Newspaper in Alabama, a similar state in many ways, gives its readers a look at Kentucky's embrace of Obamacare

The latest newspaper to look at Kentucky's embrace of Obamacare is in Alabama, a state that offers almost a mirror image of Kentucky: another Southern state with a very high poverty rate and very low health outcomes.

"Politically, both are deeply conservative, and both are home to wide expanses of rural poverty," writes Tim Lockette of The Anniston Star. But Alabama's approach to Obamacare "couldn't be more different," because it has rejected Medicaid expansion and a state-run insurance exchange.

The difference in Obamacare outcomes really is as stark as it looks, Douglas Scutchfield, a professor of health services research at the University of Kentucky, told Lockette. Scutchfield, who taught in Alabama for years, said that in demographic terms, "The only real difference is that most of your uninsured folks are black, and most of our uninsured folks are white. We have the Appalachians, you have the Black Belt." In politics, the states' governors have made a big difference.

While Democratic Gov. Steve Beshear expanded Medicaid and set up an exchange, Republican Gov. Robert Bentley and other state officials rejected both the Medicaid expansion and an exchange, citing costs.

Bentley cited the state's struggle to even cover the new enrollees that had been added since the Great Recession. Some Kentuckians are concerned about how the state will pay for its expansion. The federal government will pay all the cost of care for the newly eligible from 2014 through 2016, when the state will increasingly pick up part of the tab, rising to 10 percent by 2020. Beshear, citing a study, has said the expansion will expand the state's health-care industry enough to pay for it, and make the state more attractive to employers in the long run.

Bentley told Lockette that Alabama could not have had success with its own exchange because there is basically one major insurance company in Alabama, Blue Cross Blue Shield. But Alabama could have had more competition if the state had set up a nonprofit, cooperative insurance company, which Kentucky did.

"In Kentucky, everybody has an option," Cara Stewart, a fellow at the Kentucky Equal Justice Center, told Lockette. "Unless you're undocumented or in jail, there's something for you," she said.

Still, Stewart "said she’s run into difficulty working with people who already have employer-provided insurance, but want to switch to the exchanges to cover family members," Lockette report. Also, "The Kentucky system has refused to recognize some enrollees because they don’t have a credit history, health care advocates say." (Read more)

Kids Count shows Ky. tops in smoking by pregnant mothers, has a wide range of local data about children's well-being

By Molly Burchett
Kentucky Health News

The annual Kids Count report on children's well-being, released Tuesday by the Annie E. Casey Foundation and Kentucky Youth Advocates, says the state leads the nation in smoking by pregnant mothers and more than one in four children in Kentucky lived in poverty in 2012. It argues for improvements in preventive care and newborn health throughout the state.

The report is part of the 23rd annual release of the County Data Book, which contains a wide range of county-by-county data that are indicators of children's well-being. Unlike previous annual reports, this one ranks Kentucky counties on overall child well-being and on four domains: economic security, education, health, and family and community strength.

The county-by-county assessment found seven counties that scored substantially higher on overall child well-being rankings: Boone, Calloway, Meade, Oldham, Spencer, Washington, and Woodford. The six counties clearly at the bottom, in descending order, were Owsley, Knox, Elliot, Martin, Fulton, and Clay.

Health affects almost every aspect of child well-being. On the four scores in the Health domain (smoking during pregnancy, low-birthweight babies, asthma hospitalizations and teen births) Oldham and Boone counties scored much higher than other counties, and Bell and Fulton counties, in the southeastern and southwestern corners of the state, scored the lowest.

The chart to the right indicates how much worse Bell and Fulton ranked than similar counties. 

The data from this year’s Kids Count book, as well as new and historical data for the many other indicators Kentucky Youth Advocates tracks, can be found at the Kids Count Data Center by clicking here. The data cover counties, school districts, cities and Metro Louisville council districts.

Based on the latest available data from 34 comparable states, in 2011 Kentucky had the highest rate of women who smoked during pregnancy. Nationally, 9 percent smoked during pregnancy while 23 percent did in Kentucky.


Babies born to mothers who smoked during pregnancy are more likely to suffer low birth weight, premature birth and infant death, and almost one in every 10 babies in Kentucky were born at low birth weight, says the report. While the national average for low-birthweight babies is 8.1 percent of all live births, low-birth-weight babies made up more than 14 percent of births to mothers in Lawrence, Lewis, Martin, and Wolfe counties.

“We know smoke-free policies will reduce smoking during pregnancy and reduce the number of babies born at a low birth weight,” said Terry Brooks, executive director of Kentucky Youth Advocates. “It’s time to do what works and enact a comprehensive, statewide smoke-free law. We need to protect all children, not just those lucky enough to be born in a smoke-free community.”


In addition to babies born to mothers who smoke during pregnancy, those born to teenage mothers are at increased risk of low birth weight and other health problems, says the report.

While the state's rate of births to teenage mothers has declined each year since 2007, it remains higher than the national average, which has shown a similar decline. There were 43 teen births for every 1,000 females aged 15-19 in 2011, compared to the national rate of 31. The report says Oldham County had the lowest rate of teen births (1.3 percent) while McCreary County had the highest (8.6 percent). It also says the most effective way to keep reducing teen births rate is to educate young people about sex and risky sexual behaviors, and to provide access to contraceptive methods.

While Kentucky has made progress in providing health-care coverage for children and newborns, the state is among the leaders in childhood obesity, diabetes and asthma, and has a greater-than-average number of children with disabilities or other chronic health problems like cystic fibrosis or heart disease, the report says. "Yet families face many hurdles when they seek treatment for their children. They may lack health insurance or lack transportation," it says. "Some areas do not have enough health-care providers."

Report calls for investments in Kentucky children

Higher teen-birth rates are found among communities of color, which are also disproportionately affected by poverty, says the report. One in four of Kentucky's children live in poverty.

This rate and the number of unemployed parents, which went up by 24,000 between 2007 and 2012, have increased since the 2008-09 recession. Poverty rates in 2012 were highest among African American children (52 percent) and Hispanic or Latino children (41 percent). Living in a high-poverty area puts a child at greater risk for poor health and educational outcomes.

A widespread lack of economic security is perhaps the greatest concern for many kids in the state, says the report. The Kentucky Cabinet for Health and Family Services recently cut spending for the Child Care Assistance Program and the Kinship Care Program. As a result, 8,700 families lost assistance for child care, and financial support was also eliminated for main relatives who raise children unable to live with their parents. The report calls for restoration of these programs and more investments in Kentucky’s children.

"Taken together, the data tell a clear story: Kentucky kids need the attention of Kentucky leaders," says the report. “It’s time to make children and families a priority in our state by investing in programs that keep parents working and promote economic security,” said Brooks.

