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.

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

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

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

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

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

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

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

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

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

Health care's culture doesn't encourage doctors to report medical errors of colleagues; article says patients should come first

By Melissa Patrick
Kentucky Health News

Doctors are often aware of their colleagues' medical errors, but fail to report them because of a culture that does not support or encourage such actions, Marshall Allen writes for ProPublica, a non-profit, non-partisan journalism organization.

Medical errors are estimated to kill 400,000 people in U.S. hospitals each year according to an online article by John T. James in the Journal of Patient Safety, causing some to say that medical errors are one of the nation's leading causes of death, Allen reports.

According to a report from the U.S. Department of Health and Human Services, most health-care providers employ a philosophy of "deny and defend" when confronted with issues related to medical errors. Providers fear full disclosure will lead to more lawsuits, higher jury awards, higher insurance premiums, and the loss of reputation or coverage for the provider, the opposite is true, the HHS report says. It says honest and open communication helps to lessen malpractice costs.

The Department of Veterans Affairs Medical Center in Lexington has led the way in the move toward health-provider transparency. It has worked under a philosophy of full transparency and disclosure since 1987, requiring prompt reporting and investigation of medical errors and near misses, full investigation, full disclosure of investigation results to the patients and families who have been injured because of accidents and medical negligence, and expressions of apology and  fair remedy, including compensation for injuries, according to the HHS report.

Several years ago, Allen contacted a Las Vegas surgeon to follow up on hospital data that showed peers of this surgeon that had high rates of surgical injuries. Allen reported that before he could reveal the list of peers to the surgeon and request his services in the investigation, the surgeon shared stories of the many surgeries he and his partners did to "clean up" the mistakes of "the worst surgeons in town" and said "he did not need a database to tell him which surgeons made the most mistakes."

An article in the New England Journal of Medicine, “Talking With Patients About Other Clinicians’ Errors,” says that although there is a common belief that there is an ethical duty to inform patients who have been harmed by medical errors, physicians often do not.

The existing guidelines emphasize ethical duties related to self reporting when physicians make  errors, says the report, but offers little guidance about what to do when they discover someone else's mistake.

In a survey separate from the New England Journal of Medicine report, but led by the same main author, more than half of doctors said that in the previous year they had identified at least one error by a colleague.  Gallagher told Allen that the survey did not ask what the doctors did about it.

For the New England Journal report, Dr. Thomas Gallagher, an internist and professor at the University of Washington, led a team of 15 experts who identified possible reasons doctors stay silent about errors by their peers. One reason is the system of referrals on which doctors depend, Allen reports; if a physician "becomes known as a tattler" he or she will lose referrals, and thus suffer financially.

The report lists other reasons for not reporting colleagues' medical errors, such as lack of time to investigate, a culture that promotes loyalty and solidarity, concerns about harming one's institution or becoming involved in a medical malpractice case,  concerns about causing a colleague to face legal issues,risk of acquiring an unfavorable reputation with colleagues and issues related to cultural differences, gender, race and seniority.

The bottom line, Gallagher told Allen, is that "physicians are not learning from their errors and patients are not getting the information they need to receive proper treatment or compensation when the outcome is harmful."

Dr. Brant Mittler, a cardiologist who works as a medical malpractice attorney in Texas, told Allen that in almost four decades in medicine he often saw errors and stayed quiet because "there would have been hostility" if he had reported them. “There’s not a culture where people care about feedback,” Mittler said. “You figure that if you make them mad they’ll come after you in peer review and quality assurance. They’ll figure out a way to get back at you."

Gallagher told Allen, "The result of this culture is too much leniency toward mistakes."

The New England Journal article said that despite the challenges of disclosure, the patient comes first, and doctors should "explore, not ignore" a colleague's error, Allen notes.

Once an error is suspected, the report suggests, the doctor recognizing the error should find the facts, starting with a direct conversation with the physician who made the error so together they can decide how to inform the patient. The article also suggests that hospitals and other health-care institutions lead by supporting transparency.

Dr. David Mayer, vice president of quality and safety at Medstar Health, which runs 10 hospitals in Maryland and Washington, D.C., told Allen that "reporting of medical errors (and near misses) is a top priority at the organization so everyone can learn from mistakes, saying that each month there are about 1,400 reported safety events."

