Issues between managed care companies and Kentucky Medicaid providers still mar the state's implementation of the program

By Molly Burchett
Kentucky Health News

For many health care providers in the state, implementation of Kentucky’s Medicaid Managed Care system has been taxing, but Cabinet for Health and Family Services officials say the state is taking steps to resolve disputes between these medical providers and managed care organizations.

Despite previous attempts by state officials to address these issues, providers like Sen. Danny Carroll, chief executive officer of Easter Seals West Kentucky, an organization that provides care for disabled adults and youths, continue to complain about both delayed or denied Medicaid payments and burdensome bureaucratic hurdles, Kevin Wheatley reports for cn|2's Pure Politics.

Carroll, a Paducah Republican who chaired Thursday's legislative committee meeting, is not alone. Other nonprofits and providers serving the Medicaid population say they are still struggling to stay financially viable and deal with managed-care organizations that are not state-based and that have different rules.

“It’s very frustrating trying to navigate the rules of all the different MCOs and all the different requirements, and it’s taxing on staff, it costs more money,” Carroll said. “Being a nonprofit, we need those funds to operate, and we’re having to focus more and more on how to navigate the system to get prior authorizations approved. One MCO requires a prior authorization every 60 days. Some it’s longer, and the rules have changed fairly frequently over the last few years,” said Carroll.

Medicaid Commissioner Lisa Lee

Lisa Lee, commissioner of the Department for Medicaid Services, told the legislative panel that the state has attempted to resolve many of those criticisms in new MCO contracts that took effect July 1. These efforts included provisions like "requiring standardized forms for all five managed care groups, utilizing national uniform standards to credential health professionals and adding stiffer penalties for non-compliance," Wheatley reports.

Lee noted that Medicaid has 1.2 million members "and we have thousands of providers, and I know that we do have some issues and when we have those issues, they seem to be bigger than what they are. But we are able to do provide many services that were not provided by the traditional fee-for-service model," citing one MCO that sent a case worker to the emergency room at midnight to help one Kentuckian during a crisis situation.

Carroll and others on the committee complimented the cabinet for its work to resolve issues between providers and MCOs, but Carroll said he wished the state had greater oversight of MCOs.

He cited one Medicaid provider who has seen an increase in the percentage of Medicaid patients in his practice and has had to borrow money to make payroll: "So you tell me, is the system working under those circumstances?"



Such questions are part of the overall discussion of Medicaid expansion and the millions of dollars it may cost the state as the federal dollars decline, said Carroll. The state will begin paying a portion of expansion expenses in 2017, when the federal government will cover 95 percent, decreasing to the federal health reform law's floor of 90 percent in 2020.

Lee said the Medicaid expansion has put $2 billion into the state's economy and “has been very positive because we know that a dollar’s not spent once,” she said. “The Medicaid program pays the providers, the providers pay their employees, their employees go to the grocery store, they go spent that money in other ways out into our economy.”

However, if fewer providers are available to Medicaid patients because of managed care, regulatory requirements and low Medicaid reimbursements, critics say the Medicaid expansion won't give people the care they need and will be a continuing burden on hospital emergency rooms.

Scott County schools will have a smartphone app to let parents see cafeteria menus, look up nutritional content

For parents who have children with food allergies, it can be stressful not to know what will be served in the cafeteria. Scott County Nutrition Director Mitzi Marshall is researching two smart-phone apps that inform users of what will be served for breakfast and lunch each day at school, Dan Adkins reports for the Georgetown News-Graphic.

"Parents are on the go," Marshall told the school board. "If you're working, it's here at your fingertips." The app will also let parents single out certain food allergies and determine which dishes their children should not eat, Adkins writes. Marshall said the one app, NutriSlice, will also let parents look up nutritional content for each meal.

"Nutritionals automatically pop up, so this will help the nurses with carb counts, families . . . There are the sugars for diabetics, the carbs," Marshall said. She did not yet specify when a decision will be made about which app to implement.

