Louisville opens first needle exchange in state; officials predict rural counties will be slow to follow

Photo by Scott Utterback, The Courier-Journal

Louisville Metro Public Health & Wellness opened its mobile needle-exchange program Wednesday, June 10, making Louisville the first place in Kentucky to implement such a program.

Lexington and Northern Kentucky are expected to follow soon, but officials say that establishing needle exchanges in much of Kentucky will be "more politically complex," Mike Wynn reports for The Courier-Journal.

"We're going to see some parts of our state where this is available and others where it is not," Scott Lockard, president of the Kentucky Health Departments Association, told Wynn. "Rural areas are opting for a slow and deliberate approach, heavy on education and dialogue," he said, and some communities won't even consider a exchange because of "seemingly endless hoops to jump through."

Bullitt County, south of Louisville, is a prime example. There, officials told Wynn that they plan to do a needs assessment and host a community forum with input from law enforcement and mental health experts.

"It's a work in progress," Public Health Director Andrea Renfrow told Wynn. "We are not able to go as quickly as Louisville Metro."

One critic, Magistrate Joe Laswell, told Wynn that he had talked to many voters who are against the exchanges and want to know why police wouldn't arrest addicts when they show up to swap out dirty needles. "I believe in charging and incarcerating," he said, apparently unaware that the addicts would need to have drugs in their possession to be charged.

Lockard, who heads the Clark County Health Department, told Wynn that he won't ask his board to take a vote until August and that he can't predict the political outcome when it goes to city and county officials.

In three other Bluegrass counties, Scott, Harrison and Nicholas, the board of the Wedco District Health Department wants to start a needle exchange, reports The Cynthiana Democrat, but can't proceed in any of the counties without approval of the fiscal court.

So, despite the two-year debate that just ended in Frankfort over the law, it's not really over.

Democratic state Rep. John Tilley of Hopkinsville, the legislature's biggest proponent for needle exchanges, told Wynn that giving city councils and fiscal courts final authority over the programs was necessary to sooth critics and pass a comprehensive heroin bill this year.

Opponents of the law say the exchanges promote drug use, while proponents cite evidence that doesn't support those claims, but instead "help prevent the spread of deadly and expensive diseases and pull addicts into treatment programs while keeping dirty needles out of parks and off the streets," Wynn writes.

A Lexington Herald-Leader editorial wrote about needle exchanges: "Congressional critics rely on a gut feeling that providing needles endorses drug use, but 20 years of research argues otherwise." Listing that where there are syringe exchange programs:

• Participants are five times more likely to get treatment.
• HIV and hepatitis C declines among drug users.
• Participants can get referrals to substance abuse treatment, disease prevention education, vaccinations, condoms, counseling and testing for communicable diseases.
• Costs are more than recaptured. A 2011 European study found that $1 spent on needle-exchange programs yielded $27 in health-care cost savings, prompting an international report to call needle exchanges "one of the most cost-effective public health interventions ever funded."

The federal Centers for Disease Control and Prevention recently reported that new cases of hepatitis C more than tripled in Kentucky, Tennessee, Virginia and West Virginia between 2006 and 2012, mainly from the use of dirty needles. Officials fear an outbreak of HIV and AIDS will follow.

State health commissioner backs needle exchanges, most controversial part of anti-heroin legislation passed this year

The Kentucky General Assembly cracked down in 2012 on "pill mills" that dispense painkillers irresponsibly, and addicts responded by going for heroin, creating a big problem in much of the state. The 2015 legislature passed laws to crack down on heroin, including local needle-exchange programs, the most controversial feature of the package.

In a column distributed to Kentucky newspapers, state Health Commissioner Stephanie Mayfield defends and promotes the local programs, which are subject to local approval.

“To some, a needle exchange may sound like a program that helps intravenous drug users feed their habit,” Mayfield writes. “To the contrary, the intent of an NEP is to protect public health and create a path for heroin users to get treatment while preventing the spread of diseases through the sharing of needles.

Needle exchanges reduce the number of HIV/AIDS and hepatitis cases in a community, Mayfield writes. "The use or even the accidental stick of a dirty needle can lead to hepatitis, HIV/AIDS infection and other dangerous diseases. . . . About 15 percent of all HIV cases that have occurred in Kentucky have been among injecting drug users."

Stephanie M. Gibson

Mayfield also says needle exchanges protecting people from accidental sticks from dirty needles discarded in public places. "Intravenous drug users submit dirty needles to the NEP for proper disposal in exchange for clean needles," she writes. "Researchers have also found that injecting drug users who participated in an exchange were more likely to reduce or stop injecting than drug users who had not participated in a needle exchange."

Research has also shown that needle exchanges "do not encourage the initiation of drug use nor do they increase the frequency of drug use among current users," Mayfield writes, noting that there are 203 such programs in 34 states.

"The presence of NEPs in communities does not expand drug-related networks nor does it increase crime rates. . . . Needle exchange programs actually create a path for injecting drug users to get help because the programs offer information on how to find available treatment options. In fact, NEP participants are more likely to enter a drug treatment program than nonparticipants."

More recent studies show that needle exchanges "provide opportunities for disease testing and education leading to a decline of at-risk behaviors, resulting in HIV incidence dropping as much as 80 percent within this population," Mayfield writes. "Many Kentucky communities are desperate for the ability to reach out to members who suffer from addiction, to help slow the spread of diseases and provide treatment referrals to people they might otherwise never have the chance to reach. This law gives them that opportunity."

