Princess Health and AMA, led by Ky. doctor, says gun violence is public-health crisis; calls for research, background checks, waiting periods for all guns. Princessiccia

Princess Health and AMA, led by Ky. doctor, says gun violence is public-health crisis; calls for research, background checks, waiting periods for all guns. Princessiccia

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Gusty 06:40 Add Comment

The American Medical Association, led by a Kentucky emergency-room physician, declared gun violence a public-health crisis last week and endorsed waiting periods an background checks for purchases of all firearms, not just handguns.

"The AMA, the country's largest doctor group, also vowed to lobby Congress to overturn a decades-old ban on gun violence research by the Centers for Disease Control and Prevention," two days after the Orlando shooting that left 49 dead and 53 wounded, reports Kimberly Leonard of U.S. News and World Report. "The AMA joins the American College of Physicians in its position, which has been calling gun violence an epidemic since 1995."

Dr. Steven Stack

AMA President Steven Stack of Lexington said the research "is vital so physicians and other health providers, law enforcement and society at large may be able to prevent injury, death and other harms to society resulting from firearms. . . . With approximately 30,000 men, women and children dying each year at the barrel of a gun in elementary schools, movie theaters, workplaces, houses of worship and on live television, the United States faces a public-health crisis of gun violence."

Leonard notes, "Federal law doesn't technically outlaw the CDC from studying gun violence, but prohibits the agency from using federal dollars to advocate or promote gun control. Though President Barack Obama lifted the research ban through executive order nearly three years ago, Congress has blocked funding for these studies."

The National Rifle Association has called the public-health approach a back-door path to more gun control, Leonard writes, and "has said that doctors shouldn't be asking patients about gun ownership because they are not gun safety experts."

"Who will Congress listen to now: the healers or the merchants of death?" Lexington Herald-Leader columnist Tom Eblen asked to start his Sunday column. "The AMA's stand is unlikely to change anyone�s mind about gun control. But it underscores the absurdity of Congress� two-decade effort to block legitimate scientific research that could reduce gun deaths and injury."

Suicides accounted for about two-thirds of the 33,390 firearms deaths in the U.S. in 2014. The CDC "said 627 people were killed in Kentucky that year with firearms, a rate of 13.8 per 100,000 population, higher than the national average of 10.2," Eblen reports. He said research on gun violence could reduce those figures, just as research into auto accidents has reduced such fatalities.

Read more here: http://www.kentucky.com/news/local/news-columns-blogs/tom-eblen/article84482382.html#storylink=cpy

Read more here: http://www.kentucky.com/news/local/news-columns-blogs/tom-eblen/article84482382.html#storylink=cpy

Princess Health and Doctors trying to reverse course on opioid prescriptions can find it difficult because of addiction, shortage of good alternatives. Princessiccia

Princess Health and Doctors trying to reverse course on opioid prescriptions can find it difficult because of addiction, shortage of good alternatives. Princessiccia

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Gusty 08:37 Add Comment

The epidemic of opioid overdoses, 60 percent of which are blamed on abuse or misuse, "is changing prescribing habits, but there's still a lack of other pain medications, access to alternative therapies and knowledge among primary-care providers about multidisciplinary approaches to pain management," Modern Healthcare reports.

"The medical community turned to opioid prescriptions to address a condition many believed had been ignored or undertreated," Steven Ross Johnson writes. "And the dependence on fee-for-service payments also made it easier for providers to whip out their prescription pads rather than spend the time to help patients find alternatives. But experts now say the over-reliance on opioids for chronic pain, despite a lack of evidence on their efficacy and impact, was misguided and has distorted the public's concept of what pain is and what it means to be treated."

But reversing course can be difficult because many patients "have built up resistance to opioids and seek treatment while addicted or at risk of addiction," Johnson reports. He quotes Dr. Neel Mehta, medical director of Weill Cornell Medical College's Pain Medicine Center, which specializes in treating long-term pain as saying many come there because their doctor won't write them another prescription: �So we're sort of left with them expecting to get prescribed an opioid and we have to then calmly redirect that.�

In March the federal Centers for Disease Control and Prevention "recommended doctors prescribe alternative treatments such as over-the-counter medications, cognitive behavioral therapy and exercise before resorting to opioids. Weeks later, the Joint Commission [which accredits health-care facilities] clarified its 2001 standards for pain management and treatment to stress that opioid use was neither required nor specified for treating pain."

Other alternative treatments chiropractic care and the use of anti-inflammatory and neuropathic medications and even vitamin supplements, Johnson notes. "The problem is that few carry the punch or, for some, the pleasure of opioids. . . . The use of medical marijuana, meanwhile, has increased in several parts of the country. It's approved in 38 states and the District of Columbia for patients with illnesses such as cancer and HIV. But only some of those states allow the use of marijuana to relieve chronic pain." Kentucky does not.

Princess Health and Kentucky is the only truly Appalachian state to have put a brake on fatal overdoses from narcotics. Princessiccia

Princess Health and Kentucky is the only truly Appalachian state to have put a brake on fatal overdoses from narcotics. Princessiccia

Appalachia doctors drug abuse drugs General Assembly legislature narcotics pain pain clinics physicians prescription drug abuse prescription drugs state government

Gusty 12:08 Add Comment

Kentucky is the only truly Appalachian state to have put a brake on fatal drug overdoses, report Rich Lord and Adam Smeltz of the Pittsburgh Post-Gazette as part of a series in the about the deadly epidemic of prescription painkillers in the region.

A chart with the series' story about Kentucky shows that fatal drug overdoses were less numerous in the state in 2013 than in 2012, when the General Assembly cracked down on "pill mills," and that while fatal overdoses rose in 2014, they were still not as numerous as in 2012. Official numbers for 2015 are expected soon, and may rise because of the spread of heroin.

The series also credited a crackdown by the Kentucky Board of Medical Licensure, which "took disciplinary action for prescribing irregularities against 135 of the state�s roughly 10,600 doctors" from 2011 to 2015. "The board also moved against 33 doctors during that time for abusing narcotics themselves."

"Getting tough on doctors works," Lord wrote in the series' main story. The state story reported, "Kentucky�s per-capita opioid consumption -- though still seventh in the nation -- dropped by a steepest-in-Appalachia 12.5 percent from 2012 to 2014, according to IMS Health Inc.," Lord and Smeltz report. "Kentucky is the only state, among the seven studied by the Pittsburgh Post-Gazette, in which fatal overdoses have plateaued. Elsewhere, they have climbed relentlessly."

