Kentucky among states selected to study, address expensive problem of 'superusers' of emergency rooms

Kentucky is one of a few states teaming up with the National Governors Association to address the expensive problem of uninsured or Medicaid-covered "superusers" who over-use hospital emergency rooms or other costly health services instead of lower-cost alternatives like primary care.

“I’m proud Kentucky has been chosen to participate in this important program,” Gov. Steve Beshear said in a news release. “Across the nation, an understanding has been growing that we must focus our efforts on providing the best in coordinated care, helping to direct individuals who may be using more expensive, less effective services to more cost-efficient preventive services that provide better health outcomes in the long run. It’s by achieving these outcomes that we will build a healthier future for Kentucky.”

Kentucky, Alaska, Colorado, Kentucky, New Mexico, Puerto Rico and West Virginia will participate in a policy academy designed to help them create systems for these "superusers", enabling state officials to confront rising Medicaid expenditures while improving quality of care and health, says an NGA release.

These "superusers," sometimes called "super-utilizers" or "frequent flyers," often go to a hospital or emergency room for recurring health issues that can be treated more effectively and less expensively in other ways. Kentucky Medicaid spent more than $219 million on emergency-room use in 2012, and 4,400 Medicaid recipients used ERs 10 or more times during that year, says Beshear's release.

“There’s a handful of people who drive most of our spending,” Dan Crippen, the executive director of the governors’ association, told Kelsey Miller of Kaiser Health News. While the median ER visit cost $615 in 2009, an office-based visit with a physician cost $361, according to the federal Medical Expenditure Panel Survey.

“Kentucky has too long lagged behind in health rankings, and now is the time for us to begin truly moving the needle in the right direction,” said Cabinet for Health and Family Services Secretary Audrey Tayse Haynes. “By participating in this national effort, we can learn what has worked for other states and share Kentucky’s experiences as well.”

State leaders will first meet as a group with consultants from various health-care sectors, then officials will spend 18 months implementing the plans in their communities, says Miller. Funding for the effort is provided by the Robert Wood Johnson Foundation and the Atlantic Philanthropies.

10 years ago, Lexington's smoking ban started creating a healthier city and a movement among others in Kentucky

A decade ago, Lexington took a bold step by enacted the state's first public smoking ban, in a city that once proudly touted its status as the "World's largest burley tobacco market." As smoke-free supporters and Lexington residents celebrate the ordinance's 10th anniversary Monday, a recent editorial in the Lexington Herald-Leader highlights the dramatic benefits that have followed this historic step.

After the smoking ban took effect in April 2004, the city had 22 percent fewer emergency room visits for asthma in the next 32 months, and the Fayette County smoking rate has dropped from 26 percent to 17.5 percent, the editorial notes. These positive changes have yielded health-care savings of $21 million a year, says the University of Kentucky's Tobacco Policy Research Program.

"There is nothing quite as cost effective as smoke-free policies," the editorial quotes Ellen Hahn, a UK nursing professor and director of the Kentucky Center for Smoke-Free Policy, as saying. "We predict a 32 percent decline in smoking rates if Kentucky were to go smoke-free. That would save billions in health care costs and reduce premature death and suffering from the chronic diseases that plague Kentucky."

The editorial also says Lexington led the way for Louisville and 20 other municipalities to protect citizens from secondhand smoke; a third of the state's population now lives in a smoke-free environment, and many of the initial fears about a smoking ban are now extinguished.

Kentuckians feared economic harm, the shunning of Lexington restaurants and bars and suffering tourism or downtown attraction, but the opposite predictions came true, says the editorial. The scene in downtown Lexington is "far richer than 10 years ago... It once was an article of faith that tobacco would always be king in Kentucky, yet tobacco declined and agriculture has thrived."

Eye doctors warn about danger from fireworks, even sparklers; optometrists provide safety tips

The Fourth of July goes hand in glove with firework displays. Most families protect parents and children against the dangers of fireworks, but thousands still visit the emergency room every year, many with eye injuries.

According to a report from the U.S. Consumer Product Safety Commission, about 9,600 people were treated for injuries due to fireworks in U.S. emergency rooms during 2011; it says 17 percent of those injuries were to the eyes, and about 45 percent of those eye injuries involve children age 15 or under. Most eye injuries were bruises, cuts and other diagnoses that included foreign objects in the eye, and one in six fireworks-related eye injuries result in permanent vision loss or blindness, says the American Academy of Opthalmology.

“Celebrating the Fourth of July with fireworks is a great tradition, but safety needs to be the top priority,” Dr. Jon Shrewsbury, an optometrist in Beaver Dam, Ky., said in a Kentucky Optometric Association release.  “Children are especially vulnerable to injury from fireworks, particularly sparklers since they are handled at such close range.”

