Rep. Guthrie, in line to head health panel, says priorities include Medicare oversight, Covid-19 origins and price transparency

U.S. Rep. Brett Guthrie, R-2nd District (C-SPAN screenshot)

U.S. Rep. Brett Guthrie of Bowling Green discussed several health issues that Republicans will focus on when they take over the House during an interview with Caitlin Owens of Axios, including price transparency, investigations into the origin of Covid-19 and oversight of the Medicare drug-negotiation provision in the Inflation Reduction Act. 

Guthrie, a Republican who represents the Second District, is in line to lead the health subcommittee of the House Energy and Commerce Committee when the new Congress convenes next month. 

Asked about the evolution of the GOP's health agenda since the days when the party wanted to "repeal and replace" the Affordable Care Act of 2010, Guthrie said there are still things that need to be done with the ACA, noting that the Inflation Reduction Act recently "took $288 billion out of Medicare . . . and put it into subsidies for the Affordable Care Act." 

Actually, $288 billion was not literally removed from Medicare to pay for the ACA subsidies that were increased as part of the Inflation Reduction Act. Instead, the Congressional Budget Office estimated that provisions in the Act to lower prescription-drug costs in Medicare and reduce drug spending by the federal government would reduce the federal budget by $288 billion over 10 years.

Asked about this, Guthrie's office explained in an e-mail that under budget reconciliation rules, new spending cannot be added to the deficit without it being offset. The cost of the enhanced ACA subsidies was only $33 billion, but his office said, "Rep. Guthrie was making the argument, given the score and the reconciliation rules, that these savings from Medicare are being used to offset other parts of the Inflation Reduction Act, including ACA subsidies."

Guthrie's office said he introduced an amendment to the Act to not allow the savings from Medicare to be used to "pay for or offset any program, activity or expenditure that is not with respect to the Medicare program under such title," but the amendment was not considered. 

In the Dec. 7 Axios interview, Guthrie said of the ACA, "It's not sustainable.  . . . Prices keep going up, we subsidize it and it's pricing people out of the marketplace, which still needs to be addressed."

Guthrie said another priority for his subcommittee will be oversight of the implementation of the provisions in the Inflation Reduction Act that authorize Medicare to negotiate prices with drug manufacturers.

He said that the worst thing that can happen in the negotiations is that they will reduce innovation by drug makers, noting that one company has already announced it will not do a third-phase study of a new drug because of concerns about pricing going forward.

"We want more innovation, not less," Guthrie said. "And I'm afraid that's where we're going." 

The CBO estimates that the drug pricing and negotiation provisions in the Act "will have a very modest impact on the number of new drugs coming to market in the U.S. over the next 30 years; 13 fewer out of 1,300 or a reduction of 1%," reports the Kaiser Family Foundation.

Guthrie said Republicans will also focus on price transparency, calling it a bipartisan issue that has not yet been resolved. The Trump administration required hospitals to disclose the rates they privately negotiate with insurers and also provide online, searchable rates for 300 common services. 

"I think we need to make sure that information is out there," Guthrie said. "We need to expose if the price is right, then that's what the price is, but my guess is there seems to be a lot of steps in the supply chain of health care and we're not sure of the value of every step." 

Guthrie also said it will be important to investigate where Covid-19 originated as a way to prepare for future pandemics. "The purpose is to lead to legislation or information that we need to move forward," he said. "One of my biggest concerns as we look at what's moving forward is bringing trust back into our institutions. . . . We need to know that the groups that are supposed to put forth science are putting forth science in the public sphere so the policy makers can make decisions in the public and have confidence." 

As an example, he pointed to White House medical adviser Dr. Anthony Fauci's early dismissal of the idea that the virus came from a lab in China, even though "We now know that it probably did come from there." That is a matter of opinion, and the stated view of most experts is that the virus originated naturally.

Guthrie is co-chair of the Republican Healthy Future Task Force, which has put together a list of proposals that seeks to improve health-care choices for workers and small business owners, promotes innovation and transparency and lowers costs and increases options through competition. 

Inside Health Policy, reporting on its own interview with Guthrie, says that "If tapped as chair, he would focus on medical-product innovation, price transparency and health-agency oversight, including looking into FDA’s use of emergency use authorizations to ascertain lessons for future pandemics and the agency’s response to the infant-formula shortage to improve its handling of ongoing drug-supply issues."

Two studies, one of seniors and the other of all ages, show Covid bivalent booster shots very effective at preventing severe disease

Katelyn Jetelina, right, interviews the CDC's Dr. Ruth Link-Gelles about boosters.

By Katelyn Jetelina

Your Local Epidemiologist

We got an early holiday present. One of the last puzzle pieces about the fall Covid-19 boosters was released today: data on the effectiveness against severe disease. We have nine lab studies and one real-world study showing the fall boosters provide:

• Greater protection against infection and transmission, by boosting our first line of defense—neutralizing antibodies. (See my previous updates here.)
• Broader protection, or the ability to create antibodies that “see” more virus parts and “attach” more strongly compared to the antibodies we have right now. (See my previous updates on this here.)
• Longer protection against infection and severe disease, even just by a few months. We are still at the mercy of time for this, but have promising data from the Beta bivalent vaccine clinical trials.

Until now, we didn’t know whether they provided additional protection against severe disease and hospitalization. We now have three real world analyses, and things are looking good.

The CDC released studies answering the same question from two different perspectives. The first study , in 22 large hospitals in 18 states, found that among patients 65 and older with no Covid-19 vaccination, effectiveness of the fall booster against hospitalization was 84%; among who had received mRNA vaccines, effectiveness was 73%.

The second study, at nine hospitals in 11 states, looked at emergency room and urgent care visits (a proxy for more severe disease) for patients of all ages. It found that among people with no vaccination, effectiveness of the fall booster against emergency room or urgent-care visits was 56%. Among the vaccinated, effectiveness was less with more recent vaccination (reflecting the fact that vaccine protection wanes over time). If someone got their last mRNA shot two to four months ago, effectiveness was 31%. If the last dose was more than a year ago, effectiveness was 50%.

Dr. Ruth Link-Gelles, program lead of Covid-19 vaccine effectiveness at the CDC, told me, "These vaccines provide pretty substantial additional protection, especially if it's been a long time since you got you last monovalent dose." But we still don't know how long protection will last, so studies will continue.

