Ky.'s pro-Obamacare policies led to more enrollment and support for it, but many poor are still uninsured and under-informed

Update: This story was updated to reflect the study's results for those who said they were hurt  by and not directly impacted by the ACA. 

State policy appears to have a major impact on poor people's thinking about the Patient Protection and Affordable Care Act, as well as how they describe their experience with it, according to a Harvard University study published in the journal Health Affairs.

The study surveyed nearly 3,000 low-income residents in three Southern states that had varying approaches to the ACA and its implementation: "Kentucky, which expanded Medicaid, created a successful state marketplace, and supported outreach efforts; Arkansas, which enacted the private option and a federal-state partnership marketplace, but with legislative limitations on outreach; and Texas, which did not expand Medicaid and passed restrictions on navigators" who help people with the federal and state marketplaces.

The survey found that Kentucky, which has enrolled more than 500,000 people in Medicaid and another 109,000 in private health plans through the Kynect health-insurance exchange, had the highest success in application rates, successful enrollments and positive experiences with the ACA, followed by Arkansas and then Texas.

"This corresponds to the general pattern of state-level engagement and support for the ACA coverage expansions in these three states," the researchers write.

The study also found that limited awareness and poor information continue to be two of the greatest barriers to the ACA. Even in Kentucky, where awareness was the highest, only half of the poor people surveyed said they had heard "some" or "a lot" about the ACA's coverage options. About 10 percent of Kentuckians remain without health insurance.

Another barrier to applying for coverage was the perception that it would cost too much, but for those with incomes below 138 percent of poverty in states that have expanded Medicaid, coverage is available without having to pay a premium.

"This adds to previous evidence that information gaps about the law remain a major challenge, particularly among low-income populations who likely have the most to gain from the coverage expansions," the researchers write.

The study also found that application assistance from navigators and others was the strongest predictor of enrollment, increasing enrollment to 93.1 percent from 84.9 percent. Application assistance was most common in Kentucky (46.2 percent) and least common in Texas (31.9 percent). Navigators help consumers choose health-insurance plans to meet their needs and assist them with the application process.

Kentucky reported an overall better application experience than the other two states in the study, and had a significantly higher enrollment rate (92.4 percent) than Arkansas (87 percent) and Texas (84.8 percent).

The study found that advertising about the law didn't seem to affect whether people applied for coverage or enrolled in a plan. However, ads were strongly associated with perceptions of the law.

About 20 percent of respondents said they had read or heard more negative ads and approximately 12 percent recalled more positive ads, and two-thirds said ads were about equal. (Negative ads were most frequently reported in Arkansas, where Obamacare was an issue in a U.S. Senate race last year.)

Twice as many respondents felt that the ACA had helped them as hurt them, although the majority reported no direct impact. In Kentucky, 40 percent said it had helped them, 12 percent said it had hurt them and 48 percent said it had not impacted them directly;  In Arkansas, 30 percent said it had helped them, 17 percent said it had hurt them and 54 percent said it had not impacted them directly; and in Texas, 21 percent said it had helped them, 14 percent said it had hurt them and 66 percent said it had not directly impacted them.

"Nonetheless, 48 to 66 percent of low-income adults in all three states felt the law had not directly impacted them in 2014," the researchers wrote, "which suggests that the ACA has not yet reached many who might benefit from it."

Medicaid managed-care firms get new contracts with new rules aimed at resolving health-care providers' issues with program

Kentucky has signed new contracts with five managed-care firms that will manage Medicaid coverage for more than 1.1 million Kentuckians. Contracts were awarded to Anthem, Coventry Cares, Humana, Passport and Wellcare.

Kentucky changed Medicaid to managed care from a traditional fee-for-service model in 2011 to save money, and officials say it has worked. Health-care providers remain unhappy about denial and delay of claims by the managed-care organizations (MCOs).

“Statistics confirm that moving to a managed-care model has saved Kentucky taxpayers more than $1.3 billion in state and federal funds while simultaneously improving the delivery of health-care services to our Medicaid population," Health Secretary Audrey Haynes said in a news release.

At the same time, managed care has been a good deal for the companies, except Humana. "Last year, [they] cleared more than $500 million in income above expenses, according to statements companies must file with the Kentucky Department of Insurance," Debby Yetter reports for The Courier-Journal. "Some of the profits ranged from 7 percent to nearly 18 percent in 2014," but the new contracts limit that to about 6 percent.

They also require 82 to 87 percent of the payments to the MCOs to be spent on direct services to its members. The payments are per-person fees, based on the number of people whose care is being managed.

Haynes said the contract improvements "should please consumers, advocates and our health care providers" and "will translate into more options and improved services from our managed care companies."

The new contracts also address many of the issues about which hospitals and other providers have been unhappy, such as slow and reduced payments, complicated paperwork and other procedural differences among the companies.

The new contracts require a standardized contract and standardized forms for prior-authorization requests, grievances, appeals and claims.

Two passionately debated bills in the recent legislative session challenged some of the practices of the current MCOs: one seeking an appeals process for denial of payment and the other removing a cap of "triage fees" for emergency room services that MCOs later deem not to be emergencies.

Both issues were addressed in the new contracts. Now, MCOs must make sure they are using appropriate medical specialist to determine "medical necessity," initially and in any review process, and the cabinet will be responsible for reviewing denials of "medical necessity" appeals and denials of payment for emergency-room use.

Sen. Ralph Alvarado, R-Winchester, co-chair of the joint House-Senate Medicaid Oversight Committee, told Yetter that "he hopes the new contracts will clear up the problems" and he also hopes "the state succeeds in controlling profits of the managed-care companies, calling it an outrage that some companies are reaping millions off the program while denying care or delaying payment."

The new contracts also include incentives for MCOs and Medicaid members to decrease use of emergency rooms, and encourage the expansion of behavioral health services.

They offer incentives to to MCOs to continue to improve health outcomes for their members, and spells out new, stringent standards for companies that don't comply with their contracts.

The contracts are for one year beginning July 1, with the option of four annual renewals.

Three doctors, nine others in western half of Kentucky are indicted in the largest-ever federal 'takedown' of Medicaid fraud

Former Dr. Fred Gott of Bowling Green was arrested.
(Photo: Miranda Pederson, Bowling Green Daily News)

Twelve people in the western half of Kentucky, including three doctors, have been charged with Medicaid fraud in what the federal government calls its biggest-ever "takedown" of the problem, Andrew Wolfson of The Courier-Journal reports.

The indictments allege "a half-dozen schemes involving nearly $8 million in alleged fraudulent billings," Wolfson writes. "The offenses include $5 million in false billings for muscle-relaxant injections that were never delivered to patients, as well as a staged car wreck in which three people allegedly conspired to get controlled substances and fraudulent reimbursements."

In another case, Wolfson reports, "a medical practice that treated car wreck patients is accused of using the DEA numbers of nurse practitioners to order hydrocodone for herself and falsely billing it to an insurance company. Nationally, the sweep resulted in charges against 243 people, including 46 doctors, nurses and other licensed medical professionals."

John Kuhn, acting U.S. attorney for the Western District of Kentucky, told Wolfson that about $1 billion of annual Medicare and Medicaid expenses are fraudulent. Medicare is the federal health-insurance program for people over 65; Medicaid is the federal-state program for the poor and disabled.

Former Dr. Fred Gott of Bowling Green, a 63-year-old cardiologist, was charged with "conspiracy to dispense controlled substances, health care fraud and money laundering," Deborah Highland reports for the Bowling Green Daily News. "The Bowling Green-Warren County Drug Task Force opened an investigation into Gott’s practices after Warren County Coroner Kevin Kirby alerted the task force about drug overdose deaths involving Gott’s patients, task force director Tommy Loving said."

Republican legislators question cabinet's figures on managed-care payments and cost projections for Medicaid expansion

Audrey Haynes (cn|2 image)

"When Audrey Haynes sat down before the legislature’s Medicaid Oversight and Advisory Committee Wednesday, she expected the data she brought would persuade lawmakers that Kentucky’s expansion of Medicaid has been good for the state," Ronnie Ellis reports for CNHI News Service. "The secretary of the Cabinet for Health and Family Services, which administers the Medicaid program also may have expected her statistics to ease unhappiness with the state’s move to managed care for most Medicaid services."

