Cabinet must 'wield the stick' to get managed care under control, state auditor says

Though the state has a solid contract "filled with all the mechanisms you need for enforcement, from the carrots to the sticks," the Cabinet for Health and Family Services has to be more aggressive in cracking down on the managed care organizations (MCOs) that run the state's $6 billion Medicaid system, state Auditor Adam Edelen says.

Edelen, who has been in office a little over four months, discussed managed care with Ryan Alessi, host of cn|2's "Pure Politics." Edelen is reviewing the new system and submitted 10 recommendations for improvement to the cabinet in February.

"The issues have been enormous — providers not being paid in a timely manner, a lack of communication between the cabinet and the MCOs and the providers, has created a system in which there is a lot of uncertainty and a lot of people are being squeezed out," Edelen said.

Couple that with the fact that Appalachian Regional Healthcare, which serves more than 25,000 Medicaid patients, sued two of the three MCOs in charge of the state, claiming they are owed $18 million for services that have been provided. Last week, ARH and MCO CoventryCares came to an agreement after being ordered by a federal judge to negotiate.

Edelen pointed out the broader ramifications of the situation. "If our largest Medicaid provider in the part of the state that needs it most for some reason is not able to operate within the system because they can't manage their relationship with Coventry or vice versa, that represents a structural threat to the system," he said. "We've got to figure out a way to make it work."

In order to do so, Edelen said "the cabinet has got to be willing to wield the stick" and is able to do under the terms of its contracts with the MCOs, which allow the cabinet to cancel contracts, "sanction and punish" the MCOs and make changes to the system. He said new cabinet Secretary Audrey Haynes has a tough job ahead and said "strong leadership" is critical.

When asked if his review looks into what work is being accomplished by the state's 200 employees who used to handle Medicaid — work that is now being managed by the MCOs — Edelen said it hasn't. (Read more)

Meanwhile, the Lexington Herald-Leader weighed in on the lawsuit between ARH and CoventryCares, saying in an April 24 editorial, "Coventry should keep working with Haynes and ARH on solutions. The editorial also stated, "Beshear, a former corporate lawyer, should bring the weight of the governor's office to bear and get busy making his Medicaid managed care contracts work." (Read more)

New oral health coalition expected to spur changes in state

By Tara Kaprowy
Kentucky Health News

For the past 30 years, Dr. Fred Howard of Harlan has been seating patients in his blue dental chair and telling them to open up. When they do, he's seen all kinds of scenarios, from toddlers whose teeth are already rotten from sucking on bottle filled with soft drinks to 20-year-old adults with no teeth at all. On some occasions, children walk in with such a severe abscess in their mouth their eyes are swollen shut.

Though the view can be grim, Howard said he has seen some improvements in his decades of practice, but with new changes in Medicaid managed care, the overwhelming prevalence of children and teens drinking soda pop and an embedded cultural belief in some areas that "teeth are just something to get rid of," Howard concedes that making headway can feel like one step forward and two steps back.

Enter the newly re-established Kentucky Oral Health Coalition, a statewide force whose goal is to ensure Kentuckians have happy, healthy smiles.

Dozens of organizers and stakeholders met in March to discuss the coalition's aims, and a membership drive is underway to build financial momentum. The coalition will promote oral health education, statewide partnerships statewide and advocate oral-health legislation. "I think they will turn into the advocacy group for dental change," said Dr. Julie McKee, dental director for the state Department of Public Health. "They're working hard to come up with a plan. They've got their heads on straight."

One of the major issues facing the dental profession is possible expansion of the scope of practice for mid-level providers, such as dental therapists who can assess, clean teeth, replace sealants, provide fluoride as well as fill cavities and extract teeth. As nurse practitioners do in the medical field, having such providers could help address shortages in rural areas, said Dr. Jim Cecil, former state dental director and coalition steering committee chair. The concept is in practice in 54 other countries, but the only U.S. states with it are Minnesota and Alaska, mainly because of opposition form dentists.

Andrea Plummer, coalition member and senior policy analyst for Kentucky Youth Advocates, acknowledged that scope-of-practice issues "can be a very tense subject" and "there would have to be buy-in" from members of the committee, who include dentists, but discussion is ongoing. Cecil said the issue is "something we'll need to look at and take a stand on eventually."

Howard (pictured with Gov. Steve Beshear at signing of the bill that requires dental exams for students starting school) favors the expansion, but doesn't feel Kentucky's oral-health problems can be solved just by putting more boots on the ground.

