Kentucky legislators have pre-filed bills to cap the cost of insulin for some; advocate describes the 'real cost' of diabetes

By Melissa Patrick
Kentucky Health News

While legislators and health advocates work to control the surging cost of insulin, a mother with two children and a husband with Type I diabetes points out that the cost of diabetes care far exceeds the actual cost of the drug -- and that the latest, most efficient life-saving technologies and treatments should not be considered a luxury.

Lisa Middleton, patient advocate

Insulin pumps and continuous glucose monitors aren't luxuries, Lisa Middleton, an advocate for patients and affordable health care, said at the annual Health Watch USA 2019 Patient Safety Conference Oct. 17 in Lexington.

Insulin pumps are small, computerized devices that deliver insulin throughout the day, or variable amounts when a meal is eaten, similar to the way the body delivers insulin when it's working properly.

Continuous glucose monitors track glucose levels throughout the day and night, and send alerts to designated cell phones when a person's blood sugar fluctuates, allowing for immediate treatment.

"Things like insulin pumps and things like CGMs shouldn't be considered a luxury," Middleton said. "They should be considered the standard and therefore the standard needs to change. And the same goes for insulin."

Middleton offered an example of how a continuous glucose monitor recently alerted her when her daughter's blood sugar dropped to around 20 or 30, which is dangerously low. She said normal blood sugar levels for her family are 80 to 150.

"So, in my opinion, this right here is the absolute most important thing other than insulin," she said.

What are the "real costs"?

Middleton said that with insurance, her family paid nearly $8,000 out of pocket for one insulin pump, which has a retail cost upwards of $15,000. She said glucose monitors run around $1,800 with insurance, and that require a sensor that has to be replaced every 10 to 14 days and costs about $80. And there are other costs.

Middleton showed receipts from one family that pays $1,092 a month for insulin, and said there have been times when her family has had to pay around $1,300 a month. "And it's non-negotiable," she said, "so you do whatever you have to to make that happen."

She said insulin pens, which make measuring and delivering insulin easier, cost a maximum of $73 in other countries, but $700 in the United States, and around $400 with insurance.

In 2016, Americans with Type 1 diabetes spent $5,705 on insulin, according to an analysis of health-care claim data by the Healthcare Cost Institute.

Middleton provided a long list of supplies that make treatment expensive, such as blood-glucose meters, test strips, lancets and syringes. She pointed out a life-saving medication called glucagon, which is used when a person's blood glucose drops dangerously low, that comes in a one-time use emergency kit that in the past has cost her $300 -- with insurance.

She also pointed to a page-long list of other costs to consider, such as more expensive food to accommodate a person's blood sugar fluctuation, the cost of transportation and time-off-work for doctor's appointments, and the ongoing costs of tapes, adhesives and ointments to name a few.

Dealing with these financial barriers

High costs associated with a Type I diabetes diagnosis can lead to medical bankruptcy, significant credit-card debt or even death, Middleton said. She listed the names of 11 people who have died since 2017 because they couldn't afford their insulin.

To overcome some of the financial barriers, some people are traveling to other countries to get their insulin, she said. Some are moving to other states that offer special insurance coverage for kids with Type I diabetes, and several other states are working to cap the co-payment, as Colorado has.

She said many ration their doses, some eliminate the use of insulin pumps and continuous monitors, and some use equipment longer than it is intended. Some use cheap Walmart insulin, which she said is often not preferable, but is all many can afford.

And some who need the drug have taken to trading their insulin and other needed supplies on social media, Bailey Loosemore reports for the Louisville Courier Journal.

Louisville Courier-Journal screenshot from Facebook

"High deductibles, lack of insurance or inadequate insurance have forced people to pay more for their prescriptions," Loosemore writes. And when they can't afford the life-saving drug Marybeth Lacy of Morgan County, who has lived with Type I diabetes for 43 years, and others told Loosemore they have "hoarded insulin, skipped doses and even traded medications with friends or on social media," which Loosemore notes is "technically illegal."

Lacy told Loosemore that she is grateful that her insurance covers all the cost of her prescribed insulin, which would otherwise cost more than $1,000 a month, but it's not the type of insulin that works best for her. Sometimes, she said, the insulin that is not covered and costs her more than $300 for a two-week supply, is the only drug that will work to control her blood sugar.

In her closing PowerPoint slides, Middleton said that she has been told that some will suggest that people with diabetes need to switch to a more affordable "multiple daily injection" therapy, which requires the person to self-inject insulin several times a day as well as constantly self-monitor their blood sugar.

To this suggestion, they said "I should not have to choose between being financially stable and staying out of debt and having the best treatment for my diabetes. The standard of care for diabetes needs to be updated so that insulin pumps and CGM are affordable and available to everyone. The long term benefits to better coverage for the technology will drastically reduce the financial impact of treating complications that arise from improperly managed diabetes throughout life."

What's Kentucky doing?