"It didn’t happen," Ellis writes. "At least she didn’t persuade Republican members who openly questioned the validity of the cabinet’s data, a couple stopping just short of saying the cabinet is making up the numbers" about payments to providers by managed-care organizations, which it says are 99 percent on time. “The numbers do not appear to represent the reality on the ground,” Rep. Richard Benvenuti, R-Lexington, said after the meeting.

Sen. Ralph Alvarado

“I think those are false,” Sen. Ralph Alvarado, R-Winchester, said after the meeting. “I don’t know if they’re lying, but somebody is providing bad information.”

During the meeting, Alvarado read "segments of letters from providers who have not received full reimbursements from managed care organizations," reports Kevin Wheatley of cable channel cn|2's "Pure Politics."

"Haynes referenced a report from CHFS which showed that over 90 percent of Medicaid claims are being paid in a timely manner," reports the blog of the Kentucky Chamber of Commerce. "Sen. Alvarado replied that this statistic does not match what he is hearing from his constituents and medical providers." Haynes addressed the managed-care issue in her PowerPoint presentation, downloadable here.

Rep. David Watkins, D-Henderson, a retired physician and co-chair of the committee, "urged the panel to find ways to improve managed care."

Watkins said the managed-care organizations, which are insurance companies or their subsidiaries, should come before the committee to answer questions. “I’m not totally satisfied that they’re doing quite as good a job as your report here would portray,” he told Haynes. “I think they need to be more accountable. I think they need to be more responsive to the providers who actually are doing work in the field.”

The MCOs will appear before the joint House-Senate committee Aug. 19, Brad Bowman reports for The State Journal in Frankfort. For cn|2's three-minute clip of the discussion between Haynes and Alvarado, via YouTube, click here.

The Republican lawmakers also voiced skepticism, but offered no contrary evidence, about the cost of expanding Medicaid to households with incomes up to 138 percent of the federal poverty level, from the previous limit of 69 percent. Under the Patient Protection and Affordable Care Act, the federal government is paying the entire cost of the expansion until next year, when the state will begin paying a small part, rising to the law's cap of 10 percent in 2020.

Haynes noted projections for Democratic Gov. Steve Beshear's administration that the expansion would add $30.1 billion to the state's economy through 2021, and would pay for itself until then, even after the state starts picking up part of the cost. The numbers were not new; they were part of a study by Deloitte Consulting and the University of Louisville that Beshear released in February.

Republicans focused on the prediction that the expansion would cost the state a net $45 million in 2021. "I know that seems like a way long ways off and some of you may no longer even be in the position to deal with it, but some of us probably will and the taxpayers will," said Alvarado, a physician.

Haynes "stated that she believed with the financial boost to the economy through jobs, the costs will be offset," the blog of the Kentucky Chamber of Commerce reports.

“Now that we’re seeing the lowest unemployment that we’ve seen in our state in quite a number of years, I’m sure each of you are amazed at how that we’ve had all 120 counties in our state where the unemployment rate has gone down,” Haynes said. “As this state continues to generate revenue and hopefully, as is planned, this is a bridge program for people who basically are hard-working people, but their employer does not provide insurance or they have children and therefore that qualifies them from an income basis for Medicaid.”

Bevin says he will end all Obamacare programs in Ky., including Medicaid expansion that has added more than 400,000 to rolls

Matt Bevin, the Republican nominee for governor, has made clear that if elected he would end the Medicaid expansion that has provided free health coverage for more than 400,000 poor Kentuckians.

During his primary campaign, Bevin never made that quite plain, saying he would close the state's health-insurance exchange, Kynect, because it would cost "hundreds of millions of dollars." Kynect is paid for by insurance companies, so Bevin was alluding to to the state's projected cost of expanding Medicaid, which enrolls through Kynect.

The Washington-based publication Politico reported on June 10, after interviewing Bevin, that he would not only close Kynect but roll back the Medicaid expansion: “You may or may not have access to Medicaid going forward,” he said. “People are not on it for extended periods of time. It’s not meant to be a lifestyle. It really isn’t. The point of it is to provide for those who truly have need.”

Democratic nominee and Attorney General Jack Conway, with Gov.
Steve Beshear; GOP nominee Matt Bevin (AP photos via Politico)

Gov. Steve Beshear "is furious" about Bevin's plan, Politico reported. “I am not going to allow someone to become governor of this state who wants to take us back to the 19th century,” the governor said in a telephone interview. “For a serious candidate for governor to be advocating a simple repeal of the whole program without offering any kind of alternative which will continue health care for these people is irresponsible.”

Beshear expanded the eligibility rules for Medicaid as part of implementing the Patient Protection and Affordable Care Act, raising the income limit to the law's required 138 percent of the federal poverty level, from the state's previous level of 69 percent.

The federal government is paying the entire cost of the newly eligible Medicaid recipients though next year. In 2017, the state would begin to pay 3 percent, rising to the reform law's cap of 10 percent by 2020. A study by Deloitte Consulting and the Urban Institute at the University of Louisville  — "which Republican critics have rejected as spin," Politico says — has said the expansion more than pays for itself through 2020 by expanding health-care jobs and generating tax revenue.

Jobs are growing as projected by the study, according to the Cabinet for Health and Family Services, which handles Medicaid.

Cabinet spokeswomnan Jill Midkiff said the study estimated that 32,000 jobs would be created through 2015 as a result of the expansion. "U of L projected this growth would primarily be in the areas of retail trade, finance and insurance, administrative services, health and social services, accommodations and food services and other services," Midkiff said. "These sectors were estimated to account for more than 28,000 of the 32,000 jobs created." She said the latest Bureau of Labor Statistics figures show that "these sectors have grown by more than 29,000 jobs from 2013 until April 2015. Therefore, the most recent BLS numbers indicate that UofL’s estimates are on target to meet projections."

Politico says a Bevin victory could "blot an Obamacare bright spot," since Kynect has "worked virtually glitch-free." Through April, 106,000 Kentuckians had obtained tax-subsidized, private insurance coverage through Kynect, which is also the portal for enrolling in Medicaid.

Bevin says he would move those people to the federal exchange, which has been marred by technological issues and charges insurance companies much more to use it than Kynect does. But that plan would not work if the U.S. Supreme Court rules this month that the tax subsidies are not legally available through the federal exchange.

"That doesn’t worry Bevin," Politico reports, quoting him: “You’re worrying about a hypothesis. Let’s let the Supreme Court rule.”

And what about the new Medicaid recipients who would lose their benefits if Bevin wins? He "insists that Obamacare is coverage in name only — that Kentuckians still lack access to high-quality health care, partly because Medicaid pays doctors such low rates, partly because he says too many people rely on emergency rooms," Politico reports, quoting him: “Just having health insurance doesn’t mean you’re going to get health care.”

Attorney General Jack Conway, the Democratic nominee, declined Politico's request for an interview. Campaign spokesman Daniel Kemp said, “Jack wants to make sure that the hundreds of thousands of Kentuckians who now have health insurance through Kynect, especially kids, keep their health insurance — not play politics or push an ideology that’s out of touch with Kentucky’s values.”

Politico observes, "Conway is in the tricky spot of embracing Kynect while trying to keep his distance from Obama and Obamacare, a term that still generates ire among Kentucky residents. A September 2014 Marist [College] poll found that 61 percent of registered Kentucky voters had an unfavorable impression of Obamacare. Only 17 percent had negative feelings about Kynect."

Citing costs, Bevin has said he would shut down Kynect; actually, insurance companies pay for it; Medicaid is another matter

By Molly Burchett and Al Cross
Kentucky Health News

The governor's race between Democrat Jack Conway and Republican Matt Bevin will spotlight the Patient Protection and Affordable Care Act, an issue that affects all Kentuckians at least indirectly.

Conway, in his eighth year as attorney general, says he would have voted for the law. Bevin, who was the most conservative candidate in his primary, has said he would shut down the state's health-insurance exchange, Kynect, that was established under the law, because it will cost the state hundreds of millions of dollars.

Actually, Kynect is paid for by insurance companies that sell policies in Kentucky. Bevin appears to be referring to the projected cost of expanding Medicaid, another Obamacare-related move that Democratic Gov. Steve Beshear made at the same time he created Kynect. It raised the program's income limit to 138 percent of the federal poverty level, from 69 percent.

