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Evolving research shows that electronic cigarettes' secondhand aerosol (it's not vapor, despite what the industry says) is not without health risk, and experts warn users to not "vape" around children, Michael O. Schroeder reports for U.S. News & World Report.

"People don't, I think, always realize that the secondhand smoke emissions from vaping or e-cigarette use can be harmful," Dr. S. Christy Sadreameli, a pediatric pulmonologist at Johns Hopkins Hospital in Baltimore, and a volunteer spokesperson for the American Lung Association, told Schroeder.

And while she recognized that the debate continues about how the risks of e-cigarettes stack up against traditional cigarettes, Sadreameli added, "We don't think they're harm-free, and we don't think the secondhand emissions are safe for children."

In addition to nicotine, aerosol from e-cigarettes contain ultrafine particles that can be inhaled deep into the lungs; flavorings, like diacetyl, a chemical linked to serious, irreversible lung disease; volatile organic compounds that are known to be carcinogenic; other cancer causing chemicals; and heavy metals, including nickel, tin and lead, according to the Centers for Disease Control and Prevention.

The experts specifically pointed to the dangers of secondhand exposure to nicotine in children, explaining how the drug can harm kids' brain development by altering the reward pathways that navigate positive reinforcement. That makes a child more vulnerable, or at increased risk, for becoming addicted to products that contain nicotine and other drugs.

"Exposure to any nicotine or tobacco product is dangerous for infants and children," Dr. Jonathan Winickoff, the director of pediatric research at the Tobacco Research and Treatment Center at Massachusetts General Hospital, told Schroeder. "The developing brain is exquisitely sensitive to nicotine."

Schroeder also pointed to a study published in the medical journal Chest in January that found teens with asthma who were exposed to secondhand aerosol, and had not used e-cigarettes, were more likely to have an asthma attack.

"While experts emphasize more study is needed to understand the effects of vaping aerosol, they also reiterate there's enough potential for harm that parents should never vape around kids – or in spaces like the home or car, where they'll be," he writes.

A study published in the medical journal Pediatrics in April, found that while some parents continue to smoke traditional cigarettes around their children, many more reported that they vape around them -- "findings [that] seem to underscore an errant perception of e-cigarettes as safe," Schroeder reports.

"We saw three-fold higher rates of parents using electronic cigarettes inside their homes than smoking," Winickoff, the senior author of the study, told Schroeder.

"Of the parents interviewed who were dual users, nearly 64% had a smoke-free home policy, compared with only 26%, who had a vape-free home policy," he writes. "In addition, dual users and e-cigarette-only users together were more likely to have a smoke-free car policy, than a vape-free car policy. Still, only 35% had a smoke-free car policy and just 22% had a vape-free car policy."

Schroeder also reports on the dangers of "thirdhand" exposure to nicotine and all of the aforementioned substances, which settle on surfaces from the aerosol -- just like they do from traditional cigarette smoke.

The experts stressed, "To protect children from secondhand and thirdhand exposure, parents should adopt strictly enforced policies that prohibit e-cigarette use at all times in homes and cars."
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By Melissa Patrick
Kentucky Health News

Michael T. Rust, who led the Kentucky Hospital Association for 24 years, has retired.

Rust said it was a privilege to have worked for the KHA for 24 years, and attributed the bulk of his success to his communication and listening skills.

Michael T. Rust
"You can be the smartest person in the world, but you've got to stay in touch with these guys, the administrators and the hospitals, and you've got to listen to them," he said. "And that I think was the biggest part of my career, that I really listened to these guys. I may not have had the answer all of the time, but at least I listened and got back to them and communicated with them pretty well."

Rust added that one of his greatest accomplishments was that he was able to recruit and maintain 100 percent of the state's 127 hospitals as members of the association, which he said is quite rare among hospital associations.

Rust said he came to Kentucky by way of Florida, where he had been the senior vice president of the Florida Hospital Association. He worked there for 13 years. Prior to that he served as an administrator of a small rural hospital and the vice-president of operations for a 300-bed hospital, both in West Virginia.

