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)

Beshear says he will create state health insurance exchange if federal health reform law is upheld

Gov. Steve Beshear said today that he will wait on creating a health insurance exchange under federal health reform until the U.S. Supreme Court rules on the constitutionality of the reform law, which is expected to happen in late June. He said in a press release, “The steps we have taken to date, and the planning process we are putting in place helps ensure the state is able and ready to follow the law.”

The exchange, a requirement of the Patient Protection and Affordable Care Act, would be a market for individual health-insurance policies. It would help small employers insure their employees in health plans and "enable individuals to receive premium tax credits and premium subsidies, and qualify small businesses for tax credits," the release said.

"The state has a $57.8 million federal grant to plan and implement of programs and systems required by the law, including "building an end-to-end eligibility and enrollment system to serve both Medicaid and exchange participants," the release said. "Kentucky previously received two federal health insurance exchange planning grants totaling $8.6 million." (Read more)

With time running short, why wait to issue an order? The court's decision "may impact the nature of the executive action," said Jill Midkiff, spokeswoman for the state Cabinet for Health and Family Services. "The timing of issuance of the executive order will not impact the current work or future work that is being completed to establish a state exchange. There is nothing that we need to accomplish at this point that requires an executive order to be in place."

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)

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."

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)

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

By Tara Kaprowy
Kentucky Health News

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

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

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

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

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

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

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

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

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

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

Doctor report cards will be as big a failure as No Child Left Behind, physician contends in op-ed piece

Tying physicians' reimbursements to how well they score on a Medicare report card is akin to the federal government having schools submit to No Child Left Behind, asserts Dr. Barry Schumer, a Lexington-based internal medicine physician. As the federal education-reform effort resulted in teachers "teaching to the test," the Physician Quality Reporting Initiative will only result in doctors treating to one, Schumer's op-ed piece in the Lexington Herald-Leader reads.

"The idea that a check-list of dos, don'ts and test scores will result in an upgrade of care delivery is reminiscent of the government supposition that it alone could legislate the teacher-student relationship in the interest of improving education outcomes," Schumer writes. "It didn't work in education, and it won't work in health care."

Schumer contends the program "did not ask patients what they believe are the key elements of a high-quality doctor-patient relationship, nor was their input or opinion sought on whether they want their physician financially penalized for non-compliance with these mandates." Also ignored, he says, were primary-care providers, "any of whom could easily describe how increasing government regulations, mandating the purchase and use of expensive technology, and the threat of stiff financial penalties will not only detract from the care of patients but, worse yet, will drive already overwhelmed providers out of practice altogether." (Read more)

Kentucky has three accountable care organizations, a health-reform linchpin, but they remain to be identified

The "accountable care organization" is one of the hallmarks of the federal health-care reform law, with doctors and providers encouraged to team up to give coordinated care and be paid financial incentives to do so.

While being heavily promoted, they were recently likened to "unicorns" because "no one has ever seen one." That's what William Hazel, Virginia secretary for health and human services, at the Howard L. Bost Memorial Health Policy Forum in Somerset in September.

But now a new study has emerged indicating ACOs are popping up all over the country and that there are three in Kentucky, two part of a hospital system and the other part of an independent physician association. A spokesman at Leavitt Partners, which conducted the study, would not disclose the names of the Kentucky ACOs.

To get their count, "Leavitt Partners examined news releases, media reports, trade groups and conducted interviews and considered a health system to be an ACO if it either self-identified as one or was 'adopting the tenets of accountable care,'" reports Jenny Gold with Kaiser Health News.

Of the 164 ACO entities identified nationwide, 99 were sponsored by hospital systems, 38 by physician groups and 27 by insurers. Nationwide, 41 states had ACOs, "though there were vast regional differences. Poor and rural regions were found to have little ACO growth," Gold reports. In the Southeast and Appalachian regions of the country, there are few ACOs forming.

The findings run counter to what was discussed at a recent meeting of the Friedell Committee, whose members said there are no existing ACOs in Kentucky, though they did acknowledge ACOs would have a hard time developing in rural areas: "If you know anything at all about ACOs, you know they're driving by volume," said Cris Miller, a partner in the Louisville accounting firm of Mountjoy Chilton Medley. "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."