Legislative freshmen's bipartisan bill, now law, lets tax refund to go to pediatric cancer research, or part of it to rape crisis centers

Gov. Steve Beshear held a ceremonial signing Aug. 12 of a bill that creates a option on individual state income-tax returns to divert refunds for the study and treatment of pediatric cancer. “Cancer is the second leading cause of death in children,” Beshear noted.

From 2008-2012, Kentucky had approximately 200 cases each year of cancer among people up to the age of 19, according to the National Cancer Institute.

“This legislation will fuel innovative pediatric cancer research being done here at the University of Kentucky and will directly benefit some of the sickest children in the Commonwealth,” said Dr. Michael Karpf, UK's executive vice president for health affairs. “Thanks to this bill, now all Kentuckians will have the opportunity to advance pediatric cancer research.”

The bill was sponsored by freshman Sen. Max Wise, R-Campbellsville, whose young son is a pediatric cancer survivor. It became law June 24. Wise said he dedicated the bill “to the families who have been affected or are dealing with pediatric cancer,” and called it a testament to legislative bipartisanship.

The bill also allows individuals to designate a portion of their tax refund to a new trust fund to support rape crisis centers, incorporating legislation sponsored by freshman Rep. Chris Harris, D-Forest Hills (Pike County).

Boone County Schools strategically implement healthy changes to lunch menu

Boone County Schools began serving healthier food and offering low-fat, low-sodium meals in their lunchrooms before the Healthy, Hunger-Free Kids Act was implemented in 2010, Amy Scalf reports for the Community Press.

"Whole grain is our largest issue," Food Service Director Barbara Kincaid told the weekly paper published by The Cincinnati Enquirer. "We work really hard on that because some students find these products unacceptable. . . . Sometimes we don't point out that items are whole-grain, but they are."

Dr. Randy Poe, superintendent, said nutrition education is important in the school environment: "A healthy child can make healthier choices, which leads to improved academic performance. So, it's beneficial to not only make sure our students are eating healthy but to make sure they understand the importance of eating healthy and how it affects their brain, body functions and growth."

Kincaid said introducing new foods is a little easier with younger students, and "adding unusual vegetables as a garnish can generate interest among students," Scalf reports. "The students get used to seeing them and begin to try them," Kincaid said. "Kids who say they don't like tomatoes may try them if they're offered as a garnish." They have been careful to make a few changes at a time. Boone County school cafeterias no longer serve foods with trans fats and high-fructose corn syrup.

"Nationwide, there's a 15 percent reduction of kids eating school lunches," Kincaid said. "In the past four years, there has been a 7 percent reduction in Boone schools. That's significant, and it's still troublesome to me because those are kids we're not feeding, and I want to feed all of them."

Ashland teachers will incorporate physical activity into lessons

Teachers from Ashland Independent Schools attended a Take 10 workshop to learn how to incorporate physical activity into the classroom, Adam Black reports for The Independent: "The program, which has been provided . . . through a grant, encourages teachers to give students 10 minutes twice a day in physical activities while learning core curriculum subjects."

The workshop included colorful scarves, stress balls and Chinese jump ropes. Teachers said the alphabet backwards while jumping rope and used scarves to write out letters. John Smith, educational consultant for Flaghouse Inc., said, "There is a 42 percent obesity rate in the Ashland area." Smith told teachers who attended the workshop that the Take 10 program could positively affect their schools. "Kids get better test scores after physical activity," he said.

Smith demonstrated activities students could do even in a small classroom and shared some analogies and stories with the group. "Imagine you are a car, and you fill your tank up, drive around the block and fill up again. Eventually you will explode since you're not burning it all off," he said, Black writes.

"They are really practical activities that don't require a lot of prep time," said Oakview Elementary School music teacher Braun Ream.

