Hopkinsville paper examines doctor shortage, reasons for it

Albert Delaney waits for his wife Agnes in Hopkinsville.
(Photo by Kentucky New Era's Tom Kane)

Nick Tabor of the Kentucky New Era examines Christian County's doctor shortage, with the area averaging just one primary care physician for every 2,000 people. It's the latest health story in the small daily newspaper, which is committed to quality health reporting.

The shortage creates problems for residents, who must either travel to another area to see a doctor or go without preventive services because there is no one to see until serious illness occurs. When that happens, that "puts an undue burden" on the local hospital's emergency room.

The shortage is affected by the fact that "primary care physicians, which rural areas need in higher volumers than specialists, are entering the job market at alarmingly low rates," Tabor reports. "More medical students are becoming specialists, as these jobs promise better salaries and hours." Secondly, it is difficult to recruit doctors to rural areas. "Little old Hopkinsville is up against Boston and Chicago and all of these bigger cities," said Teresa Bowers, Jennie Stuart Medical Center's physician recruitment director. "They're not throwing darts at a map and saying, 'I'm going to Hopkinsville.'"

The problem is not a new one. A 2007 report by the Kentucky Institute of Medicine shows there have been shortage issues for decades. "Even if all the barriers that have prevented a sufficient and well-dispersed supply of physicians were suddenly to disappear, the task of recruiting and educating an ample cohort of doctors would take years to accomplish," it reads.

The problem is liken to worsen, however, if the federal health-reform law is upheld by the U.S. Supreme Court, as 30 million more Americans will have insurance to see the doctor. A recent report found medical school enrollment is up by 30 percent, but more residency placements are needed to accommodate the influx. (Read more)

Former head of Massachusetts health exchange says it's better to offer fewer, well-defined plans than set general criteria

With  Kentucky stakeholders discussing their options to set up a state-run health insurance exchange — something Gov. Steve Beshear said last week he intends to do if the Affordable Care Act is upheld by the U.S. Supreme Court — research shows the fewer plans offered in the exchange, the better.

An article in Health Affairs says officials should follow the lead Massachusetts' health-reform system when creating their own exchanges. "A hands-on exchange with the power to set standards on top of the federal health-care law will help prevent consumers from being 'overwhelmed' by the process of buying insurance," reports Sam Baker for The Hill's global affairs blog.

The Health Affairs article's lead author, Rosemarie Day, is a former deputy director of the Massachusetts exchange. She said consumers prefer choosing from "a handful of carefully vetted, clearly described health-care plans," Baker reports. The model used in Utah to allow any plan that meets criteria to be featured in the exchange is less popular, the paper found, but was more popular among conservatives.

"Findings from consumer research emphasized the value of limiting insurance plan choices on the exchange," the analysis states. "Specifically, early focus groups showed that consumers wanted four to six carrier options at 'low, medium and high' benefit levels." (Read more)

Tea Party protesters object to state-run health insurance exchange; leader says if there is one, feds should run it

By Tara Kaprowy
Kentucky Health News

A public meeting in Frankfort to get stakeholders' input about development of a state-operated health insurance exchange Monday was attended by dozens of Tea Party activists taking issue with Gov. Steve Beshear's intention to create it.

"It was absolutely a formal protest," said organizer David Adams, who writes the blog Kentucky Progress and managed Louisville businessman Phil Moffett's campaign for the Republican nomination for governor last year. "We are very, very strongly opposed and we're just getting started with our protest."

Last week, Beshear announced his intention to create a state-run exchange if the Affordable Care Act is upheld in the U.S. Supreme Court. Since 30 million Americans who don't have coverage now would be required to buy insurance under the law's mandate, the exchange would act as a marketplace in which individuals and employees of small business can choose from several plans that have coverage packages pre-approved by state and federal governments. The people buying from the exchange would be given subsidies to help pay their premiums.

States have the option to create their own exchange or have the federal government run one for them. Through February, Kentucky had received nearly $60 million to help set up an exchange, money officials said would be used for planning.

Several major business lobbies have said the state should have its own exchange, but Adams argues that if there is an exchange, the federal government should run it.

"This idea that if the state does it then we have some kind of control is like saying since we run Medicaid, we have control over Medicaid, which is absolutely not the case," he said. "If we have a state-run health insurance exchange, we will run it in the exact way that the federal government wants us to." He said he fears that once a state-run exchange is set up, "when federal funds run out, we'll be responsible for financing it."

"There is a place for helping people who absolutely can't help themselves," Adams acknowledged, but since people with an income of up to 133 percent of the federal poverty level qualify for the exchange, "We've changed the definition of who can't help themselves. We've moved that line way up into the middle class. In every part of life that we've done that, that has been very counter-productive."

Though the Supreme Court's decision about whether to uphold the mandate won't be known until June, Adams said he felt it was necessary to protest Monday's meeting "to demand that the government send back the $60 million and stop any activities of setting up an exchange." "I don't think anybody really believes that we need $60 million in federal grant money to set up a website to help people buy health insurance," he said. "We need to return that money and operate on a more fiscally feasible path."

In response to a question, Adams said the protest was not held to stir anti-Obama sentiment that might help Kentucky Republican candidates in the November elections. He said the insurance exchange is "just the tip of the spear" and that "the best thing we can do in managing our health care problems is stop going in the wrong direction."