The discrepancy might have to do with the definition of ACO. The report notes that while the term ACO has been recently adopted, its tenets are not new and organizations have been using the health care delivery model for years, just not calling it accountable care. "The study authors determined that their findings suggested a trend toward 'proclaiming oneself as an ACO with only modest changes to the care process' and not a total redesign," Gold reports. (Read more)

Kentucky and most other states continue to delay action on health-insurance exchanges, despite Jan. 1, 2013 deadline

Though states must be able to prove whether or not they're ready to run a state insurance exchange by Jan. 1, 2013, many, including Kentucky, have not made any moves toward setting one up.

Kentucky officials have said they are waiting for more guidance to come from the federal level before anything can be decided, but there were indications that the administration of Gov. Steve Beshear might have been delaying action until last month's gubernatorial election. If Kentucky were to set up its own exchange, a move would likely have to be made in the 2012 General Assembly.

Jason Millman of Politico Pro writes an easy-to-understand summary of the complex issue and what it will mean for the American public: "Set to open in January 2014, exchanges will offer a marketplace where individuals and small businesses in each state can shop for health coverage. The exchanges, which offer subsidized coverage to lower- and middle-income individuals, will absorb more than half of the law's projected expansion of health coverage to 32 million people."

Some Republican-dominated states are waiting to see if the U.S. Supreme Court will rule the federal health-care reform law or its individual mandate unconstitutional, but a ruling is not expected until June at the earliest. "If that's when they start to work on an exchange, they will certainly be challenged to have a state-based exchange in 2014," said Steve Larsen, who oversees exchange development for the U.S. Department of Health and Human Services.

Wisconsin state Sen. Frank Larsee, chairman of the insurance committee, plans to wait even longer — opting to wait until after the 2012 presidential election. "Exchanges really aren't required until 2014, so we have plenty of time after November 2012," he said, not addressing the Jan. 2013 deadline.

So far, just 13 states have passed legislation to form an exchange. (Read more)

Hike in health insurance premiums due to rising health costs, not reform law, FactCheck.org concludes

Health insurance premiums for employer-sponsored family plans shot up by 9 percent from 2010 to 2011, but the bulk of the hike is due to the increase in health care costs, not the federal health-care reform law, non-partisan FactCheck.org has found.

The law is responsible for about 1 to 3 percent of the increase, however, in large part because the law requires an increase in benefits, including: covering preventive care without co-pays or deductibles; allowing adult children to stay on parents' policies until age 26; increasing annual coverage limits; and covering children regardless of preexisting conditions.

"On the other hand, the fact that the law caused any increase at all casts more doubt on Obama's promise that the law 'could save families $2,500 in the comings years.' We've been calling that claim into question for several years now," Factcheck.org stares. "The plan fact is that — so far — the law has caused an increase in premiums, though not so large an increase as some Republicans claim." (Read more)

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.

Hospitals merging to shore up finances and, as federal health-reform law encourages, improve patient outcomes

With one expert calling it "merger mania," Robert Hadley of The Lane Report looks at how Kentucky hospitals and hospital systems are banding together as they brace for reimbursement changes mandated in the new health care law.

The most discussed merger is that of Louisville's Jewish Hospital & St. Mary's HealthCare, Lexington-based St. Joseph Health System and University Medical Center at the University of Louisville. "At stake in the plan is not only the sale of a physical asset (University Hospital) that belongs to the commonwealth, but also potential changes in delivery of care that ceding control to a faith-based organization might bring," Hadley writes. Saint Joseph is owned by Catholic Health Initiatives, which follows the Catholic directives that prohibits abortion, sterilization and euthanasia.

Baptist Hospital East has since stepped in and said University of Louisville Medical School physicians are welcome to perform needed procedures at its facility.

Though complicated issues need to be addressed, hospitals are eager to merge regardless. Why? Financial viability, especially in the face of change as a result of the federal health-care reform law, sometimes called "Obamacare." Starting in 2013, hospitals will be reimbursed for Medicare and Medicaid procedures differently. Rather than be paid using a fee-for-service model, in which facilities are paid for each procedure performed, they will be paid based on quality and outcomes. If the outcomes are good, the facility will get paid more. The goal is to encourage care with good outcomes, rather than just pay for treatment, in which the incentive might be to over-treat in order to get more reimbursement.