New health-related laws deal with heroin, dating violence, end-of-life care, prescriptions, colon-cancer and newborn screening

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – The Kentucky General Assembly passed several health-related bills this session, including high-profile measures on heroin and dating violence. It did not pass many others, including one that would have a great influence on the state's health: a statewide smoking ban, which passed the House for the first time ever, but never got out of an unfavorable committee in the Senate. Here's a roundup:

Heroin: Kentucky's heroin-overdose epidemic was caused partly by a 2012 legislative crackdown on prescription painkillers, which steered users to the illegal drug. Last year's bill died because of deadlock over sentences for traffickers and needle-exchange programs for addicts, and Gov. Steve Beshear and legislators gave this year's bill top priority. It was not finally negotiated until a few hours before passage, but Beshear signed Senate Bill 192 into law less than 12 hours after it passed so that its emergency clause could put it into effect immediately.

SB 192 includes both a needle-exchange program and harsher penalties against traffickers, the main points of contention between the House and Senate, but requires local governments to approve needle exchanges and allows judges to be lenient in sentencing addicts, to help them get treatment. It allocates money for drug-treatment programs, allows increased access to Naloxone, a drug that reverses the effects of an overdose, and allows jailers to provide medically assisted treatment for inmates with opiate addiction.

Dating violence: After 10 years of lobbying and debate, the dating violence bill will allow dating partners to get interpersonal protective orders from a judge if they have been the victim of dating violence, sexual abuse or stalking. This year's bill largely dissolved social conservatives' opposition by creating a new chapter in the law for dating violence, with the same protections as the domestic-violence law. Kentucky is the last state to offer protection to dating-violence victims. House Bill 8 was sponsored by Rep. John Tilley, D-Hopkinsville, who also sponsored the House heroin bill.

Beshear has signed these bills into law:

Prescription synchronization: SB 44, sponsored by Sen. Julie Raque Adams,R -Louisville, will 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.

Medical order scope of treatment: SB 77, sponsored by Sen. Tom Buford, R-Nicholasville. will create 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.

Colorectal cancer screening: SB 61, sponsored by Sen. Ralph Alvarado, R-Winchester, will require 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 governor also signed a similar measure, HB 69, sponsored by Rep. Tom Burch, D-Louisville, which contains an amendment by Sen. Julian Carroll, D-Frankfort, for a Medicaid savings study.

Newborn screenings for fatal disease: SB 75, sponsored by Sen. Alice Forgy Kerr, R-Lexington, will 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.

Spina bifida: SB 159, sponsored by Adams, will require medical providers to supply written, up-to-date, accurate information to parents when their unborn child is diagnosed with spina bifida so they can make informed decisions on treatment.

Emergency care for strokes: SB 10, sponsored by Sens. Stan Humphries, R-Cadiz, and David Givens, R-Greensburg, requires that local emergency services have access to a list of stroke-ready hospitals, comprehensive stroke centers and primary stroke centers in Kentucky. Emergency medical providers will set their own protocols for assessment, treatment and transport of stroke patients.

Alcohol and drug counselors: HB 92, sponsored by Rep. Leslie Combs, D-Pikeville, creates an enhanced licensing program to recognize three levels of certified alcohol and drug counselors, with different levels of education. The goal is to increase the number of counselors in the state.

UK cancer research center: HB 298, sponsored by Rep. Rick Rand, D-Bedford, revises the state budget to authorize $132.5 million, half of the cost, for a new medical research center at the University of Kentucky. The university says it will raise money to cover the other half.

These health bills awaited the governor's signature Monday morning:

Physician assistants: HB 258, sponsored by Rep. Denver Butler, D-Louisville, to allow physicians to supervise up to four physicians at the same time, rather than two.

In-home care: HB 144, sponsored by Burch, to establish a 60-day, hospital-to-home transition program through an approval waiver from the Department for Medicaid Services.

Pharmacist-practitioner collaboration: HB 377, sponsored by Rep. Dean Schamore, D-Hardinsburg, to allow collaboration between pharmacist and practitioners to manage patients' drug-related health needs.

Tax refund donations: SB 82, sponsored by Sen. Max Wise, R-Campbellsville, to put an income tax check-off box on tax forms to allow people the option of donating a portion of their tax refund to support pediatric cancer research, rape crisis centers or the Special Olympics.

Health related bills that were left hanging:

The smoking ban, HB 145, sponsored by Rep. Susan Westrom, D-Lexington, never got a hearing in the Senate Veterans, Military Affairs and Public Protection Committee, and neither did the Senate companion bill, SB 189, sponsored by Adams.

Three bills challenged Medicaid managed-care companies. SB 120, sponsored by Alvarado, would have created a process for health-care providers to appeal the companies' decisions to the state passed the Senate, but not the House.  And the following two bills that never got out of the Senate: SB 88, also sponsored by Alvarado, which challenged the $50 "triage fees" MCOs pay for emergency-room visits that they conclude were not emergencies, and would have required them to pay contracted fees instead and SB 31, sponsored by Buford, which would limited the amount of co-payments. Also not getting House action was Alvarado's SB 6 would have created review panels for lawsuits seeking damages from health-care providers.

Heroin bill finally passes and is signed into law; Naloxone program put into motion; dating-violence bill sent to Beshear

By Melissa Patrick
Kentucky Health News

The long-negotiated bill to tackle Kentucky's heroin-overdose epidemic passed in the final hours of the 2015 legislative session.

Almost immediately after the heroin bill passed the Senate, a bill to offer immediate civil protections to dating partners who are victims of dating violence was passed after being held in the chamber since February 13 -- likely because Democratic Rep. John Tilley of Hopkinsville, chair of the House Judiciary Committee, was the original sponsor of both bills.

Tilley told reporters that the passage of the two bills meant it had been a successful session.

Gov. Steve Beshear signed the heroin legislation, Senate Bill 192, into law Wednesday, March 25, less than 12 hours after it passed, so that its emergency clause could put it into effect immediately. The dating violence bill, House Bill 8, has been delivered for his signature.