The federal government is paying the entire cost of the Medicaid expansion for the first three years. In 2017, the state will pay 3 percent, gradually rising to the law's cap of 10 percent in 2020. A study for the state projects that the expansion will pay for itself until 2021 by expanding health-care jobs and generating economic activity and tax revenue.

Bevin has scoffed at those projections. Conway has said the state needs to provide health coverage, but only what it can afford.

As Kentuckians, voters, and consumers of health insurance, you may be asking: What's going on with Obamacare in the state? Are we able to afford it? Who and what should we believe? While the cost of Medicaid expansion is debatable, it's becoming clear that Kynect has avoided the problems plaguing other state-run exchanges.

So far, the Centers for Medicare and Medicaid Services has dispensed more than $4.9 billion in grants to help launch state-run exchanges. Kentucky received $253 million for the initial planning and development phases of Kynect. Now its $28 million annual cost is covered by a fee on insurance companies, state officials say.

Despite federal support and their own revenue sources, many of the 17 state-based exchanges are expecting deficits this year and in the future. Many will continue to rely on leftover federal funds to pay for operations this year, report Darius Tahir and Paul Demko of Modern Healthcare. Hawaii announced this week that it would close its exchange and transfer clients to the federal exchange because of continued funding problems.

Kynect officials say it isn't having such problems because the state has ensured that Kynect is self-supporting through fees on insurance plans.

"The governor committed that the exchange would be self-supporting and would not rely on state General Fund dollars," said Jill Midkiff, spokeswoman for the Cabinet for Health and Family Services. "Kentucky’s sustainability plan employs an existing assessment on insurers that was previously used to fund Kentucky Access, the state’s high-risk pool, which was closed [since] individuals previously enrolled are now eligible to purchase a plan through Kynect."

But to transform Kentucky Access into Kynect, Beshear used executive orders that bypassed the General Assembly, where Republicans control the Senate. They have questioned his use of executive powers but generally have not been critical of Kynect.

The fee on insurers is a 1 percent, broad-based assessment on companies offering plans through the exchange. While insurers don't pass this fee directly to consumers, it almost certainly figures into their calculation of premium calculation and thus is indirectly paid by policyholders. The federal exchange is financed in a similar way, but its fee is 3.5 percent, meaning higher costs for insurers and policyholders.

In most cases, premiums for Kynect policies are reduced by a federal income-tax subsidy that is a key part of Obamacare.

"The vast majority of Kentuckians buying health insurance through Kynect are eligible for some kind of payment assistance or subsidy," Beshear said in commenting on most health-insurance companies recent requests for premium increases. "That cost will vary from family to family, so talking about rate changes in a vacuum isn’t a very effective way to gauge how much those rate fluctuations may affect policyholders or those shopping for insurance."

Bevin says he would move Kynect customers to the federal exchange, but the U.S. Supreme Court could rule this month that the tax subsidies are not supposed to be available through the federal exchange. The plaintiffs in the case cite a passage of the law that opponents say was a drafting error and does not make sense when the law is viewed as a whole.

If the court agrees with the plaintiffs, and Congress doesn't change the law, states using the federal exchanges will see spikes in insurance premiums, and millions of people could be at risk of losing their insurance. Bevin has not said what he would do in case of such a ruling.

Independent Drew Curtis is also running for governor.

Regan Hunt, executive director of Kentucky Voices for Health, leaves for a new position at insurer Humana Inc.

The executive director of Kentucky Voices for Health, a group that worked for the implementation of the Patient Protection and Affordable Care Act, is now working for Humana Inc. as a product development consultant.

Regan Hunt

Regan Hunt switched jobs after working in a way that won her the Consumer Health Advocate of the Year Award by Families USA, which cited her work for expansion of Medicaid in Kentucky and her efforts to increase health coverage under the Affordable Care Act. In her new job, she will be a product development consultant, working on design of benefits for those covered by the Medicaid expansion.

During her time at KVH, Hunt worked with a coalition of more than 200 partners to address the many health care needs of Kentuckians, including access, prevention, quality and value. Hunt said in an interview that she was most proud of  KVH's role in enrolling so many Kentuckians in coverage during 2013-15.

"Kentucky is one of those states that did it right," she said.

Hunt said that she was also proud of the group's collaboration between Gov. Steve Beshear, the state Cabinet for Health and Family Services: "We all worked together and that was an amazing thing ... all working together to make sure that people got the information that they needed and got covered. ... It was a once-in-a-lifetime sort of thing." KVH is not a lobbying group, but many of its members are.

At Humana, Hunt will research the Medicaid expansion landscape in other states to determine what new beneficiaries that population might need or want in a benefits package, beyond what is required by law.

"I am an advocate, probably until the day I die," she said, noting that she will now work as an individual advocate, instead of under the umbrella of KVH, to help people gain access to health coverage. "I've been doing that since I was 22, so it is not something that I am going to give up doing."

Hunt is a native of Pike County, She earned her undergraduate degree at Transylvania University and her Masters in Public Administration degree from the University of Kentucky. She also holds a certificate in health-care management from the University of North Carolina, according to the KVH website.

Lexington Herald-Leader says Kentucky Hospital Association report on members' finances damages the group's credibility

The Kentucky Hospital Association's recent "Code Blue" report on its members' finances is a symptom of "financial hypochondria," the Lexington Herald-Leader said in a long editorial Sunday. It said the title, "signaling a patient needs resuscitation, is an unintentionally fitting title because the KHA's credibility could use a little CPR."

Read more here: http://www.kentucky.com/2015/05/17/3855678/hospitals-suffering-financial.html#storylink=cpy

The report "voices a universal human desire: more money, less accountability. The association implies that federal financial penalties aimed at reducing harm to patients are too onerous for hospitals that care for Kentuckians," the editorial says. "Little more than anecdotes are offered with no acknowledgment that some Kentucky hospitals are recording record bottom lines and steep drops in uncompensated care."

The newspaper offered its own anecdote, a large one, noting that the University of Kentucky's medical center is a major beneficiary of the Medicaid expansion under federal health reform: "The 2014 period saw an 83 percent drop in non-paying inpatients, a 66 percent drop in non-paying outpatients and a $60 million increase in Medicaid revenue. UK Healthcare's annual net income through March is up $70 million over the same time last year. Not all of that increase is due to the Medicaid expansion or Kynect," the state exchange for enrolling in Medicaid or buying private insurance.

"The important point," the paper says, is that "Slowing down spending on hospital care is one of the best things we can do for the economy and our health. The United States spends the highest percentage of its GDP on health care of any country but gets worse outcomes. Even by U.S. standards, Kentuckians over-utilize hospital care."

Read more here: http://www.kentucky.com/2015/05/17/3855678/hospitals-suffering-financial.html#storylink=cpy

Kentucky hospitals say they're losing money on Obamacare, as cost of treating new Medicaid patients exceeds reimbursements

By Melissa Patrick
Kentucky Health News

Kentucky hospitals are struggling financially because of the billions of dollars in cuts caused by the implementation of the Patient Protection and Affordable Care Act, and many aren't sure they will survive, the Kentucky Hospital Association said at its annual meeting May 8.

KHA applauded the successful implementation of the federal health reform in Kentucky, which has extended health insurance coverage to approximately 500,000 more Kentuckians, mainly through expansion of Medicaid, but said that has come at a "significant cost to our commonwealth hospitals."

"The expansion [of Medicaid] has infused money into some of our hospitals, which is good, but the rest of the story is the cuts," KHA President Michael Rust said.

KHA Chair Dennis Johnson, CEO of Hardin Memorial Health in Elizabethtown, said  the revenue from the expansion "is less than the cuts Kentucky hospitals will experience in order to finance the ACA."

Kevin Halter, KHA's incoming chair and CEO of Our Lady of Bellefonte Hospital in Ashland, said,
“Much has been made about the fact that Kentucky hospitals have received an additional $506 million in Medicaid payments last year through the expansion, suggesting that hospitals' bottom lines are healthier as a result, but what is often not mentioned is that hospitals lose money on every Medicaid patient they treat.”

