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)

In bipartisan way, political leaders push passage of 'pill mill' bill

A bipartisan group of political leaders issued a call today "to pass a bill that will help the state battle one of its most significant threats – prescription drug abuse," a press release from Gov. Steve Beshear's office said. Beshear, Attorney General Jack Conway, House Speaker Greg Stumbo, Senate Republican Floor Leader Robert Stivers, Sen. Jimmy Higdon, R-Lebanon, and House Judiciary Committee Chairman John Tilley, D-Hopkinsville, said the legislature should pass House Bill 4 when it returns to Frankfort for its final day April 12.

"Since the beginning of 2012, more than 400 Kentuckians have been hospitalized because of prescription drug overdoses – a statistic that the leaders say underscores the crucial need to pass this bill in this legislative session," the release said. "Kentucky has the nation’s sixth-highest rate of prescription drug overdose deaths, at nearly 18 deaths per 100,000."

Conway said in the release, “I'm hopeful everyone, including the medical community, can get on board with House Bill 4 to ensure that we don't lose another generation in Kentucky to prescription drug abuse.” The bill would move the Kentucky All Schedule Prescription Electronic Reporting (KASPER) system to Conway's office from the Kentucky Board of Medical Licensure, which is controlled by doctors and has done little to rein in "pill mills" that churn out prescriptions for painkillers.

"Law enforcement members warn that Ohio, Tennessee, West Virginia and Florida have passed legislation similar to HB 4 to address pill mills, and failing to pass similar legislation could create a diversion effect in which Kentucky could become a source state for prescription painkillers," the release said.

Stumbo, who preceded Conway as attorney general, said in the release, “Given the true epidemic we are seeing, we cannot afford to wait another year to try to pass this again.” In October, Stumbo, Beshear and Conway "announced creation of an advisory board of physicians, dentists, nurses, and pharmacists to work with KASPER officials and law enforcement professionals to create guidelines for generally accepted prescribing practices among different medical disciplines," the release said. "These criteria will be used as a guide for when a prescriber or dispenser’s KASPER reports may be flagged for unusual prescribing activity."

The bill would require all prescription providers to register and use KASPER, require pain management clinics to be owned by a licensed medical practitioner, make medical licensure boards investigate prescribing complaints within four months. 

Spend $1 on smoking cessation, save $3 in health costs, Massachusetts study finds

Every $1 spent on smoking cessation in Massachusetts, saved $3 in health costs, a study of low-income Bay State residents found. That could bode well for the impact of a new smoking-cessation benefit in Kentucky's Medicaid program.

Massachusetts added a smoking-cessation benefit to its Medicaid program in 2006 and "let members choose from any FDA-approved options," reports Martha Bebinger for National Public Radio.

Researchers at George Washington University "found that members who quit saved three times the cost of the program in fewer heart-related hospitalizations after just over one year," Bebinger reports. "The study does not take into account the benefits of avoiding cancer or other long term smoking related illnesses."

Kentucky ranked 36th in the nation for tobacco prevention spending. Though it received $389 million in tobacco-settlment funds in fiscal year 2012, and ranks first or second in tobacco use, Kentucky spent just $2.2 million of that on prevention of tobacco use. It recently added a smoking-cessation benefit to Medicaid, a program that is funded mainly by the federal government but administered by individual states.

Recession has hit health departments hard: 23,000 jobs (15%) lost, core funding cut

Funding and job cuts as a result of the economic recession have weakened the impact public health departments have on their communities, says a series of articles published in the Journal of Public Health Management and Practice.

"Continued cuts to public health services will have an unsatisfactory impact on the health of individuals and the community," said Dr. Lloyd F. Novick, the journal's editor-in-chief. "There is a heightened vulnerability at the present time for adverse health outcomes. Above all, the realization of the vital need to maintain resources for our public health delivery system is imperative."

In 2009, 23,000 jobs in public health departments were eliminated, 15 percent of the total. By 2010, more than half the agencies had a cut in core funding. As they scramble to make do with their new bottom lines, more cuts are expected. "The current, alarming trend of diminishing resources, reduced workforce and impaired capacity to maintain public health programs pose major hurdles for local agencies, with consequences that will be felt well into the future," said Dr. Rachel Willard of the University of California.

To view an article on the impact of the 2008-2010 economic recession on local health departments, one on a local health department that is providing only essential services, and one on enhancing public health value in an era of declining resources, click here.

