Thursday, July 28, 2016

Feds issue ratings on 3,662 hospitals, 82 in Ky.; none get top rank, 16 get second rank; industry says ratings oversimplify

By Danielle Ray
Kentucky Health News

The Centers for Medicare and Medicaid Services on Wednesday released its Overall Hospital Star Ratings, just two days after two U.S. House members introduced a bill that would delay the release for a year.

The ratings aim to give consumers a simple measure of hospital quality. Critics say they are too simple.

They rate 3,662 U.S. hospitals from one to five stars, with the latter representing the highest quality of care. Each hospital's rating is based on 64 measures of safety and performance in seven categories: mortality, safety of care, readmission within 30 days, patient experience, effectiveness of care, timeliness of care and efficient use of medical imaging.

"These easy-to-understand star ratings are available online and empower people to compare and choose across various types of facilities from nursing homes to home health agencies," Dr. Kate Goodrich, director of Medicare's Center for Clinical Standards and Quality, said Wednesday on CMS's official blog.

Many hospital performance experts have opposed the rankings, calling them skewed and unreliable.

"Hospitals that reported on the majority of metrics tended to get one, two or three stars," Dr. Janis Orlowski, chief healthcare officer of the Association of American Medical Collegestold Steve Sternberg of U.S. News & World Report. "Hospitals that reported on less than 40 percent of the metrics accounted for almost half of those that got five stars."

CMS planned to release the ratings April 21, but delayed them so Medicare officials could respond to criticism, which included a letter from 60 of the 100 U.S. senators and 225 of the 438 representatives calling for a delay, plus pressure from some of the nation's largest hospital organizations.

Two days before the release, Reps. James Renacci (R-Ohio) and Kathleen Rice (D-New York) introduced a bill that would have forced its delay until at least July 2017.

“I still have real concerns that this system could unfairly penalize teaching hospitals and hospitals that serve poor communities, and that patients will ultimately pay the price," Rice told Elizabeth Whitman of Modern Healthcare.

That may have been reflected in the Kentucky rankings. The hospitals at the University of Louisville and University of Kentucky got one star and two stars, respectively.

The agency chose to go ahead with the release, Goodrich said in the CMS blog, because officials "have received numerous letters from national patient and consumer advocacy groups supporting the release of these ratings." She said the ratings improve transparency and accessibility of information about hospital quality.

Of the 94 Kentucky hospitals that CMS evaluated, 82 were rated, and 12 did not have enough data to generate a rating.

Twin Lakes Regional Medical Center (Photo from abelconstruct.com)
No Kentucky hospital earned a five-star rating. Sixteen hospitals got four stars: Baptist Health Lexington, Baptist Health Louisville, Casey County Hospital in Liberty, Clark Regional Medical Center in Winchester, Flaget Memorial Hospital in Bardstown, Greenview Regional Hospital in Bowling Green, Hardin Memorial Hospital in Elizabethtown, Harrison Memorial Hospital in Cynthiana, Marcum and Wallace Memorial Hospital in Irvine, Methodist Hospital in Henderson, Pineville Community Hospital, St. Joseph Martin, St. Elizabeth Fort Thomas, St. Elizabeth Medical Center North in Edgewood, TJ Health Columbia (now only a behavioral-health facility) and Twin Lakes Regional Medical Center in Leitchfield.

The majority of the Kentucky hospitals rated, 52, earned three stars. A complete list of those hospitals can be found here.

Twelve hospitals got two stars: Ephraim McDowell Regional Medical Center in Danville, Harlan Appalachian Regional Healthcare Hospital, Hazard ARH Regional Medical Center, Jennie Stuart Medical Center in Hopkinsville, Jewish Hospital & St. Mary's Healthcare in Louisville, Kentucky River Medical Center in Jackson, Lourdes Hospital in Paducah, Monroe County Medical Center in Tompkinsville, St. Joseph Hospital in Lexington, St. Joseph East in Lexington, St. Claire Regional Medical Center in Morehead and the University of Kentucky Hospital.

Two hospitals earned just one star: University of Louisville Hospital, where a recent state inspection found problems with nursing; and Lake Cumberland Regional Hospital in Somerset, which ranked very poorly in the 2014 ratings by Consumer Reports magazine. It got two stars last year, one of only six Kentucky hospitals to do so.

Rick Pollack, president and CEO of the American Hospital Association, said he fears the ratings could mislead patients.

