Kentucky spends less than a penny of its tobacco-settlement money on prevention programs; few states do very much

By Molly Burchett
Kentucky Health News

A new report says that 15 years after the 1998 state tobacco settlement, Kentucky ranks 38th in the nation in funding tobacco prevention and cessation programs, only 3.7 percent of the amount recommended by the federal Centers for Disease Control and Prevention.

The CDC recommends that the state spend $57.2 million a year on programs to help people quit smoking, but Kentucky is only planning to spend $2.1 million in 2014 on them, says the new annual report from the Campaign for Tobacco-Free Kids. Last year's report ranked Kentucky 37th as it planned to spend the same amount.

The goal of these programs is to help kids and adults quit smoking. Of the $320.3 million in revenue the state will get from the settlement in the current fiscal year, Kentucky will spend just 0.7 percent of it on tobacco-prevention programs, or less than a penny of every dollar it collects in revenue, the campaign says in a news release and a chart.

Kentucky has the highest smoking rates in the country, a an estimated 28.3 percent of adults and 24.1 percent of high-school students smoke. Each year, tobacco claims 7,800 lives and costs the state $1.5 billion in health care bills, about $487 million of which are covered by the federal-state Medicaid program, and each Kentucky household pays an estimated $582 per year in taxes to cover smoking-caused government expenditures, the release says.

To reduce smoking and its negative consequences, health advocates are calling on Kentucky leaders to pass a comprehensive, statewide ban on smoking in workplaces and enclosed public spaces. Some advocates also call for an increase in the state's tobacco tax. The report says Kentucky has the 40th lowest cigarette tax in the country at 60 cents per pack, 93 cents below the state average. It was doubled a few years ago.

"Tobacco takes a terrible health and economic toll on Kentucky, but state leaders can do something about it by increasing funding for tobacco prevention and passing a comprehensive, statewide smoke-free law," said Matthew L. Myers, president of the campaign. "The evidence is clear that reducing tobacco use not only saves lives, it also saves money by reducing tobacco-related health care costs. It's one of the smartest investments Kentucky can make."

Nationally, the report finds that most states are failing to adequately fund tobacco prevention and cessation programs. States will collect $25 billion from the tobacco settlement and tobacco taxes in 2014, but will spend just 1.9 percent of it on prevention programs.

States are spending only 13 percent of the CDC's recommended $3.7 billion in funding for these prevention programs, and only two states – Alaska and North Dakota – spend the recommended amount.

Green = State spends 50 percent or more than recommended amount; Orange= 25-45 percent of recommended amount; Yellow = 10-24 percent of recommended amount; Gray = less than 10 percent of recommended amount 

"Tobacco use is the number one cause of preventable death in the U.S., killing more than 400,000 people and costing $96 billion in health care bills each year. Nationally, about 18 percent of adults and 18.1 percent of high school students smoke." says the report.

Since the states settled their lawsuits against the tobacco companies in November 1998, the Campaign for Tobacco-Free Kids has issued annual reports to hold states accountable for settlement spending, an amount estimated to be $246 billion over the first 25 years.

The annual report on states' funding of tobacco prevention programs, titled "A Broken Promise to Our Children: The 1998 State Tobacco Settlement 15 Years Later," was released by the campaign, the American Heart Association, the American Cancer Society Cancer Action Network, the American Lung Association, the Robert Wood Johnson Foundation and Americans for Nonsmokers' Rights.

Beshear says other governors will follow his lead on Medicaid

Associated Press file photo

Gov. Steve Beshear says states that have not expanded the Medicaid program under the federal health-reform law, as he did, will do so in the next few years because their voters will demand it.

“I believe the pressure will be so great over the next three or four or five years, on the states that haven’t gone in this direction, that they will end up just where Kentucky is,” Beshear told Alexander Burns of Politico, in the governor's latest appearance in a national publication.

Burns writes, "It’s precisely the message national Democrats are aching to hear, even – or perhaps especially – from a source as unexpected as a pro-gun, pro-coal, red-state governor who once endorsed using state tax incentives to build a creationist theme park."

The story, headlined "Kentucky's unlikely health care heartthrob," focuses on Beshear's high national profile stemming from his expansion of Medicaid to people earning up to 138 percent of the federal poverty line and the state's successful rollout of a website that is enrolling about 1,000 people a day in Medicaid or private insurance -- unlike the federal government's site, which seems to be getting in order after a disastrous rollout that made many Democrats nervous. He is the only Southern governor to take both steps.

"For anxious national Democrats who have pined for a white knight in the health-care reform debate, Steve Beshear is starting to look like the one they’ve been waiting for – implausible as that development may be," Burns writes. "Amid a torrent of negative national headlines about the Affordable Care Act, the 69-year-old Kentucky governor – a canny Southern operator who’s spent his career at arm’s length from the [national] Democratic base – has charged out of Frankfort as a kind of ambassador-by-default for the controversial law."

Burns says the verdicts on the state and national programs are "far from decided, but Beshear says his mind is entirely made up on both the merits and the politics of health care. From his perspective, voters’ opposition to the ACA is driven largely by a sense of anxiety about how the program may change their lives. If they find a year from now that the law has left their personal care unchanged, or even improved it, public opinion could shift quickly."

State Senate Republican Floor Leader Damon Thayer, "a leading Obamacare critic in the state, said Democrats would pay a price for Beshear’s decision to 'channel his inner liberal Democrat with no election ever facing him again in the future'," Burns writes, quoting Thayer: “While it appears that Kentucky has done a competent job implementing a website, it’s still a bad policy. . . . The people of Kentucky don’t like the fact that he has unilaterally implemented Obamacare without legislative approval, and they don’t like Obamcare.” (Read more)

Beshear's office says he is considering 'various ideas' for financing Ky. insurance exchange, not just a 1% fee on policies

"Gov. Steve Beshear’s administration is reconsidering how to pay for the Kentucky Health Benefit Exchange amid increased criticism from some Republicans in the legislature and a court case challenging a fee Beshear created through executive order," Ryan Alessi reports for cn|2's "Pure Politics," a service of Time Warner Cable.

