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 Ky. is already short of doctors, dentists; how will its health-care system handle expansion of Medicaid and private insurance?.Princessiccia

Princess Health and Ky. is already short of doctors, dentists; how will its health-care system handle expansion of Medicaid and private insurance?.Princessiccia

Affordable Care Act drugs General Assembly health reform Medicaid nurse practitioners Patient Protection and Affordable Care Act physician recruitment physicians

Gusty 05:26 Add Comment

By Molly Burchett and Al Cross
Kentucky Health News

In the wake of Gov. Steve Beshear�s recent decision to expand Medicaid under federal health reform, there is concern that Kentucky's health-care system will not be able to care for the newly insured.

Health reform means that an estimated 308,000 new Kentuckians will qualify for Medicaid, and 332,000 more will qualify for subsidies to buy private insurance through the state insurance exchange that will start taking enrollments Oct. 1.

But Kentucky already has a health care provider shortage, especially in rural areas. A study for the state estimates that it needs 3,790 more doctors just to meet current demand, to say nothing of what will be needed to care for those who haven't been a regular part of the health-care system, reports Laura Ungar of The Courier-Journal.

The report by Deloitte Consulting made 11 recommendations, including authority for nurse practitioners to prescribe less risky drugs without a written agreement with a doctor, and one that would be even more controversial, putting limits on medical malpractice awards, said Ungar.

The report also recommended expanding and increasing Medicaid reimbursements in rural areas, to encourage more physicians to take Medicaid patients.

It did not mention complaints by health-care  providers about getting paid by the managed-care Medicaid system that the state began in November 2011; Gov. Steve Beshear said when he announced Medicaid expansion that those problems are being worked out.

"Consultants said 61 percent of the 3,790 'full-time equivalent' physicians needed (which includes primary care doctors and specialists) were in rural counties," reports Ungar. Jonathan Felix of Deloitte said, �Primary care, dental care and behavioral health are all big needs in the state.�

The report said the state needed 183 more primary-care doctors, even before Medicaid expansion, but a 2012 Kentucky Physician Workforce Needs Assessment report by the University of Kentucky said the state needs 557 more primary-care physicians and 1,655 more total physicians to meet the national ratios for physicians to population.

The consultants said the state already needs 612 more dentists. It now has 1,711.

Complicated provider shortage problem, no easy answer

About 192 federally identified areas in Kentucky � including 47 counties � have shortages of health professionals, Ungar reports. Kentucky counties who will have the most non-elderly residents eligible for Medicaid often have fewer primary-care doctors per person, according to data analyzed by The Courier-Journal. Ungar notes that Casey County, for example, ranks in the bottom third for doctors per capita, but it has the highest portion of newly eligible residents at 13.5 percent.

�We can�t grow physicians fast enough to meet the need, in the rural areas especially,� Susan Zepeda, president and chief executive officer for the Foundation for a Healthy Kentucky, told Ungar.

Nationally, there is a primary-care shortage, partly because such doctors make less money than most, and low reimbursement rates exacerbate that. A 2012 study in the journal Health Affairs said 21 percent of office-based physicians in Kentucky did not accept new Medicaid patients in 2011, Ungar notes.

The health reform law will raise the Medicaid fees to match what Medicare pays primary-care doctors, but only for two years. Kentucky's Medicare rates are about 72 percent of the Medicare rates, compared to a national average of 59 percent, says an Urban Institute study. But the time limit leaves some practitioners wary.

�If I choose to increase the number of Medicaid patients, and two years down the road that payment drops back to two-thirds, all of a sudden I�m going to have an awful lot of trouble keeping my doors open,� Reid Blackwelder, a family practitioner and incoming president of the American Academy of Family Physicians, told Michael Ollove of Stateline. 

A report last year by the non-partisan Center for Studying Health System Change said the temporary nature of the pay raise could limit its effectiveness, particularly in Kentucky and other states that are expecting the largest percentage increases in Medicaid enrollees and that have low numbers of primary-care physicians.

�I�m not sure who�s going to pick up all those patients into their practices,� Julianne Ewen, a nurse practitioner in Lexington and president of the Kentucky Coalition of Nurse Practitioners and Nurse Midwives, told Ungar. Legislation to let nurse practitioners prescribe non-scheduled drugs without a doctor agreement failed in the state Senate this year.

While some policy analysts have touted nurse practitioners as a solution to the rural primary-care shortage because they often provide primary care in rural and isolated areas that do not have doctors nearby, they would not be covered by the two-year reimbursement increase. Ewen said the reimbursement is only $23 for a lower-level visit by an established patient.

A possible long-term solution includes greater reliance on community health centers, some say. And hospital officials said they plan to continue expanding primary care and employ telemedicine. Ruth Brinkley, president and chief executive officer of KentuckyOne Health, said her system is looking to open new primary care offices and hire more staff.

