Humana allows policyholders to keep old plans without paying more; Anthem is still deciding

Humana, one of the three insurance companies offering individual health policies on the state's insurance exchange, will allow Kentuckians to keep their insurance coverage for another year without charging them more for it.

The other two companies on the individual market are Anthem and the Kentucky Health Cooperative. Anthem hasn't responded to recent inquiries about the old policies; it said last week that it was still deciding whether or not it would extend policies that don't comply with federal health reform. Since the non-profit cooperative is a new insurance organization, it is only offering policies that comply with the law.

A Humana spokeswoman told Kentucky Health News Monday that the company communicated premium amounts to individual policyholders in October when presenting policy owners with coverage options for 2014, including the option to continue their current plan. Those premium amounts for individual policies have not changed since the most recent changes to the Affordable Care Act, she said.

Some insurance experts have warned that consumers renewing noncompliant plans will be predominantly younger and healthier, while older and sicker people will migrate to the subsidized marketplaces, which could drive up costs for plans. Some states aren't allowing insurers to renew policies. For example, Washington Insurance Commissioner Mike Kreidler said he would not allow insurers to extend the policies “in the interest of keeping the consumer protections we have enacted,” reports Kaiser Health News.

In Kentucky, at least for Humana policyholders, this is not the case. President Obama said people whose policies were being canceled because they didn't comply with the law could renew them for another year if state regulators allow it. Gov. Steve Beshear gave insurers the green light to decide whether or not to renew these policies. Humana has decided to do so without charging additional premiums short-term.

Meanwhile, Anthem is deciding what to do and some existing policy owners in other states face as much as a 24 percent increase in their premiums. Obama's extension allows non-compliant policies to stay in place only for a year. This time next year, the transition must be made to plans that are qualified under the law.

Most Kentucky hospitals will pay Medicare penalties under health reform, one the country's largest; look them up here

More Kentucky hospitals are receiving penalties than bonuses in the second year of Medicare’s quality incentive programs, one of the federal health reform law’s changes designed to create financial rewards for doctors and hospitals to provide better care. Pineville Community Hospital is being assessed the highest penalty in the country for its readmission rates.

Medicare has two quality-care incentive programs for hospitals. Value-based purchasing gives bonuses and penalties based on 24 quality measures, and the other program levies penalties for readmissions. Thirty-one Kentucky hospitals were assessed a penalty while 26 were given a bonus for improved performance, says an analysis by Kaiser Health News. Here's a screen shot of the beginning of the list:

The law allows the federal government to withhold a portion of a hospital's Medicare reimbursement money, up to a 1.25 percent penalty or bonus for every bill paid between October 2013 and September 2014, based on assessments of these quality standards.

"The incentives are among the law’s few cost-control provisions that have kicked in, but it is too early to tell how effective they will be in making hospitals operate more efficiently," reports Kaiser's Jordan Rau.

Large value-based bonuses are going to some major teaching hospitals and smaller institutions, such as Pikeville Medical Center. The state's average bonus is 0.25 percent, compared to the national average of 0.24 percent; Kentucky's penalties averaged minus 0.20 percent, for a total average of zero. It won't be known how much hospitals will receive or pay in dollar figures until next October since this depends on how much the hospital ends up billing Medicare, Kaiser reports.

However, as a result of the readmission program, Pineville Community Hospital is losing 2.57 percent of its reimbursements,the largest penalty in the country. Considering the impact of both the value-based program and readmissions program, Kaiser reports, two out of three hospitals are losing money starting last month.

Here's how the value-based score was figured: 45 percent on hospitals' use of clinical processes of care; 30 percent on patient experiences; and 25 percent on death rates. Hospitals were are also assessed by how they compared to other hospitals and how much they improved from two years ago, says Qualitynet.org.

Researchers are unsure whether the penalties are significant enough to trigger major improvements, writes Rau. And, some hospitals that have made improvements are still losing money because they haven't improved as much as other hospitals. On the other hand, some hospitals with subpar quality rankings are still getting more money because they showed improvement.

Nationwide, Medicare has raised payment rates to 1,231 hospitals and reduced payments to 1,451. Hospitals that are designated as critical access facilities and certain cancer hospitals were excluded from the program. But these facilities aren't immune to other portions of the health law, such as cuts in Disproportionate Share Hospital (DSH) program payments,for having a high percentage of Medicare and Medicaid patients.

New quality measures will be added to the value-based program for 2015, including comparisons of how much patients cost Medicare at different hospitals and rates of medical mishaps. In addition, the maximum readmission penalties grow to 3 percent next year, and a third incentive program will take an additional 1 percent of payments away from hospitals that have the most injuries or infections during patients' stays.

"Combined, these three quality programs have the potential to strip away as much as 5.5 percent of Medicare payments from the worst performing hospitals starting next October," reports Rau.

Dr. Patrick Conway, Medicare’s chief medical officer, says "We're moving away from volume and toward quality." Yet, to remain viable, some hospitals are being forced to make up for payment cuts by seeing more patients. Click here for the interactive chart.