“Various ideas for a sustainability plan for the exchange are being discussed, and such a plan will be finalized for implementation before current funding expires in 2015,” the governor's office told Alessi. Current funding comes from the federal government.

Beshear's plans have called for the exchange to be financed with a 1 percent fee on policies bought through the exchange, to be paid by insurance companies using it. "But in a statement in response to questions from Pure Politics, the governor’s office said it’s suddenly considering other ways to pay for the exchange," Alessi reports, adding that the office didn't respond to his follow-up question about whether legislative approval would be needed for whatever plan was adopted.

House Speaker Greg Stumbo, a Democrat from Prestonsburg, said during a Kentucky Hospital Association panel last month that the fee does not require approval of the General Assembly. Senate Health and Welfare Committee Chair Julie Denton, R-Louisville, told Alessi that it does. Here's a video clip:

Beshear says Medicaid plan will transform Ky. in a generation; acknowledges it was easier because he wouldn't face voters

In a generation, Kentucky will be a very different state because the federal health-reform law and expansion of Medicaid has made health insurance available to all residents of the state, Gov. Steve Beshear told Los Angeles Times political reporter Mark Z. Barabak for a story the paper published on Thanksgiving Day. And he acknowledged that his Medicaid decision was easier because he can't seek re-election.

"I knew if I was going to make a huge difference in the health status of Kentucky, it was going to take some kind of transformational tool to do that, and that's what the Affordable Care Act is for me," Beshear told Barabak. "I think we've started something here that a generation from now you'll see a very different Kentucky than what you see today."

Beshear "conceded, with a small smile, that it was easier knowing he would never face voters again," Barabak writes. "Embracing Obamacare is not without political risk. Undaunted by the early success in Kentucky, Republicans plan to make the controversial program a major issue in 2014, when the GOP will be vying to take control of the state House for the first time in close to a century."

Politics aside, "The need for care in this pretty but hard-pressed state is unarguable," Barabak writes. "Kentucky leads the nation in cancer deaths and preventable hospitalizations and suffers some of the highest rates of diabetes, cardiovascular illness and premature death." But he says "Kentuckians may feel understandably whiplashed" because the state's Republican U.S. senators firmly oppose "Obamacare." (Read more)

Beshear to study nursing-home staffing minimums, suggests homes' high liability costs are related to poorly ranked care

Responding to a letter from Kentuckians for Nursing Home Reform, which cited a low ranking for the state's nursing homes, Gov. Steve Beshear said he is "committed to taking steps toward improving the quality of care in Kentucky nursing homes," Valarie Honeycutt Spears reports for the Lexington Herald-Leader.

Beshear said he would call for forums across the state to allow the public and nursing-home residents to discuss their ideas for improvement, and would research the impacts of increased staffing in nursing homes. The reform group wants minimum staffing requirements, which the nursing-home industry opposes.

"I take this challenge very seriously and will be working with my staff and the state's Elder Abuse Committee over the coming months to explore ways in which we can improve the quality of care," the governor said in a Nov. 5 letter to Bernie Vonderheide, founder of the nursing-home reform group.

Vonderheide wrote Beshear in August after Kentucky was ranked 40th in nursing-home care by Families for Better Care, a Florida-based advocacy group for nursing-home residents. On a grade scale of A to F, the group gave Kentucky a D. The grade was determined by analyzing eight federal measures of nursing home quality, according to the group's release.

Beshear suggested in his letter that the low ranking of Kentucky's nursing homes might be related to another of their lobbying concerns — liability costs that are well above national norms. The homes want to limit those costs by subjecting lawsuits against them to medical review panels, which couldn't block the suits but would give the homes leverage in settlement negotiations.

The governor said "a trend emerges" when the low ranking is matched with an actuarial report showing that a typical 100-bed nursing home in Kentucky has annual liability costs of $535,000, while the national average is $154,000. Kentucky was among the states with high liability costs that received a below average or failing grade on the Families for Better Care report, Beshear noted.

Vonderheide said the letter marked "the first time . . . that a Kentucky governor has embraced nursing home staffing standards." Actually, as Spears reports, Beshear "said he would ask program leaders from the Cabinet for Health and Family Services to research the impact that increasing nursing home staffing could have in Kentucky." (Read more)

The Herald-Leader said in an editorial on the issue, "Listening, exploring, collecting information and ideas must lead — quickly — to action."

Haynes asks hospitals for a truce as they and state work through problems with managed-care Medicaid

Health and Family Services Secretary Audrey Haynes won a smattering of applause from Kentucky hospital officials Thursday as she called for "not a surrender, but a truce" as her cabinet continues to address the hospitals' complaints about the state's managed-care system for Medicaid, which recently entered its third year.

Haynes drew the ire of hospitals last month when she said some needed to change their business models to emphasize prevention and wellness, not cashing in on Medicaid payments for emergency-room care. Thursday, she said in a speech to the Kentucky Hospital Association in Louisville that she wants "to work more closely together, not only to improve your business practices," but to improve the health of Kentucky.

Haynes also called on the hospitals to join Appalachian Regional Healthcare and the University of Kentucky hospital in contacting past patients who lacked insurance and urge them to sign up for expanded Medicaid or private insurance on the state's Kynect website, under federal health reform. "I need your help," she said. "we're very excited about the opportunity for dramatic improvements in Kentucky's health status."