"The new CMS star ratings program is confusing for patients and families trying to choose the best hospital to meet their health care needs," Pollack said in a news release. "Health care consumers making critical decisions about their care cannot be expected to rely on a rating system that raises far more questions than answers."

A comprehensive list of Kentucky hospital CMS ratings can be found here. Nationally, Medicare gave five stars to 102 hospitals, four to 934 hospitals, three stars to 1,770 and one star to 133. Many hospitals did not produce enough data in the measured areas to warrant a rating.

Wednesday, July 27, 2016

Ky. has 54 counties at high risk for spread of HIV and hepatitis C among IV drug users but only 6 of them have needle exchanges

By Melissa Patrick
Kentucky Health News

Why, if 54 of Kentucky's 120 counties are among the nation's most vulnerable to outbreaks of HIV and hepatitis C among intravenous drug users, do only a few of them allow users to exchange used syringes for clean one to avoid spreading the diseases?

That question was asked, implicitly, by a national expert who spoke at the 2016 Viral Hepatitis Conference in Lexington July 26.

"I think it is very interesting to compare the counties we believe are at risk, based on our modeling, and then where are prevention services, such as syringe-service programs," said Dr. John Ward, director of the Division of Viral Hepatitis at the federal Centers for Disease Control and Prevention. "You can see there is a big disconnect, that there is a big gap in syringe service availability and other powerful prevention interventions, such as medication-assisted therapy."

Syringe exchanges were authorized in Kentucky under a 2015 anti-heroin law and require local approval and funding. They are meant to slow the spread of HIV and hepatitis C, which are commonly spread by the sharing of needles among intravenous drug users.

So far, 14 counties have approved syringe exchanges, according to the Cabinet for Health and Family Services, with 11 of them operating. But only six (Carter, Boyd, Pike, Knox, Mercer and Grant) are in the most-vulnerable group.

A spokeswoman for the state Department of Public Health said the agency supports the exchanges and is available to provide support, share best practices, offer technical guidance, and provide information on their effectiveness and benefits.

"In addition, DPH has hosted several statewide conference calls with local health department directors to discuss setting up syringe exchange programs," spokeswoman Beth Fisher said. "We have also coordinated several trainings for syringe-exchange staff members as well as administrators. We also work to provide education and training regarding harm reduction related to syringe use to communities."

Dr. John T. Brooks, senior medical adviser for CDC's Division of HIV/AIDS Prevention, pointed out the HIV outbreak that occurred in Scott County, Indiana last year, which drew national attention because of its high rates of HIV and hepatitis C.

He said Scott County isn't that different from many rural Kentucky counties because of its high poverty and unemployment rates, low education and life expectation, lack of HIV and hepatitis C care, insufficient addiction services and no needle exchange when the outbreak began. The CDC found that 18 Kentucky counties were more vulnerable to a hepatitis C and HIV outbreak among IV drug users.

"If we don't pay attention to history, we are doomed to repeat it at some point in the future," Brooks said. "You want to prevent this from getting introduced and recognize it the moment it is introduced so that you can do what you can to prevent it from continuing to spread."

Ward said multiple approaches are needed to stop the spread of hepatitis C. Using the Scott County outbreak as a model, he said a syringe-exchange program would decrease hepatitis C by 27 percent; adding medication-assisted therapy would make the decrease 41 percent; and adding a robust testing and treatment program would get it to 71 percent.

Brooks said syringe exchanges and medication-assisted therapies would reduce the potential spread of new HIV infections by 64 percent and 56 percent, respectively.

He encouraged Kentucky counties to gather their own data to determine the prevalence of IV drug use in their communities; to test people with substance-use disorders in jails and prisons, and those who frequent emergency rooms, for HIV and hepatitis C; and to create a countywide plan for a potential HIV or hepatitis C outbreak.

Referring to resistance to syringe exchanges, Wayne Crabtree of the Louisville exchange asked, "When has judgement, stigma or shaming ever made a difference in someone's life? When did it ever change behavior? I would say never. And we in public health know it is the hand reaching out to someone in need lifting them up and making them realize their self-worth that elicits change."

Dr. Ardis Hoven, a state infectious-disease expert, said "Stigma continues to exist everywhere around many of the issues we are discussing today and I think it is our responsibility and our challenge to begin to open up the dialogue in a way that goes to minimizing it. Because as stigma is sitting out there, we are not going to be able to get the job accomplished as well as we should."

