VA clinic, and regional cancer facility along with a number of doctors that serve the medical needs of a multi-county area that includes a portion of Eastern Kentucky.”

Anti-overdose drug naloxone (Narcan) isn't getting to enough at-risk and rural people, including many counties in Kentucky

CDC maps show rate of naloxone prescriptions (top) and ratio of naloxone prescriptions to high-dose opioid prescriptions; darker areas are more likely to have sufficient access to naloxone.

Use of the opioid-overdose rescue drug naloxone, also known by the brand name Narcan, has boomed in recent years. However, too few chronic-pain patients at high risk of overdose are receiving it, especially in rural America, including parts of Kentucky, Christine Vestal reports for Stateline.

In 2017, 47,600 Americans died from an opioid overdose. According to a new report from the federal Centers for Disease Control and Prevention, more lives could be saved if health-care providers offered naloxone to all patients at risk of overdose. "Naloxone dispensing from retail pharmacies increased from 2012 to 2018, with substantial increases in recent years. Despite increases, in 2018, only one naloxone prescription was dispensed for every 69 high-dose opioid prescriptions. The lowest rates of naloxone dispensing were observed in the most rural counties."

Enlargement of Kentucky and neighboring states shows naloxone access; Kentucky counties with the first rank of access are Adair, Anderson, Bell, Boyd, Breathitt, Bullitt, Campbell, Christian, Estill, Fleming, Floyd, Franklin, Grant, Hopkins, Jackson, Johnson, Laurel, Lawrence, Leslie, Lewis, Martin, Menifee, Owsley, Pendleton, Pike, Powell, Scott, Trigg and Union.

According to the report, overall naloxone dispensing was 25 times greater in the highest-dispensing counties than in the lowest-dispensing counties. The number of naloxone prescriptions rose from 270,000 in 2017 to 556,000 in 2018, but it would take 9 million prescriptions to provide one to every person who has a high-dose opioid prescription, the report found.

"The CDC’s 2016 guidelines for prescribing opioids for chronic pain recommended doctors prescribe naloxone for all patients taking more than the equivalent of 50 mg of morphine a day. Since then, a handful of states have required doctors to co-prescribe naloxone and warn patients about the risk of high doses of opioids," Vestal notes. "In addition, nearly all states have enacted so-called good Samaritan laws, allowing private citizens to administer the overdose-reversal medication without legal liability. And most states in the past five years have called on pharmacies to provide the easy-to-administer medication to anyone who wants it without a prescription, according to the Network for Public Health Law."

Study: Rural dentists show higher awareness of opioid epidemic in their prescribing, and are in good positions to fight it

While rural and non-rural dentists prescribe about the same number of pain pills, rural dentists do so more often in combination with ibuprofen or acetaminophen and at lower dosage rates. So says a new study, which also found that rural dentists are more likely to have suspected their patients of drug abuse -- and not prescribed opioids to them as a result of that suspicion.

AARP photo illustration

The study, published in The Journal of Rural Health, pointed out that rural dentists are in a great position to help combat the opioid crisis, largely because rural communities have been hit so hard by the opioid epidemic and because dentists prescribe about 12 percent of annual opioid prescriptions.

"Recognizing and engaging rural dentists as leaders in addressing opioid misuse will be an important step toward reducing the fatal impacts of this epidemic among rural communities," the researchers write. "Rural dentists encountering this epidemic can implement screening for opioid misuse and abuse, as well as provide a referral for treatment."

The researchers delivered an online survey to dentists in the National Dental Practice-Based Research Network to measure both rural and non-rural dentists' pain management practices, their perceptions of the scope of the problem and the perceived adequacy of their training around preventing the misuse and abuse of opioids.

The survey excluded those who did not provide an e-mail address, and those who practiced exclusively in orthodontics, oral pathology or pediatric dentistry, because those types of practices rarely prescribe opioids. Of the 822 dentists who completed the survey, 91 were in a rural practice and 731 were not; 11.1% of them were in an area that is short of health professionals. Rural practice was defined as those with a ZIP code with more than 50% of its population living in a non-metropolitan county or in a rural census tract. (Many metro counties have rural census tracts.)