Also at the meeting, state Rep. Jimmie Lee, D-Elizabethtown, the House's health-care budget subcommittee chair, said he thought Haynes and the administration of Gov. Steve Beshear had largely resolved the "prompt pay" problems of hospitals not getting money they are owed by insurance companies. But Senate Health and Welfare Committee Chair Julie Denton, R-Louisville, called for more action on the subject, such as an independent review panel to review disputed claims.

Smokers shouldn't get Medicaid or Medicare, says freshman Republican lawmaker who grows tobacco

State Rep. Jonathan Shell of Lancaster, a young Republican who grows tobacco, is against a statewide smoking ban. No surprise there, but how about this: He also says people who use tobacco should't be able to get Medicaid benefits.

“As I don’t think we have should have a smoking ban, I also think if you’re going to be smoking, you should have to sign a waiver that you will not get onto Medicaid or Medicare ... so the taxpayers [don't] have to end up forking over those dollars because you made the wrong decision to smoke and put those carcinogens into your body,” Shell told Ryan Alessi on cn|2's "Pure Politics."

Shell, who is in his first term in the House, sponsored legislation this year to require drug testing for anyone who applies for government benefits such as Medicaid or food stamps, which he said "should be a last resort." His predecessor, Republican Lonnie Napier of Lancaster, was a leading advocate of such legislation.

Most of Alessi's five-and-a-half minute interview with Shell dealt with the workings of the tobacco industry. He said the free market will determine when he switches from growing tobacco to another crop, and he is already raising vegetables and flowers. He said his free-market and indiviphilosophy makes him oppose a smoking ban.

Northern Kentucky health board supports statewide smoking ban

The main health board in Northern Kentucky, where local smoking bans have stirred much controversy. has endorsed the idea of a statewide ban on smoking in all places of employment.

"The 32-member board, which represents Boone, Campbell, Grant and Kenton counties, voted to support the ban at its Sept. 11 meeting after Dr. Lynne Saddler, director of the Northern Kentucky Health Department, presented evidence about the dangers of second-hand smoke," The Kentucky Enquirer reported.

The board also authorized the department to promote Smoke-Free Kentucky, the main group advocating smoking bans, and its work in Northern Kentucky.

Efforts to pass a statewide smoking ban have never come to a floor vote in the legislature, but "23 Kentucky communities have passed comprehensive smoke-free laws, covering 34 percent of Kentuckians," the Enquirer noted. "In Northern Kentucky, only Kenton County has a smoke-free law, and it contains exemptions for bars and restaurants." (Read more)

Kentucky has nation's first statewide, comprehensive plan for diabetes prevention; 10 percent of us have the disease

Kentucky leads the way in the fight against diabetes and towards improving health for future generations of Kentuckians by becoming the first state to legislatively require a statewide, comprehensive action plan for addressing this disease epidemic.

Over 500,000 Kentuckians, 10 percent of the state’s population, are living with diabetes, costing the state about $4.8 billion a year in direct and indirect medical costs, write R. Stewart Perry and Larry Smith, co-chairs of the American Diabetes Association's national board of directors, in an op-ed piece in The Courier-Journal. While it hasn't been widely reported, state policymakers recently tackled the issue.

In 2011, the General Assembly passed a law (KRS 211.752), sponsored by Sen. Tom Buford, R-Nicholasville, and Rep. Ruth Ann Palumbo, D-Lexington, directing the Cabinet for Health and Family Services to report every two years on the impact of diabetes on the commonwealth.  The report must include the scope of the disease, its costs and what state government is doing about it.

The law requires the Department for Medicaid Services, the Department for Public Health, the Office of Health Policy and the Personnel Cabinet to “collaborate to identify goals and benchmarks while also developing individual entity plans to reduce the incidence of diabetes in Kentucky, improve diabetes care, and control complications associated with diabetes,” Perry and Smith note.

Such reporting will encourage the development of prevention strategies that are more effective and efficient, representing an unprecedented, coordinated effort against diabetes, they write. Many other states are using Kentucky’s plan as a model for legislation. "We call on every Kentuckian to enlist in the effort to step up the fight against diabetes," they urge.

Judge OKs Medicaid expansion and health insurance exchange

A judge upheld Gov. Steve Beshear's decisions to expand Medicaid and set up the state's health-insurance exchange under federal health reform, but his adversaries say they will continue to fight in court.

Franklin Circuit Judge Phillip Shepherd's two rulings mean that implementation of the Patient Protection and Affordable Care Act, through Medicaid expansion and the health exchange will continue as planned, at least for now.

Circuit Judge Phillip Shepherd

Tea Party activist David Adams filed a lawsuit in April challenging the governor's legal authority to create the insurance exchange, which is called Kynect and begins enrollment Oct 1, without first seeking approval from the General Assembly.

Shepherd said Beshear is simply implementing a section of a federal law that has been upheld by the U.S. Supreme Court, reports Tom Loftus of The Courier-Journal. Adams said he will appeal both the Medicaid expansion and exchange orders directly to the Kentucky Supreme Court, attempting to bypass the Court of Appeals.

Republican Sen. Julie Denton of Louisville, chair of the Senate Health and Welfare Committee, told Loftus she expects major problems to occur if the administration proceeds with Medicaid expansion.

"My overriding concern from the beginning is that Medicaid is not being run well now; they’ve never gotten their hands around managed care,” said Denton. “Do we really want to expand a broken system? And do we want the government to take on another new project like the health-care exchanges?”

Beginning next year, most Americans will be required to have health insurance, and Kynect is designed to help as many as 640,000 uninsured Kentuckians get coverage through private insurance plans. The online service will allow individuals and business to shop for plans, compare benefits and determine eligibility for payment assistance or tax credits.

