University of Kentucky rural health expert, Ty Borders, appointed to national advisory committee on rural health

University of Kentucky College of Public Health Professor Ty Borders was recently appointed to the National Advisory Committee on Rural Health and Human Services.

Ty Borders

This committee is part of the Health Resources and Services Administration and includes a 21-member panel of nationally recognized rural health experts that is responsible for making recommendations to the Department of Health and Human Services on issues related to rural health. Borders's appointment will continue until April 2019.

“This appointment is an honor not only for Dr. Borders and his family, but also for Kentucky,” Rep. Andy Barr, R-Ky., said in a UK news release. “Dr. Borders possesses a broad and deep understanding of the health care challenges facing rural Kentucky and America. His unique insight about evidence-based strategies that could improve rural health and health care delivery will greatly benefit the committee.”

Borders is the chair of the Department of Health Services Management and the Foundation for a Healthy Kentucky endowed chair in Rural Health Policy. He also serves as a founding co-director of the UK Institute for Rural Health Policy and is the editor of the Journal of Rural Health, an academic publication devoted to rural health research.

Kentucky led the nation in hepatitis C cases in 2013; state's rate rose 357 percent from 2007 to 2011

By Tim Mandell
Kentucky Health News

Kentucky had the nation's highest rate of hepatitis C in 2013, with 5.1 cases per every 100,000 people, says a report by the federal Centers for Disease Control and Prevention. As many as 3.5 million people in the U.S. have hepatitis C and more than 56,000 Kentucky resident may have chronic hepatitis C infection, according to the state Cabinet for Health and Family Services. The main cause of hepatitis C is shared needles among intravenous drug users.

Hepatitis C cases rose 364 percent in Kentucky, Tennessee, Virginia and West Virginia from 2006 to 2012. The big increase was in 2007-11, when the rate rose 357 percent, a CDC state health profile says.

"Of the cases that have been reported and researchers gathered data about potential risk factors, 73.1 percent reported injecting drugs," Brian Wu reports for Science Times. Among new cases, 44.8 percent were people under 30.

While officials said HIV rates are low in the four Appalachian states, they said they fear that the increase in hepatitis C cases could lead to a rise in HIV cases, Wu writes. Officials said needle-exchange programs are key to reduce the number of potential HIV cases. Kentucky recently authorized such programs if local officials agree to them.

"About 4.5 million Americans older than 12 abused prescription painkillers in 2013 and 289,000 used heroin, according to the Substance Abuse and Mental Health Services Administration," Liz Szabo reports for USA Today. "About 75 percent of new heroin users previously abused opioid painkillers. The number of first-time heroin users grew from 90,000 people in 2006 to 156,000 in 2012, according to the CDC."

Kentucky has the third highest drug overdose mortality rate in the U.S., with 23.6 deaths per 100,000 people, says the 2013 report "Prescription Drug Abuse: Strategies to Stop the Epidemic," reports Trust for America's Health. "The number of drug overdose deaths—a majority of which are from prescription drugs—in Kentucky quadrupled since 1999 when the rate was 4.9 per 100,000."

UK HealthCare offers help to primary-care clinics; university's top health official calls it 'a game changer' for rural health providers

The Kentucky Primary Care Association and the University of Kentucky have announced a new partnership to provide support services to primary care providers throughout Kentucky.

This "groundbreaking partnership" will provide KPCA, which includes more than 800 patient care providers, access to UK HealthCare's support services, such as supply chain contracts, medical professional placement services, practice transformation support and training, and an after-hours pediatric call triage center, according to press release.

The most notable feature of the partnership is that KPCA members will have access to UK's group purchasing contracts, giving them access to services at heavily discounted rates at no charge to the facilities. This is expected to create "significant" savings for more than 250 clinics throughout the state. UK's top health official called it "a game changer."

“Primary care physicians, especially those in rural areas, have the extra burden of high patient volume, limited staff, and stretched resources,” Dr. Michael Karpf, UK's executive vice president for health, said in the release. “By partnering, UK HealthCare and KPCA members can grow important programs and services for their patients while also controlling and reducing operating costs.”

KPCA Executive Director Joe Smith said, "By addressing some of these issues related to costs, clinics with already scarce resources can instead focus on improving the quality of care.We’ve had a longstanding association with the university and UK HealthCare, and this partnership elevates that relationship by adding a strong commitment to assisting rural doctors, nurses and practice managers, who face some of the toughest transitions taking place in medicine today.”

The partnership will also allow KPCA members access to staffing services that link candidates to vacancies across the state; to Patient Centered Medical Home consultants, who help practices transition to quality and value-based models of care; and to UK HealthCare's after-hours pediatric call triage service.