The innocent-looking sparkler can be very dangerous, especially to children, who are most likely to play with them. They heat up to 2,000 degrees or hotter, and are the primary cause of fireworks-related visits to emergency rooms. In addition to not allowing younger children to play with sparklers or fireworks and ensuring that older children are supervised by an adult when doing so, the KOA offers these tips to help protect and preserve eyesight during firework season:

· Discuss firework safety with children and teens prior to the Fourth of July holiday.
· Never leave them unsupervised near fireworks.
· Wear protective eyewear when lighting and handling fireworks of any kind.
· Store fireworks, matches and lighters in a secure place where children won’t find them.
· Be aware of your surroundings, and only light fireworks when family, friends and children are at a safe distance.

“If a firework-related eye injury does occur, always follow up with a full optometric eye exam,” Shrewsbury said. “An optometrist will help ensure that the injury heals correctly and will continue to monitor for future vision problems.” To find an optometrist in your area, click here.

Haynes: Medicaid case managers threatened, and more bumps ahead, but state beginning to see advantages of new system

By Al Cross
Kentucky Health News

Some Medicaid case managers' lives have been threatened because they have tried to get Medicaid patients to go to primary-care doctors instead of emergency rooms, Health and Family Services Secretary Audrey Haynes said today.

Haynes, right, and two key legislators talked about managed care, the possible expansion of Medicaid under federal health-care reform, and the insurance exchange being set up under the law, at the Kentucky Chamber of Commerce's annual policy conference in Lexington.

The case managers work for insurance companies that oversee Medicaid under contracts with the state. Haynes said the cases of threats have been reported to police.

One key to making managed care work is more prevention, Haynes said, but "People want to go to the emergency room." She mentioned one case of a Medicaid recipient who had gone to emergency rooms 57 times in 30 days.  Under federal law, hospital emergency rooms generally cannot refuse to treat patients who present themselves.

"They will abuse the emergency room because that is the system they know," said Republican Sen. Tom Buford of Nicholasville, chairman of the Senate Banking and Insurance Committee.

Haynes said, "Our people are getting sicker, especially folks on Medicaid, and we can't allow people to use high-intensity . . . high-cost services."

Haynes, an appointee of Democratic Gov. Steve Beshear, and her cabinet have come under fire for not putting more pressure on managed-care companies to make timely payments to hospitals, doctors and other providers. She was not asked about that, but alluded to it: "There have been lots of bumps in the road, and some of them may continue."

But she said the state is only beginning to see what can be gained from the new system, which is supposed to save hundreds of millions of dollars. "We were one of the last states to look at managed care," she noted.

Buford said "I don't disagree with anything she has said," but said the Beshear administration rushed into managed care. "I don't think there's much we can do. We are in this lady's hands on this issue and we'd better support her."

Buford predicted that Beshear would try to expand the Medicaid program to households earning up to 138 percent of the poverty level, a key part of the federal reforms but one the Supreme Court said must be optional for states, not mandatory.

"It will be difficult for him to say no to the expansion of the Medicaid rolls," which the federal government would entirely cover in the first two years, Buford said. That would be reduced to 90 percent by 2020, but Buford predicted that the federal government will ask the states ot accept less because it won't have the money.

Haynes said Beshear would like to expand Medicaid, and a "deep-dive economic analysis" is being done now, with the help of the federal Department for Health and Human Services, to establish the financial parameters. "We probably won't know for several months because we're still getting a lot of guidance from HHS," she said.

Haynes said expanding Medcaid would bring $10 billion to $12 billion to the state, having a significant economic impact, and the managed-care companies came to the state expecting the expansion.

She said HHS is calling the state's effort to set up the insurance exchange, a marketplace for health coverage, a model for other states.

However, Buford said the Senate, which has 24 Republicans and 14 Democrats, in a state that voted against President Obama by a similar margin, will probably allow Beshear to re-issue the excutive order creating the exchange rather than adopting it into law. "That would be impossible to make it through the state Senate in the next two years," he said.

Buford said he favors a federal exchange as "the best bang for your buck on premium costs," but said the state is too far into its own exchange to do that now. However, when the grant funds being used to create it run out, "I don't know what this exchange will be," he said, indicating that the legislature would not authorize the fees on insurance companies that the exchange plans to levy to finance its operations.

Buford made many criticisms of the reform law, but Rep. Susan Westrom, chair of the House Health and Welfare Committee, asked, "If this is such a horrible thing," how would it be passed by Congress and "upheld by the Supreme Court?"