Two Kentucky legislators are working to fix that. Rep. Danny Bentley, a Republican from Russell who is a pharmacist, pre-filed a bill to cap the cost-sharing price, or co-pay, of insulin at $100 for a 30-day-supply; Sen. Phillip Wheeler, a Pikeville Republican, has pre-filed a bill in the Senate. So far, Colorado is the only state to have passed such a bill; it will go into effect in January.

Wheeler's bill would also require insulin manufacturers and wholesale distributors to issue all customers a rebate for expenses over $100.

Angela Lautner, founder of the advocacy group Kentucky Insulin 4 All, told Loosemore that such a cap could benefit people who receive insurance through state insurance plans or the state-federal marketplace, but it would not help those who are insured through self-funded plans by multi-state employers, because those plans are governed by federal rather than state laws.

During its last session, the legislature passed a Bentley bill to allow pharmacists to dispense insulin and respiratory inhalers in the smallest supply available in an emergency. Kentucky already had a law to allow pharmacists to dispense a 72-hour emergency supply of a prescription medication, but because insulin and most inhalers are not available in doses that small, they couldn't dispense them.

The law is called Kevin's Law for Kevin Houdeshell, an Ohio man with diabetes who died after running out of insulin on New Year's Eve in 2013, despite multiple efforts to reach his doctor to get the refill.

Four students at Grayson County High School taken to hospital after using device to vaporize hashish oil; two arrested

Leitchfield and Grayson County (Wikipedia maps)

Four students at Grayson County High School in Leitchfield were taken to the local hospital Oct. 15, and two were arrested, after inhaling vapor or aerosol from "dab pen" devices, police said.

The Leitchfield Police Department said officers and ambulances were called to the school about after several students became ill after inhaling an "unknown substance" from the dab pens. The four students were treated and released at Twin Lakes Regional Medical Center.

"Dabbing," sometimes called the "cannabis crack," involves "highly concentrated marijuana in a vaporized form," Billy Kobin reports for the Louisville Courier Journal. "According to the Center on Addiction, dabbing often involves inhaling or vaping a Tic Tac-sized drop of butane hash oil, a gooey liquid which contains a high concentration of tetrahydrocannabinol (THC), the psychoactive ingredient in marijuana.

At least 12 students "had used the dab pens and were experiencing the same symptoms, according to Leitchfield police," Kobin reports. "Additional details on the symptoms were not provided. According to the National Institute on Drug Abuse and Center on Addiction, dabbing can result in symptoms that include rapid heartbeat, loss of consciousness and psychotic reactions like paranoia and hallucinations."

After searching a Leitchfield residence, police said they located more of the substance found in the dab pen, Kobin reports: "Two juvenile suspects were arrested and charged in connection with the dabbing incident, according to Leitchfield police. The charges include 12 counts each of first-degree wanton endangerment and trafficking in a controlled substance, with additional charges pending."

Kobin notes, "The Grayson County incident comes as health officials have reported over 1,000 cases nationwide of a lung illness that has been linked to vaping devices and e-cigarettes and has killed over two dozen people."

Bevin and Beshear hotly debate governor's Medicaid work rules, their effect and their cost; and their stands on health insurance

Gov. Bevin and Attorney General Beshear debated Oct. 15. (Photo by Ryan Hermens, Lexington Herald-Leader)

By Melissa Patrick
Kentucky Health News

A key difference between Kentucky's gubernatorial candidates is that one wants to require most able-bodied adults on Medicaid to work or participate in other "community engagement activities" in exchange for their health insurance, while the other says he would immediately dismiss such a proposal if elected because it's designed to kick people off of the Medicaid rolls.

Republican Gov. Matt Bevin and his administration have tried to add such requirements through a waiver of traditional Medicaid rules. It would require, among other things, most of the state's able-bodied adults who gained coverage through the expansion of Medicaid (to people who earn up to 138 percent of the federal poverty line) to work, go to school or take job training 80 hours a month unless they are medically frail or must care for children.

A federal judge in Washington, D.C., has blocked the waiver. On Oct. 11, an appeal was heard by judges who indicated they are unlikely to revive it. Bevin has said he expects the Supreme Court to decide the issue. He has issued an executive order that would end the Medicaid expansion six months after a final ruling against his plan.

The televised debate at the University of Kentucky Oct. 15 was the first time Bevin and Attorney General Andy Beshear had locked horns over this issue and it was a lively exchange.

Bevin said, "I am a strong proponent of able-bodied, working-aged men and women who do not have dependents and have the capability of going to work, to go to work in exchange for that which is provided for them by people who do go to work."

The governor said he has empathy for such people, telling his oft-told story of how he was raised poor and no health insurance until he joined the Army.

"I also know that it is an amazing degree of bigotry that allows people to assume that someone like myself had no opportunity, needed to be babied, needed to be put in a position where I was given things as opposed to opportunity and an expectation that I seize that," he said. 

Bevin said expanded Medicaid should be "available for those who need it and the medically frail and women with children," he said.

Beshear disagreed. After calling health care "a basic human right" he declared that if he was elected Nov. 5 he would drop the waiver, which would require those covered by the community-engagement rules to report their hours monthly and be locked out of the program for non-compliance.