The safety events are analyzed for trends, Mayer told Allen.  If a patient is harmed, an investigation is conducted and the information is disclosed to the patient and family, an apology can be made and compensation can be offered.

Dr. Humayun Chaudhry, president and CEO of the Federation of State Medical Boards, which provides guidance for how state boards regulate doctors, told Allen that doctors and other providers should be more assertive about reporting errors. "Failing to tell a patient about another doctor's mistake undermines the doctor-patient relationship," Chaudhry told Allen. "It makes patients wonder if they can trust their own physicians and the profession of medicine."

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 Health Cooperative partners with UK HealthCare, extending coverage to all 120 Kentucky counties

As a result of an exclusive partnership with UK HealthCare, the Kentucky Health Cooperative, the state's new non-profit insurance carrier, expanded its coverage Wednesday to the University of Kentucky's network of over 1,000 clinicians across Kentucky.

For Kentucky residents who enroll in a Kentucky Health Cooperative insurance plan, the agreement is bringing a statewide network of high-level, accessible clinicians to all 120 Kentucky counties, Janie Miller, chief executive officer of the organization, said in a news release.

The cooperative is Kentucky's non-profit, or Consumer Operated and Oriented Plan under the federal health reform law. The co-op offers coverage to individuals and families and to employees of businesses employing two to 50 full-time equivalent employees, which can be purchased on the state health-benefits exchange, branded as Kynect, directly from the co-op website and from many brokers and agents in Kentucky.

Both Anthem and the co-op offer plans throughout the state, while Humana is offering a limited service area. Since the co-op is a new insurance carrier, forging this type of partnership with UK is an important step; UK HealthCare hass multiple locations across Kentucky, including hospitals, clinics, outreach locations and patient care services, says the release. In addition, it ensures that co-op coverage will be accepted by the more than 1,000 clinicians affiliated with the UK health system.

Part of UK HealthCare's mission is to provide Kentuckians with advanced subspecialty care, while collaborating closely with community providers, says its website. Miller said the co-op's collaboration with UK will significantly benefit both Kentuckians who seek advanced medicine and those who require rural health care, the co-op says in the release.

“We look forward to teaming up with some of the nation’s top clinicians and researchers as well as with community providers dedicated to the delivery of well-integrated health services at the community level,” Miller said. (Read more)

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.

Beshear announces rates in health-insurance exchange, says Kentuckians will like them, especially the federal 'discounts'

By Al Cross
Kentucky Health News

Tossing out the first examples of what Kentuckians will pay for required health coverage through the state health insurance exchange that opens Oct. 1, Gov. Steve Beshear predicted yesterday, "The vast majority of people are going to be very excited about what they find. . . . When they check it out, they’re gonna sign up."

Beshear said there has been much speculation about premiums, but little talk about the federal subsidies (he called them "discounts") that the exchange will offer to individuals and households with incomes up to 400 percent of the federal poverty level. He said subsidies will be available to individuals earning as much as $45,960 a year, and to families of four with income as high as $94,200 a year.

Beshear notes that 15 percent of Kentuckians are uninsured (light green in pie chart); at left is
Kynect Director Carrie Banahan; at right is Health and Family Services Secretary Audrey Haynes.

Tea Party activist David Adams, who recently lost the first round of his court battle to stop the exchange and Medicaid expansion, has said some consumers will have to pay almost double for their current coverage, and he told The Courier-Journal that the subsidies won't make up for that.

About 15 percent of Kentuckians, more than 640,000, have no health coverage. About 308,000 will become eligible for the Medicaid program, which is being expanded under federal health reform to include people with incomes up to 138 percent of the poverty level. Among the other 332,000, 85 percent of those people will qualify for subsidies, Beshear said, and in some cases the subsidy will be 100 percent.

The subsidies are available only through the insurance exchange, which the state has branded Kynect. The exchange will offer five plans, with premiums based only on age, income, geography, number of people on the plan and how many of them use tobacco.

State's example of bronze plan for a smoker earning $30,000

The ceiling for the tobacco surcharge is 40 percent, which has drawn criticism, but the state Department of Insurance said that is the most common surcharge in the state's health-insurance industry. Beshear said a 50-year-old man who smokes and earns $30,000 a year would still pay only $160 a month for coverage under the "bronze" plan, the one with the lowest premiums and highest deductibles and other out-of-pocket costs. Under the plan with the lowest deductibles, he would pay $279.