"Senate Bill 192 is tough on traffickers who bring these deadly drugs into our communities, but compassionate toward those who report overdoses or who admit they need help for their addiction," Beshear said in a release. "I applaud our legislators for putting aside partisan interests for the greater good of all Kentuckians who have been affected by this devastating drug."

The bill passed the Democrat-controlled House 100-0 and the Republican-controlled Senate 34-4. Republican senators John Schickel of Union, Joe Bowen of Owensboro, Chris Girdler of Somerset and Paul Hornback of Shelbyville voted against it.

The stickiest issues were a needle-exchange program, which many senators opposed, and tough new penalties for drug traffickers, which Tilley and many House members said would not be effective. The new law allows needle-exchange programs of approved by local governments, and the tough penalties, but allows the judge to be lenient in sentencing if the defendant is an addict.

The bill also allocates money for drug treatment programs; includes a "good Samaritan" provision that allows a person to seek medical help for an overdose victim and stay with them without fear of being charged; access for addicts and their families to the drug Naloxone, a drug that reverses the effects of an overdose; and allows the Department of Corrections to provide an approved medication to inmates to prevent a relapse in their addiction.

"The bill includes provisions that are important to law enforcement and me: increasing penalties for large volume traffickers, expanding access to treatment, and getting heroin overdose reversal kits into the hands of our first responders. I know this legislation will save lives," Attorney General Jack Conway said in a news release.

Hornback argued that "forced rehab doesn't usually work," providing addicts with Naloxone and free needles simply enables them and the bill does not allow addicts any "consequences for their actions."

He said that while he knows there are people dying from heroin overdoses,"I didn't make that decision for them and I for one, and a lot of my constituents are tired of paying for people's bad decisions and that is what this (bill) does."

Tilley said in an interview after the vote that needle exchange programs are proven to work, will save taxpayers money and are absolutely necessary to "stem the tide of two tidal-waves that are headed Kentucky's way: HIV and Hepatitis C and Hepatitis B."

"The cost of treating someone with HIV is $350,000. The cost of treating someone with Hepatitis C is $85,000. The budget now had a $55 million hit just with the explosion of Hepatitis C last year. We can't afford that in Kentucky," he said. Advocates say the programs can be a gateway to treatment and rehabilitation.

Meanwhile, Conway and first lady Jane Beshear announced that funding for Naloxone kits would be made available to the hospitals in Kentucky with the highest rates of heroin overdose deaths. The kits will be provided free to every treated and discharged overdose victim at the pilot-project hospitals.

They made the announcement at the University of Louisville, which treated 588 people in 2013 for heroin overdoses, a news release said. In 2013, the latest data available, 230 of the 722 autopsied overdose deaths, or 32 percent, were caused by heroin, according to the Kentucky Office of Drug Control Policy.

Tilley and Republican Sen. Whitney Westerfield, also of Hopkinsville, "forged a friendship that allowed the two men to work out differences on a pair of high profile bills fraught with political pitfalls," Adam Beam reports for The Associated Press. "Westerfield, a former prosecutor, is running for attorney general against the son of Democratic Gov. Steve Beshear, giving Democrats all the reason in the world not to work with him."

The AP notes that Republican Sen. Chris McDaniel wrote the first draft of the heroin bill that passed the Senate in January, but it omits McDaniel's other role: candidate for lieutenant governor on a slate headed by Agriculture Commissioner James Comer. As the Senate prepared to give the final bill final passage, Republican Floor Leader Damon Thayer accused the House of not passing McDaniel's bill because of his candidacy.

Read more here: http://www.kentucky.com/2015/03/25/3767938_political-compromises-brokered.html?rh=1#storylink=cpy

McCreary County smoking ban fails; story on hearing offers a picture of the strong feelings, pro and con, that the idea evokes

The McCreary County Fiscal Court was unable to move forward with a vote on a smoking-ban ordinance because it lacked a motion for a second reading, Janie Slaven reports for the McCreary County Record.

The ordinance was first presented to the court by Champions/UNITE for a Drug-Free McCreary County in November, but did not get its first reading until February, on a 4-1 vote. But after a public meeting on March 12 and in the presence of a "packed courtroom," County Judge-Executive Doug Stephens asked for a motion for a second reading, but didn't get one.

Approximately 20 people attended the one-hour public hearing, held two hours prior to the regularly scheduled meeting, Slaven reports.

One citizen against the ordinance vowed to "campaign against everyone who votes for this." Other opponents said that "smokers can't be blamed for every cancer occurrence." While others were concerned that there would be no end to the government's involvement, alluding to the day when caffeine might be banned because of health risk, Slaven writes.

A store owner, Rick Wilson, said that "while he respects Champions' mission, he believes the issue of smoking in businesses should be left to the business owners themselves," expressing great concern that the ordinance also included private spaces within a business, like offices and company vehicles. Other business owners agreed with him, even while recognizing the health hazards of second-hand smoke, Slaven reports.

Advocates of the ordinance also voiced their opinions. One Champions member presented the cost burden of smoking and second-hand smoke, saying the "health effects of second-hand smoke cost $10 billion per year."

The Lake Cumberland District Health Department’s Tracy Aaron noted that nearly 40 percent of people in the county smoke and asked the fiscal court to consider the ordinance a public-health issue affecting not only non-smoking customers but also employees. “People have to work, and it’s hard to find jobs,” she said. Upon this suggestion, citizen Albert Coffey urged her to return to her home county, Slaven reports.

Several citizens offered different solutions to an ordinance including increased community education and also a suggestion to put it on the ballot. State law does not allow that.

"For now, on both the county and state level, the issue is dead," Slaven writes, referring to a statewide smoking ban that passed the Democrat-controlled state House but was placed in an unfavorable committee in the Senate.

Slaven also reports that the McCreary County Board of Education is expected to consider adopting a tobacco-free policy at its March 24 meeting and notes that the school district already has an indoor smoke-free policy.