Click here to get more information about the Annie E. Casey Foundation or view its policy reports.

Book chronicles Hall's 40-year battle for health, against poverty

By Molly Burchett
Kentucky Health News

Eula Hall has been called an angel, dynamite, a force to be reckoned with, and a living legend. She has dedicated her life to combating poverty in Appalachia and providing health care to those in need. Some say that she has done more for health care in Eastern Kentucky than any other single person.

Even at age 86, Hall continues to fight against poverty, providing health care to those who need it. Hall’s story will be told in a new biography, Mud Creek Medicine: The Life of Eula Hall and the Fight for Appalachia, written by Pikeville native Kiran Bhatraju.

Hall grew up in Pike County and moved to the Mud Creek community in adjoining Floyd County at the age of 16. She witnessed the devastating impact of poverty, including lack of health care, and became a staple in the Mud Creek community, someone to whom people would turn when they were sick or hungry.

In 1973, at age 46, Hall opened the doors to The Mud Creek Clinic in Grethel, Ky., a rural community in Floyd County, with a $1,400 donation and the help of two local doctors. The clinic rented space at first, but Hall quickly moved her family out of a nice home in Mud Creek so the home could be converted into a clinic to provide health care regardless of patients' ability to pay.

For 40 years, Hall’s clinic has weathered hard times, reports Jonathan Meador of WKMS in Murray. But, with resiliency and the help of the community, the clinic now operates in five locations and continues its mission: To provide Appalachia’s poorest residents with health care and dental services they can afford.

Hall says things have improved in Appalachia in the last 40 years, but she is still concerned that growing income inequality in America is leaving too many of her patients behind, reports Meador. Appalachians still face numerous economic and health disparities that are deeply rooted in poverty.

"We still have people who don't have enough to meet their needs," Hall told Meador. "These are good people; these are honest people, hard workin' people, when they were able. But you know, they're disadvantaged now, and they just don't have the means to meet their needs and stuff, and somebody has to be concerned; somebody has to look out for 'em."

Bhatraju says that proceeds of his book will go toward funding the clinic. Click here to purchase a copy of the book.

Not only may you not get to keep your plan under Obamacare, you might not be able to keep your doctor; there are reasons

By Molly Burchett
Kentucky Health News

Part of the sales pitch for the federal health-care reform law was that people could keep their doctors, but many Americans and some Kentuckians won't because insurers are excluding some hospitals and doctors from policies in an effort to make the new, standardized plans on the insurance exchanges more affordable.

Eleven Kentucky hospitals have filed complaints with the state Department of Insurance, saying Anthem's policies on the state's exchange include only a narrow network of providers, excluding them. Limiting the number of providers on the exchanges is one seldom-mentioned way insurers are trying to reduce premiums for new policies.

The department upheld three of the complaints because the hospitals said they would be able to serve at least four of the state's eight Medicaid regions, a concern that led to their original exclusion. The department has since ordered Anthem to accept applications from those hospitals- UK Healthcare, Our Lady of Bellefonte in Ashland and Highlands Regional Medical Center in Prestonsburg, reports Mike Wynn of The Courier-Journal.

Insurance-company research shows that consumers’ highest priority when shopping for insurance is price. To compete on price, insurers contract with doctors and hospitals who charge them the lowest fees. Some prestigious and well-known academic medical schools that charge higher prices are being excluded from exchange plans, Forbes magazine reports.

These same market forces may also limit the ability for small hospitals and providers to provide care through exchange plans if their health systems lack economies of scale that enhance their negotiating power. UK has already negotiated a deal with Anthem, and the company's negotiations with Highlands and Bellefonte are ongoing.

Anthem is not the only insurance company with narrow networks. Stephen Miller, vice president of finance for the Kentucky Hospital Association, said other Kentucky insurers are also using network restrictions to "steer patients to hospitals with the best rates for the insurer," Wynn reports. Around the country, many plans have more narrow networks than previous plans in order to limit premiums, Politico reports.

This tactic lowers expenses for the insurers by bypassing higher-priced health systems but means that some patients may have to change doctors or hospitals, report Sandhya Somashekhar and Ariana Eunjung Cha in The Washington Post: "The result, some argue, is a two-tiered system of health care: Many of the people who buy health plans on the exchanges have fewer hospitals and doctors to choose from than those with coverage through their employers."

Consumer advocates say tighter networks will disrupt care and limit access for middle-and lower-income consumers, who may be sicker than the average consumer, reports Kaiser Health News: "Narrow networks present the opportunity for lower costs via discounts from select hospitals and doctors in return for patient volume. But smaller networks can require members to travel farther for care or make it hard to get appointments."

Anthem says limiting networks helps insurers save money, which is passed on to patients through reduced premiums. Critics say healthy people must pay more than their fair share to help provide coverage for sicker people. Health-reform advocates say the law's trade-offs are acceptable costs in exchange for getting health coverage to more needy people, but some wonder about that if they have to drive 30 miles to get it.

What is a narrow network?

An insurance company's health-care network is a group of physicians, hospitals and other providers that agree to provide medical services at pre-negotiated rates. The wider the insurance company's network, the more doctors and hospitals from which you can choose without paying more to see an out-of-network provider.

Anthem spokesman Tony Felts said the smaller networks are an attempt to keep exchange plans affordable and that the company worked hard to design products that would attract consumers to them. Four other companies are offering policies on Kynect, the state exchange: Humana, United Healthcare, Bluegrass Family Health and the Kentucky Health Cooperative. Anthem and the cooperative are the only two insurers offering individual plans statewide.

"Many companies have selectively entered the exchanges because they are concerned that they will be dominated by risky, high-using populations who wanted insurance and couldn't afford it" before the law took effect, Gail Wilsensky, a UnitedHealth director, told U.S. News. "They are pressed to narrow their networks to stay within the premiums."

The reform law requires insurers to provide enough doctors and hospitals to ensure quality care, but the federal government offers little guidance on how this is defined. The Kentucky Heath Benefit Exchange says at least 20 percent of available essential community providers in an exchange service area must be in its network, and insurers must contract with at least one of these providers in each county in the service area. However, these regulations don't specify a penalty for not adhering to the recommendation, and there is no guarantee that the network includes your doctor.

Consider a plan's network, premiums and out-of-pocket amounts

Patients may not realize whether or not their doctor is in a plan's network until January, when the new policies take effect. Therefore, consumers should be careful to check the details about an exchange plan's network. Consumers should also be aware of the plan's out-of-pocket costs; the cheapest exchange plans have high deductibles.

On Kynect, insurance shoppers can filter plans to see if a specific provider is included. Insurance Department spokeswoman Gwenda Bond said the agency relies on insurance companies to provide network information to be posted on the exchange. She said the department has experienced some minor issues with this process due to insurers using different names for the same provider.