"Rural dentists were significantly more likely to prescribe opioids in combination with a recommendation to use ibuprofen or acetaminophen for pain management, and were significantly less likely to prescribe six to seven days' supply of opioids," the researchers report. They also found that only one-third of the dentists said their training to prevent misuse or abuse of opioids was "sufficient and up to date." Rural dentists appeared slightly less likely to say that. The rest said their training was either sufficient, but out of date; insufficient; or that they had received no such training.

The researchers said the American Dental Association's new policy was a great support for dentists because it sets limitations for opioid dosage and duration for acute pain, elevates the significance of mandatory continuing education for prescribing opioids and other controlled substances, and provides a recommendation for dentists to use state prescription-drug monitoring programs.

The journal article concludes, "Dentists should employ recommended risk-mitigation strategies broadly, as a substantial segment of dental patients report at least some non-medical use of their pain medications, and recent substance abuse—including problematic alcohol use or illicit drug use—has been reported by approximately one in five dental patients."

The article acknowledged several limitations to the study: Self-reported data is retrospective in nature, making it subject to potential bias; no objective prescribing data was collected; a patients may live in a different ZIP code (perhaps an urban one) than the dentist; and the study did not differentiate between the complexity of procedures as potential reasons for the dentists' prescribing practices.

The corresponding author of the study report is Dr. Jenna McCauley of the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina. The editor of the Journal of Rural Health is Ty Borders, director of the Rural and Underserved Health Research Center at the University of Kentucky.

Change in Medicare reimbursement rules will mean more money for 39 rural hospitals in Kentucky, totaling $4 million a year

Photo: Rural Health Information Hub

The Centers for Medicare and Medicare Services said Friday that it will adjust its Medicare payment formula, starting in October, in a way that will boost payments to rural hospitals, which "have complained that this measure has unfairly disadvantaged some of them because wages are lower in their communities," Dan Diamond reports for the Politico Pulse newsletter.

The move is expected to mean more money for 39 Kentucky hospitals, totaling $4 million a year, according to the Kentucky Hospital Association. Some critics of the plan note that it doesn't apply to critical-access hospitals, which comprise about half the rural hospitals in the country. Kentucky has 27 such hospitals, which are generally in rural areas and have 25 or fewer beds.

The index is based on how much a hospital pays its staff, so hospitals in areas with high living costs get higher reimbursements than areas that have low cost of living -- for the same services. A labor market's wage index is the ratio of its average hourly wage to the national average hourly wage, according to CMS."

KHA says the wage-index disparities mean Kentucky's rural hospitals get approximately 26 percent less -- $1,800 per case -- than the state with the highest rural wage index. Kentucky's urban hospitals with the highest wage index get 40 percent less, $3,700 per case, than hospitals with the highest urban wage index "for providing the exact same level of care to Medicare beneficiaries," KHA says. "The wage index is a significant issue for Kentucky's hospitals because Medicare covers about one-half of all patients treated in hospitals."

The proposed rule would reduce the disparity in reimbursements by increasing the wage index for hospitals in the bottom fourth of payments and reducing the index of those in the top fourth, creating a budget-neutral shift of funds, a CMS news release said.

"After the rule's release, the American Hospital Association said it supports improving the wage index values for rural hospitals, but that CMS shouldn't have done so in a budget-neutral manner," Diamond writes. "the National Rural Health Association — which last week pointed to a new investigation on rural hospitals' financial difficulties — had previously praised CMS' proposed version of the rule."

Health departments get another year before pension hikes kick in, but some are already raising taxes in anticipation

By Melissa Patrick
Kentucky Health News

While local health departments are more than grateful that legislation passed in the recent special legislative session gives them another year to manage their looming pension crisis, several counties have already asked for a tax increase as a way to help pay for it.

The Kentucky Department of Public Health said in an email last week that it had received 63 of this year's 113 county tax resolutions and so far 10 counties have asked for a higher rate. Of those, the department said board minutes show that Boone, Boyd, Campbell and Kenton discussed the increase in the Kentucky Retirement System cost prior to voting on the tax rate.