Health foundation says consumers need price transparency; Medicaid health officer says some commercial interests want it

Kentucky Health News

The Foundation for a Healthy Kentucky says a major step needed to improve the health of Kentuckians is transparency of their health-care cost and quality.

"Consumers can (then) compare apples to apples," Susan Zepeda, the Foundation's president and CEO, told Greg Stotelmyer of Public News Service. "What is a particular procedure going to cost if I have it at this hospital versus that outpatient surgery center? What are my co-pays going to be or my deductibles under my insurance plan?"

The foundation recently recommended that Kentucky develop and establish an all-payer claims database, or APCD, for consumers and stakeholders as a tool for transparency. John Langefeld, chief medical officer of the state's Department of Medicaid Services, told Stotelmyer that "support for the idea is growing, including from many on the commercial side of health care."

But this type of transparency is not likely to happen without a law to require it, which Kentucky does not have, Stotelmyer reports.

Massachusetts is the only state that requires the type of health-care transparency the foundation is talking about. And while it is not a perfect system, with reported prices not reflecting all of the involved charges, frequent price changes and weak information about the quality of care, it is still "unlike anything else in the country," Martha Bebinger reports for Kaiser Health News.

Oregon could possibly become the second state to require health-care transparency. Two bills for it are pending in the current legislative session. One that would require hospitals to reveal their median prices for common inpatient and outpatient procedures, "is expected to get very little opposition as it makes its way through the legislative session," Chris Willis reports for KGW in Portland.

But physician and system theorist Deane Waldman argues in the Huffington Post that price transparency won't work. She says that transparency can't reflect the real cost of health-care, doesn't reflect health outcomes or quality of care, and when it does reflect outcomes, it only reflects the average outcome and not individual probabilities. She also says that because the current health-care in the U.S. is not a free market, consumers have no reason to economize.

The Foundation for a Healthy Kentucky disagrees. "Sunshine on pricing will make sure that we're all playing by the same rules," Zepeda told Stotelmyer. Kentucky has the ability to gather the data, but it still needs "the political will" to do so, she 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."

Bill to give civil protection to victims of dating violence is poised to become law, addressing a serious health issue for women

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – Victims of violence between dating partners in Kentucky are about to get a law giving them civil court protection, after years of hitting roadblocks in the state Senate. Most of the argument has been among lawyers, about legal process, but domestic violence is also a major health issue.

"There is a strong association between the experience of victimization and physical and mental health problems," Carol Jordan, executive director of the Office for Policy Studies on Violence Against Women at the University of Kentucky, said in an interview.

Rep. John Tilley

House Bill 8, sponsored by Rep. John Tilley, D-Hopkinsville, would allow a civil protective order for victims of dating violence and stalking. Under current law, this immediate level of protection is only offered to people who are married, have a child in common or who have lived together. Kentucky is the only state that offers no such protections.

As of March 8, the bill was awaiting passage in the Senate after clearing the Judiciary Committee with a substitute version that addresses a key objection by creating a new chapter in the statutes for the bill, separate from the existing domestic-violence chapter.

Senate President Robert Stivers, R-Manchester, had opposed previous bills on grounds that criminal protections exist for victims of dating violence. At the committee hearing, he said the new bill offers a "different tier of protection" and is a "solution that individuals want."

But Stivers added, "I don't want there to be an unjustified belief that a piece of paper will keep someone away" if they are intent on doing harm.

And Sen. Robin Webb, D-Grayson, declined to vote on the bill, saying it would do nothing to stop the abuser. "That perpetrator is really the one that needs some help and really needs to stop the cycle," she said. "Because if he or she can't find another victim, they're going to go create one."

But Marion Brown, director of Sanctuary Inc., a shelter, counseling and court-advocate center for victims of domestic violence in Hopkinsville, told the committee that victims of dating violence have no immediate civil protections if they are not married, don't live with or don't have a child with their abuser. These unprotected victims "walk out of our doors not feeling safe" she said. "Help us help them."

Tilley shared some chilling statistics at the hearing: 638,000 Kentucky women will experience physical violence, rape or stalking by an intimate partner; 345,000 will experience a forcible rape; and 420,000 will be stalked, which, he said, is the highest percentage in the nation.

Also in Kentucky, one in three women will be the victim of domestic violence in her lifetime and the most vulnerable population for this type of violence is females between 16 and 19, according to the Louisville-based Center for Women and Families.

Domestic violence and health

The National Intimate Partner and Sexual Violence Survey by the federal Centers for Disease Control and Prevention has found that victims of domestic violence, both men and women, are "more likely to report frequent headaches, chronic pain, difficulty with sleeping, activity limitations, poor physical health and poor mental health that men and women who had not experienced these forms of violence." It also found that women who had experienced domestic violence were also "more likely to report asthma, irritable bowel syndrome, and diabetes than women who did not experience these forms of violence."

""It is a women's health issue because the way women treat their bodies (is often) dependent on the abuser," Brown said in an interview. "The abuser degrades them so much that they don't maintain their health. Their self-confidence goes down, their self-esteem goes down and as a result, all of their health issues fall to the wayside."

"Domestic violence is a public health crisis of a staggering multitude," Marcia Roth, executive director of The Mary Byron Project, a non-profit that advocates for domestic violence issues, said in a phone interview. "It leads to $4.1 billion for direct medical and mental health services per year."

Jordan, of UK,  said she has been part of research that shows an association between breast cancer and domestic violence – not higher cancer rates, but delayed diagnoses, which can be fatal. "For many battered women, their partners are so controlling they won't let them go to the doctor," she said.

Jordan said that while physical injuries are the most obvious health issue, "it goes well beyond that," to physical stress and mental-health issues.

