Wednesday, March 4, 2015

Senate Republican leaders killed the smoking-ban bill passed by the Democratic House but some of them say its time may come

By Melissa Patrick
Kentucky Health News

On Feb. 13, for the first time, the Kentucky House of Representatives passed a statewide smoking ban to prohibit smoking in workplaces and indoor places. The bill moved to the Senate for consideration. On the same day, a state senator proposed a nearly identical bill. And on Feb. 19, both bills were assigned to a committee that was never going to give them a hearing.

Sen. Julie Raque Adams
Sen. Julie Raque Adams, R-Louisville, sponsor of the Senate bill, said it and the House bill would have been approved by the Senate Health and Welfare Committee, which she chairs. But leaders of the Senate's Republican majority sent it to the Veterans, Military Affairs and Public Protection Committee, chaired by Sen. Albert Robinson, R-London, who, like Senate President Robert Stivers, R-Manchester, opposes it.

“The time has come and gone," Adams said of chances to pass the ban.

If the bill is dead, who killed it? The most common explanation offered during a series of short interviews with senators was the "leadership," members of which have publicly said the bill didn't have the support it needed to bring it to a vote. However, some senators said it did.

“Leadership is not willing to hear it,” said Amy Barkley, chair of the Kentucky Smoke-free Coalition. “It is a small group of people in leadership who don't want to bring it to a vote. Why should a small group hold it up?” Barkley said that she would like leadership to "allow a vote, regardless of the results."

Sen. Tom Buford, R-Nicholasville, said the leadership "makes the decision about whether we hear a bill or not."

Stivers has said he opposes the bill because it would be too much government intervention into private business, and Buford said many other Republicans feel likewise. He said many members of his party "just do not want anybody to tell anybody what to do anymore."

Sen. Perry Clark of Louisville, a libertarian-oriented Democrat and Public Protection Committee member, said Republican leaders strategically placed the bill in the committee.

"It doesn't look like it will [be passed] as long as it is in Albert Robinson's committee," Clark said. "He is adamantly opposed to it. They knew that when they put it in his committee. They could have put it in Julie's committee and she is adamantly for it," he said.

The co-chair of the committee, Sen. C.B. Embry, R-Morgantown, said "Leadership determines what we vote on and when we vote. All the committees serve at the will of the leadership."

"If leadership wants it to pass, it's going to be heard," said Sen. Dennis Parrett, D-Vine Grove, a member of the committee.

Stivers, asked where the leadership stood on the issue, said "Until I see, or other people see in the leadership group, that there is support in the caucus for the issue, it is not going to come to the floor. If there is, it will. I haven't seen that groundswell of support for the issue." Floor Leader Damon Thayer, R-Georgetown, said likewise.

Another obstacle contributing to the bill's death was the Republican policy of not allowing bills to reach the full Senate unless they are favored by a majority Republicans, who have 27 of the 38 Senate seats.

Perhaps another was indicated by the latest lobbying report from the parent firm of Philip Morris Cos., Altria Group, saying that its legislative agents were lobbying against it. The sponsor of the House bill, Rep. Susan Westrom, D-Lexington, has said Kentucky Farm Bureau was her main foe.

Still, some senators thought there were enough votes for it to pass a floor vote.

“It would pass the floor," Buford said. "I think when you turn the light bulb on and they all have to show their hand, it would pass." Parrett agreed, and so did Sen. Morgan McGarvey, D-Louisville, a co-sponsor of the bill.

While Adams said she thought likewise, she also said she could not say that with "full confidence" because she had found in talking to the senators that many of the potential "yes" votes in the Senate wanted a bill without amendments. The House added provisions that these senators needed time to "digest" and "this session just wasn't long enough for us to do it," Adams said.

Advocates and sponsors continued to work on the bill even after its unfavorable assignment. Early on, co-sponsor Dr. Ralph Alvarado, R-Winchester, explored fellow senators' interest in an amendment allowing local governments to opt out of the ban, trying to make it more palatable to those who strongly favor local control. The advocacy groups opposed such an amendment.

"We rolled it out there and I just don't know that we had enough support," Alvarado said. "I asked individual members what their thoughts were and I got a lot to switch their vote and some who came to the fence, but the fence is not a yes, so that makes it a bit tougher. It would probably get some votes."

Buford said the opt-out option "keeps us from getting a vote" because he thought most senators wanted the law, if passed, to be consistent among all 120 counties.