The story quotes Kerry B. Harvey, U.S. attorney for the eastern half of Kentucky: �In much of Eastern Kentucky, the workforce is engaged in difficult, manual labor,� like mining, farming and logging, �so people would injure themselves and be prescribed these very potent narcotics, because the medical profession changed the way it looked at prescribing these kinds of narcotics for pain.� The drugs dulled the �sense of hopelessness� people had about the area�s economy, �and so for whatever reason, this sort of culture of addiction took hold.�

"Harvey said that as physicians have gone to jail, and others have faced board discipline, the painkiller business model has adapted. . . . Now the doctors take insurance, and bill the insurer or the government not just for the office visit, but for the MRI, urine screen and back brace they use to justify the addictive narcotic." Harvey said, �So instead of a cash business, in many cases now the taxpayers or the insurance companies pay. The result is the same. We end up with our communities flooded with these very potent prescription narcotics.�

Princess Health and In Pineville, a new administrator from a Texas management firm is shaking up the local hospital in an effort to save it. Princessiccia

Princess Health and In Pineville, a new administrator from a Texas management firm is shaking up the local hospital in an effort to save it. Princessiccia

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Gusty 10:16 Add Comment

Kentucky Health News

The crisis in rural hospitals is driven not only by changes in federal reimbursement and patients' increasing preference for larger hospitals, but in some towns by managerial shortcomings that may follow local tradition but hurt the bottom line. Changing those practices can be difficult, but the new administrator of the Pineville Community Hospital appears to be having success as he grabs the bull by the horns.

Stace Holland (Modern Healthcare photo by Harris Meyer)

Longtime rural hospital administrator Stace Holland has put PCH "on the road to recovery by cutting costs, bringing in more federal funds and getting staffers to change their ways," Modern Healthcare reports in a long story than delves into the details, from specific expense cuts to clashes with physicians.

The 120-bed hospital is staffed for only 30 (not counting a 26-bed nursing unit) and was losing $6 million a year. Eight months after taking over as CEO, "Holland is well on the way to turning around a struggling not-for-profit facility that still expects to lose $3 million this year. With support from the Plano, Texas-based Community Hospital Corp., which took over management of the hospital in October 2014, Holland already has made significant progress toward stabilizing its finances," Harris Meyer reports.

"Holland faced a challenge that is all too familiar to rural hospital leaders around the country: declining patient volumes; a preponderance of low-paying Medicare, Medicaid and uninsured patients; public and private rate squeezes; high incidence of chronic disease and drug abuse; difficulty in recruiting physicians; and a shortage of funds to invest in new equipment and services. . . .  To save the hospital, whose previous CEO served nearly 40 years, Holland, Chief Nursing Officer Dinah Jarvis, and CHC knew they had to take tough steps that would unsettle physicians, staffers and local residents accustomed to the old comfortable ways."

The new ways included a partnership with the Baptist Health hospital in Corbin to help PCH compete with the Appalachian Regional Hospital in nearby Middlesboro, partly with a 12-bed geriatric psychiatry unit; a federal rural health facility license that significantly boosted Medicare and Medicaid payments," and "clinical protocols to improve quality of care and reduce readmissions," which were so frequent in 2013 and 2014 that they drew Medicare's maximum penalty, Meyer reports. But the new protocols, such as "pre-discharge education of congestive-heart-failure patients about medication use and weight monitoring," riled some physicians.

Dr. Steven Morgan told Meyer, �They want to pound square pegs into round holes.� Dr. Shawn Fugate said he had to fight with CHC for "what he thought were adequate nurse staffing levels, and that CHC is making too many important decisions from afar," Meyer reports. As an employee of CHC rather than the hospital, Holland can "speak frankly," Meyer writes. "He recently told an older surgeon who serves on the board that it was time for him to retire."

Pineville is on the old Wilderness Road (in red) and US 25-E.

Pineville Mayor Scott Madon told Meyer, �Stace has an unbelievable task in what he's dealing with. He's trying to reinvent the rural hospital. He has to change the whole thinking, and people don't like it.� But longtime hospital board member David Gambrell, a real-estate agent whose son will start as a family physician there soon, said Holland's approach has been �refreshing. . . . We need that kind of honesty. It's taken Stace coming here to see we needed a new vision.�

Meyer reports, "Local leaders see the Pineville hospital's survival as pivotal to the future of the town and Bell County, which has no other hospital and has lost many coal-mining jobs. They say the hospital, the city's largest employer, is key to their economic redevelopment efforts. . . . The Pineville hospital has strong customer loyalty. Its staff�most of whom are local residents who have worked there for many years�have deep ties to the patient population." Wilma Sizemore, a 70-year-old disabled woman who was admitted in mid-February for bronchitis and dizziness, told him, �I wouldn't doctor nowhere else but this hospital. They treat me like family here.�

Princess Health and Bevin gets bill to create third-party appeals process for denied Medicaid claims, which sponsor says are all too common. Princessiccia

Princess Health and Bevin gets bill to create third-party appeals process for denied Medicaid claims, which sponsor says are all too common. Princessiccia

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Gusty 16:05 Add Comment

By Melissa Patrick
Kentucky Health News

A bill to create an independent process for Kentucky health-care providers to appeal claims denied by Medicaid managed-care organizations is on its way to the governor's desk for his signature.

Sen. Ralph Alvarado

The only appeals process for providers now is through the MCOs themselves, and the only recourse for denied claims is through the courts.

"We are looking at almost 20 percent of the claims that are out there through Medicaid being denied to providers," the bill's sponsor, Republican Sen. Ralph Alvarado of Winchester, told Kentucky Health News. "So with that there are millions of dollars that all of those providers are losing out on. This finally gives them an opportunity to keep the MCOs accountable."

WellCare of Kentucky, one of the MCOs Alvarado targeted last year while trying to get a similar bill passed, denied that it has so many disputed claims, but says it will work with the Cabinet for Health and Family Services if Senate Bill 20 is enacted.

"WellCare of Kentucky rarely disputes claims for medical necessity, with only 1 percent of claims being denied for this reason," spokesperson Charles Talbert said in an e-mail. "We are supportive of initiatives that help to ensure our members get the right care, at the right time, in the right setting."