Kentucky Health News is a 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.

Local health care centers in Ky. get $16.5 million in federal grants

Kentucky recently received $16.5 million in grant for health care centers as part of the Affordable Care Act.

Recipients include Family Health Center Inc. in Louisville ($5 million); Cumberland Family Medical Center in Burkesville ($4.86 million); Grace Community Health Center Inc. in Knox County ($4.33 million); and Big Sandy Health Care Inc. in Prestonsburg ($977,375). The grants were made through a building-capacity program, reports Greg Kocher for the Lexington Herald-Leader.

Grants given under the "immediate facility improvement program" include $425,000 for Mountain Comprehensive Health Corp. in Whitesburg; $380,000 for Family Health Center Inc. in Louisville; $360,863 for Cumberland Family Medical Center in Burkesville; and $216,543 for Big Sandy Health Care in Prestonsburg.

The awards will help serve about 29,475 new patients, states a news release from the U.S. Department of Health and Human Services. Nationwide, $728 million was awarded for renovation and construction projects. (Read more)

What will high court do on health law? 4 most possible scenarios

Last week, U.S. Supreme Court justices heard arguments about the constitutionality of the federal health-care reform law. At the center of the debate is whether the government can force people to buy health insurance, a provision often referred to as the individual mandate. There are four likely scenarios that will be the outcome of the justices' decisions, asserts Jennifer Haberkorn for Politico, all of which come with their own problems.

Scenario 1: The individual mandate is struck down, as well as insurance reforms: If these parts of the Affordable Care Act are scrapped, "Insurance companies will still be able to deny coverage based on customers' costly pre-existing conditions and charge more to older and sicker — or female patients," Haberkorn reports.

If that happens, the Obama administration and Democrats would likely blame Republicans for promoting a lawsuit that puts insurance companies in charge again. If reaction from the public is strong, Republicans may feel obligated to enact insurance reforms without an individual mandate. Ideas for doing this include "charging more if a person buys insurance at the last minute, tax incentives and a promise that if a person buys coverage, that person wouldn't lose it if he or she were to get sick and need it," Haberkorn reports.

Scenario 2: The mandate is struck down, but insurance reforms stay intact: Part of the reason why insurance companies agreed to stop denying coverage based on pre-existing conditions is they could offset the losses because the law would enlarge their insurance pool by 30 million people — the number of Americans who lack coverage.

If insurance companies are still required to stop denying coverage based on pre-existing conditions but the individual mandate is struck down "They could start a mini revolt over having to cover expensive patients without the mandate," Haberkorn reports.

Scenario 3: The entire law, or the majority of it, is axed: That would mean unpopular parts of the law would be trashed, but so would popular ones, including the pre-existing conditions piece as well as a provision that allows young adults to stay on their parents' health insurance until the age of 26.

In 2010, 26 provisions took effect and another 17 did last year. Nine new provisions are taking place this year. "Lawmakers designed the phase-in, in part, with the thought that the public would become more supportive of the law once certain provisions began to take hold," report Michael Doyle and David Lightman for McClatchy Newspapers.

Scrapping the law entirely could cause the most political fallout. "Republicans would try to move quickly to enact a small-scale health reform legislation aimed at restoring some of the popular pieces of the health law," Haberkorn reports. "But Democrats won't want to support something far less comprehensive than the Affordable Care Act, not with some 50 million Americans uninsured."

Scenario 4: The law stands: Though this is the hope of the Obama administration, "The mandate is considered relatively weak: The penalty for not obeying it starts at $95 in 2014 — that's nothing compared with the cost of insurance premiums," Haberkorn reports. The amount increases to $695 by 2016.

As for what the justices will do, "at least some of the court's conservatives seem prepared to kill the whole bill," report Doyle and Lightman. "My approach would be, if you take the heart out of the statue, the statute is gone," Justice Antonin Scalia said.

Justice Elena Kagan countered, "Half a loaf is better than no loaf," while Justice Ruth Bader Ginsburg suggested, "It's a question between a wrecking operation and a salvage job."

Some justices said the whole bill should be sacked, "on the theory that members of Congress would not have voted for it without the mandate," Adam Liptak reports for The New York Times. But Justice Sonia Sotomayor said killing the whole law "would be too broad an assertion of judicial power," Liptak notes. Justice Anthony Kennedy, the likely swing vote, said "We would be exercising the judicial power, if one provision was stricken and the others remained, to impose a risk on insurance companies that Congress had never intended."

The justices probably decided the future of the law Friday morning, reports Mark Sherman for The Associated Press. Typically, an initial vote is "followed soon after by the assignment of a single justice to write a majority opinion, or in a case this complex, perhaps two or more justices to tackle different issues. That's where the hard work begins, with the clock ticking toward the end of the court's work in early summer," Sherman writes.

In Kentucky, health advocates and officials are watching closely to see what happens. "I think the entire health-care sector and insurance sector are watching this closely because it has significant implications on both industries," said Stephen Williams, chief executive officer of Norton Healthcare. "This is very far-reaching."