Sen. Julian Carroll, D-Frankfort, a Public Protection Committee member, said he also opposed the amendment. "I think to make it an effective health statement and to attack the problem associated with so many diseases that result from not only smoking, but secondhand smoke, we have got to attack the problem itself," he said.

Senate President Pro Tem David Givens, R-Greensburg, said the opt-out option "never really caught fire" but he was "confident that it would have caught some votes."

Plans to resuscitate the smoking-ban bill are already under discussion.

"It is not going away," Adams said. "It is very near and dear to my heart, not only from a health standpoint, but from an economic development standpoint – it is very good for business in Kentucky – and finally from a fiscal standpoint, because the savings that we could realize from implementing a smoke-free statewide policy are just too dramatic to discount."

Adams said that they "would take up the House bill in the interim and see what those amendments mean and see if we can't get those people a clean smoke-free bill."

But Alvarado remains interested in compromise. "I think having an all or none response is going to probably get more of a none, so you have to find some method of coming to the middle," he said. "We are hoping that as more and more people come to side with us that they will put pressure on legislators to say this is OK."

Even Stivers offered advoctes some hope when he said that he was "one of 38" senators and that he had been known to put bills on the floor for a vote, despite his opposition, if "there was support in this chamber for that issue" and noted that more Republicans were "wanting to push the issue forward."

Republican Caucus Chair Dan Seum of Louisville said, "I think it is an idea whose time will come. It is about education and moving people (forward). It is also a generational thing."

Givens said that he did see a future for a smoke-free Kentucky, complementing the proponents and how they have conducted themselves in the discussion.

"It is an advocacy effort," he said. "What is happening is the same as what happens with lots of pieces of legislation. There is a large educational component to it and by the proponents continuing the conversation, continuing to promote the effort, they are educating the populace and educating people that elect us – when they start to move the electorate, they certainly start to move us."

Polls in the last year have shown that 57 to 66 percent of Kentucky adults support a smoking ban.

Casey County High School, which will be smoke-free next year, curbs smoking by locking the restrooms most used by smokers

For two weeks in February, Casey County High School students who wanted to smoke in one of the restrooms were unable to do so because they were locked, Editor Larry Rowell reports for the Casey County News. Principal Josh Blevins said he locked restrooms "most frequented by the students who chose to smoke."

In September, the Casey County School Board passed a prospective tobacco-free rule, so students and staff will not be allowed to smoke in school buildings next year. Locking the restrooms was a way of sending a message. "That was not my long-term plan," Blevins said. "I was using this as a launch pad saying it [smoking] wouldn't be tolerated."

Blevins started a policy requiring students to ask permission and use a sign-out sheet to use the bathroom during class. The restrooms located near the administrative offices are never locked. he said students have the option of reporting to class and asking to use the restroom.

At least one parent did not agree with the new rules. Ellena Hussey, whose daughter attends the school, told Rowell that the students should have bathroom access between classes. She said her daughter has received 10 tardy slips because she had to wait in line to use the only unlocked restroom. Blevins said he had not heard from any parents who had a problem with his actions.

Local building contractor Kenneth Blevins said one restroom with four stalls is enough for the 200 students who attend the school. "The building code says you have to have one facility for the first 49 people and an additional one for every 50 you have," he said.

Breathitt County High School employed another method to curb student smoking. "We open all bathrooms at break time between classes," Supt. Larry Hammond told the Casey County News. "They are locked during class, and they can go to the bathroom between classes, before school, during lunch and after school. They are supervised by teachers." Students who need to use the bathroom during class get a pass and use the restroom in the principal's office.

"It at least controls the smell of smoke in the school building," Hammond said. "You don't smell it down the hallway." (Read more)

Monday, March 2, 2015

Student loses 175 lbs. in 14 months after gastric-sleeve surgery

Elizabeth Whitt and Don McNay
Elizabeth Whitt, an Eastern Kentucky University communications major from Richmond, Ky., decided to have gastric sleeve weight loss surgery when she was 19, and now, 14 months later, she has lost 175 pounds, Don McNay writes for The Huffington Post. McNay had the same surgery on Dec. 1 last year and has lost 70 pounds since then. He is writing a book called Project 199: My Business Plan to Lose 175 Pounds because he wants to drop from his original weight of 377 pounds to 199.