He was also a member of the American College of Health Care Executives and became a fellow of that organization in 1998. In 2001, he was elected to the Council of Regents, the legislative body of the American College of Health Executives.

Asked about challenges facing Kentucky hospitals, Rust said the state's shift from a fee-for-service payment system to a "value-based" system in Medicaid remains a big challenge, largely because 70 percent of Kentucky's patients are covered by a government payor whose payments to hospitals don't cover the full cost to treat patients.

He said the state also struggles with healthcare workforce shortages, but “The hospitals of Kentucky are resilient and staffed with outstanding leadership and the highest quality providers. I have the utmost faith that they will face all these challenges head on and continue to succeed at providing outstanding health care for every citizen of the commonwealth.”

Nancy Galvagni
Nancy Galvagni was appointed KHA's new president and chief executive officer in May. “I am pleased to pass the baton to Nancy Galvagni as I know she will serve the association and its members with distinction," Rust said.

Galvagni joined KHA since 1979 and was senior vice president for the past 20 years, She has served as the executive director of the Kentucky Institute for Patient Safety and Quality, a federally certified patient safety organization and a subsidiary of KHA.

Galvagni is a graduate of Pennsylvania State University, is a past president of the Kentucky Society for Health Care Planning and Marketing and is a member of the American Association of Hospital Accounts. Prior to joining KHA, she worked at the New York Hospital Association.

KHA represents hospitals, related health-care organizations and integrated health-care systems. It is celebrating its 90th year. Galvagni is the only the fourth chief executive officer in its history.
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OPINION
By F. Douglas Scutchfield and Al Cross


Public health is the nexus of science and politics. Unfortunately, the two frequently do not mix well. A recent example involving childhood immunizations prompts real concern for the erosion of science in the name of politics.

State Sen. Ralph Alvarado, physician and lieutenant governor candidate with Gov. Matt Bevin, recently declared: “I think it’s good health policy to administer vaccines, but if people don’t want them, we shouldn’t force people to take them.” This followed the governor’s ill-advised exposure of his own children to kids with chicken pox, a practice discouraged by both public health and physician organizations.

These politicians are playing with fire. The U.S. is currently experiencing the worst measles epidemic since 1992, and nearly 80 percent of this year’s cases occurred in outbreaks in unvaccinated, close-knit communities, such as the Amish.

Many people oppose vaccination for measles, despite recommendations of the World Health Organization, the Centers for Disease Control and Prevention, and major physician and health organizations. Some of this opposition is the result of a fear of autism associated with vaccination, driven by a British physician whose paper on the topic has been retracted as fraudulent by editors of the leading British medical journal, and who has lost his medical license as the result of his claims.

Some people mistakenly think that vaccines contain mercury, but that has not been true for decades. Studies by the CDC, the National Academy of Medicine and the National Institutes of Health have demonstrated, repeatedly, the lack of any linkage between vaccines and autism.

Measles is not an innocuous disease. It can cause encephalitis, pneumonia and even death.

Immunizations protect us in two ways. They keep you from acquiring the disease, and with enough people immunized, a virus cannot spread, giving a population “herd immunity.”

One of the most effective ways to assure freedom from measles is to assure that all susceptible people are vaccinated. The major way of doing that is to require vaccination for enrollment in school, day care centers, kindergarten and summer camps.

All states have such laws, but in some, pressure from anti-vaccine groups watered them down so that parents can easily refuse immunizations for their children. Kentucky made it easier in 2017, by dropping the requirement that a physician sign the exemption form, and the immunization rate dropped below the 95 percent generally thought to guarantee herd immunity.

There are a few children who, because of some immune disease, should not receive live-virus vaccines, but these are rare cases and should be protected legally from immunization rules. Kentucky and some other states allow non-medical exemptions based on personal preference or belief. It is in such states that we are seeing epidemics in close-knit, unvaccinated populations. That has prompted several states to reexamine the vaccine exemptions and tighten them. Kentucky has moved in the opposite direction, and that trend needs to stop.