UK doctors use remote ultrasound program to care for at-risk expectant mothers in rural areas

Sonographer Laura Bates moved a camera in Manchester
while a doctor at UK talked with patient Mary Sizemore.
(Lexington Herald-Leader photo by Andrea Noell)

"Care often is best delivered close to home," Dr. John O'Brien, director of maternal fetal medicine at UK HealthCare, told Mary Meehan of the Lexington Herald-Leader. That's why he and other UK doctors are providing remote care for at-risk mothers in rural areas through the Blue Angels program.

Finding money and transportation to travel to Lexington, and navigating the campus, can be challenging and stressful, especially for mothers who are concerned about the trip's potential impact on their unborn children. Instead, "O'Brien reviews ultrasounds in real time via an Internet connecting using a specially designed portable ultrasound machine with a specially trained sonographer," Meehan reports. 

Patient portals at Leitchfield hospital are breached in cyber attack; officials say it did not involve any data in state system

By Melissa Patrick
Kentucky Health News

Twin Lakes Regional Medical Center's patient portals were the target of a sophisticated cyber attack earlier this year, which may have breached protected patient health information, reports The Record, a Leitchfield newspaper.

The cyber attack was made on one of the Kentucky Health Information Exchange's patient portal vendors, NoMoreClipboard. KHIE patient portals are secure, online websites that give patients access to their personal health information.

"The NoMoreClipboard breach only affected one hospital, Twin Lakes," Beth Fisher, spokeswoman for the Cabinet for Health and Family Services, said in an e-mail. "The breach affected the patient portal maintained by NoMoreClipboard, not KHIE. No information from KHIE was breached or accessed."

KHIE provides a common electronic information infrastructure that supports the exchange of electronic health information among healthcare providers and organizations throughout Kentucky. It contracts with many different vendors to provide this service.

The security notice from NoMoreClipbard said the data that might have been compromised are: an individuals’ name, home address, Social Security number, username, password, spousal information (name and potentially date of birth), security question and answer, email address, date of birth, health information, and health insurance policy information. The newspaper says that no financial or credit card information was compromised because this information is not collected or stored.

The hospital made the announcement on July 27 and asked patients to not call the hospital "since the breach did not involve any information stored by the hospital or by any local doctor's office," the newspaper writes.

As of July 30, the hospital could not determine the number of people affected by the breach, but said "It should be kept to a minimum since the system was only recently put into place," the newspaper reports.

NoMoreClipboard began contacting affected individuals on June 2, according to the online security notice. It has also established a confidential, toll-free hotline to answer any questions. The hotline is available Monday through Friday, 8 a.m. to 8 p.m. CDT and can be reached at 866-328-1987.

NoMoreClipboard is offering credit monitoring and identity protection services to affected individuals, free of charge, for the next 24 months. Click here to see the security notice sent to its clients.

Kentucky's uninsured rate continues to drop; now 9 percent

The share of Kentuckians who have no health coverage has dropped to 9 percent, according to the latest data from The Gallup Organization. That makes Kentucky second, following Arkansas, among the states in the percentage of formerly uninsured who now have insurance, either with private insurance or the federal-state Medicaid program.

In 2013, prior to implementation of the Patient Protection and Affordable Care Act, Kentucky's uninsured rate was 20.4 percent. The rate dropped to 9.8 percent in 2014 and even further to 9 percent during the first half of 2015, according to the poll. Nationally, the uninsured rate fell from 17.3 percent in 2013 to 11.7 percent in the first half of 2015.

Most of the states with the highest reduction in their percentage of uninsured rates were states that chose to expand Medicaid, establish a state-based marketplace exchange or state-federal partnership, according to the poll results. States that enacted both of these reforms saw a 44 percent reduction in their uninsured rates since 2013, compared to a 28 percent reduction in states that did one of these reforms, or neither.

Kentucky did both, creating its own state-based exchange, Kynect, and expanding Medicaid to those making up to 138 percent of the federal poverty rate. More than 521,000 people obtained health insurance coverage through Kynect in 2014, either through a private plan or Medicaid.