In Kentucky, the law extends coverage for 35,000 young adults, reports Laura Ungar for The Courier-Journal. (Read more)

Obama finally embraces the Republican term 'Obamacare'

“The Obama administration made a decision on Friday to own the term‘ObamaCare’,” NBC News reports in its First Read blog, adding a capital letter not often used. “It had been used as a pejorative by Republicans, but the White House has made the decision to embrace it and not let opponents have a word that they only drive as a negative. White House senior adviser David Plouffe noted on ‘Meet the Press’ Sunday that, in 10 years, health care will be a positive and cited polling that people don’t want to re-litigate it. We can report that last part came from Democratic polling Plouffe has seen; he was not citing any public polling on this specific issue.”

The NBC item is also based on a story yesterday from The New York Times, which reported that Democrats are “launching a Twitter campaign that seeks to build positive associations for it.” The Twitter post read, “If you’re proud of Obamacare and tired of the other side using it as a dirty word, complete this sentence: #ILikeObamacare because ...”

The story noted that “Obamacare” has been used “primarily by Republicans, as a term of disdain. Democrats have tried to limit the term’s use to reshape perceptions, but that has been a tough sell.” The Times quotes Grant Barrett, a vice president for the American Dialect Society, who said that once a word becomes political, it is very difficult to quash it: “It’s an invitation to have your heart broken. You forbid it, and they start writing it on the bathroom stalls.”

For the Times story and a nice graphic showing the history of the term, and examples of its use, by Amanda Cox, Alicia DeSantis, Alicia Parlapiano and Jeremy White, click here.

Conflicting interpretations abound regarding CBO's report about cost, coverage of Affordable Care Act

By Tara Kaprowy
Kentucky Health News

Since the Congressional Budget Office released a report with revised estimates about how many people the Affordable Care Act will cover and how much it will cost, it has spawned a whirlwind of op-ed pieces with vastly opposing interpretations.

According to Julian Pecquet in The Hill, the estimate showed the federal health-care reform law will allow 30 million more people to get insurance coverage by 2016, down from the previous estimate of 32 million. Thus, the law's coverage provisions are now estimated to cost $1.083 trillion over the next 10 years, $50 billion less than last year's projection.

The CBO also estimates that 4 million Americans will lose their employer-sponsored health insurance by 2016, not the mere 1 million figure projected last year. It also estimates that 1 to 2 million fewer people will qualify for state health-insurance exchanges than initially thought, but an additional 1 million will qualify for Medicaid or the Children's Health Insurance Provision, known in Kentucky as K-CHIP.

"CBO faults a slower than anticipated recovery for the soft numbers, along with technical changes to CBO's estimating procedures and legislative changes adopted over the past year," Pecquet reports. The changes in cost estimates are "due in part to slower growth in health-care spending resulting in an 8 percent drop in premiums, as well as taxes and penalties paid by employers and their workers as struggling businesses cut down on employer-sponsored coverage," Pecquet writes.

Conn Carroll, senior editorial writer for The Washington Examiner, has an entirely different view, saying the cost has doubled. "The gross cost of President Obama's health care law has risen from $940 billion when the bill was passed, to $1.76 trillion today. This did not sit well with Obamacare's leftist apologists," he writes. Carroll uses gross figures to arrive at his calculations.

Carroll is comparing apples to oranges, and the estimate hasn't doubled, writes Ezra Klein of The Washington Post. "The disparity in the cost estimates only comes when you take a different sample of years, in which the law is doing different things, in an economy of a different size. And even then, costs went up only if you take "gross" costs rather than "net" costs, which is a rather unusual way to think about the budget."

Paul Krugman of The New York Times weighs in too, but not on the numbers. He does say, "For all its imperfections, this reform would do an enormous amount of good. And one indicator of just how good it is comes from the apparent inability of its opponents to make an honest case against it."

Krugman said "most of the disinformation" about the reform is about costs. "Each new report from the Congressional Budget Office is touted as proof that the true cost of Obamacare is exploding, even when — as was the case with the latest report — the document says on its very first page that projected costs have actually fallen slightly."

CBO Director Douglas Elmendorf defended in his blog the changes in estimates. "We will continue to update our estimates regarding health insurance coverage as new information becomes available about the implementation of the ACA, underlying trends in the health-care and health financial systems, and the probable responses to the legislation by businesses, families and others."

Affordable Care Act helping families, seniors in rural areas, agriculture secretary says on its second anniversary

The Patient Protection and Affordable Care Act is already making an impact, including for people who live in rural America. That was the message from Agriculture Secretary Tom Vilsack today on the second anniversary of the enactment of the federal health-care reform law.

In a teleconference, Vilsack noted several pieces of the law that are benefitting people, including the 2.5 million young adults who have insurance coverage because parents can keep them on their plan up to age 26. "That's providing a degree of comfort to moms and dads," he said.

The law has also helped 3.6 million seniors on Medicare, who saved $2.1 billion on their prescription drugs in 2011 because the law allowed them to get a 50 percent discount on brand-name drugs. Vilsack said seniors saved an average of $600 last year and were also "able to get a number of services, including preventive services like mammograms, for free."