Ky.'s successful rollout of health-insurance exchange prompts New York Times to profile Beshear as 'a man on a mission'

A weekend article in The New York Times describes Gov. Steve Beshear as a man determined to prove that the health-reform law works, and says Kentucky stands out in many ways while the federal government is struggling to fix its health-insurance website. While comparisons are difficult, Trip Gabriel reports that Kentucky's health insurance marketplace is "one of the most successful" in the country.

Kentucky is the only Southern state to operate its own insurance exchange as well as to expand Medicaid coverage. "It is an anomaly on the polarized political map, and a test — in a red state that has elected to the Senate Mitch McConnell, the Republican leader, and Rand Paul, a tea-party favorite — of whether bitterness over the law will dissolve if people decide it effectively provides affordable health care," Gabriel writes.

Gov. Steven L. Beshear, right, with employees at Kynect 
headquarters. He has said Kentuckians do not have to 
like President Obama or him to like the new health care law.

President Obama said last week that Kentucky may have had the most successful exchange launch. As of last week, some 34,000 Kentuckians had begun applications on Kynect, and more than 11,000 had signed up for plans.

At the federal level, exchanges have been plagued by technical "glitches" and to date, the Obama administration has failed to release official enrollment numbers. The Republican National Committee said Monday it was sending a Freedom of Information Act request to the Centers for Medicare and Medicaid Services, seeking Obamacare enrollment numbers, reports Caroline May of The Daily Caller.

About half a million people have started applications on the federal exchanges, administration officials said Saturday. The figure is only a snapshot of applications, and since the administration isn’t planning to release until next month the number of people who have actually enrolled in a health plan, much is left unsaid, writes Joanne Kenen of Politico. For now, it can only be said that Kentucky may have the most successful roll-out, and the governor is determined to make success a certainty.

Beshear told the Times his decision to embrace the law was not political. “To me this was a moral decision,” he said. “We’ve got 640,000 Kentuckians who don’t have access to any kind of affordable health care. The last ranking I saw, we’re 44th out of 50 in health status. You take any chronic disease or condition — heart disease, cancer, smoking, obesity, you name it — and we’re either the worst or close to the worst.”

In embracing the law, Beshear decided not to seek approval from the General Assembly for the exchange or the expansion of Medicaid, moves that brought a lawsuit and a circuit-court ruling supporting him. The state Supreme Court has been asked to hear the case, brought by tea-party activist David Adams of Nicholasville. Beshear said in a recent op-ed piece in the Times, "To those more worried about political power than Kentucky’s families, I say, 'Get over it.'"

“Steve Beshear is a man on a mission,” Al Cross, the director of the University of Kentucky's Institute for Rural Journalism and Community Issues, publisher of Kentucky Health News, told Gabriel. “He no longer has to worry about politics.” Beshear, who is in his second term, cannot seek re-election in 2015.

While many Kentuckians are concerned about Obamacare's effect on their health insurance or the state budget, Beshear blamed the law’s unpopularity on Republicans who were "demonizing" it. "You don’t have to like the president; you don’t have to like me," he told Gabriel. "Because this isn’t about him, and it’s not about me. It’s about you, your family and your children. So do yourself a favor. Find what you can get for yourself. You’re going to like what you find."

Obamacare hearing highlights employers' worry and uncertainty; Yarmuth says repeal and defunding bids block needed changes

Three of Kentucky's congressmen agreement at a field hearing in Lexington Tuesday that the Patient Protection and Affordable Care Act needs changing, but had no a consensus on how it should be fixed.


From left, U.S. Reps. John Yarmuth, D-3rd District; Andy Barr, R-6th District; and Brett
Guthrie, R-2nd District, listen to Rep. Phil Roe, R-Tennessee, who chaired the hearing.

Business leaders at the hearing also called for a fix, saying the law creates challenges for employees, workers and the economy.

Republican Reps. Brett Guthrie of Bowling Green and Andy Barr of Lexington said the law should be repealed. Democratic Congressman John Yarmuth of Louisville said efforts to change the law are hindered by efforts to repeal or defund it, reports Ryan Alessi of cn|2's "Pure Politics."

Yarmuth supports changes to the law's definition of a full-time employee as one that averages 30 hours of work a week, which he says has led to unintended consequences. Many of the 130 hearing attendees also expressed concern about the 30-hour employees, Alessi reports.

The law includes a mandate that companies 50 or more full-time employees must provide those workers with health insurance or pay a $2,000 penalty per employee. Although this mandate has been delayed a year by the Obama administration, the employee mandate and complex regulations of the law has created "massive uncertainty" for U.S. employers, said Barr.

Several business owners complained about the looming mandate and uncertainty as well as the harmful financial consequences of Obamacare at the hearing, which was held by the U.S. House's Subcommittee on Health, Employment, Labor and Pension. Six of the eight speakers were Republicans expressing opposition to the law.

"What we know is what the administration is now admitting — that this massive piece of legislation is unworkable,” said Barr, who also said that the law should be permanently delayed, reports Alessi.

A majority of Americans (57 percent) disapprove of "defunding" Obamacare as a way to stop the law from being implemented, says an August poll from the Kaiser Family Foundation.  Almost 70 percent of respondents said defunding would be "using the budget process to stop a law is not the way our government should work."

