Legislature likely to tweak, clarify and limit last year's 'pill mill bill'

State lawmakers could narrow the focus of last year's "pill mill bill" during the legislative session that begins tomorrow, to concentrate on adults with long-term prescriptions for frequently abused painkillers, John Cheves of the Lexington Herald-Leader reported yesterday. Doctors, hospitals and patients have complained that HB 1 in its current from "restricts too many drugs in too many clinical settings, needlessly complicating medical care in an effort to shut down storefront pain clinics that recklessly hand out prescriptions," Cheves writes.

Under the law, people with long-term prescriptions for controlled substances must submit to urine drug testing to determine if they are actually taking the drug rather than selling it, and if other unprescribed drugs are in their systems. Some patients complained they were being charges hundreds of dollars for urine tests because their insurance companies denied coverage of such testing. One couple was charged more than $900 for tests to get prescriptions for insomnia and anti-anxiety medication.

The new rules, being drafted by the Kentucky Board of Medical Licensure, would reduce the mandate for drug screening to pain medicine prescriptions of 90 days or more. Other medications would not require testing unless the doctor thinks it's necessary. The new rules will say that other types of testing which would be cheaper, including hair, could be used. The board is also restricting its focus to powerful painkillers, including hydrocodone and oxycodone.

The new regulations are subject to approval by the legislature, which could write its own restrictions into law, but the consensus appears to be that the law needs tweaking, not major changes. for example, House Speaker Greg Stumbo said it should be changed to clarify that hospitals don't have to run a new background check on a patient every time they give another dose of a controlled substance during his stay. (Read more)

Health agencies in Rockcastle, Jackson, Clay, Harlan to lose 14 employees, some environmental and food-safety inspections

In the latest example of Medicaid changes' impact on local health departments, environmental and food-safety inspections will be reduced by layoffs in four counties served by the Cumberland Valley District Health Department, Nola Sizemore of the Harlan Daily Enterprise reports. Health departments in Harlan, Rockcastle, Clay and Jackson counties will lose a total of 14 employees later this month. (Enterprise photo: Harlan County Health Department)

Health Department Interim Director Lynett Renner told Sizemore said the layoffs, along with furlough days, are a result of decreased funding and the "advent of managed care organizations" in November 2011. The agency has almost $1 million in outstanding accounts because payments from those organizations have been slow to come in. "Also, one of the things that affected the health departments tremendously is we’re the only provider in the state required to pay a Medicaid match, which means for every service we provide for a client who has Medicaid, we have to pay the state back 20 percent and that recently increased to 28 percent," Renner said.

Renner told Sizemore that environmental services and restaurant health inspections would be most affected, adding that public health is often taken for granted by the local community. "So much is done behind the scenes to ensure the health and safety of every citizens," she told Sizemore. "My fear is they're reducing the ability of the public health infrastructure to be able to maintain that level of service that provides protection." (Read more)

Danville newspaper examines problems hospitals and doctors have with state's managed-care Medicaid program

All the talk about "Obamacare" may have obscured Kentucky's biggest health-care story, Kendra Peek of The Advocate-Messenger in Danville suggests, in a look at Kentucky's troublesome shift to managed-care Medicaid. "It's the biggest story in the state that's not being told," said Vicki Darnell, president and CEO of Ephraim McDowell Regional Medical Center in Danville, told Peek. Her story is an example of how a smaller newspaper can show the impact of a statwwide policy. (A-M photo)

On Nov. 1, 2011, Medicaid in Kentucky switched to a managed care program, which essentially means management of Medicaid was outsourced to private insurance companies Peek reports. There are three managed care organizations (MCOs) statewide: Coventry Cares of Kentucky, Kentucky Spirit and WellCare of Kentucky.

The time for payments to doctors and hospitals has doubled since MCOs were implemented, McDowell Chief Financial Officer Bill Snapp told Peek. Before, they were getting paid for Medicaid patients' care within 17 to 20 days. Immediately after the switch, he said, it took as long as 70 days. Some private physicians have been forced to make hard financial decisions because of delays, and because MCOs reimburse doctors at "significantly lower rates than private insurers," Peek reports. Some hospitals, physicians and health departments have had to lay off employees, and some doctors are refusing to see Medicaid patients because they can't afford to.

In some cases, patients have had to find doctors or hospitals where the MCO they selected would be accepted, Peek reports. Hospitals cannot legally deny treatment to anyone based on insurance, but having to find hospitals or physicians that accept particular MCOs can become expensive out-of-pocket for patients. Some primary physicians may not be allowed to work at certain facilities, requiring their patients to be shifted to another doctor.

MCOs have been in the news for these issues. Coventry Cares canceled contracts with Appalachian Regional Healthcare, a network of hospitals in Eastern Kentucky, in a move that drew significant backlash. Kentucky Spirit has announced it would end its managed-care contract in July, saying it has concerns about the sustainability of the plan. (Read more)

Fiscal-cliff deal revives program that helps rural hospitals dependent on Medicare; 200 in nation, 10 in Kentucky

Even though most of the hospital industry wasn't happy with the fiscal-cliff deal that will only pay half the $30 billion needed to avoid a 27 percent Medicare fee cut for doctors, the deal gave about 200 rural hospitals, including 10 in Kentucky, reason to celebrate. It extends a program that pays hospitals up to several millions of dollars a year because they have fewer than 100 beds, are located in rural areas and have a high percentage of Medicare patients, Phil Galewitz of Kaiser Health News reports.