Under the law, insurance companies are now required to spend 80 percent of their premium dollars on "actual health care, not overhead," Vilsack said, and they are not allowed to increase their premiums by more than 10 percent without an explanation. Children who were previously denied coverage because of pre-existing conditions can no longer denied, as per the law's mandate, and "in a couple of years that will extend to all people," Vilsack said. And thousands of new primary-care doctors and nurses are being encouraged to practice in rural areas and will receive higher payments.

Vilsack said his Department of Agriculture is working to improve the rural health-care landscape, through a joint effort with the USDA Rural Development division and the Department for Health and Human Services. In the past three years, Vilsack said 730 counties have received grants so they can "embrace telemedicine." Nearly 600 health-care facilities in rural communities have received money to fund equipment like CT scans, MRIs, ultrasound and lab equipment, Vilsack said. And rural citizens can now get care from a hospital outside their health plan's network when there is no time to get to a hospital that is farther away.

"No one should have to go without health care because of where they live, and for too long, rural Americans have been getting the short end of the health-care stick," he said. "The Affordable Care Act is helping millions of young people access health care, strengthening Medicare, and training thousands of new doctors to serve rural areas to give middle-class families the health security they deserve." (Read more)

Reform act good for kids, Kentucky Youth Advocates head says

This week marks the second anniversary of the Affordable Care Act and debate about its cost and benefits continues to be vigorous. But one thing that can't be denied "is that the ACA, on a most basic level, benefits vulnerable kids in Kentucky," writes Terry Brooks, right, executive director of Kentucky Youth Advocates, in an op-ed piece in the Lexington Herald-Leader.

"Today, because of the ACA, kids with pre-existing conditions like diabetes and asthma can't be denied the care they need," he writes. "And children across Kentucky are receiving preventive care like immunizations without their parents having to pay out-of-pocket costs so they can avoid illness and we can avoid unnecessary health care costs for preventable problems."

Brooks also notes that the ACA allows children to be covered under parents' insurance up to age 26.

If provisions of the ACA are not revoked, children can continue to benefit into their adulthood, Brooks writes: "They'll be protected from their insurance companies placing lifetime caps on their coverage and benefits, so if a child beats leukemia at age eight, she will still be able to get the care she needs if she relapses at age 20." That will translates to 360,000 children in Kentucky being protected. "And more than 180,000 Kentucky children will be able to receive preventative care such as well-child visits and other screenings with no out-of-pocket costs," he writes.

"So, yes, let's debate the pros and cons," he said. "But let's not deny the simple fact that the ACA is good for kids, and kids should be spared from the politics and animosity of this debate." (Read more)

A summary of what to expect when the Supreme Court hears arguments about the health-care reform law

How big a deal will it be when the U.S. Supreme Court hears arguments about the constitutionality of the new federal health-care reform law later this month? Big, concludes Stuart Taylor Jr. for Kaiser Health News.

"It's big enough for the justices to schedule six hours of arguments — more time than given to any case since 1966," he reports. "It's also big enough to attract more briefs than any other case in history ... and, finally, it's big enough to cause the justices to postpone until October half of the 12 cases that they were ordinarily going to hear in April in order to clear time to get started on the health care opinions."

The most pressing issues deal with the individual mandate of the law, which requires people without insurance to buy some or pay fines. The question is whether the mandate "represents an unconstitutional exercise on Congress' power to regulate commerce and to levy taxes," Taylor notes. There is also the question of state sovereignty, since the law requires states "to spend more of their own money or forfeit all of the federal Medicaid money they now receive," Taylor reports.

As for the outcome, that's the million-dollar question, Taylor writes. "It's clear that the court's four more liberal members, like almost all other liberal legal experts, will find the law constitutional in all respects. It's also clear that conservative Justice Clarence Thomas will vote to strike down much or all of the law. It's less clear what swing-voting Justice Anthony Kennedy and conservative Chief Justice John Roberts as well as Justices Antonin Scalia and Samuel Alito will do."

As for the major arguments regarding Medicaid and for and against the individual mandate, Taylor provides an excellent summary that is worth reading in its entirety. (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)

Expect more hospital mergers across the country, some with unlikely partners, Moody's Investors Service report predicts

Reflecting several hospital mergers that have already taken place in Kentucky, a new report from Moody's Investors Service predicts hospitals will continue to band together across the country as they respond to changes in health care.

"The difficult business environment and the changes expected in how hospitals will be paid for delivering care are driving many smaller, stand-alone hospital groups into the arms of larger and better-financed organizations," reports Reed Abelson for The New York Times.

Hospitals have long looked for partners to become larger in order to have more negotiating power to ask for higher payments from insurers. But now they are looking at ways to become more efficient too as they expect lower reimbursements from Medicare because of federal health-care reform. That means more consolidation, Moody's says.

While there are traditional mergers in play, there are also more atypical alliances forming. One of the nation's largest nonprofit hospital groups, North Shore-LIJ Health System, will join with Hackensack University Health Network in New Jersey, for example. There are instances of for-profit hospital groups joining with private equity firms. Health insurance companies could even become buyers, and hospitals and doctors could join forces "so they can be more of a one-stop shop," Abelson reports.

As a result, patients will ultimately have fewer hospitals from which to choose, but some small, stand-alone hospitals, especially in rural areas, will still exist. "We're not going to predict the small independent hospitals will all shutter and close," said Lisa Goldstein, one of the authors of the report. (Read more)

What's the status of a health insurance exchange in Kentucky?