Another MCO that Alvarado targeted last year as having a high rate of denied claims, Aetna Better Health of Kentucky, formerly CoventryCares, said in an e-mail, "We work tirelessly, along with our network of providers to improve access to and quality of care for our Medicaid members and we are committed to continuing these valuable collaborations."

CareSource, another MCO, declined to comment.

Kentucky implemented managed care in 2011 mainly as a way to save money. In managed care, an MCO gets a lump sum per patient, a system that encourages them to limit payments to providers. Providers have complained about denied claims and slow payments, causing some to suggest that managed care creates an incentive to deny care.

"Kentucky Medicaid MCOs have a denial rate that is four times the national average," Alvarado said in an e-mail. "These MCOs, in general, are garnering massive profits on the backs of our providers by simply not paying for services; and then claiming that they are 'managing care'."

MCOs serve about 1.1 million Kentuckians and account for about 69 percent of the state's Medicaid budget, according to a state news release.

Last year the state renegotiated all MCO contracts in hopes of decreasing the number of disputes over rejected claims, but health-care providers told the Senate Health and Welfare Committee Jan. 13 that this is still an ongoing problem, especially with behavioral health.

Nina Eisner, CEO of The Ridge Behavioral Health Systems, told the committee that there are examples all over the state of patients with homicidal thoughts unable to get their care paid for by MCOs.

Senate Bill 20 says that after providers exhaust an MCO's internal appeals process for denied claims and a final decision has been made, the provider can then seek a third-party review from an administrative hearing tribunal in the cabinet. The appeals process would apply to all contracts or master agreements entered into or renewed on or after July 1, 2016.

Alvarado said the proposed appeals structure is very similar to the one for commercial insurance appeals at the Department of Insurance. He noted that Kentucky's commercial denial rates are around 6 percent, which are close to the national average, and said he hopes this independent appeals process will bring the MCO denial rates more in line with this.

"If we go from 20 percent to 6 percent, I think most providers will accept that," he said. "This is fair. It is fundamentally American to have an appeals process and it is needed."

Alvarado sponsored a similar bill last year, but it died in the House. A similar bill passed both chambers in 2013, but then-Gov. Steve Beshear vetoed it. Alvarado said he is confident Gov. Matt Bevin will sign this year's version.

Alvarado said that once this "fractured relationship between providers and Medicaid" has been mended "it might actually open up the door for more providers to participate with Medicaid."

Sheila Schuster, a Louisville mental-health advocate, agreed, and said that while Medicaid reimbursement rates are "not great," not being paid at all for services rendered is not acceptable and has been a deterrent for providers to participate.

She said the Kentucky Mental Health Coalition and the National Alliance on Mental Illness support SB 20 because "they want providers to be fairly treated and to be able to provide the services that they need."

Princess Health and Judge denies Bevin's bid to close Lexington abortion provider, citing difficulty that would create for Eastern Ky. women. Princessiccia

Princess Health and Judge denies Bevin's bid to close Lexington abortion provider, citing difficulty that would create for Eastern Ky. women. Princessiccia

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Gusty 09:58 Add Comment

UPDATE, June 15: A three-judge panel of the state Court of Appeals reversed the ruling.

A Lexington judge has rejected Gov. Matt Bevin's request to close the city's only abortion facility, saying that it is operating legally and that closing it would restrict access to abortions by residents of Eastern Kentucky.

Circuit Judge Ernesto Scorsone said Friday that he wouldn't issue an injunction to close EMW Women�s Clinic on Burt Road because the state failed to show that it is likely to win its lawsuit or that allowing it to stay open in the meantime would cause any irreparable injury.

�In addition to the evidence indicating that EMW is operating legally and in conformity with the most important regulations of a licensed abortion facility, closing the clinic is against the public interest,� Scorsone wrote. �EMW is the only physician�s office that routinely provides abortion services in the Eastern half of the state, and both parties agree that a right to an abortion during the first trimester of pregnancy is constitutionally protected. Closing EMW would have a severe, adverse impact on the women in the eastern part of the state.�

The clinic's attorney, Scott White, said it only performs first-trimester abortions and would reopen next week. It had closed in response to the lawsuit because of potential fines. Bevin spokeswoman Jessica Ditto said the administration would take the case to the state Court of Appeals.

The state claims the clinic needs to be licensed as an abortion clinic because that is all it does.

At a hearing Wednesday, "Clinic owner Ernest Marshall said the clinic used to do more regular gynecological health care, and is open to doing more, but he said that since his partner died a few years ago, the clinic�s primary work is abortions," Linda Blackford reports for the Lexington Herald-Leader. "On Feb. 17, state inspectors with the Cabinet for Health and Family Services visited the clinic, where they reported that employees told them the clinic only performs abortions. Inspectors also found dirty conditions and expired medicine."

Scorsone wrote that he was sure the clinic would address those issues, which typically do not lead to efforts to shut down medical facilities. He wrote, �The uncontroverted testimony presented at the hearing is that it is within the standard of care to perform first trimester abortions in a doctor�s office and that these procedures are less dangerous than others routinely performed in an office setting. The procedures used do not require sedation or the services of an anesthesiologist, factors that indicate EMW is a private physician�s office exempt from the licensing requirements for ambulatory surgical centers.�

"Scorsone said that the facility is already in compliance with the two most important requirements of an abortion clinic � that it has in place a transfer agreement with a hospital and a transportation agreement with an ambulance service in case there are complications with a procedure," Joseph Gerth reports for The Courier-Journal.

The clinic performed 411 of the 3,187 abortions reported to state officials last year. Most (2,773) were done by the EMW Women's Surgical Center in Louisville, which Marshall owns.

"The Bevin administration has targeted abortion clinics for regulatory action in the first months of his term," Gerth notes. "In February, he sought to block Planned Parenthood from offering abortions at a new clinic it opened in Louisville." That clinic has suspended abortions while the suit proceeds.

Princess Health and Bill for review of medical lawsuits dies from special elections. Princessiccia

Princess Health and Bill for review of medical lawsuits dies from special elections. Princessiccia

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Gusty 09:35 Add Comment

A bill that would create panels of experts to review lawsuits against health-care providers is going nowhere, again.

State Senate President Robert Stivers said Friday that he and other leaders of the Senate's Republican majority sent Senate Bill 6 back to committee because last week's special elections continued Democratic control of the House. They did likewise with a bill for a "right to work" law that would ban union membership or fees as a condition of employment.