Requiring prescription for pseudoephedrine is 'silver bullet' against meth, drug officials say; some lawmakers disagree

By Tara Kaprowy
Kentucky Health News

If Kentucky wants to arm itself with a "silver bullet" against methamphetamine, it needs to make pseudoephedrine available only prescription. That was the advice of top drug officials in Mississippi and Oklahoma, who testified before lawmakers Thursday. Opponents of the idea did not testify but legislators on their side had their say.

"This is a high-stakes cat and mouse game which has damaging results if we don't win," said Darryl Weaver, director of the Oklahoma Bureau of Narcotics. "The bottom line is: Do you want to track meth labs or do you want to eliminate meth labs?"

Marshall Fisher, director of the Mississippi Bureau of Narcotics agreed: "There is a silver bullet and the silver bullet wasn't tracking it; it wasn't limiting the amount. Weaver and Fisher testified at the request of the Senate and House Judiciary Committees, whose members heard exclusively from officials who support prescription-only policy.

Several related bills are on the table this year, including measures by state Rep. Linda Belcher, D-Shepherdsville, and state Sen. Tom Jensen, R-London, that would reclassify the drug to make it prescription-only. State Rep. Brent Yonts, D-Greenville, would apply the prescription rule only to people who have been convicted of a meth-related charge. The bill sponsored by Sen. Jerry Rhoads, D-Madisonville, would prohibit such offenders from buying the drug for five years.

Mississippi passed a prescription-only law 18 months ago and has seen a 67 percent drop in the number of its meth labs, Fisher said. Weaver said he is pushing for a prescription-only law in Oklahoma since its meth problem continues to grow, despite efforts to electronically track and limit sales of the drug.

All efforts have just been temporary fixes in Oklahoma, Weaver said, since they resulted in "smurfing," in which meth cooks pay others to buy pseudoephedrine for them. The same thing happened when that state instituted a drug registry, in which people who had been convicted of a meth-related crime were prohibited from buying pseudoephedrine without a prescription. The problem, Weaver said, is the tracking and registry "formed more of a conspirator group," where cooks were approaching the homeless and the previously uninvolved African American community to buy the drug for them.

Lt. Col. Joe Williams, executive director of the Appalachia High Intensity Drug Trafficking Area, said smurfing is a big problem in Kentucky too, and MethCheck, the tracking system in place now, does little good in helping law enforcement find meth labs. Meth labs "find us for the most part, we don't find them," he said. "Once we find a meth lab, we'll use the electronic tracking system and use that to trace back."

That runs counter to what Maj. Tony King of the Jefferson County Sheriff's Office said Monday on KET's Kentucky Tonight. In order for pseudoephedrine to be made available only by prescription, it must be reclassified as a legend drug. But those drugs are not tracked by MethCheck, which instantly tracks purchases at the point of sale, but by KASPER, the state's slower system for monitoring prescription drug abuse. "We will lose the ability to track these people and we will lose the ability to track these labs," he said.

Several lawmakers asked whether making pseudoephedrine available only by prescription would just result in doctor shopping and cold and allergy clinics popping up like so-called prescription pill mills. Williams said smurfers just won't take that risk. "It's very hard to fake snot in your nose," he said. "It's pretty easy to fake back pain."

Belcher's proposal would exempt pills in gel-cap format from the prescription rule, which prompted Rep. Sarah Beth Gregory, R-Monticello, to ask if that wouldn't eventually become a problem. Yonts pointed out that the U.S. Drug Enforcement Administration has said pseudoephedrine is "readily extractable" from gel caps. Weaver said he's "yet to see one lab that has been made with gel caps and liquids," he said, adding, "We have to find a balance between intrusion of government and what we need to stop the problem."

But it's that intrusion that has Yonts calling his measure the "middle ground," saying it protects "the soccer moms and Walmart moms" from having to constantly take their kids to the doctor but punishes the offenders. And while officials say only 15 cold medicines would be affected by requiring a prescription, leaving 137 other options, Yonts said medicines containing pseudoephedrine account for 63 percent of sales.

Williams said the average meth lab costs $2,100 in law enforcement, including manpower, overtime, equipment and waste disposal. With 1,146 labs found in Kentucky in 2011, that translates to $2.4 million. Sen. Robert Stivers, R-Manchester, said the problem is "a much larger cost to the taxpayers" since "the majority of these people are probably indigent care and the taxpayer is paying the bill for this."