The bronze plan has a very large $6,300 deductible. The other standard plans are silver, gold and platinum; their deductibles are 20 percent (called "co-insurance") plus $4,600, $2,500 and $1,000, respectively. The exchange will also offer people under 30 a plan that provides only catastrophic coverage with a "very high deductible" and no subsidy, Beshear said.

Among other examples in the bronze plan, which has a $6,300 annual deductible: A nonsmoking farmer in his mid-50s earning $34,000 a year would pay $47; a family of four with no smokers and $70,000 annual income would pay $403; a 32-year-old single mother with two children and $40,000 income would pay $133.

Beshear offered no average cost, saying “There are too many factors to create an average that would be useful. . .. The bottom line is that families must do some research,” which the Kynect website and call center can help them with starting Oct. 1. He said the plans shouldn't be compared to individual plans offered in commercial market, because “the coverages are so much different.”

One big difference is that under the federal health reform law, all plans must cover prescription drugs, hospital care, maternity and newborn services, mental health and substance abuse services, emergency care, rehabilitative services and devices, laboratory services, preventive and wellness services, chronic disease management and pediatric services. Also, they are not allowed to have any dollar limits on coverage.

The law also bans insurance companies from denying or dropping coverage because of someone's health condition, meaning that "For the first time we’re gonna be able to provide affordable health insurance of every single Kentuckian. . . . This is a historic event in the commonwealth." The federal law requires practically every American to have health insurance.

The plans' geography is based on the state's eight Medicaid regions. Beshear said at least two insurance companies will be offering plans in each region, unlike some states. He said four companies have proposed to offer dental insurance, but those plans are still under review by Kynect and the Department of Insurance, which evaluates them for actuarial soundness.

Humana Inc., Anthem Blue Cross and the new Kentucky Health Cooperative will offer policies for individuals, while Anthem, the co-op, Bluegrass Family Health and United Healthcare will provide employee coverage for businesses. Employers with fewer than 50 workers are not required to insure them, and those with fewer than 25 employees can get tax credits for doing so.

The rates are for 2014. Beshear said companies were “understandably cautious” in setting premiums without any experience on which to base them, so he expects rates to decrease in 2015.

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

Judge OKs Medicaid expansion and health insurance exchange

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

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

Circuit Judge Phillip Shepherd

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

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

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

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

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

Beshear announced Medicaid expansion in early May

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

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

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

Online health-insurance exchange will differ in several ways from those in other states; scheduled to go online Oct. 1

Kentucky is one of 17 states setting up its own online health-insurance exchange under the Patient Protection and Affordable Care Act. A new report provides a limited update about the process, and reminds us that Kentucky doesn't have a long-term plan to pay for the Kentucky Health Benefits Exchange, branded Kynect and scheduled to go online Oct.1.

The state is writing regulations to govern the operations of the exchange, and "developing IT systems that house and execute the eligibility determination rules for exchange coverage, federal premium tax credits and cost-sharing subsidies, Medicaid, and the Children’s Health Insurance program" says the Georgetown University report, prepared for the Commonwealth Fund, which calls itself "a private foundation that aims to promote a high-performing health care system."

Most states are involving their legislatures in decisions about exchanges, says the report. This is not the case in Kentucky, perhaps because Republicans control the state Senate. Tea party activist David Adams has filed suit, challenging the legality of Gov. Steve Beshear's decision to implement the exchange without legislative approval. So far, a judge has denied the governor's request to dismiss it.

Even the exchanges with their own rulemaking authority like Kentucky have worked with the legislatures for other decisions, "such as the exchange's long-term financing mechanisms," says the report. The federal funding Kentucky is using to establish the exchange will be gone by 2015, but as of May 31, Kentucky and seven other states had no plans for a long-term revenue source.  Other states have either assessed insurers offering coverage on the exchanges or they are assessing taxes to cover the cost, says the report. Kentucky officials have indicated they will use assessments, but some Republicans have said that would be a tax, which only the General Assembly can impose.

