More dental patients using ERs, showing lack of dental coverage, shortage of dentists and the stepchild status of oral health

More patients are going to hospital emergency rooms for dental care, illustrating how oral health remains the stepchild of the health system despite health-care reform.

"An analysis of the most recent federal data by the American Dental Association shows dental ER visits doubled from 1.1 million in 2000 to 2.2 million in 2012, or one visit every 15 seconds, Laura Ungar reports for The Courier-Journal and USA Today.

Christopher Smith of Jeffersonville, Ind., had a dental
infection that put him in a Louisville hospital for a
week. (Courier-Journal photo by Sam Upshaw Jr.)

"This is something I deal with daily," Dr. George Kushner, director of the oral and maxillofacial surgery program at the University of Louisville, told Ungar. "People still die from their teeth in the U.S."

A longstanding federal law requires ERs to treat patients regardless of their ability to pay. "Although they often provide little more than painkillers and antibiotics to dental patients, the visits cost more than three times as much as a routine dental visit, averaging $749 if the patient isn't hospitalized — and costing the U.S. health care system $1.6 billion a year," Ungar reports.

Private dental insurance is not common. "Just over a third of working-age adults nationally, and 64 percent of seniors, lacked dental coverage of any kind in 2012, meaning they had to pay for everything out of pocket," Ungar writes. The Patient Protection and Affordable Care Act "requires health plans to cover dental services for children but not adults," and "Medicare generally doesn't cover dental care at all," she notes.

In Kentucky, the expansion of Medicaid under Obamacare has increased dental visits in the program by 37 percent, but it offers "only a short list of dental services," such as extractions, which patients often choose instead of restorative work, for which they would have to pay.

Another big issue is that many dentists don't accept Medicaid, which pays them only 41 percent of private reimbursement, Ungar reports. Also, Kentucky has a shortage of dentists. "A 2013 workforce study by Deloitte Consulting found the state needs 612 more to meet demand," Ungar notes.

More dentists would encourage more preventive treatment, which dentists say would save a lot of money. "If we were going to the dentist more often, we could avoid a lot of this," Dr. Ruchi Sahota, a California dentist and consumer adviser for the ADA, told Ungar. "Prevention is priceless."

Fewer than 60 percent of Kentuckians saw a dentist in 2013, making their dental-visit frequency 43rd in the nation, according to the Kentucky Health Issues Poll.

Video streaming for consultation with doctors expands and becomes more popular; 2 Ky. insurers use it and another plans to

In the past, people had to go to the emergency room to receive medical attention if they required it outside the usual hours for doctors. Now telemedicine programs such as KentuckyOne Health's "Anywhere Care" and Anthem BlueCross BlueShield's "LiveHealth Online," Kentuckians can access a doctor 24/7 through a computer or mobile device.

Photo from The Lane Report

"Patients like telemedicine because it's fast and easy to use and cheaper because it's a low-overhead service," Esther Zunker writes for The Lane Report, a Lexington-based business magazine.

UnitedHealthCare, a Minnesota-based health benefits provider for many people in Kentucky, plans to cover Skype-based doctor visits through "NowClinic," "Doctor on Demand" and "American Well." Anywhere Care and Live Health Online give clients a list of certified doctors they can chat with through video on a computer or a mobile device. The doctors can provide diagnosis and treatment and even write a prescription. They can direct patients to an emergency department if necessary.

It's affordable, too. A LiveHealth Online appointment costs the same as an office visit for eligible members. LiveHealth doctors usually charge $49 per online "visit." Anywhere Care costs $35 per visit, even if patients don't have insurance.

"As we know, care can be limited and is based on being able to get someplace when [a doctor] has an opening," said John Jesser, Anthem's vice president of provider engagement strategy. "They only have certain hours, and that doesn't always work for when people don't feel well. [Telemedicine] expands access to care for the consumers, making it much more friendly to their schedule and lifestyles."

Telemedicine is also convenient for doctors. It saves money for hospitals and allows one doctor in one location to help patients in a variety of locations. Patients can receive help with chronic conditions over periods of time without having to travel to the doctor's office.

"We've had amazingly positive feedback from patients who have tried this service," said Kathy Love, director of strategy and business development for KentuckyOne Health's Central East Kentucky Market. "People have told me they've used it multiple times when they've needed it . . . either late at night or over the weekend."