To address this problem, Kynect also provides a link to each issuer’s web site for their provider directory, said Bond. "The issuer’s provider directory web site should contain the most current list of providers available in the issuer’s network. We continue to work with insurance companies to improve the lists," she said.

"Under Obamacare’s exchanges, people who really want to keep their doctor, at any price, will often have to pay higher premiums for the privilege. And people who prefer lower premiums, above all, might need to choose a different doctor," writes Avik Roy of Forbes.

As Medicaid enrollment grows, fewer providers accept it

At the same time some providers are being excluded by insurance companies or are choosing to exclude themselves, some providers are opting out of the exchanges and are not accepting Medicaid patients. A recent survey by the Medical Group Management Association found that 40 percent of its members are still deciding if they are going to accept insurance offered on the Obamacare marketplaces, CNN reports.

About 56,000 Kentuckians have enrolled in Kynect plans as of Nov. 22, and 82 percent of those are Medicaid plans. According to the Centers for Medicare and Medicaid Services, which administers the Medicaid program, three times more doctors are refusing Medicare patients than three years ago.

Doctors cite Medicare's increasing rules and lowered payment rates as reasons for not accepting Medicaid, and those who will see some Medicaid patients are limiting the number, reports The Wall Street Journal. Doctors also say administrative hassles and delays in getting paid also discourage them from accepting Medicaid, says the Center for Studying Health System Change.

Hospitals across the state have expressed concern about delayed payments from Kentucky's managed care companies as a result of the state's quick transition to a managed care model, and state officials are working to address this problem. Still, Kentucky's Medicaid payment rates are about 72 percent of Medicare rates. The reform law raised Medicaid fees to match what Medicare pays primary-care doctors, but only for two years and after much administrative hassle.

National Rural Health Day to be held Nov. 21, including webinars on current topics

The third annual National Rural Health Day, which brings awareness to rural health issues and current efforts in addressing these issues, will be observed with events nationwide and special presentations in Sterling Heights, Mich., Nov. 21.

The National Organization of State Offices of Rural Health and all 50 state offices of rural health said in a news release that health concerns of the 60 million rural Americans include: a lack of health care providers; accessibility issues, particularly transportation and technology; and affordability, as the result of higher out-of-pocket costs and other factors.

"Meanwhile, rural hospitals and health systems face declining reimbursement rates and disproportionate funding levels that make it challenging to meet the physical, social and economic needs of their communities," organizers say.

The observance also focuses attention on state rural-health offices, which foster relationships, disseminate information and provide technical assistance that improves access to quality health care for rural citizens, according to the news release.

National Rural Health Day events include several free webinars. Topics, times, and speakers are:

• AgriSafe: Protecting the People Who Feed America (Noon EST) – Natalie Roy, executive director and Carolyn Sheridan, clinical director, AgriSafe Network(Registration: https://www3.gotomeeting.com/register/491563334)
• Rural 101: The Basics of Rural Health (1 p.m. EST) – Kristine Sande, program director, Rural Assistance Center(Registration: https://nosorh.webex.com/nosorh/onstage/g.php?t=a&d=660990830) 
• Population Based Health and Health Promotion in Rural (2 p.m. EST) – Lynda Bergsma, program director, Arizona Center of Rural Health; Caroline Ford, former director, Nevada State Office of Rural Health(Registration: https://nosorh.webex.com/nosorh/onstage/g.php?t=a&d=666479151)
• The Affordable Care Act in Rural America (3 p.m. EST) – Tom Morris, associate administrator; Deepti Loharikar, public health analyst, and Aaron Fischbach, public health analyst, federal Office of Rural Health Policy(Registration: https://nosorh.webex.com/nosorh/onstage/g.php?t=a&d=666426441)
• Resources for Recruitment, Networking, and Telehealth (4 p.m. EST) – Mike Shimmens, executive director, National Rural Recruitment and Retention Network; Rebecca Davis, executive director, National Cooperative of Health Networks Association; Kathy Hsu Wibberly, director, Mid-Atlantic Telehealth Resource Center(Registration: https://nosorh.webex.com/nosorh/onstage/g.php?t=a&d=664434416)

The rural health offices' national organization will have a National Rural Health Day press conference and celebration at the National Press Club in Washington at 10 a.m. EST Nov. 21. To learn more about the observance, visit http://celebratepowerofrural.org. Contacts: Bill Hessert at 814-360-1964, billh@nosorh.org; Teryl Eisinger at 586-850-5257, teryle@nosorh.org.

New CEO of Owensboro Health says hospitals are working to improve care, regardless of federal health reform

Philip Patterson, the new CEO of the Owensboro Health, says hospitals are moving towards health reform regardless of what happens with the Patient Protection and Affordable Care Act.

Patterson is coming to Owensboro from Bon Secours Charity Health System in New York and New Jersey, a three-hospital system with net patient revenue of nearly $500 million.  Patterson says he wants to build a stronger network for regional care in the Owensboro area.

The Affordable Care Act has changed physician and hospital payment structures, encouraging wellness participation, Patterson said in an interview with Ryan Alessi of cn|2's "Pure Politics." Patterson said the law creates incentives for hospitals to keep patients from being readmitted, and to only provide necessary care.

Regardless of what happens with the law, health organizations and providers need to be more than providers, Patterson said: They need to be health partners to their communities, to improve community members' overall health by managing care through screenings and education.

The health care law penalizes health systems for providing care that is not needed, and it encourages a change in thinking for providers who need to start providing care more economically, said Patterson. One way to do that is by building a strong network of providers who coordinate care.

"To create a sustainable system, you've got to cover a unique and significant population," he told Alessi. To cover a larger geographic area in New York and New Jersey, Patterson said, he created a loosely affiliated network of independent facilities that all worked toward the common goals of improving care coordination and quality.

As a result of Medicaid expansion in Kentucky, which now covers households earning up to 138 percent of the poverty level, an additional 400,000 people may have health insurance coverage that have never had it before.

"There's always a cost when you build something new and try to integrate a population into it," said Patterson. Unfortunately, those who lack insurance tend to have lower education levels and potentially neglected health care needs as a result of not having coverage or the perception of not having access to health care, Patterson told Alessi.

"The process of making this [integration] work is going to be clearly on the structure of health care providers as they try to manage that population to keep them out of the hospital where the most expense is," he said. Provider networks can coordinate to manage disease processes before they require care, and education and communication about how to access care is crucial, Patterson told Alessi.