It is not in Kentuckians’ best interests to water down our immunization requirements; in fact, we should be tightening personal exemptions for vaccinations. This is the policy recommendation of public health agencies and organizations, and of physician organizations.

Comments that erode support for immunization laws that protect us from vaccine-preventable diseases are detrimental to the public’s health. That is especially true of people in public life, and health professionals who know better. Such comments from such sources erode public support for our protection from illness and death. Our political leaders’ statements and actions should be driven by evidence and science.

F. Douglas Scutchfield, M.D., is the Peter P. Bosomworth Professor Emeritus in the Department of Health Management and Policy in the University of Kentucky College of Public Health. Al Cross is a journalism professor at UK, director of its Institute for Rural Journalism and Community Issues, and editor and publisher of Kentucky Health News.
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Jewish Hospital is in downtown Louisville.
Financially ailing Jewish Hospital, which has done only one heart transplant this year, says it is putting the program on "long-term inactivation" while maintaining other transplant programs.

Hospital President Ron Waldridge said in an email to employees that the Organ Procurement and Transplant Network, which directs human-tissue transplants in the U.S., "changed how heart donation are allocated" last October, Chris Larson reports for Louisville Business First. "The change resulted in fewer heart transplant cases being sent to Jewish Hospital. . . . Transplant programs must perform at least 10 heart transplant procedures over a rolling 12-month period to stay in compliance with federal standards."

The University of Louisville collaborates on the program. "U of L President Neeli Bendapudi and other U of L leaders who spoke to media downplayed the impact that stopping the program would have on the university's education mission or on U of L Health, the organization that oversees the clinical aspect of the school's medical endeavors," Larson reports.

Toni Ganzel, dean of U of L's School of Medicine, told Larson that many medical schools do not have transplant programs, "but we saw [the program] as a really valuable part of being an academic medical center."

Tom Miller, CEO of U of L Health, told Larson that advances in technology have diminished the need for heart transplants. "And he added that U of L doesn't have the space to add a heart transplant program to U of L Hospital, which is currently operating at capacity." Miller said, "That doesn't mean that we won't some time in the future —we just don't have that today." 

KentuckyOne Health and its new corporate parent CommonSpirit Health have been trying to sell Jewish Hospital and other facilities in Louisville and Shelbyville for more than two years. "U of L announced in June that it was abandoning its plan to buy assets from KentuckyOne, citing an inability to find a partner within the timeline KentuckyOne set for the talks," Larson notes.
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By Melissa Patrick
Kentucky Health News

Kentucky saw a nearly 15 percent drop in drug-overdose deaths in 2018, the first decline since 2013, and almost three times the national decline of 5.1%.

Most of the deaths were again caused by fentanyl, a synthetic opioid that can be up to 50 times more potent than heroin, according to the annual Kentucky Office of Drug Control Policy report.

The state recorded 1,333 overdose deaths in 2018. That was 233 fewer than in 2017, when 1,566 were recorded. Toxicology reports are available for 1,298 of last year's deaths; fentanyl was found in 786 autopsies, or nearly 61% -- up from 52% in 2017 and 47% in 2016.

Van Ingram, executive director of the Office of Drug Control Policy, said in a news release that the overall decline was likely the result of the state's many policy initiatives, along with a growing awareness about the dangers of opioids and the threat of overdose.

 “We’ve pushed hard to develop the most comprehensive approach possible, combining education and treatment with a multitude of other harm-reduction strategies,” Ingram said. “We still have a great deal of work to do, but it’s clear that Kentucky’s efforts are making an impact.”

The report also found an increase in deaths caused by methamphetamine, a stimulant that has long plagued Kentucky. It was found in 428 cases, up from 357 in 2017.

The report found that overdose deaths from heroin, alprazolam and gabapentin all declined in 2018.

Heroin-related deaths dropped 30%, to 188 in 2018, from 270 in 2017. Deaths from alprazolam, an anti-anxiety medicine that is often known by its brand name Xanax, dropped 20%, to 214 cases, down from 269 in 2017.