Long-time Lexington restaurant owner Joe Bologna said he is concerned that Obamacare will impact people's ability to eat out.  To prepare for this and rising health costs faced by the business, he has reduced his staff from 54 to 47 and is closed on Mondays, reports Jack Brammer of the Lexington Herald-Leader. Other business people shared similar stories about the law's negative consequences.

On the other hand, Carrie Banahan, executive director of the Kentucky Health Benefits Exchange, the state's online insurance marketplace, said the law will improve Kentucky's health. There were many supporters of the law at the hearing, and some even hissed at critics of the law, reports Alessi.

“If we could get a bipartisan agreement to actually work on tweaks legislatively, I think we could dramatically improve the law and eliminate a lot of uncertainty,” said Yarmuth. Click here to read more about testimonies form the hearing or to watch cn|2 videos.

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.

Bankruptcy filing by mental-health agency is a loser for Kentucky, where such services can be scarce and little used

By Molly Burchett
Kentucky Health News

The decision of Seven Counties Services Inc. to file bankruptcy to avoid paying into the Kentucky Employee Retirement System has created a "no win" situation for the state, and the issue may add yet another obstacle for Kentuckians to get the mental health care they need.

Louisville-based Seven Counties is one of the state's largest mental-health agencies, serving more than 30,000 adults and children with mental-health services, alcohol and drug-abuse treatment, developmental-disabilities services and preventive programs, according to its website.

And while Kentucky's mental-health system has received an F grade for its funding, the state pension system needs agencies like Seven Counties to pay in more because the system is just 27 percent funded. "Employers will have to ante up around 38 percent of annual payroll, compared with the 23 percent now required," Mike Wynn notes in The Courier-Journal.

Kentucky's need for mental health services is much greater than the supply, and an estimated 1.7 million Kentuckians live in areas designated as a "mental health professional shortage area," which means almost 40 percent of Kentucky residents lack proper access to such professionals, says a report by the Kaiser Family Foundation. About 24 percent of residents' mental-health care needs are under-served, and this situation could be worsened by federal health reform, which will expand mental-health and substance-abuse treatment benefits to more Kentuckians without adding to the number of providers.

Bankruptcy for Seven Counties is a lose-lose proposition: It could close its doors in 2014 and stop providing services to 30,000 Kentuckians or, if the bankruptcy goes through, the state's retirement system wouldn't get anticipated agency payments into the system, reports Ryan Alessi of cn|2, a news service of the Time Warner and Insight cable-TV companies.

“The only two paths this can go is we could stay in KERS until we have given them our last nickel, which is a year (or) year-and-a-half from now … (and) we close the doors and go out of business and KERS gets no more money because we’re out of business,” Dr. Tony Zipple, president of Seven Counties, told Alessi.

In addition to funding problems for mental-health services, many people with mental-health issues don't seek treatment because of its stigma, said Sheila Schuster, executive director of the Kentucky Mental Health Coalition, in a recent opinion piece sent to Kentucky newspapers.  Shuster calls on elected leaders to increase funding of mental health services and highlights the prevalence of mental health illness.

"At least one-fourth of us will experience a behavioral health issues (mental illness or substance use disorder) in a given year," Schuster writes. That number, and the number of people needing treatment, will continue to grow, she says.

Schuster also writes about the societal impact of not treating mental illness: "Depression is rated as the #1 cause of disability in this country, and is a leading cause of absenteeism and decreased productivity in the work force." Because some people avoid treatment due to stigma, they may self-medicate with drugs or alcohol, and "the effects of stigma and failure to treat the whole person can have catastrophic results," she writes.

In addition to calling for more mental health funding, Schuster asks all Kentuckians to get educated about mental illness so that its stigma can be erased. Click here to read more from Schuster about mental health and resources for help. For a PDF of her op-ed, click here; for a text version, here.

Confused or concerned about the impact of health reform on Kentucky businesses? There's a seminar for that.

To address possible confusion or concern of business people and the public about the Patient Protection and Affordable Care Act, or "Obamacare," health-care reform experts will address its impact on small and large companies across Kentucky at half-day seminars in Lexington and Louisville on May 8 and 9.

The Kentucky Health Care Reform Seminar will include specific discussions about expected cost increases and tax implications for businesses once reform is implemented, including the role of the health insurance exchange and the changing ways that coverage premiums will be determined. The seminar will be presented by The Iasis Group Inc., The Lane Report and the Kentucky Chamber of Commerce, says a chamber release.  

Guidance to employers will be provided on complying with the new rules surrounding insurance reforms and insight to whether Kentucky companies can truly afford it. The seminar is part of a statewide partnership that includes Commerce Lexington, Greater Louisville Inc., the Kentucky Society for Human Resource Management and the Northern Kentucky Chamber of Commerce (Click here for more details or to advance register)

Essential-benefits rule expands mental-health and substance-abuse coverage; Ky. needs more facilities to treat newly eligible

The Department of Health and Human Services has defined the 10 "essential health benefits" insurance plans must provide, and it included benefits for mental health and treatment of substance-abuse disorders..

Nearly 20 percent of Americans don't have access to mental-health services and over 30 percent have no coverage for substance-abuse treatment. This rule will expand mental health and substance-abuse treatment benefits to 62 million Americans, according to HHS.