Asked what will happen to hospitals if the health law is delayed or repealed, Patterson said, "It really hasn't been rolled out yet. We are still in a wait and see mode in a lot of these pieces." He said if health care systems buy into the law's overall goals, and they are already working towards the goal of better health care management. "The issue is the infrastructure and how to pay for it," he said.

"Repeal? I don't know what's going to happen there. I think as long as the goals are to create a better health model for a community, you're going to work towards them anyway," said Patterson.

Kentucky poverty rate is fifth highest in U.S., but a larger share of Kentuckians had health insurance in 2012 than in 2011

By Molly Burchett
Kentucky Health News

In 2012, as U.S. incomes remained lower and poverty rates higher than in 2007, the year before the recession, Kentucky poverty rates increased and one in four Kentucky children were living in poverty, according to estimates released Thursday by the U.S. Census Bureau. However, the percentage of Kentuckians with health insurance increased.

Kentucky had the fifth highest percentage of residents living in poverty (19.4 percent) in 2012, up from 18.8 percent in 2011. It ranked behind Mississippi (24.2 percent), New Mexico (20.8), Louisiana (19.9) and Arkansas (19.8). However, it was statistically tied with the last two states for third place because the error margin for the estimates is plus or minus 0.5 percentage points. Nationally, 2012 was the second straight year that the U.S. poverty rate had failed to improve. It remained at 15 percent, with 46.5 million people earning at or below the federal poverty line. Click here for an interactive poverty rate map from Stateline.

These findings highlight the challenges that Kentuckians face regarding economic security relative to the rest of the country. The high poverty rate should also act as a warning since it presages troubles with education, health and other areas, Terry Brooks, director of Kentucky Youth Advocates, told Chris Kenning of The Courier-Journal.

The figures are three-year rolling averages from the American Community Survey, a continuing poll of Americans. It estimated that 595,260 Kentuckians were uninsured in 2012, indicating an uninsured rate decline to 13.9 percent, from 14.7 percent. Overall, the U.S. uninsured rate dropped from 15.7 in 2011 to 15.4 percent in 2012, with the number of the uninsured statistically unchanged at 48 million. Insured rates tend to rise as employment rises.

Among the estimated 1 million Kentucky households earning less than $25,000 a year, 22.6 percent do not have health coverage. Kentuckians aged 19 to 25 had the highest percentage of unisureds for a specific age group; about 400,000 Kentuckians are in that group, and 28.1 percent of them are uninsured.

The national decline in the uninsured rate was modest compared to a bigger drop in 2011 that resulted from the federal health reform law that allowed people 26 or younger to be covered on their parents' plans. The slight dip in the national uninsured rate for 2012 was due mostly to increases in government coverage, such as Medicaid and Medicare.

Nationally, the coverage by employer-provided health insurance for people under 65 remained stable. Kentucky, Michigan and Vermont were the only states to see a statistically significant increase in the rate of private health insurance coverage from 2010 to 2012.

The Census Bureau's American FactFinder report generator provides specific information about health insurance coverage.  For example, the chart below comes from a report about the types of health insurance coverage for specific age groups, and it shows estimates of the types of coverage for Kentuckians ages from 35 through 64.

When the main provisions of the health law take effect in 2014, expansion of the state Medicaid program with federal money is expected to provide free health care to as many as 308,000 Kentuckians at up to 138 percent of the federal poverty level -- currently $15,856 for an individual or $32,499 for a family of four.

The state will also offer federal tax credits for Kentuckians who lack job-based health insurance and buy private coverage through the new state health insurance exchange, Kynect, which opens for enrollment on Oct 1. Click here to read more about Kynect or to check your eligibility for coverage or subsidies.

Earlier, the Census Bureau reported there were 46.5 million people in the U.S. living in poverty median household income remained steady from the year before and was $51,017. Kentucky had a median household income of $46,362 in 2012, compared to the U.S. median of $51,371.  Click here for an interactive median income map from Stateline.

UK's Gill Heart Institute joins Appalachian Regional Healthcare to advance specialty heart care in Eastern Kentucky

Appalachian Regional Healthcare, the Appalachian Heart Center and UK HealthCare’s Gill Heart Institute announced a new collaboration to deliver cardiovascular care to Eastern Kentuckians, which will extend the UK's sub-specialty care footprint and increase access to cardiovascular expertise in the area.

Cardiologists Dr. Vidya Yalamanchi, Dr. Rao Podapati and Dr. Srini R. Appakondu from Hazard's Appalachian Heart Center will team up with UK to provide advanced treatment options not before available in the eastern part of the state.

“We look forward to the opportunity to work closely with the physicians and health care providers at Gill Heart Institute to enhance cardiology services to patients in Eastern Kentucky,” said Dr. Yalamanchi. “This partnership is an example of teamwork that emphasizes a commitment to providing exemplary patient care.”

In addition to the combined efforts in Hazard, UK and ARH have also agreed to jointly administer and manage cardiovascular services at ARH hospitals in Harlan, Whitesburg, McDowell, Hyden and Williamson, W.Va.

 “The goal of this collaboration is to expand the scope of cardiology services provided within our community,” said Joe Grossman, president of ARH. “By providing a range of comprehensive cardiology services, including inpatient and outpatient services to residents of Eastern Kentucky, we hope to improve lives in a region where patients suffer from some of the highest rates of mortality in the nation from heart disease and stroke.”

UK officials have said their hospital must expand its geographical reach to ensure access to quality care for Kentuckians. This collaboration represents a step towards achieving both this goal and the goal of being the hospital destination for sub-specialty care in the state and region.

“This alliance further expands the UK HealthCare mission to improve access to quality health care delivery for all Kentuckians in a cost effective and responsible manner,” Dr. Michael Karpf, UK executive vice president of health affairs, said in the release. “But the real benefit for many patients and their loved ones will be the ability to stay close to home for complex cardiology care.”

Congressman visits Telehealth Primary Care Clinic in Campton

U.S. Rep. Andy Barr

U.S. Rep. Andy Barr, a freshman Republican from the Sixth District, recently visited the Telehealth Primary Care Clinic in Campton. The clinic, one of two in Kentucky funded by federal telehealth grants, opened in August 2012, and "provides access to primary and specialty care for the community through network established by KentuckyOne Health, the largest health system in the Commonwealth," reports KyForward.

Shelley Neal of KentuckyOne told KyForward, “We established these clinics to make quality health care accessible to the communities in and surrounding Powell and Wolfe counties. If we are to be successful in our mission to create a healthier Kentucky, we must continue to implement new technologies and services to reach our state’s medically underserved communities.”