Bottom line: The fall boosters work. There is now evidence fall boosters broaden protection, help against infection, protect against severe disease, and (we think and hope) provide longer protection. There is one major problem though: more than 150 million people are eligible for a fall booster in the U.S. and have yet to get one.

Link-Gelles blamed that on Covid fatigue and people seeing fewer hospitalizations and deaths from the disease, but she said now is good time to get boosted because of holiday gatherings, especially with grandparents, who are more vulnerable. She said 28 million Americans over 65 have not gotten a booster.

Ky. respiratory roundup: Hospitals filling; Covid-19 map greener; Beshear calls Fla. governor's request for vaccine grand jury 'silly'

New York Times graph, adapted by Kentucky Health News; figures in box are for Dec. 14.

By Melissa Patrick and Al Cross
Kentucky Health News

The federal risk map for Covid-19 in Kentucky got greener in the last week, but some Kentucky hospitals are filling up with increasing cases of influenza and respiratory syncytial virus.

The University of Kentucky's Chandler Hospital is at capacity and its Kentucky Children’s Hospital is close to full, the Lexington Herald-Leader reports, adding, "Staff at Baptist Health in Richmond have asked the public for patience amid extended wait times in the hospital’s emergency room." The hospital's emergency-services director said the hospital is "at or over capacity."

The hospitals also have Covid-19 patients, though hospitalizations for the disease in Kentucky have mostly declined in recent weeks. They have risen recently among Kentuckians under 18 and those 30 to 49.

CDC map

The Centers for Disease Control and Prevention's latest map showing levels of Covid-19 risk by county has 78 green counties, indicating low risk, up from 64 last week. But the number of counties rated at high risk increased slightly, to 15 from 12 the week before and 10 the week before that.

The 15 counties are the same group of nine West Kentucky counties, from Hickman to Crittenden, that were rated high last week; Nicholas, another repeater; and Rowan, Menifee, Morgan, Elliott and Greenup. Pike and Bourbon counties, which were rated high last week, dropped to medium risk.

The map is based on new cases and hospital data.

If you live in a medium or high-risk county, the CDC advises those who are at high risk of getting very sick to wear a well-fitting mask when indoors and in public and to consider getting tested before having social contact with someone at high risk for getting very sick and consider wearing a mask when indoors when you are with them.

Referring to last week's map, again Gov. Andy Beshear noted at his weekly news conference that the increases in medium and high risk counties is likely due to a post-Thanksgiving bump. 

He added that influenza remains extremely high in Kentucky and noted that the flu vaccine is "really good" against the strain that is circulation right now. "So get your flu vaccine," he said. 

He encouraged parents to be careful with their children because even though RSV is declining, almost all of the state's pediatric beds and pediatric ICU beds remain full. 

In other public-health news Thursday:

The Biden administration has announced that it is restarting a program where every household in the country is eligible to receive four free Covid-19 test kits. These at-home tests can be ordered at CovidTests.gov. This is the third round of free kits the administration has made available. 

People who have difficulty accessing the internet or need additional support placing an order can call 1-800-232-0233 (TTY 1-888-720-7489) to get help in English, Spanish, and more than 150 other languages from 8 a.m. to midnight ET, 7 days a week. More information: www.covid.gov/tests/faq.

Gov. Andy Beshear

Florida Gov. Ron DeSantis's request for a statewide grand jury investigation into the Covid-19 vaccines is "silly," Beshear said when Kentucky Health News asked about it at his weekly press briefing.

"That's silly," Beshear said. "And what it does is it denigrates the incredible work of those that came up with these vaccines so quickly and because of which so many of our relatives are still alive. And it denigrates the work of health care workers who have tried so hard to get everybody vaccinated." 

DeSantis announced Tuesday that he was asking the Florida Supreme Court for a grand jury to probe alleged "crimes and wrongdoing . . . relating to the development, promotion and distribution" of the vaccines. 

DeSantis said he could create a Public Health Integrity Committee and lead further surveillance around unexpected deaths that have occurred among people who were vaccinated, based on autopsy results, according to a news release. 

DeSantis is leading former president Donald Trump in one poll of potential Republican 2024 candidates, and Beshear has been mentioned as a potential Democratic candidate in 2028 if he is re-elected next year. At this point, they are the two youngest governors; Beshear is about 10½ months older.

Outgoing White House medical adviser Anthony Fauci said on CNN, "I don't have a clue" what DeSantis hopes to accomplish with a grand jury: “We have a vaccine that, unequivocally, is highly effective and safe and has saved literally millions of lives.”

He cited a new Commonwealth Fund study that concluded the vaccines collectively saved over 3.2 million American lives and averted more than 18.5 million hospitalizations in two years of the pandemic. DeSantis once promoted the vaccines, The Washington Post notes.

Beshear praised the safety and efficacy of the vaccines, speaking of them in the singular: "The vaccine has saved millions upon millions upon millions of lives. My goodness, it is a miracle that we got it within a year. You look at all our charts on Covid and how they're different now versus how they were before and the vaccines are a major driver. I don't believe that Covid-19 would have morphed into a less harmful variant but for the vaccines." 

Beshear suggested that such investigations are how people make news and said, "I disagree with the governor." 

He added, "Let's do what it takes to get this pandemic behind us and then let's move on. Right? Aren't we all ready? Aren't we all ready to live our lives without Covid?"

Medical cannabis bill will start in Senate; sponsor says Beshear issued order allowing it as 'wedge issue' and tool for re-election

UPDATE, Dec. 19: Senate Majority Floor Leader Damon Thayer, R-Georgetown, said on KET's "Kentucky Tonight" that the medical-marijuana bill should again start in the House, not the Senate. 

By Melissa Patrick and Al Cross
Kentucky Health News

State Sen. Stephen West said Dec. 13 that he will resume sponsoring medical marijuana legislation when the General Assembly convenes Jan. 3, and doesn't think the state should wait two years for completion of cannabis research that the legislature authorized in the last session.

"I don't believe we should wait. Of course, I'll admit I'm totally biased on the subject, obviously," West, R-Paris, told David "Kruser" Krusenklaus in an interview on Lexington's WVLK. "But I will admit and concede that there has been a lack of study in the United States on this subject." 

The legislature tasked the University of Kentucky Cannabis Center with researching the health effects of the cannabis plant, including its risks and benefits when used to treat certain medical conditions, after the state Senate again refused to hear a House-passed bill to authorize medical marijuana.