"This is red tape. This is paperwork and it is intended to tear healthcare away from people," Beshear said. "I will always stand up against that, and I'm going to rescind that Medicaid waiver in my first week of office."

Beshear noted that after Arkansas implemented Medicaid work requirements,where 18,000 people lost their coverage before the same judge who got Kentucky's case blocked the program,  "The vast majority of people who lost their coverage were already working," he said.

Harvard University researchers have found that most of those affected by the Arkansas work requirements were already working and likely lost coverage because of a "lack of awareness and confusion about the reporting requirements," Phil Galewitz reports for Kaiser Health News. "They also found that there was no evidence they had either secured jobs or other insurance coverage."

Studies indicate that if appellate courts allow the Kentucky waiver, most who would be affected by its work rules are already meeting them. One study based on polling found that 97% are already meeting the requirements; another, based on claims data, shows 64% are.

Numbers, oversimplified

Beshear added, "Governor Bevin's plan will rip 95,000 people off health care that have it for the very first time and I think that's wrong."

That line had some over-simplifications. Some people on the Medicaid expansion have had health insurance in the past, and the numbers cannot be individualized because tens of thousands of people go on and off Medicaid each month due to changes in their eligibility.

The 95,000 number comes from Bevin's original proposal, which estimated that in five years, Kentucky's Medicaid rolls would have 95,000 fewer people than they would without the waiver. Academic health experts said in a friend-of-the-court brief that a more likely range was 175,000 to 297,500. Medicaid covers 1.4 million Kentuckians, around 450,000 of them under the expansion.

Bevin replied to Beshear, "This isn't about people being, having anything ripped away from them. What I propose is that people work and or volunteer and or go to school or be in training or take care of someone in exchange." Further, he said if a person is already meeting the requirements, as was a person Beshear cited as an example, they have nothing to worry about.

Beshear also noted a recently published report by the General Accounting Office, the investigative arm of Congress, which found that Kentucky has budgeted $272 million in fiscal years 2019 and 2020 to pay for the technology and administrative costs of Bevin's plan, an amount roughly twice the combined expense of four other states that are also working to implement similar requirements.

"And his plan is going to cost $272 million of our taxpayer dollars," Beshear said. He did not note that 87 percent of the money comes from the federal government.

Talking over each other, Bevin pushed back and suggested that  Beshear and "the people who wrote your comments" didn't bother to read the report, saying it would not cost that much.

The report says the budget is based on 620,000 Kentuckians being affected by the new Medicaid requirements, which is a much larger number than has been previously reported but apparently includes people who would qualify for exemptions because of children, frailty or other reasons.

Asked about access to care, Beshear said he would fight to keep "federal health care reform" -- otherwise known as the Affordable Care Act or Obamacare -- and its expansion of Medicaid, which he said is "absolutely critical" to the survival of rural health care and rural hospitals.

"With the current lawsuit that threatens the very future of expanded Medicaid, rural health care is on the line," Beshear said. "Everybody should be able to get the health care coverage they need in their hometowns," he said.

Answering the question about access, Bevin said it is a "form of bigotry" to assume that people can't fend for themselves. "It's easy to say that health care is a right," he said, "but the reality is it's one that costs money."

Requiring insurance for pre-existing conditions

The two candidates also had a noisy discussion about whether Bevin supports taking away  protections for pre-existing conditions.

This stems from his support of association health plans (AHPs), a type of insurance that makes it easier for small employers to band together, free of many of the requirements of the ACA.

Bevin says he doesn't support any plan that denies coverage for pre-existing conditions because the  U.S. Department of Labor clearly says AHPs "may not charge higher premiums or deny coverage to people because of pre-existing conditions."

Beshear says AHPs have loopholes that allow them to deny coverage. For example, AHPs do not have to cover all the essential benefits required by the ACA, such as maternity, mental health or prescription drugs, allowing them to create benefit packages that are of limited use to people with certain health conditions. AHPs are also allowed to vary premiums based on age, gender, industry and geography, which are factors that can be used to predict or anticipate pre-existing conditions.

"You can go to the doctor and learn you have a chronic disease, but it's not covered," Beshear said. "Your kids may get the flu . . . but pediatrics isn't covered. You might get home and find out that you're expecting a child, but maternity is not covered," Beshear said. "This governor supports health care that doesn't cover anybody's basic needs."

Bevin pointed to the Labor Department ruling and said, "These are scare tactics and lies. Nothing I have ever proposed offers any of these things that he is saying. . . .  So everything that you are threatening is not true and the things that you are saying I said are not true."

Pre-existing pool for pre-existing conditions?

Beshear also pointed out that Bevin said we should go back to how pre-existing conditions were treated before federal health reform. To which Bevin said, "I never said that."

Beshear's campaign said he was referring to Bevin's comment that he would support going back to high-risk pools for people with pre-existing conditions, which Kentucky used before the ACA.