While McNay had the surgery at age 55 as a last chance to avoid an early death, Elizabeth had the surgery in college, when most people are not thinking about death. Dr. Derek Weiss at Bluegrass Bariatric in Lexington, Ky., operated on both of them. Weiss said that "doing weight loss surgery on a teenager had been rare before the gastric sleeve became more common as the risk of complications is lower than the other surgeries," McNay writes. Weiss said that "LSG is a tool. It limits the amount you can eat very successfully. But I think all LSG patients who succeed can take most of the credit themselves; they chose what to eat (and drink) and how much to exercise."

Whitt before (above) and after (below) with her health team
McNay talked with Whitt because although he had interviewed many experts already, he wanted to hear from someone who had been through the surgery. Whitt said the surgery has allowed her to be much more energetic and active. McNay asked Whitt how she was dealing with the sudden surge of attention from people who are drawn to success. She said she doesn't pay attention to men who express interest in her now but didn't talk to her when she was overweight. Whitt also noted that her parents did not support her having surgery until she presented them with research showing the benefits.

Michael and Debi Benson, the president and first spouse at EKU, said Whitt babysits their three children. President Benson said, "Debi and I are very grateful for Elizabeth and have marveled at her physical transformation. This change has allowed her inner beauty, which has always been radiant and contagious, to shine through even more."

"It took all of my forcus and courage to have the surgery at age 55," McNay writes. "There is no way I would have undertaken it at age 19. . . . When I weigh in at 199 pounds and hit the same 175 weight loss number that Elizabeth hit, I will say one thing for certain: she has been my inspiration. And my hero." (Read more)

Sunday, March 1, 2015

Poll analysis indicates Kentucky has the largest percentage of people who have gained health coverage under Obamacare

Kentucky has the nation's highest percentage of formerly uninsured people who have gained coverage under federal health reform, according to an alternative interpretation of the latest national polling data from The Gallup Organization.

Gallup again ranked Kentucky second to Arkansas in the expansion of insurance, but those rankings are based on percentage-point declines. However, the more illustrative ranking may be the percentage of formerly uninsured who are now covered.

That can be calculated, roughly, by dividing the percentage-point decline by the original percentage of uninsured. That shows Kentucky ranking first, with 52 percent of the formerly uninsured now having coverage, either with private insurance or the federal-state Medicaid program. Connecticut ranks second at 51.2 percent and Arkansas third at 49.3 percent.

The state Cabinet for Health and Family Services recently issued a press release about Kentucky staying at second in the Gallup rankings. Told about the alternative calculation, cabinet spokeswoman Jill Midkiff wrote, "While we certainly do not dispute Gallup's findings, it is accurate to say that Arkansas’s decrease in the uninsurance rate has been larger. However, Kentucky has seen the highest percentage of formerly uninsured who have become insured." Gallup did not respond to a request for comment.

Foundation for a Healthy Kentucky wants a claims database to increase transparency about health-care cost and quality in Ky.

Kentucky has experienced rapid changes in health care since the implementation of the Patient Protection and Affordable Care Act, and the next step is to implement a program that will provide more transparency about the cost and quality of health care so consumers can make informed, value-based health decisions, says a news release from the Foundation for a Healthy Kentucky.

A recent Kentucky Health Issues poll found that most Kentuckians think they can find out what doctors charge for treatments and procedures if they need this information. They seem to believe that transparency already exists, but this is often not the case.

The foundation recommends that Kentucky develop and establish an all-payer claims database, or APCD, for consumers and stakeholders as a tool to address this issue of price transparency.

"Clear, factual information about the cost and quality of health care is necessary for consumers to select value-driven care and for consumers and providers to be involved and accountable in their decision about their health and health care services," says the release.

The APCD Council defines APCDs as “large-scale databases that systematically collect health-care claims data from a variety of payer sources which include claims from most health-care providers," says the news release. The information includes patient demographics, provider codes, and clinical, financial and utilization data. This information is then made available to the public.

The foundation said it analyzed national and state expert presentations, reviewed studies and held a meeting in October with more than 60 Kentucky leaders in government, business, policy and health care to discuss the issue.