The clinics minimize "the need to travel to see a specialist therefore reducing the costs of care," KyForward writes. The newest addition is a social worker, who serves both clinics. Through the first six months of this year the social worker "helped 185 patients complete financial assistance paperwork to obtain drug assistance for 1,804 medication orders." During that same span, the clinic saw 1,417 patients from 34 counties. The clinics, which have specialists in cardiology and pulmonology, plan to add specialists in urology, obstetrics and gynecology, endocrinology, neurology and psychiatry. (Read more)

Kentucky picks up on federal Medicaid funding for inmates, which will expand when health reform takes full effect

Medicaid now covers care for inmates outside
prisons and jails, and health reform will extend
coverage to most former prisoners upon release.

By Molly Burchett
Kentucky Health News

Kentucky has missed out on millions of dollars from the federal government by not having it help pay for institutional health care of prison inmates outside prisons and jails. When the Affordable Care Act takes full effect Jan. 1, most Kentucky inmates will be eligible for expanded Medicaid coverage of hospitalizations and nursing-home stays, and the state is planning to have the feds pay almost all the cost. That should have benefits beyond saving state and local tax money.

Only a dozen states have taken advantage of the 16-year-old option to stick the federal government with 50 to 84 percent of such costs, and Kentucky is not among them, reports Christine Vestal of Stateline. The option stems from a 1997 ruling by the Department of Health and Human Services that Medicaid could cover care for Medicaid-eligible inmates who leave correctional facilities for at least 24 hours for treatment in qualified hospitals or nursing homes.

State and local governments have legal obligations to provide adequate health care to prisoners; those tapping the federal funds (Arkansas, California, Colorado, Delaware, Louisiana, Michigan, Mississippi, Nebraska, North Carolina, Oklahoma, Pennsylvania and Washington), and some scattered local governments use Medicaid to pay for hospital and nursing-home care for those prisoners qualifying for Medicaid, reports Vestal.

Kentucky has mostly been paying for such care out of the state's General Fund rather than utilizing its ability to spread the cost via Medicaid. For most states and localities, not bothering to seek Medicaid reimbursement for prisoners is an omission "that deprives them of millions of dollars in potential federal reimbursement," writes Vestal.

Fourteen years after the ruling, in September 2011, Kentucky's Cabinet for Health and Services began picking up on the deal, and Medicaid paid for the first hospital stay for a Kentucky prisoner. "Since then, improvements have been made in the processing and coordination with the State Department of Corrections," said Jill Midkiff, the cabinet's director of communications.

Expanded Medicaid makes most inmates eligible

Ever since the 1997 ruling, it has made fiscal sense to get inmates who needed outside medical attention enrolled in Medicaid, which has historically been used for inmates who are pregnant or disabled. Midkiff said Kentucky's program has mostly covered pregnant inmates.  “But in 2014 it really becomes a no-brainer,” Aaron Edwards, a legislative analyst in California who helped get the state’s program started, told Vestal.

That’s when the major elements of the Affordable Care Act take effect, and Medicaid expands in Kentucky to cover individuals at 138 percent of the poverty line -- now $15,856 for an individual or $32,499 for a family of four. Most prisoners will then qualify for Medicaid, said Midkiff. "As a result, all state prisoners requiring a hospital stay who meet requirements for Medicaid eligibility should be covered," she said.

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. One of the big changes involves the process to enroll Medicaid eligible inmates, which wasn't standardized before, and the Kentucky Health Benefits Exchange will make that process easier.

The state has projected General Fund cost savings from Medicaid coverage of inmates at $7 million to $8.4 million a year. Local governments will save money, too; the cabinet says it is working to ensure Medicaid enrollment is part of a standardized processes for jails around the state. For county-specific data about Medicaid expansion, click here for information prepared by the cabinet, which includes information about the benefit for county jails.

Prisoners' enrollment in Medicaid impacts the community in other ways. The health law requires coverage of behavioral health services, such as substance-abuse treatment and mental-health services. Upon release from prison, most inmates will have Medicaid coverage and access to these services, and studies have shown that access to services like substance abuse and mental health treatment reduces an inmate’s chances for recidivism, reports Mary Flynn of the California Health Report.

Most prisoners don't have health insurance upon release from prison, and studies show they do not receive treatment for chronic conditions but use expensive emergency rooms instead of primary-care doctors. Now, most will be covered by Medicaid and will have access to preventive services, reports Michael Ollove of Stateline.

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.

Kentucky expands Medicaid reimbursement for telehealth services, but lets managed-care firms keep authority over fees

By Molly Burchett
Kentucky Health News

Recent changes in Kentucky's telehealth regulations are making it easier for providers around the state and country to deliver health-care services to Medicaid patients, thus improving access to specialty care for many patients in Kentucky's rural areas. But the amount of their reimbursement can still be determined by Medicaid managed-care companies.

Patients in rural Kentucky sometimes need the care of a specialist not in their home community, and programs like the University of Kentucky’s telehealth program and the statewide Kentucky TeleHealth Network use videoconference tools to bring these physicians to the patients.

Kentucky has been among the leading states for driving reimbursement of telehealth services. As of July 2012, it was one of the 13 states requiring some level of private insurance coverage of telehealth. It is also one of the 15 states that requires reimbursement from Medicaid for some services, which are mostly mental-health and specialty services.

The new regulation expands the types of services eligible for Medicaid reimbursement. While the Kentucky TeleHealth Network has been operating since 2000, the old regulations limited the use of this type of technology, Rob Sprang, director of Kentucky TeleCare and chair of the state's Telehealth Board, told Greg Stotelmyer of Public News Service. "The previous regulations were very restrictive on who could see a patient on television, what services they could deliver on TV, and where those services could be delivered," he said.

The new rules lift restrictions on both the type and number of services covered by Medicaid. A much longer list of providers can be reimbursed for telehealth services, "including people like social workers, speech language pathologists, physical therapists, occupational therapists, a very broad group of providers outside of just physicians," said Sprang.

The regulation also includes certain services provided by a physician, psychiatrist, nurse practitioner, psychologist, dietitian and certified nutritionist. To provide telehealth services in Kentucky, a provider has to be approved for membership in the Kentucky Telehealth Network.

Reimbursement is technically the same as the amount paid for face-to-face services, but the regulation says managed-care firms are not required to reimburse those amounts. Thus, the role that telehealth will play in Kentucky could depend on how much the companies and the state decide to pay for it.

Still, the Foundation for a Healthy Kentucky has endorsed these changes to telehealth coverage and reimbursement, saying "it has the potential to help make quality specialty health services more accessible throughout Kentucky," reports Stotelmyer.

Telehealth will play a big role in health reform, said Sprang. "It's not rocket science," he told Stotelmyer. "You know, if you look at where providers are located today, there are no nephrologists, no kidney doctors, in most of our small communities. There are no child psychiatrists, there are no psychiatrists. There's so many medical specialties that are not available in our rural communities."