Problems with the high-risk pool, called Ky Access, were numerous. It never enrolled more than 4,837 people, cost almost $14,000 a year in 2013 and had a $2 million lifetime cap per enrollee, Lisa Gillespie reported in 2017 for Louisville's WFPL.

"Costs to both the state and individuals rose so much because there weren’t any young, healthy people to balance out all the high medical costs," Gillespie reported. "That’s according to Advocacy Action Network executive director Sheila Schuster. She helped oversee the rollout of KY Access."

“It was essentially a conglomeration of people with high-risk, chronic conditions that were going to be very costly,” Schuster told Gillespie. “The premiums were very high, but it was the only game in town.”

Kentucky ranks 3rd in child obesity, a disease tied to a long list of other health issues; treatment requires changes in family lifestyle

By Melissa Patrick
Kentucky Health News

More than one out of five Kentucky children between 10 and 17 are obese, ranking the state third in the nation, says a new report from the Robert Wood Johnson Foundation.

The state's obesity rate rose to 20.8 percent in 2017-18 from 19.3% in 2016-17, though the report notes that this uptick is not significantly significant. Mississippi had the highest rate at 24.5% and Utah had the lowest at 8.7%. The national rate was 15.3%. The data is from the National Survey of Children's Health.

The report also shows that when it comes to childhood obesity, disparities persist along geographic, racial, ethnic and socioeconomic lines.

Robert Wood Johnson Foundation graphic; click it to enlarge

Dr. Aurelia Radulescu, medical director of the Pediatric High BMI Clinic at UK Healthcare, told Kentucky Health News that this high obesity rate matters because obesity in children is associated with a long list of health conditions that children and their families are often unaware that they have, such as pre-diabetes, diabetes, high blood pressure, non-alcoholic fatty liver disease, high cholesterol and sleep apnea.

"Obesity is a disease,"said Radulescu. "It is not a cosmetic problem."

According to the report, childhood obesity costs the United States about $14 billion per year in direct health expenses.

Childhood obesity also matters because children and teens who are obese will likely grow up to be obese as adults, according to the Centers for Disease Control and Prevention. Kentucky ranks fifth for adult obesity, with 36.6% of its adults obese.

Obesity is calculated through body mass index, essentially a ratio of height to weight. A child is considered obese if the BMI is at or above the 95th percentile for children of the same age and sex; children are considered overweight at or above the 85th percentile. About 40% of the state's school-aged children are either overweight or obese, according to the Kaiser Family Foundation.

It's about health, not weight

Radulescu, who is also a pediatrician and an associate professor at the University of Kentucky College of Medicine, stressed that childhood obesity is about health, not weight: "The cornerstone of treating pediatric obesity and also adult obesity and all these medical complications associated with or resulting from excessive weight gain is healthy lifestyle changes."

Lifestyle changes include improving eating habits, getting more physically active and having good sleep habits, she said. She said children's health improves much faster with lifestyle changes than it does in adults, but to be successful, these changes must involve the whole family.

"When a family is dealing with a child who suffers from obesity, those changes have to be implemented as a family," she said. "It cannot be just an individual."

Other options to treat obesity in older children include taking approved weight-loss medications and bariatric surgery, but both of these options require a commitment to lifestyle changes, she said.

Radulescu encouraged parents to take charge by becoming aware of the weight status of everyone in their home and to talk to their pediatrician or primary-care provider about it if they are concerned.

"Providers often take the lead of the family on this issue," she said.

She acknowledged that the causes of obesity are complex; beyond genetics and lifestyle choices, other contributing factors are policies that don't support health and a general lack of resources. She said everyone must play a part in tackling this issue: the medical community, community leaders, schools and families.

Actions taken and recommended

The Foundation for a Healthy Kentucky has long considered child obesity as one of its core issues. Six of the seven grants it made to address children's health, totaling $3 million, focused on the problem. It has also worked with the Appalachian Regional Commission and the Robert Wood Johnson Foundation on a study of child obesity in Appalachia.

Most recently, along with Kentucky Voices for Health and Cairn Guidance, an education and school-health consulting company, the Kentucky foundation has established a new, statewide coalition to work on policy initiatives to improve children's health in school settings.

"The foundation is committed to bringing to bear this cross-sector coalition approach to address this issue through policy advocacy in the same way that we are working to reduce tobacco use in the commonwealth," said Bonnie Hackbarth, the foundation's vice president for external affairs.

To ensure more children grow up with a healthy weight, the report offers a long list of policy suggestions.  One is that the U.S. Department of Agriculture rescind its proposed changes to the Supplemental Nutrition Assistance Program, previously known as food stamps. If allowed to proceed, the changes will result in millions of participants losing their benefits, says the report. According to Center on Budget and Policy Priorities, more than 68% of Kentucky's 655,000 SNAP participants in 2017 were families with children.

Among other recommendations, the report also calls on the USDA to maintain the nutritional standards for school meals that were in effect before December 2018; and that the Centers for Disease Control have adequate funding to provide obesity campaign grants to all 50 states.