Expanded coverage for mental health and substance abuse treatment programs in Kentucky could bring about a dramatic shift in the delivery of these services. There is already a shortage of treatment options and centers for Kentuckians, and those suffering from addiction have not had coverage for such treatment; the proposed rule will change that.

Recovery Kentucky, a public-private partnership with residential facilities, was created to help Kentuckians recover from substance abuse. It has 10 centers, in Campbellsville, Erlanger, Florence, Harlan, Henderson, Hopkinsville, Morehead, Owensboro, Paducah, and Richmond, according to the 2012 Justice & Public Safety Cabinet report, which included the map below. 

Health-insurance plans must cover the 10 essential benefits beginning in 2014, so the state must prepare for the newly insured in addition to newly covered services. The rule defines what must be covered in insurance plans and bans discrimination based on age or pre-existing conditions. Among the core package of items and services, known as “essential health benefits" are items and services in the following categories:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care

States are given flexibility in implementing the federal health-care reform law with a benchmark approach. The Kentucky Department of Insurance has recommended that the Anthem Preferred Provider Organization plan serve as the “benchmark” plan for the Kentucky Health Benefit Exchange. HHS will review the recommendation and accept public comments prior to making a final decision. (Read more)

Medicaid expansion brings primary care access to the forefront

The federal health reform law will usher at least seven million more Americans into Medicaid, and as states like Kentucky debate Medicaid expansion, policymakers are struggling with the question of whether there will even be enough primary care doctors to provide care, reports Michael Ollove of Stateline.

The country is already short of primary-care doctors. Although many primary-care physicians would take on new Medicare or privately-insured patients, only two out of three primary-care physicians surveyed in 2011 were willing to accept new Medicaid patients.

Why? Poor compensation is one reason; on average, Medicaid pays physicians 59 percent of the amount Medicare pays for primary care services, reports Ollove. Many Kentucky primary-care providers are also deterred by existing Medciaid problems. Providers report being burdened by a lack of or delayed payments from the new managed-care system.

Congress hopes to lure practitioners to primary care with a provision that raises primary-care providers' Medicaid fees to Medicare levels. This is only a temporary fix, which went into effect at the beginning of the year and will remain in effect for two years, reports Ollove.

The impact in Kentucky remains uncertain. Lawrence Kissner, Kentucky's commissioner for health and family services, says the state’s Medicaid pay raise in 2005 resulted in a 36 percent increase in the number of primary care doctors accepting Medicaid patients, reports Ollove. This is precisely what the health-law authors hope will happen now.

Kentucky is addressing the health coverage issue in other ways.  The General Assembly is considering a bill that would repeal a burdensome supervision requirement and encourage more independent physician assistants to remain in Kentucky to serve medically underserved areas.

Although Kentucky already allows nurse practitioners to practice independently, the Medicaid rate increase applies only to physicians who provide primary care services. It does not apply to nurse practitioners, who have been touted as a potential solution to the primary care problem and often provide care in underserved areas of the state. (Read more)

Frontier Nursing University in Hyden helps bring better family health care to rural America with distance learning

Midwives and nurse practitioners who recently graduated from Frontier Nursing University in Hyden address the unique challenges of rural areas, including shortages of health care providers, by bringing local health care to rural communities across the country. FNU was featured in a recent report from the Robert Wood Johnson Foundation.

FNU, a graduate program that offers distance education to nurses with an interest in nurse-midwifery and family nurse practitioner and women’s health specialties, aims to build a pipeline of highly educated nurses serving in rural or underserved areas, reports RWJF, one of its funders.  Many scholars and grantees sponsored by RWJF go on to spearhead projects to improve access to high quality nursing care in remote areas, the foundation says.

“We’re trying to introduce primary care providers into rural areas in such a way that they can provide high quality care and preventive services too,” says Suzan Ulrich, associate dean of midwifery and women’s health at FNU and an RWJF executive nurse fellow.

Demand for health care is rising nationwide because of an aging population that is living longer, but sicker, with multiple chronic conditions. The need for health care providers will intensify next year, when millions of new patients will become eligible for health insurance under the health-reform law.

Rural parts of the country face unique challenges and shortages of health providers, including nurses, can be particularly acute in rural areas, said Alan Morgan, CEO of the National Rural Health Association. These nurses and other providers have less access to education programs, which tend to be located in more densely populated areas. Programs that offer advanced degrees, from the baccalaureate to the doctorate, can be especially difficult to access for students living in rural areas, according to RWJF.

Identifying and educating nurses from rural areas is a key goal of FNU, which offers distance education programs that enable students to remain in their home communities and a “bridge” program that allows nurses with associate’s degrees to move more easily into master’s and doctorate programs. “These students really love where they live,” Ulrich said. “If we can educate them to stay within their communities, then those communities are going to have a provider who’s going to be there a long time." (Read more)

Invisible health panel could help Ky., if it had money and met

A panel charged with helping devise solutions to the nation’s health-care workforce crisis, which includes ensuring rural areas have enough health-care providers, is having a workforce crisis of its own: It hasn’t been funded, and it’s never met, writesKyle Cheney of Politico. 

The National Health Care Workforce Commission was created by Congress nearly three years ago under the Affordable Care Act, the panelists were appointed, but that’s about it. The lack of action was noted at a hearing Tuesday of a subcommittee of the Senate Special Committee on Aging, convened by Sen. Bernie Sanders (I-Vt.), chairman of the Subcommittee on Primary Health and Aging.