A recent report by Deloitte Consulting recommends increasing reimbursement for telehealth to address the state's doctor shortage problem, and that reimbursement needs to include primary care. "Given the potential benefits of using technologies such as telehealth to reach rural areas, where Medicaid populations can be large, the lack of Medicaid reimbursement for primary care could be a barrier to the overall effectiveness of Kentucky’s current and future investments in telehealth," says the report, which was released before the new regulations were issued.

AMA president, a Kentuckian, says doctors have a duty to make sure patients know about new health-insurance exchanges

Despite the mixed messages from many physicians about the Patient Protection and Affordable Care Act, Dr. Arvis Hoven, an internal-medicine and infectious-disease specialist in Lexington and the new president of the American Medical Association, said the physicians' lobby will do whatever is within its power to promote "Obamacare."

"Our job as physicians will continue to be to get our patients the type of care they need at the right time, at the right place, with the right provider," Hoven told Sarah Kliff of The Washington Post in an interview conducted for C-SPAN’s "Newsmakers." Transparency and communication with patients are important in making sure patients know about health- insurance exchanges, and the AMA can help the American public get the type of care they need and deserve, she said.

Although the law is polarizing and some AMA members don't support it, Hoven said the physician's responsibility is to the patient. "Some supported, some did not support it, but at the end of the day the American Medical Association and its policy body, the House of Delegates, came together in support of the Affordable Care Act."

It is a physician's duty to communicate elements of the law, such as the exchanges, to the patient and his or her family, Hoven told Kliff. As millions of people get added to the health insurance system, "Our job will be to teach them how to use health care insurance, how to get prevention and wellness care on the front end, how to be healthy and stay healthy."

Amid concerns over doctor shortages and the expansion of Medicaid, Hoven said she thinks there will be enough doctors, but it is important for them to emphasize team-based, physician-led care, utilizing all providers at their highest level of training. This will certainly be crucial for the Kentucky health system, since the state needed many more doctors and other medical professionals even before the Medicaid expansion, said a recent review by Deloitte Consulting.

Physicians and communities must work together to make sure there are enough health professionals, Hoven said: "This is work not only physicians need to be involved in, but communities need to be involved in, and we’re going to have to work together both publicly and privately to get this to happen." Click here to watch the entire interview.

Kissner, six Medicaid directors from other states picked for national institute

State Medicaid Commissioner Lawrence Kissner is one of seven state program directors to participate in the year-long Medicaid Leadership Institute, which Gov. Steve Beshear said will help Kissner's ability to deliver high-quality, cost-effective health care services to Kentuckians.

The Medicaid Leadership Institute was developed in 2005 to enhance strategic thinking and leadership skills among Medicaid directors, and it is managed by the Center for Health Care Strategies and funded by the Robert Wood Johnson Foundation.

The institute is directed by Carolyn Ingram, the center's senior vice president and a former New Mexico Medicaid director. Ingram said in a news release, “Each of these seven Medicaid directors is essentially the CEO of one of the largest health insurers in his or her state. . . . Commissioner Kissner and the other Medicaid directors chosen bring a diverse array of experiences to the Institute and will spur each other to take full advantage of opportunities to transform the nation’s health care safety net.”  Click here to read more or here for more information about the Medicaid Leadership Institute.

Kissner was named commissioner of the Department for Medicaid Services in June 2012.  He is a graduate of the University of Notre Dame with a bachelor’s in business administration and has nearly 30 years of experience in the private insurance industry.  He most recently served as president and CEO of Magnolia Health Plan in Jackson, Miss. He was president of UnitedHealthcare of Kentucky from 2004 to 2006, according to the department's website. 

Employers welcome delay in coverage mandate, but individual mandate remains and many uninsured people are unaware of it

By Molly Burchett

Kentucky Health News

The Obama administration's decision to delay, for a year, the health-reform law's mandate that employers of more than 50 workers offer them coverage could jeopardize the success of the law -- which already faced several challenges.

The linchpin holding the wheels of "Obamacare" together is an individual mandate, which remains in effect. Millions of people must sign up for insurance coverage -- especially those who are healthy. About 50 million, including 640,000 Kentuckians, who haven't bought or been able to buy health insurance will have to do so or pay a tax penalty, unless they qualify for the expanded Medicaid program.

The delay in the employer mandate could reduce the number of uninsured people who will use state-based insurance exchanges to shop for insurance coverage starting Oct. 1, said Sara Rosenbaum, a professor of health law and policy at George Washington University and an advocate of the law. A White House spokeswoman disputed that, but Obama and his allies face four other broad challenges in implementing the law, as outlined in a recent Politico story by Jason Millman and Joanne Kenen:

1. Uninsured don't know they must get health coverage or pay a tax penalty

Many people know about Obamacare, but a large percentage of the uninsured do not know that they will soon be required to buy coverage, according to the most recent Gallup poll:

2. Middle-class and low-income Americans don't know about subsidies

Another part of the Obamacare message that hasn't yet gotten through to millions of Americans, at least those who need to know, is that the law offers subsidies for coverage, based on income. The challenge is that this message must get to a hard-to-reach population without inflating the law's benefits, Millman and Kenan write. And, many of those who qualify for Medicaid or subsidized coverage are low-income, may not speak English well, or may know little about health insurance.

On top of these obstacles, there can't be a consistent, nationwide message because the coverage criteria is different for states like Kentucky that aren't using a federal health insurance exchange. Kentuckians can visit the exchange website, Kynect, to see if they qualify for special discounts or tax credits to help cover the costs of coverage. For example, the website indicates that a family of four making $48,000 a year will get an estimated $252-per-month tax credit for buying insurance. For a PDF fact sheet about payment assistance, click here.

3. Appealing to young invincibles and businesses

For the new system to work, it is critical that young, healthy people buy insurance to cover the cost of care for older and sicker individuals and keep overall premium costs down. Many young people don't know what an insurance premium or co-payment is, and many don't think they need health coverage. Still, Obama administration officials have said they’re hoping 7 million people sign up for private insurance through exchanges in the first year, including 2.7 million young adults.

The delay in the employer mandate came as a relief to many employers who say it will put their businesses at the brink of survival. But the requirement has only been delayed to 2015, not repealed. Before the delay, some companies with payrolls slightly above or below the 50-employee threshold said they would cut or keep their number of full-time workers below that figure to avoid providing coverage.

Many businesses with 50 or fewer employees don't know they won't be penalized for not offering health coverage and that they can get tax credits for providing it. Kentucky businesses can use Kynect to buy coverage if they have 50 or fewer employees. Significant tax credits may be available through the site for businesses that have fewer than 25 employees with an average annual salary under $50,000; the employer must pay at least 50 percent of the premium for each employee. See the chart below or click here for more details.