"The bottom line is: We can have twice as many dentists, have more dental hygienists, but if we don't change the mindset, if we don't provide the education, I don't think we're going to solve the problem," he said.

To that end, the coalition is also investigating ways to expand school-based health and dental education, either by finding funding, collaborating with groups that are already in place or advocating legislation changes, Plummer said.

A recently enacted state law requires children to get a dental screening before entering kindergarten, but there is little else in the way of legislation that requires schools to offer services to help students with dental problems, Plummer said. "Kentucky law says that students' health does affect their learning and schools should take steps to affect their learning but it's fairly broad," she said.

An analysis by KYA last year showed school districts spend less than 1 percent of their budgets on school health services.

Examining how to get more dentists to accept Medicaid patients is another hot-button issue. Of about 2,200 dentists statewide, only about 600 are enrolled in Medicaid, Cecil said, and "They feel like they're working for free" because of the program's low reimbursements. "In many cases, they're really not meeting overhead."

The administrative burden that comes with these patients has also gotten worse since Medicaid transitioned to managed care, Cecil said. "Everything they do has to be pre-authorized," he said. "That delays approval, delays treatment, delays payment."

Under managed care, Howard said, patients now need to come in twice to get a full complement of X-rays and radiographs done, which can not only make it hard on dental practices, but for patients as well. "The more times they have to come, that gives them more opportunities to miss appointments," Howard said.

The Oral Health Coalition also sees a need for "quality, updated data," Plummer said. Getting data was one of the successes of the first coalition, formed in 1990. Run by volunteers and funded by the dental schools at the University of Kentucky and University of Louisville, it was formed after the General Assembly told the schools that they either needed to work together or one could "risk being shut down," Plummer said. The group had several successes, including working with the state to conduct an oral health survey, lobbying legislators for oral-health measures and holding an annual symposium. But after more than 15 years, "It kind of just fizzled out a little bit," Plummer said. The group went inactive in 2006 but had some assets that the new group will take over.

The group's rebirth began in 2009, when Kentucky Youth Advocates was approached by the DentaQuest Foundation, which is connected to DentaQuest, one of the largest managed-care organizations in the country that administers dental benefits. DentaQuest officials were interested in seeing the coalition resurrected and offered $80,000 to KYA so it could provide the manpower to run it, Plummer said. It was the first time the coalition had funding to back it up. The KYA talked to state stakeholders and discovered "there really did seem to be an interest in putting a coalition back together," Plummer said. Planning began in earnest and in January the steering committee drafted by-laws. In March, 70 people showed up to the first meeting.

That gathering was not just made up of dentists, oral-health advocates and experts, Howard said. Members of the media were present, along with parents, health department officials, school nurses, students and educators. That made all the difference to Howard, who said he is inspired by what changes might occur and what education can take place. "When we have people from all these different venues, we have more of an opportunity to make a difference," he said.

The coalition's next meeting will be July 25. Those interested in attending or becoming members of the coalition can contact Andrea Plummer at aplummer@kyyouth.org or 502-895-8167. Dues for individual members are $25. Government organizations pay $100, nonprofit organizations pay $250 and for-profit organizations pay $500.

Kentucky Health News is a service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Coventry agrees to keep covering ARH patients until June 30

After a two-hour hearing in federal court, managed-care firm CoventryCares agreed yesterday to keep paying Appalachian Regional Healthcare for treating Medicaid patients at its hospitals through at least June 30 while negotiations continue.

"Coventry officials said the state allowed another managed-care provider not to include ARH in its network, which meant a lot of higher-risk, higher-cost patients ended up covered by Coventry," the Lexington Herald-Leader reports. "Blaming the state, Coventry had notified ARH that it was going to terminate its contract Friday. About 25,000 Medicaid recipients in the ARH service area would have been affected."

ARH then sued Coventry in U.S. District Court and asked for an injunction to continue coverage, which Coventry had said it would end yesterday. The state ordered it to maintain coverage for 30 days, and Senior Judge Karl Forester ordered ARH and Coventry to negotiate.

After yesterday's hearing, the adversaries and the state "all said the goal was for patients to continue receiving care through Appalachian Regional Healthcare's hospitals in Eastern Kentucky on a long-term basis," the Herald-Leader reports. "If the health care chain and Coventry reach an impasse, cabinet officials said procedures could be expedited with Coventry's cooperation. That would allow Coventry members to switch to another insurance provider and continue receiving services at ARH, considered the largest health care chain in Eastern Kentucky." (Read more)

ARH has hospitals in Harlan, Hazard, Hindman, McDowell, Middlesboro, West Liberty and Whitesburg, as well as three in West Virginia, including Williamson, on the Kentucky border.