Hoven said establishing a syringe exchange requires local data and local allies, especially local police, who can "make or break a syringe-exchange program."

Tuesday, July 26, 2016

Updated directory of local health coalitions published

The Foundation for a Healthy Kentucky has released an updated directory of groups working on health in the state. It includes 230 groups representing all 120 counties as well as statewide coalitions doing work to improve the health of Kentuckians.

"These coalitions are largely local efforts involving neighbors and colleagues working on solutions to health issues where they live, work and raise their families," said Susan Zepeda, president and CEO of the foundation. "Our aim in keeping this directory updated is to raise awareness of efforts to improve health in local communities  and across the state, foster collaboration among the coalitions, increase their capacity to make a difference, and celebrate their successes."

The groups have differing goals and levels of organization. For example, some are increasing access to healthy food and physical activity; others are planning screenings and education for people at risk for serious health problems such as cancer, diabetes and other chronic diseases; others are improving the health of their communities through smoke-free or complete-streets ordinances.

Coalitions were identified by consolidating lists of known groups, reaching out at meetings and events, reviewing news clippings on local efforts, requesting additional entries from partner agencies, and conducting a web-based survey.  The directory is a living document, and the foundation welcomes established coalitions to share updates and new coalitions to be added. Contact Rachelle Seger, rseger@healthy-ky.org.

The 2016 Kentucky Health Coalitions Directory can be found on the foundation's website.

Analysis of Ind. Medicaid plan, Bevin model, shows same concern about financial hardship voiced by Ky. critics; Ind. officials reply

Gov. Matt Bevin
By Danielle Ray
Kentucky Health News

While Republican Gov. Matt Bevin works on his proposal to reform his Democratic predecessor's expansion of Medicaid, the Indiana program that was his model is suffering mixed reviews from a recent analysis.

Bevin's administration has said it hopes to file his plan with federal officials in August. The changes are modeled after Republican Gov. Mike Pence's "Healthy Indiana Plan 2.0," which includes premium contributions, health-savings accounts, incentives for healthy behaviors and a benefit lockout for people who don't pay premiums. The Indiana plan took effect last year.

A state-funded analysis by an independent consulting firm, released in early July, illustrates one of the issues raised by Kentucky critics of Bevin's plan: possible financial hardship for those required to pay monthly premiums.

Indiana Gov. Mike Pence
Among top concerns regarding the Indiana program are the number of Medicaid recipients either locked out of benefits or losing dental and vision coverage for six months after failing to pay into their health savings account.

Among the 345,656 Healthy Indiana Plan 2.0 enrollees (as of January 2016), 2,677 above the poverty line were locked out for six months for failing to pay their contribution, and 21,445 below the poverty line transitioned to basic Medicaid because of non-payment, Virgil Dickson reports for Modern Healthcare.

Those totals were 5.9 percent and 8.2 percent, respectively, of those groups, Indiana Secretary of Family and Social Services John Wernert said in a letter to Kentucky Health News. He said 56 percent of those who were locked out "had actually found other coverage, either through their work or their spouse’s work, which may explain why they stopped paying. Nearly all HIP members (166 out of 176) who applied for a waiver of the lock-out period were granted one."

The report says more than 90 percent of people in the expansion have been able to continue their HSA contributions of $3 to $25 a month depending on income level, but almost half said they worried about being able to make the contributions: 16 percent said they always worried, 7 percent said they usually worried, 22 percent said they did sometimes, and 14 percent said they did rarely. Three percent said they didn't know and 38 percent said they never worried.

Wernert said some of the "most telling" results of the survey were that members who contribute to their accounts "were more satisfied with the program (84% to 71%), had better drug adherence (84% to 67%), sought more primary (31% to 16%) and preventive care (64% to 45%) and relied less on the emergency room for treatment (775 to 1,034 visits per 1,000 member years)."

If federal officials approve the proposed changes in Kentucky, the state would make dental and vision coverage a reward, not a basic benefit. Recipients could gain the coverage, as well as non-prescription drugs and gym-membership subsidies, by enrolling in job training, volunteer work or health-related classes.

Similar to the Indiana plan, the changes would apply only to able-bodied adults, not pregnant women, the disabled or those deemed "medically frail." Working-age adult members without dependents would be required to participate in volunteer work, have a job, look for one or take job training, on a gradually increasing scale, phased in by county.