"However, the other six counties mentioned in their board minutes there was a discussion, but did not mention in the minutes details of the discussion," the email said. They are Leslie, Muhlenberg, Ohio, Union, Wayne and Webster counties.

The new law, written and signed by Gov. Matt Bevin, freezes the pension cost of health departments for another year, at 49 percent of payroll, avoiding an increase to 83 percent.

That gives them one more year to decide whether to stay in the state retirement system, with an increase in their pension contribution to 83% of payroll, or leave it -- and either pay a lump sum equal to their projected pension liabilities, or pay it off over the next 30 years in installments.

Allison Adams, director of the Buffalo Trace District Health Department, which includes Mason and Robertson counties, explained that the state has a cap of 10 cents per $100 property value for health taxing districts, and some counties have set this cap even lower through referenda.

Adams, who is also the president of the Kentucky Public Health Association, said it is a fallacy to believe that health departments can simply double their tax rate to pay for their pension obligations, as some legislators have suggested.

Using Robertson County as an example, she said the tax rate there is already set at 8 cents per $100 property value, which would allow it to request 2 more cents per $100 property value, which she said would bring in about $90,000.

But that's not enough to make any real difference, since the cost of one clerk and one nurse in that department, figuring 83% of payroll for their pension, is $175.207 -- an amount that does not include any other costs for required programs and services, Adams said.

"For those who have the tax base, it would help them," she said. "But for those who don't, it wouldn't help."

And for those counties that are levying the maximum tax rate and still don't have enough resources, even after whittling down their staff, to deliver only core and statutorily required services, Adams said, "The next thing to do is to cut services."

The Anderson County Health Department  increased its tax rate in June to help pay for the pension increase that was set to kick in on July 1, but has since been delayed until next year. But the county Board of Health rescinded a portion of the requested 75% increase, reducing it from 52.5 cents per $1,000 in assessed property value to 47.5 cents, which represents a 58% increase from the original rate of 30 cents per $1,000, Ben Carlson reported on June 19 for The Anderson News.

Public Health Director Tim Wright made the request to lower the rate at a specially called meeting after discovering he had made a mistake in his request, explaining that he was unaware that the spreadsheet he used to build his annual budget already included the increase for pension costs, so when he computed his figures the pension had been added in twice, Carlson reported.

The new rate will keep the department from tapping into its reserves to pay the looming pension costs. The new rate will generate about $230,000, and $140,000 of that will go into pension funding, according to documents provided by Wright, Carson reports. Wright said that this is the county's first rate increase in about 20 years.

J Smith, the public health director of Garrard County Health Department, told John Cheves at the Lexington Herald-Leader: “The only reason we came in under budget this year is because of all the cuts we made. But we can’t keep doing that, we’ve done all we can do there,” Smith said. “I told our Board of Health that if we want to keep the services we have left, we’re going to have to have a tax increase.

Chris Crum, public health director at Greenup Health Department, told Rachel Adkins of The Daily Independent in Ashland that because Greenup County raised its health tax last year, it was no longer at risk of closing because of the looming pension costs.

Another challenge is that some counties don't have a separate taxing district to finance their health departments, Melinda J. Overstreet reports for the Glasgow Daily Times.

Barren County Judge-Executive Micheal Hale told Overstreet that Barren is one of three counties in the eight-county Barren River District Health Department that does not have a separate taxing district for health, and without that the county is fiscally responsible for its funding. The county's health department is one that the state health department put on a list that were at risk of closing within 12 months if they didn't get a reprieve from the bigger pension obligation.

Hale told Overstreet that an overnight jump to an 83% contribution would require the county to contribute well over $1 million, which he said would be "catastrophic" for the county's budget. He added that after the final budget is decided, he would ask the committee to look into the possibility of a health taxing district.

Depending on local tax dollars to fund public health would result in huge inequities, said Scott Lockard, director of the Kentucky River District Health Department, which covers some of the state's poorest and unhealthiest counties.