Sanders issued a report estimating that 57 million Americans lack ready access to primary care. Since  millions are expected to gain coverage when the reform law goes into full effect next year, there is a looming concern over whether there are enough doctors, physicians' assistants, nurse practitioners, nurses and so on. Most of the worry relates to the lack of primary-care providers in underserved areas, which could be a huge problem for Kentucky.

In addition to exploring the health workforce needs in rural and “medically underserved” settings, the commission was supposed to address the capacity of the nursing workforce, graduate medical education policies, education and loan programs for health-care professionals and the “mental and behavioral health care workforce capacity,” writes Cheney.

Since the 15-member panel was appointed in September 2010 by the U.S. comptroller general, 10 members’ terms have expired, and they’ve been reappointed for another three years each, Cheney reports. No funding has been approved, although both Senate Democrats and President Barack Obama have proposed $3 million funding packages.

“In order for the promise of expanded coverage passed into law by ACA to become a reality, the provisions designed to reach those goals must be fully funded and implemented,” Sanders said. “We need to make sure that our health care system has the infrastructure in place to provide the care necessary to prevent diseases and improve the health of all Americans.” (Read more)

Feds plan to let states impose co-payments on Medicaid patients above poverty level to encourage them to expand the program

By Molly Burchett and Al Cross
Kentucky Health News

If Kentucky expands its Medicaid program, it will probably be able to reduce the cost by requiring patients whose incomes are above the federal poverty level to help pay for their care. That could make it more feasible for the state to expand the program to people with incomes up to 138 percent of the poverty line.

A proposed federal policy will let states charge co-payments and increased premiums for doctor visits and some prescription drugs and hospital care. Robert Pear of The New York Times reports that the policy is designed to encourage states to expand Medicaid under the federal health-care reform law, with generous federal help. By shifting costs to patients, the state and federal governments would pay less.

That adds a new perspective to the cost consideration in Kentucky's debate over expansion of Medicaid. It could influence the state's decision, Republican state Sen. Julie Denton of Louisville said Friday during a legislative panel at the Kentucky Press Association convention.

Denton cautioned that the state needs to fix its problems with Medicaid managed care before it expands the program. Democratic Gov. Steve Beshear has said he wants to expand Medicaid if the state can afford it, and since there is no deadline for deciding whether to participate in the expansion, the debate may carry over into 2014.

Some Republicans have said Kentucky can't afford the expansion. If the state expands Medicaid eligibility to 138 percent of poverty from its current threshold of 70 percent, the federal government would pay all the cost of the expansion until 2017, when the state would begin helping out, with its share reaching 10 percent in 2020. The federal share of the state's current program is 72 percent.

This proposed rule could have important implications not just for state finances, but for Medicaid patients. It means that a family of three with an annual income of $30,000 could be required to pay $1,500 in premiums and co-payments, Pear reports in the Times.

As published in the Federal Register last week, the rule proposes to "update and simplify Medicaid premium and cost sharing requirements, to promote the most effective use of services and to assist states in identifying cost-sharing flexibilities." It proposes "new options for states to establish higher cost sharing for nonpreferred drugs and to propose higher cost sharing for non-emergency use" of emergency rooms.

Barbara K. Tomar, director of federal affairs at the American College of Emergency Physicians, told Pear that the administration had not adequately defined the “nonemergency services” for which the poor might have to pay. "In many cases, she said, patients legitimately believe they need emergency care, but the final diagnosis does not bear that out," Pear writes.

The proposed rule has no limit on emergency department charges for "non-emergency use." It says the hospital will have responsibility to assess the individual clinically and ensure access to other sources of care before requiring payment, which could pose problems for hospitals.

The public has until Feb. 13 to comment on the proposed rule, which can be submitted at www.regulations.gov.

Health departments prepare for challenges posed by health-care reform law

No one really has a clue what changes from the health-care reform law will mean to Kentuckians and public health departments are preparing for the uncertainty, reports Kristy Cox of Business Lexington.

"The Affordable Care Act will have an impact on health departments.  It is going to put a whole lot more people out there on the street on health insurance" of one kind or another, Dr. Rice Leach, head of the Lexington-Fayette County Health Department, told Cox.

"I think how health departments are impacted is going to look a little different depending on what part of the state they're in," Rice said. "The United States has passed a law that creates an entitlement for 30 or 40 million people, and here in Lexington, for 10,000 or 20,000 more people to have health insurance. Now, who is going to take care of them?"

If the private sector can't handle the increased patient load, Leach said, the stress goes onto the health departments, meaning they may be expected to provide a broad "continuum" of care for acute medical needs, including doctors and laboratory services. Leach said he hopes other systems will step up to provide care so health departments can continue to focus on preventative services.

Many factors determine what health departments can and can't do as well as their ability to generate dollars. Leach called  the services mandates by state and federal governments as "mission critical activities," which include preventive health, communicable disease control, public health education, emergency response, sanitary code and restaurant inspection and public health policy, writes Cox. 