Participants discussed barriers, feasibility, solutions and other factors in implementing price transparency in Kentucky from the perspectives of the consumer, provider, policymaker and researchers. Here are some of their collective findings, according to the release:
  • Current cost and health service information are difficult to understand. 
  • Price and quality data need to be useful to the consumer through simple, useful tools, currently it is not. 
  • The state must be involved in implementing an APCD by passing laws to require the collection and sharing of data and requiring the data to be reported publicly. 
  • An effective APCD would allow estimates and cost comparisons between providers; would include expected out-of-pocket costs and quality measures that can be compared across providers; would have the ability to see spending patterns over time for all enrolled under one policy; would offer individual level data; and would offer health care value-based cost saving tips.
  • There is a significant variation in health-care pricing, and physicians may need an incentive to consider cost when making decisions for patients.
Colorado was one of the first states to establish price transparency legislation, data collection and reporting on a state-wide level. Representatives from that state's APCD said it was initially funded by foundations, but will use fees to sustain itself going forward.

Bill to cap co-payments for drugs is backed by emotional testimony, but opposed by health insurers and employer groups

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- People with chronic conditions are often denied the best medication for their condition because it is not on their insurance plan's preferred formulary, which makes the co-payment more for that medication than they can afford.

Sen. Tom Buford
Senate Bill 31, sponsored by Tom Buford, R-Nicholasville, would put a $100-per-month cap on co-payments for a 30-day supply of a medication for drugs subject to a tiered formulary, and not to exceed $200 per month total for all medications. House Bill 146, sponsored by Rep. James Kay, D-Versailles, has a similar bill that is currently in the House Banking and Insurance committee.

The Senate Health and Welfare Committee heard discussion on this bill Feb. 25, which opened with an impassioned plea from Buford to pass it. He said 18 states have passed or are in the process of passing similar bills. But they face strong opposition from the insurance industry and employers, and the bill has been on the committee agenda "for discussion only."

Buford said insurance companies have avoided big increases in premiums by raising co-payments, "which have gone over 54 percent and some 80 percent." Saying the average salary of Kentuckians is $23,700, he said many have to chose between living expenses and paying for medicine. "You may have insurance, but you may not have health care," he said.

The state Department of Insurance estimates that the bill would increase premiums by $3.20 to $4 per month and, because of greater utilization of services, raise the ultimate health-care costs of all insured Kentuckians (except those on state plans) by $2.58 to 3.23 per month.

Buford disputed the estimate, saying it essentially comes from the insurance industry. He acknowledged that capping co-pays would raise costs, but said the increase could be modest. He said that after Vermont passed a cap, the cost averaged only 32 cents per month per member for large-group plans and 74 cents per month for small-group plans.

Tom Underwood, state director of the National Federation of Independent Business, said the bill would primarily affect small-group employers, partly because small businesses have no power to negotiate with insurance companies.

Julie Davis of Glasgow, who has epilepsy, told the committee that she was forced to switch insurance this year, and a $60-per-month medication that she had been taking for seizures now cost $1,200 per month. She said they made her switched to a generic medicine, against the advice of her neurologist, and since has had her first breakthrough seizure in two and one-half years.

Getting emotional, Davis said that when she has such seizures, "I am out of commission for almost a month" and this has forced her to give up a job that she loved, move in order to be closer to a support group, and only allows her to work from home. She also said that at times she "fears for her life," and her insurance company has denied her appeals.

Deb McGrath of the Epilepsy Foundation said it had found that the most commonly prescribed and effective epilepsy drugs are on the non-preferred list of the "silver" plans on the state health-insurance exchange, the most common type of plan. A patient must pay a 40 percent co-insurance or a high deductible plus a co-pay to get a preferred drug on these plans.

She said the U.S. Department of Health and Human Services has called the practice of limiting coverage and imposing high cost-sharing for drugs that treat certain conditions "discriminatory."

McGrath said, "These barriers make it impossible, near impossible, for individuals, for those living with chronic health conditions like epilepsy, like arthritis, Alzheimers, crones disease, diabetes, and AIDS access to care that they desperately need."

Carl Breeding, a lobbyist for American Health Insurance Plans, gave the committee a letter from the Insurance Commissioner Sharon Clark, which he summarized as saying this bill would "prevent the state from being able to work" under federal health reform because of the way deductibles work and would "eliminate the bronze plan," the lowest-cost plan.

But Mark Guimond, a lobbyist for the Arthritis Foundation, said the lack of co-pay caps can increase costs because the resulting lack of medication can lead to hospitalizations, surgeries and time off work. "These are extremely expensive medications: $1000, $2000, $3000 a month," Guimond said, and patients "are being stuck with co-pays or co-insurance that may be 30-40-50 percent of these amounts."