"Communities that need public-health services the most, that have the highest poverty rate, that have the poorest health outcomes, also have the least ability to raise local revenue," Lockard told Kentucky Health News in June.

Adams pointed out  that counties with high property values could raise their tax by 0.5 cents and generate more revenue than a county with low property values that double their rates.

State health commissioner named White House fellow

Dr. Jeffrey Howard

Dr. Jeffrey Howard, the state health commissioner, is leaving to become a White House fellow, a year-long job as a full-time assistant to senior White House staff, cabinet secretaries or other major officials of the federal government.

"Howard told his staff Friday he was leaving for a fellowship in Washington, said Cabinet for Health and Family Services spokeswoman Christina Dettman, who declined to specify what Howard would be doing," reports Chris Kenning of the Louisville Courier Journal.

"Howard, who graduated medical school in 2014, was named Kentucky's acting commissioner for public health in November 2017 and led the struggling state public-health system amid years of budget cuts and layoffs, a state pension crisis and an opioid-addiction epidemic. He took the job just as Kentucky declared an outbreak of hepatitis A, a contagious liver disease spread mostly among drug users."

Howard was criticized for not taking stronger action against the outbreak, against the recommendations of the head of his infectious-disease branch. "Cabinet Secretary Adam Meier has vigorously defended Howard, who said the state responded with limited money to bolster vaccines in numbers that could feasibly be administered by county health departments," Kenning notes.

Meier issued a statement Friday calling Howard "an invaluable asset" who "led the department through one of its most challenging times, building and strengthening relationships with local health department leadership along the way. His vision and leadership have positioned Kentucky's public health system to transform successfully into a sustainable, effective, and responsive model that will be prepared to provide population health services, as well as survive the economic challenges presented by the ongoing pension liabilities."

Kenning notes, "Howard was working on a plan to overhaul the state system to meet funding challenges, including fast-rising pension costs, by narrowing and prioritizing the most critical and state-required health department duties."

Howard has said he was raised in Eastern Kentucky by a mother and stepfather who were addicted to drugs, and in and out of recovery. He said it wasn't until he turned 14 and moved in with his father, became involved in sports, found his faith and met the woman who is now his wife, that he was able to overcome the many obstacles that substance abuse had put in his way.

Conference speakers call for a more aggressive approach to eliminate hepatitis; Ky leads the nation in both hepatitis A and C

By Melissa Patrick
Kentucky Health News

Elimination of the three main types of hepatitis is possible, but will require a more aggressive approach that includes increasing vaccinations for hepatitis A and B and universal screening, non-restricted access to treatment and increased access to harm-reduction programs for those with hepatitis C.

That's been the unwavering message about the liver disease for the the last few years at the Kentucky Rural Health Association's annual Viral Hepatitis Conference, and it was again at the one held July 31 in Lexington.

Meanwhile, Kentucky leads the nation in both acute and chronic cases of hepatitis C and has the largest outbreak of hepatitis A in the nation, and how the state has managed these highly contagious liver diseases has come with both kudos and criticism.

Hepatitis C

Kentucky is often praised for its progressive response to hepatitis C, a chronic disease that is estimated to affect about 43,000 Kentuckian.

But about half of people with hepatitis C don't know they have it, according to Dr. Neil Gupta, chief of the Epidemiology and Surveillance Branch in the federal Centers for Disease Control and Prevention's Division of Viral Hepatitis.

Kentucky is recognized nationwide for its embrace of syringe-exchange programs, which allow drug users to swap dirty needles for clean ones to thwart the spread of HIV and hepatitis C, as well as offering other "harm reduction" services. Most new hepatitis C cases result from drug users sharing needles.

As of June 2, Kentucky had 62 operating syringe exchanges in 55 counties, with four more approved but not yet operational.

Mike Selick, with the national Harm Reduction Coalition, pointed to other ways Kentucky leads the nation in harm reduction, including its Good Samaritan law, its standing order for a drug that is used to reverse opioid and heroin overdoses called naloxone, and its efforts to increase access to medication-assisted therapies (MAT) such as buprenorphine.