The report says that changes in the way hospitals are paid under Obamacare are projected to result in the loss of almost $7 billion in federal cuts to Kentucky hospitals through 2024:

• Lower-than-cost Medicaid and Medicare reimbursements, 82 percent and 86 percent respectively, with actual Medicaid and Medicare payment cuts from 2010 to 2024 projected to be $4.6 billion
• Readmission penalties, which can be as much as 3 percent of Medicare payments, imposed on hospitals that readmit patients within 30 days of discharge, regardless of the reason
• Medicare cuts to hospitals that have any increase in hospital-acquired infections
• Cuts, delayed until 2017, in extra payments to hospitals that have a "disproportionate share" of Medicare and Medicaid patients.

KHA also cited impacts that aren't associated with the reform law, such as sequestration, or automatic across-the-board federal budget cuts, and other cuts in Medicare.

Hospital officials said that rural hospitals have been hit hardest by these changes because 72 percent of their patients are on Medicaid or Medicare. A recent report by state Auditor Adam Edelen found that 68 percent of Kentucky's rural hospitals have below-average of poor financial health, with 34 percent of the total in the latter classification.

Part of the problem is that the law was built on the nationwide presumption that about half of the newly insured would have private health insurance and the other half Medicaid, but in Kentucky, a poor state, 75 percent of the newly insured are covered by the Medicaid expansion, which covers those earning less than 138 percent of the federal poverty line, or about $33,000 for a family of four.

Halter said while hospitals got $506 million for treating patients covered by the expansion, that treatment costs the hospitals $617 million to deliver that care. While low Medicaid reimbursement is not a new problem, Johnson said, "There's no question it's been accelerated under the ACA."

Gov. Steve Beshear said expanded Medicaid payments had "blunted the impact of other fiscal pressures on hospitals. . . . We are very aware of the challenges that medical providers face in Kentucky. Rather than trying to turn back the clock and return to old business practices, we are working directly with providers to help them develop new strategies for better, more efficient, quality health care delivery."

The challenges are real.

A September 2014 survey found that more than 65 percent of the 109 responding Kentucky hospitals had reduced staff since June 2013, eliminating more than 7,700 positions, with more jobs lost in rural hospitals than the urban ones. About 44 percent had frozen or reduced wages, and 40 percent of had cut costs by reducing or eliminating programs, such as closing psychiatric units and outpatient clinics.

"The reality is that hospitals are being forced to reduce costs to deal with these financial pressures," said Charles Lovell, CEO Caldwell Medical Center in Princeton. "This is the third year without our employees getting an increase."

While Obamacare has reduced hospitals' losses on patients who can't pay, Halter noted that 12 percent of Kentuckians remain uninsured, and the report said hospital emergency rooms are still the first choice for many new Medicaid patients because they have't found a regular physician. Many Kentucky counties are short of doctors.

Kentucky re-bidding Medicaid managed care contracts to address complaints of patients, advocates and health-care providers

By Melissa Patrick
Kentucky Health News

State officials are re-bidding Medicaid managed-care contracts that cover more than 1.1 million Kentuckians. The news came as a delight and surprise to many health-care providers and patient advocates.

“I was both stunned and thrilled by the announcement. I did not know it was coming,” Sheila Schuster, a Louisville mental-health advocate, told Tom Loftus of The Courier-Journal. “A number of the changes that they say will be part of the new contracts are things those of us in the behavioral health community have brought up time and time again.”

Kentucky changed to Medicaid managed care from a traditional fee-for-service model in 2011 to fill a projected budget overrun of $166 million. Health Secretary Audrey Haynes said in a news release that doing so has "saved Kentucky taxpayers more than $1.3 billion in state and federal funds" and had also improved the delivery of health care to the Medicaid population.

"However, after several years of experience, we determined it was time to retool, rebid and strengthen the contracts to appropriately address concerns expressed by advocates and healthcare providers," Haynes said.

The transition to managed care has been met with consistent complaints from both patients and providers, despite efforts of the cabinet to work through the issues and keep the channels of communication open between providers, the cabinet and the managed-care organizations.

Two passionately debated bills in the recent legislative session challenged some practices of the current MCOs: one seeking an appeals process for denial of payments and the other removing a cap of "triage fees" for emergency-room services that MCOs later deem not to be emergencies.

Both issues have been challenging to the financial health of rural hospitals. State Auditor Adam Edelen addressed many such issues in a recent report on the financial health of rural hospitals.

“We are pleased to see the cabinet taking steps to improve and strengthen managed care contracts, many of which we recommended in our recent report on the financial strength of rural hospitals,”Edelen told Insider Louisville.

Some requirements for the new contracts include: required statewide coverage; standardized rules among the MCOs; improved administrative processes; increased oversight of claim denials; continued expansion of behavioral health services; incentives for MCOs to work with Medicaid patients to decrease emergency-room use and improve their health; and increased penalties to assure contract compliance. Click here for the Cabinet for Health and Family Services' complete Request for Proposal.

“I’d like to say that they heard the voice of the people,” Schuster told Insider Louisville.“If you look at the Medicaid Advisory Council, those meeting are every two months and it’s the same litany of complaints and concerns every darned time with no response. The only thing I can think of is it’s a gesture by this outgoing administration to get things right so that regardless of who comes in next year, there are strong contracts in place. I applaud them for it, and I’m stunned.”

The current contracts with Anthem, Aetna's Coventry Cares, Humana's CareSource , Passport and Wellcare expire on June 30, 2015 and proposals for the new contracts are due by May 5. The statewide contracts will be awarded to multiple MCOs for a one-year period with four, one-year renewal option, according to the news release.

New diabetes cases in expanded-Medicaid states much higher than other states; 46,000 new Ky. Medicaid clients got screened

By Melissa Patrick
Kentucky Health News

New diabetes cases among poor Americans are much more numerous in Kentucky and other states that have embraced the Patient Protection and Affordable Care Act, a medical testing company has found. The diagnoses rose 23 percent in the Obamacare states and barely rose in the others, apparently because state Medicaid programs are encouraging screening for diabetes.

Quest Diagnostics conducted the study by analyzing laboratory test results from all 50 states and the District of Columbia in its large database over two six-month periods, Sabrina Tavernise reports for The New York Times. The authors determined that because in January 2014, 26 states and the District of Columbia had expanded Medicaid and 24 had not, it was a good time to conduct this study, which is reported in the journal Diabetes Care.

The research team used the results of the basic test for diabetes, which measures a form of hemoglobin that has interacted with glucose, A1c. "In the states that expanded Medicaid, the number of Medicaid enrollees with newly identified diabetes rose by 23 percent, to 18,020 in the first six months of 2014, from 14,625 in the same period in 2013," Tavernise reports. "The diagnosis rose by only 0.4 percent — to 11,653 from 11,612 — in the states that did not expand Medicaid."

A Kentucky study indicates that more screening isn't the only reason for such numbers; the Medicaid expansion population appears to be more susceptible to diabetes than normal.

The study by Deloitte Consulting found that chronic conditions, including diabetes, were more than twice as prevalent in the expansion population than other people of the same age and gender who were on Medicaid before it expanded. That comparative group was considered to be the group most similar to the Medicaid expansion population, since the state lacks historical data for the expansion group.

The study found that the Medicaid expansion group had a 102.5 percent higher prevalence of diabetes than the comparative group. About two of every 1,000 in the expansion group had diabetes, compared to one of every 1,000 members of the traditional-Medicaid group.

About 46,000 of the 400,000 people in the expansion group had a diabetes screening in the first year of the expansion. Both studies suggest better access and utilization of preventive care and early diagnosis will promote earlier treatment and better long-term outcomes.

Kentucky ranks 17th among the states in prevalence of diabetes, according to the 2014 "States of Obesity" report.  The state Cabinet for Health and Family Services reports an estimated 233,000 adult Kentuckians have pre-diabetes. For county-by-county data on diabetes, click here.

Quest Diagnostics recognized that its study only looked at changes in raw numbers of the lab results from one company and did not have access to a federal data set. This has caused some to voice skepticism that the study results are a result of the Medicaid expansion. Others, while recognizing that the study did not "have the precision of a scientific drug trial," Tavernise writes, said "the changes in the numbers are real ... 23 percent versus zero," and that "the health-care law was the most plausible explanation for the findings." Another said, "for an observational study, it’s really very strong."