Fate of rural hospitals rests in the hands of community members, writes publisher of weekly Crittenden Press in Marion

Just like country grocery stores in rural areas often have to close because community members drive past them to chain stores to save a few cents, rural hospitals will also suffer and eventually disappear if citizens do not use them, Publisher Chris Evans writes for The Crittenden Press in Marion.

When Evans was growing up in northwest Tennessee, his grandparents had to close their grocery store, which had been the center of the community, because too many people chose to purchase their food and other items from the new Walmart eight miles down the road. "Our rural hospitals are headed down the same path of extinction unless we recognize and reverse the trend," Evans writes.

Charlie Hunt, volunteer chairman of Crittenden Health Systems, which owns the local hospital, told Evans, "The only way for rural hospitals to survive is through community support."

In Kentucky, one-quarter of the 66 rural hospitals are in danger of closing, according to state Auditor Adam Edelen. In general, "Country hospitals do not have a good record for making money or breaking even, for that matter," Evans writes in a front-page column for the weekly he and his wife own.

Based on the results of Obamacare, Evans opines, it appears that America is moving toward a single-payer health care system like Canada's. Then instead of the government paying for 85 percent of Crittenden Hospital's services, it will pay for 100 percent. "When that happens, hospitals will have to play solely by government rules or get completely out of the game," Evans writes. Most of the 50 rural hospitals that have been shuttered in the past few years have been in the rural South.

"Hunt, who chairs the board, said that approximately 10 percent of the future of this hospital rests in the hands of its leaders. The other 90 percent falls squarely on the shoulders of this community," Evans writes. The column is not online, but PDFs of the pages on which it appears are posted here.

Tennessee churches encourage healthier living

Sulphur Wells Church of Christ in Henry County, Tennessee, a few miles away from Paris, Ky., is challenging people to eat and think healthier, Amber Hall reports for Public Radio International.

Bob Palmer, lead pastor at the church, said, "We do draw some hard lines on alcohol and tobacco use and tattoos—we think, 'Oh, you're not taking care of the our temple that God has given you.'" He said the church hasn't looked at the issue holistically. "We've just kind of picked out the things we weren't going to do anyway, and we feel self-righteous about that—that we don't do them."

Then Palmer saw the County Health Rankings, a project by the Robert Wood Johnson Foundation that measures health risks, Hall writes. He said that "when we confirm someone's spiritual health and give them a thumbs up and an A-OK, that's often the end of the rehabilitation process." However, he said if he were outside the church and had only the health indicator numbers to look at, "it might make me run in the opposite direction."

In Tennessee, the Governor's Foundation for Health and Wellness is helping groups such as churches improve health in evangelical hubs through the "Healthier Tennessee" initiative, which is a "wellness program and an online wellness tool that provides faith leaders with tips, ideas and actions to get their members healthier," Molly Sudderth, the director of communications at the foundation, said.

One of the suggestions is called Walk and Worship. "You can walk and pray for those you feel need extra prayers or are going through difficulties . . ." said Barabara Kelly, a public-health educator.

About 150 churches statewide are participating in Healthier Tennessee's "Small Starts" program, but none of the churches in Henry County have joined yet. Palmer said "there could be some stigma tied to healthy living in this largely conservative area," Hall writes.

"Right-wing religious folk have kinda viewed that as 'liberal' thinking," Palmer told him. "But that hasn't been correct, I don't think. At all. Just read through early Genesis, and the very first commission that God gives anyone is to essentially take care of this created world. We don't talk about that very often for some reason—to our detriment, and these numbers reflect that." (Read more)

UK gets $2.5 million for rural child poverty nutrition center

L-R: Nancy Cox, dean of UK's College of Agriculture, Food
and Environment; Secy. Tom Vilsack; Gov. Steve Beshear.

Kentucky Health News

Agriculture Secretary Tom Vilsack announced at the University of Kentucky Thursday that the Department of Agriculture will give UK $2.5 million to establish the USDA Rural Child Poverty Nutrition Center.

"This program will target child hunger and poverty in persistently poor rural communities by partnering with agencies who have the resources and expertise to make a difference," Gov. Steve Beshear said in a UK news release. "This program will do more than offer aid. It will attack the root causes of child hunger and poverty."

UK will partner with the Altarum Institute and the Southern Rural Development Center to develop the center. They hope to administer grants to as many as 30 impoverished rural areas in up to 15 states. The communities would use the funds to better coordinate existing child-nutrition programs as well as find new ways to target child food insecurity, the release says.

Rural children who live in poverty are some of the most vulnerable, and 85 percent of all persistently poor counties in the U.S are rural. Twenty-six percent of Kentucky's children live in poverty.