That said, he also offered examples of how Kentucky could improve its harm-reduction programs, such as increasing the days and hours that syringe exchanges operate; getting rid of any requirements that the exchanges be one-for-one; increasing access to naloxone and MAT in rural areas; and getting rid of any prior-authorization insurance requirements for MAT.

Kentucky got a "B" on the report card, "Hepatitis C: State of Medicaid Access," largely because it provides "moderate access" to treatment. The report, and several speakers at the conference, called for removal of specialist restrictions in treating hepatitis C and for managed-care organizations, which care for most Medicaid patients, to follow the Medicaid fee-for-service guidelines and not impose any restrictions for liver damage or sobriety for people seeking treatment for the first time.

Selick stressed that hepatitis treatment is safe and effective for people who inject drugs, pointing to research that shows reinfections rates in this population are low. Further, he said treating this population early in their infection becomes "treatment as prevention," because it would decrease the spread of the disease.

Jon Zibbell, senior public health scientist for RTI International, an independent, nonprofit research institute, noted that people who inject drugs present the largest population of new hepatitis infections, and that only 1 to 2 percent of them are being treated each year.

"This population needs to be treated if we are to stop incident infections and achieve hepatitis C elimination," Zibell said. "We cannot achieve hepatitis C elimination if we don't massively treat people who are . . . injecting drugs, and a lot of the pay restrictions are getting in the way of that."

The state health department has launched a statewide hepatitis C elimination project to create a comprehensive and statewide strategic plan to eliminate the disease. It met for the first time July 29.

In 2018, Kentucky was the first state to pass a law to require all pregnant women to be tested for hepatitis C. The law also requires that the information be recorded in both the mother's and the infant's records, and that the child be tested at 24 months for the disease. One in 63 Kentucky births are to mothers who test positive for hepatitis C.

Gupta told the group that subject to change after public and peer-review comment, the CDC would be changing its guidance on hepatitis C screening next year to recommend it for all pregnant women, at least once in a lifetime for all adults, and periodic testing for people with risk factors.

The Kentucky Rural Health Association has started a nationally recognized provider training program called  the Kentucky Hepatitis Academic Mentorship Program, or KHAMP, which so far has trained over 100 providers to treat hepatitis C.

Hep C treatment comes at a cost

One of the challenges to treating hepatitis C is the cost, though an argument can be made that it is more expensive to care for these patients when they progress to late-stage liver damage, liver cancer or need a liver transplant.

Dr. Bennett Cecil, medical director of Hepatitis C Treatment Centers in Louisville and Russell Springs, told the group that the cost for a treatment has dropped to upwards of $30,000, down from about $80,000 several years ago.

Kathleen Winter, as assistant professor in the division of epidemiology at the University of Kentucky College of Public Health, offered some numbers to show the scope of the problem.

Her slides showed that in 2017 Kentucky screened 70,270 people on Medicaid for hepatitis C, and 21,322 of them, or 30 percent, were diagnosed with chronic hepatitis. Only 499 were treated. In 2018, when the state loosened its treatment restrictions, Medicaid screened 79,647 people, 22,342 of them were diagnosed with a chronic infection, and 1,924 were treated.

Winter also showed cost data from the Kentucky All-Payer Hospitalization Claims database that found in 2018 there were 2,973 hospital admissions for patients who had both hepatitis C and liver disease or liver cancer, and that these patients incurred more than $181 million in patient pre-negotiated charges. Adjusted, she said, that would be upwards of $90 million a year to treat chronic, late-stage hepatitis C.

It also found 68 admissions related to liver transplants associated with hepatitis C, which had $4.8 million in associated cost. She said most of these patients were either on Medicare or Medicaid.

While most of these patients were older, Winters pointed out that the largest burden of the disease is with younger adults, who are largely in the early stages of the disease process, and who if not treated will present a tremendous cost-burden to the health-care system in years to come.