She also said people who use telemedicine still need a primary-care physician: "It's something you can access 24 hours a day with a very minimal wait and very professional providers, but it shouldn't replace your very important relationship with your primary-care doctor." (Read more)

Telemedicine helps reduce waits for mental-health patients in ER and provides better health-care access in schools

Health professionals have used telemedicine to help delay Alzheimer's disease and reduce hearing loss in Appalachia, especially among children. Now the new approach is helping students access health care, and mental-health patients to get faster medical attention in emergency rooms.

AMD Global Telemedicine has been establishing telemedicine systems in schools, which allow "providers to care for students on-site with few clinicians to support it," Katie Wike writes for Health IT Outcomes. So far "the Center for Rural Health Innovation in western North Carolina used the technology to support 14 school-based programs and provide care to 4,000 students.

The health-care provider can ask the questions during the exam, and "it doesn't assume the presenter knows the questions to ask," said CRHI Executive Director Amanda Martin. This approach allows one nurse practitioner to provide care to thousands of children. Some Kentucky schools are already using the telemedicine platform, Wike reports.

Sometimes when patients seek mental-health care in emergency rooms, no psychiatric services are available. In this case, hospitals often contact and wait for a provider to arrive or send written evaluations for review, Karla Paris writes for Health IT Outcomes. Now KentuckyOne Health has a telemedicine program that gives faster response times for those requesting mental-health care. For example, patients who visit Louisville's Ss. Mary & Elizabeth Hospital for mental-health care will be able to videoconference with professionals from Our Lady of Peace Hospital. "Patients can then be referred for admission at Our Lady of Peace, another outpatient program or care center," Paris reports.

Sicker patients, competition for beds and a growing number of patients create long wait times at UK emergency room

The University of Kentucky's emergency room has the longest wait time in Kentucky and this time is also way above the national average, Mary Meehan reports for the Lexington Herald-Leader.

With beds regularly lining the halls of the ER, the average wait time for emergency care at UK — measured from the time a patient comes through the door to reaching a hospital bed — is 10 hours and 44 minutes, Meehan reports. This is 4 1/2 hours longer than the national average, according to Hospital Compare, a government website where Medicare reports data on hospitals.

Hospital officials blame the competition for beds between surgical and ER patients, the growing number of patients, and the fact that UK treats the sickest patients in the state.

Since the expansion of the ER in 2010, it annual patient count has risen to 70,000 from 30,000, chief nurse executive Colleen Swartz told Meehan.

Nearby, comparable hospitals have significantly shorter wait times. The University of Louisville Hospital, Kentucky's other Level 1 adult trauma center, has a wait time three and a half hours shorter.

UK's needs to add more rooms and beds, Dr. Michael Karpf, UK's executive vice president for health affairs, told Meehan, suggesting the hospital's empty, $763 million medical tower needs to be completed.

The UK Chandler Medical Center plans to expand its beds by shifting 35 acute-care beds from UK's Good Samaritan Hospital by the end of the year, and the tower completion is set for 2018 to 2020.

But the hopspital-accrediting Joint Commission and Eugene Litvak, a Harvard University professor and expert in hospital efficiency, think otherwise.  They told Meehan that "better communication, scheduling and staffing is the solution." The commission says those methods are "grossly underused." 

Litvak told Meehan that building more beds is not the answer.  He said that "with increased communication, hospitals can achieve an even tempo of patient flow that will reduce ER wait times," and how surgeries are scheduled is the main reason for wait-time problems.

Surgeons get priority on scheduling, and surgical patients get priority over the ER patients for rooms. Livtak said surgeries are generally covered by insurance, making them more profitable for hospitals, and ER patients often do not have insurance and are less profitable to treat. Things don't change, because "We don't want to upset our cash cows, the surgeons," Livtak told Meehan.

Swartz acknowledged that surgery and ER patients can compete for beds at the hospital, but she said "All UK patients are treated equally whether they have insurance or not."

A Herald-Leader editorial criticized Karpf for saying the ER would "muddle through" while beds are added, saying "Delays like those at UK can easily create patient-safety problems and affect the quality of care, especially as the Affordable Care Act allows more people into the health-care system."

The editorial said "UK HealthCare should not push for spending hundreds of millions on more rooms without making every effort to examine and improve the ER system that could put patients at risk," and take the advice of experts who say that more beds aren't the answer, as well as allowing people with management backgrounds, not medical backgrounds, to improve the system through "streamlining and efficiency."