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

By Al Cross
Kentucky Health News

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Health care changes are driven by more than reform law; Beshear says patients need rewards for changing their behavior

"Your doctor's visits might get longer, you deductibles probably will be higher and you might be paying cash to be treated at a Wal-Mart near you as Kentucky adapts to a vastly changing health care landscape," Mary Meehan reports for the Lexington Herald-Leader. "Nearly everything you know about how health care is paid for and provided will change during the next few years as patients and providers sort out the nuts and bolts of the Affordable Care Act."

But it's not just the health-reform law that's changing health care, Meehan reports from the Health Leadership Summit, held Thursday in Frankfort by state government and the Kentucky Hospital Association. She paraphrases the main speaker, Chas Roades, chief research officer for The Advisory Board Co., a Washington-based health consultant firm:

Read more here: http://www.kentucky.com/2015/01/29/3668247/frankfort-summit-focuses-on-changing.html#storylink=cpy

"Even if parts of the law are dismantled, he said, the health care needs of aging baby boomers are driving a fundamental change in the system. If patients have more choice, he said, it will be important for doctors to make more personal connections with patients. The focus won't be rolling patients through the door at a furious clip but on spending time with them to find out what it is going on."

Roades said the focus is shifting from treatment of illnesses to prevention, so health-care providers will be rewarded for keeping people healthy, and the transition period for health-care providers will be tough. "We need to get from fee-for-service to fee-for-value," he said, but until all government programs pay on that basis, and 75 percent of private insurance does, "We won't break even . . . We have to get everybody moving in the same direction at the same time." But he said the transition will be tough for hospitals that are small, rural and not connected with a larger organization.

State Health Secretary Audrey Haynes, who convened the meeting, said "We have to figure out how to have quality health-care services in the rural area of the state just like we do in the urban area."

One attendee at the meeting asked Roades when providers and payers could expect to see patients changing their behavior and being more responsible about their health. "We have to walk a fine line," he replied, suggesting that the focus needs to be on "rising risk" patients, 15 to 35 percent of the population, who may not have their chronic conditions under control.

Roades said educating people about better health should involve community organizations such as churches. "The average American has a fifth-grade health literacy," he said.

Gov. Steve Beshear said one key will be finding ways to reward patients for making responsible, informed choices: "We will fall short of our goals if we can't find ways to engage our patients in new and effective ways."

Read more here: http://www.kentucky.com/2015/01/29/3668247/frankfort-summit-focuses-on-changing.html#storylink=cpy

Researchers blame Walmart, other bulk suppliers for part of obesity epidemic

Part of the rise of obesity in America can be linked to the availability of cheap food sold in bulk from warehouse stores like Walmart, says a study released this week by researchers from Georgia State University, the University of Iowa, the University of Virginia and the University of Louisville, . Wal-Mart is the biggest retailer in the U.S. and a staple of many rural areas.

"We live in an environment with increasingly cheap and readily available junk food. We buy in bulk. We tend to have more food around. It takes more and more discipline and self-control to not let that influence your weight," Charles Courtemanche, assistant professor of economics at Georgia State, told Danielle Paquette of The Washington Post.

Obesity in America has surged from 1960, when 13 percent of adults were obese, to 2012, when 35 percent of adults were, Paquette writes. The first Walmart store opened in 1962, the first Sam's Club in 1983 and the first Walmart supercenter in 1988. In addition to Walmart, numerous other warehouse-style stores, like Target and Costco, have followed Walmart's lead by selling in bulk.

The study found that opening an additional Walmart store "per 100,000 residents increased an area’s average body mass index by 0.24 units, or 10.8 percent of the sample obesity rate," Paquette writes. Researchers wrote, “These estimates imply that the proliferation of Walmart supercenters explains 10.5 percent of the rise in obesity since the late 1980s.” (Read more) (Growth of Wal-Mart since 1962)(Growth of Walmart since 1962)

Officials of hospitals and state government to discuss future of Ky. health care at Jan. 29 'summit' In Frankfort

State government and the Kentucky Hospital Association will co-host a summit for hospital CEOs, hospital board members and other elected officials and decision makers on the future of health-care delivery in Kentucky on the afternoon of Jan. 29 at the Capital Plaza Hotel in Frankfort.

“The health-care market and delivery systems all across the nation are currently undergoing an unprecedented transformation,” Gov. Steve Beshear said in a statement. “The rapid pace of this transition poses challenges to healthcare stakeholders, both rural and urban, that are facing fundamental changes to how they deliver care to patients in our communities.”