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

Auditor will hold meetings in Prestonsburg, Princeton and Sonerset to discuss his report on financial status of rural hospitals

State Auditor Adam Edelen will hold three public meetings in rural communities to discuss the findings of his special report about the financial health of rural hospitals.

The meetings will be held Monday, April 21 at 1 p.m. at the Mountain Arts Center in Prestonsburg; Monday, May 4 at 11 a.m. (CT) at the Caldwell County Memorial Hospital in Princeton; and Thursday, May 6 at 1 p.m. at the Liberty center of Somerset Community College.

The report, which covers fiscal years 2011 through 2013, found that as many as one-third of Kentucky's rural hospitals were in poor financial shape, with 68 percent of them ranking below the national average financially.

“Although closure may be an unfortunate reality for some," Edelen said in the press conference, "I believe more can and should be done to help these hospitals rethink their models of business in delivering health care in the 21st century." He went on to suggest rural hospitals consider hiring outside managers, merge with larger hospitals, form coalitions with other rural hospitals or find a specialized health niche as possible alternate business models to consider.

The report calls for the creation of a state work group to monitor rural hospitals, including making sure state law gives them the flexibility to retool their business models. Susan Zepeda, president and CEO of the Foundation for a Healthy Kentucky, suggested that the proposed work "could be incorporated into the work already under way under a State Innovation Model grant, which is engaging many sectors of health service in Kentucky in an ambitious, collaborative redesign effort."

Edelen said some of the primary problems faced by rural hospitals stem from the many changes in health care since the inception of Medicaid managed care, a decrease in the number of health-care providers, and an economic climate in some areas that doesn't support the current health payment model, which depends on the majority of its users to have private health insurance.

The report suggested that the Cabinet for Health and Family Services negotiate better contracts with managed-care organizations as it approaches the June 30 deadline, especially to address provider payments, stricter penalties for non-compliance and increased administrative burdens that managed care has put on hospitals. Edelen and Haynes sounded hopeful that this was going to happen.

Gov. Steve Beshear called Edelen's report "a dated snapshot" because the 2013 data used in the report does not include 2014 information,when the federal health reform was fully implemented through expansion of Medicaid to people with incomes up to 138 percent of the federal poverty line. Beshear said hospitals received $506 million to care for such people in 2014 while seeing significant reductions in losses on patients who couldn't or wouldn't pay.

Edelen's spokeswoman, Stephenie Hoelscher, said in an email that Edelen believes the full effect of all the changes in health care to hospitals' bottom line is still not clear, and his report establishes a baseline for critical analysis going forward.

Plight of woman needing lung transplant, who has fallen through the cracks of the health-care system, gets attention from CNN

Update: CNN reports that Kentucky issued a Medicaid provider number to the University of Pittsburgh Medical Center, and the hospital confirmed that they now have enrolled in Kentucky Medicaid and are working to complete the enrollment of some of their physicians, all of which helps clear the way for Katie Prager to get her lung transplant.  "Kentucky Medicaid executives are helping us to get this done in a streamlined fashion that overcomes previous administrative hurdles and misunderstandings in this complex case," Wendy Zellner, a spokeswoman for UPMC, told CNN. Dalton, Katie's husband, has since been discharged from the Pittsburgh hospital where he received his lung transplants in November and has returned to Kentucky. CNN reports Katie and Dalton were only able to communicate through the doorway of her University of Kentucky hospital room because of his risk of getting Katie's infection, which could kill him.

A 24-year-old Kentucky woman with cystic fibrosis who needs a lung transplant to live is caught in the middle of a financial and policy battle among Medicare, Medicaid, a state agency and the University of Pittsburgh Medical Center, one of only two hospitals in the United States qualified to do lung transplants on patients with her specialized condition.

Prager at University of Kentucky hospital (Image from CNN)

"I feel like they're putting a dollar sign on my life," Katie Prager of Ewing, in Fleming County, told CNN. "I don't want to die because of money. That's stupid. Nobody should have to do that." Katie's story was first reported by The Ledger Independent of Maysville and excerpted in Kentucky Health News.

Katie longs to be with her husband, Dalton Prager, but can't until she gets her lung transplant because in addition to cystic fibrosis, she has an infection, Burkholderia cepacia, that is "horribly dangerous" to him, Elizabeth Cohen and John Bonifield report for CNN. Dalton, who also has cystic fibrosis, received his lung transplants Nov. 17 at the Pittsburgh hospital, and the immunity-suppressing drugs he takes for the transplants make him highly vulnerable to infection.

"I just want to make it to see our four-year anniversary in July and be able to hold hands and just hug. That's all I really want -- to be able to hug my husband on our fourth anniversary," Katie told CNN.

Katie and Dalton met on Facebook in 2009 when they were 18 and Dalton lived in Missouri and Katie in Kentucky. And though Katie's doctors had warned her many times that it was dangerous to be around other CF patients because of the risk of shared infections, Katie decided to meet Dalton, even after he had told her he had Burkholderia cepacia, CNN reports. They married two years later.

Photo from CNN

"I told Dalton I'd rather be happy -- like really, really happy -- for five years of my life and die sooner than be mediocre happy and live for 20 years," she told CNN. "That was definitely something I had to think about, but when you have those feelings, you just know."

Their health "quickly deteriorated, and within months, they went on oxygen full time" and had to quit work, CNN reports. They entered the Pittsburgh hospital together in August 2014 to wait for new lungs. Dalton got his in November; Katie is still waiting.

One month after Dalton got his transplants, UPMC discharged Katie because they told her "It would be psychologically good for her to get out for a while," she told CNN. After only three days out she began to have "serious trouble breathing" and tried to go back into the hospital, but was told she could not return because "she had used up her supply of Medicare days."

Medicare wouldn't pay for another hospitalization until Katie had been out of the hospital for 60 days. She is too sick to do that, and has since been a patient at the University of Kentucky, where she relies on the federal-state Medicaid program for the poor and disabled to pay for her care, and doctors have predicted that she won't live a year without new lungs, CNN reports.

Medicaid cannot pay the Pittsburgh hospital because it is not in the state's network of health-care providers. CNN reports that Katie's doctor wrote a letter to Medicaid begging them to make an exception, but the state denied his plea. In a statement to CNN, a spokeswoman for the state Cabinet for Health and Family Services said the hospital had declined to enroll as a Kentucky Medicaid provider. "Medicaid policies allow for a simplified enrollment process for out-of-state providers in such situations," Gwenda Bond, spokeswoman for the cabinet wrote, offering to expedite their application when they choose to sign up.

Hospital officials counter that Kentucky officials said they would have to "sign up hundreds of their doctors to accept Kentucky Medicaid patients," which hospital spokeswoman Wendy Zellner said is "an unusually restrictive approach and contrary to single-case agreements that we have signed with other state Medicaid programs. . . . It is up to Kentucky Medicaid to address this situation."

Katie has also since had a discussion with a federal Centers for Medicare and Medicaid Services caseworker that "didn't go very well," CNN reports. Katie told CNN that the caller was "rude, mean, and angry" and "acted like it was just a pain to have to be talking to me," but said "she would look into her situation." On April 1, CMS spokesman Aaron Albright told CNN that the federal agency was "reaching out to the state agency," and later in the day Zellner said the state agency "has reached out to us to talk. So stay tuned."

The news cheered the Pragers, who continued to talk via Skype and work on their fundraising Facebook page, while dreaming of a future together, CNN reports.

Doctors don't tell most patients or caregivers about a diagnosis of Alzheimer's until the disease advances, advocacy group says

Every 67 seconds someone in the U.S. develops Alzheimer’s disease and most don't find out they have it until their disease becomes more advanced, according to a report by the Alzheimer's Association.

The organization's 2015 Alzheimer's Disease Facts and Figures report says only 45 percent of people with the disease, or their caregivers, were told their diagnosis by their doctor.

One reason, the report says, is that they don't want to cause the patient emotional distress, but the report says studies have found that "few patients become depressed or have other long-term emotional problems" when they learn of their diagnosis.

The Alzheimer's Association says early disclosure of the diagnosis "should be standard practice" because it allows the patient to participate in early decision making about their care plans, deal with legal and financial issues, decide if they would like to participate in research, and gives them time to fulfill lifelong plans. The association said in the release that not enough resources and education are in place to help medical providers with "best practices for telling patients and their families."