Despite the challenging economic environment created by budget cuts and managed-care non-payment issues, Kentucky health departments are trying to stay focused on their big-picture mission.  Some departments are writing grants and others, like the Lincoln Trail District Health Department, has sent nurses into school systems in attempt to increase revenue through expanded clinical services, Cox reports.

Lame-duck Congress could cut funding for critical access hospitals; more than two dozen in Kentucky

Critical access hospitals, which in most states are rural facilities with fewer than 25 beds, may be under attack in the lame-duck session of Congress, former national rural-health director Wayne Myers writes for the Daily Yonder. President Obama's "budget proposes to revoke CAH status and special payments for any such hospital within 10 miles of another hospital, and to cut the extra 1 percent payment for all of the critical access hospitals," Myers writes. (Census Bureau map of CAH locations)

This would "have enormous consequences," Myers writes. "Of the hospitals that lose CAH designation probably most will close or merge with another hospital. I've seen no estimates of numbers. There are more than a few congressional budget hawks in both parties who would like to eliminate the special payments to Critical Access Hospitals entirely. If these small hospitals dodge the bullet during the lame duck session, they'll continue to be targets in the next Congress. If they are successful in reducing payments to CAHs, the net effect will be to move health care capacity and jobs from smaller to larger towns."

The issue is complex. Rural areas have less political clout than ever, because of declining population, and many rural people use urban hospitals over CAHs, even for ordinary care. "Those who do use CAHs say their experience there is just as good as that in urban hospitals, even if the quality of care isn't as good as in larger facilities," Myers writes. "Elderly patients stay at CAHs because they know the nurses and doctors and their families live close by."

Issues for CAHs arise out of how Medicare payments are made to them, Myers writes. "A long list of arcane, special funding arrangements has accumulated to try to fit small rural hospitals into a Medicare payment system designed for large city hospitals." The largest program is the "Disproportionate Share Program," or DISH, which gives $15 billion a year to states to hand out to CAHs. The program is being phased out between 2014 and 2020, along with several other programs, as part of the Patient Protection and Affordable Care Act. (Read more)

Lexington lawyer writes booklet helping Kentucky businesses to break down health-care reform law

Margaret Levi, a lawyer with the Lexington firm of Wyatt, Tarrant & Combs, has authored a new publication, The Impact of Health Care Reform on Kentucky Employers. The 68-page booklet, published by the Kentucky Chamber of Commerce, is a readable summary of The Patient Protection and Affordable Care Act, writes Greg Kocher of the Lexington Herald-Leader.

The law that started taking effect in March 2010 has had more more interpretations and critics than it has pages -- that's 2,555, if you don't count the legal citation references that require reading included within it. "There's a lot of criticism of it from people who haven't read it, and I think you have to know it before you can criticize it," said Levi, a Danville native and resident, said of the law. "I'm not taking a political position one way or another. I am neutral and I tried very hard to remain neutral."

The most common misconception about the law "is that all health care is going to be free and people can get all the care they want," Levi told Kocher. 'So there are some unrealistic expectations on behalf of consumers."

Levi also noted some confusion about how different-sized businesses qualify for different exemptions under different provisions of the law.  She said that some employers are weighing the "pay or play" mandate that takes effect in 2014. Under that provision, writes Kocher, "employers with 50 or more employees must provide 'minimum essential' health plan coverage to their eligible employees or pay a penalty if an eligible employee obtains coverage through a state-sponsored health insurance exchange and qualifies for benefits subsidized by the government. An employer who offers no health coverage will be subject to a penalty equal to $2,000 a year per employee after the first 30 employees. "I think some employers are doing the math as to whether they pay the penalty or provide insurance for their employees," Levis said. "I saw a report that said 88 percent of employers are still going to provide the coverage."

Jim Ford, vice president of business education for the Kentucky Chamber, told Kocher that the booklet "basically says here are the rules, here's what it means, here's what implementation means. We're leaving politics at the door. Here's what you need to know." (Read more) For information on buying the booklet, go here.

What it's like to lack health insurance, and how health reform is changing that: It's a story for every county, with local data

The Kentucky Standard's Randy Patrick deftly shows how the federal health-care reform law is having an effect at the individual level by telling the story of Bonnie Varnell, a Nelson County resident who is uninsured and is more than $65,000 in debt due to her fight against cancer.

For 18 years, Varnell worked at a daycare that didn't offer health insurance. She wasn't able to buy individual coverage because she had pre-exisiting conditions as a result of surgeries. She is only 59, so does not qualify for Medicare, and she didn't qualify for the federal law known as COBRA, which "allows workers to keep their company group health insurance benefits for up to 18 months after leaving their jobs, as long as they pay the entire premium," Patrick explains.

As a result, the bills kept mounting, despite hospitals giving the Varnells reduced rates through charity care. "I've been trying to pay something on every one," Varnell's husband Ed said of the bills he receives and has to delay paying in full. "It's really frustrating. We had never been late a day in our lives."

Now, Varnell has health insurance through a program created under the Patient Protection and Affordable Care Act. "It costs her $315 a month and covers most of her costs after the deductible is met, but the law stipulates that a person with a pre-existing condition must be uninsured for at least six months before she or he can be eligible," Patrick reports.