Nurse anesthetists no longer need to be supervised in Ky.

Kentucky will be the 17th state to opt out of a federal requirement that requires nurse anesthetists to be supervised by a physician, a move that Gov. Steve Beshear said will increase flexibility and efficiency in operating rooms.

The Kentucky Hospital Association applauded the effort. "Certified registered nurse anesthetists are an extremely important part of health-care delivery in Kentucky, particularly in the rural areas of the state," said Mike Rust, KHA president. "This opt-out will ensure patient access to quality anesthesia care."

"We've consulted with the Cabinet for Health and Family Services and health care providers, and this is clearly a change we need to make to improve access to critical medical care," Beshear said. "In cases like this, where the federal requirement is an obstacle to some of the best options for delivery of high-quality health care, we're pleased to take this step to opt out."

A 2010 report that analyzed Medicare data for 1999 to 2005 and published in the journal Health Affairs found no evidence opting out of the oversight requirement resulted in more patient deaths or complications. (Read more)

Neat app shows how education, income affect a county's health

Based on the premise that much of what influences health happens outside the doctor's office, the 2012 County Health Calculator uses education and income to illustrate how these factors can affect one's health any county. 

The app estimates how many cases of diabetes would be prevented, how many lives would be saved and how many diabetes costs would be eliminated if income or education levels improved by specific amounts in a specific area. For example, the Pulaski County page shows, "If 5 percent more people attended some college and 4 percent more had an income higher than twice the federal poverty level, we could expect to save 17 lives, prevent 175 cases of diabetes, and eliminate $12 million in diabetes costs every year."

The application also shows which counties have the highest and lowest education levels (best: Fayette County, worst: Clay County) and income levels (best: Oldham County, worst: McCreary County).

The interactive app was developed by the Robert Wood Johnson Foundation and Virginia Commonwealth University's Center on Human Needs and renders "ballpark estimates" of avertable deaths, diabetes and diabetes cost. Researchers obtained education and income data from the U.S Census Bureau and county death rates and estimates of the prevalence of diabetes from the U.S. Department of Health and Human Services. Estimates of diabetes prevalence were based on self-reports by people who responded to the Behavioral Risk Factor Surveillance System. Data on medical spending on diabetes derived from The Dartmouth Atlas of Health Care. (Read more)

Beshear says he will create state health insurance exchange if federal health reform law is upheld

Gov. Steve Beshear said today that he will wait on creating a health insurance exchange under federal health reform until the U.S. Supreme Court rules on the constitutionality of the reform law, which is expected to happen in late June. He said in a press release, “The steps we have taken to date, and the planning process we are putting in place helps ensure the state is able and ready to follow the law.”

The exchange, a requirement of the Patient Protection and Affordable Care Act, would be a market for individual health-insurance policies. It would help small employers insure their employees in health plans and "enable individuals to receive premium tax credits and premium subsidies, and qualify small businesses for tax credits," the release said.

"The state has a $57.8 million federal grant to plan and implement of programs and systems required by the law, including "building an end-to-end eligibility and enrollment system to serve both Medicaid and exchange participants," the release said. "Kentucky previously received two federal health insurance exchange planning grants totaling $8.6 million." (Read more)

With time running short, why wait to issue an order? The court's decision "may impact the nature of the executive action," said Jill Midkiff, spokeswoman for the state Cabinet for Health and Family Services. "The timing of issuance of the executive order will not impact the current work or future work that is being completed to establish a state exchange. There is nothing that we need to accomplish at this point that requires an executive order to be in place."

State tells Coventry Cares to keep covering ARH patients; managed-care firm says it will drop Ashland hospital

The state has ordered Medicaid managed-care firm Coventry Cares to keep paying for its members to be treated at Appalachian Regional Healthcare hospitals for at least 30 days, rather than stopping tomorrow -- when a federal judge will hold a hearing in ARH's lawsuit against Coventry, after having ordered negotiations between the parties. For more from ARH, click here.