Whatever the cost, Rep. Johnny Bell, D-Glasgow, called the issue "the most important" of the session. "I hope that we'll step forward and think about the human life and the impact it's having."

Representatives of the Consumer Healthcare Products Association said after the meeting that Pat Davis, identified as a mother of six from northern Kentucky, signed up to speak at the meeting but did not get to. She said she would have spoken about a prescription bill's "impact on consumers and parents, yet the committee was forced to watch videos of news reports and slides that have been seen several times already. It is apparent that the voices of consumers and parents aren’t important to the people running this process."

Federal cuts, financial instability and competition leave many rural hospitals fearing the future

Many rural hospitals could be forced to close because of cuts to the Critical Access Program and the fact that, according to the National Rural Health Association, , 41 percent of critical-care hospitals are losing money, reports Jenny Gold of Kaiser Health News. This would be devastating to many rural communities, with a great impact felt by low-income and elderly residents. "A small hospital is often one of the biggest employers in a rural town, and closures 'can have an outsized economic impact,'" Eric Zimmerman, a health care lawyer and Washington lobbyist, told Gold.

More than 1,300 U.S. hospitals and nearly one in four acute-care facilities are designated as "critical access," giving them slightly higher Medicare and Medicaid reimbursements in return for limits on care they can provide. Many such hospitals like Hood Memorial, about an hour outside New Orleans, are dealing with uninsured patients, inability to collect payments from patients, and fewer funds from federal and state agencies, Gold reports. Many of these hospitals "tend to provide lower quality care" and are "less financially efficient than other facilities, according to a 2010 study published in the Journal of Health Politics, Policy and Law. Hood, for example, had $700,000 in losses last year despite the higher reimbursements. "It's a lot of variables, and all of them right now are working against us," CEO Hoppie Jones told Gold.

To prevent closures of rural hospitals and ensure "Americans in in isolated areas would still have access to health care," the federal government started the critical access program in 1997. To qualify, hospitals had to have 25 or fewer beds and be at least 35 miles away from another facility. However, states could waive the distance requirement, and many did, leaving hospitals like Hood with at least four other competing hospitals "within a 26 mile radius," Gold reports.

Thursday, Nov. 17, will be first National Rural Health Day

Nov. 17, 2011 will be the first annual National Rural Health Day sponsored by the National Organization of State Offices of Rural Health. The goals of the event are to highlight rural communities as wonderful places to live and work, increase awareness of rural health-related issues and promote the roles of state rural-health offices in addressing those issues.

On Nov. 17, the organization will host a series of free webinars in conjunction with the observance. To learn more about the webinars, click here. The group also has a series of free tools newspapers can use to promote the event. (Read more) The Center for Rural Health is hosting a photo contest to promote the event. To find your state's rural health office, click here.

New Florida laws helping stem flow of pills, but loopholes remain and trade is shifting to other states

Though pill mills continue to be a big problem in Florida, where lax laws have fueled Kentucky's prescription pill trade, there is evidence that the tides are slowly turning in the Sunshine State. "Registered pain clinics in Florida have dropped from 930 last year to 736 now as the state begin to crack down," reports Laura Ungar of The Courier-Journal in the second installment of a special report on prescription drug abuse. (C-J photo by Kylene Lloyd: Broward County Detective Brann Redl)

A Florida law that took effect in July increases penalties for physicians who over-prescribe, tightens rules for prescriptions and pain-treatment regimens, and decreases the amount of time dispensers have to report the sale of prescription drugs into an electronic monitoring system that started Sept. 1.

The worry now is pill mill operators may just move to surrounding states. Georgia has seen a surge in clinics. "Each community outside of Atlanta is seeing an increased problem," said John Horn, first assistant U.S. attorney in Georgia, which has no electronic prescription-drug monitoring program. Some Kentucky addicts are heading to Ohio, Tennessee or West Virginia to get their pills, though now an interstate task force is helping to curb those efforts. (Read more)

There is also fear that the new law in Florida contains loopholes. "For example, board-certified pain specialists, such as anesthesiologists and surgeons, are exempt from pain-clinic registration and inspections," Ungar reports. The law also "doesn't require drug testing for patients."