The report also highlights the various approaches states have taken to toward selection of exchange plans. Kentucky is called a "market organizer," meaning that it "manages plan choices through limits on the number or type of plans that an insurer can offer but does not selectively contract with insurers," says the report. As required by the health-reform law, the Kentucky exchange will require participating insurers to offer at least "silver" and "gold" plans, and it is also requiring them to offer catastrophic coverage outside the metal-labeled tiers (which could have included "bronze").

Kentucky opted for no more than four plans per metal tier. Officials say limiting the number of plans will help consumers avoid being overwhelmed while giving insurers flexibility. Although the employer mandate to provide health insurance was delayed until 2015, Kentucky's exchange is still expected to offer multiple tiers through multiple insurers for employers to buy insurance, says the report.

On the advice of a 19-member board Beshear appointed to oversee the exchange, Executive Director Carrie Banahan has decided to not require plans to display quality metrics, as 10 other states plan to do, the report says. The board is chaired by Sharon Clark, commissioner of the Kentucky Department of Insurance.

The board and Banahan have gone against the grain on some other decisions. Most states are deferring to existing rules governing insurance agents; Kentucky is the only state requiring all agents to represent at least two insurers participating in the exchange.

In June, the state Cabinet for Health and Family Services issued a request for "Kynectors" to help Kentuckians shop for health insurance on the exchange. These employees and volunteers will help individuals and small businesses in determine their health-plan needs and help them choose plans to meet those needs, the cabinet said. To view the solicitation for Kynectors, click here.

The state is currently looking for exchange "kynectors"

Information for the report was gathered from minutes of the board.  Click here for a list of board members and here to view board meeting materials. Minutes of the May meeting will be posted after the board's next meeting on July 15, Midkiff said.

Eye exams are now required for children ages 3 to 6 when first starting public school or preschool

Add eye exams to your back-to-school checklist, because state law now requires children aged 3 through 6 who are entering a public school or preschool program for the first time to have a vision exam.

“Studies show that vision problems are a major factor in limiting children’s abilities to learn and succeed,” said Dr. Tonia Batts, a Mayfield optometrist, said in a news release from the Kentucky Optometric Association. “Having children’s eyes examined is one of the most important things parents can do to support their children’s education and good health. . . . Many problems may not be obvious to them or their children’s teachers.”

Early diagnosis and treatment can prevent loss of sight from amblyopia, which most people call "lazy eye." Half of amblyopia cases are not diagnosed until after age 5, when it is difficult to correct, Batts said. Amblyopia the leading cause of vision loss in people under age 40, more than injuries or any other disease, but if detected early, is 100 percent treatable.

Batts said an eye examination is particularly important if your child loses place while reading; avoids close work; tends to rub his or her eyes; complains of frequent headaches; squints to use only one eye or consistently performs below academic potential.

Eye exams are covered by many private insurance plans, Medicaid and the Kentucky Children's Health Insurance Plan. Private programs may also help families with eye exam expenses. The Kentucky Vision Project, sponsored by the Kentucky Optometric Association, has donated millions of dollars in vision care, says the group's news release. Sight for Students and the Lions Club have other programs that can help. To find an optometrist in your area, click here.

Beshear announces launch of Kynect, the state's new online shop for health insurance; open enrollment starts Oct. 1

Gov. Steve Beshear has announced the launch of Kentucky’s Healthcare Connection, which is referred to as Kynect and is Kentucky's one-stop onlineshop for the state's new health insurance exchange.

Beginning next year, most Americans will be required to have health insurance, and Kynect is designed to help an estimated 640,000 uninsured Kentuckians get coverage through private insurance plans, Medicaid or the Kentucky Children’s Health Insurance Program. The online service is also aimed to promote public education and awareness about the health benefit exchange, says a recent press release.

“When I issued an executive order last year creating a state-based health benefit exchange, I did so to ensure that our health benefit exchange would be designed to best meet the unique needs of Kentuckians,” Beshear said. “Individuals, families and small businesses will be able to use kynect for one-stop shopping to find health coverage and determine if they are eligible for payment assistance or tax credits to help cover costs.”

During open enrollment, which begins Oct. 1, Kentuckians and small businesses can compare and select health insurance plans using the Kynect website, a toll-free contact center, a mail-in application or in person, says the release. People can also use the website to find out if they qualify for payment assistance and special discounts on deductibles, co-pays and co-insurance.