Also like the Indiana plan, most Kentucky Medicaid recipients would have to pay premiums of $1 to $15 a month. Failure to pay would result in a six-month lock-out period for those above the federal poverty level, though they could re-enroll if they catch up on their payments and take a financial- or health-literacy class. Those below the poverty level or who are medically frail and don't pay premiums would shift to a co-pay system and have $25 deducted from their rewards account, which could then be suspended.

Bevin's proposal says it "represents the terms under which the Commonwealth will continue Medicaid expansion" as established by Democratic Gov. Steve Beshear. Bevin has said that if federal officials don't approve it, he would end the expansion, which provides largely free health care for about 400,000 Kentuckians who were not covered before 2014.

Bevin has said that former Gov. Steve Beshear's Medicaid expansion is financially unsustainable. His proposal attempts to offset the state's costs with what he has referred to as "skin in the game" for Medicaid recipients, meaning that they must be more active in their health care. The federal government is paying all bills for Medicaid expansion enrollees through this year. Next year the state would pay 5 percent, rising in annual steps to the federal health-reform law's limit of 10 percent in 2020. The estimated cost of the state share in the two-year budget that begins July 1 is $257 million.

Read more here about Bevin's proposed changes, including premium payments and Medicaid deductibles.

Monday, July 25, 2016

Testing for colon cancer may detect it without colonoscopy

Dr. Morris Beebe III
(Photo from Baptist Health)
Colorectal cancer is the second leading cause of cancer deaths (after lung cancer) even though effective, inexpensive, non-invasive screening options have been developed, says a Corbin gastroenterologist.

When it comes to colorectal cancer screening, patients are often embarrassed or worried about potentially painful procedures, Dr. Morris Beebe III writes in a Lexington Herald-Leader column.

Two simple screening options can be done in the privacy of a patient's own home: fecal occult blood testing (FOBT) and fecal immunochemical testing (FIT). Each test requires only an "at home" kit, collecting samples from several bowel movements.

"It’s all very private," Beebe notes.

FOBT requires minor changes to a patient's diet, such as avoiding red meat right before the test; FIT does not.

"The idea behind these tests is to see if there are small amounts of blood hidden in the stool, suggesting pre-cancerous polyps or cancerous growths," he says.

If results show hidden blood, a follow-up colonoscopy can be used for diagnosis and treatment. Colonoscopy is widely recommended as one of the most effective screening tests, Beebe says, reducing the odds of colorectal cancer deaths by as much as 60 to 70 percent. Doctors can also remove any abnormalities that are found during the same procedure.

Doctors perform a colonoscopy by inserting a scope, a flexible tube with a camera, into the rectum and threading it through the length of the colon. Air is pumped into the colon to make viewing easier. The patient is given either general anesthesia or sedation, so the procedure is much less unpleasant than the description suggests, Beebe notes.

The federal Centers for Disease Control and Prevention recommend regular colorectal cancer screenings at age 50.

"These screenings can save lives by detecting cancer at a treatable stage or even preventing it in some cases," Beebe adds.

Dean of osteopathic medical school at Pikeville University is new president of American Osteopathic Association

Boyd R. Buser, D.O.
Boyd R. Buser, dean of the Kentucky College of Osteopathic Medicine in Pikeville, is the new president of the American Osteopathic Association. The organization represents the professional interests of the nation’s more than 123,000 doctors of osteopathy and osteopathic medical students.

“We are at a turning point in health care, when the focus on wellness and prevention has never been greater,” Buser told the group at its meeting Saturday in Chicago. “Patients value our approach, how we partner with them to promote their health and well-being, whether the topic is preventing chronic disease or protecting patients from the threat of opioid addiction. As osteopathic physicians, we seek health in our patients and recognize that a person’s state of health depends on their body, mind and spirit.”

Buser is past president of the American Academy of Osteopathy. In addition to heading the osteopathic school at the University of Pikeville, he is the university's vice president for health affairs. He is best known for helping shepherd the profession through the transition to a single accreditation system for graduate medical education.

Saturday, July 23, 2016

Latest sign of IV drug spread: Hepatitis C cases among Kentucky women of childbearing age more than tripled from 2011 to 2014

Centers for Disease Control and Prevention chart shows hepatitis C rates for Kentucky and U.S.
Hepatitis C among Kentucky women of childbearing age more than tripled from 2011 to 2014, while the national rate among that group was rising only moderately, the federal Centers for Disease Control and Prevention said July 22 in a report that "offers further evidence of growing problems in the state from intravenous drug use," Bill Estep writes for the Lexington Herald-Leader.