Beshear announced Medicaid expansion in early May

Adams challenged the constitutionality of a state law mandating that Kentucky use all available federal funds for Medicaid. Shepherd said the legislation was a clear step towards achieving a state objective, to expand health care benefits to "indigent citizens," Loftus reports.

“The Kentucky Supreme Court has held that this legislative power may be delegated to the executive branch of government in these circumstances, so long as there are standards governing the exercise of discretion, and the legislature retains the authority to withdraw the delegation,” Shepherd wrote. “Those conditions are clearly met here.”

The law calls for expansion to cover people under 65 in households up to 138 percent of the federal poverty level -- currently $15,856 for an individual or $32,499 for a family of four. The federal government will pay all the cost of newly eligible Medicaid patients from 2014 to 2017, when Kentucky will increasingly pick up part of the tab, rising to 10 percent by 2020.

National magazine looks at drug companies' efforts to stop anti-methamphetamine bills, especially in Kentucky

In a strong piece of investigative reporting for Mother Jones magazine, largely about Kentucky, freelancer Jonah Engle delves into the history of how making methamphetamine became a simple task via over-the-counter cold medications, and how drug makers have warded off most state laws intended to make the decongestant pseudoephedrine more difficult to purchase. (Photo by Stacy Kranitz: Cleaning up a meth lab found on school property in London.)

Engle's well-rounded story examines the issue from the viewpoints of politics, law enforcement, drug users and the effects of their habits on their children, while looking at how small-town life -- especially in Kentucky, where meth-related cleanup and law enforcement cost the state $30 million in 2009 -- has been hit hard by the drug. When a bill in 2011 to require a prescription for pseudoephedrine, a Washington-based group representing the makers and distributors of over-the-counter medicines and dietary supplements, reportedly spent more than $303,000 in three weeks, with most of the money spent on "robocalls," or automated telephone messages. The bill failed, but in 2012 the legislature passed a law with a tighter limit on the amount of pseudoephedrine anyone can buy in a month, after a strong radio advertising campaign by the Consumer Healthcare Products Association. The drug is kept behind counters so purchases can be tracked but does not require a prescription.

Engle tells a tragic story of meth in many states, ever since 2007, when the process called "shake-and-bake" or "one-pot" method, became commonplace. "The number of clandestine meth sites discovered by police has increased 63 percent nationwide," Engel writes. "As law enforcement agencies scramble to clean up and dispose of toxic labs, prosecute cooks, and find foster homes for their children, they are waging two battles: one against destitute, strung-out addicts, the other against some of the world's wealthiest and most politically connected drug manufacturers. In the past several years, lawmakers in 25 states have sought to make pseudoephedrine—the one irreplaceable ingredient in a shake-and-bake lab—a prescription drug. In all but two—Oregon and Mississippi—they have failed as the industry has deployed all-star lobbying teams and campaign-trail tactics such as robocalls and advertising blitzes."

In Oregon, the number of meth labs found by police dropped 96 percent since the bill was passed, while in Mississippi the number dropped 74 percent, Engle writes. "Children are no longer being pulled from homes with meth labs, and police officers have been freed up to pursue leads instead of cleaning up labs and chasing smurfers. In 2008, Oregon experienced the largest drop in violent-crime rates in the country. By 2009, property crime rates fell to their lowest in 43 years. That year, overall crime in Oregon reached a 40-year low. The state's Criminal Justice Commission credited the pseudoephedrine prescription bill, along with declining meth use, as key factors."

"Everywhere else, industry has prevailed," Engle reports. "Many states have very limited laws on what lobbyists must report, and they don't monitor spending on robocalls or ads. But news reports and my interviews with legislators in Southeastern and Midwestern states where meth labs are most concentrated—and where CHPA had the biggest fight on its hands—show that the pharmaceutical industry deployed a mix of robocalls, print and radio ads, as well as a Facebook page and a website, stopmethnotmeds.com. These states include Alabama, Kansas, Missouri, North Carolina, Oklahoma, and Tennessee." (Read more)

Community-based solutions to childhood obesity show signs of progress elsewhere; will Kentucky pick up on them?

By Molly Burchett
Kentucky Health News

For decades, researchers reported with alarm the increasing trend of overweight children in America, with one in three kids on the way to developing Type 2 diabetes. Across the country, action has been taken to address this problematic trend, and now some preliminary, scattered results indicate that obesity rates have plateaued or dropped in some areas. Is Kentucky part of this success, and if not, will it learn from it?

The first set of positive signs came last year, with falling child obesity rates in New York City and Philadelphia, reports Lydia DePillis of The Washington Post. And, a recent Robert Wood Johnson Foundation brief shows similar progress in states with a large rural population as well:

• Mississippi posted a decrease from 43.9 percent of kids being overweight and obese in 2005 to 40.9 percent in 2011, three years after passage of the Mississippi Healthy Students Act. 
• In North Carolina, Vance and Granville counties saw significant declines after implementing healthy living programs based on the Centers for Disease Control’s community guide.
• Kids in Kearney, Neb., in grades one through five saw a 13.5 percent decline in obesity rates between 2005 and 2011.
• West Virginia fifth graders posted a 8.6 reduction in obesity rates over a six-year period.

Overall, progress was made through community-based solutions, including changes to make healthy foods available in schools while eliminating fried foods and working to integrate physical activity into people's daily lives while educating them about the importance of doing that, says the brief.

Kentucky, which suffers from one of the highest childhood obesity rates in the country, could learn from these successful programs. The state ties Mississippi for the highest percentage of youth in grades 9 to 12 that are obese (18 percent) and has the third highest percentage of children ages 10 to 17 who are obese (21 percent), compared to 16.4 percent nationally, says a report by Kentucky's Task Force on Childhood Obesity.