The Kentucky Association of Manufacturers, which opposes the bill, wrote in the Lexington Herald-Leader that "These increased costs take away capital that state manufacturers could otherwise deploy to reinvest in their plants and more importantly remain competitive globally, so that we can continue to employ hard-working Kentuckians."

In animated remarks to the committee, Buford replied, "I hate to say this, but I could care less if we beat Japan in making toys if it depends on someone's life and health and the ability for them to live. It's more important apparently for some to deny the insurance than it is to make that profit on the bottom line of their company."

Grant will fund Lexington signs, maps to encourage walking

A $182,000 grant will fund a pilot project in Lexington to encourage citizens to walk more, by erecting way-finding signs for pedestrians and updating walking maps.

The new Walk Lexington program will also feature signs that tell people how easy it is to get from one spot to another such as "It's only two minutes to the library." The signs are used to help people realize that walking is often faster than driving.

The grant is from the John S. and James L. Knight Foundation, which awards grants to programs in cities where the Knight brothers once owned newspapers, including the Lexington Herald-Leader.

A Herald-Leader report on the grant indicted that the recipient is the NoLi Community Development Corp., a nonprofit trying to make the North Limestone corridor a more livable place, through the Blue Grass Community Foundation, which announced it.

Saturday, February 28, 2015

Beshear says Ky. rural hospitals 'have a positive cash flow' but he can't prove it; industry says it sees 'some improvement'

By Al Cross
Kentucky Health News

FRANKFORT, Ky. -- Gov. Steve Beshear says Kentucky's rural hospitals are profitable again, thanks to his expansion of Medicaid, but he offers little evidence to support his claim, and the hospital industry disputes it.

In a long, joint interview with Colorado Gov. John Hickenlooper at the Brookings Institution in Washington, D.C., Feb. 20, Beshear said, “Our rural hospitals have a positive cash flow for the first time in a long time, so it’s working, it’s going to work, and my job is just to get it so embedded that nobody can do anything about it.”

Kentucky Health News asked Beshear's office for evidence of rural Kentucky hospitals’ positive cash flow, but the office cited only a news story about Carroll County Memorial Hospital in Carrollton, which said it turned a small profit in 2013 (thanks to federal health-reform grants for digitizing medical records) and a much larger one in 2014.

"Some of them have improved and some of them have not," said Mike Rust, president of the Kentucky Hospital Association. As a result of Medicaid expansion, he said, "Some have benefited greatly but others are still struggling."

The association's vice president of health policy, Elizabeth Cobb, said, "In general we’re seeing some improvement in rural hospital finances," largely from a decline in the number of charity cases as a result of previous patients having coverage. "We were already taking care of most of those," she said.

State figures show Medicaid payments to rural hospitals rose 20 percent in the state fiscal year that ended June 30, 2013, but only 6 percent in the next year, when the Medicaid expansion began; and that the payments to urban hospitals rose 4 percent and 10 percent the last two years.

Based on claims from July through September, the state forecasts that Medicaid payments to rural hospitals in the current fiscal year will increase 26 percent, and payments to urban hospitals will rise 15 percent. (The state has estimates for each hospital.)

Cobb said the expansion hasn't generated as many new patients as might be expected for rural hospitals because of the shortage of primary-care physicians who admit patients: "We're not seeing a huge expansion of utilization as a result of Medicaid expansion."

That keeps patients coming to hospital emergency rooms for care, some of which is deemed non-emergency by managed-care organizations, the insurance-company subsidiaries that have overseen the care of Medicaid beneficiaries since 2011. Two MCOs pay only a $50 "triage fee" in such cases, regardless of what diagnostic tests the hospital performs; that was the topic of a legislative hearing last week.

And that is just one part of hospitals' problems with the MCOs. "What we're seeing generally is that while hospitals are receiving payment for some patients who may have been uninsured previously and are now insured by Medicaid, we're still seeing the challenges of hospitals being paid by managed-care organizations," Cobb said. "There's an increase in the administrative burden for small hospitals to work with five different MCO plans that all have very different rules and criteria."

Clinton County Hospital Administrator J.D. Mullins cited MCO problems is explaining his facility's decision to file for bankruptcy last year, mainly to restructure payments on the federal loan for a $14.7 million addition completed a few years ago, the Clinton County News reported.

"These companies’ polices have restricted access to the hospital’s services and reduced our reimbursement even more," Mullins told the Albany paper. "When the idea of a new hospital facility was first proposed, no one could have foreseen the condition of health care today."