Winter also presented her research on pregnant women on Medicaid with hepatitis C, which found that many of them could not correctly identify their hepatitis C status, even though they had been tested; many did not understand how the virus was transmitted; many knew it could be treated, but didn't know what that treatment entailed; many knew treatment was important, but had widespread misunderstandings about what Medicaid would cover -- which Winter said was also a widespread problem among medical professionals.

Hepatitis A

Kentucky has made great progress in decreasing its number of new hepatitis A cases, but not without criticism for what some say was a slow response to the nation's largest outbreak of the disease.

Since August 2017, there have been 4,793 cases of hepatitis A in Kentucky, with more than half of them hospitalized (2,311) and 59 dead from it, according to a weekly surveillance report. The primary risk factors for hepatitis A are drug use and homelessness.

Andy Beshear addressed the conference.

Attorney General Andy Beshear, the second speaker of the day, was quick to criticize Gov. Matt Bevin's administration for its slow response to the hepatitis A outbreak. Beshear is running against Bevin in the Nov. 5 gubernatorial election. 

To a room full of applause, Beshear first thanked Dr. Robert Brawley, the state's former infectious-disease chief, for his "courage in doing what is right," even though it cost him his job. Brawley is a volunteer with KRHA and was a co-moderator of the event.

Beshear was referring to Brawley's request that the state have a more aggressive response to the outbreak, including $6 million to buy more vaccines and $4 million for temporary health workers to help administer them. Brawley also called for the state to declare a public-health emergency as a way to get more federal funds, the Louisville Courier Journal reported.

Health Commissioner Jeffrey Howard didn't declare an emergency but sent local health departments $2.2 million and committed to seek more funding if needed. Howard and other state officials have defended their actions, citing that logistical challenges were greater than the need for more money as the outbreak spread to rural Kentucky.

Brawley, who was allowed to resign in lieu of being fired on June 4, 2018, has maintained his position that the state has not acted aggressively enough.

Beshear said, "I think when you also look at hepatitis, we see an absolute failure by the Bevin administration that cost people their lives. They had the information, they had the ability to respond in a real way for only about $10 million, but they didn't listen. Instead they had people inexperienced and incompetent in really important positions."

The health cabinet stood by its decisions, stating in an e-mail that their response to the outbreak "followed protocol and procedures guided by the CDC and informed by an entire DPH team."

"While hindsight might provide more context for some things now, in retrospect there's not a single decision that I'm aware of that has been made in real time, with the information available at the time, that I would change," Health Secretary Adam Meier said in the e-mail.

Howard, a physician, recently resigned as commissioner to pursue a fellowship in Washington, a spokeswoman from the cabinet told the Courier Journal.

Maria Hardy, the public health director at Ashland-Boyd County Health Department, painted a pretty grim picture of the financial cost associated with the outbreak. Boyd County has been one of the counties hardest hit by the outbreak, with an incident rate of 362.7 cases per 100,000 people.

Because many of the people testing positive for hepatitis A in Boyd County kept showing up in the food-service industry, at the health department's recommendation the county passed an ordinance requiring all food workers be immunized against hepatitis A.

Hardy said her health department's hepatitis A costs have been "devastating to budget." From January 2018 to June 2018, the agency spent $718,902, including the cost of salaries, vaccines and certified mailings. She added that the department got $183,520 from the state to buy more vaccine.

Looking to the future

To applause, Zibbell suggested that it was time to turn syringe-exchange programs into medical homes for people who use drugs, largely because of the stigma in traditional health-care settings against this population.

Dr. Daniel Moore, of the emergency-medicine department at UK HealthCare, said emergency departments must play a significant role in eliminating hepatitis C because they see the "downstream" effects of the disease and are the only places that most drug users interact with the health-care system.

Moore is conducting a grant-funded pilot study that allows him to screen every patient in the UK emergency department for hepatitis C. He said research shows that risk based screening would miss about 25% of people who would test positive for hepatitis c.

Between July 2018 and July 2019, he said the ED had done about 23,000 tests, with about 11% of them testing positive for ever having been exposed to hepatitis C and more than 50% of that group testing positive for an active virus. He added that 443 of these patients had been linked to care.