The Kentucky General Assembly has not enacted legislation regarding healthy eating and physical activity like many other states, notes a National Conference of State Legislatures report, but established a task force that made various recommendations to the legislature in September for strategies that address the problem of childhood obesity and that encourage better nutrition and increased physical activity among Kentucky children.

Some of the task force's recommendations include: requiring schools to improve nutritional content of school food, including promoting the use of school gardens, adopting a statewide standard for physical activity initiatives and nutrition education in schools and encouraging physical activity through a coordinated school health program. To view that report, click here.

Kentucky has no requirements for physical activity in schools. About 65 percent of Kentucky's youth did not attend physical-education classes in 2010, and 80 percent did not attend such classes five days per week, says a 2011 Center for Disease Control and Prevention survey.

However, the state does have several programs to promote physical activity or healthy eating. They includes the Farm to School program, which has been adopted by 1,243 schools and 174 school districts and is a collaborative effort between federal and state agencies to bring local agricultural products to schools and to educate students about local food production, says the report.

Using the success of other state programs and existing Kentucky programs as a guide, Kentuckians and "the members of the Task Force on Childhood Obesity are encouraged to continue their advocacy efforts to address Kentucky’s health crisis in ways that have the greatest likelihood of preventing and reversing chronic diseases associated with childhood obesity," says the report.

As health care expands and more providers are needed, pressure grows to allow nurse practitioners more prescribing authority

By Molly Burchett
Kentucky Health News

As Kentucky expands Medicaid and implements the Affordable Care Act, more Kentuckians will have health coverage and access to care, worsening Kentucky's already existing shortage of physicians, particularly those providing primary care in rural areas. And, as the stakes get higher, so do tensions between physicians and nurse practitioners about how newly covered Kentuckians will receive their care.

Nurse practitioners say part of the solution involves removing their requirement to have a "collaborative agreement" with a doctor to write prescriptions. Nurse practitioners have been pushing for years to get rid of this requirement, saying they have the expertise to independently prescribe non-scheduled or routine drugs like cholesterol medications, reports Laura Ungar of The Courier-Journal in an article about the NPs' debate with physicians.

Doctors say collaborative agreements are necessary to protect patients, and call for a team-based approach to health care, writes Ungar. “My hope is the collaborative agreement will be strengthened,” Dr. Shawn Jones of Paducah, past president of the Kentucky Medical Association, told Ungar. “Certainly, physician manpower is an issue in Kentucky and in the U.S. ... but there’s not a great amount of evidence that collaborative agreements impair nurse practitioners from performing their duties.” But Ungar's story notes that NPs sometimes have trouble finding a collaborating physician.

Legislation to let NPs prescribe non-scheduled drugs without a doctor agreement passed the state House but failed in the Senate this year. The NPs aren't giving up, and many are working with state Sen. Paul Hornback, R-Shelbyville, on a similar bill for the next legislative session. Most agree that collaborative agreements are appropriate in the case of controlled substances, such as narcotic painkillers, but other wish to prescribe other drugs too, reports Ungar.

Seventeen states and the District of Columbia allow full prescribing authority for nonscheduled medications to nurse practitioners (see chart below), which means they do not require a signed agreement with a physician. Note that no Southern states allow nurse practitioners to work independently.

A recent report by Deloitte Consulting estimated that the state needs 3,790 more doctors just to meet current demand, which means this is what is needed even before considering the health law or Medicaid expansion. The report says that unlike the need for nurse practitioners, which is balanced between rural and urban populations, the state's doctor shortage occurs mostly in rural areas; the need was 61 percent rural in 2012 and is forecast to be 63 percent rural as Medicaid also expands.

The state needed 183 primary care physicians in 2012, and will need about 284 by 2017. The neediest counties are Bullitt and Spencer, which are close to Louisville. The need is heavily concentrated in the eight southwest border counties, and with Medicaid expansion, it will increase by 42 percent, says the report.

It's clear that large gaps appear in Kenucky's health-care workforce in Kentucky, particularly in rural areas, the Deloitte report says. A more detailed look at the county level is needed to determine the true workforce capacity issues, and can be done by provider type through an interactive tool the firm developed by clicking here.

The need for nurse practitioners in 2012 is relatively low compared to other groups -- 148, or 5 percent of the current supply, says the report. However, "If 6 percent of the current [NP] population were added to the current PCP [primary care provider] supply, the entire PCP gap could be addressed," the Deloitte report says. (NPs are generally referred to as advance practice registered nurses, or APRNs, as indicated on this map.)

To help address this overall provider shortage, Deloitte made 11 recommendations to the state, one of which included authority for nurse practitioners to prescribe less risky drugs without an agreement with a physician. This has been the issue debated by NPs and doctors at the legislature. The report says loosening collaborative agreements could do a lot to address the need for primary care. Giving nurse practitioners more authority has many benefits, including the fact that nurse practitioners who would be able to work more independently may be more likely to set up practice in rural areas.

Some other recommendations in the report include creating support programs for small practices in rural and under-served areas; considering limits on medical malpractice awards; expanding regional rural health tracks to get more new doctors to rural areas and keep them there; and increasing health-care degree and residency capacity across the state.

Ky. is already short of doctors, dentists; how will its health-care system handle expansion of Medicaid and private insurance?

By Molly Burchett and Al Cross
Kentucky Health News

In the wake of Gov. Steve Beshear’s recent decision to expand Medicaid under federal health reform, there is concern that Kentucky's health-care system will not be able to care for the newly insured.

Health reform means that an estimated 308,000 new Kentuckians will qualify for Medicaid, and 332,000 more will qualify for subsidies to buy private insurance through the state insurance exchange that will start taking enrollments Oct. 1.