Report: Bounce-house injuries to children have skyrocketed

A new report out today in the journal Pediatrics warns that, on average, 31 children a day are transported to U.S. emergency departments for treatment of bounce-house injuries, including fractured bones and muscle damage. "If this was an infectious disease, we'd call it an epidemic and it would be on the front pages all over the country," said study co-author Dr. Gary A. Smith, director of the Center for Injury Research and Policy at Nationwide Children's Hospital in Columbus, Ohio. (Associated Press photo)

Randy Dotinga of HealthDay reports that in the 15-year period between 1995 and 2010, the rate of bounce-house injuries jumped 15-fold, with the number escalating in the last few years of the study. In the new study, published online Monday and in the December print issue of Pediatrics, researchers found the most common bounce-house injuries were fractures, strains and sprains. Concussions and cuts were more common in boys. The average age of those hurt was 7.5 years old. (Read more) 

Poll: A quarter of Cincinnati and Northern Kentucky residents skip doctor visits and are behind on their medical bills

Nearly one-quarter of adults throughout Greater Cincinnati and Northern Kentucky did not always go to the doctor when they needed to during the past year, according to a Cincinnati Enquirer poll. And of those that did seek medical attention last year, a little more than one-quarter (27.5 percent) said they were not able to pay all of their medical bills. The results may not be all that surprising but do highlight health care costs’ impact on the average American. “It’s very common to see people making decisions between food and medicine,” said Kate Keller, senior program officer at the local policy group the Health Foundation of Greater Cincinnati.

Local doctors say they’re seeing all sorts of ruses from patients to try to avoid even a $25 co-pay. Rob Tracy, a family doctor at St. Elizabeth Physicians in Cold Spring (left, with patient Kathy Schneider), said some patients call and ask him to call in a prescription to the pharmacy without a visit. That allows them to avoid a co-pay on the office visit. He said delaying such visits only deepens the impact of chronic conditions and ups the costs when those patients are forced to local emergency rooms when their symptoms fail to improve. (Enquirer photo by Carrier Cochran)

Peale notes that these issues are intrinsically involved with the Patient Protection and Affordable Care Act, which was cemented by President Barack Obama's victory Tuesday. It is set to go into full effect in 2014. "The law will help insure as many as 30 million more people by requiring every American to buy insurance or pay a penalty, requiring employers to offer benefits or pay a penalty, and requiring insurers to accept anyone who applies," Peale writes. With the new law in place, the average person will likely be paying $4,775 out of pocket, including premiums and co-pays. (Read more)

Northern Kentucky group forms in response to what some consider 'epidemic' of heroin use in their area

Ashel Kruetzkamp with a vial of Naloxone
HCl, used to treat those who overdose
on heroin. (Photo by Patrick Reddy)

Heroin use is reaching such high levels in Northern Kentucky that experts are calling it "a plague." The problem is so dire that local agencies are coming together to form the Northern Kentucky Heroin Impact and Response Workgroup.

Cincinnati Enquirer reporter Terry DeMio reports that the group includes leaders from St. Elizabeth Healthcare, law enforcement, addiction treatment programs, the Northern Kentucky Chamber of Commerce and those who have been impacted by heroin. The goal of the group is “to fight, treat and prevent the destructive force of heroin in our community,” said Dr. Jeremy Engel, a family doctor with St. Elizabeth Physicians, Bellevue. Engel spearheaded the effort based on his belief that heroin use in the area has hit “epidemic” levels.

Engel points to first nine months of 2012 when St. Elizabeth Healthcare treated 311 heroin overdose patients in the emergency rooms of its five hospitals. For the same time period in 2011, the heroin overdoses presented in those emergency rooms numbered 186. With help from the chamber, St. Elizabeth Healthcare and others, Engel is forming the task force under the NKY Vision 2015 umbrella. (Read more)

State's hospitals see impressive growth spurt from nearly $1 billion in capital investment

Kentucky’s major hospital systems are going big, making high-profile, technology-forward capital investments across the commonwealth. Josh Shepherd of The Lane Report writes that every sector of the state is part of the hospital boom. The state's cumulative total of investment since 2010 is roughly a billion dollars, notes Shepherd, and has meant hundreds of construction and, soon, medical and other hospital-related jobs. Here's the list of the most notable construction projects now under way:

Owensboro Medical Health System,  $385 million, a new complex (pictured, above) that will allow expansion for the next 50 years, completion date: summer 2013.

Norton Healthcare System, Louisville, converting Suburban Hospital into Norton Women's Hospital and Kosair Children's Hospital, $120 million, completion date: 2013.

Pikeville Medical Center, new office building and parking facility, $130 million, completion soon.

Baptist Health, Lexington, expansion of Central Baptist Hospital medical services complex with parking structure, $200 million.

University of Kentucky Healthcare, Chandler Medical Center, $750 million, includes new plans for Shriners Hospital for Children.