Deaths from gabapentin, which sells under the brand names Neurontin, Gralise and Horizant, and is often taken along with other illicit drugs to enhance their effects, dropped 30%, to 255 cases, down from 363 in 2017. It also found that deaths related to oxycodone dropped, to 110 from 157 respectively, or 30%.   

“The numbers are trending down, but our state still faces incredible challenges,” Justice and Public Safety Cabinet Secretary John Tilley said in the release.“This crisis claimed more than 1,300 lives last year and inflicted untold heartbreak on our families and communities. I only hope the latest numbers serve as evidence that strong interventions and better access to treatment can and do save lives."

Of the 1,333 deaths, 1,247 of them, or 93.6 percent were Kentucky residents. County-by-county figures in the report are based on resident deaths, and are adjusted for age.

Boyd County (Ashland, Catlettsburg) had the highest rate of fatal overdoses in 2018, followed by Madison, Kenton, Clark and Campbell counties.
This story will be expanded.
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Washington Post map; click on the image to enlarge it or click here to view the interactive version. 
Between 2006 and 2012, drug companies distributed 76 billion doses of prescription pain medicine, "enough pills to supply every adult and child in the country with 36 each year," Scott Higham, Sari Horwitz and Steven Rich report for The Washington Post. And rural counties, especially in Appalachia, received some of the highest shares of pain pills per person.

That's according to a Drug Enforcement Administration database, made public for the first time by the Post and the daily newspapers in Charleston and Huntington, W.Va. The database tracks the path of every DEA-regulated pain medication in the U.S. It includes local data that shows the counties that received the most pills, fueling the prescription-opioid epidemic, resulting in nearly 100,000 deaths in that time period.

The Post reports that "rural areas were hit particularly hard." The data showed Kentucky ranked second in pills per person per year, at 63.3, topped only by West Virginia at 66.5, which had the highest opioid death rate during the period. South Carolina, mainly due to high rates along its Atlantic coast, was third at 58; Tennessee was fourth at 57.7, and Nevada was fifth at 54.7.

A 2016 report from the Kentucky Injury Prevention and Research Center found that prescription opioids contributed to the overdose deaths of 2,481 Kentuckians between 2006 and 2012.

Section of map shows counties in and near Kentucky.
The Post's interactive map shows that several counties in Eastern Kentucky had some of the highest distribution rates in the state, including: Whitley at 187, Perry at 175, Floyd at 168, Bell at 156, Johnson at 152, Pike at 146, Clay at 134 and Lee at 133.

Clinton County, at 147, stands out in the south-central part of the state, as do McCracken, at 107, and Crittenden, at 119, both in Western Kentucky.

Nearly half of the pills were distributed by three companies: McKesson, Walgreens and Cardinal Health. The top manufacturer was Mallinckrodt's SpecGx, with nearly 38 percent of the market.

Because the database is partly comprised of data that drug makers gave the DEA, it shows what they knew about the number of pills they were shipping at the epidemic's peak, the Post points out.

Drug manufacturers, distributors and pharmacies must log and report each narcotic transaction, and are supposed to report suspiciously large or frequent orders to the DEA and withhold such shipments.

Meanwhile, nearly 2,000 communities, counties and Indian tribes have alleged in federal lawsuits that the drug companies filled suspicious orders and did not report them in order to maximize profits.

 The lawsuits were consolidated into one case, which is now larger in scope than the lawsuit against cigarette manufacturers in the 1980s, the Post reports.

Attorney General Andy Beshear, the Democratic nominee for governor, has filed nine lawsuits against opioid manufacturers and distributors, including ones against the top three distributors and top manufacturer. He says that is more than any other attorney general

Beshear is the Democratic nominee for governor. In a debate Wednesday, Republican Gov. Matt Bevin asked him, "How much money have we gotten" from the suits. "We will," Beshear replied. "You blow a lot of smoke," Beshear retorted.

The database was released Monday after the Post and HD Media, which publishes the Charleston Gazette-Mail, won a years-long legal battle to access documents and data from the ongoing litigation.