"More and more of the reimbursements we receive in the future are going to be tied to performance, our quality and satisfaction scores," said Andy Sears, vice president of planning and system development for Baptist Healthcare System, which is looking to merge with Madisonville-based Trover Health System. "That's what the value-based purchasing coming out of Obamacare is all about. It's going to cause Baptist, Trover (Health System) and any other health-care organizations to begin to address how we're going to provide more value for the care we deliver."

"Pressure to leverage cost savings as reimbursement declines while being able to afford facility expansion are the two primary reasons" for the Baptist-Trover merger, Hadley reports. "As a single hospital in a rural community, Trover is finding it difficult to attract capital investment, much like University Hospital."

The Jewish-St. Joseph-University Hospital merger will mean at least a $200 million cash infusion for University Hospital alone, and nearly $1 billion of capital investment, including information technology, over the next five years, said Dr. Dan Varga, chief medical officer at St. Joseph Health System.

Essentially, with new changes coming, there is power in numbers. "Trover is a big organization and clinic," Sears said. "But they're facing the same situation a lot of stand-alone facilities are facing. Business is declining, reimbursements are declining, and when you don't have payments in, you can't take care of capital needs." (Read more)

A million more young adults have health coverage; law cited

One million more young adults ages 19 to 25 had health insurance in the first quarter of 2011 than in the same period a year ago, data from the National Health Interview Survey show.

The increase is largely due to the federal health-reform law, which allows children to remain on their parents' health insurance plans until age 26, a press release from the U.S. Department of Health and Human Services said. No other age group had a significant increase in coverage. (Read more)

Feds give Ky. $3 million to hold health insurers accountable

Kentucky will receive more than $3.2 million in federal grants to help state officials track health-insurance premium increases and make insurers more accountable.

The funds are part of guidelines set forth in the Patient Protection and Affordable Care Act, the federal health reform law. It requires makes rate increases of 10 percent or more in the individual and small-group market subject to approval by experts who will determine if the increases are reasonable. The law also requires insurers to to justify to the public rates that are considered unreasonable.

The Kentucky Department of Insurance will use the federal funds to expand the scope of its rate reviews; improve transparency by establishing a tool on its website that will give consumers access to rate filings without an open records request; hire new staff, and improve its technology. (Read more)

Work locally for health care solutions, experts say at annual policy forum; contrasting Medicaid approaches seen

By Tara Kaprowy
Kentucky Health News

After hearing experts say communities should take the lead in improving the quality of health care and lowering its cost — especially because there are so many unknowns about the new federal health care law — McCreary County mother and health activist Susan Taylor stepped up to the microphone Tuesday in Somerset.

"I hear what you're saying, but how do you go about getting our leaders motivated?" she asked a panel at the 2011 Howard L. Bost Memorial Health Policy Forum.

"That has sort of been my challenge," replied William Hazel, health and human resources secretary in Virginia. "It's an education process."

There were no simple answers, but experts, medical professionals and community members were willing to ask the tough questions and offer their views at the forum, sponsored by the Foundation for a Healthy Kentucky and named for a Kentuckian who played a major role in writing the Medicare law.

Again and again, experts said solutions can be found by going local, rather than focusing on goings-on in Washington or Frankfort. "My whole point is this: Make it work where you live and work and the whole country will want to be like that," said Len Nichols, left, professor of health policy and director of the Center for Health Policy Research and Ethics at George Mason University.

Nichols, the forum's keynoter, advised state legislators and rural Americans to stay calm about health care, focus on what can be measured and change accordingly. "Forget politics," he said. "Forget Obama. Don't watch TV at all. Focus on where you live."

He acknowledged that is easier said than done, because politicians can't talk about health reform "without making half the population mad and half the population scared." "People are scared, and why wouldn't they be scared?" he asked. "It looked and felt and still feels like the Great Depression."

But federal health reform is necessary, Nichols said, because the current system is unsustainable: 7 percent of the average family's income went toward paying health insurance premiums in 1987. By 2006, it had risen to 17 percent and by 2016, withough reform, it is projected to be 34 to 45 percent. Medicare is likewise unsustainable, Nichols said, with a projected 7.3 percent of the gross domestic product being spent on paying for Medicare alone by 2035.