State Health Secretary Audrey Tayse Haynes said the state "has been very successful in getting Kentuckians enrolled in quality, affordable health-care coverage," but "We must now translate that coverage into quality, efficient and effective treatment. . . . The methods of treatment delivery must adapt to accommodate this new population of patients.”

Under federal health reform, hospitals are moving from volume-based to value-based reimbursements, and getting a larger share of Medicare and Medicaid patients, and for some that has meant empty beds, lower revenues and in some cases bankruptcy. Many Kentuckians have chronic illnesses, "which result in very low margins for some providers," a state news release said.

Letters of invitation have been sent to all members of the General Assembly and hospital CEOs. Space is limited, so invited guests are encouraged to register soon.

Ernie Scott, Kentucky rural health leader, gets national award

Ernie Scott, director of the Kentucky Office of Rural Health, has received the 2014 Emerging Leader Award from the National Organization of State Offices of Rural Health.

Scott received his award Oct. 28 during the organization’s annual conference in Omaha. It is given annually to a state staff member who has demonstrated new leadership, initiative, involvement and commitment to the rural-health mission, a University of Kentucky news release reports.

Scott has been director of the state office since 2013. He is editor of a statewide rural health magazine, slated to begin quarterly publication in January. He has held leadership roles in state and national organizations.

Fran Feltner, director of the UK Center of Excellence in Rural Health, said in the release.“We are honored to extend our sincere congratulations to Ernie for this well-deserved recognition. The emerging leaders award appropriately reflects his passion for rural health, as well as the depth of knowledge and commitment he has for important health care issues in rural communities.” 

National Rural Health Day is Thursday, Nov. 20

The Kentucky Rural Health Association will participate in National Rural Health Day, held on the third Thursday in each November, to spread awareness of rural health-related issues and promote the efforts of all rural stakeholders, says a press release from KRHA.

The association says it advocates for the interests of rural health by bringing together multiple parties to work together rather than in silos, working in collaboration to address the needs of rural Kentuckians. This year it has worked on issues such as immunizations, rural hospital impact, health professions recruitment, and tobacco use.

The KRHA joins the National Organization of State Offices of Rural Health Thursday, Nov. 20, to celebrate National Rural Health Day with plans to draw attention to several key issues related to Kentucky's rural health including health professions training, loan repayment, substance abuse treatment, mental health and Area Health Education Centers.

Approximately 62 million people, nearly one in five Americans, live in rural and frontier communities, and in Kentucky, 1.8 million citizens, or two of five, live in rural areas, the release notes. More information about National Rural Health Day can be found by clicking here.

Collaboration, telemedicine save lives in rural Kentucky

Many rural women in Appalachia can now have their babies closer to home thanks to a partnership between Appalachian Regional HealthCare and UK HealthCare.

UK HealthCare women's health providers are now based at permanent community clinics in Morehead, Georgetown and Hazard, says a University of Kentucky news release. Prenatal emergencies are still transferred by air ambulance to the UK Chandler Hospital, but full-time obstetricians, telehealth and a partnership with ARH is allowing most women to deliver closer to home.

A Breathitt County mom, Elma Thorpe, shared her story about how Dr. James Dawson, one of two doctors based at the UK HealthCare Women's Clinic in Hazard saved her life and her newborn son's life in November 2012.

At 36 weeks pregnant, Thorpe had stomach pains and thought she was going into labor. She went immediately to the hospital and was admitted to the emergency department at Appalachian Regional HealthCare Medical Center in Hazard. Her regular doctor was on vacation, so the on-call obstetrician Dr. James Dawson, one of two doctors based at the women's clinic, stepped in to deliver Thorpe's baby.

While waiting to be taken to the labor and delivery department, Thorpe developed a placental abruption, which occurs when the placenta prematurely breaks away from the wall of the uterus and was causing bleeding from the womb. That cut off the baby's oxygen supply, and Dawson feared that the baby would die inside the womb before he was able to deliver. He also knew Thorpe was in danger from losing a high volume of blood.

"With some emergencies, you have several minutes or an hour, but this was one where we had only a few minutes," Dawson said. He and the ARH medical team performed an emergency Cesarean section to deliver baby Nicholas and then successfully worked to stop Thorpe's bleeding.

UK HealthCare's Women's Health in Hazard employs two full-time obstetricians with the intent to keep women closer to their home for prenatal care and delivery, even when emergencies arise, UKNow reports.

Dawson and colleague Dr. Misty Thompson live and work in the Appalachian community they serve. A partnership between UK and ARH allows them to be on-call for deliveries and emergencies, and provide women's health services at health departments in surrounding counties.