Kentucky is one of 16 states that got such a grant. It received $856,326 to use for evidence-based strategies at the local level to improve nutrition and physical activity. It will be allocated to 11 community health departments in Eastern and Western Kentucky.

The state Department for Public Health suggests the "5-2-1-0" prescription to significantly reduce childhood obesity: five or more servings of fruits and vegetables each day; limit screen time to no more than two hours a day; be physically active for at least one hour a day; and drink zero sweetened beverages. The website offers free resources to help meet these goals.

Attorney general hopefuls say they'd go after opioid makers

Both candidates for attorney general of Kentucky said Monday night that they would press legal action against manufacturers of opioids, and Democrat Greg Stumbo said he would pursue criminal charges against the Sackler family that owns Purdue Pharma, the make of Oxycontin.

"They are killing 30 Kentuckians a week," Stumbo said in a 55-minute forum with Republican Daniel Cameron, a former aide to U.S. Senate Majority Leader Mitch McConnell, on KET's "Kentucky Tonight."

Cameron said he would reopen the "paltry" $24 million settlement that the state got from Purdue Pharma in a lawsuit that Stumbo filed in Pike County as attorney general in 2004-07. The case was settled by his successor, Democrat Jack Conway, at the end of 2015.

Stumbo said he would seek to reopen the case if he finds that Purdue Pharma representatives lied in responding to questions in it.

Stumbo, 68, put more emphasis on the drug issue than Cameron, 33, and made his closing statement entirely about it.

Weekly editor says he's coming to Nov. 15 workshop on drug coverage because 'We cannot continue to wear blinders'

Why should journalists attend a workshop on covering local drug problems?

"We cannot continue to wear blinders and ignore this problem that is now affecting every member of our communities," writes Dennis Brown, editor and publisher of the Lewis County Herald, who has signed up to attend the Covering Substance Abuse and Recovery workshop in Ashland on Nov. 15.

"I’m looking forward to attending the workshop to get some tips on covering what has truly become an epidemic for our area," Brown told the University of Kentucky's Institute for Rural Journalism and Community Issues, which publishes Kentucky Health News and is holding the workshop with Oak Ridge Associated Universities.

"The vast majority of law enforcement activity in Lewis County is directly related to substance abuse. Our jail is overflowing," Brown wrote. "The number of deaths in our community attributed to overdosing or long-term substance abuse has skyrocketed."

Brown reported that he has written stories "on school teachers, politicians, and otherwise 'good' community members who have fallen victim to this demon. . . . I feel we should be directing much more of our attention to this matter and exploring ways we can help curb the spread of addiction and provide our community members with information on helping themselves and/or family members through the limited available avenues of recovery."

The workshop will be held at the Marriott Delta Downtown from 8:30 a,m. to 5:15 p.m. Nov. 15. space is limited, and the earlybird registration rate of $50 is good until Nov. 1. Registration will close Nov. 8. Click here to register. 

The presenters include Pulitzer Prize winners Eric Eyre of the Charleston Gazette-Mail and Terry DeMio and Cara Owsley of the Cincinnati Enquirer. Beth Macy, award-winning author of Dopesick: Dealers, Doctors, and the Drug Company That Addicted America, will appear via Skype. Sharon Burton, editor and publisher of the Adair County Community Voice in Columbia, a national leader in substance-abuse coverage by weeklies, will discuss her recent efforts.

"The lineup of presenters for the workshop have the background and experience to arm journalists with the information we need to do the job we should be doing," Brown writes.

Research by ORAU has shown that the stigma attached to drug use and addiction are major obstacles to news coverage of the problem, which makes it harder for communities to find solutions.

The workshop will be preceded by informal gathering at the Delta hotel on Thursday evening, Nov. 14. A room block with a favorable rate of $109 a night is available at the Delta. The registration site has a link to the hotel reservation site. Please contact Institute Director Al Cross with any questions: al.cross@uky.edu.

Lawmakers say drug stores' issues with Medicaid pharmacy benefit managers will be a key issue in the next legislative session

By Melissa Patrick
Kentucky Health News

State Rep. Danny Bentley didn't mince words when he told a health advocacy group that a priority of the next legislative session will be to deal with pharmacy benefit managers' Medicaid payments to drug stores.

Independent pharmacies in Kentucky and around the nation have said for years that the problems are so bad that PBMs threaten their survival.

L to R: Reps. Russell Weber, Joni Jenkins and Danny Bentley
and Sens. Stephen Meredith and Morgan McGarvey

"I'm ready to do away with all of them," Bentley said, adding later, "PBMs are not honest, period."

Bentley, a Republican from Russell in Greenup County, was speaking as part of a legislative panel titled, ""Preparing for the 2020 General Assembly" at the Oct. 11 Kentucky Voices for Health annual meeting in Lexington.

In his effort to explain what PBMs do, Bentley first noted that he had dealt with them for 44 years as a registered pharmacist and opined, "Really, they don't do anything." He said one of the main issues with them is their lack of price transparency and the lack of legislation to require them to be so.