By Tara Kaprowy
Kentucky Health News

At the end of February, Kentucky received $57.8 million in federal funds to help set up a health insurance exchange or marketplace under federal health-care reform. Officials say all the money will be used to plan for a potential exchange, even though lawmakers have made no move to introduce legislation to create one.

Jill Midkiff, spokeswoman for the Cabinet for Health and Family Services, said Kentucky has hired a planning vendor "to develop a list of detailed requirements and a potential operating model that is specific to Kentucky's information systems environment."

The exchange is meant to act as a marketplace in which individuals and employees of small businesses can shop and compare several plans that have coverage packages pre-approved by the state and federal governments. Medicaid recipients will also be able to get their insurance from the exchange. Right now, it has not been decided what plans will be offered, Midkiff said. It's also unknown if the plans in the system will be available to everyone or if there will be some plans only available to Medicaid recipients and some only for individuals who qualify.

Who would qualify? People with an income of up to 133 percent above the federal poverty level — now $14,404 for individuals and $29,326 for a family of four — will qualify for Medicaid starting in 2014. Also, the federal government will give subsidies to help Americans whose income is up to 400 percent above the poverty level. With them, they must buy private coverage through the exchanges.

Kentucky has until Jan. 1, 2013 to create a state-based exchange. If lawmakers do not introduce and pass legislation that will create an exchange, the state has two options. It can allow the federal government to operate the exchange or Gov. Steve Beshear can issue an executive order to create one. Beshear "has taken a wait and see approach to exchange planning, neither explicitly endorsing nor refusing to implement a state-run exchange," reads a state-exchange profile put together by the Henry J. Kaiser Foundation.

Kentucky started planning for an exchange in September 2010 and received a total of $8.6 million to do so prior to receiving the $57.8 million grant. Midkiff pointed out most of the activities for this latest grant "must be completed regardless of whether the state or federal government operates the exchange."

Last September, state officials said the delay in setting up an exchange was largely because the federal government had not decided what benefits needed to be offered in the exchange. In December, the Obama administration put the onus on states to come up with their own regulations pertaining to what benefits insurance companies have to offer. When asked if the change has allowed Kentucky to move forward, Midkiff said the Cabinet for Health and Family Services is working with the Department of Insurance to review the new dictate.

While the state does not have an estimate of how many people will use the exchange, Julia Costich, chair of the Department of Health Services Management at the University of Kentucky, said her research shows about 400,000 Kentuckians will be eligible for federal subsidies. After coverage expands, she estimates about 1.1 million Kentuckians will be eligible for Medicaid.

So far, 30 states and the District of Columbia have received grants to set up exchanges. Of those, only 13 and D.C. have adopted a plan for how to proceed.

Kentucky Health News is a 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.

Electronic patient records may not save money, study finds; critics question methodology

Though officials tout otherwise, a study has found electronic health records do not cut costs "and may actually encourage doctors to order expensive tests more often," reports Steve Lohr for The New York Times. (Photo by Keith Srakocic for The Associated Press)

The study, published in the journal Health Affairs, found doctors using EHRs to track tests, such as X-rays and MRIs, ordered 40 percent more tests than those using paper-based records. Doctors with access to a patient's previous image via a computer "ordered tests on 18 percent of the visits, while those without the tracking technology ordered tests on 12.9 percent of visits," Lohr reports. And when it came to more expensive and advanced tests, like MRI and CT scans, doctors using EHRs ordered more tests 70 percent of the time.

The study was based on a survey conducted by the National Center for Health Statistics, and included data from 28,000 patient visits to more than 1,100 doctors in 2008. It contradicted a 2005 study from RAND Corp., which estimated that EHRs could save as much as $80 billion a year. The Obama administration used that study as justification for $19 billion in federal spending to help providers switch to digital technology.

EHR supporters were critical of the latest study for using the NCHS data, which they say is used to assess how medical care is practiced, not how well computerized patient records work. It also "included any kind of computer access to tracking images, no matter how old or isolated the function," Lohr reports. Modern EHRs are more integrated in their function and must meet federal standards for "meaningful use" — guidelines that were not in place in 2008.

Dr. David Blumenthal, professor at Harvard Medical School and former national coordinator for health information technology for the Obama administration, found 92 percent of articles published in professional journals on EHRs were "positive over all" regarding whether the technology would improve efficiency and quality of care. Dr. Danny McCormick, lead author of the new study and assistant professor at the same school, argued his analysis "looked at not just a few cutting-edge institutions, but a nationally representative sample." (Read more)

Kentucky receives $57.9 million to set up insurance exchange

Kentucky received $57.9 million Wednesday to help set up a health insurance exchange or marketplace — though lawmakers have made no move to make that happen. Kentucky is one of 10 states to receive this latest round of federal insurance exchange establishment funds, which totals $230 million. Of these 10 states, Kentucky received the highest sum by several million.

Of the 10 latest states to receive grants, seven of them have adopted a plan or made substantial headway, reports Richardo Alonso-Zaldivar for The Associated Press. In the exchange, considered one of the cornerstones of the new health care law, individuals and employees of small businesses can choose from several plans whose benefits coverage packages have been pre-approved by the state and federal governments.