�The reality is the House does not see as the majority party in this Senate does, that right-to-work would even be another tool that could increase and expand on job recruitment and retention,� Stivers said. �The other thing is we�ve had Senate Bill 6 sitting on the board for quite some time. But, because of the elections two weeks ago, the consequences are, they would pass this chamber but die in the House.�

Princess Health and Kentucky is cracking down on Suboxone, a heroin substitute that has become a big part of the illegal trade in painkillers.Princessiccia

Princess Health and Kentucky is cracking down on Suboxone, a heroin substitute that has become a big part of the illegal trade in painkillers.Princessiccia

doctor shopping doctors drug abuse drugs health insurance health reform insurance coverage narcotics obamacare pain clinics physicians pill mills state government

Gusty 09:40 Add Comment

A drug that was supposed to help people get off heroin has "created a new cash-for-pills market and a street trade" that state officials are trying to stop, Mary Meehan reports for the Lexington Herald-Leader.

The drug is buprenorphine, the active ingredient in the brand-name drugs Suboxone and Subutex, which became more popular in 2012, when the state cracked down on "pill mills" that were freely handing out prescriptions for painkillers. "A lot of the pill mills morphed into facilities that dispense these prescriptions," Dr. John Langefeld, medical director for the state's Medicaid program, told Meehan.

Also, Meehan writes, the Patient Protection and Affordable Care Act required insurance plans to cover treatment for substance abuse, and "as more Medicaid patients and others got health-insurance coverage, more people obtained prescriptions for buprenorphine, Langefeld said. . . . According to a state report, one user obtained prescriptions from nine doctors."

Read more here: http://www.kentucky.com/2015/06/20/3910362_the-drug-that-was-supposed-to.html?rh=1#storylink=cpy

Read more here: http://www.kentucky.com/2015/06/20/3910362_the-drug-that-was-supposed-to.html?rh=1#storylink=cpy

Lexington Herald-Leader chart by Chris Ware from state data

Use of the drug in Kentucky "has increased 241 percent since 2012," Meehan reports. "And 80 percent of the prescriptions for it were being written by 20 percent of the state's 470 certified prescribers, said Dr. Allen Brenzel, medical director of the state's Department of Behavioral Health. . . . Since 2011, 10 doctors have been sanctioned by the Kentucky Board of Medical Licensure because of problems prescribing Suboxone."

Suboxone is supposed to be taken in conjunction with therapy and drug testing. "a patient receives a controlled dose of a legal drug as the dose is tapered by a physician for a safe and effective withdrawal," Meehan notes. However, "doctors started to see Suboxone patients on a cash basis, asking for as much as $300 for an office visit that included a prescription for the maximum allowable amount of Suboxone. Patients often received no therapy or drug testing. Some patients were on the maximum dose indefinitely, Brenzel said." Some doctors prescribed the drug with other painkillers, creating an illegal market.

To prevent such abuse by unscrupulous doctors, the medical-licensure board has issued regulations that require "more physician education and the requirement that the drug be prescribed only for medically supervised withdrawal and not be given to pregnant women," Meehan writes. "Patients should also be closely monitored and drug tested. If those rules are not followed, a doctor can face sanctions or restrictions to his medical license."

Suboxone was in the national news recently because the accused killer in the Charleston, S.C., shootings was arrested for illegal possession of it four months ago at a South Carolina shopping mall, the Herald-Leader notes.

Read more here: http://www.kentucky.com/2015/06/20/3910362_the-drug-that-was-supposed-to.html?rh=1#storylink=cpy

Read more here: http://www.kentucky.com/2015/06/20/3910362_the-drug-that-was-supposed-to.html?rh=1#storylink=cpy

Princess Health and Three doctors, nine others in western half of Kentucky are indicted in the largest-ever federal 'takedown' of Medicaid fraud.Princessiccia

Princess Health and Three doctors, nine others in western half of Kentucky are indicted in the largest-ever federal 'takedown' of Medicaid fraud.Princessiccia

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Gusty 06:07 Add Comment

Former Dr. Fred Gott of Bowling Green was arrested.
(Photo: Miranda Pederson, Bowling Green Daily News)

Twelve people in the western half of Kentucky, including three doctors, have been charged with Medicaid fraud in what the federal government calls its biggest-ever "takedown" of the problem, Andrew Wolfson of The Courier-Journal reports.

The indictments allege "a half-dozen schemes involving nearly $8 million in alleged fraudulent billings," Wolfson writes. "The offenses include $5 million in false billings for muscle-relaxant injections that were never delivered to patients, as well as a staged car wreck in which three people allegedly conspired to get controlled substances and fraudulent reimbursements."

In another case, Wolfson reports, "a medical practice that treated car wreck patients is accused of using the DEA numbers of nurse practitioners to order hydrocodone for herself and falsely billing it to an insurance company. Nationally, the sweep resulted in charges against 243 people, including 46 doctors, nurses and other licensed medical professionals."

John Kuhn, acting U.S. attorney for the Western District of Kentucky, told Wolfson that about $1 billion of annual Medicare and Medicaid expenses are fraudulent. Medicare is the federal health-insurance program for people over 65; Medicaid is the federal-state program for the poor and disabled.

Former Dr. Fred Gott of Bowling Green, a 63-year-old cardiologist, was charged with "conspiracy to dispense controlled substances, health care fraud and money laundering," Deborah Highland reports for the Bowling Green Daily News. "The Bowling Green-Warren County Drug Task Force opened an investigation into Gott�s practices after Warren County Coroner Kevin Kirby alerted the task force about drug overdose deaths involving Gott�s patients, task force director Tommy Loving said."

Princess Health and Seniors get a lot of anti-anxiety drugs, sometimes in dangerous combination with narcotics; Ky. ranks third in the nation in that.Princessiccia

Princess Health and Seniors get a lot of anti-anxiety drugs, sometimes in dangerous combination with narcotics; Ky. ranks third in the nation in that.Princessiccia

anxiety doctors drug abuse elderly health journalism Medicare mental health narcotics physicians prescription drugs

Gusty 04:12 Add Comment

When Medicare's drug program, called Part D, was put into place more than a decade ago, Congress decided to not pay for anti-anxiety medications. In 2013, when Medicare started paying for them, the program went from spending nothing for these medications to paying more than $377 million, Charles Ornstein and Ryann Grochowski Jones report for ProPublica, a nonprofit, investigative news organization.

Using anti-anxiety drugs in combination with narcotics increases the risk of overdoses, but Kentucky has many doctors who prescribe a lot of both. More than 100 Kentucky doctors each wrote at least 1,000 prescriptions for both types of drugs in 2013, according to data compiled by ProPublica.