The other major result of the bill's failure was a Nov. 15 executive order by Gov. Andy Beshear that, beginning Jan. 1, allows possession of up to 8 ounces of cannabis for medical use by individuals who buy it in states where it is legal and have a doctor's statement that they have one of 21 conditions treated with it.

West was asked if the order, which uses the governor's pardon power, would be helpful or hurtful to getting a more comprehensive bill passed. He said he agreed with other Republicans (including the House bill's sponsor, Rep. Jason Nemes, R-Louisville) who have said this would not be helpful. 

Sen. Stephen West

"I agree 100 percent with Rep. Nemes," West said. "The governor's approach has not been helpful in getting this thing across the finish line. You know, I'm not going to be too critical, but you know we're entering an election year and this issue polls through the roof; it's a very popular issue. And I believe the governor was just wanting to use this as a wedge issue . . . not only a wedge issue as we go into session, but also for his upcoming campaign." Beshear is on the ballot for re-election in 2023.

Beshear's office denied that the executive order was a political move.

"The governor has taken action to help veterans struggling with PTSD and Kentuckians suffering from chronic and terminal conditions, like seizures and cancer, because the General Assembly has failed to act," Beshear spokeswoman Crystal Staley said in an email. "There is nothing political about taking action on an issue that helps our Kentucky families and that 90% of Kentuckians support."

Beshear, a Democrat, created a Medical Cannabis Advisory Committee that held meetings around the state and reported that 98,6% of Kentuckians who offered an opinion on its website supported medical marijuana. West said actual public support is likely lower, but still high: probably 85% or above. A Kentucky Health Issues Poll found that 90% of Kentuckians favor medical cannabis.

West said the legislation will start in the Senate this time because it has passed the House twice but failed in the Senate. He said Republican senators who favor it agreed at a recent caucus that he would take the lead because he has sponsored such legislation in previous sessions, though not this year.

"Over the past five years, there's been progress, " he said. The House last passed a medical marijuana bill in the 2022 session by a vote of 59-34 . 

"I've been here since 2015," said West. "And my experience is that really any large-scale bill, in any subject that requires a lot of thought, takes a good four years to make it through the process. This is not unusual."

West said if legislators want to move the bill, they could do so quickly: "Our members are well aware of the issue and all the back and forth on it. If we wanted to move something, I don't think it would take a great deal of time." 

At least 37 states and the District of Columbia allow medical marijuana, according to the National Organization for the Reform of Marijuana Laws. 

West pointed to European studies that show the efficacy of medical marijuana and said anecdotally we know that there are conditions where it helps, such as seizure disorders and palliative care.

West told Kruser that his bill has not been filed yet because the Senate no longer allows senators to pre-file bills. He said as a starting point, he will be filing the same bill he filed in 2021 with the expectation that it will be changed during the legislative process.

58% of Kentucky adults say the pandemic is over for them, and resistance among the unvaccinated to getting a shot is increasing

By Melissa Patrick
Kentucky Health News

Four in seven Kentucky adults (57%) think the pandemic is over in the state and more than 80% say concerns about Covid-19 will not keep them from attending or hosting gatherings during the holiday season, according to a Foundation for a Healthy Kentucky poll taken from Oct. 29 to Dec. 4. 

"Kentuckians are, I think as a general matter, determined that this pandemic is over," Ben Chandler, president and CEO of the foundation, said Tuesday. "They're going to behave like it for the most part during the holidays."

Chandler said that's appropriate, if people are up-to-date on their Covid-19 and flu vaccinations, keeping their hands washed and staying home when they are sick. But the poll found that resistance among unvaccinated Kentuckians to getting vaccinated to protect them from the disease continues to increase.

Foundation for a Healthy Kentucky graph; click on it to enlarge.

The poll found that 59% of Kentucky adults said it is "not likely at all" that Covid-19 will prevent them from attending or hosting a small gathering with friends and family this holiday season and 22% said it is "not too likely" that Covid-19 will impact this decision. Only 4.4% said it is "very likely" and 12.5% said it is "somewhat likely" that Covid-19 will affect their decision to gather with others over the holidays. 

Being vaccinated didn't seem to matter when making the decision to attend or host a small holiday gathering, as 73% of those who were vaccinated with at least one booster, 86% of those who were  vaccinated with no boosters and 91% of those who were not vaccinated said they were either not likely at all or not too likely to let Covid-19 impact their decision to attend or host a small holiday gathering

Further, the poll found that more men (69%) than women (50.2%) said they were not likely at all to let Covid-19 prevent them attending or hosting a small holiday gathering.

Hanukkah begins Sunday, Dec. 18; Christmas is Sunday, Dec. 25, and Kwanzaa starts Dec. 26.

The poll was the latest edition of the Vaccines in Kentucky Poll, which the foundation has sponsored four times since February 2021.When asked if they thought the pandemic was over in Kentucky, 41.5% of the respondents said it was. That was an increase over the summer, when 31.7% said it was. 

The share of Kentucky adults who said the pandemic was not over decreased to 56.6% in the latest poll, down from 65.4% in the summer. 

And when asked if the pandemic was over as it pertains to their own lives, 58.1% of the respondents said it was, up from 53.3% in the summer poll. This rate was highest among Kentucky adults who were not vaccinated (80.1%), followed by those vaccinated but not boosted ( 61%) and those vaccinated with at least one booster (42.2%).  

Foundation for a Healthy Kentucky graph; click on it to enlarge.

The poll also found that nearly three-quarters of vaccinated Kentuckians (73%) were either "very likely" or "somewhat likely" to get an annual Covid-19 booster if that were recommended like annual flu shots are.

The groups of vaccinated Kentuckians most resistant to getting an annual Covid-19 booster in the future were those who live in suburban counties (37%) and those between the ages of 30 and 45 (39.5%), either saying they were either "not too likely" or "not likely at all" to receive an annual booster. 

In rural and urban counties, about 75% of Kentucky adults in these areas said they would be very or somewhat likely to get a booster if recommended.

Foundation for a Healthy Kentucky graph; click on it to enlarge.

Since the first Vaccines in Kentucky Poll was taken in February 2021, an increasing share of Kentucky adults have said that getting vaccinated is a personal choice, rather than part of everyone's responsibility to protect the health of others. That view rose to 65% in the latest poll, marginally more than the 63% found this summer. In February 2021, shortly after vaccines became available, polling showed a nearly even split on the question. (Each number in the statewide sample has an error margin of plus or minus 3.4 percentage points.)