But Kentucky already has a health care provider shortage, especially in rural areas. A study for the state estimates that it needs 3,790 more doctors just to meet current demand, to say nothing of what will be needed to care for those who haven't been a regular part of the health-care system, reports Laura Ungar of The Courier-Journal.

The report by Deloitte Consulting made 11 recommendations, including authority for nurse practitioners to prescribe less risky drugs without a written agreement with a doctor, and one that would be even more controversial, putting limits on medical malpractice awards, said Ungar.

The report also recommended expanding and increasing Medicaid reimbursements in rural areas, to encourage more physicians to take Medicaid patients.

It did not mention complaints by health-care  providers about getting paid by the managed-care Medicaid system that the state began in November 2011; Gov. Steve Beshear said when he announced Medicaid expansion that those problems are being worked out.

"Consultants said 61 percent of the 3,790 'full-time equivalent' physicians needed (which includes primary care doctors and specialists) were in rural counties," reports Ungar. Jonathan Felix of Deloitte said, “Primary care, dental care and behavioral health are all big needs in the state.”

The report said the state needed 183 more primary-care doctors, even before Medicaid expansion, but a 2012 Kentucky Physician Workforce Needs Assessment report by the University of Kentucky said the state needs 557 more primary-care physicians and 1,655 more total physicians to meet the national ratios for physicians to population.

The consultants said the state already needs 612 more dentists. It now has 1,711.

Complicated provider shortage problem, no easy answer

About 192 federally identified areas in Kentucky — including 47 counties — have shortages of health professionals, Ungar reports. Kentucky counties who will have the most non-elderly residents eligible for Medicaid often have fewer primary-care doctors per person, according to data analyzed by The Courier-Journal. Ungar notes that Casey County, for example, ranks in the bottom third for doctors per capita, but it has the highest portion of newly eligible residents at 13.5 percent.

“We can’t grow physicians fast enough to meet the need, in the rural areas especially,” Susan Zepeda, president and chief executive officer for the Foundation for a Healthy Kentucky, told Ungar.

Nationally, there is a primary-care shortage, partly because such doctors make less money than most, and low reimbursement rates exacerbate that. A 2012 study in the journal Health Affairs said 21 percent of office-based physicians in Kentucky did not accept new Medicaid patients in 2011, Ungar notes.

The health reform law will raise the Medicaid fees to match what Medicare pays primary-care doctors, but only for two years. Kentucky's Medicare rates are about 72 percent of the Medicare rates, compared to a national average of 59 percent, says an Urban Institute study. But the time limit leaves some practitioners wary.

“If I choose to increase the number of Medicaid patients, and two years down the road that payment drops back to two-thirds, all of a sudden I’m going to have an awful lot of trouble keeping my doors open,” Reid Blackwelder, a family practitioner and incoming president of the American Academy of Family Physicians, told Michael Ollove of Stateline. 

A report last year by the non-partisan Center for Studying Health System Change said the temporary nature of the pay raise could limit its effectiveness, particularly in Kentucky and other states that are expecting the largest percentage increases in Medicaid enrollees and that have low numbers of primary-care physicians.

“I’m not sure who’s going to pick up all those patients into their practices,” Julianne Ewen, a nurse practitioner in Lexington and president of the Kentucky Coalition of Nurse Practitioners and Nurse Midwives, told Ungar. Legislation to let nurse practitioners prescribe non-scheduled drugs without a doctor agreement failed in the state Senate this year.

While some policy analysts have touted nurse practitioners as a solution to the rural primary-care shortage because they often provide primary care in rural and isolated areas that do not have doctors nearby, they would not be covered by the two-year reimbursement increase. Ewen said the reimbursement is only $23 for a lower-level visit by an established patient.

A possible long-term solution includes greater reliance on community health centers, some say. And hospital officials said they plan to continue expanding primary care and employ telemedicine. Ruth Brinkley, president and chief executive officer of KentuckyOne Health, said her system is looking to open new primary care offices and hire more staff.

Dr. David Dunn, vice president for health affairs at the University of Louisville, said the university is increasing physician training in such areas as family medicine and geriatrics and using funds from its new partner, KentuckyOne, to expand the nursing work force with professionals, such as advanced nurse practitioners.

Health providers and advocates agree that getting more people insured should produce a healthier population in the end. But they said much remains unknown, including how many of those eligible for coverage under health reform will sign up for it. The state estimates that 188,000 of the 308,000 newly eligible will enroll, but some think that estimate is low.

Beshear says he will decide in four to five weeks, or July 1 at the latest, whether or not to expand Medicaid

By Al Cross
Kentucky Health News
This story has been updated.

Gov. Steve Beshear said Monday that he will decide within the next four to five weeks, or maybe by July 1, whether to expand the Medicaid program under federal health-care reform.

Beshear, who has said he would expand Medicaid if the state can afford it, told reporters that he is considering other factors, which he did not name. He said his administration has not calculated the cost of expansion, which the state would not pay immediately.

The federal government pays about 71 percent of Medicaid's cost in Kentucky, and would pay the full cost of covering those newly eligible in 2014-16. The state would have to pay 3 percent in 2017, rising to 10 percent by 2020.

About 830,000 Kentuckians are covered by Medicaid, and at least 400,000 more could be added if Beshear expanded it to include households earning up to 138 percent of the federal poverty level, as required by the reform law.

Another possibility is that Beshear would seek approval from the federal government to use federal money to subsidize purchase of private health insurance by the poor, which has been approved in Arkansas but not in Tennessee.

The governor's office, asked if the administration was considering that option and what other factors Beshear is considering, has not responded had this response: "The governor is considering multiple issues as he determines whether Kentucky will expand Medicaid eligibility.  Along with affordability for the state, he is also looking at potential economic impact through jobs and investment created by possible expansion, as well anticipated changes in health outcomes for newly-eligible Kentuckians."