That ranked Kentucky third in the nation, trailing only Florida and Alabama. Other southeastern states dominated the top 10. California, the nation's most populous state, ranked eighth; Tennessee was fourth and Ohio was ninth.

ProPublica has an application that lets you look up, by doctors' names, cities or ZIP codes, the number of Medicare claims they filed in 2013, the amount of money, the number of patients and the number of prescriptions for brand-name drugs.

The anti-anxiety drugs, some known as benzodiazepines, include popular tranquilizers such as Valium, Xanax and Ativan. 

Lawmakers initially chose to keep them out of Medicare Part D because they had been linked to abuse and an increased risk of falls among the elderly. Doctors kept prescribing them to Medicare enrollees, who found other ways to pay for them.

In 2013, the year Medicare started covering benzodiazepines, it paid for nearly 40 million prescriptions, ProPublica found. Generic versions of Xanax (alprazolam), Ativan (lorazepam) and Klonopin (clonazepam) were among the top 32 most-prescribed medications in Medicare Part D that year.

The American Geriatrics Society "discourages the use of benzodiazepines in seniors for agitation, insomnia or delirium because they can be habit-forming and disorienting and their effects last longer in older patients." The society does say the drugs "are appropriate to treat seizure disorders, severe anxiety, withdrawal and in end-of-life care," ProPublica notes.

One geriatric psychiatrist told ProPublica that the drugs are a "very real safety concern" for the elderly, and that he and others in his field don't use them as a "first-, second-, or third- line of treatment." Some geriatric psychiatrists have voiced concerns that these drugs are now being used instead of antipsychotics, since Medicare has pushed to reduce the use of antipsychotics, particularly in nursing homes, because of their risks.

Several doctors who rank among Medicare's top prescribers of the drugs told ProPublica that any risks of anti-anxiety drugs are outweighed by their benefits. One said that the drugs worked well for his patients, many of whom were trying to kick addictions to narcotics, but struggled with anxiety and depression.

However, ProPublica also found that some doctors appear to be prescribing benzodiazepines and narcotic painkillers to the same patients, which increased the risk of misuse and overdose. That's where Kentucky ranked third.

Dr. Leonard J. Paulozzi, a medical epidemiologist at the federal Centers for Disease Control and Prevention, co-authored an analysis showing that benzodiazepines were involved in about 30 percent of the fatal narcotic overdoses that occurred nationwide in 2010, ProPublica reports.

Princess Health and Paducah Sun looks at two local doctors who write many prescriptions for painkillers; such local data are easily available.Princessiccia

Princess Health and Paducah Sun looks at two local doctors who write many prescriptions for painkillers; such local data are easily available.Princessiccia

doctors drug abuse narcotics pain pain clinics pain management physicians pill mills prescription drug abuse

Gusty 11:52 Add Comment

The Paducah Sun has used some easily available information about two local doctors to shine a local light on their heavy prescribing of opioids.

The story by Laurel Black begins, "As narcotic painkiller abuse has drawn more public attention, two Paducah physicians � who have been ranked high among prescribers of such drugs � have found themselves defending their practices."

The story cites The Courier-Journal's analysis of 2012 Medicare data that showed Dr. Yogesh Malla of Paducah was "the No. 3 prescriber of narcotic painkillers in the commonwealth. A USA Today article listed Dr. Riley Love, also of Paducah, as 20th in the nation. Both reports used information the news organization ProPublica obtained under the Freedom of Information Act."

The Sun offers a quick retort from the medical director of the pain-management center where Malla practices, paraphrasung him as saying "the reports omit or minimize important factors, such as the specialty of the physicians and the morphine equivalence of the drugs they prescribe."

Dr. Laxmaiah Manchikanti also said in his written statement that his group emphasizes drugs with lower abuse potential and that more than 92 percent of patients at such centers "are already on long-term opioids; consequently, the best we can do (at these centers) is reduce the dosage."

Manchikani is CEO of the American Society of Interventional Pain Physicians, a lobbying group that advocates monitoring of painlkiller prescriptions, and a leading contributor to a wde range of political causes. The Sun doesn't note the latter point, but focuses on the issues of painkiller abuse, a major problem in Kentucky.

"With more than 1,000 deaths per year, Kentucky in 2013 had the third-highest drug overdose mortality rate in the United States, according to the Trust for America's Health," Black notes.

As for the other doctor, the Sun reports, "ProPublica's data on Love, who practices at the Lourdes Pain Management Center, reports that 59 percent of his 1,141 patients filled one or more prescriptions for a Schedule 2 drug and 51 percent filled for a Schedule 3 drug. Both figures are above the average of 45 percent and 41 percent, respectively, for his specialty in Kentucky.

"A spokeswoman for Love said Lourdes center represents the only location in the region where Medicaid patients receive inpatient pain consultations," the Sun reports, quoting her: "The patients we see are often very sick, and the treatments and medications we provide are the last resort comfort measures so the patients can spend quality time with family" as they near death.

The story is behind the Sun's paywall.

Princess Health and Video streaming for consultation with doctors expands and becomes more popular; 2 Ky. insurers use it and another plans to.Princessiccia

Princess Health and Video streaming for consultation with doctors expands and becomes more popular; 2 Ky. insurers use it and another plans to.Princessiccia

doctor shortages doctors emergency rooms primary care telemedicine

Gusty 16:16 Add Comment

In the past, people had to go to the emergency room to receive medical attention if they required it outside the usual hours for doctors. Now telemedicine programs such as KentuckyOne Health's "Anywhere Care" and Anthem BlueCross BlueShield's "LiveHealth Online," Kentuckians can access a doctor 24/7 through a computer or mobile device.

Photo from The Lane Report

"Patients like telemedicine because it's fast and easy to use and cheaper because it's a low-overhead service," Esther Zunker writes for The Lane Report, a Lexington-based business magazine.

UnitedHealthCare, a Minnesota-based health benefits provider for many people in Kentucky, plans to cover Skype-based doctor visits through "NowClinic," "Doctor on Demand" and "American Well." Anywhere Care and Live Health Online give clients a list of certified doctors they can chat with through video on a computer or a mobile device. The doctors can provide diagnosis and treatment and even write a prescription. They can direct patients to an emergency department if necessary.