The hospital is in the district of Sen. Max Wise, R-Campbellsville, who told fellow members of the Senate Health and Welfare Committee Feb. 26, "I would love to take the governor's report to the six of my seven counties out in rural Kentucky that are struggling right now in their hospitals. . . . What I'm hearing from them is the system is broken and it continues to be broken."

Wsie was referring to Beshear's recent report that Medicaid expansion is generating more money, jobs and tax revenue than forecast. Another committee member, Sen. Ralph Alvarado, R-Winchester, said, "Almost every senator here has received letters that say: This stinks, we are not getting paid, we are going under."

Cobb said some rural hospitals are reporting cuts in jobs and services. That is probably reflected in U.S. Bureau of Labor Statistics data compiled by Paul Coomes, emeritus economics professor at the University of Louisville. It shows hospital employment trending down while other health-care jobs have been going up.

While Carroll County and others are benefiting from federal digitization grants, "That funding’s going to go away," Cobb said, and "Every year you've got to pay for upgrades, and the requirements continue to increase at the federal level." Federal officials say digitization should make hospitals more efficient.

Of the Carrollton hospital, Cobb said, "That’s a special situation. That’s not a typical one." She said the facility "put in place a lot of measures to try to improve their management" and has partnered with larger hospitals to offer more services, such as cardiology, "and that’s breathed some life back in."

Rural hospitals in Nicholas and Fulton counties have closed in the last year, and state Auditor Adam Edelen, who is preparing to issue a report on rural hospitals, has warned that others are in danger, threatening to put new obstacles between rural Kentuckians and health care. "Not acknowledging the looming access issue is a disservice to the low-income and elderly Kentuckians who are depending on an intact provider network,” Edelen spokeswoman Stephenie Hoelscher said.

Friday, February 27, 2015

Bill would require Medicaid managed-care firms to pay contracted fees for ER visits; Senate hearing targets two companies

This story has been updated with comments from Wellcare of Kentucky.

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- Managed care is touted as a way to achieve value-based care in the Medicaid program, but hospital emergency rooms in Kentucky aren't finding much value in not being paid the contracted price for their services by two of the managed care organizations.

Officials of two Kentucky hospitals told the Senate Health and Welfare Committee Feb. 25 that Wellcare of Kentucky and CoventryCares of Kentucky are denying payment for as many as half of their emergency-room patients who seek care in their facilities, reimbursing the hospital a flat $50 "triage fee," less the patient's $8 co-payment, regardless of diagnostic tests performed in the ER.

Cheri Sibley, CEO of Clark Regional Medical Center in Winchester, noted that emergency rooms are required by law to screen patients with appropriate diagnostic tests to rule out an emergency condition if they come to the emergency room and ask for care.

Wellcare and Coventry are two of the five Medicaid managed-care organizations that oversee care for the state.

Wellcare said in an e-mail that it is required by the Department of Medicaid Services to "have an affirmative program to address the high cost of emergency room treatment for conditions that do not require this level of care." The company said the triage fee is just one measure it has taken; it said an "emergency room prudent layperson program" has helped "identify and sometimes prevent payments as much as 500 percent to 1,300 percent more in an emergency room as compared to a physicians office for common ailments such as ear aches and sore throats."

Sen. Ralph Alvarado, a physician from Winchester, has sponsored a bill that would require MCOs to pay the previously negotiated rate for emergency-room examinations and allow the ER doctor to determine whether a patient's condition is an emergency or not,.

"This bill is an attempt to keep our Medicaid managed-care organizations accountable," Alvarado said at the meeting. "MCOs have been shortchanging our providers and our hospitals -- and, I would argue, purposefully -- for the past three years. . . . MCOs are basically managing health-care cost by non-payments to providers."

Since the advent of managed care in 2011, hospitals have complained about late and denied payments and difficulty dealing with MCOs. "The problem has reached critical mass, threatening the survival and financial viability of our hospitals, and almost every legislature has been contacted by their local hospital provider regarding these (issues)," Alvarado said.

Kentucky implemented managed care as a way to save money. Basically, insurance company subsidiaries get a certain sum per patient and increase their profits by controlling costs. The Cabinet for Health and Family Services maintains that managed care focuses on quality and provides better accountability for care as opposed to the traditional fee-for-service model, but provider complaints about slow payments and rejections of claims have persisted since its inception.