Generally, the less education Kentuckians have, the more likely they are to consider vaccination a personal choice, but even 58% of college graduates agreed with that statement. Among high-school graduates and people who have attended college but not graduated, the number was 66%; among those with less than a high-school education, it was 73%.

The belief that vaccination is a personal choice is also strong among rural Kentuckians, with 72% of them saying they agree with that statement and 27% of them saying getting vaccinated is everyone's responsibility to protect the health of others. In suburbs, the numbers were 66% and 32%, respectively; in cities, they were 57.5% and 41.8%.

People who rated their personal health as excellent or good were more likely to consider vaccination a personal choice than those who rated it good, fair or poor; the numbers for those two groups were 70% and  61%, respectively. 

The latest poll also found that the number of unvaccinated people in Kentucky who said they will "definitely not get the vaccine" has increased to 75.2% in the latest poll, up from 63.5% in the summer. 

The poll, which was funded by the foundation, was conducted by the University of Cincinnati's Institute for Policy Research. It surveyed a random sample of 855 Kentucky adults via landline and cell phones.

Federal audits reveal widespread overcharges, other errors in Medicare Advantage plans; Humana and United stand out

Illustration by Eric Harkleroad, Kaiser Health News, from federal Medicare data

By Fred Schulte and Holly K. Hacker
Kaiser Health News

Recently released federal audits reveal widespread overcharges and other errors in payments to Medicare Advantage health plans, with some plans overbilling the government more than $1,000 per patient a year on average.

Summaries of the 90 audits, which examined billings from 2011 through 2013 and are the most recent reviews completed, were obtained exclusively by Kaiser Health News through a three-year Freedom of Information Act lawsuit, which was settled in late September.

A review of the audits reveals that health insurers that issue Medicare Advantage plans have repeatedly tried to sidestep regulations requiring them to document medical conditions the government paid them to treat.

UnitedHealthcare and Louisville-based Humana, the two biggest Advantage insurers, accounted for 26 of the 90 contract audits over the three years.

Eight audits of United plans found overpayments, while seven others found the government had underpaid. Humana's 11 audits with overpayments included plans in Florida and Puerto Rico that CMS had audited twice in three years.

The Florida Humana plan also was the target of an unrelated audit in 2021 by the Department of Health and Human Services inspector general. That audit, which covered billings in 2015, concluded Humana improperly collected nearly $200 million by overstating how sick some patients in its Medicare Advantage plans were. Officials have yet to recoup any of that money, either.

In an email, Humana spokesperson Jahna Lindsay-Jones called the audit findings "preliminary" and noted they were based on a sampling of 2015 claims.

"While we continue to have substantive concerns with how CMS audits are conducted, Humana remains committed to working closely with regulators to improve the Medicare Advantage program in ways that increase seniors' access to high-quality, lower cost care," Lindsay-Jones wrote.

Medicare Advantage is an alternative to original Medicare and is primarily run by major insurance companies. As it has gained popularity among seniors, CMS has fought to keep its audit procedures, and the mounting losses to the government, largely under wraps. That approach has frustrated both the industry, which has blasted the audit process as "fatally flawed" and hopes to torpedo it, and Medicare advocates, who worry some insurers are getting away with ripping off the government.

Insurers can have some claims excluded from the audit by claiming hardship, such as the closure of clinics where the services were rendered. Hardship requests and other documents obtained by KHN in the lawsuit shed light on the secretive audit process.

Reacting to the audit findings, Iowa Sen. Chuck Grassley called for “aggressive oversight” to recoup overcharges. Grassley is the top Republican on the Senate Finance Committee, which oversees health insurance. He said, “CMS must aggressively use every tool at its disposal to ensure that it’s efficiently identifying Medicare Advantage fraud and working with the Justice Department to prosecute and recover improper payments.”

How Medicare Advantage works

Medicare reimburses Medicare Advantage plans using a complex formula called a risk score that computes higher rates for sicker patients and lower ones for healthier people. But federal officials rarely demand documentation to verify patients' conditions. Only about 5% of Advantage plans are audited each year.

When auditors came calling, the previously hidden CMS records show, they often found little or no support for diagnoses submitted by the Advantage plans, such as chronic obstructive pulmonary disease, diabetes, or vascular disease. Though auditors look at the records of a relatively small sample of patients, they can extrapolate the error rate to the broad population of patients in the Medicare Advantage health plan and calculate millions of dollars in overpayments.

Overall, CMS auditors flagged diagnostic billing codes — which show what patients were treated for — as invalid more than 8,600 times. The audits covered records for 18,090 patients over three years.

In many cases, auditors found that the medical credentials of the health-care provider who made the diagnosis were unclear, the records provided were unacceptable, or the record lacked a signature as required. Other files bore the wrong patient’s name or were missing altogether.

The rates of billing codes rejected by auditors varied widely across the 90 audits. Seven health plans had fewer than 10% of their codes flagged, but the rate of invalid codes topped 80% at a defunct New York HMO.

One Medicare Advantage health plan submitted 57 hardship requests, more than any other insurer, though CMS approved only six. In three cases, the health plans said the records were destroyed in floods. Another cited a warehouse fire, and two said the records couldn’t be turned over because a doctor had been convicted for his role in illegally distributing millions of oxycodone pills through his network of pain clinics.

Other Medicare Advantage health plans said they had no luck retrieving medical records from doctors who had moved, retired, or died — and in some cases been arrested or lost their licenses for misconduct.

CMS found most excuses wanting, telling health plans that it granted exceptions only in “truly extraordinary circumstances.” CMS said it receives about 100 of these requests for each year it audits and approves about 20% of them.

Dara Corrigan, a CMS deputy administrator, said that as a “general matter,” its Medicare Advantage audits “are not designed to detect fraud, nor are they intended to identify all improper diagnosis submissions.”

Protecting Taxpayers

The costs to taxpayers from improper payments have mushroomed over the past decade as more seniors pick Medicare Advantage plans. CMS has estimated the total overpayments to health plans in the 2011-13 audits at $650 million, but how much it will eventually claw back remains unclear.

Payment errors continue to be a drain on the program. CMS has estimated net overpayments to Medicare Advantage plans triggered by unconfirmed medical diagnoses in 2022 at $11.4 billion.