In 2011, the hepatitis C infection rate among Kentucky women aged 15-44 was 275 per 100,000. In 2011, it was 862 per 100,000 -- an increase of 213 percent. The national increase during the period was only 22 percent.

The CDC highlighted Kentucky because "the state had the highest incidence of acute hepatitis C infections from 2011 through 2014," Estep reports. "The report found that the rate of infants born to women diagnosed with hepatitis C went up 124 percent in Kentucky in that time."

But those numbers likely understate the problem, Estep notes: "The figures were based on data from a large commercial laboratory called Quest Diagnostics and birth certificates. The report said that having to rely on data from one lab means the figures might not represent the reality across the country or in Kentucky. The numbers for Kentucky are likely low, the report said. Official figures for 2015 are not yet available. However, health department officials said early indications suggest the trend will continue for 2015."

Health officials also told Estep that the statistics make a good argument for needle exchanges where IV drug users can get clean syringes instead of sharing dirty ones and transmitting diseases such as hepatitis or HIV, the virus that causes AIDS.

There is also a financial argument, Estep notes: "One course of the drug needed to treat hepatitis C costs more than $80,000, and the lifetime cost of treating HIV can be hundreds of thousands of dollars, health officials said. Hepatitis C is the top cause of expensive liver transplants, according to the CDC."

Estep reports, "Most people with hepatitis C don’t have physical symptoms, but of every 100 people infected with the virus, 70 or more will develop chronic liver disease and as many as five will die from cirrhosis or liver cancer, according to a CDC fact sheet. . . . The agency said people born between 1945 and 1965 should talk with a doctor about being tested for hepatitis C, and that people with risk factors such as IV drug use should be tested. It also recommends that health care providers assess all pregnant women for risk factors and test those who might be at risk."

Justice Department sues to block Aetna's takeover of Humana

Getty Images
The U.S. Department of Justice has filed lawsuits to block the sale of Louisville-based Humana Inc. to Aetna Inc. and of Cigna Inc. to Anthem Inc., on grounds that consolidation of the health-insurance market will reduce competition and hurt consumers. Observers expect a protracted court battle, involving negotiations with the department's anti-trust division, reports Grace Schnieder of The Courier-Journal.

"Of the two deals, analysts and investors see Aetna and Humana as having a slight chance to reverse the decision," report Caroline Humer and Carl O'Donnell of Reuters. Aetna "faces a tough but not impossible legal battle." Also, "Aetna may also gain some leverage if the Anthem-Cigna deal breaks up first, according to some antitrust experts."

The Justice Department's major focus in the Humana-Aetna case is Medicare Advantage, the alternative insurance for seniors. "The two companies now compete in more than 600 counties, nearly 90 percent of the counties where Aetna offers Medicare Advantage plans," Schneider notes. "That fierce competition has led to lower premiums, better benefits, better provider networks and improved coordination of care, the suit said." It also said smaller insurers "lack the scope and scale" to compete.

Reuters reports, "Aetna will argue in court that the Justice Department defined the market for Medicare Advantage too narrowly, which has caused it to see competition issues where they do not exist, Chief Executive Officer Mark Bertolini said in an interview. The government has failed to take into account that seniors can not only choose between Medicare Advantage plans sold by private players, but also have the government-run Medicare program as an option. . . . The Justice Department has already rejected that argument. However, Aetna will use evidence that the Obama administration envisioned Medicare and Medicare Advantage as direct competitors as it sought support for the Affordable Care Act passed in 2010."


Friday, July 22, 2016

Lexington baby tests positive for Zika virus but shows no effects

A baby born in Lexington showed antibodies for the Zika virus but no apparent effects of it, the Lexington-Fayette County Health Department announced Friday. It is Kentucky's 10th confirmed case of Zika, which can cause birth defects such as an abnormally small head and brain.

Health Director Kraig Humbaugh said the mother had traveled early in her pregnancy to an unspecified area known to have been affected by the virus. "Health officials say the infant's mother never described symptoms of illness," Victor Puente of WKYT-TV reports.

While the baby showed antibiodies for Zika, it showed no other evidence of the virus, and apparently fought it off, Puente reports. Humbaugh said the mother and child present no risk to public health. He said pregnant women, or those planning to become pregnant, should cancel or postpone travel to Zika-affected areas.