PBMs are middlemen between insurers and drug manufacturers. They determine what drugs are offered, how much someone pays for the drug, and the payments to pharmacists.

Lawmakers have been working on PBM issues for years. Most recently, in 2018, they passed Senate Bill 5, which let the Department of Medicaid Services, rather than managed-care organizations that handle relations between patients and health-care providers, set pharmacists' reimbursement rates.

The law lets the agency regulate contracts between the MCOs, pharmacists, and PBMs; requires more transparency in how PBMs spend the $1.7 billion a year they get for processing prescriptions in Kentucky; and gives the state authority to penalize the MCOs and PBMs for noncompliance.

In a report earlier this year, "Medicaid Pharmacy Pricing: Opening the Black Box," the state said two PBMs kept $123.5 million last year from the Medicaid program by paying pharmacies a lower rate to fill prescriptions, while charging the state more for the same drug.

Medicaid Commissioner Carol Steckel assured members of the Medicaid Oversight and Advisory Committee in July that the state was committed to resolving the payment issues of PBMs, which she called "predators." The state is negotiating contracts with the MCOs, which will take effect in July 2020. MCOs hire PBMs to oversee their drug benefits.

The attorney general's office is investigating whether PBMs have overcharged the state and discriminated against independent pharmacies.

Ohio is among the states that have tried to rein in questionable payment practices of PBMs. Last year, two Ohio PBMs "billed Medicaid $244 million more in a single year than they paid pharmacies, allowing them to profit three to six times the industry standard," Catherine Candisky and Darrel Rowland reported for The Columbus Dispatch.

Ohio Medicaid officials, among other things, then banned "spread pricing," in which a PBM keeps the difference between what it bills Medicaid and what it pays the pharmacy; and imposed a "pass-through" pricing model, which requires PBMs to pay pharmacies the same amount they bill the state.

A new analysis shows that this new model "netted an additional $38 million, a 5.7% increase, in the rates paid pharmacies to fill prescriptions during the first quarter of this year compared with the final quarter of last year," the Dispatch reported.

Kentucky's Medicaid department told lawmakers in July that one of the proposed changes in the state's new MCO contracts will require all PBMs to use a "pass-through model" of payment.

Other states have fired their PBMs. Michigan has proposed to fire its PBMs and manage its drug program itself starting Dec. 1, which is expected to save the state $40 million; California will shift all Medicaid benefits from PBMs by 2021; and West Virginia fired its PBM in 2017, Axios reports.

Steckel, the Kentucky Medicaid boss, said in July that she was using Kentucky data to replicate a West Virginia study showing the impact of removing pharmacy services from MCOs, which is what the Kentucky pharmacists' lobby and many legislators want. The West Virginia study found that the state saved $54 million by removing prescription drugs from Medicaid managed care.

State Sen. Ralph Alvarado spoke at the Kentucky Voices
for Health annual meeting. (Photos by Melissa Patrick)

Sen. Ralph Alvarado, the lieutenant governor candidate running with Gov. Matt Bevin, did not participate in the panel, but spoke to the group briefly beforehand. He said if the state's analysis shows it would make financial sense to remove pharmacy services from the MCOs, "you can expect that to be brought back in" to the government.

Also on the panel were Rep. Joni Jenkins and Sen. Morgan McGarvey, Democrats from Louisville, and Sen. Stephen Meredith of Leitchfield and Rep. Russell Weber of Shepherdsville, Republicans.

The legislators said other issues likely to be brought up in the next session are medical marijuana; expanding nurse practitioners' scope of practice; insulin cost; health department funding; and electronic cigarettes. Weber, who sits on the Public Assistance Reform Task Force, said he was not sure if it would recommend legislation.

Alvarado told the group that he and Bevin had discussed ways to approach e-cigarettes, which as of Oct. 8 had been associated with 1,299 cases of lung injury and 26 deaths in the U.S. He said the ideas include outlawing "vaping" altogether, as a few states have done; taxing it at a higher rate and using the money to pay for education and getting people off of tobacco products; and placing all e-cig products behind the counter and requiring proof of age, with limits on purchases. He said that would allow adults who want to use the products in order to quit smoking combustible tobacco to get them.

Federal appeals-court judges indicate they are unlikely to revive Gov. Matt Bevin's plan for work requirements in Medicaid

Bevin is running for re-election on his Medicaid plan. This
mailer is from Americans for Prosperity, a conservative group.

Federal judges were dubious Friday of Republican Gov. Matt Bevin's campaign to add work requirements to the Medicaid program, as they heard an appeal of rulings that have blocked it.

“People are going to lose coverage … and you haven’t addressed that,” Judge Harry Edwards told Trump administration lawyers during oral arguments at the U.S. Court of Appeals for the District of Columbia Circuit in Washington.

Edwards and the other two judges asked how the plan would "fulfill the central objective of Medicaid, which is to ensure health coverage to the nation's most vulnerable citizens," reports Deborah Yetter of the Louisville Courier Journal.