For example, the website indicates that a family of four making $48,000 will receive a tax credit that can be used to pay insurance premiums, which is estimated to be $252 per month, in addition to government subsidies for medical care. A family of four making $80,000 will a receive tax credit too, and insurance premiums are estimated to be $634 per month. Small businesses can also use the website to see if they qualify for specific tax credits (Click here for a PDF fact sheet about payment assistance)

“Starting today, we are undertaking a major education and awareness campaign to ensure that all uninsured Kentuckians understand how Kynect can help them and their families find affordable health coverage,” said Audrey Haynes, secretary for the Cabinet for Health and Family Services, which will oversee Kynect along with the Kentucky Office of the Health Benefit Exchange.

Beshear created the health exchange by an executive order in July 2012. A recent lawsuit alleges this action was not authorized and should first be approved by the General Assembly. To date, Kentucky has received about $250 million in federal grants to cover the initial costs of exchange, but the state will be responsible for all funding for the exchange beginning in 2015. Kentuckians can visit the service's website or watch the video below to learn more about the program. 

Poll shows more than half of Ky. adults have no dental insurance and many go without essential dental care

Routine dental care is essential to overall health, but a new poll shows 1.7 million Kentucky adults do not have dental insurance. That is more than times the number of people who will be at Churchill Downs for the Kentucky Derby, notes the Foundation for a Healthy Kentucky, which co-sponsored the poll.

The poll also showed that many Kentucky adults are going without the dental care they need. While the poll found that few owe money for dental bills, only 61 percent said they visited a dentist or dental clinic within the past year. The national figure is 70 percent.

“Oral health is essential to overall health,” said Dr. Susan Zepeda, president and CEO of the foundation. “Yet, our research indicates a majority of Kentuckians do not have dental coverage, so it is not surprising that a large number of adults do not have a personal dentist or oral health provider.”

Poor oral health or oral pain can lead to poor nutrition and can reduce someone's quality of life by making it difficult to sleep, work or interact with others, and having dental insurance is an important factor in determining whether someone is getting the dental care they need.  More than 50 percent of poll respondents indicated not having dental insurance of any kind, and almost half of that group said they skipped getting dental care or check-ups in the past year due to its cost.

Whether or not someone has a normal source of care is also an important factor in determining health care outcomes because those with a personal dentist or doctor are more likely to seek care. Almost 40 percent of poll respondents, however, said they do not have a personal dentist or oral health provider, and almost 80 percent of those respondents said its been more than five years since they last visited a dentist or dental clinic.

The poll was funded by the foundation and the Health Foundation of Greater Cincinnati. The poll was conducted last year from Sept. 20 through Oct. 14 by the Institute for Policy Research at the University of Cincinnati. A random sample of 1,680 adults from throughout Kentucky was interviewed by telephone, including landlines and cell phones, and the poll has a margin of error of plus or minus 2.5 points.

Baucus sees a health-reform 'train wreck,' fearing insurance exchanges won't be ready

Max Baucus (J. Scott Applewhite, AP)

Senator Max Baucus, who as Senate Finance Committee chair helped write the health-care reform law, has become the highest-ranking Democrat to publicly voice concerns about its implementation, saying he thinks it’s headed for a collision with itself.

“I just see a huge train wreck coming down,” the Montanan told Health and Human Services Secretary Kathleen Sebelius during a budget hearing.

Matt Gouras of The Associated Press notes that polls show that Americans are confused by the complex law, which is designed to cover about 30 million uninsured people through a mix of government programs and tax credits. Baucus told Sibelius he’s “very concerned” that new health insurance exchanges will not open on time in every state and residents will not have enough information to make choices even if they do open on time, as Kentucky's seems likely to do.

"The administration’s public-information campaign on the benefits of the Affordable Care Act deserves a failing grade,” Baucus lectured. “You need to fix this.” Baucus’ office later told Gouras that the senator still thinks the Affordable Care Act is a good law, but questions its roll-out.