“This isn’t a partisan issue,” said Sen. Sherrod Brown (D-Ohio). “I’ve requested a plan from CMS as to how they plan to recoup these taxpayer-funded overpayments and prevent future overbilling.”

Leslie Gordon, acting director of health care for the Government Accountability Office, the auditing arm of Congress, said CMS needs to speed up the audit and appeals process to get quicker results.

“That is money that should be recovered,” Gordon told Kaiser Health News.

As Medicare Advantage faces mounting criticism from government watchdogs and in Congress, the industry has tried to rally seniors to its side while disputing audit findings and research that asserts the program costs taxpayers more than it should.

America's Health Insurance Plans, an insurance industry lobby, criticized Kaiser’s reporting on the newly released audits as “misleading,” while the pro-industry group Better Medicare Alliance said the audits were “in some cases, more than a decade old.”

Jeff De Los Reyes, a senior vice president at the GHG Advisors health-care consulting group, said he believes the health plans have improved their documentation in recent years. But, he said, “Coding is never 100% perfect and there will be errors despite the best of intentions.”

Rep. Katie Porter, a Democrat from Southern California and a critic of Medicare Advantage, countered: “When big insurance bills taxpayers for care it never intends to deliver, it is stealing our tax dollars.”

Kaiser Health News is a national newsroom that produces in-depth journalism about health issues. Together with policy pnalysis and polling, KHN is one of the three major operating programs of the Kaiser Family Foundation, an endowed nonprofit organization providing information on health issues to the nation.

New cases of the flu outnumber new cases of the coronavirus in Kentucky, but deaths from Covid-19 went back up last week

Centers for Disease Control and Prevention map, adapted by Kentucky Health News

By Melissa Patrick and Al Cross
Kentucky Health News

Newly confirmed cases of influenza are outpacing new cases of the coronavirus in Kentucky, and the state is among the national leaders in new flu cases. Meanwhile, though, deaths from Covid-19 are going up.

The Centers for Disease Control and Prevention has Kentucky, 10 other states and the District of Columbia in the “very high” category of flu-like illnesses. That's based on reports for the week ending Dec. 3, when Kentucky had at least 7,192 new cases. The previous figure was 6,398. The CDC says "at least" because unlike Covid-19, flu cases do not have to be reported to health authorities.

In the week ended Sunday, Dec. 11, the state Department for Public Health reported 5,214 new coronavirus cases, an average of nearly 745 per day. That's 9% lower than the week before, when the state was averaging 821 new cases per day. Of last week's cases, 14.5% were in people 18 and younger.

The state attributed 51 more deaths to Covid-19, up from 28 the week before and higher than a month of weekly reports before that, which showed an average of 45 deaths per week. Kentucky's pandemic death toll totals 17,580. 

The flu has killed at least 29 Kentuckians this season. The Lexington-Fayette County Health Department reported Dec. 7 that six were in its jurisdiction. “The flu is hitting hard in Lexington,” spokesman Kevin Hall said in an email. “There are already more total lab-reported cases in the first 9 weeks this season than in the previous three years combined.”

The state's weekly Covid-19 report shows that the share of Kentuckians testing positive for the coronavirus was 8.63%, up just a bit from 8.14% the week before. The figures do not include at-home tests. 

All said, it appears that when it comes to cases and positivity rates, Covid-19 Kentucky remains on a the rough plateau seen for about three months.. 

Covid-19 hospitalizations barely increased last week, after taking a big jump in the last one, and the number of severely ill patients went down. Hospitals reported 388 patients with Covid-19 Monday morning, an increase of five over the prior Monday; 45 were were in intensive care, down 14; and 19 were in need of mechanical ventilation, down 10. 

The weekly new-case incidence rate was 15.82 cases per 100,000 residents, down from 16.29 the week before. The top 10 counties were Bath, 38.9 cases per 100,000;  Powell, 33.5; Washington, 33.1; Leslie, 30.4; Calloway, 30; Hart, 29.3; Simpson, 27.7; Metcalfe, 27; Montgomery, 26.9; and Union, 26.8.

The New York Times ranks Kentucky's coronavirus incidence rate 20th among states, even with a 16% drop in cases in the last two weeks. 

Nationwide, the Times reports, "Conditions are worsening across the country, with reported cases and hospitalizations up more than 25 percent in the past two weeks and test positivity rates rising quickly."

Flu has killed 27 adults and two children in Kentucky this season

Kentucky Department for Public Health map, adapted by Kentucky Health News

By Melissa Patrick
Kentucky Health News

Kentucky's latest flu report showed a smaller jump in cases than in previous weeks, but the jump in deaths was the biggest yet this season, showing the disease's worst possible outcome.

The state Department for Public Health said Friday that 29 Kentuckians (27 adults and two people under 18) have died from the flu this season, with 15 of those deaths (14 adults and one child) reported since the last weekly report.

State graph, adapted by Ky. Health News

The latest report shows that flu activity in Kentucky continues to increase. In the week ending Dec. 3, the state confirmed 7,192 new cases, up from 6,378 the week before. So far, the total of confirmed cases this season is 23,101. 

Most of the cases continue to be in Kentuckians under the age of 20. It's important to remember that the state surveillance system only includes lab-confirmed cases and does not require providers to report results from rapid-flu tests, which means that the numbers are likely much higher than is reflected in the state report.

The Centers for Disease Control and Prevention recommends everyone 6 months and older get vaccinated every flu season. It takes up to weeks for protection to develop after getting the vaccine, so the sooner the better. Click here to see where to get a flu vaccine near you. 

"I think the most important message is that the best tool we have is vaccination," said Dr. Nicholas Van Sickels, an infectious-disease specialist at UK HealthCare. "It will prevent you from getting very sick or ending up in the hospital. It will help protect your community. That's the biggest thing I can stress this season. . . . It's not too late. If you haven't gotten it, go get it." Flu season runs until May.

Four of the state's 16 health regions showed increases in flu activity on the latest report. Counties with some of the highest confirmed numbers in the week ending Dec. 3 were Allen, 62; Barren, 266; Bell, 50; Boone, 228; Boyd, 82; Campbell, 127; Daviess, 284; Fayette, 525; Floyd, 116; Grant, 81; Harlan, 89; Hart, 70; Henderson, 63; Hopkins, 112; Jefferson, 1,704; Jessamine, 69; Kenton, 335; Knox, 113; Laurel, 136; Madison, 98; McCracken, 84; Metcalfe, 58; Monroe, 56; Muhlenberg, 273; Nelson, 115; Pike, 296; Shelby, 66; Warren, 162; and Whitley, 161.