A recent Gallup poll released in July found that almost equal numbers of Americans approve and disapprove of the eeform law. This is a huge shift from last year when 37 percent said they approved of the law and 56 said they disapproved. Differences continue to be defined by political party lines, with 83 percent of Democrats and 14 percent of Republicans saying they approved of the law in this most recent poll. The error margin in this poll is plus or minus 3 percentage points.

"This is happening as uninsured rates for most states have continued to decline," the report notes.

For the 2013 poll in Kentucky, the sample size was 2,755, for an error margin of plus or minus 1.87 percentage points. For the first half of 2015, the sample size was 1,350, for an error margin of plus or minus 2.67 percentage points.

New combination vaccine for children, researched at U of L, could reduce number of children's shots if approved by FDA

A new combination vaccine, awaiting its approval by the federal Food and Drug Administration, may reduce the number injections a child in the U.S. must get in order to be fully immunized, according to a University of Louisville news release.

“Hopefully, this vaccine combination will improve coverage rates," Gary S. Marshall, lead author of the study and professor of pediatrics, said in the release. "Studies show that when you use combination vaccines, more kids get vaccinated on time and by two years of age more are fully protected. When you make it easier, you get better coverage.”

The vaccine protects against six childhood diseases: diphtheria, tetanus, pertussis, polio, Haemophilus influenza type b, and hepatitis B. It could mean an infant receives one to four fewer injections, depending on which vaccine combinations are used, says the release.

"A similar hexavalent vaccine has been available in Europe for more than a decade and has resulted in more timely immunizations," says the release.

U of L, led by Marshall, coordinated the multi-center trials for the vaccine, which included nearly 1,500 children across the U.S. Results from these trials are published in the August 2015 issue of Pediatrics.

The research determined the drug to be "effective, safe and well-tolerated," says the release. The Pediatrics report said that the new vaccine provided equal immunity to the existing immunization regimen; children who were given the combination vaccine reported "a slightly higher rate of redness at the injection site and slightly higher rate of self-limited fever following the injections, as compared with the established regimen"; and no adverse health events were reported in either group for six months following the final dose.

“Once it is licensed, we can take pride in having brought this new vaccine to the pediatric community and having done our part to simplify the routine immunization schedule,” Marshall said.

FINANCIAL DISCLOSURE: Dr. Marshall has been an investigator on clinical trials funded by GlaxoSmithKline, Merck, Novartis, Pfizer and Sanofi Pasteur, and he also has received honoraria from these companies for service on advisory boards.

Lawmakers and health officials meet to discuss increased use of heroin during pregnancy and thus, more addicted babies

Health officials and lawmakers met at the University of Kentucky Hospital Aug. 10 to discuss the increasing use of heroin among pregnant women and how this has caused a huge increase in the number of babies being born addicted to the drug.

"The number of infants born with neonatal abstinence syndrome continues to increase, which speaks to the issue of the amount of opioid dependence that's present in our population right now," Dr. Lon Hays, chair of UK's Department of Psychiatry, told the lawmakers, Mike Linden reports for WKYT.

Neonatal abstinence syndrome, or NAS, is the term used for babies who are born addicted to the drug or drugs that its mother took during pregnancy, causing the child to suffer from withdrawal after it is born. Dr. Henrietta Bada, UK pediatrics professor, said that she estimates it costs taxpayers $65,000 on average for the hospital to treat babies with NAS, Linden reports.

Kentucky hospitalizations for drug-dependent newborns increased 48 percent between 2013 and 2014, from 955 to 1,409 respectively, according to the Kentucky Office of Drug Control Policy. In 2000, there were only 28.

“Whenever I would make rounds on the unit at Samaritan up until two years ago, I would hear about oxycodone," Hays told the legislative panel, Stu Johnson reports for WEKU-FM in Richmond."I would hear about hydrocodone. I would rarely ever hear the word heroin. When I made rounds on call the week before last, any woman that I saw mentioned heroin."