So far, 30 states and the District and Columbia have received grants. Of those, only 13 and the District of Columbia have adopted a plan for how to proceed. States have until Jan. 1, 2013.

"Kentucky has not determined whether it will establish a health benefit exchange in light of challenges to the Affordable Care Act and the lack of federal guidance and a tangible federal exchange model to consider," said Kerry Richardson, communications director for the Office of Gov. Steve Beshear, said at the end of January. "However, impending ACA deadlines require considerable planning, evaluation, design and development of systems to address exchange issues whether the state or the federal government operates the exchange, and we are engaged in those efforts."

In September 2010, the Kentucky Cabinet for Health and Family Services' Office of Health Policy received a $1 million exchange planning grant. In August, it received another $7.7 million to fund information technology systems. No bill has been introduced that would establish a state-based health insurance exchange so far. (Read more)

Pat Boone commercial about Medicare has many inaccuracies

A television commerical misleads seniors into believing the federal health-care reform law will ration and deny care and contains other inaccuracies, according to FactCheck.org, a non-partisan, non-profit service based at the University of Pennsylvania.

The ad features singer Pat Boone and is being aired repeatedly in Ohio (and presumably in Northern Kentucky) by the conservative 60 Plus Association. It claims the Patient Protection and Affordable Care Act will create the Independent Payment Advisory Board, made up of elected bureaucrats who "can ration care and deny certain Medicare treatments so Washington can fund more wasteful spending."Boone says,"Unaccountable bureaucrats should never have the power to deny you the care you deserve."

The board is neither made up of bureaucrats, nor can it ration care. "The IPAB is tasked with finding ways to reduce the growth in Medicare spending," FactCheck reports. "Its 15 voting members won't be bureaucrats, according to the health care law (see page 502); they will be doctors and medical professionals, economists and health care management experts."

The law also says proposals from the IPAB "shall not include any recommendation to ration health care, raise reveneues or Medicare beneficiary premiums ... increase Medicare beneficiary cost-sharing (including deductibles, coinsurance and copayments), or otherwise restrict benefits or modify eligibility criteria."

The ad says the law will cut $500 billion from Medicare, but fails to mention that cut is in the future growth of Medicare over 10 years and will come from the supplemental Medicare plans seniors can buy.  Moreover, though Boone suggests seniors should object to the $500 billion in cuts, they are meant to extend the funding of Medicare Part A by 12 years.

The ad also states Medicare will be bankrupt in nine years. "The truth is that Medicare Part A — the hospital insurance trust fund, one of four parts of Medicare — is expected to be insolvent by 2020, according to the projections from the Congressional Budget Office, or perhaps 2024, according to the Social Security and Medicare Boards of Trustees," FactCheck reports. "Shortfalls have been projected for Part A 'almost from inception,' says a Congressional Research Service report," but Congress has always found a way to extend the program. (Read more)

Retailers like Walmart, CVS getting into primary care, eyeing the prize that awaits if health reform takes effect in 2014

Last week, a document leaked showing Walmart's intention to become the country's largest provider of primary health services, but the company's interest is not unique. Drug retailers like CVS Caremark and Walgreens are eyeing the same prize: "the millions of Americans with costly illnesses such as diabetes and heart disease," reports Julie Appleby of Kaiser Health News. CVS already has 550 retail clinics, the most in the country. Walgreens has also set up programs aimed at diabetic customers, which includes counseling with pharmacists.

The retail industry is looking at ways it can use its clout to save money and offer a primary care infrastructure that experts say will be short by 21,000 doctors by 2015, largely because of the 30 million more people becoming insured by 2014 under the federal health-care reform law. "It's sad that the existing health care establishment has not figured out a way to make primary care affordable and accessible," said Jerry Avorn, a professor of medicine at Harvard University. "We should not be surprised if someone outside of our world comes in and does it for us."

Costs at retail clinics are "roughly 30 percent to 40 percent less than similar care at a doctor's office and 80 percent cheaper than at an emergency room," Appleby reports, referring to a study in the American Journal of Managed Care. Those savings appeal to insurers. Retail clinic use by people with health insurance increased tenfold from 2007 to 2009, with clinics accounting for 7 percent of all medical visits for 11 common acute conditions, the study found. "If these trends continue, health plans will see a dramatic increase in retail clinic utilization ... particularly among young, healthy and higher income patients living close to retail clinics," the study concluded.

Patients like the clinics for the predictability, with costs made clear ahead of time. And employers — who under the new health law could get incentives to provide wellness programs for their employees — may partner with the clinics to provide blood testing, nutrition counseling and diabetes management. However, there are still many unknowns. While the clinics have proved useful for acute care, it remains to be seen how they will deal with complicated issues like diabetes management.

Some states prevent clinics from employing physicians, nurse practitioners or physician assistants. "Other states cap the number of nurses each doctor can oversee," Appleby reports. The vast majority of clinics are staffed not by doctors, but physician assistants and nurse practitioners. A report by the Convenient Care Association shows 95 percent of the clinicians are nurse practitioners. With these practitioners able to provide basic care, part of the fear among doctors is they will be left to treat only the sickest patients and won't be reimbursed accordingly.