The West Virginia newspaper won a Pulitzer Prize in 2018 for reporting on drug distribution, using other data. The Post reports that the DEA, the Justice Department and drug companies all fought hard against release of the data. The companies said it would reveal information that could give competitors an unfair advantage, and Justice said the data could compromise DEA investigations.
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By Melissa Patrick
Kentucky Health News

The state Cabinet for Health and Family Services has updated its requirements for tattoo studios in Kentucky, and they no longer prohibit tattoos on scarred skin, as first proposed.

WFPL photo
The cabinet said in a news release it had received more than 600 public comments on this proposal. In addition, WHAS-TV reported that almost 100 people from all over the state attended a public hearing about the issue May 28 in Frankfort.

"Based on comments received, we elected to remove the language relating to scar tissue," Dr. Jeff Howard, commissioner of the state health department, said in the release.

Opponents of the proposal have said there is no medical reason to ban such tattoos. Others have said such a ban is a violation of their civil rights, and there are already industry rules around this issue. Still others pointed out the many reasons people want to cover their scars, including cancer survivors who want to cover their mastectomy scars.

The state announced the original amendment to the regulation in April, which simply said "tattooing over scarred skin is prohibited." The proposal did not give any reason for adding this language; when asked about it, a cabinet spokesman said only that the proposal was made in an effort to update a regulation that hadn't been updated in 15 years.

In May, the health commissioner issued another release, saying the proposal to ban tattooing on scarred skin in the regulation "had some unintended consequences" and that the language regarding this issue would be addressed once the public comment period ended on May 31.

On Tuesday, July 16, the cabinet announced that the ban had been removed, citing a "a lack of available evidence to support this prohibition." It said the intent of the first revision was to prohibit the tattooing of freshly scarred skin, but "freshly" was left out.

Under the new rule, which next goes before the Administrative Regulation Review subcommittee, a person registering as a tattoo artist will have to complete training about blood-borne pathogens. The rules also outline a registration process for tattoo studios and increased fees to offset inspection cost.

The regulation also updates requirements for disinfecting and sterilizing equipment and adds a new rule to require a notarized statement of parental consent for a minor who is seeking a tattoo without a parent or legal guardian present.
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By Melissa Patrick
Kentucky Health News

Public health officials are reminding Kentuckians about the dangers of rabies exposure from bats and other wildlife.

Photo from Kentucky Department of Fish & Wildlife
“We want to highlight the importance of rabies prevention and control efforts in our communities, while also reminding Kentuckians of the existing dangers of coming into contact with rabid bats and other wildlife," Kelly Giesbrecht, veterinarian with the state Department of Public Health, said in a news release. "To avoid possible rabies exposure, wildlife should not be fed, handled or treated as pets.”

Rabies is a viral disease that affects the nervous system. It is transmitted from animals to humans by the saliva of a rabid animal, usually from a bite or scratch. The virus cannot infiltrate intact skin.

Because bats are so small, it is sometimes difficult to know if you have been bitten or scratched by one, so the health department warns that any suspected exposure should not be taken lightly. "If untreated, rabies is fatal," says the release.

Rule number one when it comes to protecting yourself from rabies is to never handle a bat.

If you find one in your home, call the local animal control office to remove it and then call a healthcare provider or local health department to determine if preventive treatment is required.

Only a small percentage of bats have rabies, but health officials warn that you can't tell if they have the disease just by looking at them -- though they advise extra precautions around bats that are flying during the day, are in locations where they are normally not found, like your home, or are unable to fly at all.

University of Kentucky Cooperative Extension graphic
It's also important to protect your home by sealing all of the holes that are larger than a quarter-inch. The health department says the best time to do this is in the fall or winter so that any bats that might already be inside are not unintentionally trapped.

The University of Kentucky Cooperative Extension Service offers further tips on how to protect your home from bats, noting that it's important to take the time to to seal all points of entry because bats return each year to their "nursery colony."

The most common ways for bats to enter homes are through chimneys, vents and openings behind shutters or under doors, siding, eaves and shingles.

The release also points out that it is illegal to remove bats from an area between May and August because that is when they raise their young. Instead, health officials say to consult with the Kentucky Department of Fish and Wildlife if you have a bat problem in your home during these months.