"There is a lot of research that would suggest that other systems within the body are also very much harmed by the experience of living in that constant fear, constant stress, constant tension that so many battered women do," she said. "Depression begins to sink in" when women feel they have no way out, get repeated messages that they are not worthy, or are in constant fear of harm.

Jordan said the bill will provide another escape outlet for victims. When they show up for help and answer no to these three questions: "Are you married? Are you living together? or Do you have a child together?" and can't get an immediate protective order, she said, their sense of helplessness is confirmed.

State Senate passes bill for independent appeals process for managed-care claims; hearing gets into details of the problem

By Melissa Patrick
Kentucky Health News

Managed-care organizations' contracts allow them to deny Medicaid claims and not reimburse for services if they deem them not medically necessary. That means health-care providers often don't get paid for providing care, and their only recourse is an internal review by the MCO.

Sen. Ralph Alvarado

"It appears some of our MCOs are using this denial method in order to, as they term it, 'manage care'," Republican Sen. Ralph Alvarado said at a Senate Health and Welfare Committee hearing on his Senate Bill 120, which would set up an independent appeals process for providers, much like those in Georgia and Virginia.

The  bill, which had been in the works for several years, passed the Senate March 2 and was received in the House March 3. Its prospects in the House appear poor because it is opposed by the Cabinet for Health and Family Services, which oversees Medicaid. Its main targets are MCOs WellCare of Kentucky and Coventry Cares of Kentucky.

Alvarado, a Winchester physician, said in an interview that he pointed out these companies because they have the highest denial rates. While other companies also have complaints, "They are very small and minor, what you would expect in the normal course of business," he said. "It is WellCare and Coventry; these two are the names that keep coming up over and over again."

Asked for comment, Coventry said in an e-mail, "Coventry continues to monitor the legislation as it moves through the process. We are working with lawmakers to protect the integrity of the managed Medicaid program and be responsible with taxpayer dollars."

WellCare said in an e-mail that its appeals process is adequate, offering two additional remediation alternatives, negotiation and arbitration. The company said MCOs are "continuously subjected to rigorous oversight by state, federal and national accreditation entities," which ensure that they "adhere to strict standards and evidence-based guidelines in determining medical necessity."

Nina Eisner, board member of the Kentucky Hospital Association and chair of its Chemical Dependency Treatment Program, told the committee that providers deserve the same sort of state appeals process that patients have for denial of service.

"Kentucky's providers are under tremendous pressure from payment cuts from Medicare and slowed and denied payments by MCOs," Eisner said. "It is untenable and unreasonable to expect that Kentucky providers can provide health care services for free."

She said that many of the disputes stem from MCO reviews using out-of-state physicians who "don't always understand the rural nature of our state and the lack of resources." She said one example is discharging rural patients from inpatient to outpatient behavioral-health or substance-abuse treatment where no outpatient services are easily acessible.

"The MCOs in Kentucky are quite profitable," Eisner said, citing a November analysis by Citi Research that found Kentucky's MCO plans generated over $450 million in earnings before interest, taxes and depreciation from the state Medicaid program. "This is a margin of 10.6 percent, which is more than two times the 3 to 5 percent margin most Medicaid plans target."

Sen. David Givens, R-Greensburg, said he was compelled to remind those at the hearing that private companies need to be profitable to keep the system working. Later, Sen. Danny Carroll, R-Paducah, disagreed, saying MCOs' profits need to be more balanced.

Medicaid Commissioner Lisa Lee said that it is balanced, because MCOs were required to spend 87 percent of their payments on the population newly eligible for Medicaid or give it back to the federal government, and that rates going forward depend on what they spend today.

KHA's Nancy Galvagni said another reason for a state appeals process is the variation between plans' denial rates, ranging from a low of 7 percent to a high of 18 percent. She said that providers have gone to state hearings on behalf of their patients and had favorable opinions, only to have them overturned by the Cabinet.

Tina Heavrin, general counsel for the cabinet, said that occurs because the cabinet only has authority to decide whether patients received services, and if they did, there is no claim and any dispute regarding payment is between the MCO and the health-care provider.

Sen. Julie Raque Adams, the committee chair, replied, "I think that is the impetus behind this bill, that once the patient receives their service, they are done, but the provider is not. ... I don't want to go to work and not be paid for it. And I don't think that is an unreasonable thing to request or require and I think that is all that this bill does."

Heavrin said that providers do have a process to resolve these issues, "It is called the judiciary." She said the cabinet can't run an appeals process for MCOs because it "as part of the executive branch, doesn't have jurisdiction or legal authority over an adjudication of private contract rights." She added, "The MCOs are our contractors and it would be difficult to not have a financial interest in the outcomes of those appeals," meaning that upholding an appeal would cost the state money.

Lee said the cabinet acknowledges issues with MCOs. She said that while state officials should not get in the middle of contract disputes, "We do listen to our providers" and "want to hold our MCOs accountable," noting that they had "made some significant progress with managed care" since its inception in 2011.

Carroll, who deals daily with MCOs through his non-profit agency that provides therapy services and medical-based child care, said, "It is an absolute nightmare dealing with MCOs," because of all the "hoops to jump through in order to get reimbursement."

He asked if there was any way for the cabinet to work these issues out in its new contracts and said it felt like the state had "brought in these MCOs and basically washed their hands of all the issues associated with it."

Heavrin said it would not be possible to include a state appeals process in the contracts because "We can't be a judiciary."

Lee told Carroll that state officials had not "washed their hands" of the MCOs and closely monitor their activities. "We also have an obligation to the Center for Medicare and Medicaid Services to make sure that every single thing that we pay for does meet medical necessity," she said. CMS is the federal agency that oversees those programs.