"Telling patients the truth about their diagnosis allows them to seek treatment early, when it’s likely to be more effective, and gives them a voice in planning how they want to live the rest of their lives," DeeAnna Esslinger, executive director of the Greater Kentucky and Southern Indiana Chapter of the Alzheimer’s Association, said in a press release.

The report says an estimated 5.3 million Americans have Alzheimer’s disease, including 68,000 Kentuckians. And barring the development of medical breakthroughs, the report says the number of Americans with the disease will rise to 13.8 million by 2050. Other items from the report:

• Almost half a million people age 65 or older will develop Alzheimer’s in the U.S. this year.
• By 2050, an American will develop the disease an average of every 33 seconds.
• Two-thirds of Americans over age 65 with Alzheimer’s (3.2 million) are women.
• Alzheimer’sis the sixth-leading cause of death in the U.S.
• In Kentucky, 1,462 people died with Alzheimer’s in 2012, a 74 percent increase since 2000.
• Nationwide from 2000-2013, the number of Alzheimer’s deaths increased 71 percent, while deaths from other major diseases decreased.

The cost to care for Americans with Alzheimer's and other dementias in 2015 are estimated at $226 billion, of which $153 billion is the cost to Medicare and Medicaid alone, making Alzheimer's the costliest disease to society, the release says. The report projected this cost will increase to more than $1 trillion in 2050.

“Alzheimer’s is a triple threat unlike any other disease — with soaring prevalence, lack of effective treatment and enormous costs. Promising research is ready for the pipeline, but there’s an urgent need to accelerate federal funding to find treatment options that effectively prevent and treat Alzheimer’s," Beth Kallmyer, vice president of constituent services for the Alzheimer’s Association, said in a release.

Up to 1/3 of rural hospitals in poor financial shape, auditor finds, calling report a baseline for local decisions that could be tough

By Melissa Patrick and Al Cross
Kentucky Health News
For a video of Edelen's press conference, click here. For a cn|2 report with video, go here.

FRANKFORT, Ky. -- As many as one-third of Kentucky's rural hospitals are in poor financial shape, and the survival of some will likely depend on their willingness to adopt new business models, state Auditor Adam Edelen said Monday.

Unveiling a nine-month study, Edelen said 15 of the 44 hospitals examined were in "poor financial health," and warned, "Closure may be an unfortunate reality for some."

Rural hospitals in purple declined to make useful financial information available to the auditor's office.

The study did not include 22 of the 66 Kentucky hospitals that are located outside metropolitan areas, which declined to participate or didn't provide the type of information requested. Edelen said those hospitals are mainly privately owned. If they had been included, Kentucky Hospital Association CEO Michael Rust said, the financial picture "would be better, but I don't think they would be substantially different."

Gov. Steve Beshear said the report was "a dated snapshot" because its most recent data was from 2013, before federal health reform was fully implemented. "Conditions are no longer the same," Beshear said in a news release. "Hospitals received more than $506 million in 2014 through new Medicaid expansion payments, while seeing significant reductions in uncompensated care costs.  Those are huge changes to hospitals’ bottom lines that are not shown here."

Edelen, who was Beshear's first chief of staff, said the full effect of federal health reform isn't certain. His report noted that Kentucky hospitals have had higher-than-average penalties from Medicare for readmitting patients within 30 days, a newly implemented feature of the law. Forty of the 63 hospitals penalized were rural, and nine of the 39 in the U.S. that got the maximum penalty were in Kentucky.

"This report doesn't speak to causation" by the reform law or the state's relatively new managed-care system for Medicaid, Edelen said, it is "not a rebuke" of either, but provides "a baseline for monitoring" by policymakers at the state and local levels.

The report says that to survive, rural hospitals must adapt to new business models, such as merging with larger hospitals or hiring them as managers, forming coalitions with other rural hospitals, or finding a health-care niche that hasn't been served.

Edelen cited Rockcastle Regional Hospital, which has become a niche provider of ventilator dependent care and the coalition formed by Morehead's St. Claire Regional Medical Center and Highlands Regional Hospital in Paintsville to provide more efficient care, improve patient access and adapt to changes under the reform law.

Adaptations might be a hard pill to swallow for many rural hospitals because they call for yet more change in the rapidly changing health-care landscape of electronic health records, managed care, Medicaid expansion and full implementation of the Patient Protection and Affordable Care Act.

Edelen said adaptation is important for rural communities, for whom "the importance of rural hospitals cannot be understated. They provide health care to 45 percent of Kentuckians and in every community they serve they act as one of the larger employers, paying a significantly higher wage than the average the community experiences."

He also cited the many small hospitals that have formed relationships with larger networks to relieve the increased administrative burden associated with the three-year-old managed-care system. The report says half the hospitals studied have reported an increase in hours spent on administration.

The report suggested that the state Cabinet for Health and Family Services negotiate better contracts with managed-care organizations, partly to streamline MCO rules and paperwork to reduce the administrative burden. "We are optimistic that the current work of the cabinet to improve those contracts is going to bear real fruit," Edelen said.

The new contracts will start July 1. In an interview, cabinet Secretary Audrey Haynes sounded optimistic about them but said she couldn't give details.

Haynes has been saying since she became secretary three years ago that many hospitals must change the way they do business. She said in an interview that the readmission penalties have forced hospitals to change by providing better discharge planning, and utilizing outpatient services like home health, nursing homes and rehabilitation.

One Kentucky hospital, in Nicholas County, has closed in the last year. Haynes said the cabinet is working with Fulton County, whose hospital is scheduled to close March 31, to explore how to continue providing care at the facility, such as an emergency room or an ambulatory surgical center.

Haynes recommended in the interview that all nonprofit hospitals put audited financial records and their tax returns on their websites and adhere to open-meeting laws.

In a lengthy response, included in the report, Haynes rejected Edelen's suggestion that her cabinet regularly monitor the fiscal strength of rural hospitals. She said in the interview that would pose a conflict of interest, since the cabinet regulates the hospitals.

Edelen's analysis of hospitals' financial health was based on percentage of revenue kept as profit, number of days of cash on hand, debt financing and depreciation. It found that the financial condition of 68 percent of Kentucky’s rural hospitals scored below the national average.

Edelen's office also surveyed rural hospital administrators, held 11 public hearings and met with representatives of all five Medicaid managed-care companies. His report found that:

• Rural hospitals that were geographically well-positioned, such as Pikeville Medical Center, scored high while geographically-isolated hospitals, like those in Clinton and Wayne counties, scored low. The Clinton County Hospital is in bankruptcy to restructure debt incurred for an expansion and modernization.
• The Pikeville hospital, formerly Pikeville Methodist, was one of only three judged to be in excellent financial health. The others were critical-access hospitals in Franklin and Morganfield.
• Critical-access hospitals, which limit their beds, services and patient stays to qualify for federal reimbursement at 101 percent of cost, scored better than regular acute-care hospitals. They accounted for seven of the 14 that were above the national average and thus were rated "good."
• Fifteen hospitals were rated "fair" and 15 were rated "poor." Westlake Regional Hospital in Columbia, which is in bankruptcy, was at the bottom, far worse than the next highest, St. Joseph Mount Sterling.
• The number of health-care providers across the state – particularly in rural Kentucky – dropped significantly between 2013 and 2014. The cabinet disputed that finding, based on different measurements.

Here are the rankings (click on the image for a slightly larger version):

Woman needing lung transplant falls through cracks of health-care system, says she's treated as nothing more than a 'price tag'

Katie Prager, a 24-year-old cystic fibrosis patient from Ewing in Fleming County, needs a lung transplant, but has been denied one because she has met her lifetime maximum on Medicare, Christy Hoots reports for The Ledger Independent in Maysville.

Photo from The Ledger Independent

"They've put a price tag on my name. That's all I am to these people right now," Prager told Hoots from her hospital bed at the University of Kentucky's Chandler Medical Center.

Prager has had cystic fibrosis her entire life, but it was a diagnosis of an infection called burkholderia cepacia in 2009 that caused her lung function to rapidly decline and caused the need for a lung transplant. She was told in 2013 that the UK Center for Cystic Fibrosis does not do transplants on cystic fibrosis patients with this infection, so she was sent to the University of Cincinnati hospital, Hoots reports.