Most of the clinics are in the South and Midwest. In January, Merchant Medicine listed 40 retail clinics in Kentucky, with more to open in 2011. The clinics "are more likely to be in areas with lower overall poverty and only 12.5 percent were in medically underserved areas," Appleby reports, though 21 percent of the U.S. population lives in those areas.

The clinics have typically offered vaccinations and simple physical exams and treatment for strep throat and ear infections, but plan to expand their services and enlarge retail's foothold in the medical world. "Think about Toyota; they didn't start off by competing with Cadillac and BMW. They started with cheap little cars but got better and better over time," said Mark Smith, president and CEO of the California Healthcare Foundation. (Read more)

Even the experts seem to have more questions than answers when it comes to the federal health-care reform law

By Tara Kaprowy
Kentucky Health News

LEXINGTON, Ky. -- Confusion, primary care doctors overwhelmed by an influx of new patients, and employers opting to pay fines rather than health insurance are among the fears experts have about the federal health-care reform law. The experts discussed the issues this week in Lexington at the fall meeting of the Friedell Committee for Health System Transformation, a non-partisan, non-profit group formed several years ago to improve health in Kentucky.

Under the Patient Protection and Affordable Care Act, 30 million more people will become eligible for health insurance by 2014. People who have an income 133 percent above the federal poverty level — now $14,404 for individuals or $29,326 for a family of four — will qualify for Medicaid starting in 2014. Additionally, the federal government will give subsidies to help Americans whose income is up to 400 percent above the poverty level. With them, they must buy private coverage through state insurance exchanges.

The experts see problems arising from both options. "If you look at the overall population, it's very clear that the majority of these patients are going to be in the Medicaid program," said Elizabeth Cobb, vice president of health policy at the Kentucky Hospital Association. "Since Medicaid only pays hospitals at 85 percent of cost, that's a real concern" for providers. Cobb estimated that Kentucky hospitals will lose nearly $1 billion in revenue in the next 10 years because of the Medicaid expansion, along with cuts to other federal programs.

While hospitals will feel the stretch, so will doctors, with Kentucky lacking the primary-care infrastructure it needs to support the influx of new patients, said Dr. Steve Davis, acting commissioner for the state Department of Public Health. Davis said the average age of a practicing dentist in Kentucky is 58 years, and "in a few years," the state will have 3,000 fewer primary-care doctors.

"We don't have enough clinicians to meet those needs and that's a real problem," added Kevin Shuer, assistant professor at the University of Kentucky's College of Health Sciences.

Kentucky has taken no firm steps toward creating a state insurance exchange, a marketplace in which people will have to choose from a variety of plans. That will likely have to be done in the 2012 legislative session if the state opts to run its own exchange.

One reason for the delay is a lack of information, said Cris Miller, a partner in the Louisville accounting firm of Mountjoy Chilton Medley. "We know there will be four plans," each paying 60, 70, 80 or 90 percent of the covered benefit, she said. "We know the bronze plan is going to pay 60 percent of the covered benefit, but what is the covered benefit?"

Despite the unanswered questions, Julia Costich, chair of the Department of Health Services Management at UK's College of Public Health, believes Kentucky will set up a state-specific health insurance exchange, rather than let the federal government handle it, and will do so alone rather than partner with other states, since "the logistics to make that happen would be very complicated."

Costich's research shows about 400,000 Kentuckians will be eligible for federal subsidies as part of the exchange. Medicaid will eventually be included in the exchange and, after coverage expansion, the program's numbers could grow from its current 830,000 participants to 1.1 million in Kentucky. The federal government would cover the initial cost, but the state would gradually pick up a share, just as it does for current Medicaid patients.

The area of the state with the highest uninsured population is between Somerset and Bowling Green, according to Costich's research. There, one in four people under the age of 65 don't have any form of insurance. County-specific estimates show Franklin, Fayette and Jefferson counties have the lowest percentage of people without any form of insurance (4 to 8 percent) and Edmonson, Todd and Elliott have the highest (38 to 45 percent).

In 2014, employers with more than 50 employees who don't provide health coverage will be required to pay a penalty. The experts said paying the fines may be cheaper than offering insurance. According to global consulting firm Towers Watson, 3 in 10 American corporations are considering ending employee health coverage when the exchanges begin.

Though about 58 percent of Kentuckians have insurance through their employer, that's down from about 70 percent a decade ago, said Mark Lamberth, president-elect of the Kentucky Association of Health Underwriters. Lamberth said the drop is not surprising. "We've built a system that is really strapped on the back, for premium purposes, on employers," he said.

Another unknown is how accountable care organizations will work in Kentucky. Starting in 2012, providers that are part of an ACO — in which providers and hospitals team up to take care of a specific population in a coordinated way — will start receiving increased reimbursements from Medicare and Medicaid.

So far, there are no ACOs in Kentucky, which Miller said is not surprising. "If you know anything at all about ACOs, you know they're driven by volume," she said. "We're going to have a few in Louisville, probably as many as three in Lexington. Maybe have one in Bowling Green, one in Paducah. But I can promise you we will not have one in Pikeville, we will not have one in Somerset. There's not enough population."