4. Threats to public messaging campaigns from the opposition

While the success of Obamacare may depend upon public awareness and outreach efforts, the efforts of those opposing it create additional challenges for supporters. Many Republicans used the delay announcement to advance the cause of overall repeal or delay of the individual mandate. House Speaker John Boehner said, “I hope the administration recognizes the need to release American families from the mandates of this law as well. This is a clear acknowledgment that the law is unworkable.”

Senate Republican Leader Mitch McConnell of Kentucky said, “The White House seems to slowly be admitting what Americans already know, and what I hear consistently in my travels around Kentucky regarding the regulatory burden on employers.”

On the other hand, former White House health policy adviser Ezekiel Emanuel said on MSNBC’s "Morning Joe" that the delay of the employer mandate will affect a relatively small number of companies and is no big deal. The provision only applies to about 200,000 employers who have 50 or more employees working full-time (which the law defines as 30 hours or more a week), he said, and “94 percent already offer health insurance.”

Kids Count report shows where children in your county and school district rank, in a huge number of measures

Conditions have improved slightly for Kentucky children, especially in education and health, and the state's overall well-being ranking has gone up one spot, from 35th to 34th in the nation. But economic conditions for young Kentuckians have slipped since last year, says the Kids Count report released Monday by the Annie E. Casey Foundation.

The annual report measures how the country and its 50 states are doing according to four measures of child well-being – education, health, economic well-being, and family and community. How well Kentucky's children score in each domain paints a picture of Kentucky's future.

One of the many data sets available by county and school district

The report includes a wide range of data for every county and school district. The data include current and five-year rates of child poverty; median family income and median household income; infant mortality rate; child death rate; teen death rate; child abuse and neglect cases; foster care cases; births to mothers who are teenagers, who smoke, who are not high-school graduates, and who get early and regular prenatal care; pre-term births; low-weight births; newborns breastfed when they leave the hospital; early childhood obesity, number and percentage of child-support collections; asthma hospitalizations; recreational facilities; number and percentage of children receiving food stamps, Medicaid, child-care subsidies, Supplemental Security Income, and benefits from the Women, Infants and Children nutrition program; the number and percentage eligible for reduced-price meals at school; the number and percentage in publicly funded preschool; the hourly wage needed to pay fair-market rent and the percentage of renters unable to afford such rent; juvenile justice data; percentage of students ready for college and careers; and the six-year college graduation rate.

Statewide, the report shows that Kentucky has made gains in education, and the state ranks 28th on this measure. Since 2005, more children are attending preschool, more fourth-graders are proficient in reading and more eighth-graders are proficient in math, says the report.

Kentucky has also improved in many health measures. There are fewer low birth-weight babies, fewer children without health insurance and fewer teens who abuse alcohol or drugs. Medical coverage should only continue to improve as the state expands Medicaid coverage to households at 138 percent of the poverty line. However, youth advocates say gains in education and health may not be maintained if more children continue to live in poverty.

Unfortunately, Kentucky children continue to struggle economically, weighing in at 32nd in the nation. The report says 37 percent of Kentucky children have parents who lack stable employment, up from 33 percent last year, and 32 percent of children live in households that are burdened by housing costs, up from 27 percent.

The state's lowest ranking is 38th, on the family and community measure. Its constituents: More than 27 percent of children live below the poverty line, compared to the national average of 23 percent, and the number of children in single-parent families has increased from 31 percent in 2006 to 36 percent in 2011. On the bright side, teen births declined during that period.

With the hard work of child advocates, community agencies, educators and policymakers, the report shows progress has been made to improve children's well-being, but there is still much to be done. Click here for Kentucky's profile or here to go to the data center.

New York Times starts series that will study Affordable Care Act's implementation and impact in Louisville area

It's the calm before the health-care storm, and amid the uncertainty of how the health-care reform law will be implemented, health-care conditions in Louisville, Ky., seem to make it a good environment for a New York Times series that will study the process and its impact.

Reporter Abby Goodnough writes that Louisville, a city with four hospitals, a medical school and one of the nation's largest health insurers, "embodies both the triumphs and the shortcomings of the medical system in the United States." She notes that despite such resources, Kentucky continues to have dismal health outcomes, including some of the nation’s highest rates of smoking, prescription-drug abuse, and deaths due to cancer, diabetes and heart disease.

To watch the six-minute New York Times video, click here.

The health law is intended to address some of those shortcomings, and the potential health benefits to the state are huge. About 90,000 people could get Medicaid coverage in Louisville alone, and the law could also "create thousands of jobs in Kentucky and, if its aspirations are realized, provide better care at lower cost," notes Goodnough.

However, there are many concerns about the law's implementation among health-care providers and Americans in general, both insured and uninsured. Republican Sen. Mitch McConnell says the 2,700-page bill and more than 20,000 pages of regulation is "a massive bureaucracy" not understood by doctors, hospitals, states, small business and most Americans. Regardless, in January the law will require most Americans to have health insurance, or they or their employers will pay a penalty.

Providers and patients: Challenges to providing and receiving care on the front line

For providers, "This is a period of fevered preparation for the far-reaching changes," and many clinics, practices, and health systems are hiring coaches and consultants to meet the demands of the federal health care overhaul, writes Goodnough.

She focuses on the challenges ahead of one such coach, Danny DuBosque. He was hired by Family Health Centers, one of the many clinics and practices across the state that must prepare to treat thousands more newly insured individuals as a result of the law, while simultaneously converting paper charts to electronic medical records to avoid federal penalties. Many practices, particularly in Kentucky's rural areas, are already struggling to stay open, due partly to resources required for this conversion process and problems associated with Medicaid payments from managed care  companies.

Clinics like Family Health Centers, which provide services to patients regardless of their ability to pay, are at a front line of the health law's changes, writes Goodnough. They represent many obstacles now faced by primary-care providers in Kentucky: They serve Kentuckians who are often unhealthy and tend to put off preventive care; they earn less than most physicians; and they are worried about having the staff and money to treat newly insured patients.

Front-line providers like Alaina Brohm, a nurse practitioner in Louisville's West End, treat "a diverse and challenging population: the unemployed, the chronically depressed, the obese, patients with advanced diabetes and feeble hearts," reports Goodnough. She describes the heartfelt stories about patients trapped in the health care system and investigates anticipation of medical coverage from the patients' perspective. (Click here for more details.)

Brohm's patients are often unable to pay for necessary treatments and medications, and they have a hard time even finding transportation to the clinic. One such diabetic patient, identified only as Ms. Edwards, cannot afford medicine to control her blood sugar, and she is depressed by that and her lack of insurance, writes Goodnough. But she will qualify for Medicaid under expansion next year.