Frankfort Regional Hospital,  $8 million expansion, emergency department.

Trigg County Hospital, $7 million, surgery and rehabilitation unit.

Lifepoint Hospitals-owned Clark Regional Medical Center, $60 million, 79-bed hospital. (Read more)

Rural health care is a notch below care in urban areas, but its costs are lower and its emergency rooms are faster, study finds

A national study has found a narrow gap between the quality of health care in rural and urban settings, but it does recognize the "significant differences" differences between urban and rural care.

The report is an update to "Rural Relevance Under Healthcare Reform: A Tracking Study," by iVantage Health Analytics, and evaluates performance measures across physician, outpatient, hospital and emergency room settings. According to a press release, the report reveals that in Medicare could save about $7.2 billion if costs per patient were the same in rural and urban settings. The report also finds that for rural patients, physician payments are 18 percent lower and hospital payments are 2 percent lower than in urban areas, but outpatient payments are 14 percent higher. The overall cost per Medicare patient is 3.7 percent lower for rural patients.

Rural emergency care is faster overall than urban emergency room care, with rural patients seeing a doctor 30 percent faster (once the patient gets to the hospital, we should add). This results in fewer hospital admissions. The full report can be accessed here.

New law will allow officers to make arrests in emergency-room assaults that they do not witness

Emergency-room workers who treat individuals under the influence of drugs or alcohol will have greater legal protection, and those who misbehave in ERs will have less protection, under a law that will take effect next month.

The measure, sponsored by Sen. John Schickel, R-Union, will allow peace officers to make an arrest or issue a citation for a fourth-degree assault that occurs in a hospital emergency room, even if the officer didn’t witness the crime, as long as the officer has probable cause to believe the offense occurred.

“Hospital emergency personnel treat individuals in the worst of conditions – and sometimes that means putting themselves at risk, if a patient comes in intoxicated or high,” Gov. Steve Beshear said at a ceremonial signing of the bill today.  “This law gives medical staff the security of knowing that an offender will be held accountable for an assault that takes place when they’re brought in for care.”

Under current law, a hospital worker has to swear out a warrant alleging assault. Fourth-degree assault is a Class A misdemeanor, punishable by up to a year in jail.

ER at Louisville's University Hospital says it is pushed to brink; many other hospitals seeing more emergency patients

Louisville's University Hospital is straining to meet the vastly increased demand of patients coming to the emergency room. Last year, there were 58,010 visits to the ER to the facility, which is meant to act as a safety net for indigent care. That's way up from 33,058 in 2006.

"The safety net is frayed and getting ready to break completely," said Bill Wagner, executive director of Family Health Centers and ex-officio member of the Louisville Metro Board of Health. "The current situation isn't sustainable ... The system is broken and it's gonna get worse."

"The rising number of uninsured patients is a major driver" of the exploding ER volume, reports Laura Ungar of The Courier-Journal. Between 2008 and 2010, 663,000 Kentuckians — or 15.5 percent of the population — lacked health insurance. In 2010, University Hospital received almost $69 million from federal, state and local governments to pay for indigent care, but it fell short by $20 million of the actual cost.

The strain has strapped the facility for cash to make improvements such as adding beds — to deal with overflow, 12 have been installed in the facility's hallways — or upgrading technology. Recently, University tried to merge with Jewish Hospital & St. Mary's HealthCare and Catholic Health Initiatives to gain an influx of funds, but Gov. Steve Beshear blocked the move, since it would mean losing University as a public asset. University is now looking for other merger options.

Some of the increase in visits is due to the fact that fewer people are leaving the ER without being treated because of long waits. In 2009, 15 percent left for that reason, but "That's down to 1.7 percent this year, after a push to attend to patients immediately and get physicians to see them more quickly," Ungar reports.

But there's evidence there are just more patients coming to the hospital for treatment, as is the case in a program called First Care, meant for patients with less serious ailments, such as tooth abscesses. "Two-thirds or more of First Care patients are uninsured, and in recent years increased demand has led the hospitals to expand its beds from six to 13, become a 24-7 facility and hire a handful of new nurse practitioners," Ungar reports. "First Care cases, which are not included in the hospital's ER volume totals, rose from 8,353 in 2006 to 20,546 last year." Of those patients two-thirds or more were uninsured.

Other area hospitals have also seen increases in ER visits. From 2006 to 2010, visits increased from 45,377 to 49,462 at Kosair Children's Hospital; from 27,836 to 29,357 at Norton Hospital; and from 29,779 to 33,508 at Jewish Hospital. Some hospitals have seen slight declines, such as Baptist Hospital East, but that may be due in part to its retail clinics in Walmart and increased numbers of urgent-care centers. (Read more)