It's affordable, too. A LiveHealth Online appointment costs the same as an office visit for eligible members. LiveHealth doctors usually charge $49 per online "visit." Anywhere Care costs $35 per visit, even if patients don't have insurance.

"As we know, care can be limited and is based on being able to get someplace when [a doctor] has an opening," said John Jesser, Anthem's vice president of provider engagement strategy. "They only have certain hours, and that doesn't always work for when people don't feel well. [Telemedicine] expands access to care for the consumers, making it much more friendly to their schedule and lifestyles."

Telemedicine is also convenient for doctors. It saves money for hospitals and allows one doctor in one location to help patients in a variety of locations. Patients can receive help with chronic conditions over periods of time without having to travel to the doctor's office.

"We've had amazingly positive feedback from patients who have tried this service," said Kathy Love, director of strategy and business development for KentuckyOne Health's Central East Kentucky Market. "People have told me they've used it multiple times when they've needed it . . . either late at night or over the weekend."

She also said people who use telemedicine still need a primary-care physician: "It's something you can access 24 hours a day with a very minimal wait and very professional providers, but it shouldn't replace your very important relationship with your primary-care doctor." (Read more)

Princess Health andUK HealthCare offers help to primary-care clinics; university's top health official calls it 'a game changer' for rural health providers.Princessiccia

Princess Health andUK HealthCare offers help to primary-care clinics; university's top health official calls it 'a game changer' for rural health providers.Princessiccia

doctors physicians primary care rural health

Gusty 20:01 Add Comment

The Kentucky Primary Care Association and the University of Kentucky have announced a new partnership to provide support services to primary care providers throughout Kentucky.

This "groundbreaking partnership" will provide KPCA, which includes more than 800 patient care providers, access to UK HealthCare's support services, such as supply chain contracts, medical professional placement services, practice transformation support and training, and an after-hours pediatric call triage center, according to press release.

The most notable feature of the partnership is that KPCA members will have access to UK's group purchasing contracts, giving them access to services at heavily discounted rates at no charge to the facilities. This is expected to create "significant" savings for more than 250 clinics throughout the state. UK's top health official called it "a game changer."

�Primary care physicians, especially those in rural areas, have the extra burden of high patient volume, limited staff, and stretched resources,� Dr. Michael Karpf, UK's executive vice president for health, said in the release. �By partnering, UK HealthCare and KPCA members can grow important programs and services for their patients while also controlling and reducing operating costs.�

KPCA Executive Director Joe Smith said, "By addressing some of these issues related to costs, clinics with already scarce resources can instead focus on improving the quality of care.We�ve had a longstanding association with the university and UK HealthCare, and this partnership elevates that relationship by adding a strong commitment to assisting rural doctors, nurses and practice managers, who face some of the toughest transitions taking place in medicine today.�

The partnership will also allow KPCA members access to staffing services that link candidates to vacancies across the state; to Patient Centered Medical Home consultants, who help practices transition to quality and value-based models of care; and to UK HealthCare's after-hours pediatric call triage service.

Princess Health andHow has the federal health-reform law changed your care?.Princessiccia

Princess Health andHow has the federal health-reform law changed your care?.Princessiccia

cancer screening doctors electronic health records immunizations obamacare physicians prevention vaccinations women's health

Gusty 15:04 Add Comment

Despite the controversy that continues to surround the Patient Protection and Affordable Act five years after its passage, it has probably changed the way your health care is delivered as it drives new models of payment, forces providers to approach care differently, and changes how health care is evaluated, Kavita Patel and Domitilla Masi report for the Brookings Institution.

Here are five ways the authors say that your health care might be different than it was five years ago because of the reform law:

Your physician might be part of a patient care team. New payment models in the ACA encourage an interdisciplinary team-based approach, which evidence shows "can lead to higher quality care and better health outcomes for patient." This approach allows the physician to spend more time diagnosing and devising a treatment plan, while the patient may spend more time interacting with non-physician staff for support care.

Prevention and wellness are more important than ever. The ACA requires health plans to cover all preventive screenings, immunizations and well visits for women at no cost, as part of the minimum benefits required in order for health-insurance plans to participate in exchanges like Kynect. The new payment models also pay physicians who work toward keeping their patients healthy, instead of just treating them when they are sick. " Since the policy took effect in September 2010 it is estimated that an additional 76 million people now receive preventive care," the authors write.

You may have better access to care on evenings and weekends. New payment models are driving this change as practices are often required to offer extended hours to decrease the overuse of emergency departments. Many offices now offer clinical advice around the clock with a clinician who has immediate access to their medical records.

Chances are your health information is being stored in an electronic health record, not a paper file. A separate law encouraged the use of EHRs, but "participation in the new ACA-promoted delivery models is practically impossible" without them. And while EHRs can be used to greatly improve patient care, not all EHRs are created equal and it will take time before patients see seamless integration and exchange between different doctors and settings in "real-time".

You can access care remotely, wherever you are. Doctors are using mobile technology and tele-health in rural and remote areas to provide more efficient care to patients. Insurance companies and employers are beginning to recognize this mode of treatment not only as a way to save money, but to also provide timely access to care, that does not involve the emergency room.

Princess Health and Princess Health andNew rule allows Medicare to drop doctors for irresponsible prescribing.Princessiccia

Princess Health and Princess Health andNew rule allows Medicare to drop doctors for irresponsible prescribing.Princessiccia

doctor shopping doctors Medicare physicians pill mills prescription drug abuse prescription drugs

Gusty 17:28 Add Comment

Medicare physicians who prescribe drugs in abusive ways can now be expelled by the federal government, Charles Ornstein reports for ProPublica.

This increased oversight of Medicare Part D prescribers could help decrease the availability of prescription drugs to abusers in Kentucky. More than 1,000 Kentuckians die each year from prescription drug overdoses, and the state has the third-highest overdose death rate in the nation.

Opoids, which are often found in pain medicine, are the most commonly abused prescription drugs, according to the National Institute on Drug Abuse. Hydrocodone, an opoid, is the most commonly prescribed controlled substance in Kentucky, according to the Kentucky All Schedule Prescription Electronic Reporting (KASPER) system, and is also the most prescribed drug in Part D program, according to ProPublica's Prescriber Checkup, a tool that compares physicians' prescribing patterns among specialties and states.

The Centers for Medicare and Medicaid Services proposed the new rule after ProPublica documented "how Medicare's failure to oversee Part D effectively had enabled doctors to prescribe inappropriate or risky medications, had led to the waste of billions of dollars on needlessly expensive drugs and had exposed the program to rampant fraud," Ornstein writes.