She and her husband Dalton Prager, who also has cystic fibrosis, were then sent to the University of Pittsburgh Medical Center because it is only one of two hospitals that will transplant a lung into a patient with this infection. They began evaluations in January 2013.

Dalton Prager was quickly approved and successfully received a double lung transplant in November 2013. Katie Prager wasn't approved until June 2013. While waiting for a donor lung, she was discharged to spend Christmas with her family, only to hear from the hospital that she could not return there because the Medicare maximum had been reached.

"At first, I thought I might be able to use Medicaid, but was told that it wouldn't cover my transplant due to UPMC being out of network," Katie Prager told Hoots. "After explaining to Medicaid that there are only two places in the country who would operate, due to cepacia, they still refused to work together to help me. In January 2015 I filed an appeal with Medicaid to have them reconsider. The appeal was denied."

She was recently told she would never be eligible to return to UPMC for a transplant and there was nothing else they could do for her, Hoots reports.

"They told me to basically stop wasting my time," she told Hoots. "These are people who we're trusting with our lives and they say that. Most people have no problems when they have to have medical treatments or transplants, and I'm being given the runaround. I'm not trying to be a burden on the system -- that isn't what I want. If I could work and get my own insurance, I would. All I want is a normal chance at life. I want to get my bachelor's degree, get up every day and go to work, run a 5K and have a normal life with my husband. I want to do all the things that young people in love get to do. Is that so much to ask?"

Health reform law has been good for hospital finances, health-care costs, Obama administration says

U.S. hospitals have saved billions of dollars because the federal health-reform law has provided coverage for patients who were once charity cases, the Obama administration announced Monday, the fifth anniversary of the Patient Protection and Affordable Care Act.

"Hospitals also saw fewer emergency room visits, which rack up far higher costs and often leave hospitals with the tab," Sarah Ferris writes for The Hill, which covers Congress. "The government’s report, which focuses on the benefits of Medicaid expansion, is an effort to entice states that have been politically resistant to expanding the program."

Kentucky hospitals have acknowledged that the law has reduced their losses from "uncompensated care," but say other aspects of the law have created a mixed effect, depending partly on hospitals' ability to adapt. The increase in coverage has brought hospitals much more money, but they say continued problems with managed-care Medicaid have cause them financial difficulty.

From paying patients' point of view, the law appears to have reduced inflation in health-care costs, but has not achieved advocates' goal of reducing costs. A White House report said, "Since the Affordable Care Act was enacted, health care prices have risen at the slowest rate in nearly 50 years. Thanks to exceptionally slow growth in per-person costs throughout our health care system, national health expenditures grew at the slowest rate on record from 2010 through 2013."

For the White House's Kentucky-specific list of benefits of the law, click here.

Beshear cites signs toward better health: kids are more active and getting more dental care; adults are getting more screenings

Kentucky Health News

Kentucky is moving toward achieving the broad, ambitious goals for better health that Gov. Steve Beshear laid out when he started the "Kyhealthnow" initiative in February 2014, his office says.

"More Kentuckians have health insurance, are covered by smoke-free policy, can access physical activity resources, seek care for heart disease and cancer prevention, and get dental services" since the initiative began, Beshear said in a press release.

The program builds on federal health reform, which has made Medicaid or private insurance available to hundreds of thousands of Kentuckians, many of whom were previously uninsured and unable to afford health coverage. According to a Gallup Poll released in February, 9.8 percent of Kentucky’s population is uninsured, down from 20.4 percent in 2013.

Kyhealthnow targets seven major health goals to be met by 2019, focusing on increasing health insurance coverage; reducing the smoking rate and tobacco use; lowering the prevalence of obesity; lowering cancer deaths; reducing cardiovascular disease; treating and reducing dental decay; and reducing drug overdoses and mental health issues in Kentucky.

The report said more adults have been screened and identified as having high blood pressure and are able to control their hypertension, and more adults have had their cholesterol checked.

Significantly more children on Medicaid are being seen by dentists, and the number of children enrolled in Medicaid receiving two fluoride dental varnishes per year has increased. The state has given money to five health departments for dental-hygiene programs, and will fund five more this year. "These programs broaden access to hygiene services, such as cleanings, screening and referrals, by providing staff and resources to supply mobile units to deliver care in schools," the release said.

School districts are showing an increase in the amount of time devoted to physical activity, the state reports. The Comprehensive School Physical Activity Program has been implemented at proficient or distinguished levels at all grade levels in 515 of the state's 746 elementary schools, 186 of the 329 middle schools and 109 of the 228 high schools. Also, more schools report they are using body-mass index data to inform school wellness policy.

The state health department is using federal funds to implement physical activity and obesity-prevention curricula in early-childhood care centers. "The goal is to develop healthy habits in children before the age of 5 and prevent obesity," the news release says.

To increase physical activity and deter obesity among older children and adults, the state is establishing “trail towns.” Morehead and Olive Hill were recently certified by the state Office of Adventure Tourism and eight more are expected to be certified this year. The Dawkins Trail, an ongoing rail-to-trail project in Eastern Kentucky, has reached a length of 18 miles.

Diabetes management has improved among adults, and a study of Medicaid patients showed an overall decrease in those with poor diabetes control, the release said. State employees now have easier access to the nationally recognized Diabetes Prevention Program, which helps people who are at risk of developing diabetes reverse the onset of the disease.

Dr. Stephanie Mayfield, the state health commissioner and vice chair of Kyhealthnow, has emphasized the importance of reducing tobacco use to make Kentuckians healthier. Beshear has expanded the ban on tobacco products and e-cigarettes on executive branch properties, making Kentucky one of only five states in the country with such a policy. Smoking bans exist in 24 communities, 37 school districts and 51 college or university campuses.

Kyhealthnow, chaired by Lt. Gov. Crit Luallen, includes people from many areas of state government who develop innovative strategies for addressing the state’s health woes and challenge local governments, businesses, schools, nonprofits and individuals to take meaningful steps toward improving health in their communities, the release said.

Advocates of state appeals for Medicaid managed-care claims make last-ditch effort to get it passed, by hijacking another bill

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- Advocates of a bill to create a state appeals process for health-care providers to appeal decisions of Medicaid managed-care companies are trying to jam it through at the end this short legislative session on the coattails of an unrelated bill that appears to be uncontroversial.

Rep. Joni Jenkins

Senate Bill 120, sponsored by Sen. Ralph Alvarado, a Republican physician from Winchester, would create an administrative appeals process in the Cabinet for Health and Family Services, which opposes the idea. A Senate committee has attached Alvarado's language as an amendment to House Bill 71, sponsored by Rep. Joni Jenkins, D-Louisville, that would allow judges to order a person who is "incapacitated by alcohol and other drug abuse" into treatment.

"I think it has the potential of killing this bill," Jenkins said in an interview. "I heard there was a really large price tag put on [Senate Bill 120], a large fiscal load. So this late in a non-budget year, it is probably going to kill it."

Sen. Julie Raque Adams, chairperson of the Senate Health and Welfare Committee, disagreed. "Everybody in the Senate [is] very supportive of Rep. Jenkins' bill, and we have also passed out Senate Bill 120 from this chamber," she said in an interview.

SB 120 passed the Senate 35-0 on March 2. HB 71 passed the House 90-1 on Feb. 26.

Rep. Robert Benvenuti of Lexington, Republican co-chair of the Democrat-controlled House Health and Welfare Committee, said he thought SB 120 "has a lot of support" on the House floor if leaders of the House's Democratic majority allowed it to come up for a vote.

But to get a floor vote it must first come out of the committee, and that appears unlikely. The legislature can still pass bills on March 23 and March 24, after the 10-day recess for Democratic Gov. Steve Beshear to veto bills, but if he vetoes bills passed then there is no opportunity to override vetoes.

"I think it is a bill that properly sets up a process for providers who believe they have not been properly reimbursed to have some redress," Benvenuti said in an interview. "Our health care providers who serve this commonwealth need to have an avenue of redress so that they can be properly paid for medically necessary services that they provide."

Alvarado has said an administrative appeals process is necessary because managed-care organizations are denying claims for medically necessary treatments and then denying the providers' appeals, which means providers are not getting paid for their work.

The cabinet says it should not be responsible for an appeals process for MCOs because they do not have any legal authority between a contract made between a provider and the MCO. They have also said it would cost the state money. MCOs are paid a flat fee for each person whose care they manage, but an increase in approval of initially denied claims could give them leverage in negoiations for the next annual contract.