He said the next step toward elimination of this disease will be to bring drug treatment and hepatitis C interventions to the point of contact in the ED, just like they already do for patients who have had a stroke or a heart attack.

"This is a disease that has a cure," he said. "The patients are in front of me and there is a cure."

$80,000 donation wipes out $8 million in medical debt

Hundreds of people in Appalachia, most of them in Eastern Kentucky, have had $8 million in medical debts paid off by a nonprofit organization that uses donations to buy "bundles of old debt for pennies on the dollar and abolish it at often 10 or 15 percent of the original cost," Alex Acquisto reports for the Lexington Herald-Leader.

"RIP Medical Debt, a New York-based nonprofit debt buying company, announced last week it had paid outstanding medical bills for people in more than 50 counties across Central and Eastern Kentucky, as well as residents in Appalachian regions of Virginia and West Virginia," Acquisto writes. Letters to the debtors went out July 29, company co-founder Craig Antico said Aug. 2.

Acquisto explains how it works: "Debt collectors, knowing this type of debt is unlikely to be repaid, have a vested interest in selling it to another debt buyer willing to offer immediate money, even if it only covers a fraction of the total amount. . . . A $100 donation through the organization can slash up to $10,000 in medical debt."

She offers more detail: "Antico and his company purchase bundled debt portfolios from debt sellers and medical providers that are the least likely to be repaid -- least likely because the debt has existed for typically between two and seven years, and the people who’ve accrued this debt earn less than two times the federal poverty level."

Tim Marema of The Daily Yonder reports, "The organization sends notifications to the affected individuals and reports the erasure to credit bureaus, which improves credit scores. About 300,000 people have had a combined debt of $800 million forgiven through the organization; the average person has $2,600 of debt forgiven."

RIP Medical Debt targets certain regions or populations, and allows donations for that purpose. The main contributors toward the Appalachian debt relief were Jim and Sharon Branscome of Montrose, Colo., who met when they worked for the Appalachian Regional Commission. The son of a coal miner in Southwest Virginia who died of black-lung disease, Branscome said they gave $80,000 partly to help disabled miners and those struggling with opioid addiction. Branscome, a former reporter for The Mountain Eagle in Whitesburg, was managing director of equity research for Standard and Poor's.

Appalachian Regional Commission, working on substance abuse and the workforce issues, calls for 'recovery ecosystem'

The Appalachian Regional Commission held six listening
sessions about substance abuse and workforce issues,
including one in March in Pineville, Ky. (Photo from ARC)

The Appalachian Regional Commission hosted six listening sessions this year to better understand the challenges around substance abuse and how it relates to the Appalachian workforce, and came up with themes to work toward building a "recovery ecosystem."

ARC's mission is economic development, but its leaders say the region's drug problem is an obstacle to those efforts. People in the region, especially those of working age, have been hard hit by the opioid epidemic.

 An ARC-commissioned study in 2016 found that opioid-related death rates were 49 percent higher in the ARC region, compared to the rest of the country: 24.6 deaths per 100,000 people between the ages of 15 and 64 in Appalachia, compared to 16.5 per 100,000 in the non-Appalachian U.S. Among Appalachians between the ages 25 and 44, the study found the overdose death rate was more than 70% higher, compared to those living outside the region.

The sessions focused on "gathering effective goals, strategies and programs to address substance abuse issues in an economic development context," says the commission's report on the "Recovery-to-Work" sessions, from which five themes emerged:

First, participants stated the importance of establishing a "recovery ecosystem" that involves multiple sectors and services to support people who suffer from addiction. This would include health, mental health, social work, criminal justice, housing, transportation, education and employment services.

The report recognized that the availability of services to support such an ecosystem varies in each community.

Graphic from ARC "Recovery-to-Work" sessions report

The sessions also identified the need to have "recovery communities" to help with the recovery needs of this population.The report said the most frequently discussed needs were: sober housing; child and elder care; transportation; ongoing attendance with support groups; and assistance with medical, mental health and dental care. It added that the lack of adequate clothing and poor hygiene can also serve as barriers to getting a job.