Several of the speakers noted the importance of follow-up care, not only for the baby, but also for the mother, saying there are good protocols in place for opiod abuse, unlike other drugs, Johnson reported.

“If you have a good environment and the mothers are treated, then you will have a better outcome," Bada said. "But if you have a mother who’s treated, and then the environment is still lousy or bad, then you cannot see an improvement."

The group met as part of a committee created to oversee implementation and enforcement of the anti-heroin law passed by the 2015 General Assembly.

The governor's office recently announced that Kentucky was one of 11 states chosen to get a $3 million, three-year federal grant to provide expanded substance abuse treatment for pregnant and postpartum women in the Bluegrass and Cumberland regions of the state.

The state has also allotted $1 million to be used for neonatal abstinence syndrome, which is part of a $10 million appropriation of money approved in the heroin bill.

Legislators wary of commenting on study that says Medicaid expansion will pay for itself by creating jobs and tax revenue

By Al Cross
Kentucky Health News

Kentucky legislators reflected mainly partisan attitudes about the state's implementation of federal health reform in a statewide call-in interview show about the state budget Monday night, but were generally cautious in discussing the financial impact of reform.

The lawmakers on KET's "Kentucky Tonight" were Sens. Chris McDaniel, R-Union, and Robin Webb, D-Grayson; and Reps. Rick Rand, D-Bedford, and Steven Rudy, D-West Paducah. Rand and McDaniel chair the budget-writing committees in the House and Senate.

Kentucky Health News asked the legislators if they thought the predictions of the study that says the state's Medicaid expansion of Medicaid eligibility will pay for itself through 2020 – by expanding health-care jobs and raising income-tax revenue – will be proven accurate.

McDaniel, answering first, noted that the expansion enrolled many more people than expected and their benefits would cost the state about $250 million in the next two-year budget, beginning in July 2016. He did not comment on the state-financed study by Deloitte Consulting LLC, which Republican gubernatorial nominee Matt Bevin has called "nonsense."

Rand replied, "We're talking about real people and real people's health," and noted that the expansion has saved the state money in several ways, such as largely eliminating the state appropriation for charity care at the University of Louisville Hospital. He said "Kentucky is one of the unhealthiest states in the United States," and told the story of a constituent who had never had health insurance but was able to get Medicaid treatment for a serious health episode.

"I think the Medicaid expansion is working" and is "creating jobs and reducing costs," Rand said, but also did not comment on the study.

Later in the discussion, Webb said, "I am concerned any the cost, the potential cost, because the numbers have been very elusive." She also said that expanded Medicaid treatment for the mentally ill and substance abusers was "much needed."

McDaniel steered the discussion away from Medicaid to health reform in general, noting that many people with private insurance are paying higher deductibles and "There has been mixed reviews at best about all that's going on."

Asked by host Bill Goodman how will it turn out in Kentucky, McDaniel said that would depend largely on what happens in the election for governor on Nov 3.

Bevin first said he would abolish the expansion, but recently said he would cut costs by making it more like expansions in some other states such as Indiana, where Medicaid clients can pay premiums to get better coverage and get some of their money back if they don't use the benefits. Conway has said the state must find a way to pay for the expansion, while reserving the right to cut back on it.

McDaniel then jumped to a separate subject, the Kynect insurance exchange where Kentuckians with incomes under 138 percent of the federal poverty level can sign up for free Medicaid and others can get private insurance that is subsidized by the federal government.

Bevin has called for abolishing Kynect and moving Kentuckians to the federal exchange. Critics of that idea note that the federal exchange charges a 3 percent fee on policies while Kynect charges 1 percent, but McDaniel said the latter fee is paid by all Kentucky policyholders, even those who don't use Kynect, so those people would pay less. Subsidized insurance through Kynect is available based on income; a family of four can make $95,400 a year and still get a small subsidy

Rand replied, "I think Kynect by any stretch has been a tremendous success. . . . You're probably talking about people who are working, We need to keep Kynect. It's an important part of making a healthier Kentucky."