Beshear says health decisions based on Kentuckians' needs, not politics; wishes he could have been more persuasive on vaccines

Beshear is interviewed by Kentucky Health News.

By Melissa Patrick
Kentucky Health News

Gov. Andy Beshear says the decisions he's made when it comes to the pandemic and medical marijuana have been made to help Kentuckians, and were not based on politics.

In an interview with Kentucky Health News Dec. 7, Beshear said he decided to suspend in-person school classes, as other states also did, to save lives. 

"Every decision I made was about trying to preserve as many Kentucky lives as we could, because I believe that is our job," he said. 

One reason the risks were bigger than in other states is that Kentucky ranks No. 1 for the rate of grandparents raising grandchildren, he said. In Kentucky, 84.5% of the 17,530 Kentuckians who have died from Covid-19 have been 60 and older.

"We can catch a child up on learning loss, but we can't replace that grandparent that is raising them, that might be the last adult that cares about them," he said. "They are better off still having that individual here and in their life. And while we can make up for learning loss, we can't make up for lost life." 

To criticism that his policy led to learning loss and increases in mental-health issues among young people, Beshear said, "So when I look at learning loss, I don't view it as some political issue to beat each other up over; I view it as our next challenge we've got to tackle." 

Further he said, learning loss and test-score declines were already happening in Kentucky before Covid-19.

"The only way for us to make it up to this generation is to have the educators we need," he said, noting that the state has 11,000 teacher vacancies. He said his Education First Plan, which includes teacher raises, funding for universal pre-K and social and mental health supports, addresses this.

"So Republicans can criticize. I'm trying to do something about it," he said. "And if they would join me, we can catch our kids up."

Asked if his recent executive order to allow possession of up to 8 ounces of cannabis for medical purposes for some individuals was timed to be closer to the 2023 legislative session and elections, he said the timing was based on figuring out what his administration could do responsibly. 

Asked if he was trying to get the legislature to pass a broader medical-marijuana law, he said, "I'm not trying to pressure the General Assembly, but the people of Kentucky ought to be, because this is something the vast majority demand and their elected representatives are refusing to do it." 

He added, "Either your elected representatives say, well, 80-plus percent of Kentuckians want to do something so it's our job to do it, or they're saying that they're better or smarter than we are. And to me, that's that's not acceptable." 

Asked to name the biggest health challenge right now in Kentucky, he said it is the flu, which has killed over two dozen Kentuckians. "We really need people to get their flu shot," he said. "It's going to be really effective against this strain and those that have not had the flu shot are getting pretty sick." 

Longer-term, he noted that too many Kentuckians still struggle with a long list of health conditions, like heart disease, cancer, lung cancer, and diabetes, and that it's important that we get back to addressing those issues, saying it's time to move from treatment to prevention for these conditions. 

"We need to make sure our kids are healthy in their youth to learn, in their adulthood to work and in their senior years to enjoy," he said. "So health and healthcare will always be a fundamental priority of this administration." 

Asked what he would do over when it comes to health in Kentucky in his last year as governor, Beshear named three things: He would have expanded Medicaid to include hearing, dental and vision benefits earlier than he did; would have already expanded the number of pediatric beds in the state (an effort he said the administration is discussing); and he wishes he could have figured out what else to say to get more Kentuckians vaccinated and boosted against Covid-19.

Seemingly describing his own thinking, Beshear said, "What's that next thing you could say that will get more people to get vaccinated, and that's not just me, that's everyone."

UK's Sanders-Brown center is among first sites to test a promising new drug to slow Alzheimer's, and is looking for study participants

Mike Brown of Morehead is one of the participants in the current Alzheimer's disease study at UK.

Story and photos by Hillary Smith

University of Kentucky

The University of Kentucky is a site for the first-ever clinical trial to test an investigational antibody for people who have no cognitive symptoms of Alzheimer’s disease but may have “preclinical” AD. 

In September, drug maker Eisai announced positive results from a third-phase study evaluating lecanemab, an investigational antibody for treatment of mild cognitive impairment due to AD and mild AD dementia (collectively known as early AD) with confirmed presence of amyloids, abnormal proteins that form plaques that disrupt brain function.

Just last week, at the International Clinical Trials on Alzheimer’s Disease meeting in San Francisco, Eisai presented results that demonstrate an almost complete removal of amyloid plaques from the brain of those with early Alzheimer’s, an effect that was associated with a 27 percent slowing of mental decline. The study also showed that lecanemab leads to a 31% lower risk of the next stage of disease.

The next study will test whether those effects in the clinically symptomatic population are similar in people whose lab tests indicate they have amyloids in the brain, or preclinical AD. That excites Dr. Greg Jicha, director of clinical trials at UK’s Sanders-Brown Center on Aging, one of 75 sites for the study.

Dr. Greg Jicha (UK photo by Mark Cornelison)

“When doctors, researchers and scientists from across the globe, including myself, saw the data for the first time, the excitement was contagious,” Jicha said. “We all realized that for the first time ever in the history of drug development for Alzheimer’s disease, we have broken down the barriers that will one day move us to a cure. Our excitement was propelled by the knowledge that we can succeed eventually in eradicating Alzheimer’s and that even better medicines are on their way.”

Jicha says UK has been working with patients to provide access to lecanemab for over a decade, and has successfully removed amyloids from dozens of brains.

“We think we are taking this one over the finish line,” Jicha said. “I see hundreds of patients each year that are shocked that they have received the death sentence of Alzheimer’s disease. As of now, there are no cures for this fatal disease that is the sixth-leading cause of death in the U.S. We need to know if we can screen and stop this disease before it destroys the lives of those we love or takes our own lives.”

Looking for a path forward as they age as well as a way to help others are big reasons why many get involved in research at UK.

“I’m retired and just want to help people anyway I can,” said Mike Brown, who participates in research at Sanders-Brown alongside his friend Jim Jackson. The duo travels from Morehead every two weeks along with their wivefor their visit.

“We make a fun little day out of it,” said Sharon Jackson, Jim's wife. “We always try to eat somewhere different.”