A peer-support model was suggested as an essential way to link those with substance-use disorders to resources, adding that there is a growing need for more certified peer-recovery support persons to support such efforts.

The listening groups also called for better coordination of services for people with substance use disorders, noting that the current lack of coordination often leads to relapse. Further, they recommended community based assessments and planning to better organize local and regional efforts toward this end.

Employment was emphasized as a long-term goal of the recovery ecosystem.

"For people in recovery, securing work is considered a contributing factor to successful recovery outcomes as employment provides motivation and a sense of hope in addition to providing for the physical needs of individuals and their families," the ARC report says.

The listening groups identified many barriers to employment for people who have substance-use disorders, including education, skill training child and elder care, transportation, court-ordered appointments, lack of jobs that pay living wages and have potential for advancement, and the stigma that exist around hiring a person in recovery among employers and generally in communities.

The report also noted that employers struggle with recruiting drug-free workers, high rates of employee turnover, and a reluctance to build or expand businesses due to workforce availability.

The groups also stressed that Appalachian communities need more information about effective practices and programs to help them assess, plan and develop local and regional efforts that promote a recovery ecosystem.

For example, they suggested toolkits should be made available to human-resources departments and employee assistance program managers to explain recovery and effective methods of hiring and retaining individuals with substance use disorders.

ARC Federal Co-Chair Tim Thomas said in the news release, "Solutions to the substance abuse crisis in our region and our country as a whole are not going to come from Washington, D.C., but from the collective wisdom of those fighting this epidemic on the ground, from local policymakers and treatment providers, to employers and those in recovery."

Not mentioned in the report, but noted as a workforce-related problem at the Portsmouth, Ohio, listening meeting is that Medicaid will stop paying for medication-assisted treatment in the midst of treatment if the recipient begins to make too much money to no longer qualify for coverage, Tayler Sisk reported in May for West Virginia Public Radio.

Besides Portsmouth, the listening sessions were held in Big Stone Gap, Va.; Wilkesboro, N.C.; Muscle Shoals, Ala.; Pineville, Ky; and Beckley, W.Va., from December 2018 to April 2019. They included representatives from local and state governments, treatment and recovery service providers, workforce development groups, employers, law enforcement and people in recovery.

The sessions focused on "gathering effective goals, strategies and programs to address substance abuse issues in an economic development context," says the commission's report.

Carolyn Richey of Allen County Health Department named latest Healthy Kentucky Policy Champion for 'veggie tasting' program

Carolyn Richey receives the Healthy Kentucky
Policy Champion award from Ben Chandler,
CEO of the Foundation for a Healthy Kentucky.
(Photo by Foundation for a Healthy Kentucky)

The Foundation for a Healthy Kentucky has named Carolyn Richey, a nurse supervisor with the Allen County Health Department who has worked to increase access to health foods for youth, as the latest Healthy Kentucky Policy Champion.

Richey, who has served nearly 30 years at the agency, organized the Community Health Action Team, bringing together representatives of schools, extension, library, chamber, Rotary Club and other organizations to address food access issues. From this collaboration, Richey created a farm-to-school "veggie tasting" pilot program.

"Carolyn has created and nourished many collaborative partnerships, applied for and won several grants, and established extensive health education programming along the way," Foundation CEO Ben Chandler said in a news release. 

Chandler presented Richey with the award on July 24 in Scottsville at the Need More Acres Farm, which the release notes is an "important element" of the farm-to-school project. Richey was nominated by Michelle Howell, co-owner of the farm, who said in the release that Richey's efforts "have increased the consumption of fruits and vegetables as well as raised awareness of the local farming community."

The programs Richey launched "provide numerous healthy food options for kids not only during the school year but also during the summer at multiple community locations," added Melanie Harston, her co-worker at the health department.

Richey is now eligible for the Healthy Kentucky Policy Champion of the Year award, which comes with a $5,000 grant from the foundation to a Kentucky-based nonprofit of the winner's choice. The winner will be announced at the foundation's annual health policy forum Sept. 23 in Lexington.