Obstetricians in Hazard also have access to the latest ultrasound technology and consultations with UK specialists in Lexington through telemedicine if they partner with UKHealthCare.

Dr. Wendy Hansen, chair of UK's Department of Obstetrics and Gynecology, said these collaborative resources and support "will improve the level of care for women in every part of Kentucky" and will also "help recruit doctors to an historically underserved area that struggles to attract providers."

Rural Ky. hospitals make sure they are ready for Ebola

Rural hospitals in Kentucky are making sure they are prepared in the event they get a patient with the Ebola virus, Bill Estep reports for the Lexington Herald-Leader.

The risk of Ebola coming to rural Kentucky is low and there have been no cases in the state, according to officials of the state Department of Public Health, but rural hospitals are getting ready just in case, Estep reports.

It's not known where a patient might enter the health care system, so every hospital must be prepared, State Health Commissioner Stephanie Mayfield, told Estep.

Hospital officials all over the state have told Estep that they are making sure they are prepared in case they get an Ebola patient, saying they are reporting up-to-date daily information on dealing with Ebola to their employees; staying apprised of what the state health department and the federal Centers for Disease Control recommend; updating patient-screening processes to help determine the risk of Ebola, reviewing isolation procedures; taking stock of protective gear; and providing staff education.

"The protocol for rural hospitals would be to put an Ebola patient in isolation, then contact the local or state health department for guidance on whether to transfer the patient," Joe Murrell, chief executive officer at the 25-bed Wayne County Hospital in Monticello, told Estep, because "most rural hospitals don't have the resources to treat an Ebola patient for a long period."

But is this level of preparation enough?

Health care workers continue to be concerned because the two nurses in Dallas who were caring for the infected man from Liberia who has since died, and now have Ebola, "reportedly got the virus despite wearing protective gear," Estep writes.

Initially Dr. Tom Frieden, director of the CDC, said any hospital could safely take care of Ebola, Kimberly Leonard reports for U.S. News & World Report. “You need a private room with a private bathroom, and rigorous, meticulous training and materials to make sure that care is done safely so caregivers aren’t at risk,” he said, Leonard writes.

But Linda Greene, an infection prevention manager at Highland Hospital in Rochester, N.Y., and a member of the Professionals in Infection Control and Epidemiology Regulatory Review Panel, told Leonard, "Despite the best efforts, we do know in many hospitals that infection-prevention control measures are under-resourced,” and "There may be need for even more specialization than we initially thought."

But Greene goes on to say that despite these challenges,"Every hospital, however, should be able to screen and identify a patient at risk and immediately put them into isolation as necessary and do the initial triage, Leonard reports.

This is what Kentucky hospitals seem to be doing, despite concerns of some that it might not be enough.

Kevin Kavanagh, a Somerset physician and board member of Health Watch USA, told Estep that there are still "unanswered questions" about care for patients with Ebola, citing "his understanding that the CDC still doesn't know how the Dallas nurses got infected despite wearing protective gear" and "what plans hospitals have to dispose of the medical waste" and the "extent of the knowledge about how the disease spreads."

Nine hospitals in Kentucky get maximum Medicare penalty for readmissions; they blame socioeconomic factors

Article updated 10/20/2014
Nine hospitals in Kentucky, eight of them in Appalachia, have been hit with the highest penalty possible by Medicare for high rates of patient readmission.

This is the third year the program has fined hospitals, under the federal health-reform law, for having too many patients return within 30 days for additional treatment.

This year, the maximum penalty is a 3 percent reduction in Medicare payments for all patient stays in the fiscal year beginning Oct. 1. Last year, the cut was 2 percent. The fines are based on readmissions from July 2010 through June 2013.

Kentucky hospitals fined the maximum amount this year are the Appalachian Regional Healthcare hospitals in Harlan, Whitesburg and Hazard; Memorial Hospital in Manchester; Methodist Hospital in Henderson; Pineville Community Hospital in Bell County; Three Rivers Medical Center in Louisa; Monroe County Medical Center in Tompkinsville; and Westlake Regional Hospital in Columbia. All except Henderson are in Appalachia, and most are in Eastern Kentucky.

“Some of the specific challenges that have faced hospitals in Eastern Kentucky is that they see a greater proportion of patients who have suffered from heart attacks, heart failure and pneumonia,” Elizabeth Cobb, vice president for health policy at the Kentucky Health Association, told Kevin Halpern of the Middlesboro Daily News.

Cobb also said the region has "higher numbers of chronically ill patients, who require a greater amount of hospitalization," and that high rates of obesity and smoking, which affect how well a patient does after discharge, as well as a lack of oupatient services in rural areas, also contribute to readmissions. The formula for calculating readmission penalties does not take such problems into account.