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

By Melissa Patrick
Kentucky Health News

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

Sen. Julie Raque Adams

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

By Melissa Patrick
Kentucky Health News

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

Sen. Tom Buford

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

By Melissa Patrick
Kentucky Health News

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Smoking-ban bills get unfavorable committee assignment in state Senate, but supporters say they'll keep trying to get votes

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – The state Senate's Republican leaders have assigned both the Republican and Democratic smoking-ban bills to a committee that appears unlikely to send them to the full Senate.

The Veterans, Military Affairs and Public Protection Committee got House Bill 145, which the House had passed 51-46, and Senate Bill 189, filed by Sen. Julie Raque Adams, R-Louisville.

Adams is chair of the Health and Welfare Committee, and smoke-free advocates had hoped the bills would go there, improving its chances in a Senate that doesn't appear disposed to pass it.

Senate President Robert Stivers defended the assignment, saying the bills relate to public protection. Last year, a smoking-ban bill sponsored by the previous Health and Welfare chair, Republican Julie Denton of Louisville, was sent to the Judiciary Committee and never heard.

Stivers was asked if Adams' bill was sent elsewhere because of her support for it. He acknowledged that it could have been considered a health issue, and "It was a choice." Pushed to answer, he said, "I don't recall anything being made, because we put a lot of bills in chairman's committees that they support whether leadership supports it or not."

Adams did not respond to requests for comment, but Amy Barkley, chair of the Smoke-free Kentucky Coalition, said she had hoped the bill would go to Health and Welfare because it addresses a health issue.

"We hope it gets a hearing in the Senate," Barkley said. "We are hoping that even if those individuals in leadership are not supportive, that they will at least let the bill have a fair hearing and hopefully a vote – and they can vote no if they are not supportive, but we think it deserves to have a vote so we know where people stand."

Sen. Morgan McGarvey, of Louisville, a Democratic co-sponsor of the Senate bill, said he understood how a smoking ban could be perceived as a public-protection matter, but used the assignment as an argument for the legislation.

"There is no bill we can pass this session that would save the state more money than a comprehensive statewide smoking ban," he said. "It will make Kentuckians healthier; it will save the state money."

Advocates' job will be to persuade Republicans, whose policy is not to allow bills to reach the full Senate unless they are favored by a majority of the 26 Republican senators.

The chairman of the Public Protection Committee, Sen. Albert Robinson, R-London, said through his assistant that he wasn't ready to talk about the bills because they had just been assigned to his committee. He told the Lexington Herald-Leader, "I don't know if there is support for it in my committee." He told The Courier-Journal that he opposes the bill.

The legislation has been debated in the legislature for five years. Senate Bill 189 is identical to the original House bill, which was amended. Both bills would prohibit smoking in workplaces and indoor places, and within 15 feet of their entrances, to protect others from secondhand smoke, which is estimated to kill 950 Kentuckians annually.

House Bill 145 passed with three changes: an exemption for cigar bars, cigar clubs, tobacco stores, private clubs and market-research facilities; significantly lower fines for violation; and preservation of any weaker or stronger local bans in effect when the bill would become law, in late June.

The fundamental conflict about the bill, largely along party lines, is whether individual liberties or public health take priority.

Stivers reiterated his stance, siding with those who support individual liberties.

"I do not like smoking. I don't patronize places that smoke. I have allergies," he said. "It costs you money to take your suits to the cleaners and things of that nature, but I just don't think it is the role of government to start telling private businesses what they can and can't do from that perspective."

He suggested that his opposition wasn't decisive. "I am one of 38 [senators] and if you go back and look at respective bills, there have been bills that I haven't voted on that have made it to the floor because they have the support of the body. Actually, I think we voted on one this week or maybe late last week that I did not vote for, but there was support in this chamber for that issue."

Stivers noted that more Republican senators support the ban than last session, mentioning Adams and Sen. Ralph Alvarado, a Winchester physician. Both were elected to the Senate last fall.

Alvarado explained why he values health over liberty on this issue. He said we all have the right to swing punches at another person, but at the point of contact, that person's rights have been violated. "My individual rights to do something ends when it affects the rights of another individual is my perspective, and secondhand smoke is just that," he said.

Alvarado said he continues to talk to senators about why they should support a statewide smoking ban, saying," It would cost nothing to implement and the benefit from a fiscal perspective and lives saved . . . would be tremendous."

As a rookie public official, Alvarado said he still has a "romantic idea" that it is possible to persuade senators to change their positions and "find at least some type of compromise to get more people covered and to reduce (secondhand smoke) exposure."

Sen. Perry Clark of Louisville, a libertarian-oriented Democrat on the Public Protection Committee, said it was too early to say how he might vote on the issue because the bill might be amended. It has been suggested that the bill could pass if local governments could opt out of the ban, but Barkley told The Courier-Journal that would fatally weaken it.

Besides Clark and Robinson, other members of the committee are Republicans C.B. Embry of Beaver Dam, Carroll Gibson of Leitchfield, Ernie Harris of Prospect, Stan Humphries of Cadiz, Chris McDaniel of Taylor Mill, Dan Seum of Louisville, Whitney Westerfield of Hopkinsville, Mike Wilson of Bowling Green and Max Wise of Campbellsville; and Democrats Julian Carroll of Frankfort and Dennis Parrett of Vine Grove.

State Senate passes bills to lower a barrier to colon-cancer screening and allow patients to synchronize their prescriptions

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – Two health-related bills, one to remove a financial barrier for colorectal cancer screenings and the other to allow consumers to synchronize prescriptions so they can get all of their medications on the same day, passed the state Senate Feb. 19.

Senate Bill 61, sponsored by Sen. Ralph Alvarado, R-Winchester, would clarify that a fecal test to screen for colon cancer, and any follow-up colonoscopy, are preventive measures that federal health reform require to be covered by insurance. It went to the House on a vote of 31-3.

"The purpose of this bill is to identify and correct ongoing discrepancies in the coding and billing portion of this screening and prevention continuum," said Alvarado, who is a physician.