But there are efforts on the national level by the U.S. Drug Enforcement Agency to stem the problem. Operation Pill Nation, launched in 2010, resulted in the DEA and other agencies making 340 undercover buys from more than 60 doctors working in more than 40 clinics in the first nine months of the operation. "The first arrests came in late February, when 22 people were picked up in one day," Ungar reports. A Florida strike force that started in March resulted in 937 arrests, including 17 doctors, and the confiscation of more than 250,000 pills.

There is also evidence that state drug monitoring systems work because they are a "major deterrent to doctor-shopping and a main reason Kentuckians go to Florida for drugs," Ungar reports.(Read more)

Despite new laws, Florida still fuels 'pill pipeline' to Kentucky

If you thought Florida's recent moves to stop the "pill pipeline" to Kentucky have worked, think again. "Cash-only clinics continue to operate throughout the Sunshine State, with doctors indiscriminately doling out prescriptions for such drugs as oxycodone and Xanax, often after little more than a cursory physical examination or a glance at an old MRI scan," Laura Ungar of The Courier-Journal reports from Fort Lauderdale. (C-J photo by Kylene Lloyd: Florida addict Bree Saghy shoots up crushed oxycodone, for which she has a prescription)

Florida has "new laws that forbid felons from owning clinics, strengthen penalties for doctors who over-prescribe painkillers and tighten rules for prescriptions and pain-treatment regimens," Ungar writes for the Louisville newspaper. "But anti-drug activists and officials worry they don’t go far enough, that pain-clinic operators, for example, will continue to charge hundreds of dollars in fees to customers or send them to associated pharmacies that may give the clinics a share of the profits — and Kentucky will keep paying the price. Local law enforcement and drug-policy officials estimate that 60 percent of Kentucky’s illicit pills come from Florida. . . . Police in Hazard, Ky., say there are neighborhoods in that Appalachian city where nearly every other household includes an addict or a dealer, and Deputy Chief Joseph Engle lays the blame squarely on Florida’s pain clinics, calling the doctors who allegedly fuel the trade 'murderers.'"

And the pills continue to be easy to get. The first step is usually to get an MRI, which gives the doctor an excuse to write a prescription. "Some bring old scans, try to pass off other people's as their own or get new ones at Florida imaging centers that sometimes have referral arrangements with clinics," Ungar reports. One recovering addict said he paid $500 to get an MRI and gave it to a doctor in Boca Raton. "You go down there, and they act so professional. But you are both knowing that nothing's wrong with you," he said.

The result has had a big effect on the Appalachian region of Kentucky. Dr. John Robert Morgan, who has worked in several Eastern Kentucky hospitals, spoke of one overdose patient "who came in with a bottle containing more than 200 oxycodone pills prescribed by an obstetrician/gynecologist in Miami. However, the patient was a man," Ungar reports.

The C-J devotes most of its Sunday front page and four inside pages to the issue. To read it and view videos online, click here. UPDATE, Oct. 17: A second installment takes most of the front plus two pages inside; there's also an interactive map and video narrative from Ungar; click here for the whole series.

Health exchange could cost up to $34 million in Ohio; Kentucky still biding its time -- until after the election?

As 27 states, including Kentucky, bide their time in setting up a health care exchange — a key component of the federal health-reform law — Ohio officials have said setting one up in their state will cost $19 million to $34 million.

The undertaking could cost $8 million a year just for staff salaries, with 170 employees needed to run the exchange, reports Cliff Peale of the Cincinnati Enquirer. Marketing could cost $5 million a year, said a health-care consultant at Milliman Inc., an actuarial and consulting firm.

"Ideally, we want to see Obamacare repealed," said Susan Verble, deputy chief of staff for Ohio Lt. Gov. Mary Taylor, who also directs the Ohio Department of Insurance. "Whether it's a state or federal-run exchange, it's going to be costly for taxpayers."

Starting in January 2014, "the law will require all Americans to buy health insurance or pay a penalty and require companies with more than 50 workers to offer benefits or pay a penalty," Peale reports. Ohio and Kentucky have each received $1 million from the federal government to research how to start an exchange.