The fiscal note for this bill says the cabinet estimates its administrative cost for an appeals process would be at least $1 million a year, which would increase in later years. Alvarado maintains that the added cost to the state should be minimal.

Jenkins, whose nephew, Wesley, died of a heroin overdose two years ago, said that this is the fourth year she has tried to pass this bill, with a lack of funding to pay for the program its main obstacle, "but with the passage of the ACA, it has opened up private insurers and Medicaid to pay."

Jenkins said if the House didn't concur with the changes made by the Senate, she hoped the Senate would withdraw its amendment.

Adams said if the House didn't concur, she would be "very receptive" to going into conference committee to resolve their differences because Rep. Jenkins "has got a very important bill that we need to pass."

As session nears end, bills on heroin, dating-violence orders, managed-care appeals and lawsuit review panels are hanging fire

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – The General Assembly has sent Gov. Steve Beshear four health-related bills, and several more could reach his desk in the legislative session that ends Wednesday. Legislators will return briefly after 10 days to reconsider any bills Beshear vetoes; they could also pass more bills, but would not be able to override any vetoes.

Here are some of the health-related bills that were pending on Monday; bills with two readings are ready for floor action.

Heroin: tougher penalties and needle exchanges?

Both the Senate and the House have heroin bills and both remain in committee in the other chamber, but hope remains high in both chambers that a compromise can be reached so that a heroin bill will pass this session. Senate Bill 5 is sponsored by Sen. Christian McDaniel, R-Latonia; House Bill 213 is sponsored by Rep. John Tilley. The main differences are how traffickers would be punished and whether to start needle-exchange programs for addicts. The Senate's penalties are tougher and it has opposed needle exchanges, which advocates say prevent disease and death from dirty needles and can lead addicts to treatment.

Now the Senate is moving toward accepting needle exchanges, James Pilcher reports for The Cincinnati Enquirer. Rep. Dennis Keene, D-Wilder, and Sen. Wil Schroder, R-Wilder, said exchanges "are much more likely to be included than when the session started," Pilcher writes. Schroeder told him, "I think there is a real possibility that we could include needle exchanges and then get our tougher penalties." Pilcher reports, "The possible legislative position shift comes as health officials throughout the Tristate have expressed deep concerns about the spread of diseases that can be contracted using dirty needles."

Protective orders for dating violence

House Bill 8, sponsored by Rep. John Tilley, D-Hopkinsville, has received its second reading and is awaiting passage in the Senate. This bill would allow dating partners to petition for interpersonal protective orders if they have been the victim of domestic violence, sexual abuse or stalking. Such orders are now available only to those who are married, live together or have lived together, or an unmarried couple with a child in common.

Kentucky is the only state that offers no protection for such victims. Legislation to do that has stalled in the Senate in earlier sessions, but a Senate committee substitute addresses a key objection, by creating a new chapter in the statutes for the bill, separate from the existing domestic-violence chapter.

Advocates say domestic violence is a health issue not just because of the physical injuries it causes. They say victims are more likely to be depressed, have unplanned and premature pregnancies, go to fewer prenatal visits, and to miss more well-child visits with their children.

Prescription synchronization, managed-care appeals

Senate Bill 44, sponsored by Sen. Julie Raque Adams, R-Louisville, has had its second reading in the House. This bill would allow patients with multiple prescriptions, in consultation with their health-care provider and their pharmacist, to synchronize prescriptions so that they may be picked up at the same time.

House Majority Caucus Chair Johnny Bell, D-Glasgow, has filed a floor amendment on an unrelated issue, to create a state appeals process for health-care providers to appeal decisions of Medicaid managed-care companies. It is the same as or similar to Senate Bill 120, sponsored by Sen. Ralph Alvarado, which has given it a first reading without assigning it to a committee. The Cabinet for Health and Family Services opposes a state appeals process, saying it would have a conflict of interest (successful appeals would cost the state money) and providers have the courts available to them to resolve contractual issues. UPDATE: Bell withdrew his floor amendment to Senate Bill 44 March 9. 

Review panels for suits against health-care providers: Senate Bill 6, filed by Alvarado, remains in the House Judiciary Committee, but a discharge petition was filed March 4 to bring it to the floor, bypassing leaders of the House's Democratic majority. This bill would establish panels of three medical experts, two chosen by each side and the third chosen by the other two, to review suits against health-care providers to determine if the case has merit before the lawsuit can proceed. Panel findings would be admissible in court, but not legally binding. Opponents say that Kentucky already has laws to punish attorneys for filing frivolous cases and that this just adds another barrier for patients seeking justice.

Newborn screenings for fatal disease: Senate Bill 75, sponsored by Sen. Alice Forgy Kerr, R-Lexington, has had two readings. It would require all newborns to be tested for Krabbe disease, a neurological disorder that destroys the protective coating of nerve and brain cells and is fatal once symptoms occur. Treatment with stem cells from an umbilical cord blood transplant is sometimes successful it the infant is treated early enough. The cabinet opposes the bill, saying the screening will cost half a million dollars a year at a time when local health departments are suffering budget cuts.

Spina bifida: Senate Bill 159, sponsored by Sen. Julie Raque Adams, R-Louisville, is in the House and the three-day posting rule has been waived. This bill would require medical providers to supply written, up to date, accurate information to parents when their unborn child is diagnosed with spina bifida so parents can make informed decisions on treatment

Physician assistants: House Bill 258, sponsored by Rep. Denver Butler, D-Louisville, is awaiting Senate passage. This bill allows a physician to supervise up to four physician assistants at the same time, rather than two.

In-home care: House Bill 144, sponsored by Rep. Tom Burch, D-Louisville, is awaiting Senate passage. It would establish a 60-day, hospital-to-home transition program through an approval waiver from the Department for Medicaid Services. The daily cost would have to be less than the average daily nursing home payment allowed by Medicaid. The bill would also provide non-medical support services to the applicant as needed.

BILLS SENT TO THE GOVERNOR

Colorectal cancer screening: Senate Bill 61, sponsored by Sen. Ralph Alvarado, R-Winchester, received final passage in the House March 4. This bill requires that a fecal test to screen for colon cancer, and any follow-up colonoscopy, be considered preventive measures that health insurance is required to cover without imposing additional deductible or co-insurance cost. The bill would apply to health plans issued or renewed on or after Jan. 1, 2016, if it becomes law. A similar measure, House Bill 69, sponsored by Rep. Tom Burch, D-Louisville, is awaiting passage in the Senate with a committee substitute by Sen. Julian Carroll, D-Frankfort, calling for a Medicaid savings study.

Medical order scope of  treatment (MOST) form: Senate Bill 77, sponsored by Sen. Tom Buford, R-Nicholasville, received final passage in the House March 3. This bill creates a medical order scope of treatment (MOST) form that specifically directs the type of treatment a patient would like to have, and how much intervention he or she would like to have, during end-of-life care. It is considered a physician's order, travels with the patient between health care facilities, and must be reviewed annually. The bill clearly defines the order of controlling documents for end-of-life care: the living will first, the MOST form second and the health-care surrogate, which is chosen by the patient and listed on the form, third. The MOST form is already used in 32 states.

Emergency care for strokes: Senate Bill 10, sponsored by Sens. Stan Humphries, R-Cadiz, and David Givens, R-Greensburg, received final passage in the House March 4. The bill requires that a list of all acute stroke-ready hospitals, comprehensive stroke centers and primary stroke centers in Kentucky be posted to the cabinet's website and be made available to all emergency medical services providers, who are required to set their own internal protocols toward assessment, treatment and transport of stroke patients.

Funding for UK cancer research center: House Bill 298, sponsored by Rep. Rick Rand, D-Bedford, received final passage in the Senate March 4. This bill authorizes the state to appropriate $132.5 million, half of the cost, for construction of a new medical research center at the University of Kentucky. The university will raise money to cover the other half. The facility will target prevalent diseases in Kentucky, including cancer, diabetes and cardiovascular disease. The bill required a 60 percent vote in each chamber because it affects the state budget and the legislature is in a non-budget session; it passed the House 83-9 and the Senate 36-1 (Sen. John Schickel, R-Union).