Nationwide, 2,610 hospitals received a readmissions penalty, but only 39 were hit with the full 3 percent. In Kentucky, 63 hospitals, about two-thirds of the state's total, were penalized, with the average penalty being a 1.21 percent reduction in payment, according to an analysis of federal records from Kaiser Health News.

Halpern, citing KHA, reported that Kentucky represented a "disproportionate share of (the) hospitals receiving the maximum penalty, with nine hospitals, representing 23 percent of the total."

KHA supports pending legislation that will require the Centers for Medicare and Medicaid Services to adjust its program to account for socioeconomic conditions that "are beyond a hospital's control," Halpern reports. Opponents say "hospitals that have many readmissions are providing substandard care and should not be let off the hook," Kaiser's Jordan Rau reports.

The penalties have forced hospitals to provide better follow-up care for their patients after discharge in efforts to avoid readmission. The days of handing a patient a written discharge plan and expecting the patient to follow them without follow-up are quickly becoming a thing of the past, Rau reports.

Instead, hospitals are finding ways to ensure patients are not readmitted like ensuring outside doctors monitor discharged patient's recoveries; providing free medication for those who can't afford them; or sending a nurse to a patients home to make sure they are taking care of themselves.

But some hospitals are still struggling with these new guidelines, resisting many such efforts because they aren't paid for these services, Rau reports, and some continue to readmit patients because it has been financially beneficial to the hospital in the past.

Medicare officials estimate that $17 billion of the $26 billion Medicare pays for readmissions is a result of "potentially avoidable readmissions," Rau reports.

2014 Kentucky Rural Health Day observance includes a photography contest; submissions are due by Nov. 7

Part of the 2014 Kentucky Rural Health Day celebration this year is the "Bridges to Rural Health" Photo Contest.

Participants are asked to submit photos that express this year's theme, "Bridges." Whether you depict this with a photograph of one of the many beautiful bridges in Kentucky or creatively (a bridge can be many things) the organizers say to submit pictures that depict what rural means to you.

Only Kentucky residents are eligible to participate in the contest and all photos must have been taken in Kentucky. Submissions are due by 11:59 p.m. Eastern Time on Friday, Nov. 7. Click here for contest details. For more information email chris.salyers@uky.edu or follow the Kentucky Office of Rural Health on Facebook.

Ky. Rural Health Assn. gives UK's James Norton the Dan Martin Award for Lifetime Contributions to Rural Health

James Norton of the University of Kentucky is this year's recipient of the Dan Martin Award for Lifelong Contributions to Rural Health, which honors a health care professional who has shown a long-standing commitment to solving health challenges in rural areas across the state, UKNow reports.

James Norton

This year the Kentucky Rural Health Association presented the award, a handmade and locally crafted dulcimer, to Norton prior to the annual conference, since he was traveling abroad during the September conference when it is normally presented. Norton is a past president of the KRHA and has served on the committee that chooses the recipient of this award.

"It's really gratifying," Norton said of receiving the award. "You do this for a long time, and it's nice to have your peers convey to you that they think what you've done has value in the long pull."

Norton is the associate dean for educational engagement at UK College of Medicine; leads the Western Kentucky Initiative, which places third-year medical students in rural clinical sites in Western Kentucky; is the director of CE Central, which manages continuing education for doctors and pharmacists; and serves on state and national boards that include the National Rural Health Association and on groups that are part of the Association of American Medical Colleges.

 "For over 30 years, Dr. Norton has been a major contributor and leader in developing programs directed to developing future health care providers for rural and underserved communities," Linda Asher, chair of the KRHA selection committee, said in the release.

Started in 2003, the award is named after its inaugural honoree Dan Martin of the Trover Foundation in Madisonville.

Free-standing emergency departments could be the solution to keeping hospital services in rural areas

The tribulations of rural hospitals in Georgia, and the response, could signal a new direction for saving such facilities. Four rural hospitals in Georgia "have closed in the past two years, and several more either have closed or significantly reduced services since 2001," Bob Herman reports for Modern Healthcare. "Nationwide, more than two dozen rural hospitals have shut down since 2013. For people in rural areas, a closed hospital means they have to travel farther, sometimes hours, for care. And that could mean life or death in situations such as cardiac arrest, car accidents, workplace injuries and other emergencies."

Republican-led Georgia, where officials have refused to expand Medicaid under federal health reform, "has proposed a regulatory change that some observers think could help rural hospitals across the country," Herman writes. Republican Gov. Nathan Deal said in March that "financially struggling rural hospitals can offer fewer inpatient services and still keep their hospital licenses. In essence, they can convert into free-standing emergency departments that stabilize and transfer patients to bigger hospitals. Under Deal's proposal, these rural facilities also could offer other basic services such as labor and delivery."