Rudy, raising yet another subject, said lawmakers "need to look at how providers are being compensated" by managed-care companies that oversee Medicaid clients. He said the closure of the Fulton hospital, in his district, was partly a result of managed-care payment issues.

Rand noted that Gov. Steve Beshear rebid the managed-care contracts to resolve such problems problems, and said "One hospital in my district is in black earlier in the year than ever." He and Webb noted that hospitals have fewer bad debts to write off because more patients have coverage.

Opioid overdose deaths remain a huge concern in poverty-stricken Eastern Kentucky counties; Boston Globe takes note

Drug overdoses from opioid use remain a concern in Eastern Kentucky, especially in poverty-stricken regions where coal mines have shuttered, Brian MacQaurrie reports for The Boston Globe. In 2014 Kentucky had 1,087 deaths from opioid overdoses, more than from traffic mishaps.

In Bell County (Wikipedia map) nearly two-thirds of adults "do not have jobs, and addiction to opioid painkillers has metastasized," MacQuarrie writes. "Miners often turned to painkillers after injuries, and many of their children became dependent on opioids stashed as close as the medicine cabinet. Nearly everyone here knows someone who has become addicted or died from opioids."

"The opioid death rate in 2013 was 93.2 per 100,000 people in Bell County, nearly double that of any other Kentucky county," MacQuarrie writes. "But C. Frank Rapier, who directs a federal task force attacking the epidemic in Appalachia, said the devastation in Bell County also reflects what is happening in neighboring counties, where federal officials believe opioid deaths have been grossly underreported."

"The death rate in Bell County dropped in 2014, but the figure remains troublingly high," MacQuarrie writes. "Many children are raised by grandparents, some mothers prostitute their daughters, and hospice providers lock medications in theft-proof safes at the homes of the soon-to-be deceased. Nancy Hale, who leads the drug-prevention efforts in the region, told him, “We’ve lost a whole generation of people who would have been paying taxes, and buying homes, and contributing to society."

Former state trooper and Pineville native Micky Hatmaker said the blame mostly falls on big pharmaceutical companies for "aggressively marketing painkillers and on unscrupulous doctors and pharmacists who dispense them," MacQuarrie writes. Hatmaker told him, “This thing took over Appalachia like a cancer." Purdue Pharma paid a federal-court settlement of hundreds of millions of dollars in 2007 for its promotion of Oxycontin, and Kentucky has its own lawsuit pending.

In an attempt to eliminate pill mills, Kentucky in 2012 became the first state "to enact a strict mandate that physicians check a patient’s drug history before writing new prescriptions," MacQuarrie writes. As part of the plan, Attorney General Jack Conway has been "aggressively targeting doctors whose practices are designed to profit from addiction." As a result, "prescriptions of oxycodone, a powerful opioid, have dropped 10.5 percent. Prescriptions for hydrocodone—also used to relieve pain—have fallen 11 percent."

Judges have handed down harsher sentences for owners of pain clinics, including a 14-year sentence given in June to the owner of two clinics, MacQuarrie writes. Another area of success "has been Operation UNITE, a large nonprofit group that has carried a drug-prevention message to tens of thousands of students in venues from classrooms to archery camps. More than 3,700 people have received $5,000 vouchers from the group for substance-abuse treatment. And police detectives working with Operation UNITE have removed $12.3 million of drugs from the street since 2003." Operation UNITE has received much federal funding, thanks to House Appropriations Committee Chairman Harold "Hal" Rogers, who represents most of Eastern Kentucky.

The Boston Globe did its story because Massachusetts also faces an opioid overdose epidemic, with 1,256 deaths from opioid overdoses in 2014. That has led to a shared bond between the two states, with Senate Majority Leader Mitch McConnell (R-Ky.) and Sen. Edward J. Markey (D-Mass.) joining forces to ask for a surgeon general’s report on the crisis and detailed answers on how the Department of Health and Human Services will measure progress on opioid deaths and addiction. (Read more)