In the U.S., rabies is most commonly spread by bats, raccoons, skunks, coyotes and foxes.
Once clinical symptoms are present, there is no known medical cure for rabies.

Symptoms of rabies can initially mimic the flu, including general weakness, fever and headache. A person can also have a strange sensations at the site of the bite from a rabid animal. These symptoms can progress within days to symptoms of anxiety, confusion and agitation. Further progression of the disease includes symptoms of hallucinations, insomnia and fear of water, all of which are quickly followed by death, according to the federal Centers for Disease Control and Prevention.

There are usually only one or two human cases of rabies in the U.S. each year, and the most common source is from bats. The health department reports that the last case of human rabies in Kentucky from a bat was in 1996.

"Among the 19 naturally acquired cases of rabies in humans in the U.S. from 1997 to 2006, 17 were associated with bats. Among these, 14 patients had known encounters with bats. In these cases, the bat was inside the home," says the CDC.

Tips to protect yourself from rabies:
  • Do not touch a bat, and teach children to not touch them.
  • Keep your pets vaccinated; it's not only good practice, it's the law in Kentucky.
  • Do not interact with wildlife, or intentionally feed wildlife.
  • If you've been bitten or scratched, wash the wound immediately with soap and water for at least 10 minutes and call your health-care provider.
  • Remember, bats have very small teeth which may leave marks that disappear quickly. If you are unsure, seek medical advice.
  • If a bat is found in a room with an unattended child or near a mentally impaired or intoxicated person, seek medical advice.
  • Report all animal bites to your local health department
  • If possible, confine the animal so it can be quarantined or tested.
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Juul Labs CEO Kevin Burns, left, and NBC reporter Carl
Quintanilla tour a Wisconsin Juul facility. (CNBC photo)
A new CNBC documentary exploring the increasing popularity of electronic cigarettes, especially among teens, features a surprising message from one industry CEO: an apology.

Kevin Burns is CEO of Juul Labs, which has about 40 percent of the e-cigarette market. It sells liquid nicotine pods in sweet flavors that are a prime driver in getting teenagers to try vaping. Reporter Carl Quintanilla asked Burns what he would say to a parent whose child was addicted to Juul.

Burns, who joined Juul in late 2017, replied: "First of all, I’d tell them that I’m sorry that their child’s using the product . . . It’s not intended for them. I hope there was nothing that we did that made it appealing to them. As a parent of a 16-year-old, I’m sorry for them, and I have empathy for them, in terms of what the challenges they’re going through."

Angelica LaVito reports for CNBC, "The Food and Drug Administration has declared teen vaping an 'epidemic,' citing federal survey data that showed nearly 21 percent of high school students vaped last year. Former FDA Commissioner Scott Gottlieb and health care advocates blame the surge in teen vaping on Juul."
"Vaporized: America's E-cigarette Addiction" will first air tonight at 10 p.m. ET.
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By Melissa Patrick
Kentucky Health News

Kentucky legislators were assured at a July 8 meeting that the state is committed to resolving the payment issues that the states' independent pharmacies have with pharmacy benefit managers in Medicaid, issues that the pharmacies have said are so bad they threaten their survival.

Medicaid Commissioner Carol Steckel
“We are not going to tolerate it, and we will do whatever we have to do to ensure that the taxpayers of the commonwealth and the beneficiaries of the Medicaid program are treated the way they should be treated,” Medicaid Commissioner Carol Steckel told the Medicaid Oversight and Advisory Committee.

Pharmacy benefit managers, or PBMs, are the middlemen between insurance companies and drug companies. They determine what drugs are offered, how much someone pays for the drug and the payments to pharmacists.

Steckel said her agency had a “new-found spine” when it comes to how much control it has over PBMs, and will build on that “power and control” in the updated contracts it is negotiating with managed-care organizations, which will take effect in July 2020. The MCOs subcontract with PBMs.

Steckel, who has worked with Medicaid for 30 years, later referred to the PBMs as “predators” and said, “It makes me angry to have this kind of player in the Medicaid program.”