Jim Jackson is a retired pediatrician. With his medical background, “I knew I wanted to be part of it,” he said “This is the way science works.”

Dr. Jim Jackson of Morehead is another participant in the study.

Jackson and Brown have been participating for several months in the Eisai study, starting the medication in May 2020. That part of the study, as in most clinical trials, had a placebo group. They are still blinded for that part of the study, so they do not know yet if they had been receiving lecanemab. “You just have to be optimistic and know you are helping others,” Jackson said.

Both of them qualified for, and are now in, the open-label extension of the study, which began in November 2021. This allows them to confidently get lecanemab for several months. Hearing the recent news about the early results for this drug provided an extra dose of enthusiasm for the couples.

“I am just so thankful Jim is part of this, because if it prolongs his memory any amount, it is very much worth it,” said Sharon. “Dr. Jicha and the team here at UK are so great and informative. We always have a comfortable experience here. We are so blessed to have a place like this right here in Kentucky. More people should consider getting involved and using the resources offered at Sanders-Brown.”

Jicha says they are proud that Sanders-Brown, founded by Col. Harland Sanders and John Y. Brown Jr. of Kentucky Fried Chicken fame, is at the forefront of these discoveries.

“You might think such possibilities are limited to the rich and famous; you might think such possibilities are only available in Washington, D.C., New York, Chicago or L.A.," Jicha said. "But you should know that the UK Sanders-Brown Center on Aging is at the forefront of these discoveries, bringing them here to Kentucky long before they may be available to others in the United States.”

The study is the first AD trial to recruit people as young as 55 who are at risk of developing symptoms of AD as they get older.  

Researchers want to make sure the opportunity is available to a wide range of the population. “We especially want to reach out to those that have experienced health care discrimination,” said Jicha. “If you live in a rural area or are a person of color, you should know that we value you as much as we do everyone else. An effort this important needs to be available to everyone.”

Jicha says researchers believe the future of healthy brain aging is within their grasp. “For many, it may be too late for lecanemab to help, but we are not giving up on them either. We have over a dozen active experimental medicine trials for anyone at risk, currently experiencing memory loss, or even those with more advanced stages of Alzheimer’s disease or other forms of dementia. If you are looking to do more for yourself or a loved one, please reach out to us now.”

The study is funded by the National Institutes of Health and Eisai, a U.S. subsidiary of the Tokyo -based firm Eisai Co. Ltd. It seeks 1,165 participants from North America and has more than 100 study locations, including Japan, Singapore, Australia and Europe.

To learn more about the study, call 1-800-AHEAD-70 or to find a trial site location enrolling near you, visit www.AHEADstudy.org. Learn more about enrolling in aging studies at Sanders-Brown here.

Number of Ky. counties with high and medium Covid-19 risk tick up a bit; Beshear says it's likely due to 'post-Thanksgiving bump'

CDC map, adapted by Ky. Health News

By Melissa Patrick
Kentucky Health News

The number of Kentucky counties with high and medium risk of Covid-19 transmission on the latest Centers for Disease Control and Prevention map released Thursday were about the same as the week before, when they were higher than they had been for a while. 

At his weekly news conference Thursday, which was held before the map was released, Gov. Andy Beshear said recent increases in counties with high and medium transmission risk in the previous map, and the increase in cases on Monday's weekly state report, were likely due to a "post-Thanksgiving bump." He said the pandemic in Kentucky still appears to be on a general plateau, but he expects cases will tick up for a few weeks before they come back down. 

"Here's the good news, though: It is nowhere near what we saw after each of these holidays the last couple of years," Beshear said. "This means Covid has fundamentally changed and our highs are going to be a lot lower and that's a very good thing for all of us." 

The latest risk map, which looks at both cases and hospital data to determine risk of transmissions, shows 12 Kentucky counties at high risk, up from 10 the week before. High-risk counties, shown in orange, were in Western Kentucky except for Bourbon, Nicholas and Pike counties. 

In high-risk counties, the CDC continues to recommend that you wear a well-fitting, high-quality mask in public indoor spaces, and if you are at high risk of getting very sick, consider avoiding non-essential indoor activities in public where you could be exposed.

Medium-risk counties, shown in yellow, numbered 44 this week, down from 48 on the previous map. These counties are found in several pockets across the state, mainly in the east and south. Again, barely a majority of the state's 120 counties (64) have a low risk of Covid-19 transmission, shown in green. 

If you live in a medium or high-risk county, the CDC advises those who are at high risk of getting very sick to wear a well-fitting mask when indoors and in public and to consider getting tested before having social contact with someone at high risk for getting very sick and consider wearing a mask when indoors when you are with them.

The CDC also has a transmission-level map that shows the level of virus spread in each county, at one of four levels. It shows 13 Kentucky counties with a moderate level of transmission and the rest have either substantial or high levels of transmission. This data is largely used by researchers and health-care facilities.

State officials have encouraged Kentuckians to use the other CDC map to guide their preventive measures.

Too many pregnant Kentuckians and babies in 'maternity deserts' and Ky. has no birthing centers; midwives say they could help

Laura Browning, an Eastern Kentucky doula and midwife student, with her four children in a selfie.

By Sarah Ladd
Kentucky Lantern

During three of her four pregnancies, Laura Browning drove three hours round-trip past hospitals to get prenatal care from midwives in Lexington, the only place that offered what she needed.

She even made the trip while in labor with her first baby, feeling that “the care that I was receiving” from midwives “was worth that risk” of birthing in her car.

As deaths from pregnancy rise in the United States, Browning and other advocates say Kentucky could fill gaps in prenatal care by educating and certifying more midwives, attracting more to the doula profession and encouraging the creation of freestanding birth centers in the state.

The shortage of care for pregnant people is documented in a recent March of Dimes report, “Nowhere To Go: Maternity Care Deserts Across the U.S.”

More than 2 million Americans, most of them rural, live in “maternity care deserts,” defined in the report as having “no hospitals providing obstetric care, no birth centers, no obstetrician/gynecologist and no certified nurse midwives.”

In 2021, 14.2 percent of mothers received inadequate prenatal care, says the March of Dimes, which gave Kentucky an F on its annual report card this year, making it one of just nine states (plus Puerto Rico) to get a failing rating.

Almost half of Kentucky’s 120 counties — 48% — are maternity-care deserts, according to the March of Dimes study.