The two primary ways to screen for colon cancer are colonoscopy or a non-invasive fecal blood test.

This bill was prompted because patients are being charged for a diagnostic procedure instead of a preventive one if they do a non-invasive fecal test that comes back positive, and then get a follow-up colonoscopy. The non-invasive fecal test is coded as a preventive screening, which is covered by insurance, but the colonoscopy is coded as a diagnostic procedure, which comes with a hefty price-tag, sometimes upwards of $1,000, Alvarado said.

Patients are also being charged for a diagnostic procedure if lesions are removed during the screening process, which is standard procedure to do so, since the patient would otherwise have to return for a second colonoscopy to remove them.

This is ironic, Alvarado said in a news release, because if the patient had chosen the more expensive and invasive colonoscopy initially, the insurance company would have paid for it.

This is a "barrier to screening," he said, in a state that leads the nation in colorectal cancer and until recently led the nation in deaths caused by it.

A sister bill, House Bill 69, sponsored by Rep. Tom Burch, D-Louisville, passed the House Feb. 9 and was assigned to the Senate Health and Welfare committee Feb. 12.

By a 34-0 vote, the Senate passed SB 44, sponsored by Sen. Julie Raque Adams, R-Louisville. It would allow patients with multiple prescriptions, in consultation with their health care provider and their pharmacist, to synchronize them so that they may be picked up from the pharmacy at the same time.

"This bill will allow patients to refill and pick up their prescribed medications for chronic conditions on the same day of the month instead of making multiple trips to the pharmacy," Adams said.

"This bill is not just about convenience," Adams said, but also helps make sure patients take their medication, "improving health outcomes and lowering health care cost overall." She cited a study that found patients who participated in a med-synchronization program at their pharmacy were 30 percent more likely to take their medicine as prescribed.

Some are concerned about the front-end cost of this program, "but fail to see the potential cost savings to the health care system overall," Adams said, saying a Medicare Part D cost-benefit analysis found there was an estimated savings of $1.8 billion to the system, and also showed improved medication adherence.

A sister bill, House Bill 140, sponsored by Rep. Addia Wuchner, R-Florence, was assigned to the House Banking and Insurance Committee on Jan. 9.

Statewide smoking ban passes Kentucky's Democratic House, but its chances don't look good in the Republican Senate

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – A statewide smoking ban passed the Democrat-controlled state House Friday for the first time, but its chances appear grim in the Republican-controlled Senate though a clear majority of Kentuckians support the bill.

House Bill 145, which would prohibit smoking in workplaces and indoor places, passed 51-46 after the narrow defeat of two amendments opposed by its advocates and three changes that may have put it over the top. Nine of the 44 Republicans joined 42 of the 56 Democrats to pass it.

Amendments to the bill added exemptions for cigar bars, cigar clubs, tobacco stores, private clubs and market-research facilities; significantly reduced the fine for violation, to $25 for individuals and $50 for businesses; and would preserve any weaker or stronger local bans that are in effect when the bill would become law, in late June.

House Speaker Greg Stumbo told Tom Loftus of The Courier-Journal that the latter amendment was key to the bill's passage. Rep. Tanya Pullin, D-Greenup, told the House that it won her vote because it creates a "window of opportunity" for localities to enact their own bans. It was proposed by Democratic Caucus Chair Johnny Bell of Glasgow.

The defeated amendments would have exempted electronic cigarettes and well-ventilated adult establishments prominently displaying a "Smoking Establishment" sign. The e-cig amendment, proposed by Republican Caucus Chair Stan Lee, lost 46-49; the other one, offered by freshman Rep. Jim DuPlessis, R-Elizabethtown, lost 44-45. For the roll calls, click here.

"A couple of the amendments are problematic," Amy Barkley, chair of the Smoke-free Kentucky Coalition, said in a phone interview. "The existing laws in these communities may not protect all workers," she said. "And localities can pass weak laws (before this bill becomes law) and have that forever."

Nevertheless, Barkley said, "This is really a historic moment."

More compromise may be necessary to get the bill through the Senate, where Republican Sen. Julie Raque Adams of Louisville filed a similar bill as the House measure was coming up for a vote.

Senate President Robert Stivers told Bruce Schreiner of The Associated Press, "I am personally not a fan of smoking, but I just don't believe it is the government's role to tell [a business] that you cannot have a facility that smoking takes place in — be it a pool hall a bar or restaurant." He added, "I don't see there being that type of support in the Senate to pass a bill like that."

Barkley disagrees. "There is a lot of support in the Senate," she said.

The sponsor of HB 145, Rep. Susan Westrom, D-Lexington, said "I cannot predict what will happen in the Senate. Stivers has said from the beginning that he wouldn't let it have a hearing."

Barkley said advocates are asking Senate leaders to "let your members have the vote and go on record with their position." The next clue to the leaders' attitude will be where they send the bill. If it doesn't go to the Health and Welfare Committee, which Adams chairs, that would be a bad sign for it.

Westrom repeately said that the bill does not ban smoking. "This bill just requests that a smoker step outside 15 feet," she said. "Fifteen feet is not too far to walk to know that 950 people in this state won't die from secondhand smoke related illness." That is the estimated number of deaths each year in Kentucky from secondhand smoke.

Westrom said afterward that she had hoped for a larger margin than five votes, but "I couldn't be happier. This is a historic moment and there is lots to be proud of," referring to the many people and organizations that committed themselves to the cause.

The Kentucky Health Issues Poll last fall found that 66 percent of Kentucky adults favored the ban. It won 57 percent support in last year's Bluegrass Poll for news organizations.

During the House debate, opponents of the bill spoke mainly of private-property rights and individual liberty.

I deplore smoking," said Rep. Brian Linder, R-Dry Ridge, "but my love for liberty is greater than my hate, therefore I vote no."