Varnell's fear now is the program will be taken away if the Affordable Care Act is repealed after the November election. Patrick gives opponents of the law their say. (Read more)

There are stories like Varnell's in every county. Patrick, who recently joined the Bardstown thrice-weekly after editing papers in Nicholasville and Winchester, sets the bar high for how to tell such stories.

Varnell is among the estimated 15 percent of people in Nelson County who didn't have health insurance in 2009, the last year for which estimates are available. Statewide, the census estimate was 16.5 percent. For a list of all Kentucky county estimates, click here. For the Census Bureau website that is the source of the data, go here. 

Questions about health-care reform law answered in comprehensive Courier-Journal report

Reporter Laura Ungar has put together an excellent primer in The Courier-Journal that appears to answer all the key questions people have about the federal health-care reform law. Reporters would do well to refer to Ungar's report when writing about the Patient Protection and Affordable Care Act.

The piece breaks down how the law will affect adults, young people, senior citizens and business owners. "Experts agree the changes will be sweeping," Ungar reports.

Ungar asks questions like:
• What is the individual mandate? It means everyone must have health insurance by 2014 or pay a fine. By 2016, the penalty will increase to $695 for individuals and $2,085 for families or 2.5 percent of their income.

• Will I become eligible for Medicaid under the new law? That's not yet clear because Kentucky hasn't decided whether or not to expand the program. If it does choose to expand, people who earn up to 138 percent of the federal poverty level will qualify, which means individuals who earn up to $15,415 or a family of four that earns up to $31,809.

• Are there any new taxes under the law? Yes. The individual mandate can be interpreted as a tax. Also people who earn more than $200,000 and married couples who earn $250,000 combined will pay a payroll tax of 2.35 percent, up from 1.45 percent.

• How will I find health insurance? A state health insurance exchange will be set up by 2014 so people who earn up to 400 percent of the federal poverty level — an annual income of about $90,000 for a family of four —can buy health insurance.

• How can young people stay on their parents' health insurance plan? They are eligible under the new law to stay on their parents' plan until the age of 26. So far, 35,600 young adults in Kentucky have gotten coverage this way.

• What if my young child gets married or pregnant? The child will be covered and so would the pregnancy if the parents' plan allows for that. The plan doesn't have to cover the baby, however.

• Will my premiums go up if I get insurance through my job? That's still unclear. "There are provisions that could push up premiums slightly, such as the elimination of lifetime caps on coverage, but there are also provisions that could push them down, such as the influx of many more healthy young people," Ungar reports.

• How does the law affect Medicare coverage? Benefits have not changed, but there will no longer be co-pays for preventive services like mammograms and prostate-cancer screenings, "a provision that has affected more than 1.2 million seniors in Kentucky," Ungar reports.

The report is worth reading in its entirety and could be used as a regular reference about the law. (Read more)

What health reform changes to expect in 2012 — assuming the Supreme Court doesn't strike down the entire law

The U.S. Supreme Court is set to hear arguments later this month about the federal health care-reform law, and is expected to decide the law's future this summer. While the court mulls the constitutionality of an individual mandate to buy health insurance, "implementation marches on, and a number of notable changes will take effect for consumers this year," writes Michelle Andrews for Kaiser Health News.

If the high court strikes down the Patient Protection and Affordable Care Act, "all bets are off," Andrews writes. Popular provisions, such as allowing children to stay on their parents' insurance until age 26 and the 50 percent discount on brand-name drugs for seniors under the prescription drug doughnut hole, could be eliminated — and provisions set to take effect this year could be cancelled. But, if the Supreme Court does not invalidate the entire law, here's a list of new provisions consumers can expect this year:

Free contraception coverage: "Women in a new health plan or in an existing one that has changed its benefits enough to not be considered grandfathered under the law will be able to receive contraceptives without an out-of-pocket charge," Andrews writes. Insurance plans will also have to provide basic health services for women, including screening for gestational diabetes; HPV testing; STD counseling; screening and testing for HIV; and screening and counseling for interpersonal and domestic violence. Religious employers such as churches are exempt from the new regulation, but colleges, hospitals and other employers that are religiously affiliated are not — though they do have a one-year grace period to implement it. Employees of those institutions will receive their free benefit from their employer's insurance.

Consumer rebates: Under the law, insurance companies have to spend at least 80 to 85 of their premium revenues on medical claims and quality improvement. If they don't, they have to pay the difference to policyholders, which, in most plans, means the employer. If the provision had been in place in 2010, an analysis by the National Association of Insurance Commissioners estimated that would have meant $2 billion going to consumers. In December, the Obama administration said that about 9 million Americans could receive rebates that added up to $1.4 billion.

Clearer descriptions: Starting in September, all health plans will have to give consumers benefits information that is easy to understand. "Every plan will be required to give people a short summary of coverage and a uniform glossary of terms," Andrews reports. "It will also have to provide examples of how much the plan would cover if someone had a baby or was managing Type 2 diabetes — two common situations that should make it easier for people to compare plans."