Sebelius said that the administration is on track to fully implement exchanges in January, and to be open for open enrollment on Oct. 1, 2013, reports Gouras. Kentucky is among the states that have chosen to build a fully state-based exchange. Others have chosen a state-federal partnership exchange, or defaulted into a federally facilitated exchange. The map below shows the lay of the land about that decision. Yellow states have defaulted to a federal exchange, light blue states are planning for a partnership and blue states have chosen a state-based exchange.

Map provided by the Kaiser Family Foundation

Poll shows health care costs are a burden for many Kentuckians

A recent statewide survey shows health-care costs are a burden for many Kentuckians, especially for those who are poor and don't have insurance and put off getting care they need because they can't afford it.

More than 60 percent of Kentucky adults in the poll said high costs forced them or a family member living in their home to delay getting care in the past year. Not surprisingly, almost 90 percent of uninsured respondents reported going completely without care in the past year.

The Kentucky Health Issues Poll also showed that 48 percent have relied on home remedies when they are sick instead of going to a doctor, 43 percent have postponed care they needed, 37 percent have not filled a prescription or skipped a dental visit or checkup, 36 percent skipped a recommended medical test or treatment, and 16 percent have cut pills in half or skipped doses of medicine for financial reasons. Overall, 64 percent answered "yes" to at least one of those questions.

“Although our economy is improving, many Kentucky families are still struggling financially. Our research shows healthcare costs have a significant impact on Kentuckians’ actions,” said Dr. Susan Zepeda, president and CEO of the Foundation for a Healthy Kentucky, which co-sponsored the poll. “Timely access to quality, affordable healthcare is important to restore and maintain Kentuckians’ health and productivity. When we delay or go without care, illness severity and costs can escalate. Based on the KHIP results, many Kentuckians are taking risks with their overall health because of the expense.”

Rising costs of health care do not affect all Kentuckians in the same way; almost 40 percent of Kentucky adults reported that paying for health care and health insurance is not a financial burden. Those who did say costs were a burden said they were burdened equally by the costs of doctor visits, prescription drugs and insurance premiums or deductibles.

The poll was funded by the foundation and the Health Foundation of Greater Cincinnati. The poll was conducted Sept. 20 and Oct. 14 of last year by the Institute for Policy Research at the University of Cincinnati. A random sample of 1,680 adults from throughout Kentucky was interviewed by telephone, including landlines and cell phones, and the poll has a margin of error of plus or 2.5 points.

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)

Will Kentucky expand Medicaid, and if so, how?

By Molly Burchett
Kentucky Health News

Kentucky is one of the last states to decide whether to expand Medicaid under federal health reform, and now that the General Assembly has gone home, Democratic Gov. Steve Beshear can turn his attention to the many questions that linger. Some Republican legislators think he will expand the program, but they worry about the cost when the state would have to start helping cover the new expenses, beginning in 2017.

Republican Gov. Bill Haslam of Tennessee decided Wednesday that he will not pursue Medicaid expansion, saying that it could put hospitals in financial jeopardy by giving them more patients on which they lose money, reports Michelle Kaske of Bloomberg. If he is right and the same logic applies to Kentucky, Medicaid expansion in the state could harm the rural hospitals and providers -- some of whom are already squeezed by the issues with the new managed-care system.

Along with Kentucky, 10 other states are undecided about Medicaid expansion: Alaska, Indiana, Kansas, Nebraska, New York, Oregon, Utah, Virginia, West Virginia and Wyoming. The map by The Advisory Board Company shows the lay of the land; for an interactive picture that outlines the research behind the map, click here.

Red=Not participating; Pink=Leaning toward not participating;
Gray=Undecided; Blue=Participating; Light Blue=Leaning toward participating

Only three states with Democratic governors are undecided; 18 Republican governors have rejected expansion. Kentucky is shown as leaning for it because Beshear has repeatedly said that he will expand Medicaid if the state can afford it. He has also mentioned that the state can reserve the right to pull out of the deal in 2017, when it must paying 3 percent of the cost of covering the newly insured, reaching 10 percent in 2020. Still, the questions about cost and affordability remain, and Beshear could be considering another option.

Tennessee has joined Ohio and Arkansas in negotiating with the Obama administration over plans to use federal Medicaid money to purchase private insurance for those who can't afford it but don't qualify for Medicaid now. However, Haslam's plan has been held up because the administration placed too many conditions on the money, writes Kaske. Republicans in other states, including Florida, Louisiana, Pennsylvania and Texas, have expressed interest in this option since Gov. Mike Beebe of Arkansas, a Democrat, ignited the wildfire of creating a hybrid of the two alternatives, reports Robert Pear of The New York Times.