Earlier, Westrom said, "Our freedoms only extend until they begin to affect others."

Democratic Gov. Steve Beshear hailed the House vote as "an extremely important and significant event," adding, "It sends a very strong statement ... that it is time to move in this direction. It is just such a health problem and health issue in the commonwealth; so many of our chronic conditions relate directly back to smoking."

Sponsor of local opt-out amendment says smoking-ban bill needs it to pass; sponsor and House leaders don't care for it

By Melissa Patrick
Kentucky Health News

UPDATE: The House didn't vote on this amendment, but Sen. Jimmy Higdon, R-Lebanon, says it or something like it would give the bill a better chance of passing the Republican-controlled Senate.

FRANKFORT, Ky. – Rep. Steve Riggs of Louisville has proposed an amendment to the statewide smoking ban bill that would allow cities and counties to opt out of the ban every two years, saying he wants to improve the bill's chances of becoming law.

Riggs

“This amendment would negate a lot of concern about taking away local rights,” Riggs, a Democrat who supports the ban, said in a press release.

His Floor Amendment 9 to House Bill 145 proposes that local governments be able to opt out of the ban, but would be required to take another vote every two years to prevent the ban from taking effect in their jurisdiction.

Rep. Susan Westrom, five-year sponsor of the ban, first said she welcomes amendments because that is "how we edit our legislation," but still needed to talk to Riggs – and when asked if she thought this amendment was a good idea, she said it "goes against the intent of the bill."

"It is a little bit too late for this amendment," the Lexington Democrat said. "We have made too much progress."

House Speaker Greg Stumbo, who says he supports the bill but has clashed with Westrom about its handling, agreed. "I think if you started from day one with that as the idea," he said, "it might have been more palatable."

Stumbo and Republican Leader Jeff Hoover said the amendment would defeat the bill's purpose.

Hoover

Hoover noted, "Advocates have said for many years that we have to have a state-wide smoking ban because of the health concerns all across Kentucky."

Riggs said in an interview that the legislation hasn't had the votes for the past five years and it is time to do something different.

"If you keep swinging at the ball and missing time after time, you probably ought to change your stance," he said. "And that is what they need to do. They need to make a change to get more votes so it will pass."

Westrom said, "We have the votes." But House leaders told her Friday, Feb. 6, that she would need to have commitments from 55 of the 100 House members before they would bring her bill up for a vote.

"What it really says is, it takes 51 votes to pass, but we want 55 commitments because we can't trust everybody," Hoover said. "It's not about having a cushion; it's about they can't trust their own members when they say they are going to vote for something." He said Democratic leaders "should have the discipline to keep amendments, such as this one, from being filed."

Riggs said as chair of the House Local Government Committee, he is sensitive to the needs of cities and counties, and "If we give those people an option to opt out of it, we might be able to get some votes up here to pass the bill."

He said his amendment would allow the bill's advocates to get 90 to 95 percent of what they want to accomplish. "Most people consider that an A, excellent," he said. "This bill might bring in another 10 votes, because people feel if they have the option to opt out, that is liberty and freedom."

Riggs also said the idea might improve the bill's poor chances for passage in the Senate because some senators showed interest in the approach last year.

This is the right thing to do because they don't have enough votes to pass the bill in the House and the Senate," Riggs said.

He said smoke-free advocates don't want any changes to this bill and have not been willing to compromise for the past five years, and asked, "How much illness can we put at their feet because they won't change their swing?"

James Sharp of the American Cancer Society's lobbying arm, the Cancer Action Network, declined to comment.

Hoover, one of the relatively few Republicans for the bill, said he is mindful of opponents' arguments about personal property rights, but also of the "associated health risk with smoking and second hand smoke and the cost that this state is incurring in treating those folks who have diseases related to smoke and second hand smoke."

He concluded, "When I do the balancing test for me personally, I come down on the side that this is a step in the right direction to reduce health care cost and save lives."

Panel OKs new medical-order form that would clearly define a person's end-of-life wishes on nutrition, hydration, medication

A bill to create a medical order form that details a person's wishes for end-of-life care passed the Senate Health and Welfare Committee Feb. 4 and seems headed for passage in the full Senate.

Advocates say that while many physicians discuss end-of-life care with their patients and families and document it, this information is often buried deep in the chart and is not easily accessible in an emergency situation.

"This issue comes to play on a daily basis," Christian Furman, vice-chair of geriatric medicine at the University of Louisville and medical director of two nursing homes in Louisville, told the committee.

Sen. Tom Buford

Senate Bill 77, sponsored by Sen. Tom Buford, R-Nicholasville, would creates a new Medical Order for Scope of Treatment form to specifically direct the type of treatment a patient would like to have and how much medical intervention they would like to have during end-of-life care. The MOST form is used in 32 states, Furman said.

The form is more detailed than a living will because it addresses not only the question of resuscitation, but specifies which life-saving measures, such as nutrition, hydration and medication, that a person wants to receive and under what circumstances.

The form must be reviewed annually. It allows for information sharing between providers and is part of the patient's electronic health record.

Furman said the order of controlling documents for end-of-life care is clearly defined in the bill: 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.

Sen. Ralph Alvarado, R-Winchester, who is a physician, told his fellow committee members that the MOST form will not only assure a person's personal wishes are honored, but will also save an "immense" amount of money "just in terms of doing unnecessary treatments for folks."

"Five percent of Medicare beneficiaries die each year and their end-of-life care accounts for about 30 percent of total Medicare spending with as much as one-third spent in the last month of life," Bill First writes for Morning Consult, citing an article from the peer-reviewed journal Health Affairs.

Sen. Reggie Thomas, D-Lexington, a lawyer, said the medical community and patients need to be made aware that such forms exist. Buford said he trusted this would happen.