Women leading Kentucky health: State health commissioner sees 'stars aligned' for Kentucky to finally get healthier

Health Commissioner Stephanie Mayfield Gibson

This is the third in a series of stories about four high-ranking female state officials who have guided the state's embrace of the Patient Protection and Affordable Care Act.

By Melissa Patrick

Kentucky Health News

“The stars have aligned” and Kentucky has at last “created an infrastructure” to make the state healthier, says Dr. Stephanie Mayfield Gibson, commissioner of the state Department for Public Health.

“What a great time to be in my position,” Mayfield said in an interview, in which she enthusiastically ticked off a list of aligned stars:

• Her bosses, including the governor and lieutenant governor, who are “extraordinarily supportive of health care;”
• The expansion of the federal-state Medicaid program to households with incomes up to 138 percent of the federal poverty level;
• The Kentucky Health Benefits Exchange, branded as Kynect, where Kentuckians sign up for Medicaid or subsidized private insurance;
• The Kentucky Health Information Exchange, an electronic network that makes a wide range of health information easily available; and
• Programs that enhance the quality of care to get better outcomes and decrease costs, such as the programs to stop over-use of emergency rooms.

Mayfield says her top priority is to decrease exposure to tobacco, because so many of Kentucky’s health issues are related to its most famous crop. About 28 percent of Kentuckians smoke, and “The single most important factor that negatively impacts the health of the commonwealth . . . is exposure to tobacco smoke,” Mayfield said. “I want people well.”

She said Kentucky must also address the epidemic of painkiller abuse, which has made it one of the top three states in deaths related to abuse of opioids; and obesity, which is connected to cancer, diabetes and cardiovascular disease. Kentucky ranks in the top five in each of those diseases, and is in the top 10 for child and adult obesity.  

“Who wants the reputation for being number one in cancer deaths?” Mayfield asked. “We know we can do better. These are winnable battles.”

These and other issues are included in Kentucky Health Now, a plan Gov. Steve Beshear has set forth to improve the health of Kentuckians, with specific goals to be reached by 2019, the end of the next gubernatorial term. Beshear’s term ends in December 2015.

Mayfield is vice-chair of the team overseeing the effort, led by Lt. Gov. Jerry Abramson.  She seems to have the full confidence of Audrey Haynes, the secretary of the Cabinet for Health and Family Services, who lit up when asked about her, but Haynes said she had to make sure that Mayfield, a pathologist who ran the state health lab for seven years, was cut out to be the state’s top doctor.

“It’s a job where … you have to kind of have a better understanding of politics,” Haynes said.  “But I wanted her to rise above all that because she is the public health commissioner. Hers is more about the science.  I need her to be honest and tell the truth.”

Haynes said she told Mayfield, “You are going to tell people what they don’t want to hear sometimes, but always stick with science.  You have to rise above the rhetoric, no matter what.”

“And so I recommended her to the governor and they also fell in love with her.” She became commissioner on Oct. 1, 2012.

Kentucky’s health problems have mounted for decades, but Mayfield is optimistic that they can be overcome because of the Medicaid expansion and increased access to health insurance under the federal health-reform law. Thousands of people have sought care for problems that went untreated because they had little or no money or no insurance.

The federal government is paying the entire cost of those newly eligible for Medicaid until 2017, when the state will begin paying 3 percent, rising to the law’s cap of 20 percent in 2020.  Republican legislators and candidates for governor have voiced concern about the state’s ability to pay its Medicaid bills.

Mayfield said the state is working on controlling costs, through the managed-care system that began in 2011.  One target of cost control is the “super-utilizers” of emergency rooms, or those who come to hospital emergency departments 10 or more times per month.

Mayfield, who was put in charge of finding a way to reduce super-utilizers, said 80 percent of them have mental-health issues, so she is working on the problem with Medicare, the state Department of Behavioral Health and Kentucky’s three medical schools. Kentucky is one of six states accepted into the National Governors Association Policy Academy to address super-utilization.

Dr. William Hacker, who preceded Mayfield as commissioner, said her broad training and deep experience in the department uniquely qualified her to succeed Dr. Steve Davis, who was interim commissioner after Hacker retired.

“She is multidisciplinary and thinks beyond the public-health world,” Hacker said. “She has done an excellent job.”

Mayfield, who has been nationally recognized for her contributions to the state’s electronic health information exchange, also stresses the importance of using technology to improve the health of Kentuckians – especially those who live in rural areas, far from specialists.