Meanwhile, the Lexington Herald-Leader reports that Coventry plans to stop paying for services at King's Daughters Memorial Hospital in Ashland, one of the largest health-care facilities in the region. Hospital spokesman Tom Dearing told the newspaper, "Coventry's obvious lack of commitment to the people of Eastern Kentucky, putting profits ahead of lives, will potentially leave thousands of Medicaid recipients without adequate health care options." He said the hospital had 29,000 cases covered by Coventry from Nov. 1 to March 31. (Read more)

Read more here: http://www.kentucky.com/2012/05/02/2172494/judge-orders-hospital-chain-medicaid.html#storylink=cpy

Appalachian Regional Healthcare asks federal judge to make managed-care firm keep it under contract

Appalachian Regional Healthcare, a hospital chain in Eastern Kentucky and southern West Virginia, is seeking an emergency injunction by a federal judge ordering Coventry Cares to let its Kentucky members continue receiving services from the hospitals, and to avoid widespread layoffs the chain says will happen if the judge doesn't intervene, reports Bill Estep of the Lexington Herald-Leader. Coventry Cares is one of three state-approved companies to provide managed care services through Medicaid. It said it would cancel its ARH contract after Friday, which would affect about 25,000 Medicaid recipients.

With a few exceptions, Coventry members would lose access to treatment or have to travel long distances to get to other facilities approved by the company, which ARH and officials in affected counties say would be difficult for most because they don't have money or reliable transportation to make the trip. Coventry spokesman Matthew Eyles said the company would continue paying for some services at ARH hospitals, including ob-gyn services to women who are more than 12 weeks pregnant and have a relationship with an ARH doctor.

The state switched to managed-care last year as a way to save money, but as Estep reports, the move has been "rocky." Providers have complained about delayed payments from the companies and their cumbersome pre-approval processes for treatments. ARH sued Coventry and Kentucky Spirit, another provider, claiming the companies owed more than $18 million for services ARH had provided.  Estep notes, "The state allowed another managed care provider not to include ARH in its network, which meant a lot of higher-risk, higher-cost patients ended up covered by Coventry, the company said." The company also said the state failed to implement a method to assess risks that would adequately compensate managed-care providers who have more high-risk patients."

ARH and its Coventry patients think the company is trying to get more money out of the state. Many of ARH's patients are covered by Coventry, and ARH spokeswoman said about 300 to 400 jobs would be cut if Coventry cancels its contract. State officials are encouraging continues negotiation between ARH and Coventry. (Read more)

Meanwhile, Bardstown pediatrician and Passport Health Plan board member James Hendrick wrote a letter to the editor of The Courier-Journal offering Passport's services to "help the state get Medicaid back on track." He said he's been very impressed with the nonprofit's "strong and engaged provider network, and an intense focus on delivering services at a cost that doesn’t diminish quality," adding that because Passport is a nonprofit, it's not concerned with appeasing shareholders. Passport has been managing Medicaid in the Louisville region for several years.

Meds-for-meth bill drew record lobbying expenses, not even including radio and newspaper ad campaigns

Makers of over-the-counter drugs spent more than any lobbying interest ever had during a single Kentucky legislative session in their effort to defeat a bill requiring prescriptions for the key ingredient in methamphetamine, Bill Estep reports for the Lexington Herald-Leader.

"The Consumer Healthcare Products Association spent $457,053 on lobbying activities in the first three months of this year's legislative session, according to reports filed with the state Legislative Ethics Commission," Estep writes. "The group's lobbying effort was so dominant that it spent more than the next five groups combined in that period, January through March, according to spending reports."

And the figure doesn't even included hundreds of thousands of dollars that the trade group spent on radio and newspaper campaigns, because the lobby-reporting requirements do not apply to messages aimed only at the general public. The group did report spending on "a phone-bank operation to put people in contact with legislators to voice concerns about legislation to require a prescription for medicine containing pseudoephedrine, which is now available over the counter," Estep writes.

Read more here: http://www.kentucky.com/2012/04/30/2170495/makers-of-cold-medicines-set-new.html#storylink=cpy

The efforts, dating back to 2010, were partly successful. The legislature passed a bill "that will require a doctor's prescription for pseudoephedrine, but only after someone has bought 24 grams of the medicine a year," Estep notes. "A 48-count box of the generic medicine with 30-milligram pills contains 1.44 grams of pseudoephedrine. The bill excludes limits on gel caps and liquid pseudoephedrine." (Read more)

The lobbying effort wasn't only about Kentucky. The makers of Sudafed and other pseudoephedrine preparations are trying to stave off similar efforts in other states, and viewed Kentucky as a sort of firewall after seeing prescription-only laws pass in Oregon and Mississippi.