Part D covers 37.5 million seniors and disabled patients, and one in every four prescriptions in the U.S. is paid for by Medicare, costing taxpayers $62 billion in 2012, and experts have complained that Medicare is more interested in providing drugs to patients than in targeting problem prescribers, Ornstein notes. The U.S. Department of Health and Human Services' inspector general has called for tighter controls.

The new rule allows Medicare to drop doctors "if it finds their prescribing abusive, a threat to public safety or in violation of Medicare rules," or if their Drug Enforcement Administration registration certificates are suspended or revoked, Ornstein writes. Problem providers will be identified by prescribing data, disciplinary actions, malpractice lawsuits and other information.

Opponents of the rule have called its definition of "abusive" prescribing too vague. Some worry that patients will lose access to necessary medication if their doctor is removed from the program, Ornstein writes. Medicare officials said they intend to expel providers only in "very limited and exceptional circumstances," saying "It will become clear to honest and legitimate prescribers . . . that our focus is restricted to cases of improper prescribing that are so egregious that the physician or practitioner's removal from the Medicare program is needed to protect Medicare beneficiaries."

The new rule also allows the Medicare center to "compel health care providers to enroll in Medicare to order medications for patients covered by its drug program, known as Part D," Ornstein writes. Now, doctors not enrolled in Medicare can prescribe for Part D patients; they will have to enroll or opt out of the program by June 1, 2015.

The doctors most affected by this will be dentists and Department of Veterans Affairs physicians who provide services not covered by Medicare but have patients who fill prescriptions covered by the program, Ornstein notes. Most health providers are already enrolled. (Read more)

Princess Health and Princess Health andCenters for Disease Control honors Lexington physician for her work in promoting immunizations in Kentucky.Princessiccia

Princess Health and Princess Health andCenters for Disease Control honors Lexington physician for her work in promoting immunizations in Kentucky.Princessiccia

awards doctors immunizations physicians public health

Gusty 08:21 Add Comment

Grace F. Maguire

Grace F. Maguire, medical director of the Thomas H. Pinkstaff Medical Home Clinic in Lexington, has been named 2014 Childhood Immunization Champion in Kentucky by the federal Centers for Disease Control and Prevention for her efforts to promote childhood immunization in central Kentucky.

As a pediatrician, Maguire has seen patients with almost every vaccine-preventable disease and has long been a vaccine information resource for her medical colleagues.

For many years, she was the primary immunization educator for trainees at the University of Kentucky in the Department of Pediatrics. She led the immunization programs for the university's outpatient clinics and helped develop the state's immunization registry.

Now she is medical director of a clinic that serves a unique population of children � those in foster care and those with birth defects, brain injury, cerebral palsy, and other special health care needs. The clinic, under her direction, assures these children receive all appropriate vaccines, including those indicated for high-risk populations.

�Dr. Maguire's leadership and dedication to protecting vulnerable children against disease is not only admirable, but vital to public health�s work in preventing the spread of communicable disease,� Stephanie Mayfield, commissioner of the Kentucky Department for Public Health, said in a news release.

Each year, the CDC and its foundation honor health professionals and community leaders around the country with immunization-champion awards to acknowledge exemplary individuals who go above and beyond to promote immunization among children in their communities.

Princess Health and Princess Health andHouse passes bill creating new type of order for end-of-life care, to be signed by patient and physician.Princessiccia

Princess Health and Princess Health andHouse passes bill creating new type of order for end-of-life care, to be signed by patient and physician.Princessiccia

doctors end-of-life care General Assembly legislature physicians

Gusty 14:02 Add Comment

An end-of-life order known as �medical order for scope of treatment� would be allowed in Kentucky under a bill that passed the Kentucky House on an 86-7 vote Thursday, March 6.

Unlike advance directives, such orders spell out a patient�s wishes for end-of-life care are also signed by the patient�s physician. A standard form for the orders would be developed by the Kentucky Board of Medical Licensure for use statewide.

�As a physician, I want to help people live and have a quality of life as long as they can,� said Rep. David Watkins, D-Henderson, the sponsor of House Bill 145. �But I sure don�t want to prolong suffering and agony � It�s our duty to make sure we keep our people in the final hours and final days of their life as comfortable as possible, and also to follow their wishes as close to the letter of the law as we can.�

The House defeated, 18-69, an amendment by Rep. Joe Fischer, R-Fort Thomas, that would have prohibited such orders from allowing food and water to be withheld from a patient unless death was �inevitable and imminent.� The bill now goes to the Senate.

Princess Health and Princess Health andPrimary care, a big focus of health reform, faces challenges as Kentucky doctors deal with change.Princessiccia

Princess Health and Princess Health andPrimary care, a big focus of health reform, faces challenges as Kentucky doctors deal with change.Princessiccia

doctors health insurance health journalism health reform hospitals insurance exchange Medicaid nurse practitioners obamacare physicians

Gusty 12:02 Add Comment

Craig Dooley, newly covered by Medicaid under health
reform, got an X-ray in Dr. Sven Jonsson's Baptist Health
office. (Photo by Luke Sharrett for The New York Times)

Primary-care doctors are key to the nation's health by providing preventive care to people who haven't been getting it but are now under federal health reform. However, some independent physicians in Kentucky and other states are struggling to run their businesses due to "flat or dropping reimbursement rates and new federal rules," many related to reform, Abby Goodnough writes for The New York Times. Goodnough's story is the latest in a series lookine at health reform through Kentucky examples.

Dr. Sven Jonsson joined Kentucky's Baptist Health System two years ago after leaving private practice in Louisville, fearing the law's often-expensive requirements. Now he is treating more patients, in the rural exurb of Taylorsville, and Baptist is handling all the details of the transition into the new health-care system.  "This is just a much saner place for me right now," he said. Primary care is more in demand because many states used it to expand Medicaid to people earning up to 138 percent of the poverty line.

Conversely, Dr. Tracy Ragland owns a small private practice in the wealthy suburb of Crestwood, and is concerned about the rules and payments associated with the new system. "The possibility of not being able to survive in a private practice, especially primary care, is very real," she said.

According to the American Medical Association, 40 percent of family doctors and pediatricians are independent. Ragland supports the idea of providing health coverage to more Americans, but says Medicaid and some private plans offered through Kentucky's health-insurance exchange don't pay enough, so she does not treat those patients. She says she values the flexibility of her private practice and the ability to spend as much time with patients as they need.