"The government argued that in order for states to maintain a certain level of quality of coverage for everyone, states can compel able-bodied adults that are covered by Medicaid under the Affordable Care Act to work for a certain amount of time each month to promote general physical health and financial stability," Alexandra Marquez reports for the Lexington Herald-Leader.

The law doesn't allow "states to make people prove they are working in order to keep coverage, said Judge David Sentelle, brushing aside arguments from the states that requiring people to prove they are working or volunteering could make them more engaged in their communities and become healthier," Yetter writes.

Sentelle was appointed by Ronald Reagan, and Edwards by Jimmy Carter. Judge Cornelia Pillard, a Barack Obama appointee, "questioned claims by states and the Trump administration that the changes could help make people healthier and move from Medicaid to commercial insurance," Yetter reports:

"Where is the evidence that this kind of stuff is even plausibly going to have that effect?" she asked Alisa Klein, a U.S. Justice Department lawyer representing the Trump administration, which has approved such plans in nine states and has 10 more requests pending.
"It is very difficult to prove causation," Klein said.
"Indeed," replied Pillard dryly, triggering a burst of laughter in the packed courtroom.

Bevin wants to require "able-bodied" Medicaid members without children to spend 80 hours a month working, going to school or taking job training, and report their hours monthly. His administration has estimated that in five years, the state's Medicaid rolls would have 95,000 fewer people with the rules than without them, with noncompliance being one of the main reasons.

Kentucky was the first state to get work requirements approved, but a lower-court judge blocked its plan and one that had already taken effect in Arkansas.

"There is no set date for a judges’ ruling on the case, but the Justice Department has asked for an expedited decision," Marquez reports. "Depending on the decision, the suing Kentucky and Arkansas residents or HHS will have the option to appeal the case to the entire D.C. Circuit Court of Appeals or directly to the Supreme Court," either of which can refuse to hear the case.

Bevin has said he expects the Supreme Court to decide the issue. He has issued an executive order that would end the Medicaid expansion six months after a final ruling against his plan. His opponent in the Nov. 5 election, Attorney General Andy Beshear, has promised to drop the work rules.

Beshear's father, then-Gov. Steve Beshear, used the 2010 reform law in 2014 to expand Kentucky Medicaid to about 500,000 people with incomes less than 138 percent of the federal poverty level. That limit is $23,336 for a couple and $35,535 for a family of four. The federal government pays 90 percent of the expansion's cost, and about 70 percent of the cost of traditional Medicaid.

The Trump administration is giving states hundreds of millions of dollars to implement work rules. The General Accounting Office of Congress said Thursday that the Centers for Medicare and Medicaid Services is "not conducting adequate oversight" of the money, but "CMS rejected GAO’s recommendation to consider the administrative costs of such programs when looking at whether [they] are budget neutral," which the law requires, James Romoser reports for Inside Health Policy.

"Work requirements may cause significant increases in Medicaid administrative costs as states seeking to adopt the policy update their eligibility and enrollment systems, educate beneficiaries, train staff, and develop ways to monitor compliance," Romoser writes. "According to GAO, CMS officials said the agency did not review the Kentucky contract and approved Kentucky’s request based on the state’s assertion that the costs were specific to technology."

Kentucky's budget of $271 million for the work (more than $100 million of which has been spent, 87 percent of it federal money) is much larger than the five other states examined by the GAO. That's apparently because it presumes that the plan would affect 620,000 Medicaid members, a much higher number than previously published. The GAO report, which includes many details about the programs in the five states, says the figure includes people who might qualify for an exemption, so it could reflect the total number of expansion members over three years; tens of thousands of members go on and off the program each month.

Feds will remind doctors to ask people with respiratory illness whether and how much they use electronic cigarettes

Federal health agencies are about to warn doctors that they need to ask "every patient with an apparent respiratory infection" about their history of using electronic cigarettes, Julie Steenhuysen of Reuters reports.

The Centers for Disease Control and Prevention said many of the early symptoms of e-cigarette injury are the same as common respiratory infections and influenza, and flu season has started.

Through Oct. 8, the CDC and state health agencies had confirmed that 1,299 Americans, most of them under 35, had confirmed or probable lung injuries linked to e-cigarettes, and 26 had died.

"Of 573 patients whose vaping habits have been evaluated so far, 76 percent reported using THC, the psychoactive ingredient in marijuana," Reuters reports. Some also used nicotine e-cigarettes; nearly a third said they only used THC products, while 13% said they only vaped nicotine.

"In addition to flu, many respiratory infections, including fungal infections, can cause symptoms that could confound doctors and delay a vaping injury diagnosis," Reuters notes.

West Nile virus blamed for a death in Louisville

Health officials have confirmed that one person in Louisville has died from West Nile virus and one other has been infected with it, Billy Kobin reports for the Louisville Courier Journal. 

No details have been released about the patient's death, due to patient privacy, Kobin reports.

Ann Robinson Burks, who was infected with the West Nile virus in September, told the Courier Journal that she is still fighting the virus.