Read more here: http://www.kentucky.com/2012/04/30/2170495/makers-of-cold-medicines-set-new.html#storylink=cpy

Read more here: http://www.kentucky.com/2012/04/30/2170495/makers-of-cold-medicines-set-new.html#storylink=cpy

Managed-care firm blames state for problems leading to impending end of contract with ARH hospitals

In the face of a lawsuit that alleges it did not pay claims promptly, Coventry Health and Life Insurance Co. blamed the state for problems that have surfaced since managed care was implemented. Coventry has canceled its contract with Appalachian Regional Healthcare, which has sued the company as well as Kentucky Spirit Health Plan Inc., reports Nola Sizemore for the Harlan Daily Enterprise.

"The current crisis would have never occurred except for the commonwealth's failure to make timely and reasonable decisions on three major issues," Coventry Executive Vice President Timothy Nolan said in a letter to ARH President Jerry W. Haynes. The issues are "a failure to implement a risk adjustment methodology, failure to find a solution to the supplemental hospital payment issue and errors in the original data book and failure to ensure all MCOs meet the same robust standards for network adequacy," Sizemore reports. MCOs are managed-care organizations.

Conventry Health and Kentucky Spirit are two of three MCOs chosen to manage the state's Medicaid program. Since they took over Nov. 1, there have been repeated complaints about delayed payments, as well as burdensome rules requiring doctors to get pre-authorization from the companies before they can provide care.

ARH treats about 25,000 Medicaid patients at its eight hospitals. In the past six months, nearly 11,000 Medicaid visits have been made at the Harlan facility alone, with 7,800 of them covered by Coventry, said Mark Bell, community and patient advocate. This will "present a complex and serious crisis for everyone," he said. (Read more)

State prescription drug databases like KASPER cut back doctor shopping and drug abuse, new study shows

Photo by iStockphoto

Research from the University of North Carolina indicates drug databases like the Kentucky All Schedule Prescription Electronic Reporting system do reduce doctor shopping and change prescribing behavior.

Another article showed state drug databases "facilitate a relative decrease over time in prescription drug misuse, despite state differences in program administration," reports Maggie Clark for Stateline, the freshly revised news service of The Pew Center on the States.

A 2010 evaluation of KASPER showed 90 percent of doctors who used the system found it effective in preventing drug abuse and doctor shopping. A new Kentucky law "mandates that all physicians and pharmacists who prescribe schedule II and III drugs, such as oxycodone and hydrocodone, check the patient's prescription records before writing or filling a prescription," Clark reports. Dispensers must also register prescriptions in the state database without 24 hours of writing or filling the prescription.

Clark points out the legislation change sparked a debate about "how to balance patient privacy and law enforcements needs in fighting a serious criminal and public health problem." Attorney General Jack Conway, who wanted KASPER put into his office's hands, lost that fight as part of the legislative compromise. It will remain the responsibility of the Cabinet for Health and Family Services and, by extension, the doctor-run Kentucky Board of Medical Licensure.

Privacy issues have likewise surfaced in Vermont. "The discussion really is about what kind of access the police will have to electronic personal health information," said Allen Gilbert, executive director of the Vermont Civil Liberties Union. (Read more)

Major newspapers publish reflections, reactions and details (including videos) on new law that will fight 'pill mills'

Reflections on the new law to fight "pill mills" are in both of Kentucky's major metropolitan newspapers today.

The Courier-Journal, which rightly takes partial credit for focusing attention on the issue, has a story by Laura Ungar that summarizes what the bill will do and not do. In the Lexington Herald-Leader, Kentucky Medical Association President Shawn Jones has an opinion piece defending his organization's lobbying against key parts of the bill.

"Unfortunately, in a desire to pass something, many did not consider the details of proposed legislation, and many of the details were extremely troublesome," writes Jones, right. "Most troubling were the proposed infringements on patient privacy through access to the state's Kentucky All Scheduled Prescription Electronic Reporting, or KASPER, system, which contains what is essentially a log of all of the controlled substances an individual has bought. A controlled substance is not just what many people have characterized as 'pain medicine.' It also includes prescriptions for medicines for anxiety, depression or attention deficit disorder." (Read more)

Jones is among the people featured in videos posted with The Courier-Journal's story. Others include Dr. Greg Cooper of Cynthiana; attorney Fox DeMoisey, who represents physicians accused of malpractice; and Dr. Patrick Murphy, a pain-management physician, talking about the various responsibilities of doctors in his field.