That is also the case with There has still been no response from Humana Inc., which does much of its business through government-financed health plans. The Louisville-based insurance company was asked if it has had discussions with the Beshear administration about the idea of a Medicaid expansion that would use federal money to buy, or subsidize the purchase of, private health insurance.

"Beshear said Monday that he is getting a lot of pressure from the medical field – particularly hospitals – to green-light the expansion," Beth Musgrave of the Lexington Herald-Leader writes. "Hospitals will lose additional money they receive through Medicaid on Jan. 1 as part of the Affordable Care Act. Hospitals in Ohio and other states have also put pressure on state governments to expand Medicaid rolls."

Beshear said, “I think they look at the expansion as a means to at least replace some of that (money) that they are going to lose.”

Many Republicans have opposed expansion, "saying that the state could not afford it," Musgrave writes. "The Republican-led state Senate passed a bill during the legislative session that would have required that the two-term Democratic governor get legislative approval before expanding the health care program. But the measure died in the Democratic-controlled House. Beshear could expand the program via executive order."

Beshear said today, “We have a very large uninsured population and we have a very unhealthy population. Anything that we can do — that we can afford — to make our population more healthy, I”m certainly in favor of doing.” He added, “We are looking long-term as well as short-term from a financial standpoint to see if it makes sense for us.”

While he said he would act within four to five weeks, Beshear gave himself some wiggle room, saying also that he would make the decision by July 1, the beginning of the state's fiscal year. (Read more)

Lawsuit alleges state health insurance exchange is unauthorized

Tea Party activist David Adams filed a lawsuit Monday challenging Gov. Steve Beshear's legal authority to create Kentucky's health insurance exchange without approval from the General Assembly. The governor created the exchange by executive order to offer health insurance plans for Kentuckians under federal health reform, but did not ask the legislature to approve it.

Adams claims state law requires the exchange to get legislative approval, and he seeks an injunction against it. The law allows the governor to temporarily reorganize units of state government and calls for them to be approved by the General Assembly.

Beshear's office says he exercised his constitutional authority to meet the requirements of federal law, reports Jack Brammer of the Lexington Herald-Leader.

Adams said in a telephone interview, "There is nothing in the constitution that allows him to set up a new bureaucracy that taxes, gains fees or spends money without legislative approval." He added, "This isn't about politics. It is simply about gubernatorial authority in the absence of legislative approval."

Kentucky has received about $250 million from the federal government to cover the initial costs of exchange, but Adams said that is being spent rather quickly and funds will be exhausted by 2014, he said. The state will be responsible for all funding for the exchange beginning in 2015; it plans to fund it with fees from participating insurance companies.

Kentucky is one of 17 states that the federal government approved to build its own exchange, which will be operated by the Cabinet for Health and Family Services and is expected to help insure more than 600,000 Kentuckians. (Read more)

Beshear vetoes prompt-pay bill but takes several steps to address problems in Medicaid; he and Haynes say it's working

Gov. Steve Beshear has vetoed the bill designed to make Medicaid managed-care firms pay health-care providers more quickly, but is taking administrative steps to address the issue.

Beshear said he agreed with the intent of House Bill 5 but it might have interfered with the contractual relationship between the state and the four managed-care companies. The bill would have subjected that relationship to the state Department of Insurance's review and investigation process for private-insurance payment complaints. 

"That language would have resulted in excessive costs for state government and taxpayers due to the expansion of the review process beyond the current parameters used for private insurance," Beshear's office said in a press release.

Instead, Beshear ordered the department to take over responsibility for review of prompt-payment complaints from the Department for Medicaid Services. "If improper payment practices are discovered, DOI can impose sanctions," the release said. He also ordered the department to audit each of the managed-care firms operating statewide – Wellcare, Coventry Cares, and Kentucky Spirit – at their cost.

Meanwhile, the firms have agreed to meet with every hospital they have under contract to reconcile outstanding accounts.  "This effort will begin immediately and continue until every hospital’s accounts receivable has been reconciled," the release said.  "The results will . . . be made public, in order to provide transparency and accountability." The firms have  agreed to meet with any other provider who wants a meeting.

Also, the Cabinet for Health and Family Services will hold eight regional forums for providers, managed-care firms, and Insurance Department representatives to discuss concerns and how to improve the system. Part of this effort will focus on "emergency room management that meets community needs without an ER operating as a de facto primary-care office," the release said. "A key component of controlling costs and improving health in a healthcare system is to provide the right treatment in the most cost-effective setting."

CHFS Secretary Audrey Tayse Haynes said the switch to managed care, made in November 2011, is working. “We are already seeing a tremendous increase in the use of preventive services, which improve health-care outcomes, while also reducing the enormous costs for treating chronic health conditions” such as diabetes-related amputations, she said.

Beshear said his plan would solve "lingering implementation problems" with managed care "while preserving the significant improvements in patient care and health care cost savings."

"Getting our people healthy and keeping them that way is not just good health policy, it’s good economics," Beshear said. "That’s why we will never return to the old fee-for-service system.  This is a significant cultural shift in medical care that has already happened across the country in both the private insurance market and in the Medicaid system."

Senate sends bill for prompt payment by managed-care firms to Beshear, who won't say whether he will sign or veto it

A bill aimed at resolving payment disputes between medical providers and Medicaid managed-care companies passed unanimously Monday in the Senate, and has been sent to Gov. Steve Beshear for his consideration.

House Bill 5, sponsored by House Speaker Greg Stumbo, D-Prestonsburg, would apply existing prompt-payment laws to managed-care firms and would set up an appeal process in the Department of Insurance to handle disputes between them and medical providers. Those claims are now handled by the Cabinet for Health and Family Services, which administers Medicaid and has had some problems with the bill.