Kentucky has not decided whether it will operate an exchange. Officials with the Cabinet for Health and Family Services said last month Kentucky is still awaiting guidance from the federal government, but didn't respond directly when asked if the impending election for governor was also a factor. (Read more)

Tonight, acting Gov. Earl Ray Tomblin of West Virginia narrowly won a special election for the remainder of an unexpired term, after losing a big lead. The final television commercial from the Republican Governors Association was an attack that Kentucky Gov. Steve Beshear may be trying to avoid: A link between a Democratic governor and the unpopular Democratic president's health-care law, passed with only Democratic votes. --Al Cross, Institute for Rural Journalism and Community Issues

Some worry that patient care will get shortchanged as Kentucky Medicaid moves to managed care

While moving Kentucky's Medicaid patients to managed care for will likely reduce costs to the taxpayers, patient care shouldn't be shortchaged in the effort to save a buck, Deb McGrath writes in an op-ed piece in The Courier-Journal.

"It is critical for quality patient care to always remain a priority," writes McGrath, executive director of the Epilepsy Foundation of Kentuckiana. "All citizens, including the 540,000 Kentuckians under the new managed care plans, deserve access to the best possible care recommended by their doctors."

McGrath is concerned about the "fail first" policy, also known as step therapy. "In this practice, the insurer will initially cover only the least costly medication in any drug class, forcing doctors to prescribe these medications first," she writes. "This is problematic because many times there are different medications that the physician feels would be the most effective treatment."

The policy can adversely affect Kentucky's 90,000 patients who have epilepsy, a disease that comprises 40 different seizure types and epileptic syndromes. "Fail first is not something a person with epilepsy wants to hear, especially when this policy can compromise their well-being and even their life," McGrath writes. "I urge Gov. Steve Beshear, the Cabinet for Health and Family Services, our state legislators and the new managed care organizations to keep patient care in mind as they get ready to implement this new system on Nov. 1." (Read more)

Ky., Ohio, Tenn. and W.Va. join forces to fight prescription-drug abuse amid questions about use of Ky. system

Kentucky has formed a partnership with Ohio, Tennessee and West Virginia to help fight prescription drug abuse, "even as questions linger over how well the state has used its own electronic monitoring resources," reports Mike Wynn of The Courier-Journal.

The Interstate Prescription Drug Task Force will comprise about 30 experts from law enforcement and drug agencies. They are charged to come up with ways to lessen prescription drug abuse and sales. "We do a good job from a law enforcement standpoint, but by working together, we can better identify prescribers, dispensers and patients who are exploiting our borders," Gov. Steve Beshear said in announcing the task force Wednesday.

Task force members will share drug information the state collects on who receives and prescribes certain medications. Kentucky's system is known as KASPER, short for Kentucky's All Schedule Prescription Electronic Recording system. How well the data compiled by the system are being used came into question last week when House Speaker Greg Stumbo, D-Prestonburg, pressed the Kentucky Board of Medical Licensure to explain why it wasn't analyzing the numbers, which it had asked for permission to obtain, Wynn notes.

Kentucky and Ohio are now exchanging prescription data, but system needs more use by health-care providers and police

Kentucky and Ohio are now automatically exchanging data on prescription drugs, with a new electronic network called the Prescription Monitoring Information Exchange. PMIX links the Kentucky All- Schedule Prescription Electronic Reporting (KASPER) system and the Ohio Automated Rx Reporting System (OARRS). Now perhaps all we need is a Big Old Automatic Terminal (BOAT) so Kasper can row it with the Ohio oars.

Kidding aside, "The announcement marks a highly anticipated milestone for prescription drug monitoring programs and ongoing work to fulfill a need to share data across state lines," Gov. Steve Beshear's office said in a press release. "Kentucky’s Cabinet for Health and Family Services oversees KASPER, which is considered a national model for prescription drug monitoring." The Ohio-Kentucky linkup is federally funded.

Authorized users in the two states can securely access prescription monitoring data from both systems. "A physician in Kentucky will be able to request a KASPER patient report and stipulate that they need Ohio data included on the report," the release says. "Doctor shoppers often seek controlled substances from multiple providers and cover increasingly large territories to obtain the drugs."

Kentucky and several other states allow a prescriber, dispenser, or law-enforcement officer from another state to register and get their prescription data, but "Due to the effort required to establish and maintain separate accounts with each state and review multiple reports and formats, only a limited number of practitioners and law enforcement officers have done so," the release says, then quotes KASPER coordinator Dave Hopkins: “We think the PMIX pilot will facilitate efforts to share prescription drug monitoring program data among all states.”