While the majority of the new health law won't be implemented until 2014, and with repeal still a possibility if Obama loses the 2012 presidential election, community-based changes can contain health care costs.

In West Tennessee, businesses have banded together and formed the Memphis Business Group on Health, which represents 350,000 employers, employees and their families. The group chooses its providers based on value and performance and, because its numbers are significant, providers are willing to comply with the group's requirements. CEO Cristie Upshaw Travis said the private sector can "transform the market" by banding together in this way. "They've had absolutely no choice but to change how they do their benefits," she said.

Hospitals, physicians and health plans are all assessed using survey reporting instruments, whether that means an administrator answering questions about the number of pressure ulcers in a hospital or an insurance agent evaluating a plan on consumer engagement or chronic disease management. "Having this public report in our community has had an impact on the improvement, quality and efficiency of care," Travis said. "In one way, it gave them something to focus on."

In North Carolina, the state has turned to patient-centered medical homes for Medicaid patients. In this model, a family doctor's office becomes the hub of a patient's care. With the help of physician assistants and nurse practitioners, doctors use electronic health records to track patients between visits, communicate with specialists, monitor blood sugar and blood pressure and are actively involved in whether patients are getting enough exercise or taking their medicine.

There are 1,400 medical homes in North Carolina, the first of which was developed in a rural county in the late 1980s. "There was a huge access problem, the emergency room was overrun," said Tork Wade, executive director of Community Care of North Carolina. But by increasing access points, linking patients with a primary care physician and engaging community leaders — "That was another key thing," Wade said — the effort worked. "We got money to go to another 12 counties," Wade said. "(The model) responded to a real need, it wasn't just top down."

The state's embrace of Wade's non-profit program, which is effectively a managed-care plan for Medicaid, struck a contrast with Kentucky's current shift to a managed-care system run by competing, for-profit companies. "My problem with a competing system is that it doesn't lift all boats," Wade said at a breakout session, where advocates said the Kentucky plan seems more concerned with saving money than ensuring quality.

Kentucky Health and Human Services Secretary Janie Miller, left, a McCreary County native who gave openign remarks, said Medicaid should provide what patients need, "but there hasn't really been a strong, deliberate, structured method . . . to really assure we're getting the best bang for the buck."

Though the North Carolina program is now statewide, the key was that the answers came from the communities, Wade said: "It has to be local. If it doesn't work in the community, it's not going to work. So you might as well start there." Getting buy-in from rural communities was easier than in urban centers because "in urban areas there are competing health systems," Wade said. "In rural areas, there is a single system of care and a history of people working together."

Susan Taylor is going the local route by focusing on prevention with Get Healthy McCreary County, which the health department there formed in 2007. The mission is to create awareness about healthy living in the community and promote any events that relate to it.

Though the group has hosted a few events, including a cooking class for kids and an educational session on the health reform law, Taylor says she is having trouble generating interest. "I just think they haven't really realized how important our health is," she said. "Once we get sick, then we'll go to the doctor and worry about it. They don't understand prevention."

Taylor went to Tuesday's forum to find answers, but came away with more questions. As for the federal health care law fixing community problems, Taylor — whose personal interest even prompted her to get a copy of the 1,200-page health care law from her congressman — admitted she doesn't know if that will happen. "I think we saw that" at the forum, she said. "Even amongst the people who seem aware, still no one really know how it's going to play out."

States all over the map in setting up health insurance exchanges; Kentucky officials say they await more federal guidance

A breakdown of where states stand in implementing pieces of the federal health-care reform law shows Kentucky lagging behind. But Kentucky officials say they're awaiting more direction from the federal government before they decide their next move.

A map compiled by the Center for Budget and Policy Priorities shows Kentucky is one of 11 states that did not even introduce legislation to form a health insurance exchange, considered one of the cornerstones of the new health care law. The center says 33 states have considered bills to establish an exchange, and 10 passed. Another nine have approved bills declaring the state's intent to establish them.

The state exchanges, which are to be launched in 2014, will act as insurance marketplaces. In the exchange, individuals and employees of small businesses can choose from several plans from companies such as Anthem or Bluecross/Blueshield, whose benefits coverage packages have been pre-approved by the state and federal governments.