However, Ragland did join an "accountable care organization," a group of independent physicians who arrange care for a number of patients. "These networks, encouraged by the new law, reap financial rewards if they improve patients' health and spend less doing it," Goodnough notes. Ragland and her associates know that primary-care doctors can receive higher, Medicare-level reimbursements for seeing Medicaid patients, but this only lasts through 2014 and they didn't take the bait.

Doctors who have joined hospitals, like Jonsson, receive a baseline salary with bonuses for extra productivity, but that will probably change because the reform law will base payments on results. When Jonsson owned his own practice, he didn't accept Medicaid. At his new workplace at Baptist Medical Associates, he can treat Medicaid patients because the practice has space to grow, said Donna Ghobadi, an assistant vice president at the hospital.

Recently Kentucky passed a bill that will "give experienced nurse practitioners more leeway to practice independently," Goodnough reports. Ragland went to the state Capitol to ask legislators to give scholarships to medical and nursing students who will practice in under-served areas. "I don't get the emphasis on primary care is so important, but primary care physicians aren't," she said. Lawmakers said they will consider her ideas next year. (Read more)

Here's a video version of Goodnough's story:

Princess Health and Legislature eases physician assistant rules; nurse practitioners' prescription power, Medicaid prompt-payment bills, others linger.Princessiccia

Princess Health and Legislature eases physician assistant rules; nurse practitioners' prescription power, Medicaid prompt-payment bills, others linger.Princessiccia

children's health doctor shortages doctors General Assembly health care access insurance legislation managed care Medicaid nurse practitioners physician assistants prescription drugs state government

Gusty 05:38 Add Comment

By Molly Burchett and Al Cross
Kentucky Health News

The Kentucky General Assembly has joined other states in easing the restrictions on physician assistants� medical practice, but has held up a similar move for advanced registered nurse practitioners. Both issues relate to the shortage of medical practitioners in many Kentucky counties, and the quality of medical care.

The Senate added the physician assistant language of Senate Bill 43 to House Bill 104, an art-therapy bill, in order to preserve an agreement between the Kentucky Medical Association and the Kentucky Academy of Physician Assistants. It will repeal the law that bans PAs from practicing for their first 18 months unless a physician is on site; one will still have to be available by telephone. The amended bill has been sent to Gov. Steve Beshear for his signature or veto.

The amendment was used because the House had tacked onto SB 43 an amendment from advance practice registered nurses that would have repealed the need for them to have a collaborative agreement with a physicians to prescribe non-narcotic drugs. The KMA opposes that idea.

"It's looking like the doctors win," said Sen. Julie Denton, R-Louisville, who favors the repeal. "I'm not hopeful" it can pass, she said, but added that some physicians also favor it: "With Obamacare coming in, we're going to need all the front-line physicians we can get." Leading opponents of the measure, Republicans Katie Stine of Fort Thomas and Carroll Gibson of Leitchfield, didn't return a call seeking comment.

Nurse practitioners say that SB 43 is necessary to allow them to fill health-care gaps in rural Kentucky and address the state's shortage of primary-care providers. The Kentucky Coalition of Nurse Practitioners and Nurse Midwives says in an article prepared for Kentucky newspapers that NPs have never been required to practice under physician supervision and 17 states allow full prescribing authority for non-scheduled medications.

The Medicaid prompt-payment bill, HB 5, went to a conference committee after the House refused to go along with Senate changes, and may be considered when the legislature returns later this month, ostensibly to consider any bills Beshear vetoes. The bill would apply prompt-payment laws to managed-care organizations and would move Medicaid late-payment complaints to the insurance department; those are now handled by the Cabinet for Health and Family Services, which administers Medicaid.

In the final crunch to pass legislation before the veto recess, lawmakers attached seven health care-related bills to HB 366, which had focused on identifying congenital heart disease in newborns. It had 10 additional measures "hung on it like a Christmas tree before the free conference committee of House and Senate members," reports Ryan Alessi of cn|2's "Pure Politics."

The bills still hanging on the measure, dubbed the "healthy Christmas tree," are:

• HB 187, addressing a free prescription-drug program for under-insured Kentuckians.
• HB 79, which would exempt licensed health care providers from being disciplined for prescribing naloxone in the event of an overdose.
• HB 387, which aims to provide nutritional supplements for low-birth-weight newborns.
• SB 201, which addresses licensed diabetes educators.
• SB 38, to require Medicaid to accept provider credentialing by a Medicaid managed-care organization.
• SB 108, relating to managed-care contracts with the IMPACT Plus program, a behavioral health program for children.

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Princess Health and Poll shows Kentucky health-care providers often fail to discuss HIV testing with patients.Princessiccia

Princess Health and Poll shows Kentucky health-care providers often fail to discuss HIV testing with patients.Princessiccia

AIDS doctors Foundation for a Healthy Kentucky HIV medical education nurse practitioners physician assistants physicians poll

Gusty 14:51 Add Comment

A new poll suggests that most Kentucky health-care providers follow guidelines for discussing HIV screening with their patients, despite the the importance of early treatment to prevent its progression to AIDS.

Although the Centers for Disease Control and Prevention recommends routine HIV screenings for most patients, just 32 percent of Kentucky adults aged 18 to 64 report discussing HIV testing with their medical provider, according to the Kentucky Health Issues Poll.

About 40 percent of Kentucky adults reported they had never been tested for HIV. It�s estimated that 4,500 Kentuckians are living with HIV infection and it is estimated nationally that one in five people who have HIV do not know they do.

�It made headlines earlier this month when a little girl - the second person in history - was cured of HIV. As exciting as this development was, for most people, HIV remains a life-long condition that must be managed through medication to keep it from progressing to AIDS. The CDC�s recommendations are meant to improve the overall population health by detecting HIV so treatment can begin,� said Dr. Susan Zepeda, president and CEO of the Foundation for a Healthy Kentucky, which co-sponsored the poll.

�It appears that Kentucky providers are either not adhering to the routine screening recommendations or not communicating this message clearly to patients,� she said.

The poll, co-sponsored by the Health Foundation of Greater Cincinnati, was taken Sept. 20 through Oct. 14 by the Institute for Policy Research at the University of Cincinnati. A random sample of 1,680 adults throughout Kentucky was interviewed by landline and cell telephones. The poll's margin of error is plus or minus 2.5 percentage points