Smaller doughnut hole: "This is the break in Medicare prescription drug benefits that, in a standard plan, begins after total drug spending by the beneficiary and the health plan exceeds $2,930 and continues until the beneficiary has hit the $4,700 out-of-pocket limit," Andrews reports. Last year, people on Medicare with high drug costs got a 50 percent discount on brand-name drugs once they reached the doughnut hole. This year, they'll also get a 14 percent discount on generic drugs. (Read more)

Health reform means millions more will be covered and more illness will be prevented, federal health official says at UK

By Tara Kaprowy
Kentucky Health News

What will the healthvcare system look like in 2020? Assistant Secretary of Health Dr. Howard Koh told a packed house in Lexington Monday that millions more people will have insurance, the patient will be at the center of a coordinated system, and there will be a great emphasis on prevention and public health "so the patient doesn't become the patient in the first place."

Koh talked about federal health-care reform during a panel discussion at the University of Kentucky's Albert B. Chandler Hospital. It also included Dr. Steve Hester, senior vice president of Norton Healthcare; Dr. Richard Lofgren, vice president of health care operations and chief clinical officer at UK HealthCare; and Stephen Wyatt, dean of UK's College of Public Health.

Koh said the current health-care system "is fragmented, it's episodic, it's not as coordinated as we would like, and there is still not enough attention to quality outcomes." But he said implementation of key parts of the health-care law would address those issues.

He said insurance is already more accessible, since companies can no longer refuse children with pre-existing conditions. By 2014, the same will be the case for adults. State insurance exchanges, which he called "a one-stop shop where buyers can compare plans," will inject "transparency in the whole market" and will ensure basic levels of coverage.

Insurance will also become more affordable, he said. The Medicare prescription "donut hole" is being covered; young adults can stay on their parents' plan until the age of 26; insurance companies must assure that 80 percent of their expenses go toward medical care and not overhead; and there will be a rate-review process, in which insurance companies wanting to increase their rates by 10 percent or more must formally defend their request.

Patient-centered medical homes will put the patient at the center of care and accountable care organizations, and "voluntary networks who have agreed to care for a defined Medicare population and also share in savings," will make coverage more coordinated, Koh said.

The law also puts systems in place for prevention and public health. On the individual level, new plans must cover "high-value preventive services and screenings," Koh said. Businesses are being encouraged to focus on wellness. The Centers for Disease Control and Prevention are offering community transformation grants so communities "can designs ways to make the healthy choice the easy choice," he said. And a national prevention counsel has been formed dedicated to public health.

The law also provides millions for health-care technology, which Hester said will revolutionize the health-care landscape and "the way we respond to patients." Koh agreed, saying a paper-based system "was another example of fragmentation. . . . prevSometimes you could find the chart, sometimes you couldn't. The electronic-based system will coordinate."

Hester said patients have recently become more equipped to accept the technology of electronic health records because they've become used to devices like smart phones. Logren said that, traditionally, patient records have been "proprietary." Electronic records will get information moving from place to place and will no longer be "owned."

Koh acknowledged one of the greatest challenges of the health-reform law is sustainability, but by 2020, he said "We will see stable funding and stable results" in public health and prevention. While the law has created divisiveness in the political arena, Koh said strong opinions about health care are a good thing because they generate discussion and passion. "We can debate many parts of the health reform law," he said, "but in the meantime, we are making progress."

Health insurance exchange benefits will be decided at the state level; Kentucky can now proceed to set up its exchange

For months, Kentucky officials have said the state cannot move forward with setting up a health-insurance exchange under the new federal health law because there weren't enough details about which benefits they had to offer. On Friday, the Obama administration answered that question when it "let states, rather than the federal government, define which medical benefits insurance companies will have to offer consumers starting in 2014," reports Noam L. Levey of the Los Angeles Times. "This is significantly more state-flexible and friendly than many would have expected," Alan Weil, head of the National Academy for State Health Policy, told Levey.

The law says that by 2014, each state must offer an insurance exchange, an online insurance marketplace in which people can choose from a variety of plans from companies like Anthem or Bluecross/Blueshield and then, for the most part, be given federal subsidies to help pay their premiums. About 30 million individuals and employees of small businesses are expected to use the exchanges. The plans in an exchange must cover a basic set of benefits, including hospitalizations, emergency care, newborn and maternity care and pediatric services, but until now the federal government could have decided how generous the benefits had to be.

"Under the guidance issued Friday, state leaders can define their own set of benefits by using an existing major health plan in their state as a benchmark," Levey reports. "That means that some states may require insurers to cover services such as chiropractic therapy and in vitro fertilization, while others may not."

It's this variability between states that worries some. "In passing a good deal of the decision-making to states, the administration has guaranteed that Americans will continue to face a patchwork of state regulations that make coverage uneven and inefficient," report Gardiner Harris, Reed Abelson and Robert Pear in a news analysis for The New York Times.

Some consumer advocates also worry the move will allow states to make benefits too meager. Timothy Jost, a law professor at Washington and Lee University, said the policies "could restrict, for example, the number of covered visits a pregnant woman could make to her obstetrician or which prescription drugs to pay for."

However, by passing the responsibility on to the states, "President Obama will most likely make his plan for health care reform more politically palatable," the Times reporters write. "States will be allowed to set benefits at levels similar to what they are now, making coverage not much more expensive than it is today."

While some Republican state officials were happy with the decision, saying it makes it easier for states to comply with the law, others opposed to the law were critical. "All they're trying to do is avoid making tough calls before the election," said Ed Haislmaier, a senior research fellow at the Heritage Foundation. (Read more)