Hospitals, doctors and other health-care providers have complained that the cabinet is not resolving their payment disputes with managed-care firms, putting many rural hospitals, clinics and health departments in serious financial binds.  Mental health centers have also reported cutting back services.

Asked last night what he would do with the bill, Beshear said the cabinet "has worked with the managed-care organizations and health-care providers to reduce problems during the change, and many concerns have been addressed.  However, I recognize that some issues persist.  I will review this bill carefully.”

Beshear has 10 days, excluding Sundays, to decide whether to veto the bill, sign it into law or allow it to become law without his signature. Stumbo said that if bill is vetoed it would likely be House Bill 1 in the 2014 session, reports Jessie Halladay of The Courier-Journal. The bill is a top priority for many health-care providers.

Legislature eases physician assistant rules; nurse practitioners' prescription power, Medicaid prompt-payment bills, others linger

By Molly Burchett and Al Cross
Kentucky Health News

The Kentucky General Assembly has joined other states in easing the restrictions on physician assistants’ medical practice, but has held up a similar move for advanced registered nurse practitioners. Both issues relate to the shortage of medical practitioners in many Kentucky counties, and the quality of medical care.

The Senate added the physician assistant language of Senate Bill 43 to House Bill 104, an art-therapy bill, in order to preserve an agreement between the Kentucky Medical Association and the Kentucky Academy of Physician Assistants. It will repeal the law that bans PAs from practicing for their first 18 months unless a physician is on site; one will still have to be available by telephone. The amended bill has been sent to Gov. Steve Beshear for his signature or veto.

The amendment was used because the House had tacked onto SB 43 an amendment from advance practice registered nurses that would have repealed the need for them to have a collaborative agreement with a physicians to prescribe non-narcotic drugs. The KMA opposes that idea.

"It's looking like the doctors win," said Sen. Julie Denton, R-Louisville, who favors the repeal. "I'm not hopeful" it can pass, she said, but added that some physicians also favor it: "With Obamacare coming in, we're going to need all the front-line physicians we can get." Leading opponents of the measure, Republicans Katie Stine of Fort Thomas and Carroll Gibson of Leitchfield, didn't return a call seeking comment.

Nurse practitioners say that SB 43 is necessary to allow them to fill health-care gaps in rural Kentucky and address the state's shortage of primary-care providers. The Kentucky Coalition of Nurse Practitioners and Nurse Midwives says in an article prepared for Kentucky newspapers that NPs have never been required to practice under physician supervision and 17 states allow full prescribing authority for non-scheduled medications.

The Medicaid prompt-payment bill, HB 5, went to a conference committee after the House refused to go along with Senate changes, and may be considered when the legislature returns later this month, ostensibly to consider any bills Beshear vetoes. The bill would apply prompt-payment laws to managed-care organizations and would move Medicaid late-payment complaints to the insurance department; those are now handled by the Cabinet for Health and Family Services, which administers Medicaid.

In the final crunch to pass legislation before the veto recess, lawmakers attached seven health care-related bills to HB 366, which had focused on identifying congenital heart disease in newborns. It had 10 additional measures "hung on it like a Christmas tree before the free conference committee of House and Senate members," reports Ryan Alessi of cn|2's "Pure Politics."

The bills still hanging on the measure, dubbed the "healthy Christmas tree," are:

• HB 187, addressing a free prescription-drug program for under-insured Kentuckians.
• HB 79, which would exempt licensed health care providers from being disciplined for prescribing naloxone in the event of an overdose.
• HB 387, which aims to provide nutritional supplements for low-birth-weight newborns.
• SB 201, which addresses licensed diabetes educators.
• SB 38, to require Medicaid to accept provider credentialing by a Medicaid managed-care organization.
• SB 108, relating to managed-care contracts with the IMPACT Plus program, a behavioral health program for children.

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

Bill encouraging schools to stock EpiPens to stop deadly allergic reactions will become law

A bill encouraging Kentucky schools to stock EpiPens, or epinephrine auto-injectors, to stop anaphylaxis, a life-threatening allergic reaction, has passed will soon be signed into law by Gov. Steve Beshear.

When someone has anaphylaxis, the sooner you use an EpiPen, the better the outcome can be, said Thomas Sternberg, an allergist at Graves-Gilbert Clinic in Bowling Green, told Alyssa Harvey of the Daily News.

Under House Bill 172, schools could keep at least two EpiPens in case of emergency, and school boards would develop and approve policies and procedures for managing a student’s life-threatening allergic reaction, reports Harvey.

The bill also helps schools receive or buy the auto-injectors through local health departments and directs the state Department for Public Health to develop clinical protocols for using the auto-injectors in schools. Harvey reports that EpiPens can be donated to schools, and the EpiPens for Schools Program will provide up to four free auto-injectors per school year; if more are needed, they can be purchased at a discounted rate.

"You don’t know when someone could have an anaphylactic reaction,” Rep. Addia Wuchner, R-Florence, who sponsored the bill, told the Daily News. She alluded to an incident in Virginia, where a 7-year-old student died last year after an anaphylactic reaction, and no medications were available at the school to treat her. "There could be a hero in the school who was able to reach for that epinephrine pen and save a child’s life and not a tragedy like in Virginia,” Wuchner said. She filed the bill late in the 2012 session, but the language has been revised for this year's session to encourage rather than mandate schools to stock EpiPens.

Amy Wallace, treasurer and former president of the Bowling Green area's Food Education Allergy Support Team, told Harvey she was disappointed schools will not be required to make necessary provisions, but said advocates of the bill are happy to see that the problem is being addressed. (Read more)