Hospitals bill insurance and Medicaid based on the level of complexity of emergency-room care provided based on the symptoms the patient presents, regardless of the final diagnosis. Payment has typically been based on a fee that was pre-negotiated between the hospital and the MCO.

Wellcare and Coventry have since implemented a non-negotiated "triage policy," which allows these organizations to determine, after the fact, whether a patient had an emergency. If they determine that a patient was a non-emergency, regardless of presenting symptoms and cost of diagnostic procedures (X-rays, CT scans, lab tests, and so on), they only pay $50 minus the $8 co-payment, or $42. Wellcare implemented this policy in September 2012 and Coventry in April 2013.

The legislaure's Administrative Regulation Review Subcommittee found last May that the triage policies did not follow federal standards, according to Sibley and Alvarado.

"One side seems to be meeting their contractual obligation, while the other side seems to be deficient in meeting their contractual obligations," said Sen. Julie Raque Adams, R-Louisville, chair of the committee.

Hospitals can appeal MCOs' decisions, but "hospitals report that only a small number of these are overturned with no explanation of decision given," Sibley said.

Sibley gave an example of a claim that had been determined a non-emergency by one of these companies at her hospital: An 18-month-old girl was brought to the ER because she was blue in color, wheezing and short of breath. She had an X-ray, other diagnostic tests and a breathing treatment, but the hospital was paid $42 by the MCO plus the $8 co-payment, if the patient paid it.

"The two MCOs in question should not be deciding which patients are non-emergencies," Sibley said. "They should be abiding by their negotiated contract and paying the contract rate," 95 percent of allowed cost.

Sibley presented Kentucky Hospital Association data from 64 hospitals affected by these triage policies. The report found that during calendar year 2014, the hospitals reported submitting nearly 380,000 emergency room claims to Wellcare and Coventry, of which 140,000 were denied except for the $50 fee. The overall denial rate was about 37 percent; Wellcare's was 48 percent.

The KHA report said the difference in the flat fee and the contracted rate totaled $37.4 million, and that the more complex visits (and this likely the more expensive) were the ones most often denied payment.

"With one in four Kentuckians now on Medicaid, this problem is only going to get worse, if this is not corrected by this Senate Bill 88," Alvarado's legislation, Sibley said.

Georgetown Community Hospital CEO William Haugh said almost 30 percent of its ER visits in 2014 were Coventry or Wellcare clients. Wellcare classified almost 60 percent as triage cases and paid only $50 each. The hospital appealed 92 percent of those cases, with a success rate of 16 percent, or 285 patient encounters. Haugh said that amounted to a $334,258 underpayment, plus an estimated $40,000 cost for preparing and prosecuting the appeals.

Haugh said Coventry classified 26.4 percent of its clients' Georgetown ER visits as triage and paid only $50 each. The hospital appealed 94 percent of those and had a success rate of 36 percent, or 366 patient encounters. He estimated an underpayment of $148,000 plus $22,000 in labor for appeals, and said the overall financial impact to the hospital was $543,894.

Wellcare said its appeals process allows three opportunities for review, with at least two independent medical directors.

The state Medicaid program's chief medical officer, Dr. John Langefeld, said the emergency-room problems are not a "straightforward, easy issue," He said many patients go to ERs for reasons beyond medical care. The cabinet has said that some hospitals have relied too much on ER revenues.

Sen. Reginald Thomas, D-Lexington, said rural hospitals need to change their business models and wondered if the bill was an attempt to mask that problem. Meanwhile, he added later, there is "documentation that hospitals have benefited from Medicaid expansion" under the federal Patient Protection and Affordable Care Act, in a recent report from Gov. Steve Beshear.

Adams replied that Beshear says, ""It is great, and it's putting all this money back in the system," but in fact we are not seeing it on the provider level."

Alvarado said, "There is a difference between what actually happens and what the governor's office wants to show you. So when you have KentuckyOne [Health] coming out publicly declaring a $218 million dollar loss in one year, that is hardly a profitability for them based on the ACA."

Alvarado said Citibank reported the companies have made $155 million in profits off of Kentucky Medicaid. "I'd get rich, too, if I didn't pay my bills," Alvarado said. "It is an outrage."

Thursday, February 26, 2015

Most Kentuckians don't communicate with doctors electronically; most are confident about access to pricing information for care

Most Kentuckians don't communicate with their doctor electronically, according to the latest Kentucky Health Issues Poll.