Most people with the virus do not experience symptoms, according to the Centers for Disease Control and Prevention. But about one in five who are infected will develop a fever with other symptoms such as headache, body aches, join pains, vomiting, diarrhea or rash. 

Most people with the virus will recover completely, but the CDC warns that about one in 150 people with the virus can develop a serious illness, like inflammation of the spinal cord or brain. Older people and those with certain medical conditions, such as cancer, diabetes, hypertension, kidney disease and organ transplants, are at greater risk for serious illness if they contract West Nile.

The West Nile virus is most commonly spread to humans by bites from infected mosquitoes.

There is no vaccine or specific antiviral treatment for the virus. To reduce your exposure to mosquitoes minimize your time outside when mosquitoes are most prevalent, such as dawn, dusk and early evening, wear clothing that covers your skin when outdoors, apply mosquito repellent and to cover your infant's stroller or playpen with mosquito netting.

Medicare open enrollment begins Tuesday, Oct. 15

The open enrollment period for Medicare begins Tuesday, Oct. 15 and runs through Dec. 1. This is the period in which Medicare beneficiaries can select new health-insurance plans and adapt to changes in costs and coverage and their health-care needs. If they do nothing, their current coverage will continue in 2020.

The new year will see the end of the Medicare Part D "donut hole." Beneficiaries will pay no more than 25 percent of the cost of brand-name and generic prescription drugs after any deductible, until they reach the limit on out-of-pocket spending. Also, some Medicare Advantage (Part C) plans will offer nontraditional services, such as transportation to a doctor's office, home safety improvements, or services of nutritionists.

"Because Medicare is such a large program — serving close to 60 million or almost one in five Americans — it’s also a big target for scammers," the Danville Advocate-Messenger says in an editorial. It notes that the Kaiser Family Foundation "recommends using the Medicare.gov website or calling 1-800-MEDICARE (633-4227) to find a Medicare plan you like."

The foundation has many frequently asked questions about Medicare, with answers. It advises, “If you are covered by Medicare, and you are interested in reviewing and comparing your Medicare options, make sure the plans you are considering during the Medicare open enrollment period are Medicare plans, not Marketplace plans. Medicare plans are not sold through the federal or state Marketplace websites,” which are used to sell federally subsidized insurance under the Patient Protection and Affordable Care Act, often called Obamacare.

States crack down on opioid treatment scams that can kill

An opioid treatment scam is snaring young adult victims across the nation, sometimes leading to patients' deaths after enrolling in programs that provide poor or nonexistent treatment. The scam hasn't been reported in Kentucky, but the state is susceptible to it because of its high levels of addiction and prescriptions for the most common drug used in medication-assisted treatment.

"Here’s how the scam works: Seemingly caring people join recovery-related online chat groups, answer addiction hotlines advertised online, or show up at fundraisers for addiction recovery. They typically say they’re in recovery themselves and are therefore uniquely qualified to help," Christine Vestal reports for Stateline. "People with addiction and their families often don’t want to ask their doctors or pastors for help because they’re ashamed and want to hide their illness. So, turning to a stranger can be appealing."

The scammers, who call themselves "patient brokers," usually sweeten the deal by offering free plane tickets and pocket money as well as waiving insurance deductibles. Patient brokers can make as much as $2,000 in commissions per patient, plus extra money when they re-enroll the same patients after relapse, Vestal reports.

"Within two to four weeks of a patient checking into a sober home where treatment is subpar or nonexistent, insurers may stop paying claims under standard protocols for that type of service, and the fraudulent operators dump their young clients on the street, prosecutors say," Vestal reports. Many then begin using drugs again and many end up homeless.

Some get lured into other fraudulent treatment programs, which insurers are required to pay for. "Past cases show that the cycle can continue until the insurance company stops paying on the patient’s 26th birthday, when the Affordable Care Act allows insurers to drop dependent care coverage under a parent’s policy," Vestal reports. In addition to spotty or nonexistent treatment, many of the fraudulent programs make extra cash by ordering excessive numbers of urine drug tests to extract more money from insurance companies.

Several states have enacted laws to outlaw patient brokering and crack down on the bogus treatment programs: Arizona, California, Florida, New York, Tennessee, and Utah. Donna Johnson, who lost her son after falling for a treatment scam in Florida, says she worries scammers are setting up shop in Maryland, and has persuaded state Rep. Karen Lewis Young to draft a similar bill, Vestal reports. Florida officials are talking to advocates in Georgia, North Carolina, New Jersey, Ohio and Pennsylvania about creating their own laws.

The anti-kickback laws work, according to Florida officials. The state enacted the nation's first such law in 2016, which has served as a template for other states' laws, Vestal reports. In Palm Beach County, for example, where fraudulent treatment programs were popular, drug overdose deaths dropped from 647 in 2017 to 400 in 2018, a nearly 40 percent decline.

There's a federal anti-kickback law, but it "only applies to federal health care programs and is not broad enough to address the full range of false marketing, insurance fraud and patient brokering that is occurring in the industry," Vestal reports.