The idea of privatizing Medicaid expansion appeals to many doctors and hospitals because they typically receive higher payments from commercial insurance than from Medicaid. However, many Kentucky hospitals and providers are concerned about the managed-care program that is run by three private organizations, and are calling for immediate action. Beshear has not said whether he will sign or veto a bill that would subject the managed-care firms to the prompt-payments and dispute-resolution rules of the state Department of Insurance.

"Action is needed to address the problems that patients and hospitals are experiencing with Medicaid managed care and to make the system work properly," wrote Harold "Bud" Warman, chair of the Kentucky Hospital Association, and Charles Lovell, chair-elect of the association, in a recent Herald-Leader article that laid out the various problems with the system. "And with the possibility that Medicaid will be expanded in Kentucky to include an additional 350,000 people, it is critical that these issues be addressed right away to avoid even greater problems in the future."

Either using federal dollars to buy private insurance in order to cover newly qualified individuals (the hybrid plan) under the health law's expansion  or expanding in the "traditional" way will not change the current managed care structure of Medicaid in Kentucky. Yet, it would mean that 350,000 more Kentuckians would be covered under managed care; Medicaid would cover those earning up to 138 percent of the federal poverty level, currently up to $15,856 a year for an individual.

The money that the federal government offers for expansion is very tempting. The question then may be, how will it be used?

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

Newly formed Kentucky Health Cooperative gets OK to offer plans in state's health insurance exchange

The new Kentucky Health Cooperative's health-insurance plans have received approval from the state Department of Insurance and will be available on Kentucky's insurance exchange market when it opens in October.

“This is a red-letter day for Kentuckians,” Janie Miller, CEO of the cooperative, said in a news release. “Although health-care cooperatives have offered quality care and lower overhead expenses to members since the 1930s, they’re the ‘newest kid’ on Kentucky’s health insurance block. Efforts are underway to help the public become familiar with the cooperative concept.” The cooperative was formed with a mixture of private capital and federal loans.

Miller, a former secretary of the state Cabinet for Health and Family Services, said the cooperative is like member-owned and member-operated credit unions, rural electric cooperatives and food co-ops. “Think agriculture cooperative extension offices, and consider the impact such organizations have made,” she said. “Doing so makes it easy to imagine the potential, similar value to the citizens of our Commonwealth offered by a health cooperative.”

Joe Smith, chair of the cooperative's board of directors, said “A gateway has been opened to individuals and small businesses seeking more affordable, consumer-friendly, quality-driven health insurance options.”

Details about the cooperative plans offered to individuals and businesses with 50 or fewer employees on the nw state insurance exchange will be announced in the coming months. (Read more at the KYHC website)

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

By Molly Burchett and Al Cross
Kentucky Health News

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

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

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

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

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

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

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

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

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

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

Kentucky families struggle to care for violent, mentally ill children, and say their plight has been made worse by managed-care firms

Kentucky families struggle to care for violent, mentally ill children, and say their plight has been made worse by managed-care companies that fragment mental-health care and make it harder to find appropriate, stable treatment, which ultimately places the larger public at risk, Laura Ungar reports for The Courier-Journal.

Ungar writes that the lives of these Kentucky families resemble in part the one that lead to a devastating outcome in Newtown, Conn., where 20-year-old Adam Lanza, who had poor mental health and was under his mother’s care, went on a shooting rampage in an elementary school and killed 20 students and six staff members.

To represent the Kentucky families fighting, this battle, Ungar tells the story of the Davies family, who battle to keep themselves safe from the violent rage of their 14-year-old daughter, Lucy, while struggling to find the help she needs. Lucy has threatened to kill her 16-year-old sister, Katie, and herself, she’s tried to throw Katie and her father Dan down the basement stairs, and she’s been abusive to her mother.