Thursday, July 21, 2016

Health advocates, providers and faith leaders voice concerns about Medicaid plan; one says it's based on false assumptions

By Melissa Patrick
Kentucky Health News

FRANKFORT -- Health advocates, providers and faith leaders spoke out against Gov. Matt Bevin's proposed changes to the state's Medicaid program at a news conference July 20, saying it creates barriers to access, is too complex and is based on false assumptions.

"The proposed changes to Medicaid by Governor Bevin and his staff will impact the health and economic wellbeing of hardworking, low-income Kentuckians, families and our most vulnerable citizens across the Commonwealth," said Rich Seckel, executive director of the Kentucky Equal Justice Center.

The news conference was sponsored by KeepKYCovered, a campaign coordinated by Kentucky Voices for Health, an umbrella organization for groups focused on sustaining access to affordable health coverage in Kentucky.

Col Owens, a director of KVH and a retired Legal Aid lawyer, was one of the most vocal opponents of the Medicaid proposal, saying it is based on inaccurate assumptions.

He said the notion that low-income workers don't sign up for health insurance because they don't know how it works is false. He said it "has little to do with understanding insurance and virtually everything to do with affordability." He noted that the costs of health insurance and health care are rising faster than wages, which have remained stagnant for decades, and that fewer employers than ever are offering health insurance: 56 percent, down from 70 percent in 1980.

As for the idea that people need "skin in the game," as Bevin contends, Owens said, "Low-wage workers do not earn enough money to achieve economic stability for their families, and it is simply untrue, demonstrably untrue, that they have enough sufficient disposable, discretionary income in order to pay co-pays, deductibles or premiums."

As for the work requirements, he said, "It is a great fallacy to believe that low-income people must be forced to work by holding out goods or services for things that they need. ... The truth about Medicaid is quite the opposite: it is what allows people to work."

The Kentucky Center for Economic Policy found that more than half of Kentuckians who gained Medicaid through the 2014 expansion by then-Gov. Steve Beshear are working.

Bevin's proposed work and volunteer requirements were particularly upsetting to entrepreneurs and farmers, jobs that require long hours and often the need to work a second job to make ends meet.

“The work requirements of the new proposal feel like a slap in the face to hard-working families like mine,” Oldham Coutny farmer Bree Pearsall said in a prepared statement. “To assume that because I am low-income that I have an inferior investment in my family’s health is an insult. I would like to see the governor act with compassion, instead of creating a culture of shame for families who receive health care coverage through Medicaid.”

Tyler Offerman, 27, of Lexington, who recently started an outdoor-adventure company while working full-time in a restaurant, said the expansion of Medicaid “allowed me to follow the American dream, and it supports other young entrepreneurs in doing the same. To assume people like me are lazy or are mooches to the system is totally offensive. I am an entrepreneur. I am trying to create jobs, to create a living for myself, and the kind of  rhetoric that is coming out of the Bevin administration is very offensive.”

Under Bevin's plan, Medicaid recipients would be required to pay premiums, which initially range between $1 and $15. Non-payment would result in a six month lock-out for those who are above the federal poverty level, though they can re-enroll if they get current on their payments and take a financial- or health-literacy class. Those below the poverty level or who are medically frail and don't pay premiums would shift to a co-payment system and have $25 deducted from their rewards account, which is then suspended.

Father Dan Noll of the Catholic Conference of Kentucky said that the complexity of the plan would discourage access, and strongly opposed the premiums.

"Kentucky cannot sacrifice people because they are poor," Noll said. "Many more lower income individuals and families in Kentucky will lack the resources to meet the financial burdens of their healthcare under Governor Bevin's health-care plan. To these families, an increase in premiums, cost-sharing charges and a lock-out period will be significant barriers to obtaining coverage or seeing a doctor, much less a dentist or eye-doctor."

Dr. Eli Pennington Pendleton, a family practice physician in Louisville who cares for the poor, said he was "deeply troubled and dismayed" by the plan.

"I had people come to me with tears in their eyes, overjoyed that they were finally able to take charge of their health problems. I had people quit smoking, get their blood pressure and diabetes under control, get much needed glasses, and finally address long-standing dental issues. Many of these patients were able to then enthusiastically rejoin the work force," he said.