The poll, taken Oct.8-Nov.6, found that 73 percent of Kentuckians have not communicated with their doctor using text, email or a website during the last year. A national poll found similar results.

This finding was consistent in all age groups, but there was a difference among socioeconomic groups.

Seventy-nine percent of those whose incomes are 200 percent of the federal poverty level or below said they had no electronic communication with their doctor in the past year, but only 66 percent of those above this level said they had had no electronic contact. In 2013, 200 percent of poverty level was $47,100 for a family of four.

Electronic communication with doctors was most common in Northern Kentucky and least common in Eastrern and Western Kentucky.

The Kentucky Health Information Exchange, the hub that connects participating providers with each other to share health information via certified electronic health records, is now working to connect patients to their electronic health records via a pilot program.

Research has found that patients who are better informed about their health and health care cost are more engaged with their health, according to the release.

Patients at UKHealthCare who have access to their "patient portals" seven days after discharge are an example of how few Kentuckians are engaging with their health care provider via electronics.

“About 8 to 10 percent of hospitalized patients look at their patient portals, of our inpatients,”Dr. Carol Steltenkamp, chief medical information officer at UKHealthCare, said in a phone interview “We would love for that to increase.”

Steltenkamp said that patients often don't understand how to use their portals and that the hospital is working diligently to educate them.

The poll also found that most Kentuckians think they can find out what doctors charge for treatments and procedures if they need this information, finding 36 percent extremely or very confident that they could find out how much treatments and procedures cost; 34 percent moderately confident and 28 percent not too confident or not confident at all. These answers did not vary by income, age or region.

The poll is conducted by the Institute for Policy Research at the University of Cincinnati and was funded by the Foundation for a Healthy Kentucky and Interact for Health, formerly the Health Foundation of Greater Cincinnati. It surveyed a random sample of 1,597 adults via landline and cell phone, and has a margin of error of plus or minus 2.5 percentage points.

Wednesday, February 25, 2015

Kynect opens special enrollment period March 2-April 30 to give people without health insurance a chance to avoid tax penalty

The state health-insurance exchange, Kynect, is reopening enrollment in March and April to allow signups by Kentuckians who discovered that not having health insurance means they have to pay a federal tax penalty.

“We believe that many Kentuckians did not realize those who do not obtain health coverage could face significant penalties when they file their taxes,” Gov. Steve Beshear said in a news release. And given that the personal risks of not having health coverage are even greater than the penalties, we have decided to continue a special enrollment period to allow those individuals more time to sign up.”


The penalty for not having health coverage last year is 1 percent of income, or $95 for each adult in the household and $47.50 for each child, whichever is greater. For 2015, the penalty will be 2 percent or $325 for each adult and $167.50 for each child.

"Individuals taking advantage of this special enrollment period will still owe a fee for any months they were uninsured and did not qualify for an exemption in 2014 and 2015," the news release warns. "This special enrollment period is designed to allow such individuals the opportunity to get covered for the remainder of the year and avoid additional fees for 2015."

If your household income is between 100 and 138 percent of the federal poverty level, which makes you eligible for expanded Medicaid, you will still be charged a penalty if you don't sign up. Medicaid enrollment is open year-round, but the special enrollment for private insurance will end April 30.

Visit https://kynect.ky.gov or call 1-855-4kynect (459-6328) to learn more.

Tuesday, February 24, 2015

Humana plan members can join Weight Watchers free for six months, get 'a significant discount thereafter,' companies say

Humana Inc. and Weight Watchers International Inc. are teaming up to help employers attack the rising level of obesity and its health-related impacts.

Employees in Humana-managed, employer-sponsored health plans now have free and discounted access to Weight Watchers through an integrated wellness program built into their health plan, the first program of its kind, the two companies said in a news release.

Plan members who want to lose weight can join Weight Watchers free for six months, "and at a significant discount thereafter," the release said. "Weight Watchers helps people adopt a healthier lifestyle that results in achieving and learning to maintain a healthy weight."

Remke Markets, a family-owned grocer with 12 locations in Kentucky and Ohio, is offering the program to its 900 employees.

“What I like about this program is that it actively connects people who want to get to a healthy weight with a trusted, well-known and effective program, and then helps make it affordable,” President Matthew Remke said. “The health risk that extra weight poses for our associates and their families is reason enough to want to attack the problem, but there are also serious consequences of an unhealthy workforce for an employer trying to compete in a tough marketplace.”