Some people are critical of the idea. Brock Slabach, a senior vice president at the National Rural Health Association, "said the financial sustainability of free-standing rural EDs in Georgia as outlined by Deal would be low," Herman writes. Salbach told him, “Emergency departments would be nice for access, but that doesn't provide (insurance) coverage. These rural communities are still going to be having problems of paying for these services. We need to try to find a way to expand coverage to these poor populations in a way that's not going to be called Obamacare.”

There are somewhere between 400 to 500 EDs in the U.S., Herman writes. Most "are affiliated with a hospital or health system, serving as a feeder for patients needing inpatient care. The EDs usually are within 20 miles of a full-service hospital. More recently, for-profit ED companies have been building in affluent suburbs, targeting privately insured patients who see the EDs as more convenient than making an appointment with a primary-care physician."

The problem is that few are located in rural areas, Herman writes. For urgent-care centers and free-standing EDs to survive in underserved rural areas the “operating model will need to adapt,” said Alan Ayers, a vice president for Concentra, the urgent-care subsidiary of giant Louisville-based insurer Humana Inc. "They will have to use mid-level clinicians including physician assistants and nurse practitioners, reduce operating hours, and offer other high-volume services such as primary care and occupational medicine. That could help rural facilities offset the typically high fixed costs, Ayers said."

"Perhaps the most feasible solution for rural areas is a hybrid model, mixing lower-level emergency care with primary-care services," Herman writes. "An example is Carolinas HealthCare System Anson in Wadesboro, N.C., a town of 5,800. In 2012, Carolinas HealthCare System—a large system based in Charlotte, N.C., with $4.7 billion in annual revenue—decided to overhaul Anson Community Hospital, a Hill-Burton facility with 125 staffed acute-care and nursing beds."

"The system spent $20 million and downsized the hospital's inpatient capacity from 30 beds to 15," he writes. "The new facility, which opened in July, offers 24/7 emergency care in addition to the limited number of acute beds. Carolinas officials said Anson's major innovation and attraction is that it uses a patient-centered medical home model, offering residents access to primary-care providers with the help of a patient navigator." (Read more)

Edelen says rural hospitals are top issue for rural U.S. and rural Kentucky; says some pols in state want to give up on rural Ky.

By Molly Burchett and Melissa Patrick
Kentucky Health News

BOWLING GREEN, Ky. – State Auditor Adam Edelen has finished his series of town-hall meetings across the state to get a better understanding of the struggles faced by rural hospitals, but this isn't the last you will hear from him about the brewing crisis among these hospitals – a crisis that he says is not just a Kentucky problem but "the most important issue facing rural America."

Hours before his last town hall, in Bowling Green on Sept. 19, Edelen told Kentucky Health News that the tour was not just about assessing the finances of these hospitals, because he has heard politicians in both parties say "We just have to give up on rural Kentucky. . . . I'm passionate about not giving up on rural Kentucky."

Challenges faced by rural hospitals are very different than those faced by suburban or urban hospitals, Edelen said, so a "one-size-fits-all" approach won't keep Kentucky's rural hospital network in vibrant or sustainable.

He noted that Medicare and Medicaid reimburse hospitals at below the cost of providing care, with the expectation that they will make it up from private payers, but such payers are in short supply at many rural hospitals because the economic recovery is "nonexistent in rural areas."

Changes in the health-care system

Some rural hospitals are expressing concerns about the expanding Medicaid rolls under the Patient Protection and Affordable Care Act, but Edelen said in the interview that most of the complaints he heard are about Kentucky’s move to put Medicaid under managed care in 2011.

He said in Bowling Green that Kentucky rolled out in six months what should have taken 18 months, creating a "extraordinarily complex" and costly Medicaid system that still has no-pay and slow-pay issues. Then came the PPACA, generally known as Obamacare, creating an unprecedented level of complexity.

The extra administrative overhead is particularly difficult for small hospitals and health-care providers, he said, and payment disputes with managed-care companies can be existential threats to community hospitals with small cash reserves. The Nicholas County Hospital in Carlisle closed in May.

"We've got a number of hospitals in Kentucky who have less than 15 days of cash reserves," Edelen said. "One hospital in particular told me that leaders meet weekly to figure out about who's getting paid and how much just to keep the doors open. . . . County officials are afraid they are going to lose their hospital, while the cabinet says all is well."