The Medicare Dependent Hospital Program was created in 1990 and is one of several payment programs designed to help small, rural hospitals deal with financial challenges that larger hospitals don't face. The program is based on the idea that "some rural hospitals have such a high percentage of Medicare patients they are unable to get enough money from higher paying privately insured patients to make up for the lower government reimbursements," health lawyer Eric Zimmerman told Galewitz.

The program has come under scrutiny. Congress allowed it to expire in September 2012, but two senators from New York and Iowa made sure $100 million for the program made it into the budget deal. The Medicare Payment Advisory Commission said hospitals in the program will receive about 25 percent higher reimbursements as a result of the funding. (Read more)

The Kentucky hospitals in the program are Clinton County Hospital, Fleming County Hospital, Harrison Memorial Hospital, Jewish Hospital Shelbyville, Logan Memorial Hospital, Monroe County Medical Center, Parkway Regional Hospital in Fulton, Rockcastle Regional Hospital, Taylor Regional Hospital and Westlake Regional Hospital in Columbia. The Appalachian Regional Hospital in Williamson, W.Va., is also considered a Kentucky hospital in the program.

Painkiller epidemic was driven in part by drug makers' financial relationships with researchers who discounted the risks

For almost a decade, medical officials and experts claimed OxyContin rarely posed problems of addiction for patients. The drug's label, which was approved by the Food and Drug Administration, said addiction risks were small. Research published in the New England Journal of Medicine also said OxyContin wasn't addictive; so did a study in another journal, which OxyContin manufacturer Purdue Pharma reprinted 10,000 times. Since the drug first hit the market, it has fueled a large-scale swath of prescription pain killer addiction, beginning in Central Appalachia, that has grown into a national epidemic, especially in rural areas.

The epidemic was driven in no small part by doctors' lack of knowledge about OxyContin, which was perpetuated by the drug's manufacturer through false claims that became scientific consensus. But now, "Many in the medical profession have rediscovered the destructive power of opiates," and are calling that consensus into question, Peter Whoriskey of The Washington Post reports. "A closer look at the opioid painkiller binge, in which retail prescriptions have roughly tripled in the past 20 years, shows that the rising sales and addictions were catalyzed by a massive effort by pharmaceutical companies to shape medical opinion and practice."

Doctors were wary of prescribing painkillers to any patient except those with cancer for years. But manufacturers and some pain specialists "helped create a body of scientific research assuaging the long-standing worries about opioids and pushed to expand the use of the drugs in people with chronic pain: bad backs, arthritis, sore knees," Whoriskey reports.

Through an examination of key scientific papers, court documents and FDA records, the Post found that many of the studies claiming OxyContin wasn't addictive were supported by Purdue Pharma. The conclusions those studies reached were sometimes not supported by data, and when the FDA needed to develop an opioid policy, it turned to a panel of doctors who had financial relationships with Purdue Pharma and other drug makers. (Read more)

Health reform drives hospital mergers and affiliations, and makes clinical collaborations more important

Is your community's hospital one of the many rural hospitals considering sale, merger or affiliation with a larger hospital or group of hospitals, all options that are becoming more common, partly due to federal health-care reform? A recent article in HealthLeaders magazine, which examines some of the considerations, may inform your coverage.

Basing decisions on past experiences "is difficult because the creativity surrounding partnerships among hospitals and health systems is expanding rapidly," writes Philip Betbeze, the magazine's senior leadership editor. For example, clinical collaborations have become more important in affiliations. "Whether they own or don't own each other doesn't matter as much as coming up with a structure for sharing those value-based purchasing points together," Joseph R. Lupica, chairman of Newpoint Healthcare Advisors, told Betbeze, who writes: "That's a sea change compared to prior affiliations or mergers. In the past, such deals were driven by traditional aims around increasing market share and increasing bargaining power."

Health reform will create incentives for better patient outcomes, which upsets the old "iron trangle" of hospitals: "volume, rates, and the ability to decrease unit costs," said Dr. Gregg Meyer, chief medical officer of Dartmouth-Hitchcock, a New Hampshire hospital group that recently affiliated with the Mayo Clinic, more than 1,000 miles away, "because we know that patients who come to us for care will often seek a second opinion. In the past, that meant going to Boston or New York, and we lost out on that because we lost the ability to keep that care local. Now we can have a virtual second opinion with arguably the most famous health system in the world."

The article has several more examples. to read it, click here.

Chart shows how to get coverage under federal health reform

The core of the Patient Protection and Affordable Care Act is helping people get health insurance, beginning next year. That will be relatively simple for some people, but complicated for others, as this infographic produced by the Kaiser Family Foundation for the Journal of the American Medical Association shows. For a larger, clearer, PDF of the chart, click here. In most states, including Kentucky, a key question remains unanswered: Will the state opt to expand Medicaid eligibility to households with incomes up to 133 percent of the federal poverty level (138 percent with a fudge factor)?