Lucy suffers from a long list of disorders: neurological problems from fetal alcohol spectrum disorder, a mood disorder, post-traumatic stress disorder, and cognitive difficulties, Ungar reports. "Since Lucy was adopted at age 9, she’s received fragmented treatment in more than six facilities and doctors’ offices, none of which have been able to stop her violent outbursts," Ungar writes. Now, her Medicaid managed-care insurer, Coventry Cares, won’t cover her treatment in an Illinois facility called NeuroRestorative, which Ungar says offers her the best chance at improvement.

"The care tracking is just so fragmented, and we have managed-care companies that determine from afar what care people can get. They go from provider to provider. It’s a tragedy," said Louise Howell, president of Buckhorn Children and Family Services, where Lucy was treated briefly before becoming too violent for the staff. “This child is a perfect example of someone in need of a strong therapeutic community," Howell said. "And there’s so many of them."

Before going to Buckhorn, Lucy was at Rivendell Behavioral Health Services in Bowling Green, where she received brief treatment after threatening to kill her sister. From Buckhorn she got an emergency transfer to Our Lady of Peace in Louisville, which could handle her high level of violence. She was released when she moved from the Medicaid plan Kentucky Spirit, which plans to break its contract with the state, to Coventry Cares, with which Our Lady of Peace had severed ties.

Lucy's mother told Ungar that every switch of caregiver and facility increases the trauma to her daughter, who desperately needs stable care. Lucy’s parents say she would have such stability at NeuroRestorative, where her fetal alcohol syndrome could be addressed on a long-term basis. But two doctors working for Coventry, who have never examined Lucy, told her parents that Conventry "won’t cover the placement because there’s no evidence that inpatient care for brain trauma is medically necessary," Ungar reports.

Her eyes full of tears, Cynthia Davies told Ungar, “You cannot look into my daughter’s eyes and tell me she doesn’t deserve care. She’s a human being.” (Read more)

Feds letting Arkansas privatize Medicaid expansion; idea could spread like wildfire, as in Florida, but cost questions remain

Arkansas has turned heads nationally with its preliminary plan to expand Medicaid using the private insurance market, showing that the Obama administration is willing to give states more flexibility than expected in expanding the program.

Health and Human Services Secretary Kathleen Sebelius has agreed to a proposal by Arkansas Gov. Mike Beebe to reject the Medicaid expansion but use federal money to buy private health insurance for the 200,000 people who would have been covered under ordinary expansion, reports Sandhya Somashekhar of The Washington Post.

States that have come down on either sides of the Medicaid-expansion issue may reconsider their decision in light of the Arkansas proposal, said Sara Rosenbaum, a health law professor at George Washington University. "If Arkansas is allowed to do this, I expect it to spread like wildfire," Rosenbaum told the Post.

The first place could be Florida, where a state Senate committee rejected Republican Gov. Rick Scott's expansion plan and proposed a privatization plan like that in Arkansas. Last week, a House committee voted to reject any expansion of the program. Scott "made it clear he was not going to lobby the Legislature on Medicaid," preferring to emphasize other issues, The New York Times' Lizette Alvarez reports. For coverage from the Tampa Bay Times and The Miami Herald, click here.

Could the wildfire spread all the way up to Kentucky?

Gov. Steve Beshear has said he wants to expand Medicaid in Kentucky if the state can afford it, but many Republican lawmakers oppose the idea, saying it would not be fiscally responsible. On the national level, 26 states and the District of Columbia have expressed a desire to expand Medicaid, 17 have said they reject it and seven are undecided, according to the nonpartisan Kaiser Family Foundation.

A more flexibile arrangement could be a game changer because it makes expansion more appealing, especially for states where expanding Medicaid has been politically unpopular and polarizing. in Arkansas, which has a Democratic governor and a Republicna legislature, officials say that from an ideological standpoint, using private insurance appeals to lawmakers from both parties, reports Somashekhar. She reports that even Democratic-led states might prefer this arrangement because it gets rid of some bureaucratic hurdles.

However, there are questions about cost. The Congressional Budget Office estimates that private insurance plans cost $3,000 more per person than Medicaid, reports Somashekhar. On the other hand, Arkansas officials say the move could ultimately save money in administrative charges along with other cost-control measures.

Although the Arkansas proposal is not concrete, it provides proof that the Department for Health and Human Services encourages innovative, state-based approaches to promote expansion. Many states may develop a new route best suited to their specific needs, without having to leave federal money on the table. (Read more)