Dr. David Dunn, vice president for health affairs at the University of Louisville, said the university is increasing physician training in such areas as family medicine and geriatrics and using funds from its new partner, KentuckyOne, to expand the nursing work force with professionals, such as advanced nurse practitioners.

Health providers and advocates agree that getting more people insured should produce a healthier population in the end. But they said much remains unknown, including how many of those eligible for coverage under health reform will sign up for it. The state estimates that 188,000 of the 308,000 newly eligible will enroll, but some think that estimate is low.

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

Princess Health and Poll finds four out of five Kentuckians are comfortable seeing a nurse practitioner or physician assistant for routine care.Princessiccia

Princess Health and Poll finds four out of five Kentuckians are comfortable seeing a nurse practitioner or physician assistant for routine care.Princessiccia

dental care dental health Foundation for a Healthy Kentucky nurse practitioners physician assistants poll

Gusty 14:06 Add Comment

New poll figures indicate the majority of Kentuckians are comfortable seeing a nurse practitioner, physician assistant or mid-level clinician for their routine care, especially if they have been treated by such clinicians. The findings come as the General Assembly considers a bill that would allow physician assistants to practice more independently.

In the Kentucky Health Issues poll last fall, 79 percent of Kentucky adults said they would be comfortable seeing a nurse practitioner for routine health care, and half of those people said they would be very comfortable. Eighty-one percent said they would be comfortable seeing a physician assistant for routine health care, and 42 percent of those respondents said they would be very comfortable.

Reported comfort was higher among people who had received care from a nurse practitioner or physician assistant in the past year; 86 percent of those people said they would be comfortable seeing an NP again for routine care. Eighty-eight percent of those who had received care from a PA in the past year said they would be comfortable doing that again.

The poll also inquired about a proposed new �mid-level� profession: advanced dental hygiene practitioners. These practitioners would provide routine dental care, including diagnostic and preventive services such as filling cavities. Although advanced dental hygiene practitioners cannot currently be licensed to practice in Kentucky, polling data indicated 73 percent of Kentucky adults would be comfortable with such a practitioner providing routine dental care.

"As providers move to create a system of care that includes a range of skill sets and training in its care teams, new strategies emerge that hold promise to increase access to affordable care � not just in urban centers but also in rural and underserved communities,� said Dr. Susan Zepeda, president and CEO of the Foundation for a Healthy Kentucky, which sponsored the poll. �The data suggest that the public is very receptive to health care services from different types of clinicians.�

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. (Read more)

Princess Health and Frontier Nursing University in Hyden helps bring better family health care to rural America with distance learning.Princessiccia

Princess Health and Frontier Nursing University in Hyden helps bring better family health care to rural America with distance learning.Princessiccia

Affordable Care Act health care access health care law health reform medical education midwifery nurse practitioners nurses Patient Protection and Affordable Care Act rural health rural medicine

Gusty 06:20 Add Comment

Midwives and nurse practitioners who recently graduated from Frontier Nursing University in Hyden address the unique challenges of rural areas, including shortages of health care providers, by bringing local health care to rural communities across the country. FNU was featured in a recent report from the Robert Wood Johnson Foundation.

FNU, a graduate program that offers distance education to nurses with an interest in nurse-midwifery and family nurse practitioner and women�s health specialties, aims to build a pipeline of highly educated nurses serving in rural or underserved areas, reports RWJF, one of its funders.  Many scholars and grantees sponsored by RWJF go on to spearhead projects to improve access to high quality nursing care in remote areas, the foundation says.

�We�re trying to introduce primary care providers into rural areas in such a way that they can provide high quality care and preventive services too,� says Suzan Ulrich, associate dean of midwifery and women�s health at FNU and an RWJF executive nurse fellow.

Demand for health care is rising nationwide because of an aging population that is living longer, but sicker, with multiple chronic conditions. The need for health care providers will intensify next year, when millions of new patients will become eligible for health insurance under the health-reform law.

Rural parts of the country face unique challenges and shortages of health providers, including nurses, can be particularly acute in rural areas, said Alan Morgan, CEO of the National Rural Health Association. These nurses and other providers have less access to education programs, which tend to be located in more densely populated areas. Programs that offer advanced degrees, from the baccalaureate to the doctorate, can be especially difficult to access for students living in rural areas, according to RWJF.

Identifying and educating nurses from rural areas is a key goal of FNU, which offers distance education programs that enable students to remain in their home communities and a �bridge� program that allows nurses with associate�s degrees to move more easily into master�s and doctorate programs. �These students really love where they live,� Ulrich said. �If we can educate them to stay within their communities, then those communities are going to have a provider who�s going to be there a long time." (Read more)