The 2019 Kentucky General Assembly was an active session for legislation pertaining to health issues. Bills were passed dealing with tobacco and health insurance plans that should lead to improved health outcomes for Kentuckians. However, there is still more work to be done on many fronts to help reduce the high rates of cancer, heart disease, diabetes, and other health maladies in the commonwealth.
In this episode of Kentucky Health, host Dr. Wayne Tuckson welcomes the president of the Kentucky Medical Association to discuss the legislation that passed in Frankfort earlier this year, how it will benefit health care in the state, and the KMA’s health policy priorities for 2020.
Dr. Bruce Scott is an otolaryngologist – an ear, nose, and throat doctor. He has specialized practice in plastic surgery and is president of Louisville-based Kentuckiana Ear, Nose, & Throat. Dr. Scott was installed as 2018-2019 president of KMA last August. The KMA dates back to 1851 and represents physicians from all areas of the medical field throughout the commonwealth.
“One of the things that the KMA tries to do is to help physicians help their patients,” Scott says. “And try to improve health care in Kentucky. That’s what physicians are in this for, and that’s what the Kentucky Medical Association is here for.”
Two New Bills to Improve Kentucky’s Health
The KMA organizes its priorities for health policy via a program called AIM – Administrative Improvements in Medicine. It also supports legislation to improve five major diseases/conditions affecting Kentucky: tobacco use, obesity, diabetes, drug abuse, and flu/pneumonia. Two bills passed in the 2019 General Assembly will lead to improved health metrics in the state by reducing youth tobacco use and help people get their prescription medication and procedures approved faster by their insurance plans.
“Kentuckians smoke at a rate double the national average,” Scott says. “Twenty-five percent of female adults in Kentucky are smoking and using tobacco products. The impact on Kentucky is huge. Financially, $3.9 billion was spent last year on tobacco-related health care in Kentucky. $600 million of that was for Medicaid patients, and if you want to bring that down to an individual family level, that’s over $1,100 per household in the state of Kentucky, whether you smoke or not.”
Scott says that through the AIM program a few years ago, the KMA devised the Commit to Quit initiative targeting tobacco use. As part of this initiative, the KMA and other groups supported legislation passed during the 2017 General Assembly that made tobacco cessation products and courses covered under health insurance plans in Kentucky. For 2019, the KMA and cohorts turned their efforts to address tobacco use in schools.
In 2018, it was estimated that roughly 26 percent of high school students in the state smoked, Scott says. For middle schoolers, the estimate is 8 percent. “Yes, believe it or not, in 58 school districts in Kentucky, smoking was still was allowed on the premises of the school,” he adds.
House Bill 11, passed by the legislature and signed by Gov. Matt Bevin, bans tobacco use on all school premises in the state and also bans tobacco use at all school functions, such as athletic events and plays.
House Bill 11 “is important because it eliminates secondhand smoke,” Scott says. “But the more important thing is, it eliminates the example of adult role models who are smoking in front of the kids.”
Scott explains that e-cigarettes are included in the ban, and hopefully once it is implemented in 2020 the rapidly rising rate of e-cigarette use by Kentucky teens will plateau and then recede. He adds that the KMA’s next priority is to support a bill raising the age to purchase tobacco products from age 18 to 21. Legislation was introduced in the 2019 General Assembly that raised the legal age limit, but it did not pass.
On the administrative front, Scott says the KMA was behind the passage of Senate Bill 54, sponsored by physician and KMA member Sen. Ralph Alvarado (R-Winchester) that reduces the wait time for patients to get their medications and procedures authorized by health insurance plans.
Scott says that prior authorization – where health insurance companies examine doctor’s prescription medications or recommendation for procedures and judge whether they would be covered and the medical providers will be reimbursed – used to happen less frequently, and usually only for experimental drugs or new procedures. But nowadays, prior authorization happens far more often and for routine drugs and procedures, such as a biopsy. Waiting for the insurance company’s go-ahead can result in delays of several weeks for patients – and for some patients, that delay is more than an inconvenience, it is a health crisis.
“Now, we didn’t eliminate prior authorization with Senate Bill 54, I wish we did,” Scott says. “But we changed it for the patients to where they’re only going to have to wait one day for anything their doctor says is urgent or a maximum or five days for things the doctor say are not urgent but still need to be prior authorized.
“I know that in my practice, you see the stress when you tell a patient that you need this biopsy or you need this X-ray study, and they say, ‘Okay, let’s get it done,’” he continues. “And I say, ‘Well, I got to ask permission from your health plan before I can do this test on you,’ and they go wait. Under the old rules they may be waiting three weeks or more. Under the new rules – five days. A big improvement. I wish it was even further improvement, but you know, we chip away and try to get things that are right for our patients.”
The legislation takes effect on Jan. 1, 2020.
Policy Goals for 2020
Scott says that another administrative issue is in the KMA’s crosshairs for 2020: the rising in influence of pharmacy benefit managers. A pharmacy benefit manager is “basically, a new middleman,” Scott says. “They’re put in between you, the patient who gets a prescription from your doctor, and the pharmacy where you’re going to pick it up from. This is a group that works with your insurance plan to negotiate the lowest possible price with a pharmacy, but then tells you that it’s a higher price – and they keep the difference. In some cases they share the difference with health plans, and in some cases they don’t.”
He offers an example of how this works to the detriment of the patient. He says that last year, Kentucky’s Medicaid program was paying $5.46 to the benefit manager for a drug to treat acid reflux. But manager was paying the pharmacy 49 cents. The cost difference is a burden for taxpayers who partially fund Medicaid. This has “been a black box, and people exactly haven’t been able to figure out how you determine the prices, and there have been kickbacks, there have been rebates, and refunds, and nobody seems to know where the money goes,” Scott says. “But it’s a lot of money, and it’s coming out of Kentuckians’ pockets.” There wasn’t a bill addressing pharmacy benefit managers in the 2019 General Assembly, but Scott is hoping for one in the 2020 session.
Another health policy priority that the KMA continues to push going forward to increase flu vaccination rates in Kentucky. The organization has created public awareness via their Focus on the Flu program, and Scott says that early data suggests that flu vaccinations in Kentucky during this past 2018-19 season rose to around 50 percent, up from 35 percent during a 2017-18 season that was one of the worst for flu in recent years.
Another disease the KMA is targeting is diabetes, Scott says. Their efforts to curb Kentucky’s high diabetes rates focus on spreading awareness about sugary drinks and the importance of getting exercise. Both of these campaigns concentrate on childhood obesity.
As a final message, Scott urges patients to discuss health policy and proposed legislation with their doctors, and also to contact their legislators once bills are introduced that aim to improve public health. “A lot of people are hesitant to call their legislators, but they work for us,” he says.