A few days later, Attorney General Andy Beshear announced his office would be submitting a request for more legal help to further its investigation of PBMs' pricing practices.

Beshear, the Democratic nominee for governor, launched an investigation in March to find out whether PBMs have overcharged the state and discriminated against independent pharmacies. “We all want to know if the actions of these companies have resulted in all of us paying too much for prescription drugs – and we’re going to find out," Beshear said in a news release.

Lawmakers have been working on this issue for years. Sen. Ralph Alvarado, a Winchester physician who is Gov. Matt Bevin's running mate for lieutenant governor, reminded the group that it once again felt like “Groundhog Day” -- which Senate Democratic Leader Morgan McGarvey has said before.

Senate Bill 5 of the 2018 legislative session put the Department of Medicaid Services, rather than the managed-care companies, in charge of setting pharmacists' reimbursement rates. It allows the department to regulate contracts between the companies, PBMs and pharmacists; requires more transparency in how PBMs spend the $1.7 billion a year they get for processing prescriptions; and gives the state authority to penalize the companies and PBMs for noncompliance.

In a report earlier this year, "Medicaid Pharmacy Pricing: Opening the Black Box," the state said two PBMs kept $123.5 million last year from the Medicaid program by paying pharmacies a lower rate to fill prescriptions, while charging the state more for the same drug. Much of the discussion at the July 8 meeting was around SB 5 and the MCO contracts now being negotiated.

Trevor Ray, an independent pharmacist and co-owner of Midway Pharmacy, which has four locations in Grayson County, praised the efforts behind SB 5, but said many issues still need to be addressed to ensure “fair, transparent and adequate reimbursement” for community pharmacies.

Ray said low dispensing fees are still an issue, even though the Medicaid department increased this fee to $2 per prescription after SB 5 became law. The Centers for Medicare and Medicaid Services says this amount should be around $10,64, plus the cost of the drug being dispensed.

Mark Glasper, executive director and CEO of the Kentucky Pharmacists Association, told Kentucky Health News in an e-mail that while the newfee helps, the amount barely scratches the surface of what is needed. "Independents are scratching to stay in business," he said. "The $2 dispensing fee afforded by SB 5 is merely a Band-Aid."

Ray questioned “backdoor fees” and "spread pricing,” in which a PBM keeps the difference between what it bills Medicaid for medications and what it pays the pharmacy to dispense the drugs. The Medicaid department said that spread pricing in Kentucky through May of this year was 12.92 percent. This number doesn't include data from WellCare because it does not use this model.

Ray also explained a process in which pharmacies are paid one price for a drug, only to have a chunk of it taken back several months later, which he said is a problem with both spread pricing and “pass-through pricing,” which is what WellCare does. In pass-through pricing, an MCO pays the actual discounted pharmacy price that the PBM negotiated with the retail pharmacy network.

The Medicaid department went over the changes proposed in the MCO contracts, including new language from SB 5; requirements that all PBMs use a “pass-through model;” language banning “take-back” fees; and language to remove any barriers to claims data. The new contracts will take effect July 1, 2020.

Steckel also told the lawmakers that DMS was using Kentucky data to replicate a West Virginia study showing the impact of removing pharmacy services from MCOs, which is what the pharmacists' lobby and many legislators would like to see happen.  The West Virginia study found that the state saved $54 million by removing prescription drugs from Medicaid managed care.

Ray concluded, “We're not asking for more money just to get paid more, we just want to be paid fairly.”

In 2016, Kentucky passed a law that allows the state Department of Insurance to regulate PBMs much like insurance companies are regulated, and to provide an appeal mechanism to resolve pricing disputes between pharmacies and PBMs.

The law has resulted in CVS Caremark, a PBM for all but one of the Medicaid management companies in Kentucky, being issued a $1.5 million fine in July 2018 for hundreds of reimbursement violations involving individual pharmacies, and for giving the department 'inaccurate or inconsistent" information. It also resulted in Caremark PCS Health being put on probation for one year. 

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