"I worry that Gov. Bevin's plan will erase all of this progress and more. We know that premiums tend to decrease overall coverage; we know that co-pays decrease frequency of visits and discourage people from seeking immediate care; lock-outs compromise the management of complex chronic disease and decrease downstream cost, both for the patient and the system as a whole; and impoverished patients... are not helped by complex requirements for extended coverage."

Deacon William Grimes, who runs the New Hope Clinic in Bath County, one of the state's poorer counties, said many of his patients have no income and don't have enough money to pay for a $4 generic prescription.

"If they can't pay a $4 generic, how are they going to pay a co-pay, how are they going to pay premiums, how are they going to pay for anything?" he asked. "Yes, there are some people who this 'skin in the game' might help, but the people I deal with can't afford it."

Foundation for a Healthy Kentucky has many concerns about new Medicaid plan; health officials say current plan is not sustainable

By Melissa Patrick
Kentucky Health News

FRANKFORT -- At a legislative committee meeting July 20, health advocates urged the administration of Gov. Matt Bevin to make sure the final plan is evidence-based and that they fully understand the people it will affect. Administration officials said changes are needed because the 2014 expansion of the program isn't sustainable.

"We are asking, as in any well-designed program, that it starts with an awareness of who are these people we are trying to help, what jobs are available in their communities, what is their education level, are they already working two or three jobs, or not able to find a job, do they have access to a computer?" said Susan Zepeda, president and CEO of the Foundation for a Healthy Kentucky.

Bevin's plan calls for participants to pay premiums and have a higher level of involvement in their care, including community engagement and work requirements for able-bodied adults who aren't primary caregivers or dependents -- requirements that Bevin calls "skin in the game," but health advocates call "barriers to care."

"Kentuckians who don't have paid sick leave, reliable transportation or a bank account already face greater barriers to obtaining and keeping insurance coverage and participating in their own health improvement. Their lost wages and time investment are their 'skin in the game'," Zepeda said in a news release. "A Medicaid reform plan that creates more barriers will exacerbate the state's already challenging health statistics and health disparities."

In her testimony, Zepeda praised several aspects of the waiver proposal, including the expansion of substance abuse treatment services, sustaining the behavioral health services in the state, managed care organization reforms and its healthy behavior incentives.

But she also came with a long list of concerns, such as the loss of dental and vision benefits from the core benefit package, denial of services and monetary penalties for nonpayment of premiums, the work requirements, the loss of non-emergency transportation to and from medical appointments, the reduction in smoking-cessation options, and the premiums for all income levels.

Despite provisions for regaining coverage after nonpayment, Zepeda said, "In some ways we liken this to taking a hungry child with a bad tooth ache who is misbehving in school, can't pay attention and kicking that child out of school and then wondering why he or she isn't learning."

Republican Rep. Addia Wuchner of Florence said she supported the requirements for able-bodied Kentuckians to have to earn their dental and vision benefits because it will "help them to be an engaged health-care consumer."

But Zepeda said poor people struggle to save money, especially when they don't make enough to buy groceries or pay the rent. She said many in this population work, and wouldn't have time to peform extra tasks to get dental or vision services.

Wuchner also supported the work and volunteer requirements. "If this would incentivize that individual to take the extra step to gain more education so that there are other jobs available to them, I just say that that is an incentive, not a disincentive," she said.

Gabriela Alcalde, vice president of policy and programming at the foundation, said research does not support the effectiveness of work requirements for the poor. While voluntary skills and education training have been found to have very positive outcomes, mandatory work requirements do not have lasting effects, she said, so once people get out of the program, the effects disappear.

"They also increase poverty in some cases and do not in any way eliminate the barriers to access," Alcalde said. "So we actually have people lose coverage, but not maintain gains with certain strategies."

Zepeda said Bevin's request to the federal government, for a waiver of normal Medicaid rules, would better seek such things as price transparency, which would allow participants to price-shop for their health care; integration of behavioral health, oral health and primary care under one roof; or to deliver care where people are, like schools.

"There are lots and lots of opportunities for care delivery reform that will lift up Kentuckians, make the access to care more equitable and help the state prosper," she said.

Sen. Danny Carroll, R-Paducah, who earlier in the meeting said that the requirement for individuals to be on their employee based health plan if possible would likely add a financial burden to small businesses, summed it up.

"If you have to choose between some requirements and ownership or not being able to serve that population at all, I think it is clear that we have to require the ownership and some input and some investment from these folks to keep the system going," he said. "I think it is a good balance on what we are trying to do without totally doing away with expanded services, but being able to afford it as a state."