With pieces of the law still undergoing legal scrutiny — the Supreme Court seems likely to decide by July whether Americans can be required to buy health insurance — and with many wondering what will remain of the law after the 2012 presidential and congressional elections, it's unclear what answers, if any, consumers might get before the end of the year. For now, "mass confusion" is what the experts are witnessing, Lamberth said. Miller agreed. "The biggest things we are hearing from our customers is fear."

Louisville hospital merger would be just one of dozens across the country, driven by economic and regulatory concerns

Hospitals are banding together to create organizations better able to withstand the changing tides of the economy and health-care policy. The proposed merger of Louisville's Jewish Hospital & St. Mary's HealthCare, Lexington-based Saint Joseph Health System and University Hospital at the University of Louisville is just one of many examples.

"The small, community hospital is soon to go the way of the dinosaurs," said Angela Mattie, associate professor of health-care management of Connecticut's Quinnipiac University, told Laura Ungar of The Courier-Journal.

Through September, 2011 had seen 71 mergers nationwide involving 132 hospitals worth $6.9 billion, plus another four deals in October. In all of last year, there were 74 mergers involving 126 hospitals and $5.8 billion, Ungar reports.

The poor economy is part of the reason for hospital systems merging because "people don't use hospitals as often; even those with insurance sometimes forego care to avoid co-pays," Ungar reports. In a tight economy, credit is more difficult to obtain, but bigger, richer systems have less trouble. Finances are a major impetus behind the big Louisville merger, with officials at University Hospital and Jewish arguing "if they don't merge they'll lack the money to make improvements going forward, partly because of economic pressures such as rising levels of indigent care," Ungar reports.

Catholic Health Initiatives, which owns the Saint Joseph Health System, plans to invest $320 million "to launch the merged network and strengthen its balance sheet," said CHI spokeswoman Mary Elise Biegert. Of another $300 million that would be generated by operations, two-thirds would be invested in Louisville's academic health center and $100 million would help pay for a switch to electronic health records.

Experts also say big systems have more bargaining power with health insurers, nd the federal health-care reform law means "It makes sense to enlarge a hospital system to capture as many as possible of the 30 million Americans expected to eventually be newly insured under the new law," Ungar writes.

Mergers also allow hospitals to consolidate and save costs, "by having one human resource or finance department instead of three," Ungar reports. (Read more) For another story on what has been termed "merger mania," click here.

Conway supports, P'Pool opposes meds-for-meth law; Conway defends decsion not to join lawsuits about federal health reform

In a debate where most of the sparks flew over often-specious questions about conflicts of interest, one of the biggest substantive disagreements between the candidates for attorney general Monday night was about whether to require a prescription for the cold medicine used to make methamphetamine. They also debated President Obama's health-care reform law.

Democratic Attorney General Jack Conway. left, said he supports such a law, which failed in this year's General Assembly, while Hopkins County Attorney Todd P'Pool, right, said he opposes it. The candidates were interviewed by Bill Goodman on KET's "Kentucky Tonight" as part of a series of debates between statewide candidates in the Nov. 8 election.

Republican P'Pool, the first to respond to Goodman's question, said he opposes making pseudoephedrine a scheduled drug because "I think it creates a burden for law-abiding citizens. . . . Let's don’t put a burden on soccer moms." He said he would support "a lifetime ban," which he did not explain, "for anyone convicted of a meth crime."

Conway said his position in favor of scheduling "is not the most politically popular position," but said he responded to a plea from "my friend Hal Rogers," the Republican congressman from Somerset who is a leading advocate. "I know it's not popular with some soccer moms," Conway said, and "I know it's inconvenient" to require a prescription, "but when you see a kid in a burn unit that’s gone through a meth lab it tears your heart." He said children at present at 80 percent of meth labs.

Conway said he is open to changing his position if opponents can show him how to prevent "smurfing," the use of surrogates to avoid the recordkeeping of pseudoephedrine purchases. He said many drug stories do not use the online recordkeeping system. He added that Oregon and Mississippi had "dramatic declines" in the number of meth labs after they scheduled pseudoephedrine.

P'Pool began the debate by sharply criticizing Conway's decision not to join lawsuits by Republican attorneys general challenging the constitutionality of the federal health-reform law: "He's absent form the fight against Obamacare … because he supports Barack Obama and his re-election." Conway replied, "I'm not gonna take some of the valuable resourecs of the office of the attorney general and put 'em on a lawsuit on health care when it’s an issue that’s gonna get decided anyway." He said some attorneys general are supporting the law in court, and "I didn’t join them either because I wanted to focus on Kentucky first."

As Goodman pressed the point, P'Pool said, "It’s really not about health care; it's about the proper role of the federal government." He said Kentucky could join the case with the stroke of a pen, but "My opponent has not been bashful in his support of Barack Obama and that’s why he’s on the sidelines."

Conway replied that the lawsuit "might undo some of the underpinning" of Social Security and Medicare laws. "This is not a perfect bill; some things need to be fixed in health-care reform," he said, but he implicitly defended the bill's requirement to buy health insurance: "It costs Americans on average $46 billion a year to cover the uninsured," he said. "They’re going to the emergency room to get their care … They’re already in the market. This is about being more efficient."

Click here for a story on the debate by Deborah Yetter of The Courier-Journal. Video of the debate is posted online here.