Prenatal care provided by midwives has been shown to prevent costly complications in mothers and babies, including cesarean deliveries and low birth weights. The March of Dimes reports that “midwifery care has been associated with an increased chance of having a low-intervention birth and lower cost of care due to significantly lower odds of medical intervention.”

Yet only about 8% of births in the U.S. are attended by midwives. In Kentucky, 700 to 800 babies are born every year outside hospitals, and are usually delivered with midwives present. There were 51,688 live births in Kentucky in 2020.

Certified nurse-midwives and certified midwives are accredited by the Accreditation Commission for Midwifery Education and pass national exams after graduate-level studies, according to the American College of Nurse Midwives.

The midwives and midwifery students who spoke with the Kentucky Lantern expressed passion for serving their communities and reported low rates of transfer to hospitals, easing the burden of hospital staff shortages.

Mary Harman

Also, midwives can provide important inclusive services to people who are “beyond the binary,” said Mary Harman, the only midwife within a two-hour drive from Pike County who travels that far for clients.

“Not every person needs an OB-GYN,” Harman said, but they cannot accept insurance or Medicaid, which is another barrier to their practice, Canary Nest Midwifery.

Research also suggests that freestanding birth centers, which are staffed by midwives and offer holistic birthing options for people who qualify, reduce the cost of care while producing higher patient satisfaction.

Kentucky is in the minority of states that have no freestanding birth centers. The American Association of Birthing Centers reports that more than 384 freestanding birthing centers are operating in 37 states and the District of Columbia, a 97 % increase since 2010.

Advocates attribute the lack of birthing centers to the difficulty of obtaining the state-required certificate of need in the face of opposition from hospitals that can mount costly legal battles, such as the one waged by three hospitals against a retired Army officer who tried to open a birthing center in Elizabethtown.

She prevailed in Franklin Circuit Court, which overturned a hearing officer’s denial of a certificate of need, but was forced to give up in 2017 when the hospitals won on appeal.

Rep. Jason Nemes, R-Louisville, has sponsored legislation in the past to remove the certificate-of-need requirement for birthing centers and will continue to support them. He has called the law mandating the certificate “very cumbersome.”

In 2019, the legislature did take action aimed at licensing more certified professional midwives, after the Kentucky Hospital Association and Kentucky Medical Association dropped their years of opposition.

The results have been underwhelming. In the almost four years since the law was enacted, the number of certified nurse-midwives and certified midwives in Kentucky has increased by only 12 — to 131 providers, reports the American Midwifery Certification Board.

Some hospitals have doula and midwife programs, such as the University of Kentucky’s midwife clinic and Norton Healthcare’s doula program.

Among the barriers to increasing midwifery care in Kentucky is the $1,000 cost of renewing a Certified Professional Midwife license. Compare that with $110 in Tennessee, $200 in California or $322 in New York.

Earlier this year, Kentucky took advantage of an opportunity in the American Rescue Act Plan to put in place one of the March of Dimes recommendations by increasing postpartum care under Medicaid from 60 days to 12 months. The change will allow an estimated 10,000 Kentucky mothers to maintain their health coverage for one year after giving birth.

Stark racial disparities in maternal mortality

The March of Dimes reports that deaths from pregnancy are increasing in the United States, which already has one of the highest maternal death rates among high-income countries.

About 900 women in the U.S. died from pregnancy-related issues in 2020, up 14% from 2019 and up a whopping 30% from 2018. Sixty-three percent of pregnancy-related fatalities are preventable, says the report. In Kentucky, preterm births increased in 2021 to 12%, up from 11% in 2020.

Pregnancy is especially dangerous for Black Americans, who are three times more likely to die from pregnancy than their white counterparts. Conversely, white women are more likely to have access to good prenatal care than Native, Black, Pacific Islander, Asian and Hispanic women. 

Those stark disparities are not lost on the expectant mothers who turn to doulas to guide them through their pregnancies and births. Doulas provide moral, physical or other support to pregnant people throughout pregnancy, delivery and postpartum.

Meka Kpoh, a doula in Louisville, founded the nonprofit Black Birth Justice to help mothers and babies get off to a healthy start all the way through the critical postpartum period. She has been in birth work long enough that the March of Dimes report wasn’t news to her.

She said these gaps in care should be taken seriously.

“The maternity care deserts aren’t going to just erase themselves,” said Kpoh, who is also in training to be a midwife. “It’s not going to be like next year there’s going to be a new hospital and every community has a hospital at least 30 to 40 minutes away. That’s not going to happen, at least not anytime soon. So it’s really important for there to be options for families like licensed certified home birth midwives.”

Kpoh said many of the clients she sees are driving hours from rural areas. “It’s really insane to me,” she said, “that we are their only option.”

In addition to more doulas and midwives, she said Kentucky needs freestanding birthing centers.

“Pregnant people are driving three hours just to get prenatal care, just to give birth, just to have postpartum appointments,” she said. “It’s ridiculous.”

To get the kind of care they want, Kpoh said many pregnant people end up facing a difficult choice: “Either they drive three hours to a hospital or they catch their baby by (themselves),” she said, adding: “I don’t recommend that for anyone.” 

Renee Basham, a doula, founded the nonprofit community doula program Hope’s Embrace to help pregnant people who are often cut off from help. Basham and her 30 doulas serve those who are unhoused and those with drug addictions.

“You’re not necessarily treated well if you are by yourself,” said Basham. “And so having people … vouch for you, or speak up for you or remind you to speak up for yourself … all of that … contributes to better outcomes.”

 
The stigma of going against the norm

Anihhya Trumbo, a doula who serves the Lexington area, said there remains a stigma about birth outside a hospital.

“Kentucky is a state where it’s always been preached that doctors know best,” she said. “It’s a bit of a taboo if you go outside of what is … considered the norm here.” 

Doula and midwife-assisted birth isn’t a new thing, either, she said.

“This is something that’s been going around since the beginning of time,” said Trumbo, who is also a military veteran. “We just got Western medicine and that’s what changed the norm but home birth and having the natural birth — that’s how we got here.”

Browning was so committed to midwifery care for herself that from six weeks gestation to birth, she drove three hours for her prenatal appointments. She’s now living in Laurel County but lived in Estill at the time of that first pregnancy.

Already a doula, Browning told the Kentucky Lantern that she is in midwifery school herself now “because women should not have to drive that far for care.”

“It’s definitely a need that we have here.”