Cabinet for Health and Family Services Secretary Audrey Haynes said in an email, "There is little doubt that Kentucky's health-care industry has gone through tremendous transformation since November 2011." She said managed care within and "many other important changes . . . have created a health-care delivery system with more accountability; increased focus on prevention and early detection; decreased use and high costs of our emergency rooms for non-medical emergencies; and are actually treating and managing both mental and physical healthcare of our Medicaid consumers to achieve healthier outcomes."

Haynes added, "With the assistance of managed care, we saved Kentucky taxpayers $1.3 billion of state and federal funds in the last biennium budget ending June 2014," while providers "had a record revenue year, receiving over $3.4 billion." She concluded, "I realize the implementation of managed care has not always been easy for our hospitals and other health-care providers, but we continue to work closely with them and make adjustments and improvements."

Edelen said in the interview that hospitals "know their business models have to change," but health-access to care is still an issue, and if hospitals close, those issues will grow. He said he understands that not all rural hospitals can survive, but "You gotta try."

He also said rural hospitals are needed to deliver on the promise of Obamacare: "What's the good of having everybody insured if there's no one to provide care?" What's the government doing to soften the blow coming with these health-care changes?"

Kentucky is not alone

Kentucky has handled implementation of the reform law better than other states, Edelen said, but there are still big problems that no one is thinking about.

Like other rural hospitals across the country, community hospitals in Kentucky have long relied on federal subsidies of facilities with high numbers of Medicaid patients and uninsured people. Since the reform law was designed to cut the number of uninsured, it will also phase out Disproportionate Share Hospital (DSH) Medicaid payments to hospitals by 2020.

Kentucky's DSH money shrank by 4.2 percent in the fiscal year that ended June 30. The allocation is determined federally, but state officials have considerable discretion in how the cuts are applied to individual hospitals.

"I fear that the disappearance of DSH payments could be a death knell for Kentucky's rural hospitals," which would have serious economic repercussions for their communities, Edelen said. "We have an opportunity to be a thought leader here because this is going on all over the nation."

Nationwide, many rural hospitals are closing down just like the hospital in Nicholas County. Reuters reported that 24 rural hospitals have closed across the country since the start of 2013, double the pace of the previous 20 months, leaving whole communities without quick access to acute care.

"This needs to be an issue for rural America in the 2016 presidential campaign," Edelen said. "Now that the Farm Bill's passed, this is the most important issue facing rural America, and the competition's not even close."

Not just a health-care problem

Research shows rural hospitals contribute significantly to local economies. Health care accounts for 15 percent to 20 percent of all jobs in rural communities,  Dr. Mary Wakefield, now the administrator of the federal Health Resources and Services Administration, told a congressional hearing in 2000. Furthermore, health services and schools are important quality-of-life factors for attracting and retaining employers and retirees.

"When you lose your rural hospital you lose not only one of the primary employers in a county, but you tend to lose the leading corporate citizen," Edelen said in the interview. "You lose things like ambulance services and providers networks and then the burden on health departments becomes more pronounced; that is not sustainable long term."

For prosperity, a community needs an educated work force, a healthy economic environment and a network that provides health care, he said. "These are the things that are the non-negotiables in the 21st Century if you are going to bring prosperity to every part of Kentucky," he said in Bowling Green.

Edelen told the audience of about 120 that he wanted them to go home and talk about this issue in their communities to make Frankfort, with its "fifteen-minute attention span," pay attention. "Kentucky at its core is always going to be a state with a rural character," he said.

The auditor's office is compiling a report that will also include a financial "stress test" of 66 rural hospitals. Edelen said he aims to release it in November or December. "I want to clearly define the problem," he said, "and then facilitate a conversation to solve the problem."

He said in Bowling Green, "What this is really about in a nutshell is whether the political leadership in Kentucky is going to give up on rural Kentucky."

Public hearing to be held in Bowling Green Sept .19 to discuss fiscal health of Kentucky's rural hospitals

On Sept. 19 in Bowling Green, state Auditor of Public Accounts Adam Edelen will hold the last of 11 public hearings, which have been held across Kentucky this summer, to talk about the financial health of rural hospitals.

These hearings, along with a study by the auditor's office, are meant to help understand the challenges that face small, community hospitals, which provide health care to 45 percent of Kentuckians and are key economic drivers in those communities, an Edelen press release says.

The auditor is looking at some 66 public, non-profit and for-profit hospitals in rural Western and Eastern Kentucky. His office will conduct a survey about the fiscal health of these hospitals and plans to issue a report later this year.

The hearing will be held at the Holiday Inn University Plaza, 1021 Wilkinson Trace, Bowling Green, on Friday, Sept. 19 at 11 a.m. CDT, following the conclusion of the Kentucky Rural Health Hospital Association annual meeting.