Administration defends plan

Medicaid Commissioner Steve Miller said that almost 500,000 people have been added to the Medicaid rolls through the expansion, which allows those with incomes to 138 percent of the federal poverty line to get Medicaid, with no long-term plan to pay for them.

"One of the concerns from the very beginning has been the sustainability of Medicaid expansion as we know it today," he said, noting that the cost to the state between 2017 and 2021 will be $1.2 billion. The federal government pays for the expansion through this year, but next year the state will be responsible for 5 percent, rising in annual steps to the reform law's limit of 10 percent in 2020.

The Steve Beshear administration said the expansion would pay for itself by creating health-care jobs and tax revenue, but the Bevin administration has said that hasn't happened. No one has offered definitive figures.

"The funding will just not be available," Miller averred. He said Medicaid's budget has been increased by approximately $600 million over the next two years, while the consensus revenue projection is that new revenue coming into the state during the same time frame will be $585 million.

"Medicaid consumes every new dollar of revenue that comes into the state over the next two years," without change, Miller said, and that will continue in the following budgets. That means that paying for Medicaid will crowd out all other initiatives, like pension funds, education, and corrections, he added.

The administration estimates that the waiver would reduce total Medicaid spending over five years by $2.2 billion dollars, but only $331 million of that would be state money, as a result of lower enrollment and less use of the program.

Adam Meier, Bevin's deputy chief of staff, said the new plan's goals are to improve participants' health, to instill personal responsibility, to move people into commercial health insurance plans, to empower people to seek employment and to achieve fiscal sustainability.

Wednesday, July 20, 2016

Study finds no link between tighter controls on prescription opioids and increased use of heroin; some researchers disagree

National overdose-death rates for heroin (red) and prescription opioids (blue)
By Al Cross
Kentucky Health News

Soon after Kentucky cracked down on "pill mills" where prescription painkillers were easily available, officials noticed a jump in heroin arrests and overdoses, and many presumed that one helped lead to the other. A study published in the New England Journal of Medicine found no link between the two, at least on a national scale, but some other experts disagree.

The study was conducted by physician William Compton of the National Institute on Drug Abuse, pharmacy Dr. Christopher Jones of the Department for Health and Human Services and public-health specialist Grant Baldwin of the federal Centers for Disease Control and Prevention.

They wrote, "It appears that the shift toward heroin use among some non-medical users of prescription opioids was occurring before the recent policy focus on prescription-opioid abuse took hold." They note that heroin use began to increase by 2007, and that a pill-mill crackdown in Florida, similar to Kentucky's, was followed by only a small increase in heroin overdoses.

"The results of these studies consistently suggest that the transition to heroin use was occurring before most of these policies were enacted, and such policies do not appear to have directly led to the overall increases in the rates of heroin use," the researchers wrote. "Although the majority of current heroin users report having used prescription opioids non-medically before they initiated heroin use, heroin use among people who use prescription opioids for non-medical reasons is rare, and the transition to heroin use appears to occur at a low rate."

They said the shift from prescription opioids to heroin is most prevalent among "persons with frequent non-medical use and those with prescription opioid abuse or dependence," and is driven mainly by cheaper, purer and more accessible heroin.

Those conclusions drew a letter to the journal from researchers who have concluded otherwise. Theodore Cicero and Matthew Ellis of the Washington University School of Medicine in St. Louis wrote, "A growing body of research has shown direct associations between the introduction of reformulated OxyContin and increases in rates of heroin use." The reformulated drug was much harder to inject; the federal researchers looked at the possible effect of the change and discounted it.

The critics didn't mention state crackdowns, but wrote, "It would be unwise for the agencies that the authors represent to ignore unanticipated negative aspects of efforts to limit supply, such as a shift to heroin in some persons, even if they represent a small part of the total heroin problem."

The federal researchers concluded their report with lines few could disagree with: "Fundamentally, prescription opioids and heroin are each elements of a larger epidemic of opioid-related disorders and death. Viewing them from a unified perspective is essential to improving public health. The perniciousness of this epidemic requires a multi-pronged interventional approach that engages all sectors of society."

"The last sentence is the most important," said Van Ingram, director of the Kentucky Office of Drug Control Policy. "Prescribing regulations are more about slowing the creation of new people obtaining an opioid-use disorder. If we keep prescribing at the same rates this country has been this problem never gets solved."