As part of the new law, individuals with income as much as 400 percent above the poverty level may qualify to buy insurance from the exchange. Individuals that do qualify will be given federal subsidies to help pay their premiums, subsidies people can only get if they buy their insurance through the exchange. "They'll be incentivized to buy their insurance through it," said Carrie Banahan, executive director of the Office of Health Policy in the Cabinet for Health and Family Services.

So far, though, Kentucky has not made any moves toward setting up its exchange. Banahan said that is largely because the federal government has not decided what benefits the plans in the exchange must include. "They'll basically set up a minimum of what these plans need to include," she said. "We're still awaiting federal guidance."

Asked if the administration of Gov. Steve Beshear is delaying action so the health-care law won't become an issue in the Nov. 8 election, in which Beshear is seeking a second term, chief cabinet spokeswoman Jill Midkiff replied in an email, "The federal government has not issued final guidance through regulations on the exchange. States cannot make decisions to establish an exchanghe without knowing the requirements in order to determine programmatic and financial implications."

If states don't set up an exchange on their own, the federal government will do it for them, though Banahan said Kentucky officials are reluctant to let that happen. "The federal government is encouraging states to operate their own exchanges," she said. "They're looking at states to take the lead so they can model and craft their own exchange to meet the needs of their state. If the federal government came in, they don't know Kentuckians like we know Kentuckians."

As indicated by the map, several states have chosen to create an exchange by passing legislation. In some others, governors have done it through executive orders. Banahan said there is still time for Kentucky to weigh its options. "We haven't missed the boat," she said. "We're still just looking ... No final decisions have been made."

Other states' decisions do not necessarily follow party lines. Nevada and California passed exchange bills under the leadership of Republican governors. Delaware and Rhode Island, which have Democratic governors, have not budged on exchange legislation.

Only Florida and Louisiana have "expressly stated they won't build the marketplace," Sarah Kliff wrote for The Washington Post. Both have Republican governors, "But there are a lot of other states in the gray area above that could fall either way. If a few larger ones like Texas or New York aren't able to move forward in the next year or so, that's going to have the federal government playing a really big role in setting up what was meant to be a state-based law." (Read more)

Ultimately, whether Kentucky sets up its own exchange or the federal government does, Banahan said an exchange is needed. "We think it's a good thing that more people will have health insurance accessible to them," she said.

Sept. 13 forum in Somerset will explore how rural communities can get healthier and get better care at lower cost

"In an era of tight budgets and strained resources, Kentucky and its rural communities can no longer afford 'business as usual' in the delivery of health care services," write Susan Zepeda and Amy Watts of the Foundation for a Healthy Kentucky. "As health care costs increase and health status declines, the question becomes: How can we ensure rural Kentuckians get better health care at lower costs?"

Zepeda, the foundation's president, and Watts, is senior program officer, see "promising opportunities" for rural communities to reshape health care, such as working with local health departments and civic leaders to "create communities that support healthy behaviors" and better integrate the health system, with special attention for the chronically ill.

These and other issues and ideas for rural health are on the agenda of the foundation's ninth annual Howard L. Bost Memorial Health Policy Forum, to be held Tuesday, Sept. 13 at the Center for Rural Development in Somerset. The forum will include state and national leaders. "Rather than wait for solutions from Washington, forum speakers will share strategies Kentucky’s civic leaders can put into place at the local, state and regional levels. Many will share ways that Kentucky is already doing this," Zepeda and Watts write in an op-ed article distributed to Kentucky newspapers.

The keynote speaker will be Dr. Len Nichols, who founded and directed Health CEOs for Health Reform, a group that helped policymakers see that reform of health insurance and health-care can be reformed together. Dr. Kavita Patel, a physician and former RAND Corp. researcher now at the Brookings Institution, will bring insights on how to achieve better care and better health at lower costs. Other experts from Kentucky, Virginia, Tennessee and North Carolina will share "practical policy strategies for positive health change in these challenging times," and smaller sessions will allow participants to engage with the speakers, Zepeda and Watts write, saying the forum's goal is to "provide accessible, safe and effective health care to nearly half of Kentucky’s citizens who call rural Kentucky home." More information is available on the foundation’s website, http://www.healthy-ky.org/.