Yet, patients like Ms. Edwards and Mr. Elson, who is unable make health insurance premium payments because his diabetic condition led to a 400 percent cost increase, are still skeptical or fearful of the health care law, writes Goodnough. "I don't see it helping anybody, just making everybody get insurance," he told her. Family Health Centers' providers are worried too. Brohm told Goodnough she is concerned that poor, newly-eligible Kentuckians will be required to pay part of their medical costs and she knows of a business that may be sold because it cannot afford employee insurance. (Many businesses don't know about subsidies available for that.)

On the other hand, Gov. Steve Beshear's decision to expand Medicaid with the law is a historic, long-awaited one for Bill Wagner, director of Family Health Centers, reports Goodnough. It will allow about 308,000 Kentuckians to gain insurance coverage, which is almost half of the state's uninsured population, and it may solve the $3 million budget shortfall faced by the center, she writes. As a Federally Qualified Health Center, it has already received $5.4 million to expand its facilities.

Placing waterproof boots on the ground while Louisville prepares for the storm, Goodnough sets the stage for an interesting and highly complex view of the health law's impact that, rather than focusing on the political debate surrounding the health care law, tells tales of patients and providers in the eye of the storm of change. Stay tuned for more alerts.

Health care providers, employers and patients can click here to contribute to Goodnough's reporting by telling about expectations for the health law and their previous experiences with health care in the Louisville area.

As Medicaid eligibility expands in Kentucky, so will subsidy of undocumented immigrants' health care

As Washington lawmakers struggle to find consensus on immigration reform, U.S. taxpayers continue to shell out money to subsidize health care for illegal, undocumented immigrants. Those expenses will probably increase, with the full effect of the Affordable Care Act and Medicaid expansion in Kentucky.

Although rarely talked about, There is an "emergency Medicaid" that reimburses a hospital for emergency care to an immigrant who is in the country illegally, reports Sandhya Somashekhar of The Washington Post. The program defines "emergency" a "sudden-onset conditions that threaten life or could cause serious impairment." It reimburses hospitals for emergency and maternity care given to people who, based on their income and other factors, would be eligible for regular Medicaid if they were legal citizens.

So, if an undocumented immigrant meets Kentucky's requirements for Medicaid, which will soon be expanded to 138 percent of the federal poverty line, he or she qualifies for the emergency program.

In 2011 alone, the federal government paid out $1.3 billion under the program, reports Somashekhar. A large percentage of those illegal immigrants receiving care are pregnant women, and so the care that's being provided is labor and delivery for children that will become U.S. citizens. "From the perspective of our health-care system, when people show up and they’re sick, the health-care system is obligated to take care of them,” Diane Rowland, executive vice president for the nonpartisan Kaiser Family Foundation, told Somashekhar.

Doctor shortage news: Residencies are filling the pond with primary care doctors, but U.S. and Ky. need an ocean of them

Despite a critical shortage of primary care in the country, only 25 percent of newly educated doctors go into this field, and even worse for the mostly-rural Kentucky, less than 5 percent go on to practice in rural areas, says a study by researchers at the George Washington University School of Public Health and Health Services (SPHHS).

The report, which was just released in the “Published Ahead-of-Print” section in Academic Medicine,  suggests that not only are we facing a primary care shortage, but also that the problem is not likely to be solved soon. There's been a lot of talk about the need to get primary care doctors to practice in Kentucky, specifically in the state's rural areas, without mention of the underlying issue that the study makes clear: there are not even close to enough doctors being trained as primary care physicians in the first place.

In addition to finding that just 4.8 percent of the graduate medical education system practiced in rural areas, 198 institutions (26 percent) produced no rural physicians and 283 institutions (37 percent) produced no Federally Qualified Health Center or Rural Health Clinic physicians, which were created to enhance the provision of primary care services in underserved communities.

“If residency programs do not ramp up the training of these physicians the shortage in primary care, especially in remote areas, will get worse,” said lead study author Dr. Candice Chen, a professor at SPHHS. “The study’s findings raise questions about whether federally funded graduate medical education institutions are meeting the nation’s need for more primary care physicians.”

Currently, the U.S. is producing primary care physicians at rates that are “abysmally low” and unless changes are made to the system, the nation will have an even greater shortfall of primary care doctors just as the Affordable Care Act ramps up demand for these services, said Chen in a Newswise release. And in Kentucky, the additional need for primary care doctors as a result Medicaid expansion is piled onto the heap of issues.

The study's authors said policymakers should take a hard look at the skewed incentives and other factors that have led to the current primary care crisis and develop a more accountable graduate medical education system. It is critical to find a better balance in medical specialties and more primary care physicians to build an effective, affordable health system.

UK Board of Trustees OKs $31 million plan to outfit another floor of new hospital with eye toward federal certification for heart work

The University of Kentucky Board of Trustees has given UK HealthCare the green light for its $31 million plan to outfit the eighth floor of Pavilion A at UK Chandler Hospital over the next few months to make room for a growing cardiovascular program and to clear the way for a federal "Center of Excellence" certification.

After the project is complete, the floor will hold 64 beds, including 24 intensive-care beds for the cardiovascular program that offers heart transplantation, artificial hearts and ventricular devices, reflecting UK's focus on receiving the federal certification.

In the near future, such a designation will be necessary to get enough referrals from doctors and smaller hospitals to maintain important services, including cardiovascular services, and to guarantee that Kentuckians can get the care they need inside the state, Dr. Michael Karpf, executive vice president for health affairs, said in an interview with Kentucky Health News this spring.

Karpf and other UK HealthCare officials are also recommending a $30 million cost-reduction program for their system because Medicare and Medicaid reimbursements are expected to decline as competition stiffens over the next few years, reports Linda Blackford of the Lexington Herald-Leader.

In response to these forces, UK has a goal to secure half the available business from out-of-state competitive areas over the next 10 years to remain viable in a highly competitive market. And, focusing on complex care should drive revenue for the hospital because UK makes money on the complex stuff, Karpf told KHN.

Read more here: http://www.kentucky.com/2013/06/10/2673382/uk-healthcare-using-30-million.html#storylink=cpy

The $592 million, 12-floor patient tower has remained half-empty since 2010, and when the estimated $530 million project to fully occupy the tower is added to the initial cost of constructing Pavilion A, the total price tag will top $1 billion over 20 years, reports Blackford.

The overall construction and expansion is expected to support patient care for the next 100 years, says a recent UK press release. Once it's fully occupied, the the 1.2 million-square-foot facility will include 512 private patient rooms.

Read more here: http://www.kentucky.com/2013/06/10/2673382/uk-healthcare-using-30-million.html#storylink=cp