Mayfield describes her style of leadership as one of action.  “If we say we are going to do something, then let’s build that infrastructure and let’s get it done,” she said.

Hacker said, “Dr. Mayfield is a thoroughbred.  She is on the go at 90 miles per hour.  She is focused on accomplishing goals.”

Haynes said Mayfield “led massive change at the lab” and knows “how to cajole and support and lead” – and when to be firm. “There are times you have to stick to your guns. You have to choose sort of your poison and you have to say ‘I’ll give you this, but I’m not giving this.’ I needed somebody that didn’t feel the political pressure to give in, and that would stick with it. And really just be a great public face of public health.  And she is all of that.”

Hospitals say too many of the newly insured are using emergency rooms for primary care; state says it's working on the problem

By Melissa Patrick
Kentucky Health News

More people with health insurance, a shortage of primary-care physicians and a steep learning curve for the newly insured all add up to more patients than ever using emergency rooms for non-emergency purposes.

More than 413,000 Kentuckians are newly enrolled in health care coverage under the Patient Protection and Affordable Care Act, and nearly three out of four of those enrolled under the Medicaid expansion, which covers residents earning up to 138 percent of the federal poverty line.

Because many of these newly insured are using the emergency room for non-emergency reasons, emergency rooms are feeling the strain, Don Weber reports for cn|2's "Pure Politics," a service of TimeWarner Cable.

"In the past three months, we are seeing about a 12 percent increase per month in our emergency room visits," Sheila Currans, CEO of Harrison Memorial Hospital in Cynthiana, told Weber in a broadcast.

“Many of the patients that come have multiple chronic conditions that have been undeserved," Currans said in the broadcast. "Diabetic. Obesity. Vascular disease. And so they come with chronic conditions and they don’t really have a primary-care physician. And so the ability to get them into a primary-care setting, into specialty-care settings, becomes more difficult without that primary-care person to refer and to kind of coordinate and manage that care."

Currans added, “Primary-care physicians have got to lead this transformation in health care, because  … they can take care of the whole patient. We have to reform the payment system so that the primary-care physician can spend 30 minutes with you and/or can spend 15 minutes with you, but can hand you off to a professional within their office that can help educate, continue to educate, re-mediate.”

Norton Hospital in Louisville has also seen a 12 percent spike in the number of patients, many for non-emergency reasons, Laura Ungar reported in The Courier-Journal. Weber reports that the 12 percent increase in emergency room visits is "pretty consistent with the state average."

This is not a new problem, according to Jill Midkiff, spokeswoman for the Cabinet for Health and Family Services.

“Kentuckians suffer poorer health than many other Americans, and have traditionally utilized emergency rooms at a higher rate. This is not a new phenomenon," Midkiff said in an e-mail. She said Kentucky is working on the problem, focusing on so-called "super-utilizers" who use ERs at least 10 times in a year.

"Last summer, Kentucky was one of seven states chosen to participate in the National Governors Association Policy Academy on emergency-room utilization, with particular focus on managing super-utilizers," Midkiff said.

People who have never had insurance often don't know how to use their benefits, which also adds to the number of people using the emergency room instead of seeking a primary care physician, Midkiff said. "There is a steep learning curve to navigating the healthcare system and all providers and the insurance companies must help educate the newly insured," she said.

Part of that effort is being handled by the companies that manage the care of Medicaid patients under contracts with the state that reward them when expenses are less than expected.

The Kentucky Health Benefits Exchange, branded as Kynect, "is developing some very basic 'Insurance 101' materials to help educate the newly insured about how to find a primary care physician, when to seek health care services, when to visit the ER, how to use pharmacy benefits, as well as providing a glossary of commonly used insurance terms," Midkiff said. "We think this fills a real need and will help consumers more appropriately and efficiently use their health-care coverage."

Midkiff said emergency rooms have long been considered the "de facto primary care center," with some hospitals even advertising the average wait times on websites and remote-controlled billboards. "This provides a confusing message to those who are newly covered," she said. "Many hospitals across the country have revised their health-care delivery model to include both emergency services and immediate care to adapt to the increased and changing demand for services."

Many hospitals around the country have done that, and are profiting. "Hospital chains and insurers are making more money, more patients using ERs are paying for their care, and the country as a whole is enjoying slower growth in its health-care spending," Alex Wayne and Shannon Pettypiece of Bloomberg News report, on the basis of public filings by hospital chains.